Post operative care of patiens with surgical drains by adiblog


									                                                                                                                                                            Vol. 4 No.4

                                                                            Recovery Strategies from the OR to Home

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                                                                              Postoperative                                                          uca
                                                                                                                                                 g ed tio
         rains continue to be a common

                                                                              Care of Patients
         facet of the postoperative man-                                                                                                        n

         agement of surgical patients.

                                                                                                                                                                 or nursin
                                                                              with Surgical
While they serve an important function
they also are associated with compli -
cations, including hemorrhage, tissue

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-

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
                                                                                                          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

         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

(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-
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
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-
                                                  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.                     
       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.

                                                                                                             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
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
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

                                                             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.

        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.

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.             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.

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_______
                                                              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,       
   New York: McGraw-Hill, 2001: 637-657.                                                                                or:         Fax: (561) 988-6301

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

                                         Supported by an educational grant from Dale Medical Products Inc.

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