sdlp: icc and uwsd

THE CANBERRA HOSPITAL

STAFF DEVELOPMENT UNIT

Nursing Management of a Patient with an:

Intercostal Catheter and

Underwater Seal Drainage System

A Self Directed Learning Package

Intercostal Catheters and Underwater Seal Drainage

DEVELOPED BY:

Jamie Ranse, Registered Nurse – Emergency Department

AUGUST 2003

ACKNOWLEDGMENTS:

Margaret Hodge; Medical Nurse Educator

Dot Hughes; Nurse Educator – Intensive Care Unit

Jeni Ritchie; Clinical Development Nurse – Emergency Department

Tracey Duggan; Clinical Nurse Consultant – Ward 6A

The Canberra Hospital – Staff Development Unit


TABLE OF CONTENTS

Module Page

Introduction 5Introduction 5Instructions for Completion 5Review Date 5References 6

Anatomy and Physiology of the Respiratory System 8Learning Objectives 8Direction of Use 8

Assessment: Anatomy and Physiology Review 8

Nursing Management – Intercostal Catheter 11Learning Objectives 11Indications for a Intercostal Catheter 11

Pneumothorax 11Haemothorax 13Empyema 13Pleural Effusion 14

Insertion of an Intercostal Catheter 15Physical Assessment 16Set-Up of Equipment 16Documentation 18

Apical and Basal Intercostal Catheters 18Intercostal Catheter Dressings 19Removal of an Intercostal Catheter 19

Assessment: Clinical Case Study (Part A) 21

Nursing Management – Underwater Seal Drainage Systems 23Learning Objectives 23Types of Underwater Seal Drainage Systems 23

Used at the Canberra HospitalChambers and their Actions 24

Water Seal Chamber 24Suction Control Chamber 24Collection Chamber 25One, Two and Three Chamber Systems 26

26



Routine ProceduresChanging the Collection Chamber 27Adjusting the Suction Level 27Sampling Drainage Fluid 28

Nursing Observations of the Underwater Seal 28Drainage SystemLeak / Bubble 28Oscillation / Swing 29Documentation 29

The Environment and Equipment 31Clamping 31Position of the System 31

Assessment: Clinical Case Study (Part B) 33

Nursing Management – General 36Learning Objectives 36Patient Assessment 36Patient Education 36

Assessment Competency Based Assessment 37

Evaluation 40



Introduction

INTRODUCTION

This self directed learning package is designed to assist the Registered Nurse to

develop the competencies necessary to care for the patient with an intercostal

catheter and underwater seal drainage system. This package is divided into three

broad sections:

Anatomy and Physiology

Nursing Management

Assessment

INSTRUCTIONS FOR COMPLETION

This package should take approximately 8 hours to complete. Please complete

the relevant readings then attempt to complete the questions. It is advisable to

utilise the reading list supplied to assist you in the completion of this package.

Please return the completed package to your Educator or Clinical Development

Nurse within one month of receiving it and arrange for a mutually agreeable time

to complete the competency assessment.

REVIEW DATE

This package will be reviewed in conjunction with evaluations from the first five

staff members to complete the package. It will then be reviewed as a needs

basis, if not every three years in accordance to Australian Health Care Standards

[AHCS]. The aim being to maintain the currency of practice with evidence based

literature.



REFERENCES

A.D.A.M (2002) http://www.adam.com/

Anderson, K. N., and Anderson, L. E., (eds.), (1998) Mosby’s Medical, Nursing, and Allied Health Dictionary (5 th ed.) . Mosby-Year Book Inc., St Louis, Missouri.

Australian Nurses Council Inc (2000) Competencies for Registered Nurses.

Black, J. M, and Matassarin-Jacobs, E., (1997) Medical-Surgical Nursing: Clinical Management for Continuity of Care (5 th ed.) . W. B. Saunders Company, USA.

Charnick, Y., (2001) The Nursing Management of Chest Drains: a Systematic Review No. 16 The Joanna Briggs Institute for Evidence Base Nursing and Midwifery, Adelaide, Australia.

Diepenbrock, N.H., (1999) Quick Reference to Critical Care, Lippincott, Williams and Wilkins, Philadelphia, USA.

Hickman, R. J., and Caon, M., (1995) Nursing Science: Matter and Energy in the Human Body (2 nd ed.) . McMillan Education, Melbourne, Australia.

Hudak, C.M., Gallo, B.M., and Morton, P.G., (1998), Critical Care Nursing – A Holistic Approach (7 th ed.) . Lippincott-Raven Publishers, Philadelphia, USA.

Joanna Briggs Institute (2002) Acute Care Practice Manual. The Joanna Briggs Institute for Evidence Base Nursing and Midwifery, Adelaide, Australia.

Kozier, B., Erb, G., Blais, K., and Wilkinson, J. M., (1998) Fundamentals of Nursing: Concepts, Process, and Practice (5 th ed.) . Addison-Wesley Publishing Company, Inc., Califonia, USA.

Lazzara, D., (2002) Eliminate the Air of Mystery from Chest Tubes. Nursing 2002, 32(6): 36 - 45

Leahy, J. M., & Kizilay, P. E., (1998) Foundations of Nursing Practice: A Nursing Process Approach. W. B. Saunders Company, USA.

Marieb, E. N., (1998a) Human Anatomy and Physiology (4 th ed) ., Benjamin Cummings Science Publishing Company Inc. California.

Marieb, E. N., (1998b) Study Guide for Human Anatomy and Physiology (4 th ed) ., Benjamin Cummings Science Publishing Company Inc. California.



Porth, C. M., (1998) Pathophysiology: Concepts of Altered Heath States (5 th ed.) ., Lippincott.

Seeley, R. R., Stephens, T. D., and Tate, P., (1995) Anatomy and Physiology (3 rd

ed.). Mosby-Year Book Inc., St Louis, Missouri.

Simulab Corporation (2003) http://www.simulab.com/

The Canberra Hospital (2002) Management of a patient with an intercostal catheter. http://tchi/Content.asp?p=48

The Canberra Hospital (2001) Nursing Service - Nursing Practice Standards: Intensive Care Unit 2.4.0 / ICU



Anatomy and Physiology of the Respiratory System

LEARNING OBJECTIVES To review the anatomy and physiology of the Respiratory System, focussing

specifically on:

Physiology of the lungs, and

Mechanisms in respiration

DIRECTION OF USE

This section is primarily self directed, and acts as a prerequisite for the remainder

of the package. It is suggested that you familiarise yourself with the anatomy and

physiology of the respiratory system by utilising an anatomy and physiology book

that you may have at home or one of the many available at the Canberra

Hospital. Examples are included in the above reference list [page 6].

ASSESSMENT: ANATOMY AND PHYSIOLOGY REVIEW

The following exercises are abstracts from Marieb, E. N., (1998b).

Complete the following questions and answer them in the space provided.

1. What are the four main events of respiration?

i)

ii)

iii)

iv)

2. The respiratory system is divided into conducting zone and respiratory zone

structures.

i) Name the respiratory zone structures

ii) Name the conduction zone structures



3. Figure 1 illustrates the anatomy of the lower respiratory system. Intact

structures are shown on the left; isolated respiratory passages are shown on

the right. Label the diagram with the following:

Apex of lung (superior lobe) Mediastinum Plural space

Base of lung (inferior lobe) Clavicle Diaphragm

Using a different colour shade the following areas of the lung, ensure that you

also shade the name of the corresponding area with the same colour.

Trachea Larynx Intact Lung

Visceral Pleura Parietal Pleura

Primary Bronchi Secondary Bronchi Tertiary Bronchi


Figure 1: conducting respiratory passages and anatomical relationships of organs in the thoracic cavity (Marieb, 1998b)


4. Using either A, B or C, match the following facts about pressure within the lungs.

A Atmospheric Pressure B Intrapulmonary Pressure C Intrapleural Pressure

1 Baring pneumothorax, this pressure is always lower than atmospheric pressure (negative pressure)

1 Pressure outside the body

2 As it decreases, air flows into the passageways of the Lungs

3 As it increases over atmospheric pressure, air flows into the lungs

4 If this pressure becomes equal to atmospheric pressure then the lungs collapse

5 Rises well over atmospheric pressure during a forceful cough

6 Also known as intra-alveolar pressure

5. Many changes occur within the lungs as the diaphragm (and intercostal

muscles) contract and then relax. These changes cause air to flow into and

out of the lungs. The activity of the diaphragm is given in the left column of the

following table. Several changes in internal thoracic conditions are listed in

the column heads to the right. Compare the table by ticking () the

appropriate column to correctly identify the change that would be occurring in

each case relative to the stated diaphragm activity.

Changes inActivity of diaphragm: = increase = decreased

Internal volume of thorax

Internal pressure in thorax

Size of lungs Direction of air flow

Into lungs

Out of lungs

Contracted,Moves downwardRelaxed, moves superiorly



Nursing Management – Intercostal Catheters

LEARNING OBJECTIVES

List the indications for an intercostal catheter.

Outline the care for a patient with an intercostal catheter.

Outline the process of insertion and removal of an intercostal catheter.

INDICATIONS FOR AN INTERCOSTAL CATHETER

An intercostal catheter is sometimes known as a chest tube (Diepenbrock, 1999).

However, for the purpose of this package, it will be referred to as an intercostal

catheter.

An intercostal catheter is indicated when a patient has excessive fluid or air

within the pleural or mediastinal cavities. This may include conditions such as;

pneumothorax, haemothorax, empyema, or pleural effusion (Porth, 1998). The

primary aim of an intercostal catheter is to promote lung re-expansion by

restoring and maintaining respiratory and haemodynamic status (Charmock,

2001). Poor management of an intercostal catheter can prevent the drainage of

fluid and/or air, therefore delaying lung re-expansion, and exacerbating the

patients current condition.

Pneumothorax

A pneumothorax is defined as a collection of air or gas in the pleural space

(Marieb, 1998a; Seeley, et. al., 1995). There are several types of pneumothorax,

which are classified by cause. This includes spontaneous pneumothorax,

traumatic pneumothorax, and tension pneumothorax.

A spontaneous pneumothorax is the occurrence of a pneumothorax without a

clear cause (Porth, 1998). Primary spontaneous pneumothorax occurs when

there is no known underlying lung disease. However, spontaneous

pneumothorax is thought to be caused by the rupture of a small, air-filled sac in

the lung called a bleb or a bulla (Marieb, 1998a; Porth, 1998). The disease most

frequently affects tall, thin men between the ages of twenty and forty years old


Figure 2: a chest x-ray displaying a left sided pneumothorax (A.D.A.M 2002)


(Kozier, et. al., 1998; Marieb, 1998a; Porth, 1998). Secondary spontaneous

pneumothorax is a complication of underlying pulmonary disease such as,

chronic obstructive pulmonary disease, asthma, cystic fibrosis, tuberculosis or

whooping cough.

A traumatic pneumothorax results from a traumatic injury to the chest.

This trauma may be blunt or penetrating. In blunt chest trauma, a rib may

lacerate lung tissue or an artery, causing blood to collect in the pleural space. In

penetrating chest trauma, a weapon such as a knife or bullet lacerates the lung

(Black and Matassarin, 1997; Porth, 1998).

A tension pneumothorax is caused when excessive pressure builds up around

the lung, forcing it to collapse. The excessive pressure can also prevent the heart

from pumping blood effectively, therefore leading to cardiogenic shock (Black and

Matassarin-Jacobs, 1997; Seeley, et. al., 1995).

Signs and Symptoms of a pneumothorax may include:

sudden sharp chest pain, especially made worse by a deep breath or a

cough,

shortness of breath,

chest tightness,

tachycardia,

cyanosis,

nasal flaring,

anxiety / stress, and

hypotension.

Diagnosis of a pneumothorax is by

chest x-ray to determine presence of air outside the lung,

arterial blood gases, and

auscultation of the lungs.


Figure 3: a left sided haemothorax (Simulab Corporation, 2003)


Haemothorax

A haemothorax is defined as a collection of blood in

the pleural cavity. The most common cause of a

haemothorax is chest trauma (Anderson and

Anderson, 1998). Haemothorax can occur in patients

with lung or pleural cancer, or in patients with a

defect in the blood clotting mechanisms.

Haemothorax is common after thoracic or heart

surgery, as well as in patients who have suffered a

pulmonary infarction (Hudak, et. al., 1998). Shock is

often secondary to a large haemothorax in the

trauma patient. Haemothorax may also be

associated with a pneumothorax.

Signs and Symptoms are similar to those in a pneumothorax, with the addition

that the patient may be actively producing red frothy blood-stained sputum.

Diagnosis of a pneumothorax is by

chest x-ray,

thoracentesis,

pleural fluid analysis, and

chest auscultation.

Empyema

Empyema is caused by an infection that spreads from the lung and leads to an

accumulation of pus in the pleural space (Anderson and Anderson, 1998). The

infected fluid can build up to a large quantity, which puts pressure on the lungs,

causing shortness of breath and pain. Risk factors include recent pulmonary

conditions such as, bacterial pneumonia, lung abscess, thoracic surgery, trauma

or injury to the chest, and rarely, thoracentesis (Black and Matassarin, 1997;

Porth, 1998).



Signs and symptoms may include

a dry cough,

fever or rigours,

excessive sweating, especially night sweats,

general discomfort, uneasiness, or ill feeling,

weight loss, and

chest pain that is worse on inspiration.

Diagnosis of empyema is by

chest x-ray,

thoracentesis,

pleural fluid gram stain culture, and

chest auscultation - abnormal findings, such as decreased breath sounds or a

friction rub, may be noted on.

Pleural Effusion

A pleural effusion is defined as an

accumulation of fluid between the layers of

the membrane that lines the lungs and

thoracic cavity (Anderson and Anderson,

1998). Normally pleural fluid is formed in

small amounts to lubricate the surfaces of the

pleura. A pleural effusion is an abnormal

collection of this fluid. Two different types of

effusions can develop. Transudative and

exudative effusions (Porth, 1998).

Transudative pleural effusions are usually caused by a disorder in the normal

pressure present in the lung. Congestive cardiac failure is the most common

cause of transudative effusion (Porth, 1998).


Figure 4: diagrammatic representation of a pleural effusion (A.D.A.M 2002)


Exudative effusions form as a result of inflammation of the pleura, which is often

caused by lung disease, such as, cancer, drug reactions, asbestosis, sarcoidosis,

pneumonia, tuberculosis and other lung infections (Porth, 1998).

Signs and symptoms may include

shortness of breath,

chest pain, usually a sharp pain that is worse with coughing or deep breaths,

cough,

hiccups, and

tachypnoea.

Diagnosis of pleural effusion is by

chest x-ray,

thoracic CT,

chest ultrasound,

thoracentesis,

pleural fluid analysis, and

chest auscultation.

INSERTION OF AN INTERCOSTAL CATHETER

The insertion of a chest tube includes

the surgical insertion of a hollow,

flexible drainage tube into the chest. A

medical officer completes the

insertion, usually with the assistance

of a registered nurse (The Canberra

Hospital, 2002).

Nursing interventions prior to the

insertion of the intercostal catheter

should include a physical assessment, set-up of equipment and documentation.


Figure 5: instruments used in the insertion of an intercostal catheter (A.D.A.M 2002)

Figure 6: air movement in the insertion of an intercostal catheter (Simulab

Corporation, 2003)


Physical Assessment

assess the patient's breath sounds, heart

rate, blood pressure, temperature, respiratory

rate and rhythm, and oxygen saturation.

assess the patients pain level and administer

ordered analgesia as needed.

assessment of the patients bedside is

important to ensure it is clear of clutter.

Oxygen and suction should be available and

operational.

Set-Up of Equipment

Outlined below is the correct procedure in setting-up for the insertion of an intercostal catheter.

1. Clean large procedure trolley with alcohol. Remove major procedure pack from plastic covering and place in centre of trolley.

2. Touching only the light green areas of the cloth, open the pack outwards. Open a cheatle forcep carefully and use this to arrange the sterile field as shown.



3. Add Betadine to one of the bowls, whilst maintaining a sterile field.

4. Add alcohol to the other bowl on the field. Ensure that your hand and the container are kept at least fifteen centimetres above the field.

5. Open Howard Kelly Clamp set onto sterile field. 6. Open chest Tube onto the field. Make sure that the ends do not protrude over the edge of the field.

7. Open two occlusive dressings onto field. 8. Open Mersilene suture pack, add a 10ml syringe and a 23 and 25 gauge needle.



Your set-up for an intercostal catheter is now complete.

9. Have local anaesthetic ready for drawing up [Lignocaine 1% and Lignocaine with adrenaline].

Documentation

Document in the patient progress notes:

the pre-insertion assessment findings,

the patients response to the procedure, and

any complications.

NOTE: Refer to the Canberra Hospital Nursing Practise Standards [08.5.2:001] or The Canberra Hospital – Intensive Care Unit Nursing

Standard 2.4.1 / ICU for the procedure of inserting an Intercostal Catheter.

APICAL AND BASAL INTERCOSTAL CATHETERS

In some circumstances, a patient may require

the insertion of more than one intercostal

catheter into the same pleural cavity. For

example, a trauma patient who has sustained

significant chest injuries, which result in both a

haemothorax and a pneumothorax.


Figure 7: an inserted ‘apical’ intercostal catheter (Simulab Corporation, 2003)

Figure 8: securing an intercostal catheter. Figure 9: securing an intercostal catheter.


An apical intercostal catheter is inserted into the apex of the pleural cavity.

This intercostal catheter will primarily remove air form the pleural cavity, and

therefore promote lung re-expansion.

A basal intercostal catheter is inserted into the base of the pleural cavity. This

intercostal catheter will primarily remove fluid – as fluid is heavier than air, it

therefore consolidates or pools at the base of the pleural cavity.

INTERCOSTAL CATHETER DRESSINGS

The intercostal catheter should be dressed with an occlusive dressing, such

as tegedermtm or opsitetm to allow visualisation of the insertion site. This

dressing must be routinely checked each shift and changed at least every

forty-eight hours or as necessary (Joanna Briggs Institute, 2002).

Changing the intercostal catheter dressing should be done using the

principles of aseptic technique, to reduce the risk of infection. The dressing

should be secured as per The Canberra Hospital Nursing Practice Standards.

REMOVAL OF AN INTERCOSTAL CATHETER

A medical officer conducts the removal of an intercostal catheter with the

assistance of a registered nurse. In some circumstances two registered

nurses may remove the intercostal catheter [these circumstances include the

removal of an intercostal catheter in specialty areas by registered nurses that



have successfully completed a relevant educational program] (The Canberra

Hospital, 2002).

In the adult, an intercostal catheter is considered ready for removal only after

all of the following conditions have been met:

resolution of pneumothorax,

less than 100ml of pleural drainage evacuated over the preceding 24 hour

period,

absence of air leak on valsalva manoeuvre or forceful cough,

appropriate documentation by a medical officer which indicates the intercostal

catheter is to be removed.

Charnock (2001) states that when nurses educate and support patients on the

removal of the intercostal catheter, patients experience less pain and anxiety

during the procedure. As a result, these patients have fewer complications post

intercostal catheter removal.

After catheter removal, a follow-up chest x-ray should be obtained to document

continued lung re-expansion. X-rays should be obtained at least four hours post

removal of the intercostal catheter. This ensures that conditions such as a slowly

re-occurring pneumothorax is not missed (Hudak, et al., 1998).

NOTE: Refer to the Canberra Hospital Nursing Practise Standards [08.5.2:001] or The Canberra Hospital – Intensive Care Unit Nursing

Standard 2.4.8 / ICU for the removal of an Intercostal Catheter.

After the removal of an intercostal catheter the nurse must attend to regular

observation of the patient. Including an assessment for breathlessness,

tachycardia, and diminished breath sounds.



ASSESSMENT: CLINICAL CASE STUDY (PART A)

Date: 01 January 2005, Time: 1300

You have commenced care for a patient who was admitted to your ward after

presenting to the emergency department with a fever, dry cough, and chest pain

which is worse on inspiration. The patient’s only significant medical history is

thoracic surgery, which he had four weeks ago.

In determining a diagnosis and subsequent treatment for the patient, the medical

staff order a number of diagnostic test. Firstly, a x-ray is performed which shows

a large amount of fluid in the left lower lobe, following the x-ray, a thoracentesis

and pleural fluid analysis is performed and the medical staff diagnoses

empyema.

The plan for this patient is the insertion of an intercostal catheter and underwater

seal drainage, with -10 centimetres of suction assisted by wall suction. In addition

the patient is commenced on antibiotics, to fight the infection, and analgesia, to

alleviate their pain.

10.Explain the differences between empyema and pleural effusion?

11.Outline nursing interventions prior to insertion of an intercostal catheter.



12.Using this package and The Canberra Hospital Nursing Practise Standards, or The Canberra Hospital – Intensive Care Unit Nursing Standard, or The Canberra Hospital – Emergency Department Protocol,

a) Discuss the type of dressing used for an intercostal catheter, and outline the purpose of this dressing.

b) Describe how the intercostal catheter should be secured.

13. In the removal of an intercostal catheter, what is the role of the registered nurse?


Figure 10: Thora-Seal® III (A.D.A.M 2002)


Nursing Management – Underwater Seal Drainage Systems

LEARNING OBJECTIVES

Identify different drainage systems used at The Canberra Hospital,

Describe mechanisms of drainage,

Describe the purposes of the collection, water seal and suction control

chamber, and

Identify complications of an underwater seal drainage system.

TYPES OF UNDERWATER SEAL DRAINAGE SYSTEMS USED AT THE CANBERRA HOSPITAL

The Canberra Hospital uses two types of underwater seal drainage systems. The

systems are the Thora-Seal® III, and the Aqua-Seal tm.

CHAMBERS AND THEIR ACTIONS

The Thora-Seal® III, and the Aqua-Seal tm have three chambers, figure 11 shows

the different chambers of the Aqua-Seal tm. These chambers include a water seal

chamber, a suction control chamber, and a collection chamber.


Figure 11: Aqua-Seal tm (A.D.A.M 2002)


Water Seal Chamber

Water seal drainage is achieved by connecting the intercostal catheter to a

drainage system that utilises water as a seal or ‘one way valve’. The seal allows

fluid and air to be drained from the thorax and prevents return (Hickman and

Caon, 1995; Hudak, et. al., 1998).

The water seal chamber achieves this one way

movement by separating the atmospheric pressure from

the interthoracic pressure. When the pressure in the

atmosphere is less than the pressure in the thoracic

cavity, the air is forced down the pressure gradient into

the atmosphere via the water seal. On the other hand,

when the pressure in the atmosphere is greater than the

air in thoracic cavity, the air can not enter the thorax due

to the presence of the water seal (Porth, 1998).

It is important to note that it is due to this water seal and the interplay between

the atmospheric and interthoracic pressure that air and fluid is ‘sucked-out’ of the

thoracic cavity.

Suction Control Chamber

The suction control chamber is used in the presence of excess fluid and/or air. If

the suction control chamber is not used the underwater seal drainage system is

said to be on ‘free drainage’ - using the forces of gravity.

However, if sterile water is applied to the suction control chamber, the system is

said to be ‘on-suction’. The level of water is determined in centimetres of water

[usually between -10 and -20 centimetres]. This level is

prescribed by a medical officer and determines the

amount of suction (The Canberra Hospital, 2002).


Figure 12: the water seal chamber (A.D.A.M 2002)


In addition, the underwater seal drainage system maybe connected to a wall

suction outlet, if this is the case, the unit is said to be ‘on wall suction’. This alone

does not facilitate the suction of air or fluid from the thoracic cavity – it only

assists with an additional ‘pull’. This suction is usually applied via a device, which

facilitates ‘low wall suction’. However, if this device is

not used, the only effect will be a faster evaporation of

the water in the suction control chamber. Therefore wall

suction can be achieved without a ‘low wall suction device’ (Charnick, 2001;

Lazzara, 2002).

Collection Chamber

The aim of the collection chamber is to collect any fluid that is drawn from the

lungs. It facilitates the accurate monitoring of volume, rate, colour and nature of

the drainage (Black and Matassarin, 1998).

To effectively drain fluid from the pleural cavity, the

tubing should be positioned so no loops are present. In

addition there should be no kinks in the tube. A loop or

kink can trap fluid and work against the negative

pressure, therefore inhibiting drainage (Joanna Briggs

Institute, 2002).

One, Two and Three Chamber Systems

The one chamber system combines the drainage chamber and the water seal

chamber. The tube from the patient extends below the level of the water in the

chamber, therefore allowing the air to escape via a water seal. This system is not

practical in conditions that have excessive drainage (Hickman and Caon, 1995).


Figure 13: the suction control chamber (A.D.A.M

2002)

Figure 14: the collection chamber (A.D.A.M 2002)


The two chamber system has the drainage chamber separate from the water seal

chamber. This allows drainage and measurement of fluid from the pleural cavity

(Hickman and Caon, 1995; Hudak, et. al., 1998).

The three chamber system consists of a collection chamber, water seal chamber

and a suction control chamber. The three chamber system has been discussed

above (Hickman and Caon, 1995).

ROUTINE PROCEDURES

Whilst you are caring for a patient with an underwater seal drainage system, you

may need to conduct some routine procedures. The most common procedures

you may need to conduct include, changing the collection chamber, adjusting the

suction level or sampling the drainage fluid (The Canberra Hospital, 2002).

Changing the Collection Chamber

If the collection chamber of the Aqua-Seal tm becomes full, then the whole unit

must be changed. On the other hand, if the collection chamber on the Thora-

Seal® III becomes full, the collection chamber can easily be changed.


Figure 15: one, two and three chamber systems (A.D.A.M 2002)


simply double clamp the drainage tube,

carefully unscrew the collection chamber,

screw-on the new chamber, and

remove the clamps.

Once the collection chamber is removed from the unit,

ensure that the contents are disposed of appropriately

in an infectious waste disposal container (Charnick,

2001). Document the time and date that the chamber

was changed, and the amount / colour of the fluid in the

chamber. This should be documented in the patient

progress notes, fluid balance chart, and on the

underwater seal drainage observation chart (Lazzara,

2002).

This procedure is best conducted with two nurses as it, firstly, reduces the time

that the intercostal catheter is clamped and, secondly, reduces the risk of spilling

the contents of the chamber (The Canberra Hospital, 2002).

Adjusting the Suction Level

Suction levels may need adjusting when the water level falls below the

prescribed limit or when additional suction is to be applied. This is achieved by

simply adding sterile water to the suction control chamber via the fill port at the

top of the system (Hudak, et. al., 1998; Joanna Briggs Institute, 2002).

If a medical officer prescribes a level of water less than what is currently in the

suction control chamber, then the underwater seal drainage system will require

replacing.

Sampling Drainage Fluid

To obtain a sample of fluid from the patient, it is advised to get the ‘freshest’

possible sample as this will indicate the current status of pleural fluid when

compared to the fluid in the collection chamber (Charnick, 2001). Simply follow


Figure 16: a collection chamber(A.D.A.M 2002)


the process as outlined in The Canberra Hospital Nursing Practise Standard

[08.5.2:001].

In addition it is important to note that the specimen must be obtained from the

flexible drainage tube, close to the connection of the intercostal catheter. The

flexible drainage tube has specific properties, which facilitate the tube to ‘self

seal’ following the removal of the fine bore needle.

NOTE: Refer to the Canberra Hospital Nursing Practise Standard [08.5.2:001] for obtaining a specimen form the pleural cavity for

laboratory analysis.

NURSING OBSERVATIONS OF THE UNDERWATER SEAL DRAINAGE SYSTEM

Observations of the underwater seal drainage system should be conducted every

hour, unless indicated otherwise by a medical officer. Observations should be

conducted with ‘wall suction’ turned off. Observations of leak / bubble and

oscillation / swing are obtained by viewing the water seal chamber not the suction

control chamber (The Canberra Hospital, 2001).

Leak / Bubble

Leak / bubbles will be present in the water seal chamber immediately following

insertion of the intercostal catheter (Charnick, 2001). Intermittent bubbles may

continue to be present when the patient coughs or takes a deep breath. This

bubble represents air in the pleural cavity. If bubbles are vigorous and continuous

this may indicate a leak within the drainage system. On the other hand, no

bubble / leak indicates a secure underwater seal drainage system and a re-

expanded lung (Dipenbrock, 1999; Hudak, 1998; Lazzara, 2002).

Oscillation / Swing

Oscillation is observed when there is a change in pressure in the pleural cavity.

The oscillation in the water seal chamber will be low on expiration and water will

rise up the tube on inspiration (Dipenbrock, 1999). In addition oscillation / swing



may be observed in the flexible drainage tube (Dipenbrock, 1999; Hudak, 1998;

Lazzara, 2002).

Documentation

Documentation should be completed in The Canberra Hospital – underwater seal

drainage observation chart. Below is an example of the observation chart.

………………………… Hourly Observations

Date Time Resp Air/ Oscillation/ Suction Drainage CommentsBubbling Swing

Figure 17: an example of The Canberra Hospital – Underwater Seal Drainage Observation Chart

In the event of a trauma patient with an intercostal catheter and underwater seal

drainage system. Observations should be commenced on The Canberra Hospital

– Emergency Department Nursing Trauma Flowsheet. The observation section is



located on the back of the flowsheet. An example of the observation section is

below.

UWSDLeft Right

Time Leak Swing Suction Time Leak Swing SuctionAdmitting Doctor:

Figure 18: an example of The Canberra Hospital – Emergency Department Nursing Trauma Flowsheet [underwater seal drainage observation section]

Below is a summary of the management overview for the underwater seal drainage system.

Leak / bubble? Oscillation / Swing?

Yes Yes Indicates that the patient has air in the pleural cavity and the lungs have not re expanded.

The greater the degree of bubble and oscillation the greater the extent of the air and lung collapse

No No Indicates resolution of air and lung re expansion [slight swing may still be present].

Check the collection tube to ensure it is not kinked or obstructed.

Yes No Indicates a possible connection or system air leak.

Momentarily clamp the intercostal catheter close to the insertion site. If bubbling still occurs secure and tape all connections.

No Yes Can be observed with partial or total pneumonectomy and disease states associated with decreased lung compliance.

In addition to The Canberra Hospital underwater seal drainage observation chart

or the Intensive Care Unit Flow Chart, the patient progress notes should be

completed with the information such as;

patient observations and physical assessment findings,

amount of fluid drained over the period of the shift,

any abnormalities or complications with the underwater seal drainage system,

any interventions from the nursing staff, such as, adding additional water to a

chamber, changing of a chamber, changing the intercostal catheter dressing,



patient education,

patient compliance with exercise and the underwater seal drainage system in

general.

(Leahy and Kizilay, 1998; The Canberra Hospital, 2002)

THE ENVIRONMENT AND EQUIPMENT

In general the environment around the patient should be free of clutter. In

addition, the patient’s bedside oxygen and suction equipment must be

operational.

Clamping

Two padded Howard Kelly clamps should be kept with the patient at all times.

The patient requires a set of two clamps for each intercostal catheter (The

Canberra Hospital, 2002). Clamping of the flexible drainage tube should be done

whenever a risk of air or fluid entering the pleural space exists, such as

accidental disconnection or breakage. The clamps must be applied in opposite

directions at least two and a half centimetres apart (Charnick, 2001; Joanna

Briggs Institute, 2002; The Canberra Hospital, 2002). It is important to note that

the clamps should only be applied to the flexible drainage tube and not the

intercostal catheter, as the clamps may damage the intercostal catheter.

Position of the System

The underwater seal drainage system should be positioned below the patient’s

chest level to facilitate drainage. The Joanna Briggs Institute (2002) states that

the underwater seal drainage system should be at least sixty centimetres below

the chest.

Whilst the patient is resting in bed or sitting out in a chair, ensure that the system

has the following applied:

the floor stand at a ninety degree angle to the underwater seal drainage

system, or

the underwater seal drainage system hanging on the bed or chair.



ASSESSMENT: CLINICAL CASE STUDY (PART B)

The following day [02 January 2005] you are caring for a patient with empyema -

the same patient as outlined in Part A of this Clinical Case Study. They have an

intercostal catheter and underwater seal drainage system [Thora-Seal® III]. The

system has 10 centimetres of water in the suction control chamber and has a low



wall suction device operating.

14.At the beginning of your shift, what assessment are you going to conduct on the patient, equipment and the environment?

You disconnect the underwater seal drainage system from the suction device and

attend to the patient’s hourly observations at 1300

15.Complete the observation chart on Page 29 - Figure 17 with the following additional information: The drainage collection chamber has 2800mls of blood stained fluid, The water seal chamber has a swing of about 5 centimetres, and you

notice intermittent bubbling, The suction control chamber has vigorous bubbling.

16.Briefly describe the primary function of the following:

a) Collection Chamber

b) Water Seal Chamber

c) Suction Control Chamber

The Medical Officer has ordered the suction level to be adjusted from –10 centimetres of water to –20 centimetres of water.

17.Outline how you would adjust the suction level of the underwater seal drainage system.



It is now 1400 and you attend to the patient’s hourly observations

18.Complete the observation chart on Page 29 - Figure 17 with the following additional information: The drainage collection chamber has 2850mls of blood stained fluid, The water seal chamber has a swing of about 4 centimetres, and you

notice continuous bubbling, The suction control chamber has vigorous bubbling.

19.Bubbling / leak:

a) If bubbling / leak is present, what may this indicate?

b) If bubbling / leak is absent, what may this indicate?

20.Swing / oscillation:

a) If swing / oscillation is present, what may this indicate?

b) If swing / oscillation is absent, what may this indicate?


21.Complete the observation chart on Page 29 - Figure 17 with the following additional information: The drainage collection chamber has 2890mls of blood stained fluid, The water seal chamber has a swing of about 3 centimetres, no bubbling /

leak is present, The suction control chamber has vigorous bubbling.

22.At 1400 the water seal chamber was bubbling continuously, however, at 1500 the bubbling is absent. What nursing interventions may have taken place between 1400 and 1500?




23.Complete the observation chart on Page 29 - Figure 17 with the following additional information: The drainage collection chamber has 2910mls of blood stained fluid, The water seal chamber has a swing of about 3 centimetres, no bubbling /

leak is present, The suction control chamber has vigorous bubbling.

24.You identify that the drainage collection chamber requires changing. a) Outline the process of changing the chamber.

b) What documentation should be completed once the chamber has been changed?

Nursing Management – General

LEARNING OBJECTIVES

Demonstrates appropriate patient assessment,

Identifies key points in patient education.



PATIENT ASSESSMENT

It is important to regularly evaluate the patient’s physical condition. This includes

skin colour, breathing rhythm and rate, discomfort, and emotional state. Every

four hours the following assessment should be conducted:

general observations, such as, pulse, respirations, temperature, oxygen

saturation’s.

physical assessment, including:

- observation of the insertion site, patients effort to breath,

- palpation, to determine symmetric air entry, and feel for subcutaneous

emphysema,

- auscultation of the chest to determine lung status, and identify any

change.

(Leahy and Kizilay, 1998)

PATIENT EDUCATION

Patient education should be ongoing. The patient should be aware of the

following:

if any change in general feeling of well being to notify nursing / medical staff

member immediately,

do not disconnect any tubes from the underwater seal drainage system,

if the underwater seal drainage system is accidentally knocked over, or a tube

is disconnected, notify a nursing staff member immediately,

deep breathing and coughing exercises are beneficial to the re-expansion of

the lungs.

(Leahy and Kizilay, 1998)

Assessment

COMPETENCY BASED ASSESSMENT

The following competencies used are according to the Australian Nurses Council Inc. (2000) Competencies for Registered Nurses.

As the assessor, please document evidence to support the below competency units while observing the assessee caring for the patient with an intercostal



catheter and underwater seal drainage system. The assessee should be observed: Checking the patients environment Conducting an assessment of the patient, the intercostal catheter, and the

underwater seal drainage system Performing the removal of a chest tube

DOMAIN: Professional and Ethical PracticeAs assessor for a registered nurse, I hold the view that the registered nurse:

COMPETENCY UNIT 1: Functions in accordance with legislation and Evidencecommon law affecting nursing practice.

[1.3] Demonstrates knowledge of policies and procedural guidelines that have legal implications for practice.

COMPETENCY UNIT 3: Protects the rights of individuals and groups in relation to health care.

[3.3] Involves the individual/group as an active participant in the process of care.

[3.6] Provides relevant and current health care information to individuals and groups in a form which facilitates their understanding

[3.7] Encourages and supports individuals/groups in decision making

COMPETENCY UNIT 4: Accepts accountability and responsibility for own actions within nursing practice

[4.2] Consults with an experienced registered nurse when nursing care requires expertise beyond own scope of competence

DOMAIN: Critical Thinking and AnalysisAs assessor for a registered nurse, I hold the view that the registered nurse:

COMPETENCY UNIT 5: Acts to enhance the professional development of self and EvidenceOthers.

[5.4] Contributes to the learning experiences and professional development of others

DOMAIN: Management of CareAs assessor for a registered nurse, I hold the view that the registered nurse:

COMPETENCY UNIT 7: Carries out a comprehensive and accurate nursing Evidenceassessment of individuals and groups in a variety of settings.

[7.1] Uses a structured approach in the process of assessment.

[7.2] Collects data regarding the health and functional status of individuals and groups



[7.3] Analyses and interprets data accurately.

COMPETENCY UNIT 8: Formulates a plan of care in consultation with individuals and groups

[8.1] Establishes priorities for resolution of identified health needs in consultation with the individual/groups

[8.2] Identifies expected outcomes including a time frame for achievement in consultation with individuals and groups

[8.3] Develops and documents a plan of care to achieve optimal health, rehabilitation or a dignified death

COMPETENCY UNIT 9: Implements planned nursing care to achieve identified outcomes within scope of competency

[9.1] Provides planned care

[9.2] Plans for continuity of care as appropriate

[9.3] Educates individuals or groups to maintain and promote health

COMPETENCY UNIT 10: Evaluates progress towards expected outcomes and reviews and revises plans in accordance with evaluation data

[10.1] Determines the progress of individuals or groups towards planned outcomes

[10.2] Revises nursing interventions in accordance with evaluation data and determines further outcomes

DOMAIN: EnablingAs assessor for a registered nurse, I hold the view that the registered nurse:

COMPETENCY UNIT 11: Contributes to the maintenance of an environment which Evidencepromotes safety, security and personal integrity of individual and groups

[11.1] Acts to enhance the safety of individuals and groups at all times

[11.2] Provides for the comfort needs of individuals and groups

[11.3] Applies strategies to promote individual/group self esteem

[11.4] Establishes, maintains and concludes caring, therapeutic and effective interpersonal relationships with individuals or groups

[11.5] Acts to maintain the dignity and integrity of individuals/groups

COMPETENCY UNIT 12: Communicates effectively with individuals and groups



[12.1] Communicates using formal and informal channels of communication

[12.2] Ensures documentation is accurate and maintains confidentiality

COMPETENCY UNIT 13: Manages affectively the nursing care of individuals and groups

[13.1] Organises workload to facilitate planned nursing care for individuals and groups

[13.2] Delegates to others activities commensurate with their abilities and scope of practice

[13.3] Uses a range of supportive strategies when supervising aspects of care delegated to others

[13.4] Responds effectively in unexpected or rapidly changing situations

COMPETENCY UNIT 14: Collaborates with other members of the health care team

[14.1] Recognises the role of members of the health care team in the delivery of health care

[14.2] Participates with other members of the health care team and the individual/group in decision making

Competency met: Yes Not Yet Completed

Assessor:Name and signature: Date: / /

Assessee:Name and signature: Date: / /

Evaluation

Would you please take the time to complete the following evaluation form, to help in the planning of future packages? Please rate the following items on a scale of 1 [unsatisfactory] to 6 [excellent]

1. Did you find the package easy to follow?

1 2 3 4 5 6



Comments

2. Did you find the package easy to read?

1 2 3 4 5 6

Comments

3. Do you find this type of learning beneficial to meet your needs?

1 2 3 4 5 6

Comments

4. Do you think this package has been beneficial to you?

1 2 3 4 5 6

Comments

5. Do you feel the assessments were relevant?

1 2 3 4 5 6

Comments



6. In retrospect is there anything you would change about the package?

7. General Comments:

Thankyou for your time and assistance


sdlp: icc and uwsd

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