Proforma for Registration of Subject for Dissertation s5

A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING CHEST TUBE DRAINAGE AMONG 3rd YEAR B.SCNURSING STUDENTS OF SELECTED NURSING COLLEGES, TUMKUR.

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

SUBMITTED BY JEENA JOSEPH MEDICAL SURGICAL NURSING

ARUNA COLLEGE OF NURSING TUMKUR

1 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FORDISSERTATION

01. Name of the candidate and address : Jeena Joseph

1st year M.Sc. Nursing

Ring road, Maralur,

Tumkur- 572105.

02. Name of the institution : Aruna College of nursing

Ringroad, Maralur,

Tumkur-572105.

03. Course of the study and subject : 1st Year Msc,Nursing

Medical Surgical Nursing

04. Date of Admission :

05. Title of the topic : A study to assess the effectiveness of structured teaching programme on knowledge regarding chest tube drainage among 3rd year B.SC nursing students of

2 selected nursing Colleges Tumkur

6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION:

Constant attention by a good nurse may be just as important as a major operation by a

surgeon.

Dag Hamma rskj old

Health (or health care) is the diagnosis, treatment and prevention of disease,

illness, injury, and other physical and mental impairments in humans. Health care is

delivered by practitioners in medicine, dentistry, nursing, pharmacy and allied health.1

Nurses care for patients continuously, 24 hours a day. They help patients to do

what they would do for themselves if they could. Nurses take care of their patients,

making sure that they can breathe properly, seeing that they get enough fluids and enough

nourishment, helping them rest and sleep, making sure that they are comfortable, taking

care of their need to eliminate wastes from the body, and helping them to avoid the

harmful consequences of being immobile, like stiff joints and pressure sores. The nurse

often makes independent decisions about the care the patient needs based on what the

nurse knows about that person and the problems that may occur. 2

Trauma is the leading cause of mortality and disability, especially during the

productive age, and is the third most common cause of death. 1 Accidents which are

unexpected and unplanned events are becoming the major epidemic of the present

3 century. The number of accidental deaths in India is even higher than in the Western

World. 1 Thoracic trauma contributes heavily to these figures besides head injury, abdominal injury and orthopedic injuries. Approximately one quarter of civilian trauma deaths are caused by thoracic trauma and many of these deaths can be prevented by prompt diagnosis and correct management. 2 In spite of the high mortality rates, about

90% of the patients with life-threatening thoracic injuries can be managed by a simple intervention like drainage of the pleural space by tube thoracostomy.3

Your lungs make up one of the largest organs in your body, and they work with your respiratory system to allow you to take in fresh air, get rid of stale air, and even talk.4

Thoracic trauma forms one of the major parts of multiple trauma and is responsible for significant mortality and morbidity specially at younger ages. A retrospective study was conducted to assess the general spectrum of chest injury patients at PGIMS Rohtak in one year. Clinical details of the patients were recorded from their case sheets and were analysed with reference to their age, sex, mode of injury, severity of injury, treatment employed, etc. The majority of the patients could be managed by simple inter-costal drainage and thoracotomy was required only in few patients.3

Trauma, disease, or surgery can interrupt the closed negative-pressure system of the lungs, causing the lung to collapse. Air or fluid may leak into the pleural cavity.

Introducing a chest tube is a routine emergency procedure in trauma victims. A chest tube is inserted and a closed chest drainage system is attached to promote drainage of air and

4 fluid. Chest tubes are used after chest surgery and chest trauma and for pnuemothorax or hemothorax to promote lung re-expansion.5

A chest tube (chest drain or tube thoracostomy in British medicine or intercostal drain) is a flexible plastic tube that is inserted through the side of the chest into the pleural space. It is used to remove air (pneumothorax) or fluid (pleural effusion, blood, chyle), or pus (empyema) from the intrathoracic space. It is also known as a Bülau drainor an intercostal catheter.

The indications for chest tube insertion are Pneumothorax, Pleural effusion,

Chylothorax: a collection of lymphatic fluid in the pleural space ,Empyema: a

pyogenic infection of the pleural space , Hemothorax: accumulation of blood in the pleural space and Hydrothorax: accumulation of serous fluid in the pleural space .6

Pneumothorax is the most common reason for inserting a chest tube. Leading to partial or complete lung collapse, it's caused by external air entering the pleural space from a hole in the chest wall or by air in the lungs entering through a hole in the pleura.

The collected air disrupts the normal negative pressure within the lungs-the vacuum that keeps them expanded. Loss of this vacuum causes the lung to collapse; a collapse of greater than 15% can lead to respiratory compromise, so insertion of a chest tube is necessary. 7

Major complications are hemorrhage, infection, and reexpansion pulmonary edema. Chest tube clogging can also be a major complication if it occurs in the setting of bleeding or the production of significant air or fluid. When chest tube clogging occurs in this setting, a patient can suffer from pericardial tamponade, tension pneumothorax, or in

5 the setting of infection, an empyema. All of these can lead to prolonged hospitilization and even death.6

The physician is responsible for inserting the chest tube and is usually responsible for its removal. (Some nurse practiced acts allow nurses to remove chest tubes.) The nurse assists with the insertion procedure, assesses the patient's respiratory status afterwards, and maintains a patent chest tube.8

An article on thoracic drainage reported pleural pathology is a frequent clinical problem. Treatment includes draining the cavity by inserting a catheter in the pleural sack to drain the presence of air; liquid or blood which causes a variable degree of lung collapse having a clinical consequence in function of the reserve breathing capacity the patient previously had and the degree of collapse. Nursing is fundamental in this entire process, including in the preparation of the patient for this treatment, the insertion of the catheter and the adequate maintenance so that this procedure succeeds as well as during the removal of the catheter and the subsequent care required. It is fundamental that the nursing professionals know the materials used as well as their maintenance. A good technique to cure the punt/orifice where a catheter is inserted will prevent numerous complications which could be deadly for the patient. An article reported creating a procedural protocol for nurses to use when treating patients who have thoracic drains; this protocol deals with changing the catheters as well as the entire process related to how to treat patients with a pleural drain. This protocol should serve as reference material and as a guide to a systematic and homogenous working procedure.9

Critical care nurses routinely care for patients who require chest tube management. To obtain the best patient outcome, critical care nurses develop standards of

6 practice from research derived recommendations. Although there are several studies

recommending chest tube management practices, there is limited research in some areas

of chest tube management. The authors analyze the body of research and recommend

clinical practice changes and timely research projects on chest tube management.10

The education should always begin from the basic level.Structured teaching

programmes helps student nurses to improve their knowledge on patient care and

management of chest tube drainages and helps in increasing their competencies in future.

6.1. NEED FOR THE STUDY

Chest injury occurs in a significant number of trauma patients and commonly

affected victims are males of productive age. The majority of these patients can be

managed by simple intervention i.e., intercostal drainage .

Blunt trauma, mainly road-side accidents formed the most common cause of chest

injury, followed by blunt assault, stab by knives and falls etc. Increased automobile

traffic and ever increasing population together with intentional or unintentional ignorance

of traffic rules account for the predominance of road-side accidents producing chest

trauma. The right side of the chest was involved commonly after blunt injury while left

side involvement was more common after penetrating injuries, which is consistent with

assault by a right-handed assailant. Muckart et al. have observed a similar finding in

which 61% of stab wounds occurred in the left pleural cavity.3

The incidence of chest trauma among all trauma cases admittedto a hospital in

Andhra Pradesh during a 5-year study period was 9% (90/1000).Of these 90 patients, 83

(92%) were male and 7 (8%) were female.The majority (55.6%) were less than 40 years

7 of age with 10(11.1%) less than 20 years old, 40 (44.4%) in the age range21 to 40 years,

12 (13.3%) between 41 and 60 years, and 28 patients(31.1%) over 60 years old.

Blunt injuries, mostly resulting from falls and vehicular accidents,were seen in 56 patients (62.2%). Penetrating chest trauma occurredin 34 patients (37.8%), with stab and bull gore injuries beingthe most common. Fractures of the clavicle or long bones wereseen in 19 (21%) and associated head injuries were found in9 patients (10%).

Associated abdominal injury, neurovascularinjury, and contused lacerated wounds occurred in 3 cases each(3.3%). Multiple rib fractures were noted in 51.1% of patientswith 35.6% having hemopneumothorax.11

A prevalence of Chest Trauma at an Apex Institute of North India reported that out of a total of 402 patients, the maximum (139) was in the age group of 21-30 years and the next common decade was in the age group, 31-40 years, with 98 patients. The incidence was low for very young and very old patients. There were 340 male and 62 female patients. Blunt trauma was responsible for the injury in 351 patients and 51 patients sustained chest injury after penetrating trauma. In blunt trauma, road-side accidents was the commonest cause (268 patients), others being fall from height, assault, etc.

In the majority of 295 patients, tube thoracostomy was the main treatment employed. Initially, the cases were treated by simple intercostal drainage (i.e., 198 patients) and they required tube drainage for 2-9 days. And lately we have started applying negative suction to the drainage system (i.e., 97 patients) requiring intercostal drainage for 2-6 days.T he final outcome of all the chest injury patients (402) showed,

343 patients were discharged in satisfactory condition within 7-10 days, while hospital

8 stay was prolonged in 36 patients because of some complications of ICD and 23 patients could not be saved despite adequate and aggressive treatment. Complications seen after

ICD were residual haemothorax, recurrent pneumothorax and empyema .3

A study revealed the overall incidence of pneumothorax was 42.3% .Chest tube placement was required for 11.9% (55/464) of pneumothoraces(5.0% [55/1,098] of the total number of procedures). The significantindependent risk factors for pneumothorax were no prior pulmonary surgery(p = 0.001), lesions in the lower lobe (p< 0.001), greaterlesion depth (p< 0.001), and a needle trajectory angle of< 45° (p = 0.014); those for chest tube placement for pneumothoraxwere pulmonary emphysema (p< 0.001) and greater lesion depth(p< 0.001).12

A study reported among 289 patients who underwent percutaneous CT-guided lung biopsy developed pneumothorax as the most common complication of, despite improved techniques. The rate of pneumothorax reported in the literature ranges from 19 to 60%. Seventy-seven patients (26.6%) had pneumothorax after percutaneous CT-guided lung biopsy. Forty-one of the 77 patients (53.2%) who had pneumothorax (14.2% of the entire series) required placement of a chest tube.13

125 patients with malignant pleural effusion with trapped lung or failed previous pleurodesis underwent insertion of ambulatory pleural drain, The use of ambulatory pleural catheters for managing malignantpleural effusion is a safe and effective strategy.

It has only minorcomplications that are related to prolonged drainage.14

An article reported the importance of refining chest tube management measures after analyzing the state of practice. Critical care nurses routinely care for patients who require chest tube management. To obtain the best patient outcome, critical care nurses

9 develop standards of practice from research derived recommendations. Although there are several studies recommending chest tube management practices, there is limited research in some areas of chest tube management. The authors analyze the body of research and recommend clinical practice changes and timely research projects on chest tube management.15

Malposition of percutaneously inserted chest tubes is considered as a rare complication in critically ill patients. Its incidence, however, remains uncertain. Chest tube position was classified as intrapleural, intrafissural, or intraparenchymal. Factors predicting chest tube malposition were analyzed by studies of univariate and multivariate analysis. Malposition was detected in 30% of percutaneously inserted chest tubes, a higher incidence than previously reported. Avoiding the use of a trocar may reduce significantly the incidence of chest tube malposition.16

Medical personnel who care for patients with thoracictrauma should understand the risks of mortality and clinicaldeterioration as well as associated injuries. The aim shouldbe to restore normal cardiorespiratory function, control bleeding,treat associated injuries, and prevent sepsis.11

The investigator while working as staff nurse found nurses having limited knowledge in various areas of chest tube drainage. This information regarding chest tubes and its management need to be inculcated from the basic B.Sc level and decided to carryout the study among 3rd year B.Sc nursing students.

10 6.2 REVIEW OF LITERATURE

Review of related literature is an integral component of any study or research

project. It enhances the depth of the knowledge and inspires a clear insight into the crux

of the problem. Literature review throws light on the studies and their findings reported

about the problem under study.

A survey was conducted to acceptance of physician assistants(PAs/NPs) and nurse

practitioners in trauma centers.Two hundred forty-six (246) of 464 surveys were

returned, for a response rate of 53%. Approximately one-third of reporting major trauma

centers reported utilizing PAs/NPs. Nineteen percent (19%) of respondents who did not

currently utilize PAs/NPs indicated that they intended to do so in the future . Fewer than

half of reporting facilities indicated that PAs/NPs performed more invasive procedures,

such as inserting arterial lines, central lines, chest tubes, and intracranial pressure

monitors.This evaluation of the utilization of PAs/NPs in direct care to trauma patients

indicates acceptance of PAs/NPs in trauma staffing models.17

A study was conducted on visual characteristics of aspirates from feeding tubes

as a method for predicting tube location. A sample of 880 feeding tube aspirates were

classified as being primarily clear or cloudy and as having one of six colors. However,

respiratory aspirates often contained blood and therefore failed to have the expected

characteristics of respiratory fluid. Staff nurses were shown photographs of a sample of

106 aspirates and asked to predict tube position. Their ability to identify 50 gastric

aspirates improved significantly after reading a list of suggested characteristics of feeding

tube aspirates (81.33% to 90.47%, p < .0001). Similarly, their ability to identify 50

intestinal aspirates improved from 64.07% to 71.53% after reading the list of criteria.

11 However, nurses were often unable to identify respiratory aspirates; the accuracy of their predictions decreased after reading the list of suggested characteristics (from 56.67% to

46.11%). The appearance of aspirates is often helpful in distinguishing between gastric and intestinal placement, but is of little value in ruling out respiratory placement.18

An exploratory descriptive survey was conducted on the nurses' knowledge of chest drain care and the need for nurses to have in service education to provide the best care for clients with chest drains.This study aimed to identify the nurses' levels of knowledge with regard to chest drain management and to ascertain how nurses keep informed about the developments related to the care of patients with chest drains. The data were collected using survey method. The results of the study revealed deficits in knowledge in a selected group of nurses and a paucity of resources. Nurse managers are encouraged to identify educational needs in this area, improve resources and the delivery of in service and web-based education and to encourage nurses to reflect upon their own knowledge deficits through portfolio use and ongoing professional development.19

A study was conducted on ambulatory intercostal drainage for the management of malignant pleural effusion. The aim of the study was use of ambulatory drains (Pleurex drains) in this malignant pleural effusions with particular reference to hospital stay, duration of drainage, and incidence of complications. Of 125 patients with malignant pleural effusion with trapped lung or failed previous pleurodesis who underwent insertion of ambulatory pleural drain, 41 patients were under local anesthesia and 84 patients were under general anesthesia. Mean age was 66.5 years with male:female = 80:45. Data were

12 collected retrospectively from the clinical notes, and the family doctors'clinics were contacted to enquire about the patients' survival. Mean duration of catheter placement was 87.01 days (5-434).The result showed the use of ambulatory pleural catheters for managing malignant pleural effusion as a safe and effective strategy. It had only minor complications that were related to prolonged drainage. 14

A study was conducted on the incidence of and Risk Factors for Pneumothorax and Chest Tube Placement After CT Fluoroscopy–Guided Percutaneous Lung Biopsy .

The objective of the study was to retrospectively evaluatethe incidence of and the risk factors for pneumothorax and chesttube placement after CT fluoroscopy–guided lung biopsy.A total of 1,098 CT fluoroscopy–guided lungbiopsies were analysed. The results showed the overall incidence of pneumothorax was 42.3% (464/1,098).Chest tube placement was required for 11.9% (55/464) of pneumothoraces(5.0% [55/1,098] of the total number of procedures). The significantindependent risk factors for pneumothorax were no prior pulmonary surgery(p = 0.001), lesions in the lower lobe (p< 0.001), greaterlesion depth (p< 0.001), and a needle trajectory angle of< 45° (p = 0.014); those for chest tube placement for pneumothoraxwere pulmonary emphysema (p< 0.001) and greater lesion depth(p< 0.001). The study concluded that pneumothorax frequently occurred and placement ofa chest tube was occasionally required for pneumothorax afterCT fluoroscopy–guided lung biopsy.20

A study was conducted on the prevalence of Chest Trauma at an Apex Institute of North India. Out of a total of 402 patients, the maximum (139) was in the age group of 21-30 years and the next common decade was the 4th i.e., 31-40 years, with 98 patients. So more than half of all the patients were in the 3 rd and 4th decade of life

13 and the incidence was low for very young and very old patients. There were 340 male and 62 female patients. Blunt trauma was responsible for the injury in 351 patients and 51 patients sustained chest injury after penetrating trauma. In blunt trauma, road-side accidents was the commonest cause (268 patients), others being fall from height, assault, etc.In the majority of patients i.e., in 295 cases, tube thoracostomy was the main treatment employed. Initially, we were treating these cases by simple intercostal drainage

(i.e., 198 patients) and they required tube drainage for 2-9 days. And lately we have started applying negative suction to the drainage system (i.e., 97 patients) requiring intercostal drainage for 2-6 days.If we analyse the final outcome of all the chest injury patients (402), 343 patients were discharged in satisfactory condition within 7-10 days, while hospital stay was prolonged in 36 patients because of some complications of ICD and 23 patients could not be saved despite adequate and aggressive treatment.

Complications seen after ICD were residual haemothorax, recurrent pneumothorax and empyema.3

A descriptive study was conducted on a profile of chest trauma. A total of 90 patients with chest injurieswere retrospectively assessed for the incidence, presentation,and outcome of thoracic trauma. The majority (55.6%) were lessthan 40 years of age and 83

(92%) were male. The mode and extentof injury, specific intrathoracic organ injuries, associatedinjuries, flail chest, ventilatory requirements, management,morbidity, and mortality were analyzed. Blunt injuries wereseen in 56 (62.2%) and penetrating injuries in 34 (37.7%). Multiplerib fractures with hemopneumothorax was the most frequent presentationwith orthopedic and head injuries being most commonly associated.Patients with tachypnea, cyanosis, lung contusion, partial pressureof aterial oxygen less than 60

14 mm Hg, and those with more than6 rib fractures most often required ventilation but the

majority(54.4%) were treated with a chest drain only. The mortality rate was

6.7%,mainly due to respiratory insufficiency. Subcutaneous emphysemarequiring

releasing incisions accounted for most of the morbidity.Mean hospital stay was 9.5 days.

Chest injuries were of majorconcern in multisystem trauma patients and early planned

managementis recommended in a mostly vulnerable section of our populationin an age of

violence and vehicular accidents.11

An article on management of pleural drain reported a series on complex

interventions nurses have to manage in acute general wards and in the community. This

article looks at the management of pleural drains and gives an overview of the relevant

anatomy and physiology. Some of the conditions that may result in a chest tube being

inserted are described and the nursing care discussed.21

These reviews helped the researcher to state the problem and establish the need

for the study.

6.3 STATEMENT OF THE PROBLEM

A study to assess the effectiveness of structured teaching programme on knowledge

regarding chest tube drainage among 3rd year B. Sc nursing students of selected nursing

colleges, Tumkur.

6.4 OBJECTIVES OF THE STUDY

15  To assess the knowledge on chest tube drainage among 3rd

year B. Sc nursing students

 To assess the effectiveness of structured teaching programme

on knowledge regarding chest tube drainage among 3rd year B. Sc nursing students

 To find the association between level of knowledge with

selected socio demographic variables.

6.5 OPERATIONAL DEFFINITIONS

 Assess-in this study assess refers to determining the knowledge

score of nurses regarding chest tube drainage using a self administered knowledge

questionnaire.

 Effectiveness- It refers to significant gain in knowledge of

student nurses regarding chest tube drainage determined bysignificant difference between

pre-test and post test knowledge scores.

 Knowledge In this study knowledge refers to the correct

responses given by the student nurses as it is elicited through self administered

knowledge questionaire

16  Structured teaching programme- In this study it refers to a

systematically organized teaching strategy of one hour duration on definition, indications,

complications and management of chest tube drainage by using appropriate A.V aids.

 3rd year B. Sc nursing students - Students in Third year B.Sc

nursing of selected nursing colleges of Tumkur.

 Chest tube drainage- In this study it refers to a flexible plastic

tube that is inserted through the side of the chest into the pleural space, which is used to

remove air or fluid or pus from the intrathoracic space. It is also known as intercoastal

drainage.

6.6 HYPOTHESIS

H1:There is significant difference in pretest and post test knowledge scores on chest tube

drainage among 3rd year B. Sc nursing students.

H2: There is significant association between knowledge level with selected socio

demographic variables.

6.7 ASSUMPTION

17  The 3rd year B. Sc nursing students have limited knowledge

regarding chest tube drainage.

 Structured teaching programme is one of the best teaching

strategies in implementing the knowledge on chest tube drainage.

7. MATERIALS AND METHODS:

7.1. SOURCES OF DATA

o Research approach : Evaluatory approach.

o Research Design : One group pre-test post- test design.

o Settings of the study : Selected nursing colleges of Tumkur

o Sampling technique : Simple random sampling technique

o Sample size : 100

18 Research variables

Dependent variable : Knowledge of 3rd year B. Sc nursing

students on chest tube drainage.

Independent variable : Structured teaching

programme on chest tube drainage.

Demographic variables

 Age

 Gender

 Religion

 Family income

 Type of family

 Source of information

Population : 3rdyear B.Sc Nursing students.

 Sampling criteria

Inclusion criteria

1. Third year B.Sc nursing students of selected nursing colleges at Tumkur.

19 2. 3rd year B. Sc nursing students who are willing to participate.

3. 3rd year B. Sc nursing students who can read and understand English.

Exclusion criteria

1. 3rd year B. Sc nursing students who are on leave or absent at the time of data

collection.

2. Who have already undergone training programmes on chest tube drainage.

7.2 Methods of data collection.

 Method of data collection : Self administered knowledge

questionnaire.

 Tool of data collection :

Tool 1:-Section A: This section deals with demographic data such as Age, Gender,

Religion, Family income, Type of family, Source of information.

 Section B: Structured knowledge questionnaire to assess the

knowledge of 3rd year B. Sc nursing students on chest tube drainage.

 Tool 2:-

 Structured teaching programme on chest tube drainage.

20 Method of data analysis and interpretation:

Data will be analyzed by using descriptive and inferential statistics.

 Demographic variables analyzed by using frequency and

percentage distribution.

 Frequency and percentage distribution to assess the knowledge

of student nurses on chest tube drainage.

 Mean and standard deviation to assess the knowledge of

student nurses on chest tube drainage.

 Paired t-test to compare the pre-test and post-test assessment

level of knowledge of student nurses on chest tube drainage.

 Chi-square test to analyze the association of the demographic

variables with the post assessment level of knowledge of student nurses on chest tube

drainage.

 Duration of study : 6 weeks.

7.3 Does the study require any investigation or intervention to be conducted on

patients or other human beings or animals?

7.4 Has ethical clearance been obtained from institution?

21 YES. Ethical committees report is here with enclosed.

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