NURSING MANAGEMENT INTERCOSTAL DRAIN

(I.C.D.)

Surgical Staff Nurses

UNDERWATER SEAL DRAINAGE is a routine part of treatment for

thoracic trauma, surgery and infection. Many aspects of the management of patients with a chest drain come into the nursing domain yet practices are inconsistent and many nurses lack confidence in caring for patients with these drains.

Care of Intercostal tubes (ICC)

PURPOSE OF INTERCOSTAL TUBES (ICC) To drain air and/or fluid from the pleural cavity to

allow full lung re-expansion. WHERE IS THE CHEST TUBE INSERTED?

Two sites: anterior and lateral1. ANTERIOR CHEST TUBES: Landmarks- Second

(2nd) intercostal space in the mid clavicular line (MCL).

2. LATERAL CHEST TUBES: Landmarks - between the mid - axillary line, the anterior axillary fold and the level of the nipple / 5th intercostal space.

Nursing Care Management Plan

DRESSINGS:

It is unnecessary, and indeed potentially dangerous, to have major obtrusive dressings around the chest tube which can give rise to kinking of the tube, therefore, rendering the tube useless and potentially allowing the accumulation of air and the formation of a tension pneumothorax.

A piece of gauze around the tube entry site into the skin is sufficient. Cover the tube and gauze with an opsite or tegaderm dressing.

CHEST XRAY: Ordered post insertion of the chest tube and

daily thereafter. The nurse must ensure that a medical officer competent at inspecting chest x-rays is available to assess the position of the chest tube on the chest x-ray.

OBSERVATIONS:

ICU: Report immediately chest drainage of >200mls of

blood in a 1 to 2 hour time frame. Continuous 02 Sa monitoring. Titrate 02 via whatever mode

(ie. ventilator, 02 mask or nasal prongs) to keep 02 Sa > 96%. Observe the swings of fluid in the chest tube bottle. With inspiration water will rise up into the chest tube, with expiration, water will fall. If the swing is less than 2 cm, the lung is not likely to be fully expanded and therefore suction may need to be increased.

NEVER CLAMP AN INTERCOSTAL TUBE: WHY??

Because somebody may forget to remove the clamp and a tension pneumothorax may develop. Two tubing clamps should be left at the patients bedside to clamp the tube in the event of emergency action being required if the tubing became dislodged from the chest tube bottle and air is at risk of entering the chest cavity.

Spontaneous Tension Pneumothorax

Tension Pneumothorax

is a life-threatening condition that results from a progressive deterioration and worsening of a simple pneumothorax, associated with the formation of a one-way valve at the point of rupture.

Signs and symptoms

Decreased or absent breath sounds on the affected side

Jugular venous distension Tracheal deviation towards unaffected side Hyperesonance on percussion Unequal chest rise Dyspnea Tachypnea Tachycardia Hypotension Hypoxia Pale, cool, clammy skin Subcutaneous air Cyanosis

Treatment

Initial treatment involves the insertion of a large bore cannula or needle into the second intercostal space on the mid-clavicular line (known as "needle thoracostomy", or more commonly, "needle decompression"), thereby releasing the pressure in the pleural cavity and converting the tension pneumothorax to a simple pneumothorax, which is then treated at the earliest opportunity by inserting a chest tube

PATIENT POSITION:

1ST DAY ON THE WARD:

Lying fully on ICC side 2 - 4 hourly so blood is able to

drain from mediastinum drain into ICC.

2ND DAY ON WARD:

side lying continues until removal of ICC - usually day 2 - 3. Sit patient out of bed to improve coughing, lung volumes and lung compliance.

ASSESS AND REPORT ANY OF THE FOLLOWING:

Sudden drop of Sa 02 < 90% increased restlessness and anxiety of the patient.cessation of swing, or swing < 2cm. absent or decreased breath sounds on the side of the pneumothorax. tympany or hollow sound on chest percussion.

LATE SIGNS OF TENSION PNEUMOTHORAX:

evidence on chest x-ray of air in pleural space and mediastinal shift. ECG-reduction in amplitude of QRST complex. Rhythm - electrical mechanical dissociation - normal rhythm with reduced cardiac output. tracheal deviation.

Contents of the chest bottle

The contents of the chest bottle should be sterile solution that is not toxic to the lungs should the fluid inadvertently enter the chest. Therefore, water, saline or dextrose.

Removal of a chest tube

Explain procedure to patient and place in a position of comfort. Remove sterile dressing. Cut suture. Ask patient to take a deep breath and hold it - then remove the tube and place a sterile piece of gauze and airtight over the site.

Managing the patient with a chest drain: a

review

Six clinical questions were identified for which research-based answers were

sought. These were:

Should connections be taped?How frequently should bottles be changed? What type of dressing should be used around the insertion site? Should the tubing be milked/stripped? Should tubing be clamped when moving the patient? What is the recommended breathing pattern during removal of a drain?

Should drain connections be taped?

Accidental disconnection of tubing may lead to air entry and hence some lung collapse. Some authors (Carroll 1991, Macy and Landstrom 1993) claimed that taping the connection secures it, thus avoiding potential disconnection. Welch (1993) stated that taped tubes may disconnect without being seen, thus allowing air entry. A third group (Foss 1987, O'Hanlon-Nichols 1996) suggested ways of using tape without completely covering the connection.

When should drainage bottles be changed?

Sometimes it is clear that the bottle should be changed, for example, if it is damaged or full. However, many patients being treated for pneumothorax will have a drain in place for some days. It may not accumulate fluid so it is not clear if or when the bottle should be changed.

What type of dressing should be used at the drain insertion site?

Where occlusive dressings are advocated, one article suggested that it should be left in place for three days, and another stipulated that it should not be changed unless it is soiled, or there are signs of infection. Petroleum gauze is mentioned twice as part of the airtight dressing. Betadine ointment is recommended once with an occlusive dressing, and once with a dry dressing. Bacteriostatic ointment is also mentioned once. Two articles stated that the dressings should be 'changed as ordered' and 'changed as required'. From 1993, all advice has been for occlusive dressings.

Should drain tubing be stripped/ milked?

There have been a few studies undertaken on this

question, although the groups of patients studied are predominantly cardiac. These papers were published between 1982 and 1993. Articles published before this date mainly endorsed routine stripping/milking.

Should drains be clamped when moving a patient?

A patient who is moving may inadvertently disconnect his or her drainage bottle. If it is clamped, air cannot enter the lung via the tube. Another school of thought says that if there is an air leak within the lung, clamping the drain may cause a tension pneumothorax. The gravity of this complication may outweigh any risk from disconnection, especially when good management should make sure that all connections are secure.

What breathing technique is advised during chest drain removal?

A variety of instructions for patients are recommended, and again, there is no trend over time for this advice. Welch (1993) stated that 'some authors recommend the patient exhales and performs the Valsalva manoeuvre, but in the UK the patient is usually asked to inhale deeply and hold his or her breath'.

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