Wound Drains and T-Tubes

Nursing guidelines for the management of

March 2010

Clinical Practice - Wound Drains. Updated December 2009

THE ROYAL FREE HAMPSTEAD NHS TRUST

Wound Drains and T-Tubes Nursing Guidelines for the Management of

Supportive Information - Wound Drains Guidelines for Nursing Care of Wound Drains Guidelines for Changing a Vacuumed Bottle - Redivac Guidelines for Shortening of Drains Guidelines for Removal of Drains Supportive Information - T Tubes Guidelines for Removal of T-Tube References
Equality and Health inequalities Impact Assessment Screening Checklist

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Clinical Practice - Wound Drains. Updated December 2009

Validation Grid
Title Author Nursing Guidelines for the Management of Wound Drains and T-Tubes Original author: Lesley Mattin, Matron surgery, orthopaedics, trauma and tissue viability Updated by Yasmin Uddin, Specialist Sister, tissue viability Clinical practice Group Nursing & midwifery? Tissue Viability Nursing Clinical Practice Group Clinical directorates Clinical Practice Aseptic technique Clinical Practice Guideline Infection Control Policy manual

Associate author Commissioning body Target Audience Stakeholders consulted

Clinical Practice/ Advanced Practice Associated policies / guidelines

Flushing of external biliary drains

Guideline replacement Date of submission Review date Key words No updated 2003 version April 2010 April 2012 Wound drain, drain, T tube, Robinsons drain, redivac , pigtail drain

Clinical Practice - Wound Drains. Updated December 2009

Staff Who May Undertake This Procedure Within this Trust caring for wound drains is regarded as a clinical practice. A clinical practice may be defined as an aspect of care which may be undertaken by Registered Nurses who accept accountability for their actions and feel competent to undertake the procedure. There is no formal assessment for these practices but they may be aspects of care which require a period of supervised, guided practice. They should form part of preceptorship or mentorship programmes. Student nurses may undertake this practice under the supervision of a registered nurse who feels competent in this aspect of care and in the supervisory role. In line with guidance laid down by the NMC on record keeping (2009), there must be clear evidence of arrangements made for future and on going care for patients with wound drains. The plan must incorporate on-going evaluation and reassessment of care and evidence that relevant interventions and observations have been communicated to appropriate members of the multidisciplinary team. Supportive Information - Wound Drains A drain describes any material or equipment used to prevent formation of a haematoma or to carry fluid from inside the body to the surface. Allowing unwanted fluid or blood to remain in a wound may be a potential source of infection. It may also impede healing, and could result in wound breakdown and dehiscence. The fluid may be blood, body fluid, or pus where there has been an infective source. Drains may also be used to monitor leakage, for example, a bile leak following biliary operation or to divert body fluids away from a particular site, for example T Tube after a bile duct exploration (McConnell, 2002). Drains may be inserted either through the incision during surgery or via a separate stab wound. Type of operation and the site will influence the number and kind of drains used.

Types of Drains
Closed Drains These are the most common forms of drains used following surgery. They consist of a plastic tube which is placed into the wound. This external end is connected to a collecting device. The drain is secured with a suture. Use of a closed system lowers the risk of potential infection for patients and reduces staff contact with body fluids.

Clinical Practice - Wound Drains. Updated December 2009

Robinsons Drain: This is a closed drainage system in which a collecting bag is attached to the external end of the plastic tubing. This allows fluid to drain by gravity. Redivac: This is a closed drainage system in which a vacuumed container is attached to the end of the plastic tubing which will draw fluid from the wound. Minivac Drains: These are small vacuum drains with a capacity of approximately 50 ml. The vacuum is obtained by compressing the drain and then attaching it to the tubing. N.B. Sometimes these drains are used without vacuum, for drainage only. Open Drains / Corrugated Open drains are inserted directly into the wound bed and they drain into a dressing. They are made of latex or plastic, and some may have corrugations along their length. As they have an open end there is the potential for infection as organisms may track up along the drain. It is usual for the drain to be secured by a suture, and may have a safety pin attached close to the skin. Pigtail drains Pigtail drains may be inserted into collections of fluid in the abdominal cavity or pleural cavity to allow drainage of the fluid. The drains are inserted under radiological guidance to ensure accurate positioning and are held in place with a suture. To prevent them being easily dislodged they have a locking mechanism. This is effected by a fine drawstring attached to both the end of the drain and the locking mechanism. When the lock is turned the drawstring shortens and this causes the end of the drain to curl round hence pigtail. Pigtail drain with drawstring visible

Clinical Practice - Wound Drains. Updated December 2009

Guidelines for Nursing Care of Wound Drains Intervention Document volume of drainage. This should be done a minimum of 2 hourly, on the day of surgery, then 4 hourly afterwards Document, colour, consistency and/or type of fluid drained, Rationale Large amounts of drainage post operatively may suggest potential haemorrhage. Large amounts of other fluid may indicate a leakage of bile or a fistula. Drainage may be blood stained following surgery. It may then become serous. Any blood stained drainage, or blood clots following this may indicate haemorrhage. The colour, consistency and odour must be recorded. To prevent infection To commence appropriate treatment as soon as possible To maintain the patentcy of drain and ensure patient comfort To ensure free flow of drainage fluid, prevent the drain being accidentally pulled out and ensure patient comfort

Maintain a clean dry site using an aseptic technique. Monitor the drain site for signs of infection. Support any drainage bag or bottle so it does not pull Ensure the tubing is not kinked or under tension

Robinsons only: Ensure the tap on bag is closed properly To prevent leakage and entry of microorganisms Redivac vacuum drains only: Ensure the red vacuum indicator is depressed to the Max line. Minivac drains only: If a vacuum is required check the drain is compressed. If the drain is full or the vacuum needs restoring the drain should be changed not emptied. Open drains The dressing must be assessed regularly and changed if it is wet. It may be necessary to weigh the dressings before and after use to assess the amount of drainage. It may also be necessary to mark any leakage on the This signifies if a vacuum is present. The bottle must be changed if the vacuum is lost. This signifies a vacuum is present.

To maintain universal precautions and avoid contact with bodily fluid

Wet dressings are uncomfortable and are a potential source of infection. The use of a sterile bag such as a stoma or urostomy bag prevents drainage fluid coming into contact with the skin causing maceration and Clinical Practice - Wound Drains. Updated December 2009 6

dressing. Sterile adhesive drainage bags may be used over these drains especially if the drainage is likely to excoriate the skin or needs careful measurement.

breakdown, particularly if digestive enzymes are likely to be in the fluid.

Pigtail drains To ensure the drain remains patent and These drains, especially if they have the fluid is able to drain been inserted into the biliary tract, may need flushing. Please refer to Flushing of External Biliary Drains clinical practice

Clinical Practice - Wound Drains. Updated December 2009

Guidelines for Changing a Vacuumed Bottle - Redivac The vacuum bottle should be replaced if the bottle is full or if the vacuum is lost. Equipment required New sterile bottle Non sterile gloves Disposable apron Yellow disposable bag

Intervention Explain the procedure to the patient Perform the procedure using a no touch technique Put on gloves & apron Close the white clamp below the luer lock connector on the used bottle Close the clear clamp on the tubing Take the new bottle out of packaging. Ensure the white clamp is closed and the red vacuum indicator is depressed to the maximum line Unlock luer lock connection and lock new bottle into position Open both white and clear clamps Dispose of used bottle into yellow waste bag Document actions on fluid chart and in nursing records.

Rationale To gain consent and co-operation To prevent cross infection To prevent cross infection and contamination To prevent spillage of contents To prevent air and pathogens entering the wound via the drain To ensure that drainage bottle has a vacuum

Re-establish vacuum drainage For contaminated waste.

Clinical Practice - Wound Drains. Updated December 2009

Guidelines for Shortening of Drains Robinsons and open drains may be shortened once or twice before removal at the request of the medical staff. This usually occurs when a tract may have formed, it is done to encourage the space left behind to collapse, otherwise a cavity might be left that could fill with fluid and give rise to an abscess. If the drain is likely to fall back into the wound (open drains) a sterile safety pin is used to maintain its position. Equipment Required Suture cutter Sterile dressing pack Fluids for cleansing/irrigation Adhesive tape Intervention Establish the amount by which the drain is to be shortened with the medical staff Explain the procedure to the patient Ensure the patient has adequate analgesia Use an aseptic technique throughout the procedure Remove any dressing documenting the amount and type of drainage Clean the site if necessary Remove securing suture Gently extract the drain by the required length Place a sterile safety pin through the drain if required. If open drain - cut off surplus drain. Document actions in nursing notes To prevent drain retracting back into the wound and facilitate dressing To maintain patient comfort For ongoing evaluation To gain consent and co-operation This intervention may cause some pain or discomfort To prevent cross infection To expose drain and ensure appropriate documentation is maintained

Disposable apron Sterile scissors or stitch cutters Sterile safety pin if required Sterile gloves Rationale

A sterile adhesive drainage bag may be placed over the drain if there is excessive leakage following shortening, especially if the drainage needs careful measurement, or is likely to excoriate the skin.

Clinical Practice - Wound Drains. Updated December 2009

Guidelines for Removal of Drains Equipment Required Pair sterile gloves Suture cutter Sterile dressing pack Fluid for cleansing/irrigation (check date of expiry) Dry/sterile dressing Disposable apron Sterile dressing towel Rationale To gain consent and co-operation This intervention may cause some pain or discomfort

Intervention Explain the procedure to the patient Ensure the patient has adequate analgesia Wash hands and put on apron Perform the procedure using an aseptic technique Prepare the equipment and place dressing towel under drain site. If Redivac- release the suction on the bottle as follows: 1. close both the white and clear clamps. 2. disconnect the tubing from the bottle 3. place end of tubing on sterile dressing towel 4. open the clamps on the tubing attached to the patient and the bottle 5. reconnect the tubing to the bottle Clean the drain site if necessary Remove the suture using the forceps Apply gentle traction to remove the drain. Drains that do not move smoothly may be eased by rotating the tube slightly If any obstruction is felt, seek help.Traction should not be applied to drains if they are stuck ~ Refer to Medical team Clean the site and apply a sterile

To prevent cross infection and contamination of patients clothing and bedding

To maintain sterility and absorb any fluid spillage This releases the suction

This reduces the chance of contact with body fluid To ensure the suture is visible and accessible To prevent skin damage To prevent pulling of the surrounding tissue

To absorb any exudate and prevent 10

Clinical Practice - Wound Drains. Updated December 2009

dressing Dispose of used equipment in clinical waste bag Document drainage on fluid chart and removal of drain in nursing records. If pigtail drain unlock the locking mechanism by 1. Turning the screw thread on the locking mechanism anti clockwise Clean the drain site if necessary Remove the suture using the forceps Apply gentle traction to remove the drain. If any resistance is felt, seek help. Traction should not be applied to drains if they are stuck ~ Refer to Medical team Clean the site and apply a sterile dressing Dispose of used equipment in clinical waste bag Document drainage on fluid chart and removal of drain in nursing records. If there is a large amount of drainage once the drain is removed, a sterile adhesive drainage bag may be used over the site, especially if the drainage is likely to excoriate the skin or needs careful measurement.

infection during healing To ensure appropriate disposal of contaminated waste To provide ongoing assessment

To ensure that the pigtail straightens out and can be removed. To ensure the suture is visible and accessible To prevent skin damage To prevent pulling of the surrounding tissue

To absorb any exudate and prevent infection during healing To ensure appropriate disposal of contaminated waste To provide ongoing assessment To prevent fluid damaging the skin.

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Supportive Information - T Tubes Following surgery on the common bile duct it may become oedematous, and this can lead to obstruction of the bile flow into the duodenum. Insertion of a Ttube will facilitate bile flow until the swelling subsides. Due to changes in surgical practice T-tubes are used only infrequently. A T-tube is inserted with the arms of the tube lying within the lumen of the common bile duct It is usually sutured into position and a dressing applied to the skin site. The long drainage arm emerging from the wound is attached to a drainage bag. Bile drainage should be recorded daily noting quantity and colour. Bile is normally a yellowish green clear fluid. Approximately 300-800 mls are secreted daily by the liver (McConnell, 2002). If there is a sudden cessation of bile drainage, a kinked or compressed tube may be the cause. The drainage bag must be supported to prevent traction on the tube and or accidental removal. T-tubes may be kept on free drainage or clamped depending on medical instructions. Sometimes the T-tube is elevated to stop drainage in preference to clamping. Any pain experienced by the patient in relation to a clamped or elevated tube requires medical attention as it suggests bile flow may be obstructed. T-tube cholangiograms are usually carried out prior to removal of the tube to ensure patency of the duct.

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Guidelines for Removal of T-Tube Equipment Required Non sterile gloves Suture cutter Sterile dressing pack Intervention Explain the procedure to the patient Review analgesia Fluid for cleaning/irrigation (check date of expiry) Dry/ sterile dressing Disposable apron Rationale To gain consent and co-operation This procedure is painful but only for short time and large amounts of analgesia are unnecessary. Patient preparation is more important. Prevent introduction of infection

Use an aseptic technique through out Expose the site and clean if necessary Remove the suture Ask the patient to take a deep breath. Give a sharp pull on the tube to remove it. If resistance is felt stop and refer to the medical team. Clean the site and cover with a sterile dressing

Absorb exudate and introduction of prevent infection during healing. If bleeding occurs put pressure over the site with quage until bleeding or leakages stops or minimise. Facilitate evaluation

Document all actions in nursing records

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References There is very little current literature on care of wound drains. These guidelines are based on the limited research available and manufacturers advice, as well as advice from nurses currently caring for patients with wound drains. Aldeman C (1989) Wound Drainage. Nursing Standard., 35, (3) Alexander M, Fawcett J, and Runciman P, Nursing Practice Hospital and Home THE ADULT (1994) Churchill Livingstone London.
th Jamieson EM et al (2002). Clinical Nursing Practice. 4 edition. Churchill Livingstone: Mosby

Long, BC et al (1997) . Adult Nursing: A nursing process Approach. Mosby: London McConnell, E (2002). Managing a T-Tube. Nursing. June, pp 17 Nightingale K (1989) Making Sense of wound drainage. Nursing Times, 85, (27). Walker, J (2007) Patient preparation for safe removal of surgical drains, Nursing Standard. 21, (49), pp 39-41 August 15.

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Equality and Health inequalities Impact Assessment Screening Checklist

Name of policy/service Is this a new or existing policy/service Purpose of the policy/service Stakeholders in policy/service development Person responsible for policy/service impact assessment Proposed date for implementation of policy/service Nursing Guidelines for the Management of Wound Drains and T-Tubes Update of existing guideline To promote safe and effective practice See validation Grid Lesley Mattin December 2009

Do you think the policy/service will impact upon any group within the population based upon: Race/ethnicity Gender Religion/belief Disability (including long term conditions and mental health) Age Sexual orientation or gender identity No No No No No No Lower socio-economic groups Involvement in the criminal justice system Homelessness Looked after children Population groups more at risk of developing certain conditions (based on community health profile data) Any other groups No No No No No No

What impact will the policy/service have on lifestyles? For example: Diet and nutrition Exercise and physical activity Substance use; tobacco, alcohol, drugs Risk taking behaviour Education and learning or skills Functional ability Quality of life Will the policy/service have any impact on the social environment? For example: Social status Employment (paid or unpaid) Social/family support Stress Income Will the policy/service have any impact upon: Discrimination? Equality of opportunity? Relations between groups? Improving uptake of services by under represented groups? Will the policy/service have any impact on the physical environment? For example: Living conditions Working conditions Pollution or climate change Accidental injuries or public safety Infection control Will the policy/service impact on access to and experience of services? For example: Healthcare Transport Social services Housing services Education

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Equality impact assessment screening checklist summary sheet

1. Positive impacts (Note groups affected) 2. Negative impacts (note groups affected) The policy promotes principles of good care and safety for all groups Appropriate communication will be employed for all groups to ensure consent and understanding is gained. The trust has a robust interpreting service, enabling patients to access information in different languages/formats. 3. Additional information/evidence required The policy promotes principles of good care and safety for all groups.

The procedure will be the same for all patient groups to maintain patient safety 4. Recommendations

Language and communication requirements are routinely recorded in the nursing documentation, to enable access of appropriate interpreting services employed by the trust 5. As a result of completing the impact checklist, have any negative impacts been identified, and if so is a full impact assessment recommended?

Nil identified 6. If impact assessment has not been recommended please state the reasons why.

The procedure will be the same for all patient groups to maintain patient safety

Date for completion of screening checklist review /completion of full impact assessment : January 2010 Managers name and signature: Lesley Mattin Matron, Surgery, Orthopaedics & Trauma, and Tissue Viability Approved by Operational manager for Equality and Diversity (name and signature) Dawn Atkinson Date: January 2010

Date: 1 March 2010

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