Exudate Assessment

(Adapted from M, Romanelli et al., 2010; WUWHS, 2019)

Assessment is the first stage in the management of highly exuding wounds. The assessment process should include a description of the nature and amount of the exudate, as well as identification of the cause.

Wounds have traditionally been classified as lightly, moderately or heavily exuding, and it is often assumed that nurses can differentiate between these. However, little evidence has been published in support of this commonly held belief (Thomas, 1997).

Assess the exudate

Note the colour, consistency and odour of the exudate on the dressing and in the wound.

• Increased protein content due to infection or inflammation may cause exudate to become thick and sticky (Adderley, 2008)
• Exudate that is thin or runny may be due to a low protein content that may be associated with venous or congestive cardiac disease or malnutrition (WUWHS, 2019; Wounds UK, 2013)
• Infection, necrotic tissue or a particular contributory factor may explain the findings
• Assess the wound base/edge and periwound skin
• Establish aetiology, stage of healing, size and depth, and condition of the wound base and edge
• How far from the wound edge does any maceration/excoriation extend?

(WUWHS, 2019)

Odour

Unpleasant odours may be related to bacterial growth and infection (Gardner, 2012). However, malodour maybe related to certain dressing types, such as hydrocolloids (Adderley, 2008).