Wounds, Drains, Tube Patency and Central Lines

Wound Healing, Drainage Characteristics, and Dressing Management

Caring for surgical and traumatic wounds requires careful data collection at every dressing change. When inspecting a wound base, healthy cellular proliferation appears as red granulation tissue, which must be guarded against mechanical trauma. In contrast, nonviable tissue can impede healing and presents as either yellow slough or firm black eschar. Whether nonviable tissue requires debridement depends on the individual wound and treatment plan established by the healthcare team, but stable, dry heel eschar is generally left intact.

Exudate provides essential clues about healing and infection. Serous drainage appears clear, thin, and watery. Sanguineous drainage consists primarily of blood and looks red to bright red, with increasing amounts serving as a warning sign of active bleeding. Serosanguineous drainage presents as a light pink to blood-tinged, thin, and watery fluid. Purulent drainage is thick, opaque, and yellow, green, or brown, which typically signals a localized wound infection.

Accurate documentation tracks wound progress over time. Length and width are measured using a disposable measuring guide, while wound depth is checked with a sterile, single-use cotton-tipped applicator according to facility procedure. If undermining or tunneling is present, the practical nurse tracks and documents these areas using the face of a clock as a directional reference. Fresh surgical dressings must be inspected regularly for odor, saturation, and strike-through bleeding. If strike-through drainage appears on an initial surgical dressing, the practical nurse does not remove the dressing; instead, the nurse reinforces it and promptly notifies the registered nurse.

Preventing infection requires meticulous technique and client education. The practical nurse reinforces client teaching regarding careful hand hygiene before and after changing dressings. Localized infection presents with erythema, warmth, edema, purulent drainage, foul odor, and worsening pain. If the infection spreads systemically, the client may exhibit fever, chills, tachycardia, leukocytosis, and general malaise, all of which require prompt reporting to the RN.