Using our senses is a large part of the initial wound assessment, followed by accurate documentation. ![]() Tissue repair can happen either through regeneration or scar tissue formation.When assessing and documenting a wound, it is important to note the amount and type of wound exudate (drainage). This process depends on the injury type and the particular tissue involved. Through tissue repair, the structure and function of damaged tissue are restored. The formation of increased tissue fluid helps remove pathogens and cell debris through lymphatic drainage. Fibrinogen protein converts into fibrin, which forms the temporary wound matrix. It is a thick, opaque exudate that is brown, yellow, or green and indicates a high bacterial load and infection.Įxudate may also contain plasma proteins, including immunoglobulins, complements, and fibrinogen. Serosanguineous exudate is thin and watery in consistency and pale red to pink in color. It is also generally produced in small amounts during the inflammatory stage. Sanguineous exudate appears red, thin, and watery in deep partial or full-thickness wounds. It is expected during the inflammatory stage of wound healing, and smaller amounts are considered normal. Serous exudate is a transparent, amber-colored, thin, and watery plasma. The common types of exudate include serous, sanguineous, serosanguinous and purulent. Likewise, the exudate's color, viscosity, and texture from an infected wound will vary. Exudate, however, can differ depending on the state of wound healing. The typical wound exudate is odorless, transparent, straw-colored, thin, and watery. The inflammatory exudate released from the wound has high protein content and a specific gravity above 1.020. The changes during the cellular and vascular stages allow exudate formation at the site of inflammation. The immune system's inflammatory response destroys the invading pathogen, permitting the tissue to heal. ![]() It also brings in fibrin, which forms a mesh-like matrix that helps prevent the spread of bacteria and promotes healing. The protein accumulation brought in due to the vascular response contains globulin proteins involved in blood clotting and fighting infection. In addition, the fluid increase dilutes the toxins and increases lymphatic drainage, which removes waste products and the pathogen. Sanguineous or hemorrhagic exudate mainly consists of red blood cells, whereas purulent, also called suppurative exudate, mostly contains white blood cells and bacteria. It may also contain a minimal amount of proteins, white blood cells, or certain microorganisms. Serous exudate contains a clear, or amber colored fluid similar to plasma, which consists mainly of electrolytes and sugar. ![]() It may be serous, sanguineous or purulent. The inflammatory exudate varies in composition. This exudate has a high protein and cellular debris content. The inflammatory response serves as a safeguard mechanism that can eradicate invading pathogens, permitting the tissue to heal.Ĭhanges during the cellular and vascular stages result in the collection of fluid, dead tissue cells, and white blood cells at the site of inflammation.
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