Pressure ulcer(完整)

ThemorningoffofolddepartmentinestablishingaffiliatedhospitalofTCM中医附院老年病房晨间交班晨间交班Theheadnurse:WangMeimeinurses:ZhangZejuWangJingXiaoHongPRESUREULCERDefinitionThelocaltissueofbodyispressedforalongtimeandbloodcirculationgetdisorder,causinglocaltissuebecomesustainedischemia,hypoxiaandpoornutrition.Theaboveresultinlossofnormalfunctionoftheskinandthenleadtodestructionandnecrosisofthetissue.Factorsthatleadtopressureulcers•StressfactorsVerticalpressure、Friction、Shearingforce【剪切力】•Incontinence【失禁】Urine/fecesonskin•MalnutritionLowproteinintakeInabilitytofeedbythemselves•Age•Risingtemperature•1、Verticalpressureactiontime2～4h•2、FrictionItoccurswhenrelativemovementhappensandeasytodamagethecuticle(角质层)•3、ShearingforceTherelativedisplacementoftwolayersoftissueleadstoshearingforceStressfactorspressureverticalpressureshearingforcefrictionPressureulcersusuallyoccurinno-musclewrappedorthinmuscleboneprotuberancewhichisapttobepressedandlackofprotectionofadiposetissue.Differentpositionandpressurepointscancausedifferentpredilectionsites(好发部位)SusceptiblepartsSupine123451.Occipitalprotuberance(枕骨粗隆)2.Scapular（肩胛部）3.Elbow4.Sacrococcygeal(骶尾部)5.heelLateralposition12457631.ear；2.acromion（肩峰）；3.elbow；4.ribs；5.hip6.insideandoutsideoftheknee7.insideandoutsideofankleProneposition2651341.Cheekandpinna（耳廓）；2.acromion；3.breast（female）；4.Genitals（生殖器）；5.knee；6.toeSeatpositionScapularregion←elbow←Ischialtuberosity←Howdoespressureulcerform?•Residentlyinginbedontheirback.•Buttocks,byforceofgravitysinkintomattress.•Softtissuepressesagainstthebonesthatdon’tgoanywhere.•Bloodvesselsarepinchedbetweenboneandweightofgravity.•Bloodflowtosofttissueiscutoff.•Cellstarvationanddeathoccur•Pressureulcerisborn.PRESSURETissue&BloodVesselsBONEHowdoesnecrosis【坏死】form?(celldeath)【清除代谢产物的能力降低】Staging•6levelsprogression:•StageI:ruddygorestage•StageII:inflammatoryinvasionstage•StageIII:theshallowulcerstage•StageIV:necroticulcersstage•SDTI:suspiciousofdeeptissueinjury•UnstagebaldeeppressuresoresNoopenareaDeepwoundStageI:ruddygorestage•Intactskin•Non-blanchingredness【非热烫红】、swelling【肿】、heat,、pain•Precursor【前体】topressureulcerStageII:inflammatoryinvasionstage•Partialthicknessskinloss•Blister【水泡】•ShallowCrater•Abrasion【磨损】StageIII:theshallowulcerstage•Fullthicknessskinloss•Notthroughfatlayer•Deepcrater•DamageorNecrosisStageIV:necroticulcersstage•Extensivedestruction•Necrosis•Muscle/Bonedamage•Tunneling(窦道)Suspiciousofdeeptissueinjury(SDTI)Localcompletebutcanappearcolorchange，purpleorreddishbrown,orahyperemicbruises【充血的瘀伤】orblisters【水泡】Pain、lump【肿块】、hotorcoldUnstagebaldeeppressuresoresFullthicknesstissuelossCarrion【腐肉】coveredattheulcerbase（Yellow,brown，gray,green）Woundwithescharadhesion【焦痂粘附】（Carboncolor,brown,black）Assessmentscales1、ScoringmethodofBraden:score12，high-riskpatients评分内容1分2分3分4分感觉完全丧失严重丧失轻度丧失未受损害潮湿持久潮湿十分潮湿偶尔潮湿很少发生潮湿活动卧床不起局限于椅上偶尔步行经常步行活动能力完全不能严重限制轻度限制不受限营养恶劣不足适当良好摩擦和剪力有有潜在危险无明显问题无2、ScoringmethodofNorton:score14,pressureulceriseasytohappen记分一般状况精神状况活动能力运动能力粪尿失禁4好警觉自由活动不受限无3一般冷淡帮助下活动轻度受限偶尔2差迷惑依赖轮椅很大受限尿1很差昏迷卧床不能运动粪尿ThewaysofclinicalrecordDealing1.Debridement【清创】–toremovemoist,devitalizedtissue.sharpdebridement–useofascalpelorotherinstrumentusetoscrapeoffdeadtissuesmechanicaldebridement–wet-to-drydressings.useminimalmechanicalforcewhencleansingtoavoidtraumatothewoundbed.Dealing2.Woundcleansing–useNSSformostcases.avoiduseofantiseptics(e.g.hydrogenperoxide,iodine).Dealing3.Dressings–protectthewoundmoistenedgauze【纱布】film(transparent)hydrocolloid(moistenedandoxygenretaining)【水状胶质】Nursing•RelieveorEliminatetheSource【缓解并减除压力源】•OptimizetheEnvironment【优化伤口愈合环境】•Enhancehumanimmunity【提高人体免疫力】•ProvideEducation（提供教育）Relieveoreliminatethepressuresource•Keeppressureoffarea/ulcer•Bedriddenturnandrepositionevery1-2hours（每隔1－2小时给病人翻身）•Chairorwheelchair:teachtoshiftevery15minutesornurserepositionandshiftpointsofpressureevery1hour•Makeawrittenscheduleandkeepitvisible/document•Usepositioningpillow【软枕】&wedges【支架】toraisePressureUlceroffsupportsurface.30DegreeLateralPosition【压力分布：30度侧卧】PressuredistributionOptimize【优化】theEnvironment•Debridenecrotictissue【清除坏死组织】•Cleanwound•Applytopicalwoundcare(filldeadspace)•Eliminateexcessmoisture【渗液】•CheckforSignsofInfectionEnhancehumanimmunity•CorrectUnderlyingProblems【纠正潜在的病因】diarrheaUrinaryIncontinence【小便失禁】•AssessandManagePain•ProvideAttentiontoNutritionalStatus，Linkbetweenpressureulcerandmalnutrition,nutritionalassessment•ProvideAdequatedietaryintaketopreventmalnutrition(mayneedsupplementation)•Providenutrientstosupporthealing【愈合】ProvideEducation1、PatientandFamilyneedtounderstandcause、contributingfactors、preventionmeasures、SignificanceofNutrition2、GiveResourceInformationatbedside3、Educationoffamily,patient,caregiver,nurseetcisthekeytopreventionandsuccessfulmanagementofexistingpressureulcer.PREVENTION•SuperiorCare!•KeenObservation!•PromptReporting!Preventionismoreimportantthantreatment!RiskPopulationTheObesityMalnourishedpatientsTheoldNeurologicaldiseasesPatientswithfeverPatientsreceivingcastimmobilizationPatientswithedemaPeoplewithpainI