The amount and characteristics of wound exudate should be documented with each wound assessment and/or dressing change in the medical record. It is important for clinicians to be able to assess whether the amount of exudate being produced by a wound is normal, too low or too high, and, importantly, whether it has changed since the previous assessment. Maintaining an environment for wound healing involves a moist environment. What is the relationship between the amount of wound exudate and healing? Copious – Wound tissues bathed in fluid and freely draining with >75% saturated superabsorbent dressings.Large – Wound tissues bathed in fluid drainage freely expressed may or may not be evenly distributed in the wound drainage involves >75% of the dressing.Moderate -Wound tissues saturated drainage may or may not be evenly distributed in the wound drainage involves >25% to ≤75% of the dressing.Small– Wound tissues are wet and moisture is evenly distributed in the wound (typically drainage involves ≤25% of the dressing).Scant– Wound tissue is moist, but no measurable exudate.What are some common terms used for documenting wound exudate?Ĭommon terms to document the amount of exudate include: While there is no standard amount of exudate production or method for measuring the rate of production, monitoring the exudate amount is important to support wound healing assessment and to support dressing selection and reimbursement requirements. The amount of drainage should also be noted. Purulent (or pus) – Yellow, green, tan, creamy or other drainage that is also cloudy may be watery or viscous.Serosanguinous – Pink/reddish, watery drainage.

Sanguineous (or bloody) – Red, bloody-looking watery drainage.Any odor, such as sweet, fruity, fishy, ammonia-like, and foul, should also be described.Įxudate should also be documented by common terminology that includes: When assessing exudate, the fluid consistency - such as watery or viscous - should be documented. How should you assess and document wound exudate? Excessive or insufficient exudate or changes in the biochemical composition of the fluid may result in delayed healing and chronic wounds. What are the benefits of wound exudate?Įxudate fluid provides a variety of growth factors, proteins, enzymes and a cellular-rich source to prevent tissues from drying out, provide immune dense functions, stimulate cellular growth and regulation and support tissue remodeling. It is also relatively clearer than exudate in appearance. It typically has a lower protein content, lower specific gravity, and fewer cell counts than exudate. Transudate may accumulate in tissues and cause edema.

This is different from fluid that occurs as a result of disturbances of hydrostatic or colloid osmotic pressure (not inflammation) which is known as transudate. The fluid that exudes out of a tissue or its capillaries because of injury or inflammation is known as exudate. The body produces fluid to an injured site for appropriate and timely healing as a normal response to tissue damage.

Serosanguineous exudate