Professional Documents
Culture Documents
19
• Wounds characterised by whether they are
acute or chronic
Acute wounds
Characterised by:
• No underlying aetiology i.e. trauma
• Short duration
• Normal inflammatory phase
• Heal and do not breakdown
21
Chronic wounds
Characterised by:
• Underlying pathology e.g. venous
insufficiency
• Prolonged duration
• Hyperactive state
• Persistent state of inflammation
22
• Wounds go through 4 distinct phases
Normal Wound Healing Response
Proteoglycans
Collagen
Fibroblasts remodelling
Collagen Scar maturation
Neutrophils Angiogenesis MATURATION
Macrophages
Lymphocytes PROLIFERATION
Platelets
Fibrin INFLAMMATION
HAEMOSTASIS
Moist Dehydrated
Shiny Dull
35
Granulating
(WHRU)
Necrosis
(WHRU)
Slough
Clinical appearance
of
surrounding skin
Maceration
Excoriation
Erythema and oedema
Eczema and dry skin
Exudate
• Quantity – Small , moderate copious is
dressing containing exudate?
• Colour – Green? serous?, haemoserrous?
• Consistency – Thick?Thin,
Pain
• When does it occur?
• How bad (intense) is it?
• How does the patient
describe it?
• What makes it better?
• If there are any changes in the wound report
immediately to your nurse in charge
• Any delay in a reassessment may result in
inappropriate treatment