Wound Care - Wound Drains

Nursing Skills

Wound Care – Wound Drains

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3 05.05 Wound Care – Wound Drains NCLEX Questions

Question 1 of 3

After surgery, a client has a Jackson-Pratt drain inserted to the surgical site. The nurse knows that the drain is ready to be discontinued when which of the following is observed?

23 mL has been collected in the past 24 hours

The drainage is clear for 48 hours

The drainage has clotted off in the tube

3 tablespoons of drainage has been collected in 12 hours

Question 2 of 3

After surgery, a client has a Jackson-Pratt (JP) drain inserted to the surgical site. The nurse is checking the drainage within the first 24 hours post-op. Which of the following colors would be concerning to the nurse? Select all that apply.

Tan

Bloody

Light Yellow

Cloudy Yellow

Clear

Question 3 of 3

A nurse is caring for a post-op client who has developed wound dehiscence at their surgical site. The nurse notes with assessment that the client’s abdominal organs have eviscerated through the wound opening, so the nurse places a saline-soaked gauze over the wound site. Which of the following are appropriate actions for the nurse to take? Select all that apply.

If no pre-soaked dressing is available, the nurse should cover the wound with her hand

The client should lie on their back with knees bent, if possible

The nurse should use a non-adherent dressing

The nurse should call for help and have the surgeon paged immediately

The nurse should push the organs back into the client’s body cavity

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Study Tools For Wound Care – Wound Drains

Wound Vac Therapy (Image)

Hydrogel Dressing (Image)

Rolled Gauze (Image)

Hydrocolloid Dressing (Image)

Types of Dressings (Image)

Wound Drainage Types and Devices (Picmonic)

Wound Drains (Cheatsheet)

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Outline

Overview

Purpose
1. Wound drains are utilized to remove drainage from a wound through a closed system
2. Drainage collecting in a wound can be a source of infection

Nursing Points

General

Types
1. Penrose Drain
  1. Open drainage system
  2. Held in place by a sterile safety pin
  3. Could be covered with gauze or contained within a wound pouch
2. Jackson-Pratt bulb
  1. Long tube with fenestrations (holes) inside the wound
  2. Connected to bulb
  3. Bulb is squeezed to create suction
3. Hemovac
  1. Tube with holes inside the wound
  2. Accordion press to create suction
4. Wound Vac
  1. Foam dressing in wound
  2. Covered with transparent film
  3. Hole cut in film to attach vacuum suction
  4. Vacuum machine attached and turned on to physically pull drainage out
  5. Improves granulation and wound healing
Supplies needed
1. Graduated cup for measurement of drainage
2. Towel or incontinence pad

Assessment

Assess color, clarity, and amount of drainage
Usually done every 8 hours or as needed if drain is full

Nursing Concepts

Steps and Nursing Considerations
1. Gather supplies
2. Perform hand hygiene
3. Don clean gloves
4. Explain procedure to patient
5. Place towel or incontinence pad below wound drain
6. Inspect the drainage for color and characteristics
7. Carefully open the port of the drain
8. Turn the drain upside down to empty into graduated container
  1. May have to gently squeeze the bulb or accordion to ensure it is completely empty
9. Once the drain is empty, set the cup on the bedside table
10. Gently squeeze the bulb or accordion drain to create new suction and quickly replace the cap of the port
  1. If the cap cannot shut properly due to excess drainage, wipe clean with an alcohol pad, then close
11. If the tubing has clots in it, gently squeeze or milk it – never strip the tubing
  1. This creates excessive suction that can cause damage to the wound
12. Hold the graduated cup at eye level and measure the output of the drain.
13. Dispose of the drainage in the toilet or other facility approved disposal location
14. Clean out graduated cup if needs to be reused, otherwise dispose appropriately
15. Remove gloves
16. Perform hand hygiene
17. Document findings of drainage
  1. Color, characteristics
  2. Output volume
Discuss with surgeon/provider regarding expected output
1. Report unexpected findings asap
  1. Excessive output
  2. Unexpected bloody output

Patient Education

Purpose for wound drain
Patients who go home with wound drains should be taught how to manage and empty them

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Transcript

In this video we’re going to look at how to empty a wound drain, specifically a Jackson-Pratt bulb drain. These drains help to carry drainage away from the wound so they can heal faster with a lower risk for infection.

First, you need a graduated cup of some sort that will allow you to measure the output. Urine specimen cups are my go-to, because I can put a lid on it when I’m done!
Place a towel or incontinence pad below the drain in case you spill.
Now, before you empty the drain, make sure you inspect the drainage for its color and characteristics. Is it serous and clear, is it bright red blood, is it full of clots, is it pus?
Now, you can carefully open the port of the drain and then turn it upside down to empty into the cup. You may have to gently squeeze the bulb to make sure it’s fully empty.
Once the drain is empty, set the cup on the bedside table while you close the drain.
Gently squeeze the bulb to create new suction and quickly replace the cap of the port. If it’s covered in drainage, you can wipe it with an alcohol pad, then squeeze the bulb and close the cap.
If you find that the tubing has clots or blockages in it, you gently squeeze or milk it – but you never strip the tubing – it can create excessive suction that can cause damage to the wound.
Now you can measure the output by looking at the drainage at eye level. Make note of the volume.
Now you can dispose of everything appropriately and document the details about the output.

That’s it. Make sure you know specifically how to manage whatever drain your patient has – if you aren’t sure, ask!

Now, go out and be your best selves today. And, as always, happy nursing!

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