If you plan on transferring to critical care or med/surg, you'll quickly learn that drains come with the territory. In fact, postop patients who undergo orthopedic, cardiac, or general surgery often come back from the OR with more than one. That's because drains serve a necessary function postop: They promote healthy wound healing, prevent infection, and reduce pain.
But don't be fooled. While drains are helpful, they're not innocuous. In this review, we'll cover some of the most common postop drains and how to properly manage patients who have them.
Different drains do different things
Drains remove blood, serum, lymph, and other fluids that accumulate in the wound bed after a procedure. If allowed to build, these fluids put pressure on the surgical site as well as adjacent organs, vessels, and nerves. The decreased perfusion delays healing; the increased pressure causes pain. In addition, a buildup of fluid serves as a breeding ground for bacteria.
Fluid can be removed from a wound using either a passive or active surgical drain. Passive drains rely on gravity to evacuate fluid, while active drains are attached to a vacuum device or wall suction. A surgeon chooses a drain that both fits the operative site and can handle the type and amount of drainage expected. For instance a T-tube is a fairly large passive drain that's typically placed during a cholecystectomy to accommodate the 200 – 500 ml of bile that's expected to accumulate in the early postop period.
The Penrose is another passive drain. But it's usually placed to manage much smaller amounts of drainage. That's good, because it's typically left open, meaning its free end, which protrudes a mere inch above the skin, isn't usually attached to a bag or pouch to collect the drainage. Instead, fluid from the wounds seeps out onto a gauze pad.
Active drains like the Jackson-Pratt (JP) and Hemovac always have a drainage collection reservoir attached. Drains that have some type of pouch are often called closed systems. Unlike the Penrose, which looks like a large limp straw, the tubing on a JP or Hemovac is a little stiffer so that it won't flatten under the pressure exerted by suction. The tips of these drains are fenestrated, meaning they have multiple holes to facilitate draining.
In any case, a drain may exit a wound through the suture line or from a small opening near the incision.
Complications: Anticipate and limit them
The downside of a drain is that it can be painful going in and coming out. For that matter, it can be painful just sitting in the wound. That's because the drain destroys nearby tissue that it rubs up against. A drain also provides a pathway for bacteria to get into the wound.
In fact, the risk of infection from a drain rises significantly by the third or fourth day postop, and so does the degree of mechanical damage to local tissue. To minimize these problems, the surgeon will place a drain so that it reaches the skin by the shortest, safest route. That way the drain exerts the least amount of pressure on adjacent tissue.
However, to be effective, a drain also has to reach the deepest, most dependent area of a wound to adequately evacuate excess fluid. Unfortunately, the deeper a drain goes, the greater the risk of complications.
And because the drain is foreign, the body quickly starts to wall it off by encasing it in granulation tissue. This can hamper the drain's ability to function, so making sure that it's patent is part of basic care.
Follow the basics for all drains
A systematic approach to drain care can limit complications and ensure the best outcome for the patient. It helps to first label each drain with a number for easy identification, and consistency in documentation. Note the location and type of fluid that ought to be draining from each.
Next, you will need to monitor drainage for color, consistency, and quantity of drainage. During the initial postop period, drainage tends to be sanguineous, which is dark red and thick from leftover blood around the operative site.
There's a gradual decrease in output, as the wound heals, and in a day or two the color turns serosanguineous, or pink. The consistency is thinner because there's less blood in the drainage. Once blood is gone, the drainage turns thin and serous, or pale yellow, and slows to a trickle.
A sudden change in color, consistency, or amount may indicate a serious problem for your patient. For instance, serous drainage that suddenly turns bloody and profuse may be a sign of hemorrhage from erosion of an adjacent vessel; a change from thin and pink to thick and brown could mean fecal material is leaking into the wound from a failed bowl resection. An increase in volume coupled with a color change to purulent green can indicate infection, which could lead to sepsis.
It's important to promptly report and document changes like these. In addition, report a sudden cessation of drainage, or leaking around the drain, which may signify a blockage in the system, or dislodgement.
Beyond the basics: The Penrose drain
Managing a Penrose drain requires skilled nursing. That's because a Penrose is generally not sutured into place, and often exits the wound through the incision. Therefore, you should use sterile technique when caring for this drain, and never delegate its care to unlicensed personnel.
To remove a soiled dressing from a Penrose, gently pull it toward the drain. That way you minimize stress on the incision, and won't accidentally pull it out.
You'll see a sterile safety pin in the free end of this drain. The pin prevents the drain from slipping back into the wound. If you don't see the pin, call the physician immediately.
Stay on top of the skin assessment around the Penrose site. Gently clean the skin with sterile water or saline, and apply ointment if ordered.
If you have an order to advance the Penrose, which means pulling the drain out of the wound little by little (usually a quarter of an inch, daily), don't be overly tentative. Just advance slowly to the desired length, and insert a new sterile safety pin about 2.5 cm above the skin. Snip off the excess tubing with sterile scissors.
Next, gently cover the drain with one or more split, sterile 4 x 4-inch gauze pads. If you don't have them on hand, create them by cutting halfway down the center of the pads on hand with sterile scissors. You want the gauze to fit like a wrap-around skirt, but not so tight that you're in danger of accidentally pulling the drain out on the next dressing change.
Use enough padding to absorb the drainage. Then cover the drain with an uncut gauze pad, and tape it down to secure. Change the dressing as ordered, and PRN. Don't allow the dressing to become fully saturated.
Active drains are simple to manage
The tubing of a JP or Hemovac drain is usually anchored to the skin by one or two sutures. Clean technique is all that's required for monitoring drainage and emptying the reservoir. You can delegate this task to a properly trained unlicensed assistant.
First, open the plug on the drainage port and pour the contents into a graduated cup to measure the amount of drainage. Be sure to chart the quantity, color, and consistency of the drainage.
To activate the suction, completely squeeze the reservoir with one hand. Clean the end of plug with your other hand by swabbing it with an alcohol pad. Then, close the plug before letting go of your grip on the reservoir.
Drainage should be measured once a shift, or as ordered, and anytime the reservoir is more than half full to maintain proper suction.
Because the drainage is contained, the exit site around these drains is usually dry. Nevertheless, the tubing can irritate the skin, so expect a little redness around the site. You can limit the redness by keeping the drain immobile. To do that, wrap a piece of tape around the tubing and pin the tape to the patient's gown. Keep a dry dressing around the site.
To ensure patency of these drains, gently milk the tubing as needed to remove shreds of debris or small clots that may be blocking the flow. Do this by gently squeezing the tube between your gloved thumb and forefinger along the length of the tubing.
If necessary, flush or irrigate the drain with sterile water. Document your observations per your hospital's policy.
Removing a drain is the easy part
When a drain is ready to come out, it's your job to pull it. The first thing you should do is look over the chart and document the amount of drainage produced over the last 24 hours to serve as a comparison should any draining from the site continue.
Gather supplies. You'll need gloves, a disposable drape, dressings, and a suture removal kit. Explain to the patient what you're about to do, and that he may experience some momentary discomfort during removal. Offer him something for pain before you begin.
Then, don gloves and any other personal protective equipment deemed necessary, such as a gown, mask and goggles. Place a disposable drape next to the site. Remove any stitches first. Lift the suture with the sterile tweezers and snip the stitch near the knot. Gently pull out the suture by the knot and discard.
Next, carefully loosen the drain, especially if it's been in for some time, as it will have a buildup of granulation tissue surrounding it. With a 4 x 4-inch gauze pad, firmly grasp the drain close to its exit site with your dominant hand. Stabilize the skin around the drain with your other hand.
Before you start to pull, have your patient take a deep breath, as it can ease the discomfort by reducing anxiety. Once he inhales, steadily and swiftly withdraw the drain and place it on the drape. You should not feel any resistance. If you do, stop and notify the physician. The drain may need to be surgically removed.
If you're successful, cover the site with a dry, sterile dressing and document the outcome. Continue to record the type and amount of any ongoing drainage, which should be minimal and stop within 24 hours. If a site drains more than expected, it may be a sign that fluid is continuing to accumulate, and a new drain may have to be placed.
Managing drains is an important part of the postop healing process. With your knowledge and skill, you'll contribute to the best possible outcome.
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