Managing Surgical Drains Following Breast Surgery

Following a mastectomy, a woman may be discharged home with one or more drains coming
from the incision site on her chest or under her arm. Care instructions should be given prior to leaving
the hospital on how often to observe and empty the drainage container. The purpose of the drain is to
keep fluid from collecting in the area of your incision. Fluids that collect in a wound create an
environment for bacteria growth and an infection could develop.

Surgical drains are tubes placed near surgical incisions in the post-operative patient, to remove
pus, blood or other fluid, preventing it from accumulating in the body. The type of drainage system
inserted is based on the needs of patient, type of surgery, type of wound, how much drainage is
expected and surgeon preference.

Wound Drain System Maintenance

Knowledge of proper wound drain system maintenance is also critical for optimal wound healing
and patient outcomes.

Closed, negative pressure wound drainage systems need to be emptied and reactivated. Drains
connected to a reservoir should be emptied before the fluid collected reaches the maximum volume; if
the reservoir fills completely, drainage will stop. Accurate recording of the volume of drainage, as well as
the character of its contents, is vital to promote proper healing. Monitor for excessive bleeding.
Depending on the amount of drainage, a patient may have the drain in place one day to several weeks.
According to the CDC’s Guideline For Prevention Of Surgical Site Infection, drains should be removed as
soon as possible, since bacterial colonization of an initially sterile drain tract increases with the duration
of time the drain is left in place.
General guidelines for care and maintenance of closed drains are as follows.
 Emptying
o Wash hands thoroughly and don gloves before handling the reservoir.
o Unplug the drainage plug from the emptying port.
o Hold the reservoir upside down over a measuring container.
o Squeeze the reservoir to empty all of the collected fluid.
o Observe and record the amount of fluid collected, as well as the appearance of the
drainage (clear, cloudy, bloody, etc.) on a drainage volume chart.
 Reactivation
o Squeeze to compress the reservoir as completely as possible.
o With the reservoir compressed, insert the drainage plug into the emptying port as far as
possible and release the reservoir. The reservoir should expand gradually as it fills with
fluid.
o Attach the reservoir using the plastic strap to the patient’s clothing as directed.
o Place the reservoir below the drain site to maintain adequate drainage.
o Dispose of drainage appropriately. (If in the home setting, instruct the patient to flush
drainage down the toilet.)
o Remove gloves and wash hands thoroughly. During the reactivation process, care should
be taken so that the tubing connected to the reservoir is not disconnected, kinked, or
punctured. In addition, the reservoir should not be allowed to fill completely, because
the drainage will stop.

Observe the draining for:

 Amount: The drainage will be greater just after surgery and will taper off as time goes by.
Amounts of 100cc’s or greater are considered normal, decreasing to about 30 cc’s or less just
before the drain is removed.
 Consistency: Initially, the consistency is slightly thicker than water and moves easily through the
tubing. It should become thinner with time. If the fluid becomes thicker or will not move easily
through the tubing, notify your surgeon.
 Color: The drainage will be cherry red for about 24 hours, but will become more yellow-straw
colored prior to removal. If the drainage does not change from red after about two to three days,
notify your surgeon.
 Exudate: Exudate, which is the medical term for drainage, comes in a variety of forms. The way
the drainage looks, along with how the incision looks, indicates whether the wound is healing
normally or if it needs medical attention.
Types of Drainage from a Surgical Wound:
 Serous Drainage: Clear, watery and no blood present.
Serous drainage is clear and may be slightly yellow or colorless in appearance. It is thin
and watery and may make a bandage wet without leaving a stain of color. Serous exudate, or
discharge, is normal from a wound in the early stages of healing, typically in the first 48-72 hours
after the incision is made.
 Serosanguinous Drainage: Mostly clear but is pink from the small amount of blood present.
This discharge may appear slightly pink from the red blood cells that are present. This is
normal in the early stages of healing, as the blood is present in small amounts. It is important to
keep in mind that a very small percentage of blood in the fluid can make serum appear pink.
 Sanguinous Drainage: More than blood tinged, but not entirely bloody.
A notable amount of blood mixed with other bodily fluids. This blood tinged drainage is
not typical of a healing wound and may indicate that the wound hasn't been treated gently
enough during incision care, the patient is being too active too quickly after surgery or another
type of stress is affecting the incision site.
 Hemorrhage: A large amount of pure blood, seek medical attention.
Hemorrhage is the term for severe bleeding from a wound that can be life-threatening,
depending on the amount of blood loss, how difficult the bleeding is to control, how long the
bleeding goes unchecked, and other injuries. The term hemorrhage refers specifically to blood
being lost at a rapid rate. Medical attention is an absolute necessity for treating hemorrhages,
and may include blood transfusions and fluid resuscitation. In terms of drainage, hemorrhage is
pure blood or nearly all blood.
 Purulent Discharge (Pus): This discharge is often smelly, comes in unusual colors such as green
and creamy yellow or white, and it is a sign of infection. Seek medical attention.
Purulent drainage is not a normal finding in an incision. This type of exudate can be a
variety of colors, including white, yellow, grey, green, pink, and brown. Color alone does not
indicate infection, but a change from clear drainage to colorful drainage should be reported to
the surgeon. In addition to being a variety of colors, purulent discharge may also have
unpleasant or foul smells. While this smell is not always present, it is typical with this type of
infection. Foul smelling discharge should not be ignored as it is never considered normal.

The physician should be notified if:

 The reservoir cannot be reactivated, i.e., it does not expand gradually and collect fluid.
 The drain becomes dislodged.
 The fluid in the reservoir has a foul odor.
 The patient has a fever.
 Abnormal drainage, increased redness or swelling is observed near the drain site.
 Air/fluid leaks or other malfunctions occur.
 Clots form in the tubing causing an obstruction.
Patient and Family Education
Because procedures are being performed more frequently on an outpatient basis and more
patients are being discharged from an acute care facility to a home care setting earlier in their recovery
period, surgical wound care and wound drain system maintenance are being provided by the patient,
the patient’s family members, or home health care providers in increasing numbers. Therefore, in
addition to providing effective wound care and maintaining wound drain systems, nurses are now
educating patients and their families/significant others about wound care, aseptic technique, and
medical waste disposal. Patient compliance with wound care and wound drain system maintenance is an
important factor in preventing infection and optimizing wound healing.

For home care, the patient should be provided with the following instructions, both verbally and in
writing:

 Warning signs. The signs and symptoms that should be reported to the physician or nurse
include:
o Erythema, marked swelling (e.g., beyond one-half inch from the incision site),
tenderness, increased warmth around the wound, or red streaks near the wound.
o A temperature of greater than 37.7°C (> 100°F) or chills.
o Purulent drainage or a foul odor.
 Special instructions:
o Confirm with the physician if bathing or showering is permitted.
o Review dressing change and wound care products with the patient and/or caregiver;
explain the procedure and how often it should be performed.
o Emphasize the need to keep the wound clean and dry.
o Advise on the need to assemble all supplies needed for wound care before starting the
procedure.
o Explain how to maintain the sterility of the supplies.
o Provide instruction on proper disposal of soiled dressings and drainage.
o Instruct on proper hand washing techniques and to wash hands before and after wound
care.
o Instruct on proper dressing removal, i.e., remove tape gently to avoid traumatizing the
skin, proper disposal of the old dressing.
o Instruct on wound inspection, reviewing the warning signs that should be reported.
o Describe the proper procedure and solution for cleansing the wound and drain site as
ordered by the physician.
o Provide instruction on how to reapply the dressing.
Signs of an Infected Wound
1. Feelings of Malaise
Malaise is a common non-specific sign of a localized systemic infection. It is a feeling of tiredness and a
lack of energy. You may not feel up to completing normal activities or begin sleeping more than usual.
While this type of feeling is associated with surgical recovery, there is a big difference from what is
typical and what is a sign of infection. People who are recovering from surgery without an infection feel
a little better day by day. Those recovering from surgery who contract an infection might feel good and
then suddenly become exhausted.
2. Running a Fever
Running a fever can cause headaches and decrease your appetite. Running a low-grade fever of 100
degrees Fahrenheit or less is typical following surgery. If your temperature reaches 101 degrees or more,
it may be indicative of a wound infection. If this happens, consult your surgeon or physician immediately.
Keep in mind that if your fever is due to an open or chronic wound, antiseptics in the form
of impregnated dressings containing honey or silver may be helpful.
3. Fluid Drainage
It is quite normal to have some fluid drainage from the incision area after surgery. Expect clear or
slightly yellow-colored fluid to drain from your wound. If the drainage fluid is cloudy, green, or foul
smelling, this could be a sign that the wound is infected. Healthy wound drainage can be managed
by absorbent dressings like hydrocolloids or negative pressure therapy. Contact your health care
provider to find out what types of wound care supplies you need to treat the infection.
4. Continual or Increased Pain
While pain is common after surgery, it should gradually subside as your body heals. Pain medication can
help, but you should be able to stop taking them comfortably over time. To prevent unwarranted pain,
follow your doctor’s wound care directions and avoid strenuous activities. If you continue to experience
pain or suddenly have increased pain, it may be a sign of infection. If this happens, consult with your
surgeon or physician.
5. Redness and Swelling
Some redness is normal at the wound site, but it should diminish over time. However, if your surgical
incision or wound continues to be red or exhibit radiating streaks known as lymphangitis, this is a
warning sign of a wound infection. Like redness, some swelling is to be expected at the wound site and
should decrease over time. If the swelling does not go down during the initial phases of the wound
healing process, you could have an infection.
6. Hot Incision Site
When an infection develops in a wound or incision, the body sends infection-fighting blood cells to the
location. This may make your wound or incision feel warm to the touch. If the hot temperatures
continue, the infection may cause you to develop other infection symptoms.
Modified radical mastectomy

Mastectomy is the removal of the whole breast. A modified radical mastectomy is a procedure in which
the entire breast is removed, including the skin, areola, nipple, and most axillary lymph nodes; the
pectoralis major muscle is spared. Historically, a modified radical mastectomy was the primary method
of treatment of breast cancer.

A modified radical mastectomy involves the removal of both breast tissue and lymph nodes:
 The surgeon removes the entire breast.
 Axillary lymph node dissection is performed.
 No muscles are removed from beneath the breast.

Modified radical mastectomy

Who usually gets a modified radical mastectomy?
Most people with invasive breast cancer who decide to have mastectomies will receive modified radical
mastectomies so that the lymph nodes can be examined. Examining the lymph nodes helps to identify
whether cancer cells may have spread beyond the breast.