When it comes to nurses and a wound there is much terminology one must know and understand to be able to properly chart and use the correct terminology when describing a wound to another health care provider.
Exudate/Drainage rainage are probably one of the hardest things for new nurses to remember. What we once saw in simple colors we know have to look at on another level with a whole new terminology to be efficient in our jobs.
Types of Exudate/Drainage:
Serous – (white) Clear, watery fluid that has separated from its solid element.
Sanguineous – (pink) Fluid that contains blood
Serosanguineous – (red) Thin, red, composed of both of serum and blood.
If the tissue contains drainage/exudate that is brown-green purulent the wound is then infected.
Exudate is when cells, fluids or other substances have slowly exuded from cells or blood vessels through breaks in the cell membrane or small pores.
Drainage is the removal of fluids from a wound, body cavity or other source of discharge through one or more methods.
The type and amount that is produced depends on the organs and tissues involved, any more then 300ml in the first 24 hour period should be treated as an abnormality, bearing in mind that when your patient first starts to ambulate there may be an increase in the amount of exudates/drainage.
When a nurse does there wound assessment she should always note the color, amount, consistency, any odors, type of dressing and if there is a drainage system the nurse will want to note this as an abnormal and state any drainage from the drainage system and the way the wound looks around the drain. Good charting should be able to let other health care providers close their eyes and visualize exactly what you are describing. The nurse should also note the measurements, if any staples or stitches are present, if they are intact and how many stitches or staples are there.
Proper charting for the amount of exudates/drainage can be tricky because what you feel is one size to another is something else. This is why it’s safe to use standard sized items, quarter, penny, dime, instead of apple, orange, walnut. Who’s to say what someone may think if you say the size of an apple, is this a large, medium or small sized apple? Using words like scant (little), moderate(medium) and saturated (full) are acceptable terms when charting for the amounts.
