Reference — Perioperative Nursing

Chest Tubes & Surgical Drains

Surgical drains and chest tubes remove unwanted fluid, blood, or air from surgical sites or body cavities — reducing infection risk, monitoring output, and facilitating healing. Nurses manage and document drain output, assess function, and recognize complications including dislodgement, blockage, and hemorrhage.

Educational use only. Drain management protocols are individualized and facility-specific. Always follow provider orders for drain care, stripping/milking, and removal criteria. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.

Chest Tubes — Pleural Drainage

A chest tube (thoracostomy tube) is a flexible tube inserted through the chest wall into the pleural space (or occasionally the mediastinum) to drain air, blood, fluid, or pus. Most chest tubes are connected to a three-chamber water-seal drainage system (e.g., Pleur-evac).

Indications by Tube Placement

Pneumothorax	Air in pleural space — apical tube placement (air rises)	Lung re-expansion
Hemothorax	Blood in pleural space — basilar tube placement	Drain blood; monitor for hemorrhage
Hemopneumothorax	Both air and blood — may require two tubes	Drain air and blood
Pleural effusion	Fluid accumulation — basilar placement	Improve respiratory function
Empyema	Infected pleural fluid — drainage + antibiotics	Infection source control
Post-cardiac/thoracic surgery	Mediastinal and/or pleural tube — placed at end of case	Drain surgical site; monitor bleeding

Three-Chamber Water-Seal Drainage System

Collection Chamber

Collects drainage from the pleural space. Measure at eye level. Mark level at each assessment interval.

✦Record output: volume, color, character
✦Sudden increase in bright red drainage = hemorrhage — notify provider STAT
✦Expected: decreasing output over time

Water Seal Chamber

Prevents air from entering the pleural space. Filled with 2 cm of water. Fluctuation (tidaling) with breathing is normal and confirms tube patency.

✦Tidaling: water level rises with inspiration, falls with expiration (normal)
✦Constant bubbling = air leak (identify source)
✦No fluctuation = tube may be kinked, clamped, or lung fully re-expanded

Suction Control Chamber

Controls suction level — filled with water to prescribed depth (typically 20 cm). Gentle continuous bubbling in this chamber = correct suction applied.

✦Gentle bubbling = correct suction (vigorous bubbling does NOT mean more suction)
✦Suction applied only per provider order
✦Water evaporates — maintain prescribed level

Chest Tube Emergency Situations

Tube disconnected from drainage system

Submerge the tube end in sterile water (creates water seal). Notify provider. Do NOT clamp tube unless provider directs.

Tube accidentally removed (dislodged)

Cover insertion site immediately with gloved hand OR petroleum gauze (Vaseline gauze) sealed on 3 sides. Notify provider and prepare for emergency tube reinsertion or chest X-ray.

Continuous bubbling (air leak) in water-seal chamber

Trace from patient to system to identify source. Clamp near patient briefly — if bubbling stops, air leak is from patient/insertion site. Notify provider.

No tidaling, no drainage — suspected tube obstruction

Assess tube for kinking or clamping. Reposition patient. Do NOT strip tube unless ordered (can cause barotrauma). Notify provider — chest X-ray may be ordered to confirm tube position.

General Chest Tube Nursing Care

✦Keep drainage system upright and BELOW the level of the chest at all times

✦Never lift drainage system above chest — fluid can siphon back into pleural space

✦Do NOT routinely clamp chest tubes (unless ordered for disconnection emergency or brief trial)

✦Assess for subcutaneous emphysema (crepitus) around insertion site

✦Monitor for respiratory distress — report changes in rate, depth, or SpO2

✦Position: semi-Fowler (30–45°) improves breathing with chest tube in place

✦Encourage deep breathing and coughing to facilitate lung re-expansion

✦Tape all connections; loop tubing to prevent dependent loops that impede drainage

Surgical Drains

Jackson-Pratt (JP) Drain

Active — closed-suction

Mechanism

Bulb-shaped reservoir that creates negative pressure (suction) when compressed and capped. Connected to a flat perforated drain placed at the surgical site.

Common Uses

✦Post-mastectomy
✦Abdominal/pelvic surgery
✦Lymph node dissection
✦Major orthopedic surgery

Nursing Management

✦Empty when half full OR per protocol (typically every 4–8 hours)
✦Compress bulb fully and recap to re-establish suction
✦Record output: volume, color, and character at each empty
✦Expected output: decreasing over days; bright red → serosanguineous → serous
✦Secure tubing to avoid traction or dislodgement
✦Do NOT strip JP tubing routinely (can damage tissue)
✦Mark skin at exit site — migration inward indicates tube has moved

Hemovac Drain

Active — spring-loaded closed-suction

Mechanism

Flat, accordion-style reservoir that creates suction when compressed. Larger capacity than JP drain — used when higher output volumes are expected.

Common Uses

✦Total joint replacement (hip, knee)
✦Large abdominal or orthopedic surgeries
✦Any surgery with anticipated high drainage volume

Nursing Management

✦Empty when half full or per protocol
✦Compress flat (squeeze) and cap — spring tension creates suction as reservoir expands
✦Record output with each emptying
✦Check that suction is maintained (reservoir should remain compressed between emptying)
✦Secure tubing and reservoir below the surgical site for gravity-assisted drainage

Penrose Drain

Passive — open drainage

Mechanism

Flat, soft rubber tube that allows fluid to drain by gravity and capillary action. No suction mechanism — simply provides a path of least resistance for fluid to escape.

Common Uses

✦Abscess drainage
✦Superficial wound drainage
✦Bile leak drainage post-cholecystectomy
✦When active suction is NOT desired

Nursing Management

✦Drain site requires frequent dressing changes — absorptive dressings needed
✦Measure drainage by weighing dressings or estimating area of saturation
✦Protect periwound skin from maceration — drainage is continuous
✦Pin or suture at exit site to prevent complete withdrawal
✦Assess drainage: amount, color, odor (foul odor may indicate infection)
✦Provider advances or shortens drain gradually as wound heals

Blake Drain

Active — closed-suction (fluted)

Mechanism

Silicone drain with longitudinal fluted channels along the surface that facilitate drainage via capillary action and negative pressure. Less traumatic to tissue than older round drain designs.

Common Uses

✦Abdominal surgery
✦Thoracic surgery
✦Hepatobiliary surgery
✦Increasingly replacing older drain designs

Nursing Management

✦Similar care to JP drain — connected to closed-suction drainage reservoir
✦Assess output each shift: volume, color, character
✦Minimal manipulation — secure and protect from traction
✦Monitor for signs of obstruction (sudden decrease in output with continued symptoms)

General Drain Documentation — Every Shift

✦Amount of drainage (mL) — cumulative per shift AND total since insertion

✦Color of drainage (bright red = active bleeding; serosanguineous = normal healing; serous = late healing; purulent = infection)

✦Character (consistency, odor — foul odor suggests infection)

✦Drain site assessment (intact suture, periwound skin integrity, signs of infection)

✦Drain type and patency (suction maintained for active drains)

✦Patient tolerance and pain at drain site

✦Any complications or provider notifications

NCLEX Pearls — Drains & Chest Tubes

✦Chest tube tidaling: water rises with inspiration, falls with expiration (normal) — indicates patent tube

✦Constant bubbling in water-seal chamber = air leak — trace from patient outward to find source

✦Drainage system must ALWAYS be below chest level — never lift above chest

✦If chest tube disconnects: submerge end in sterile water or petroleum gauze — do NOT leave open to air

✦If chest tube is dislodged: cover with gloved hand or petroleum gauze sealed 3 sides — STAT notify provider

✦JP drain: compress bulb fully before capping — this creates the suction

✦Hemovac: compress flat (squeeze all air out) before capping — spring tension provides suction

✦Penrose drain: passive, open — wound drainage absorbs into dressings; frequent dressing change required

✦Sudden increase in bright red drainage from ANY drain = possible hemorrhage — notify provider STAT

✦Expected drain output progression: bright red → serosanguineous → serous over days

Related Resources

Surgical Drain Comparison ChartJP, Hemovac, Penrose, Blake, chest tube side-by-side

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Postoperative Nursing Care GuidePACU assessment including drain and output monitoring

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Wound Drainage Types ReferenceSerous, sanguineous, serosanguineous, purulent drainage characteristics

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Surgical Complications GuideHemorrhage recognition and intervention in the postoperative period

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Pneumothorax Types Comparison ChartSimple, tension, open, and hemothorax — causes, findings, and first actions

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Standards & sources

Fact-checked Jun 21, 2026

This page is written to align with AORN Guidelines for Perioperative Practice · American Society of Anesthesiologists (ASA). It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →