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Wound Management - Coggle Diagram

- - - - Constant pressure to skin and underlying muscle. (i.e. mattress or wheelchair). Constant pressure leads to reduced blood flow which results in tissue death.
        
        High Risk Areas
        
        Upper back and shoulder blades
        
        Lower back, coccyx, buttocks
        
        Back of head and ears
        
        Hips and heels
  - - - Typically occurs where surgical incisions are found. The surgical incision will have a partial or complete separation of the tissue layers during healing.
        
        Evidenced based practice indicates suturing body cavities and deeper structures so they are closed while layers of skin remain open. This allows free drainage of pus and other materials to drain while the swelling decreases. These patients typically have additional surgery to assess the wound, irrigate it, debride it, and close it. It MUST BE SAFE TO DO SO! Wound is healed by tertiary intention. (Clarke, Santy-Tomlinson, J., 2014)
    - - Occurs when there is total separation of the tissue layers, causing the visceral organs to "pop out" of the incision. Strain such as lifting, coughing, or vomiting can cause evisceration.
        Example: People who have had hernia surgery are advised not to lift heavy objects for at least 6 weeks after surgery while they heal.
- - - - Woven gauze (sponges) – absorb exudate from wound
      - Nonadherent material – does not stick to wound bed
      - Damp to damp – Used to mechanically debride a wound until granulation tissue starts to form in wound bed. Must remain moist at all times to prevent pain and disruption of wound healing
      - Self-adhesive, transparent film – temporary “second skin”. Good for small, superficial wounds.
      - Hydrocolloid – occlusive dressing that swells in the presence of exudate. Composed of gelatin and pectin. Forms a seal at wound’s surface to prevent evaporation of moisture from skin. Can stay in place 3 – 5 days.
      - Hydrogel – Mostly water. For infected, deep wounds or necrotic tissue. Provides a moist wound bed. Soothing for pain. Prevents skin breakdown in high-pressure areas such as the sacrum.
      - Aliginates – Nonadherent dressings that conform to the wound’s shape and absorb exudate.
      - Collagen – Helps stop bleeding
- - - - Starts with the injury. Lasts 3-6 days. During this stage, the blood vessels are retracting and constrincting, and clots are forming. WBCs, O2, and nutrients are being delivered to the site via blood supply. Phagocytosis is occuring.
    - - Lasts 3 - 24 days. Lost tissue is being replaced with granulated tissue and collagen. The wound's edges are being reduced to focus on the healing area and new epithelial cells are being resurfaced.
    - - Starts around day 21. The collagen scar is strengthened and a more normal appearance occurs. This stage can take over a year to complete.