wound healing and GI Flashcards
2 wound types and their description
- Acute - generally heal in a couple days to weeks, but can become chronic E.g., surgery or trauma
- Chronic- takes >12 weeks to heal E.g., Pressure ulcers, diabetic foot ulcers
Descriptions of ulcer stages
- Stage 1 sores are not open wounds. The skin may be painful, but it has no breaks or tears.. In a dark-skinned person, the area may appear to be a different color than the surrounding skin Skin temperature is often warmer. And the stage 1 sore can feel either firmer or softer than the area around it.
- At stage 2, the skin usually breaks open, wears away, or forms an ulcer. The sore expands into deeper layers of the skin. At this stage, some skin may be damaged beyond repair or may die.
- During stage 3, the sore gets worse and extends into the tissue beneath the skin, forming a small crater. Fat may show in the sore, but not muscle, tendon, or bone.
At stage 4, the pressure injury is very deep, reaching into muscle and bone and causing extensive damage. Damage to deeper tissues, tendons, and joints may occur.
Factors that impact wound healing
Nutrition-related • Protein • Energy • Hydration • Micronutrients • Hyperglycemia
Other factors: • Edema • Circulation • Smoking • Stress • Alcohol • Medications: Corticosteroids and NSAIDs
Medical management/prevention of ulcers
• Minimize friction and pressure • Repositioning every 1-2 hours • Incontinence (wet wounds won't heal) - Scheduled toileting - Frequent changing • Education - Staff, resident, families
Phases of wound healing
3 main phases:
1. inflammatory:
- pro-inflammatory pathway involving cytokines. Redness, heat, swelling. Maybe pain
- coagulation pathway with platelets+fibrinogen to create a clot.
Inflammatory stage lasts 4-6 days; starts immediately
High need for energy, protein and micronutrients.
2. proliferative; Day 4-14
Also known as constructive phase
Epithelization begins- skin cells migrate to the wound to repair it- this also requires energy and nutrients
adequate blood supply is also required to deliver enough oxygen. this is gonna be a problem if there is not enough iron - impairment of oxygen delivery via hemoglobin
3. maturation: day 8-12 months
collagen is organized to increase tensile strength and form a scar- can take a long time
for the first 14 days- there are high energy, protein and micronutrient needs
Nutrients for healing
Adequate intakes for:
• Ca, Zn
• Vitamins A, D
Possibly elevated needs for: • Energy • Protein • Vitamins C, E, K, • Fe, Se, Cu
Energy for healing reccs
high protein/ high energy diet
30-35kcal/kg for those at risk and for those with pressures ulcers
Use IBW for obese
Fortified foods and ON
Protein for healing reccs
- 1.25-1.5g/kg for those at risk and for those with pressures ulcers
- Use IBW for obese
- Fortified foods and ONS
- Arginine (stage 3-4 wound)- AA that helps transfer other AA into tissue, support protein production and insulin secretion
hydration reccs for wound healing
- Use rule of thumb
- Additional fluids if fever, vomiting, profuse sweating, diarrhea, heavily exuding wounds
- If concerned about overhydration 1kcal/ml is a good place to start
- Assess hydration status daily
vit/mineral reccs for wound healing
likely to need a vitamin and mineral supplement
• Multivitamin/mineral indicated
• Encourage food sources of zinc,
iron, copper, calcium, selenium, (ZICCS), vitamins A,D,E C, K-> not necessarily need to supplement them, especially in 1-2 stage
encourage food sources
• ONS for wounds might be indicated (stage 3-4)
what is celiac>
Celiac disease = autoimmune disease
• Immunological reaction to gluten
resulting in damage to intestinal mucosa
is there a genetic component with celiac?
big genetic component in developing celiac disease
Genetic and autoimmune linkages
• Major genes HLA-DQ2 and HLA-DQ8 in 95% of patients
WHat is the part of the gluten that is the root cause of problem
Gluten is made of prolamin and glutelin
Prolamin is the problematic part
What are the 3 main grains known for celiac triggers
wheat
rye
barley
Pathophysiology of Celiac Disease
• Gluten protein in lumen induces inflammatory response
- Cytokines released by WBC
- Cytotoxic T-cells
• Damage to villi; reduced height,
flattened
• Decreased enzyme function and surface area
• Maldigestion and malabsorption
celiac co-morbidities
• Osteoporosis: bone loss is multifactorial, but part of it is related to Vit D deficiency and calcium malabsorption
when celiac disease is treated, bone density will come back to normal in kids, but not in adults-> important to identify celiac disease early on to attenuate bone loss
• Thyroid dysfunction: as people with celiac are predisposed to other autoimmune disease like thyroid disease
• Anemia (B12, Iron, Folate): due to malabsorption
• Increased mortality due to increased risk of malignancy: as they are at risk of developing cancer
avoiding gluten decreases the risk
- Non-Hodgkin’s lymphoma (3-6x more likely)
- Oropharyngeal, esophageal, and small intestinal adenocarcinoma.
Clinical Manifestations of Celiac Disease
“Classic”
• Diarrhea, abdominal pain, cramping, bloating, gas
Extraintestinal symptoms can be present without any GI symptoms • Bone and joint pain • Muscle cramping, fatigue • Peripheral neuropathy, seizures • Skin rash • Mouth ulcerations
Common celiac symptoms
Diarrhea • Fatigue • Borborygmus- gurgling in intestines • Abdominal pain • Weight loss • Abdominal distention • Flatulence
Uncommon celiac symptoms
- Osteopenia/ osteoporosis
- Abnormal liver function
- Vomiting
- Iron-deficiency anemia
- Neurologic dysfunction
- Constipation
- Nausea
How many celiac cases present common vs uncommon symptoms
Up to 38 % Asymptomatic & ~85% non-classical symptoms- Screening is thus important in high risk groups
Not all symptoms follow the “classic” pattern. Can delay diagnosis.
what are the most common presenting symptoms?
- abdominal pain (83%),
- diarrhea (76%), and
- weight loss (69%).
Diagnoses made prior to celiac disease included
- anemia (40%),
- stress (31%), and
- irritable bowel syndrome (29%)
• Osteoporosis was common.
Those with __ symptoms are fewer than those __ or with__ symptoms
Those with outward symptoms are fewer than those asymptomatic or with less specific symptoms
Diagnosis & Treatment Overview steps
- 1st: Physical exam and blood testing
- 2nd: Duodenal biopsy
- 3rd: Implement gluten-free diet
algorithm for evaluation of celiac disease
https://www.dynalife.ca/Portals/0/pdf/Symposium/2013/7%20-%20Celiac%20Disease%202013_Karina%20Capote.pdf
low suspicion
1. Blood work
wait for blood work results before biopsy
no antibodies-> look for other diagnosis
antibodies-> intestinal biopsy (as it confirms the diagnosis)
if high suspicion:
- blood testing right away: serology testing (looking for antibodies in the blood for gluten as antigen
- we screen for TTG and EMA antibodies )
step 2:
- intestinal biopsy
if there’s high suspicion, biopsy and blood tests will be done at the same time
