CLINICAL GUIDELINES/NURSING

GUIDELINES FOR THE MANAGEMENT A PATIENT WITH

UNDERWATER SEAL CHEST DRAINAGE.
Reference
Date approved
Approving Body
Supporting Policy/ Working in
New Ways (WINW) Package
Implementation date
Supersedes
Consultation undertaken

Target audience
Document derivation /
evidence base:
Review Date
Lead Executive
Author/Lead Manager

Matrons Forum

May 2012
Version 1
Nursing Practice Guidelines Group, Ward
Sisters/Charge Nurses, Practice
Development Matrons (PDMs), Clinical
Leads, Matrons, Dr Wei Shen Lim
Respiratory Consultant, Dr Tim Harrison, Mr
John Duffy (Thoracic Surgeon) Beth Beeson
(Medical Physics)
Clinical staff

May 2015
Director of Nursing
Liz Aston (original author) 2009, Holly
Scothern PDM 2012

Further Guidance/Information
Distribution:
Ward Sisters/Charge Nurses, PDMs, Clinical
Leads, Matrons, Nursing Practice Guidelines
Group (includes University of Nottingham
representative), Clinical Quality, Risk and
Safety Manager, Trust Intranet.

NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST

NURSING PRACTICE GUIDELINES

MANAGEMENT OF A PATIENT WITH UNDERWATER SEAL

CHEST DRAINAGE

This guideline has been registered with the Trust. However, clinical
guidelines are guidelines only. The interpretation and application of
clinical guidelines will remain the responsibility of the individual clinician.
If in doubt contact a senior colleague or expert. Caution is advised when
using guidelines after the review date.
INTRODUCTION
Chest drainage may be indicated when a lung lesion, chest trauma or
cardiac/thoracic surgery punctures the pleura, or when a spontaneous puncture
of the pleura occurs. Air or fluid may be drawn into the pleural space by its
negative pressure, causing lung recoil and collapse. A chest tube is inserted
into the pleural space to drain air, blood or fluid, re-establishing negative
pressure and allowing lung re-expansion (OHanlon-Nicols, 1996).
A chest drain is usually attached to an underwater seal drainage system which
acts as a one-way valve allowing fluid and air to leave the pleural space during
expiration and coughing and preventing it from being sucked back in during
inspiration (Allibone, 2005).
The number and sites of chest tubes inserted will depend on the underlying
reason for chest drainage and on what needs to be removed from the pleural
space.
The medical staff will advise on whether suction needs to be applied to the
drainage system. If suction is applied it must be via a thoracic suction system.
In addition, in certain clinical situations there are drainage systems that
utilise a flutter valve (Pleur x drains) rather than an underwater seal to
prevent air re-entry to the patient. (Sullivan, 2008). Please seek expert
advice on how these systems should be managed from a senior
colleague, the Oncology department, the Radiology department or the
lung cancer nurse specialist team. See separate guideline. Caution is
advised when using guidelines after the review date.
Best Practice
Insertion of a chest drain is reported to be a painful and frightening procedure
and patients must be given an explanation of what is going to happen and an
2
assurance that they will receive analgesia before the procedure is carried out
(Bourke, 2003; Luketich et al, 1998 cited in Allibone, 2005).

PROCEDURE FOR INSERTION OF AN UNDERWATER SEAL CHEST DRAIN

This procedure is an aseptic procedure and is undertaken by medical staff with
a nurse assisting, under guidance of ultrasound.
Analgesia should be prescribed and administered before the procedure
wherever possible and effectiveness established.
EQUIPMENT
1 CSSD pack for intercostal drainage
1 pair sterile gloves
Cleansing agent Alcoholic Povidone Iodine 10% or Alcoholic Chlorhexidine
0.5%
Selection of syringes and needles
Scalpel
Lignocaine 1% or 2%
1 sterile drainage bottle or other drainage system (there are drainage systems
that do not contain water)
1 collection canister
1 sterile chest drainage tubing
Sterile water (if using a drainage bottle) for underwater seal as per chest drain
instructions for use
Dated label for bottle change
Intercostal drain and trochar, (size as requested there is no consensus on the
size of the optimal chest tube for drainage) (Davies, et al, 2003)
Suture material (Ethicon W797) (If required)
Sterile saline
Sterile dressing
Sterile scissors
Hypo-allergenic tape
Sterile gown and towel
Tray/holder
Roberts clamps for specialist areas
Correct sized sharps container (to accommodate a trochar)
Refer to general principles for all guidelines

1. PREPARATION OF EQUIPMENT - NURSING RESPONSIBILITIES

3

ACTION
1

2.

3.

RATIONALE

Ensure informed consent has

been obtained from the patient.

To ensure the patient is fully informed

about the procedure and any potential
risks associated with the procedure.
Prepare the drainage system and To minimise the risk of infection.
tubing using an aseptic
technique.

Fill the drainage bottle with sterile

water to the prime level. This will
ensure the rod end of the tubing
is 2cms below the fluid line. The
green cap should be inserted into
the suction port when suction is
not being used as it acts as a
dust cover

To ensure that air cannot re-enter the

pleural space.
The GREEN cap marked V (for vent) is
a venting cap, which allows the free
flow of air from the bottle IT DOES
NOT SEAL THE BOTTLE (Rocket
Medical 2011)

Best Practice
In some specialist areas where cell salvage is required e.g the Emergency
department the bottle is filled with saline and not water. Please seek medical
advice and refer to local guidelines where this is the case.

4.

If required place the system in a

holder/tray.

To minimise the risk of the bottle being

overturned and breaking.

5.

Ensure easy access to an

oxygen administration system.

In case of need in an emergency.

6.

Record baseline observations of

pulse, respirations, blood
pressure, oxygen saturation
levels and early warning scores
(EWS).

For comparison with post-procedure

observations.

2. INSERTION OF THE CHEST DRAIN NURSING RESPONSIBILITIES

ACTION

RATIONALE

1..

To help maintain patient comfort and to

In consultation with the doctor
allow access to the insertion site.
who will be inserting the drain,
position the patient sitting up,
leaning over a bed table or lying
on the unaffected side, according
to the patients general condition.

2.

Assist the doctor, who will :

a Cleanse the skin and allow to
. air dry.

To reduce the risk of introducing

infection.

b Inject local anaesthetic into

. the chosen site allowing time
for tissue infiltration. Check
effectiveness before
proceeding.

To minimise pain during the procedure.

c
.

To prevent the drain being dislodged

and to maintain the seal.
The purse string suture is used for
closing the insertion site when the drain
is removed. It can also be closed very
quickly if the tube is accidentally
dislodged or removed.

Insert the chest drain and

anchor it using a standard
suture if required. A pursestring suture may also be
inserted around the tube
insertion site especially if the
drain size is 28FG or greater.

d Attach the drainage system

. ensuring all connections are
firmly and securely pushed
together. If appropriate,
longitudinal strips of tape can
be used across connections.

Longitudinal strips of tape allow visual

checking of the connection to be made.
However, taping of tubing is
controversial (Godden, 1998). Some
studies show it is unnecessary, whilst
others advocate the use of tape to
reduce the risk of accidental
disconnection of the system and to
prevent air leak.

3. MANAGEMENT OF THE WOUND

ACTION

RATIONALE

1.

Apply a sterile keyhole dressing

around the chest drain and
secure with hypo-allergenic tape,
if required.

To absorb any wound exudate and to

ensure patient comfort.

2.

Re-dress the wound as

necessary e.g. if it becomes
moist with exudate. Swab site if
clinically indicated.

To ensure patient comfort and to detect

signs of infection.

3.

Observe the area around the

tube insertion for signs of air
infiltration e.g. swelling or
crackling on palpation.

Subcutaneous emphysema is a
possibility and, if this travels to the
neck or face, it can compromise airway
patency and cause respiratory distress
(OHanlon-Nicols, 1996).

4. MANAGEMENT OF THE PATIENT FOLLOWING CHEST DRAIN INSERTION

ACTION
1.

2.

3.

4.

5.

RATIONALE

Take and record the patients

pulse, respirations, blood
pressure, oxygen saturation
levels and EWS. The frequency
of subsequent observations
should be determined according
to the patients clinical condition.

To provide a comparison with baseline

observations. Noting the respiratory
rate, depth and rhythm and the
patients skin colour are particularly
important in assessing the
effectiveness of the chest drainage
treatment and early detection of
complications.

Assess the patency of the chest

drainage system by:
a. Noting the fluctuation of the
fluid level in the drainage tubing
(swinging) and/ or bubbling
during normal respiration and
following a deep breath.

Swinging indicates the tube is in the

correct position. Bubbling indicates
continued air leak

b. Asking the patient to cough

whilst observing for swinging in
the bottle or movement in the
drainage tube
A chest X-ray should be
performed as soon as possible
after chest drain insertion.
Administer further prescribed
analgesia following insertion of
drain if required.

Swinging in the bottle following a

cough indicates the tube is in the
correct position.

Encourage mobilisation
according to the patients
condition reminding patient to
keep bottle below insertion site
(see 5.1 below). Also see
section on suction (page 12).

This facilitates optimum drainage from

the pleural cavity and so promotes lung
ventilation and gaseous exchange.
Patients will often not mobilise if they
are in pain.

To check the position of the chest

drain.
There may be considerable discomfort
because of the drain presence and
analgesia is required (Hilton, 2004).
Discomfort and pain may also interfere
with adequate lung ventilation and
patient mobility (Gallon, 1998).

5. NURSING MANAGEMENT OF THE DRAINAGE SYSTEM

ACTION
1.

2.

RATIONALE

The chest drainage system must

be kept below the drain insertion
site.
DO NOT clamp the chest drain
unless
a It is at the direct request of a
. senior doctor. The Doctor
should document length of
time for drain to be clamped.
If the patient becomes
acutely short of breath then
clamps must be removed
immediately and the doctor
informed.
NB: When clamped the
patient must be monitored for
signs of respiratory distress
(Carroll, 1995)

To prevent backflow of fluid into the

pleural space and to promote gravity
drainage.

The chest drain is sometimes clamped

before removal to assess how the
patient will tolerate removal and to
ensure that the lung will remain reexpanded.

Bubbling indicates an active leak of air

from the pleural space. Clamping may
cause a tension pneumothorax

A bubbling chest drain should

never be clamped
3.

Routinely assess the patency of

the system when carrying out
EWS or when clinical condition
indicates

To insure that drainage of the pleural

space is maintained. If fluctuation or
bubbling of the fluid level stops either
the lung has fully expanded, the
system is obstructed (Schuster, 1998)
or the air leak has stopped.

4.

Ensure the tubing is free of kinks,

there are no dependent loops
and that all connections are
secured.

Dependent loops have a negative

effect on fluid and air drainage from the
pleural space (Gordon, Norton and
Merrell, 1995; Carroll 1995).

This loop should not become

dependent, that is, below the fluid
level in the bottle
5.

If the drain is patent then the fluid

level will move with respiration. If
it is not moving, the following
should be checked:
the drainage tubing for
kinks and/or blood clots. If
present, reposition the
patient and encourage
him/her to breathe deeply.
Then re-check for
fluctuations in fluid level.

It is possible that a tension

pneumothorax may be developing
which is a life threatening condition. A
rapid increase in pressure within the
chest can cause mediastinal shift
which can impair venous return to the
heart and will affect cardiac function
(Mattson Porth, 2005).

the patients respiratory

rate, depth and volume, the
pulse rate, blood pressure
and ask the patient if they
have any chest pain. If
necessary, inform the
doctor.

Cardio-respiratory distress may be

indicated by a low BP, increased pulse
rate and reduced oxygen saturation
levels, increased CVP, distended neck
veins, increased dyspnoea and chest
pain (Gallon, 1998).

Regularly check the tubing for

air leaks.

To ensure the system remains

functional (Gallon, 1998).

ACTION
8.

RATIONALE

Identify and record the amount

and colour of any fluid draining (if
appropriate) at least daily but
more frequently if requested by
the medical staff or local
protocols.
Large pleural effusions should be
drained in a controlled
fashion to reduce the risk of reexpansion pulmonary
oedema. Monitor patients EWS
as clinically indicated.

To monitor the amount and type of

drainage.

If large volumes of fluid are drained

quickly this can cause a re-expansion
pulmonary oedema

Only allow the amount

specified and documented by
medical staff to drain off at one
time It is recommended that this
should be a maximum of 1500
ml in the first hour and then
1500ml in two hour intervals
(Roberts et al 2010).
The rate of fluid removal may be
controlled by elevation of the
tubing over a drip stand or
pillows. However some drains
(Seldinger type) have a 3 way tap
supplied in the circuit which may
be used to control drainage
where specified by a medic.

10

Stop draining if the patient

develops chest discomfort,
persistent cough or vasovagal
symptoms and seek urgent
medical guidance

Signs of re-expansion pulmonary

oedema

11

12.

13.

14.

15.

When drainage falls below 200

ml per day, a chest x-ray may be
ordered .If there is still pleural
fluid on the chest X-ray, the
doctor may request suction may
be applied
When mobilising, ensure the
drainage system is kept below
waist level.
In an emergency, such as the
chest drainage bottle breaking or
drainage tube disconnection, reestablish a sterile system as
soon as possible (Carroll, 1995;
Schuster, 1998).
If the tube accidentally falls out
get help and ask for the medical
staff and /or Critical care
outreach to be alerted urgently.
Apply dressing to chest drain site
and record full set of
observations
If an air leak is present, only
apply tape to 3 sides of the
dressing to allow air to escape
whilst seeking urgent medical
CCOT advice.

To assess re inflation of the lung and to

assist the removal of air/fluid from the
pleural space

Trauma patients with a

haemothorax require drainage to
be measured hourly or according
to medical instruction. Inform
medical staff if blood drainage
exceeds agreed parameters.
Ensure parameters documented
by medical staff

Significant blood loss must be

addressed.

To prevent backflow of fluid into the

pleural space.
To prevent infection and maintain the
drainage system.

To prevent air entering the potential

lumen created by the drain and
causing a tension pneumothorax
(Allibone, 2005).

To allow any air to escape from the

pleural space,

6. CHANGING THE CHEST DRAIN BOTTLE

:
ACTION
RATIONALE
Too full a bottle leads to a rise in
1.
The bottle should be changed:
pressure in the system which in
turn leads to difficulty in drainage
a) when 500ml level is reached
and is therefore counter-productive
To minimise the risk of infection
b) or after 7 days in situ. If the
drain has been in situ for 7
days the tubing should be
replaced as well
2.
Fill the new drainage bottle with
To ensure that air cannot re-enter
Sterile water to the prime level.
the pleural space
This will ensure the rod end of
the tubing is 2cms below the fluid
line.
3.
Kink the tube and release the
To prevent air or fluid from entering
tubing from the old bottle by
the pleural space
unscrewing the red button
4.
Insert the tubing into the new
To create an intact circuit and
bottle, ensuring that the end of
prevent fluid from entering the
the rod is under the level of the
pleural space
water
5.
Release the kinked tubing and
To allow drainage from the pleural
ensure the tube is patent by
space
observing for fluid movement in
the tubing
To minimise the risk of infection
6.
Seal and dispose of old chest
drain bottle and contents into the
designated chest drain disposal
box according to waste
management procedures
7.
Document drainage amount in
To maintain accurate records
old bottle on fluid balance
chart/nursing records

7. FLUSHING A SELDINGER CHEST DRAIN

Seldinger chest drains are small diameter chest drains, the name of which
comes from the method of insertion. These drains can be prone to blockage.
Therefore flushing the drain may be required on a regular basis i.e. 4 times a
day, to maintain the patency of the drain when a patient has a pleural effusion.
This is not necessary for pneumothorax. ( ODriscoll R and Pyne H 2008)
5

This procedure is undertaken by medical staff. Only registered nurses, who

have been supervised and assessed as competent may undertake this
procedure.

1.

2.

3.

4.

ACTION
RATIONALE
To reduce the risk of
In a designated clean area of
contaminating the saline flush.
the ward, draw up 10mls of
normal saline into the 10ml
syringe, check and place
syringe on the injection tray
ensuring that it is checked in
accordance with the local policy.
Take the syringe of normal
To ensure patient safety.
saline to the patient, checking
the identity of the patient in
accordance with the local policy.
Position the patient to allow
To facilitate the procedure
access to the chest drain,
ensuring the patient is
comfortable.
Perform hand hygiene.
To minimise the risk of
infection.

5.

Open the sterile dressing towel To minimise the risk of

and place under the chest drain. infection.

6.

Clean the bungs on the 3-way

tap supplied with the seldinger
drain, using the swab and allow
drying.
Clean hands and apply alcohol
gel.

7.

8.

To minimise the risk of

infection.

To minimise potential
contamination of the drain
and/or equipment used.

To ensure the normal saline is

Apply the sterile gloves and
instilled along the diameter of
attach the syringe of saline to
the chest drain.
the clean bung. Ensure the 3
way tap is closed towards the
drainage tubing on the chest
drain system. Instil the 10mls of
normal saline into the chest
6

drain.

9.

10.
11.

ACTION
Remove the empty syringe from
the 3-way tap and ensure the 3way tap is open to the drainage
tubing on the chest drain
system, checking that the saline
is draining from the chest drain.
Dispose of all equipment
according to local policy.
If the drain is attached to an
underwater seal drainage
system, ensure the drain is
patent by:

RATIONALE
To facilitate drainage of the
normal saline and to check the
patency of the chest drain.

To prevent the risk of cross

infection.
To assess and monitor the
patency of the drainage
system.

a) ensuring the fluid level is

fluctuating in the drainage
tubing. (Allibone, 2003)

12.

b) asking the patient to cough

and observe for fluctuation
of the fluid in the drainage
tubing.
Observe the patient by
monitoring the temperature,
pulse, respirations and blood
pressure 4 hourly (Allibone,
2003). In addition, monitor the
patient for chest pain and/or
discomfort and continue to
assess the patency of the
drainage system if the drain is
attached to an underwater seal
drainage system.

To monitor the patient for any ill

effects from the procedure and
to facilitate the early detection
of complications.

8. APPLYING SUCTION TO THE DRAINAGE SYSTEM

If the insertion of a chest drain is insufficient for the removal of air/fluid from the
pleural space, suction via a thoracic suction regulator may be applied to assist
in this process following a decision from medical staff.
Suction pressure should be set according to either specific written instructions
in the patients records or locally agreed written protocols. There is currently no
7

consensus on how much suction should be applied (Avery, 2000) nor is there
sound evidence or clinical consensus to base specific guidelines in this area
(Davies et al, 2003).
Note, when suction is applied to a chest drainage system, an intermediate
collection jar or canister must be placed between the suction regulator
and chest drain bottle. This is to prevent activation of pipeline protection
and subsequent loss of suction which could lead to a tension
pneumothorax, should the chest drain bottle overflow. (MHRA
MDA/2010/040, and Supplementary advice for MDA/2010/040 All chest
drains when used with high-flow, low-vacuum suction systems (wall
mounted).)
Thoracic
regulator with
pipeline
protection filter

Tubing

Intermediate
collection
canister
(E.g. Seres)

Tubing

Chest
Drain Bottle

Tubing

Patient

2 and 3
4&5
Ensure that the following is adhered to;
Non-sterile suction tubing (bubble tubing) connects the suction
regulator unit (1) to the outlet port on the intermediate collection
jar/canister (2)
Non-sterile suction tubing (bubble tubing) then connects the inlet port
on the intermediate collection jar/canister (3) with the chest drain bottle
(4)
The integral sterile suction tubing that comes as part of the chest drain
bottle package connects the chest drain bottle (5) to the patient (6)

ACTION

RATIONALE
8

1.

Fix one end of the suction tubing

onto the suction unit and the
other onto the collection canister
between the regulator and the
chest drain bottle. Connect the
collection canister to the chest
drain bottle with non sterile
suction tubing.
Ensure an inline filter is used to
protect the piped suction system.
Only use thoracic suction
systems

The suction pressure assists the

drainage of fluid/air from the chest
cavity.

2.

Set the suction rate according to

the written instructions or local
protocol. This will normally be
between 10 to 20cm H2O, (1
and 2 Kpa )

If the suction is applied at too high a

pressure, it can harm lung tissue or
trap lung tissue in the chest tube
eyelets (Tooley, 2002)

3.

Check frequently that the suction

is set as instructed.

To ensure the correct level of suction is

maintained.

4.

Change the drainage system

when fluid levels go above
500mls.

High fluid levels will

efficiency of suction.

5.

Disconnect the suction system

If the suction unit only is turned off
before switching off to reduce the there is no valve in the system to allow
risk of mimicking clamping
air/fluids to travel down to the drain
this has the same effect as
clamping.

affect

the

9. REMOVAL OF THE CHEST DRAIN

Once drainage of fluid or air has diminished to little or nothing and/or
fluctuations in the water-seal chamber have ceased, the chest drain may be
removed at the request of the medical staff. The drain may be removed by
medical staff or by nurses who have been assessed as competent in the
procedure.
A chest X-ray may be performed prior to removal to establish that the lung has
re-expanded. Sometimes, if requested by medical staff, the patient is given a
trial period with the chest drain clamped to ensure that the lung will stay inflated
and respiratory distress avoided.
EQUIPMENT
Medium basic pack - if required
Stitch cutter if required
Sterile dressing
Hypo-allergenic tape
2 pairs non-sterile gloves
Sterile scissors and specimen container, if required
Clinical waste bag
Gel sachets
ACTION

RATIONALE

1.

Administer prescribed analgesia

20 minutes prior to removal, if
appropriate.

The patient may experience shortlasting but intense pain on removal

(Hilton, 2004)

Position the patient on the

unaffected side or sitting up wellsupported by pillows.

To facilitate the drain removal.

2.

Ask the patient to practice

holding their breath for 3 5
seconds.

To facilitate the procedure.

3.

Perform hand hygiene and apply

gloves.
Remove the dressing

To minimise the risk of cross infection

4.
5.

10

To allow access to the insertion site

ACTION

RATIONALE

If the drain is sutured in place, this is a 2 person procedure.

6.

Remove the suture if present.

Cut the purse-string knot and
loosely tie the ends, ready to pull
a tight knot.

7.

Ask the patient to perform a

Valsalva manoeuvre. This
manoeuvre requires the patient
to take a deep breath and then
strain against a closed airway
(most easily achieved by closing
the vocal cords) in order to
increase intra-thoracic pressure.
The nurse should explain this to
the patient (perhaps using the
example of straining to pass a
motion). The patient should
rehearse this procedure to the
nurses satisfaction prior to
removal of the tube and then
perform it at the nurses request
during the removal of the tube
(Godden, 1998). The tube
should then be removed and
placed on the sterile field on the
trolley.

Allows tube to be removed only when

the least negative pressure can be
generated. Positive pressure is rarely
achieved (Marieb, 2004), thereby
reducing the risk of complications

If the patient is not able to hold

his/her breath, remove during
expiration.
8

If a purse-string suture is present, To prevent air from entering the pleural

the second person ties it securely space via the drain site
immediately as the drain comes
out. If no purse string consider
the use of steri -strips to close
the wound.

11

If there are signs or evidence of

infection, send the end of the
drain for microbiological
investigations and swab the site.

To detect the presence of any

pathogens.

Apply a sterile dressing to the

drain site.

To reduce the risk of infection and to

prevent air re-entering the pleural
space until the wound is sealed.

9.

Monitor the patients respiratory

status and wound drainage as
clinically indicated.
Seek urgent medical advice if
clinically indicated.

Shortness of breath, sudden chest pain

or deterioration in observations may
indicate collapse of the lung and/or reaccumulation of fluid.

10.

The purse-string suture, if

present, is usually removed 5-7
days after chest drain removal
once the drain site has healed.

11.

Check with medical staff if a

chest X-ray is required following
removal of the drain.
Seal and dispose of old chest
drain bottle and contents into the
designated chest drain disposal
box according to waste
management procedures

In patients who have had a

pneumonectomy, a large volume of
fluid fills the space. There is a risk of
fluid leakage and infection and so the
suture is normally left in place for 7
days.
To check that air has not entered the
pleural space during removal of the
drain
To minimise the risk of infection

8.

12.

12

REFERENCES and Further Reading

Allibone L (2005) Principles for inserting and managing chest drains Nursing
Times Vol. 101 No. 42 pp. 45-49
Avery S (2000) Insertion and management of chest drains Nursing Times Plus
Vol. 96 No. 37 pp.3-6
British Thoracic Society Management of Pleural Infection in adults: British
Thoracic Society Pleural disease guidelines 2010. Thorax 2010; 65(suppl
2):ii41-ii53
www.brit-thoracic.org.uk

Bourke S J (2003) Lecture Notes on Respiratory Medicine 6th Edition Oxford:

Blackwell
Carroll P (1995) Chest drains made easy Registered Nurse Vol. 8 No.12 pp.
215-225
Gallon A (1998) Pneumothorax Nursing Standard Vol. 13 No. 10 pp. 35-39
Godden J, Hiley C (1998) Managing the patient with a chest drain: a review
Nursing Standard Vol.12 No. 32 pp. 35-39
Gordon P Norton J, Merrell R (1995) Refining chest tube management: analysis
of the state of practice Dimensions of Critical Care Nursing Vol. 14 No. 1 pp. 613
Hilton P (2004) Evaluating the treatment options for spontaneous pneumothorax
Nursing Times Vol. 100 No. 28 pp. 32-33
Luketich J. D., Kiss, M., Hershey, J., Urso, G.K., Wilson, J., Bookbinder, M.,
Ginsberg, R., (1998) Chest tube insertion: a prospective evaluation of pain
management Clinical Journal of Pain Vol. 14 No. 2 pp. 152-154
Marieb, E. N. (2004) Human anatomy and physiology 6th Edition
Benjamin Cummings, Menlo Park, California, USA.
Mattson Porth C (2005) Pathophysiology: Concepts of altered health states
7th edition Philadelphia, USA: Lippincott
Mimnaugh L (1999) Sensations experienced during removal of tubes in acute
post-operative patients Applied Nursing Research Vol. 12 No. 2 pp. 78-85
13

NPSA (2008) Risks of chest drain insertion NPSA/2008RRR003

ODrisoll Robert and Pyne H (2008) Insertion of a Seldinger intra pleural chest
drain www.srft.nhs.uk (accessed 2011)
OHanlon-Nichols T (1996) Commonly asked questions about chest tubes
American Journal of Nursing Vol. 96 No 5 pp. 60-64
Rocektmedical(2011)
http://www.rocketmedical.com/pdf/Catalogues/Cardiac%20Products%20Issue%
204.pdf
Schuster P (1998) Chest tubes: to clamp or not to clamp Nurse Educator Vol.
23 No. 3 pp. 9-13
Sullivan B (2008) Nursing management of patients with a chest drain
British Journal of Nursing Vol. 17 No. 6 pp.388-393
Tooley C (2002) The management and care of chest drains Nursing Times Vol
98 No 26 pp.48-50
NNPDG Link Members: Jill Wakefield/Holly Scothern with thanks to Debbie
Raffle, Lucy Briggs and Rhona Al-Bazzaz for their help in compiling this
procedure.
AUDIT POINTS
Is the patients safety assured with respect to chest drain procedures?
Has the patients dignity and comfort been effectively maintained prior to, during
and after chest drain procedures?
Has the patient received timely analgesia prior to chest drain procedures?
Has the patient received appropriate explanation prior to chest drain
procedures?
Is there evidence of prevention of infection throughout chest drain procedures?
Is there confirmation that chest drain procedures are successful following
removal of a chest drain (i.e. is the patients breathing pattern and rate within
normal adult limits; are oxygen saturations within normal limits for the patient;
are vital signs satisfactory?)

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Is there any evidence of pain associated with breathing following the removal of
the chest drain?

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