(i)

A STUDY TO EVALUATE THE EFFECTIVENESS OF A SELF

INSTRUCTIONAL MODULE (SIM) ON NURSING
MANAGEMENT OF PATIENTS WITH CHEST
TUBE DRAINAGE FOR STAFF NURSES IN
A SELECTED HOSPITAL
AT MANGALORE

By

Beena A Nair

Dissertation submitted to the Rajiv Gandhi University of Health Sciences,

Bangalore, Karnataka.

In partial fulfillment
of the requirement for the degree of

Master of Science in Nursing

in

Medical Surgical Nursing

Under the guidance of

Prof. (Mrs.) Vijayalakshmi

Department of Medical Surgical Nursing
S.C.S. College of Nursing Sciences
Mangalore
2006
 (ii)

Rajiv Gandhi University of Health Sciences, Karnataka

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation/thesis entitled “A study to evaluate the

effectiveness of a self Instructional Module (SIM) on nursing management of

patients with chest tube drainage for staff nurses in a selected hospital at

Mangalore” is a bonafide and genuine research work carried out by me under the

guidance of Mrs. Vijayalakshmi, Professor and Head of the Department of

Medical Surgical Nursing, S.C.S College of Nursing Sciences, Mangalore.

Date:

Place: Mangalore Beena A Nair

 (iii)

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “A study to evaluate the

effectiveness of a self Instructional Module (SIM) on nursing management of

patients with chest tube drainage for staff nurses in a selected hospital at

Mangalore” is a bonafide research work done by Beena. A. Nair in partial

fulfillment of the requirement for the degree of Master of Science in Nursing

(Medical Surgical Nursing).

Date: Mrs. Vijayalakshmi, M.Sc. (N)

Place: Mangalore Professor and Head of the Department
Medical Surgical Nursing
 (iv)

ENDORSEMENT BY THE HOD, PRINCIPAL/HEAD OF THE

INSTITUTION

This is to certify that the dissertation entitled “A study to evaluate the

effectiveness of a self Instructional Module (SIM) on Nursing management of

patients with chest tube drainage for staff nurses in a selected hospital at

Mangalore” is a bonafide research work done by Beena A Nair, under the guidance

of Mrs. Vijayalakshmi, Professor and Head of the Department of Medical

Surgical Nursing.

Seal and Signature of HOD Seal and Signature of Principal

Prof. (Mrs.) Vijayalakshmi Prof. (Mrs.) Thereza Mathias
Medical Surgical Nursing S.C.S. College of Nursing Sciences
S.C.S. College of Nursing Sciences Mangalore
Mangalore
Date: Date:
 (v)

COPYRIGHT

Declaration by the Candidate

I hereby declare that the Rajiv Gandhi University of Health Science,

Karnataka shall have the rights to preserve, use and disseminate this

dissertation/thesis in print or electronic format for academic/research purpose.

Date:

Place: Mangalore Beena A. Nair

© Rajiv Gandhi University of Health Sciences, Karnataka

 (vi)

ACKNOWLEDGEMENT

“They will speak of the glorious splendour of your majesty,

and I will meditate on your wonderful works”.

I owe a deep sense of gratitude to those who have contributed to the successful

completion of this endeavour.

First, I praise and thank the ‘Lord Almighty’ for His immeasurable grace and

abundant blessings all through my study.

I express my deep sense of gratitude and heartfelt thanks to

Prof. (Mrs.) Thereza Mathias, Principal, S.C.S College of Nursing Sciences for her

inspiring guidance, suggestions and constant encouragement which made this study a

success.

I extend my sincere thanks to my guide Mrs. Vijayalakshmi, Professor and

HOD, Department of medical surgical nursing, S.C.S College of Nursing Sciences for

her assistance and timely support.

I am deeply grateful to my co-guide Dr. Jeevaraj Sorake, Managing Director,

S.C.S. Hospital, Mangalore for his valuable suggestions and for granting me the

permission to conduct the study.

I am extremely thankful to Dr. Amarnath Sorake, President, K.E.C.T trust,

Mangalore for providing facilities for the completion of the study.

I express my sincere thanks and appreciation to Mr. U.K. Khalid for his

immense support and encouragement.

I am grateful to Dr. Sanjay Daded, cardio-thoracic Surgeon, Dr. Hema,

Anaesthetist and Sister Jhansi, Nursing Manager, Narayana Hrudayalaya Institute

of Cardiac Sciences for their valuable suggestions and support.

 (vii)

I express my sincere thanks and appreciation to Mrs.DarlingB.Bibiana,

Assoc. Prof. and principal Shree Devi College of Nursing, Dr. Ratna Prakash, Dean

and HOD, MAHE, Manipal, for their timely assistance, co-operation, encouragement

and valuable suggestions.

My sincere thanks to Mrs. Shilpakala, statistician, for her expert guidance in

preparing the data analysis of my study.

I am grateful to the experts who contributed their valuable time and expert

suggestions in validating the tool.

I am thankful to all the participants of the study for their Co-operation without

whom this study would not have been possible.

I remain indebted to the management of MAHE, Manipal, for letting me use

their library, without which it would have been impossible to collect adequate

literature for my study.

I am thankful to all the faculty members of S.C.S. College of Nursing Sciences

for their encouragement and co-operation.

I am thankful to all the staff of ‘Saraswathi Graphics’, Regal Arch Building,

Bendoorwel, Mangalore, for their sincere efforts in developing this manuscript on

time.

I am immensely thankful to my friends, Asha, Arya, Shailaja, Ankik bhaiya

and Kruti for their constant support encouragement and sincere prayers throughout

my study.

I am grateful to my seniors Lolita and Veena for their timely support and

assistance during my study.

 (viii)

I owe a deep sense of respect, appreciation and gratitude to my beloved

Husband, Madhuettan, for his inspiring words, constant encouragement and immense

support in developing this manuscript.

I am deeply indebted to my dear Achan, Amma, Bhavi, Dinu, Unni, Varsha,

and my in-laws for their constant reassurance, support and prayers throughout my

study.

My sincere thanks to all those who have directly and indirectly helped me in

the completion of this task.

Date:

Place: Beena A. Nair

 (ix)

LIST OF ABBREVIATION USED

v A.V.aids - Audio Visual aids

v ABG - Arterial Blood Gas
v Assoc - Associate
v BTS - British Thoracic Society
v CF - Cumulative Frequency
v CTD - Chest Tube Drainage
v Dept - Department
v GNM - General Nursing and Midwifery
v H0 - Null Hypothesis
v H1 - Research Hypothesis
v HOD - Head of the Department
v ICU - Intensive Care Unit
v Min - Minutes
v n - Total Number of Samples
v P - Probability
v PREP - Post Registration Education and Practice
v Prof - Professor
v PTP - Planned Teaching Programme
v ROM - Range of Motion
v Rs - Rupees
v r - reliability
v RTA - Road Traffic Accident
v SD - Standard Deviation
v SIM - Self Instructional Module
v Sl.No - Serial Number
v SPO2 - Partial Pressure of Oxygen
v UK - United Kingdom
v UKCC - United Kingdom Central Council
v US - United States
v USA - United States of America
v VHS - Very Highly Significant
v Vs - Versus
v WHO - World Health Organization
 (x)

ABSTRACT

One group pre-test post test design with an evaluative approach was adopted

to evaluate the “effectiveness of self instructional module on nursing management of

patients with chest tube drainage” for staff nurses in a selected hospital at Mangalore.

The objectives of the present study are:

1. Determine the existing knowledge of nurses regarding the “management of

patients having chest tube drainage”.

2. Develop a SIM on “Nursing Management of patients with chest tube

drainage”.

3. Find the effectiveness of SIM on “Nursing Management of patients having

chest tube drainage” in terms of gain in knowledge.

The conceptual framework for the study was developed by the investigator based on

the “Ludwig Von Bertalanffy General System’s theory”. The research hypothesis was

stated as:

H1: The mean post- test knowledge scores of the staff nurses regarding management

of patients with chest tube drainage is significantly higher than the mean pretest

knowledge scores.

In view of the nature of the problem and to accomplish the objectives of the

study, a self instructional module was prepared on “Nursing management of patients

with chest tube drainage” for staff nurses. A structured knowledge questionnaire was

prepared to assess the level of knowledge of the staff nurses and later the

effectiveness was determined by using the same questionnaire.

A panel of seven experts ascertained the content validity of the tool.

Reliability (r = 0.865) of the tool was tested by Karl Pearson’s correlation formula.

Content validity of the structured questionnaire and the self instructional module was
 (xi)

established by seven experts against criteria checklist in the field of cardio – thoracic

medicine and medical surgical nursing. A pilot study was conducted with 10 staff

nurses in a selected hospital, at Mangalore to find out the feasibility of the study.

The sample consists of 30 staff nurses working in medical and surgical wards,

cardio thoracic wards, intensive care units, post operative wards and trauma units, in a

selected hospital in Mangalore. Self Instructional Module was given to the

respondents. Data gathered was analysed by using descriptive and inferential

statistics.

With regard to the pre-test knowledge assessment, the mean percentage of

response was 56.37% with mean and SD of 19.73 + 4.46, which increased to 91.7%

with mean and SD of 32.10 + 2.55 in the post- test. Area wise mean percentage was

58.83% in the area of mechanisms and principles involved in chest tube drainage and

(54.57%) in the area of anatomy and physiology including signs and symptoms.

In the post-test a significant increase in knowledge was found in all the areas.

The mean percentage was (92.86%) in the area of assessment and care of patient with

chest tube drainage. The overall mean percentage of knowledge scores had drastic

improvement from (56.37%) in pre- test to (91.71%) in post- test, showing that the

self instructional module was very effective.

The area-wise effectiveness of SIM on nursing management of patients with

chest tube drainage revealed that the overall mean percentage of effectiveness was

(35.34%).

Further effectiveness of self instructional module was tested by inferential

statistics using paired ‘t’ test

Key Words: Chest tube drainage; staff nurses; Nursing management; Self

Instructional module; effectiveness.

 (xii)

TABLE OF CONTENTS

v 1 Introduction 1-14

v 2 Objectives 15

v 3 Review of Literature 16-29

v 4 Methodology 30-41

v 5 Results 42-72

v 6 Discussion 73-78

v 7 Conclusion 79

v 8 Summary 80-85

v 9 Bibliography 86-92

v 10 Annexures 93-144
 (xiii)

LIST OF TABLES

Page
Sl.No Tables
No.

1. Frequency and percentage distribution of demographic variables 44

of staff nurses

2 Level of knowledge of staff nurses regarding management of 49

patients with chest tube drainage

3 Distribution of Sample according to Area-wise Mean, SD and 50

Mean Percentage of Knowledge Scores

4a Item-wise percentage of correct responses of staff nurses on 51

Anatomy and physiology including signs and symptoms

4b Item-wise percentage of correct responses of staff nurses on 52

‘Anatomy and physiology including signs and symptoms’

5 Item-wise percentage of correct responses of staff nurses on 54

‘mechanisms and principles involved in chest tube drainage’

6a Item-wise percentage of correct responses of staff nurses on 56

‘assessment and care of patient with chest tube drainage’

Item-wise percentage of correct responses of staff nurses on 58

6b
‘assessment and care of patient with chest tube drainage’

7 Area-wise Mean, SD and Mean percentage of the knowledge 61

scores in pre-test and post test

8a Item-wise effectiveness of SIM with regard to percentage of 63

correct responses by staff nurses on ‘anatomy and physiology
including signs and symptoms’
 (xiv)

8b Item-wise effectiveness of SIM with regard to percentage of 64

correct responses by staff nurses on ‘anatomy and physiology
including signs and symptoms’

9 Item-wise effectiveness of SIM with regard to percentage of 66

correct responses by staff nurses on mechanisms and principles
involved in chest tube drainage

10a Item-wise effectiveness of SIM with regard to percentage of 67

correct responses by staff nurses on assessment and care of
patients with chest tube drainage

10b Item-wise effectiveness of SIM with regard to percentage of 69

correct responses by staff nurses on assessment and care of
patients with chest tube drainage

11 Significance of the difference between pre-test and post-test 72

knowledge scores of staff nurses on management of patients
with chest tube drainage
 (xv)

LIST OF FIGURES

Page
Sl.No Figures
No.

1 Conceptual framework based on general systems theory of 13

Ludwig Von Bertalanffy for evaluating the effectiveness of
SIM regarding nursing management of patients with chest
tube drainage

2. Schematic representation of study design 31

3 Percentage distribution of staff nurses according their age in 45

competed years.

4 Percentage distribution of staff nurses according to their 46

gender

5 Percentage distribution of staff nurses according to their

47
professional qualification

6 Percentage distribution of staff nurses according to total

48
years of experience

7 Less than Ogives of pre-test and post-test scores of staff

59
nurses on management of patients with chest tube drainage

8 Comparison of pre-test and post-test knowledge scores of

staff nurses on management of patients with chest tube 60
drainage
 1

1. INTRODUCTION

“Lord, We’re not what we want to be, we’re not what we need to be, we’re not what
we’re going to be but thank God Almighty,
We are not what we used to be”.
An African American prayer

Nursing staff development process helps to shape the future of the Profession

and of nursing service. Staff development is the key to quality nursing care that helps

to facilitate the competence of nurses in practice. It began with Florence Nightingale’s

efforts in the Crimean war when she worked with nurses to improve the care they

were providing. Part of her responsibility as a supervisor or director of nursing care

was to ensure that the “nurses” provided care based on standards. She also encouraged

nurses to continue to learn, saying. “Let us never consider ourselves finished nurse’s

we must be learning all our lives”1.

Malcolm Knowles says that “in an era of knowledge explosion and

accelerating social change, people who do not continue to learn become obsolete and

obsolete human beings are a drain on our resources. Thus learning is a continuous

process and in today’s world no one can complete education2.

Teaching is a deliberate intervention that involves the planning and

implementation of instructional activities and experiences to meet intended learner

outcomes according to a teaching plan. Teaching is also a highly versatile strategy

that can be applied in preventing, promoting maintaining and modifying a wide

variety of behavior in a learner who is receptive, motivated, and adequately

informed3.
 2

Nurses play a key role in improving the nations health, and they recognize the

importance of life long learning to keep their knowledge and skills current3.

Nurses with their holistic approach to care delivery, should capture the

educator role and make it part of their unique professional domain3.

A study conducted by Minami, (1993) on chest tube drainage among 71

patients with spontaneous pneumothorax revealed that if the chest tubes are removed

too soon, after lung re-expands and the air leak ceases, there is high likelihood of

recurrence. Hence he suggested that adequate education regarding management of

chest tube drainage is necessary to prevent complications4.

A study carried out by Sharman (1995) stated a collapse rate of 25% in 20

patients in whom chest tube was removed 48 hours after lung expansion. Hence the

investigator recommended that chest tubes must be left in place for 24 hours after the

lung has reexpanded and air leak ceases. Then the chest tubes should be clamped for

an additional 24 hours and only removed if the lung does not recollapse. Hence

adequate education regarding care of patient before, during and after removal of chest

tubes should be given more importance to prevent lung collapse4.

“At its best, an adult learning experience should be a process of self-directed

enquiry, with the resources of the teacher, fellow students and materials being

available to the learners, but not imposed on them. The primary and immediate

mission of every adult educator is to help adults satisfy their needs of learning and

thus achieve their goals2.”

Chest tube drainage are the most common intervention performed in ICU

patients especially with Pneumothorax. Chest tubes are inserted into a large fluid
 3

collection and are usually connected to a water-seal drainage. Maintaining chest tube

patency to achieve adequate drainage is often a problem in the ICD5.

The management of critically ill patients has become increasingly important in

the modern medical and nursing system. At the same time the number of intensive

care beds in hospitals has grown. The complexity of medical and nursing problems

and the severity of illness in critically ill patients has also increased. Critically ill

population now occupying intensive care units demand appropriate diagnosis as well

as management skills. The management of a critically ill patient therefore represents a

continual balancing act in which the risks and benefits of diagnostic procedures and

interventions must be carefully weighed6.

This study is intended to determine the existing knowledge of nurses regarding

the management of patients having chest tube drainage, with a view to develop a self

instructional module on management of patients with chest tube drainage and to test

its effectiveness.

STATEMENT OF THE PROBLEM:

“A study to evaluate the effectiveness of a self instructional module on

Nursing Management of patients with chest tube drainage for staff nurses in a

selected hospital in Mangalore”.

 4

NEED FOR THE STUDY

“The beautiful thing about learning is none can take it away from you”.

(B.B. King)

Staff education is the process of influencing the behavior of nurses by

producing changes in their knowledge, attitudes, values and skills. The purpose here

is to help nurses maintain and improve their competencies as required for the delivery

of quality care to the consumer3.

It is estimated that in the US, 90,000 cases of empyema thoracis are registered

every year. Two thirds (60,000) of them are post-pneumonic and one third are due to

other cases7.

Primary pneumothorax remains a significant global problem occurring in

healthy subjects with a reported incidence of 18.28/10,0000 per year for men and 1.2

to 6/10,0000 per year for women7.

Hospital admission rates for combined primary and secondary pneumothorax

are reported in U.K at between 5.8/10,0000 per year for women and 16.7/10,0000 per

year for men. Mortality in the UK was 0.62/million/year for women and

1.26/million/year for men between 1991 and 19957.

Spontaneous pneumothorax is a disease with an estimated incidence of 4 to 9

out of 100,000 patients / year and a 5:1 male predominance. Mortality rates as high as

16% have been reported. Here full lung expansion must be achieved and may require

additional chest tubes8.

 5

Approximately one million pleural effusion cases are diagnosed each year in

India. The clinical importance of pleural effusions ranges from incidental

manifestations of cardiopulmonary diseases to symptomatic, inflammatory or

malignant diseases that require urgent evaluation and treatment7.

According to the medical records department in S.C.S. Hospital, Road Traffic

Accidents are the major cause for insertion of chest tube drainage. The statistical data

reported that approximately 90 patients with chest tube drainage was treated in the

hospital during the year 2004-2005 with 10:1 male predominance. Hence staff nurses

should be given adequate education regarding management of patients with chest tube

drainage for a better prognosis of the patient ensuring positive results.

Woodruff (1999) identified iatrogenic causes of pneumothorax in which air or

gas in present in the pleural cavity as a result of therapeutic intervention9.

The four main pleural complications of traumatic hemothorax or the retention

of clotted blood in the pleural space, increases the incidence of subsequent

emapyema, Pleural effusion and fibrothorax10.

Previous studies indicate that early evacuation of blood collected in a

haemothorax results in decreased operative blood loss, decreased morbidity and

mortality, shortened hospital stay, limited thoracic incision and avoidance of

complications of empyema and fibrothorox11.

The treatment of choice for patients with traumatic hemothorax is the

immediate insertion of a chest tube. Chest tubes should be removed as soon as they

stop draining or cease to function because they can serve as conduits for pleural

infection4.
 6

Traumatic pneumothorax can result from both penetrating and nonpenetrating

chest trauma .chest tubes are nessasary for pneumothoraxes.If a haemopneumothorax

is present ,one chest tube is placed in the superior part to remove air and another tube

is placed in the inferior part of haemothorax to remove the blood4.

Kollef (1994) in his study on prevention of complication among patients with

tension pneumothorax in North America revealed that, if a tension pneumothorax is

present, the patient should be prepared for immediate insertion of a large chest tube.

The investigator reviewed 464 patients in medical ICU over a one year period and the

treatment was successful among 384 patients, the success rate being 82.75%4.

Brunner (1990) in his study on role of antibiotics in patients with an isolated

chest injury, in USA, randomly allotted 90 patient to receive cefazoline, immediately

before and then every 6 hrs until chest tube removal. He concluded that use of

antibiotics showed a drastic reduction in pleural infection10.

A study by Wilson (1999), in North America on high incidence of pleural

effusion after tube thoracostomy for hemothorax reported that 27 out of 290 patients

(13%) with hemothorax, developed pleural effusion after removal of chest tubes and

40 out of 118 patients with hemothorax had pleural effusion at the time of being

discharged from hospital. Hence he suggested that staff should be given adequate

education regarding prevention of pleural effusion in patients with hemothorax12.

An improper, handling of chest tubes can lead to complication such as

infection and subcutaneous emphysema. Nurses should have skills to take care of

patients with chest tube drainage and provide timely intervention to minimize the

associated problem and complications while the patients are undergoing chest tube

drainage.
 7

The British thoracic society (U.K, 2000) conducted a randomized study to

present recommendations on the use of prophylactic antibiotics in a patients with

traumatic hemopneumothorax undergoing tube thoracostomy7. The target study was

on individuals with traumatic hemopneumothorax undergoing chest tube insertion.

The guideline developers made recommendations regarding implementation.

Implementation involves extensive education and in servicing of nursing, resident and

attending staff members and has one important guiding principle that it must be

available to the clinician in real time while they are actually seeing the patient7.

Conducting the educational intervention in the work place increased the

participation of staff that would otherwise have been too busy to attend13.

Interventions in the form of ward-based educational programme specifically

designed enhances nursing compliance, perceive gaps in their knowledge and would

welcome the opportunity to be updated regularly14.

“Using chest tubes and chest drainage units is a complex and critical nursing

function. By learning about their components and techniques needed to use them, you

have protected your patient and helped him recover from a serious pulmonary

problem”15.

In view of the above factors and considering the researchers personal

experience, nurses do not have adequate knowledge regarding the management of

patients with chest tube drainage. The rectification of this problem requires attention

to improve the knowledge of staff nurses, in this specific area. Hence the investigator

felt the need to prepare a self instructional module on nursing management of patient

with chest tube drainage for staff nurses.

 8

OPERATIONAL DEFINITIONS

Self Instructional Module (SIM):

Self-Instructional module is a self contained written instructional material

necessary for achieving pre-specified objectives. In this study, the self-instructional

module refers to learning package for gaining information about management of

patient with chest tube drainage for the staff nurses in a selected hospital at

Mangalore.

Effectiveness:

According to oxford dictionary effectiveness refers to achieving the intended

result. In this study it refers to determining the extent to which the SIM has achieved

the desired effect in terms of gain in knowledge.

Chest tube drainage (CTD):

A Catheter inserted through the chest wall to the pleural space to remove the

excess air and fluid.

Staff Nurses:

In the study staff nurses refer to registered nurses working in medical and

surgical wards, cardiothoracic wards, Intensive care units, post operative wards and

trauma units, in a selected hospital in Mangalore.

Nursing Management:

According to Oxford dictionary management is defined as managing the

people who manage a business. In this study nursing management refers to the ability

of the nursing personnel to apply the acquired knowledge in providing care to the

patient having chest tube drainage.

 9

VARIABLES

A variable is a measurable or potentially measurable component of an object

or event that may be different in quantity or quality from one individual object or

event to another individual object or event of same general class16.

Independent variable

An independent variable is a stimulus or activity that is manipulated or varied

by the researcher to create an effect on the dependent variables17. In the present study,

independent variable was self instructional module on management of patients with

chest tube drainage.

Dependent Variable

A dependent variable is the response, behavior or outcome the researcher

wants to predict or explain. In the present study, dependent variable was effectiveness

of SIM in terms of knowledge of staff nurse17.

ASSUMPTIONS

1. Staff Nurses have some knowledge regarding Nursing management of Patients

having chest tube drainage.

2. Self Instructional Module will enhance the knowledge of staff nurses.

HYPOTHESIS

H1:The mean post-test knowledge scores of the staff nurses regarding management of

patients with chest tube drainage will be significantly higher than the mean

pre-test knowledge scores.

 10

DELIMITATIONS

The study is delimited to,

1) Nurses who are willing to participate in the study.

2) Nurses who are present at the time of study.

3) Nurses who have passed general nursing, B.Sc Nursing or Post basic B.Sc
Nursing course.

4) Nurses who are having state council registration.

CONCEPTUAL FRAMEWORK

Conceptual framework is defined as a theoretical approach to the study of

problems that are scientifically based, which emphasizes the selection, arrangement

and classification of its concepts. A conceptual framework states functional

relationships between events and is not limited to statistical relationship18.

This study is intended to evaluate the effectiveness of self –instructional

module in terms of improving the knowledge of staff nurses regarding Nursing

management of patients with chest tube drainage.

The conceptual framework of the present study is based on general systems

theory with input, process, output and feed back, first introduced by Ludwig Von

Bertalanffy19.

A system consists of interacting components within a boundary that filters the

type and rate of exchange with the environment. All living systems are open in that

there is continual exchange of matter, energy and information.

For survival, all system must receive varying types and amounts of matter,

energy and information from the environment. Through the process of section, the

system regulates the type and amount of input received. The system uses input
 11

through self-regulation to maintain the system’s equilibrium or homeostasis. Matter,

energy and information are continuously processed through the system and released

as outputs. The system continuously monitors itself and the environment for

information to guide its operation. This feed back information of environment

responses to the system’s output is utilized by the system in adjustment, correction

and accommodation to the interaction with the environment. Feedback may be

positive, negative or neutral.

In the present study, these concepts can be explained as follows:

Input: Subject is a system and has input within the system, itself and acquired from

the environment. These inputs include subject’s background like area of working, age,

gender, professional qualification and total years of experience. These may influence

the knowledge of subjects.

Process: It is the action needed to accomplish the desired task. To achieve the desired

output ie, to evaluate the effectiveness of self Instructional module on staff nurses

regarding the management of patients with chest tube drainage, the following process

was adopted. Preparation of blue print for self instructional module on management of

patients with chest tube drainage, Preparation of self Instructional module,

Preparation of blue print for knowledge questionnaire, assessment of knowledge using

a knowledge questionnaire prior to and after administration of self-Instructional

module.

Out put: The Output indicates gain in knowledge of staff nurses after administration

of self Instructional module.

Feed back: It is the process that provides information about the system output and

will act as input.

 12

Increase in knowledge of staff nurses regarding management of patients with chest

tube drainage.

Environment: Staff Nurses environment is the fixed constraints that influence the

effectiveness of self instructional module. It includes, the interpersonal relationship

with the cardio thoracic surgeons interest and participation in-service educational

programme regarding chest tube drainage management physical surroundings, social

responsibilities, mass media, attitude of staff nurses, learning resources and readiness

to learn.
13
 14

Summary

This chapter has dealt with the introduction, statement of the problem, need

for the study operational definitions, assumptions, hypothesis, delimitations and

conceptual framework.
 15

2. OBJECTIVES

The objectives of the study are :

1. Determine the existing knowledge of nurses regarding the “Management of

patients having chest tube drainage”.

2. Develop a SIM on “Nursing Management of patients with chest tube

drainage”.

3. Find the effectiveness of SIM on “Nursing Management of patients with chest

tube drainage” in terms of gain in knowledge scores.

 16

3. REVIEW OF LITERATURE

“The first step to knowledge is to know that we are ignorant”

(Richard Cecil)

The term review of literature refers to the activities involved in identifying and

searching for information on a topic and developing an understanding of the state of

knowledge of the topic. This term is also used to designate a written summary of the

state of the art on a research problem20.

The literature reviewed has been presented under the following headings :

v 1. Literature related to chest tube drainage as an effective interventional

strategy.

v 2. Literature related to SIM as an effective teaching strategy.

v 3. Literature related to construction of SIM

v 4. Literature related to continuing professional education

LITERATURE RELATED TO CHEST TUBE DRAINAGE AS AN

EFFECTIVE INTERVENTIONAL STRATEGY

A chest tube is a catheter inserted through the thorax to remove the fluid or air

and thus promote lung expansion. Chest tubes are inserted to remove air and fluid

from the pleural space, to prevent air and fluid from re-entering the pleural space and

to re-establish normal interapleural and intra-pulmonic pressures15.

Chest tubes are indicated for the conditions such as pneumothorax,

pleuraleffusion, hemothorax, empyema, injuries to chest, tension pneumothorax,

chylothorax and prevent complications after open heart surgeries.

 17

Ashbaugh (1991)21 conducted a study on “Empyema thoracis: Factors

influencing morbidity and mortality “in university of Washington, Seattle. One

hundred and twenty two patients with empyema thoracis were analysed. Patients

eligible for study were divided into treatment groups of chest tube only (C.T=39),

open drainage (OD=19) or decortications (DC=65). The finding of this study revealed

that delay in chest tube drainage increased mortality from 3.4 percentage to 16

percentage. Thus the researchers concluded that adequate knowledge regarding

treatment modalities and early interventional strategies can reduce the morbidity and

mortality rates. Hence knowledge regarding management of patients having chest

tube drainage can bring out successive changes in morbidity and mortality rates.

Sahn, Strange, Lemense (1991)22 conducted a study on “Empyema thoracis,

therapeutic management and outcome” at a teaching institution Charleston, USA.

Retrospective chart review of 43 patients over a 44 month period were reviewed. The

results of the study revealed that, out of 43 patients, 24(56%) cases were

parapneumonic empyema. 40(93%) patient had symptoms attributable to empyema.

Seventy-nine procedures were needed to treat 43 patients. Success rates ranged from

11 percentage for tube thoracostomy to 95 percentage for decortications. (P=0.0001).

Mean recovery after successful intervention ranged from 9 to 19.3 days depending on

the procedure and the delays between procedures. To conclude, multiple options exist

for the treatment of thoracic empyema. Adequate knowledge regarding selection of

optimal therapy or selection of most appropriate procedure for each patient can bring

out speedy recovery. Hence nurses require adequate knowledge regarding each

procedure especially in managing a patient with chest tube drainage as this procedure

is indicated for thoracic empyema.

 18

Klein J, Barbieri C, Mcdonald J. (1995)23 conducted a study on “Management

of parapneumonic effusion and the impact of practice patterns on clinical outcome”,

in a testing care medical center in Phoenix, Ariz, USA. 39 patients with complicated

parapneumonic effusion and separate group of 191 patients admitted with community-

acquired pneumonia were analysed. The findings of the study revealed that, 38 out of

39 patients with complicated purapneumonic effusions underwent thoracentesis that

was “delayed” in 16 patients. Chest tube or surgical pleural drainage was delayed in

10of 38 patients who underwent thoracentesis. Delay in initiating drainage were

associated with prolonged hospitalization (P=.04). Delayed interventions accounted

for a mean cost increment per patient of $ 8462 for delayed thoracentesis and $ 9332

for delayed drainage. Of the 191 patients with community acquired pneumonia 99

(52%) had pleural effusions but only 15(15%) underwent thoracentesis. So the study

concluded that the physicians practice patterns of delaying thoracentesis and chest

tube drainage leads to longer and more costly hospitalization. Thus adequate

knowledge regarding the initiation of chest tube drainage will account for lesser

duration of hospitalization.

Hsu-Chia Huang, Han-Yu Chang, Chang-Wen Chen, Cheng-Hung Lee and

Tzuen-Ren Hsiue (1999)24, conducted a study to determine the predicting factors for

outcome of tube thorcostomy in complicated parapneumonic effusion or empyema. A

retrospective chart review over a 55-month period at a tertiary referred medical

center, college of medicine, Taiwan was conducted. One hundred and twenty one

patients with empyema were selected for the study. One hundred of these patients had

received tube thoracostomy drainage with 53 successful outcomes. They concluded

that loculation and pleural effusion leukocyte count 6,400/µ were independent

predicting factors of poor outcome of tube thoracostomy drainage. The study shows
 19

that tube thoracostomy drainage is an effective measure to treat patients with

complicated parapneumonic effusion or enpyema.

Sasse et al (1997) 25 conducted a study to determine the impact of the timing of

chest tube insertion ,an outcome for the treatment of empyema, using an animal

model of empyema. A prospective, controlled randomized, blinded design was used.

The study was conducted in an animal research laboratory. After induction of

empyema, the rabbits were divided into 4 groups. Fourteen rabbits had chest tubes

placed at 24 hrs after empyema induction. 17 rabbits had chest tubes placed at 48 hrs

and 14 rabbits had chest tubes placed at 72 hrs after empyema induction. Twenty-one

rabbits served as control rabbis and had no chest tubes placed. The median gross

score mean pleural peel sore and median microscopic score were calculated for each

rabbit. They were significantly higher in rabbits that underwent late chest tube

placement (72h) relative to those that underwent early chest tube placement (24 or

48h). They concluded that early chest tube placement is beneficial for the treatment of

empyema.

Edward (1997) 26 reported in Oklahoma that the evacuation of empyemas first

performed centuries ago, marked the beginning of thoracic 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.

Hiley C (1998)27 stated in an article on managing the patient with chest drain

that under water seal drainage is a routine part of treatment for thoracic trauma,

surgery and infection. Many aspects of the management of patients with a chest drain

come into the nursing domain, yet practices are inconsistent and many nurses lack

confidence in caring for patients with chest drains due to lack of knowledge.
 20

Mengoli (1985) 28 stated in an article on “Giant lung abscess treated by tube

thoracostomy”, that in the treatment of a lung abscess 8cm or larger tube

thoracostomy is an effective form of drainage, safer than pulmonary resection and

may yield a superior result, rather than being reserved as a desperation measure for

poor risk patients, tube thoracostomy should be considered early in the hospital

course.

Colice et al (2000)29 conducted a study on Medical and surgical treatment of

para pneumonic effusions in Washington Hospital Center, Washington. The literature

review revealed 24 articles eligible for full review by the panel, 19 of which dealt

with the primary management approach to parapneumonic effusion and 5 with a

rescue approach after a previous approach has failed. Of the 19 involving primary

management approaches to parapneumonic effusions, there were 3 randomized,

controlled trials, 2 historically controlled series and 14care services. The pooled

proportion of deaths was higher for no drainage and less for tube thoracostomy

(8.8%). The investigators recommended that therapeutic thoracentesis or tube

thoracostomy, are steps before a subsequent drainage procedure, may result in

complete resolution of Parapneumonic effusion.

Naunhein KS, Mack MJ, Hazelrigg SR, Keenan RJ, Land Reneau RJ (1996)30

conducted a study on “Thoracoscopy for empyema and hemothorax” in 99 patients

with complex empyemas or hemothoracis in USA. The causes associated with the

thoracic empyemas were parapneumonic collections in 47 after hemothorax in 8; 63

patients (83%) were treated with thoracoscopic drainage. Chest tubes were removed

3.3 +/-2.9 days postoperatively in 67 patients. All were successfully treated with

thoracosopic drainage and there were no complications.

 21

Gift A, Bolgiano G, Cunnigham J (1991)31, conducted a study on “patient

experiences when chest drain was removed” in 36 patients in USA. The sample

included patients with pleural drains (n=16) and patients with mediastinal drains

(n=20). Sensations reported by patients with pleural drains at the point of removal

included pain (n=7), burning (n=6) and pulling (n=4). Eight of the patients with

pleural drains had received analgesia. An exploratory longitudinal design was adopted

for the study. The investigators concluded that, most of the patients thought that being

told that the chest drain was to be removed, provided inadequate information. This

shows that due to decreased knowledge of staff nurses regarding chest drain, the

patient has more pain. Hence staff nurses must be aware of the psychological aspect

of the patients during management of patients with chest tube drainage.

Fox Valerie; Gould Dinah; Davies Nigel and Owen Suzanne (1999)32

Conducted a replication study on patients experience of having an under water seal

drain in UK. All data were collected in a regional cardio- thoracic unit in the UK.

Consecutive patients were recruited to meet the planned target of 20 subjects. Mc gill

pain questionnaire was used to collect data. Results revealed that all patients

experienced pain if they lay on the drainage tubes and were most comfortable in an

upright position; either upright in bed (n=10) or supported by pillows in a chair

(n=13). Nine out of 15 patients claimed that discomfort interfered with movement and

two were anxious in case the drainage tubing became disturbed. Thirteen out of 15

patients experienced difficulty in sleeping because of pain and discomfort, especially

if they inadvertently rolled on to the drainage tubing. The investigators concluded that

issues of patient information and adequate pain control measures require more

emphasis to be laid.
 22

The above study shows that staff nurses who manage patients with chest tube

drainage should be very informative regarding the same.

Lancey A. Robert, Gaca Charlene and Vander Salm T.J. (2001)33, conducted a

study on” Use of smaller more flexible chest drain following open heart surgery. A

retrospective analysis of the medical records and data on total amount of drainage, no

of days of drainage, length of post operative stay was done. A total of 202 patients

were selected for the study. Tubes were left in an average of 2.4 days, with a mean of

826.7 ml collected during that time. The investigator concluded that use of small

caliber drains have been found to be an adequate means of drainage after open heart

surgery.

Verstracten Andre, Slabbynck Hans, Peter Driesen, Alexander Patrick,

Noppen Mare (2003)34 conducted a randomized, prospective multicenter pilot study

on manual aspiration versus chest tube drainage in first episodes of primary

spontaneous pneumothorax in UK. 60 patients with a first episode of primary

spontaneous pneumothorax were randomly allocated to manual aspiration (n=27) or

chest tube drainage (n=33). Immediate success was obtained in 16 out of 27 (59.3%),

in the manual aspiration group, and in 21 out of 33 (63.6%) in the chest tube drainage

group (P=0.9). In the chest tube drainage group, treatment was successful within 72

hours in 21 out of 33 or 63.6% of patients. One week success rate in the chest tube

drainage group was 28 out of 33 or 85%.

Miller and Harvey (1993)35 conducted a study on success rate of simple

aspiration compared to chest tube drainage. A prospective randomized study was

performed. The investigators reported a higher success rate with chest tube drainage

(93%, n=28) as compared with simple aspiration (67%/ n=33). A subsequent group of

patients (n=35) in an uncontrolled phase of this study had only a 68.5% success rate
 23

with simple aspiration. The investigators concluded that thoracic drainage via a chest

tube was significantly more effective in the treatment of pneumothorax, than simple

aspiration.

LITERATURE RELATED TO SIM AS AN EFFECTIVE TEACHING

STRATEGY

Verma (2003)36 conducted a quasi-experimental study on “impact of self

Instructional module for the nurses on nursing management of patients having chest

tube drainage” in Nehru Hospital Chandigarh, India. The sample comprised of

randomly selected 100 staff nurses. The findings revealed that, all age groups had

shown a significant (P<0.001) increase in their knowledge scores during post-test.

Subject with B.sc. Nursing were possessing more level of knowledge in their pre-test

and post- test (13.28 and 21.00) respectively. The difference in mean course of

pre-test and post-test were maximum in the subjects having maximum bedside

experience subjects having previous experience of handling patients with chest tube

drainage more mean score in pre-test (12.16) as well as in post- test (19.50) related to

their level of knowledge. After introduction of SIM, the scores in post- test increased

significantly (P<0.001).

Fraser et al (2002)37 conducted pre and post intervention observational study

on effect of self instructional module on decreasing catheter related blood stream

infection in the surgical intensive care unit in an urban teaching hospital, USA. A total

of 4283 patients were admitted to the intensive care unit between January 1, 1998 and

Dec 31, 2000. A programme primarily directed toward registered nurses was

developed by a multidisciplinary task force to highlight correct practice for central

venous catheter insertion and maintenance. The programme consisted of a 10 page

self-study module on risk factors and practice modification involved in catheter

 24

related infection as well as a verbal in-service at staff meetings. The main results

showed that, 74 primary blood stream infection occur in 6874 catheter days

(10.8/1000 catheter days) in the 18 months before the intervention. After

implementation of the educational module, the number of primary blood stream

infection fell to 26 in 7044 catheter days (3.7/1000 Catheter days), decrease of 66

percentage (P<0.001). Thus the research concluded that education programmes may

lead to a substantial decrease in cost, morbidity and mortality attributable to the

research problem.

Sams (1997)38 conducted an evaluative study on “Effectiveness of the

structured self Instructional Module (SIM) on selected drugs used in the critical care

units for the staff nurses working in these units, in a selected hospital of Karnataka”.

The objectives of the study were to identify the learning needs of staff nurses on

selected drug used in critical care units; determine the knowledge level of staff nurses

on selected drugs used in critical care units; assess the effectiveness of the SIM in

terms of knowledge gained, opinion of staff nurses on SIM as indicated by

acceptability scores and to determine the relationship between the pre-test knowledge

and selected variables. The study was conducted in two phases, survey approach was

used to identify the learning needs and one group pre-test post- test design was used

for determining the effectiveness of SIM. The major findings of the study were more

than 60% of the sample expressed the need for learning as “necessary and desirable in

all 21 learning needs areas, the SIM was found to be effective in increasing the

knowledge of staff nurses ±(29)=9.227, P <0.05, there was no significant association

between post-test knowledge level and acceptability scores of staff nurses (x2=0,

P>0.05) and there was no significant relationship between pre-test scores and learners
 25

level of nursing experience, level of working experience in critical care units, and

type of postings in critical care units except for age level.

Machado (1996)39 conducted a study with the objectives of determining the

learning needs of staff nurses regarding care of children receiving oxygen therapy

finding association between learning needs and selected variables, age, total years of

experience, experience in pediatric ward, married, with or without children,

determining validity of self-instructional module on “care of child receiving oxygen

therapy,” and evaluating the effectiveness of the self instructional module or SIM.

The study was conducted in 2 phases. A survey approach was used for Phase-1 and

one group pre-test post-test design was adopted of phase-II. The total sample of the

study was 30 staff nurses of 6 months experience in pediatric ward. The findings of

the study showed high learning need status in most of the areas and the staff nurses

also expressed the desirable need for learning in detail. It was found that age, total

years of experience, experience in pediatric ward and married with or without

children were independent of their learning need. SIM was effective in term of gain in

knowledge score as well as acceptability and utility scores of staff nurses.

Balasaraswathy (1995)40, Conducted a study to determine the effectiveness of

a self instructional manual for nurses on administration of selected emergency drugs

to critically ill patients. Thirty subjects were selected by purposive sampling

technique. One group pretest, post- test design was used to assess the effectiveness of

the SIM. The findings revealed that the mean post- test score was found to be

significantly higher than the mean pre-test score (‘t’ =6.905, P<0.001) suggesting that

SIM was effective in increasing the knowledge of the respondents.

Swank, Christianson, Prows, West and warren (2001) 41, conducted a study to

evaluate the effectiveness of a self instructional module in increasing the nurse’s

 26

knowledge of genetics. Study materials were mailed to 262 registered nurses involved

in screening egg donors at one seventy seven reproductive health centres in the United

States. One hundred of 262 eligible nurses completed the present and 65 of these 100

nurses also completed the post test. One group pretest-posttest design was used. The

finding of the study showed that mean post- test knowledge sores was significantly

higher than their mean pre-test knowledge score (‘t’(64)= 11.74, P<.0001).

The findings indicate that nurses can gain knowledge if time to time self-

learning materials are provided which eventually improves the quality of care.

LITERATURE RELATED TO CONSTRUCTION OF SIM

The WHO on the development of self-leaving materials suggested that

following 3 phases in the constructions of self-learning material based on systems

theory42.

1) Preparatory Phase: The phase refers to input, concerned with collection of data

regarding target groups, their characteristics, job responsibilities and learning needs.

This information serves as baseline information for constructing learning materials.

2) Implementation phase: This phase refers to the process comprising the

programme definition, preparation, production, dissemination, assessment of

monitoring of activity and utilization of instructional material.

3) Evaluation Phase: This phase is a process of arriving at judgment and decisions

based on a careful appraisal of all aspects of the trained performance. It included the

evaluation of the whole process and impact on the knowledge of the people involved.

This information provides concrete and precise idea of developing a SIM

based on systems theory.

 27

An evaluative study was conducted by Cardoza (2000)43, to determine the

effectiveness of self-instructional module on management of cancer chemotherapy in

a cancer specialty hospital in Bangalore. The self instructional module prepared

adopted the following steps.

1. Assessment of learning needs of cancer patients.

2. Preparation of SIM based on learning needs.

3. Criteria checklist to validate SIM.

4. Assessment of the knowledge on management of cancer chemotherapy by

interview schedule before administration of SIM.

5. Assessment of the knowledge by using the same knowledge questionnaire after

the administration of SIM.

6. Assessment of opinion on acceptability of SIM.

The format used by the investigator contained content outline, purpose of

SIM, guide lines sidelines for using the SIM content on management of cancer

chemotherapy followed by unit exercise, references and key answers to the unit

exercises. The effectiveness was tested using group of 30 cancer patients.

Acceptability of the SIM by cancer patients was assessed by administering an

opinionnaire.

The SIM was found to be effective in increasing the knowledge of cancer

patients as evidenced by increased scores in the post-test, (‘t’(29)=9.8206, P<0.05).

 28

LITERATURE RELATED TO CONTINUING PROFESSIONAL

EDUCATION

American Nurses Association (1984)44 defined continuing professional

education as “planned education activities intended to build upon the educational and

experimental bases of the professional nurse for the enhancement of practice,

education, administration, research or theory development to the end of improving the

health of the public”.

According to the United Kingdom Central Council (UKCC 1992)45, Post

Registration Education and Practice (PREP) proposal is the requirement that nurses

are accountable for maintaining and improving their professional knowledge and

competence as laid down in the nursing code of professional conduct.

Thurston (1992)46 makes note of the ‘plethora’ of papers that have advocated

the need for continuing education whilst there has been a ‘Paucity of well designed

research studies’ aimed at investigating changes in nurses’ practice after continuing

education studies. The investigator commented that continuing professional education

courses can positively affect clinical practice, there by increasing patient care.

Waddel (1991)47conducted a meta analysis 34 published and unpublished

studies relating to the casual relationships between continuing education and practice.

From this study, the investigator comments that, greater confidence regarding the

positive effects of continuing professional education upon the practice of the nurses

involved can be achieved when education is given in clinical settings.

Connors (1989)45 used a pre and post course test methodology to assess the

effects of a North American state-wide continuing professional education programme

upon the practice of community and hospital based nurses. Data suggested that a
 29

statistically significant improvement (P<0.0001) in knowledge and perceived

performance resulted from the course.

Coye (1980)45 stated that continuing education consists of systematic learning

experience designed to build upon pre-service knowledge and skills. It includes an

organized planned programme and an independent endeavour as the part of the

learner.

Curran (1977)45 conducted a study on the factors affecting participation in

continuing education activities and identified learning needs of registered nurses. The

findings revealed that younger nurses believed that courses for college credit were

important. The study emphasized the necessity of offering courses at accessible time

and place.

Pataliah (1989)48 conducted a study to assess learning needs of nursing

personnel working in the cancer institute ,Bangalore ,Karnataka state with a view to

identify priority learning needs and their opinion towards organization of in-service

education programme. The findings of the study revealed that the nursing personnel

expressed their desire to learn and preferred to have in-service education programme

inorder to update their knowledge and skills for providing effective patient care.

Majority, 98.75% expressed that in-service education programme help in increasing

nursing knowledge and skills.

Findings indicate that continous professional education is directly related to

staff development and quality of care rendered.

Summary
This chapter includes the review of literature to the topic categorized under

headings, literature related to chest tube drainage as an effective interventional

strategy, literature related to SIM as an effective teaching strategy, literature related to

construction of SIM and literature related to continuous professional education.

 30

4. METHODOLOGY

The methodology of research indicates the general pattern together valid and

reliable data for the problem under investigation. This chapter present the

methodology adopted for this study, including research approach and design, steps

taken in the development of tool, description of the setting, sample and the sampling

technique, and the development of the self instructional module (SIM). It also

presents in brief the procedure for data collection and the plan for data analysis.

RESEARCH APPROACH

An evaluative approach is used for the study. Evaluative approach was used

to test the effectiveness of self Instructional module prepared for staff nurses. An

evaluative research is an applied from of research that involves finding out how well a

programme, practice, procedure or policy is working. The main goal is to assess or

evaluate the success of a programme20.

RESEARCH DESIGN

A researcher’s overall plan for obtaining answers to the research questions or

for testing the research hypothesis is referred to as the research design20

One group pre-test post-test design (O1 x O2) was adopted for the study. The

study design comprises of 2 phases as shown in the figure below, the phase 1 deals

with preparation, validation of tool and SIM. Phase II comprises of assessment of

knowledge of staff nurses on ART by structured knowledge questionnaire (O1),

administration of SIM on same day (x), post test on 7th day using the same

questionnaire (O2). Finally evaluation of effectiveness of SIM was done by

 31

descriptive and inferential statistics. The schematic representation of the study design

is as follows.

Phase I Phase II
Administration
Sample Tool techniques Pre-test Post-test
of SIM
Using simple ? Development of Administration Administration Administration
structured
random sampling of structured of prepared SIM of structured
knowledge
knowledge on first day (X) knowledge
questionnaire
questionnaire questionnaire
B.Sc G.N.M PCB.Sc Part I
on the 1st day on the 7th day
Personal profile
O1 O2
Staff…Nurses Part II

working is post Structured

operative wards, knowledge

questionnaire.
trauma units,

medical surgical ? Development of

wards and intensive SIM on nursing

management of
care units.
patients with chest
tube drainage

Fig 2: Schematic representation of study design. Were O1,–Pre-test,

O2 – Post-test, x – Self Instructional Module (SIM).

 32

SETTING OF THE STUDY

The study was conducted in S.C.S. Hospital, Mangalore. This is also an

educational institution offering Post-graduate, graduate and diploma programme in

various branches of Medical Education including, Physiotherapy, Nursing and

Ayurveda. Both diploma and graduate nurses are posted in the various departments of

this hospital. Here the nurses are posted in all departments as per their rotation plan.

POPULATION

The population of the study consists of the registered GNM, B.Sc. and Post

basic B.Sc. nurses working in S.C.S. Hospital, Mangalore.

SAMPLE AND SAMPLING TECHNIQUE

The set of sampling units chosen for the study is called as sample. Sampling

is the process of selecting a portion of the population to represent the entire

population 20.

The sample for the study comprised of 30 staff nurses. Random sampling

technique was used to select 30 staff nurses working in S.C.S Hospital, Mangalore.

CRITERIA FOR THE SELECTION OF THE SAMPLE

Inclusion Criteria

- Nurses who are willing to participate in the study.

- Nurses who are present at the time of study.

- Nurses who have passed General nursing, B.Sc. Nursing, and Post-basic B.Sc.

Nursing course.

- Nurses who are having state council registration.

 33

Exclusion Criteria

- Nurses who are not willing to participate in this study

- Nurses who are working in General OT and Labour room.

- Nurses who are not present at the time of study

- Nurses who are not registered.

DATA COLLECTION INSTRUMENT

A structured knowledge questionnaire was used for the data collection.

According to Polit and Hungler a structured questionnaire is a method of gathering

self report information from respondents through self-administration of questionnaire

in a paper and pencil format20.

In this study, the tool consisted of structured knowledge questionnaire on

management of patients with chest tube drainage for staff nurses in SCS Hospital,

Mangalore.

DEVELOPMENT OF THE TOOL

A structured knowledge questionnaire was thought to be appropriate for

assessing the knowledge of staff nurses based on the assumption that they have some

knowledge regarding management of patients with chest tube drainage.

The following steps were adopted in the development of the tool.

v Review of literature which provided adequate content for tool preparation.

v Consultation with experts of cardiothoracic department of various hospitals

including doctors and nursing personnel.

v The past clinical experience of the investigator.

 34

This provided relevant data necessary to construct the tool on management of

patients with chest tube drainage. The investigator developed a blue print on

management of patients with chest tube drainage prior to the preparation of

knowledge questionnaire.

The following steps were undertaken to prepare the final tool

Preparation of the blue print

A blue print on structured knowledge questionnaire on management of

patients with chest tube drainage was prepared, which consists of three sections. It

depicted the distribution of items according to the content areas based on three

domain namely, knowledge, comprehension and application. Knowledge domain had

seventeen items (48.6%), comprehension fifteen items (42.8%) and application had

three items (8.6%).

Testing of the tool

Development of criteria checklist

Criteria checklist for validation of tool was developed. Part I comprised of

demographic proforma. Part II comprised of structured knowledge questionnaire on

management of patient with chest tube drainage which had “agree” / “disagree” and

“remarks/suggestions” of experts regarding accuracy, relevancy, and appropriateness

of the content.

Content validity

Content validity refers to the degree to which an instrument measures what it

is supposed to measure20. The prepared instrument along with the objectives, blue

print and criteria checklist was submitted to 7 experts; one is a cardio thoracic

surgeon, one an anesthetist and five nursing experts. After the scrutiny, they were
 35

found to be adequate and relevant. The tool consisted of 35 items. Based on the

suggestion given by seven validators, modification and rearrangement of few items

was made. Thus the final draft of 35 items was made.

Pre-testing of the tools

The pre-test helps the researcher to determine whether the subjects understand

the items and whether the directions are clear49. The tool was tried out on ten staff

nurses of a private hospital who met the inclusion criteria, in-order to assess the

clarity of the items in the tool. Almost all items were clearly understood and the

responses were found appropriate. The time taken by the nurses to complete the tool

was approximately 45 minutes.

Reliability of the tools

Reliability of research instrument is defined as the extent to which the

instrument yields the same results on repeated measures. It is then concerned with

consistency, accuracy, precision, stability, equivalence and homogeneity 50.

The final tool was tested for reliability on ten staff nurses of a selected hospital

in Mangalore. The subjects completed the questionnaire within 45 minutes. All the

subjects found the test items comprehensive. The reliability of the tools was

established by using split half technique, which measures the coefficient of internal

consistency. The reliability of the test was found by using Karl Pearson’s correlation

formula.

Spearman Brown’s formula was used to find out the reliability of the full test.

The reliability of the tool was found to be r= 0.865 which indicated that tool

was reliable.
 36

Description of the final tool

The final tool comprised of 2 parts.

Part I = Demographic Proforma

It consisted of 7 items, such as subject number, designation, clinical area, age,

sex, professional qualification and total years of experience.

Part II = Structured knowledge questionnaire on nursing management of

patients with chest tube drainage.

Structured knowledge questionnaire on management of patients with chest

tube drainage consisted of 35 knowledge questionnaire covering areas like anatomy

and physiology of chest, meaning and indication of chest tube drainage and signs and

symptoms of pneumothorax, 15 items (43%), mechanisms and principles involved in

chest tube drainage, 6 items (17%), assessment and care of patient with chest tube

drainage and prevention of complications, 14 items (40%). The total possible score

was 35.

DEVELOPMENT OF SELF-INSTRUCTIONAL MODULE (SIM)

The following steps were adopted for development of self-instructional

module.

Criteria checklist

A criteria checklist was prepared as a first step towards the development of

self-instructional module after reviewing of literature and consulting the experts. The

areas included in the criteria checklist were objectives, section of content,

organisation, presentation of content, language and practicability. The criteria

 37

checklist included major criteria and sub criterion for which experts were asked to

give their rating “agree”/ “disagree” and “remarks/suggestions”.

Preparation of first draft of SIM

The first draft of SIM, was prepared on the basis of criteria checklist

developed for evaluating the SIM, literature on chest tube drainage and related

anatomy and physiology of the chest meaning and indications of chest tube drainage,

signs and symptoms of pneumothorax, principles and mechanisms involved in chest

tube drainage, assessment and care of patients during chest tube insertion, position

used for chest tube drainage and care of patients after insertion and prevent

complications, opinion of experts in the field of cardiothoracic surgery, nursing

personnel working in cardiothoracic unit and experience of the investigator.

Pre-testing of self-instructional module

The pre-test of the self-instructional module was done by giving it to 10 staff

nurses working in intensive care units and trauma units in a selected hospital. The

subjects found the SIM easy to understand.

Preparation of final draft of SIM

The final draft of SIM on nursing management of patients with chest tube

drainage contained the following contents.

v Introduction

– General objective

– Specific objective

– Guidelines for using SIM

 38

v Unit – I

– Objectives

– Anatomy and physiology of chest

– Meaning of chest tube drainage

– Indications of chest tube drainage

– Signs and symptoms of pneumothorax

v Unit – II

– Objectives

– Mechanisms and principles involved in chest tube drainage

v Unit – III

– Objectives

– Care of patients during chest tube insertion

– Patients used for chest tube drainage

– Care of patients after insertion and prevention of complications.

v Summary

Content validity of the SIM was done by giving it to 7 experts and 100%

agreement was obtained on the aspects. The factors such as convenience and

independent learning were considered while preparing the self instructional module.

The self instructional module was given to 7 experts, one a cardiothoracic surgeon,

one an anesthetist and five medical surgical nursing experts. The illustrations were

presented in the self instructional module along with the cover page title “Self

Instructional Module on nursing management of patients with chest tube drainage”.

 39

PILOT STUDY

Pilot study is a small preliminary investigation of the same general character

as the major study, which is designed to acquaint the researcher with problems that

can be corrected in preparation for larger research project51.

The purpose of the pilot study was to find out the feasibility of the study,

clarity of language of the tool and the self instructional module.

The pilot study was conducted in a private hospital in Mangalore from 14th

October to 21st October. The written permission to conduct the study was obtained

from the managing director of the institution.

The data was collected from 10 staff nurses working in intensive care units

and the trauma unit in the selected hospital. Simple Random sampling was adopted.

Informed written consent was obtained. Confidentiality was assured to all the

subjects.

On the first day of commencing the study, pre-test was conducted by a

structured knowledge questionnaire after which the Self Instructional Module was

administered. The investigator informed the subjects to go through the self

instructional module for 7 days and called them for post-test on the 8th day which was

also a day for the follow up. Each written test was completed within 35-40 min.

Data analysis was done using descriptive and inferential statistics. The

findings of the pilot study revealed that the tool was feasible, practicable and

acceptable.
 40

METHOD OF DATA COLLECTION

The investigator obtained written permission from the Managing Director of

the hospital prior to the data collection period. The data collection period extended

from 22.10.05 to 29.10.05.

The investigator met the respondents individually in the respective wards and

units. The purpose of the study was explained to them and informed consent was

obtained. Confidentiality was assured to all the subjects to get their co-operation.

The pre-test was conducted using a structured knowledge questionnaire. The

time taken to conduct pre-test was 40-45 min. The pre-test was conducted on 33 staff

nurses and Self Instructional Module was administered on the same day with the

following instructions.

- Keep the Self Instructional Module with them for 7 days

- Read the Self Instructional Module thoroughly

- Come for the post-test on the 8th day

- Post-test was conducted on the 8th day to find out the effectiveness of SIM in

terms of their gain in knowledge.

Out of the 33 staff nurses, 2 of them were on leave and one had an off on the

post-test day. Hence post-test was done on the rest of the 30 staff nurses. The subjects

were very co operative. The data collection process was terminated by thanking the

subjects. The investigator did not face much difficulty in collecting data from the

subjects since the investigator personally requested all the subjects to participate in

the study.
 41

PLAN FOR DATA ANALYSIS

Data analysis is the systematic organization and synthesis of research data and

testing of research hypothesis using those data 20.

The data obtained was planned to be analysed using both descriptive and

inferential statistics, on the basis of objectives and hypothesis of the study.

- Demographic data containing sample characteristics would be analysed using

frequency and percentage.

- The knowledge before and after the administration of self-instructional

module will be calculated by using frequency, percentage, range, mean,

median, standard deviation and paired ‘t’ test.

- Ogive, bar diagram and pie diagram will be used to depict the data.

Summary

This chapter dealt with the research approach, design, setting of the study,

sample and sampling technique. It included preparation of tools and steps followed in

the preparation of self instructional module. This chapter also dealt with pilot study,

data collection procedure and plan for data analysis.

 42

5. RESULTS

Kerlinger defines ‘analysis’ as the categorizing, ordering, manipulating and

summarizing of the data to obtain an answer to a research question. The purpose of

analysis is to reduce data to an intelligible and interpretable form so that, the relations

of research problems can be studied and tested52.

According to Talbot interpreting the finding is most challenging and structured

step in the research process. Interpreting the research findings requires the

investigator to be creative45.

Organization of the findings

The data was collected from 30 staff nurses before and after the administration

of SIM. The collected data was organized, tabulated, analysed and interpreted by

using descriptive and inferential statistics. The collected information was organized

and presented in four parts: part I, part II, part III, and part IV.

Part I : Description of demographic variables of staff nurses

Part II : Analysis of pre-test knowledge scores of the staffnurses on

management of patients with chest tube drainage.

Section A : Assessment of the level of knowledge of staff

nurses

Section B : Area-wise mean, SD and mean percentage of

knowledge scores

Section C : Item-wise percentage of correct responses

 43

Part III : Evaluation of the effectiveness of SIM on management of

patients with chest tube drainage and testing of hypothesis

Section A : Evaluation of effectiveness of SIM

a) Quartile distribution of the pre test and post-

test knowledge scores of staff nurses

b)Comparison of pre-test and post-test

knowledge scores of staff nurses

:
Section B Area-wise effectiveness of SIM

Section C : Item-wise effectiveness of correct responses

by the staff nurses

Part IV : Testing of hypothesis

 44

PART I

DESCRIPTION OF DEMOGRAPHIC VARIABLES OF STAFF NURSES

Table 1

Frequency and percentage distribution of demographic variables of staff nurses

n=30
Sl. No. Variables Frequency Percentage

1 Age

20-30 yrs. 17 56.67

31-40 yrs. 7 23.33

41-50 yrs. 4 13.33

> 50 yrs. 2 6.67

2. Gender

Male 10 33.33

Female 20 66.67

3. Professional Qualification

GNM 14 46.67

B.Sc. Nursing 15 50

Post Basic B.Sc. Nursing 1 3.33

Any other 0 0

4. Total years of experience

Below 5 yrs 17 56.67

6-10 yrs 9 30

> 11 yrs 4 13.33

 45

Part I: Description of demographic variables of staff nurses

Age in years :

Percentage distribution of staff nurses according to their age in completed

years shows that the highest percentage (56.67%) of the respondents were in the age

group, 20-30 years. 23.33% of respondents were between 31-40 years and 13.33% of

respondents were between 41-50 years. Age of 6.67% of respondents were more than

50 years.

56.67%
60

50

40
Percentage

30 23.33%

20 13.33%
6.67%
10

0
20-30 yrs. 31-40 yrs. 41-50 yrs. > 50 yrs.
Age

Fig 3: Percentage distribution of staff nurses according to their age in completed

years
 46

Gender :

Distribution of staff nurses with respect to their gender shows 66.67% of the

samples were females and 33.33% of the samples were males.

33.33
66.67
Male
Female

Fig 4 :Percentage distribution of staff nurses according to their gender

 47

Professional Qualification :

Analysis reveal that highest percentage (50%) of samples were B.Sc. nursing

graduates and 46.67% of the samples were general nurses. Only a minority of 3.33%

of the sample were post-basic B.Sc. nurses.

50%
46.67%
50
45
40
Percentage

35
30
25
20
15
3.33%
10
5
0
GNM B.Sc Nursing Post Basic BSc.
Nursing

Qualification

Fig 5: Percentage distribution of staff nurses according to their professional

qualification
 48

Total Experience in years:

Analysis reveals that most of samples (56.67%) had below 5 years of

experience. Thirty percentage of the sample had 6-10 years of experience and a

minority of 13.33% of samples had experience above 11 years.

56.67%
60

50
Percentage

40
30%
30

20 13.33%

10

0
Below 5 yrs 6-10 yrs > 11 yrs
Total Experience

Fig 6:Percentage distribution of staff nurses according to total years of

experience
 49

PART II

ANALYSIS OF PRE-TEST KNOWLEDGE OF STAFF NURSES REGARDING

MANAGEMENT OF PATIENTS WITH CHEST TUBE DRAINAGE

Section A:

Level of knowledge of staff nurses regarding management of patients with chest

tube drainage.

In order to find out the level of knowledge of the staffnurses ,a three point

scale was used. Categorization of the staff nurses on the basis of level of knowledge

was done as follows, scores 0-35 percentage shows poor knowledge level, scores

35-70 percentage shows average knowledge level and scores 70-100 percentage

shows good knowledge level.

Table 2
Level of knowledge of staff nurses regarding management of patients with chest
tube drainage

n=30
Level of Percentage of Number of
Percentage (%)
knowledge scores respondents
Poor 0-35 2 6.67

Average 35-70 27 90

Good 70-100 1 3.33

Total 30 100

Assessment of the level of knowledge of the staff nurses reveals that majority

of respondents (90%) had only average knowledge whose percentage of score ranged

between 35-70. Only 3.33% of the respondents had good knowledge and 6.67% of the

respondents had poor knowledge level regarding management of patients with chest

tube drainage.
 50

Section B: Area-wise Mean, SD and Mean Percentage of Knowledge Scores

Table – 3

Area-wise Mean, SD and Mean Percentage of Knowledge Scores

n=30
Maximum Mean Mean
Knowledge area SD
possible score score %
a) Anatomy and physiology
15 8.2 2.34 54.57
including signs and symptoms

b) Mechanisms and principles

6 3.53 1.61 58.83
involved in chest tube drainage

c) Assessment, care of patients with

chest tube drainage and 14 8 2.30 57.14

prevention of complications

Total 35 19.73 4.46 56.37

The total mean percentage of the knowledge scores was 56.37% with mean

and SD 19.73 + 4.46. Area-wise mean percentage of knowledge scores was 58.83%

in the area of ‘mechanisms and principles involved in chest tube drainage’ with mean

and SD 3.53 + 1.61. In the area of ‘assessment, care of patient with chest tube

drainage and prevention of complications’ the mean percentage was 57.14% with

mean and SD 8 + 2.30. The last mean percentage (54.57%) was observed for the

item, ‘anatomy and physiology including signs and symptoms’ with mean and

SD 8.2 + 2.34.
 51

Section C: Item-wise analysis of correct responses of staff nurses on

‘management of patients with chest tube drainage’

Table – 4 (a)

Item-wise percentage of correct responses of staff nurses on Anatomy and

physiology including signs and symptoms

n=30
Sl. No of correct Percentage
Items
No. responses (%)
8. Heart is located in the mediastinum 22 73.33

9. Right lung has 3 lobes 21 70

10. Pleurae is the covering of lungs 25 83.33

Visceral pleura is the inner membrane

11. 21 70
covering the lungs

Lubrication and prevention of friction are the

12. 14 46.66
functions of intra pleural fluid

Average amount of intra pleural fluid in a

13. 13 43.33
healthy adult is 20-25 ml

Respiratory centre is situated in pons and

14. 18 60
medulla

During inhalation diaphragm contracts and

15 15 50
chest cavity increases

Findings reveal that majority of the samples (83.33%) responded correctly to

the item ‘pleurae is the covering of the lungs’ 73.33% of respondents knew that ‘heart

is located in the mediastinum’. Similar percentage (70%) of respondents responded

correctly to items, ‘right lung has 3 lobes’ and ‘visceral pleura is the inner membrane

covering the lungs’. Sixty percentage of respondents knew respiratory centre is

situated in pons and medulla. Half of the respondents (50%) responded correctly to
 52

the item, during inhalation, diaphragm contracts and chest cavity increases. Almost

similar percentage of respondents responded correctly to the items 12 and 13 46.66%

of respondents knew ‘lubrication and prevention of friction are functions of intra

pleural fluid’ and 43.33 percentage of respondents responded that ‘average amount of

intra-pleural fluid in a healthy adult is 20-25 ml’.

Table – 4 (b)
Item-wise percentage of correct responses of staff nurses on ‘Anatomy and
physiology including signs and symptoms’

n=30
Sl. No of correct Percentage
Items
No. responses (%)

16. Pneumothorax is the health problem when

excessive is collected within the pleural 21 70

space

17. Chest tube drainage promotes lung

12 40
expansion

18. Pneumothorax is the most common

17 56.66
indication for inserting a chest tube

19. Coronary artery bypass grafting is an

13 43.33
indication for chest tube drainage

20. Open Pneumothorax is the opening of outer

chest wall allowing air to enter inside 20 66.66

pleural space

21 Palpable subcutaneous emphysema is

2 6.66
appropriate for the term crepitus

22. Increased respiratory rate is a major sign

noticed during assessment of a patient with 12 40

pneumothorax
 53

The findings showed that seventy percentage of the respondents responded

correctly to the item, ‘pneumothorax is the health problem when excess air is

collected within the pleural space’. More or less similar percentage of respondents

(66.66%) responded correctly to the item ‘open pneumothorax is the opening of outer

chest wall allowing air to enter inside the intrapleural space’. More than half of the

respondents (56.66%) knew that pneumothorax is the most common indication

inserting a chest tube less than half (43.33%) of the respondents responded correctly

to the item ‘coronary artery bypass grafting is an indication for inserting a chest tube’.

A similar percentage (40%) of respondents responded correctly to the item, ‘chest

tube drainage promotes lung expansion and increased respiratory rate is a major sign

noticed during assessment of a patient with Pneumothorax’. The least percentage

(6.66%) of correct responses was found for the item, ‘palpable emphysema is

appropriate for the term crepitus’.

 54

Table – 5

Item-wise percentage of correct responses of staff nurses on ‘mechanisms and

principles involved in chest tube drainage’

n=30
Sl. No of correct Percentage
Items
No. responses (%)

Gravity, water-seal and suction are the

23. 20 66.66
major principles of chest tube drainage

Water-seal drainage acts as a barrier

24. between atmospheric and intrapleural 12 40

pressure

Normal atmospheric pressure is 760 mm

25. 24 80
of Hg

26. Negative pressure increases and the lung

14 46.66
expands when chest tube insertion begins

27. Suctioning in a water-seal drainage

systemic done when a person’s coughing 17 56.66

and respirations are weak

28. Bubbling at the end of drainage tube

indicates presence of persistent air leak 18 60

from the lung

Item-wise analysis of correct responses reveals that majority of the sample

(80%) responded correctly to the item, ‘normal atmospheric pressure is 760 mm of

Hg’. The item, ‘Gravity, water-seal and suctions are the major principles of chest

tube drainage’ was answered correctly by 66.66% of respondents. More or less

similar percentage (60%) responded correctly to the item, ‘bubbling at the end of
 55

drainage tube indicates presence of persistent air leak from the lung’. More than half

percentage (56.66%) of sample drainage knew that, ‘suctioning in a water-seal

drainage system is done when a persons coughing and respirations are weak’. Less

than half of the respondents (46.66%) knew that negative pressure increases and the

lung expands and chest insertion begins. The least percentage (40%) of correct

responses was found for the item, ‘water-seal drainage acts as a barrier between

atmospheric and intra-pleural pressure’.

 56

Table – 6 (a)

Item-wise percentage of correct responses of staff nurses on ‘assessment and care

of patient with chest tube drainage’

n=30
Sl. No of correct Percentage
Items
No. responses (%)

29. Subcutaneous emphysema is the presence

of “rice-crispies” which is painless and 6 20

spongy

30. Assessment to be carried out before

inserting chest tube, includes, SPO2
17 56.66
reading, ABG monitoring and coagulation
profile

31. Chest tube is inserted between 4th and 6th

11 36.66
intercostal space in haemothorax

High fowlers position is best suitable for

32. 24 80
chest tube insertion in pneumothorax

33. Chest tube is inserted between 2nd and 3rd

17 56.66
intercostals space in pneumothorax

34. Water level marked on the bottle shows

17 56.66
the amount of fluid collected

35. Kinking and looping of chest tubes must

be avoided as it produces back pressure, 17 56.66

thus enhancing back flow

High fowlers position is encouraged for a

patient with chest tube drainage as it
36. 9 30
prevents postural deformity and
contractures
 57

Findings reveal that majority of the samples (80%) responded correctly to the

item, ‘High fowlers position is best suitable for chest tube insertion in pneumothorax’.

A similar percentage of respondents (56.66%) responded correctly to items,

‘assessment to be carried out before inserting chest tube, includes SPO2 reading,

ABG monitoring and coagulation profile’ and ‘chest tube is inserted between 2nd and

3rd inter costal space in pheumothorax’. Similar percentage (56.66%) responded

correctly to items, ‘water level marked on the bottle shows the amount of fluid

collected and kinking and looping of chest tubes must be avoided as it produces

pressure, thus enhancing back flow’. The item, ‘chest tube is inserted between 4th and

6th intercostals space in haemothorax’ was responded correctly by 36.66% of

respondents. Thirty percent of respondents knew that, ‘high fowler’s position is

encouraged for a patient with chest tube drainage, as it prevents postural deformity

and contractures’. Only twenty percent of respondents knew that, ‘subcutaneous

emphysema is the presence of “rice-crispies” which is painless and spongy’.

 58

Table – 6 (b)

Item-wise percentage of correct responses of staff nurses on ‘assessment and care

of patient with chest tube drainage’
n=30
Sl. No of correct Percentage
Items
No. responses (%)
37. ROM exercises lessens postoperative pain
8 26.66
for a patient with chest tube drainage
38. Milking and stripping of the chest tubes
14 46.66
helps in maintaining potency of the tubes
39. Fluctuation of fluid in the tubing stops
21 70
when the lungs re-expand
40. Drainage system is kept at the lowest
level from the chest while transporting the 26 86.66
patient
41. During chest tube removal, the patient is
25 83.33
advised to hold the breath
42. When tube becomes disconnected
accidentally, clamp the tube, cut off
28 93.33
contaminated end of the tube and reattach
immediately to the drainage system

Findings reveal that the majority of samples (93.33%) responded correctly to

the last item, ‘when tube becomes disconnected accidentally, clamp the tube, cut off

contaminated end of the tube and reattach immediately to the drainage system’. More

or less similar percentage (86.66%) responded correctly to items, ‘drainage system is

kept at the lowest level from chest while transporting the patient’ and a percentage of

83.33% responded correctly to the item, ‘during chest tube removal the patient is

advised to hold breath’. Seventy percent of respondents responded correctly to the

item, ‘fluctuation of fluid in the tubing stops when the lungs re-expand’. Less than

half of the respondents (46.66%) responded correctly to the item, ‘milking and

stripping of chest tubes helps in maintaining the patency of the tubes’. Only 26.66%

of the samples knew that range of motion (ROM) exercises lessens postoperative pain

for a patient with chest tube drainage.

 59

PART III

EVALUATION OF THE EFFECTIVENESS OF SIM

Section A: Evaluation of the effectiveness of SIM

a) Quartile distribution of pre-test and post-test scores of staff nurses

35

30

25

20
Post-test
CF

Pre-test
15

10

35
13

0
0 2 6 10 14 18 22 26 30 34 38
Scores

Fig 7: Less than Ogives of pre-test and post-test scores of staff nurses on

management of patients with chest tube drainage

The data presented in the form of Ogives show significant difference between

pre-test and post-test knowledge scores. By graphical method, the pre-test median

score is 13 whereas post-test median score is 35. The Ogive plotted shows that the

first quartile score of the post-test is higher than the third quartile score of pre-test and

there is a large gap between all the quartiles of pre-test and post-test score. However

the difference between the different quartiles of pre test and post-test is more. It

reveals higher effectiveness of SIM. So the Ogives indicate that there is significant

increase in the knowledge of staff nurses after administration of SIM.

 60

b) Comparison of pre-test and post-test knowledge scores of staff nurses

25

20

15
Post-test
CF

Pre-test
10

0
0 2 6 10 14 18 22 26 30 34 38
Scores

Fig 8 : Pre test and post- test knowledge scores of staff nurses on management of
patients with chest tube drainage

The data presented in the form of graph shows that there is an increase in the

knowledge scores of staff nurses after the administration of SIM. In the pre test

maximum number of staff nurses (17) scored between 18-22, whereas in the post- test

the maximum number of staff nurses (20) scored between 34-38. In the pre test none

of them scored above 22, whereas in the post- test all the staff nurses scored above 22,

hence findings show the effectiveness of SIM.

 61

Section B: Area-wise effectiveness of SIM on management of patients with chest

tube drainage

Table 7

Area-wise Mean, SD and Mean percentage of the knowledge scores in pre-test

and post-test

n=30
Max Pre-test (x1) Post-test (x2) Effectiveness (x2-x1)
Knowledge
possible Mean + Mean Mean + Mean Mean + Mean
areas
scores SD % SD % SD %
a) Anatomy
and
physiology
15 8.2+2.34 54.57 13.6+1.13 90.67 5.4+2.63 36.1
including
signs and
symptoms

b) Mechanisms
and
principles
6 3.53+1.61 58.83 5.5+0.57 91.67 1.97+1.52 32.84
involved in
chest tube
drainage

c) Assessment
and care of
patient with 14 8+2.30 57.14 13.0+1.36 92.86 5+2.61 35.72

chest tube
drainage

35 19.73+4.46 56.37 32.10+2.55 91.71 12.37+4.67 35.34

Comparison of mean percentage of the knowledge scores of the pre-test and

post-test reveals an increase of 35.34% in the mean knowledge score of the staff

nurses after administration of SIM. Comparison of Area-wise mean, and SD of the

 62

knowledge scores in the area of ‘anatomy and physiology including signs and

symptoms’ shows that the pre-test mean knowledge scores was, 54.57% (8.2+2.34)

whereas post-test mean knowledge score was 90.67% (13.6+1.13). This shows an

increase of 36.1% in the mean knowledge score of staff nurses.

In the area of knowledge on ‘mechanisms and principles involved in chest

tube drainage’ shows that the pre-test mean knowledge score was only 58.83%

(3.53+1.61) whereas post-test mean knowledge score was 91.67% (5.5+0.57).

Effectiveness of SIM observed in the area of ‘mechanisms and principles involved in

chest tube drainage’ was 32.84%.

In the area, of ‘assessment and care of patients with chest tube drainage’ the

pre-test mean knowledge score was 57.14% (8+2.30) whereas post-test mean

knowledge score was 92.86% (13.0+1.36). This shows an increase of 35.72% in the

mean knowledge score of staff nurses.

The overall findings reveal that the percentage of post- test knowledge scores

was more when compared to the pre-test knowledge scores. Hence it is observed that

the SIM was effective in increasing the knowledge of staff nurses on ‘management of

patients with chest tube drainage’.

 63

Section C: Item-wise effectiveness of correct responses by the staff nurses

Table 8 (a)

Item-wise effectiveness of SIM with regard to percentage of correct responses by

staff nurses on ‘anatomy and physiology including signs and symptoms’
n=30
Pre test (x1) Post- test (x2) Effectiveness
S.No Items
No % No % (x2-x1%)
8. Heart is located in the
22 73.33 30 100 26.67
mediastinum
9. Right lung has 3 lobes 21 70 30 100 30
10. Pleura is the covering of the
25 83.33 30 100 16.67
lungs
11. Visceral pleura is the inner
21 70 28 93.33 23.33
membrane covering the lungs
12. Lubrication and prevention of
friction is the function of intra 14 46.66 19 63.33 16.67
pleural fluid
13. Average amount of
intrapleural fluid in a healthy 13 43.33 30 100 56.67
adult is 20-25 ml
Respiratory centre is situated
14. 18 60 29 96.66 36.66
in pons and medulla
During inhalation, diaphragm
15. contracts and chest cavity 15 50 29 96.66 46.66
increases

Item-wise comparison reveals that 56.67% of effectiveness was observed for

the item, ‘average amount of intra pleural fluid in a healthy adult is 20-25 ml’. An
effectiveness of 46.66% was found for the item, ‘during inhalation diaphragm
contracts and chest cavity increases’. The mean percentage of effectiveness was
36.66% for the item, ‘respiratory centre is situated in pons and medulla’. Thirty
percentage of effectiveness was found for the item, ‘right lung has 3 lobes’. More or
less similar percentage of effectiveness (26.67%) was observed on the item, ‘heart is
located in the mediastinum’ and 23.33% of effectiveness was observed on the item,
‘visceral pleura is the inner membrane covering the lungs’. The least percentage
(16.67%) of effectiveness was observed on the item, ‘lubrication and prevention of
friction are the functions of intra pleural fluid’.
 64

Table 8 (b)
Item-wise effectiveness of SIM with regard to percentage of correct responses by
staff nurses on ‘anatomy and physiology including signs and symptoms’

n=30
Pre test (x1) Post- test (x2) Effectiveness
S.No Items
No % No % (x2-x1%)

16. Pneumothorax is the health

problem when excess air is
21 70 30 100 30
collected within the pleural
space

17. Chest tube drainage promotes

12 40 23 76.66 36.66
lung expansion

18. Pneumothorax is the most

common indication for 17 56.66 30 100 43.34

inserting a chest tube

19. Coronary artery bypass

grafting is an indication for 13 43.33 29 96.66 53.33

chest tube drainage

20. Open pneumothorax is the

opening of outer chest wall
20 66.66 27 90 23.4
allowing air to enter inside
pleural space

21. Palpable subcutaneous

emphysema is appropriate for 2 6.66 18 60 53.34

the term crepitus

22. Increased respiratory rate is a

major sign noticed during
12 40 27 90 50
assessment of a patient with
pneumothorax
 65

Analysis reveals that more or less similar percentage of effectiveness was

observed on the items, ‘palpable subcutaneous emphysema is appropriate for the term

crepitus’ (53.34%) and ‘coronary artery bypass grafting is an indication for chest tube

drainage’ (53.33%). Fifty percentage increase in the mean knowledge score was

observed on the item, ‘increased respiratory rate is a major sign noticed during

assessment of a patient with pneumothorax’. A net increase of 43.34% correct

responses was seen for the item, ‘pneumothorax is the most common indication for

inserting a chest tube’. More or less similar percentage of effectiveness was seen on

the items, ‘chest tube drainage promotes lung expansion’ (36.66%) and

‘pneumothorax is the health problem when excess air is collected within the pleural

space’ (30%). The least percentage (23.4%) of effectiveness was seen on the item,

‘open pneumothorax is the opening of outer chest wall, allowing air to enter the

pleural space’.
 66

Table-9
Item-wise effectiveness of SIM with regard to percentage of correct responses by
staff nurses on ‘mechanisms and principles involved in chest tube drainage’.

n=30

Post- test Effectivene

Sl. Pre-test (x1)
(x2) ss
No Items
No. % No. % (x1-x2)%
23. Gravity, water-seal and suction 20 66.66 30 100 33.34
are the major principles of chest
tube drainage
24. Water-seal drainage acts as a 12 40 16 53.33 13.33
barrier between atmospheric and
intrapleural pressure
25. Normal atmospheric pressure is 24 80 30 100 20
760mm of Hg.
26. Negative pressure increases and 14 46.66 30 100 53.34
the lung expands when chest tube
insertion begins.
27. Suctioning in a water-seal 17 56.66 30 100 43.34
drainage system is done when a
person’s coughing and
respirations are weak.
28. Bubbling at the end of the 18 60 29 96.66 36.66
drainage tube, indicates presence
of persistent air leak from the
lungs.

Finding reveals that the highest percentage (53.34%) of effectiveness was

observed on the item, ‘negative pressure increase and the lung expands when chest
tube insertion begins. An effectiveness of 43.34% was seen in the item ‘suctioning in
a water-seal drainage system is done when a person’s coughing and respirations are
weak’. More or less similar percentage of effectiveness was found on the items,
‘Bubbling at the end of drainage tube indicates presence of persistent air leak from the
lung’ (36.66%) and ‘gravity, water-seal and suction are the important principles of
chest tube drainage’ (33.34%). Twenty percentage of effectiveness was observed on
the item, ‘normal atmospheric pressure is 760mm of Hg’. The least percentage
(13.33%) of effectiveness was seen on the item, ‘water-seal drainage acts as a barriers
between atmospheric and intra pleural pressure’.
 67

Table –10 (a)

Item-wise effectiveness of SIM with regard to percentage of correct responses by
staff nurses on ‘assessment and care of patients with chest tube drainage’

n =30

Post- test
Pre-test (x1) Effectiveness
Sl. (x2)
Items
No (x1-x2)%
No. % No. %

29. Subcutaneous emphysema is the

presence of “rice-crispies” which 6 20 27 90 70
is painless and spongy.

30. Assessment to be carried out

before chest tube insertion
includes SPO2 reading, ABG 17 56.66 30 100 43.34
monitoring and coagulation
profile.

31. Chest tube is inserted between 4th

93.3
and 6th intercostal space in 11 36.66 28 56.67
3
haemothorax

32. High fowler’s position is best

suitable for chest tube insertion in 24 80 30 100 20
pnemothorax.

33. Chest tube is inserted between 2nd

and 3rd intercostals space in 17 56.66 30 100 43.34
pneumothorax

34. Water level marked on the bottle

shows the amount of fluid 17 56.66 30 100 43.34
collected.

35. Kinking and looping of chest

tubes must be avoided as it
17 56.66 27 90 33.34
produces back pressure, thus
enhancing back flow.

36. High fowler’s position is

encouraged for a patient with
66.6
chest tube drainage as it prevents 9 30 20 36.66
6
Postural deformity and
contractures.
 68

Results show that 70% of effectiveness was observed on the item,

‘subcutaneous emphysema is the presence of “rice-crispies” which is painless and

spongy’. An effectiveness of 56.67% was seen on the item, ‘chest tube is inserted in

the 4th and 6th intercostals space in heamothorax’. A similar percentage of

effectiveness was found on items, ‘assessments to be carried out before chest tube,

insertion includes, SPO2 reading, ABG monitoring and coagulation profile’,

(43.34%), ‘chest tube is inserted between 2nd and 3rd intercostal space in

pneumothorax’, (43.34%), and ‘water level marked on the bottle shows the amount of

fluid collected’ (43.34%). An effectiveness of 36.66% was found on the item, ‘high

fowler’s position is encouraged for a patient with chest tube drainage as it prevents

postural deformity and contractures’. More or less similar percentage (33.34%) of

effectiveness was found on the item, ‘kinking and looping of chest tubes should be

avoided as it produces back pressure thus enhancing back flow’. The least percentage

(20%) of effectiveness was seen on the item, ‘high fowler’s position is best suitable

for chest tube insertion in pneumothorax’.

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Table –10 (b)

Item-wise effectiveness of SIM with regard to percentage of correct

responses by staff nurses on ‘assessment and care of patients with chest tube
drainage’.

n=30
Post- test Effectiveness
Sl. Pre-test (x1)
(x2)
No Items
No. % No. % (x1-x2)%

37. ROM exercises lessen

post operative pain for a patient 8 26.66 27 90 63.34
with chest tube drainage.

38. Milking and stripping of the chest

tubes helps in maintaining 14 46.66 28 93.33 46.67
patency of the tubes.

39. Fluctuation of fluid in the tubing

21 70 27 90 20
stops when the lungs re-expand.

40. Drainage system is kept at the

lowest level from the chest while 26 86.66 30 100 13.34
transporting the patient

41. During chest tube removal, the

patient is advised to hold the 25 83.33 30 100 16.67
breath.

42. When tube becomes disconnected

accidentally, clamp the tube, cut
off contaminated ends of the tube 28 93.33 29 96.66 3.33
and reattach immediately to the
drainage system.
 70

Findings reveal that the highest percentage (63.34%) of effectiveness was

observed on the item, ‘ROM exercises lessen post-operative pain for a patient with

chest tube drainage’. An effectiveness of 46.67% was seen on the item, ‘milking and

stripping of the chest tubes helps in maintaining patency of the tube’. Twenty

percentage of effectiveness was observed on the item, ‘fluctuation of fluid in the

tubing stops when the lungs expand’. An effectiveness of 16.67% was observed on

the item, ‘during chest tube removal the patient is advised to hold breath’. More or

less similar percentage of effectiveness was found on the items, ‘drainage system is

kept at the lowest level form the chest while transporting the patient’, (13.34%). The

least percentage (3.33%) was found on the item, ‘when tube becomes disconnected

accidentally, clamp the tube, cut off contaminated ends and reattach immediately to

the drainage system’.

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PART IV

TESTING OF HYPOTHESIS

To evaluate the effectiveness of SIM a null hypothesis was formulated.

Ho: There is no significant difference between the pre-test and post-test knowledge of

staff nurses on management of patients with chest tube drainage.

Paired ‘t’ test was used to analyze the difference in knowledge scores of staff

nurses in the pre-test and post-test on management of patients with chest tube

drainage.

Table –11

Significance of the difference between pre-test and post-test knowledge scores of

staff nurses on ‘management of patients with chest tube drainage’.

n=30
Knowledge Mean Table value at Level of
‘t’ value
area effectiveness 0.5% significance
Section A 5.4 ± 2.63 11.229 2.756 P<0.005
Section B 1.97 ± 1.52 7.089 2.756 P<0.005
Section C 5 ± 2.61 10.481 2.756 P<0.005
Total 12.37 ± 4.67 14.498 2.756 P<0.005

Findings revealed that the mean post-test score of staff nurses was

significantly higher than the mean pre-test score. The calculated ‘t’ value was greater

than the table value at 0.5%. Hence null hypothesis was rejected and research

hypothesis was accepted indicating that gain in knowledge was not by chance.

Therefore it is concluded that the gain knowledge of staff nurses through self

instructional module on management of patient with chest tube drainage was very

highly significant.
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Summary

This chapter dealt with the analysis and findings of the data collected from 30

staff nurses. Findings revealed that the mean knowledge scores of the staff nurses in

the pre-test was 19.73 ± 4.46 whereas the post- test mean knowledge score was

32.01 ± 2.55. The paired ‘t’ test shows that there is very high significant difference in

the knowledge of staff nurses regarding management of patients with chest tube

drainage, after the administration of SIM. The demographic data was analyzed

statistically and presented in tables and figures in the chapter. Result shows that the

SIM was very effective in increasing the knowledge of staff nurses regarding

management of patients with chest tube drainage.

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6. DISCUSSION

The present educational programme was prepared with the aim of improving

the knowledge of staff nurses regarding management of patients with chest tube

drainage. In order to achieve the objectives of the study, a one group pretest post test

design was adopted for the study. An evaluative approach was used for the study.

Simple random sampling technique was used to selected the respondents. The samples

for the study comprises, 30 staff nurses, to whom self instructional module was

administered.

The findings of the study are as follows:-

PART I: Percentage distribution of sample characteristics

PART II: Analysis of Pretest knowledge scores of the staff nurses on management of

patients with chest tube drainage

PART III: Evaluation of the effectiveness of SIM on management of patients with

chest tube drainage.

PART IV: Testing of hypothesis.

PART I

PERCENTAGE DISTRIBUTION OF SAMPLE CHARACTERISTICS

Percentage distribution of staff nurses according to the age in completed years show

that the highest percentage (56.6%) of the respondents were in the age group, 20-

30years. Age of 23.33 percentage of respondents were between 31-40 years and

13.33% of respondents were between 41-50 years. Age of 6.67% of respondents were

above than 50years.

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Distribution of staff nurses according to their gender shows 66.67% of them

were females and 33.3% of them were males. Percentage distribution of staff nurses

according to their professional qualification shows that majority, (50%) of the

samples were B.sc nurses and 46.6% of the sample were general nurses. Only a

mnority of 3.33% of the sample were post basic B.sc nurses.

Percentage distribution of staff nurses according to total years of experience

reveals that the majority of samples (56.67%) had below 5 years of experience. Thirty

percentage of the samples had 6-10 years of experiences and a majority of 13.33% of

samples had experience above 11years.

PART II

ANALYSIS OF PRE-TEST KNOWLEDGE OF STAFF NURSES REGARDING

MANAGEMENT OF PATIENTS WITH CHEST TUBE DRAINAGE.

A: Assessment of knowledge level of staff nurses regarding management of

patients with chest tube drainage.

The findings revealed that majority of respondents (90%) had only average

knowledge whose percentage of scores ranged between 35-70. Only 3.33% of the

respondents had good knowledge and 6.67% of the respondents had poor knowledge

level regarding management of patients with chest tube drainage.

A similar study conducted by Janet (2002)53 on ‘Effectiveness of self

instructional module on assisted reproductive technology for staff nurses in a selected

hospital in Mangalore reveals that, majority of respondents (60%) fall in the category

of poor, whereas a few respondents (6.67%) fall in the category of very good. There

was no one with poor or average scores.

 75

B. Area-wise analysis of knowledge scores of staff nurses regarding

“management of patients with chest tube drainage”.

The total mean percentage of the knowledge scores was 56.37% with mean

and SD 19.73 ± 4.46. Area-wise mean percentage of knowledge scores was 58.83%in

the area, of ‘Mechanisms and principles involved in chest tube drainage’ with mean

and SD 3.53 ± 1.61. In the area of ‘assessment, care of patient with chest tube

drainage and prevention of complication’, the mean percentage was 57.14% with

mean SD 8 ± 2.30. The least mean percentage (54.57%) was observed on the item,

‘anatomy and physiology including signs and symptoms’, with mean and SD 8.2 ±

2.34.

C. Item-wise analysis of correct responses of staff nurses on “management of

patients with chest tube drainage”.

(a) Items related to knowledge on ‘Anatomy and physiology including signs and

symptoms'

Analysis revealed that the highest percentage (83.33%) of respondents

responded correctly to the item ‘pleurae is the covering of lungs’ and only 43.33% of

respondents responded that ‘average amount of intra-pleural fluid in an healthy adult

is 20-25ml’. A minority of 6.66% of samples had knowledge of the item, ‘palpable

emphysema is appropriate for the term ‘crepitus’’.

(b) Items related to knowledge on ‘mechanisms and principals involved in chest tube

drainage’

Item-wise analysis of correct responses revealed that majority of the sample

(80%) responded correctly to the item ‘normal atmospheric pressure is

760mm of Hg’. The least percentage (40%) of correct responses was found on the
 76

item, ‘water-seal drainage acts as a barrier between atmospheric and intra pleural

pressure’.

(c) Items related to knowledge on ‘assessment and care of patient with chest tube

drainage and prevention of complications’.

Findings revealed that majority of the samples (93.33%) responded correctly

to the last item, “when tube becomes disconnected accidentally, clamp the tube, cut

off contaminated ends of the tube and reattach immediately to the drainage system”.

Only 20% of respondents knew that ‘subcutaneous emphysema is the presence of

‘rice crispies’, which is painless and spongy.

PART III

EVALUATION OF THE EFFECTIVENESS OF THE SELF INSTRUCTIONAL

MODULE ON MANAGEMENT OF PATIENTS WITH CHEST TUBE DRAINAGE

A: a) Quartile distribution of pre-test and post-test scores of staff nurses

regarding management of patients with chest tube drainage

The data presented in the form of Ogives showed significant difference

between pre- test and post- test knowledge scores. By graphical method, the pre-test

median score is 13 whereas the post-test median score is 35. The difference between

the different quartiles of pre-test and post-test is more. This revealed that there is

significant increase in the knowledge of staff nurses, regarding management of

patients with chest tube drainage.

b) Comparison of pre-test and post-test knowledge scores of staff nurses

regarding management of patients with chest tube drainage

The data presented in the form of graph showed that in the pre-test, maximum

number of staff nurses (17) scored between 18-22, whereas in the post-test, the

maximum number of staff nurses (20) scored between 34-38. This revealed that there
 77

is a significant increase in the knowledge scores of staff nurses after administration of

SIM.

B: Area-wise effectiveness of SIM regarding management of patients with

chest tube drainage.

The area-wise, mean, SD and mean percentage of the knowledge scores of the

pre-test and post-test reveals an increase of 35.34% in the mean knowledge score after

administration of SIM.

In the area of ‘assessment and care of patients with chest tube drainage’ there

was an increase of 35.72% in the mean knowledge score with mean and

SD of 5 ± 2.61.

In the area of ‘anatomy and physiology including signs and symptoms’ there

was an increase of 36.1% in the mean knowledge score with mean and

SD of 5.4 ± 2.63.

In the area of ‘mechanisms and principles involved in chest tube drainage’,

there was an increase of 32.84% in the mean knowledge score with mean and

SD of 1.97 ± 1.52.

C: Item-wise effectiveness of SIM with regard to correct responses by staff

nurses on management of patients with chest tube drainage.

(a) Items related to “anatomy and physiology including signs and symptoms”.

Item-wise comparison revealed that 56.67% of effectiveness was observed on

the item ‘average amount of intra-pleural fluid in a healthy adult is 20-25ml’. The

least percentage (16.67%) of effectiveness was observed on the item, ‘Lubrication and

prevention of friction are the functions of intra-pleural fluid’.

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(b) Items related to ‘mechanisms and principles involved in chest tube drainage’.

Findings revealed that the highest percentage (53.34%) of effectiveness was

observed for the item ‘negative pressure increases and the lung expands when chest

tube insertion begins’. The least percentage (13.33%) of effectiveness was seen in the

item, ‘water-seal drainage acts as a barrier between atmospheric and intra-pleural

pressure’.

(c) Items related to ‘assessment and care of patients with chest tube drainage’.

Results show that 70% of effectiveness was observed on the item,

‘subcutaneous emphysema is the presence of “rice crispies which is painless and

spongy’. The least percentage of effectiveness (3.33%) was found on the item, ‘when

tube becomes disconnected, accidentally, clamp the tube, cut off contaminated ends

and reattach immediately to the drainage system’.

PART IV

TESTING OF HYPOTHESIS

The findings of the study showed a significant increase in the post-test

knowledge scores and the mean gain was very highly significant.

Hence it can be inferred that the SIM was effective in increasing the

knowledge of staff nurses regarding management of patients with chest tube drainage.

These findings have their support in a prior study by Verma (2003)36,

Machado (1996)39 and Balasaraswathy (1995)40, which reported that self instructional

module is an important teaching strategy that help nurses to gain up to date

knowledge, regarding the concerned topic and to enhance their self-learning skills.
 79

7. CONCLUSION

Assessment of the level of knowledge of staff nurses regarding nursing

management of patients with chest tube drainage revealed that majority of

respondents (90%) had poor knowledge. A minority of only 6.67% of

respondents had average knowledge level and only 3.33% of respondents had

good level of knowledge.

Area-wise mean percentage of knowledge scores in pre-test was

(58.83%) in the area of ‘mechanisms and principles involved in chest tube

drainage’ with mean and SD 3.53 + 1.61. The least mean percentage (54.57%)

was observed for the item, ‘anatomy and physiology including signs and

symptoms’ with mean and SD 8.2 + 2.34. Area-wise mean percentage of

knowledge scores in post test was highest (92.86%) in the area ‘assessment and

care of patient with chest tube drainage’ with mean and SD 13.0 + 1.36. The

least mean percentage (90.67%) was observed on the item ‘anatomy and

physiology including signs and symptoms’ with mean and SD 13.6 + 1.13.

Area wise effectiveness of self instructional module was found to be

highest (36.1%) in the area ‘anatomy and physiology including signs and

symptoms’ with mean and SD 5.4 + 2.63. The effectiveness was lowest

(32.84%) in the area ‘mechanisms and principles involved in chest tube

drainage with mean and SD 1.97 + 1.52.

The findings of the study showed that a very high significant increase in

the post-test knowledge scores and the mean gain (P<0.005) in all the areas of

management of patients with chest tube drainage. The study revealed that the

self instructional module was very effective in increasing the knowledge of

staff nurses on ‘management of patient with chest tube drainage’.

 80

8. SUMMARY

Chest tube drains are used to manage various thoracic conditions by safely

removing air (pneumothorax) or liquid (hemothorax, pleural effusion) from the

Pleural cavity, preventing it from being reintroduced and enabling the lungs to

expand. Maintain chest tube potency to achieve adequate drainage is often a problem

in the intensive care units5.

Many decisions related to the use of chest drains appear to be based on

personal preference rather than clinical evidence and complications are more likely if

the nurses caring for patients with chest drains do not have the necessary skills and

training56. Hence nurses should be well equipped with the necessary knowledge and

skills regarding management of patients with chest tube drainage.

The investigator used an evaluative research approach with one group

pre-test post-test design the sample consisted of 30 staffnurses, working in a selected

hospital in Mangalore .A random sampling technique was used for the study. A

structured knowledge questionnaire with 35 items on management of patients with

chest tube drainage was used to assess the know ledge of staff nurses before and after

administration of SIM .The data obtained was analysed by using descriptive and

inferential statistics.

Findings of the study are summarized as follows:

Sample Characteristics

? Majority of the respondents (56.67%) were within the age group of 20-30
years.

? Most of the respondents (66.67%) were females

? Most of the respondents (50%) were registered B.Sc. nurses.

? Majority of respondents (56.67) had below 5 years of experience.

 81

Pre test knowledge scores of staff nurses regarding management of patients with

chest tube drainage.

? Assessment of knowledge level of staff nurses regarding management of

patients with chest tube drainage revealed that majority of respondents (90%)

had poor knowledge and only 3.33% of respondents had good level of

knowledge.

? The total mean percentage of the knowledge scores was 56.37% with mean and

SD 19.73 ± 4.46. Area-wise mean percentage of knowledge scores was 58.83%

in the area, ‘mechanisms and principles of chest tube drainage ’with mean and

SD 3.53 ± 1.61.

? Item-wise analysis of pre-test scores in the area ‘ anatomy and physiology

including signs and symptoms’ revealed that the highest percentage (83.33%) of

respondents responded correctly to the item, ‘ pleura is the covering of lungs’. In

relation to the area of ‘mechanisms and principles involved in chest tube

drainage’ 80% of respondents knew that ‘normal atmospheric pressure is

760mm of Hg’. In relation to the area of ‘assessment, and care of patients with

chest tube drainage and prevention of complications’, 93.33% of respondents

responded correctly to the item “when tube becomes disconnected accidentally,

clamp the tube, cut off contaminated ends of the tube and reattach immediately

to the drainage system”.

 82

? Quartile distribution of the pre-test and post-test scores of staff nurses regarding

management of patients with chest tube drainage showed a very high

significance between pre- test and post- test knowledge scores. This revealed

that there is significant increase in the knowledge of staff nurses after

administration of self instructional module.

? Comparison of pre-test and post-test knowledge scores of staff nurses showed

that in pre-test maximum number of staff nurses (17) scored between 18-22 and

in post-test maximum number of staff nurses (20) scored between 34-38. This

revealed that the self instructional module was effective.

 83

IMPLICATIONS

The findings of the study have implications for nursing education, practice,

administration and nursing research.

Nursing practice:

Nurses play a vital and major role in the health care delivery system. There is

a fundamental link between ‘education and practice’ as the need for education is to

inform and influence the development of nursing practice and thereby improve the

delivery of patient care. The concept of enhanced professional recognition was

highlighted as important to the nurse’s ability to deliver high standards of care. By

using teaching strategies that are best suited to staff nurses, a nurse educator can

motivate them to deliver higher standards of patient care.

Nursing Education

The nursing curriculum is responsible for preparing the future nurses. The

nursing curriculum should emphasize much on different aspects of patient care and

management. Management should be focused on certain critical procedures in the

intensive care units. Since chest tube drainage is the most common intervention

performed in ICU patients, student nurses should be able to provide care for patients

with chest tube drainage. But little is taught about the same in nursing programmes,

so nurse educators have the additional responsibility to update the knowledge of staff

nurses through various educational programme.

 84

Nursing administration

Nurse administrators should be able to identify the educational needs of staff

nurses through continuous scrutiny and periodical examination systems. As a result

of which in-service educational programme and post-registration education

programme should be organized for maintaining and improving the nurse’s

professional knowledge and competence. Nurse administrators must see that a

separate budget should be allocated for post-registration education programme for

nurses working in various departments.

Nursing research

There is a great need for research in the area of nursing education in clinical

settings particularly about management of patients with chest tube drainage. Also

research on newer methods of teaching, focusing on the nurse’s interest, quality of

nursing care and cost effectiveness is needed.

Limitations

1. The study was confined to a fewer number of subjects, which limit the

generalization of the findings.

2. A structured knowledge questionnaire was used for data collection, which

restricts the amount of information that can be obtained from the respondents.

3. Only the knowledge of staff nurses on management of patients with chest tube

drainage was assessed, no attempt was made to assess the subsequent

application of knowledge gained into practice.

4. No attempt was made to do the follow up, to measure retention of knowledge

of staff nurses.
 85

5. The study did not use a control group. The investigator had no control over

the events that took place between pre- test and post-test.

Recommendations

1. The study can be repeated on a larger sample thereby findings can be

generalized.

2. A similar study can be conducted using other teaching strategies like PTP.

3. A similar study can be conducted in terms of gain in skill of staff nurses.

4. An experimental study can be undertaken with a control group.

5. A study to determine cost effectiveness of educational materials can be

conducted.
 86

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Lippincott Williams and Wilkins publishers; 2001.

 92

59. Pritchard Phylip A., Mallet J. The royal marsden hospital-manual of clinical

nursing procedures. 3rd ed. Great Britan: Blackwell scientific Publications;

1994.

60. Blank-Reid A.C. Taking the tension out of traumatic pneumothoraxes.

Nursing 99; 2001; 119: 41-48.

www.nursingcenter.com
http://www.springnet.com

61. Tortora J.G., Grabowski S.R., Principles of anatomy and physiology. 10th ed.

USA: Johnwiley and sons Inc; 2003.

62. Ellis R.J., Hartley C.L. Nursing in todays world. 2nd ed. USA: J.B.Lippincott

company; 1984.

63. Gupta S.P. Statistical methods. 26th ed. New Delhi : Sultanchand and sons

publishers; 1994.

64. Mahajan B.K. Methods in Biostatistics. 6th ed. New Delhi: Jaypee brothers

medical publishers; 2004.

65. Rao P.S.S.S., Richard J. An introduction to biostatistics. 3rd ed. New Delhi:

Ashok publishers; 2003.

 105

ANNEXURE – 10

DESCRIPTION OF THE TOOL

Instructions to the reader

v This questionnaire is based on a self-instructional module regarding nursing

management of patients with chest tube drainage.

v Mark the correct answer (in the given brackets) from the given choices.

v This questionnaire consists of 2 parts.

PART I : structure questionnaire to collect the demographic data. It consists of seven

items such as sample number, designation, area of working, age, gender, professional
qualification and total years of experience

PART II : Review questions to assess the knowledge of staff nurses on nursing

management of patients with chest tube drainage.

Unit I : Anatomy and physiology of chest including signs and symptoms (15 items).

Unit II : Mechanisms and principles of chest tube drainage (6 items)

Unit III : Assessment and care of patients with chest tube drainage (14 items)
 106

QUESTIONNAIRE FOR ASSESSING THE KNOWLEDGE REGARDING

NURSING MANAGEMENT OF PATIENTS WITH CHEST TUBE
DRAINAGE

PART – I

DEMOGRAPHIC PROFORMA

1 Code no. : ( )
2 Designation : ( )
3 Area of working : ( )
4 Age : ( )

(4.1) 20-30 yrs ( )

(4.2) 31-40 yrs ( )

(4.3) 41-50 yrs ( )

(4.4) > 50 yrs ( )

5 Gender : ( )

(5.1) Male ( )

(5.2) Female ( )

6 Professional qualification : ( )

(6.1) GNM ( )

(6.2) B. Sc. Nursing ( )

(6.3) Post basic B.Sc. Nursing ( )

7 Total years of experience : ( )

(7.1) Below 5 yrs ( )

(7.2) 6-10 yrs ( )

(7.3) > 11 yrs ( )

 107

PART- II
REVIEW QUESTIONS

UNIT I – ANATOMY AND PHYSIOLOGY INCLUDING SIGNS AND

SYMPTOMS

8 Which organ is located in the mediastinum ?

(8.1) liver ( )

(8.2) heart ( )

(8.3) kidney ( )

(8.4) spleen ( )

9 How many lobes does the right lung have?

(9.1) one ( )

(9.2) two ( )

(9.3) three ( )

(9.4) four ( )

10 Which of the following is the covering of lungs?

(10.1) peritoneum ( )

(10.2) pleurae ( )

(10.3) pericardium ( )

(10.4) periosteum ( )

11 Which one of the following is the inner membrane covering the lungs?

(11.1) epicardium ( )

(11.2) peritoneum ( )

(11.3) visceral pleurae ( )

(11.4) pericardium ( )
 108

12 What are the functions of intra pleural fluid?

(12.1) lubrication and promotion of friction ( )

(12.2) lubrication and prevention of friction ( )

(12.3) lubrication and lung expansion ( )

(12.4) lung expansion and promotion of friction ( )

13 What is the average amount of fluid present in the intra-pleural space in an

healthy adult?

(13.1) < 10ml ( )

(13.2) 10-15 ml ( )

(13.3) 15-20ml ( )

(13.4) 20-25ml ( )

14 Where is the respiratory centre situated?

(14.1) pons and cerebrum ( )

(14.2) medulla and pons ( )

(14.3) cerebrum and cerebellum ( )

(14.4) medulla and cerebrum ( )

15 What happens during Inhalation?

(15.1) diaphragm contracts and chest cavity increases ( )

(15.2) diaphragm relaxes and chest cavity decreases ( )

(15.3) diaphragm contracts and chest cavity decreases ( )

(15.4) diaphragm relaxes and chest cavity increases ( )

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16 What is the name of the health problem when excess air is collected within
the pleural space?

(16.1) pneumothorax ( )

(16.2) hemothorax ( )

(16.3) chylothorax ( )

(16.4) hemopneumothorax ( )

17 What is the advantage of chest tube drainage?

(17.1) it promotes lung expansion ( )

(17.2) it helps to increase positive pressure ( )

(17.3) it helps in maintaining lung elasticity ( )

(17.4) it helps to decrease negative pressure ( )

18 Which is the most common indication for inserting a chest tube?

(18.1) pneumothorax ( )

(18.2) pneumonia ( )

(18.3) emphysema ( )

(18.4) chylothorax ( )

19 Which of the following is an indication for chest tube drainage?

(19.1) coronary artery bypass grafting ( )

(19.2) pneumonectomy ( )

(19.3) laparotomy ( )

(19.4) balloon angioplasty ( )

 110

20. What happens in an open pneumothorax ?

(20.1) opening of outerchestwall allowing air to enter inside ( )

pleural space

(20.2) intact outer chestwall allowing air in pleural space ( )

(20.3) opening of outer chest wall allowing blood to enter ( )

pleural space

(20.4) intact outer chest wall preventing air to go out of ( )

pleural space

21 Which of the following is appropriate for the term

“crepitus” ?

(21.1) muffled heart sound ( )

(21.2) palpable subcutaneous emphysema ( )

(21.3) soft whistling sound on inspiration ( )

(21.4) loss of breath sound on affected side ( )

22. Which of the following is a major sign, noticed during assessment

of a patient with pneumothorax ?

(21.1) decreased heart rate ( )

(21.2) increased respiratory rate ( )

(21.3) decreased central venous pressure ( )

(21.4) decreased respiratory rate ( )

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UNIT – II -MECHANISMS AND PRINCIPLES INVOLVED IN CHEST TUBE

DRAINAGE

23. What are the major principles of chest tube drainage?

(23.1) gravity, suction and friction ( )

(23.2) water-seal, suction and exposition ( )

(23.3) gravity, water-seal and suction ( )

(23.4) gravity, water-seal and repulsion ( )

24. What is the important advantage of a water-seal drainage?

(24.1) It acts as a barrier between atmospheric and Intrapleural ( )

pressure

(24.2) It acts as a barrier between subatmospheric and Intrapleural ( )

pressure

(24.3) It helps to prevent backflow of water into intrapleural space ( )

(24.4) It helps to suck back the atmospheric pressure into the ( )

pleural space

25. What is the normal atmospheric pressure?

(25.1) 620mmHg ( )

(25.2) 670mmHg ( )

(25.3) 720mmHg ( )

(25.4) 760mmHg ( )

26. Which of the following process occurs when chest tube drainage insertion
begins?

(26.1) the negative pressure increases and the lung expands. ( )

(26.2) the positive pressure increases and lung collapses. ( )

(26.3) the negative pressure increases and lung collapses. ( )

(26.4) the positive pressure increases and lung expands. ( )

 112

27. Which one of the following is an indication for suctioning in a water seal
drainage system?

(27.1) when gravity drainage is adequate ( )

(27.2) when a person’s coughing and respirations are weak ( )

(27.3) when air-leak to the pleural space is slower ( )

(27.4) when the removal of air from pleural space is adequate ( )

28. What is the inference of bubbling at the end of drainage tube?

(28.1) presence of persistent air leak from the lung ( )

(28.2) inadequacy in suctioning ( )

(28.3) intact and air tight drainage system ( )

(28.4) need for more deeper insertion of the tube in the water-seal ( )

UNIT – III- ASSESSMENT, CAREOF PATIENT WITH CHEST TUBE

DRAINAGE AND PREVENTION OF COMPLICATION

29. What is the sign to be assessed for subcutaneous emphysema in the patient ?

(29.1) presence of “rice crispies” which is painless and spongy ( )

(29.2) presence of bluish discolouration in the chest area ( )

(29.3) presence of tenderness around the chest area

(29.4) presence of subcutaneous nodules around the chest area ( )

30. Which assessment is to be carried out before inserting chest tube ?

(30.1) SPO2 reading ( )

(30.2) ABG reading ( )

(30.3) coagulation Profile ( )

(30.4) All the above ( )

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31. Which is the site for inserting chest tube in haemothorax ?

(31.1) between 2nd and 3rd intercostal space ( )

(31.2) between 4th and 6th intercostal space ( )

(31.3) between 6th and 8th intercostal space ( )

(31.4) between 1st and 2nd intercostal space ( )

32. Which of the following positions is best suitable for chest tube insertion in
pneumothorax ?

(32.1) high- fowler’s position ( )

(32.2) prone position ( )

(32.3) left-lateral position ( )

(32.4) trendelenberg position ( )

33. Which is the best site for inserting chest tube in pneumothorax ?

(33.1) in the 2nd and 3rd intercostal space ( )

(33.2) in the 4th and 5th intercostal space ( )

(33.3) in the 6th and 7th intercostal space ( )

(33.4) in the 7th and 8th intercostal space ( )

34. Why should the water level be marked on the bottle daily?

(34.1) it serves as a basis for fluid replacement. ( )

(34.2) it serves as a basis for air replacement ( )

(34.3) it shows the amount of fluid collected ( )

(34.4) it shows the amount of air collected. ( )

35. Why should kinking and looping of chest tubes be avoided?

(35.1) this produces back pressure, thus enhancing back flow. ( )

(35.2) this decreases back pressure thus decreasing back flow. ( )

(35.3) this helps to maintain normal intrapleural pressure. ( )

(35.4) this does not help to force drainage into intra pleural space. ( )
 114

36 What is the reason for encouraging high fowler’s position for a patient with
chest tube drainage?

(36.1) this helps in preventing kinking and looping. ( )

(36.2) this helps in preventing postural deformity and ( )

contractures.

(36.3) this helps in preventing accumulation of fluid and air ( )

(36.4) this helps in maintaining normal intrapleural pressure. ( )

37 What is the advantage of ROM (Range Of Motion) exercises for a patient with
chest tube?

(37.1) it helps in maintaining lubrication. ( )

(37.2) it helps in lessening post operative pain. ( )

(37.3) it helps in preventing air leak from the drainage system. ( )

(37.4) it help maintaining normal intrapleural pressure ( )

38 Which of the following helps maintaining the patency of the chest tubes

(38.1) milking and tidaling ? ( )

(38.2) deep breathing and coughing. ( )

(38.3) milking and stripping. ( )

(38.4) stripping and tidaling. ( )

39 When does the fluctuation of fluid in the tubing stops?

(39.1) when the lungs reexpand ( )

(39.2) when the tubings are patent ( )

(39.3) when there is no dependent loops ( )

(39.4) when suction is operating properly ( )

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40 Which is the most important precaution to be taken while transporting a

patient with chest tube drainage?

(40.1) keep the drainage system at the lowest level from chest. ( )

(40.2) keep the drainage system at the chest level. ( )

(40.3) keep the drainage system above the chest level. ( )

(40.4) disconnect the drainage system from the tubings. ( )

41 Which one of the following should be practiced during chest tube removal?

(41.1) advising the patient to hold breath. ( )

(41.2) advising the patient to cough. ( )

(41.3) instructing the patient to close eyes. ( )

(41.4) checking the patency of the tube. ( )

42 What is the immediate intervention when tube becomes disconnected accidentally

from chest drainage system?

(42.1) reattach tube immediately to drainage system. ( )

(42.2) discontinue suction immediately and reattach the tube ( )

(42.3) clamp the tube, cut off contaminated end of the tube and ( )
reattach immediately.

(42.4) cut off the tube while suctioning is continued. ( )

 116

ANSWER KEY TO THE STRUCTURED KNOWLEDGE QUESTIONNAIRE

S. No. Answers. S. No. Answers.

(8) 8.2 (31) 31.2
(9) 9.3 (32) 32.1
(10) 10.2 (33) 33.1
(11) 11.3 (34) 34.3
(12) 12.2 (35) 35.1
(13) 13.4 (36) 36.2
(14) 14.2 (37) 37.2
(15) 15.1 (38) 38.3
(16) 16.1 (39) 39.1
(17) 17.1 (40) 40.1
(18) 18.1 (41) 41.1
(19) 19.1 (42) 42.3
(20) 20.1
(21) 21.2
(22) 22.2
(23) 23.3
(24) 24.1
(25) 25.4
(26) 26.1
(27) 27.2
(28) 28.1
(29) 29.1
(30) 30.4
 117

Self-Instructional Module on
Nursing Management
of Patients with Chest
tube drainage
 118

ANNEXURE - 11

LIST OF CONTENTS

Sl. No. Content Page No

1 Introduction 119

2 Objectives 120

3 Guidelines 120

4 Unit-I-Objectives 121

5 Anatomy and physiology of chest 121

6 Meaning and Indications of chest tube drainage 123

7 Signs and symptoms 125

8 Unit II- Objectives 126

9 Principles involved in chest tube drainage 126

10 Mechanisms of Chest tube drainage 128

11 Unit III- Objectives 132

12 Assessment and care of patient during chest tube Insertion 132

13 Positions used for chest tube drainage 133

Nursing care of patient after insertion and prevent

14 134
complications

15 Summary 140
 119

SELF INSTRUCTIONAL MODULE ON NURSING

MANAGEMENT OF PATIENTS WITH CHEST TUBE
DRAINAGE

Introduction

Lungs are the vital organs for respiration. Our lungs are protected by 12 pairs

of ribs, which shape and support our chest wall. The lungs are covered by a double-

layered serous membrane called pleura. They are the visceral and parietal pleurae.

The space between the pleura is the intra pleural fluid which helps in lubrication and

prevents friction between the lungs and chest wall.

Any condition that hampers the normal intra-pleural pressure can lead to the

accumulation of air or fluid in the chest cavity causing lung collapse. When lung

collapse occurs, chest tubes are inserted to the intra-pleural space to allow drainage to

restore normal intra- pleural pressure and permit the expansion of lung.

Nurses working in cardio-thoracic units must have a thorough knowledge

regarding the care of patient from life-threatening situations.

This package helps to acquire knowledge regarding care of patient with chest

tube drainage.

General Objective:-

After studying this self instructional module, the staff nurses will be able to

understand the definition, indications, mechanisms and complication, signs and

symptoms and care of patient with chest tube drainage.

 120

Specific objective:-

- Meaning of chest tube drainage.

- List the indications of chest tube drainage.

- Explain the mechanisms and principles involved in chest tube drainage.

- Describe the care of patient with chest tube drainage.

Guidelines for using Self Instructional Module:-

Self-instructional module is one of the educational materials that help in

individualized learning. It is important to go through the module in a systematic way

from beginning till the end. This module consists of 3 units. Each unit has its own

objectives.

- Take your own time to read this material.

- Try to answer the questions given in structured questionnaire on nursing

management of patients with chest tube drainage.

 121

UNIT-I

This unit deals with anatomy and physiology, definition, indication and signs

and symptoms of chest tube drainage.

Objectives: -

After reading this unit, you must be able to

1. Review the anatomy and physiology of lungs.

2. Meaning of chest tube drainage.

3. List the indications of chest tube drainage.

4. List the signs and symptoms of pneumothorax

UNIT-I

ANATOMY AND PHYSIOLOGY OF CHEST

Heart is a pumping organ that lies in an area called mediastinum. The

mediastinum also encloses the esophagus, trachea, aorta and major vessels, the vagus,

and phrenic nerves and other lymphatic glands.

The trachea or wind pipe is about 4 inches and extends from the larynx to

about the level of fifth thoracic Vertebra, where it divides into 2 bronchi. The bronchi

passes downwards and outwards towards the roots of the lungs.

 122

The lungs are the principal organ of respiration and are two in number. They

fill the chest cavity, lying one on each side separated in the middle by the heart and

blood vessels. The lungs are cone shaped organs, with apex above, rising a little

higher than the clavicle into the root of the neck and base of the lungs lying on the

floor of the thoracic cavity on the diaphragm.

The lungs are divided into lobes by fissures. The right lung has three lobes and

left lung has 2 lobes. Each of these lobes are composed of a number of lobules. A

small bronchial tube enters each lobule and subdivides, into smaller bronchioles and

finally ends in dialated sacs called alveoli.

Each lung is covered by a double serous membrane called pleurae. Pleurae are

of 2 layers. The parietal pleura lines the chest cavity and the visceral pleura lines the

lungs. The space between these membranes is known as the intrapleural space. A

healthy adult has approximately 20-25ml of fluid in the intrapleural space.

Breathing involves both inspiration and expiration. It is an event that is

regulated by the CNS through the respiratory centres in the medulla and pons. During

inhalation air is taken into the lungs and the diaphragm flattens or contracts. The size

of chest-cavity increase allowing the lungs to expand. During exhalation, the

diaphragm relaxes and the size of chest cavity is decreased.

Negative pressure is present in the intra pleural space and creates a vaccum or

suction called intrapleural pressure. This keeps the lungs against the chest wall, for,

expansion of the lungs against the chest wall during inhalation. When the intrapleural

pressure is lost or disrupted the lung collapses.

 123

Ø Meaning
Chest tube drainage is the insertion of a tube into the pleural space to evacuate

air or fluid, to help regain negative pressure and thus promote lung expansion.

Ø Indications Of Chest Tube Drainage

(1) Pneumothorax A Pneumothorax is defined as air within the

intrapleural space.

Pneumothorax

Pneumothorax are of 2 types

(1) Open and (2) closed

Open Pneumothorax Occurs when an opening in the outer chest wall allows

air to enter the pleural space.

Closed Pneumothorax Occurs when the outer chest wall and Parietal Pleura
remain intact but the injured visceral pleura allows air to escape into the pleural space
from the lung

Open Pneumothorax Closed Pneumothorax

 124

(2) Tension Pneumothorax It is an injurious hazardous condition which

occurs when air is allowed to escape into the pleural space during inspiration but

cannot escape during expiration. As this increase, there is a small shift of the

mediastinum.

(3) Hemothorax A hemothorax in defined as blood within the pleural

space.

Blood

(4) Pleural effusion Accumulation of fluid within the pleural space

that compress the lung tissue is called as pleural effusion.

(5) Empyema Pleural effusion which is purulent secondary to

pneumonia, abscess or contamination from injury.

(6) Chylothorax Lymph fluid within the pleural space.

(7) Post Operative Cardiothoracic surgery Such as coronary artery graft,

valve replacement and lobectomy.

A chest tube is not placed for a patient undergoing surgical Pneumonectomy.

 125

Signs and Symptoms of Pneumothorax

Ø Shortness of breath

Ø Increased respirations-tachypnoea

Ø Falling SaO2 values

Ø Loss of breath sounds on the affected side

Ø Palpable subcutaneous emphysema or crepitus

Ø Lack of movement on affected side

Ø Falling blood pressure.

Ø Distended neck veins

Ø Increased central venous pressure

Ø Tracheal deviation to the unaffected side

Ø Cyanosis

Ø Muffled heart sound

Ø Severe cough and cold.

 126

UNIT – II

This unit deals about the mechanisms and principles involved in chest tube

drainage.

Objectives

After reading this unit, you must be able to,

1) List the principles involved in chest tube drainage system.

2) Explain the mechanisms involved in the chest tube drainage system.

UNIT-II

MECHANISMS AND PRINCIPLES INVOLVED IN CHEST TUBE

DRAINAGE

Principles Used In Closed Chest Drainage Systems

Three principles are used in all closed drainage system

Ø Gravity

Ø Water-seal

Ø Suction

Ø Gravity: - Air and fluid flow from a higher level pressure to a lower level

pressure. Therefore always keep chest drainage apparatus below

the level of the persons chest.

Ø Water Seal: - A water seal provides a barrier between atmospheric

pressure (pressure on the outside of the body) and subatmospheric (negative)

 127

Intrapleural pressure (normal, 754 to 758mm of Hg).

On Expiration Air and fluid from pleural space,

?
From chest travel through the drainage into 1st
To suction
chamber compartment
?
Air bubbles up through the bottle
and enters atmosphere air.
Drainage fluid Water Seal

On Inspiration water seal prevents atmospheric air from being sucked back to

the Pleural space.

As air and fluid drainage starts, the pressure in the pleural Space becomes

negative.

REMEMBER “The greater the negative pressure, the more the lung expands”.

Negative pressure increases

Lung expansion

Ø Suction:- Suction is a pull force of less than atmospheric pressure.

To
From suction
Water
seal
 128
Normal Atmospheric
pressure ? 760mmhg

L
Ø Suction is applied for the following cases:-

Ø (i) If gravity drainage is not adequate.

Ø (ii) If a persons cough and respirations are too weak to force air and fluid out of

the pleural space through chest catheters.

Ø (iii) If air is leaking into the pleural space faster than it can be removed by a

water-seal apparatus.

Ø (iv) To speed up the removal of air from the pleural space.

Suction is regulated by pulling atmospheric air through the long tube that is

immersed in 10-20 cm of water. The immersed tube provides a barrier between

atmospheric air and water.

REMEMBER ? “The deeper the tube is immersed in water, the more suction is

created”.

Mechanisms Of Chest Tube Drainage

Ø Single-Bottle water-seal system

Ø Two-Bottle water-seal system

Ø Three-Bottle water-seal system

Ø Pleur-Evac system.
 129

- Chest drainage system

(A) ? Placement of &
chest catheter in the
pleural space
(B) ? Three types of
mechanical drainage
From chest From chest
systems

From chest
To suction

? The single–bottle water seal system

The single-bottle water seal system will initially contain 100ml of sterile water

along with an air tight cap with 2 vent tubes. The air vent is the shorter tube. The air

vent should always be patent so that pressure won’t build up inside the bottle.

The tube from the patient extends approximately 2.5cm (one inch) below the

level of the water in a container. The water level fluctuates as the patient breaths. It

goes up when patient inhales and down when patient exhales.

Airvent (patent)
Air tight cap

The single – bottle waterseal system

2.5cm
 130

REMEMBER ? At the end of the drainage tube, bubbling may or may not be

visible. Bubbling can mean either persistent leakage of air from the lung or a leak in

the system.

Two – bottle water-seal system

Air vent

Drainage bottle Water-seal bottle

This system consists of a fluid-collection bottle and a water-seal chamber.

The drainage is similar to that of a single unit, except that when pleural fluid

drains, the water seal system is not effected by the volume of the drainage.

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

the system.

? Three – bottle water-seal system

The three-bottle system is similar in all respect to the two-bottle system,

except for the addition of a third bottle to control the amount of suction applied.
To suction
From chest

3-bottle water seal

system

Drainage fluid Water Seal Suction control

 131

In the three-bottle system (as in other two systems) drainage depends on

gravity or the amount of suction applied. The amount of suction in the 3-bottle system

is controlled by the manometer bottle.

In the third bottle, A short tube above the water-level comes from the water-

seal bottle. Another short tube leads to the vacuum or suction motor or wall suction.

The third tube is along tube that extends below the water level in the bottle.

REMEMBER The deeper the tube, more is the suction or vacuum created.

× The Pleur –Evac operating system

The Pleur Evac

operating system

Pleur-Evac operating system is having 3 chambers

1. The collection chamber.

2. The water-seal chamber
3. The suction control chamber

The pleur-Evac is a single unit operating system with all 3-bottles identified as

“chambers”. The principles of Pleur-Evac drainage remains the same as the 3-bottle

systems.
 132

UNIT-III

This unit deals with the assessment and care of patient with chest tube

drainage, during insertion, after insertion and during removal of the chest tube and

also to prevent complications.

Objectives

After reading this unit, you must be able to,

1. Assess the patient before chest tube insertion.

2. Provide care during insertion of chest tube.

3. Manage a patient with chest tube drainage and prevent complication.

4. Provide care during removal of chest tubes.

UNIT III

Nursing Care of Patient with Chest Tube Drainage and Complications

Nursing assessment

? Assess the vital signs, lung sounds, skin colour, and cardiac status of the patient.

? Assess the patient for pneumothorax, hemothorax, and also presence of respiratory

distress.

? Check for the presence of “rice crispies” feeling which occurs in subcutaneous

emphysema due to presence of air beneath the skin around the chest area. This is

painless and spongy.

? Assess the level of anxiety of the patient and explain the steps of the procedure

involved.
 133

? Tell the patient to expect a needle prick feeling and a sensation of slight pressure

during infiltration anaesthesia.

? Obtain an informed consent from patient if alert or from family members.

? Provide privacy and emotional support.

? Assess the level of consciousness, SpO2, ABGs and coagulation profile.

Nursing Care of Patient During Chest Tube Insertion

? After assessment and taking consent from the patient the site is shaved when

indicated.

? After preparation of patient, gather all the equipments necessary for chest tube

drainage. This include; sterile gloves, sterile drape, betadine solution, 1% lidocaine,

alchohol sponge, 10CC syringe, 22G 1 inch and 22G 5/8th inch needles, sterile

forceps and scalpel, one rubber tipped clamp for each chest tube inserted, sterile

gauze pads, sterile 4 x 4s, trocar, suture kit and thoracic drainage system with its

collection tubc. A # 16-20 French catheter is inserted for air or serous drainage; a #

28 to # 40 is inserted for serous, thick on purulent drainage.

? An oxygen source, suction and emergency equipment must be ready

? Administer pain medication and sedation as ordered

? Reduce anxiety, make the patient comfortable and explain the procedure to the

patient

? Positions Used For Chest Tube Drainage

Ÿ For hemothorax Patient is made to sit up and leaned over a bedside table,

hugging several pillows. Here chest tube is inserted between fourth and sixth

intercostal space at the mid axillary line.

 134

Site for hemothorax

Ÿ For pneumothorax Patient is placed supine, high fowlers position or semi

fowlers positon. The tube is inserted in the second or third intercostal space in the

anterior chest at the midclavicular line.

Pneumothorax

? After proper positioning, remind and assist the patient to avoid movement or

coughing during the insertion of tube.

 135

? Once the chest tube is inserted, it may either be clamped or connected to the

drainage system

? Reassure the patient and explain the steps of the procedure

? Vaseline gauze may be placed over the chest tube insertion site to ensure adequate

seal

Nursing Care of Patient after Insertion and Prevent Complication

? Attach the drainage tube from the pleural space (the patient) to the tubing that leads

to a long tube with end submerged in sterile normal saline.

? Check the tube connections periodically. Tape it if necessary

(a) Long tube should be approximately 2.5cm below the water level.

(b) Short tube is left open to the atmosphere

? Mark the original fluid level with tape on the outside of the drainage

bottle. Mark hourly/daily increments that include, the date, time and

amount of drainage collected.

Why ?

L
Marking will show the amount of fluid
loss and how fast fluid is collecting in the
drainage bottle. It serves as a basis for
blood replacement.
 136

? Make sure the tubing does not loop or interfere with the movements of

the patient
??
?

L
Kinking, looping or pressure on the
drainage tubing can produce back
pressure, thus possibly forcing drainage
back into the pleural space.

? Encourage the patient to assure a position of control and also encourage

good body alignment.

The patients position should be changed

Ha ha ha I know frequently to promote drainage and body
is kept in good alignment to prevent
postural deformity and contractures

? Put the arm and shoulder of the affected side through range of motion

exercises several times daily. Some pain medications may be necessary.

L
Exercises help to avoid ankylosis of the
. . !!!! I don’t know why? shoulder and assist in lessening
postoperative pain and discomfort.

? “Milk” the tubing in the direction of the drainage bottle as often as ordered

Insertion
in
chest
(a) Stripping (b) Milking

To drainage
 137

“Milking” and “stripping” chest tubes is performed carefully to remove blood clots.

Constant attention to maintain the patency of the tube will facilitate prompt expansion

of the lung and minimize complications.

? Watch for leaks of air in the drainage system as indicated by constant bubbling in

the water-seal bottle.

(a) Report excessive bubbling in the water

seal drainage immediately as leaking

and trapping of air in the pleural space

can result in tension pneumothorax.

Caution
Please !!! (b) “Milking” of chest tubes in patient with

air leak should be done only if requested

by surgeon.

? Observe for and report immediately signs of rapid, shallow breathing,

cyanosis, pressure in the chest, subcutaneous emphysema, or

haemorrhagic symptoms.

? Encourage patient to breathe deeply and cough at frequent intervals.

Remember

L
Deep breathing and coughing help to
raise the intrapleural pressure, which
allows drainage of any air or fluid
accumulated in the pleural space.
 138

Remember

L
This is done only as per different
institutional policies because stripping
and milking can cause increased
intrapleural pressure.

? Make sure there is fluctuation (“tidaling”) of the fluid level in the long
glass tube.

L
1. Fluctuation of the water level in the tube shows
???? Why is it so ?
that there is effective communication between
the pleural space and the drainage bottle.

2. It also provides valuable indication of the

patency of the drainage system.

? Fluctuation of fluid in the tubing will stop when:-

Remember

L
(1) The lung has reexpanded

(2) The tubing in obstructed by clots.

(3) A dependent loop develops.

(4) Suction is not properly operating.

If the chest tube becomes dislodged then

(a) Immediately cover the site with a dry
sterile dressing and call the clinician.
(b) If you hear air leak from the site, tape the
Hmm…That
is so dressing on only two or three sides to
serious….
allow air escape and prevent a tension
pneumothorax.

L c) Closely monitor the patient and prepare

for insertion of a new chest tube.

d) Assess for the collection of air or gas

under skin and if present notify as this
indicates subcutaneous emphysema.
 139

? If there is any sign of incision pain, adequate pain medications are given

as indicated.

? If patient has to be transported to another area, place the drainage

system (or bottle) below the chest level. (as close to the floor as

possible).

The drainage apparatus is kept at a

Listen carefully … ok
???
level lower than the patient’s chest

L L to prevent backflow of fluid into the

pleural space.

? If the tube accidentally becomes disconnected…

What will
I do?

L
(a) Cut off the contaminated ends of the tube.

(b) Submerge the chest tubes distal end in 2.5 cm of sterile 0.9% normal saline.

(c) Insert a sterile connector in the chest tube tubing and reattach to drainage system
in case of chest drainage units in less than one minute.

Nursing care of patient during chest tube removal.

Ø Administer pain medications 30 minutes before removal of chest tubes.

Ø Disconnect the suction generally 24 hrs before anticipated removal. This varies

according to different physician order.

Ø Don’t clamp the chest tube before discontinuing suction because it can cause the

lung to collapse.
 140

Ø Explain the procedure to the patient and provide psychological support

Ø Reassure the patient and advise the patient to follow the instructions

Ø Instruct the patient to perform a gentle Valsalva maneuver or to take deep breath

and hold it when instructed or ordered.

Ø The chest tube is clamped and removed.

Ø Simultaneously, a small bandage is applied and made air tight with petroleum

gauze covered by a 4X4 inch gauze and thoroughly covered and sealed with tape.

Ø Check the site for any complications regularly (by taking vital signs, daily

dressing, and maintaining stability of the patient).

Summary

High quality nursing care for a patient with chest tube drainage can be

provided only if the staff nurses are having thorough knowledge regarding anatomy

and physiology of chest, mechanisms and principles of chest tube drainage and the

care of patient before insertion, during insertion and during removal of the chest tube.

This module provides all the necessary information regarding the care of patient with

chest tube drainage.

 141

ANNEXURE – 12

FORMULAE USED FOR ANALYSIS AND INTERPRETATION

 ANNEXURE - 13
MASTER DATA SHEET ON DEMOGRAPHIC VARIABLES

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
4 4.1 ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü
4.2 ü ü ü ü ü ü ü
4.3 ü ü
4.4 ü ü
5 5.1 ü ü ü ü ü ü ü ü ü ü
5.2 ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü
6 6.1 ü ü ü ü ü ü ü ü ü ü ü ü ü ü
6.2 ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü
6.3 ü
7 7.1 ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü
7.2 ü ü ü ü ü ü ü ü ü
7.3 ü ü ü ü

142
 ANNEXURE - 14
MASTER DATA SHEET ON PRE-TEST KNOWLEDGE SCORES
ITEMS
SUBJECTS 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42
1 ü ü ü ü ü ü ü ü ü ü 0 0 0 0 0 ü ü 0 0 0 0 0 0 0 ü 0 ü ü 0 0 ü ü ü ü ü
2 ü ü ü ü ü ü ü 0 0 0 ü 0 0 0 0 ü ü ü 0 ü ü 0 ü 0 ü 0 ü ü 0 0 0 ü ü ü ü
3 ü ü ü ü ü 0 0 ü 0 0 ü 0 ü 0 0 ü ü ü ü ü ü 0 0 0 ü ü ü ü 0 0 ü ü ü ü ü
4 ü ü ü ü 0 0 0 0 0 0 ü 0 0 0 ü ü ü ü ü ü ü 0 ü 0 0 ü ü ü ü 0 ü ü ü ü ü
5 0 0 ü 0 0 0 0 ü 0 ü 0 ü ü 0 ü ü 0 ü ü ü 0 ü ü ü ü ü 0 0 ü ü ü ü ü ü 0
6 0 0 0 0 0 0 0 0 0 ü ü 0 0 0 ü 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ü
7 ü ü ü ü ü 0 ü ü ü 0 ü 0 ü 0 0 0 0 ü ü ü ü 0 0 0 ü ü ü ü 0 0 ü ü ü ü ü
8 0 ü 0 ü 0 ü ü 0 ü 0 0 ü ü 0 ü 0 0 ü ü 0 0 ü ü ü 0 ü 0 ü 0 0 0 ü ü ü ü
9 ü ü ü 0 ü 0 0 0 0 0 ü 0 ü 0 0 ü ü ü ü ü 0 0 ü 0 ü ü 0 ü 0 0 ü ü ü ü ü
10 ü ü ü ü ü ü ü ü ü 0 ü ü ü 0 0 0 0 ü 0 0 0 0 0 0 ü ü ü ü ü 0 0 0 ü ü ü
11 0 ü ü ü 0 ü ü ü ü 0 0 ü ü 0 0 ü 0 ü ü ü ü ü ü 0 ü ü 0 ü 0 ü 0 ü ü ü ü
12 ü ü ü ü 0 0 ü ü ü 0 0 ü 0 0 0 ü 0 ü 0 ü ü ü ü ü ü 0 ü 0 0 ü 0 0 ü 0 ü
13 ü 0 0 ü 0 0 0 0 ü ü ü 0 ü 0 0 ü 0 ü ü ü ü ü ü 0 ü 0 0 ü 0 0 0 ü ü ü ü
14 ü 0 ü 0 0 ü 0 0 ü 0 ü ü ü 0 0 0 ü 0 0 ü ü 0 ü 0 ü 0 ü ü ü ü ü ü ü ü ü
15 ü 0 ü ü 0 0 0 ü ü 0 0 0 0 0 ü 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ü ü ü
16 ü ü ü ü ü 0 ü ü ü 0 ü 0 0 0 0 ü 0 0 0 ü ü 0 0 ü ü ü ü ü 0 0 ü 0 0 ü ü
17 ü ü ü ü ü ü ü ü ü ü 0 0 ü 0 0 ü ü ü 0 ü ü 0 0 0 ü 0 ü ü 0 0 0 ü ü ü ü
18 ü ü ü ü ü ü ü ü ü 0 ü ü ü 0 ü ü ü ü 0 ü ü 0 ü ü ü ü 0 0 0 0 0 ü ü ü ü
19 ü ü ü ü ü 0 ü ü ü 0 0 0 ü 0 0 ü ü ü ü ü ü 0 ü 0 ü 0 ü ü 0 0 ü ü 0 0 ü
20 ü ü ü 0 0 0 ü ü ü 0 ü 0 ü 0 0 ü ü ü 0 0 0 0 ü ü ü 0 ü 0 0 0 0 0 ü ü ü
21 ü ü ü 0 0 ü 0 0 0 ü ü ü ü 0 0 ü 0 ü ü 0 0 0 ü 0 ü ü ü ü ü 0 0 0 ü ü ü
22 ü 0 ü 0 ü ü ü 0 0 ü 0 ü ü ü ü ü 0 ü 0 ü ü 0 ü 0 ü ü 0 ü ü ü ü ü ü ü ü
23 ü ü ü 0 0 0 0 0 0 ü 0 ü ü ü ü 0 0 ü ü 0 ü ü ü 0 ü 0 ü 0 ü ü ü ü ü ü ü
24 0 ü ü ü ü 0 ü ü ü 0 0 0 0 0 ü 0 ü ü ü 0 0 0 0 ü ü ü ü ü ü 0 0 ü ü ü ü
25 ü 0 ü ü 0 ü ü 0 ü ü 0 ü ü 0 0 0 ü ü ü ü 0 0 0 0 ü ü ü ü 0 0 ü ü ü ü ü
26 ü ü ü ü 0 0 0 0 ü ü ü ü ü 0 ü ü 0 ü 0 ü ü ü ü ü 0 ü 0 0 ü ü ü 0 0 0 ü
27 ü ü ü ü 0 ü 0 ü 0 ü ü ü 0 0 ü 0 0 ü ü 0 0 0 0 ü ü 0 ü 0 0 0 0 ü ü ü ü
28 0 ü 0 ü 0 0 ü ü ü ü ü 0 0 ü 0 ü 0 ü ü ü ü 0 ü ü ü ü 0 0 ü 0 0 ü ü ü 0
29 ü ü 0 ü ü ü ü ü ü 0 ü 0 ü ü ü 0 ü ü 0 ü ü 0 0 0 0 0 0 0 0 0 0 0 ü 0 ü
30 0 ü 0 ü 0 0 ü 0 ü ü 0 0 ü 0 ü ü 0 ü 0 ü ü 0 ü ü ü ü 0 0 0 0 0 ü ü ü
KEY:
ITEMS : 8-22 ? Anatomy and physiology of chest including signs and symptoms.
22-28 ? Mechanisms and principles of chest tube drainage.
29-42 ? Asssessment and care of patients with chest tube drianage.
143
 ANNEXURE - 15
MASTER DATA SHEET ON POST-TEST KNOWLEDGE SCORES
SUBJECTS ITEMS
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42
1 ü ü ü ü 0 ü ü ü ü 0 ü ü ü 0 ü ü 0 ü ü ü ü ü ü ü ü ü ü 0 0 ü 0 ü ü ü ü
2 ü ü ü ü ü ü ü ü ü ü ü ü ü 0 ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü
3 ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü 0 ü ü ü ü ü 0
4 ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü 0 ü ü ü ü ü ü
5 ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü
6 ü ü ü ü ü ü ü ü ü ü ü ü 0 ü ü ü 0 ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü
7 ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü 0 0 0 0 ü ü ü
8 ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü 0 ü ü 0 ü ü ü
9 ü ü ü 0 ü ü ü ü ü 0 ü ü ü ü ü ü 0 ü ü ü ü 0 ü ü ü ü 0 0 ü ü ü ü ü ü ü
10 ü ü ü ü 0 ü ü ü ü 0 ü ü ü ü ü ü 0 ü ü ü 0 0 ü 0 ü ü ü 0 ü ü ü ü ü ü ü
11 ü ü ü ü ü ü ü ü ü 0 ü ü 0 ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü 0 ü ü ü ü ü ü
12 ü ü ü ü 0 ü ü ü ü 0 ü ü ü ü ü ü 0 ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü
13 ü ü ü ü 0 ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü
14 ü ü ü ü 0 ü ü ü ü ü ü ü ü ü ü ü 0 ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü
15 ü ü ü ü 0 ü ü ü ü ü ü 0 ü ü ü ü 0 ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü
16 ü ü ü ü 0 ü ü ü ü ü ü ü ü ü ü ü 0 ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü
17 ü ü ü ü 0 ü ü ü ü ü ü ü ü ü ü ü 0 ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü
18 ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü
19 ü ü ü ü 0 ü ü ü ü ü ü ü ü ü ü ü 0 ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü
20 ü ü ü ü 0 ü ü ü ü ü ü ü ü ü ü ü 0 ü ü ü ü ü ü 0 ü ü ü ü ü ü ü ü ü ü ü
21 ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü
22 ü ü ü ü ü ü ü 0 ü ü ü ü ü ü ü ü 0 ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü
23 ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü 0 ü ü ü ü ü
24 ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü 0 ü ü ü ü ü ü ü ü ü ü ü 0 0 ü ü ü ü ü
25 ü ü ü ü ü ü ü ü ü ü ü ü 0 ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü
26 ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü 0 ü ü ü ü ü ü
27 ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü 0 ü ü ü ü ü ü
28 ü ü ü ü 0 ü ü ü ü ü ü ü ü 0 ü ü ü ü ü ü ü 0 ü ü ü ü ü 0 ü ü ü ü ü ü
29 ü ü ü ü ü ü ü ü ü 0 ü ü ü ü ü ü 0 ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü
30 ü ü ü 0 ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü 0 ü ü ü
KEY :
ITEMS : 8-22 ? Anatomy and physiology of chest including signs and symptoms.
22-28 ? Mechanisms and principles of chest tube drainage.
29-42 ? Asssessment and care of patients with chest tube drianage.

144