Wound Management with Excessive Drainage
PREREQUISITE NURSING KNOWLEDGE
• Wound exudate is produced in response to the inflammatory phase of the healing process. As wounds heal, the amount of exudate should diminish. Chronic, nonhealing wounds may produce exudate for prolonged periods of time, necessitating effective management of the fluid.1,2,7,9–11
• Goals of wound care must be clearly identified so that proper wound care products are used.10 Wound healing is best achieved through adequate cleansing, débridement, and dressing of the wound bed on the basis of wound characteristics.
• Excessive wound fluid may create pressure in the wound bed and compromise perfusion. Excessive moisture may cause periwound tissue damage and extend the wound or skin injury.5,6
• Assessment of wound exudate should include the quantity, color, consistency, and odor of drainage. When changes in wound exudate occur, the cause should be explored. These changes along with other clinical signs and symptoms may indicate possible increase in bacterial burden or infection.
• Drains are placed in wounds to facilitate healing by providing an exit for excessive fluid accumulating in or near the wound bed. Most wound drains are surgically placed; drains may or may not be secured with sutures.
• Excessive wound fluid may provide a source for proliferation of microorganisms. Wound drains may be ports of microorganism entry; aseptic techniques must be strictly observed.
• Pouching is an effective means of collecting wound and fistula drainage.3,8 Suction may be used with pouching systems to pull fluid away from the wound bed.5
• Excessive wound drainage is removed to allow for wound healing to occur without tissue congestion, microorganism proliferation, and skin maceration.
• Excessive wound drainage may need to be calculated into the assessment of a patient’s daily intake and output.
• Negative-pressure wound therapy (see Procedure 131) stimulates tissue growth and promotes wound healing. The closed system also provides active withdrawal of excessive wound fluid to assist in the management of exudating wounds.4
• Assess the patient’s nutritional needs, specifically for protein, with exudating wounds.
• Excessive wound exudate production may result in the loss of up to 100 g of protein daily in wound exudate.2,9 Nutritional supplementation of protein is necessary for wound healing.
EQUIPMENT
• Nonsterile and sterile gloves; sterile field
• Personal protective equipment: gowns and face protection
• Sterile gauze (4 × 4 pads); abdominal pad (e.g., ABD) or other absorptive dressings may be needed
• Sterile water or normal saline (NS) solution for cleansing
• Liquid skin barrier, skin barrier wafers, paste, powder and sealant, or hydrocolloid to protect periwound surface
