6.2 Wound Drainage Observation & Simple Dressing Changes

Wound Drainage Observation & Simple Dressing Changes

Three NCCT tasks describe the PCT's role in wound care: observe dressings for wound condition changes (for example, sanguineous, serous, purulent), perform simple, non-medicated dressing changes, and assist with wound care and dressing changes. The PCT's eyes are often the first to catch a wound getting worse, and a well-applied dry dressing protects the wound from contamination and injury.

What the PCT May and May Not Do

Always confirm the order and the nurse's delegation before touching a wound.

Types of Wound Drainage

Describing the Amount

Record the amount in the terms your facility uses. Many facilities estimate it by how much of the dressing is saturated, for example scant (only a trace), small (less than about 25%), moderate (about 25% to 75%), and large (more than about 75%). For drains such as Jackson-Pratt or Hemovac, measure the volume in milliliters and record it as output (Section 4.5). Always note color, consistency, odor, and amount, and compare with earlier findings. A change is more important than any single observation.

Warning Signs to Report

• Infection: spreading redness, warmth, swelling, increasing pain, purulent drainage, foul odor, or fever.
• Bleeding: bright red drainage that is increasing or soaking through the dressing.
• Dehiscence: the edges of an incision pull apart. Patients may say something "gave way" or "popped" after coughing or straining.
• Evisceration: organs protrude through a separated wound. This is an emergency. Call for help and stay with the patient, keep them still in a low Fowler's position with the knees bent to reduce tension on the abdomen, and do not push anything back in. The nurse covers the wound with sterile dressings moistened with sterile normal saline, and the surgeon is notified immediately.
• Skin around the wound: redness, blisters from tape, or white, soggy (macerated) skin from drainage.

Performing a Simple Dry Dressing Change

1. Check the order and delegation. Confirm the type of dressing and whether cleansing is ordered.
2. Identify the patient, explain, and provide privacy. Offer pain relief through the nurse beforehand if the patient finds dressing changes painful.
3. Gather supplies: two pairs of clean gloves, the ordered dressing, tape or other securement, sterile saline and gauze if cleansing is ordered, a waste bag, and a pen for labeling.
4. Perform hand hygiene, position the patient, and place the waste bag within reach so you never carry a soiled dressing across the bed.
5. Put on gloves. Loosen the tape by pulling it toward the wound, supporting the skin with your other hand; use adhesive remover on fragile skin.
6. Remove the old dressing and look at it before discarding it. Note the drainage type, amount, and odor, then discard it with your gloves in the waste bag.
7. Perform hand hygiene and put on clean gloves.
8. Clean only if ordered. For a straight incision, use a fresh saline-moistened gauze for each stroke, moving from the top to the bottom of the incision, then working outward on each side, always from cleanest to least clean. For an open round wound, clean from the center outward in circles. Never go back over a cleaned area with the same gauze.
9. Pat the area dry and apply the new dressing without touching the side that will contact the wound.
10. Secure it with paper or silicone tape on fragile skin, a gauze wrap, or Montgomery straps (tie straps) when dressings are changed frequently. Never wrap tape all the way around a limb, because swelling can turn it into a tourniquet.
11. Label the dressing with the date, time, and your initials.
12. Remove gloves, perform hand hygiene, make the patient comfortable, and document and report what you saw.

Assisting With Wound Care

When the nurse performs a sterile or complex dressing change, the PCT may position and support the patient, hold a limb, open packages without touching the sterile inner surfaces, adjust lighting, and dispose of waste. Stay out of the sterile field, and speak up if you see a break in technique.

Preventing Skin Tears and Tape Injuries

Older adults have thin, fragile skin that tears easily. Use lift sheets instead of dragging, pad side rails and wheelchair arms when needed, avoid adhesive tape on fragile skin, and remove any adhesive slowly and low to the skin. Report every skin tear so the nurse can assess and document it.

Clinical Trap: Throwing Away the Evidence

A PCT removes a soiled dressing, drops it straight into the trash, and applies a new one. Later the nurse asks how the drainage looked, and the PCT cannot say. Always inspect the old dressing before discarding it; the drainage on it is one of the best clues to how the wound is healing.