A Descriptive Study to Assess the Knowledge of Staff Nurses Regarding Chest Drainage In

“A DESCRIPTIVE STUDY TO ASSESS THE KNOWLEDGE OF STAFF NURSES REGARDING CHEST DRAINAGE IN SELECTED HOSPITALS OF BANGALORE WITH A VIEW TO PREPARE A HEALTH EDUCATIONAL PAMPHLET”

M.Sc Nursing Dissertation Protocol Submitted To

Rajiv Gandhi University Of Health Sciences, Bangalore.

By

VIPIN GHOSH.S.S

MSC NURSING FIRST YEAR

2011-2013

UNDER THE GUIDANCE OF

Mrs. J. JAYALAKSHMI

Head of the Department

DEPARTMENT OF MEDICAL SURGICAL NURSING

Anuradha College Of Nursing

Gandhadakaval,

Hegganahalli cross

Vishwaneedam post

Bangalore-91

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BENGALURU, KARNATAKA

ANNEXURE-II

PROFORMA FOR THE REGISTRATION OF

SUBJECT FOR DISSERTATION

1 / NAME OF CANDIDATE AND ADDRESS / VIPIN GHOSH.S.S
1 YEAR M Sc NURSING
ANURADHA COLLEGE OFNURSING,
BANGALORE.
2 / NAME OF THE INSTITUTION / ANURADHA COLLEGE OF NURSING
3 / COURSE STUDY AND
SUBJECT / I YEAR M.SC. NURSING
MEDICAL SURGICAL NURSING
4 / DATE OF ADMISSION TO COURSE / 16-05-2011
5 / TITLE OF THE TOPIC / A DESCRIPTIVE STUDY TO ASSESS THE KNOWLEDGE OF STAFF NURSES REGARDING CHEST DRAINAGE IN SELECTED HOSPITALS OF BANGALORE WITH A VIEW TO PREPARE A HEALTH EDUCATIONAL PAMPHLET

1

6.  BRIEF RESUME OF THE INTENDED WORK

Introduction

The concept of "available, accessible and affordable" is central to the successful implementation of any planned program.

Achest drain(chest tubeortube thoracostomyin British medicine orintercostal drain) is a flexible plastic tube that is inserted through the side of the chest into thepleural space. It is used to remove air (pneumothorax) or fluid (pleural effusion,blood,chyle), or pus (empyema) from the intrathoracic space. It is also known as a Bülaudrainor an intercostal catheter1.

Before we discuss the chest drainage in detail, it is important to briefly review normal anatomy and physiology of the thorax with emphasis on the physiology of respiration. This will help us understand what can go wrong in the structure and function of the chest and how these problems can be treated. CHEST WALL: The chest wall is made up of bones and muscles. The bones, primarily ribs, sternum and vertebrae, form a protective cage for the internal structures of the thorax. The main muscles of the chest wall, the external and internal intercostals, extend from one rib to the rib below. The external intercostals enlarge the thoracic cavity by drawing the ribs together and elevating the rib cage, while the internal intercostals decrease the dimensions of the thoracic cavity
MEDIASTINUM: Within this musculoskeletal cage of the thorax are three subdivisions. The two lateral subdivisions hold the lungs. Between the lungs is the mediastinum, which contains the heart, the great vessels, parts of the trachea and esophagus, and other structures

LUNGS: The lungs consist of airways (trachea and bronchi) that divide into smaller and smaller branches until they reach the air sacs, called alveoli. The airways conduct air down to the alveoli where gas exchange takes place.
The lung itself is covered with a membrane called the visceral (or pulmonary) pleura. The visceral pleura are adjacent to the lining of the thoracic cavity which is called the parietal pleura. Between the two membranes is a thin, serous fluid which acts as a lubricant – reducing friction as the two membranes slide across one another when the lungs expand and contract with respiration. The surface tension of the pleural fluid also couples the visceral and parietal pleura to one another, thus preventing the lungs from collapsing. Since the potential exists for a space between the two membranes, this area is called the pleural cavity
RESPIRATION: Respiration is a passive, involuntary activity. Air moves in and out of the thorax due to pressure changes. When the diaphragm, the major muscle of respiration, is stimulated, it contracts and moves downward. At the same time, the external intercostals move the rib cage up and out. The chest wall and parietal pleura move out, pulling the visceral pleura and the lung with it. As the volume within the thoracic cavity increases, the pressure within the lung decreases. Intrapulmonary pressure is now lower than atmospheric pressure; thus air flows into the lung inhalation2.
When the diaphragm returns to its normal, relaxed state, the inter-costal muscles also relax and the chest wall moves in. The lungs, with natural elastic recoil, pull inward as well and air flows out of the lungs -exhalation. The lungs should never completely collapse for there is always a small amount of air, called residual volume, in them. Under normal conditions, there is always negative pressure in the pleural cavity. This negative pressure between the two pleurae maintains partial lung expansion by keeping the lung pulled up against the chest wall. The degree of negativity, however, changes during respiration. During inhalation, the pressure is approximately –8 cm H2O; during exhalation, approximately –4 cm H2O. If a patient takes a deeper breath, the intrapleural pressure will be more negative. Under normal conditions, the mechanical attachment of the pleurae, plus the residual volume, keep the lungs from collapsing.

INDICATIONS

·  Pneumothorax: accumulation of air in the pleural space

·  Pleural effusion: accumulation of fluid in the pleural space

·  Chylothorax: a collection oflymphaticfluid in the pleural space

·  Empyema: apyogenicinfectionof the pleural space

·  Hemothorax: accumulation of blood in the pleural space

·  Hydrothorax: accumulation of serous fluid in the pleural space

CONTRAINDICATIONS

Contraindications to chest tube placement include refractorycoagulopathy, lack of cooperation by the patient, and diaphragmatic hernia. Additional contraindications include scarring in the pleural space (adhesions)

TECHNIQUE

The insertion technique is described in detail in an article of theNEJM. The free end of the tube is usually attached to an underwater seal, below the level of the chest. This allows the air or fluid to escape from the pleural space, and prevents anything returning to the chest. Alternatively, the tube can be attached to aflutter valve. This allows patients withpneumothoraxto remain more mobile.

British Thoracic Society recommends the tube is inserted in an area described as the "safe zone", a region bordered by: the lateral border of pectoralis major, a horizontal line inferior to the axilla, the anterior border of latissimus dorsi and a horizontal line superior to the nipple More specifically, the tube is inserted into the 5th intercostal space slightly anterior to the mid axillary line.

Chest tubes are usually inserted under localanesthesia. The skin over the area of insertion is first cleansed withantisepticsolution, such as iodine, beforesteriledrapes are placed around the area. The local anesthetic is injected into the skin and down to the muscle, and after the area is numb a small incision is made in the skin and a passage made through the skin and muscle into the chest. The tube is placed through this passage. If necessary, patients may be given additionalanalgesicsfor the procedure. Once the tube is in place it is sutured to the skin to prevent it falling out and a dressing applied to the area. Once the drain is in place, achest radiographwill be taken to check the location of the drain. The tube stays in for as long as there is air or fluid to be removed, or risk of air gathering.

Chest tubes can also be placed using a trocar, which is a pointed metallic bar used to guide the tube through the chest wall. This method is less popular due to an increased risk of iatrogenic lung injury. Placement using theSeldinger technique, in which a blunt guidewire is passed through a needle (over which the chest tube is then inserted) has been described.

COMPLICATIONS

Major complications arehemorrhage, infection, and reexpansionpulmonary edema. Chest tube clogging can also be a major complication if it occurs in the setting of bleeding or the production of significant air or fluid. Whenchest tube cloggingoccurs in this setting, a patient can suffer from pericardial tamponade, tension pneumothorax, or in the setting of infection, an empyema. All of these can lead to prolonged hospitilization and even death. To minimize potential for clogging, surgeons often employ larger diameter tubes. These large diameter tubes however, contribute significantly to chest tube related pain. Even larger diameter chest tubes can clog.In most cases, the chest tube related pain goes away after the chest tube is removed, however, chronic pain related to chest tube induced scarring of the inter-costal space is not uncommon.

In recent years surgeons have advocated using softer, silicone Blake drains rather than more traditional PVC conventional chest tubes to address the pain issues. Clogging and chest tube occlusion issues have been a problem, including reports of life threatening unrecognized bleeding that occurs in the chest due to an occluded or clogged drain.Thus when a chest tube is inserted for whatever reason, maintaining patency is critical to avoid complications.

Injury to theliver,spleenordiaphragmis possible if the tube is placed inferior to the pleural cavity. Injuries to the thoracicaortaandhearthave also been described. Minor complications include a subcutaneoushematomaorseroma, anxiety, shortness of breath (dyspnea), and cough 3.

6.1 NEED FOR THE STUDY

In current hospital practice chest drains are used in many different clinical settings and doctors in most specialties need to be capable of their safe insertion. The emergency insertion of a large bore chest drain for tension pneumothorax following trauma has been well described by the Advanced Trauma and Life Support (ATLS).

It has been shown that physicians trained in the method can safely perform tube thoracostomy with 3% early complications and 8% late. The safe insertion of chest tubes in the controlled circumstances usually encountered by physicians needs training4.

A review of 114 thoracic empyema cases attended in the thoracic unit of the Muhimbili Medical Centre from July 1986 to July 1990 is presented. 87.7% of the cases were males. Their ages ranged from 9 to 79 years with a mean of 32 years. Tuberculosis was the major cause accounting for 63.2% of all the cases. 53.4% of the patients underwent either open chest drainage decortication or thoracoplasty. The duration of hospital stay ranged from 2-8 months with a mode around 3.5 months. A 7% mortality was noted.

Quantifying the frequency of hemothorax in the general population is difficult. A very small hemothorax can be associated with a single rib fracture and may go undetected or require no treatment. Because most major hemothoraces are related to trauma, a rough estimate of their occurrence may be gleaned from trauma statistics. Approximately 150,000 deaths occur from trauma each year. Approximately 3 times this number of individuals are permanently disabled because of trauma, and the majority of this combined group are victims of polytrauma. Chest injuries occur in approximately 60% of polytrauma cases; therefore, a rough estimate of the occurrence of hemothorax related to trauma in the United States approaches 300,000 cases per year.

In a 34-month period at a large level-one trauma center, 2086 children younger than 15 years were admitted with blunt or penetrating trauma; 104 (4.4%) had thoracic trauma.Of the patients with thoracic trauma, 15 had hemopneumothorax (26.7% mortality rate), and 14 had hemothorax (57.1% mortality rate). Many of these patients had other severe extrathoracic injuries. Nontraumatic hemothorax carries a much lower mortality rate.

In another series of children with penetrating chest injuries (ie, stab or gunshot wounds), the morbidity rate was 8.51% (8 of 94). Complications included atelectasis (3), intrathoracic hematoma (3), wound infection (3), pneumonia (2), air leak for more than 5 days (2), and septicemia (1). Note that these statistics apply only to traumatic hemothorax5.Spontaneous pneumothorax is more common in males than in females. The annual incidence of PSP is 18–28 per 100,000 in males and 1.2–6.0 in females. Secondary spontaneous pneumothorax is less common, with 6.3 for males and 2.0 for females. Risk of recurrence depends on underlying lung disease. Once a second episode has occurred, there is a high likelihood of subsequent further episodes.Smokers have an increased risk of contracting a first spontaneous pneumothorax of approximately ninefold among women and 22-fold among men compared to non-smokers. The incidence in children has not been well studied, but it is probably less than that of adults and often reflects underlying lung disease.

Death from pneumothorax is very uncommon (except for tension pneumothorax). British statistics have revealed an annual mortality of 1.26 per million per year in men and 0.62 in women.Mortality is higher in older people and those with secondary pneumothorax.Thoracotomy may be performed to diagnose or treat a variety of conditions; therefore, no data exist as to the overall incidence of the procedure. Lung cancer, a common reason for thoracotomy, is diagnosed in approximately 172,000 people each year and affects more men than women (91,800 diagnoses in men compared to 80,100 in women).

One study following lung cancer patients undergoing thoracotomy found that 10–15% of patients experienced heartbeat irregularities, readmittance to the ICU, or partial or full lung collapse; 5–10% experienced pneumonia or extended use of the ventilator (greater than 48 hours); and up to 5% experienced wound infection, accumulation of pus in the chest cavity, or blood clots in the lung. The mortality rate in the study was 5.8%, with patients dying as a result of the cancer itself or of postoperative complications6.

(American Lung Association, June 2005)

§  Morbidity: Primary spontaneous pneumothorax affects 9,000 persons per year and is more common in tall, thin men between 20 and 40 years of age.

§  Recurrence rate: Is about 40% for both primary and secondary spontaneous pneumothorax, occurring in intervals of 1.5 to 2 years.

§  Mortality: Rate is 15% for those with secondary pneumothorax.

The following statistics relate to the incidence of Pneumothorax:

·  1.011 per 1,000 hospitalized at risk patients developed iatrogenicpneumothoraxin America 2000-2002

·  33,571 cases of iatrogenic pneumothorax occurred in the US 2000-2002

·  18.57% of cases of iatrogenic pneumothorax resulted in death in the US 2000-2002

·  Incidence rate statistics forIatrogenic Pneumothoraxin the USA:

Estimated 0.738 Iatrogenic pneumothorax occurred per 1,000 hospital discharges (excluding patients with trauma, thoracic surgery, lung or pleural biopsy or cardiac surgery and neonates) of people aged over 65 in the US 2000 (National Healthcare Quality Report, AHRQ, DHHS, 2003)