Drainage management

Recommendations

Identify and Treat the Cause
1 Take a careful history, assess the patient and analyze the drainage problem to determine the cause and how to treat it. Level of Evidence
Not Assessed


Address Patient-centered Concerns
2 Consider the potentially serious adverse effects that the drainage problem has on a patient’s quality of life Level of Evidence
Not Assessed
3 Contain drainage to maintain patient comfort and quality of life and prevent problems with odour and skin breakdown. Level of Evidence
Not Assessed
4 Educate the patient and family on self-care techniques. Level of Evidence
Not Assessed


Provide Local Care
5 Select appropriate drainage absorption or containment systems based on the amount and type of drainage. Level of Evidence
Not Assessed
6 Consider absorbant products as: - a coping strategy pending definitive treatment - an adjunct to other ongoing therapy - long term management of urinary incontinence only after other treatment options have been explored Level of Evidence
Not Assessed
7 For patients with incontinence, inspect genital-perineal area daily to identify signs of contact dermatitis and skin breakdown. Level of Evidence
Not Assessed
8 For patients with incontinence, prevent skin breakdown by providing immediate cleansing after an incontinent episode and utilizing appropriate skin and barrier creams. Level of Evidence
Not Assessed


Provide Organizational Support
9 Facilitate healthcare professionals to gain relevant knowledge and skills to offer appropriate advice and information. Level of Evidence
Not Assessed


Background

Management of drainage, whether due to an exudative wound, stoma, enterocutaneous fistula, or incontinence, poses a similar challenge: effluent management, skin protection and odour control. Effluent management can be achieved through the use of fluid managers and collecting systems. Patient and family education and confidence with self-care routines is an integral part of effective management.

Wound
Wound exudate provides the moist environment that is optimal for healing, but large amounts of exudate can damage periwound skin. Control of moderate to heavy wound exudate can be achieved through the use of absorbent dressings, such as alginate, hydrofibre, and foam dressings. If these provide inadequate exudate control, pouch techniques or a wound drainage collector may be required.

Stoma
Many types of one- and two-piece pouch drainable or closed systems are available to manage stoma output. Accessories, such as convex inserts, belts and pouch covers, may increase pouch comfort and performance. Effective pouch function depends on selection of the appropriate system, patient knowledge and ostomy care abilities, an intact seal and appropriate pouch wear times.

Urinary incontinence
A variety of absorbent pads and undergarments are available for patients with urinary incontinence who remain incontinent despite specific treatment. These fluid management systems may also be appropriate for nocturnal use by patients who are effectively managed by prompted voiding during the day. External catheters may be used for male patients with intractable incontinence, and intermittent catheterization can manage urinary retention and overflow incontinence. Long-term indwelling catheters have been overused in nursing homes; these catheters significantly increase the risk of complications, especially urinary tract infection. As a result, their use should be restricted to specific indications and the principles of catheter care should be followed.

Fecal incontinence
Several containment options exist for patients who still have fecal incontinence despite appropriate management, including dietary and lifestyle management, biofeedback, pharmacotherapy, and surgery. Disposable absorbent pads and undergarments can effectively absorb liquid feces. Other fluid management devices include anal bags, which consist of a drainable pouch attached to an adhesive wafer that fits around the anal opening, and various catheters or tubes attached to fecal collection bags.

Fistula
The technique selected to manage drainage from an enteric fistula depends primarily on the discharge volume. Drainage from low-volume fistulas can usually be managed adequately using hydrocolloid, alginate, hydrofibre, or foam dressings, whereas drainage from high-volume fistulas can be managed with one- or two-piece ostomy systems (depending on the need for a window), a fecal incontinence collector, a customized pouching system, or a vacuum-assisted closure dressing.

Management of any odour is an important patient consideration. The primary approach to managing odour is to address the cause and, when possible, to control the fluids. Depending on the clinical problem, containment can be achieved using dressings and pouching or drainage devices. Appropriate use and securement of wafer barriers, pastes and adhesives can prevent leakage and odour. Topical metronidazole and secondary dressings containing charcoal may also be helpful.

Maintenance of skin integrity is important both for patient comfort and to prevent infection, wound extension and other skin complications. Selection of the right skin barriers and protectants and their correct use can restore and maintain skin integrity and prevent further skin damage.

References

Essential Publications
1 Incontinence management system trial Quality Indicator
 Type: Non-randomized controlled trial
Al-Samarrai NR. Uman GC. Al-Samarrai T. Alessi CA. Introducing a new incontinence management system for nursing home residents. Journal of the American Medical Directors Association. 8(4):253-61, 2007 May.
This article presents the results of a comparative study evaluating the introduction of the One Step Incontinence System (OSIS), an integrated incontinence product, in the Nursing Home setting (2 sites) by comparing it with the provision of a box of wipes at the bedside. It was found that cleansing was done more frequently using the OSIS system than the wipes.


Enablers for practice

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