Skill 8-6

Caring for a Jackson-Pratt 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 Jackson-Pratt (JP) or grenade drain collects wound drainage in a bulblike device that is compressed to create low suction (negative) pressure (Figure 1). It consists of perforated tubing connected to a portable vacuum unit. 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 via a separate incision. These drains are usually sutured in place. A sterile dressing is usually maintained for 24 to 48 hours; the use of a dressing after this time depends on the site assessment and amount of drainage (Orth, 2018). The site may be treated as an additional surgical wound, but often these sites are left open to air 24 hours after surgery. This type of drain is typically used with breast and abdominal surgery.

As the drainage accumulates in the bulb, the bulb expands and suction is lost, requiring recompression. These drains should be emptied and recompressed when the bulb is approximately 25% to 50% full for optimal accuracy and maintenance of adequate suction (Mamuyac et al., 2019; Yue et al., 2015). However, based on nursing assessment and judgment, the drain could be emptied and recompressed more frequently.

Delegation Considerations

Care for a JP drain insertion site is not delegated to assistive personnel (AP). Depending on the organization's policies and procedures, the drain may be emptied and reconstituted by 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

Graduated container for measuring drainage
Clean, disposable gloves
Additional PPE, as indicated
Cleansing solution, usually sterile normal saline
Sterile gauze pads
Skin protectant/barrier wipes
Sterile drain sponges
Sterile gloves
Sterile cotton-tipped applicators, if appropriate
Sterile container to hold cleaning solution
Plastic bag or other appropriate waste container for soiled dressings
Waterproof pad and bath blanket
Additional dressings and supplies needed or as required for prescribed wound care

Assessment

Assess the situation to determine the need for site care, a dressing change, and/or emptying of the drain. Assess the patient's level of comfort and the need for analgesics before 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. Assess for the presence of excess drainage or bleeding or saturation of the dressing. Assess the patency of the JP drain and the drain site. Note the characteristics of the drainage in the collection bag.

If a surgical wound is present, inspect the wound and the surrounding tissue. Assess the appearance of the incision 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 characteristics of any drainage. Also assess the surrounding skin for color, temperature, and 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 outcome to achieve when performing care for a JP drain is that the drain remains patent and intact, site care is accomplished without contaminating the area or causing trauma, and the patient does not 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, drainage amounts are measured accurately at the frequency required by facility policy and recorded as part of the intake and output record, 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 care plan validates the correct patient and correct procedure. Preparation promotes efficient time management and 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 drain. Place a waterproof pad under the drain site.	Patient positioning and the use of a bath blanket provide for comfort and warmth. Waterproof pad protects underlying surfaces.
Emptying Drainage
10. Put on gloves; put on mask or face shield, as indicated.	Gloves prevent the spread of microorganisms; mask reduces the risk of transmission should splashing occur.
11. Using sterile technique, open a gauze pad, making a sterile field with the outer wrapper.	Using sterile technique deters the spread of microorganisms.
12. Place the graduated collection container under the drain outlet. Without contaminating the outlet valve, pull off the cap. The chamber will expand completely as it draws in air. Empty the chamber's contents completely into the container (Figure 2). Use the gauze pad to wipe the outlet. With one hand, fully compress the chamber along the long axis, side to side (Mamuyac et al., 2019), and replace the cap with your other hand (Figure 3).	Emptying the drainage allows for accurate measurement. Cleaning the outlet reduces the risk of contamination and helps prevent the spread of microorganisms. Compressing the chamber along the long axis, side to side, reestablishes the suction. And generates higher negative pressure compared to the bottom-up methods (Mamuyac et al., 2019). Refer to the Evidence for Practice at the end of this Skill.
13. Check the patency of the equipment. Bulb should remain compressed (Figure 4). Check that the tubing is free from twists and kinks.	Compressed chamber establishes suction. Patent, untwisted, or unkinked tubing promotes appropriate wound drainage.
14. Carefully measure and record the character, color, and amount of the drainage. Discard the drainage according to facility policy.	Documentation promotes continuity of care and communication. Appropriate disposal of biohazard material reduces the risk for microorganism transmission.
15. Remove gloves. Perform hand hygiene.	Removal of gloves and hand hygiene prevents the transmission of microorganisms.
Cleaning the Drain Site
16. Put on gloves. 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 the 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. Dressing protects the site. Checking ensures that a drain is not removed accidentally. 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).
17. 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.	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.
18. Note the presence, amount, type, color, and odor of any drainage on the dressings. Place soiled dressings in the appropriate waste receptacle. Remove your gloves and perform hand hygiene.	The presence of drainage should be documented. Proper disposal of soiled dressings and used gloves prevents the spread of microorganisms. Hand hygiene prevents the transmission of microorganisms.
19. Inspect the drain site for appearance and drainage. Assess if any pain is present. Check the status of sutures, adhesive closure strips, and staples, if present. Note any problems to include in your documentation.	The wound healing process and/or the presence of irritation or infection must be documented.
20. Remove gloves and perform hand hygiene.	Removal of gloves and performance of hand hygiene prevent transmission of microorganisms.
21. Using sterile technique, prepare a sterile work area and open the needed supplies. Refer to facility policy and prescribed interventions regarding use of a sterile approach to site care.	Supplies are within easy reach and sterility is maintained. A sterile dressing is usually maintained for 24 to 48 hours; the use of a dressing after this time depends on the site assessment and amount of drainage (Orth, 2018). The site may be treated as an additional surgical wound, but often these sites are left open to air 24 hours after surgery. Refer to facility policy and prescribed interventions regarding need for sterile approach to site care and use of dressing.
22. Open the sterile cleaning solution. Pour it into the basin. Add the gauze sponges.	Sterility of dressings and solution is maintained.
23. Put on sterile gloves. Alternatively, clean gloves (clean technique) may be used based on facility policy and care setting.	The use of sterile gloves maintains surgical asepsis and sterile technique and reduces the risk of microorganism transmission. Clean technique is appropriate for cleaning chronic wounds, wounds in the home, or pressure injuries (Baranoski & Ayello, 2020; EPUAP, NPIAP, & PPPIA, 2019a; Taylor et al., 2023).
24. 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. Use each gauze sponge or applicator only once. Discard and use new gauze/applicator if additional cleansing is needed. (Refer to Figure 1 in Skill 8-5.)	Cleaning is done from the least to most contaminated area so that a previously cleaned area is not contaminated again.
25. Dry with new sterile gauze 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.	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).
26. Place a pre-split drain sponge under the drain. (Refer to Figure 2 in Skill 8-5.) Apply gauze pads or other cover dressing, such as a transparent dressing, as indicated by facility policy, over the drain. Secure the dressings with tape, as needed. Remove and discard gloves. Perform hand hygiene.	The gauze absorbs drainage and prevents the drainage from accumulating on the patient's skin. Transparent dressing, tape or other securing products keep the dressing in place. Proper disposal of gloves prevents the spread of microorganisms. Hand hygiene prevents the transmission of microorganisms.
27. Secure the drain tubing to the patient's skin using a tape or a commercial securement/stabilization device, allowing slack in the tubing to avoid excessive tension. Be careful not to kink the tubing and ensure the collection bag remains below the drain site. Label the dressing with date and time.	Securing the tubing prevents accidental dislodgement or movement and avoids excessive tension on tube. Kinked tubing could block drainage. Maintaining the drain collection bag remains below the drain site facilitates proper drainage. Recording date and time provides communication and demonstrates adherence to plan of care.
28. Alternatively, if the drain site is open to air, observe the sutures that secure the drain to the skin. Look for signs of pulling, tearing, swelling, or infection of the surrounding skin. Gently clean the sutures with the gauze pad moistened with normal saline. Dry with a new gauze pad. Apply skin protectant/barrier to the surrounding skin. Remove and discard gloves. Perform hand hygiene.	Early detection of problems leads to prompt intervention and prevents complications. Gentle cleaning and drying prevent the growth of microorganisms. Skin barrier/protectant prevents skin irritation and excoriation from tape, adhesives, and wound drainage (Fumarola et al., 2020; Kelly-O'Flynn et al., 2020). Proper removal of gloves prevents the spread of microorganisms. Hand hygiene prevents the transmission of microorganisms.
29. Remove all remaining equipment; place the patient in a comfortable position, with side rails up as indicated and bed in the lowest position.	Proper patient and bed positioning promotes safety and comfort.
30. 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.
31. Check drain status at least every 4 hours. Empty and reengage suction (compress device) when device is approximately 25% to 50% full (Mamuyac et al., 2019). 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 drain ensures proper functioning and early detection of problems. Emptying and compression ensure appropriate suction. Adequate suction pressure declines as bulb volume increases; bulb emptying should occur when the bulb is approximately 25% to 50% full for optimal accuracy and maintenance of adequate suction (Mamuyac et al., 2019; Yue et al., 2015). Checking dressings ensures the assessment of changes in patient condition and timely intervention to prevent complications.

Evaluation

The expected outcome has been met when the drain has remained patent and intact, site care was accomplished without contaminating the area or without causing trauma to the wound, the patient did not experience pain or discomfort, the drainage amounts were measured accurately at the frequency required by facility policy and recorded as part of the intake and output record, and the patient has demonstrated understanding of drain care.

Documentation

Guidelines

Document the location of the drain, the assessment of the drain site, and patency of the drain. Note if sutures are intact. Document the presence and characteristics of drainage on the old dressing upon removal. Include the appearance of the surrounding skin. Document cleansing the drain site. Record any skin care and the dressing applied. Note that the drain was emptied and recompressed. 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. Document the amount and characteristics of drainage obtained on the appropriate intake and output record.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Patient has a JP drain in the right lower quadrant following abdominal surgery. The record indicates it has been draining serosanguineous fluid, 40 to 50 mL every shift. While performing your initial assessment, you note that the dressing around the drain site is saturated with serosanguineous secretions and there is minimal drainage in the collection chamber: Inspect the tubing for kinks or obstruction. Assess the patient for changes in condition. Remove the dressing and assess the site. Often, if the tubing becomes blocked with a blood clot or drainage particles, the wound drainage will leak around the exit site of the drain. Cleanse the area and redress the site. Notify the health care team of the findings and document the event in the patient's record.
Patient calls you to the room and says, “I found this in the bed when I went to get up.” He has his JP drain in his hand. It is completely removed from the patient: Assess the patient for any new and abnormal signs or symptoms and assess the surgical site and drain site. Apply a sterile dressing the drain site. Notify the health care team of the findings and document the event in the patient's record.

Special Considerations

A sterile dressing is usually maintained for 24 to 48 hours; the use of a dressing after this time depends on the site assessment and amount of drainage (Orth, 2018). The site may be treated as an additional surgical wound, but often these sites are left open to air 24 hours after surgery. Refer to facility policy and prescribed interventions regarding need for sterile approach to site care and use of dressing.
Often patients have more than one JP drain. Number or letter the drains for easy identification. Record the drainage from each drain separately, identified by the number or letter, on the intake and output record.
When the patient with a drain is ready to ambulate, empty and compress the drain before activity. Secure the drain to the patient's gown below the wound, making sure there is no tension on the drainage tubing. This removes excess drainage, maintains maximum suction, and avoids strain on the drain's suture line.
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

Maintaining Adequate Pressure in a Jackson-Pratt Drain

Surgical drains, such as the Jackson-Pratt (JP) drain, are used to prevent fluid accumulation in surgical sites and promote wound healing. The JP drain must be emptied and recompressed to maintain the negative pressure as the bulb fills. How can optimal functioning of the device be supported?

Related Research

Mamuyac, E. M., Pappa, A. K., Thorp, B. D., Ebert, C. S. Jr, Senior, B. A., Zanation, A. M., Lin, F. C., & Kimple, A. J. (2019). How much blood could a JP suck if a JP could suck blood? The Laryngoscope, 129(8), 1806-1809. https://doi.org/10.1002/lary.27710

The purpose of this study was to determine whether two methods for compression of the JP bulb resulted in similar amounts of negative pressure and to examine the effect of various baseline reservoir volumes on bulb suction. Three separate JP bulbs of the same brand, type, and volume were compressed, and pressure recordings were measured with a digital manometer. The JP bulbs were randomly compressed either by squeezing them perpendicular to the long axis (side to side; side-in) or perpendicular to the short axis (bottom-up), and pressure was recorded; random compressions were continued until triplicate values from the three separate bulbs using each compression technique were achieved. Negative pressure was also tested by compressing a bulb in the side-in manner while the bulb contained specific measurements of water (25 mL, 50 mL, 75 mL, 100 mL). The volumes of water were placed into the bulb, air was evacuated, and the pressure was recorded.

The average pressure after a side-in compression of the JP bulb was 87.4 cm H₂O versus 17.7 cm H₂O for the bottom-up compression (p ; .0001). The average pressure in the empty bulb using the side-in compression was 87.4 cm H₂O. Upon addition of the four volumes of water, the pressure generated using the side-in compression dropped to 72.6 cm H₂O (25 mL), 41.3 cm H₂O (50 mL), 37 cm H₂O (75 mL), and 35.6 cm H₂O (100 mL). The researchers concluded the specific method for evacuating the bulb (side-in) and the amount of fluid in the bulb significantly affect the performance of the JP drain. The researchers suggested emptying and recompression of a JP drain should occur when the bulb is approximately 25% full, and the drain should be compressed using the side-in method to generate higher negative pressure to support optimal functioning of the vacuum and optimal drainage of the wound bed, supporting improved postoperative healing.

Relevance for Nursing Practice

Nurses must make use of evidence-based interventions to support excellence in nursing care and achieve the best patient outcomes possible. Nurses should be proactive in assessing current practice and policy and procedures to ensure care interventions align with evidence for practice.

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 8-6

EVIDENCE FOR PRACTICE

EVIDENCE FOR PRACTICE