“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

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 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BENGALURU, KARNATAKA
ANNEXURE-II

PROFORMA FOR THE REGISTRATION OF

SUBJECT FOR DISSERTATION

1 NAME OF CANDIDATE VIPIN GHOSH.S.S

AND ADDRESS 1 YEAR M Sc NURSING
ANURADHA COLLEGE OFNURSING,
BANGALORE.
2 NAME OF THE ANURADHA COLLEGE OF NURSING
INSTITUTION
3 COURSE STUDY AND I YEAR M.SC. NURSING
SUBJECT MEDICAL SURGICAL NURSING
4 DATE OF ADMISSION 16-05-2011
TO COURSE
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

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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.

A chest drain (chest tube 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 drain or 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

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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 inhalation 2.
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 of lymphatic fluid in the pleural space

 Empyema: a pyogenic infection of the pleural space

 Hemothorax: accumulation of blood in the pleural space

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  Hydrothorax: accumulation of serous fluid in the pleural space

CONTRAINDICATIONS

Contraindications to chest tube placement include refractory coagulopathy, 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 the NEJM. 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 a flutter valve. This allows patients
with pneumothorax to 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 local anesthesia. The skin over the area of insertion
is first cleansed with antiseptic solution, such as iodine, before sterile drapes 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 additional analgesics for 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, a chest radiograph will 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.

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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 the Seldinger 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 are hemorrhage, infection, and reexpansion pulmonary 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
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 the liver, spleen or diaphragm is possible if the tube is placed inferior to the
pleural cavity. Injuries to the thoracic aorta and heart have also been described. Minor
complications include a subcutaneous hematoma or seroma, anxiety, shortness of breath
(dyspnea), and cough 3.

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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%

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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.

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(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

iatrogenic pneumothorax in 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 for Iatrogenic Pneumothorax in 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)
The following are statistics from various sources about deaths and Pneumothorax:

1. 2,347 deaths from iatrogenic pneumothorax were attributable to a patient safety

incident in the US 2000-2002 (Patient Safety in American Hospitals, Health Grades
2004)
2. 6.99% of deaths from iatrogenic pneumothorax were attributable to the patient
safety incident in the US 2000-2002 (Patient Safety in American Hospitals, Health
Grades 2004)

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The following are statistics from various sources about hospitalizations and
Pneumothorax:

 0.07% (9,054) of hospital consultant episodes were for pneumothorax in England

2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
 73% of hospital consultant episodes for pneumothorax required hospital
admission in England 2002-03 (Hospital Episode Statistics, Department of Health,
England, 2002-03)

 72% of hospital consultant episodes for pneumothorax were for men in England
2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)

Thoracotomy and pulmonary resection are infrequently required for lung trauma. Tube
thoracostomy and supportive measures successfully manage the vast majority of chest
traumas. Nursing management of chest drains is important. A comprehensive
understanding of the operations of the chest drain systems and areas requiring special
attention would be important to reduce the complications arising from chest tube
drainage7.

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6.2 REVIEW OF LITERATURE

The review of literature is defined as broad, comprehensive in-depth,

systematic and critical review of scholarly publications, unpublished scholarly print
materials, audio visual materials and personal communications.

Lehwaldt D, Timmins F conducted a study on “Nurses' knowledge of chest drain care:

an exploratory descriptive survey” which says that chest drains are a common feature of
patients admitted to acute respiratory or cardio-thoracic surgery care areas. Chest drains
are either inserted intra-operatively or as part of the conservative management of a
respiratory illness or thoracic injury. Anecdotally, there appears to be a lack of consensus
among nurses on the major principles of chest drain management. Many decisions tend to
be based on personal factors rather than sound clinical evidence. This inconsistency of
treatment regimes, together with the lack of evidence-based nursing care, creates a
general uncertainty regarding the care of patients with chest drains. This study aimed to
identify the nurses' levels of knowledge with regard to chest drain management. The
research objective of this study was to describe the nurses' levels of knowledge regarding
the care of the patient with chest drains. The data were collected using survey method.
The results of the study revealed deficits in knowledge in a select group of nurses.
Several service-led options exist with regard to improving knowledge in this area, such as
service study days as well as ward-based tutorials. However, in an era of increasing
accountability together with the impetus for each nurse to provide evidence-based care, it
is crucial for individual nurse responsibility in the pursuit of knowledge in this
area. Nurses must be supported by local practice development and through personal
portfolio use to identify gaps in knowledge and seek appropriate training and resources8.

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 Lehwaldt D, Timmins F conducted a study on “The need for nurses to have in
service education to provide the best care for clients with chest drains” which says that
chest drains are a widespread intervention for patients admitted to acute respiratory or
cardiothoracic surgery care areas. These are either inserted intra-operatively or as part of
the conservative management of a respiratory illness or thoracic injury. Anecdotally there
appears to be a lack of consensus among nurses on the major principles of chest drain
management. Many decisions tend to be based on personal factors rather than sound
clinical evidence. This inconsistency of treatment regimes, together with the lack of
evidence-based nursing care, creates a general uncertainty regarding the care of patients
with chest drains. This study aimed to identify the nurses' levels of knowledge with
regard to chest drain management and identify 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 knowledge
deficits through portfolio use and ongoing professional development9.

Elsayed H, Roberts R et al conducted a study on “Chest drain insertion is not a

harmless procedure--are we doing it safely?” which says that the incorrect insertion of
a chest drain can cause serious harm or even death. All elective drains should be inserted
in the 'triangle of safety' in line with the British Thoracic Society guidelines. The aim of
this study was to test the awareness of nurses involved in inserting chest drains with these
guidelines. Fifty nurses were questioned. Participants were asked to grade their
experience of chest drain insertion and mark on a diagram where they felt was the
optimum site for inserting a drain for a large pneumothorax in an elective situation. Only
44% (n=22) of nurses indicated they would insert a chest drain within the safe triangle.
Level of experience, seniority and specialty all had an effect on knowledge of the correct
site. Of those who had inserted drains unsupervised, 48% (n=16) would site the drain
outside the safe triangle as would 75% (n=6) of those who had performed the procedure
supervised. Only 25% of medics knew where to insert a drain, compared with 58% of
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nurses working in surgery. The majority of nurses do not have the basic knowledge to
insert a chest drain safely. Further training in this procedure is needed for nurses10.

Sim KM, Ng AS conducted a study on “A questionnaire survey on practice of

chest tube management” with the aim towards better education of junior medical staff on
chest tube management, we designed a questionnaire to survey their practice and at the
same time to assess their level of understanding of the physical principles of chest tube
and its drainage system.The questionnaire was distributed to 130 junior medical staff
(house officers, medical officers, trainee medical officers and specialist medical officers)
from 7 Medical and Surgical Departments in Singapore General Hospital. Eighty-seven
(66.9%) candidates responded. The mean age of the respondents was 27 +/- 2.1. They had
an average of 3.2 +/- 1.9 years after basic medical qualification and 5 hospital postings.
Nine respondents had obtained higher medical qualifications.About a quarter of the
respondents, and 40% of those with higher medical qualifications gave appropriate
answers. Ninety percent indicated that they received no lectures on chest tube
management. Incomplete response ranged from 0% to 6%. To improve education on
chest tube management, our results and the feedback we obtained from the respondents,
suggest that lectures on important physical principles of chest tube and its drainage
system should be delivered to all junior medical staff11.

Munnell ER conducted a study on “Thoracic drainage” which says that the

evacuation of empyemas first performed centuries ago, marked the beginning of thoracic
drainage. The subsequent acquisition of a greater knowledge of the anatomy, physiology,
and pathology of the pleural space directed the design of thoracic catheters and drainage
systems and the development of the methods by which they are used. Furthermore, a
better understanding of the physics of vacuum and air flow brought about improvements
in the use of suction with drainage. Today, thoracic catheters, chest drainage systems, and
most vacuum sources are well designed and well made and incorporate components
needed to achieve the best care of the pleural-mediastinal space. This review covers the
development and important considerations in the current use of thoracic drainage.

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Knowledge of the principles of chest tube drainage is important to evaluate adequately
the function of a tube thoracostomy12.

Sullivan B conducted a study on “Nursing management of patients with a chest

drain” which says that Chest drains incorporate the use of a one-way valve to drain fluid
or air from the pleural cavity. The valve prevents back-flow of air and fluid into the
pleural cavity. They are indicated for use when collections of fluid or air are present in
the pleural space, and by draining the collection they restore efficient gaseous exchange.
Little has been written on the nursing management of chest drains and the literature
highlights a lack of national standardized guidelines for due to the range of thoracic
conditions encountered by clinical staff. Themes such as pain management and
mechanism of breathing occur frequently; however, there is a lack of up-to-date literature
for the nurse to refer to. This article examines the nursing role in chest drain management
from insertion to removal and includes aspects of pain management and features of a
functioning chest drain. The variety of chest drainage systems now available makes it
more important than ever for nurses to understand what's out there and how these systems
work. Nurses are responsible for managing chest drains and need to know which drain is
best suited for which situation13.

Charnock Y, Evans D conducted a study on “Nursing management of chest

drains: a systematic review” with the aim to summarize the best available evidence
relating to the nursing management of chest drains. Studies included were those involving
hospital patients with a chest drain in situ. A comprehensive and systematic search of the
literature was undertaken that included all major databases. Methodological quality was
assessed using a developed checklist. The randomized controlled trial (RCT) design was
rarely used and therefore evidence was summarized using a narrative discussion. Studies
using other methods were also assessed for inclusion in this narrative summary. The
findings of this review highlight the lack of research on most aspects of the nursing
management of patients with chest drains in situ. RCTs suggest that chest drains remain
patent with or without stripping and milking of tubes, but that the total drainage was

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greater from manipulated tubes. There is little evidence relating to other aspects of chest
drain management such as dressing of insertion site, actions following accidental
disconnection and tube removal. There is therefore a need for rigorous research in many
areas of the nursing management of chest drains, particularly with subjects under the age
of 18 years14.

Avilés Serrano M, García Díaz M et al conducted a study on “Thoracic

drainage” which says that the Pleural pathology is a frequent clinical problem. In some
cases, treatment includes draining the cavity which can be carried out by thoracentesis
evacuators, but on occasions treatment requires maintaining a drainage permanently
inside the pleural cavity Pleural drainage consists in 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. There are various models of thoracic
tubes as well as systems to drain the pleural cavity and their spot for insertion depends on
the type of pathology being dealt with for the patient under treatment. 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. The
authors create 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 as a guide to a systematic and homogenous working procedure.
Knowledge of the indications, placement, and management of chest tubes in the intensive
care unit is essential for the care of the critically ill patient. Awareness of the
complications and mechanical difficulties that can occur with chest tubes and their
drainage systems is essential for the safe and effective use of these devices15.

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 Aylwin CJ, Brohi K et al conducted a study on “Pre-hospital and in-hospital
thoracostomy: indications and complications” which says that Pleural drainage with chest
tube insertion for thoracic trauma is a common and often life-saving technique. Although
considered a simple procedure, complication rates have been reported to be 2-25%. We
conducted a prospective cohort observational study of emergency pleural drainage
procedures to validate the indications for pre-hospital thoracostomy and to identify
complications from both pre- and in-hospital thoracostomies. Data were collected over a
7-month period on all patients receiving either pre-hospital thoracostomy or emergency
department tube thoracostomy. Outcome measures were appropriate indications, errors in
tube placement and subsequent complications. Ninety-one chest tubes were placed into
52 patients. Sixty-five thoracostomies were performed in the field without chest tube
placement. Twenty-six procedures were performed following emergency department
identification of thoracic injury. Of the 65 pre-hospital thoracostomies, 40 (61%) were for
appropriate indications of suspected tension pneumothorax or a low output state. The
overall complication rate was 14% of which 9% were classified as major and three
patients required surgical intervention. Twenty-eight (31%) chest tubes were poorly
positioned and 15 (17%) of these required repositioning. Pleural drainage techniques may
be complicated and have the potential to cause life-threatening injury. Pre-hospital
thoracostomies have the same potential risks as in-hospital procedures and attention must
be paid to insertion techniques under difficult scene conditions. In-hospital chest tube
placement complication rates remain uncomfortably high, and attention must be placed
on training and assessment of staff in this basic procedure16.

Gordon PA, Norton JM, Merrell R conducted a study on “Refining chest tube
management: analysis of the state of practice” which says that 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.

15
The authors analyze the body of research and recommend clinical practice changes and
timely research projects on chest tube management17.

Griffiths JR, Roberts N conducted a study on “Do medical staff know where to
insert chest drains safely?” which says that the safe insertion of a chest drain is a skill
medical staff across specialties require. Incorrect placement can lead to significant
morbidity and even mortality.This audit surveyed medical staff working in a teaching
hospital about their specialty and level of experience with inter-costal drains. They were
then asked to mark on a photograph where they would insert a chest drain for a
pneumothorax in a non-emergency situation. Of the 55 medical staff surveyed, 45% were
outside the safe area of chest drain insertion as defined by the British Thoracic Society.
The most common error was a choice of insertion site too low (24%). In this audit 45% of
medical staff surveyed would have placed a chest drain outside the safe triangle
recommended by the British Thoracic Society. The common mistake of a choice of
insertion site too low should be discussed in in-service teaching programmes18.

Dalbec DL, Krome RL conducted a study on “Thoracostomy” which says that the
tube thoracostomy in the Emergency Department is an integral part of trauma and care
and treatment of nontraumatic intrapleural collections. An understanding of
pleuropulmonary anatomy, physiology, and pathophysiology forms the basis for
appropriate and safe application of this procedure. Rapid diagnosis and treatment of
intrapleural collections in the trauma patient is essential when one considers the grave
prognosis of untreated tension pneumothorax or massive hemothorax. Prior knowledge of
possible procedural complications with particular attention to thoracostomy site, sterile
technique, and careful blunt dissection makes chest tube placement straightforward and
safe. Most post-procedural complications can be avoided through a thorough
understanding of the collection system and careful monitoring of the patient19.

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6.3 STATEMENT OF THE PROBLEM

“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”

6.4 OBJECTIVES OF THE STUDY

1. To assess the knowledge regarding the chest drainage, among staff nurses.

2. To find out the association of knowledge among staff nurses regarding chest

drainage with selected demographic variables.

3. To prepare and distribute an educational pamphlet

6.5 OPERATIONAL DEFINITIONS

Knowledge: In this study knowledge refers to the information possessed by staff nurses
regarding the chest drainage as assessed by structured knowledge questionnaire.
Assess: In this study assess refers to measurement of the level of knowledge among staff
nurses regarding chest drainage.
Staff nurses: In this study staff nurses refers to the persons who are working in hospitals
with prescribed qualification and registered in concerned nursing council.
Chest drainage: In the study it refers to the procedure in which a flexible plastic tube is
inserted through the side of the chest into the pleural space, to remove air or fluid or pus
from the intra-thoracic space.

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Educational pamphlet: In this study, educational pamphlet refers to systematically
prepared health package which includes information regarding chest drainage which can
be easily understood by staff nurses irrespective of their knowledge.

6.6 HYPOTHESIS

1. H1- There is a significant variation in the knowledge of staff nurses regarding

chest drainage.

2. H2- There is a significant association between the knowledge regarding chest

drainage among staff nurses with selected demographic variables.

6.7 ASSUMPTIONS

1. The staff nurses may have minimal knowledge about the chest drainage.

2. The knowledge regarding chest drainage will help in practicing the procedure

effectively and in reducing complications.

6.8 VARIABLES UNDER STUDY

Dependent Variables: Knowledge regarding chest drainage among staff nurses.

Demographic Variables: Age, sex, education, work experience, source of

information.

6.9 DELIMITATIONS

The study is limited to the staff nurses who,

 Will be present during the period of data collection.

 Are willing to participate in the study.

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  The sample size is limited to 60 staff nurses.

6.10 PILOT STUDY

The pilot study will be conducted with 10 staff nurses and who will be excluded in
the main study. The purpose of pilot study is to find out the feasibility of conducting study
and design on plan of statistical analysis. The findings of the pilot study samples will not
be included in main study.

7.0 MATERIALS AND METHODS

A written permission will be obtained from the concerned authority prior to the
onset of the study, the purpose of the study and method of data collection will be
explained to the participants and informed consent will be taken, confidentiality will be
assured to all subjects to get their co-operation. Data will be collected from 60 staff
nurses in selected hospitals as per the inclusion criteria for the study. At the end subjects
will be thanked for their co-operation during the study.
7.1.1 SOURCES OF DATA

Data will be collected from staff nurses in selected hospitals, Bangalore.

7.1.2 RESEARCH DESIGN

The design is selected for the present study is descriptive design.

7.1.3 RESEARCH APPROACH

The non-experimental survey approach will be considered appropriate for this

study.

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7.1.4 RESEARCH SETTING

The study will be conducted in selected hospitals, Bangalore.

7.1.5 POPULATION

Population in the study consists of staff nurses in selected hospitals, Bangalore.

7.1.6 METHODS OF COLLECTION OF DATA

The data collection procedure will be carried out for a period of one months.

The study will be initiated after obtaining prior permission from the concerned authorities
as per guidelines from the university.

The researcher will collect the data from the students by using structured questionnaires
to assess the knowledge regarding chest drainage.

7.2.1 SAMPLE SIZE

Total sample of the study will consist of 60 staff nurses in selected hospitals,
Bangalore.
7.2.2 SAMPLE TECHNIQUE
Non-probability convenient sampling will be used for the study.
7.2.3 SAMPLING CRITERIA
 INCLUSION CRITERIA
1. Staff nurses those who are working in hospitals.
2. Staff nurses those who are available at the time of data collection.
 EXCLUSION CRITERIA

1. Staff nurses who are not willing to participate in the study.

7.2.4 TOOL FOR DATA COLLECTION

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Tools for data collection are divided into following categories:

Part I: Items on demographic variables will be listed under structured questionnaire.

Part II: Items on knowledge of staff nurses regarding the chest drainage will be assessed

by structured knowledge questionnaire.

7.2.6 METHOD OF DATA ANALYSIS & INTERPRETATION

The data will be organized, tabulated and analyzed by using descriptive and

inferential statistics. The data will be planned to present in the form of tables and

figures.

 Descriptive statistics:

To describe demographic variable by percentage, mean, mode, median and

standard deviation.

 Inferential statistics:

1. Chi square test to determine the association between the selected demographic

variables and the knowledge level of staff nurses regarding the chest drainage.

7.2.7 TIME AND DURATION OF THE STUDY

The time and duration of the study will be limited to 6 weeks as per the guidelines of the

university.

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR

INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR
OTHER HUMAN OR ANIMAL?
No, since the study is descriptive, study interventions are not required.

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7.4 HAS THE ETHICAL CLEARANCE BEEN OBTAINED FROM
YOUR INSTITUTION?
Yes, the pilot study and the main study will be conducted after the approval from the
research committee of Anuradha College of nursing, Bangalore. Permission will be
obtained from the concerned head of the institutions. The purpose and details of the
study will be explained to the study subjects and an informed consent will be obtained
from them. Assurance will be given to the study subjects on the confidentiality and
anonymity of the data collected from them

8.0 LIST OF REFERENCES

1. Chest drainage, www.wikipedia.com

2. Chest Drainage Systems,

http://www.teleflex.com/en/usa/ucd/chest_drainage_systems.php

3. Chest drainage, www.wikipedia.com

4. BTS guidelines for the insertion of a chest drain,

http://thorax.bmj.com/content/58/suppl_2/ii53.full

5. Hemothorax, http://emedicine.medscape.com/article/2047916-overview

6. Pneumothorax, www.wikipedia.com

7. Statistics of pneumothorax,
http://www.rightdiagnosis.com/p/pneumothorax/stats.htm

8. Lehwaldt D, Timmins F, Nurses' knowledge of chest drain care: an exploratory

descriptive survey, nursing in critical care 2005 Jul-Aug;10(4):192-200.

9. Lehwaldt D, Timmins F, The need for nurses to have in service education to

provide the best care for clients with chest drains, journal of nursing management,
2007 Mar;15(2):142-8.

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10. Elsayed H, Roberts R et al, Chest drain insertion is not a harmless procedure--are
we doing it safely?, ,Interactive Cardiovascular and Thoracic Surgery. 2010
Dec;11(6):745-8. Epub 2010 Sep 23.

11. Sim KM, Ng AS, A questionnaire survey on practice of chest tube management,
Singapore Medical Journal, 1996 Dec;37(6):572-6.

12. Munnell ER, Thoracic drainage, the Annals Thoracic Surgery. 1997
May;63(5):1497-502.

13. Sullivan B, Nursing management of patients with a chest drain, British Journal of
Nursing. 2008 Mar 27-Apr 9;17(6):388-93.

14. Charnock Y, Evans D, Nursing management of chest drains: a systematic review,

Australian Critical Care journal. 2001 Nov;14(4):156-60.

15. Avilés Serrano M, García Díaz M et al, Thoracic drainage, Rev Enferm. 2007
Jun;30(6):42-8.

16. Aylwin CJ, Brohi K, Pre-hospital and in-hospital thoracostomy: indications and
complications, Annals of Royal College of Surgeons England. 2008
Jan;90(1):54-7.

17. Gordon PA, Norton JM, Merrell R, Refining chest tube management: analysis of
the state of practice, Dimensions of Critical Care Nursing. 1995 Jan-Feb;14(1):6-
12; quiz 13.

18. Griffiths JR, Roberts N, Do medical staff know where to insert chest drains
safely?, Postgraduate Medical Journal. 2005 Jul;81(957):456-8.

19. Dalbec DL, Krome RL, Thoracostomy, Emergency Medical Clinics of North
America. 1986 Aug;4(3):441-57.

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9 SIGNATURE OF THE CANDIDATE

10 REMARKS OF THE GUIDE

11 11.1 NAME AND DESIGNATION OF Mrs. J. JAYALAKSHMI

GUIDE
Head of the Department

11.2 SIGNATURE

11.3 CO-GUIDE

11.4 SIGNATURE

11.5 HEAD OF THE DEPARTMENT Mrs. J. JAYALAKSHMI

11.6 SIGNATURE

12 12.1 REMARKS OF THE PRINCIPAL.

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12.2 SIGNATURE

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