Skill 8-5

Caring for a Penrose Drain

Wound drainage devices (drains) are inserted into or near a wound when it is anticipated that a collection of fluid in a closed area would delay healing and increase the potential for infection (Morton & Fontaine, 2018); removal of excess fluid decreases pressure in the wound area, promoting healing and decreasing complications (Bauldoff et al., 2020). A Penrose drain is a hollow, soft, flexible, open-ended rubber tube. It does not have a collection device and allows fluid to drain passively, with the drainage moving from the area of greater pressure (in the wound) to the area of less pressure (the dressing) (Orth, 2018). Penrose drains are commonly used after a surgical procedure or for drainage of an abscess. After a surgical procedure, the surgeon places one end of the drain in or near the area to be drained. The other end passes through the skin, directly through the incision or through a separate opening referred to as a stab wound. A Penrose drain is not sutured. A large safety pin or small tab is usually placed in the end of the drain outside the wound to prevent the drain from slipping into the wound (Memorial Sloan Kettering Cancer Center, 2019). The patency and placement of the drain are included in the wound assessment.

Delegation Considerations

Care for a Penrose drain insertion site and wound care is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, these procedures may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Sterile gloves
Gauze dressings
Sterile cotton-tipped applicators, if appropriate
Sterile drain sponges
Surgical or abdominal pads
Sterile dressing set or suture set (for the sterile scissors and forceps)
Sterile cleaning solution as prescribed (commonly 0.9% normal saline solution)
Sterile container to hold cleaning solution
Clean safety pin
Clean, disposable gloves
Plastic bag or other appropriate waste container for soiled dressings
Waterproof pad and bath blanket
Skin protectant/barrier wipes
Additional dressings and supplies needed or as required for prescribed wound care

Assessment

Assess the situation to determine the necessity for wound cleaning and a dressing change. Confirm any prescribed interventions relevant to drain care and any drain care included in the plan of care. Assess the patient's level of comfort and the need for analgesics before wound care. Assess if the patient experienced any pain related to prior dressing changes and the effectiveness of interventions employed to minimize the patient's pain. Assess the current dressing to determine if it is intact, and assess for the presence of excess drainage, bleeding, or saturation of the dressing. Assess the patency of the Penrose drain. Inspect the drain site and characteristics of the drainage.

Inspect the wound and the surrounding tissue. Assess the appearance of the surgical site for the approximation of wound edges, the color of the wound and surrounding area, and signs of dehiscence. Note the stage of the healing process and the characteristics of any drainage.

Assess the surrounding skin for color, temperature, and the presence of edema, ecchymosis, or maceration.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Infection risk
Altered body image perception
Knowledge deficiency

Outcome Identification and Planning

The expected outcomes to achieve when performing care for a Penrose drain are that the Penrose drain remains patent and intact, and the site care is accomplished without contaminating the area or causing trauma and without causing the patient to experience pain or discomfort. Other outcomes that are appropriate may include the following: the surgical wound shows signs of progressive healing without evidence of complications, and the patient demonstrates understanding of drain care.

Implementation

Action	Rationale
1. Review the patient's health record for prescribed wound care or the plan of care related to wound/drain care. Gather necessary supplies.	Reviewing the health record and plan of care validates the correct patient and correct procedure. Preparation promotes efficient time management and an organized approach to the task.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Assemble equipment on the overbed table or other surface within reach.	Organization facilitates performance of the task.
5. Close the curtains around the bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient.	This ensures the patient's privacy. Explanation relieves anxiety and facilitates engagement.
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 the analgesic to achieve its effectiveness before beginning the procedure.	Pain is a subjective experience influenced by past experience. Wound care and dressing changes may cause pain for some patients.
7. Place a waste receptacle at a convenient location for use during the procedure.	Having a waste container handy means that the soiled dressing may be discarded easily, without the spread of microorganisms.
8. Adjust the bed to a comfortable working height (VHACEOSH, 2016).	Having the bed at the proper height prevents back and muscle strain.
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.	Patient positioning and the use of a bath blanket provide for comfort and warmth. Waterproof pad protects underlying surfaces.
10. Put on gloves; put on mask or face shield, as indicated. Check the position of the drain or drains before removing the dressing. Loosen the tape on the old dressings by removing in the direction of hair growth and the use of a push-pull method (Fumarola et al., 2020). Push-pull method: lift a corner of the dressing away from the skin, and then gently push the skin down and away from the dressing/adhesive (Fumarola et al., 2020). Continue moving fingers of the opposite hand to support the skin as the product is removed (Fumarola et al., 2020). Once all adhesive is loosened from the skin, carefully lift dressing from the surrounding skin to prevent medical adhesive-related skin injury (MARSI). Remove the sides/edges first, then the center. If the patient is at increased risk for MARSI (see Box 8-2 in Skill 8-2), requires repeated application or removal of adhesive devices, or there is resistance, use an adhesive remover (Barton, 2020; Fumarola et al., 2020; Kelly-O'Flynn et al., 2020).	Gloves protect the nurse from contaminated dressings and prevent the spread of microorganisms; mask reduces the risk of transmission should splashing occur. Checking ensures that a drain is not removed accidentally if one is present. Gloves protect the nurse from contaminated dressings and prevent the spread of microorganisms. Removal of the tape in the direction of hair growth minimizes trauma to the skin (Fumarola et al., 2020). Pushing the skin down and away from the adhesive reduces the risk for medical adhesive-related skin injury (MARSI) (Fumarola et al., 2020). The use of adhesive remover allows for the easy, rapid, and painless removal without the associated problems of skin stripping and helps reduce patient discomfort (Barton, 2020; Fumarola et al., 2020; Kelly-O'Flynn et al., 2020).
11. Carefully remove the soiled dressings. If any part of the dressing sticks to the underlying skin, use small amounts of sterile saline to help loosen and remove it. Note the presence, amount, type, color, and odor of any drainage on the dressings. Place soiled dressings in the appropriate waste receptacle.	Cautious removal of the dressing is more comfortable for the patient and ensures that any drain present is not removed. Sterile saline moistens the dressing for easier removal and minimizes damage and pain. The presence of drainage should be documented. Discarding dressings appropriately prevents the spread of microorganisms.
12. Inspect the drain site for appearance and drainage. Assess if any pain is present.	The wound healing process and/or the presence of irritation or infection must be documented.
13. Remove gloves and perform hand hygiene.	Removal of gloves and performance of hand hygiene prevent the transmission of microorganisms.
14. Using sterile technique, prepare a sterile work area and open the needed supplies.	Supplies are within easy reach and sterility is maintained.
15. Open the sterile cleaning solution. Pour it into the basin. Add the gauze sponges.	Sterility of dressings and solution is maintained.
16. Put on sterile gloves.	Sterile gloves help to maintain surgical asepsis and sterile technique and prevent the spread of microorganisms.
17. 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 (Figure 1). Use each gauze sponge or applicator only once. Discard and use new gauze if additional cleansing is needed.	Using a circular motion ensures that cleaning occurs from the least to most contaminated area and a previously cleaned area is not contaminated again.
18. Dry the skin with a new gauze pad in the same manner. Apply skin protectant/barrier to the skin around the drain; extend out to include the area of skin that will be taped. Place a pre-split drain sponge under and around the drain (Figure 2). Assess the status of the safety pin or tab in the drain. If the pin/tab or drain is crusted, replace the pin with a new sterile pin. Take care not to dislodge the drain.	Drying prevents skin irritation. Skin barrier/protectant prevents skin irritation and excoriation from tape, adhesives, and wound drainage (Fumarola et al., 2020; Kelly-O'Flynn et al., 2020). The gauze absorbs drainage and prevents the drainage from accumulating on the patient's skin. Microorganisms grow more easily in a soiled environment. A large safety pin or small tab is usually placed in the end of the drain outside the wound to prevent the drain from slipping into the wound because the drain is not sutured in place (Memorial Sloan Kettering Cancer Center, 2019).
19. Apply gauze pads over the drain (Figure 3). Apply surgical pad, ABD, or other cover dressing over the gauze.	The gauze absorbs drainage. Pads provide both extra absorption for excess drainage and a moisture barrier.
20. Apply additional materials, such as a transparent dressing or tape, to secure the dressings. Remove gloves and perform hand hygiene.	Tape or other securing products keep the dressing in place. Proper disposal of gloves and hand hygiene prevent the spread of microorganisms.
21. 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 as indicated and bed in the lowest position.	Recording date and time provides communication and demonstrates adherence to care plan. Proper patient and bed positioning promotes safety and comfort.
22. Remove additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.
23. Check all wound dressings at least every shift. More frequent checks may be needed if the wound is more complex, or dressings become saturated quickly.	Checking dressings ensures the assessment of changes in patient condition and timely intervention to prevent complications.

Evaluation

The expected outcomes have been met when the Penrose drain has remained patent and intact, wound care was accomplished without contaminating the wound area or causing trauma to the wound, the patient did not experience pain or discomfort, the wound has showed signs of progressive healing without evidence of complications, and the patient has demonstrated understanding of drain care.

Documentation

Guidelines

Document the location of the wound and drain, the assessment of the wound and drain site, and patency of the Penrose drain. Document the presence of drainage and characteristics on the old dressing upon removal. Include the appearance of the surrounding skin. Document cleansing of the drain site. Record any skin care and the dressing applied. Note pertinent patient and family/caregiver education and any patient reaction to this procedure, including patient's pain level and effectiveness of nonpharmacologic interventions or analgesia if administered.

Sample Documentation

3/13/25

1400 Patient medicated with morphine 3 mg IV prior to dressing change. Dressing to right forearm removed. Dressings noted with small amount of serosanguineous drainage. Forearm with gross edema and erythema. Penrose drain intact, with safety pin in place. Incision edges approximated, staples intact. Area cleansed with normal saline, dried, and redressed with nonadherent gauze, ABD pads, and roller gauze. Reinforced the importance of keeping arm elevated on pillows, with patient verbalizing understanding.

—P. Towns, RN

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Assessment of the drain site reveals significantly increased edema, erythema, and drainage from the site, in addition to drainage via the drain: Cleanse the site, as prescribed, or per the plan of care. Obtain vital signs, including the patient's temperature. Document care and assessments. Notify the health care team of the findings.
Assessment of the drain site reveals that the drain has slipped back into the incision: Follow facility policy and the prescribed interventions related to advancing Penrose drains. Document assessments and interventions. Notify the health care team of the findings and interventions.
When preparing to change a dressing on a Penrose drain site, the nurse's assessment reveals that the drain is completely out, lying in the dressing material: Assess the site and the patient for symptoms of pain, increased edema/erythema/drainage. Provide site care, as prescribed. Notify the health care team of situation. Often, depending on the patient's stage of recovery, the drain is left out. Document the findings and interventions.

Special Considerations

Evaluate a sudden increase in the amount of drainage or bright-red drainage and notify the health care team of these findings.
Wound care is often uncomfortable, and patients may experience significant pain. Assess the patient's comfort level and past experiences with wound care. Offer analgesics, as prescribed, and nonpharmacologic comfort/pain interventions to maintain the patient's level of comfort.
Appropriate nutritional support is critical in achieving successful wound healing and may be overlooked (Quain & Khardori, 2015). Collaborate with the registered dietician and dietary staff to develop an individualized nutrition intervention plan for the patient (Baranoski & Ayello, 2020).

Community-Based Care Considerations

Drain site care in the community setting is a clean, not sterile, procedure. Patients will use soap and water to clean the skin around the drain site (Memorial Sloan Kettering Cancer Center (2019).

EVIDENCE FOR PRACTICE

Prevention of Medical Adhesive-Related Skin Injuries

Fumarola, S., Allaway, R., Callaghan, R., Collier, M., Downie, F., Geraghty, J., Kiernan, S., & Spratt, F. (2020). Overlooked and underestimated: Medical adhesive-related skin injuries. Best practice consensus document on prevention. Journal of Wound Care, 29(Suppl 3c), S1-S24. https://doi.org/10.12968/jowc.2020.29.Sup3c.S1

This consensus document is the result of a review of the literature on medical adhesive-related skin injury (MARSI) by a panel of wound care experts, educators, and researchers. This best practice guideline provides recommendations for the assessment and prevention of MARSI, with the goal of standardizing care across all health care settings.

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Skill 8-5

EVIDENCE FOR PRACTICE