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Clinical comment feature title to go here
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The thickness of exudate: does it matter? Abstract The majority of chronic wounds are managed in the community by the district nursing team. With increasing constraints on the health-care budget, it can be tempting to manage exudate by focusing solely on the exudate-handling capability of some of the more absorbent dressings available. However, exudate levels and viscosity can change depending on the patient Key words:
Exudate
Dressings
Wound assessment
June Jones email: [email protected] Independent Nurse Consultant, Southport, Lancashire
E
xudate management in complex and chronic wounds continues to present a challenge for many nurses. In a small study (n=24) of nurses’ understanding of the different types of exudate, Smith and Gibson (2013) found that some nurses had difficulty with both recognising different types of exudate and choosing an appropriate dressing. It is vital to remember that uncontrolled exudate is not only a costly clinical challenge, but a source of untold misery for patients, since, at its worst, it can result in malodour, pain, maceration, infection and unsightly soiled dressings. These can have a negative impact on a patient’s quality of life, triggering feelings of self-loathing, disgust and low self-esteem (Jones et al, 2008). Treating thick or viscous exudate encapsulates the negative and difficult aspects of exudate management in chronic and/or non-healing wounds.
© 2015 MA Healthcare Ltd
and the wound, with exudate being a marker of potential infection. Ongoing assessment of the wound, the exudate and the patient is pivotal to effective wound management, with timely and appropriate intervention being key. This article discusses this management, with particular focus on dealing with thick exudate.
What is exudate? Exudate consists of water, electrolytes, nutrients (glucose), proteins (cytokines), inflammatory mediators, white cells, protein-digesting enzymes (matrix metalloproteinases (MMPs)), growth factors and waste products (World Union of Wound Healing Societies (WUWHS), 2007). It is notable that not all
exudate is bad, and the importance of moisture in the wound environment has been incorporated into concepts such as the TIME (which stands for tissue, infection/inflammation, moisture balance and edge of wound) guidelines (WUWHS, 2007), where one of the primary components of wound bed preparation is moisture balance, since it is known to promote cell proliferation and assist healing. However, it has been suggested that chronic wound exudate should be regarded as a wounding agent in its own right in the sense that exudate itself can breach the integrity of the skin (Trengrove et al, 2008). In a non-healing or chronic wound, exudate production tends to continue excessively, while the constituents take on negative changes (Jones, 2013).
Types of exudate Ousey and Cook (2012) remind us that the assessment of exudate forms a vital part of any wound assessment and should include information regarding its colour, consistency, odour and quantity. Wound exudate is described utilising the terms identified in Table 1. The consistency or viscosity of exudate may vary from thin and watery to thick and viscous. Healthy exudate is thin, watery, pale yellow or light red and does not adhere to the wound bed. Exudate of high viscosity can appear thick and sometimes sticky; it may be cloudy and/or malodorous. Thick and sometimes sticky (or viscous) exudate can be indicative of high protein content, pointing towards infection or the inflammatory process. It may result from liquefying necrotic material and bacteria, bringing with it a concomitant odour. The colour range from clear or cloudy through to yellow or brown depends on the constituents (Benbow, 2007). High levels of highly viscous exudate could lead to potential protein loss and therefore needs to be appropriately managed (Kerr, 2014).
Community Wound Care March 2014 2015 h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 129.096.252.188 on October 16, 2015. For personal use only. No other uses without permission. . All rights rese
Clinical comment: Thickness of exudate
Table 1. Types of wound exudate Serous
Clear, amber, thin and watery
Serous
Opaque and straw-coloured, thin and watery
Fibrinous
Cloudy and thin, with strands of fibrin
Serosanguinous
Clear, pink, thin and watery
Sanguinous
Reddish, thin and watery
Seropurulent
Creamy yellow or tan, cloudy and thick
Purulent
Opaque, milky, sometimes green
Haemopurulent
Reddish, milky and viscous
Haemorrhagic
Red, thick
Source: Wounds UK (2013), based on Benbow (2007) and WUWHS (2007)
Wound exudate and infection It is important to monitor any increase or changes in colour of the exudate, as this should alert the clinician that the wound and patient are at increased risk of problems, as well as being indicative of the causative bacteria. For example, if infection is due to the presence of Pseudomonas aeroginosa (P. aeroginosa), the exudate becomes thicker and greenish-blue in colour. Systemic antibiotics and an antimicrobial dressing are required to resolve the infection and progress the wound towards healing. Antimicrobials, such as iodine, silver, honey and polyhexamethylene biguanide (PHMB), act against multi-resistant organisms such as methicillinresistant Staphylococcus aureus (MRSA) (Butcher, 2013). Biofilms, which cannot be seen with the naked eye, are known to have a significant negative influence in chronic wounds (Phillips et al, 2010). It has been postulated that there may be a link between biofilms and slough (which can be seen) (Cutting et al, 2010). Biofilms stimulate inflammation, which in turn increases vascular permeability and production of wound exudate and the build-up of fibrinous slough (Wolcott et al, 2008), suggesting that slough may be indicative of biofilms in the wound.
Dressing selection A key challenge for clinicians is to maintain a moist wound bed while tackling any infection and exudate, if the wound is deemed to be infected.The production of exudate can be affected by the underlying condition of the patient, the pathology and the size of the wound, as well as dressing selection. Dressings remain the mainstay and most accessible option for managing wound exudate. Good dressing selection makes a real difference to the progress of the wound and, importantly, the comfort and quality of life of the patient (WUWHS, 2007; Romanelli et al, 2010). It is well documented that effective exudate management through appropriate dressing selection can reduce time to healing, reduce dressing change frequency and, as a consequence, nurse input and time (WUWHS, 2007; Romanelli et al, 2010). Nursing time is arguably the most expensive aspect of wound
management (Drew et al, 2007). Furthermore, dressing change is one of the most common triggers for pain in chronic wounds (Meaume et al, 2004;Woo, 2010). Clinicians may also opt to utilise superabsorbent dressings specifically designed to hold more fluid, as well as ‘locking’ any fluid into the structure of the dressing.This helps to reduce dressing frequency, with a reduction in number of dressing changes seen as an important consideration, particularly in the community where visits have to be planned in advance.There is also a concomitant reduction in nurse time and, therefore, a potential cost saving in the use of superabsorbent dressings. However, there is sometimes a fine balance to be negotiated in reducing the frequency of dressing changes and risking leaving a patient with a saturated dressing with the potential for macerated and sore skin (Gardner, 2012). Leakage of exudate through the dressing (strikethrough) also provides a portal for the ingress of pathogens into the wound (White, 2011). Reducing the number of visits can therefore be a false economy and, more importantly, have a negative impact on the patient.
Conclusion Frequent assessment and clear documentation is the key to managing chronic wounds in what is often a non-linear process, since wounds can regress in susceptible patients, where even low levels of bacterial burden can impair wound healing and increase exudate production and viscosity. It is essential that community nurses are able to interpret wound-bed changes and type of exudate accurately and respond appropriately. CWC Benbow M (2007) Managing exuding wounds. Practice Nurse 34(2): 23–28 Butcher M (2013) Assessment, management and prevention of infected wounds. Journal of Community Nursing 27(4): 25–33 Cutting KF,Wolcott R, Dowd SE, Pericval SL (2010) Biofilms and significance in wound healing. In: Percival S (ed), Microbiology of Wounds. CRC Press, London Drew P, Posnett J, Rusling L (2007) The cost of wound care for a local population in England. Int Wound J 4(2): 149–55 Gardner S (2012) Managing high exudate wounds. Wound Essentials 7(suppl. 1): 1–4 Jones J (2013) Exploring the link between the clinical challenges of wound exudate and infection. In: Bianchi J (ed), Exudate management: patient-centred wound care. MA Healthcare, London. pp. 4–8 Jones JE, Barr W, Robinson J (2008) Impact of exudate and odour from chronic venous leg ulceration. Nurs Stand 22(45): 53–61 Kerr A (2014) How best to record and describe wound exudate. Wounds UK 10(2): 50–7 Meaume S, Telom L, Lazareth I et al (2004) The importance of pain reduction through dressing selection in routine wound management: the MAPP study. J Wound Care 13(10): 409–13 Ousey K, Cook L (2012) Wound assessment made easy. Wounds UK 8(2): 1–4 Phillips PL, Wolcott RD, Fletcher J, Schultz GS (2010) Biofilms made easy. Wounds International 1(3): 1–6 Romanelli M, Vowden K, Weir D (2010) Exudate management made easy. Wounds International 1(2): 1–6 Smith G, Gibson E (2013) The development of algorithm to support nurses choosing dressings for chronic exudate. Wounds UK 9(2): 64–7 Trengrove NJ, Bielefeldt-Ohman H, Stacey MC (2008) Mitogenic activity and cytokine levels in non-healing and healing chronic leg ulcers. Wound Repair Regen 8(1): 13–25 White R (2011) Wound dressings and other topical treatment modalities in bioburden control. J Wound Care 20(9): 431–9 Wolcott RD, Rhoads DD, Dowd SE (2008) Biofilms and chronic wound inflammation. J Wound Care 17(8): 333–41 Woo K (2010) Wound-related pain: anxiety, stress and wound healing. Wounds UK 6(4): 92–8 World Union of Wound Healing Societies (2007) Wound exudate and the role of dressings: a consensus document. Medical Education Partnership, London. http://bit.ly/1l4n7ol (accessed 5 February 2015) Wounds UK (2013) Best practice statement: effective exudate management. Wounds UK, London. http://bit.ly/1yVGckB (accessed 5 February 2015)
© 2015 MA Healthcare Ltd
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Community Wound Care March 2015 h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 129.096.252.188 on October 16, 2015. For personal use only. No other uses without permission. . All rights rese
Clinical comment feature title to go here
S19 S19
The thickness of exudate: does it matter? Abstract The majority of chronic wounds are managed in the community by the district nursing team. With increasing constraints on the health-care budget, it can be tempting to manage exudate by focusing solely on the exudate-handling capability of some of the more absorbent dressings available. However, exudate levels and viscosity can change depending on the patient Key words:
Exudate
Dressings
Wound assessment
June Jones email: [email protected] Independent Nurse Consultant, Southport, Lancashire
E
xudate management in complex and chronic wounds continues to present a challenge for many nurses. In a small study (n=24) of nurses’ understanding of the different types of exudate, Smith and Gibson (2013) found that some nurses had difficulty with both recognising different types of exudate and choosing an appropriate dressing. It is vital to remember that uncontrolled exudate is not only a costly clinical challenge, but a source of untold misery for patients, since, at its worst, it can result in malodour, pain, maceration, infection and unsightly soiled dressings. These can have a negative impact on a patient’s quality of life, triggering feelings of self-loathing, disgust and low self-esteem (Jones et al, 2008). Treating thick or viscous exudate encapsulates the negative and difficult aspects of exudate management in chronic and/or non-healing wounds.
© 2015 MA Healthcare Ltd
and the wound, with exudate being a marker of potential infection. Ongoing assessment of the wound, the exudate and the patient is pivotal to effective wound management, with timely and appropriate intervention being key. This article discusses this management, with particular focus on dealing with thick exudate.
What is exudate? Exudate consists of water, electrolytes, nutrients (glucose), proteins (cytokines), inflammatory mediators, white cells, protein-digesting enzymes (matrix metalloproteinases (MMPs)), growth factors and waste products (World Union of Wound Healing Societies (WUWHS), 2007). It is notable that not all
exudate is bad, and the importance of moisture in the wound environment has been incorporated into concepts such as the TIME (which stands for tissue, infection/inflammation, moisture balance and edge of wound) guidelines (WUWHS, 2007), where one of the primary components of wound bed preparation is moisture balance, since it is known to promote cell proliferation and assist healing. However, it has been suggested that chronic wound exudate should be regarded as a wounding agent in its own right in the sense that exudate itself can breach the integrity of the skin (Trengrove et al, 2008). In a non-healing or chronic wound, exudate production tends to continue excessively, while the constituents take on negative changes (Jones, 2013).
Types of exudate Ousey and Cook (2012) remind us that the assessment of exudate forms a vital part of any wound assessment and should include information regarding its colour, consistency, odour and quantity. Wound exudate is described utilising the terms identified in Table 1. The consistency or viscosity of exudate may vary from thin and watery to thick and viscous. Healthy exudate is thin, watery, pale yellow or light red and does not adhere to the wound bed. Exudate of high viscosity can appear thick and sometimes sticky; it may be cloudy and/or malodorous. Thick and sometimes sticky (or viscous) exudate can be indicative of high protein content, pointing towards infection or the inflammatory process. It may result from liquefying necrotic material and bacteria, bringing with it a concomitant odour. The colour range from clear or cloudy through to yellow or brown depends on the constituents (Benbow, 2007). High levels of highly viscous exudate could lead to potential protein loss and therefore needs to be appropriately managed (Kerr, 2014).
Community Wound Care March 2014 2015 h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 129.096.252.188 on October 16, 2015. For personal use only. No other uses without permission. . All rights rese
Clinical comment: Thickness of exudate
Table 1. Types of wound exudate Serous
Clear, amber, thin and watery
Serous
Opaque and straw-coloured, thin and watery
Fibrinous
Cloudy and thin, with strands of fibrin
Serosanguinous
Clear, pink, thin and watery
Sanguinous
Reddish, thin and watery
Seropurulent
Creamy yellow or tan, cloudy and thick
Purulent
Opaque, milky, sometimes green
Haemopurulent
Reddish, milky and viscous
Haemorrhagic
Red, thick
Source: Wounds UK (2013), based on Benbow (2007) and WUWHS (2007)
Wound exudate and infection It is important to monitor any increase or changes in colour of the exudate, as this should alert the clinician that the wound and patient are at increased risk of problems, as well as being indicative of the causative bacteria. For example, if infection is due to the presence of Pseudomonas aeroginosa (P. aeroginosa), the exudate becomes thicker and greenish-blue in colour. Systemic antibiotics and an antimicrobial dressing are required to resolve the infection and progress the wound towards healing. Antimicrobials, such as iodine, silver, honey and polyhexamethylene biguanide (PHMB), act against multi-resistant organisms such as methicillinresistant Staphylococcus aureus (MRSA) (Butcher, 2013). Biofilms, which cannot be seen with the naked eye, are known to have a significant negative influence in chronic wounds (Phillips et al, 2010). It has been postulated that there may be a link between biofilms and slough (which can be seen) (Cutting et al, 2010). Biofilms stimulate inflammation, which in turn increases vascular permeability and production of wound exudate and the build-up of fibrinous slough (Wolcott et al, 2008), suggesting that slough may be indicative of biofilms in the wound.
Dressing selection A key challenge for clinicians is to maintain a moist wound bed while tackling any infection and exudate, if the wound is deemed to be infected.The production of exudate can be affected by the underlying condition of the patient, the pathology and the size of the wound, as well as dressing selection. Dressings remain the mainstay and most accessible option for managing wound exudate. Good dressing selection makes a real difference to the progress of the wound and, importantly, the comfort and quality of life of the patient (WUWHS, 2007; Romanelli et al, 2010). It is well documented that effective exudate management through appropriate dressing selection can reduce time to healing, reduce dressing change frequency and, as a consequence, nurse input and time (WUWHS, 2007; Romanelli et al, 2010). Nursing time is arguably the most expensive aspect of wound
management (Drew et al, 2007). Furthermore, dressing change is one of the most common triggers for pain in chronic wounds (Meaume et al, 2004;Woo, 2010). Clinicians may also opt to utilise superabsorbent dressings specifically designed to hold more fluid, as well as ‘locking’ any fluid into the structure of the dressing.This helps to reduce dressing frequency, with a reduction in number of dressing changes seen as an important consideration, particularly in the community where visits have to be planned in advance.There is also a concomitant reduction in nurse time and, therefore, a potential cost saving in the use of superabsorbent dressings. However, there is sometimes a fine balance to be negotiated in reducing the frequency of dressing changes and risking leaving a patient with a saturated dressing with the potential for macerated and sore skin (Gardner, 2012). Leakage of exudate through the dressing (strikethrough) also provides a portal for the ingress of pathogens into the wound (White, 2011). Reducing the number of visits can therefore be a false economy and, more importantly, have a negative impact on the patient.
Conclusion Frequent assessment and clear documentation is the key to managing chronic wounds in what is often a non-linear process, since wounds can regress in susceptible patients, where even low levels of bacterial burden can impair wound healing and increase exudate production and viscosity. It is essential that community nurses are able to interpret wound-bed changes and type of exudate accurately and respond appropriately. CWC Benbow M (2007) Managing exuding wounds. Practice Nurse 34(2): 23–28 Butcher M (2013) Assessment, management and prevention of infected wounds. Journal of Community Nursing 27(4): 25–33 Cutting KF,Wolcott R, Dowd SE, Pericval SL (2010) Biofilms and significance in wound healing. In: Percival S (ed), Microbiology of Wounds. CRC Press, London Drew P, Posnett J, Rusling L (2007) The cost of wound care for a local population in England. Int Wound J 4(2): 149–55 Gardner S (2012) Managing high exudate wounds. Wound Essentials 7(suppl. 1): 1–4 Jones J (2013) Exploring the link between the clinical challenges of wound exudate and infection. In: Bianchi J (ed), Exudate management: patient-centred wound care. MA Healthcare, London. pp. 4–8 Jones JE, Barr W, Robinson J (2008) Impact of exudate and odour from chronic venous leg ulceration. Nurs Stand 22(45): 53–61 Kerr A (2014) How best to record and describe wound exudate. Wounds UK 10(2): 50–7 Meaume S, Telom L, Lazareth I et al (2004) The importance of pain reduction through dressing selection in routine wound management: the MAPP study. J Wound Care 13(10): 409–13 Ousey K, Cook L (2012) Wound assessment made easy. Wounds UK 8(2): 1–4 Phillips PL, Wolcott RD, Fletcher J, Schultz GS (2010) Biofilms made easy. Wounds International 1(3): 1–6 Romanelli M, Vowden K, Weir D (2010) Exudate management made easy. Wounds International 1(2): 1–6 Smith G, Gibson E (2013) The development of algorithm to support nurses choosing dressings for chronic exudate. Wounds UK 9(2): 64–7 Trengrove NJ, Bielefeldt-Ohman H, Stacey MC (2008) Mitogenic activity and cytokine levels in non-healing and healing chronic leg ulcers. Wound Repair Regen 8(1): 13–25 White R (2011) Wound dressings and other topical treatment modalities in bioburden control. J Wound Care 20(9): 431–9 Wolcott RD, Rhoads DD, Dowd SE (2008) Biofilms and chronic wound inflammation. J Wound Care 17(8): 333–41 Woo K (2010) Wound-related pain: anxiety, stress and wound healing. Wounds UK 6(4): 92–8 World Union of Wound Healing Societies (2007) Wound exudate and the role of dressings: a consensus document. Medical Education Partnership, London. http://bit.ly/1l4n7ol (accessed 5 February 2015) Wounds UK (2013) Best practice statement: effective exudate management. Wounds UK, London. http://bit.ly/1yVGckB (accessed 5 February 2015)
© 2015 MA Healthcare Ltd
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Community Wound Care March 2015 h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 129.096.252.188 on October 16, 2015. For personal use only. No other uses without permission. . All rights rese
