Procedure Manual
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Comment on this procedure
* Registered Nurses and Enrolled Nurses are approved to care for patients with Underwater Seal Drainage (UWSD).
* Changes in management of UWSD are by written instruction of attending medical officer and may include the addition of suction; the clamping and/or removal of UWSD.
* Removal of UWSD may be attended by RNs in ICU, otherwise may only be attended by a medical officer. Indications for removal being a re-expanded lung or a blocked intercostal drain.
* Dressings to intercostal drain sites to be changed when integrity impaired, every 2 days or when otherwise ordered.
OUTCOMES:
* Insertion of an intercostal catheter and commencement of UWSD allows for:
- expansion of the lung
- escape of air from the pleural cavity and maintenance of lung expansion
- drainage of pus, blood and fluid
- the prevention of air being sucked back into the chest which would cause a pneumothorax.
SPECIAL
CONSIDERATIONS:
* Ensure patient is aware of the procedure for insertion of intercostal catheter as appropriate.
* Position and prepare patient as required with the application of oxygen as required, assessment of base line observations, administration of analgesia as required.
R : 5.1
* DO NOT CLAMP INTERCOSTAL DRAIN when patients are on Positive Pressure Ventilation or Continuous Positive Airway Pressure when changing bottles and/or tubing, nursing procedures, chest physiotherapy or during transportation.
* Two rubber-tipped Harrison-Cripps forceps for each UWSD should be positioned at the head of the spontaneously breathing patient's bed for cases of accidental disconnection from underwater seal.
* When changing UWSD bottles and/or tubing on a spontaneously breathing patient, CLAMP INTERCOSTAL DRAIN at two points close to the patient's chest. * Ensure drainage bottles are kept at a lower level than the chest to prevent fluid syphoning into pleural cavity.
* UWSD bottles should be securely taped to tubing and positioned so as to prevent dislodgement of intercostal drain and entry of air into pleural space.( please refer to attached diagram re correct taping of UWSD).
* UWSD site should be dressed appropriately and securely to prevent entry of air into pleural space.
* Ensure two bottle system is used to prevent UWSD bottle being placed inappropriately on high suction.
(Please refer to diagram attached re setting up of two bottle suction system).
EQUIPMENT:
Drapes, including fenestrated drape Hibitane solution
Sterile gown Tinc benz solution
Mask Local anaesthetic agent
Sterile gloves Basic dressing pack
Universal instrument pack Elastoplast - 8cm wide and 2.5cm wide
Harrison-Cripps forceps Disposable underpad
Intercostal catheter - appropriate size Kendall curity thorax 1 - single use UWSD system
Scalpel blade (tubing and underwater drainage bottle)
Gauze squares 1 x 5ml syringe
2/0 black silk suture on straight needle 1 x 25g, 1 x 19g needles
R : 5.2
For Dressing Intercostal Catheter Exit Site/Securing Intercostal Drain:
Basic dressing pack Hibitane solution
Sterile gauze squares Sterile scissors
Elastoplast: Sterile cotton wool swabs
2 x 20cm pieces with trouser legs, Tinc benz solution
1 x 15cm pieces, Disposable underpad
3 x 8cm pieces for each connection
For Removal of Intercostal Drain:
Basic dressing pack Gauze squares
Fenestrated drape Combine (small)
Universal instrument pack Elastoplast
Stitch cutter 1 x 5ml syringe
Hibitane solution 1 x 19g needle, 1 x 25g needle
Sterile gloves
Suture material, local anaesthetic, 1 x 5ml syringe, 1 x 19g and 25g needle, OR Jenonet
for sealing over exit site.
PROCEDURE:
* Assemble equipment
* Position patient in appropriate lateral position to ensure easy access with affected side uppermost
* Maintain continuous observation of patient during procedure, report any change in vital signs.
* Set up two bottle suction system as per attached diagram so as to deliver appropriate level of suction.
* Assist medical officer with connection of tubing and ensure connections secure. Secure connections with 8cm pieces of brown elastoplast, one lengthwise each side of tubing and one around centre of connection.
* Place drainage bottle at a position below patient's chest.
R : 5.3
* Assist medical officer with application of sterile dressing to insertion side of intercostal catheter and with the securing of tubing to patient's chest wall.
* Cleanse area appropriately to insertion site with Hibitane solution, apply gauze squares from opposite sides of drain, Tinc benz solution to areas where elastoplast will be applied. Apply two 20cm pieces of elastoplast with trouser legs on apposite sides of drain and one 15cm piece.
* Monitor vital signs and record post procedure.
* Monitor and record observations on UWSD including observations on presence and quantity of air leak and amount/presence of oscillation hourly.
* Maintain an aseptic technique when working with intercostal catheter, dressing, tubing and drainage bottle. Change UWSD bottle and tubing each 24hr period and 12 midnight and monitor amount of drainage, re-secure tapes as discussed previously. Review dressing and change as appropriate.
.
R : 5.4 For Removal of Intercostal Drain:
* Assemble equipment.
* Position patient in appropriate lateral position with affected side uppermost.
* Ensure explanation and reassurance of procedure adequately given.
* Instruct patient to perform the VALSALVA MANOEUVRE (forced exhalation against a closed glottis, holding breath) during procedure.
* Apply occlusive dressing of Jelonet, small combine and elastoplast over exit site.
* Record procedure and amount of drainage.
* Continue observation of patient for signs of respiratory distress. Record and report any changes to medical officer.
* Assist with post removal chest x-ray.
* Review exit site two days post removal, replacing dressing with Hansapor dressing.
Reviewed January 1996
R : 5.5
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