Wound Assessment: Wound Exudate

Author
Nancy Morgan
Category
Pressure Injuries
Wound Assessment: Wound Exudate
7
Jul

By Nancy Morgan, RN, BSN, MBA, WOC

 Nancy Morgan Wound Care brings you information you can apply in your daily practice.  

Support Resources 

Infographics, 

  1.  Wound Exudate Infographic
  2.  Wound Exudate Volume Infographic 

The drainage from a wound is called exudate. This substance is produced by the body in response to tissue damage. Exudate may be present in wounds as they heal. It consists of fluid that has leaked out of blood vessels and closely resembles blood plasma. Exudate can also result from conditions that cause edema, such as inflammation, immobility, limb dependence, and venous and lymphatic insufficiency. 

Accurate assessment of exudate is important throughout the healing process because the color, consistency, odor, and amount which can change because of various physiologic processes and underlying complications. 

Teamwork: It’s good to ensure clear communication among clinicians. Here are terms you should keep in mind when assessing the wound, evaluating, and documenting your findings. 

 Exudate Characteristics 

  • Serous—thin; clear; amber, or straw colored; watery plasma   
  • Serosanguineous – slightly thicker than water; clear; pink to light red; plasma with red blood cells 
  • Sanguineous—thin; watery; red (fresh bleeding)   
  • Seropurulent – thin; cloudy; creamy; yellow or tan 
  • Purulent—thick; opaque; milky; yellow, tan, or brown, and/or green  

Exudate Volume 

  • None—Wound tissues are dry  
  • Scant—Wound tissues are moist, but there is no measurable drainage  
  • Small/minimal—Wound tissues are very moist or wet; the drainage covers less than <25% of the dressing  
  • Moderate—Wound tissues are saturated; drainage may not be evenly distributed; covers >25% to  75% of the dressing  
  • Large or copious—Wound tissues are filled with fluid; drainage may not be evenly distributed; covers >75% of the dressing  

Exudate Consistency 

  • Low viscosity – thin, runny  
  • High viscosity – thick or sticky; doesn’t flow easily  

 Exudate Odors 

  • Odor or no odor present – Strong, foul, pungent, fecal, musty, or sweet 

 Exudate visible on primary and secondary wound dressings 

DRY…No visible exudate on primary dressing upon removal; dressing may adhere to wound bed 

MOIST…Small amounts of exudate are visible when dressing is removed; primary dressing may have light markings of drainage 

SATURATED…The primary dressing is very wet, and strikethrough can occur 

LEAKING…The dressings are saturated, and exudate is leaking from primary and secondary dressings onto the patient’s clothes 

 Selected References 

Gefen, Amit; Santamaria, Nick.  Saturation of a dressing applied to an exuding wound: the gap between clinical judgment and laboratory testing.  Wounds International.  (May 19, 2021).  Retrieved from https://www.woundsinternational.com/resources/details/saturation-dressing-applied-exuding-wound-gap-between-clinical-judgment-and-laboratory-testing 

Milne, Catherine; Thomason, Helen; Hughes, Maria. (2020). Managing highly exuding wounds — removing the risk of infection. Sophia University Institute.  Retrieved from https://www.coursehero.com/file/98260384/managing-highly-exuding-wounds-removing-risk-infection1pdf/ 

World Union of Wound Healing Societies (WUWHS) Consensus Document. Wound exudate: effective assessment and management Wounds International. (2019).  Retrieved from https://www.wuwhs.org/wp-content/uploads/2020/09/exudate.pdf 

Nancy Morgan RN, BSN, MBA, WOCN is an experienced clinician, successful business leader, and accomplished nurse educator in the field of wound management. She is the co-founder of the Wound Care Education Institute, (WCEI®), Wild on Wounds Productions; and, most recently established Nancy Morgan Wound Care offering innovative, educational resources including seminars, webinars, social media and wound care marketing tools to assist and support wound care clinicians at the bedside.  Nancy is one of the most distinguished wound care educators, delivering nearly 1200 lectures, conference keynote addresses, seminars, webinars, and bedside consultations during her career. 

Information is courtesy of Nancy Morgan Wound Care, copyright 2022.  

 

DISCLAIMER:  All clinical & legal information, text and graphics, in this blog are intended to assist with determining appropriate wound therapy or proper legal information.  It is not intended to be a substitute nor constitute providing legal or medical care or advice, diagnosis, or treatment.  Responsibility for final decisions and actions related to legality and care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians  and their legal representation.  Individuals should always contact their healthcare providers for medical or emergency-related care and/or contact their retained attorneys or their legal representation.

 

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