Chapter 48 wound drainage systems – Flashcards
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delayed
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If drainage accumulates in the wound bed, wound healing is
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drainage
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is removed by using either a closed or open drain system
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the drain
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is inserted directly through a small stab wound near the suture line into the area of the wound.
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an open drain a.k.a a Penrose drain
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removes drainage from the wound and deposits it onto the skin surface. Insert a sterile safety pin through this drain, outside the skin, to prevent the tubing from moving into the wound.
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to remove a Penrose drain
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the health care provider may pull the drain in stages as the wound heals from the bottom up. Nursing interventions include caution to prevent accidental removal of the drain during dressing changes and to protect skin surfaces in direct contact with the irritating drainage
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closed drain systems
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Jackson-Pratt drain Hemovac drain
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closed drain systems such a Jackson-Pratt drain or a Hemovac drain
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relies upon the presence of a vacuum to withdraw accumulated drainage from around the wound bed into the collection device
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a JP drain
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collects fluid that is in the range of 100 to 200 mL/24 hr
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Hemovac drain
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accommodates more drainage, usually up to 500 mL/24 hr
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drainage
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collects in a closed reservoir or a suction bladder.
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the closed system
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collects fluid but operates only if the tubing is patent and a vacuum exists. You empty the drainage periodically from the reservoir, record the amount, and re-establish the vacuum.
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nursing assistive personell (NAP)
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The assessment of wound drainage and maintenance of drains and the drainage system cannot be delegated to
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The nurse directs the Nap by
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Discussing any modification of the skill such as increased frequency of emptying the drain other than once a shift. Instructing to report to the nurse any change in amount, color, or odor of drainage. Reviewing the I&O procedure.
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a wound culture
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may be ordered to identify bacteria growing within a wound
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Identify presence, location, and purpose of
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closed wound drain or drainage system as patient returns from surgery. Assess drainage present on patient's dressing. Drainage tubing is usually placed near the wound through small surgical incision.
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identify
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number of drain tubes and what each one will be draining. Label each drain tube with a number or label. Assigning a labeling system to each drain helps with consistent documentation when a patient has multiple drainage tubes.
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Assess
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if drain tube needs self-suction, wall suction, or no suction by checking the health care provider's orders. Some drain tubes, such as Hemovacs, can be used with self-suction or wall suction.
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Inspect
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system to determine presence of one straight tube or Y-tube arrangement with two tube insertion sites. Allows nurse to plan skin care and identifies quantity of sterile dressing supplies needed.
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inspect
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system to ensure proper functioning
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a complete systematic inspection
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includes the insertion site, drainage moving through tubing in direction of reservoir, patency of drainage tubing, airtight connection sites, and presence of any leaks or kinks in the system
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a properly functioning system
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maintains suction until the reservoir is filled or drainage has ceased.
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tension
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on the drainage tubing increases injury to the skin and underlying muscle
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uipment necessary to empty a wound drainage system includes
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Graduated measuring cylinder Alcohol sponge Gauze sponges Sterile specimen container, if culture is needed Sterile dressings Clean gloves Disposable drape Goggles, if splash risk is present Safety pin(s)
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Expected outcomes following completion of procedure
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Wound healing continues. Vacuum is re-established. Tubing is patent.
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observing drainage in a suction device
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Indicates presence of vacuum, patency of tubing, and functioning of drainage suction device.
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Y site
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site in the drainage tubing is especially prone to clogging.
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seroma
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Inspect wound for drainage or collection of drainage fluid under the skin, causing a
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drainage
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should not be significant under suture line. May indicate inadequate functioning of drainage suction device.
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8 to 12 hours
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Empty drainage collection reservoir every __________ and as needed for large drainage volume
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collect diagnostic specimen
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in the presence of unexpected purulence or pungent odor, report findings to the health care provider, and record in progress or nurse's note.
