美国医师协会压疮指南

AMDAClinicalPracticeGuideline(CPG)forPressureUlcers美国医师协会压疮临床实践指南ForMedicalDirectorsandAttendingPhysicians适合于卫生主管和主治医师WhatisaPressureUlcer?压疮是什么?Anyskinlesion–usuallyoverabonyprominence–causedbyunrelievedpressureresultingindamagetounderlyingtissue皮肤损伤_通常发生在骨隆突处_是压力和/或剪力、摩擦力对皮下组织损伤的结果。PressureUlcersMayNotbePreventable有些压疮是难以避免的Aggressivemeasurescanreducebutnoteliminatetheincidenceofpressureulcers积极的预防措施能够降低压疮的发生率，但并不能彻底消灭压疮；Candevelopdespitebesteffortsofclinicalteaminhighriskpatients尽管临床小组作出最大的努力,但高风险的病人仍有压疮发生Everyeffortshouldbemadetopreventpressureulcers要通过任何方式的努力来预防压疮；Asystematicapproachtorecognizeandmanagepressureulcersisneeded需要用系统化的管理方法来识别和管理压疮。FactorsAffectingPressureUlcerDevelopment促成压疮发生的四大直接因素Pressure压力Shearing剪切力Friction摩擦力Moisture潮湿AMDAPressureUlcerCPGSteps压疮临床实践指南包括：Recognition识别Assessment/RootCauseAnalysis评估和分析根本原因Treatment治疗Monitoring监护PressureUlcersCPGRecognition压疮识别Documentanyhistoryofpressureulcersinthemedicalrecord在病历中记录压疮的全部历史资料；Thoroughlyexamineallskinsurfacesonadmission入院时仔细全面检查病人的皮肤；Identifyallprimaryriskfactors识别所有基本的风险因素PressureUlcersCPGRecognition压疮识别Distinguishtypesofulcers辨别溃疡的类型Vascularinsufficiency/ischemia(venousstasisandarterialischemiculcers)血管机能不全/局部缺血（静脉淤滞和动脉缺血性溃疡）Neuropathic神经性的Pressure压力性的PressureUlcersCPGRecognition压疮识别Primaryriskfactorsfordevelopmentofpressureulcersare:形成压疮的原发危险因素：Impaired/decreasedmobility活动性受到限制或者减少Co-morbidconditions,e.g.,diabetesmellitus糖尿病等合并症Urinaryorfecalincontinence失禁Undernutrition,malnutrition,&hydrationdeficits营养不良、脱水Impaireddiffuseorlocalizedbloodflow血流灌注受限或者局部淤血Drugssuchassteroidsthatmayaffectwoundhealing类固淳药品的使用影响伤口康复；Historyofahealedpressureulcer压疮痊愈的经历Residentrefusalofsomeaspectsofcare&treatment居民拒绝给予局部的护理和治疗Intrinsicrisksduetoaging老龄化为固有的危险因素PressureUlcersCPGRecognition压疮识别MajorRiskFactorsforDevelopingPressureUlcers发生压疮的主要因素Alterationsinsensationorresponsetocomfort对舒适与否的感觉反应能力发生变化Degenerativeneurologicaldisease退化性神经疾病Cerebrovasculardisease脑血管疾病Centralnervoussystem(CNS)injury中枢神经系统受损伤Depression抑郁等情绪PressureUlcersCPGRecognition压疮识别MajorRiskFactorsforDevelopingPressureUlcers形成压疮的主要危险因素Causesofimpaired/decreasedmobility活动性受限或减少Neurologicdisease/injury神经疾病/神经损伤Fractures骨折Pain疼痛Restraints受到束缚PressureUlcersCPGRecognition压疮识别ComorbidConditionsThatMayAffectUlcerHealing多种可能影响压疮康复的身体状况Malnutritionanddehydration营养和水合作用Diabetesmellitus糖尿病End-stagerenaldisease晚期肾脏疾病Thyroiddisease甲状腺疾病Congestiveheartfailure充血性心力衰竭PeripheralVascularDisease外周血管疾病Vasculitis/othercollagenvasculardisorders血管炎和其他胶原血管疾病Immunedeficiencystates免疫缺陷状态Malignancies恶性肿瘤COPD慢性阻塞性肺病Depressionandpsychosis精神状态抑郁Drugsthataffecthealing药物影响康复Contracturesatmajorjoints关节处大范围的挛缩PressureUlcersCPGAssessment压疮评估PressureUlcerClassifications分级Stage1:Observable,pressure-relatedalterationofintactskin,includingchangesinskintemperature,tissueconsistency,sensation,and/ordefinedareaofpersistentrednessinlightskin(red,blueorpurplehuesindarkskin)一期压疮Stage2:Partialthicknessskinlossinvolvingepidermis,dermis,orboth.Theulcerissuperficialandpresentsclinicallyasanabrasion,blister,orshallowcrater二期压疮PressureUlcersCPGAssessment压疮评估PressureUlcerClassifications–continuedStage3:Fullthicknessskinlossinvolvingdamageto,ornecrosisof,subcutaneoustissuethatmayextenddownto,butnotthrough,fascia.Theulcerpresentsclinicallyasadeepcraterwithorwithoutunderminingofadjacenttissue三期压疮Stage4:Fullthicknessskinlosswithextensivedestruction,tissuenecrosisordamagetomuscle,bone,orsupportingstructures(e.g.,tendon,jointcapsule).Underminingandsinustractsalsomaybeassociated四期压疮PressureUlcersCPGAssessment压疮评估EthicalIssuesToConsider对伦理的考虑ReviewAdvanceDirectives检查病人预先的医嘱Identifychoicesthatlimitthescope,intensity,durationandselectionofvariouswound-relatedoradjunctivetreatments选择治疗作用区域、强烈程度和持续时间最小化的治疗，配合相应的伤口治疗和辅助治疗方式。PressureUlcersCPGAssessment压疮评估Aneffectiveassessmentincludes有效的评估包括：Defineandinterpretfactorsaffectingtreatmentandwoundhealingsuchasphysical,functionalandpsychosocialfactors定义和解释关于治疗和伤口康复的影响因素，例如身体的，功能的和心理方面的因素。Defineprognosis–identifyrealisticgoals解释预测——识别现实的各个目标Identifymanagementpriorities识别需要处理的优先项目。PressureUlcersCPGAssessment压疮评估Certainclinicalfindingsmayhavepriority确定临床所见现象能够治疗的优先顺序。Addresssystemicandlife-threateningissues标明对系统或生命有威胁的问题；Stage3and4ulcers三期、四期压疮Significantpain明显疼痛的疮口Fluidandelectrolyteabnormalities渗出物或电解质异常Nutritionaldeficits营养不足Needforsurgicalinterventiontoremovenecrotictissue需要通过外科手术来清理掉坏死组织。Soft-tissueinfection软组织感染。FactorsThatAffectPUWoundHealing影响压疮伤口康复的因素包括：PUWoundhealingisacomplexmultifactorialprocess压疮的康复是一个复杂的、多因素的、缓慢的过程！SoftTissueInfection软组织感染SystemicIllness系统性疾病Osteomyelitis骨髓炎WoundEnvironment伤口周边环境Pressure压力Oxygen氧供能力Perfusion灌注状况SystemicHealingAbility组织的复原能力Compliance组织顺应性Edema浮肿Nutrition营养状况压疮导致病人疼痛，感染甚至危及病人生命，治疗昂贵且漫长！压疮的关键工作在于预防！LEANMASSErosion(catabolism)ofmuscleproteinVisceralproteinforglucoseproduction肌肌肉蛋白腐化（分解代谢），内脏蛋白利用葡萄糖ENERGYPRODUCTIONMainlyfromglucoseandaminoacids能量生产主要来自于葡萄糖和氨基酸Amarkedincreaseinenergydemandsandleanbodymasslo