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Managing Wound Drainage

Overview: To contain the drainage, protect the skin, and control odor.

Preparation
● Draining wounds may be a result of trauma, surgery, or disease.
● Fluid and electrolyte problems and disruptions in skin integrity may occur.
● Appropriate management increases patient comfort and can reduce complications and facilitate healing.
● Equipment will be chosen depending on type and quantity of drainage: Copious: over 50 mL per day can best be managed with pouching, especially if the effluent is harmful to the skin. Less copious: under 50 mL per day and not harmful to the skin can be managed with absorbent dressings and skin sealants to protect the peri-wound skin.

Special Considerations
• Provide teaching of wound care and pouching to client and/or caregiver before discharge.

Geriatric and Pediatric Patients
• Take extra time and care because skin is fragile.
• Involve parent/caregiver in wound drainage management.

Home Health Patient
• During discharge planning, make arrangements for home health to follow, and monitor patient and/or caregiver compliance and skill with wound-drainage management.

Relevant Nursing Diagnoses
● Impaired skin integrity related to trauma or surgery
● Potential for infection related to invasion of infectious microorganisms into wound
● Pain/discomfort related to impaired tissue and irritation of wound drainage

Expected Outcomes
● Skin will be protected against excessive drainage
● Patient will experience increased comfort due to drainage containment and odor control
● Drainage can be measured accurately

Equipment/Supplies
Wound drainage pouch
Nonsterile gloves, gauze,wound cleanser, bag for disposal of soiled dressings
Skin sealant, drainage collector, paste, adhesive tape

Implementation
1. Wash hands.
Rationale: Reduces transmission of microorganisms.

2. Organize equipment.
Rationale: Enhances efficiency and patient safety.

3. Explain procedure to patient/family.
Rationale: Reduces anxiety, reinforces teaching.

4. Position patient for access to wound.
Rationale: Facilitates procedure.

5. Don nonsterile gloves, remove dressing and place in bag for disposal.
Rationale: Reduces transmission of microorganisms.

6. Gently flush wound with wound cleanser.
Rationale: Removes necrotic debris, reduces spread of infection.

7. Assess wound for healing.
Rationale: Assessment of wound identifies healing or deterioration and contributes to decision-making for subsequent care.

8. Dry periwound area by patting gently.
Rationale: Allows application of skin sealant and wound-drainage device.

Pouching procedure:
1. Trace pattern on back of pouch cut opening 1/8- to 1/4-inch larger than opening on skin.
Rationale: Too large an opening will expose skin to harmful drainage. Too small an opening will cause leakage and decrease wear time.

2. Apply paste around wound opening to fill in uneven spaces and cover exposed skin.
Rationale: Protects exposed skin from drainage and extends wear time by preventing leakage under the edge of the pouch.

3. Apply pouch, centering pouch opening over wound opening.
Rationale: Provides for proper location of pouch, collection of drainage, and protection of the skin.

4. Apply tape to picture-frame edges of pouch.
Rationale: Promotes increased wear time.

5. Connect pouch to drainage bag.
Rationale: Draining effluent away from pouch increases wear time, prevents leakage onto skin, and aids in measurement of drainage.

6. Remove gloves and discard into disposal bag.
Rationale: Reduces spread of infection.

7. Wash hands.
Rationale: Reduces spread of infection.

Evaluation and Follow-up Activities
● Reassess efficacy of wound management system at each change
● Assess patient’s tolerance of the wound management system
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