When assessing and documenting a wound, it is important to note the amount and type of wound exudate (drainage). Using our senses is a large part of the initial wound assessment, followed by accurate documentation. Wound exudate or drainage gives us significant information about what is going on...
By Holly Hovan MSN, GERO-BC, APRN, CWOCN-AP
When assessing and documenting a wound, it is important to note the amount and type of wound exudate (drainage). Using our senses is a large part of the initial wound assessment, followed by accurate documentation. Wound exudate or drainage gives us significant information about what is going on with the wound, all the way down to a cellular level, and it is one of the wound components that guide our topical treatments. As mentioned in prior blogs, a dry cell is a dead cell, but a wound with too much moisture will also have delayed healing. Additionally, infection, poor nutrition, impaired mobility, impaired sensory perception, and even malignancy in the wound can impair the healing process.
In acute wounds, drainage typically decreases over several days while the wound heals, whereas in chronic wounds, a large amount of drainage is suggestive of prolonged inflammation with failure to move into the proliferative phase of wound healing.1 An increase in drainage with malodor can be an indication of infection and should be treated appropriately based on the overall picture and goals of wound care.
There are many different types, consistencies, colors, and characteristics of wound drainage. In this blog, we discuss the most common types and what they could mean.
Common Colors and Consistencies of Wound Drainage
Serosanguineous: Serosanguineous drainage is typically seen in a normal, non-infected wound. It is made up of blood and serous fluid and is typically pink-red and thin. This drainage is common in many wounds.1
Serous: This is thin, watery, clear drainage. It is also common in many wounds throughout the healing process and may also be seen in vascular wounds, specifically venous wounds (think of weeping legs from edema).1
Green: Malodorous, sweet-smelling, bright blue-green drainage is often indicative of Pseudomonas infection in the wound. This drainage may thicken and may also appear purulent, in large amounts. There may also be necrotic tissue present within the wound itself, and healing time will be prolonged as tissue destruction progresses.1
Yellow: This is sometimes a tricky color to document and interpret. Is the wound drainage truly yellow or purulent because of infection, or are you looking at liquefied slough or drainage brought on by the properties of the topical treatment?1 (See my prior blog on liquefied slough vs. purulent drainage for more information on this.)
Bloody (red): Bloody drainage is typically seen in fresh postoperative wounds or a fresh injury. The amount and color (bright red vs. dark red vs. pink) should be accurately documented and reported as appropriate.1
Important note: Certain topical treatments will change color when the antimicrobial properties have been used, when drainage is absorbed into them, or when removed. Think of topical silver or iodine products or topical treatments that contain methylene blue or gentian violet. Understanding the way the topical treatment works and application guidelines is important here, especially when it comes to accurately documenting and understanding what is going on with the wound.
As the expert clinician, it is imperative to be aware that wound drainage is often one of the most difficult features for a patient with a wound. Managing drainage, controlling odor, and maintaining a moist wound bed conducive to healing are very important. Wound drainage impacts quality of life and overall wound healing, and it should be managed appropriately for our patient population only to heal but also to use a wound care product that promotes good quality of life throughout the healing process (e.g., manages odor, drainage, fits under clothing as able).1
Accurate assessment of wound drainage and color is sometimes difficult because of the timing of the dressing changes, the products used, and extrinsic variables. It is important to make an accurate assessment and to use descriptive documentation to paint a picture of what is going on with the wound and the entire patient. Certain types of topical treatments can cause a change in wound drainage consistent with what is expected when that particular treatment is used.
A Few Tips When Documenting Wound Exudate
- Remove the old dressing; note the drainage in the wound bed itself and on the old dressing when making an assessment (is the wound bed wet, dry, scabbed? How much drainage is present on the old dressing? Think percentages here).
- What type of dressing was on the wound previously (hydrogel [moist] vs. hydrofiber or alginate [absorptive])? It is important to recall the properties of the topical treatment in use and what they’re intended to do in terms of the healing process.
- How long has the previous dressing been in place? If you’re removing it just a few hours after the treatment was applied for an assessment, wound drainage could be underreported.
- Cleanse the wound prior to documenting the presence of an odor. Many chronic wounds will have a “wound odor,” from old drainage, that goes away after cleansing. This would not be documented as active wound odor.
- Clinical judgment in terms of wound documentation requires training, knowledge, and experience. Additionally, knowledge of absorptive properties of the topical treatment along with suggested wear times is important. If you’re ever unsure, consult with your wound care specialist prior to documenting.
Accurate and clear documentation is a key factor in appropriate wound assessment and treatment. Painting an accurate picture of what is going on with a particular wound and patient through documentation is important for many reasons. In addition to the tips and knowledge shared here, your wound care specialist and the interprofessional team are great resources to manage the whole patient (not just the hole in the patient!).
- Bates-Jensen BM. Assessment of the patient with a wound. In: Doughty DB, McNichol LL, eds. WOCN Society Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:38-67.
About the Author
Holly is a board certified gerontological nurse and advanced practice wound, ostomy, and continence nurse coordinator at The Department of Veterans Affairs Medical Center in Cleveland, Ohio. She has a passion for education, teaching, and our veterans. Holly has been practicing in WOC nursing for approximately six years. She has much experience with the long-term care population and chronic wounds as well as pressure injuries, diabetic ulcers, venous and arterial wounds, surgical wounds, radiation dermatitis, and wounds requiring advanced wound therapy for healing. Holly enjoys teaching new nurses about wound care and, most importantly, pressure injury prevention. She enjoys working with each patient to come up with an individualized plan of care based on their needs and overall medical situation. She values the importance of taking an interprofessional approach with wound care and prevention overall, and involves each member of the health care team as much as possible. She also values the significance of the support of leadership within her facility and the overall impact of great teamwork for positive outcomes.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.