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CHAPTER 32 Skin Integrity & Wound Healing

irrigation volume would be needed if the wound is highly contaminated. Chemical burns also require more irrigation. Preventing Infection When Irrigating ■ You need to use gowns, masks, and googles because there is a risk of splattering when irrigating. ■ A plastic shield at the end of the irrigating syringe reduces splashing, particularly for IV sites and other open areas. ■ Sterile technique is used for acute surgical wounds, for wounds that have recently undergone sharp débride- ment, or when prescribed by the provider. ■ Most wound irrigations use clean technique. For the complete steps, See Chapter 32, Procedure 32-2: Performing a Sterile Wound Irrigation , in Volume 2. Caring for Wounds with Drainage Devices A variety of drains may be inserted into wounds to allow fluid and exudate to exit. Drains prevent exces- sive pressure from building up in the tissues. Drains are usually placed during a surgical procedure. Some are sutured into place, whereas others are simply placed into the cavity. Types of Drains A Penrose drain is a flexible, flat latex tube that is placed in the wound bed but usually not sutured into place. A clamp or pin may be attached to the drain at the insertion site to keep it from slipping into the wound. You may be asked to advance the drain by gradually removing it from the wound bed, or it may be removed all at one time. For complete guidelines, See Chapter 32, Procedure 32-13: Shortening a Wound Drain, in Volume 2. Some drains are attached to a collection device, such as the Hemovac and Jackson-Pratt drains (Fig. 32-12). The provider may order a device to be “placed to suction.” This means you will compress the device to create suction and facilitate the removal of drainage (Fig. 32-13). For complete guidelines, See Chapter 32, Procedure 32-14: Emptying a Closed Wound Drainage System, in Volume 2. If a specific pressure is to be applied, some drains can be connected to wall suction. The provider will prescribe the amount of suction. For example: “Place Hemovac to 20 mm Hg suction at all times.” Nursing Activities for Maintaining Drains As a nurse, you are responsible for monitoring wound drains. ■ The provider will describe the number and type of drains present. Describe drain placement using the drain’s position on a clock face. Consider the patient’s head to be at the 12 o’clock position.

FIGURE 32-12 (Left) Penrose drain. (Center) Jackson-Pratt device. (Right) Hemovac drainage system.

FIGURE 32-13 Compress the bulb of the Jackson-Pratt drain to create suction and remove wound drainage.

■ Some patients have more than one drainage device in a wound. Label the drains numerically with a marker or by placing tape on the collection apparatus so that each caregiver provides consistent care. ■ When removing dressings or irrigating wounds, be careful to avoid dislodging the drain. Remember, many drains are not sutured in place. ■ Monitor the amount and character of the drainage, and record this information in your nursing notes as well as on the intake and output (I&O) record. ■ Report to the provider any significant change in the amount or character of the drainage. ■ If you suspect a drain is occluded, check the drain line from the insertion site to the collection device. Remove any kinks in the tubing. If this does not cor- rect the problem, notify the provider of the blockage. ■ You need to empty the collection apparatus at a des- ignated volume to maintain suction. As the device fills, suction pressure decreases. If there is significant drainage, you may need to empty the device several times during your shift.