2. Integrated Case Studies: Advanced Case Study: Damian Wallace
Suggested Responses for Integrated Nursing Care
Damian Wallace

Damian Wallace, age 19, was admitted to the emergency department approximately 4 hours
ago with a stab wound to the chest that he received in a knife fight while intoxicated. You are
asked to care for Damian while his nurse attends to a new emergency. She gives you the
following report: He was admitted in respiratory distress and bleeding from the stab wound. His
wound is on the right side at the sixth intercostal space and is approximately 1 in in length,
sutured and intact. The chest x-ray confirmed a right hemothorax and, as a result, the ED
physician inserted a chest tube. The chest tube is connected to a disposable drainage system
and placed to suction at −20 cm H 2 O. The chest tube is draining a small amount of dark-red
blood. There has not been any new drainage for the past 2 hours.
Damian’s most recent vital signs were as follows: temperature, 98.4°F; pulse, 88 beats/min;
respirations, 24 breaths/min; blood pressure, 112/74 mm Hg. He is receiving oxygen via face
mask at 30% and is on continuous pulse oximetry. The oxygen saturation level is currently 96%.
He says he feels short of breath. He does not have labored breathing and is not using accessory
muscles. He reports pain at the chest tube insertion site and stab wound site. He has a patent
IV infusing in his left forearm. His laboratory work reported a blood alcohol level of 0.12. The
nurse giving report says, “Good luck—He says he’s in pain, but I think he already drank his pain
medication from a bottle.”
Damian turns on his call light. When you approach him, you notice his breathing is labored with
subclavicular retractions. The pulse oximeter reads 95%. Damian says, “This thing in my side
really hurts.”
You take another set of vital signs: temperature, 98.6°F; pulse, 90 beats/min; respirations, 37
breaths/min; blood pressure, 118/78 mm Hg. You find the breath sounds are diminished on the
right. The chest drainage tubing is in the bed without a dependent loop, and Damian has been
lying on a segment of the tubing. You ask him to describe his pain and rate it on a scale of 1 to
10 (10 = worst), and he says, “Really bad, sharp, about a 5, like I’m being stabbed again!” You
ask if the medicine he got earlier helped with the pain, and he replies, “it didn’t help one bit!”
When you review the eMAR, you find that Damian has been prescribed ketorolac 30 mg IV,
which was given 3 hours ago, and hydrocodone 5 mg and acetaminophen 325 mg po for pain
unrelieved by ketorolac, which has not been administered. You find his nurse and ask if pain
medication was administered. The nurse responds, “Are you kidding? If he’s tough enough to
drink and fight, he’s tough enough for a little chest tube. If the anti-inflammatory doesn’t help,
he doesn’t deserve anything stronger.”

Prescribed Interventions
Chest tube with drainage system to suction at −20 cm H 2 O
Intravenous fluids: NSS at 100 mL/hr
Oxygen at 30% via face mask
Ketorolac 30 mg IV q6h prn pain

Hydrocodone 5 mg and acetaminophen 325 mg po q4-6h prn pain unrelieved by ketorolac
Continuous pulse oximetry

a. Which of Damian’s needs is your first priority? Describe your assessments
related to your first priority.
b. How would you troubleshoot his chest tube drainage system?
c. What could be the source of his respiratory distress?
d. Describe the purpose of a chest tube drainage system for a hemothorax.
e. Discuss valid reasons a nurse might not give a pain medication when there is a
prn order.
f. Discuss prejudices nurses may have that may prohibit adequate pain management.