The nurse is changing the surgical dressing on an older patient's abdomen and sees the item pictured in the diagram below. How should the nurse care for this device?
: Select all that apply.
1. Plan to replace the precut gauze as part of the dressing change.
2. Cleanse around the tube with the cleanser ordered or according to protocol.
3. Use the safety pin to secure the outermost bandage to the dressing.
4. Remove the tube, culture the wound, and cleanse it with saline gauze
5. Remove the safety pin
Correct Answer: 1, 2
This is a Penrose drain. The nurse cares for this device by cleansing around it per hospital protocol and replacing the precut gauze dressing as necessary. The pin should not be used to secure the dressing as that would make it very easy to inadvertently pull the drain out when the dressings are removed to be changed. The drain is there to passively remove drainage from the wound bed and it should not be removed until there is a physician order to do so. A culture is necessary only if there are assessment findings that indicate possible infection. The safety pin is in place to keep the drain from slipping back into the patient, so it should not be removed.
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