It is never considered normal in a wound bed, and new purulent drainage should always be reported to the health care provider. Purulent: Purulent exudate is thick and opaque.Serosanguinous: Serosanguineous exudate contains serous drainage with small amounts of blood present.It’s normal during the inflammatory stage of wound healing, and small amounts are considered normal wound drainage. Serous: Serous drainage is clear, thin, watery plasma.Sanguineous: Sanguineous exudate is fresh bleeding.The type of wound drainage should be described using medical terms such as serosanguinous, sanguineous, serous, or purulent. Large or copious amount of drainage: Wound tissue is filled with fluid, and exudate covers more than 75% of the bandage.Moderate amount of drainage: Wound tissue is wet, and drainage covers 25% to 75% of the size of the bandage.Minimal amount of exudate: Exudate covers less than 25% of the size of the bandage.Scant amount of exudate: The wound is moist, but no measurable amount of exudate appears on the dressing.Use the following descriptions to select the appropriate terms : The amount of drainage from wounds is categorized as scant, small/minimal, moderate, or large/copious. The color, consistency, and amount of exudate (drainage) should be assessed and documented at every dressing change. Tunneling and undermining should also be assessed, documented, and communicated. The appearance of slough (yellow) or eschar (black) in the wound base should be documented and communicated to the health care provider because it likely will need to be removed for healing. It bleeds easily with minimal contact and may be covered with biofilm. It is moist, painless to the touch, and may appear “bumpy.” Conversely, unhealthy granulation tissue is dark red and painful. Recall that healthy granulation tissue appears pink due to the new capillary formation. Wound BaseĪssess the color of the wound base. Refer to the “Staging” subsection of “Pressure Injuries” in the “ Basic Concepts Related to Wounds” section for more information about tissue damage. It is important to continually assess the degree of tissue damage in pressure injuries because the level of damage can worsen if they are not treated appropriately. For successful healing, different types of wounds require different treatments based on the cause of the wound.įigure 20.16 Wound Documentation Degree of Tissue Damage For example, a wound over the sacral area of an immobile patient is likely a pressure injury, and a wound near the ankle of a patient with venous insufficiency is likely a venous ulcer. The location of a wound also provides information about the cause and type of a wound. See Figure 20.16 for an example of facility documentation that includes images to indicate wound location. Many agencies use images to facilitate communication regarding the location of wounds among the health care team. This will ensure that if more than one wound is present, the correct one is being assessed and treated. The location of the wound should be documented clearly using correct anatomical terms and numbering. These components are further discussed in the following sections. Wound assessment should include the following components: Wounds should be assessed and documented at every dressing change.
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