The nurse is instructed to discontinue the client's surgical wound drain today. What is the priority action?

The nurse is instructed to discontinue the client's surgical wound drain today. What is the priority action?

• A. Do not remove the drain, call healthcare provider
• B. Remove the drain immediately
• C. Clamp the drain and observe
• D. Notify the family

Answer: (A)

The priority is to obtain a provider’s order before removing a surgical wound drain. Drains are kept in place according to the surgeon’s plan to prevent fluid from collecting under the wound, which can lead to hematoma, seroma, infection, or wound dehiscence if removed prematurely. Even when told to discontinue today, you must verify with the healthcare provider and secure an explicit order for removal and any specific steps. In the meantime, maintain the dressing, monitor the drainage, and assess the site for signs of complications. Notifying the family and clamping or removing the drain without an order are not appropriate actions in this situation.

The priority is to obtain a provider’s order before removing a surgical wound drain. Drains are kept in place according to the surgeon’s plan to prevent fluid from collecting under the wound, which can lead to hematoma, seroma, infection, or wound dehiscence if removed prematurely. Even when told to discontinue today, you must verify with the healthcare provider and secure an explicit order for removal and any specific steps. In the meantime, maintain the dressing, monitor the drainage, and assess the site for signs of complications. Notifying the family and clamping or removing the drain without an order are not appropriate actions in this situation.