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Wound Management - Coggle Diagram

- - - - Typically occurs where surgical incisions are found. The surgical incision will have a partial or complete separation of the tissue layers during healing.
    - - Occurs when there is total separation of the tissue layers, causing the visceral organs to “pop out” of the incision.
  - - - Stage 2: Skin may appear with a blister, have a scraped appearance to it, or the top layer of skin may be worn off. (University of Texas, Houston, 2003)
      - Stage 3: These are full-thickness and extend into the subcutaneous tissue. Undermining and tunnelling may be present.
      - Stage 1: Skin has different appearance. Does not blanch when applying and releasing pressure. In people with darker skin, a stage 1 pressure injury may appear darker than their normal skin, or it can appear as blue, gray, or purple. Skin can feel spongy or raised. (University of Texas, Houston, 2003)
      - Stage 4: Involves the exposure of muscle, bone, tendons, and/or cartilage. If bone is present, then infection of the bone is very likely.
      - Stage 0: Filled with necrotic tissue. Can’t accurately identify underlying tissue type so wound can’t be staged. – MUST KNOW TISSUE TYPES.
  - - - Constant pressure to skin and underlying muscle. (i.e. mattress or wheelchair). Constant pressure leads to reduced blood flow which results in tissue death.
        
        EVP suggests certain factors increase risk for pressure ulcers (Miller, M. W.,et al. (2020))
        
        Inability to reposition self
        
        Incontinence
        
        Poor nutrition
        
        Lowered mental status
        
        High Risk Areas:
        
        Back of head and ears
        
        Upper back and shoulder blades
        
        Lower back, coccyx, and buttocks
        
        Hips and heels
      - Nurse's role in prevention
        
        Asses during bathing, toileting, incontinence maintenance, turning in bed, assisting with dressing