Vol. 4 No.4 Recovery Strategies from the OR to Home �� ���� ����� Postoperative uca g ed tio D rains continue to be a common Care of Patients facet of the postoperative man- n nf continui agement of surgical patients. or nursin with Surgical While they serve an important function they also are associated with compli - cations, including hemorrhage, tissue Drains inflammation, retrograde bacterial migra- g tion, drain entrapment or loss, pain, and fluid, electrolyte, and protein loss. Proper postoperative care from post-anesthesia By Jody Scardillo, RN, MS, CWOCN care to hospital discharge can avoid com- T plications, promote healing, and achieve a positive outcome. he use of surgical drains and tubes passive fashion. They are used for a variety continues to be a common facet of abdominal surgeries, myocutaneous flap Pancreatic cancer is a very aggressive tu- of the postoperative management surgery, and breast and orthopedic proce- mor with a poor prognosis. The reported of surgical patients. Postoperative dures. 5-year survival rate is less than 5%. The care and recovery strategies, from post- only curative treatment is a pancreatico- anesthesia care to hospital discharge, can Types of drains duodenectomy for those few who have avoid complications, promote healing, and Active drains resectable disease. This procedure has achieve a positive outcome. These low-pressure suction devices become the standard of care, but it is a Shorter lengths of stay in the acute- continuously remove fluids against gravity complex procedure and recovery is dif- care setting mean that nurses in home- and via a closed drainage system. The drain is at- ficult. Nursing care must focus on patient long-term care need a basic knowledge of tached to a collapsible reservoir that exerts education, both to prepare the patient tube and drain management. This article negative pressure to pull accumulated fluids preoperatively and postoperatively. Ms. discusses the management of surgical from the wound bed. The collection reser- Daniels discusses the procedure and drains and prevention of related complica- voir expands, as it collects drainage. The postoperative interventions to promote tions in postoperative patients. advantages of active drains include: a successful discharge. minimal tissue trauma Indications for surgical tubes and accurate drainage quantification drains a closed system, which decreases Advisory Board Surgical drains are indicated for de- infection risk Cheryl Bressler, MSN, RN, CORLN compression in areas with:1,4 Oncology Nurse Specialist, Oncology Memorial Hospital, Houston, TX a large potential dead space The consistency of fluid that is drain- Lois Dixon, MSN, RN necrotic or infected tissue ing, tube diameter and length, and amount of Adjunct Faculty, Trinity College of Nursing, Moline, IL uncertain hemostasis negative pressure can impact the effective- Pulmonary Staff Nurse, Genesis Medical Center, Davenport, IA a fistula ness of active drains.1,2 Jan Foster, RN, PhD, MSN, CCRN a significant amount of fluid Jackson-Pratt and Hemovac drains are Asst. Professor for Adult Acute and Critical Care Nursing Houston Baptist University, TX accumulation common active drains. Most Jackson-Pratt Mikel Gray, PhD, CUNP, CCCN, FAAN reservoirs hold 100 cc of fluid, while Hemo- Nurse Practitioner/Specialist, Associate Professor of Nursing, Drains serve an important function vac reservoirs hold 500 cc. Jackson-Pratt Clinical Assistant Professor of Urology, University of Virginia, Department of Urology, Charlottesville, VA but are associated with complications, in- drainage tubing is more flexible than Hemo- cluding hemorrhage, tissue inflammation, vac tubing.3 Victoria-Base Smith, PhD (c), MSN, CRNA, CCRN Clinical Assistant Professor, Nurse Anesthesia, retrograde bacterial migration, drain entrap- The nurse ensures that tubing is in a University of Cincinnati, OH ment or loss, pain, and fluid, electrolyte, dependent position and free of kinks. The Mary Sieggreen, MSN, RN, CS, NP and protein loss. The appropriate use and drainage reservoir is kept in an empty, col- Nurse Practitioner, Vascular Surgery, Harper Hospital, Detroit, MI early removal of drains decrease the risk of lapsed position to maintain negative pres- Franklin A. Shaffer, EdD, DSc, RN some complications.1 sure and suction. The use of a commercially Vice-president, Education and Professional Development, Drains can function in an active or Continued on page 4 Executive Director, Cross Country University Supported by an educational grant from Dale Medical Products Inc. Perioperative management The use of MRI has not proved to be as accurate as CT.3,7,8 of patients with resectable A laparoscopy may be performed as a routine part of the work-up in the outpatient setting. However, most surgeons do it im- pancreatic cancer mediately before a laparotomy. If unresect- able disease is found, the procedure can be concluded.8 Although no standardized clinical by Betty Thomas Daniel, MS, RN, AOCN and pathological staging system of pancre- atic cancer exists in the USA, the American Joint Commission on Cancer (AJCC) has P ancreatic cancer is a very aggres- Diagnosis and staging developed a staging system. This system is sive tumor with a poor prognosis. With the recent advances in diagnostic based on local disease, nodal involvement, The reported 5-year survival rate techniques, our ability to detect pancreatic and distant metastasis.3,9 Unfortunately, it is less than 5%. The only curative cancer and obtain tissue for diagnosis has lends itself more to pathologic evaluation of treatment is a pancreaticoduodenectomy. greatly improved. All patients with sus- resected specimens. With the advances in The 5-year survival rate in patients who pected pancreatic cancer should receive techniques and skills, the use of diagnostic have this procedure is 15% to 20%.1 Pancre- an abdominal CT scan and transabdominal imaging and endoscopic procedures make atic cancer is the second most common ultrasound (US). Endoscopic retrograde it possible to use clinical staging reliably to cancer of the gastrointestinal tract and the cholangiopancreatography (ERCP) is per- formulate realistic treatment plans. fourth leading cause of cancer deaths in the formed to visualize the pancreatic duct and USA. The American Cancer Society estimat- biliary tree in patients presenting with jaun- Treatment ed 30,300 new cases and 29,700 deaths due dice. Newer imaging techniques whose roles Of all cancers, pancreatic can- to pancreatic cancer in 2002.2 Median age of are still evolving include endoscopic ultra- cer is most likely to have metastasis at the patients with pancreatic cancer is about 70 sound (EUS), positron emission tomography time of diagnosis – a primary reason why years, and most are over the age of 65. The (PET), and magnetic resonance imaging it continues to be one of the most difficult incidence is higher in the black population, (MRI).7,8 gastrointestinal cancers to treat. Surgery is with black men at the highest risk world- Transabdominal ultrasound is a rela- the treatment of choice; however, only 15% wide.3 tively inexpensive and non-invasive proce- of patients meet the criteria for curative sur- Although little is known about the dure. It has a sensitivity of 70% and specific- gery.11 etiology of pancreatic cancer, a few risk fac- ity of over 90% for the diagnosis of pancre- Radiation therapy is used preopera- tors have been identified. The most signifi- atic cancer. It is commonly used as an initial tively, to make locally advanced tumors re- cant environmental risk factor is cigarette screening technique for biliary-pancreatic sectable, or postoperatively to eliminate any smoking. Heavy cigarette smokers have disease.7 This test is usually followed by residual disease. Pancreatic cancer is very twice the risk of nonsmokers.3 Diet is the an abdominal CT scan. Using spiral or heli- chemoresistant; however; new approaches second most important risk factor, although cal CT imaging, unresectable tumors are are being investigated. For the purpose of data are not as consistent as that for smok- predicted in 85% of patients and resectable this paper, only the surgical intervention for ing. Generally, a higher risk is associated tumors in 70% of patients. A mass at the resectable adenocarcinoma of the pancreas with animal protein and fat consumption head of the pancreas is the most common will be presented. and less risk, with the intake of vegetables finding.3,7 Evidence of unresectability on CT and fruit.4 Genetic predisposition is impli- scanning includes regional lymphadenopa- Pancreaticoduodenectomy (Whipple cated in 5% to 10% of patients with pancre- thy, encasement or occlusion of the superior procedure) atic cancer. Other inconclusive risk factors mesenteric or celiac artery, portal vein in- Once the staging work-up is com- are chronic pancreatitis, diabetes, alcohol volvement, liver metastasis, invasion of ad- pleted and the patient is identified as a can- use, and occupations, such as chemists, coal jacent organs, or peritoneal spread. didate for curative surgery, the preoperative and gas exploration workers, and those in Endoscopic retrograde cholangiopan- phase begins. Typically, the patient receives metal industries, leather tanning, textiles, creatogram is indicated in the presence of a complete history and physical, and the aluminum milling, and transportation.4,5,6,7 obstructive jaundice. Brand refers to it as team reviews the imaging films and pathol- the “gold standard for the visualization of ogy reports. Consultations are requested Clinical manifestations the pancreatic duct and biliary system.”7 for cardiology clearance, and additional Jaundice, associated with adenocar- Endoscopic ultrasonography is a more consultations are requested as indicated. cinoma in the head of the pancreas, is pres- recent technique that is felt to be more sen- Blood work, which includes CEA and CA19- ent in about 50% of patients at diagnosis. It sitive in diagnosing and staging adenocarci- 9 (serum markers for following disease is associated with a less advanced stage of noma of the pancreas. Accuracy is reported and assessing adequacy of resection), is disease than other symptoms. However, few to be as high as 90%. 3 completed.3 If the patient has undergone patients present with early disease, because PET is based on the assumption that prior abdominal surgery, an arteriogram is signs and symptoms are usually vague and glucose use is higher in malignant cells. In requested. nonspecific. They include anorexia, weight pancreatic cancer, there is a higher uptake loss, abdominal discomfort or pain, and nau- of glucose analog. Identification of pancre- Preoperative patient instructions sea.3 These complaints may delay diagnosis atic cancers using the PET scan is greater Patient instructions are provided by for months. The pain is described as severe, than 93%, but false-negative reports and all healthcare professionals, and printed gnawing, and radiating to the mid or low specificity is also high. Thus, the role of PET educational materials are provided. The pa- back. It is due to tumor invasion of the ce- in diagnosing adenocarcinoma of the pan- tient receives instructions about all aspects liac ganglia and mesenteric nerve plexus.5 creas remains unclear.7 of surgery, including the placement of jeju- nostomy tube (J-tube) and gastrostomy tube 2 (G-tube), length of stay, and healthcare pro- of the falciform ligament over the stump of fessionals involved in their care. the gastroduodenal artery. The vascularized Preoperative instructions include in- falciform is placed between the stump and formation about diagnostic tests, smoking afferent limb of jejunum to prevent hepatic cessation, donation of blood, anesthesia, artery pseudoaneurysm formation at the and discontinuing the use of aspirin, anti-in- origin of the gastroduodenal artery, causing flammatory medication, and anticoagulants an arterio-enteric fistula. This complication for 10 days prior to surgery. The patient is is usually due to a leak at the pancreaticoje- informed how to prepare for surgery, what junostomy and results in localized infection to expect on the day of surgery, about the or abscess formation. Although infrequent, intensive care experience, what will happen this complication is usually fatal; prevention on the hospital unit before discharge, and is the best treatment.5 about home care. The patient learns how to use the incentive spirometer, patient- Postoperative management Foley Catheter Holder. Dale Medical Products Inc. controlled analgesia pump, and how to do After surgery, the patient is admitted breathing exercises preoperatively, as these peritoneal margin. The pathologist and sur- to the surgical intensive care unit. The pa- devices are very important to the recovery geon should evaluate the specimen together tient will have a nasogastric tube (NGT) to process. Detailed written instructions de- to determine if any margin is positive. If low-wall suction, a G-tube to bedside gravity scribe what is expected of the patient and positive, re-resection if performed.5 drainage, a Foley catheter, two closed suc- caregiver and review what the patient can Reconstruction after pancreaticoduo- tion drains, a clamped J-tube, and compres- expect from the healthcare team on a daily denectomy occurs in four steps: pancreati- sion boots. basis. cojejunostomy, hepaticojejunostomy, gastro- Management of some of the post-op- jejunostomy, and insertion of drains. erative drains and tubing can be aided by Surgical procedure Firstly, the pancreatic remnant is the application of Velcro® type holders for Four surgical procedures are used moved away from the retroperitoneum and the Foley catheter and drainage bulb (Dale to treat adenocarcinoma in the head of the splenic vein by about 2 to 3 cm. The resected Medical, Plainville, MA). The Foley catheter pancreas. They include the standard Whip- jejunum is brought retrocolic through the holder helps prevent movement of the cath- ple pancreaticoduodenectomy (PD), pylorus defect in the transverse mesocolon to the eter within the urethra, reducing the risk of preserving PD, regional pancreatectomy, left of the middle colic vessels. A two-layer, urethral irritation or erosion, bladder spasm and total pancreatectomy.12 For the purpose end-to-side, duct-to-mucosa pancreaticoje- or inadvertent catheter “pull-out.” The ap- of this paper, the standard PD will be pre- junostomy is performed over a stent. If the plication of a drainage bulb holder will help sented. pancreatic duct is not dilated, the stent is to promote drain function, allowing quick The recommended approach is a bi- not necessary. easy access for emptying or drain removal lateral subcostal incision.5 The liver and Secondly, a biliary anastomosis is per- and to provide your patient with the piece of peritoneum are examined to identify any formed, carefully aligning the bile duct and mind that the tube will not be accidentally metastasis. The procedure does not proceed jejunum to avoid tension on the pancreatic dislodged. in the presence of metastasis. There are and biliary anastomosis. Thirdly, an end- Postoperative day (POD) one, the pa- six steps to surgical resection. Firstly, the to-end gastrojejunostomy is constructed. tient remains in intensive care. The NGT will superior mesenteric vein is exposed at the Gastrostomy and feeding jejunostomy tubes be removed, if the patient is extubated. The inferior border of the pancreas. Secondly, an are placed. Two closed-suction drains are patient will be instructed to use an incen- extended Kocher maneuver is performed, placed. The gastrostomy tube (G-tube) is tive spirometer and turn, cough, and deep removing all fibrofatty and lymphatic tis- placed for intermittent drainage. The feed- breathe every hour. Nebulizer treatments are sue anterior to the inferior vena cava and ing jejunostomy tube (J-tube) is placed for administered three times daily. The patient aorta. The third step is dissection of the postoperative alimentation. This step is will be expected to be out of bed after extu- porta hepatis, which begins with dissection important, because the most common com- bation. of the common hepatic artery and ligation plications associated with the PD are poor POD two, the patient is still in inten- and division of the gastroduodenal artery. gastric emptying and inadequate nutritional sive care. The dietitian will see the patient The hepatic duct or common bile duct is support.5 to write orders for tube feedings to start on divided, and the gallbladder removed from The last procedure performed before Continued on page 6 the liver bed. Fourthly, the stomach is tran- closure of the abdomen is the placement sected at the level of the third or fourth transverse vein on the lesser curvature and Resources for Pancreatic Cancer at the confluence of the gastroepiploic veins on the greater curvature. Fifthly, transsec- www.pancreasfoundation.org tion of the jejunum is followed by ligation The National Pancreas Foundation – supports the research of diseases of the pancreas and provides information and humanitarian services to those people who are suffering from such illness. and division of its mesentery. Step six is the transsection of the pancreas at the level of www.cancer.gov/cancer_information/cancer_type/pancreatic/ the portal vein. If there is evidence of tumor The National Cancer Institute – provides information about cancer of the pancreas (treatment, prevention, genetics, adherence to the portal vein or superior causes, screening and testing, clinical trials, cancer literature, and related information. mesenteric vein, the pancreas is divided at a more distal location. The head of the pan- www.mdanderson.org/DEPARTMENTS/pancreatic/ The University of Texas M. D. Anderson Cancer Center – provides information to physicians, patients, and the public creas is separated from the superior mesen- about the diagnosis, treatment, and study of pancreatic cancer at M. D. Anderson Cancer Center. teric vein by ligating and dividing the small venous tributaries. www.cancer.org The high incidence of recurrence after The American Cancer Society – describes different kinds of cancer, methods of prevention and treatment, and includes PD mandates careful attention to the retro- recent news about clinical trials and research. 3 tric suction in many conditions. It is used Postoperative Care of Patients with Surgical to decompress the stomach after gastro- Tubes and Drains — Continued from page 1 Initially, drainage from a intestinal surgery to prevent vomiting.8 It is radiopaque with a drainage lumen and available device that accommodates up to smaller vent lumen. Airflow through the vent four Jackson Pratt tubes can allow for easy access for monitoring and emptying of the surgical wound is prevents a vacuum from forming or the plug- ging of tube holes by gastric mucosa. The bulbs (Figure 1). larger drainage lumen is connected to the Initially, drainage from a surgical suction mechanism. Continuous low suction wound is serosanguinous or sanguinous. serosanguinous or is used. It becomes more serous in appearance as The nurse assesses the tube every two healing progresses. The amount and color hours for adequate function. The blue vent of drainage is closely monitored. The res- ervoir is emptied when half-full to maintain sanguinous. It becomes should be placed above the patient’s mid- line. Many tubes have an anti-reflux valve. A maximum function. To unclog blood or tis- low whistling sound signals that the air vent sue shreds, the tubing is gently milked or stripped, away from the patient’s body.4 more serous in appearance is sumping air. After insertion, the tube is taped se- A dry gauze dressing is sometimes curely or held in place with a commercially used around the surgical site. It is changed available tube device to prevent injury or daily or as needed. as healing progresses. pressure areas on the nostril or nasal mu- cous membrane. The tubing is angled below Passive drains the nares, rather than upward, to prevent na- Passive drains provide an exit for flu- lumen. Air breaks the vacuum, displacing air sal damage from pressure or tension. Some ids, pus, blood, or necrotic debris that inter- and fluid into the larger lumen. patients experience significant pain or ir- fere with wound healing or provide a source Certain types of sump drains have a ritation from the tube. Pain can be managed for bacterial proliferation. The passive drain third lumen. It is used for infusing a wound with a topical anesthetic spray, oral throat is usually placed in a stab wound near the irrigation, while maintaining suction from lozenge, or petrolatum ointment. Frequent incision site. the other lumen. Sump drains are more com- mouth care promotes patient comfort. The Penrose drain is a common pas- mon in complex abdominal surgeries. sive drain. Made of soft flat, flexible latex Sump drains are sutured in place and Tracheostomy tubes material, it enables fluid to escape by gravity covered with a dry dressing. Careful intake These tubes are inserted through a and capillary action. A safety pin or holder is and output must be maintained, when caring tracheotomy, a stoma in the airway that as- often used on this drain to prevent migration for patients with a sump drain. sists breathing, either surgically or by tradi- into the wound.2 The surgeon may select tional percutaneous techniques. Tracheos- this type of drain when drainage is expected Percutaneous drainage catheter tomy tubes are used for: to be too viscous to pass through an active Occasionally, a postoperative patient postoperative care in some head and drain.2 needs a percutaneous drainage catheter. Im- neck surgeries Dry gauze dressings are used over the plantation, performed by an interventional pulmonary toilet passive drain to contain drainage. Split or radiologist, enables non-operative diagnosis managing airway secretions fenestrated gauzes are particularly useful. and drains fluid collections at many body These dressings are changed when saturat- maintaining the airway over time with sites. ed, with care, so the drain is not accidentally Indications for use include: or without mechanical ventilation extracted when gauze is removed. concern that a fluid collection is treating upper airway obstruction infected Sump drain need for characterization of fluid The tubes may be temporary or per- Sump drains are double-lumen tubes if the collection is producing manent, depending on the patient’s need. with a large outflow lumen and smaller in- symptoms to justify drainage5 They place the patient at risk of local infec- flow lumen. Venting occurs when air enters tion, peritubular skin breakdown, tracheal the drainage area through the small inflow The catheter is connected to a depen- stenosis, tracheo-esophageal fistula, aspira- dent drainage system. A urinary leg bag or tion, and accidental dislodgement, and alter bile bag works well with these drains. The the ability for verbal communication.6 length of time needed for drainage depends on the patient’s individual situation. Sometimes, tube irrigation is per- formed to maintain patency of a percuta- neous drainage catheter. When irrigating, the nurse uses an aseptic technique and the prescribed type, frequency, and volume of irrigant solution. Force or aspiration is never used to return the fluid. The return, color, and consistency of fluid, along with the patient’s tolerance of the procedure, are documented. Salem sump The Salem sump is used for nasogas- Figure 1. Jackson-Pratt Holder. Dale Medical Products Inc. Figure 2. Tracheostomy Holder. Dale Medical Products Inc. 4 After tubal placement, the tracheoto- dislodgment. The nurse notifies the physi- my site is monitored for signs of bleeding. Tracheostomy tubes are often sutured in Tubing should remain free cian if a sudden increase in amount or a change in the character of drainage occurs. place for the first four to five days. A priority for nurses is the accurate Cotton-tip applicators permit a thor- measurement and recording of drainage ough cleansing of the intact skin around and under the tracheostomy flange. This area of kinks, debris, or small output. This information helps the clinician to determine how long the drain needs to is gently cleansed with a mixture of half- remain in place. When the patient has more strength normal saline and hydrogen per- oxide. Precut drain sponges or fenestrated clots. In tubes or drains that than one drain, the nurse labels each by lo- cation or number and records output sepa- foam gauze dressings can be used around rately. Labeling should be consistent from the tube to absorb excess secretions or one caregiver to another to avoid confusion bloody drainage. Commercially available precut dress- function by dependent or about the volume and character of output. The nurse notes the instillation of irrigation ings decrease the risk of gauze fibers enter- solution separately on the intake form. ing the stoma. The tracheostomy tube is best secured with commercially available gravity drainage, such as a Stabilization of the drain prevents dislodgment and the infection or irritation securing devices. Tube holders secure the of surrounding skin. A secure tube or drain tube well but are loose enough to prevent can function properly; however, securing the skin breakdown (Figure 2). As postoperative biliary or gastrostomy tube tube too tightly can put excess tension on edema subsides, ties should be monitored the drain and insertion site. The application for proper fit. of a commercial tube holder (Dale Medical Leakage of mucous secretions around the GI tract to enlarge and results in leakage Products) will help prevent the tube from the tracheostomy tube may cause local skin of gastric contents around the tube. Sutur- being secured too tightly and keep multiple irritation. Adequate suctioning and manage- ing the tube in place prevents inward and bulbs organized. ment of secretions help to minimize this outward movement but does not prevent Tubing should remain free of kinks, problem. Nurses are advised to store extra lateral movement. Dry gauze dressings are debris, or small clots. In tubes or drains that tubes or obturators at bedside in case of used over the G-tube. It is not uncommon function by dependent or gravity drainage, emergencies, such as accidental dislodge- for the clinician to apply an abdominal bind- such as a biliary or gastrostomy tube, the ment. Securing the tracheostomy tube can er over the dressings to prevent tube move- collection device should be maintained be- prevent this all-too-common occurrence. ment and patient tampering. G-tubes are low the level of the tube. Because the Dale Specialized tracheostomy tube holders, such often connected to gravity drainage or low Drainage Bulb Holder can be applied in a as the Dale tracheostomy holder, can pre- intermittent suction sources. variety of positions, the holder can always vent dislodgement. This holder has a wider be positioned below the drainage bulb. diameter neckband that distributes pressure Biliary tubes If the tube or drain is not working and prevents skin irritation. Velcro®-type A biliary tube or T-tube is a soft, thin, properly, the nurse should check its patency hook fasteners is used to secure the tube, rubber tube that passes through the skin from the patient’s skin to the collection making it easier and faster to apply. The and liver into the bile ducts to facilitate bile device and verify proper placement. Tub- holder has elastic in the band, promoting drainage. It is used to temporarily drain bile ing is checked for kinks, shreds of mucous, tube security and allowing patient move- before or after surgical procedures, relieve or blood clots. The tube is gently milked, ment. blockage of the bile ducts, or bypass an away from the patient’s body, if any kinks To lessen the risk of infection, nurses opening in the duct. A surgeon or interven- or debris are spotted. The suction source is must use an aseptic technique when suc- tional radiologist places the biliary tube. It checked to ensure that it is working with the tioning and cleansing tracheostomy tubes. is connected to dependent drainage. prescribed amount of suction. A disposable inner cannula, if used, must be The biliary drainage tube must be Early mobilization is another impor- replaced daily. anchored to prevent dislodgment or back- tant facet of postoperative recovery. The flow of bile and secured to prevent kinking. presence of a tube or drain does not affect Gastrostomy tubes Some practitioners prescribe daily tube the patient’s ability to walk. The Jackson- Gastrostomy tubes are used for post- flushing to prevent blockage.7 Pratt or Hemovac drain reservoir can be operative decompression. Sometimes, they secured to clothing by pinning to the plastic are chosen instead of a nasogastric tube to Management tab or using the attached clip. The Salem promote patient comfort, prevent nasal ir- Before managing the postoperative sump tube can be disconnected from suction ritation and rhinitis, or when a prolonged patient, a nurse must know4: and clamped, while the patient is walking. need for the tube is anticipated.4 type and purpose of surgical drain Other types of dependent drainage recepta- The surgeon may select a commer- location of surgical drain cles can be carried beside the patient. cially available gastrostomy (G-) tube or proper management strategies When drain removal is planned, the the traditional Foley catheter. The commer- potential problems patient is informed that momentary pain or cial G-tube has an external disk or bumper, how to troubleshoot complications discomfort may occur as the tube is pulled while the Foley catheter is sutured in place. out. The patient’s need for pain medication The G-tube is connected to gravity drainage In the immediate postoperative pe- is assessed. After the drain is removed, a or low intermittent suction. riod, the nurse should connect the tube or dry dressing is placed over the site. It can be A bumper or disk or G-Tube holder drain to the suction source, if indicated. replaced, as needed. Some drainage from the (Velcro®-type) stabilizes the G-tube. It is Suction is set at the prescribed volume, site commonly occurs until the tract heals. important to stabilize the Foley catheter to then monitored. Whatever drain is used, the Drains left in place for an extended period avoid dislodgment or movement in the gas- nurse ensures that its system is intact and may be difficult to remove, if tissue growth trointestinal (GI) tract. Movement causes that the drain is secured carefully to prevent has occurred around the drain. 5 Skin care essential when a patient is discharged with The risk to surrounding skin depends a surgical tube or drain. When the patient Perioperative management of patients with on the type and volume of drainage. The or caregiver has the ability to manage these resectable pancreatic cancer — continued from skin around all insertion sites must be kept devices at home, he or she regains a sense page 3 clean and dry to prevent infection and skin of control over bodily functions. irritation. When instructing the patient or care- POD three. Diet is advanced to sips of clear Dry gauze dressings are used around giver, clear, concise written and verbal liquids and popsicles. and over drains and tubes to protect them instructions are needed. A return demon- On POD three, the patient is trans- from damage or external contamination, ab- stration of the technical aspects of care con- ferred to the floor if the following criteria sorb small amounts of drainage, and assist firms that both patient and caregiver have are met: extubated, hemodynamically stable, with tube stabilization. These dressings are understood their lessons. The patient should afebrile, pain score less than five, and stable replaced, as needed. know the: fluid status. The case manager is consulted A pouching system is used to contain purpose of the tube to identify any patient home needs and to high-volume output that exceeds the capac- expected output check insurance approval for enteral feed- ity of dressings or to contain leakage around drain care and emptying ings and pump. Tube feedings are initiated, a tube or drain. Pouching helps the nurse to how to troubleshoot and instructions on G- and J-tube manage- quantify output and protects the patient’s whom to contact ment and wound care begin. The patient is skin. Before applying a pouch, it is impor- encouraged to be out of bed and walking tant to determine the cause of leakage. The Patients and caregivers are instructed with assistance. WOC(ET) nurse can assist in managing to wash their hands before and after han- On POD four, the caregiver performs a these complex situations. dling the drain or site. They are shown how return demonstration of the management of Appropriate dressing size is deter- to measure and record output on a form that G- and J-tubes. The diet is advanced to clear mined by the wound size, patient’s body can be brought to physician visits. Some- liquids, if tolerated. habits, and expected volume of drainage. times, a home-care referral is needed, so the On POD five, the G-tube is clamped Absorptive dressings, such as those made patient can learn how to assess and monitor for three hours on and one hour off. J-tube of calcium alginate, foam, or hydrofiber, complications. feedings are increased by 10cc/hr per day, are used if drainage exceeds the capacity of if bowel movements or flatus is present. In- standard gauze. These dressings are usually Conclusion structions begin for insulin administration, changed as needed, when saturation oc- Surgical tubes and drains are often if indicated. curs. If irritation is present or there is high used in patient care. Frequent assessment, On POD six, the G-tube is clamped output from a drain, a barrier wipe or cream meticulous care, and prevention of com- and released only if the patient experiences is applied after the surrounding skin is gen- plications are key to promoting a positive nausea/vomiting or abdominal distention. tly cleansed. The manufacturer’s directions outcome. Nebulizer treatments are discontinued. The guide the application of skin barriers. diet may be advanced to full liquids, if toler- References ated. J-tube feedings continue. Instructions Preventing complications 1. Memon MA, Memon B, Memon MI, Donohue JH. on the management of the G- and J-tubes Preventing complications, such as The uses and abuses of drains in abdominal surgery. and diabetes management are reinforced, as infection, is an important aspect of caring Hospital Medicine 2002;63(5):282-288. needed. for the post-operative patient with tubes and 2. Dougherty SH, Simmons RL. The biology and On POD seven, the diet is advanced to practice of surgical drains, part I. Current Problems drains. The nurse should maintain: in Surgery 1992;29: 559-623. regular, if tolerated, and calorie counts are preventive measures, such as hand- 3. Noble K. Name that tube. Nursing 2003:56-63. started and continued for three days. J-tube washing before and after patient care 4. Meehan P, Fraher J. Gastrointestinal tubes and feedings are decreased, if the patient toler- use of aseptic techniques when drains: Nursing management. Progressions ates a regular diet. The patient should be 1995;17(3):3-18. walking without assistance. cleansing and dressing surgical tubes 5. Standards of Practice Committee, Society of and drains Cardiovascular & Interventional Radiology, Quality On POD eight, care is focused on appropriate containment and disposal Improvement Guidelines for Adult Percutaneous preparing for discharge in two days. In- of drainage Abscess and Fluid Drainage. www.sirweb.org/ structions are reinforced, as needed. J-tube clinical/T25.htm 1995. formula is changed per dietitian. Take-home maintaining a closed system, 6. Harkin H, Russell C. Tracheostomy patient care. whenever possible Nursing Times 2002;97:34-36. supplies are ordered. implementing appropriate precautions 7. McConnell EA: Caring for a biliary drainage tube. On POD nine, the calorie count is con- against infection, e.g., avoid contact Nursing 1993;93:26. tinued. The G-tube should be clamped. The with anyone who has a respiratory, Jud it h N. Sca rd i l lo, patient should be out of bed most of day. wound or skin infections, including MS, RN, CWOCN, is a On POD 10, instructions for home major skin abscess, cellulitis, or Clinical Nurse Specialist care are completed. Intravenous access is pressure ulcers with uncontained in Enterostomal Therapy drainage at Albany Medical Cen- Table 1: Discharge criteria use of individual disposal containers ter, A lba ny, NY. She clamped G-tube for each person’s drains to avoid cross teaches wound, ostomy, no nausea contamination and continence nursing, drains are removed correct procedures for disposal of co - chairs the Advanced no fever walks without assistance drains, e.g., the use of chest tube Practice Nurse Group, and is a member of enteral feeding (2-4 cans per night) receptacles, active drains, sump Albany Medical Center’s Education Council. clean incision drains She is a Trustee of the Capital District affi liate no pulmonary complications or infections of the Wound, Ostomy, and Continence Nurses caregiver demonstrates ability to manage Patient education Society. In 2003, Nancy received the Albany G- and J-tubes and diabetes (if necessary) Patient and caregiver education is Ambassador award. 6 discontinued. The patient is discharged. Dis- 6. Stanford P. Surgical approaches to pancreatic cancer. Nursing Clinics of North America Cross Country University is an charge criteria are listed in Table 1. 2001;36(3):567-577. ac cred it ed provider of con tinu ing The patient has a follow-up visit in 7. Brand R. The diagnosis of pancreatic cancer. The education in nursing by the American one week, one month, and then every four Cancer Journal 2001;7(4):287-295. Nurses Credentialing Commission on months with the surgeon. 8. Todd KE, Reber HA. Surgical management of cancer accreditation. of the pancreas. In Silberman H and Silberman A (eds.). Surgical Oncology: Multidisciplinary Postoperative complications Approach to Difficult Problems. New York: Oxford . After reading this article, the learner should be able to: Perioperative death after PD is cur- University Press, 2000: 556-569. 1. Describe commonly used drains in the post- rently >6% at major surgical centers, where 9. Daniel BT. Gastrointestinal cancers. In Otto S (ed.). operative patient. surgeons are more experienced with the Oncology Nursing. 4th ed. St. Louis: Mosby, 2001: procedure.3,,12 Morbidity still remains high, 185-212. 2. Discuss management and prevention of 10. Evans DE, Wolff RA, Abbruzzese JL: Cancer of the complications related to drain use in the post- with complications, such as delayed gastric pancreas. In Pollock RE, (ed.). Manual of Clinical operative patient emptying, anastomotic leak, and fistula or Oncology 7th ed. New York: Wiley-Liss, 1999:453-475. abscess formation. Delayed gastric emptying, 11. Kim HJ, Conlon KC. Laparoscopic staging. In Evans To receive continuing education credit, simply do the number one cause of morbidity, occurs DB, Pisters PWT, Abbruzzese JL (eds). Pancreatic the following: Cancer. Springer: New York, 2002:151-121. in about 35% of PD patients.12 Prophylactic 1. Read the educational offering. 12. Spanknebel K, Conlon KCP. Advances in the surgical use of intravenous erythromycin postop- management of pancreatic cancer. The Cancer 2. Complete the post-test for the educational offering. eratively reduced the incidence of delayed Journal 2001;7(4):312-23. Mark an X next to the correct answer. (You may gastric emptying by 37%.12 Anastomic leaks make copies of the answer form.) and fistulas are seen in 5% to 15% of patients. Betty Daniel, MS, RN, AOCN recently re- 3. Complete the learner evaluation. Most fistulas close spontaneously with the tired as a Clinical Nurse Specialist at M.D. 4. Mail, fax, or send on-line the completed learner addition of somatostatin analog treatment. Anderson Cancer Center, Texas. Ms. Daniel evaluation and post-test to the address below. Fistulas heal with conservative measures in has written and lectured extensively in the 5. 1.0 contact hours for nurses are awarded by Cross 80% of patients.3 area of gastrointestinal oncology, in particu- Country University, the Education and Training larly esophageal and colorectal cancer. Ms. Division of Cross Country Inc., which is accredited as a provider of continuing education in nursing Conclusion Daniel is also a specialist in the field of endo- by the American Nurses Credentialing Center’s Pancreatic cancer continues to be a crinology. Among her numerous awards, Ms. Commission on Accreditation. Cross Country challenge for patients as well as healthcare Daniels was honored as Oncology Nurse of University is an approved provider with the Iowa professionals. Early diagnosis is rarely seen, the Year by the American Cancer Society. Board Of Nursing, approved provider #328. This course is offered for 1.0 contact hours. Cross so many patients are diagnosed at late stag- Country University is approved by the California es, when curative surgery is not an option. Board of Registered Nursing, Provider #CEP 13345, Perspectives, a quarterly newsletter focusing on Pancreaticoduodenectomy is the treatment for 1.0 contact hours. postoperative recovery strategies, is distributed of choice for those few who have resectable 6. To earn 1.0 contact hours of continuing education, disease. This procedure has become the stan- free-of-charge to health professionals. Perspec- you must achieve a score of 75% or more. If you do tives is published by Saxe Healthcare Commu- not pass the test, you may take it again one time. dard of care, but it is a complex procedure and recovery is difficult. Nursing care must nications and is funded through an education 7. Your results will be sent within four weeks after the form is received. focus on patient education, both to prepare grant from Dale Medical Products Inc. The 8. The administrative fee has been waived through an the patient preoperatively and postoperative- newsletter’s objective is to provide nurses and educational grant from Dale Medical Products, Inc. ly. During the postoperative period, the nurse other health professionals with timely and rel- 9. Answer forms must be postmarked by August 15, focuses on patient comfort, nutrition, activ- 2005, 12:00 midnight. evant information on postoperative recovery ity, and home-care instructions. It is with good nursing care that the patient is able to strategies, focusing on the continuum of care return home successfully. from operating room to recovery room, ward, or home. Name ___________________________________ References Credentials _______________________________ The opinions expressed in Perspectives are 1. Evans DE, Abbruzzese JL, Willett CG. Cancer of the those of the authors and not necessarily of Position/title ______________________________ pancreas. In DeVita VT Jr, Hellman S, Rosenberg SA, Address__________________________________ (eds.). Cancer: Principles and Practice of Oncology, the editorial staff, Cross Country University, 6th ed., Philadelphia: Lippincott Williams and Wilkins, or Dale Medical Products Inc. The publisher, City___________________ State ___ Zip_______ 2001:1126-1151. Cross Country University and Dale Medical Phone ___________________________________ 2. Jemal A, Thomas A, Murray T, Thun, M. Cancer statistics, 2002. CAA Cancer Journal for Clinicians Corp. disclaim any responsibility or liability for Fax _____________________________________ 2002;52(1):23-45. such material. License #: ________________________________ 3. Brower ST, Benson AB, Myerson RJ, Hoff PM. Pancreatic, neuroendocrine GI, and adrenal cancers. We welcome opinions and subscription requests * Soc. Sec. No. _____________________________ In Pazdur R, Coia R, Hoskins WJ, Wagman LD (eds.). Cancer Management: A Multidisciplinary Approach, from our readers. When appropriate, letters to E-mail ___________________________________ 5th ed. Melville, NY: PRR, 2001:227-239. the editors will be published in future issues. * required for processing 4. Li, D. Molecular epidemiology. In Evans DB, Pisters PWT, Abbruzzese JL (eds.). Pancreatic Cancer. New Please direct your correspondence to: York: Springer, 2002: 3-13. Saxe Healthcare Communications 5. Breslin TM, Pisters, PWT, Lee JE, Abbruzzese, JL, Mail to: Cross Country University Evans DB. Exocrine neoplasms of the pancreas. In P.O. Box 1282, Burlington, VT 05402 6551 Park of Commerce Blvd. N.W., Suite 200 Bland KI, Daly JM, Karakousis CP (eds.). Surgical Fax: (802) 872-7558 Boca Raton, FL 33487-8218 Oncology: Contemporary Principles and Practice, firstname.lastname@example.org New York: McGraw-Hill, 2001: 637-657. or: Fax: (561) 988-6301 www.perspectivesinnursing.org 7 1. The first action the nurse would take 6. What should the nurse instruct the 11. Mr. Smith is 2 days post-op from a total when caring for the patient with leakage patient to expect when a surgical drain prostatectomy. He asks the nurse why from around a drainage tube is to is removed? the bulb on his Jackson-Pratt drain is a. identify the cause of leakage a. drainage from the site collapsed. The best response by the b. apply a dressing around the tube b. pain as the drain is removed nurse is to: c. irrigate the tube c. gauze dressing until drainage stops a. connect the drain to low wall suction d. apply a skin barrier to the surrounding d. all of the above b. instruct the patient that the negative skin pressure of the system is working 7. Which drain has a lumen that can be c. empty the drain and record the output 2. A commonly used tube for gastric used to infuse an irrigating solution? d. tell the patient that the drain should be decompression after abdominal surgery a. Penrose drain removed is the b. Sump drain a. Penrose drain 12. Ms. Smith is having copious amounts of c. Jackson-Pratt drain b. Jackson-Pratt drain serous drainage from a sump drain. The d. Salem sump best action by the nurse is to: c. Salem sump 8. A patient notices sanguinous drainage a. irrigate the drain d. biliary tube in her Hemovac drain one day after b. apply an ostomy pouch 3. A patient would receive a gastrostomy surgery. The best response by the nurse c. use extra gauze dressings tube instead of a nasogastric tube after is to: d. notify the physician abdominal surgery if: a. Notify the surgeon a. it is the surgeon’s preference b. Irrigate the drain 13. Jane has a nephrostomy tube. What b. the patient chooses c. Explain that this is normal remark indicates she understands what c. prolonged use is anticipated she has been taught about infection d. Empty the drain control? d. there is increased risk of infection 9. A priority nursing action when the nurse a. I need to follow-up with my physician for 4. A passive drain would be used by the assesses postoperative drains is to: regular tube changes. surgeon when: a. ensure that the drain is intact b. I don’t have to worry about bladder a. viscous drainage is anticipated b. check the patient’s vital signs infections. b. an extended length of time for drainage is c. irrigate all drains c. I am glad I can take a tub bath. anticipated d. I am not going to flush the tube. d. administer pain medication c. accurate output is needed 10. After checking for placement and 14. What drain would the surgeon most d. a closed system is indicated function the best action by the nurse likely use when irrigation solution needs 5. When the collection device is to manage large amounts of leakage to be infused? compressed on a Jackson-Pratt drain, around a percutaneous drain is to: a. Penrose drain this indicates that the drain: a. reposition the drain b. Jackson Pratt drain a. needs irrigation b. cleanse the skin with antiseptic c. Sump drain b. is clogged c. apply antibiotic ointment d. Levin tube c. is ready to be removed d. place an ostomy pouch d. is functioning well Mark your answers with an X in the box next to the correct answer A B C D A B C D A B C D A B C D A B C D A B C D A B C D 1 3 5 7 9 11 13 A B C D A B C D A B C D A B C D A B C D A B C D A B C D 2 4 6 8 10 12 14 Participant’s Evaluation 1. What is the highest degree you have earned? 1. Diploma 2. Associate 3. Bachelor’s 4. Master’s 5. Doctorate Using 1 =Strongly disagree to 6= Strongly agree rating scale, please circle the number that best reflects the extent of your agreement to each Strongly Disagree Strongly Agree 2. Indicate to what degree you met the objectives for this program: 1. Describe commonly used drains in the post-operative patient. 1 2 3 4 5 6 2 Discuss management and prevention of complications related to 1 2 3 4 5 6 drain use in the post-operative patient 3. Have you participated in a home study in the past? Yes No 4. How many home-study courses do you typically use per year? 5. What is your preferred format? video audio-cassette written combination 6. What other areas would you like to cover through home study? For Iowa nurses, you may submit the evaluation to Iowa Board of Nursing. Mail to: Cross Country University, 6551 Park of Commerce Blvd. N.W., Suite 200, Boca Raton, FL 33487-8218 or Fax: (561) 988-6301 University ark N.W E-mail: perspectivesinnursing.org 8 Supported by an educational grant from Dale Medical Products Inc.