IntroductionChest drains also known as under water sealed drains (UWSD) are a drainage system of three chambers consisting of a water seal, suction control and drainage collection chamber. UWSD are designed to allow air or fluid to be removed from the pleural cavity, while also preventing backflow of air or fluid into the pleural space. This allows for the expansion of the lungs and restoration of negative pressure in the thoracic cavity. Appropriate chest drain management is required to maintain respiratory function and haemodynamic stability. Chest drains may be placed routinely in theatre, PICU and NICU; or in the emergency department and ward areas in emergency situations. Some patients will have Redivac drains inserted, these are different from a UWSD. Please refer to Pleural and Mediastinal Drain Management after Cardiothoracic Surgery guideline. Show
AimTo provide a clear guide for nursing staff to promote the safe, correct and competent management of the UWSD in the ward setting. This clinical guideline is written from the perspective of a cardiac and renal ward management; however, it also outlines management from the perspective of other speciality areas where care may differ. Definition of terms
Indications for Insertion of a Chest Drain
Insertion of a Chest DrainPlease see the Chest Drain Insertion CPG below:
RCH access only: See Aseptic Technique Policy and Procedure Chest Drain Assessment & ManagementStart of shift checks
UWSD LabellingIt is imperative that the UWSD is labelled in a way that is clear and visible. This is extremely important when removing the drain to ensure the correct drain is removed. Please refer to the image below for the correct labelling of an UWSD. The criteria for correct labelling includes the following:
Patient AssessmentVital signs
For ward areas
Drain insertion site and dressing assessment:
Skin integrity:
UWSD Unit and Tubing
Pain
Suction
Drainage
VolumeDocument hourly the amount of fluid in the drainage chamber (for each drain if multiple present) in the Fluid Balance flowsheet on EMR Assess the cumulative total of drainage output and notify medical staff of the following:
If the chamber tips over and blood has spilt into next chamber, simply tip the chamber up to allow blood to flow to original chamber Colour and ConsistencyColour and consistency of drainage should be documented hourly along with documentation of volume amounts. If there is a change (eg. Haemoserous, bright red, serous, chylous/creamy) notify medical staff immediately
Air Leak (bubbling)
Oscillation (Swing)
Other Considerations
Patient Positioning
Patient Transport
Specimen CollectionCollect drainage specimens for culture through the needless sampling port located by the in-line connector. Equipment Required
Procedure: 1. Wait for the fluid to collect in a loop of the tubing 2. Perform hand hygiene, then don gloves & eye protection 3. Clean the sampling port ( See feature labelled as 1 in the image below) with an alcohol wipe and leave to dry for 20 seconds 4. Temporarily clamp the tubing above where the fluid has collected 5. Connect a 10ml Luer lock syringe to the sampling port and aspirate the fluid out of the tubing. Do not pierce tubing/sampling port 6. Place fluid in sterile specimen container 7. Once the syringe is disconnected remove all clamps and kinks 8. Perform hand hygiene Chest Drain DressingsDressing Change
Equipment Required
Procedure:1. Perform hand hygiene and then don gloves 2. Remove old dressing
3. Clean the drain site using the appropriate chlorhexidine solution:
4. Once the site is dry apply two layers of split gauze in the direction where the split facing up and it wraps around the drain. Another two layers of split gauze should then be placed on top of the first layer of gauze in the opposite direction (split facing down). 5. Cover gauze using hypafix TM (approx two pieces, enough to cover the gauze completely) 6. Remove gloves and perform hand hygiene For cardiac surgical patients with drains inserted intraoperatively: Ensure dressing does not communicate with sternotomy dressing or woundAnchoring drain tubing
Removal of Dressings
Changing the Chamber
Procedure1. Perform hand hygiene 2. Use personal protective equipment to protect from possible body fluid exposure 3. Using an aseptic technique, remove the unit from packaging and place adjacent to old chamber 4. Prepare the new UWSD as per manufacturer’s directions supplied with drain 5. Ensure patients drain is clamped to prevent air being sucked back into chest 6. Disconnect old chamber by holding down the clip on the in-line connector to pull the tubing away from the chamber. 7. Insert the tubing into the new chamber until you hear it click. 8. Unclamp the chest drain 9. Check drain is back on suction 10. Place old chamber into yellow infectious waste bag and tie 11. Perform hand hygiene Removal of Chest DrainsImportant considerations for drain removal
Indications
Equipment required
Patient and pre-procedure preparation
Procedure1. Perform hand hygiene 2. Opening dressing pack and add sterile equipment and 0.9% saline 3. Don disposable gloves 4. Remove all dressings around the area 5. Clamp drain tubing and ensure suction is disconnected – double check with assisting nurse. If there are multiple drains in-situ, clamp all drains before removal. Once the required drains are removed, unclamp remaining drains 6. Remove disposable gloves, perform hand hygiene and don sterile gloves 7. Place sterile towel under tubes 8. Clean around catheter insertion site and 1-2cm of the tubing with age appropriate skin cleaning solution 9. If purse string present (cardiac patients) unwind in preparation for assistant to tie 10. Remove suture securing drain (ensuring purse string suture not cut)
11. Instruct patient to exhale and hold if they are old enough to cooperate; if not, time removal with exhalation 12. Pinching the edges of the skin together, remove the drain using smooth, but fast, continuous traction 13. The assistant pulls purse string suture closed as soon as the drain is removed, tying 2 knots and ensuring the suture is not pulled too tight. Cut tails of suture about 2cm from knot 14. If there is no purse string present remove drain and quickly seal hole with occlusive dressing (i.e. TegadermTM) 15. Apply steristrips over insertion site if needed 16. Remove and discard equipment into a yellow infectious waste bag and tie 17. Perform hand hygiene Post Procedure Care
Complications and Troubleshooting
Bleeding at the drain site
Infection of insertion site
Accidental disconnection of system
Accidental drain removal
Purse string cut or not present
Unable to remove chest drain
Retained drain during removal
Family Centred Care
Companion Documents
Evidence Table
Please remember to read the disclaimer The development of this nursing guideline was coordinated by Charmaine Russell, CNS, Koala, and Emily Mohd Faizal, RN, Koala, and approved by the Nursing Clinical Effectiveness Committee. Updated October 2022. What are the indications for chest tube insertion?Chest tubes are used to treat conditions that can cause the lung to collapse, such as:. Air leaks from the lung into the chest (pneumothorax). Bleeding into the chest (hemothorax). After surgery or trauma in the chest (pneumothorax or hemothorax). Lung abscesses or pus in the chest (empyema). When is a chest tube indicated?Chest tubes are often needed to remove air from around the lung. Failure to remove such air can be life- threatening if there is a lot of air or a continued leak. Removing the air allows the lung to re-expand and seal the leak. insert a chest tube to remove the fluid.
What are indications for chest tube drainage?Indications for chest drain insertion include pneumothorax, hemothorax, pleural effusion, and empyema. Ultrasonography, CT, fluoroscopy, or any combination of these techniques may accurately guide chest drain placement.
What are 5 potential diagnosis for the use of a chest tube?Reasons for a chest tube insertion
a lung infection like bacterial pneumonia complicated by collection of pus. pneumothorax, which is air around or outside the lung. bleeding around your lung, especially after a trauma (like a car accident) fluid buildup due to another medical condition, like cancer or pneumonia.
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