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[pic]Lesson plan

Subject : Medical Surgical Nursing

Topic: Chest Drainage and Thoracetesis

Submitted to: Submitted By:

Mrs. Serin Shaji Thomas Sreeraj R N

Nursing Lecture 3rd year Bsc Nursing.

Subject : Medical surgical Nursing

Unit : Unit V

Topic : Chest Drainage and thoracentesis

Level of students : 3rd year Bsc Nursing

Date :

Time :

Place : 3rd year Bsc Nursing class room

Method of Teaching : Lecture and discussin

Name of supervisor : Mrs. Serin shaji Thomas

Previous knowledge of students : Student should have the basic knowledge about the chest drainage and thoracentesis

General objectives:

At the end of the class the students will gain the deep knowledge about the chest drainage and thoracentesis

Specific objectives:

At the end of the class the student should be able to,

➢ list down the definition of chest drainage and thoracentasis

➢ list down the purpose of chest drainage and thoracentasis

➢ list down the site and position

➢ list down the general instructions

➢ list down the complications

|TIME |OBJECTIVES |CONTENTS |AV AIDS |TEACHERS/ |EVALUATION |

| | | | |LEARNERS | |

| | | | |ACTIVITY | |

|1 min |Explain about chest drainage |Definition: |Black board & chalk |Lecture and discussion |Describe chest drainage? |

| | |Closed chest drainage is intented to allow air or fluids to escape from | | | |

| | |pleural space and promote lung reexpansion done by inserting a catheter to | | | |

| | |thorax through intercostals space. | | | |

| | | | | | |

| | |Indication: | | | |

| | |It is indicated after thorasic and thraco abdominal surgeries chest injuries | | | |

| | |in pneumothorax, pleural effusion etc. | | | |

| | | | | | |

| | |Types of chest drainage: | | | |

| | |Single bottle system | | | |

| | |Two bottle system | | | |

| | |Three bottle system | | | |

| | |1.Single Bottle system: | | | |

| | |The end of the drainage tube from the patients chest is submerged in water, | | | |

| | |which permits drainage of air and fluid from the pleural space but does not | | | |

| |Explain the types of chest |allow air to more back in to the chest. Functionally drainage depends on |Black board & chalk |Lecture and discussion |Describe the types of chest |

|10 min |drainage |gravity and on the mechanics of respiration. As the fluid level in the bottle | | |drainage? |

| | |increase . It becomes progressively more difficult for air and fluid to exit | | | |

| | |the chest. There fore suction may be added. | | | |

| | | | | | |

| | |2.Two Bottle system: | | | |

| | |The tow bottle system consists of the same water seal chamber plus a fluid | | | |

| | |collection bottle. Drainage is similar to that of a single unit. Except that | | | |

| | |when pleural fluid accumulates the under water seal system is not affected by | | | |

| | |the volume of drainage. | | | |

| | |Effective drainage depends on gravity or on the amount of suction added to the| | | |

| | |system. The amount of suction applied to the system is regulated by the wall | | | |

| | |gauge . | | | |

| | | | | | |

| | |3.Three bottle System: | | | |

| | |The three bottle system is similar to the two bottle system except for the | | | |

| | |addition of a third bottle to control the amount of suction applied. The | | | |

| | |amount of suction is determined by the depth to which the trip of the venting | | | |

| | |glass tube is submerged. The amount of suction in this system is controlled by| | | |

| | |the manometer bottle. The mechanical suction motor or wall suction creates a | | | |

| | |negative pressure through out the entire classed drainage system. | | | |

| | |When the vacuum in the system becomes greater than the depth to which the tube| | | |

| | |is submerged , outside air is sucked in to the system. This results in contant| | | |

| | |bubbling in the monometer bottle, which indicates that the system is | | | |

| | |functioning properly. | | | |

| | |Factors influencing the chest drainage: | | | |

| | |Proper placement of chest catheters | | | |

| | |Proper placement of the drainage apparatus | | | |

| | |Length of the drainage | | | |

| | |Maintaining the patency of the drainage tubing | | | |

| | |Maintaince of an air tight drainage system | | | |

| | |Position of the patient | | | |

| | |Activity of the patient | | | |

| | |General instructions: | | | |

| | |1.When caring for a person with close chest drainage it is important to | | | |

| | |understand the following facts | | | |

| | |a)The principles and purpose of the chest drainage | | | |

| | |b)A thorough knowledge of the specific apparatus being used , so that one can | | | |

| | |tell, when it is functioning correctly | | | |

| | |c)The necessary precautions are to be kept in mind | | | |

| | |d)Early signs and symptoms of impending complications in the patient | | | |

| | |eg: tension pneumothorax | | | |

| | |2.Instruct the bystanders and the patient how to act in emergencies. They | | | |

| | |should be demonstrated how to apply the clamps if the bottles are broken or it| | | |

| | |the tubes are disconnected. | | | |

| | |3)Affix a bocud with clear instructions on it for the visitors and others “Not| | | |

| | |to handle the equipment and displace any parts of it” | | | |

| | |4)Although the chest tubes are sutured to the patients skin, it should be | | | |

| | |taped to the dressing with adhesive tapes. | | | |

| | |5)The positions of the patient is adjusted in such a way that the patient is | | | |

| | |not lying over the tubing and blocking the drainage . A semi fowlers position | | | |

| | |aids in the drainage from the pleural cavity. | | | |

| | |6)All bottles in the drainage apparatus are sealed with tight stoppers and all| | | |

| | |connections are taped to ensure air tight drainage system. | | | |

| | |7)Observe strict asepsis to prevent introduction of infection in to the | | | |

| | |pleural cavity. Maintain a sterile field an practice asepsis whenever the | | | |

| | |bottles , tubing and connections are changed. Protect the open ends of the | | | |

| | |tubes with sterile dressings wash hands thoroughly. | | | |

| | |8)Ascertain the status of the patient by assessing his vital signs and the | | | |

| | |appearance frequently | | | |

| | |9)The following advice is given to these patients on discharge form the | | | |

| | |hospital | | | |

| | |To have deep breathing and coughing exercise | | | |

| | |To maintain good nutrition | | | |

| | |To maintain good hygiene especially oral hygiene | | | |

| | |To avoid activities or environment that can cause irritation of the trachea | | | |

| | |bronchial tree and could cause the respiratory infections |Black board & chalk |Lecture and discussion | |

| |Explain about factors |They are advised not to smoke, to avoid, dusty place and to avoid exposure to | | |What are the factors? |

|2 min | |the persons having respiratory infections . | | | |

| | |To consult the physician if symptoms of upper respiratory infections or other | | | |

| | |ailments develop | | | |

| | |To obtain a fitness certificate before they join their duty. | | | |

| | |Thoracentesis: | | | |

| | |Definition: Thoracentesis refers to the puncture by needle through the chest | | | |

| | |wall in to the pleural space for the purpose of removing pleural fluid, The | | | |

| | |thoracentes is performed for diagnostic or | | | |

| | |Therapeutic purposes. | | | |

| | |Purpose: | | | |

| | |To Study the chemical bacteriological and cellular composition of the pleural | | | |

| | |fluid. The cellular composition may reveal the presence of neoplastic cells. |Black board & chalk |Lecture and discussion | |

| |Explain about general |Effusions characterized by lymphacytosis occur in patient with tuberculosis, | | |What are the general |

| |instruction |lymphoma, carcinoma etc. | | |instructions? |

|10 min | |To remove excessive pleural fluid which could become infected and cause | | | |

| | |emphysema | | | |

| | |To relieve lung compression, pain, respiratory distress caused by the | | | |

| | |accumulation o fluid or aid in the pleural space. | | | |

| | |To instill medications in to the thoracic cavity | | | |

| | |The site of thoracentesis and the position of the patient : | | | |

| | |The common site for the pleural aspiration is the area just below the inferior| | | |

| | |angle of the scapula at the seventh intercostals space . The physician uses a | | | |

| | |chest X ray for the purpose of measuring the fluid level and level at which | | | |

| | |the aspiration would be performed . The lower level of the scapula is used as | | | |

| | |a land mark and then the distance of the fluid below this landmark is | | | |

| | |measured. | | | |

| | |The position of the patient during the thoracentesis helps to widen the | | | |

| | |thoracentesis helps to widen the intercostals space, so injury to the | | | |

| | |intercostal space, so injury to the intercostal nerves and blood vessels are | | | |

| | |avoided . The thoracentesis is most effectively. Performed with the patient | | | |

| | |sitting upright with the aims and shoulders raised. | | | |

| | |The positions usually used for the thoracentessi are : | | | |

| | |Have the patient seated at the edge of the bed with the feet supported on a | | | |

| | |stool. Place an over bed table infront of the patient place a soft pillow over| | | |

| | |the over bed table and have the patient can over the pillow with arms, | | | |

| | |shoulders and head resting on it. | | | |

| | |The patient is positioned in a fowlers position, resulting on the unaffed side| | | |

| | |. The hand on the affected side is raised over the head or place the palms | | | |

| | |resting on the opposite shoulders. | | | |

| | |If the patient is too ill to maintain an upright position turn the patient on | | | |

| | |to unaffected. Side and place the arm on the affected side one the head. | | | |

| | |If the patient is able to get out of bed, have the patient seated on a chair, | | | |

| | |turned towards, the back of the chair and learning one its back with the arms | | | |

| | |and shoulders raised. | | | |

| | |Procedure: | | | |

| | |The procedure is done under strict aseptic technique. After giving a local | | | |

| | |anaesthesia at the puncture site, aspiration needle fitted with a 3 way | | | |

| | |adaptor is introduced through the intercostals space in to the pleural cavity.| | | |

| | |The adaptor should be in a closed position to prevent the air entering the | | | |

| | |pleural cavity. As soon as the needle is in position the syringe is attached .| | | |

| | |The suction produced pulls the fluid from the chest cavity. | | | |

| | |Preparation of the articles: | | | |

| | |A Sterile tray containing: | | | |

| | |Sponge holding forceps -1 | | | |

| | |Syringe 5ml and 2 needles for giving local anaesthesia | | | |

| | |20ml syringe with 1liters lack to aspirate the fluid | | | |

| | |Aspiration needles with tubing | | | |

| | |3 way adaptor with tubing | | | |

| | |Small bowl 2 , to take the cleaning lotions | | | |

| | |Dissecting forceps | | | |

| | |Specimen bottles and slides | | | |

| | |Gown, masks and gloves for the doctor | | | |

| | |Sterile dressing towels /slit | | | |

| | |Cotton swabs , gauze piece and cotton pads. | | | |

| | |An unsterile tray containing : | | | |

| | |Mackintosh and towel | | | |

| | |Kidney tray and paper bag | | | |

| | |Spirit ,iodine etc | | | |

| | |Lignocaine 2 per cent | | | |

| | |Suction apparatus with water seal drainage system | | | |

| | |Complications that may occur during thoracentesis: | | | |

| | |Complication: Signs and Symptoms: | | | |

| | |1.Pneumothorax & | | | |

| | |Haemothorax | | | |

| | |Sudden rise of sharp pain in the chest | | | |

| | |Persistent cough | | | |

| | |Shortness of breath | | | |

| | |Fall in blood pressure | | | |

| | |Rapid pulse | | | |

| | |Anxiety restlessness and faintness, profuse sweating | | | |

| | |2.Tension Pneumothorax | | | |

| | |Marked dyspnoea | | | |

| | |Cyanosis, reduced or absence of breath sounds and decreased movement of chest | | | |

| | |on respiration on the affected side. | | | |

| | |Acute chst pain , increased pulse and respiration | | | |

| | |3.Mediastinal shift | | | |

| | |Cyanosis, severe dyspnea | | | |

| | |Deviation of the larynx and trachea from their normal midline position towards| | | |

| | |the unaffected , side, shifting of the heart beat. | | | |

| | |Distented neck veins | | | |

| | |Decreased BP | | | |

| | |4.Pulmonary oedema | | | |

| | |Blood tinged frothy sputum, coughs, rales, wheezing, severe dyspnea, cyanosis,| | | |

| | |tachypnoea ,tachy cardia, distended , neck veins |Black board & chalk |Lecture and discussion | |

| | |Peripheral oedoma | | |Describe the thoracentasis |

| |Explain the thoracentasis |General instructions: | | | |

| | |The patient should be prepared both physically and psychologically for the | | | |

|2 min | |procedure. He should be given adequate explanations about the procedure to | | | |

| | |wins his confidence and co operation | | | |

| | |The patient should be warned that any sudden movement during the procedure may| | | |

| | |cause injury to the lungs, blood vessels etc. | | | |

| | |The 3way adaptor should be fitted with the needle before it is introduced in | | | |

| | |to the chest cavity. | | | |

| | |The level of aspiration needle should be short to prevent picking of the | | |Describe the purpose? |

| | |lungs. | | | |

| | |The needle is not introduced below the level of 9th intercostal space. The | | | |

| | |diaphragm may get pierced and may injure the liver and other abdominal organs.| | | |

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| | |The nurse should check the syrings and needles for air tightness . It these | | | |

| | |are not air tight ,air may enter the pleural cavity and collapse the lungs. | | | |

| | |The suction exerted by the syringe should be minimal to prevent sucking at the| | | |

| | |lung tissue in to the needle . | | | |

| | |The nurse should remain with the patient and watch his general condition | | | |

| | |during the procedure . She should watch the pulse, respiration etc. | | | |

| | |Both doctor & the nurse should follow strict aseptic technique to prevent | | | |

| | |introduction of infection into the pleural cavity. | | | |

| | |If the fluid content at the pleural cavity is purulent it may cause difficulty| | | |

| | |to drain the fluid, A closed water seal drainage system may be set up. | | | |

| | |Conclusion: | | | |

| | |Student are ale to tell about the thoracentasis, its site and position and | | | |

| | |complications of thoracentasis. | | | |

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| | | |Black board & chalk |Lecture and discussion |Describe the site and position |

| | | | | |of the thoracentesis? |

| |Explain the site and position | | | | |

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| | | |Black board & chalk |Lecture and discussion |Describe the procedure? |

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| |Explain the procedure | | | | |

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| | | |Black board & chalk |Lecture and discussion | |

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| |Explain about the articles | | | | |

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| | | |Black board & chalk |Lecture and discussion | |

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| |Explain the complications | | | | |

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| | | |Black board & chalk |Lecture and discussion | |

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| | | | | |Describe the general |

| |Explain the general instructions| | | |instructions? |

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Chalk board summary

REFERANCES

TEACHERS REFERANCES

1. Sr. NANCY ,” STEPHANIES PRINCIPLES & PRACTICE OF NURSING “, VOLUME II NR

PUBLICATIONS, INDORE, 3RD EDITION,

PAGE NO: 199-211,291-296.

2. SMELTZER C SUZANNE, BAXE G BRENDA, “ BRUNNER & SUDDARTHS , TEXT BOOK

OF MEDICAL SURGICAL NURSING “ , 9TH EDITION LIPPICOTT PUBLICATIONS ,

PAGE NO: 515-517.

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No of students : 47

No of students presents:

Topic : Chest Drainage and Thoracentesis

➢ Definition

➢ Purpose

➢ Site and position

➢ Procedure

➢ Complication

➢ General condition

➢ Conclusion

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