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Wound Drain Systems
in Perioperative Nursing
An Online Continuing Education Activity
Sponsored By
Grant funds provided by
Welcome to
Wound Drain Systems in
Perioperative Nursing
(An Online Continuing Education Activity)
CONTINUING EDUCATION INSTRUCTIONS
This 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:
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Pfiedler Enterprises, 2101 S. Blackhawk Street, Suite 220, Aurora, Colorado 80014
www.pfiedlerenterprises.com Phone: 720-748-6144 Fax: 720-748-6196
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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IACET
Pfiedler 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.
Disclaimer
Pfiedler Enterprises does not endorse or promote any commercial product that may be
discussed in this activity
Support
Funds to support this activity have been provided by CardinalHealth
Authors/Planning Committee/Reviewer
Julia A. Kneedler, RN, MS, EdD
Program Manager/Planning Committee
Pfiedler Enterprises
Rose Moss, RN, MN, CNOR
Nurse Consultant/Author
C & R Moss Enterprises
Judith I. Pfister, RN, BSN, MBA
Program Manager/Planning Committee/Reviewer
Pfiedler Enterprises
Kristine L. Winters, RN, BSN
Nurse Consultant/Reviewer
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Aurora, CO
Casa Grande, AZ
Aurora, CO
Aurora, CO
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for Those in a Position to Control Content for this
Activity
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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
5
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Wound Drain Systems in Perioperative Nursing
(An Online Continuing Education Activity)
Introduction
The 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 healthcareassociated 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 Healing
In 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 Skin
The 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 Wounds
In 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 Healing
Wounds 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 Healing
Wound 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
9
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
Inflammatory (Reactive)
Phase
1 to 4 days
Proliferative (Regenerative or Reparative) Phase
5 days to 2 weeks
Remodeling (Maturation)
Phase
2 - 4 weeks to 1 year or
more
10
Events
Inflammation
- Vasodilation
- Phagocytosis
- Formation of a seal to assist in
preventing fluid loss and bacterial invasion
Reepithelialization
Collagen synthesis
Wound contraction
Collagen remodeling
- Collagen production and collagen breakdown are balanced;
- Randomly deposited connective
tissue is arranged in linear and
lateral orientation
Surgical Wound Classifications
The 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 Process
There 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.
•
At least 1 of the following is present:
−
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 culturenegative,
−
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.
•
At least 1 of the following is present:
−
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.
12
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
Penicillin
Effect
 Interferes with the tensile strength of the wound by
affecting the cross-linking of collagen
Anticoagulants
 Leads to hematoma formation
Anti-inflammatory agents,
including steroids
 Suppresses inflammation
 Inhibits the formulation of granulation tissue
Ibuprofen
 Suppresses protein synthesis
Naproxen
 Suppresses epithelialization
 Increases the incidence of bleeding
Aspirin
 Inhibits activation of platelets
Warfarin (Coumadin®)
 Impairs blood clotting
Chemotherapeutic 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 aggregation
Gingko
 Inhibits platelet activation
Ginseng
 Inhibits platelet activation
St. John’s Wort
 Inhibits neurotransmitter uptake
 Incudes enzymes that affect warfarin and other drugs
Wound Assessment: Key Nursing Considerations
Proper 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,
14
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.
15
• 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 Types
Drains 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 Drains
A Penrose drain is a thin-walled cylinder made of radiopaque latex or silicone (ie, latexfree) 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.
16
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 Systems
A 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).
17
Figure 3–Closed Wound Drainage
Silicone Wound Drains
There 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.
18
• 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) Drains
Based 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/Tubes
Postoperatively, 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.
19
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 Applications
There 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 Systems
A 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.
20
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
21
evacuate postoperative hematomas or seromas, however, the timing of drain removal is
also important.26
Negative Pressure Wound Drainage Systems
Negative 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.
22
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 Systems
An 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
23
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
Rationale
General
Upper abdominal
procedures
Colon resections
Various PVC &
silicone drains
100cc Silicone bulb
400cc Silicone bulb
Reservoirs permit easy activation of
suction, identification and measurement of exudate
Internal, anti-reflux valve prevents
backflow of fluid to the patient
Reservoirs are easy to empty and
reactivate
Orthopedics
Total hip arthroplasty
Total knee arthroplasty
Round PVC
drain
3-spring reservoir
Tougher PVC material withstands
the rigors of the particular anatomy
Cost effective
Thoracic & Cardiovascular
Thoracotomy
Lobectomy
CABG (on-pump
or off-pump)
Valve replacement 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/Gynecology
Labor & delivery
Hysterectomy
Silicon drains
(flat, round or
T-drain)
Silicone bulb
Silicone is a good option due to its
softness
Plastic/ Reconstructive
Surgery
Skin flaps
Breast reconstruction
Facial 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
Neurosurgery
Craniotomy
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
24
Drain Insertion
When 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.
25
Wound Care and Preventing Infection
Proper 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-cleancontaminated, 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;
26
•
•
•
•
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
• 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
Outcome Indicators
• Skin condition of the surgical
wound:
-The incision is wellapproximated 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
27
• 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 Practices
Care of Wounds and Wound Drainage Sites
Effective 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.
28
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).
29
○○ 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.
30
• 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 Education
Because 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.
31
○○ 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 Maintenance
Knowledge 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.
32
connect the tubing from the reservoir at any time.
Figure 12 – Emptying a 100cc Bulb Reservoir
you begin:
pty:
Drain
(tubing)
throom or have supplies ready.
Unplug drainage
m the emptying
CAUTION
d the reservoir
nnect the tubing fromEmptying
the reservoir at any time.
Port (B)
n over a toilet or
Reservoir
Drainage
container (as directed
DrainPlug (A)
ysician) and squeeze
(tubing)
Figure
r to empty
Figurethe
13 –collected
Sample Drainage Volume
Chart 1
plug drainage
the reservoir
is emptied of TIME
DATE
AMOUNT
the emptying
u will need
to reactivate it.
DAY 1
the reservoir
Emptying
DAY 2
Port (B)
over a toilet or
DAY 3
Reservoir
Drainage
ntainer (as directed
DAY 4
Plug (A)
cian)
and
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queeze
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DAY 5
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DAY 6
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CHARACTER OF
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DAY 7 is emptied of
With the reservoir
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• Reactivation
d, insert the
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Do
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○○ Squeeze to compress the reservoir as completely as possible (see Figurecontact y
o the emptying14).
port
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Figure 14 – Compressing the Reservoir
Do not le
r. The to
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(A) Figure 2
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and
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33
Figure
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by your physician.
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ivate:
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contact
emptying port
ible and release
○○ With the reservoir compressed, insert the drainage plug (A) into the
e reservoir emptying port (B) as far as possible and release the reservoir (see Figure
Figure
2
15). The reservoir should
expand gradually
as it fills with fluid.
gradually as it fills
Figure 15 – Reactivating the 100cc Bulb Reservoir
reservoir does
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ually and collect
• The rese
ur physician.
(B)
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voir (using the
• The fluid
your clothing
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oir below the
• Abnorma
Figure 3
ntain adequate
○○ Attach the reservoir using the plastic strap to the patient’s clothing as swelling
tain to empty directed.
the
○○ Place the reservoir below the drain site to maintain adequate drainage.
• Air/fluid
○○ Dispose of drainage appropriately. (If in the home setting, instruct the patient
the fluid collected
to flush drainage down the toilet.)
• No fluid
cc mark.
○○ Remove gloves and wash hands thoroughly.
During the reactivation process, care should be taken so that the tubing
• Clots
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 Removal
Health 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.
34
for
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.
Summary
The 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.
35
Glossary
Clean 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
(SSI) An infection involving deep soft tissue, fascia, and
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.
36
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.
37
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
(Delayed Primary Closure) Healing that occurs when approximation of
wound edges is intentionally delayed by three or
more days after surgery or injury.
38
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.
39
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