Safety

• Attach the drainage tubing to the patient’s gown with tape and a safety pin, so that the suction device is below the level of the wound and does not pull on the insertion site.
• Notify the health care provider of any signs of infection, including purulent drainage, odor, redness, increased white blood cell count, and temperature elevation.
• If bleeding appears in or around the drainage collector:
  • Determine the amount of bleeding, and notify the health care provider if it is excessive.
  • Assess for tension on the patient’s drainage tubing.
  • Secure the tubing to prevent pulling and pain.
• If the drainage suction device is not accumulating drainage:
  • Assess the drainage tubing for clots.
  • Assess the drainage system for air leaks or kinks.
  • Notify the health care provider.
• Take measures to prevent a confused patient from pulling out a drain collector.

Equipment

(Roll cursor over items to see labels)

Graduated measuring cylinder

Alcohol swab

Gauze 4x4 split drain sponges

Goggles (optional)

Sterile specimen container

Sterile dressings:

• Gauze pads
• ABD bandage

Clean gloves

Safety pin

Metapore tape

Waterproof pad

Delegation

The assessment of wound drainage, the maintenance of drains, and the maintenance of drainage systems may not be delegated to nursing assistive personnel (NAP). However, the task of emptying a closed drainage container or pouch, measuring the amount of drainage, and recording the amount on the patient’s intake and output (I&O) record may be delegated. Be sure to inform NAP of the following:  

• Discuss any modification of the skill necessary for the patient, such as increasing the frequency of drain emptying.
• Instruct NAP to report any change in the amount, color, or odor of drainage.
• Review the I&O procedure.

Preparation

• Identify the presence, location, and purpose of the closed-wound drain and drainage system as the patient returns from surgery. Assess any drainage on the patient’s dressing.
• Identify the type and number of wound drainage tubes and what each will be draining. Label each drain tube with a number or label.
• Check the health care provider’s orders to see if the drain tubes need self-suction, wall suction, or no suction.
• Inspect the system to determine the presence of one straight tube or Y-tube arrangement with two tube insertion sites.
• Inspect the system to ensure that it functions properly. This must include inspection of the insertion site, inspection of the drainage moving through the tubing in the direction of the reservoir, inspection of the patency of the drainage tubing and of the airtight connection sites, and inspection for the presence of any leaks or kinks in the system.

Follow-up

• Check for drainage in the suction device.
• Look for clots or large collections of debris that may block the flow of drainage. The Y site in the drainage tubing is especially prone to clogging.
• Inspect the wound for drainage, and look for seroma caused by accumulation of drainage fluid under the skin.
• Assess the patient’s level of comfort using a 0 to 10 scale.

Documentation

• Record emptying of the drainage suction device and the reestablishment of a vacuum in the suction device.
• Record the amount, color, and odor of drainage. Record the dressing change at the drain site and the appearance of the drain insertion site.
• Record the amount of drainage on the patient’s I&O record.
• Immediately report to the health care provider any sudden change in the amount of drainage, whether increased output or absence of drainage flow. Also report drainage with pungent odor, new evidence of purulence, severe pain, or dislodgment of the drainage tube.