NUR 116 Wounds and Nutrition

Infection

Can lead to development of chronic wound, osteomyelitis, sepsis

Hemorrhage

Caused by dislodged clot from wound, slipped suture, infection, erosion of blood vessel

Dehiscence

Splitting or bursting open of a pod or wound

Evisceration

The removal of internal organs

Fistula formation

Abnormal connection or tunnel between two surfaces, such as an organ and the skin or two organs

Abscess

Collection of infected fluid that hasn’t drained, pressure to surrounding tissue

Nutritional intervention

need high calorie, high protein, vitamin A C and Zinc, hydrate

Cold therapy

Constricts blood vessels, reduce muscle spasms, promote comfort, treats direct trauma, chronic pain, dental pain, muscle spasms

Heat therapy

Dilates blood vessels, increases tissue metabolism, reduces blood viscosity, reduce muscle tension, sometimes reduce pain, treats infection, surgical wounds, inflamed tissue, arthritis, joint and muscle pain, dysmenorrhea, chronic pain

Hemostasis phase

Bleeding phase

Inflammatory phase

Temporary layer of skin forms

Proliferation phase

Repair phase, cells regenerate

Maturation phase

Remodeling phase, cells rebuild

consistent carbohydrate diet

Limits number of carbs per day, indicated for diabetes

Fat restricted diet

Low fat diet, indicated for HTN, hyperlipidemia, coronary artery disease, history of stroke, chronic cholecystitis, prevent atherosclerosis

Low fiber diet

Less than 10 g/day, indicated for preoperative, ulcerative colitis, diverticulitis, and Crohn disease

Sodium restricted diet

500-3000 mg/day, indicated for HTN, hyperlipidemia, coronary artery disease, history of stroke, renal and liver disease

Renal diet

Restrict protein, sodium, potassium, and fluid, indicated for CKD, AKI, dialysis, kidney stone/ and nephrotic syndrome

Hemoglobin decreased

Anemia

Hematocrit decreased

Anemia

Prealbumin decreased

Protein depletion and malnutrition

Transferrin decreased

Anemia, protein deficiency, loss from burn or malnutrition

Blood urea nitrogen increased

Starvation, high protein intake, severe dehydration

Blood urea nitrogen decreased

Malnutrition, low protein diet, over hydration

Serum creatinine increased

Dehydration

Serum creatinine decreased

Reduction in total muscle mass, severe malnutrition

Stage I

Non blanchable redness

Stage II

Partial thickness tissue loss, shallow open ulcer or ruptured intact blister

Stage III

Full thickness tissue loss, adipose tissue present

Stage IV

Full thickness tissue loss, exposed bone, cartilage, tendon, muscle

Deep tissue injury

Non blanchable maroon or darker skin tones, can be intact or not, can be blood filled blister

Unstageable

Full thickness tissue loss, slough or eschar is blocking view