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CHAPTER 32 Skin Integrity & Wound Healing
The drain will need to be evaluated to be sure it remains intact, which it mostly likely will. Drainage tubing is secured under the
skin surface and will probably not be dis- lodged with shortening.
What if . . . ■ I shorten the drain too much? Immediately notify the surgeon who placed the drain.
Evaluation ■ Assess the local area of skin around the drain after manip- ulating it. ■ Note the patency of the drain after shortening it. ■ Be sure the drain is secure after shortening. ■ Evaluate for complications occurring related to shortening procedure. Patient Teaching ■ Patients should not shorten their own drains. Consult a healthcare provider if concerned about the length of tubing or drains. Documentation ■ Record the intervention. ■ Note the amount and characteristics of the drainage.
■ Document the appearance of the wound. ■ Note any complications that occur with shortening a drain (e.g., manipulation of tubing causes bleeding or drainage at the site). Sample Documentation mm/dd/00/00/0000 0930 Penrose shortened 2.0 cm by postop orders. Drain intact. Pt tolerated procedure without complication. —M. Garcia, RN
Thinking About the Procedure
The video Shortening a Wound Drain, along with questions and suggested responses, is available on the Davis’s Nursing Skills Videos Web site on FADavis.com.
Procedure 32-14 ■ Emptying a Closed-Wound Drainage System ➤ For steps to follow in all procedures, refer to the Universal Steps for All Procedures on the inside back cover.
Equipment ■ Drainage container with graduated markings ■ Nonsterile gloves ■ Disposal sink for biomedical material ■ Biohazard disposal receptacle
Preprocedure Assessment ■ Assess the appearance of the drainage tube site and sutures, if in place. ■ Inspect for warmth, edema, redness, or pus where tubing penetrates the skin. ■ Check to be sure the closed-wound drainage system is securely fastened at the connections and within the wound. ■ Determine whether suction (electric, portable, or manual) is working properly.
Delegation This procedure may be delegated to a UAP who is trained in the skill. Assessment of the wound and drainage characteris- tics is a licensed professional’s responsibility and cannot be delegated.
➤ When performing the procedure, always identify your patient according to agency policy, using two identifiers, and be attentive to standard precautions, hand hygiene, patient safety and privacy, body mechanics, and documentation. (continued on next page)
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