#KINKS COLOR CHECKLIST SKIN#

Ensure the water seal is maintained at 2 cmĪppropriate and regular pain relief (IV opioid infusion, PCA etc).Prevent pulling of the drain (See image below)

#KINKS COLOR CHECKLIST SKIN#

Patient bed to prevent accidental removal and anchored to the patient’s skin to

Drain tubing should always be secured to.

The unitĪnd all tubing should be below patient’s chest level to facilitate drainage.Įnsure the unit is securely positioned on its stand or hanging on the bed Tubing should have no kinks or obstructions that may inhibit drainage Should occur at the beginning of the shift and every hour throughout the shift.

Assessment of chest tube and system tubing.

Ensure all connections between chest tubes.

EffectiveĪnchoring below the insertion sites will assist with preventing this. Injuries particularly where the tubing is in contact with the skin.

Assess skin at a minimum four hourly for pressure.

Secure (particularly long term drains where sutures may erode over time)

Observe that the sutures remain intact and.

Infection/inflammation every hour and document this within EMR:Īmounts of ooze can be a normal presentation post operatively, however if anyĪbnormal presentations are observed: Notify the medical team, consider takingĪnd sending swabs of the site and take a clinical photo and

Assess for any ooze, bleeding or signs of.

Check that the dressing is clean and intact.

On insertion of chest drain monitor andĭocument on EMR flowsheets patient observations (HR, SpO2, BP, RR, respiratoryįor 4 hours then 1-4 hourly as indicated by patient conditionĭrain insertion site and dressing assessment:.

Patient is on an opioid infusion continuous monitoring is required and hourlyĬardiorespiratory observations (HR, SpO2, BP, RR) should be documented

Routine four hourly observations including.

Nurse changing the UWSD or bedside nurse). Operatively on the ward, the responsibility of labelling lies with the directĬare giver (e.g. Should be completed by the Cardiac theatre nurses / surgeons post operatively prior to transfer The criteria for correct labelling includes theįont and capital letters) on a label that can be complete stuck down Please refer to the image below for the correct This is extremely important when removing the drain to ensure theĬorrect drain is removed. It is imperative that the UWSD is labelled in a way that is clear and Risk of tension pneumothorax development if clamped That the drain in not clamped (unless ordered by medical staff). Image below for labelling of each chamber)įor any leakages or movement in water chamber That the amount of suction correlates with the medical team order on EMR (See

Drain is on suction (i.e Red bellow out) and.

Of each drain tube in accordance with EMR documentation (See The drain dressing to ensure it is intact and for any signs of infection Suction outlets - x1 chest drain and x1 for airway management Two drain clamps per drain (For use in emergency only) That there is emergency equipment at bedside including: See Aseptic Technique Policy and Procedure Chest Drain Assessment & Management Start of shift checks

Chest Drain (Intercostal Catheter) Insertion Clinical Practice Guideline.

Please see the Chest Drain Insertion CPG below: Indications for Insertion of a Chest Drain

Tension Pneumothorax: Air builds up in the pleural space and forces a mediastinal shift leading to decreased venous return to the heart and lung collapse/compression causing acute life-threatening respiratory and cardiovascular compromise.

Pneumothorax: Collection of air in the pleural space.

Haemothorax: Collection of blood in the pleural space.

Chylothorax: Collection of lymph fluid in the pleural space.

However, it also outlines management from the perspective of other specialityĪreas where care may differ. Is written from the perspective of a cardiac and renal ward management To provide a clear guide for nursing staff to promote the safe, correct and competent management of the UWSD in the ward setting. This clinical guideline Please refer to Pleural and Mediastinal Drain ManagementĪfter Cardiothoracic Surgery guideline. Some patients will have Redivac drains inserted,

Routinely in theatre, PICU and NICU or in the emergency department and wardĪreas in emergency situations. Respiratory function and haemodynamic stability. Appropriate chest drain management is required to maintain This allowsįor the expansion of the lungs and restoration of negative pressure in the UWSD are designed to allow air or fluid to be removed from the pleural cavity, whileĪlso preventing backflow of air or fluid into the pleural space. Under water sealed drains (UWSD) are a drainage system of three chambersĬonsisting of a water seal, suction control and drainage collection chamber.

Kinks color checklist