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SUBMITTED BY
JEENA JOSEPH
MEDICAL SURGICAL NURSING
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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
Tumkur- 572105.
Ringroad, Maralur,
Tumkur-572105.
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6. BRIEF RESUME OF THE INTENDED WORK
INTRODUCTION:
surgeon.
Dag Hammarskjold
Health (or health care) is the diagnosis, treatment and prevention of disease,
illness, injury, and other physical and mental impairments in humans. Health care is
Nurses care for patients continuously, 24 hours a day. They help patients to do
what they would do for themselves if they could. Nurses take care of their patients,
making sure that they can breathe properly, seeing that they get enough fluids and enough
nourishment, helping them rest and sleep, making sure that they are comfortable, taking
care of their need to eliminate wastes from the body, and helping them to avoid the
harmful consequences of being immobile, like stiff joints and pressure sores. The nurse
often makes independent decisions about the care the patient needs based on what the
nurse knows about that person and the problems that may occur. 2
Trauma is the leading cause of mortality and disability, especially during the
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productive age, and is the third most common cause of death. Accidents which are
unexpected and unplanned events are becoming the major epidemic of the present
century. The number of accidental deaths in India is even higher than in the Western
3
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World. Thoracic trauma contributes heavily to these figures besides head injury,
abdominal injury and orthopedic injuries. Approximately one quarter of civilian trauma
deaths are caused by thoracic trauma and many of these deaths can be prevented by
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prompt diagnosis and correct management. In spite of the high mortality rates, about
90% of the patients with life-threatening thoracic injuries can be managed by a simple
Your lungs make up one of the largest organs in your body, and they work with
your respiratory system to allow you to take in fresh air, get rid of stale air, and even
talk.4
Thoracic trauma forms one of the major parts of multiple trauma and is
retrospective study was conducted to assess the general spectrum of chest injury patients
at PGIMS Rohtak in one year. Clinical details of the patients were recorded from their
case sheets and were analysed with reference to their age, sex, mode of injury, severity of
injury, treatment employed, etc. The majority of the patients could be managed by simple
the lungs, causing the lung to collapse. Air or fluid may leak into the pleural cavity.
Introducing a chest tube is a routine emergency procedure in trauma victims. A chest tube
is inserted and a closed chest drainage system is attached to promote drainage of air and
fluid. Chest tubes are used after chest surgery and chest trauma and for pnuemothorax or
4
A chest tube (chest drain or tube thoracostomy in British medicine or intercostal
drain) is a flexible plastic tube that is inserted through the side of the chest into the
pleural 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 Bülau
The indications for chest tube insertion are Pneumothorax, Pleural effusion,
pleural space and Hydrothorax: accumulation of serous fluid in the pleural space .6
Pneumothorax is the most common reason for inserting a chest tube. Leading to
partial or complete lung collapse, it's caused by external air entering the pleural space
from a hole in the chest wall or by air in the lungs entering through a hole in the pleura.
The collected air disrupts the normal negative pressure within the lungs-the vacuum that
keeps them expanded. Loss of this vacuum causes the lung to collapse; a collapse of
greater than 15% can lead to respiratory compromise, so insertion of a chest tube is
necessary. 7
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. When chest tube clogging occurs in
this setting, a patient can suffer from pericardial tamponade, tension pneumothorax, or in
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the setting of infection, an empyema. All of these can lead to prolonged hospitilization
The physician is responsible for inserting the chest tube and is usually responsible
for its removal. (Some nurse practiced acts allow nurses to remove chest tubes.) The
nurse assists with the insertion procedure, assesses the patient's respiratory status
problem. Treatment includes draining the cavity by inserting a catheter in the pleural
sack to drain the presence of air; liquid or blood which causes a variable degree of lung
collapse having a clinical consequence in function of the reserve breathing capacity the
patient previously had and the degree of collapse. Nursing is fundamental in this entire
process, including in the preparation of the patient for this treatment, the insertion of the
catheter and the adequate maintenance so that this procedure succeeds as well as during
the removal of the catheter and the subsequent care required. It is fundamental that the
nursing professionals know the materials used as well as their maintenance. A good
technique to cure the punt/orifice where a catheter is inserted will prevent numerous
complications which could be deadly for the patient. An article reported creating a
procedural protocol for nurses to use when treating patients who have thoracic drains;
this protocol deals with changing the catheters as well as the entire process related to how
to treat patients with a pleural drain. This protocol should serve as reference material and
6
Critical care nurses routinely care for patients who require chest tube
management. To obtain the best patient outcome, critical care nurses develop standards of
practice from research derived recommendations. Although there are several studies
recommending chest tube management practices, there is limited research in some areas
of chest tube management. The authors analyze the body of research and recommend
clinical practice changes and timely research projects on chest tube management.10
The education should always begin from the basic level.Structured teaching
programmes helps student nurses to improve their knowledge on patient care and
management of chest tube drainages and helps in increasing their competencies in future.
affected victims are males of productive age. The majority of these patients can be
Blunt trauma, mainly road-side accidents formed the most common cause of chest
injury, followed by blunt assault, stab by knives and falls etc. Increased automobile
traffic and ever increasing population together with intentional or unintentional ignorance
of traffic rules account for the predominance of road-side accidents producing chest
trauma. The right side of the chest was involved commonly after blunt injury while left
side involvement was more common after penetrating injuries, which is consistent with
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The incidence of chest trauma among all trauma cases admittedto a hospital in
Andhra Pradesh during a 5-year study period was 9% (90/1000).Of these 90 patients, 83
(92%) were male and 7 (8%) were female.The majority (55.6%) were less than 40 years
of age with 10(11.1%) less than 20 years old, 40 (44.4%) in the age range21 to 40 years,
Blunt injuries, mostly resulting from falls and vehicular accidents,were seen in 56
patients (62.2%). Penetrating chest trauma occurredin 34 patients (37.8%), with stab and
bull gore injuries beingthe most common. Fractures of the clavicle or long bones
wereseen in 19 (21%) and associated head injuries were found in9 patients (10%).
out of a total of 402 patients, the maximum (139) was in the age group of 21-30 years and
the next common decade was in the age group, 31-40 years, with 98 patients. The
incidence was low for very young and very old patients. There were 340 male and 62
female patients. Blunt trauma was responsible for the injury in 351 patients and 51
patients sustained chest injury after penetrating trauma. In blunt trauma, road-side
accidents was the commonest cause (268 patients), others being fall from height, assault,
etc.
In the majority of 295 patients, tube thoracostomy was the main treatment
employed. Initially, the cases were treated by simple intercostal drainage (i.e., 198
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patients) and they required tube drainage for 2-9 days. And lately we have started
applying negative suction to the drainage system (i.e., 97 patients) requiring intercostal
drainage for 2-6 days.T he final outcome of all the chest injury patients (402) showed,
343 patients were discharged in satisfactory condition within 7-10 days, while hospital
stay was prolonged in 36 patients because of some complications of ICD and 23 patients
could not be saved despite adequate and aggressive treatment. Complications seen after
A study revealed the overall incidence of pneumothorax was 42.3% .Chest tube
were no prior pulmonary surgery(p = 0.001), lesions in the lower lobe (p< 0.001),
greaterlesion depth (p< 0.001), and a needle trajectory angle of< 45° (p = 0.014); those
for chest tube placement for pneumothoraxwere pulmonary emphysema (p< 0.001) and
lung biopsy developed pneumothorax as the most common complication of, despite
improved techniques. The rate of pneumothorax reported in the literature ranges from 19
lung biopsy. Forty-one of the 77 patients (53.2%) who had pneumothorax (14.2% of the
125 patients with malignant pleural effusion with trapped lung or failed previous
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pleural catheters for managing malignantpleural effusion is a safe and effective strategy.
after analyzing the state of practice. Critical care nurses routinely care for patients who
require chest tube management. To obtain the best patient outcome, critical care nurses
are several studies recommending chest tube management practices, there is limited
research in some areas of chest tube management. The authors analyze the body of
research and recommend clinical practice changes and timely research projects on chest
tube management.15
complication in critically ill patients. Its incidence, however, remains uncertain. Chest
predicting chest tube malposition were analyzed by studies of univariate and multivariate
higher incidence than previously reported. Avoiding the use of a trocar may reduce
Medical personnel who care for patients with thoracictrauma should understand
the risks of mortality and clinicaldeterioration as well as associated injuries. The aim
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The investigator while working as staff nurse found nurses having limited
knowledge in various areas of chest tube drainage. This information regarding chest tubes
and its management need to be inculcated from the basic B.Sc level and decided to
project. It enhances the depth of the knowledge and inspires a clear insight into the crux
of the problem. Literature review throws light on the studies and their findings reported
nurse practitioners in trauma centers.Two hundred forty-six (246) of 464 surveys were
returned, for a response rate of 53%. Approximately one-third of reporting major trauma
centers reported utilizing PAs/NPs. Nineteen percent (19%) of respondents who did not
currently utilize PAs/NPs indicated that they intended to do so in the future . Fewer than
half of reporting facilities indicated that PAs/NPs performed more invasive procedures,
such as inserting arterial lines, central lines, chest tubes, and intracranial pressure
as a method for predicting tube location. A sample of 880 feeding tube aspirates were
classified as being primarily clear or cloudy and as having one of six colors. However,
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respiratory aspirates often contained blood and therefore failed to have the expected
106 aspirates and asked to predict tube position. Their ability to identify 50 gastric
tube aspirates (81.33% to 90.47%, p < .0001). Similarly, their ability to identify 50
intestinal aspirates improved from 64.07% to 71.53% after reading the list of criteria.
However, nurses were often unable to identify respiratory aspirates; the accuracy of their
predictions decreased after reading the list of suggested characteristics (from 56.67% to
and intestinal placement, but is of little value in ruling out respiratory placement.18
chest drain care and the need for nurses to have in service education to provide the best
care for clients with chest drains.This study aimed to identify the nurses' levels of
knowledge with regard to chest drain management and to ascertain how nurses keep
informed about the developments related to the care of patients with chest drains. The
data were collected using survey method. The results of the study revealed deficits in
knowledge in a selected group of nurses and a paucity of resources. Nurse managers are
encouraged to identify educational needs in this area, improve resources and the delivery
of in service and web-based education and to encourage nurses to reflect upon their own
12
A study was conducted on ambulatory intercostal drainage for the management of
malignant pleural effusion. The aim of the study was use of ambulatory drains (Pleurex
drains) in this malignant pleural effusions with particular reference to hospital stay,
pleural effusion with trapped lung or failed previous pleurodesis who underwent insertion
of ambulatory pleural drain, 41 patients were under local anesthesia and 84 patients were
under general anesthesia. Mean age was 66.5 years with male:female = 80:45. Data were
collected retrospectively from the clinical notes, and the family doctors'clinics were
contacted to enquire about the patients' survival. Mean duration of catheter placement
was 87.01 days (5-434).The result showed the use of ambulatory pleural catheters for
managing malignant pleural effusion as a safe and effective strategy. It had only minor
A study was conducted on the incidence of and Risk Factors for Pneumothorax
The objective of the study was to retrospectively evaluatethe incidence of and the risk
were no prior pulmonary surgery(p = 0.001), lesions in the lower lobe (p< 0.001),
greaterlesion depth (p< 0.001), and a needle trajectory angle of< 45° (p = 0.014); those
for chest tube placement for pneumothoraxwere pulmonary emphysema (p< 0.001) and
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greater lesion depth(p< 0.001). The study concluded that pneumothorax frequently
occurred and placement ofa chest tube was occasionally required for pneumothorax
an Apex Institute of North India. Out of a total of 402 patients, the maximum (139) was
in the age group of 21-30 years and the next common decade was the 4th i.e., 31-40 years,
with 98 patients. So more than half of all the patients were in the 3rd and 4th decade of life
and the incidence was low for very young and very old patients. There were 340 male
and 62 female patients. Blunt trauma was responsible for the injury in 351 patients and 51
patients sustained chest injury after penetrating trauma. In blunt trauma, road-side
accidents was the commonest cause (268 patients), others being fall from height, assault,
etc.In the majority of patients i.e., in 295 cases, tube thoracostomy was the main
treatment employed. Initially, we were treating these cases by simple intercostal drainage
(i.e., 198 patients) and they required tube drainage for 2-9 days. And lately we have
started applying negative suction to the drainage system (i.e., 97 patients) requiring
intercostal drainage for 2-6 days.If we analyse the final outcome of all the chest injury
patients (402), 343 patients were discharged in satisfactory condition within 7-10 days,
while hospital stay was prolonged in 36 patients because of some complications of ICD
and 23 patients could not be saved despite adequate and aggressive treatment.
Complications seen after ICD were residual haemothorax, recurrent pneumothorax and
empyema.3
14
A descriptive study was conducted on a profile of chest trauma. A total of 90 patients
outcome of thoracic trauma. The majority (55.6%) were lessthan 40 years of age and 83
(92%) were male. The mode and extentof injury, specific intrathoracic organ injuries,
mortality were analyzed. Blunt injuries wereseen in 56 (62.2%) and penetrating injuries
with tachypnea, cyanosis, lung contusion, partial pressureof aterial oxygen less than 60
mm Hg, and those with more than6 rib fractures most often required ventilation but the
majority(54.4%) were treated with a chest drain only. The mortality rate was
releasing incisions accounted for most of the morbidity.Mean hospital stay was 9.5 days.
Chest injuries were of majorconcern in multisystem trauma patients and early planned
interventions nurses have to manage in acute general wards and in the community. This
article looks at the management of pleural drains and gives an overview of the relevant
anatomy and physiology. Some of the conditions that may result in a chest tube being
These reviews helped the researcher to state the problem and establish the need
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6.3 STATEMENT OF THE PROBLEM
regarding chest tube drainage among 3rd year B. Sc nursing students of selected nursing
colleges, Tumkur.
To assess the knowledge on chest tube drainage among 3rd year B. Sc nursing students
To find the association between level of knowledge with selected socio demographic
variables.
Assess-in this study assess refers to determining the knowledge score of nurses regarding
tube drainage determined bysignificant difference between pre-test and post test
knowledge scores.
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Knowledge In this study knowledge refers to the correct responses given by the student
3rd year B. Sc nursing students - Students in Third year B.Sc nursing of selected nursing
colleges of Tumkur.
Chest tube drainage- In this study it refers to a flexible plastic tube that is inserted
through the side of the chest into the pleural space, which is used to remove air or fluid or
6.6 HYPOTHESIS
H1:There is significant difference in pretest and post test knowledge scores on chest tube
H2: There is significant association between knowledge level with selected socio
demographic variables.
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6.7 ASSUMPTION
The 3rd year B. Sc nursing students have limited knowledge regarding chest tube
drainage.
Structured teaching programme is one of the best teaching strategies in implementing the
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Research variables
Demographic variables
Age
Gender
Religion
Family income
Type of family
Source of information
Sampling criteria
Inclusion criteria
3. 3rd year B. Sc nursing students who can read and understand English.
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Exclusion criteria
1. 3rd year B. Sc nursing students who are on leave or absent at the time of data
collection.
questionnaire.
Tool 1:-Section A: This section deals with demographic data such as Age, Gender,
Tool 2:-
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Frequency and percentage distribution to assess the knowledge of student nurses on chest
tube drainage.
Mean and standard deviation to assess the knowledge of student nurses on chest tube
drainage.
Paired t-test to compare the pre-test and post-test assessment level of knowledge of
Chi-square test to analyze the association of the demographic variables with the post
YES
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BIBLIOGRAPHY
1.http://wikipedia.org
2.http://www.wpro.who.in.google
8242.
5.http://www. medtrng.com/blackboard/chest_tube.
6. http://www.wikipedia.google
7. http://www. google.co.in
8. http:// www.enotes.com/nursing-encyclopedia/c...
8.
10. Gordon PA, Norton JM, Merrell RRefining chest tube management: analysis of the
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Experience. Asian Cardiovasc Thorac Ann 1999;7:124-127,1999.
Konaka, Harubumi Kato. The Incidence and the Risk of Pneumothorax and Chest Tube
single center experience.Ann Surg Oncol. 2009 Dec;16(12):3482-7. Epub 2009 Sep 24.
15. Gordon PA, Norton JM, Merrell R. Refining chest tube management: analysis of the
study.JAnesthesiology 2007.Jun;106(6):1112-9.
17.Nyberg SM, Keuter KR, Berg GM, Helton AM, Johnston ADJAAPA.Acceptance of
physician assistants and nurse practitioners in trauma centers. 2010 Jan;23(1):35-7, 41.
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19. Lehwaldt D, Timmins F. The need for nurses to have in service education to provide
the best care for clients with chest drains. 2007 Mar;15(2):142-8.
20. Takao Hiraki1, Hidefumi Mimura, Hideo Gobara, Kentaro Shibamoto, Daisaku
Inoue, Yusuke Matsui and Susumu Kanazawa . Incidence of and Risk Factors for
Lung Biopsy: Retrospective Analysis of the Procedures Conducted Over a 9-Year Period.
21. http://www.pubmed.com.
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