Fundamentals of Nursing Practice · Skin and Wound Care

Wound Assessment, Dressings, Drains, and Thermal Therapies

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In 30 seconds
Why this matters
The college version
Eli explains
Worked example
Key takeaway
Study tools

In 30 seconds

is a systematic, ongoing evaluation of a wound's appearance, size, drainage, and surrounding skin, often organized with the acronym (redness, edema, ecchymosis, discharge, approximation). Drainage, or , is described as , , , or . Dressings are matched to the wound's needs — protecting, absorbing, moistening, or debriding. Drains such as the Jackson-Pratt, , and remove fluid or air that could otherwise slow healing. Heat and relieve discomfort and swelling but carry specific .

Why this matters

Accurate, factual wound and drainage documentation is both a clinical duty and part of the legal health record. The nurse uses person-centered language, maintains privacy and dignity during wound care, and communicates with objective descriptors (type, color, amount, odor) rather than vague terms. Dressing selection, placement and removal, debridement, and heat/cold orders are provider-driven; the nurse's role is assessment, ordered care, monitoring, documentation, and escalation. Specific techniques, solutions, and documentation standards vary by institution and jurisdiction and must be learned through skills-lab checklists and supervised clinical training.

The college version

1. Wound assessment

Wound assessment happens at regular intervals so progress and problems are recognized. A common framework is REEDA:

R — Redness: how much surrounds the wound and whether it is changing.
E — Edema: swelling of the wound or surrounding tissue.
E — Ecchymosis: bruising or discoloration nearby.
D — Discharge (drainage/exudate): type, amount, color, and odor of fluid.
A — Approximation: how well the wound edges are coming together.

The nurse also measures the wound — length, width, and depth — using a consistent method so changes compare objectively, and cleans and irrigates it (gently flushing with fluid) when ordered to remove debris and support healing, per provider order and policy.

Exudate (drainage) is described by appearance: serous (clear, thin, watery), sanguineous (bright red, fresh blood — may signal active bleeding), serosanguineous (pink to light red, a mix of clear fluid and blood, common early on), and purulent (thick yellow, green, or tan, often odorous — suggests infection).

2. Dressings

A dressing protects the wound, absorbs drainage, maintains moisture, and supports healing; choice depends on depth, drainage, and infection or dead tissue, and is provider-ordered:

Dry sterile dressing: a simple sterile covering for closed or minimally draining wounds.
Wet-to-dry dressing: moist gauze left to dry so removal lifts away dead tissue (mechanical debridement) — used only as ordered, as it can also remove healthy tissue and is painful.
Hydrocolloid: a gel-forming, moisture-retaining dressing for shallow, low-drainage wounds.
Hydrogel: a water-based dressing that adds moisture to a dry wound and softens dead tissue.
Foam: a highly absorbent dressing for moderate to heavy drainage.
Alginate: a seaweed-derived dressing that absorbs large volumes of drainage; for heavily draining wounds.

Dressings are secured with tape or Montgomery straps (reusable fabric ties that protect fragile skin from repeated tape removal). A binder is a wide wrap that supports an abdominal or chest wound, reduces movement discomfort, and holds dressings in place.

3. Drains and thermal therapies

A drain removes fluid or air that could collect, raise pressure, and delay healing or promote infection. A Jackson-Pratt (JP) drain is a closed-suction drain with a soft bulb that, when compressed, pulls fluid out; the bulb is emptied and its output measured and documented per policy. A Hemovac is a closed-suction drain using a spring-loaded disc. A Penrose is an open, non-suction rubber tube that lets fluid drain by gravity into a dressing (no collection container).

Heat therapy increases blood flow and relaxes tissue, easing stiffness and muscle spasm. Cold therapy constricts vessels, reducing swelling, inflammation, and pain. Both are used for limited periods per order. Contraindications and cautions include avoiding heat over areas with reduced sensation, impaired circulation, active bleeding, or acute injury (where it can worsen swelling), and avoiding cold over areas with poor circulation or in people who cannot sense or report temperature. The nurse assesses skin before, during, and after therapy and documents the response, applying therapies only under supervision and per policy and faculty guidance.

How it works

The nurse assesses the wound with REEDA, describes and measures drainage, and checks surrounding skin and any drain.
Findings are matched to the ordered plan: a dressing protects, absorbs, moistens, or debrides as the wound requires.
A drain removes fluid or air, and its output is measured and documented.
Heat or cold therapy is applied for limited periods per order, with skin assessed before, during, and after.
Reassessment and documentation show whether the wound is progressing or the plan must change; concerning changes are communicated and escalated.

Common confusions

Do not confuse	With	Difference
Serous	Serosanguineous	Serous is clear and watery; serosanguineous is pink (clear fluid mixed with blood)
Sanguineous	Serosanguineous	Sanguineous is bright red (fresher blood); serosanguineous is pink and thinner
Hydrocolloid	Hydrogel	Hydrocolloid retains existing moisture and gels; hydrogel adds moisture to a dry wound
Jackson-Pratt	Penrose	JP is closed suction with a collection bulb; Penrose is open and drains passively into a dressing
Heat therapy	Cold therapy	Heat increases blood flow and relaxes tissue; cold constricts vessels and reduces swelling

Memory aids

Remember drainage types as "SSSP — Serous (clear), Sanguineous (red), Sero-sanguineous (pink), Purulent (pus)." For suction drains: "JP = soft Bulb, Hemovac = spring Disc — both Closed; Penrose = Passive."

Quick review

Topic Recap

Wound assessment uses REEDA — redness, edema, ecchymosis, discharge, approximation — plus measurement and observation of surrounding skin.
Exudate is described as serous, sanguineous, serosanguineous, or purulent; purulent suggests infection.
Dressings range from dry sterile and wet-to-dry to hydrocolloid, hydrogel, foam, and alginate; tape, Montgomery straps, and binders secure and support.
Jackson-Pratt and Hemovac are closed-suction drains; Penrose is open and passive.
Heat and cold therapy relieve symptoms but carry contraindications, especially with impaired sensation or circulation.

Knowledge Check

What does the REEDA acronym stand for?
A wound drains thick yellow-green fluid with an odor. What is this, and what does it suggest?
Which dressing suits a heavily draining wound — hydrogel or alginate? Why?
How does a Jackson-Pratt drain differ from a Penrose drain?
Name one contraindication or caution for heat therapy and one for cold therapy.

Answers and Rationales

Answer: Redness, edema, ecchymosis, discharge, approximation. Why: These are the five features systematically assessed to monitor healing.
Answer: Purulent exudate, suggesting infection. Why: Thick yellow/green drainage with odor is a classic infection sign and should be reported promptly.
Answer: Alginate. Why: Alginate absorbs large amounts of drainage; hydrogel adds moisture and suits dry wounds.
Answer: A Jackson-Pratt is a closed-suction drain with a compressible bulb that collects and measures drainage; a Penrose is an open tube that drains passively into a dressing. Why: Closed suction actively pulls fluid; an open drain relies on gravity and capillary action.
Answer: Heat is avoided over areas with reduced sensation, impaired circulation, active bleeding, or acute injury; cold is avoided over poor circulation or in people unable to sense or report temperature. Why: Both can cause burns or tissue injury when sensation or circulation is impaired.

Eli explains

The same idea, in plain words

Explain it like I’m 10

Think of a wound like a plant you are trying to grow: you check it regularly — is the soil too wet or too dry, is anything unwanted growing, are the edges of the bed holding? Wound assessment is that regular check, looking at color, edges, fluid, and surrounding skin. Dressings are like choosing the right cover — some hold moisture in, some soak up extra, some protect. A drain is a small gutter carrying away extra water so the roots do not rot. Heat and cold are adjusting sun and shade to help the plant along.

The comparison stops being exact because a wound is living tissue that can become infected and must be handled with clean or sterile technique, and because dressing and therapy choices are made by or with a qualified clinician rather than by guesswork. That is why the nurse learns to describe wounds precisely and to follow orders and institutional policy for any hands-on care.

Simple Example

A healing surgical incision shows minimal redness, well-approximated edges, and a little serosanguineous (pink-tinged) drainage — normal early healing. A wound that turns increasingly red, warm, and swollen with thick yellow-green (purulent) drainage is a warning sign to communicate to the provider.

Worked example

Assess: Evaluate the wound with REEDA; document exudate type, color, amount, and odor; measure the wound; and check the surrounding skin and any drain's output and insertion site.
Diagnose: Identify Risk for Infection, Impaired Skin Integrity, or Impaired Tissue Integrity as findings indicate.
Plan: Set expected outcomes (edges remain approximated with decreasing redness, no infection) and confirm the ordered dressing, drain, and therapy plan.
Implement: Carry out ordered wound care, dressing changes, drain care, and heat/cold therapy using prescribed technique and precautions, with clean or sterile technique as ordered.
Evaluate, document, communicate, escalate: Reassess after interventions, document findings and drainage output factually, and communicate increases in redness, swelling, pain, purulent or foul drainage, fever, or sudden drain-output change; escalate signs of infection, hemorrhage, or wound breakdown for qualified evaluation. Drain removal, debridement, and treatment decisions remain with the provider or wound-care clinician.

Key takeaways

High yield: REEDA = redness, edema, ecchymosis, discharge, approximation.
High yield: Exudate types: serous (clear), sanguineous (bright red), serosanguineous (pink), purulent (thick, yellow/green — suggests infection).
High yield: Purulent or foul drainage, increasing redness/swelling/pain, or fever are warning signs to report promptly.
High yield: Hydrocolloids and hydrogels keep wounds moist; foam and alginate absorb heavy drainage; dry sterile dressings cover minimal-drainage wounds.
High yield: Wet-to-dry dressings mechanically debride but can harm healthy tissue; used only as ordered.
High yield: Jackson-Pratt and Hemovac are closed-suction (output collected and measured); Penrose is open and drains passively.
High yield: Heat increases blood flow; cold constricts vessels — each has contraindications, especially with impaired sensation or circulation.
Montgomery straps and binders protect skin and support wounds without repeated adhesive trauma.
Drain output and wound measurements must be documented objectively and consistently.

Keep learning

Ready to build on this? Continue to the next lesson.

Study tools & related lessonsYou’ll learn to · Key vocabulary · Related

You’ll learn to

Describe a systematic wound assessment using the REEDA framework and exudate characteristics.
Distinguish the major types of wound dressings and the purpose each serves.
Explain the purpose and differences among common drains.
Describe the concepts, uses, and contraindications of heat and cold therapy.

Key vocabulary

Wound assessment: Systematic, ongoing evaluation of a wound and surrounding skin
REEDA: Redness, edema, ecchymosis, discharge, approximation
Exudate: Fluid (drainage) that comes from a wound
Serous: Clear, thin, watery drainage
Sanguineous: Bright-red drainage with fresh blood
Serosanguineous: Pink, thin drainage mixing clear fluid and blood
Purulent: Thick yellow/green/tan drainage, often odorous
Measurement: Documenting length, width, and depth consistently
Cleaning: Gently removing debris from a wound
Irrigation: Flushing a wound with fluid
Dry sterile dressing: Simple sterile covering
Wet-to-dry dressing: Moist gauze that dries and debrides on removal
Hydrocolloid: Moisture-retaining, gel-forming dressing
Hydrogel: Water-based dressing that adds moisture
Foam: Highly absorbent dressing
Alginate: Seaweed-derived, highly absorbent dressing
Tape: Adhesive securing dressings
Montgomery straps: Reusable fabric ties securing dressings
Binder: Wide wrap supporting an abdominal or chest wound
Drain: Tube or strip removing fluid or air
Jackson-Pratt drain: Closed-suction drain with a compressible bulb
Hemovac: Closed-suction drain with a spring-loaded disc
Penrose: Open, non-suction rubber tube
Heat therapy: Applying warmth to increase blood flow
Cold therapy: Applying cold to constrict vessels
Contraindications: Conditions under which a therapy should not be used

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