Wound Drain Systems in Perioperative Nursing

An Online Continuing Education ActivitySponsored By Grant funds provided by

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Welcome to

Wound Drain Systems inPerioperative Nursing(An Online Continuing Education Activity)

CONTINUING EDUCATION INSTRUCTIONSThis educational activity is being offered online and may be completed at any time.

Steps for Successful Course Completion

To earn continuing education credit, the participant must complete the following steps:1. Read the overview and objectives to ensure consistency with your own learning

needs and objectives. At the end of the activity, you will be assessed on the attainment of each objective.

2. Review the content of the activity, paying particular attention to those areas that reflect the objectives.

3. Complete the Test Questions. Missed questions will offer the opportunity to re-read the question and answer choices. You may also revisit relevant content.

4. For additional information on an issue or topic, consult the references.5. To receive credit for this activity complete the evaluation and registration form. 6. A certificate of completion will be available for you to print at the conclusion. Pfiedler Enterprises will maintain a record of your continuing education credits and

provide verification, if necessary, for 7 years. Requests for certificates must be submitted in writing by the learner.

If you have any questions, please call: 720-748-6144.

CONTACT INFORMATION:

© 2015All rights reserved

Pfiedler Enterprises, 2101 S. Blackhawk Street, Suite 220, Aurora, Colorado 80014www.pfiedlerenterprises.com Phone: 720-748-6144 Fax: 720-748-6196

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OVERVIEW Wound healing is the complex and dynamic process of restoring disrupted cellular structures and tissues. Wound closure and healing are essential for achieving optimal outcomes for all surgical patients. The primary goal of nursing care for the surgical patient is prevention of postoperative surgical site infections, because they are a major source of clinical complications and economic consequences today. Wound drains inserted at the time of surgery provide a route through which air and body fluids can be evacuated from the operative site to prevent their accumulation and risk for infection, thereby facilitating the process of wound healing. Perioperative personnel should be aware of the different types of wound drains and drainage systems available today in order to use them properly and promote positive patient outcomes. This continuing education activity will provide a review of the basic principles of wound healing. Key wound assessment factors will be outlined. The various types of wound drains and drainage systems, including their use and applications, will be described. Standards of care and recommended practices for wound care, infection prevention, and wound drainage system maintenance will be discussed.

OBJECTIVES Upon completion of this continuing education activity, the participant should be able to:

1. Identify the basic principles of wound healing. 2. Describe key clinical considerations related to wound assessment. 3. Differentiate the various types of wound drains and their applications. 4. Distinguish the three types of wound drainage systems. 5. Recognize the importance of proper wound care for preventing infection. 6. Discuss standards of care and recommended practices regarding wound care and

wound drainage system maintenance.

INTENDED AUDIENCE This continuing education activity is intended for perioperative nurses, surgical technologists, and other health care professionals who are interested in learning more about the processes of wound healing and the role of wound drainage in promoting positive patient outcomes.

CREDIT/CREDIT INFORMATION State Board Approval for Nurses Pfiedler Enterprises is a provider approved by the California Board of Registered Nursing, Provider Number CEP14944, for 2.0 contact hours.

Obtaining full credit for this offering depends upon attendance, regardless of circumstances, from beginning to end. Licensees must provide their license numbers for record keeping purposes.

The certificate of course completion issued at the conclusion of this course must be retained in the participant’s records for at least four (4) years as proof of attendance.

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IACETPfiedler Enterprises has been accredited as an Authorized Provider by the International Association for Continuing Education and Training (IACET).

CEU Statements• As an IACET Authorized Provider, Pfiedler Enterprises offers CEUs for its programs

that qualify under the ANSI/IACET Standard. • Pfiedler Enterprises is authorized by IACET to offer 0.2 CEUs for this program.

RElEASE AND ExPIRATION DATE:This continuing education activity was planned and provided in accordance with accreditation criteria. This material was originally produced in May 2015 and can no longer be used after May 2017 without being updated; therefore, this continuing education activity expires May 2017.

DISClAIMERPfiedler Enterprises does not endorse or promote any commercial product that may be discussed in this activity

SUPPORTFunds to support this activity have been provided by CardinalHealth

AUTHORS/PlANNING COMMITTEE/REVIEWERJulia A. Kneedler, RN, MS, EdD Aurora, CO Program Manager/Planning CommitteePfiedler Enterprises

Rose Moss, RN, MN, CNOR Casa Grande, AZNurse Consultant/AuthorC & R Moss Enterprises

Judith I. Pfister, RN, BSN, MBA Aurora, CO Program Manager/Planning Committee/ReviewerPfiedler Enterprises

Kristine l. Winters, RN, BSN Aurora, CO Nurse Consultant/Reviewer

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DISClOSURE OF RElATIONSHIPS WITH COMMERCIAl ENTITIES FOR THOSE IN A POSITION TO CONTROl CONTENT FOR THIS ACTIVITy Pfiedler Enterprises has a policy in place for identifying and resolving conflicts of interest for individuals who control content for an educational activity. Information below is provided to the learner, so that a determination can be made if identified external interests or influences pose potential bias in content, recommendations or conclusions. The intent is full disclosure of those in a position to control content, with a goal of objectivity, balance and scientific rigor in the activity. For additional information regarding Pfiedler Enterprises’ disclosure process, visit our website at: http://www. pfiedlerenterprises.com/disclosure Disclosure includes relevant financial relationships with commercial interests related to the subject matter that may be presented in this continuing education activity. “Relevant financial relationships” are those in any amount, occurring within the past 12 months that create a conflict of interest. A commercial interest is any entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients.

Activity Authors/ Planning Committee/Reviewer

Julia A. Kneedler, RN, MS, EdD Co-owner of company that receives grant funds from commercial entities

Rose Moss, RN, MN, CNOR No conflicts of interest

Judith I. Pfister, RN, BSN, MBA Co-owner of company that receives grant funds from commercial entities

Kristine l. Winters, RN, BSN No conflicts of interest

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Wound Drain Systems in Perioperative Nursing (An Online Continuing Education Activity)

INTRODUCTIONThe ability to heal wounds is one of the most powerful defensive properties that humans possess.1 The wound healing process is a complex, highly organized response to tissue disruption; in the absence of endogenous and exogenous infections, mechanical interferences, or certain disease processes, this is a highly reliable process.

One of the primary goals for the perioperative team is the prevention of surgical site infections (SSIs), as they are common complications and represent one of the leading causes of postoperative morbidity and mortality; they may also be associated with enormous additional costs for hospitals and health care systems.2 In the United States, approximately 300,000 SSIs occur annually, accounting for 17% of all healthcare-associated infections, second only to urinary tract infections; SSIs occur in 2% to 5% of patients undergoing inpatient surgery.3 Patients with an SSI are hospitalized postoperatively for approximately 7 to 10 days longer and have a 2 to 11 times higher risk of death compared to patients without an SSI; 77% of deaths among patients with a surgical site infection are directly attributable to the infection. While the costs associated with an SSI vary, depending on the type of procedure as well as the type of pathogen, estimates range from $3,000 to $29,000 per infection; furthermore, SSIs are believed to account for up to $10 billion annually in health care expenditures.

All members of the perioperative team share the responsibility for reducing the surgical patient’s risk for SSI through optimal wound healing. Proper wound care, including the use and maintenance of surgical drains and drainage systems, are critical factors in achieving this goal.

BASIC PRINCIPlES OF WOUND HEAlINGIn order to care for wounds properly and understand the role of surgical drains in promoting optimal patient outcomes, the wound healing process, beginning with a brief overview of the anatomy of the skin, must be reviewed.

Anatomy of the SkinThe skin is the largest organ of the body and serves as the first line of defense in preventing infection.4 The skin provides protection and sensation, regulates fluid balance and temperature, and produces vitamins (eg, Vitamin D) as well as components of the immune system. Any wound or disruption of the integrity of the skin can provide an entryway for bacteria and possible infection. The key structures of the skin are the primary layers as defined below:

• Epidermis–this is the outermost layer of the skin; it lines the ear canals, and is contiguous with the mucous membranes. It is composed of several layers, consisting of lipids and keratin; keratin is the substance that hardens hair and nails and also protects the body from fluid loss and pathogen invasion.

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• Dermis–the epidermis is supported by the dermis, which is thicker than the epidermis and composed of collagen. The dermis is the largest portion of the skin and provides strength and structure; it is vascularized and innervated, and contains blood vessels, lymph ducts, hair roots, and sebaceous and sweat glands.

• Subcutaneous layer–this is the innermost layer of the skin and is composed of adipose tissue that joins with the deepest layer of the dermis to provide insulation, shape, and support.

Etiology of WoundsIn discussing the wound healing process, it is also helpful to review the etiology of the wound. Wound etiology is defined as one of the following:5

1. Traumatic-due to mechanical, thermal, or chemical destruction.2. Chronic (eg, pressure ulcers or venous leg ulcers)-caused by an underlying

pathophysiological condition. 3. Surgical-as a result of an incision or excision.

Types of Wound HealingWounds heal by three mechanisms:6

• Primary intention. Healing by primary intention occurs when wounds are created aseptically, with minimal tissue destruction and postoperative tissue reaction. Wounds that are closed with sutures or staples soon after the injury are examples of wounds that heal by primary intention. Because these wounds are created under aseptic conditions, healing is optimized and the process begins almost immediately. Healing by primary intention occurs under the following conditions:

○ The edges of an incised wound in a healthy patient are promptly and accurately approximated.

○ Contamination is minimized by adherence to strict aseptic technique. ○ Trauma to the tissue is minimized. ○ No tissue loss occurs. ○ Upon completion of closure, no dead space remains to become a potential infection site.

○ Drainage is minimal.

• Secondary intention (granulation). Wound healing occurs by secondary intention in surgical wounds characterized by tissue loss and the inability to approximate the wound edges. This type of wound is typically not closed; it is allowed to heal from the inside toward the outer surface. The area of tissue loss gradually fills with granulation tissue; scar tissue is extensive and relative to the size of the tissue gap that must be closed. Wound healing by secondary intention is usually seen in chronic, dirty, or traumatic wounds where large areas of tissue are lost.

• Tertiary intention (delayed primary closure). Healing by tertiary intention occurs when approximation of the wound edges is intentionally delayed by three or more days after the injury or surgical procedure. This type of wound may require

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debridement and usually requires a primary and secondary suture line (eg, retention sutures). Closure may be delayed for any of the following scenarios:

○ Removal of an inflamed organ; ○ Heavy wound contamination; or ○ The critical nature of the patient intraoperatively, eg, a trauma patient that is hemodynamically unstable.

Phases of Wound HealingWound healing refers to the body’s replacement of destroyed tissue by living tissue by regeneration and repair. Knowledge of the underlying physiology of the wound healing process is essential for effective wound management, as it enables the health care professional to distinguish healthy and unhealthy tissue and thereby assess the wound for proper healing and/or the development of complications. Healing of clean, full-thickness wounds is a complex biological process that occurs in three overlapping phases: inflammatory, proliferative, and remodeling phases, as outlined below and summarized in Table 1.7, 8

• Phase 1–Inflammatory Phase (also known as the reactive stage). Inflammation is a requirement for wound healing and is the vascular and cellular response to dispose of bacteria and other foreign material. This phase begins within minutes after an injury and is necessary to establish hemostasis and begin mobilization of the immune system. Increased blood flow to the area causes the wound to begin to clot. As the blood supply to the area increases, the basic inflammatory process begins. The increase in the number of leukocytes helps to fight bacteria in the wound area and through phagocytosis, assist in removing damaged tissue.

In this phase, an exudate containing blood, lymph, and fibrin begins to clot and loosely bind the severed edges of the wound together. The severed tissue is quickly glued together by strands of fibrin and a thin layer of clotted blood, which forms a scab; plasma escapes to the surface and forms a dry, protective crust. This seal assists in preventing fluid loss and bacterial invasion; however, in the first few days of the wound healing process, this seal has little tensile strength.

The inflammatory phase usually lasts between 1 and 4 days. During this period, the edges of the skin may appear mildly swollen and slightly red due to the inflammatory process.

• Phase 2–Proliferative Phase (also known as the regenerative or reparative stage). This phase begins within hours of an injury and allows for new epithelium to cover the wound. Epithelial cells migrate to and proliferate in the area of the wound, covering the surface of the wound in order to close the epithelial defect. This also provides a protective barrier, which serves as a mechanism to prevent fluid and electrolyte loss and prevent the introduction of bacteria into the wound, thus reducing the incidence of infection. As reepithelialization occurs, collagen synthesis and wound contraction are also taking place.

Collagen synthesis produces fiber molecules that crosslink to strengthen the

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wound. Epithelial migration is limited to approximately 3 cm from the point of origin; this limited epidermal migration is why larger wounds may require skin grafting.

Approximately 5 days after the onset of a wound, contraction begins; it peaks at 2 weeks and gradually shrinks the entire wound. With a surgical wound, granulation tissue will form underneath the edges of the incision and are palpated as a hard ridge; this eventually resolves in the remodeling phase.

• Phase 3–Remodeling Phase (also known as the maturation stage). This phase begins after approximately 2 to 4 weeks, depending on both the size and nature of the wound; it may last one year or more. During this final stage, scar tissue has formed during healing in terms of bulk, form and strength; this allows for the wound to be strengthened. During normal wound healing, collagen production and collagen breakdown are balanced; this turnover of collagen allows randomly deposited connective tissue to be arranged in linear and lateral orientation. As the scar ages, fibers and fiber bundles are more closely packed in a crisscross pattern, ultimately forming the final shape of the wound. At most, the tensile strength of scar tissue is never higher than 80% of that of nonwounded tissue.

Table 1 – Phases of Wound Healing

Phase Time Period EventsInflammatory (Reactive) Phase

1 to 4 days Inflammation- Vasodilation- Phagocytosis- Formation of a seal to assist in

preventing fluid loss and bacte-rial invasion

Proliferative (Regenera-tive or Reparative) Phase

5 days to 2 weeks ReepithelializationCollagen synthesisWound contraction

Remodeling (Maturation) Phase

2 - 4 weeks to 1 year or more

Collagen remodeling- Collagen production and col-

lagen breakdown are balanced;- Randomly deposited connective

tissue is arranged in linear and lateral orientation

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Surgical Wound ClassificationsThe Centers for Disease Control and Prevention (CDC) has outlined four surgical wound classifications, as described below:9

• Class I-Clean Wound. A clean wound is defined as an uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tract is not entered. A clean wound is primarily closed and, if necessary, can be drained with closed wound drainage. Operative incisional wounds that follow nonpenetrating (ie, blunt) trauma should be included in this category if they meet the criteria. Clean wounds show no signs of infection.

• Class II-Clean-Contaminated Wound. A clean-contaminated wound is defined as an operative wound in which the respiratory, alimentary, genital or urinary tracts are entered under controlled conditions and without unusual contamination. Specifically, surgical procedures involving the biliary tract, appendix, vagina, and oropharynx are included in this category, as long as no evidence of infection or major break in technique is encountered.

• Class III-Contaminated Wound. Contaminated wounds are open, fresh, accidental wounds. Also included in this class are procedures with major breaks in aseptic technique (eg, open cardiac massage) or gross spillage from the gastrointestinal tract, and incisions in which acute, nonpurulent inflammation is encountered.

• Class IV-Dirty Infected Wound. Infected wounds include old traumatic wounds with retained devitalized tissue as well as those that involve an existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the operative field prior to the procedure.

Factors that Interrupt the Wound Healing ProcessThere are several factors that may impair or interrupt tissue repair and healing; these include the patient’s nutritional status, oxygenation level, and overall recuperative power, all of which are critical in tissue repair and healing.10 Both the inflammatory response and oxygen tension are dependent upon microcirculation to deliver vital components to the wound. A decrease in oxygen tension to the wound area inhibits fibroblast migration and collagen synthesis, thereby resulting in a reduction in the tensile strength of the wound. Nutritional status is also an important consideration in the wound healing process because of the need for an adequate supply of protein, which is necessary for growth of new tissue. Protein is also required for the regulation of the osmotic pressure of the blood and other body fluids and the formation of prothrombin, enzymes, hormones, and antibodies. Other required nutritional elements include water; vitamins A, C, B6, and B12; iron; calcium; zinc; and an adequate calorie intake. Another important factor for the surgical patient is to maintain normothermia in the operating room (OR), because hypothermia contributes to vasoconstriction, which can have an adverse effect on wound healing.

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Surgical site infection is the most common cause of delayed wound healing in the surgical patient. There are various potential causes of SSIs, such as the patient’s susceptibility to and the severity of illness; microbial contamination by the patient’s own (ie, endogenous) microflora; and exogenous wound contamination from the OR environment and/or personnel.11 For purposes of standardized reporting, SSIs have been defined and classified as superficial incisional SSIs, deep incisional SSIs, and organ/space SSIs, as outlined in Table 2.

Table 2 – Criteria for Defining Surgical Site Infections12

Superficial Incisional SSI• Infection occurs within 30 days of the operation.

• Infection involves only skin or subcutaneous tissue.

• At least 1 of the following is present:

− Purulent drainage,

− Positive culture from the incision,

− At least 1 symptom of infection (pain or tenderness, localized swelling, redness, heat) and incision is opened by surgeon, unless incision is culture-negative, or

− Diagnosis of SSI by surgeon or attending physician.Deep Incisional SSI• Infection within 30 days of the operation if no implant is left in place or within 1 year if implant is in place

and the infection appears to be related to the operation.

• Infection involves deep soft tissues.


− Purulent drainage from the deep incision but not from organs/spaces associated with the surgical site,

− Spontaneous dehiscence of deep incision or deliberate opening by a surgeon when the patient has at least 1 symptom of infection (fever, localized pain, or tenderness), unless site is culture-negative,

− Abscess or other evidence of infection involving the deep incision found on direct examination, during reoperation, or by histopathology or radiography, or

− Diagnosis of SSI by surgeon or attending physician.Organ Space SSI• Infection within 30 days of the operation if no implant is left in place or within 1 year if implant is in place

and the infection appears to be related to the operation.

• Infection involving any part of the anatomy (e.g., organs or spaces), other than the incision, which was opened or manipulated during an operation.


− Purulent drainage from drain placed into the organ/space,

− Positive culture of fluid or tissue from the organ/space,

− Abscess or other evidence of infection involving the deep incision found on direct examination, during reoperation, or by histopathology or radiography, or

− Diagnosis of SSI by surgeon or attending physician.

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The wound healing process may also be interrupted by additional factors, including:

• Poor surgical technique, ie, rough handling of tissue causing trauma, which leads to bleeding and other conditions that may promote infection.13 Examples of surgical techniques that facilitate wound healing are: achieving and maintaining adequate hemostasis; utilizing precise cutting and suturing techniques; using time efficiently in order to minimize wound exposure to air; eliminating dead spaces; and exerting minimal pressure with the use of retractors and other instruments.

• Patient-related factors, such as:14 ○ Age (both the very young and very old); ○ Altered nutritional status (eg, obesity, malabsorption syndromes, excessive alcohol intake or poor diet);

○ Inadequate oxygenation due to cardiovascular or respiratory impairments; ○ Stress level; ○ Poor hygiene; ○ Smoking history; ○ Autoimmune disorders, such as lupus erythematosus, multiple sclerosis, Crohn’s disease, and rheumatoid arthritis; or

○ Preexisting conditions, eg, anemia, cancer, chronic inflammatory disease, Cushing’s syndrome, diabetes, human immunodeficiency virus (HIV), peripheral vascular disease, peripheral neuropathy, radiation therapy.

• Certain drugs and herbal supplements.15 Impaired wound healing is a side effect of many drugs as well as supplements, because many types of drugs interact with certain phases of the healing process. Herbal medications should be taken into consideration preoperatively since many of them can inhibit platelet activity, increase blood pressure, or exacerbate the effects of anticoagulant medications. Because many patients do not consider herbal supplements to be “drugs,” it is important that the patient is asked specifically about these agents. Examples of various drugs and supplements that affect wound healing are outlined in Table 3.

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Table 3 – Drugs and Supplements that Affect Wound Healing16

Drug/Supplement EffectPenicillin Interferes with the tensile strength of the wound by

affecting the cross-linking of collagenAnticoagulants Leads to hematoma formationAnti-inflammatory agents, including steroids

Suppresses inflammation Inhibits the formulation of granulation tissue

Ibuprofen Suppresses protein synthesisNaproxen Suppresses epithelialization

Increases the incidence of bleedingAspirin Inhibits activation of plateletsWarfarin (Coumadin®) Impairs blood clottingChemotherapeutic agents Arrests cell replication

Suppresses inflammation Suppresses protein synthesis Reduces white blood cell count

Colchicine (Colcrys®; used in the treatment of gout)

Arrests cell replication Suppresses collagen transport

Feverfew (used for migraine headaches and rheumatoid arthritis)

Inhibits platelet activity

Guarana (used as a weight loss supplement; contains caffeine, theophylline, and theobromine, which are chemicals similar to caffeine)

Decreases platelet aggregation

Garlic Inhibits platelet aggregationGingko Inhibits platelet activationGinseng Inhibits platelet activationSt. John’s Wort Inhibits neurotransmitter uptake

Incudes enzymes that affect warfarin and other drugs

WOUND ASSESSMENT: KEy NURSING CONSIDERATIONSProper assessment of a wound is a critical component in effective wound management, as an improper or incomplete wound assessment can lead to various problems, including incorrect diagnosis and treatment.17 Wound assessment requires good observational skills, current knowledge, and the use of the proper terminology in order to accurately communicate among members of the health care team. The key components and related terminology of a thorough wound assessment are discussed below.18

• Location. The anatomic location of the wound should be documented, using landmarks to further define the location. Directions such as superior, posterior,

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medial, etc. should be used to describe areas near landmarks, eg: “Rash noted in right inguinal area extending from midpoint laterally to iliac crest”. The correct terminology should also be used, eg, trochanter, gluteal fold, ischium, maleolus, sacrum.

• Dimensions. Wounds measurements should not be described in terms of fruits or vegetables (eg, pea-sized) or coins (eg, quarter-sized). Wounds should be measured in millimeters or centimeters; linear measurements should be taken at the greatest length and width perpendicular to each other.

• Periwound skin and wound edges. The condition, color, and temperature of the wound should be described using the appropriate terminology:

○ Ecchymosed (bruised); ○ Erythematous (red); ○ Indurated (firm); and ○ Edematous (swollen).

The quality of the wound margins should also be defined. Proper terminology to describe wound edges includes diffuse, well defined, or rolled. It should also be noted whether or not the edges are attached to the wound bed or unattached; unattached wound edges usually indicate some type of disruptive process.

• Pattern. Pattern or distribution refers to the dispersion of lesions within a certain area. Arrangement refers to the position of nearby lesions; the arrangement of lesions can assist in confirming a diagnosis.

○ Satellite lesions are small peripheral areas around a larger central lesion. ○ Linear lesions are found in a straight line pattern.

• Wound tissue. The types of tissue found in the wound should also be described. ○ Normal granulation tissue has a beefy, red, shiny and textured appearance that bleeds readily. Hypergranulation tissue has a flaccid texture, which is very different from normal granulation tissue.

○ Necrotic tissue is usually yellow-gray and soft is called slough. ○ Black-gray, hard, leathery tissue is called eschar.

• Drainage. Wound exudate is the accumulation of fluid and can contain cellular debris, white blood cells, and bacteria. The appropriate terminology to describe drainage is:

○ Serous (clear), ○ Serosanguinous (blood-tinged), ○ Sanguinous (bloody), ○ Purulent (pus) Drainage from a heavily colonized wound may have a tan or milky appearance.

The amount, color, and consistency of wound drainage should be noted.

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• Odor. An odor in a wound is a significant diagnostic tool. Blue-green drainage combined with a musty odor typically indicates presence of Pseudomonas in the wound. It is important to make sure that the odor is coming from the wound and not from the dressing. Certain types of dressings (i.e. foams and hydrocolloids) have characteristic odors that are enhanced by the proteins present in wound drainage.

WOUND DRAINAGE TyPESDrains are used both prophylactically and therapeutically; the most common use is prophylactically after surgery to control ecchymosis and provide a route through which body fluids (eg, blood, serous exudates, intestinal secretions, bile, and pus) and air can be evacuated from the operative site and thus prevent their accumulation.19, 20 In any surgical procedure in which a dead space (eg, a cavity) is created, the body has a natural tendency to fill this space with fluid or air. Drains may also be used to form a controlled fistula, eg, after common bile duct exploration. Therefore, the use of drains helps to prevent the development of deep wound infections and thus facilitate the wound healing process.

The action of wound drains is defined as either passive or active:21

• Passive drains depend on the higher pressure inside the wound, combined with capillary action and gravity to draw fluid out of a wound or body cavity (ie, the difference in pressure between the inside and the outside of the wound forces the fluid out of the wound). In contrast to an active drain, a passive drain, eg, a Penrose drain does not require special attention. The wound dressing is changed when it becomes saturated with drainage; if the drain is attached to a reservoir, the reservoir is emptied or changed when it is full.

• Active drains use low or high negative pressure (ie, suction) to remove accumulated fluid from a wound. Active drains do require some special maintenance. The collection reservoir of an active drain expands as fluid is collected by exchanging negative pressure for fluid; if the vacuum is lost, the drain will lose its effectiveness.

There are several types of passive and active wound drains available today; each of these is described in greater detail.

Penrose DrainsA Penrose drain is a thin-walled cylinder made of radiopaque latex or silicone (ie, latex-free) which is available in various diameters (see Figure 1) from ¼ inch to 2 inches (6 mm to 5 cm), depending on the surgeon’s preference.22 Perioperative personnel should ensure that the patient is not allergic to latex before considering the use of a Penrose drain made of latex.

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Figure 1–Penrose Drains (latex – left; silicone – right)

Penrose drains are commercially available sterile and individually prepackaged, many with a safety pin; however, if they are prepared in the facility for onsite steam sterilization, a gauze wick is inserted to allow steam penetration of the lumen. A Penrose drain is supplied to the sterile field in a 6- to 12-inch (15- to 30-cm) length that the surgeon will cut to the desired length. Once inserted, the sterile safety pin is attached on the outside of the drain close to the skin to prevent the drain from retracting into the wound (see Figure 2). If the safety pin is used, the head should be crimped closed using a large forceps so that it does not open and scratch or pierce the patient. A Penrose drain uses gravity to draw fluids out along its surfaces into the wound dressings.

Figure 2–Penrose Drain with Safety Pin

Close Wound Drainage SystemsA closed wound drainage system consists of a wound drain and a fluid collection reservoir. The fluid collection reservoir is either a manually activated, bulb evacuator or a spring-loaded device that has variable preset suction levels (see Figure 3).

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Figure 3–Closed Wound Drainage

Silicone Wound DrainsThere are various types of silicone wound drains available for use with a closed wound drainage system as described below.

• Flat Drains (see Figure 4). Flat perforated drains are constructed of silicone that is impregnated with barium for x-ray detection of the drain. A flat drain typically has a low-profile, hubless design which helps to promote tissue plane approximation. The inner lumen is ribbed to help prevent drain collapse and clogging and help preserve drain patency. Flat drains are available in variable widths (eg, 7mm or 10mm) either partially or fully perforated.

Figure 4–Silicone Flat Drain

• Round Drains. Round perforated silicone drains are available for use with a closed drainage system. These drains also have a radiopaque stripe for radiographic detection and are available in several sizes (eg, 7, 10, 15 or 19 Fr) with 5 cm. and 10 cm markings to aid the surgeon in drain placement. Round silicone drains are available with or without a trocar.

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• T-Drains. Silicone T-tube drains (see Figure 5) are indicated for hysterectomy and cholecystectomy. These drains are soft and pliable to help reduce patient trauma during removal.

Figure 5–Silicone T-Tube Drain

Polyvinylchloride (PVC) DrainsBased on physician preference, round drains are also available in PVC; a PVC round drain will also have a radiopaque stripe running the entire length of the drain for x-ray detection.

Chest Drains/TubesPostoperatively, drainage of the pleural cavity must allow for complete expansion of the lungs; therefore, both air and fluid must be evacuated from the pleural space (see Figure 6).23

Figure 6–Pleural Space

For procedures such as on-pump or off-pump coronary artery bypass graft (CABG), valve replacement or repair, thoracotomy, or lobectomy a standard chest tube or large sized channel drain could be used in these procedures.

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Figure 7–Channel Drains

A channel drain does not have holes on the drain surface; instead, it has an a four channel design that allows for better drainage than traditional perforated drains. The no hole design minimizes tissue ingrowth providing greater patient comfort upon removal.

WOUND DRAINAGE SySTEMS AND APPlICATIONSThere are three types of wound drainage systems:25

• A closed drainage system, which is a system of tubing or other apparatus that removes fluids in an airtight circuit via suction and prevents any type of environmental contaminants from entering the wound or area being drained.

• A negative pressure drainage system, which uses a pump or mechanical device to help evacuate excessive fluid or air from the body.

• An open drainage system, which is generally a tube or drain which is inserted into the body and drains the fluid out onto a dressing.

These wound drainage systems and their applications are discussed in greater detail below.

Closed Wound Drainage SystemsA closed wound drainage system drains into a sterilized airtight tubing and container; some type of suction-generating device is used. A Jackson-Pratt® or a Hemovac® drainage system are examples of closed wound drainage systems. In this system, the tubing connects to a reservoir (either a bulb evacuator or a spring-loaded device, as previously noted) which uses negative pressure (ie, suction) to draw fluid out of the wound/incision via the drain; as such, the reservoir is used both as a mechanism of providing continuous suction pressure and as the reservoir for fluid collection.

• Bulb reservoirs, usually 100 cc or 400 cc. The clear silicone (ie, latex-free) walls of bulb reservoirs permit easy activation of suction and facilitate identification and measurement of the wound exudate; they are also easy to empty and reactivate. These reservoirs have an internal, anti-reflux, one-way valve to prevent backflow of fluid to the patient.

21

A 100cc reservoir is used more frequently, but both are used in outpatient surgery as well as after the patient has been discharged. Typically, a 100cc bulb may have a Luer lock emptying port (see Figure 8) which connects directly to either a Luer lock syringe for collection of a culture sample or to an exudate disposal bag to provide a closed system for safe disposal of exudate.

Figure 8–100cc Bulb Reservoir

• A 3-Spring, 400cc reservoir (see Figure 9) is commonly used in orthopaedic surgery.

Figure 9 – 400 cc 3-Spring Reservoir

A 3-spring reservoir design provides easy activation of suction. In addition, an anti-reflux (eg, one-way) valve in the reservoir helps to prevent backflow of fluid to the patient. Clamps on the evacuator tubing allows for activation-and-hold. The transparent sidewall has clearly marked graduations that facilitate identification and measurement of the exudate. Most of these types of reservoirs have a universal wound drain Y-connector which can be cut to accept various diameter wound drains.

According to the Centers for Disease Control and Prevention’s (CDC) Guideline for Prevention of Surgical Site Infection, the risk of SSI appears to be reduced when closed suction drains, rather than open drains, are used; closed suction drains effectively

22

evacuate postoperative hematomas or seromas, however, the timing of drain removal is also important.26

Negative Pressure Wound Drainage SystemsNegative pressure wound drainage is used mainly to speed recovery in burn patients and to enhance healing of chronic or severe wounds; it is also useful in the treatment of diabetic foot ulcers, traumatic wounds, and venous insufficiency ulcers (see Figure 10).27 In this type of drainage system, the vacuum adds negative pressure to the wound area, which facilitates drainage by removing fluid and desiccated tissue, enhancing blood flow through the affected region, lowering bacterial levels, stimulating cell growth, closing the wound edges, and promoting granulation tissue. The wound dressing may need to be changed frequently when saturated.

Figure 10 – Negative Pressure Drainage System

Negative pressure vacuum drains are classified according to the degree of pressure used, ie, high or low:28

• High negative pressure vacuum drains (eg, bottled vacuum drains) are sealed, closed-circuit systems that are easily monitored and allow safe disposal of the drainage. This type of system consists of a clear, plastic reservoir with a rubber cap and indicator wings that monitor the presence of vacuum pressure and an opening in which the drainage tube connects. For example, when a vacuum is present in the system, the wings on the rubber cap are close together; if the vacuum is lost, the wings are apart. The end of the drainage tube inserted in the wound has numerous openings on its inner side which serve to evacuate fluid from the wound. The wound should be closed before opening the clamps on the drain, otherwise the vacuum will be lost as the tube pulls in atmospheric air.

• Low-pressure vacuum drains have a plastic bulb-shaped reservoir or spring reservoir and a drainage tube (eg, a Jackson-Pratt or Hemovac type drainage system as described above), with multiple side holes in the end of the tubing that is inserted into the wound. When the bulb is compressed, air is forced out, which creates negative pressure in the system. This type of drain works gently to evacuate excess fluid and air.

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There are five mechanisms by which the application of negative pressure wound drainage may facilitate the healing process:29

• Wound retraction. Wound retraction under negative pressure helps to approximate the wound edges, while putting mechanical stress on the tissue. This externally applied stress is believed to induce the mechanisms responsible for increasing matrix synthesis and cell proliferation within the wound

• Stimulation of granulation tissue formation.

• Continuous wound cleansing (following adequate primary surgical debridement). Continuous wound cleansing may decrease the bacterial burden present in a wound and remove substances that inhibit wound healing.

• Continuous removal of interstitial fluid (ie, exudate). Exudate that accumulates in a wound can mechanically compress local capillaries, thereby restricting the flow of blood into the wound.

• Decreased interstitial edema. Removal of exudate from a wound may also decrease tissue edema and promote blood flow back into the wound area.

Open Wound Drainage SystemsAn open, passive drain, such as a Penrose drain (see Figure 11), is generally used more often in suppurative than in nonsuppurative wounds, as an open drain ensures that the wound remains open for drainage of thick suppurative and necrotic materials.30 As previously noted, this type of drain is usually secured with a safety pin or it may be sutured to the patient’s skin to prevent the drain from being dislodged or pulled either into or out of the wound. A common practice with an open drain is to gradually remove it over several days; this practice facilitates drainage and collapse of the abscess cavity.

Figure 11–Open Wound Drain

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While the specific drain used in various surgical specialties may vary based on surgeon preference, general applications for the types of drains discussed above are outlined in Table 4.

Table 4–Surgical Wound Drain Applications

Surgical Specialty Drain Reservoir RationaleGeneral Upper abdominal

proceduresColon resections

Various PVC & silicone drains

100cc Silicone bulb400cc Silicone bulb

Reservoirs permit easy activation of suction, identification and measure-ment of exudate

Internal, anti-reflux valve prevents backflow of fluid to the patient

Reservoirs are easy to empty and reactivate

OrthopedicsTotal hip arthro-

plastyTotal knee arthro-

plasty

Round PVC drain

3-spring reservoir Tougher PVC material withstands the rigors of the particular anatomy

Cost effective

Thoracic & Cardio-vascularThoracotomyLobectomyCABG (on-pump

or off-pump)Valve replace-

ment or repair

Silicone large channel drain (Chest tube)

Chest drain reservoir

Silicone bulb

PVC chest drains are large and stiff; they also have large exposed drainage holes which allow tissue ingrowth

Silicone channel drain is less painful in body and upon removal

Obstetrics/GynecologyLabor & deliveryHysterectomy

Silicon drains (flat, round or T-drain)

Silicone bulb Silicone is a good option due to its softness

Plastic/ Reconstructive SurgerySkin flapsBreast recon-

structionFacial procedures

Smaller size channel drain

Flat drain

100cc Silicone Bulb Soft silicone material, combined with lack of exposed holes, yield optimal results

Flat drain has a low profile

NeurosurgeryCraniotomy

Small sized silicone (flat or round) drain

100cc Silicon Bulb Smaller size and soft silicone drain is less abrasive to nerves and other sensitive areas

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Drain InsertionWhen a drain is required, it is usually inserted at the end of the surgical procedure.31 Typically, the drain is inserted through a separate stab wound, which is created a few centimeters from the primary incision in order to reduce the risk of a postoperative wound infection. One of the two following methods are used to insert a vacuum-type drain.

• The first method is utilized with drains that have a sharp trocar attached to the tube. The surgeon uses the trocar attached to some drains to pierce the skin from the inside of the wound at the desired site; the attached tube is then pulled out through the stab wound. The inner end of the tube is placed at the required site and the trocar is detached. The surgeon may secure the drain to the patient’s skin with a suture. After the wound is closed, the scrub person connects the tube to the reservoir; suction may be attached to the appropriate reservoir to facilitate wound drainage.

• The second method is used for drains that do not have an attached trocar. For this type of drain, the surgeon uses a forceps to pierce the abdominal wall from the inside of the wound and pushes the forceps through the subcutaneous tissue; the overlying skin is then incised with a scalpel. The tip of the forceps is opened and the end of the drain tube is grasped; the drain is then pulled into the wound to the desired location. The surgeon may secure the tube to the patient’s skin with a suture. After the wound is closed, the scrub person connects the tube to the appropriate reservoir.

Because a drain site is left to heal by secondary intention, the site may form a puckering scar; therefore, when possible, the surgeon may place the drain in a skin crease to help prevent an unsightly scar.32

As noted above, drains are made of strong silicone or PVC plastic and while they are not likely to break, breakage can occur.33 Perioperative personnel should use caution during drain insertion to so that the drain is not nicked, cut, torn, or otherwise damaged, as this may lead to breakage. For example, silicone is nick sensitive; common sources of nicks include puncturing with a suture needle, crimping with serrated forceps, or nicking with a scalpel. For this reason, drains or tubing should not be handled with any instruments.

The perioperative nurse should clearly document the location and type of drain on the operative record; he/she should also ensure that the drain is working properly before the patient is transferred from the OR.34 This information is important for continuity of care, since some wounds produce significant amounts of drainage and must be monitored closely throughout the patient’s postoperative course of care.

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WOUND CARE AND PREVENTING INFECTIONProper care of surgical wounds and drains is a key factor in preventing infection. As previously noted, infection is the most common cause of delayed wound healing in the surgical patient.

One of the expected outcomes for all surgical patients is that he/she is free from signs and symptoms of infection, such as pain, induration, foul odor, purulent drainage, and/or fever.35

An infection will manifest itself in a variety of ways; however, the signs of an acute wound infection typically will include:36, 37

• Advancing erythema, in response to the vascularization process;• Fever;• Increased temperature of the involved area;• Edema;• Pain and tenderness due to irritation of local nerve endings; and• Purulent exudate.

Wound complications frequently have systemic manifestations, such as tachycardia as well as fever.

Microbial contamination of the surgical site is a prerequisite for an SSI; the risk of an SSI increases with the dose of bacterial contamination and the virulence of the bacteria; alarmingly, more SSIs are attributable to antibiotic-resistant microorganisms, such as methicillin-resistant Staphylococcus aureus.38 As discussed above, the source of microbial contamination of the surgical site may be either the endogenous or exogenous microorganisms; however, most SSIs are caused by the patient’s own bacterial flora.39

When introduced into body tissues by surgery or through invasive medical devices, the pathogenic potential of endogenous microorganisms increases.

The pathogenic microorganisms isolated from infections vary, primarily on the classification of the surgical wound.40 For example, in Class I-clean procedures, ie, those in which the gastrointestinal, gynecologic, or respiratory tracts have not been entered, Staphylococcus aureus from either the exogenous environment or the patient’s own skin flora is the usual cause of infection. In other surgical wound classifications, including Class II-clean-contaminated, Class III-contaminated, and Class IV-dirty-infected, the polymicrobial aerobic and anaerobic flora closely resembling the normal endogenous microflora of a surgically resected organ are the most frequently isolated pathogen.

In addition to Staphylococcus aureus, other pathogens that commonly cause SSIs include:41

• Coagulase-negative staphylococci;• Enterococcus species (E. faecalis, E. faecium, and those not otherwise specified);• Escherichia coli;• Pseudomonas aeruginosa;• Enterobacter species;

27

• Klebsiella pneumonia;• Candida species (C. albicans and other Candida species not otherwise specified);• Acinetobacter baumannii; and• Klebsiella oxytoca.

In regard to wound and drain care as it relates to infection prevention, the potentially applicable nursing diagnoses, examples of interim outcome statements, and outcome indicators are outlined in Table 5.

Table 5–Nursing Diagnoses, Interim Outcome Statements, and Outcome Indicators for Postoperative Wound Care42

Potentially Applicable Nursing Diagnoses

Examples of Interim Outcome Statements Outcome Indicators

•Risk for infection: at risk for being invaded by pathogenic organisms

•Risk for impaired skin integrity: at risk for the skin being adversely altered

• Impaired skin integrity: altered epidermis and/or dermis.

•Delayed surgery recovery.

• At the time of discharge the patient’s wound is free from signs and symptoms of infection; including pain, redness, swelling, drainage, or delayed healing.

• The patient’s surgical wound is clean and primarily closed with a dry, sterile dressing at time of discharge from the OR

• The patient has a Class III wound covered with a dry, sterile dressing

• The patient’s wound is intact and free from signs of infection 30 days postoperatively

• The patient’s immune status remains within expected level 5 days postoperatively

• The patient’s white blood cell count remains within expected levels 5 days postoperatively

• Preoperative and postoperative antibiotics are given according to recommended guidelines

• Skin condition of the surgical wound:

- The incision is well-approximated and free from heat, redness, induration, swelling, or foul odor

- Drains are covered with a sterile dressing and/or connected to continuous drainage

- Wound class is identified

• Immune status- The patient is afebrile- White blood cell and

leukocyte counts are within expected range 30 days postoperatively

•Medication regimen- No antibiotics are

used for symptoms of postoperative surgical infection

•Documentation- Wound class and

infection control measures and interventions are documented according to facility policy

Even though surgical drains are inserted to prevent excessive fluid accumulation and prevent bacterial proliferation, they can increase the risk of infection through retrograde bacterial migration.43 Reducing the patient’s risk for infection requires proper handling of a drain by all members of the perioperative team; therefore, the following considerations should be kept in mind when preparing and inserting drains.44

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• Drains are designed for single patient use only; they should never be reused.• Drains are kept sterile and ready for use; no device or equipment should be

opened until the surgeon specifies the style and size needed.• Verify if the patient has any sensitivity or allergy to latex; if present, do not use a

drain or other tubing with any latex components.• The scrub person maintains the sterility of the drain until it is connected to the

sterile end of the drainage tubing.• All tubing/reservoir connections must be physically tightened and secured; the

connections should not be completely obscured by wrapping them with tape.• The drain site should be dressed separately from the operative incision site. A

nonadherent dressing can be used as the contact layer around the drain. Gauze dressings can be cut into a Y-shape to fit snugly around the base of the drain.

• Avoid placing tension on the drain as well as kinks in the drain tubing; a gentle loop can be made and secured with tape at the time the dressing is applied.

• Collection devices connected to passive drains must be kept well below the level of the body cavity where the drain is inserted and below the level of the drainage tubing to prevent retrograde flow. The amount of drainage should be documented.

• With closed or negative pressure vacuum drains, the circulating nurse must check the suction level to ensure that it is set according to the surgeon’s order or activate the suction as appropriate for the system being used.

• If ordered, a radiograph may be taken to verify proper placement of the drain.• Care should be taken to protect and secure drains and drainage systems. For

example, drains may become tangled in the patient’s other lines and equipment (eg, IV tubing, electrocardiogram leads), clothing, or linen and accidentally pulled out, which can result in pain or bleeding.45

STANDARDS OF CARE AND RECOMMENDED PRACTICESCare of Wounds and Wound Drainage SitesEffective wound care focuses on the restoration of function and physical integrity, with a minimum of deformity, without the development of an infection. In order to protect all surgical patients from transmission of potentially infectious agents:46,47

• Hand hygiene should be performed before and after each patient contact. • Standard Precautions should be used in the care of all patients.• In addition to the consistent use of Standard Precautions, additional

Transmission-Based Precautions (ie, Contact Precautions) should be followed for patients with draining wounds, uncontrolled secretions, pressure ulcers, or presence of other bags draining body fluids.

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Standards of care for wound and invasive device sites are described below.48, 49

• Wound Site Care ○ Dress the wound at the completion of the procedure.

▪ Use sterile gloves to touch wound or dressing materials and drainage device insertion sites.

▪ Use sterile supplies and equipment to prevent contamination. ▪ Select dressing materials based on clinical needs ▪ Select tape based on assessment of the patient’s skin condition,

allergies, amount of strength and elasticity required, and anticipated frequency of dressing changes.

▪ Apply drainage bag/reservoir as needed/ordered. ○ Observe the characteristics of wound drainage. ○ Change dressings over closed wounds. ○ Assess the wound if the patient exhibits signs or symptoms of infection (eg, fever, unusual wound pain, redness or heat at the wound site, edema).

○ Evaluate drainage for signs of infection, including the type, consistency, amount, and color of drainage.

○ Examine and compare the characteristics of the incision regularly. ▪ Observe for well-approximated incision edges. ▪ Observe for signs of infection (eg, heat, redness, swelling, unusual

pain, odor, dehiscence, or evisceration). ○ Clean all areas of the wound as ordered, using aseptic technique.

▪ Rinse the wound with sterile normal saline to provide a moist environment for healing and promote granulation formation.

▪ Use the antiseptic agent ordered by the physician. Some antiseptic solutions, eg, povidone-iodine, hydrogen peroxide, can cause tissue injury and delay wound healing.

▪ Cleanse the wound before cleaning the surrounding area to prevent contamination of the open site. If gauze is used for cleansing, it should not be dragged across the open wound.

○ Aseptically irrigate and pack open wounds as ordered. ○ Dress incisions and wounds with appropriate dressing materials. ○ Assess skin condition and evaluate for signs of infection when dressings are removed.

• Care of Invasive Device Sites (eg, drainage tubes) ○ Examine and compare the characteristics of drainage device sites regularly.

▪ Assess the drain insertion site for signs and symptoms of infection (eg, heat, redness, swelling, odor, drainage, unusual pain).

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○ Maintain patency of invasive devices: ▪ Connect drainage tubes and monitors to prevent twists, kinks, leaks,

and obstructions, ▪ Maintain and monitor suction devices that may be connected for

drainage. ○ Provide care to the invasive devices according to the manufacturer’s instruction and patient’s condition, including but not limited to: closed drainage systems, drainage tube systems and thoracic drainage systems

○ Use aseptic technique when providing care to invasive device sites or systems by:

▪ Using sterile gloves to touch drainage device insertion sites. ▪ Using sterile supplies and equipment. ▪ Wearing a mask, hair cover, or sterile gown according to facility policy

or evidence-based practices. ▪ Cleansing or changing the tube drainage site and system according to

facility policy. ▪ Applying sterile dressing after providing site care by:

• Selecting the dressing and tape materials based on clinical need and the patient’s needs, allergies, and sensitivities,

• Securing dressings with tape. ○ Maintain the patency of invasive devices by:

▪ Ensuring the tube or drainage system is functioning properly. ▪ Securing the tube or drainage system properly to ensure patient safety. ▪ Reporting any concerns to the appropriate member(s) of the health care

team. ○ Provide care for the following invasive device sites:

▪ Drain tube systems• Examine and compare the characteristics of the drainage

device sites regularly.• Change dressings and evaluate the site for signs or symptoms

of infection, as noted above.• Secure drainage devices.• Use sterile gloves to touch drainage device insertion sites.• Use sterile supplies to prevent contamination.• Connect drainage tubes so that they are free from twists, kinks,

leaks, and obstructions. • Maintain and monitor suction devices that may be connected for

drainage (eg, standard chest drainage systems). ▪ Thoracic drainage systems

• Check water level in the water-seal chamber.

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• Check for fluctuation in the water-seal chamber as the patient breathes.

• Check for intermittent bubbling in the water-seal chamber. • Verify the water level in the suction-control chamber and add

sterile distilled water as needed.• Check for gentle bubbling in the suction-control chamber.• Check air vent in the system for proper functioning.• Secure the system to the bedside.• Avoid kinks, dependent loops, or pressure on the tubing.• Avoid raising the drainage system above the patient’s chest to

prevent fluid backflow into the pleural space. • Assess the patient’s breath sounds. • Avoid disrupting sutures or irritating the site.• Select dressing materials according to the patient’s needs.• Secure dressings. • Ensure suction is maintained at the prescribed setting.

Patient and Family EducationBecause procedures are being performed more frequently on an outpatient basis and more patients are being discharged from an acute care facility to a home care setting earlier in their recovery period, surgical wound care and wound drain system maintenance are being provided by the patient, the patient’s family members, or home health care providers in increasing numbers.50 Therefore, in addition to providing effective wound care and maintaining wound drain systems, nurses are now educating patients and their families/significant others about wound care, aseptic technique, and medical waste disposal. Patient compliance with wound care and wound drain system maintenance is an important factor in preventing infection and optimizing wound healing. For home care, the patient should be provided with the following instructions, both verbally and in writing:51

• Warning signs. The signs and symptoms that should be reported to the physician or nurse include:

○ Erythema, marked swelling (eg, beyond one-half inch from the incision site), tenderness, increased warmth around the wound, or red streaks near the wound.

○ A temperature of greater than 37.7°C (> 100°F) or chills. ○ Purulent drainage or a foul odor.

• Special instructions: ○ Confirm with the physician if bathing or showering is permitted. ○ Review dressing change and wound care products with the patient and/or caregiver; explain the procedure and how often it should be performed.

○ Emphasize the need to keep the wound clean and dry. ○ Advise on the need to assemble all supplies needed for wound care before starting the procedure.

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○ Explain how to maintain the sterility of the supplies. ○ Provide instruction on proper disposal of soiled dressings and drainage. ○ Instruct on proper handwashing techniques and to wash hands before and after wound care.

○ Instruct on proper dressing removal, ie, remove tape gently to avoid traumatizing the skin, proper disposal of the old dressing.

○ Instruct on wound inspection, reviewing the warning signs that should be reported.

○ Describe the proper procedure and solution for cleansing the wound and drain site as ordered by the physician.

○ Provide instruction on how to reapply the dressing.

Wound Drain System MaintenanceKnowledge of proper wound drain system maintenance is also critical for optimal wound healing and patient outcomes. The key considerations for wound drain system care and maintenance are discussed below.

• Open Drains. With an open drain, the drainage can be irritating to the skin; therefore, frequent dressing changes with continuous assessment of the surrounding skin are often needed.52 A wound drainage bag may be necessary to protect the patient’s skin when there is a large amount of drainage.

• Closed, negative pressure wound drainage systems need to be emptied and reactivated. Drains connected to a 100cc reservoir should be emptied before the fluid collected reaches the maximum volume; if the reservoir fills completely, drainage will stop. Accurate recording of the volume of drainage, as well as the character of its contents, is vital to promote proper healing. Monitor for excessive bleeding. Depending on the amount of drainage, a patient may have the drain in place one day to several weeks. According to the CDC’s Guideline For Prevention Of Surgical Site Infection, drains should be removed as soon as possible, since bacterial colonization of an initially sterile drain tract increases with the duration of time the drain is left in place.53

General guidelines for care and maintenance of closed drains are as follows.

• Emptying (see Figure 12) ○ Wash hands thoroughly and don gloves before handling the reservoir. ○ Unplug the drainage plug from the emptying port. ○ Hold the reservoir upside down over a measuring container. ○ Squeeze the reservoir to empty all of the collected fluid. ○ Observe and record the amount of fluid collected, as well as the appearance of the drainage (clear, cloudy, bloody, etc.) on a drainage volume chart (see Figure 13 for a sample chart). If educating the patient and/or family members, instruct them to bring the completed drain volume chart to review with the surgeon on each postoperative visit.

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Figure 12 – Emptying a 100cc Bulb Reservoir

To empty:Figure 1: Unplug drainage plug (A) from the emptying port (B), hold the reservoir upside down over a toilet or measuring container (as directed by your physician) and squeeze the reservoir to empty the collected fluid. When the reservoir is emptied of all fluid, you will need to reactivate it.

To reactivate:Figure 2: Squeeze to compress the reservoir as completely as possible.

Figure 3: With the reservoir compressed, insert the drainage plug (A) into the emptying port (B) as far as possible and release the reservoir. The reservoir should expand gradually as it fills with fluid. If the reservoir does not expand gradually and collect fluid, contact your physician.

Attach the reservoir (using the plastic strap) to your clothing as directed by your physician. Place the reservoir below the drain site to maintain adequate drainage. Be certain to empty the reservoir before the fluid collected reaches the 100cc mark.

Summary:1. Observe and record the amount of fluid

collected on the drainage volume chart.

2. Wash hands thoroughly (wear gloves if directed by your physician) before handling the reservoir.

3. Holding the reservoir over the toilet or measuring container, unplug the drainage plug and squeeze the reservoir until empty.

4. Reactivate the drainage system by compressing the reservoir and inserting the drainage plug as far as possible.

5. Flush the drainage fluid down the toilet. Wash hands thoroughly.

Caution: Do not disconnect, kink or puncture the

tubing connected to the reservoir.

Do not let the reservoir completely fill because the drainage will stop.

Do not disconnect the tubing from the reservoir.

If any of these problems occur, contact your physician.

Call your physician for any of the following:• The reservoir cannot be reactivated.

• The drain falls out.

• The fluid in the reservoir has a foul odor.

• The patient has a fever.

• Abnormal drainage, increased redness or swelling is observed near the drain site.

• Air/fluid leaks or other malfunctions occur.

• No fluid collects in the reservoir.

• Clots form in the tubing and block drainage.

CAUTIONDo not disconnect the tubing from the reservoir at any time.

(B)(A)

Figure 2

Before you begin:Be in the bathroom or have supplies ready.

(A)

Figure 3

(B)

Drain(tubing)

Emptying Port (B)

Drainage Plug (A)

Reservoir

Figure 1

You have had surgery which requires you to continue the use of a Jackson-Pratt® wound drainage system. General care of the drain site may include changing the dressing daily and cleaning the skin around the drain with mild soap and water. The wound drainage system will require you, or someone caring for you, to empty and reactivate it. While in the hospital, your nurse will show you the techniques used to care for your drain site and wound drainage system.

After surgery, you will have a Jackson-Pratt® suction reservoir with a drain (tubing). The Jackson-Pratt® system operates by using suction — as the reservoir expands, the suction created will pull out excess fluid. To prevent fluid from collecting and causing infection, your physician will determine the intervals at which the reservoir should be emptied.

Be certain to follow your physician’s instructions carefully.

Use the guidelines in this pamphlet and

the drainage volume chart as directed.

Figure 13 – Sample Drainage Volume Chart

DATE TIME AMOUNT CHARACTER OF DRAINAGE

DAY 1

DAy 2

DAY 3

DAy 4

DAy 5

DAY 6

DAy 7

• Reactivation ○ Squeeze to compress the reservoir as completely as possible (see Figure 14).

Figure 14 – Compressing the Reservoir

























(B)(A)

Figure 2


(A)

Figure 3

(B)

Drain(tubing)

Emptying Port (B)

Drainage Plug (A)

Reservoir

Figure 1






34

○ With the reservoir compressed, insert the drainage plug (A) into the emptying port (B) as far as possible and release the reservoir (see Figure 15). The reservoir should expand gradually as it fills with fluid.

Figure 15 – Reactivating the 100cc Bulb Reservoir

























(B)(A)

Figure 2


(A)

Figure 3

(B)

Drain(tubing)

Emptying Port (B)

Drainage Plug (A)

Reservoir

Figure 1






○ Attach the reservoir using the plastic strap to the patient’s clothing as directed.

○ Place the reservoir below the drain site to maintain adequate drainage. ○ Dispose of drainage appropriately. (If in the home setting, instruct the patient to flush drainage down the toilet.)

○ Remove gloves and wash hands thoroughly.

During the reactivation process, care should be taken so that the tubing connected to the reservoir is not disconnected, kinked, or punctured. In addition, the reservoir should not be allowed to fill completely, because the drainage will stop.

The physician should be notified if:

The reservoir cannot be reactivated, ie, it does not expand gradually and collect fluid.

The drain becomes dislodged. The fluid in the reservoir has a foul odor. The patient has a fever. Abnormal drainage, increased redness or swelling is observed

near the drain site. Air/fluid leaks or other malfunctions occur. Clots form in the tubing causing an obstruction.

Drain RemovalHealth care personnel should use caution during drain removal to prevent the drain from breaking. As noted, silicone is nick sensitive; therefore during removal of the drain, care should be taken so that it is not nicked, cut, torn, or otherwise damaged.

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In a closed suction drainage system, the negative pressure in the drain reservoir should be released by removing the plug from the exit Valve; the bulb or reservoir should be disconnected prior to removing the drain.54 If the drain is sutured in place, the suture should be cut and then the drain should be pulled out smoothly. Because drain removal may be painful for some patients, an oral analgesic to be administered prior to removing the drain may be ordered.

If a drain remains in place for a long period of time, it may become difficult to remove.55 In some cases, a drain may have been stitched to the wound during closure of deeper layers. The nurse should report any difficulty he/she encounters during drain removal to the surgeon, as the wound may need to be temporarily opened in order to remove the drain.

After the drain has been removed, the nurse or patient should clean the drain tube site with an antiseptic solution and a small dry cotton swab. If the site is oozing, a gauze dressing may be applied; if there is a large quantity of drainage, a stoma bag may be used.

SUMMARyThe wound healing process is a complex, highly organized response by an organism to tissue disruption caused by injury; it is a highly reliable process in the absence of infections, mechanical interferences, or certain disease processes. One of the primary goals for all surgical patients is that he/she is free from the signs and symptoms of a surgical site infection, as it is one of the leading causes of postoperative morbidity and mortality. Surgical wound drains are inserted to prevent excessive fluid and air accumulation and bacterial proliferation, in order to reduce the risk for SSI and promote wound healing. Because there are various types of surgical wound drains and drainage systems available today, perioperative nurses and other health care professionals must remain aware of the proper use, applications, and maintenance of these devices. In addition, effective wound care requires good observational and assessment skills, as well as the use of proper terminology to accurately communicate between members of the health care team; without a correct assessment of the wound, proper diagnosis and treatment cannot occur. Through this knowledge and these skills, every member of the perioperative team can play an integral role in promoting optimal wound healing and ultimately positive outcomes for all surgical patients.

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GlOSSARyClean Wounds (Class I) Uninfected operative wounds in which no

inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tract is not entered.

Clean/Contaminated Wounds Operative wounds in which the respiratory, (Class II) alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination.

Contaminated Wound (Class III) Open, fresh, accidental wounds; operations with major breaks in sterile technique (e.g., open cardiac massage) or gross spillage from the gastrointestinal tract, and incisions in which acute, nonpurulent inflammation is encountered.

Crosslink A covalent bond (i.e., linkage) between two polymers (chains) or between different regions of the same polymer.

Deep Incisional Surgical Site An infection involving deep soft tissue, fascia, and (SSI) Infection muscle.

Dermis The largest portion of the skin that provides strength and structure; contained within the dermis are blood vessels, lymph ducts, hair roots, nerves and sebaceous and sweat glands.

Desiccated Dried out.

Dirty/Infected Wounds (Class IV) Old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera; this definition suggests that the organisms causing postoperative infection were present in the operative field before the operation.

Endogenous Growing from or on the inside; caused by factors within the body or arising from internal structural or functional causes.

Epidermis The outermost layer of the skin that lines the ear canals and is contiguous with the mucous membranes.

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Erythema Redness of the skin, due to dilatation and congestion of the capillaries; this is often a sign of inflammation or infection.

Exogenous Growing from or on the outside; caused by factors (as food or a traumatic factor) or an agent (as a disease-producing organism) from outside the organism or system; introduced from or produced outside the body.

Exudate The discharge of fluid, cells, pus, or other substances from cells, blood vessels, or wounds.

Fibrin The insoluble protein that is essential to clotting of blood; it is formed from fibrinogen by the action of thrombin.

Granulation Tissue The fibrous collagen formed to fill the gap between the edges of a wound healing by secondary intention. Capillaries and fibrous collagen project into the wound during the healing process, filling the wound as it heals.

Infection The invasion and multiplication of microorganisms in body tissues that cause cellular injury and clinical symptoms.

leukocyte A white blood cell, whose primary function is to protect the body against microorganisms causing disease.

Microorganism An organism that is too small to be seen with the naked eye and requires a microscope. Bacteria, viruses, fungi, and protozoa are generally called microorganisms.

Normothermia Core body temperature between 36 – 38°C (96.8° – 100.4°F).

Organ or Space Surgical Site An infection that involves any part of the anatomy Infection (SSI) (e.g., organs or spaces), other than the incision, which was opened or manipulated during an operation.

Oxygen Tension The partial pressure of oxygen molecules dissolved in a liquid, such as blood plasma.

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Pathogen A microorganism that causes disease.

Phagocytosis The process by which certain cells (eg, leukocytes) engulfing and destroy microorganisms, bacteria, cellular debris, or other foreign bodies.

Platelet A small, disk or plate-like structure, the smallest of the formed elements in blood. Platelets, also called thrombocytes, are disc-shaped, non-nucleated blood elements with a fragile membrane. They tend to adhere to uneven or damaged surfaces.

Primary Intention Healing that occurs when wounds are created aseptically, with a minimum of tissue destruction and postoperative tissue reaction.

Reepithelialization Restoration of epithelium over a denuded area by natural growth.

Secondary Intention (Granulation) Healing that occurs when surgical wounds are characterized by tissue loss with an inability to approximate wound edges.

Standard Precautions The primary strategy for successful infection control; standard precautions are used for the care of all patients, regardless of their diagnosis or presumed infectious status.

Subcutaneous Layer The innermost layer of the skin; it is composed of adipose tissue that merges with the deepest layer of the dermis to provide insulation, shape, and support.

Suppurative Wound A wound that forms or discharges pus.

Surgical Site Infection (SSI) An infection at the site of a surgical incision; the infection may be superficial, deep, or it may extend to organs.

Tensile Strength Resistance to a pulling force; the amount of stress a material is able to withstand when being pulled before permanent deformity results.

Tertiary Intention Healing that occurs when approximation of (Delayed Primary Closure) wound edges is intentionally delayed by three or more days after surgery or injury.

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Transmission Based Precautions Second-tier precautions designed to be used when caring for patients with known or suspected infection or colonization with highly transmissible or epidemiologically significant pathogens for which additional precautions are needed to prevent transmission.

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5. McEwen DR. Wound healing, dressings, and drains. Alexander’s Care of the Patient in Surgery, 14th ed; JC Rothrock, Ed. St. Louis, MO: Elsevier Mosby; 2011: 250.

6. McEwen DR. Wound healing, dressings, and drains. Alexander’s Care of the Patient in Surgery, 14th ed; JC Rothrock, Ed. St. Louis, MO: Elsevier Mosby; 2011: 250-251.

7. McEwen DR. Wound healing, dressings, and drains. In: Alexander’s Care of the Patient in Surgery, 14th ed; JC Rothrock, ed. St. Louis, MO: Elsevier Mosby; 2011: 251-253.

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9. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999; 20(4):247-278.

10. McEwen DR. Wound healing, dressings, and drains. In: Alexander’s Care of the Patient in Surgery, 14th ed. JC Rothrock, ed. St. Louis, MO: Elsevier Mosby; 2011: 253.

11. McEwen DR. Wound healing, dressings, and drains. In: Alexander’s Care of the Patient in Surgery, 14th ed. JC Rothrock, ed. St. Louis, MO: Elsevier Mosby; 2011: 253-254.




15. Seifert S, Mower J. Planning and providing care. In: Assisting in Surgery: Patient-Centered Care. JC Rothrock, PC Seifert, eds. Denver, CO: CCI; 2009:320.

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18. Worley CA. Assessment and terminology: critical issues in wound care. http://www.medscape.com/viewarticle/493949. Accessed October 5, 2012.

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25. Nurse’s guide to wound drainage systems and types of drains. http://voices.yahoo.com/nurses-guide-wound-drainage-systems-types-of-3847010.html?cat=5. Accessed October 8, 2012.


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35. Petersen C. Infection. In: Perioperative Nursing Data Set: The Perioperative Nursing Vocabulary. Denver, CO: AORN; 2011: 254.

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39. Barnard BM. Fighting surgical site infections. Infection Control Today [serial online]. April 2002. http://www.infectioncontroltoday.com/articles/241feat1.html. Accessed October 11, 2012.

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42. Petersen C. Infection. In: Perioperative Nursing Data Set: The Perioperative Nursing Vocabulary. Denver, CO: AORN; 2011: 254-255.


44. Wound healing. In: Berry & Kohn’s Operating Room Technique, 11th ed. N Phillips, ed. St. Louis, MO: Mosby, Inc.; 2007: 594.


46. AORN. Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2012: 341-351.

47. CDC. Basic infection control and prevention plan for outpatient oncology settings. http://www.cdc.gov/HAI/settings/outpatient/basic-infection-control-prevention-plan-2011/transmission-based-precautions.html. Accessed October 11, 2012.

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48. Petersen C. Infection. In: Perioperative Nursing Data Set: The Perioperative Nursing Vocabulary. Denver, CO: AORN; 2011: 270-272.

49. Wound healing. In: Berry & Kohn’s Operating Room Technique, 11th ed. N Phillips, ed. St. Louis, MO: Mosby, Inc.; 2007: 599-600.



52. Moss R, Schramm C. Facilitate care after the procedure. In: Competency for Safe Patient Care During Operative and Invasive Procedures. ML Phippen, BC Ulmer, MP Wells, eds. Denver, CO: CCI; 2009: 571.

53. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection,1999. Infect Control Hosp Epidemiol. 1999; 20(4):247-278.



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Wound Drain Systems in Perioperative Nursing

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