S18 S18
Clinical comment
Exudate: friend or foe?
Abstract Wound exudate is an essential component in the normal process of wound healing. However, excess exudate has always been a major challenge for clinicians and a source of embarrassment and discomfort for the patient. The challenge for healthcare staff is to provide a wound
Key words:
Acute/chronic wound exudate
healing environment that offers the optimal amount of exudate to promote healing. This article provides the reader with an understanding of the benefits and problems associated with exudate.
Colour of exudate
Holistic assessment
Menna Lloyd Jones email: [email protected] Independent Tissue Viability Nurse
E
xudate is often described as wound fluid, wound drainage and ‘what is coming out of the wound’ (World Union of Wound Healing Societies (WUWHS), 2007). Exudate is a serous fluid closely resembling blood plasma. It leaks from capillaries as a consequence of increased capillary permeability during the inflammatory phase of healing as part of the body’s response to the initial injury or as part of the host response to large numbers of bacteria in the wound bed. Exudate is similar to the fluid that would normally bathe and provide nutrients to the cells in intact dermis (WUWHS, 2007; Dowsett, 2008;Davies, 2012). Although our current understanding of exudate is limited, it is understood to be produced in response to a complicated interaction between wound aetiology, wound healing physiology, wound environment and compounding pathological processes (WUWHS, 2007).
Winter (1962) listed the benefits of moist wound healing as improving healing rates, reducing pain and discomfort, and decreasing rates of wound infection. Providing a moist wound healing environment also enhances the rate of granulation tissue and epithelial migration (Dowsett, 2011). Too little exudate can lead to desiccation of the wound bed, which can cause pain and discomfort as well as contributing to a delay in healing (Panca et al, 2013). Exudate bathes the wound bed with a serous fluid that is mainly made up of water but also contains electrolytes, nutrients, proteins, growth factors, white blood cells (such as neutrophils, macrophages and platelets) and matrix metalloproteins (MMPs) (WUWHS, 2007; Dowsett, 2011). MMPs contribute to the breakdown of dead and devitalised tissue, while growth factors and cytokines contribute to the building of new tissue (Davies, 2012; Menon, 2012). The production of exudate is a vital component in wound healing and has a beneficial effect on healing by providing the optimal environment to promote cell proliferation and autolysis. Although the optimal amount of exudate required for healing is unknown, the amount of wound exudate produced does vary throughout healing— normally decreasing as wound healing progresses. However, differences have been identified between the amount and characteristics of acute and chronic wound exudate production (Dowsett, 2008).
© 2014 MA Healthcare Ltd
Benefits of exudate
Community Wound Care June 2014 Journal of Community Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 14, 2015. For personal use only. No other uses without permission. . All rights re
S20 S20
Clinical comment: Exudate: friend or foe?
Chronic wound exudate
increased risk of infection. However, it should be noted that wound infection itself is a cause of increased exudate Dowsett (2011) explains that the exudate found in acute (Dowsett, 2008; Panca et al, 2013). Excess exudate can also wounds is rich in leukocytes and essential nutrients and, lead to a significant loss of protein and electrolyte imbalance as explained above, provides the optimal environment for (Menon, 2012). Increased exudate can also leak out on to wound healing. However, as wound the surrounding skin, causing maceration exudate becomes chronic, rather and excoriation of the periwound skin ‘It is important to than promoting healing it becomes and possibly contributing to an increase destructive. The levels of proteases in the size of the wound (Dowsett, 2008; understand the role increase and slow down or block Menon, 2012). of exudate in wound the proliferation of keratinocytes, Excessive exudate can also be very fibroblasts and endothelial cells. distressing for the patient, requiring bulky healing, the properties It is suggested that, in chronic dressings which are uncomfortable and and function of the wounds, there is an imbalance in make wearing certain clothing and shoes the number of MMPs and tissue difficult. Strikethrough of exudate on to different dressings inhibitors of MMPs (TIMPs), the dressing can be both visually offensive with an increase in MMPs and a and also a source of malodour, which can available, and, most decrease in TIMPs. Therefore, the be distressing and embarrassing for the importantly, to undertake patient. Leakage can also soil clothing, MMPs continue to break down the wound matrix as there are bedding and furniture, increasing the a holistic assessment’. insufficient TIMPs to slow down the amount of laundry. Excess exudate can process. Consequently, the wound is cause isolation for the patient, which suspended between the inflammatory and proliferative stage in turn can cause depression (Dowsett, 2008; Davies, 2012; of healing (Davies, 2012; Probst and Huljev, 2013). Menon, 2012). There is also an increase in bacterial colonisation. In chronic wounds (unlike acute wounds), exudate can increase Management of exudate rather than decrease in volume and become difficult to manage (Dowsett, 2008; Cutting, 2009; Menon, 2012). WUWHS (2007) states that the aim of exudate management is to minimise detrimental effects and maximise positive Excessive exudate effects. In order to do this, it is important to understand the role of exudate in wound healing, the properties and function The amount of exudate produced by a wound is attributable of the different dressings available, and, most importantly, to to several factors (see Box 1). Exudate becomes problematic undertake a holistic assessment, looking at patient factors when the amount of exudate produced causes the dressing as well as assessing the wound. A wound assessment should to leak, necessitating high-frequency dressing changes. include assessing the exudate and dressings used (see Box 2). The production of excessive amounts of exudate can lead Assessing exudate to strikethrough of the dressings, which can lead to an WUWHS (2007) suggests that the information gathered from assessing the exudate will assist in the provision of appropriate care for the patient. Box 1. Causes of excessive exudate
The size of the wound—the larger the wound the greater the volume of exudate
Wound types—i.e. leg ulcers, burns and donor sites tend
Box 2. Patient assessment when managing exudate Patient assessment should include:
to produce higher volumes of exudate
Comorbidities
Increased bacterial load/wound infection Medical conditions—e.g. cardiac disease, peripheral
Medication
oedema Malnutrition Presence of foreign bodies and/or necrotic tissue Lack of concordance with recommended therapy
Issues with concordance
Adapted from WUWHS (2007), Benbow and Stevens (2010)
Mobility Psychosocial issues Nutritional status Dressings Adapted from Menon (2012)
© 2014 MA Healthcare Ltd
At wound healing stage, amount of exudate depends upon:
Community Wound Care June 2014 Journal of Community Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 14, 2015. For personal use only. No other uses without permission. . All rights re
Clinical comment: Exudate: friend or foe?
S21
Exudate volume Although it is important to record the volume of exudate, in clinical practice this is not so easy as there is no validated tool for its measurement. Traditionally, the volume of exudate has been recorded using ‘+’, ‘++’ and ‘+++’ to indicate a high, medium or low level, respectively. However, this method is considered to be subjective and far from accurate. Weighing dressings has also been considered, but again this method is considered to be inaccurate, time-consuming and of little value in improving patient care (Benbow and Stevens, 2010; Menon, 2012). However, it is suggested that it is more useful to document the frequency of dressing changes, how saturated the dressing is, whether there is strikethrough and how the dressing is managing the exudate by looking at the condition of the surrounding skin, noting any maceration and/or excoriation of the surrounding skin. Frequent dressing changes and maceration of the surrounding skin (see Figure 1) is an indication that the dressing selected is inappropriate. For example, if a dressing is designed to stay in place for 24 hours, if the exudate is controlled and the surrounding skin is intact at dressing change 24 hours later, then it could be considered that the exudate has been managed. If the dressing is saturated with strikethrough and/or there is maceration of the surrounding skin, then the dressing needs to be reviewed. In the same way, if the wound bed is dry and sticking to the wound bed, causing pain and discomfort for the patient, this is also an indication to review the dressing (Dowsett, 2008).
Table 1. Significance of exudate colour Clear, amber
Often considered to be ‘normal’ but it can be associated with infection by fibrinolysin-producing bacteria such as Staphyloccus aureus. It may also be due to fluid from a urinary or lymphatic fistula
Cloudy, milky or creamy
May indicate the presence of fibrin stands (fibrinous exudate—a response to inflammation) or infection (purulent exudate containing white blood cells and bacteria)
Pink or red
Due to the presence of red blood cells and may indicate the presence of wound infection, an underlying bleeding disorder or wound trauma.)
Green
May be indicative of bacterial infection e.g. Pseudomonas aeruginosa
Yellow or brown
May be due to the presence of wound slough or material from an enteric or urinary fistula
Grey or blue
May be related to the use of silvercontaining dressings
When all other causes have been excluded, recognising that some medications are known to discolour urine; considerations should be made to the possibility that drugs could also be a cause of exudate discolouration. Adapted from WUWHS (2007) and Dowsett (2008)
Exudate colour See Table 1 for guidance on the significance of exudate colour.
Exudate odour
Menna Lloyd Jones (used with subject permission)
Menna Lloyd Jones (used with subject permission)
© 2014 MA Healthcare Ltd
Exudate odour can also be an indication of the cause of excessive exudate, for example Pseudomonas aeruginosa infection along with its characteristic fluorescent-green staining on a dressing also has a distinct malodour (Benbow and Stevens, 2010).
However, it should be noted that no matter how much information is collected, in order to be of benefit in terms of monitoring the wound’s progress or reviewing the selected dressings, the information needs to be collected and documented in the same way by all team members (Benbow and Stevens, 2010; Menon, 2012; Davies, 2012).
Figure 1. Maceration and excoriation of surrounding skin caused by excessive exudate
Figure 2. Wound prior to sharp debridement displaying excessive exudate due to autolytic debridement of necrotic tissue
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S22 S22
Clinical comment: Exudate: friend or foe?
Menna Lloyd Jones (used with subject permission)
As a minimum, any dressing selected should be able to absorb and contain exudate and enhance a moist wound healing environment. Dressing manufacturers will normally provide literature that demonstrates the amount of exudate that a dressing will absorb, recommended wear time and other information (Dowsett, 2008; Davies, 2012; Milne, 2013).
Topical negative pressure
Dressing selection for the management of excessive exudate The findings of a holistic assessment will identify factors that may influence exudate production, and this information should inform the management options for the excess exudate—firstly by managing contributory factors and any underlying cause. For example, high levels of exudate are a complication associated with venous leg ulcers (VLUs), and although absorbent or superabsorbent dressings may help to mop up the exudate, they will never cure the problem. The recommended treatment for VLUs is compression, and if there is a concordance issue, the patient should be informed and offered different options that are available to them—for example, compression hosiery may be a preferred option to four-layer bandaging for some patients (WUWHS, 2007; Probst and Huljev, 2013).
Dressings and debridement Dressings may be selected to treat contributory factors such as debridement. Dressings can aid with autolytic debridement and the dressing selected should be able to manage exudate and aid autolytic debridement, e.g. hydrofibre or alginate dressings. Where there is excessive exudate, it is not advisable to use a dressing that donates fluid, i.e. hydrogel dressings (WUWHS, 2007; Dowsett, 2008). Where the wound is infected, it may be appropriate (depending on local policies) to apply an antimicrobial dressing to address the infection. In the same way as dealing with debridement, the antimicrobial dressing selected should also be able to absorb exudate and not donate extra fluid to an already wet wound (WUWHS, 2007; Dowsett, 2011). Today there are a plethora of dressings available to absorb exudate. However, these dressings manage exudate in different ways. Therefore, in order to select the most appropriate dressing for a particular patient, it is important have an understanding of the properties and available sizes of the dressing options within the local formulary (Dowsett, 2011).
Box 3. Effective exudate management Treatment of contributory or underlying factors Enhance patient quality of life Optimise wound bed Provide moist wound healing environment Prevent and treat exudate-related problems Source: WUWHS (2007)
Box 4. Factors to consider when selecting an appropriate dressing for exudate management The dressing should: Absorb and retain exudate Be acceptable to the patient Be available on local formulary
Be comfortable and conformable without impeding physical activity
Be easy to apply and remove Reduce pain Reduce odour Be clinically and cost effective Be available in a variety of sizes Adapted from WUWHS (2007); Dowsett (2008; 2011)
To ensure that the dressing selected is appropriate, managing the exudate and preventing strikethrough, it is important to reassess the wound and re-evaluate the dressing. Also, as the wound progress to healing, the wound exudate will reduce and a highly absorbent dressing can cause a ‘drawing’ pain and/or stick to the wound bed, causing
© 2014 MA Healthcare Ltd
Figure 3. Wound post-sharp debridement displaying vastly reduced exudate
In some cases, topical negative pressure (TNP) is an effective alternative to dressings in the management of excess exudate. TNP will reduce the frequency of dressing changes, and it is suggested that TNP has the added benefit of removing MMPs and bacterial substances from the wound bed, further enhancing the wound healing environment. However, the use of TNP is dependent on availability and local policies (Dowsett, 2008; Menon, 2012).
Community Wound Care June 2014 Journal of Community Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 14, 2015. For personal use only. No other uses without permission. . All rights re
Clinical comment: Clinical Exudate: friend friend or foe? Exudate:
S23
further pain and discomfort for the patient. Furthermore, the dressing would then need to be changed for a less absorbent dressing (Dowsett, 2011).
S23 S23
KEY POINTS Wound exudate is an essential component in
Care of the peri-wound skin
moist wound healing
Caring for the skin surrounding heavy exuding wound and the prevention of maceration and excoriation is also an important factor in exudate management. Where appropriate, the surrounding skin should be washed and dried, with a barrier product applied according to local policies and manufacturers’ instructions (Menon, 2012).
The level of exudate changes through the wound healing process
Chronic wound exudate is detrimental to wound healing
The aim of exudate management is to
Conclusion Acute wound exudate is an essential component in wound healing. However, it has been recognised that chronic wound exudate can be problematic and lead to high levels of exudate production. Excessive exudate has often been seen as a challenge for clinicians and a source of anxiety and distress for the patient. However, today there are a wide variety of dressings (and TNP) available to assist in the management of exudate. Nevertheless, decisions regarding the management of excessive exudate should be made following a holistic assessment. In order to provide cost-effective and efficient care, the clinician must be familiar with the way the different dressings handle exudate, the variety of sizes available and the expected wear time of the dressings. Ongoing assessment and evaluation will ensure that the dressing selected meets the objectives set by minimising the detrimental effects and maximising the positive effects of exudate. CWC Benbow M, Stevens J (2010) Exudate, infection and patient quality of life. Br J Nurs 19(20): S30–6 Davies P (2012) Exudate assessment and management. Br J Community Nurs 17(5) S18–24 Dowsett C (2008) Exudate management: a patient-centred approach. J Wound Care
minimise the detrimental effects and maximise the positive effects of exudate
Exudate management is dependent on the findings of a holistic assessment
17(6): 249–52 Dowsett C (2011) Moisture in wound healing: exudate management. Br J Community Nurs 16(supp. 4): S6–12 Cutting K (2009) Managing wound exudate using a super-absorbent polymer dressing: a 53-patient clinical evaluation. J Wound Care 18(5): 200–5 Menon J (2012) Managing exudate associated with venous leg ulceration. Br J Community Nurs 17(supp. 4): S6–15 Milne J (2013) Managing highly exuding wounds. Br J Nurs 22(15): S12 Panca M, Cutting K, Guest JF (2013) Clinical and cost-effectiveness of absorbent dressings in the treatment of highly exuding VLUs. J Wound Care 22(3): 109–18 Probst S, Huljev D (2013) The effective management of wounds with high levels of exudate. Br J Nurs 22(6): S34 Winter GC (1962) Formation of the scab and the rate of epithilisation of superficial wounding of the skin of the young domestic pig. Nature 193: 293–4 World Union of Wound Healing Societies (WUWHS) (2007) Principles of Best Practice: Wound Exudate and the Role of Dressings: A Consensus Document. MEP, London. http://tinyurl.com/phx3aya (accessed 20 May 2014)
© 2014 MA Healthcare Ltd
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Community Wound Care June 2014 Journal of Community Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 14, 2015. For personal use only. No other uses without permission. . All rights re
Clinical comment
Exudate: friend or foe?
Abstract Wound exudate is an essential component in the normal process of wound healing. However, excess exudate has always been a major challenge for clinicians and a source of embarrassment and discomfort for the patient. The challenge for healthcare staff is to provide a wound
Key words:
Acute/chronic wound exudate
healing environment that offers the optimal amount of exudate to promote healing. This article provides the reader with an understanding of the benefits and problems associated with exudate.
Colour of exudate
Holistic assessment
Menna Lloyd Jones email: [email protected] Independent Tissue Viability Nurse
E
xudate is often described as wound fluid, wound drainage and ‘what is coming out of the wound’ (World Union of Wound Healing Societies (WUWHS), 2007). Exudate is a serous fluid closely resembling blood plasma. It leaks from capillaries as a consequence of increased capillary permeability during the inflammatory phase of healing as part of the body’s response to the initial injury or as part of the host response to large numbers of bacteria in the wound bed. Exudate is similar to the fluid that would normally bathe and provide nutrients to the cells in intact dermis (WUWHS, 2007; Dowsett, 2008;Davies, 2012). Although our current understanding of exudate is limited, it is understood to be produced in response to a complicated interaction between wound aetiology, wound healing physiology, wound environment and compounding pathological processes (WUWHS, 2007).
Winter (1962) listed the benefits of moist wound healing as improving healing rates, reducing pain and discomfort, and decreasing rates of wound infection. Providing a moist wound healing environment also enhances the rate of granulation tissue and epithelial migration (Dowsett, 2011). Too little exudate can lead to desiccation of the wound bed, which can cause pain and discomfort as well as contributing to a delay in healing (Panca et al, 2013). Exudate bathes the wound bed with a serous fluid that is mainly made up of water but also contains electrolytes, nutrients, proteins, growth factors, white blood cells (such as neutrophils, macrophages and platelets) and matrix metalloproteins (MMPs) (WUWHS, 2007; Dowsett, 2011). MMPs contribute to the breakdown of dead and devitalised tissue, while growth factors and cytokines contribute to the building of new tissue (Davies, 2012; Menon, 2012). The production of exudate is a vital component in wound healing and has a beneficial effect on healing by providing the optimal environment to promote cell proliferation and autolysis. Although the optimal amount of exudate required for healing is unknown, the amount of wound exudate produced does vary throughout healing— normally decreasing as wound healing progresses. However, differences have been identified between the amount and characteristics of acute and chronic wound exudate production (Dowsett, 2008).
© 2014 MA Healthcare Ltd
Benefits of exudate
Community Wound Care June 2014 Journal of Community Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 14, 2015. For personal use only. No other uses without permission. . All rights re
S20 S20
Clinical comment: Exudate: friend or foe?
Chronic wound exudate
increased risk of infection. However, it should be noted that wound infection itself is a cause of increased exudate Dowsett (2011) explains that the exudate found in acute (Dowsett, 2008; Panca et al, 2013). Excess exudate can also wounds is rich in leukocytes and essential nutrients and, lead to a significant loss of protein and electrolyte imbalance as explained above, provides the optimal environment for (Menon, 2012). Increased exudate can also leak out on to wound healing. However, as wound the surrounding skin, causing maceration exudate becomes chronic, rather and excoriation of the periwound skin ‘It is important to than promoting healing it becomes and possibly contributing to an increase destructive. The levels of proteases in the size of the wound (Dowsett, 2008; understand the role increase and slow down or block Menon, 2012). of exudate in wound the proliferation of keratinocytes, Excessive exudate can also be very fibroblasts and endothelial cells. distressing for the patient, requiring bulky healing, the properties It is suggested that, in chronic dressings which are uncomfortable and and function of the wounds, there is an imbalance in make wearing certain clothing and shoes the number of MMPs and tissue difficult. Strikethrough of exudate on to different dressings inhibitors of MMPs (TIMPs), the dressing can be both visually offensive with an increase in MMPs and a and also a source of malodour, which can available, and, most decrease in TIMPs. Therefore, the be distressing and embarrassing for the importantly, to undertake patient. Leakage can also soil clothing, MMPs continue to break down the wound matrix as there are bedding and furniture, increasing the a holistic assessment’. insufficient TIMPs to slow down the amount of laundry. Excess exudate can process. Consequently, the wound is cause isolation for the patient, which suspended between the inflammatory and proliferative stage in turn can cause depression (Dowsett, 2008; Davies, 2012; of healing (Davies, 2012; Probst and Huljev, 2013). Menon, 2012). There is also an increase in bacterial colonisation. In chronic wounds (unlike acute wounds), exudate can increase Management of exudate rather than decrease in volume and become difficult to manage (Dowsett, 2008; Cutting, 2009; Menon, 2012). WUWHS (2007) states that the aim of exudate management is to minimise detrimental effects and maximise positive Excessive exudate effects. In order to do this, it is important to understand the role of exudate in wound healing, the properties and function The amount of exudate produced by a wound is attributable of the different dressings available, and, most importantly, to to several factors (see Box 1). Exudate becomes problematic undertake a holistic assessment, looking at patient factors when the amount of exudate produced causes the dressing as well as assessing the wound. A wound assessment should to leak, necessitating high-frequency dressing changes. include assessing the exudate and dressings used (see Box 2). The production of excessive amounts of exudate can lead Assessing exudate to strikethrough of the dressings, which can lead to an WUWHS (2007) suggests that the information gathered from assessing the exudate will assist in the provision of appropriate care for the patient. Box 1. Causes of excessive exudate
The size of the wound—the larger the wound the greater the volume of exudate
Wound types—i.e. leg ulcers, burns and donor sites tend
Box 2. Patient assessment when managing exudate Patient assessment should include:
to produce higher volumes of exudate
Comorbidities
Increased bacterial load/wound infection Medical conditions—e.g. cardiac disease, peripheral
Medication
oedema Malnutrition Presence of foreign bodies and/or necrotic tissue Lack of concordance with recommended therapy
Issues with concordance
Adapted from WUWHS (2007), Benbow and Stevens (2010)
Mobility Psychosocial issues Nutritional status Dressings Adapted from Menon (2012)
© 2014 MA Healthcare Ltd
At wound healing stage, amount of exudate depends upon:
Community Wound Care June 2014 Journal of Community Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 14, 2015. For personal use only. No other uses without permission. . All rights re
Clinical comment: Exudate: friend or foe?
S21
Exudate volume Although it is important to record the volume of exudate, in clinical practice this is not so easy as there is no validated tool for its measurement. Traditionally, the volume of exudate has been recorded using ‘+’, ‘++’ and ‘+++’ to indicate a high, medium or low level, respectively. However, this method is considered to be subjective and far from accurate. Weighing dressings has also been considered, but again this method is considered to be inaccurate, time-consuming and of little value in improving patient care (Benbow and Stevens, 2010; Menon, 2012). However, it is suggested that it is more useful to document the frequency of dressing changes, how saturated the dressing is, whether there is strikethrough and how the dressing is managing the exudate by looking at the condition of the surrounding skin, noting any maceration and/or excoriation of the surrounding skin. Frequent dressing changes and maceration of the surrounding skin (see Figure 1) is an indication that the dressing selected is inappropriate. For example, if a dressing is designed to stay in place for 24 hours, if the exudate is controlled and the surrounding skin is intact at dressing change 24 hours later, then it could be considered that the exudate has been managed. If the dressing is saturated with strikethrough and/or there is maceration of the surrounding skin, then the dressing needs to be reviewed. In the same way, if the wound bed is dry and sticking to the wound bed, causing pain and discomfort for the patient, this is also an indication to review the dressing (Dowsett, 2008).
Table 1. Significance of exudate colour Clear, amber
Often considered to be ‘normal’ but it can be associated with infection by fibrinolysin-producing bacteria such as Staphyloccus aureus. It may also be due to fluid from a urinary or lymphatic fistula
Cloudy, milky or creamy
May indicate the presence of fibrin stands (fibrinous exudate—a response to inflammation) or infection (purulent exudate containing white blood cells and bacteria)
Pink or red
Due to the presence of red blood cells and may indicate the presence of wound infection, an underlying bleeding disorder or wound trauma.)
Green
May be indicative of bacterial infection e.g. Pseudomonas aeruginosa
Yellow or brown
May be due to the presence of wound slough or material from an enteric or urinary fistula
Grey or blue
May be related to the use of silvercontaining dressings
When all other causes have been excluded, recognising that some medications are known to discolour urine; considerations should be made to the possibility that drugs could also be a cause of exudate discolouration. Adapted from WUWHS (2007) and Dowsett (2008)
Exudate colour See Table 1 for guidance on the significance of exudate colour.
Exudate odour
Menna Lloyd Jones (used with subject permission)
Menna Lloyd Jones (used with subject permission)
© 2014 MA Healthcare Ltd
Exudate odour can also be an indication of the cause of excessive exudate, for example Pseudomonas aeruginosa infection along with its characteristic fluorescent-green staining on a dressing also has a distinct malodour (Benbow and Stevens, 2010).
However, it should be noted that no matter how much information is collected, in order to be of benefit in terms of monitoring the wound’s progress or reviewing the selected dressings, the information needs to be collected and documented in the same way by all team members (Benbow and Stevens, 2010; Menon, 2012; Davies, 2012).
Figure 1. Maceration and excoriation of surrounding skin caused by excessive exudate
Figure 2. Wound prior to sharp debridement displaying excessive exudate due to autolytic debridement of necrotic tissue
Community Wound Care June 2014 Journal of Community Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 14, 2015. For personal use only. No other uses without permission. . All rights re
S22 S22
Clinical comment: Exudate: friend or foe?
Menna Lloyd Jones (used with subject permission)
As a minimum, any dressing selected should be able to absorb and contain exudate and enhance a moist wound healing environment. Dressing manufacturers will normally provide literature that demonstrates the amount of exudate that a dressing will absorb, recommended wear time and other information (Dowsett, 2008; Davies, 2012; Milne, 2013).
Topical negative pressure
Dressing selection for the management of excessive exudate The findings of a holistic assessment will identify factors that may influence exudate production, and this information should inform the management options for the excess exudate—firstly by managing contributory factors and any underlying cause. For example, high levels of exudate are a complication associated with venous leg ulcers (VLUs), and although absorbent or superabsorbent dressings may help to mop up the exudate, they will never cure the problem. The recommended treatment for VLUs is compression, and if there is a concordance issue, the patient should be informed and offered different options that are available to them—for example, compression hosiery may be a preferred option to four-layer bandaging for some patients (WUWHS, 2007; Probst and Huljev, 2013).
Dressings and debridement Dressings may be selected to treat contributory factors such as debridement. Dressings can aid with autolytic debridement and the dressing selected should be able to manage exudate and aid autolytic debridement, e.g. hydrofibre or alginate dressings. Where there is excessive exudate, it is not advisable to use a dressing that donates fluid, i.e. hydrogel dressings (WUWHS, 2007; Dowsett, 2008). Where the wound is infected, it may be appropriate (depending on local policies) to apply an antimicrobial dressing to address the infection. In the same way as dealing with debridement, the antimicrobial dressing selected should also be able to absorb exudate and not donate extra fluid to an already wet wound (WUWHS, 2007; Dowsett, 2011). Today there are a plethora of dressings available to absorb exudate. However, these dressings manage exudate in different ways. Therefore, in order to select the most appropriate dressing for a particular patient, it is important have an understanding of the properties and available sizes of the dressing options within the local formulary (Dowsett, 2011).
Box 3. Effective exudate management Treatment of contributory or underlying factors Enhance patient quality of life Optimise wound bed Provide moist wound healing environment Prevent and treat exudate-related problems Source: WUWHS (2007)
Box 4. Factors to consider when selecting an appropriate dressing for exudate management The dressing should: Absorb and retain exudate Be acceptable to the patient Be available on local formulary
Be comfortable and conformable without impeding physical activity
Be easy to apply and remove Reduce pain Reduce odour Be clinically and cost effective Be available in a variety of sizes Adapted from WUWHS (2007); Dowsett (2008; 2011)
To ensure that the dressing selected is appropriate, managing the exudate and preventing strikethrough, it is important to reassess the wound and re-evaluate the dressing. Also, as the wound progress to healing, the wound exudate will reduce and a highly absorbent dressing can cause a ‘drawing’ pain and/or stick to the wound bed, causing
© 2014 MA Healthcare Ltd
Figure 3. Wound post-sharp debridement displaying vastly reduced exudate
In some cases, topical negative pressure (TNP) is an effective alternative to dressings in the management of excess exudate. TNP will reduce the frequency of dressing changes, and it is suggested that TNP has the added benefit of removing MMPs and bacterial substances from the wound bed, further enhancing the wound healing environment. However, the use of TNP is dependent on availability and local policies (Dowsett, 2008; Menon, 2012).
Community Wound Care June 2014 Journal of Community Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 14, 2015. For personal use only. No other uses without permission. . All rights re
Clinical comment: Clinical Exudate: friend friend or foe? Exudate:
S23
further pain and discomfort for the patient. Furthermore, the dressing would then need to be changed for a less absorbent dressing (Dowsett, 2011).
S23 S23
KEY POINTS Wound exudate is an essential component in
Care of the peri-wound skin
moist wound healing
Caring for the skin surrounding heavy exuding wound and the prevention of maceration and excoriation is also an important factor in exudate management. Where appropriate, the surrounding skin should be washed and dried, with a barrier product applied according to local policies and manufacturers’ instructions (Menon, 2012).
The level of exudate changes through the wound healing process
Chronic wound exudate is detrimental to wound healing
The aim of exudate management is to
Conclusion Acute wound exudate is an essential component in wound healing. However, it has been recognised that chronic wound exudate can be problematic and lead to high levels of exudate production. Excessive exudate has often been seen as a challenge for clinicians and a source of anxiety and distress for the patient. However, today there are a wide variety of dressings (and TNP) available to assist in the management of exudate. Nevertheless, decisions regarding the management of excessive exudate should be made following a holistic assessment. In order to provide cost-effective and efficient care, the clinician must be familiar with the way the different dressings handle exudate, the variety of sizes available and the expected wear time of the dressings. Ongoing assessment and evaluation will ensure that the dressing selected meets the objectives set by minimising the detrimental effects and maximising the positive effects of exudate. CWC Benbow M, Stevens J (2010) Exudate, infection and patient quality of life. Br J Nurs 19(20): S30–6 Davies P (2012) Exudate assessment and management. Br J Community Nurs 17(5) S18–24 Dowsett C (2008) Exudate management: a patient-centred approach. J Wound Care
minimise the detrimental effects and maximise the positive effects of exudate
Exudate management is dependent on the findings of a holistic assessment
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