Wound Management

Skills
A. Wound care (cleaning & dressing)
B. Care of the drain site and emptying the wound drainage.
C. Removing suture & staples

A. Wound Care (Cleaning & Dressing)

Wound is a breakdown in the surface of the skin, with or without loss of underlying
connective tissue (i.e. muscle, bone, nerves).

Changing a Dressing is a process of removing the old dressing, cleaning the wound, and
covering the wound.
Purpose of wound Dressing:
1. To protect the wound from mechanical injury
2. To splint or immobilize the wound
3. To absorb drainage
4. To prevent contamination from bodily discharges (feces, urine)
5. To promote hemostasis, as in pressure dressings
6. To debride the wound by combining capillary action and the entwining of necrotic
tissue within its mesh
7. To inhibit or kill microorganisms by using dressings with antiseptic or
antimicrobial properties
8. To provide a physiologic environment conducive to healing
9. To provide mental and physical comfort for the patient.
Types of Dressings
● Dry dressing
o Used primarily for wounds closing by primary intention.
o Offers good wound protection, absorption of drainage, and aesthetics for
the patient and provides pressure (if needed) for hemostasis.
o Disadvantage—they adhere to the wound surface when drainage dries.
(Removal can cause pain and disruption of granulation tissue.)
● Wet-to-dry dressing
o These are particularly useful for untidy or infected wounds that must be
debrided and closed by secondary intention.
o Gauze saturated with sterile saline (preferred) or an antimicrobial solution
is packed into the wound, eliminating dead space.
o The wet dressings are then covered by dry dressings (gauze sponges or
absorbent pads).
 o As drying occurs, wound debris and necrotic tissue are absorbed into the
gauze dressing by capillary action.
o The dressing is changed when it becomes dry (or just before). If there is
excessive necrotic debris on the dressing, more frequent dressing changes
are required.
● Wet-to-wet dressing
o Used on clean open wounds or on granulating surfaces. Sterile saline or an
antimicrobial agent may be used to saturate the dressings.
o Provides a more physiologic environment (warmth, moisture), which can
enhance the local healing processes as well as ensure greater patient
comfort. Thick exudate is more easily removed.
o Disadvantage—surrounding tissues can become macerated, there is an
increased risk for infection, and bed linens become damp.
Equipment for Changing Dressing
● Clean gloves and sterile gloves

● Sterile scissors, forceps (disposable packs available)

● Appropriate sterile dressing materials
● Sterile saline solution is the cleansing agent of choice. Topical antiseptics
(ie, povidone-iodine, hexachlorophene) may be used on intact skin
surrounding the wound but should never be used within the wound.
● Sterile basin.
● Sterile cotton-tipped swabs
● Culture tubes (if infection suspected)
● Sterile drape.
● For draining a wound: add extra sterile gauze and packing material,
absorbent pads, and an irrigation set
● Tape, proper size and type
● Pads to protect the patient's bed
● Gown for the nurse if the wound is purulent or infected
● PPE: Goggles and mask (used when spray from wound is a risk).
● Plastic bag for discarded dressings (Biohazard bag).
 Nursing Rationale
Actions
1. Identify patient using two identifiers (i.e., name Ensures correct patient.
and birthday or name and account number) Complies with The Joint
according to agency policy. Compare identifiers Commission standards
with information on patient’s identification and improves patient
bracelet. safety
2. Prepare environment of dressing to be free Diminish chance
from visitors & air draft….etc. of contamination

3. Wash your hands thoroughly

4. Gather the necessary equipment and dressing
supplies on a clean, flat surface (over-bed
table).
● Cut (or tear) off pieces of tape to be used Ensures easy disposal of
soiled dressings.
in dressing change. Prevents contamination
● Place a disposable biohazard bag within of outer surface of bag.
reach of your work area. Fold the top of the
bag to make a cuff.
5. Create a sterile field on the over-bed table, use a Keeps items sterile.
sterile dressing tray or commercial kits or open
the individually sterile cleaning supplies (cotton-
tipped applicators, sterile gauze sponges, sterile
solution cup)
6. Pour a sterile solution (preferably saline) into Preparation for
the solution cup. sterile procedure.
7. Place a clean towel or linen saver pad under part
of the body where the wound is located.
8. Position the patient comfortably, ensure privacy To respect the patient’s
by drawing the curtains or closing the door, and modesty and prevent the
drape him to expose only the wound site. Instruct patient from being
the patient not to touch the wound or the sterile chilled.
supplies.
9. Perform hand rub & apply gown, goggles, and Use of PPE
mask (if there is a risk of spray) and apply clean reduce
disposable gloves. transmission of
microorganisms
1 Perform indirect assessment through inspection Determines
0. & palpation of skin around dressing for redness, wound's
bruising, hotness….etc. progression
1 Removing old dressing
1.
a. Gently remove tape: use nondominant hand to Pulling tape toward dressing
support dressing and, with your dominant hand, reduces stress on suture line
pull tape parallel to skin and toward dressing. If or wound edges and reduces
dressing is over hairy area, remove in direction irritation and discomfort.
of hair growth. Remove any adhesive from
skin.
b. With gloved hand or forceps remove dressing Hasty removal of dressings
one layer at a time, observing appearance and can cause trauma to the
drainage of dressing. Carefully remove outer wound and dislodge existing
secondary dressing first; then remove inner drains.
primary dressing that is in contact with wound
bed. If drains are present, slowly and carefully
remove dressings and avoid tension on any
drainage devices. Keep soiled undersurface
from patient’s sight.
● If moist-to-dry dressing adheres to
Moist-to-dry dressing
wound, gently free dressing and alert should debride wound. Do
patient of discomfort. not wet dressing; it should
● If dry dressing adheres to wound that is not be dry.
Prevents injury to wound
to be debrided, moisten with normal saline surface and periwound
and remove. during dressing removal.
c. Inspect wound and periwound for appearance,
color, size (length, width, and depth), drainage, Assesses condition of
edema, presence and condition of drains, skin wound and periwound
around any drainage devices, approximation condition.
(wound edges are together), granulation tissue, Indicates status of healing.
or odor. Use measuring guide or ruler to
measure size of wound. Gently palpate wound
edges for bogginess or patient report of
increased pain.
d. Fold dressings with drainage contained inside
and remove gloves inside out. With small
dressings remove gloves inside out over
dressing. Dispose of gloves and soiled dressing
according to agency policy. Cover wound
lightly with sterile gauze pad and perform hand
hygiene.
Contains soiled dressings,
prevents contact of nurse’s
hands with drainage, and
reduces cross-
contamination.
1 Cleansing the Simple Surgical Wound and Drain Site
2.
a. Perform hand hygiene.
b. Put on sterile gloves, or apply clean gloves Minimizes risk of infection.
with sterile forceps for a no-touch technique,
depending on the status of the wound and on
agency policy.
c. Use gauze or cotton ball moistened in saline
or antiseptic swab (per physician order) for
each cleansing stroke or spray wound
surface with wound cleanser.
d. Clean along the wound edges from one end of Prevents transfer of
the incision to the other; be sure to clean each micro- organisms from
side of the wound separately. Cleanse from the previously cleaned area.
least contaminated area to the most Cleaning in this
contaminated. direction prevents
e. Repeat the process using another moistened introduction of
gauze or swab until the entire incision is clean. organisms into wound.
Do not scrub back and forth across the incision
line. Used applicators should not be
reintroduced into the sterile solution.
a. If the suture line requires cleansing, it should To prevent contamination
be done gently. and mechanical trauma of
wound.
b. Repeat the same process with the drain site. Reduces the risk of
Always clean the drain site separately from cross- contamination
the primary incision site.
● Use circular motion starting near drain and
moving outward and away from insertion
site
● Also clean the sutures
 c. Pat the incision site and drain the site dry with To reduce excess moisture,
a sterile dressing sponge. Working from the which harbor
least contaminated area to the most microorganisms. To prepare
contaminated area (use same technique as for the wound for final dressing.
cleaning).
d. Apply antiseptic ointment (if ordered) with Helps reduce growth
sterile Q-tip or gauze, using same technique to of microorganisms
apply as for cleaning.
e. Dispose of gloves and perform hand hygiene.
1 Dressing the wound (with dry dressing)
3.
a. Maintain sterile technique with the use of sterile
gloves (or clean gloves per the agency policy).

b. Apply loose woven gauze as contact layer Promotes proper absorption

of drainage.
c. If drain is present, apply precut, split 4 × 4– Secures drain and
inch gauze around drain. promotes drainage
absorption at site.
d. Apply additional layers of gauze as needed. Ensures proper coverage
and optimal absorption.
e. Apply thicker woven pad (e.g., This type of cover dressing
Surgipad, abdominal [ABD] pad) is used on postoperative
wounds when there is
excessive drainage.

Placing dry gauze dressing over simple wound. Placing ABD pad over gauze dressing
 Applying split gauze dressing around Jackson-Pratt drain
tube
1 For moist-to-dry dressing
4.
a. Apply sterile gloves. Reduces transmission
of infection
b. Place fine-mesh or loose 4 × 4–inch gauze Moist gauze absorbs
in container of prescribed sterile solution. drainage and, when allowed
to dry, traps debris
c. Wring out the excess solution (gauze is to Inner gauze should be
be damp, not dripping). moist, not dripping wet, to
● If using ―packing strips,‖ use sterile absorb drainage and adhere
to debris. Excessive
scissors to cut the amount of dressing that moisture may cause
you will use to pack the wound. Do not let maceration of the
the packing strip touch the side of the bottle. periwound skin.
Pour prescribed solution over the packing
gauze or strip to moisten it.
d. Apply moist fine-mesh or open-weave gauze Gauze should conform to
as single layer directly onto wound surface. base and side of wound to
● If wound is deep, gently pack gauze into obliterates dead space,
absorbs exudate, adheres to
wound with sterile gloved hand or forceps the debris and necrotic tissue
until all wound surfaces are in contact with when allowed to completely
moist gauze, including dead spaces from dry.
sinus tracts, tunnels, and undermining. Wound is loosely packed to
● Fill the wound, but avoid packing it too tightly facilitate wicking of drainage
into absorbent outer layer of
● Be sure that gauze does not touch dressing. Moisture that
periwound skin (avoid the gauze to extend escapes dressing often
beyond the top of the wound). macerates the periwound
area.
e. Apply dry sterile 4 × 4–inch gauze over moist Dry layer pulls moisture
gauze. from wound.
 f. Cover with ABD pad, Surgipad, or gauze. Protects wound from
entrance of
microorganisms.

1 Secure the dressing with rolled gauze for Supports wound and
5. circumferential dressings; with tape, or with a ensures placement and
binder. Use only the amount of tape required for stability of dressing
secure attachment of dressing. Excessive use of tape can
● Apply tape 1 to 2 inches (2.5 to 5 cm) cause irritation and trauma to
intact skin.
beyond dressing.
1 Dispose of used supplies and equipment. Clean environment
6. enhances patient comfort.
1 Remove gloves and any PPE used dispose of Reduces transmission
7. them according to agency policy of microorganisms.

1 Label tape over dressing with your initials and Provides timeline for
8. date dressing is changed. when next dressing
change is to be scheduled.
1 Help patient to comfortable position Promotes patient’s sense
9. of well-being.
2 Perform hand hygiene. Reduces transmission
0. of microorganisms.
2 Document and report the patient’s response
1. and expected or unexpected outcomes.

https://www.youtube.com/watch?v=RtpRuXnIfXQ
 Care of the Wound Drain
(Hemovac Drain, Jackson-Pratt Drain & Penrose Drain)

A Hemovac drain is placed into a wound cavity where blood drainage is expected after
surgery, such as with abdominal and orthopedic surgery.
A Jackson-Pratt (J-P) or grenade drain collects wound drainage in a bulblike device that
is compressed to create gentle suction.
A Penrose Drain is a hollow open ended tube that allows fluid to drain into absorbent
dressings or for drainage of an abscess.
Equipment:
1. Hemovac drain
2. Jackson-Pratt (J-P) drain
3. Safety pin(s)
4. Graduated container for measuring drainage
5. Clean disposable gloves
6. Additional PPE, as indicated
7. Dressing materials for site dressing (if used): cleansing solution, usually sterile
normal saline and/or povidone-iodine, precut sterile gauze, sterile gauze pads and
skin-protectant wipes.
8. Waterproof pad
9. Bath blanket
10. Face mask or face shield (if indicated)

Hemovac Drain Jackson Pratt Drain

 Penrose Drain
Assessment
1. Identify patient using at least two identifiers (e.g., name and birthday or name
and medical record number) according to agency policy. Rationale: Ensures
correct patient..
2. Review medical record to identify presence, location, and purpose of closed wound
drain and drainage system as patient returns from surgery. Rationale: Drainage tubing
is usually placed near wound through small surgical incision.
3. Perform hand hygiene. Apply clean gloves if there is a risk of contacting drainage.
Assess drainage present on patient’s dressing. Identify number of wound drain tubes
and what each one will be draining. Label each drain tube with a number or label.
Rationale: Helps with consistent documentation when patient has multiple drainage
tubes.
4. Inspect system to determine presence of one straight tube or Y-tube arrangement with
two tube insertion sites. Rationale: Allows nurse to plan skin care and identi es
quantity of sterile dressing supplies needed.
5. Inspect system to ensure proper functioning. Complete systematic inspection includes
insertion site, drainage moving through tubing in direction of reservoir, patency of
drainage tubing, airtight connection sites, and presence of any leaks or kinks in
system. Remove and dispose of gloves. Perform hand hygiene. Rationale: Properly
functioning system maintains suction until reservoir is filled or drainage is no longer
being produced or accumulated. Tension on drainage tubing increases injury to skin
and muscle.
6. Determine if drain tube needs self-suction, wall suction, or no suction by checking
health care provider’s orders. Rationale: Some drain tubes such as Hemovac can be
used with self-suction or wall suction.
7. Identify type of drainage containers that patient has. Rationale: Determines frequency
for emptying drainage.
8. Assess patient’s level of understanding of purpose of drainage system and precautions
to take to avoid accidental removal. Rationale: Determines extent of instruction
required.

Implementation:
Nursing Actions Rationa
le
1 Close room door or bedside curtains. Provides privacy.
.
2 Gather the necessary equipment and
. supplies on a clean, flat surface (over-bed
table).
3 Wash hands Reduces transmission
. of microorganisms.
4 Assist the patient to a comfortable position Patient positioning and use of a bath
. that provides easy access to the drain and blanket provide for comfort and
wound area. warmth. Waterproof pad protects
underlying surfaces.
● Use a bath blanket to cover any
exposed area other than the wound.
● Place a waterproof pad under the
wound site.
5 Put on clean gloves; put on mask or To prevent the spread
. face shield, if indicated. of microorganisms.
6 Place open graduated measuring container Permits accurate measurment
. on bed between you and patient under the and discarding of wound
outlet of the drain. drainage
7 Emptying the Hemovac or ConstaVac
.
a. Maintain asepsis while opening plug Avoids entry of pathogens. Vacuum
on port indicated for emptying will be broken, and reservoir will
drainage reservoir. The chamber will pull air in until chamber is fully
expand completely as it draws in air. expanded.
b. Tilt suction container in direction of plug. Drains fluid toward plug.

c. Slowly squeeze two flat surfaces together, Prevents splashing of contaminated

 tilt it toward measuring container. drainage. Squeezing empties
reservoir of drainage.
d. Drain contents completely into Contents counted as fluid output.
measuring container
e. Hold uncovered antiseptic swab Cleaning plug reduces transmission
in dominant hand. of microorganisms into drainage
evacuation

Emptying drainage content in Hemovac

Drain.
f. Place drain device on a flat surface Compression of surface of
with open outlet facing upward; Hemovac creates vacuum
continue pressing downward until (reestablishes the suction).
bottom and top are in contact.
g. Holding surfaces together with one Cleaning the outlet reduces the risk
hand and using antiseptic swab, of contamination and helps prevent
quickly clean opening, plug with other the spread of microorganisms.
hand, and immediately replace plug.

Compressing the Hemo- vac and securing

Use gauze pad to clean the outlet. the cap.

h. Check device for reestablishment of Patent, untwisted, or unkinked

vacuum, patency of drainage tubing, and tubing facilitates wound drainage
absence of stress on tubing and prevents tension on drainage
tubing
8 Emptying the Jackson-Pratt Drain
.
a. Without contaminating the outlet valve, Breaks vacuum for drain.
pull off the cap, open port on top of
bulb- shaped reservoir. The chamber will
expand completely as it draws in air.
b. Tilt bulb in direction of port and drain
toward opening
c. Empty drainage from device
into measuring container

Remove the cap to the collection bulb spout. Pour the drainage into a measuring
container
d. Clean end of emptying port and plug Reduces transmission
with antiseptic wipe. of microorganisms.
e. Compress bulb over drainage container. Reestablishes vacuum.
While compressing bulb, replace plug
immediately.

Compressing Jackson-Pratt drain

and replacing cap.

9 Place and secure drainage system below Pinning drainage tubing to

. wound site with safety pin on patient’s patient’s gown prevents tension
gown. Be sure that there is slack in tubing or pulling on tubing and insertion
from reservoir to wound (i.e. making sure site.
that there is no tension on the tubing).
1 Note characteristics of drainage in Contents count as fluid output.
0 measuring container: measure volume and Appropriate disposal of
. discard by flushing in commode or biohazard material reduces the
according to facility policy. risk for microorganism
transmission.
1 Discard soiled supplies and remove and Reduces transmission
1 dispose of gloves and perform hand of microorganisms.
. hygiene.
1 Apply clean gloves. Proceed with dressing Prevents entrance of bacteria
2 change around drain site and inspection of into surgical wound.
. skin if indicated or ordered. Split-drain
sponge dressings are often used around
drain tubes and taped in place. (see wound
care)
1 Discard contaminated materials and Reduces transmission
3 remove gloves and perform hand hygiene. of microorganisms.
.
1 Check drain status every 4 hours. Check to ensures proper functioning and
4 all wound dressings every shift. More early detection of problems.
. frequent checks may be needed if the Checking dressings ensures the
wound is more complex or dressings assessment of changes in patient
become saturated quickly. condition and timely intervention to
prevent complications.
Care for Penrose Drain
1 Apply steps numbers 1 to 4
5
.
1 Check the position of the drain or drains Checking the position ensures that a
6 before removing the dressing. drain is not removed accidentally
. if one is present.
1 Carefully and gently remove the soiled Cautious removal of the dressing is
7 dressings. If there is resistance, use a more comfortable for the patient and
. silicone-based adhesive remover to help ensures that any drain present is not
remove the tape. removed.
● If any part of the dressing sticks to the
underlying skin, use small amounts of
sterile saline to help loosen it.
1 Note the presence, amount, type, color, The presence of drainage should be
8 and odor of any drainage on the dressings. documented. Discarding dressings
. appropriately prevents the spread of
● Discard the soiled dressings with the
microorganisms.
gloves in the appropriate waste
receptacle.
1 Inspect the drain site for appearance The wound healing process and/or
9 and drainage. Assess if any pain is the presence of irritation or infection
. present. must be documented.
2 Using sterile technique, prepare a sterile Supplies are within easy reach and
0 work area and open the needed supplies. sterility is maintained.
.
2 Open and pour the sterile cleansing solution Sterility of dressings and solution is
1 into the basin. Add the gauze sponges. maintained.
.
2 Put on sterile gloves. To maintain surgical asepsis and
2 sterile technique and prevent the
. spread of microorganisms.
2 Cleanse the drain site with the cleansing Using a circular motion ensures that
3 solution. Use the forceps and the moistened cleaning occurs from the least to
. gauze or cotton-tipped applicators. most contaminated area and a
previously cleaned area is not
● Start at the drain insertion site,
contaminated again.
moving in a circular motion toward
the periphery.
● Use each gauze sponge or applicator
only once.
● Discard and use new gauze if
additional cleansing is needed.
2 Dry the skin with a new gauze pad in the Drying prevents skin irritation.
4 same manner.
.
2 Apply skin protectant to the skin around the Skin protectant prevents skin
5 drain and the area of skin that will be taped. irritation and breakdown.
.
2 Place a presplit drain sponge under the The gauze absorbs drainage and
6 drain. Closely observe the safety pin in the prevents the drainage from
. drain. If the pin or drain is crusted, replace accumulating on the patient’s skin.
the pin with a new sterile pin. Take care not Microorganisms grow more easily in
to dislodge the drain. a soiled environment. The safety pin
ensures proper placement because
the drain is not sutured in place.

2 Apply gauze pads over the drain. Apply The gauze absorbs drainage. Pads
7 ABD pads over the gauze. Label tape over provide extra absorption for excess
. dressing with your initials and date. drainage and a moisture barrier
2 Discard contaminated materials and Reduces transmission
8 remove gloves and perform hand hygiene. of microorganisms.
.
2 Documentation
9
.