BY: NANCY MORGAN, RN, BSN, MBA, WOCN, WCC, CWCMS, DWC
We’ve talked about types of exudate (drainage). Now let’s consider the amount of exudate in wounds, which is a key part of our assessment.
No exudate present: The wound is too dry.
Scant amount of exudate present: The wound is moist, even though no measurable amount of exudate appears on the dressing.
Small or minimal amount of exudate on the dressing: Exudate covers less than 25% of the bandage.
Moderate amount of drainage: Wound tissues are wet, and drainage involves 25% to 75% of the bandage.
Large or copious amount of drainage: Wound tissue is filled with fluid, and exudate covers more than 75% of the bandage.
Always take into account the amount of exudate when selecting the dressing. We want to promote moist wound healing, with a moist wound and no adverse effects of moisture, such as maceration of the periwound.
Do you always document the amount of drainage by using the terms none, scant, small, moderate or large? Or does your clinical setting use percentages instead? Is a certain level of drainage needed before you can institute a moisture barrier or skin sealant for periwound protection? Do you see a lot of “dry” wounds or a lot of heavily draining wounds?
DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.
