underwater seal chest drainage

8/10/2019 Underwater Seal Chest Drainage

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CLINICAL GUIDELINES/NURSING

GUIDELINES FOR THE MANAGEMENT A PATIENT WITHUNDERWATER SEAL CHEST DRAINAGE.

Reference

Date approved

Approving Body Matrons Forum

Supporting Policy/ Working inNew Ways (WINW) Package

Implementation date May 2012Supersedes Version 1

Consultation undertaken Nursing Practice Guidelines Group, WardSisters/Charge Nurses, PracticeDevelopment Matrons (PDMs), ClinicalLeads, Matrons, Dr Wei Shen LimRespiratory Consultant, Dr Tim Harrison, MrJohn Duffy (Thoracic Surgeon) Beth Beeson(Medical Physics)

Target audience Clinical staff

Document derivation /evidence base:

Review Date May 2015

Lead Executive Director of Nursing

Author/Lead Manager Liz Aston (original author) 2009, HollyScothern PDM 2012

Further Guidance/InformationDistribution: Ward Sisters/Charge Nurses, PDMs, ClinicalLeads, Matrons, Nursing Practice GuidelinesGroup (includes University of Nottinghamrepresentative), Clinical Quality, Risk andSafety Manager, Trust Intranet.


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NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUSTNURSING PRACTICE GUIDELINES

This guideline has been registered with the Trust. However, clin icalguidelines are guidelines only. The interpretation and application ofclinical guidelines will remain the responsibili ty of the individual clinic ian.

If in doubt contact a senior col league or expert. Caution is advised whenusing guidelines after the review date.

INTRODUCTIONChest drainage may be indicated when a lung lesion, chest trauma orcardiac/thoracic surgery punctures the pleura, or when a spontaneous punctureof the pleura occurs. Air or fluid may be drawn into the pleural space by itsnegative pressure, causing lung recoil and collapse. A chest tube is insertedinto the pleural space to drain air, blood or fluid, re-establishing negative

pressure and allowing lung re-expansion (OHanlon-Nicols, 1996).A chest drain is usually attached to an underwater seal drainage system whichacts as a one-way valve allowing fluid and air to leave the pleural space duringexpiration and coughing and preventing it from being sucked back in duringinspiration (Allibone, 2005).The number and sites of chest tubes inserted will depend on the underlyingreason for chest drainage and on what needs to be removed from the pleuralspace.The medical staff will advise on whether suction needs to be applied to the

drainage system. If suction is applied it must be via a thoracic suction system.

In addition, in certain clinical situations there are drainage systems thatutilise a flutter valve (Pleur x drains) rather than an underwater seal toprevent air re-entry to the patient. (Sullivan, 2008). Please seek expertadvice on how these systems should be managed from a seniorcolleague, the Oncology department, the Radiology department or thelung cancer nurse specialist team. See separate guideline. Caution isadvised when using guidelines after the review date.

MANAGEMENT OF A PATIENT WITH UNDERWATER SEALCHEST DRAINAGE

Best Practice

Insertion of a chest drain is reported to be a painful and frightening procedureand patients must be given an explanation of what is going to happen and anassurance that they will receive analgesia before the procedure is carried out(Bourke, 2003; Luketich et al, 1998 cited in Allibone, 2005).


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PROCEDURE FOR INSERTION OF AN UNDERWATER SEAL CHEST DRAIN

This procedure is an aseptic procedure and is undertaken by medical staff witha nurse assisting, under guidance of ultrasound.

Analgesia should be prescribed and administered before the procedurewherever possible and effectiveness established.

EQUIPMENT

1 CSSD pack for intercostal drainage1 pair sterile glovesCleansing agent Alcoholic Povidone Iodine 10% or Alcoholic Chlorhexidine0.5%

Selection of syringes and needlesScalpelLignocaine 1% or 2%1 sterile drainage bottle or other drainage system (there are drainage systemsthat do not contain water)1 collection canister1 sterile chest drainage tubingSterile water (if using a drainage bottle) for underwater seal as per chest draininstructions for use

Dated label for bottle changeIntercostal drain and trochar, (size as requested there is no consensus on thesize of the optimal chest tube for drainage) (Davies, et al, 2003)Suture material (Ethicon W797) (If required)Sterile salineSterile dressingSterile scissorsHypo-allergenic tapeSterile gown and towelTray/holderRoberts clamps for specialist areasCorrect sized sharps container (to accommodate a trochar)Refer to general principles for all guidelines

1. PREPARATION OF EQUIPMENT - NURSING RESPONSIBILITIES


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ACTION RATIONALE

1 Ensure informed consent hasbeen obtained from the patient.

To ensure the patient is fully informedabout the procedure and any potential

risks associated with the procedure.2. Prepare the drainage system and

tubing using an aseptictechnique.

To minimise the risk of infection.

3. Fill the drainage bottle with sterilewater to the prime level. This willensure the rod end of the tubing

is 2cms below the fluid line. Thegreen cap should be inserted intothe suction port when suction isnot being used as it acts as adust cover

To ensure that air cannot re-enter thepleural space.

The GREENcap marked V (for vent) isa venting cap, which allows the freeflow of air from the bottle IT DOESNOT SEAL THE BOTTLE (RocketMedical 2011)

4. If required place the system in aholder/tray.

To minimise the risk of the bottle beingoverturned and breaking.

5. Ensure easy access to anoxygen administration system.

In case of need in an emergency.

Best Practice

In some specialist areas where cell salvage is required e.g the Emergencydepartment the bottle is filled with saline and not water. Please seek medicaladvice and refer to local guidelines where this is the case.


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6. Record baseline observations ofpulse, respirations, bloodpressure, oxygen saturationlevels and early warning scores(EWS).

For comparison with post-procedureobservations.

2. INSERTION OF THE CHEST DRAIN NURSING RESPONSIBILITIES

ACTION RATIONALE

1.. In consultation with the doctor

who will be inserting the drain,position the patient sitting up,leaning over a bed table or lyingon the unaffected side, accordingto the patients general condition.

To help maintain patient comfort and to

allow access to the insertion site.

2. Assist the doctor, who will :

a. Cleanse the skin and allow toair dry. To reduce the risk of introducinginfection.

b.

Inject local anaesthetic intothe chosen site allowing timefor tissue infiltration. Checkeffectiveness beforeproceeding.

To minimise pain during the procedure.

c.

Insert the chest drain andanchor it using a standardsuture if required. A purse-string suture may also beinserted around the tubeinsertion site especially if thedrain size is 28FG or greater.

To prevent the drain being dislodgedand to maintain the seal.The purse string suture is used forclosing the insertion site when the drainis removed. It can also be closed veryquickly if the tube is accidentallydislodged or removed.


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d.

Attach the drainage systemensuring all connections arefirmly and securely pushedtogether. If appropriate,longitudinal strips of tape can

be used across connections.

Longitudinal strips of tape allow visualchecking of the connection to be made.However, taping of tubing iscontroversial (Godden, 1998). Somestudies show it is unnecessary, whilst

others advocate the use of tape toreduce the risk of accidentaldisconnection of the system and toprevent air leak.

3. MANAGEMENT OF THE WOUND

ACTION RATIONALE

1. Apply a sterile keyhole dressingaround the chest drain andsecure with hypo-allergenic tape,if required.

To absorb any wound exudate and toensure patient comfort.

2. Re-dress the wound as

necessary e.g. if it becomesmoist with exudate. Swab site ifclinically indicated.

To ensure patient comfort and to detect

signs of infection.

3. Observe the area around thetube insertion for signs of airinfiltration e.g. swelling orcrackling on palpation.

Subcutaneous emphysema is apossibility and, if this travels to theneck or face, it can compromise airwaypatency and cause respiratory distress(OHanlon-Nicols, 1996).


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4. MANAGEMENT OF THE PATIENT FOLLOWING CHEST DRAIN INSERTION

ACTION RATIONALE

1.

Take and record the patients

pulse, respirations, bloodpressure, oxygen saturationlevels and EWS. The frequencyof subsequent observationsshould be determined accordingto the patients clinical condition.

To provide a comparison with baseline

observations. Noting the respiratoryrate, depth and rhythm and thepatients skin colour are particularlyimportant in assessing theeffectiveness of the chest drainagetreatment and early detection ofcomplications.

2. Assess the patency of the chestdrainage system by:

a. Noting the fluctuation of thefluid level in the drainage tubing(swinging) and/ or bubblingduring normal respiration andfollowing a deep breath.

b. Asking the patient to coughwhilst observing for swinging in

the bottle or movement in thedrainage tube

Swinging indicates the tube is in thecorrect position. Bubbling indicatescontinued air leak

Swinging in the bottle following acough indicates the tube is in the

correct position.

3.A chest X-ray should beperformed as soon as possibleafter chest drain insertion.

To check the position of the chestdrain.

4.Administer further prescribedanalgesia following insertion ofdrain if required.

There may be considerable discomfortbecause of the drain presence andanalgesia is required (Hilton, 2004).Discomfort and pain may also interfere

with adequate lung ventilation andpatient mobility (Gallon, 1998).

5.Encourage mobilisationaccording to the patientscondition reminding patient tokeep bottle below insertion site(see 5.1 below). Also seesection on suction (page 12).

This facilitates optimum drainage fromthe pleural cavity and so promotes lungventilation and gaseous exchange.Patients will often not mobilise if theyare in pain.


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5. NURSING MANAGEMENT OF THE DRAINAGE SYSTEM

ACTION RATIONALE

1.

The chest drainage system must

be kept below the drain insertionsite.

To prevent backflow of fluid into the

pleural space and to promote gravitydrainage.

2. DO NOT clamp the chest drainunlessa.

It is at the direct request of asenior doctor. The Doctorshould document length oftime for drain to be clamped.

If the patient becomesacutely short of breath thenclamps must be removedimmediately and the doctorinformed.NB: When clamped thepatient must be monitored forsigns of respiratory distress(Carroll, 1995)

A bubbling chest drain shouldneverbe clamped

The chest drain is sometimes clampedbefore removal to assess how thepatient will tolerate removal and toensure that the lung will remain re-

expanded.

Bubbling indicates an active leak of airfrom the pleural space. Clamping maycause a tension pneumothorax

3.Routinely assess the patency ofthe system when carrying outEWS or when clinical conditionindicates

To insure that drainage of the pleuralspace is maintained. If fluctuation orbubbling of the fluid level stops eitherthe lung has fully expanded, thesystem is obstructed (Schuster, 1998)

or the air leak has stopped.


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4. Ensure the tubing is free of kinks,there are no dependent loopsand that all connections aresecured.

This loop should not become

dependent, that is, below the fluidlevel in the bottle

Dependent loops have a negativeeffect on fluid and air drainage from thepleural space (Gordon, Norton andMerrell, 1995; Carroll 1995).

5. If the drain is patent then the fluidlevel will move with respiration. Ifit is not moving, the followingshould be checked:

the drainage tubing forkinks and/or blood clots. Ifpresent, reposition thepatient and encouragehim/her to breathe deeply.Then re-check forfluctuations in fluid level.

the patients respiratoryrate, depth and volume, thepulse rate, blood pressureand ask the patient if theyhave any chest pain. Ifnecessary, inform thedoctor.

Regularly check the tubing forair leaks.

It is possible that a tensionpneumothorax may be developingwhich is a life threatening condition. Arapid increase in pressure within thechest can cause mediastinal shiftwhich can impair venous return to theheart and will affect cardiac function(Mattson Porth, 2005).

Cardio-respiratory distress may beindicated by a low BP, increased pulserate and reduced oxygen saturationlevels, increased CVP, distended neck

veins, increased dyspnoea and chestpain (Gallon, 1998).

To ensure the system remainsfunctional (Gallon, 1998).


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ACTION RATIONALE

8.Identify and record the amountand colour of any fluid draining (if

appropriate) at least daily butmore frequently if requested bythe medical staff or localprotocols.

To monitor the amount and type ofdrainage.

9 Large pleural effusions should bedrained in a controlledfashion to reduce the risk of re-expansion pulmonaryoedema. Monitor patients EWS

as clinically indicated.

Only allow the amountspecified and documented bymedical staff to drain off at onetime It is recommended that thisshould be amaximumof 1500ml in the first hour and then1500ml in two hour intervals

(Roberts et al 2010).

The rate of fluid removal may becontrolled by elevation of thetubing over a drip stand orpillows. However some drains(Seldinger type) have a 3 way tapsupplied in the circuit which maybe used to control drainage

where specified by a medic.

If large volumes of fluid are drainedquickly this can cause a re-expansionpulmonary oedema

10 Stop draining if the patientdevelops chest discomfort,persistent cough or vasovagalsymptoms and seek urgentmedical guidance

Signs of re-expansion pulmonaryoedema


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11 When drainage falls below 200ml per day, a chest x-ray may beordered .If there is still pleuralfluid on the chest X-ray, thedoctor may request suction may

be applied

To assess re inflation of the lung and toassist the removal of air/fluid from thepleural space

12.When mobilising, ensure thedrainage system is kept belowwaist level.

To prevent backflow of fluid into thepleural space.

13.In an emergency, such as thechest drainage bottle breaking ordrainage tube disconnection, re-establish a sterile system assoon as possible (Carroll, 1995;

Schuster, 1998).

To prevent infection and maintain thedrainage system.

14.

15.

If the tube accidentally falls outget help and ask for the medicalstaff and /or Critical careoutreach to be alerted urgently.Apply dressing to chest drain siteand record full set ofobservationsIf an air leak is present, only

apply tape to 3 sides of thedressing to allow air to escapewhilst seeking urgent medicalCCOT advice.

Trauma patients with ahaemothorax require drainage tobe measured hourly or accordingto medical instruction. Inform

medical staff if blood drainageexceeds agreed parameters.Ensure parameters documentedby medical staff

To prevent air entering the potentiallumen created by the drain andcausing a tension pneumothorax(Allibone, 2005).

To allow any air to escape from the

pleural space,

Significant blood loss mustbeaddressed.


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6. CHANGING THE CHEST DRAIN BOTTLE:

ACTION RATIONALE

1. The bottle should be changed:

a) when 500ml level is reached

b) or after 7 days in situ. If thedrain has been in situ for 7days the tubing should bereplaced as well

Too full a bottle leads to a rise inpressure in the system which in

turn leads to difficulty in drainageand is therefore counter-productiveTo minimise the risk of infection

2. Fill the new drainage bottle withSterile water to the prime level.This will ensure the rod end of

the tubing is 2cms below the fluidline.

To ensure that air cannot re-enterthe pleural space

3. Kink the tube and release thetubing from the old bottle byunscrewing the red button

To prevent air or fluid from enteringthe pleural space

4. Insert the tubing into the newbottle, ensuring that the end ofthe rod is under the level of thewater

To create an intact circuit andprevent fluid from entering thepleural space

5. Release the kinked tubing andensure the tube is patent byobserving for fluid movement inthe tubing

To allow drainage from the pleuralspace

6. Seal and dispose of old chestdrain bottle and contents into thedesignated chest drain disposalbox according to wastemanagement procedures

To minimise the risk of infection

7. Document drainage amount inold bottle on fluid balancechart/nursing records

To maintain accurate records

7. FLUSHING A SELDINGERCHEST DRAIN

Seldinger chest drains are small diameter chest drains, the name of whichcomes from the method of insertion. These drains can be prone to blockage.

Therefore flushing the drain may be required on a regular basis i.e. 4 times aday, to maintain the patency of the drain when a patient has a pleural effusion.This is not necessary for pneumothorax. ( ODriscoll R and Pyne H 2008)


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This procedure is undertaken by medical staff. Only registered nurses, whohave been supervised and assessed as competent may undertake thisprocedure.

ACTION RATIONALE

1. In a designated clean area ofthe ward, draw up 10mls ofnormal saline into the 10mlsyringe, check and placesyringe on the injection trayensuring that it is checked in

accordance with the local policy.

To reduce the risk ofcontaminating the saline flush.

2. Take the syringe of normalsaline to the patient, checkingthe identity of the patient inaccordance with the local policy.

To ensure patient safety.

3. Position the patient to allowaccess to the chest drain,ensuring the patient is

comfortable.

To facilitate the procedure

4. Perform hand hygiene. To minimise the risk ofinfection.

5. Open the sterile dressing toweland place under the chest drain.

To minimise the risk ofinfection.

6. Clean the bungs on the 3-waytap supplied with the seldingerdrain, using the swab and allowdrying.

To minimise the risk ofinfection.

7. Clean hands and apply alcoholgel.

To minimise potentialcontamination of the drainand/or equipment used.

8. Apply the sterile gloves andattach the syringe of saline tothe clean bung. Ensure the 3way tap is closed towards thedrainage tubing on the chestdrain system. Instil the 10mls ofnormal saline into the chest

To ensure the normal saline isinstilled along the diameter ofthe chest drain.


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drain.

ACTION RATIONALE

9. Remove the empty syringe fromthe 3-way tap and ensure the 3-way tap is open to the drainagetubing on the chest drainsystem, checking that the salineis draining from the chest drain.

To facilitate drainage of thenormal saline and to check thepatency of the chest drain.

10. Dispose of all equipmentaccording to local policy.

To prevent the risk of crossinfection.

11. If the drain is attached to anunderwater seal drainagesystem, ensure the drain is

patent by:

a) ensuring the fluid level isfluctuating in the drainagetubing. (Allibone, 2003)

b) asking the patient to coughand observe for fluctuationof the fluid in the drainage

tubing.

To assess and monitor thepatency of the drainagesystem.

12. Observe the patient bymonitoring the temperature,pulse, respirations and bloodpressure 4 hourly (Allibone,2003). In addition, monitor thepatient for chest pain and/ordiscomfort and continue toassess the patency of the

drainage system if the drain isattached to an underwater sealdrainage system.

To monitor the patient for any illeffects from the procedure andto facilitate the early detectionof complications.

8. APPLYING SUCTION TO THE DRAINAGE SYSTEM

If the insertion of a chest drain is insufficient for the removal of air/fluid from thepleural space, suction via a thoracic suction regulator may be applied to assistin this process following a decision from medical staff.Suction pressure should be set according to either specific written instructionsin the patients records or locally agreed written protocols. There is currently no


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consensus on how much suction should be applied (Avery, 2000) nor is theresound evidence or clinical consensus to base specific guidelines in this area(Davies et al, 2003).

Note, when suct ion is applied to a chest drainage system, an intermediate

collection jar or canister must be placed between the suction regulatorand chest drain bottle. This is to prevent activation of pipeline protectionand subsequent loss of suction which could lead to a tensionpneumothorax, should the chest drain bottle overflow. (MHRAMDA/2010/040, andSupplementary advice for MDA/2010/040 All chestdrains when used with high-flow, low-vacuum suction systems (wallmounted).)

1 2 and 3 4 & 5 6

Ensure that the following is adhered to;

Non-sterile suction tubing (bubble tubing) connects the suctionregulator unit (1) to the outlet port on the intermediate collectionjar/canister (2)

Non-sterile suction tubing (bubble tubing) then connects the inlet porton the intermediate collection jar/canister (3) with the chest drain bottle(4)

The integral sterile suction tubing that comes as part of the chest drainbottle package connects the chest drain bottle (5) to the patient (6)

ACTION RATIONALE

Thoracic

regulator withpipelinerotection filter

Intermediate

collectioncanister(E.g. Seres)

Chest

Drain BottlePatient

TubingTubing Tubing


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1. Fix one end of the suction tubingonto the suction unit and theother onto the collection canisterbetween the regulator and the

chest drain bottle. Connect thecollection canister to the chestdrain bottle with non sterilesuction tubing.Ensure an inline filter is used toprotect the piped suction system.Only use thoracic suct ionsystems

The suction pressure assists thedrainage of fluid/air from the chestcavity.

2. Set the suction rate according tothe written instructions or localprotocol. This will normally bebetween 10 to 20cm H2O, (1and 2 Kpa )

If the suction is applied at too high apressure, it can harm lung tissue ortrap lung tissue in the chest tubeeyelets (Tooley, 2002)

3. Check frequently that the suction

is set as instructed.

To ensure the correct level of suction is

maintained.

4. Change the drainage systemwhen fluid levels go above500mls.

High fluid levels will affect theefficiency of suction.

5. Disconnect the suction system

before switching off to reduce therisk of mimicking clamping

If the suction unit only is turned off

there is no valve in the system to allowair/fluids to travel down to the drain this has the same effect asclamping.


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9. REMOVAL OF THE CHEST DRAIN

Once drainage of fluid or air has diminished to little or nothing and/orfluctuations in the water-seal chamber have ceased, the chest drain may beremoved at the request of the medical staff. The drain may be removed by

medical staff or by nurses who have been assessed as competent in theprocedure.

A chest X-ray may be performed prior to removal to establish that the lung hasre-expanded. Sometimes, if requested by medical staff, the patient is given atrial period with the chest drain clamped to ensure that the lung will stay inflatedand respiratory distress avoided.

EQUIPMENT

Medium basic pack - if requiredStitch cutter if requiredSterile dressingHypo-allergenic tape2 pairs non-sterile glovesSterile scissors and specimen container, if requiredClinical waste bagGel sachets

ACTION RATIONALE

1.Administer prescribed analgesia20 minutes prior to removal, ifappropriate.

The patient may experience short-lasting but intense pain on removal(Hilton, 2004)

2.Position the patient on theunaffected side or sitting up well-

supported by pillows.

To facilitate the drain removal.

3.Ask the patient to practiceholding their breath for 3 5seconds.

To facilitate the procedure.

4.Perform hand hygiene and applygloves.

To minimise the risk of cross infection

5.Remove the dressing To allow access to the insertion site


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ACTION RATIONALE

If the drain is sutured in place, this is a 2 person procedure.

6. Remove the suture if present.Cut the purse-string knot andloosely tie the ends, ready to pulla tight knot.

7. Ask the patient to perform aValsalva manoeuvre. Thismanoeuvre requires the patientto take a deep breath and then

strain against a closed airway(most easily achieved by closingthe vocal cords) in order toincrease intra-thoracic pressure.The nurse should explain this tothe patient (perhaps using theexample of straining to pass amotion). The patient shouldrehearse this procedure to the

nurses satisfaction prior toremoval of the tube and thenperform it at the nurses requestduringthe removal of the tube(Godden, 1998). The tubeshould then be removed andplaced on the sterile field on thetrolley.

If the patient is not able to holdhis/her breath, remove duringexpiration.

Allows tube to be removed only whenthe least negative pressure can be

generated. Positive pressure is rarelyachieved (Marieb, 2004), therebyreducing the risk of complications

8 If a purse-string suture is present,the second person ties it securelyimmediately as the drain comesout. If no purse string considerthe use of steri -strips to close

the wound.

To prevent air from entering the pleuralspace via the drain site


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8.If there are signs or evidence ofinfection, send the end of thedrain for microbiologicalinvestigations and swab the site.

To detect the presence of anypathogens.

9 Apply a sterile dressing to thedrain site.

To reduce the risk of infection and toprevent air re-entering the pleuralspace until the wound is sealed.

9. Monitor the patients respiratorystatus and wound drainage asclinically indicated.Seek urgent medical advice if

clinically indicated.

Shortness of breath, sudden chest painor deterioration in observations mayindicate collapse of the lung and/or re-accumulation of fluid.

10. The purse-string suture, ifpresent, is usually removed 5-7days after chest drain removalonce the drain site has healed.

In patients who have had apneumonectomy, a large volume offluid fills the space. There is a risk offluid leakage and infection and so thesuture is normally left in place for 7days.

11. Check with medical staff if achest X-ray is required followingremoval of the drain.

To check that air has not entered thepleural space during removal of thedrain

12. Seal and dispose of old chestdrain bottle and contents into thedesignated chest drain disposalbox according to wastemanagement procedures

To minimise the risk of infection


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REFERENCES and Further Reading

Allibone L (2005) Principles for inserting and managing chest drains NursingTimes Vol. 101 No. 42 pp. 45-49

Avery S (2000) Insertion and management of chest drains Nursing Times PlusVol. 96 No. 37 pp.3-6

British Thoracic Society Management of Pleural Infection in adults: BritishThoracic Society Pleural disease guidelines 2010. Thorax 2010; 65(suppl2):ii41-ii53www.brit-thoracic.org.uk

Bourke S J (2003) Lecture Notes on Respiratory Medicine 6th Edition Oxford:Blackwell

Carroll P (1995) Chest drains made easy Registered Nurse Vol. 8 No.12 pp.215-225

Gallon A (1998) Pneumothorax Nursing Standard Vol. 13 No. 10 pp. 35-39

Godden J, Hiley C (1998) Managing the patient with a chest drain: a reviewNursing Standard Vol.12 No. 32 pp. 35-39

Gordon P Norton J, Merrell R (1995) Refining chest tube management: analysisof the state of practice Dimensions of Critical Care Nursing Vol. 14 No. 1 pp. 6-13

Hilton P (2004) Evaluating the treatment options for spontaneous pneumothoraxNursing Times Vol. 100 No. 28 pp. 32-33

Luketich J. D., Kiss, M., Hershey, J., Urso, G.K., Wilson, J., Bookbinder, M.,

Ginsberg, R., (1998) Chest tube insertion: a prospective evaluation of painmanagement Clinical Journal of Pain Vol. 14 No. 2 pp. 152-154

Marieb, E. N. (2004) Human anatomy and physiology 6thEditionBenjamin Cummings, Menlo Park, California, USA.

Mattson Porth C (2005) Pathophysiology: Concepts of altered health states7th edition Philadelphia, USA: Lippincott

Mimnaugh L (1999) Sensations experienced during removal of tubes in acutepost-operative patients Applied Nursing Research Vol. 12 No. 2 pp. 78-85


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NPSA (2008) Risks of chest drain insertion NPSA/2008RRR003

ODrisoll Robert and Pyne H (2008) Insertion of a Seldinger intra pleural chestdrain www.srft.nhs.uk (accessed 2011)

OHanlon-Nichols T (1996) Commonly asked questions about chest tubesAmerican Journal of Nursing Vol. 96 No 5 pp. 60-64

Rocektmedical(2011)http://www.rocketmedical.com/pdf/Catalogues/Cardiac%20Products%20Issue%204.pdf

Schuster P (1998) Chest tubes: to clamp or not to clamp Nurse Educator Vol.23 No. 3 pp. 9-13

Sullivan B (2008) Nursing management of patients with a chest drainBritish Journal of Nursing Vol. 17 No. 6 pp.388-393

Tooley C (2002) The management and care of chest drains Nursing Times Vol98 No 26 pp.48-50

NNPDG Link Members: Jill Wakefield/Holly Scothern with thanks to DebbieRaffle, Lucy Briggs and Rhona Al-Bazzaz for their help in compiling this

procedure.

AUDIT POINTS

Is the patients safety assured with respect to chest drain procedures?

Has the patients dignity and comfort been effectively maintained prior to, duringand after chest drain procedures?

Has the patient received timely analgesia prior to chest drain procedures?

Has the patient received appropriate explanation prior to chest drainprocedures?

Is there evidence of prevention of infection throughout chest drain procedures?

Is there confirmation that chest drain procedures are successful followingremoval of a chest drain (i.e. is the patients breathing pattern and rate withinnormal adult limits; are oxygen saturations within normal limits for the patient;

are vital signs satisfactory?)


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Is there any evidence of pain associated with breathing following the removal ofthe chest drain?

underwater seal chest drainage

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