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CHAPTER 32 Skin Integrity & Wound Healing
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UNIT 4 Supporting Physiological Functioning
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.
Procedure 32-13 ■ Shortening a Wound Drain ➤ For steps to follow in all procedures, refer to the Universal Steps for All Procedures on the inside back cover.
What if . . . ■ I shorten the drain too much? Immediately notify the surgeon who placed the drain.
the tube (e.g., if the tube diameter is not sufficient size to handle drainage output) or, more likely, an obstruction within the tubing. ■ Assess the characteristics of the drainage, including color, volume of drainage, presence of blood, odor, pus, and any change in the type or amount of drainage through the tubing. A sudden decrease in drainage might indicate a blocked drain. Pres- ence of fresh blood might be a sign of irritation within the wound. Pus and odor in the drainage could indicate wound infection. ■ Check the suction apparatus to be sure it is functioning properly. A self-suction apparatus might need to be recompressed from time to time to maintain effective vacuum. Electric suction units can fail, delivering too much suction, which can lead to injury.Too little suc- tion can contribute to insufficient drainage, which can lead to pres- sure on sutures if present, or cause the wound to become infected or heal more slowly.
Equipment ■ Nonsterile gloves ■ Sterile gloves ■ Sterile scissors ■ Two safety pins or other clips (sterile) ■ Sterile gauze
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
Delegation Assessment of the incision line or wound and the drain is a registered nurse’s responsibility and cannot be delegated.This procedure should not be delegated to a UAP. The risk for accidently losing the drain into the body or pulling it out of the wound is too high. Preprocedure Assessment ■ Inspect the site around the drain, noting skin excoriation, tenderness, erythema, warmth to the touch, and drainage seeping from the wound. Could indicate a wound infection or irritation of the drain at the skin site. Excoriation can be the result of seeping drainage around
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.
➤ 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.
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.
Procedure Steps 1. Perform hand hygiene and don nonsterile gloves. Remove wound dressings. 2. Remove soiled gloves and discard in a moisture-proof biohazard collec- tion container. Perform hand hygiene. 3. Open sterile supplies (scissors, etc.). 4. Don sterile gloves; use sterile scis- sors to cut halfway through a sterile gauze dressing (for later use) or use a sterile precut drain dressing. 5. If the drain is sutured in place, use sterile scissors to cut the suture. 6. Firmly grasp the full width of the drain at the level of the skin and pull it out by the prescribed amount (e.g., 5 cm [2 in.]). 7.Insert a sterile safety pin or clamp through the drain at the level of the skin. Hold the drain tightly between your fingers and insert another pin above your fingers.
9. Cleanse the wound, using ster- ile gauze swabs and the prescribed cleaning solution. In some situa- tions, you may use sterile forceps to manipulate the swabs. 10.Apply precut sterile gauze around the drain; then redress the wound.
The pin or clamp keeps the drain from dis- appearing into the wound.
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.
8.Using sterile scissors, cut the drain about 2.5 cm (1 in.) above the skin and pin.
➤ 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)
11. Remove gloves and discard in a biohazard container. Perform hand hygiene. 12. Leave the patient in a safe and comfortable position.
Over 230 step-by-step procedures with rationales teach students how to perform and master essential nursing skills.
4798_Ch32_658-704.indd 691 What if... sections pose questions about special situations and explain alternate ways to perform procedures to aid students in knowing what to do.
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