RATIFIED BY NNPDG SEPTEMBER 2006 FOR REVIEW 2009

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1 NOTTINGHAM UNIVERSITY HOSPTIALS/RUSHCLIFFE PCT NURSING PRACTICE GUIDELINES GUIDELINES FOR CARE OF A PATIENT WITH A WOUND DRAINAGE SYSTEM CONTENTS PAGE Introduction and Types of Drains 1 Procedure for Applying a Drain Dressing 3 Procedure for Changing a Disposable Vacuum Wound Drainage System (e.g. Redivac and Closed Drainage Systems) 4 Procedure for Shortening of a Wound Drain 6 Procedure for Removal of a Vacuum Wound Drainage System (Redivac and Closed Drainage Systems) 8 Procedure for Removal of a Wound Drain (Corrugated, Latex) 10 Further Reading 11 Elements for Assessment of Clinical Competency 12 Wound Drainage, August 2003

2 INTRODUCTION A drain is used to prevent accumulation of fluid in a wound bed, which may delay healing and predispose the wound to infection. Indications for use include: a. to redirect body fluids to allow time for a new suture line to heal b. to drain collections of pus from the body cavities c. to drain collections of fluid post-operatively d. when haemostasis has not been achieved during surgery The most common types of surgical wound drains include: 1. vacuum 2. latex or rubber (Pauls) tubing 3. corrugated 4. Jackson Pratt (abdominal) drain. 1. VACUUM This is a closed vacuum wound drainage system inserted via a stab wound into the wound bed, for example, Redivac, Manovac, J Vac etc. It is necessary to check the wound drainage system to ensure maintenance of the vacuum within the bottle (according to manufacturer s instructions) and to observe and measure any drainage. The drain should not be placed on the floor (to minimise the risk of cross infection) but should be positioned below the level of the wound (to facilitate drainage). If the vacuum of the wound drainage system is continually being lost, check all the connections for evidence of an air leak and for any wound drain perforations exposed above skin level. Check the patency of the tubing ensuring it is not clamped, blocked or kinked, to facilitate the flow of fluid. A lack of flow may indicate: a. all the exudate has been removed b. the wound drain is clogged and may require irrigation and aspiration - consult medical staff c. loss of vacuum. 1

3 2. LATEX TUBING This is a relatively wide-bore tube made of latex which is sutured in situ and attached to a sterile drainage bag, to create a closed, gravity drainage system. Latex tubing is commonly used in major abdominal surgery. When considering the use of any latex material, be mindful of latex allergy and refer to local Health and Safety Guidelines on the Use of Latex. 2a. PAULS TUBING This is an open wound drainage system made of soft rubber tubing, allowing drainage of exudate into a wound drainage bag (if copious) or onto a sterile dressing (if only minimal). 3. CORRUGATED DRAIN This is an open wound drainage system made of a flat corrugated rubber or plastic/latex strip, allowing free flow of exudate from the wound into a wound drainage bag (if copious) or onto a sterile dressing (if only minimal). 4. JACKSON PRATT (ABDOMINAL) DRAIN This is the brand name for a self-contained suction system which promotes healing by draining fluid from the wound, preventing swelling and pooling of blood and fluid from the wound site. REMOVAL OF A DRAIN A drain should only be removed following either specific instructions from medical staff or according to local protocol. Medical notes should be checked prior to any procedure to ensure the correct procedure i.e. correct drain removal is undertaken. BEST PRACTICE Prior to any of the following procedures it is important to consider analgesia. This will minimise pain, distress and trauma. 77% of patients reported pain on removal of a Jackson Pratt abdominal drain in a study by Minnaugh et al (1999). Analgesia to cover this should be considered prior to, during and following the procedure (Shepard et al 2000). Drains when in situ should be emptied frequently to reduce the strain on the suture line and ensure maximum suction (Springhouse 2000). However, the dangers of introducing infection should be weighed against the need to empty the drain. Tubing should also be kept free of kinks and twists. Redivac bottles are not empied but renewed when full. If a patient has more than one drain these need to be numbered to prevent confusion when charting exudates and when preparing to remove one of them. (Springhouse 2000). All nursing procedures must be documented in the nursing documentation including analgesia administered, the length of drain in situ (if shortened) and the number of the drain removed (if more than one). Contents of the drain must be documented on the fluid balance chart. 2

4 BEST PRACTICE Wound / drain site swabs should only be taken if infection is suspected. Signs of infection include pain, inflammation at wound margins, oedema, pyrexia and purulent exudates. Any wounds that show signs of infection should be reported to the medical staff. PROCEDURE FOR APPLYING A DRAIN DRESSING EQUIPMENT Sterile dressing pack Pair of non-sterile gloves Pair of sterile gloves Sachet sterile sodium chloride 0.9% Alcohol swab Sterile dry dressing of choice Hypo-allergenic tape 1 pair of sterile scissors Refer to General Principles for All Procedures 1. Ensure privacy. To prevent undue distress to the patient. 2. Apply the non-sterile gloves and remove the dressing. To protect the nurse against exposure to the patient s body fluids. 3. Dispose of gloves and dressing as appropriate. Clean hands. Apply pair of sterile gloves. To minimise cross-infection. 4. Prepare equipment and apply a sterile protective field under drainage site. To maintain asepsis and prevent soiling. 5. If exudate is present, clean around the wound site using saline and gauze swabs. Note: Do not use cotton wool balls as cotton fibres may be left in the wound. To remove debris. 3

5 6. Check for any wound drainage perforations (if appropriate) exposed above skin level as evidence of an air leak. Also ensure tubing is not bent or kinked. To maintain the vacuum of the wound drainage system (if a closed system) and to maintain the patency of the line. 7. Check that the skin suture (if used) is intact. To minimise move and prevent the drain falling out. 8. If the skin around the drain site is becoming sore or excoriated, protect with a stomahesive wafer/ no-sting barrier film. To prevent excoriation of the skin caused by wound exudate. 9 Cover the drain site with a sterile dressing. This may be a keyhole dressing, cut with sterile scissors. Secure with tape. To minimise risk of cross-infection and to promote patient s comfort. 10 Ensure vacuum is present in the wound drainage system (if appropriate). To ensure that drainage continues. EQUIPMENT New drainage system Non-sterile gloves Artery forceps/clamp PROCEDURE FOR CHANGING A VACUUM WOUND DRAINAGE SYSTEM Refer to General Principles for All Procedures (e.g. Redivac and Closed Drainage Systems) 1. Apply gloves To minimise risk of infection and to protect the nurse against exposure to the patient s body fluids. 2. Clamp the tubing of the existing drainage bottle above and below the point of disconnection. Remove drainage bottle. To prevent air and contaminants entering the wound via the drainage tubing and also to prevent leakage from the tubing. 4

6 3. Attach new, already vacuumed drainage bottle to the drainage tubing. 4. Release clamps or artery forceps and the clamp on the bottle. To re-establish drainage system. 5. Ensure new drainage bottle remains vacuumed. To maintain drainage. 6. If vacuum is being lost, remove dressing around drain entry site and examine. To determine whether the vacuum has been lost due to the drain becoming dislodged. 7. Measure and record the contents of the old drainage bottle by either: a. Redivac-type (disposable) use the markings on the bottle. Dispose of bottle and contents To maintain accurate wound drainage records. Ensure safe disposal of equipment and body fluids. b. Pump-type (disposable) empty contents into measuring jug and then dispose of into the sluice. Dispose of the bottle as per local clinical waste disposal policy 5

7 PROCEDURE FOR SHORTENING OF A WOUND DRAIN EQUIPMENT Sterile dressing pack Sachet sterile sodium chloride 0.9% Alcohol swab Sterile scissors Sterile safety pin Pair of non-sterile gloves Pair of sterile gloves Sterile dry dressing or drainage bag Hypo-allergenic tape Measuring jug Refer to General Principles for All Procedures 1. Apply the disposable gloves and remove the dressing or drainage bag. To minimise the risk of cross infection. 2. Remove the gloves and clean hands. 3. Put on sterile gloves. To minimise the risk of cross infection and to facilitate easy insertion of the safety pin. 4. Place a sterile protective field under the drainage site. To maintain asepsis and prevent soiling. 5. If exudate is present clean the wound using normal saline. To remove debris. 6. If the drain is sutured in place, remove the suture (as per procedure). 7. Holding the tubing with gloves or gauze gently but firmly withdraw the drain, (approximately 3-4 cms or as directed by the medical staff) whilst applying gentle counter pressure around the drain site, using a gauze square. To prevent undue pulling at wound tissue and minimise the pain. To allow healing from the base of the wound. 6

8 8. Rest the tubing on the sterile or protective field. To minimise the risk of cross infection. 9. Manually place a sterile closure clip on the To prevent the drain from retracting back into the drain ensuring it is close to the skin as possible. wound. BEST PRACTICE An alternative to a sterile closure clip is a sterile pin which needs to be inserted through the drain to prevent the drain from retracting back into the wound. However, this method involves the added risk of a needlestick injury and should be used with extreme caution. 10. Using sterile scissors cut 3-4 cm from the distal end of the drain. To minimise the risk of infection and to promote patient's comfort. 11. If exudate is present clean wound site using saline and gauze. Note: Do not use cotton wool balls as cotton fibres may be left in the wound. To minimise the risk of infection and to promote patient's comfort. 12. Re-apply drain or dressing bag, as appropriate. 7

9 PROCEDURE FOR REMOVAL OF A VACUUM WOUND DRAINAGE SYSTEM (Redivac and Closed Drainage Systems) EQUIPMENT 2 pairs non-sterile gloves Sterile dressing pack Sachet of sterile sodium chloride 0.9% Alcohol swab Sterile stitch cutter Sterile dry dressing Hypo-allergenic tape Sterile scissors Sterile universal specimen container (only if tubing tip is required for culture) Sharps box Measuring jug (if required) Refer to General Principles for All Procedures 1. Check the medical notes to ensure removal of the drain is required, the correct one identified and documented. 2. Ensure privacy to reduce unnecessary distress for the patient 3. Clean hands and apply the disposable gloves and remove the dressing. To minimise the risk of infection. 4. Dispose of gloves and dressing, as appropriate. To minimise risk of infection to the patient and nurse. 5. Clamp the tube to discontinue suction and stop drainage. To reduce discomfort on removal. 6. Clean hands and apply second pair of gloves. Place a sterile protective field under drainage site. To maintain asepsis and prevent soiling. 7. If exudate is present clean the wound using saline and gauze. To remove debris. 8

10 8. If the drain is sutured in place, remove the suture (as per guidelines). 9. Holding the tubing with gloves or gauze gently, but firmly, withdraw the drain whilst applying gentle counter pressure around the drain site, using a gauze square. To prevent undue pulling at wound tissue and to minimise the pain. 10. If the tip of the tubing is requested for culture, cut off the first 2 cm using the sterile scissors and place into a labelled sterile universal specimen container. To identify possible micro-organisms. 11. If exudate is present irrigate the wound using saline. For the cleanliness and comfort of the patient and to remove debris. 12. Cover the drain site with a sterile dressing and secure with tape. To minimise the risk of infection and to promote the patient's comfort. 13. Measure the contents and dispose of the drainage bottle as per local policy. BEST PRACTICE Wound drain tips should only be sent for culture if the patient has sins and symptoms of infection. These include pain, inflammation at wound margins, oedema, pyrexia and purulent exudates. Any wounds that show signs of infection should be reported to the medical staff. 9

11 PROCEDURE FOR REMOVAL OF A VACUUM WOUND DRAINAGE SYSTEM (Corrugated or latex) EQUIPMENT Sterile dressing pack Sachet sterile sodium chloride 0.9% Sterile scissors or stitch cutter 2 pairs of non-sterile gloves Sterile dry dressing Hypo-allergenic tape Sharps box if stitch cutter used Measuring jug (optional) Alcohol swab Receptacle (kidney dish) Refer to General Principles for All Procedures 1. Apply the gloves and remove the dressing. If necessary, remove drainage bag and place in a receptacle on the bottom of the trolley. To minimise risk of cross infection. 2. Dispose of gloves and dressing, as appropriate, and clean hands. Apply second pair of gloves. 3. Place a sterile protective field under drainage site. To maintain asepsis and prevent soiling. 4. If exudate is present clean the wound using saline. To remove debris. 5. If the drain is sutured in, remove the suture (as per procedure). 6. Holding the tubing with gauze or gloves, gently but firmly withdraw the drain, whilst applying gentle counter pressure around the drain site using a gauze square. To prevent undue pulling at wound tissue and minimise the pain. 7. If exudate is present clean the wound using saline. For the cleanliness and comfort of the patient and to remove debris. 10

12 8. Cover the drain site with a sterile dressing and secure with tape. To minimise the risk of infection and to promote the patient's comfort. 9. Where appropriate, measure and record the contents of the drainage bag. To maintain an accurate record of wound drainage. 10. Dispose of clinical waste as per local policy. FURTHER READING David J A (1987) Wound Management: A comprehensive guide to dressing and healing London: Martin Dunitz Limited Doughty L & Lister S (2004) The Royal Marsden Hospital Manual of Clinical Nursing Procedures 6 th Edition Oxford: Blackwell Science Griffin-Perry A and Potter P (2002) Clinical Nursing Skills and Techniques St Louis, USA: Mosby,. pp Gruendemann B J and Mangum S S (2001) Infection Prevention in Surgical Settings. Philadelphia, USA: W B Saunders. Morison M J (1992) A Colour Guide to the Nursing Management of Wounds London: Wolfe Publishing Limited. Mimnaught L et al (1999) Sensations experienced during removal of tubes in acute post-operative patients Applied Nursing Research Vol. 12 No. 2. pp Sheppard M & Wright M (2006) Principles and Practice of High Dependency Nursing 2 nd Edition. London: Bailliere Tindall Springhouse Corporation (2004) Nursing Procedures 4 th Edition Philadelphia: Lippincott Williams & Wilkins Original Author: Reviewed By: NNPDG Member Sarah Lewis, Staff Nurse Ward E15 Surgical Sisters, QMC Campus Philip Daly, Head of Practice Development, QMC September 2006 Review Date:

13 ELEMENTS FOR ASSESSMENT OF CLINICAL COMPETENCE (Below is an example taken from the Chest Drain guidelines, 2006) KNOWLEDGE Possession of a working knowledge of respiratory physiology. Knowledge of the reasons for the insertion of the chest drain. Explain the problems that may arise as a result of chest drain insertion. Explain the signs that may occur in respiratory distress Explain why analgesia is important at all stages of the procedure Explain the importance of not clamping chest drains Explain the reasons for not draining pleural fluid too rapidly Explain the actions to be taken should the system be disconnected in any way Explain why thoracic low pressure suction systems may be utilised SKILLS Demonstrate the ability to prepare the drainage system and tubing avoiding contamination Demonstrate the ability to record baseline vital signs (including pulse oximetry) Apply the principles of asepsis at all stages of the process Demonstrate the ability to check the patency of the tubing Demonstrate that effective analgesia has been administered Document accurately the amount and type of drainage over a period of time Demonstrate the ability to remove a chest drain safely in accordance with local policy Demonstrate effective teaching skills to empower the patient in the management of their chest drain ATTITUDES Demonstrate a caring attitude towards a patient who is experiencing an anxiety provoking and painful procedure Demonstrate ongoing support and empathy for a patient with a chest drain in situ 12