A nurse on the Medical-Surgical unit is assessing a patient’s wound dressing, and observes a watery light red-pink drainage. The nurse should document this drainage as which of the following?
A.
Sanguineous.
B.
Serous.
C.
Purulent.
D.
Serosanguineous.
The Correct Answer and Explanation is:
The correct answer is D. Serosanguineous.
Explanation:
Wound drainage types are categorized based on their appearance and composition, which can provide insight into the healing process and potential complications. In this scenario, the drainage described is “watery light red-pink,” which corresponds to the term serosanguineous.
- Serosanguineous Drainage:
- Description: Serosanguineous drainage is a combination of serum (the clear, yellowish fluid part of blood) and a small amount of red blood cells. It appears as a light pink or pale red fluid and is often seen during the early stages of wound healing. This type of drainage is typically thin and watery.
- Clinical Relevance: Serosanguineous drainage is common and expected in the initial phases of wound healing. It indicates that the wound is still in the inflammatory phase but is transitioning towards the proliferative phase. The presence of this type of drainage suggests that the wound is not infected and is healing appropriately.
- Sanguineous Drainage:
- Description: Sanguineous drainage is predominantly composed of red blood cells, making it appear bright red and thicker than serosanguineous drainage.
- Clinical Relevance: This type of drainage is often observed in the early stages of wound healing or when a wound has been recently disturbed or reopened. Excessive sanguineous drainage may indicate bleeding or a need for further evaluation.
- Serous Drainage:
- Description: Serous drainage is a clear, yellowish fluid that resembles serum. It is typically thin and watery.
- Clinical Relevance: Serous drainage is indicative of a wound in the inflammatory phase of healing and is common in the early stages of wound healing. It does not contain blood cells.
- Purulent Drainage:
- Description: Purulent drainage is thick and may be yellow, green, or brown, indicating the presence of pus, which is a result of infection.
- Clinical Relevance: Purulent drainage is a sign of infection and requires immediate medical attention to address potential pathogens and treat the infection.
In summary, the “watery light red-pink” drainage observed is best described as serosanguineous, reflecting a normal part of the healing process where serum and a small amount of blood are present. It indicates that the wound is progressing through the healing phases without immediate signs of infection or abnormal bleeding.