05.05 Wound Care – Wound Drains

Overview

1. 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

1. 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
2. Supplies needed
   1. Graduated cup for measurement of drainage
   2. Towel or incontinence pad

Assessment

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

Nursing Concepts

1. 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
2. Discuss with surgeon/provider regarding expected output
   1. Report unexpected findings asap
      1. Excessive output
      2. Unexpected bloody output

Patient Education

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