A licensed practical nurse (LPN) is making a home health visit to a 22-year-old woman who was discharged 3 days ago after a spontaneous pneumothorax repair with a chest tube placed to a portable drainage system. The client reports mild soreness at the insertion site but no difficulty breathing. Vital signs: BP 112/70 mmHg, HR 88/min, RR 18/min, SpO2 97% on room air, temp 37.1°C. The drainage system is upright at the bedside, positioned below the level of the chest, with 20 mL of serosanguineous fluid collected over the shift and gentle fluctuation (tidaling) noted in the tubing with respiration. The insertion site dressing is dry and intact. Which action should the nurse take regarding the chest drainage system?
- Focus the visit on teaching incisional wound care since the chest tube findings appear unremarkable and can wait.
- Milk the chest tube gently to clear any debris and raise the collection unit onto the bedside table for easier viewing.
- Chart the tidaling and vital signs in the record without informing the registered nurse or provider of the visit findings.
- Continue monitoring the drainage system, keeping it upright and below chest level, and document the tidaling and output.