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Model For Identifiication &Provision Of Nutritional Needs

Identify clients at risk


Record history
Dietary social, medical/ surgical, druugs
Living environment
Safe, hygienic food preparation and storage
Accessibility to appropriate food choices
Carer/ community assistance available
Knowledge
Of nutrition
Of food preparatio
Cognitive
Ability to appreciate nutritional need
Psychomotor skills
Ability to obtain, arrange for, or prepare food
or fluids

Assess Resources Available


Assess:
Cost: limitations
Carer/ Family Ssistance
Community Services

Patient Client Outcomes


Increased:
Satisfaction
Knowledge of nutrition, food planning, meal
preparation and community resources
Improved:
Eating abits
Health status
Wound healing

Identify clients needs


Sign and symptoms of malnutritin. Obesity,
dehidration:
Physical asseesment
Anthropometry
Laboratory analysis
Identify additional nutritional needs due to:
Wound healing
infection
Assess:
cognitive learning skills
psychomotor skills
carer/ community resources

Nutrition interventions
Encourage better eating habits
Assist with menu planning
Arrange community services when needed
and unable to do so

Wound mangement practice


Inappopriate wound management practices greatly affect healing to identify and prevent
problems, the physiology of wound healing must be understood as should the needs of the
healing wound. There needs to be an understanding of the effects of commonly used
antiseptics on wounds. Knowledge of the various categories of wound care products and their
mode of action is essential. Wounds must be managed in a way that is considerate of the
compromised state of tissue. Wound, personal and environmental hygiene must be optimal, to
reduce the risk of cross infection.
Hydration of the wound
Thaditional wound management practice have encouraged a dry wound environment, in he
belief that it would prevent wound infection. However, Winter (1962) demostrated that
healing occurred more rapidly if the wound was kept moist. Todays new generation
dressings are designed to promote moisture balance in wounds.
Desiccation of the wound retards epithelial cell migration. A moist wound environment helps
the fragile cells to remainviable and it facilitates their migration across the wound surface. A
moist environment wil also facilitate autolitic debridement. Pain in the wound is reduced or
elimitated if the nerve endings are kept moist and air excluded.
Wound temperature
In a study of the effects of temperature in wound healing, Lock (1979) demostrated that a
constant temperature approximately 37o Celcius had a significanteffect, an increase of 108%,
on mitotic activity in wounds. Thus, if healing is to be promoted, a stable wound temperature
must be maintained. The frequent undressing of wounds and the use of cold solutions needs
to be questioned. Dressings that eliinate the need for frequenr change and which maintain
moisture and warm are more conductive to healing.
Pressure, friction & Shearing Force
Capillaries are very fragile and they are one cell thin. The pressure resistance at the arterial
end of the capillary is approximately 30 mmHg with the pressure gradient decreasing towards
the venous end. If sustained occlusion of the blood vessels occurs, tissue hypoxia and death
results. Necrotic eshar acts as a foreign body in a wound and retards healing.
Pressure, friction and shearing forces can result from:

Activities or inactivity

Restrictive appliances or clothing

Abrasive or compressive wound dressings and practices

Protection of the wound is essential to promote vascularity and healing.

Presence of Foreign Bodies


Any foreign body in a wound retards healing. The most common foreign bodies found in
wounds are:

Wound debris

Suture or surgicallly implanted materials

Environmental debris eg. Dirt, hair, glass

Dressing product debris rg. Cotton wool fibres

Infection

All wounds, but especially those that fail to heal, should be inspected for foreign bodies and
x-ray may be required. Cleansing of the wound should be gentle but through. Solution used
should be nontoxic (such as normal saline).

Wound Infection
All wounds are contaminated, but this does not necessary lead to sepsis (Smith, 1983).
Bacteria exists as part of the natural flora the skin, and organisms migrate into the wound
from the surrounding skin.
Type of Wound
a. An acute wound is any surgical wound that heals by primary intention, or any
traumatic or surgical wound that heals by secondary intention, and which proceeds
through an orderly and timely reparative process that result in sustained restoration of
anatomical integrity.
b. A chronic wound occurs when the reparative process does not process through an
orderly and timelly process as anticipated and healing in comlicated and delayed by
intrinsic and extrinsic factors that impact on the person, the wound or the environment
(Lazarus et al, 1994)
Aetiology
T is impact to ascertain the aetiology or cause of wounding in order to guide management and
future preventative strategies. The commones aetiologies will be trauma or surgical
interventations, but infection, disease processes, skin manifestations, ischaemaand facititious
wounding (self-harm) can result in wound.
Type of Healing
a. Primary Intention

When there is minimal tissue loss and the edes of the wound are held in close
apposition by either suture, clips or tape. Minimal scarring result.
b. Delayed Primary Intention
When the wound is infected or contains foreign bodies and requires intensive
cleaning, prior to primary closure 3-5 days later.
c. Secondary Intention
Woundhealing is delayed and occurs by an obvious process of granulation,
contraction and ephitelisation. Scarring results.
d. Skin Graft
Partial or full thickness skin grafts are used to speed up the healing process and
reduce the risk of infection.
e. Flap
Surgical relocation of skin and subcutaneous tissue to the wound from an adjacent or
distant site.
Tissue Loss
Tissue loss can be calculated by two and three dimensionaal measurement or according to a
devised classification system. Two and theee dimensional measurement of the wound will be
used to record linear or volume measurement of tissue loss. Akthough it is difficult to obtain
an accurate linear three dimensional assesment when there is an uneven wound base.
Occasionally, the degree of tissue loss is referred to in the following broad terms.

Superficial wound- involves the epidermis

Partial wound-involves the epidermis and dermis

Full thickness wound-involves the epidermis, dermis, subcutaneous tissue and


extending to musle, bone and tendon.

Assesment classification systems have been devised for certain wound types such as burns,
pressure ulcerss and skin tears.

Assesment of Burns
Burns are usually classified as follows:
Classification of Burn

Degree of Tissue Loss

Superficial

Involves the epidermis

Superficial partial-thickness

Involves the epidermis and extends into the papillary or


superficial layer of the dermis

Deep partial-thickness

Extends into the reticular or deeper layer of the dermis

Full thickness

Involves the epidermis, dermis and subcutaneous tissue

ubdermal

Involves the muscle, bone, tendon, and interstitial tissue

The degree of burn is also referred to and equates t the classification of burn as follows.
Degree of Burn

Calssification of Burn

First

Superficial

Second (suprficial)

Superficial partial-thickness

Second (deep)

Deep partial-thickness

Third

Full-thickness

Fourth

Subdermal

(Wilson, 2000)
Percentage of burn in relation to total body surface area (TBSA) or body surface area (BSA)
is determined according to:
Gambar nine of rules

Wallaces rule of nines

Age-dependent burn graphs

Palmer surface assesment.

TBSA burn estimate chart for different age groups


Burn area

0.1-

Head
Neck

year

1-4 years

5-9 years

10-14
years

15 years

Adult

19%

17%

13%

11%

9%

7%

2%

2%

2%

2%

2%

2%

Anterior
trunk

13%

13%

13%

13%

13%

13%

Posterior
trunk

13%

13%

13%

13%

13%

13%

Each
buttockq

2.5%

2.5%

2.5%

2.5%

2.5%

2.5%

Genitalia

1%

1%

1%

1%

1%

1%

Lower arm

3%

3%

3%

3%

3%

3%

Hand

2.5%

2.5%

2.5%

2.5%

2.5%

2.5%

Thigh

5.5%

6.5%

8%

8.5%

9%

9.5%

Leg

5%

5%

5.5%

6%

6.5%

7%

Foot

3.5 %

3.5%

3.5%

3.5%

3.5%

3.5%

Modified Lund and Browder Chart (Carrougher & Helvig, 1998).

Assesment of Pressure Ulcers


The classification system ost commonly used to stage tissue loss in pressure ulcers is the four
stage classification recommended by te National Pressure Ulcer Advisory Panell (1989) and
adopted by the aaustralian Wound Management Association (2001).
Stage 1
Observable pressure-related alteration(s) of interact skin whose indicators as compared to the
adjacent or opposite area on the body may include changers in one or more of the following:
skin temperature (warmth or cooliness), tissue coesitency (firm or boggy feel) and/ or
ensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly
pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue
or purple hues.
gambar

Stage 2
Partial thickness skin loss involving epidermis and/ or dermis. The ulcer is superficial and
presents clinically as an abration, blister or shallow crater.
gambar

Stage 3

Full thickness skin loss involving damage or necrosis of subcutaneous tissue tthat may extend
down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with
or without undermining of adjacent tissue.
gambar
Stage 4
Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone,
or supporting structures (for example, tendon or joint capsule). Undermining and sinus tracts
may also be associated with Stage 4 pressure ulcers.
gambar
(Nation Pressure Ulcer Advisory Panel (1989).

Standards for wound management


Standard 1 collabotative practice and interdiciplinary care
The optimal healing of the individual with a wound or potential wound is promoted by a
collaborative and interdisciplinary approach to wound management.
Standard 2 professional practice
The safety and wound healing potential of the individual is ensure by clinical practice in
wound management that respects and complies with legislation, codes of practice, clinical
practice guidelines and organisational policies.
Standard 3 clinical decision making in wound management
The optimal healing of the individual with a wound is facilitated by on going process of
clinical decision making in order to determine the risk of wounding, wound actiology and
wound healing responses.
Standard 4 best practice in wound healing
Wound management is practoced according to the best available evidence for optimising
healing in acute or chronic wounds.
Standard 5 documentation
Documentation in the individuals record or management plan must facilitate communication
and continuity of care between interdisciplinary team member and fulfil legal requirements.
Standard 6 education
Education of the indivdual and their carers should facilitate better health seeking behaviours.
The clinician maximises opportunities for advancing self knowledge and skills in wound
management.

Standard 7 reseach
Wound healing is dynamic process, and the clinician must anticipate that wound management
practices will change, as new scentific evidence becomes available.