Monitoring the patency and integrity of the drainage system
Rationale: Actions taken directly from the text in book. No tube can drain effectively if it is clogged or damaged in any manner. The water seal level is marked for most effective level of use. Overfilling it adds no additional effectiveness. Clamps are readily available at the bedside for emergency purposes, such as dislodgement of the tube. Monitoring of client status after tube insertion includes all vital signs, and is set according to client need and hospital guidelines.
Nursing Process: Implementation
Client Need: Physiological Integrity
Cognitive Level: Application
Strategy: Use nursing knowledge and the process of elimination to make a selection
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