PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

Mr. Salman .A. Merchant

1St Year M.Sc (Nursing)

Medical Surgical Nursing

Year 2011 -2013

SUSHRUTHA COLLEGE OF NURSING

BANGALORE 560 085

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. / NAME OF THE CANDIDATE AND ADDRESS / Mr. SALMAN .A. MERCHANT
1ST YEAR MSc. NURSING
SUSHRUTHA COLLEGE OF NURSING,
#23, PAPAIAH GARDEN,
DIAGONAL ROAD,
CHENNAMANAKERE, ACHUKATTU,
BANASHAKARI III STAGE,
BENGALURU – 560085
2. / NAME OF THE INSTITUTION / SUSHRUTHA COLLEGE OF NURSING
3. / COURSE OF THE STUDY AND SUBJECT / 1ST YEAR MSc NURSING
(MEDICAL SURGICAL NURSING)
4. / DATE OF ADMISSION TO THE COURSE / 03-06 – 2011
5. / TITLE OF THE TOPIC / “A STUDY TO DETERMINE THE EFFECTIVENESS OF SELF INSTRUCTIONAL MODULE ON THE KNOWLEDGE OF STAFF NURSES RELATED TO CARE AND MAINTENANCE OF CHEST TUBE DRAINAGE IN SELECTED HOSPITALS OF BANGALORE CITY”.

6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

“Knowledge is the key to healthier life and education is powerful medicine”

-  K Park.

Respiratory system plays a crucial role in delivering oxygen to the cells of our body. The cells of our body require a continuous supply of oxygen, without this oxygen we would die within a minutes. Every day we breathe about 20,000 times. All of this breathing couldn’t happen without help from the respiratory system. At the same time our heart should beat (without fail) 35 million times a year. Every beat should move oxygen enriched blood throughout our system. Therefore, no stretch to say that, the function of our heart and lungs is vital for a healthy and productive life. Conditions affecting the thoracic cavity range from acute problems to long term chronic disorders. Many of these disorders are serious and often life threatening. Supporting the structure and function of the heart and lungs is a matter of life and death.1

The lungs are paired organs situated in the thoracic cavity that performs respiration. Although respiratory disease is often thought of as only lung problem, the malfunction of any component in the thoracic cavity can cause respiratory dysfunction. For example if hemothorax occurred as result of chest trauma or any thoracic surgery will leads to an increase in the intrapleural pressure and results in respiratory dysfunction. The important management for this condition is chest tube drainage. The purpose of chest tube drainage is to remove the excess air, fluid or pus from the pleural space and to restore normal intra pleural pressure, so that the lungs can re-expand.2

A chest tube insertion is a surgical procedure in which a hollow, flexible drainage tube is inserted through the side of the chest in to the pleural space in order to drain the pleural cavity of air, blood, pus or lymph. The water seal container connected to the chest tube allows one way movement of air and fluid from the pleural cavity. The chest tube is used to restore the intrapleural pressure and to prevent the collapse of lungs. Chest tube management includes the actions to keep the tube functioning properly, which is the prime role of nurses while caring of patients with chest tube drainage.3

The common indications of chest tube drainage are pneumothorax (accumulation of air in the pleural space), pleural effusion (accumulation of fluid in the pleural space), chylothorax (collection of lymphatic fluid in the pleural space), and empyema (a pyogenic infection of the pleural space), hemothorax (accumulation of serous fluid in the pleural space). In addition to these cardiothoracic surgeries and chest trauma are common indications of chest tube insertion.4

Blunt chest trauma can cause severe acute pulmonary dysfunction due to hemo or pneumothorax, rib fractures and lung contusion. The number of accidental deaths in India is even higher than in Western world.5 Thoracic trauma contributes heavily to these figures besides head injury, abdominal injury and orthopaedic injuries. Approximately one quarter of civilian trauma deaths are caused by thoracic trauma and many deaths can be prevented by prompt diagnosis and correct management.6 Inspite of high mortality rate, 90% of patients with life threatening thoracic injuries can be managed by a simple intervention like drainage of pleural space by tube thoracostomy.7

A study conducted in USA on chest tube drainage found that every year more than 300,000 patients undergo cardiothoracic surgery and requiring placement of at least one chest tube. Following thoracic surgery, a tension pneumothorax is one of the main causes of cardiac arrest in the initial post operative period. Immediate diagnosis and appropriate treatment in such situation is crucial. Decompression by needle thoracentesis followed by the insertion of a chest tube is indicated in this situation.8

A study conducted in United Kingdom on the prevalence of pneumothorax, estimated that hospital admission rates for combined primary and secondary pneumothorax are reported in UK between 5.8/10, 0000 per year for women and 16.7/10, 0000 per year for men. Mortality in the UK due to pneumothorax was 0.62/million/year for women and 1.26/million/year for men between 1991 and 1995. The researcher concluded that chest tube drainage management appears to be an effective treatment modality for pneumothorax.9

Spontaneous pneumothorax is a disease with an estimated incidence of 4 to 9 out of 100,000 patients per year and 5:1 male predominance. Mortality rate as high as 16% have been reported. Here full lung expansion must be achieved and may require additional chest tube.10

Pleural diseases, specifically pleural effusions, is one of the more common clinical problems encountered by the internist. Estimates of the incidence of pleural effusions vary, with some estimating an annual incidence of up to 1 million in the United States. Pleural effusions are often associated with advanced malignancies such as carcinoma of lung or breast. Over 150,000 new cases of malignant pleural effusion are diagnosed each year. In these patients a chest tube insertion is done not only for the therapeutic purpose but also for the removal of fluid for the diagnostic purpose.11

Several drainage systems are available and it is important that the nurse is aware of the function of each one. The most common employed one is the one-bottle system, but traditionally there is two and three bottle system which is now less commonly used. Instead some manufactures have produced plastic multichamber units. The knowledge on the design and functioning of such systems will enhance the understanding and management of such units.12

Using chest tubes and chest tube drainage units is a complex and critical nursing function. By learning about their components and techniques needed to use them, you have protected your patient and helped him recovered from a serious pulmonary problem.13

6.1 NEED FOR THE STUDY

Disorders of the thoracic cavity are common and are encountered by nurses in every setting from the community to the intensive care unit. Chest tubes are used after chest surgery and chest trauma and for pneumothorax or hemothorax to promote lung re-expansion. While caring a patient with a chest tube drainage the nurse requires problem solving skill and critical thinking ability. After the chest tube has been inserted, it is the nurse's responsibility to maintain a patent (clear) and intact pleural drainage system. Several complications can occur when managing a patient with a chest tube due to the carelessness of the health care professionals. It is important that nurses receive appropriate training in the management of chest drains and ensure that patients are cared for safely and competently.14

Most of the nurses working in an acute care setting will encounter patients with chest drains at some point in their careers. So even the non specialist nurse requires a good working knowledge of chest drain system. It is fundamental that the nursing professionals should know the materials used in the chest tube drainage as well as their maintenance.15

A professional nurse engages in lifelong learning that will influence practice and ultimately impact the quality of care that a patient receives. The technical skills and critical demonstrated by the critical nurse at the bed side are not enough to sustain an evidence based practice. They need to adopt a healthy work environment that gives merit to continuing education.16

Chest drains are routinely inserted during thoracic surgery and to conservatively manage spontaneous pneumothorax. An extensive search for the literature revealed only a small number of highly prescriptive articles to advise the nurse on the specific care needs of this patient group. Patency and integrity of mediastinal and pleural catheters are crucial for the preservation of cardiopulmonary performance. Despite the relatively brief period of time these catheters dwell, knowledge of their placement, function and current research findings relevant to their care is essential for appropriate nursing intervention.17

Most often the nursing management of patient, who have a chest drain insitu, has received little attention. After a chest tube is inserted; nurses are responsible persons for managing the chest tube and drainage system. They should have adequate knowledge regarding the chest-tube position, controlling fluid evacuation, identifying when to change or empty the containers, and caring for the tube and drainage system during patient transport. By following a logical system of practice, the critical care nurse will be able to master the art of chest drainage with little difficulty.18

A study was conducted on chest tube drainage management the study results showed that Critical care nurses routinely care for patients who require chest tube management. To obtain the best patient outcome, critical care nurses should develop standards of practice from research derived recommendations. The study revealed that, although there are several studies recommending chest tube management practices, there is limited research in some areas of chest tube management. The authors analyze that the body of research and recommend clinical practice changes and timely research projects on chest tube management.19

A study conducted on management of patients with chest tube drainage stated that chest tube drainage or under water seal drainage is a routine part for thoracic trauma, surgery and pulmonary infection. Many aspects of the management of patients with chest drain come in to the nursing domain, yet practices are inconsistent and many nurses lack confidence in caring for patients with chest drain due to lack of knowledge.20

Professional development takes place throughout the nurse's career. Levels of development occur over time with advanced experience and learning. Educational programs need to be planned to meet needs and promote professional growth of nurses at various levels of expertise. To improve skills and knowledge throughout the nursing career, nursing skills must be maintained and improved up on through training, continuing education, professional conferences, and work experience. This provides high quality and effective health care for patients and is necessary to improve up on nursing skills in order to keep up with new technologies and procedures.21

Lifelong learning is essential for the nurse to maintain and increase competence in nursing practice. There are many different means to meet continuing professional development needs. Formal means include continuing education, staff development, academic education, and research activities. However, many individuals also continue their professional growth through informal means such as consultation, professional reading, experiential learning, and self-directed activities. The purpose here is to help the nurses to maintain and improve their competencies as required for the delivery of quality care to the consumer. Interventions in the form of ward based educational programme specifically designed nursing compliance, perceive gaps in their knowledge and would welcome the opportunity to be updated regularly.22

The above facts made the investigator to realize the importance of research study on the particular problem in the current situation, and determine the self instruction module on knowledge of staff nurses, thereby enhancing their knowledge on chest tube drainage management.

6.2 REVIEW OF LITERATURE

The review of literature is a key step in research process. Literature review is a standard requisition of scientific research. It means reading and writing the pertinent information of the attempt in research topic to understand better about the proposed topic.

For the present study, the researcher made an extensive review of literature to collect information related to research topic, the researcher has made use of various journals, research reports, unpublished thesis, texts, Medline research and internet to avail the information pertaining to nursing management of chest tube drainage.

The review of literature for the present study is organized as follows,

6.2.1 Studies related to the incidence and prevalence of chest tube drainage insertion.

6.2.2 Studies related to the chest tube drainage and its management.

6.2.3 Studies related to the complications of chest tube drainage.

6.2.4 Studies related to the knowledge of staff nurses regarding the management of chest tube drainage.

6.2.5 Studies related to the Self instructional module.

6.2.1. Studies related to the incidence and prevalence of chest tube insertion

A retrospective study was conducted on management of patients with pneumothorax. The study included all adult patients admitted as an emergency in 12 public hospitals in Hong Kong in the year of 2004, with a discharge diagnosis of pneumothorax. Altogether these patients had 1091 episodes (476 primary spontaneous pneumothorces, 483 secondary spontaneous pneumothorces, 87 iatrogenic pneumothorces and 45 traumatic pneumothorces). Conservative treatment was offered in 182 (17%) episodes, which were more common among patients with small primary spontaneous pneumothorces (71%). Simple aspiration was performed to treat 122 (11%) of such episodes and had a success rate of 15%. Intercostal tube drainage was employed in (82%) episodes with success rate of 77%.23

A prospective study was conducted on 40 consecutive patients with empyema thoracic admitted to the tuberculosis and chest diseases ward of a teaching hospital. The result reported that two patients received antibiotics with repeated thoracentesis only, intercostal chest tube drainage was required in 38 cases (95%) and more aggressive surgery was performed on 2 patients. The average duration for which the chest tube was kept in the complete expansion cases was 22.3 days.24

A prevalence study was conducted to analyze the safety and outcome of medical thoracoscopy in the treatment of multiloculated empyema among 3,564 patients hospitalized for pneumonia, between 2000 and 2003, of which 216 patients (6%) acquired pleural empyema. Of these, 32 patients (15%) with multiloculated empyema were treated with medical thoracoscopy and 23 patients (11%) were treated with surgical VATS or thoracotomy with pleurectomy; 161 of 216 patients (75%) were treated with chest tube drainage. Chest tube drainage was maintained for a median of 7 days (range, 2 to 23 days). Time of drainage was ≤ 7 days and ≤ 14 days in 58% and 93% of cases, respectively.25