The client at risk for dehydration is on strict intake and output. In addition, the client has a large draining wound. What action should the nurse take regarding fluid lost through wound drainage?
A. No action needs to be taken because wound drainage is considered insensible loss and is of no consequence.
B. Estimate the amount of wound drainage by the color of the stains on the dressing.
C. Weigh the dressing materials before and after the dressing change.
D. Weigh the client before and after the dressing change.
C
One mg of body fluid is considered to be 1 mL in volume. A reasonable way to measure wound drainage is to subtract the dry weight of the dressing from the weight of the dirty dressing. The difference in milligrams can be considered the volume of drainage in milliliters.
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