Ulcer or wound moisture balance

Optimal wound healing is achieved by maintaining an appropriate moisture balance. An optimally moist wound environment facilitates autolytic debridement and stimulates granulation tissue. Excessive moisture or exudate can lead to leakage and soiling, formation of unhealthy granulation tissue, and maceration of the surrounding skin (which impairs epithelialisation). Insufficient moisture or exudate can result in a dry wound bed, delayed autolysis, or the dressing adhering to the wound.

Moisture can be controlled by the choice of dressing and the frequency of dressing changes (the dressing regimen). For information about choosing a dressing based on wound characteristics, see Overview of appropriate wound dressings based on wound characteristics and Dressings for specific ulcer or wound characteristics.

Assessment of wound moisture includes identifying the type of exudate and describing its characteristics. Normal (serous) exudate is clear or a pale amber colour, with a watery consistency. Other types of exudate include haemoserous (sanguineous), haemopurulent, seropurulent, and purulent. The main factors to assess when describing exudate are colour, quantity, and consistency. Record the volume of exudate as none, scant, small, moderate or heavy in clinical notes. Persistent excessive amounts of exudate require investigation (eg inadequate therapy for venous leg ulcers).

Note: Reassess the dressing regimen at each dressing change.

To determine if a wound dressing regimen is appropriate, assess the dressing in situ and on removal (ie before discarding the dressing or cleansing the wound). Wound moisture levels vary over time, and the appropriateness of the dressing regimen should be reassessed at every dressing change. This includes reviewing the degree of dressing saturation, its absorbency capacity, and the duration in situ. However, unless there is a clear problem (eg pain, excessive exudate; see c_lwg2-c17-s4.html#lwg2-c17-s4__tlwg2-c17-tbl15), do not alter the dressing regimen. Ideally, a dressing regimen should remain constant for at least 2 weeks.