Goal: The Penrose drain remains patent and intact; the care is accomplished without contaminating the wound area, or causing trauma to the wound; and without causing the patient to experience pain or discomfort.
1. Review the medical orders for wound care or the nursing plan of care related to wound/drain care.
2. Gather the necessary supplies and bring to the bedside stand or overbed table.
3. Perform hand hygiene and put on PPE, if indicated.
4. Identify the patient.
5. Close curtains around bed and close door to room if possible. Explain what you are going to do and why you are going to do it to the patient.
6. Assess the patient for possible need for nonpharmacologic pain-reducing interventions or analgesic medication before wound care dressing change. Administer appropriate prescribed analgesic. Allow enough time for analgesic to achieve its effectiveness before beginning procedure.
7. Place a waste receptacle at a convenient location for use during the procedure.
8. Adjust bed to comfortable working height, usually elbow height of the caregiver (VISN 8, 2009).
9. Assist the patient to a comfortable position that provides easy access to the drain and/or wound area. Use a bath blanket to cover any exposed area other than the wound. Place a waterproof pad under the wound site.
10. Put on clean gloves. Check the position of the drain or drains before removing the dressing. Carefully and gently remove the soiled dressings. If there is resistance, use a silicone- based adhesive remover to help remove the tape. If any part of the dressing sticks to the underlying skin, use small amounts of sterile saline to help loosen and remove.
11. After removing the dressing, note the presence, amount, type, color, and odor of any drainage on the dressings. Place soiled dressings in the appropriate waste receptacle.
12. Inspect the drain site for appearance and drainage. Assess if any pain is present.
13. Using sterile technique, prepare a sterile work area and open the needed supplies.
14. Open the sterile cleaning solution. Pour the cleansing solution into the basin. Add the gauze sponges.
15. Put on sterile gloves.
16. Cleanse the drain site with the cleaning solution. Use the forceps and the moistened gauze or cotton-tipped applicators. Start at the drain insertion site, 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.
17. Dry the skin with a new gauze pad in the same manner. Apply skin protectant to the skin around the drain; extend out to include the area of skin that will be taped. Place a presplit drain sponge under the drain. Closely observe the safety pin in the drain. If the pin or drain is crusted, replace the pin with a new sterile pin. Take care not to dislodge the drain.
18. Apply gauze pads over the drain. Apply ABD pads over the gauze.
19. Remove and discard gloves. Apply tape, Montgomery straps, or roller gauze to secure the dressings.
20. After securing the dressing, label dressing with date and time. Remove all remaining equipment; place the patient in a comfortable position, with side rails up and bed in the lowest position.
21. Remove additional PPE, if used. Perform hand hygiene.
22. Check all wound dressings every shift. More frequent checks may be needed if the wound is more complex or dressings become saturated quickly.
3 comments:
The non-clinical Nursing skills necessary for success. Effective communication. As a nurse, you're on the front lines of care. Flexibility. As a nurse, you never know what the day will bring. Critical thinking. A sharp and critical mind is essential for excelling in the nursing field. Desire to learn.
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