Development of a Drainage Tube (Jackson-Pratt Drain or Hemovac) Management Protocol

Dongwon Choi; Hyunjin Lee; Min-Jung Choi; Kyunghee Kim; YunHee Shin; Ji-Su Kim

doi:10.7739/jkafn.2023.30.3.371

J Korean Acad Fundam Nurs > Volume 30(3); 2023 > Article

Choi, Lee, Choi, Kim, Shin, and Kim: Development of a Drainage Tube (Jackson-Pratt Drain or Hemovac) Management Protocol

Original Article

J Korean Acad Fundam Nurs 2023; 30(3): 371-381.

Published online: August 31, 2023

DOI: https://doi.org/10.7739/jkafn.2023.30.3.371

Development of a Drainage Tube (Jackson-Pratt Drain or Hemovac) Management Protocol

Dongwon Choi¹⁾

, Hyunjin Lee²⁾

, Min-Jung Choi³⁾

, Kyunghee Kim⁴⁾

, YunHee Shin⁵⁾

, Ji-Su Kim^4),

¹⁾Associate Professor, College of Nursing, Incheon Catholic University, Incheon, Korea

²⁾Assistant Professor, College of Nursing, Eulji University, Uijeongbu, Korea

³⁾Assistant Professor, College of Nursing, The Catholic University of Korea, Seoul, Korea

⁴⁾Professor, College of Nursing, Chung-Ang University, Seoul, Korea

⁵⁾Professor, Wonju College of Nursing, Yonsei University, Wonju, Korea

Corresponding author: College of Nursing, Chung-Ang University 84 Heukseok-ro, Dongjak-gu, Seoul 06974, Korea Tel: +82-2-820-5991, Fax: +82-2-824-7961, E-mail: jisu80@cau.ac.kr

*This research was supported by a grant from Korean Academy of Fundamentals of Nursing (2022).

Received April 18, 2023 Revised July 4, 2023 Accepted August 18, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

This study aimed to develop a drainage tube management protocol for nursing students to enhance their core nursing skills and improve the quality of the nursing practicum.

Methods

A drainage tube (Jackson-Pratt drain or Hemovac) management protocol for nursing students was developed in four stages: a preliminary survey (stage 1), establishment of criteria for the implementation of the protocol (stage 2), finalization of the protocol (stage 3), and development of nursing scenarios to implement the developed protocol (stage 4).

Results

The final drainage tube management protocol outlined 23 steps, and the scoring system reflected whether each step was fully performed (2), partially performed (1), and not performed (0) for a total possible score of 46. The example nursing scenario was designed to evaluate the process through which nursing students provide care for a postoperative patient with a Jackson-Pratt drain (or Hemovac) with level 1 (fundamentals of nursing practice for sophomores in the first stage).

Conclusion

It is important to educate and evaluate nursing students on core nursing skills that must be learned and acquired during their school years, owing to their high frequency of use and importance in nursing practice. To this end, standardized protocols for each core nursing skill should be used to ensure consistent education and evaluation in nursing situations that resemble the clinical setting, in which continual updating of core nursing protocols is required.

Key words: Drainage, Nursing, Patient Care Management, Wounds and Injuries

INTRODUCTION

The Korean Accreditation Board of Nursing Education (KABNE) designated 20 core nursing skills with high frequency and importance to be essentially acquired during nursing education, and categorized these core basic nursing skills into advanced, intermediate, and beginner cate-gories for evaluation [1]. However, with the launch of the fourth evaluation phase in 2021, KABNE revised its approach. Instead of providing a protocol for the 18 core nursing skills, KABNE now presents only an overview of the difficulty level, objectives, prerequisite knowledge, and required supplies, and requires individual schools to implement a consistent and validated protocol for evalu-ating core nursing skills [2]. Drainage tube management, pressure injury management, fall prevention, and pain management have been modified or added, and protocols for these nursing skills need to be developed.

Drainage tubes are placed to remove secretions from body organs for various therapeutic purposes, and nurses perform several interventions involving drainage tubes, such as checking the positioning of the drainage tube, patency, and signs of infection. Previous studies [3-6] have reported that nursing skills education and training based on intentional protocols can enhance nurses’ nursing skills competencies. Therefore, drainage tube management education and training for nursing students is crucial for pro-moting the prevention and early detection of drainage tube-related complications. Additionally, valid protocols for managing commonly used drainage tubes, such as the Jackson-Pratt (JP) drain or Hemovac are essential for inclusion in the nursing practicum. Nevertheless, drainage tubes are managed according to the type of surgery, type of drainage tube, and guidelines at each institution [7]. Hence, a consistent protocol must be developed to ensure guideline-based, repetitive, and systematic education. Given this context, this study aimed to develop a drainage tube management protocol for nursing students to enhance their core nursing skills and improve the quality of the nursing practicum.

1. Literature Review

The historical evolution of drainage tubes can be traced back to the 5th century BC when an ancient Greek physician named Hippocrates recognized the importance of “ drain” in incising and draining abscesses [7]. Based on this, he attempted to perform a “ passive drainage” using gauze, metal, and glass tubes [7]. In subsequent centuries, there are records of various uses of drainage tubes, including the use of gravity drainage via metal intubation in the abdominal cavity by the Roman physician Celsus during the 1st century, and the discovery of the capillary effect in passive drains by Leonardo da Vinci during the Renaissance period [7]. Drainage tubes were further diversified in subsequent years with the introduction of the Penrose drain in 1890 and the development of the active drain by Heaton in 1889. Since 1947, suction drains have been used to prevent postoperative exudate pooling, and closed suction drains have been used since 1952 [7].

Wound drainage tubes have been used to prevent infection for a considerable amount of time, particularly in surgical patients. The absence of a drainage tube may cause certain wounds to appear externally healed while inter-nally harboring abscesses. However, empirical data have revealed that the incidence of site infections was 7.1% in patients without drainage tubes, 7.4% in patients with one tube, and 25.7% in those with two or more tubes, indicating a positive correlation between the number of tubes used and incidence of site infection [8]. Consequently, systematic management is imperative to optimize the bene-fits of drainage tubes while minimizing their adverse effects [9].

The fundamental concept of drainage tube management is consistent across the different types of drainage tubes, although some variations may exist. Nurses must ensure that the drainage tube functions properly and monitor for signs of infection or inflammation around the area [9]. Education on when to request drainage tube emptying, potential discomfort, situations where patients need to notify healthcare staff, and how to educate patients on the management of drainage tubes at home after discharge is essential [10]. The timing of drainage tube removal is controversial, but it is generally removed when the volume of drainage is less than 25∼30 mL per day or less than 1 mL per hour. Given that there is no standard duration for drainage tube placement, with varying criteria depending on the type of surgery, type of drainage tube, and the country and institution, the current practice is to adhere to the guidelines of each institution [7].

To reduce the risk of internal damage at the insertion site and minimize tissue irritation, drainage tubes should be made of a soft material that does not corrode or degrade. They should also be sufficiently sturdy to remain in place and be easy to remove. Drainage tubes are classified into two types: open passive drains (e.g., Penrose drains) and closed active drains, which are the most commonly used (e.g., JP drain or Hemovac). Closed active drains reduce the risk of microbial invasion through the tube into the wound and allow for accurate measurement of drainage volume [11]. These types of drainage tubes must be managed to maintain negative pressure in the reservoir to prevent it from expanding, and their patency must be maintained by squeezing each tube at an appropriate time to prevent blockage [7,8]. Furthermore, to prevent infection, hand hygiene should be maintained, gloves worn, and the drainage port should not be touched when managing drainage tubes, such as when emptying them [10]. Wearing personal protective equipment, such as an apron, can help prevent contamination of the drainage fluid and cross-contamination. Nurses are also instructed to continuously monitor and notify the provider in case of drainage tube dysfunction, sudden changes in drainage, or signs and symptoms of infection [11]. Therefore, basic drainage tube management skills for nurses in clinical settings should include understanding the roles and functions of different types of drainage tubes and anticipating and responding to changes in drainage and possible adverse events. In particular, the level of difficulty (medium) and objectives of drain management (explaining the purpose and process of drain management/gathering the supplies needed for drain management/performing drain management/docu-menting the results of drain management), a core nursing skill defined by the KABNE [1], must be considered when developing a drainage tube management (JP drain or Hemovac) protocol for nursing students.

Based on the literature review, the types of drainage tubes, management, and nursing interventions required for the development of a drainage tube management (JP drain or Hemovac) protocol for nursing students were discussed.

METHODS

The drainage tube management (JP drain or Hemovac) protocol for nursing students was developed in four stages-preliminary survey (stage 1), establishment of criteria for the implementation of the protocol (stage 2), finalization of the protocol (stage 3), and development of nursing scenarios to implement the developed protocol (stage 4). The drainage tube management protocol was developed between August 2022 and December 2022.

Stage 1. Preliminary Survey

In stage 1, the literature pertaining to evaluation tools for drainage tube management guidelines in Korea and abroad was searched. Relevant studies were collected from PubMed, Cochrane, CINAHL, and Web of Science. Additionally, the fundamentals of nursing textbooks were searched to confirm the specific procedures for drainage tube management.

Stage 2. Establishment of Criteria for the Protocol

In stage 2, the level of difficulty and objectives applicable to nursing students were identified. To this end, “ postoperative nursing” was referred to among the core basic purging skills described by the KABNE, which includes the skill of drainage tube management.

Stage 3. Protocol Development

The items in the protocol, supplies, and evaluation scoring were developed in stage 3. The content validity of the preliminary protocol items-that is, whether they reflect the latest knowledge and skills required in nursing practicum and education-was evaluated by three experts (one nursing professor with 20 years of teaching experience; one nursing professor with working experience as an infection management nurse; and one wound, ostomy, and con-tinence nurse). Each protocol item was rated on a four-point scale (1=not relevant at all, 2=not relevant, 3=relevant, 4=highly relevant), and the content validity index (CVI)-the percentage of experts rating the item as 3 or 4-was calculated for each item.

Stage 4. Nursing Situation Development

In Stage 4, nursing scenarios reflecting the actual clinical setting were developed to implement the protocol, and the relevance of the scenarios was evaluated by three experts (educational purpose, fundamentals of nursing practice for grade 2 in the first stage, nursing school lab en-vironment, and supplies).

RESULTS

Stage 1. Preliminary Survey

During the preliminary investigation in the first stage, we did not find domestic or international standardized practical guidelines related to drainage tube management, and there was no standardized protocol for nursing fundamentals in the nursing textbooks. Accordingly, it was confirmed that a preliminary protocol that is applicable to JP drain or Hemovac drainage tube management by utilizing the 4.1 edition of the core basic nursing skill evaluation protocol published by KABNE should be developed [12].

Stage 2. Establishment of Criteria for the Protocol

Following stage 1, the objectives and level of difficulty were set at “ medium” for drainage tube assessment and management based on the 4.1 edition of the KABNE core basic nursing skill evaluation protocol [12] (Appendix 1).

Stage 3. Protocol Development

First, a preliminary protocol was developed by utilizing the 4.1 edition of the core basic nursing skill evaluation protocol published by KABNE [12]. The following procedures were added: 1) Number of times hand hygiene is practiced; 2) privacy protection of patients; 3) distinguishing between dressing conditions and infection symptoms and signs; 4) specific procedures for negative pressure formation by drainage tube type; and 5) patient education (maintaining patency, keeping it clamped, and maintaining negative pressure). The CVI of the preliminary protocol items was computed as 1, confirming good content validity [13]. In addition, the following items were revised by obtaining expert opinions: 1) Hand hygiene with water and soap separate from hand hygiene with sanitizer; and 2) redness as a symptom and sign of infection. The final drain tube management protocol outlined 23 steps, and the scoring system reflected whether it was fully performed (2), partially performed (1), or not performed (0), for a total possible score of 46 (Table 1, Appendix 2).

Table 1.

Drainage Tube Management (JP drain or Hemovac) Protocol (English)

No.	Steps	Fully performed (2)	Partially performed (1)	Not performed (0)	Note
1	Perform hand hygiene with soap and water.
2	Gather the necessary supplies.
3	Take the supplies to the patient and introduce yourself.
4	Perform hand hygiene with sanitizer.
5	Ask for the patient's name to confirm their identity, and confirm their name and registration number on the arm band with that on the patient list (or prescription).
6	Explain to the patient about the purpose and procedure of drainage tube management.
7	Close the curtain (screen) to protect the patient's privacy.
8	Perform hand hygiene with sanitizer.
9	Wear disposable gloves.
10	Unlock the fixed drain and check the patency and whether there are no twisted or occluded parts.
11	Check the dressing (e.g., exudate, blood) around the drainage tube and for signs and symptoms of infection (e.g., elevated temperature, local warmth, erythema, and pain).
12	Clamp the upper part of the drain, safely hold the suction bulb, and carefully open the stopper.
13	Transfer the drainage to a measuring container.
14	Wipe the opening and bulb cap with an alcohol pad, discard the pad in an emesis basin, and close the stopper while pressing the suction bulb to apply negative pressure (For JP drain, use one hand to compress the suction bulb completely along the vertical axis and the other hand to close the stopper. For Hemovac, keep pressing until the suction bulb is completely compressed, and then close the stopper).
15	Open the clamp at the top of the drainage tube and check for drainage.
16	Check the drainage for volume, color, and transparency.
17	Discard the gloves and perform hand hygiene with sanitizer.
18	Safely fix the drainage tube, and ensure the patient is comfortable.
19	Educate the patient about how to manage the drain (maintaining patency, keeping it clamped, and maintaining negative pressure)
20	Perform hand hygiene with sanitizer.
21	Wear disposable gloves, gather all used supplies, and take the drainage to the soiled utility room to dispose in the clinical sink.
22	Dispose the gloves and perform hand hygiene with soap and water.
23	Document your activity. 1) State of the drainage dressing. 2) Drainage characteristics (e.g., volume, color, and transparency 3) Patient education
Total

Stage 4. Nursing Situation Development

The example nursing scenario was designed to evaluate the process through which nursing students provide care for a postoperative patient with a JP drain (or Hemovac). According to the evaluation of three experts, the nursing scenario was found to be relevant in terms of the objectives, Level 1 (fundamentals of nursing practice for sophomores in the first stage), and nursing school lab en-vironment and supplies (Table 2, Appendix 3). In addition, the scenario was designed such that it could be modified and adapted to various real-world clinical situations.

Table 2.

Example Nursing Scenario (English)

A 68-year-old male named Bae-Aek Kim had laparoscopic cholecystectomy due to cholelithiasis and had a JP drain (or Hemovac) placed. Patient is currently on postoperative day 2 and is draining through the tube. The day shift nurse is assessing the drainage tube site and emptying the suction bulb to measure intake and output (I & O).

DISCUSSION

This study aimed to develop a standardized drainage tube management protocol for nursing students to enhance their core nursing skills and improve the quality of the nursing practicum. To foster nursing students’ practical skills, the KABNE continuously evaluates core basic nursing skills based on the nursing education system [1]. In the 4th cycle (2021) of nursing education accreditation evaluation, “ drainage tube management” was proposed as a new core nursing skill based on a job analysis of new graduate nurses [2]. Thus, this study aimed to develop a validated protocol for drainage tube management to ensure a standardized and consistent nursing practicum, which is expected to contribute to repetitive and systematic nursing practicum.

In accordance with the objectives of “ drainage tube management” presented by the KABNE [1], the types of drainage tubes and scope of practice were limited to ensure Level 1 (fundamentals of nursing practice for grade 2 in the first stage). JP drain and Hemovac were chosen as the drainage tubes because they are the most commonly used in clinical practice [6,14] and require caution regarding negative pressures in the reservoir. The scope of drainage tube management was defined in terms of the frequency of practice and patient safety. Thus, the following items were adopted from the Core Basic Nursing Skill, 4.1 edition: checking the patency of the drainage tube, assessing the dressing for symptoms and signs of infection, emptying the drainage bag to measure drainage volume, and checking the drainage. The following items were added to address aspects that are often overlooked, such as hand hygiene, patient privacy, and patient education: item 7 (ensure patient privacy by closing the curtains [screen]), item 17 (taking gloves off and performing hand hygiene with a sanitizer), item 18 (fixing the drainage tube safely and ensuring patient comfort), and item 19 (educate patients on how to manage the drainage tube-maintain patency, close the cap, maintain negative pressure). We developed a Level-1 scenario involving a patient who under-went laparoscopic cystectomy and had a drainage tube placed, which was confirmed to be relevant by clinical experts. A protocol for drainage tube management (JP drain or Hemovac) was presented. The developed scenario and protocol were rated by experts as appropriate for Level-1 nursing students (fundamentals of nursing practice for sophomores), contained the latest knowledge and skills, and utilized specific action words such that the instructor could objectively assess students’ performance.

JP drain and Hemovac [7], the most commonly used drainage tubes, are circular, closed wound drainage systems made of silicone for suctioning exudates from surgical sites [15]. Maintaining negative pressure is essential for the proper functioning of the tubes. Without proper negative pressure, foreign substances can be introduced into the drainage site, causing infection. Therefore, nurses must manage the suction force by emptying the contents of the suction bulb and applying negative pressure on the wound suction bulb. Previous studies have provided use-ful evidence for maintaining negative pressure in a JP drain [16,17]. Therefore, we added specific instructions on how to compress the suction bulb vertically to the long axis of the JP drain in our protocol.

Generally, placing drainage tubes increases the risk of surgical site infections [7,18,19]. Preventing and managing site infections is crucial because they can lead to longer hospital stays, increased antibiotic use, and higher mortal-ity and morbidity rates [7,18]. Patients with drainage tubes have a six-fold higher risk of developing surgical site infections than those without drainage tubes [18], and fac-tors such as location, number, depth, and duration of drainage tube insertion have been reported to be significantly associated with an increased risk of infection [20,21]. However, many studies have found no statistically significant differences in infection rates between patients with and without drainage tubes [22-24]. In light of previous findings showing different patterns of microorgan-isms isolated from wounds, these conflicting results suggest that external contamination through drainage tubes is a possible cause of infection [25]. Therefore, nurses must adhere to standard precautions for drainage tube management and infection monitoring. Hand hygiene is the best way to prevent surgical site infections. Nurses should perform hand hygiene before and after touching the patient, before and after contact with drainage, and before and after wearing gloves, in addition to frequently changing gloves to prevent pathogen transfer to other parts of the body [26]. Nurses must also adhere to a series of infection management guidelines, such as avoiding touching the in-side of the suction bulb when opening or closing the drainage tube and cleaning the area with an alcohol swab after emptying the bag [27]. To assess surgical site infection, nurses should monitor whether the tube-site skin and dressing are clean and dry [28]; whether there are changes in the amount, color, transparency, and odor of drained fluid [26]; and whether they wear appropriate personal protective equipment (PPE), including gloves, to protect themselves from sudden exposure to body fluids [6]. The drainage tube management protocol, which includes these infection control principles, is expected to serve as specific learning material for nursing students to assess surgical site infections and prevent the transmission of infections related to drainage tubes.

Closed negative-pressure drainage tubes must be managed regularly to ensure that the suction bulb does not expand, and that the tubes are not blocked. Although this is the responsibility of the nurses who manage the drainage tube, the patient who has the tube placed should also check. In other countries, research and educational materials have been developed for patients with drainage tubes, including methods for emptying and measuring drainage, timing of drain emptying, maintaining patency (including removing impurities), identifying signs of infection, and seeking medical attention [9,29,30]. Educational videos on drain management and disinfection are also available in Korea for discharged patients; however, research on educational programs and materials for inpatients is scant. Therefore, we recommend that future studies develop and validate educational materials and programs for drainage tube management of inpatients.

This study has several limitations. First, we could not address open or closed drainage tubes other than the JP drain and Hemovac. Subsequent studies should develop standardized protocols tailored to different types of drainage tubes with varying roles and functions for use in clinical practice by nursing students. Second, the protocol lacks detailed nursing activities for identifying infections and inflammation around the drainage tube site and providing wound care. These activities are important for the prevention of complications due to drainage tubes and early detection of risks, but the “ drainage tube management” protocol developed in this study focuses mainly on emptying the drain. However, the basic scope of drainage tube management required by nurses in clinical practice varies across hospitals and attending physicians, making the consistent implementation of this protocol difficult. Nursing theories on drainage tube management suggest that nurses should check the wound while emptying the drainage tube [15]; therefore, further consideration is needed on how to practically implement this aspect of the protocol. Third, this study's protocol was designed for Level-1 nursing students (fundamentals of nursing practice for sophomores) and does not cover nursing actions for managing a blocked drainage tube, symptoms of infection and hemorrhage, maintenance of appropriate negative pressure, preparation for drainage tube removal, or methods of communicating changes in drainage volume and patterns within the healthcare team. Subsequent studies should develop nursing situations and protocols that pro-mote critical thinking in nursing students, including various issues in drainage tube management at varying levels of clinical nursing practices for third-and fourth-year nursing students.

CONCLUSION

It is important to educate and evaluate nursing students on core nursing skills that must be learned and acquired during their school years, owing to their high frequency and importance in nursing practice. To this end, standardized protocols for each core nursing skill should be used to ensure consistent education and evaluation in nursing situations that resemble the clinical setting, which requires continual updating of the core nursing protocols. In particular, despite the common postoperative use of closed suction drainage systems such as JP drains and Hemovac for surgical wound drainage, the drainage tube management guidelines vary across institutions, hindering nurses from providing quality care. Therefore, we aimed to address this issue by developing a standardized drainage tube management protocol.

Notes

CONFLICTS OF INTEREST

The authors declared no conflict of interest.

AUTHORSHIP

Study conception and design acquisition - Choi D, Lee H, Choi M-J, Kim K, Shin YH, & Kim J-S; Data collection - Choi D, Lee H, Choi M-J, & Kim J-S; Data analysis & Interpretation - Choi D, Lee H, Choi M-J, & Kim J-S; Drafting & Revision of the manuscript - Choi D, Lee H, Choi M-J, Kim K, Shin YH, & Kim J-S.

DATA AVAILABILITY

The data that support the findings of this study are available from the corresponding author upon reasonable request.

REFERENCES

1. Korean Accreditation Board of Nursing Education. Accreditation assessment standards for education of Korea (the course of the nursing bachelor's degree) [Internet]. Seoul: Korean Nurses Association; 2014. [cited 2022 February 6]. Available from: http://www.kabone.or.kr

2. Korean Accreditation Board of Nursing Education. Accreditation assessment standards for education of Korea (the course of the nursing bachelor's degree) [Internet]. Seoul: Korean Nurses Association; 2021. [cited 2022 February 6]. Available from: http://www.kabone.or.kr/participation/frequentlyQ.do

3. Yang YS, Kim DH. Nurses’ professionalism and job satisfaction on the level of delegation of nursing activities in long-term care hospitals. Journal of Korean Gerontological Nursing. 2013; 15(2):175-184.

4. Chung JA, Choi HR. A comparative study on the clamping protocols of a biliary external drainage tube in adult living-donor liver transplant recipients. Journal of Korean Critical Care Nursing. 2014; 7(1):33-39.

5. Yang SH. Dreaming of change: action research on intentional nursing rounds of clinical nurses [dissertation]. Gwangju: Chonnam National University; 2016. p. 19-140.

6. Jang HS. Development and implementation of intentional nursing rounds protocol of elderly nursing hospital nurses [dissertation]. Gwangju: Chonnam National University; 2016. p. 54-62.

7. Kim SG. Programme for surgical nurses: types of drainage tubes and proper care. The 61th Annual Congress of the Korean Surgical Society. 2009 November 7-9. Grand InterContinental Seoul Parnas; Seoul: 2009. p. 113-116.

8. Ahn YJ, Sohng KY. Factors related to surgical site infections in patients undergoing general surgery. Journal of Korean Academy of Fundamentals of Nursing. 2005; 12(1):113-120.

9. Laurence K, Colin T. Surgical Drains: Indications, Management, and Removal [Internet]. Leeds: Patient Acess. 2021. [cited 2022 December 27]. Available from: https://patient.info/doctor/surgical-drains-indications-management-and-removal

10. Memorial Sloan Kettering Cancer Center. Caring for Your Jack-son-Pratt® Drain [Internet]. New York: Memorial Sloan Kettering Cancer center; 2019. [cited 2022 December 27]. Available from: https://www.mskcc.org/pdf/cancer-care/patient-education/caring-your-jackson-pratt-drain

11. Sohng KA, Choi DW, Yang JH, Kim YH, Kim SS, Kim KM, et al. Fundamentals of nursing. Seoul: Soomoonsa; 2023. p. 230.

12. Korean Accreditation Board of Nursing Education. Accreditation assessment standards for education of Korea. Core basic nursing evaluation item protocol 4.1 ed. Seoul: Korean Nurses Association; 2017. [cited 2022 February 6]. Available from: http://www.kabone.or.kr

13. Lynn MR. Determination and quantification of content validity. Nursing Research. 1986; 35(6):382-385.

14. Schein M. To drain or not to drain? The role of drainage in the contaminated and infected abdomen: an international and personal perspective. World Journal of Surgery. 2008; 32(2):312-321. https://doi.org/10.1007/s00268-007-9277-y

15. Won JS. Fundamentals of nursing skills.. 4th ed.. Seoul: Hyunmoonsa; 2023. p. 522-524.

16. Mamuyac EM, Pappa AK, Thorp BD, Ebert Jr CS, Senior BA, Zanation AM, et al. How much blood could a JP suck if a JP could suck blood? The Laryngoscope. 2019; 129(8):1806-1809. https://doi.org/10.1002/lary.27710

17. Taylor CR, Lynn PB, Bartlett JL. Fundamentals of Nursing: The Art and Science of Personcentered Care.. 10th ed.. Pennsylva-nia: Wolters Kluwer Health; 2022. p. 1213.

18. Barbadoro P, Marmorale C, Recanatini C, Mazzarini G, Pelleg-rini I, D'Errico MM, et al. May the drain be a way in for microbes in surgical infections? American Journal of Infection Control. 2016; 44(3):283-288. https://doi.org/10.1016/j.ajic.2015.10.012

19. Mujagic E, Zeindler J, Coslovsky M, Hoffmann H, Soysal SD, Mechera R, et al. The association of surgical drains with surgical site infections - A prospective observational study. The American Journal of Surgery. 2019; 217(1):17-23. https://doi.org/10.1016/j.amjsurg.2018.06.015

20. Reiffel AJ, Barie PS, Spector JA. A multi-disciplinary review of the potential association between closed-suction drains and surgical site infection. Surgical Infections. 2013; 14(3):244-269. https://doi.org/10.1089/sur.2011.126

21. Jung HK, Lee EN. Validation of the risk prediction tool for wound infection in abdominal surgery patients. Journal of Korean Critical Care Nursing. 2022; 15(3):75-87. https://doi.org/10.34250/jkccn.2022.15.3.75

22. Picchio M, De Angelis F, Zazza S, Di Filippo A, Mancini R, Pattaro G, et al. Drain after elective laparoscopic cholecystectomy. A randomized multicentre controlled trial. Surgical En-doscopy. 2012; 26(10):2817-2822. https://doi.org/10.1007/s00464-012-2252-1

23. Rondelli F, Desio M, Vedovati MC, Balzarotti Canger RC, Sanguinetti A, Avenia N, et al. Intra-abdominal drainage after pancreatic resection: is it really necessary? A meta-analysis of short-term outcomes. International Journal of Surgery. 2014; 12(1):S40-S47. https://doi.org/10.1016/j.ijsu.2014.05.002

24. Kim EY, Lee SH, Lee JS, Yoon YC, Park SK, Choi HJ, et al. Is rou-tine drain insertion after laparoscopic cholecystectomy for acute cholecystitis beneficial? a multicenter, prospective randomized controlled trial. Journal of Hepato-Biliary-Pancreatic Sciences. 2015; 22(7):551-557. https://doi.org/10.1002/jhbp.244

25. Cerise EJ, Pierce WA, Diamond DL. Abdominal drains: their role as a source of infection following splenectomy. Annals of Surgery. 1970; 171(5):764-769. https://doi.org/10.1097/00000658-197005000-00016

26. Orth K. Preventing surgical site infections related to abdominal drains in the intensive care unit. Crit Care Nurse. 2018; 38(4):20-26. https://doi.org/10.4037/ccn2018254

27. Lagnese MS, Travaline JM. Drainage tube management. In: Criner GJ, Barnette RE, D'Alonzo GE, editors. Critical care study guide. NY: Springer New York; 2010. p. 70-80.

28. Makama J, Ameh E. Surgical drains: what the resident needs to know. Nigerian Journal of Medicine. 2008; 17(3):https://doi.org/10.4314/njm.v17i3.37389

29. Reid RR, Dumanian GA. A minimalist approach to the care of the indwelling closed suction drain: a prospective analysis of local wound complications. Annals of Plastic Surgery. 2003; 51(6):575-578. https://doi.org/10.1097/01.sap.0000095650.39621.41

30. Clinical Center National Institutes of Health. HoW To Care For The Jackson-Pratt Drain [Internet]. Maryland: Clinical Center National Institutes of Health; 2015. [cited 2022 December 27]. Available from: https://cc.nih.gov/ccc/patient%5Feducation/pepubs/jp.pdf

Appendices

Appendix 1.

배액관 관리 (JP drain 또는 Hemovac) 간호상황과 성취목표, 선행지식, 준비물품＜난이도: 중＞

1. 시나리오 요약	․ 68세 김배액 (남), 담석으로 복강경 담낭 절제술을 받고 JP drain (또는 Hemovac)을 삽입한 채 수술 후 2일째 되는 날
1. 시나리오 요약	․ 삽입된 배액관으로 분비물이 배액되고 있음
2. 성취목표	․ 배액관 관리의 목적과 절차를 설명할 수 있다.
	․ 배액관 관리에 필요한 물품을 준비할 수 있다.
	․ 배액관 관리를 수행할 수 있다.
	․ 배액관 관리 수행결과를 기록할 수 있다.
	․ 배액관 삽입의 목적
3. 선행지식	․ 배액관 종류에 따른 관리방법
3. 선행지식	․ 배액관 삽입 후 합병증
4. 준비물품	․ 상반신 모형 또는 전신 모형
	․ 소독솜
	․ 쟁반 (Tray), 곡반
	․ 배액관 (JP drain, Hemovac)
	․ 배액 측정컵
	․ 일회용 장갑
	․ 손소독제
	․ 간호기록지
	․ 의료폐기물 전용용기 (일반)
	․ 커튼 또는 스크린

Appendix 2.

배액관 관리 (JP 또는 Hemovac) 프로토콜

번호	수행항목	완전 수행 (2)	부분 수행 (1)	미수행 (0)	비고
1	물과 비누로 손위생을 실시한다.
2	필요한 물품을 준비한다.
3	준비한 물품을 가지고 대상자에게 가서 간호사 자신을 소개한다.
4	손소독제로 손 위생을 실시한다.
5	대상자의 이름을 개방형으로 질문하여 대상자를 확인하고, 입원팔찌와 환자리스트 (또는 처방지)를 대조하여 대상자 (이름, 등록번호)를 확인한다.
6	대상자에게 배액관 관리의 목적과 절차에 대해 설명한다.
7	커튼 (스크린)으로 대상자의 사생활을 보호해 준다.
8	손소독제로 손 위생을 실시한다.
9	일회용 장갑을 착용한다.
10	고정되어 있는 배액관을 풀어 배액이 잘되고 있는지, 배액관이 꼬이거나 접혀있지 않은지, 막힌 부분이 없는지 확인한다.
11	배액관 삽입 부위 dressing 상태 (삼출물, 출혈 등)와 감염의 증상과 징후 (체온 상승, 국소적 열감, 발적, 통증 등)를 확인한다.
12	배액관 위쪽을 잠금장치 (clamp)로 잠근 후 흡인백을 안전하게 잡고 주의 깊게 마개를 연다.
13	흡인백의 내용물을 눈금이 있는 배액용기에 옮겨 담는다.
14	소독솜으로 배출구와 흡인백 마개를 닦고 사용한 소독솜을 곡반에 버린 후 흡인백을 눌러 음압이 유지된 상태에서 배출구를 닫는다. (JP의 경우, 한 손으로 흡인백의 세로축을 따라 좌우로 흡인백을 완전히 압축하고 다른 손으로 마개를 닫는다. Hemovac의 경우, 흡인백이 완전히 압축될 때까지 누른 상태에서 마개를 닫는다.)
15	배액관 위쪽의 잠금장치 (clamp)를 열어서 배액 여부를 확인한다.
16	배액용기에 수집된 배액물의 양상 (양, 색깔, 투명도)을 확인한다.
17	장갑을 벗고 손소독제로 손 위생을 실시한다.
18	배액관을 안전하게 고정하고 대상자를 편안하게 해준다.
19	대상자에게 배액관 관리방법을 교육한다 (개방성 유지, 마개의 잠금 및 음압 유지).
20	손소독제로 손 위생을 실시한다.
21	일회용 장갑을 착용한 다음 사용한 물품을 정리하고 배액물을 오물처리실로 가져가 오물배출구 (clinical sink)에 버린다.
22	장갑을 벗고 물과 비누로 손위생을 실시한다.
23	수행결과를 간호기록지에 기록한다. 1) 배액관 dressing 상태 2) 배액양상 (배액의 양, 색깔, 투명도 등) 3) 교육내용
합계

Appendix 3.

교수자용 간호상황 요약서

간호수행 지시서	다음 상황에 따라 배액관 관리를 위한 간호를 수행하시오.
상황 요약	담석증으로 복강경 담낭 절제술을 받고 JP drain (또는 Hemovac)을 삽입한 채 수술 후 2일째 되는 날로 배액관을 통해 분비물이 배액되고 있다. 낮 근무 중인 담당간호사가 섭취량과 배설량 체크를 위해서 배액관 삽입 부위 상태를 사정하고 흡인백을 비우고 있다.
환자 역할	침상에서 JP drain (또는 Hemovac)을 삽입한 채 누워있다.
진단명	담석증	수술명	복강경 담낭 절제술
환자이름	김배액
환자특성	연령: 68세	성별: 남
	신장: 168cm	체중: 68kg
	- 병색/표정/기분/목소리/자세/몸짓/외모/복장: 환자는 환자복을 입고 있으며, 수술 후 통증 (NRS 3점)이 있으나 일상생활이 모두 가능한 상태
	- 배액의 특성: 양 (흡인백의 1/3 정도), 양상 (Sanguineous)
	- Dressing 상태: 깨끗하고 건조한 상태
	- 활력징후: 혈압 120/68mmHg, 맥박 68회/분, 호흡 18회/분, 체온 36.8℃
	간호사에 대한 태도: 협조적이며 의료진에 대한 신뢰가 있음
관련 병력	환자가 말하는 주호소: 수술 후 통증 (NRS 3점)
	질병의 경과: 담석증을 진단받고 복강경 담낭 절제술을 받은 상태
	과거병력: 10년 전 고혈압 진단
	가족력: 아버지가 고혈압이 있었음
표준화 환자 주요질문	1. 배액관은 어떻게 관리해야 하나요?
	2. 배액관 부분의 감염을 어떻게 알 수 있나요?