RN BasicsA client is being monitored after cardiac surgery with a mediastinal chest tube. Which finding should the nurse report immediately?
- Tidaling in the water-seal chamber with each breath
- Serosanguineous drainage of 80 mL in the first hour
- Drainage of 50 mL in the first hour that slows in the second
- A sudden drop in drainage with muffled heart sounds
Why each answer is right or wrong
Answer: D
- A. Not a sign of bleeding or tamponade. Tidaling follows chest pressure changes and is common with pleural tubes; a mediastinal tube may show little or none, so it is not the urgent finding.
- B. That amount and character is expected early after surgery.
- C. Modest drainage is expected.
- D. Correct. Drainage that suddenly decreases while the heart rate rises and the heart sounds become muffled suggests cardiac tamponade from clotted drainage collecting around the heart.
Cardiac tamponade after cardiac surgery: sudden drop in chest tube drainage, hypotension, tachycardia, jugular venous distention, muffled heart sounds, narrowed pulse pressure and pulsus paradoxus. The nurse notifies the surgeon at once and prepares for pericardiocentesis or return to the operating room.
Sources: Ignatavicius, Med-Surg Nursing, 11th ed.; Lewis's Medical-Surgical Nursing, 13th ed.
