RNSP: Advanced RN Intervention
Policies and ProceduresRNSP: Advanced RN InterventionTitle:CHEST TUBES: IRRIGATION AND/ORADMINISTRATION OF A MEDICATION TOTHE PLEURAL SPACEI.D. Number: 1016Authorization:[X] SHR Nursing Practice Committee[X] Critical Care Executive CommitteeSource: NursingDate Revised: November 2016Date Effective: September 2016Scope: SPH ICUAny PRINTED version of this document is only accurate up to the date of printing 9-Jan-17. Saskatoon Health Region (SHR)cannot guarantee the currency or accuracy of any printed policy. Always refer to the Policies and Procedures site for themost current versions of documents in effect. SHR accepts no responsibility for use of this material by any person ororganization not associated with SHR. No part of this document may be reproduced in any form for publication withoutpermission of SHR.DEFINITIONS:Health Care Professional- for the purpose of this policy, Health Care Professional will be used to referto the Registered Nurse, physician or their designateIntrapleural instillation is the delivery of the medication into the pleural space. The goal is tobreakdown any areas of infective material or fibrin within the pleural space that may impair the flowof drainage.Pleurodesis fusion of the visceral and parietal pleura by instilling a sclerosing agent through a chesttube or via talc insufflations.ROLES:Registered Nurses (RNs): RNs identified by the manager in targeted practice settings will be certifiedin this RN Specialty Practice (Advanced RN Intervention): Intrapleural Irrigation and /or medicationadministration via Chest Tubes1. PURPOSE1.1 To safely irrigate the pleural space1.2 To safely administer medications into the pleural spacePage 1 of 6
Policies & Procedures: Chest Tubes: Irrigation and/or Administration of a Medicationto the Pleural SpaceI.D. #10162. POLICY2.1 The RN certified in this RNSP will have first completed the following learningmodules/activities prior to performing intrapleural irrigation and /or medicationadministration via chest tubes: Attended an educational session on intrapleural irrigation and /or medicationadministration into chest tubes: Completed the learning package and quiz and returned it to the CNE Complete skills checklist with a certified RN during first intrapleural irrigation and/ormedication administration into chest tubes, to validate and ensure safety checks arefollowed appropriately.2.2 A written physicians order is required for intrapleural irrigation or administration of anintrapleural medication. They must specify the type, amount of solution or medication,frequency and length of dwell time.2.3 All RN’s may add the irrigation set up to the chest drainage system2.4 Only a Registered Nurse who has received the RNSP certification or the physician mayirrigate and instill into the chest tube.2.5 Pleurodesis is performed by the physician only.2.6 For single dose medication, intrapleural medications are administered manually with asyringe not an infusion pump.2.7 For irrigations or antibiotic instillation over several hours, an infusion pump may be used.2.8 Notify the physician if the patient experiences any of the following symptoms Difficulty breathing during/after irrigation/instillation Signs and symptoms of bleeding Significant pain during/after irrigation/instillation3. PROCEDURES3.1 Patient teaching:3.1.1 Explain the purpose and the goal of the procedure3.1.2 Explain to the patient what to expect during and after the procedure3.1.2.1 During the procedure some pressure and slight discomfort during theprocedure3.1.2.2 After the procedure: the chest tube may be clamped for a few hours asordered by the physician and once the chest tube is unclamped there maybe more drainage. This will be closely monitored by the nurse. There should beno drainage around the chest tube site, but if this occurs the nurse will notifythe physician. If bleeding occurs the nurse will immediately notify thephysician.3.1.2.3 Advise the patient to notify the nurse immediately if any of the followingoccur: Difficulty with breathing Any drainage from the chest tube site Any pain during/after instillation of solutionPage 2 of 6
Policies & Procedures: Chest Tubes: Irrigation and/or Administration of a Medicationto the Pleural SpaceI.D. #10163.2 Supplies: Sterile gloves Sterile drape Facemask with shield Chlorhexidine 2 Chest tube clamps per chest tube Needleless adaptor ex. Microclave T-connector or stopcock as indicated belowo See Appendix A for photos3.3 Adding the Irrigation Set Up to the Chest Drainage System (All RNs can do)Note: the small bore drains (pigtail drains) often are already connected to a stopcock andchest drainage set (ex. Truclose drainage), the system is already set up forirrigation/instillation.3.3.1 Wash hands and don gloves and mask with face shield. Proceed using aseptictechnique3.3.2 Clamp the chest tube closest to the patient using 2 clamps in opposite direction3.3.3 Chest tube should be clamped less than one minute3.3.4 Insert the stop cock or T-connector between the chest tube and the chest drainageset. If using an T-connector, apply a needleless adaptor to the remaining stopcockport3.3.5 Remove the chest tube clamps.3.3.6 Secure the non-luer lock connections with waterproof tape3.3.7 Assess the chest drainage system for signs of a leak.3.4 Intermittent Intrapleural Irrigation of the chest tube (RNSP Certified RNs only)3.4.1 Prepare the non-medicated (NaCl 0.9%) irrigation solution3.4.2 Turn off suction if applicable3.4.3 Stopcock inline:3.4.3.1Turn the stopcock “off” to drainage3.4.3.2Clean the injection cap of the needleless adaptor on the 4-way stopcockwith an alcohol swab and allow air to dry ( contact time 30 seconds)3.4.3.3Insert syringe in the injection cap3.4.3.4Instill the prescribed amount of solution. Stop instillation and notify physicianif a lot of resistance is felt or the patient complains of pressure or pain3.4.3.5Clamp the chest tube for the prescribed time (keeping the stopcock off todrainage).3.4.3.6If the chest tube is not ordered to be clamped after the irrigation, open thestopcock between the chest tube and the drainage system and turn thesuction back on if applicable.Page 3 of 6
Policies & Procedures: Chest Tubes: Irrigation and/or Administration of a Medicationto the Pleural SpaceI.D. #10163.4.4 T-connector with needleless adaptor in place:3.4.4.1Clamp the chest tube below the connector3.4.4.2Clean the injection cap of the needleless adaptor on the T-connector withan alcohol swab and allow air to dry ( contact time 30 seconds)3.4.4.3Insert syringe in the injection cap3.4.4.4Instill the prescribed amount of solution. Stop instillation and notify physicianif resistance is felt or the patient complains of pressure or pain3.4.4.5Clamp the chest tube for the prescribed time (keeping the stopcock offtoward the patient).3.4.4.6If the chest tube is not ordered to be clamped after the irrigation, turn thesuction back on if applicable.3.5 Administration of medication in the pleural space: (RNSP Certified RNs only)3.5.1 Prepare the prescribed medication3.5.2 Turn off suction if applicable3.5.3 Stopcock inline:3.5.3.1Turn the stopcock “off” to drainage3.5.3.2Clean the injection port of the needleless adaptor on the 4-way stopcockwith an alcohol swab and allow air to dry ( contact time 30 seconds)3.5.3.3Insert syringe in the injection cap3.5.3.4Instill the prescribed medication. Stop administration and notify physician ifresistance is felt or the patient complains of pressure or pain3.5.3.5Clamp the chest tube for the prescribed time (turn stopcock off toward thepatient.3.5.3.6If the chest tube is not ordered to be clamped after the medicationadministration, open the stopcock between the chest tube and thedrainage system and turn the suction back on if applicable3.5.4 T-connector with needleless adaptor in place:3.5.4.1Clamp the chest tube below the connector3.5.4.2Clean the injection needleless adaptor on the T-connector with an alcoholswab and allow air to dry ( contact time 30 seconds)3.5.4.3Insert syringe in the injection cap3.5.4.4Instill the prescribed medication. Stop medication administration and notifyphysician if resistance is felt or the patient complains of pressure or pain3.5.4.5Clamp the chest tube for the prescribed time3.5.4.6If the chest tube is not order to be clamped after the medicationadministration, turn the suction back on if applicable3.5.5 Administration of a continuous infusion (antibiotic or Normal Saline)3.5.5.1Clean the injection port of the needleless adaptor on the 4- way stopcockwith an alcohol swab and allow to dry (contact time 15 seconds)3.5.5.2Connect the infusion tubing to the needleless adaptor3.5.5.3Cover all injection ports with colored tape3.5.5.4Program the infusion pump to the prescribed rate3.5.5.5Identify infusion pump as “intrapleural” infusion ( e.g. put tape across pumpand label as Intrapleural Infusion )3.5.5.6Monitor patient as per medication administration policy and per chest tubepolicyPage 4 of 6
Policies & Procedures: Chest Tubes: Irrigation and/or Administration of a Medicationto the Pleural Space3.6 Assess Note:I.D. #1016patient and chest tube system in 15 minutes then q 1hr prnVital signs including Sp02Rate, depth and ease of respirationsSkin colorLung auscultationInsertion siteAmount and type of drainageOccurrence of subcutaneous emphysema or any other signs of distressPatient comfortOccasionally, if there is a loculated effusion, the lytic effect of the medication maybe quite dramatic and may result in a pressure-like pain. This may also causedrainage around the insertion site.3.7 Document amount of solution or medication given and any change in patient condition ordrainage noted.4. REFERENCESChest drainage (small and large bore chest tube) adding an irrigation set up to a drainagesystem and intrapleural irrigation, instillation. Nursing policies, procedure & protocols the OttawaHospital 2007.New England Journal of oa1012740?viewType Print&viewClass Print 1/5/2016Rahman et al. Intrapleural use of tissue plasminogen activator and DNase in pleural infection.Rahman, Najib M .Intrapleural agents for pleural infection: fibrinolytics and beyond .Volume 18,Number 4 July 2012. www.co-pulmonarymedicine.comTissue Plasminogen Activator (TPA, Activase) and Pulmozyme (dornase alpha) Intrapleural forloculated empyema protocol. 07/2014 Gwinnett Hospital SystemPage 5 of 6
Policies & Procedures: Chest Tubes: Irrigation and/or Administration of a Medicationto the Pleural SpaceI.D. #1016Appendix AConnection Devices to be used between chest tubes and collection deviceA T-connector or stop-cock to be placed between the chest tube and the collection device, the item willbe dependent on the size of the 2 ends213451. Custom contrast /fluidManagement kit [SKU 46882]2. 4-way stopcock [SKU 40090]3. ¼ x 3/8 inch T-connector(Special order)4. 3/8 x 3/8 inch T- connector(Special order)5. Sterile 5 in 1 connector[SKU 536455]Chest tube drainage systemChest tube1.Small bore chest tubeex. Pig tail2.Midsize chest tubeex. 20 Fr thoracicsilicone catheter3.Large bore chest tubeor Thoracic siliconcatheterex. Size 24 or larger orThal-quick chest tubeUnderwater Chest Drainage Set 4-way stopcock SKU 40090Fluid management kit SKU 46882T- connector needleless adaptor(¼ x 3/8 inch)Truclose Drainage 4-way stopcock SKU 40090 T- connector needleless adaptor(¼ x 3/8 inch)Fluid management kit ** this is the only chest tube that needsthis size connector T connector needleless adaptor(3/8 x 3/8 inch)SKU 46882 T connector needleless adaptor(3/8 x 3/8 inch)Fluid management kitSKU 46882Page 6 of 6
3.3.2 Clamp the chest tube closest to the patient using 2 clamps in opposite direction 3.3.3 Chest tube should be clamped less than one minute 3.3.4 Insert the stop cock or T-connector between the chest tube and the chest drainage set. If using an T-connector, apply a
Special Nursing Practice (RNSP) competencies shall monitor patients receiving mechanical ventilation. 4.2 The RN certified in this RNSP will have first completed the following learning modules/activities prior to performing the nursing care of a mechanically ventilated patient: 4.2.1 Review the policy and procedure.
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