慢性伤口处理

woundcleaning--Techniques伤口清洁---技术•Componentswhichneedtoberemovedfromwoundbed•需要从创面去除的部分•Surplusexudate多余渗出物•Necrotictissue坏死组织•Deadcells死亡细胞•Breadinggroundforbacteriaandcomponentswhichmightbesupportivetothedevelopmentofbiofilms.•细菌滋养环境以及可能会促进生物被膜形成的成分woundcleaning伤口清洁•Generalgoal•总体目标•Toremovedebriesandfroeignbodies.去除碎屑与异物•Necrotictissue坏死组织•Deadcells死亡细胞•Fibrin纤维蛋白•Toxins，MMP毒素，MMP•Foreignbodies(forinstanceremainsforpreviouslyuseddressings)•异物（例如先前使用的敷料）Woundcleaning--Techniques伤口清洁-----技术•Requirementsonwoundrinsingsolutions•对伤口冲洗液的要求•Shouldbesterilie无菌•Notcolored无色•Genteltocells/nontoxic细胞温和型/无毒•Bodytemperature(coolingdownwoundbedreducesorinactivatescellactivity)28℃nofunction•体温（冷却创面、减少细胞活性或使其灭活）28℃无效Woundcleaning伤口清洁•Ways•方法•Basiccleanningofwoundbed,woundedgesandsurroundingarea•对伤口创面、边缘以及周围进行基本清洗•Antibacteiracleanning抗菌剂清洗•Woundrinsing伤口冲洗•WoundcleaningWettodry干燥清洗伤口•Debridement清创术•Negtivepressure负压Woundcleaning伤口清洁----技术•CleanigwithRinsingsolution•采用冲洗溶液进行清洗•Saline生理盐水•Ringersolution林格氏液•Indication:Cleaningwound适应症：清洁伤口•Nontouchtechnique非接触技术Woundcleaning伤口清洁----技术•Cleanningwithantisepticsolution•采用消毒溶液进行清洗•Octenidin-di-hydrochlorid奥替尼啶盐酸化合物•Polyhexanid聚已缩胍•Iodine碘•Indication:Infectedandcontaminatedwound•适应症：感染伤口和污染伤口•Nontouchtechnique:Fromoutsidetocenterofwoundinordertoavoidfurtherspreadingofbacteriatothesurroundingarea.•非接触技术：从外围向中间清洗以避免细菌向周围进一步播散Woundcleaning--Antisepticsolution伤口清洁--消毒溶液•Octenidin-di-hydrochlorid奥替尼啶盐酸化合物•Polyhexanid聚已缩胍•Advantages优点•notcolored,notinacticatedbybodyfluids无色、不会被体液灭活•donotinitiateresistance,skinirritationandallergies不会引起抗药性、皮肤刺激或过敏•Disadvantages缺点•notavailableandreimbursedinmanycountries在许多地区不能使用而且不能报销•不能采用高压将奥替尼啶注入腔内加以应用•Bothshouldnotbeappliedoncartilageandincontactwithinternalorgans(abdominalcavity)二者均不能在软骨上运用，且不能与内部器官接触（腹腔）Woundcleaning--Antisepticsolution伤口清洁--消毒溶液•Iodine•Advantages优点•EffevtiveagainstGrampostiveandGramnegtivebacteria•可有效对抗革兰阳氏和阴性菌•Availableindifferentformsforapplication(ointment,lotions)•可以采用不同形式加以运用（软膏、洗液）•Disadvantages缺点•Colored(makeswoundassessmentdifficult)有色（难以对伤口进行评估）•Inactivatedbybodyfluids会被体液灭活•Sensitivitymightoccur可能会发生过敏•Systemicsideeffectsduetoabsortion吸收会导致全身副作用Wounddebridement清创术•Incaseofachronic,difficulttohealwoundcleaningcanbesupportedwithdifferentwaysofdebridement•在慢性、难愈合性伤口的清洁中可才采用不同的清创术进行支持治疗•Requirements要求：•Asgentleaspossible尽可能温柔•Asthoroughaspossible尽可能彻底•Assoonaspossible尽早Debridementopportunity清创时机•病情许可，越早越好•Illnesspermission,thesooner,thebetter•无明显感染表现，均可清创•Noapparentinfection,debridementperformance•已有感染，但伤口有异物或较多坏死组织，也可清创，清创后伤口暂不缝合•IftheWoundisinfected,buthaveaforeignbodyormuchnecrotictissue,wecanalsodebridement,anddonotwoundclosureafterdebridement•急性伤口理想时间：伤后8小时以内，头面、手部伤口12小时以内•Theidealtime:8hoursafterthewound,andthehead,handwithin12hoursafterthewoundDebridementmethods伤口清创方法•机械清创（伤口清洗和伤口浴，水下低频超声波处理、聚氨酸脂类软性泡沫复合物产品等）•Mechanicaldebridement•外科清创（剪刀、手术刀、锋利勺、刮器）Surgicaldebridement•酶清创（蛋白质、肽类）Enzymaticdebridement•生物清创Biosurgicaldebridement•自溶性清创（内活性伤口敷料、如水胶体、水凝胶）AutolyticdebridementWounddebridemen清创术•Mechanical机械性清创•Wipe(mechancialyclean)thewoundwithsterilegauze•无菌纱布擦拭伤口（机械型清洗）•Gauzecanbemoistordry可以采用湿性或干性纱布•Cave:mightbepainfulforpatient孔洞：可能造成患者疼痛•Aternative选择Soakedgauzeisappliedtowoundandshouldberemovedgently.Everytimesomeofwounddebriswillremainingauze.对伤口使用浸湿纱布，而且去除纱布时动作应当轻柔。每次都会有一些伤口碎屑留在纱布内。Wounddebridemen清创术•Surgical手术清创•Removalofdebriswithcurette,abrasororscapel采用刮匙、刮除器或手术刀去除碎屑•Usuallyperformedbysurgeonorspeciallytrainednursesundersupervisionofsurgeon.通常由外科医生执行清创或者在外科医生的监督下由护士进行清创。•Cave空洞•Mightbepainfulforpatient可能会引起患者疼痛•Chanceofbleeding可能会出血•InseverecasesintmustbeconductedinOR严重时必须采用手术进行处理Wounddebridemen清创术•Enzymatic酶解清创术•Removalofdebriswithemzymes采用酶法•Havetoberenewedfrequently•必须经常更新•Needamoistandbodywarmenvironmenttobeeffective•需要保肢潮湿和体温环境才能产生作用•Havetobeappliedattheareaofdebris•必须在清创区域使用•CollegesSanty1Z**Ointment(胶原酶Santy1)•Enzymaticdebridingagent(清创酶)Wounddebridemen清创术•Biosurgicalwithmaggots采用蛆进行生物手术•Serratiamarcecens沙雷杆菌•Advantage优点•Veryselectivecleaning/Antisepticeffect选择性清洁/防腐作用•Stimulategranulation刺激肉芽生长•Almostpainfree几乎无痛•Disadvantage缺点•Notalwayseasytoapplyandkeepinplace不容易使用而且不容易固定。•Ethicalaspectsneedconsideration.需要对伦理学方面加以考虑。Wounddebridement清创术•Autolytic自熔性清创术•Facilitatebodyownsofmechanismofdebridementmoistdressing•采用适当的湿性敷料促进机体自身清创机制•Advantage优点•Cellfriendly细胞亲和性•Almostpainfree几乎无痛•Easytodo容易操作•Disadvantage缺点•Tasksmoretimethanforinstancesurgicaldebridement比手术清创方法花费更多时间•Needstobeadaptedtotheindividualrequirementsofwound需要适合伤口的个体要求•Notalwayseffectiveforinstanceincaseofthicknecroticlayer在诸如坏死层较厚的情况下Theevolutionandapplicationofdressings•Gauze•OilYam、sticking•Hydrocolloiddressings•Antibacterialdressings干纱布油砂、敷贴水胶体抗菌敷料、生物活性敷料Wounddressings-General伤口敷料—总体•Requirements要求•Maintainmoistenvironment保持环境湿润Sterile无菌Removeexcessexudate去除多余渗出物Nontoxic无毒性Nonsenstizing无过敏性Protectthewoundfromfurthertrauma保护伤口防止进一步损伤Allownontraumaticremoval去除时不会产生损伤Protectfrommigrationofbacteria保护伤口防止细菌迁移Keepwoundatbodytemperature(Isulation)