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Three phases of wound healing
1. Inflammation and debridement
2. Repair/proliferation
3. Maturation
Inflammation and Debridement Phase Action of:
- Macrophages initially
- Neutrophils
- Macrophages subsequently
- Fibroblasts
Migration of leucocytes into wound bed
- Macrophages produce IL-1 to stimulate endothelial cells to make IL-8 to attract neutrophils
- Neutrophils kill bacteria and degrade necrotic tissue
- Macrophages produce fibronectin and growth factors that stimulate mitosis. Also phagocytosis of necrotic tissue.
- Fibroblasts are stimulated to produce the matrix of granulation tissue
NB: as wound becomes free of bacteria and necrotic tissue macrophage number decreases resulting in fewer cells being attracted. In chronic (+/- infected) wounds macrophages persist
Four processes in Repair/Proliferative Phase
Angiogenesis (new capillaries)
Fibroplasia (collagen production and change from type 3 to type 1)
Wound Contraction (migration of myofibroblasts)
Epithelialisation
screening tools for malnutrition - 4 points
Recent weight loss, recent appetite, BMI and disease severity
When to institute nutritional support
Anorexic for more than 3-5 days or hyporexic - 75 percent RER - for more than 7 days
Physiologic benefits of enteral nutrition
Prevention of intestinal villous atrophy, maintenance of intestinal mucosal integrity - helps with prevention of bacterial translocation, and preservation of GI immunologic function
Refeeding syndrome
Electrolytes
Clinical signs
Hypophosphatemia is the most common and critical electrolyte disturbance
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