SDLP: ICC and UWSD

THE CANBERRA HOSPITAL
STAFF DEVELOPMENT UNIT

Nursing Management of a
Patient with an:

Intercostal Catheter
and
Underwater Seal
Drainage System

A Self Directed Learning
Package

Intercostal Catheters and Underwater Seal Drainage

DEVELOPED BY:
Jamie Ranse, Registered Nurse – Emergency Department
AUGUST 2003

ACKNOWLEDGMENTS:
Margaret Hodge; Medical Nurse Educator
Dot Hughes; Nurse Educator – Intensive Care Unit
Jeni Ritchie; Clinical Development Nurse – Emergency Department
Tracey Duggan; Clinical Nurse Consultant – Ward 6A

The Canberra Hospital – Staff Development Unit Page 2


TABLE OF CONTENTS

Module Page

Introduction 5
Introduction 5
Instructions for Completion 5
Review Date 5
References 6

Anatomy and Physiology of the Respiratory System 8
Learning Objectives 8
Direction of Use 8
Assessment: Anatomy and Physiology Review 8

Nursing Management – Intercostal Catheter 11
Indications for a Intercostal Catheter 11
Pneumothorax 11
Haemothorax 13
Empyema 13
Pleural Effusion 14
Insertion of an Intercostal Catheter 15
Physical Assessment 16
Set-Up of Equipment 16
Documentation 18
Apical and Basal Intercostal Catheters 18
Intercostal Catheter Dressings 19
Removal of an Intercostal Catheter 19
Assessment: Clinical Case Study (Part A) 21

Nursing Management – Underwater Seal Drainage Systems 23
Types of Underwater Seal Drainage Systems 23
Used at the Canberra Hospital
Chambers and their Actions 24
Water Seal Chamber 24
Suction Control Chamber 24
Collection Chamber 25
One, Two and Three Chamber Systems 26



Routine Procedures 26
Changing the Collection Chamber 27
Adjusting the Suction Level 27
Sampling Drainage Fluid 28
Nursing Observations of the Underwater Seal 28
Drainage System
Leak / Bubble 28
Oscillation / Swing 29
Documentation 29
The Environment and Equipment 31
Clamping 31
Position of the System 31
Assessment: Clinical Case Study (Part B) 33

Nursing Management – General 36
Patient Assessment 36
Patient Education 36

Assessment Competency Based Assessment 37

Evaluation 40



Introduction

INTRODUCTION
This self directed learning package is designed to assist the Registered Nurse to
develop the competencies necessary to care for the patient with an intercostal
catheter and underwater seal drainage system. This package is divided into three
broad sections:
 Anatomy and Physiology
 Nursing Management
 Assessment

INSTRUCTIONS FOR COMPLETION
This package should take approximately 8 hours to complete. Please complete
the relevant readings then attempt to complete the questions. It is advisable to
utilise the reading list supplied to assist you in the completion of this package.
Please return the completed package to your Educator or Clinical Development
Nurse within one month of receiving it and arrange for a mutually agreeable time
to complete the competency assessment.

REVIEW DATE
This package will be reviewed in conjunction with evaluations from the first five
staff members to complete the package. It will then be reviewed as a needs
basis, if not every three years in accordance to Australian Health Care Standards
[AHCS]. The aim being to maintain the currency of practice with evidence based
literature.



REFERENCES

A.D.A.M (2002) http://www.adam.com/

Anderson, K. N., and Anderson, L. E., (eds.), (1998) Mosby’s Medical, Nursing,
and Allied Health Dictionary (5th ed.). Mosby-Year Book Inc., St Louis,
Missouri.

Australian Nurses Council Inc (2000) Competencies for Registered Nurses.

Black, J. M, and Matassarin-Jacobs, E., (1997) Medical-Surgical Nursing: Clinical
Management for Continuity of Care (5th ed.). W. B. Saunders Company,
USA.

Charnick, Y., (2001) The Nursing Management of Chest Drains: a Systematic
Review No. 16 The Joanna Briggs Institute for Evidence Base Nursing and
Midwifery, Adelaide, Australia.

Diepenbrock, N.H., (1999) Quick Reference to Critical Care, Lippincott, Williams
and Wilkins, Philadelphia, USA.

Hickman, R. J., and Caon, M., (1995) Nursing Science: Matter and Energy in the
Human Body (2nd ed.). McMillan Education, Melbourne, Australia.

Hudak, C.M., Gallo, B.M., and Morton, P.G., (1998), Critical Care Nursing – A
Holistic Approach (7th ed.). Lippincott-Raven Publishers, Philadelphia,
USA.

Joanna Briggs Institute (2002) Acute Care Practice Manual. The Joanna Briggs
Institute for Evidence Base Nursing and Midwifery, Adelaide, Australia.

Kozier, B., Erb, G., Blais, K., and Wilkinson, J. M., (1998) Fundamentals of
Nursing: Concepts, Process, and Practice (5th ed.). Addison-Wesley
Publishing Company, Inc., Califonia, USA.

Lazzara, D., (2002) Eliminate the Air of Mystery from Chest Tubes. Nursing
2002,
32(6): 36 - 45

Leahy, J. M., & Kizilay, P. E., (1998) Foundations of Nursing Practice: A Nursing
Process Approach. W. B. Saunders Company, USA.

Marieb, E. N., (1998a) Human Anatomy and Physiology (4th ed)., Benjamin
Cummings Science Publishing Company Inc. California.

Marieb, E. N., (1998b) Study Guide for Human Anatomy and Physiology (4th ed).,
Benjamin Cummings Science Publishing Company Inc. California.



Porth, C. M., (1998) Pathophysiology: Concepts of Altered Heath States (5th ed.).,
Lippincott.

Seeley, R. R., Stephens, T. D., and Tate, P., (1995) Anatomy and Physiology (3rd
ed.). Mosby-Year Book Inc., St Louis, Missouri.

Simulab Corporation (2003) http://www.simulab.com/

The Canberra Hospital (2002) Management of a patient with an intercostal
catheter. http://tchi/Content.asp?p=48

The Canberra Hospital (2001) Nursing Service - Nursing Practice Standards:
Intensive Care Unit 2.4.0 / ICU



Anatomy and Physiology of the Respiratory System

LEARNING OBJECTIVES
To review the anatomy and physiology of the Respiratory System, focussing
specifically on:
 Physiology of the lungs, and
 Mechanisms in respiration

DIRECTION OF USE
This section is primarily self directed, and acts as a prerequisite for the remainder
of the package. It is suggested that you familiarise yourself with the anatomy and
physiology of the respiratory system by utilising an anatomy and physiology book
that you may have at home or one of the many available at the Canberra
Hospital. Examples are included in the above reference list [page 6].

ASSESSMENT: ANATOMY AND PHYSIOLOGY REVIEW
The following exercises are abstracts from Marieb, E. N., (1998b).
Complete the following questions and answer them in the space provided.

1. What are the four main events of respiration?
i)
ii)
iii)
iv)

2. The respiratory system is divided into conducting zone and respiratory zone
structures.

i) Name the respiratory zone structures

ii) Name the conduction zone structures



3. Figure 1 illustrates the anatomy of the lower respiratory system. Intact
structures are shown on the left; isolated respiratory passages are shown on
the right. Label the diagram with the following:

Apex of lung (superior lobe) Mediastinum Plural space
Base of lung (inferior lobe) Clavicle Diaphragm

Figure 1: conducting respiratory passages and anatomical relationships of organs in
the thoracic cavity (Marieb, 1998b)

Using a different colour shade the following areas of the lung, ensure that you
also shade the name of the corresponding area with the same colour.

Trachea Larynx Intact Lung
Visceral Pleura Parietal Pleura
Primary Bronchi Secondary Bronchi Tertiary Bronchi



4. Using either A, B or C, match the following facts about pressure within the
lungs.

A Atmospheric Pressure B Intrapulmonary Pressure C Intrapleural Pressure

1 Baring pneumothorax, this pressure is always lower
than atmospheric pressure (negative pressure)
1 Pressure outside the body
2 As it decreases, air flows into the passageways of the
Lungs
3 As it increases over atmospheric pressure, air flows
into the lungs
4 If this pressure becomes equal to atmospheric
pressure then the lungs collapse
5 Rises well over atmospheric pressure during a forceful
cough
6 Also known as intra-alveolar pressure

5. Many changes occur within the lungs as the diaphragm (and intercostal
muscles) contract and then relax. These changes cause air to flow into and
out of the lungs. The activity of the diaphragm is given in the left column of the
following table. Several changes in internal thoracic conditions are listed in
the column heads to the right. Compare the table by ticking ( ) the
appropriate column to correctly identify the change that would be occurring in
each case relative to the stated diaphragm activity.

Changes in
Activity of diaphragm: Internal volume of Internal pressure in
Size of lungs Direction of air flow
↑ = increase thorax thorax
↓ = decreased Into Out of
↑ ↓ ↑ ↓ ↑ ↓
lungs lungs
Contracted,
Moves downward
Relaxed,
moves superiorly



Nursing Management – Intercostal Catheters
LEARNING OBJECTIVES
 List the indications for an intercostal catheter.
 Outline the care for a patient with an intercostal catheter.
 Outline the process of insertion and removal of an intercostal catheter.

INDICATIONS FOR AN INTERCOSTAL CATHETER
An intercostal catheter is sometimes known as a chest tube (Diepenbrock, 1999).
However, for the purpose of this package, it will be referred to as an intercostal
catheter.

An intercostal catheter is indicated when a patient has excessive fluid or air
within the pleural or mediastinal cavities. This may include conditions such as;
pneumothorax, haemothorax, empyema, or pleural effusion (Porth, 1998). The
primary aim of an intercostal catheter is to promote lung re-expansion by
restoring and maintaining respiratory and haemodynamic status (Charmock,
2001). Poor management of an intercostal catheter can prevent the drainage of
fluid and/or air, therefore delaying lung re-expansion, and exacerbating the
patients current condition.

Pneumothorax
A pneumothorax is defined as a collection of air or gas in the pleural space
(Marieb, 1998a; Seeley, et. al., 1995). There are several types of pneumothorax,
which are classified by cause. This includes spontaneous pneumothorax,
traumatic pneumothorax, and tension pneumothorax.

A spontaneous pneumothorax is the occurrence of a pneumothorax without a
clear cause (Porth, 1998). Primary spontaneous pneumothorax occurs when
there is no known underlying lung disease. However, spontaneous
pneumothorax is thought to be caused by the rupture of a small, air-filled sac in
the lung called a bleb or a bulla (Marieb, 1998a; Porth, 1998). The disease most
frequently affects tall, thin men between the ages of twenty and forty years old



(Kozier, et. al., 1998; Marieb, 1998a; Porth, 1998). Secondary spontaneous
pneumothorax is a complication of underlying pulmonary disease such as,
chronic obstructive pulmonary disease, asthma, cystic fibrosis, tuberculosis or
whooping cough.

A traumatic pneumothorax results from a traumatic injury to the chest.
This trauma may be blunt or penetrating. In blunt chest trauma, a rib may
lacerate lung tissue or an artery, causing blood to collect in the pleural space. In
penetrating chest trauma, a weapon such as a knife or bullet lacerates the lung
(Black and Matassarin, 1997; Porth, 1998).

A tension pneumothorax is caused when excessive pressure builds up around
the lung, forcing it to collapse. The excessive pressure can also prevent the heart
from pumping blood effectively, therefore leading to cardiogenic shock (Black
and Matassarin-Jacobs, 1997; Seeley, et. al., 1995).

Signs and Symptoms of a pneumothorax may include:
• sudden sharp chest pain, especially made worse by a deep breath or a
cough,
• shortness of breath,
• chest tightness,
• tachycardia,
• cyanosis,
• nasal flaring,
• anxiety / stress, and
• hypotension.

Figure 2: a chest x-ray displaying a left sided
Diagnosis of a pneumothorax is by pneumothorax (A.D.A.M 2002)

• chest x-ray to determine presence of air outside the lung,
• arterial blood gases, and
• auscultation of the lungs.



Haemothorax
A haemothorax is defined as a collection of blood in
the pleural cavity. The most common cause of a
haemothorax is chest trauma (Anderson and
Anderson, 1998). Haemothorax can occur in patients
with lung or pleural cancer, or in patients with a
defect in the blood clotting mechanisms.
Haemothorax is common after thoracic or heart
surgery, as well as in patients who have suffered a
pulmonary infarction (Hudak, et. al., 1998). Shock is
often secondary to a large haemothorax in the
Figure 3: a left sided haemothorax
trauma patient. Haemothorax may also be (Simulab Corporation, 2003)

associated with a pneumothorax.

Signs and Symptoms are similar to those in a pneumothorax, with the addition
that the patient may be actively producing red frothy blood-stained sputum.

Diagnosis of a pneumothorax is by
• chest x-ray,
• thoracentesis,
• pleural fluid analysis, and
• chest auscultation.

Empyema
Empyema is caused by an infection that spreads from the lung and leads to an
accumulation of pus in the pleural space (Anderson and Anderson, 1998). The
infected fluid can build up to a large quantity, which puts pressure on the lungs,
causing shortness of breath and pain. Risk factors include recent pulmonary
conditions such as, bacterial pneumonia, lung abscess, thoracic surgery, trauma
or injury to the chest, and rarely, thoracentesis (Black and Matassarin, 1997;
Porth, 1998).



Signs and symptoms may include
• a dry cough,
• fever or rigours,
• excessive sweating, especially night sweats,
• general discomfort, uneasiness, or ill feeling,
• weight loss, and
• chest pain that is worse on inspiration.

Diagnosis of empyema is by
• chest x-ray,
• thoracentesis,
• pleural fluid gram stain culture, and
• chest auscultation - abnormal findings, such as decreased breath sounds or a
friction rub, may be noted on.

Pleural Effusion
A pleural effusion is defined as an
accumulation of fluid between the layers of
the membrane that lines the lungs and
thoracic cavity (Anderson and Anderson,
1998). Normally pleural fluid is formed in
small amounts to lubricate the surfaces of the
pleura. A pleural effusion is an abnormal
collection of this fluid. Two different types of
effusions can develop. Transudative and
Figure 4: diagrammatic representation of a
exudative effusions (Porth, 1998). pleural effusion (A.D.A.M 2002)

Transudative pleural effusions are usually caused by a disorder in the normal
pressure present in the lung. Congestive cardiac failure is the most common
cause of transudative effusion (Porth, 1998).



Exudative effusions form as a result of inflammation of the pleura, which is often
caused by lung disease, such as, cancer, drug reactions, asbestosis, sarcoidosis,
pneumonia, tuberculosis and other lung infections (Porth, 1998).

Signs and symptoms may include
• shortness of breath,
• chest pain, usually a sharp pain that is worse with coughing or deep breaths,
• cough,
• hiccups, and
• tachypnoea.

Diagnosis of pleural effusion is by
• chest x-ray,
• thoracic CT,
• chest ultrasound,
• thoracentesis,
• pleural fluid analysis, and
• chest auscultation.

INSERTION OF AN INTERCOSTAL CATHETER
The insertion of a chest tube includes
the surgical insertion of a hollow,
flexible drainage tube into the chest. A
medical officer completes the
insertion, usually with the assistance
of a registered nurse (The Canberra
Hospital, 2002).

Nursing interventions prior to the Figure 5: instruments used in the insertion of an intercostal
catheter (A.D.A.M 2002)
insertion of the intercostal catheter
should include a physical assessment, set-up of equipment and documentation.



Physical Assessment

• assess the patient's breath sounds, heart
rate, blood pressure, temperature, respiratory
rate and rhythm, and oxygen saturation.

• assess the patients pain level and administer
ordered analgesia as needed.

• assessment of the patients bedside is
Figure 6: air movement in the insertion
important to ensure it is clear of clutter. of an intercostal catheter (Simulab
Corporation, 2003)
Oxygen and suction should be available and
operational.

Set-Up of Equipment

Outlined below is the correct procedure in setting-up for the insertion of an
intercostal catheter.

1. Clean large procedure trolley with alcohol. 2. Touching only the light green areas of the
Remove major procedure pack from plastic cloth, open the pack outwards. Open a
covering and place in centre of trolley. cheatle forcep carefully and use this to
arrange the sterile field as shown.



3. Add Betadine to one of the bowls, whilst 4. Add alcohol to the other bowl on the field.
maintaining a sterile field. Ensure that your hand and the container are
kept at least fifteen centimetres above the
field.

5. Open Howard Kelly Clamp set onto sterile field. 6. Open chest Tube onto the field. Make sure
that the ends do not protrude over the edge of
the field.

7. Open two occlusive dressings onto field. 8. Open Mersilene suture pack, add a 10ml
syringe and a 23 and 25 gauge needle.



Your set-up for an intercostal catheter
is now complete.

9. Have local anaesthetic ready for drawing up
[Lignocaine 1% and Lignocaine with
adrenaline].

Documentation

Document in the patient progress notes:

• the pre-insertion assessment findings,

• the patients response to the procedure, and

• any complications.

NOTE: Refer to the Canberra Hospital Nursing Practise Standards
[08.5.2:001] or The Canberra Hospital – Intensive Care Unit Nursing
Standard 2.4.1 / ICU for the procedure of inserting an Intercostal
Catheter.

APICAL AND BASAL INTERCOSTAL CATHETERS

In some circumstances, a patient may require
the insertion of more than one intercostal
catheter into the same pleural cavity. For
example, a trauma patient who has sustained
significant chest injuries, which result in both a
haemothorax and a pneumothorax.
Figure 7: an inserted ‘apical’ intercostal
catheter (Simulab Corporation, 2003)


An apical intercostal catheter is inserted into the apex of the pleural cavity.
This intercostal catheter will primarily remove air form the pleural cavity, and
therefore promote lung re-expansion.

A basal intercostal catheter is inserted into the base of the pleural cavity. This
intercostal catheter will primarily remove fluid – as fluid is heavier than air, it
therefore consolidates or pools at the base of the pleural cavity.

INTERCOSTAL CATHETER DRESSINGS

The intercostal catheter should be dressed with an occlusive dressing, such
as tegedermtm or opsitetm to allow visualisation of the insertion site. This
dressing must be routinely checked each shift and changed at least every
forty-eight hours or as necessary (Joanna Briggs Institute, 2002).

Changing the intercostal catheter dressing should be done using the
principles of aseptic technique, to reduce the risk of infection. The dressing
should be secured as per The Canberra Hospital Nursing Practice Standards.

Figure 8: securing an intercostal catheter. Figure 9: securing an intercostal catheter.

REMOVAL OF AN INTERCOSTAL CATHETER

A medical officer conducts the removal of an intercostal catheter with the
assistance of a registered nurse. In some circumstances two registered
nurses may remove the intercostal catheter [these circumstances include the
removal of an intercostal catheter in specialty areas by registered nurses that



have successfully completed a relevant educational program] (The Canberra
Hospital, 2002).

In the adult, an intercostal catheter is considered ready for removal only after
all of the following conditions have been met:

• resolution of pneumothorax,

• less than 100ml of pleural drainage evacuated over the preceding 24 hour
period,

• absence of air leak on valsalva manoeuvre or forceful cough,

• appropriate documentation by a medical officer which indicates the intercostal
catheter is to be removed.

Charnock (2001) states that when nurses educate and support patients on the
removal of the intercostal catheter, patients experience less pain and anxiety
during the procedure. As a result, these patients have fewer complications post
intercostal catheter removal.

After catheter removal, a follow-up chest x-ray should be obtained to document
continued lung re-expansion. X-rays should be obtained at least four hours post
removal of the intercostal catheter. This ensures that conditions such as a slowly
re-occurring pneumothorax is not missed (Hudak, et al., 1998).

NOTE: Refer to the Canberra Hospital Nursing Practise Standards
[08.5.2:001] or The Canberra Hospital – Intensive Care Unit Nursing
Standard 2.4.8 / ICU for the removal of an Intercostal Catheter.

After the removal of an intercostal catheter the nurse must attend to regular
observation of the patient. Including an assessment for breathlessness,
tachycardia, and diminished breath sounds.



ASSESSMENT: CLINICAL CASE STUDY (PART A)
Date: 01 January 2005, Time: 1300
You have commenced care for a patient who was admitted to your ward after
presenting to the emergency department with a fever, dry cough, and chest pain
which is worse on inspiration. The patient’s only significant medical history is
thoracic surgery, which he had four weeks ago.

In determining a diagnosis and subsequent treatment for the patient, the medical
staff order a number of diagnostic test. Firstly, a x-ray is performed which shows
a large amount of fluid in the left lower lobe, following the x-ray, a thoracentesis
and pleural fluid analysis is performed and the medical staff diagnoses
empyema.

The plan for this patient is the insertion of an intercostal catheter and underwater
seal drainage, with -10 centimetres of suction assisted by wall suction. In addition
the patient is commenced on antibiotics, to fight the infection, and analgesia, to
alleviate their pain.

10. Explain the differences between empyema and pleural effusion?

11. Outline nursing interventions prior to insertion of an intercostal catheter.



12. Using this package and The Canberra Hospital Nursing Practise
Standards, or The Canberra Hospital – Intensive Care Unit Nursing
Standard, or The Canberra Hospital – Emergency Department Protocol,
a) Discuss the type of dressing used for an intercostal catheter, and outline
the purpose of this dressing.

b) Describe how the intercostal catheter should be secured.

13. In the removal of an intercostal catheter, what is the role of the registered
nurse?



Nursing Management – Underwater Seal Drainage Systems

LEARNING OBJECTIVES
 Identify different drainage systems used at The Canberra Hospital,
 Describe mechanisms of drainage,
 Describe the purposes of the collection, water seal and suction control
chamber, and
 Identify complications of an underwater seal drainage system.

TYPES OF UNDERWATER SEAL DRAINAGE SYSTEMS USED AT THE CANBERRA
HOSPITAL

The Canberra Hospital uses two types of underwater seal drainage systems. The
systems are the Thora-Seal® III, and the Aqua-Seal tm.

Figure 11: Aqua-Seal tm III
Figure 10: Thora-Seal® (A.D.A.M 2002)
(A.D.A.M 2002)
CHAMBERS AND THEIR ACTIONS
The Thora-Seal® III, and the Aqua-Seal tm have three chambers, figure 11 shows
the different chambers of the Aqua-Seal tm. These chambers include a water seal
chamber, a suction control chamber, and a collection chamber.



Water Seal Chamber
Water seal drainage is achieved by connecting the intercostal catheter to a
drainage system that utilises water as a seal or ‘one way valve’. The seal allows
fluid and air to be drained from the thorax and prevents return (Hickman and
Caon, 1995; Hudak, et. al., 1998).

The water seal chamber achieves this one way
movement by separating the atmospheric pressure from
the interthoracic pressure. When the pressure in the
atmosphere is less than the pressure in the thoracic
cavity, the air is forced down the pressure gradient into
the atmosphere via the water seal. On the other hand,
when the pressure in the atmosphere is greater than the
air in thoracic cavity, the air can not enter the thorax due
to the presence of the water seal (Porth, 1998). Figure 12: the water seal
chamber (A.D.A.M 2002)

It is important to note that it is due to this water seal and the interplay between
the atmospheric and interthoracic pressure that air and fluid is ‘sucked-out’ of the
thoracic cavity.

Suction Control Chamber
The suction control chamber is used in the presence of excess fluid and/or air. If
the suction control chamber is not used the underwater seal drainage system is
said to be on ‘free drainage’ - using the forces of gravity.

However, if sterile water is applied to the suction control chamber, the system is
said to be ‘on-suction’. The level of water is determined in centimetres of water
[usually between -10 and -20 centimetres]. This level is
prescribed by a medical officer and determines the
amount of suction (The Canberra Hospital, 2002).



In addition, the underwater seal drainage system maybe connected to a wall
suction outlet, if this is the case, the unit is said to be ‘on wall suction’. This alone
does not facilitate the suction of air or fluid from the thoracic cavity – it only
assists with an additional ‘pull’. This suction is usually applied via a device, which
facilitates ‘low wall suction’. However, if this device is
Figure 13: the suction
not used, the only effect will be a faster evaporation of control chamber (A.D.A.M
2002)
the water in the suction control chamber. Therefore wall
suction can be achieved without a ‘low wall suction device’ (Charnick, 2001;
Lazzara, 2002).

Collection Chamber
The aim of the collection chamber is to collect any fluid that is drawn from the
lungs. It facilitates the accurate monitoring of volume, rate, colour and nature of
the drainage (Black and Matassarin, 1998).

To effectively drain fluid from the pleural cavity, the
tubing should be positioned so no loops are present. In
addition there should be no kinks in the tube. A loop or
kink can trap fluid and work against the negative
pressure, therefore inhibiting drainage (Joanna Briggs
Figure 14: the collection
Institute, 2002). chamber (A.D.A.M 2002)

One, Two and Three Chamber Systems
The one chamber system combines the drainage chamber and the water seal
chamber. The tube from the patient extends below the level of the water in the
chamber, therefore allowing the air to escape via a water seal. This system is not
practical in conditions that have excessive drainage (Hickman and Caon, 1995).



The two chamber system has the drainage chamber separate from the water seal
chamber. This allows drainage and measurement of fluid from the pleural cavity
(Hickman and Caon, 1995; Hudak, et. al., 1998).

The three chamber system consists of a collection chamber, water seal chamber
and a suction control chamber. The three chamber system has been discussed
above (Hickman and Caon, 1995).

Figure 15: one, two and three chamber systems (A.D.A.M 2002)

ROUTINE PROCEDURES
Whilst you are caring for a patient with an underwater seal drainage system, you
may need to conduct some routine procedures. The most common procedures
you may need to conduct include, changing the collection chamber, adjusting the
suction level or sampling the drainage fluid (The Canberra Hospital, 2002).
Changing the Collection Chamber
If the collection chamber of the Aqua-Seal tm becomes full, then the whole unit
must be changed. On the other hand, if the collection chamber on the Thora-
Seal® III becomes full, the collection chamber can easily be changed.



• simply double clamp the drainage tube,
• carefully unscrew the collection chamber,
• screw-on the new chamber, and
• remove the clamps.

Once the collection chamber is removed from the unit,
ensure that the contents are disposed of appropriately
in an infectious waste disposal container (Charnick,
2001). Document the time and date that the chamber
was changed, and the amount / colour of the fluid in the
chamber. This should be documented in the patient
progress notes, fluid balance chart, and on the Figure 16: a collection chamber
(A.D.A.M 2002)
underwater seal drainage observation chart (Lazzara,
2002).

This procedure is best conducted with two nurses as it, firstly, reduces the time
that the intercostal catheter is clamped and, secondly, reduces the risk of spilling
the contents of the chamber (The Canberra Hospital, 2002).

Adjusting the Suction Level
Suction levels may need adjusting when the water level falls below the
prescribed limit or when additional suction is to be applied. This is achieved by
simply adding sterile water to the suction control chamber via the fill port at the
top of the system (Hudak, et. al., 1998; Joanna Briggs Institute, 2002).

If a medical officer prescribes a level of water less than what is currently in the
suction control chamber, then the underwater seal drainage system will require
replacing.
Sampling Drainage Fluid
To obtain a sample of fluid from the patient, it is advised to get the ‘freshest’
possible sample as this will indicate the current status of pleural fluid when
compared to the fluid in the collection chamber (Charnick, 2001). Simply follow



the process as outlined in The Canberra Hospital Nursing Practise Standard
[08.5.2:001].

In addition it is important to note that the specimen must be obtained from the
flexible drainage tube, close to the connection of the intercostal catheter. The
flexible drainage tube has specific properties, which facilitate the tube to ‘self
seal’ following the removal of the fine bore needle.

NOTE: Refer to the Canberra Hospital Nursing Practise Standard
[08.5.2:001] for obtaining a specimen form the pleural cavity for
laboratory analysis.

NURSING OBSERVATIONS OF THE UNDERWATER SEAL DRAINAGE SYSTEM

Observations of the underwater seal drainage system should be conducted every
hour, unless indicated otherwise by a medical officer. Observations should be
conducted with ‘wall suction’ turned off. Observations of leak / bubble and
oscillation / swing are obtained by viewing the water seal chamber not the
suction control chamber (The Canberra Hospital, 2001).

Leak / Bubble
Leak / bubbles will be present in the water seal chamber immediately following
insertion of the intercostal catheter (Charnick, 2001). Intermittent bubbles may
continue to be present when the patient coughs or takes a deep breath. This
bubble represents air in the pleural cavity. If bubbles are vigorous and continuous
this may indicate a leak within the drainage system. On the other hand, no
bubble / leak indicates a secure underwater seal drainage system and a re-
expanded lung (Dipenbrock, 1999; Hudak, 1998; Lazzara, 2002).

Oscillation / Swing
Oscillation is observed when there is a change in pressure in the pleural cavity.
The oscillation in the water seal chamber will be low on expiration and water will
rise up the tube on inspiration (Dipenbrock, 1999). In addition oscillation / swing


may be observed in the flexible drainage tube (Dipenbrock, 1999; Hudak, 1998;
Lazzara, 2002).

Documentation
Documentation should be completed in The Canberra Hospital – underwater seal
drainage observation chart. Below is an example of the observation chart.

………………………… Hourly Observations
Date Time Resp Air/ Oscillation/ Suction Drainage Comments
Bubbling Swing

Figure 17: an example of The Canberra Hospital – Underwater Seal Drainage Observation Chart

In the event of a trauma patient with an intercostal catheter and underwater seal
drainage system. Observations should be commenced on The Canberra Hospital
– Emergency Department Nursing Trauma Flowsheet. The observation section is



located on the back of the flowsheet. An example of the observation section is
below.

UWSD
Left Right
Time Leak Swing Suction Time Leak Swing Suction
Admitting Doctor:

Figure 18: an example of The Canberra Hospital – Emergency Department Nursing Trauma Flowsheet
[underwater seal drainage observation section]

Below is a summary of the management overview for the underwater seal
drainage system.
Leak / bubble? Oscillation / Swing?
Yes Yes Indicates that the patient has air in the pleural cavity and the
lungs have not re expanded.

The greater the degree of bubble and oscillation the greater
the extent of the air and lung collapse
No No Indicates resolution of air and lung re expansion [slight
swing may still be present].

Check the collection tube to ensure it is not kinked or
obstructed.
Yes No Indicates a possible connection or system air leak.

Momentarily clamp the intercostal catheter close to the
insertion site. If bubbling still occurs secure and tape all
connections.
No Yes Can be observed with partial or total pneumonectomy and
disease states associated with decreased lung compliance.

In addition to The Canberra Hospital underwater seal drainage observation chart
or the Intensive Care Unit Flow Chart, the patient progress notes should be
completed with the information such as;
• patient observations and physical assessment findings,
• amount of fluid drained over the period of the shift,
• any abnormalities or complications with the underwater seal drainage system,



• any interventions from the nursing staff, such as, adding additional water to a
chamber, changing of a chamber, changing the intercostal catheter dressing,
• patient education,
• patient compliance with exercise and the underwater seal drainage system in
general.
(Leahy and Kizilay, 1998; The Canberra Hospital, 2002)

THE ENVIRONMENT AND EQUIPMENT
In general the environment around the patient should be free of clutter. In
addition, the patient’s bedside oxygen and suction equipment must be
operational.

Clamping
Two padded Howard Kelly clamps should be kept with the patient at all times.
The patient requires a set of two clamps for each intercostal catheter (The
Canberra Hospital, 2002). Clamping of the flexible drainage tube should be done
whenever a risk of air or fluid entering the pleural space exists, such as
accidental disconnection or breakage. The clamps must be applied in opposite
directions at least two and a half centimetres apart (Charnick, 2001; Joanna
Briggs Institute, 2002; The Canberra Hospital, 2002). It is important to note that
the clamps should only be applied to the flexible drainage tube and not the
intercostal catheter, as the clamps may damage the intercostal catheter.

Position of the System
The underwater seal drainage system should be positioned below the patient’s
chest level to facilitate drainage. The Joanna Briggs Institute (2002) states that
the underwater seal drainage system should be at least sixty centimetres below
the chest.

Whilst the patient is resting in bed or sitting out in a chair, ensure that the system
has the following applied:
• the floor stand at a ninety degree angle to the underwater seal drainage
system, or


• the underwater seal drainage system hanging on the bed or chair.

ASSESSMENT: CLINICAL CASE STUDY (PART B)
The following day [02 January 2005] you are caring for a patient with empyema -



the same patient as outlined in Part A of this Clinical Case Study. They have an
intercostal catheter and underwater seal drainage system [Thora-Seal® III]. The
system has 10 centimetres of water in the suction control chamber and has a low
wall suction device operating.

14. At the beginning of your shift, what assessment are you going to conduct on
the patient, equipment and the environment?

You disconnect the underwater seal drainage system from the suction device and
attend to the patient’s hourly observations at 1300

15. Complete the observation chart on Page 29 - Figure 17 with the following
additional information:
• The drainage collection chamber has 2800mls of blood stained fluid,
• The water seal chamber has a swing of about 5 centimetres, and you
notice intermittent bubbling,
• The suction control chamber has vigorous bubbling.

16. Briefly describe the primary function of the following:
a) Collection Chamber

b) Water Seal Chamber

c) Suction Control Chamber

The Medical Officer has ordered the suction level to be adjusted from –10
centimetres of water to –20 centimetres of water.



17. Outline how you would adjust the suction level of the underwater seal
drainage system.

It is now 1400 and you attend to the patient’s hourly observations

• The water seal chamber has a swing of about 4 centimetres, and you
notice continuous bubbling,

19. Bubbling / leak:
a) If bubbling / leak is present, what may this indicate?

b) If bubbling / leak is absent, what may this indicate?

20. Swing / oscillation:
a) If swing / oscillation is present, what may this indicate?

b) If swing / oscillation is absent, what may this indicate?


• The water seal chamber has a swing of about 3 centimetres, no bubbling /
leak is present,
22. At 1400 the water seal chamber was bubbling continuously, however, at 1500
the bubbling is absent. What nursing interventions may have taken place
between 1400 and 1500?




• The water seal chamber has a swing of about 3 centimetres, no bubbling /
leak is present,

24. You identify that the drainage collection chamber requires changing.
a) Outline the process of changing the chamber.

b) What documentation should be completed once the chamber has been
changed?

Nursing Management – General

LEARNING OBJECTIVES
 Demonstrates appropriate patient assessment,


 Identifies key points in patient education.

PATIENT ASSESSMENT
It is important to regularly evaluate the patient’s physical condition. This includes
skin colour, breathing rhythm and rate, discomfort, and emotional state. Every
four hours the following assessment should be conducted:
• general observations, such as, pulse, respirations, temperature, oxygen
saturation’s.
• physical assessment, including:
- observation of the insertion site, patients effort to breath,
- palpation, to determine symmetric air entry, and feel for subcutaneous
emphysema,
- auscultation of the chest to determine lung status, and identify any
change.
(Leahy and Kizilay, 1998)

PATIENT EDUCATION
Patient education should be ongoing. The patient should be aware of the
following:
• if any change in general feeling of well being to notify nursing / medical staff
member immediately,
• do not disconnect any tubes from the underwater seal drainage system,
• if the underwater seal drainage system is accidentally knocked over, or a tube
is disconnected, notify a nursing staff member immediately,
• deep breathing and coughing exercises are beneficial to the re-expansion of
the lungs.
(Leahy and Kizilay, 1998)

Assessment
COMPETENCY BASED ASSESSMENT



The following competencies used are according to the Australian Nurses Council
Inc. (2000) Competencies for Registered Nurses.

As the assessor, please document evidence to support the below competency
units while observing the assessee caring for the patient with an intercostal
catheter and underwater seal drainage system. The assessee should be
observed:
 Checking the patients environment
 Conducting an assessment of the patient, the intercostal catheter, and the
underwater seal drainage system
 Performing the removal of a chest tube

DOMAIN: Professional and Ethical Practice
As assessor for a registered nurse, I hold the view that the registered nurse:

COMPETENCY UNIT 1: Functions in accordance with legislation and
common law affecting nursing practice. Evidence

[1.3] Demonstrates knowledge of policies and procedural guidelines that have
legal implications for practice.

COMPETENCY UNIT 3: Protects the rights of individuals and groups in relation to
health care.

[3.3] Involves the individual/group as an active participant in the process of care.

[3.6] Provides relevant and current health care information to individuals and
groups in a form which facilitates their understanding

[3.7] Encourages and supports individuals/groups in decision making

COMPETENCY UNIT 4: Accepts accountability and responsibility for own actions
within nursing practice

[4.2] Consults with an experienced registered nurse when nursing care requires
expertise beyond own scope of competence

DOMAIN: Critical Thinking and Analysis

COMPETENCY UNIT 5: Acts to enhance the professional development of self and
Others. Evidence

[5.4] Contributes to the learning experiences and professional development of
others

DOMAIN: Management of Care

COMPETENCY UNIT 7: Carries out a comprehensive and accurate nursing
assessment of individuals and groups in a variety of settings. Evidence



[7.1] Uses a structured approach in the process of assessment.

[7.2] Collects data regarding the health and functional status of individuals and
groups

[7.3] Analyses and interprets data accurately.

COMPETENCY UNIT 8: Formulates a plan of care in consultation with individuals
and groups

[8.1] Establishes priorities for resolution of identified health needs in consultation
with the individual/groups

[8.2] Identifies expected outcomes including a time frame for achievement in
consultation with individuals and groups

[8.3] Develops and documents a plan of care to achieve optimal health,
rehabilitation or a dignified death

COMPETENCY UNIT 9: Implements planned nursing care to achieve identified
outcomes within scope of competency

[9.1] Provides planned care

[9.2] Plans for continuity of care as appropriate

[9.3] Educates individuals or groups to maintain and promote health

COMPETENCY UNIT 10: Evaluates progress towards expected outcomes and
reviews and revises plans in accordance with evaluation data

[10.1] Determines the progress of individuals or groups towards planned outcomes

[10.2] Revises nursing interventions in accordance with evaluation data and
determines further outcomes

DOMAIN: Enabling

COMPETENCY UNIT 11: Contributes to the maintenance of an environment which
promotes safety, security and personal integrity of individual and groups Evidence

[11.1] Acts to enhance the safety of individuals and groups at all times

[11.2] Provides for the comfort needs of individuals and groups

[11.3] Applies strategies to promote individual/group self esteem

[11.4] Establishes, maintains and concludes caring, therapeutic and effective
interpersonal relationships with individuals or groups



[11.5] Acts to maintain the dignity and integrity of individuals/groups

COMPETENCY UNIT 12: Communicates effectively with individuals and groups

[12.1] Communicates using formal and informal channels of communication

[12.2] Ensures documentation is accurate and maintains confidentiality

COMPETENCY UNIT 13: Manages affectively the nursing care of individuals and
groups

[13.1] Organises workload to facilitate planned nursing care for individuals and
groups

[13.2] Delegates to others activities commensurate with their abilities and scope of
practice

[13.3] Uses a range of supportive strategies when supervising aspects of care
delegated to others

[13.4] Responds effectively in unexpected or rapidly changing situations

COMPETENCY UNIT 14: Collaborates with other members of the health care
team

[14.1] Recognises the role of members of the health care team in the delivery of
health care

[14.2] Participates with other members of the health care team and the
individual/group in decision making

Competency met: Yes Not Yet Completed

Assessor:
Name and signature: Date: / /

Assessee:
Name and signature: Date: / /

Evaluation

Would you please take the time to complete the following evaluation form, to help
in the planning of future packages? Please rate the following items on a scale of
1 [unsatisfactory] to 6 [excellent]



1. Did you find the package easy to follow?
1 2 3 4 5 6

Comments

2. Did you find the package easy to read?
1 2 3 4 5 6

Comments

3. Do you find this type of learning beneficial to meet your needs?
1 2 3 4 5 6

Comments

4. Do you think this package has been beneficial to you?
1 2 3 4 5 6

Comments

5. Do you feel the assessments were relevant?
1 2 3 4 5 6

Comments



6. In retrospect is there anything you would change about the package?

7. General Comments:

Thankyou for your time and assistance


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