Pressure ulcer完整

The morning off of old department in establishing affiliated hospital of TCM中醫(yī)附院老年病房晨間交班晨間交班,The head nurse: Wang Meimeinurses: Zhang Zeju Wang Jing Xiao Hong,PRESURE ULCER,Definition,The local tissue of body is pressed for a long time and blood circulation get disorder, causing local tissue become sustained ischemia, hypoxia and poor nutrition. The above result in loss of normal function of the skin and then lead to destruction and necrosis of the tissue.,Factors that lead to pressure ulcers,Stress factors Vertical pressure、Friction、Shearing force【剪切力】Incontinence【失禁】 Urine/feces on skinMalnutrition Low protein intake Inability to feed by themselvesAgeRising temperature,1、Vertical pressure action time 24h2、Friction It occurs when relative movement happens and easy to damage the cuticle (角質(zhì)層)3、Shearing force The relative displacement of two layers of tissue leads to shearing force,Stress factors,pressure,Pressure ulcers usually occur in no-muscle wrapped or thin muscle bone protuberance which is apt to be pressed and lack of protection of adipose tissue . Different position and pressure points can cause different predilection sites (好發(fā)部位),Susceptible parts,Supine,1.Occipital protuberance(枕骨粗隆)2.Scapular（肩胛部）3.Elbow4.Sacrococcygeal(骶尾部)5.heel,Lateral position,1.ear ； 2.acromion（肩峰）； 3.elbow ； 4.ribs ； 5.hip 6.inside and outside of the knee 7.inside and outside of ankle,Prone position,1.Cheek and pinna（耳廓）； 2. acromion ；3.breast（female）； 4.Genitals（生殖器）；5.knee； 6.toe,Seat position,Scapular region,elbow,Ischial tuberosity,How does pressure ulcer form?,Resident lying in bed on their back.Buttocks, by force of gravity sink into mattress. Soft tissue presses against the bones that dont go anywhere.Blood vessels are pinched between bone and weight of gravity.Blood flow to soft tissue is cut off.Cell starvation and death occurPressure ulcer is born.,How does necrosis【壞死】 form?(cell death),【清除代謝產(chǎn)物的能力降低】,Staging,6 levels progression:Stage I: ruddy gore stageStage II:inflammatory invasion stageStage III:the shallow ulcer stageStage IV:necrotic ulcers stage SDTI:suspicious of deep tissue injuryUnstagebal deep pressure sores,Stage I:ruddy gore stage,Intact skinNon-blanching redness【非熱燙紅】、swelling【腫】、 heat,、painPrecursor 【前體】to pressure ulcer,Stage II:inflammatory invasion stage,Partial thickness skin lossBlister【水泡】Shallow CraterAbrasion【磨損】,Stage III:the shallow ulcer stage,Full thickness skin lossNot through fat layerDeep craterDamage or Necrosis,Stage IV:necrotic ulcers stage,Extensive destructionNecrosisMuscle/Bone damageTunneling(竇道),Suspicious of deep tissue injury (SDTI),Local complete but can appear color change ， purple or reddish brown, or a hyperemic bruises【充血的瘀傷】 or blisters【水泡】 Pain、lump【腫塊】、hot or cold,Unstagebal deep pressure sores,Full thickness tissue lossCarrion【腐肉】 covered at the ulcer base（Yellow, brown，gray, green）Wound with eschar adhesion【焦痂粘附】（Carbon color, brown, black）,Assessment scales,1、Scoring method of Braden : score12，high-risk patients 評分內(nèi)容 1分 2分 3分 4分 感覺 完全喪失 嚴(yán)重喪失 輕度喪失 未受損害 潮濕 持久潮濕 十分潮濕 偶爾潮濕 很少發(fā)生潮濕 活動 臥床不起 局限于椅上 偶爾步行 經(jīng)常步行 活動能力 完全不能 嚴(yán)重限制 輕度限制 不受限 營養(yǎng) 惡劣 不足 適當(dāng) 良好 摩擦和剪力 有 有潛在危險 無明顯問題 無,2、Scoring method of Norton: score sharp debridement use of a scalpel or other instrument use to scrape off dead tissues mechanical debridement wet-to-dry dressings. use minimal mechanical force when cleansing to avoid trauma to the wound bed.,Dealing,Wound cleansing use NSS for most cases. avoid use of antiseptics (e.g. hydrogen peroxide, iodine).,Dealing,3.Dressings protect the wound moistened gauze【紗布】 film (transparent) hydrocolloid (moistened and oxygen retaining)【水狀膠質(zhì)】,Nursing,Relieve or Eliminate the Source 【緩解并減除壓力源】Optimize the Environment 【優(yōu)化傷口愈合環(huán)境】Enhance human immunity 【提高人體免疫力】Provide Education （提供教育）,Relieve or eliminate the pressure source,Keep pressure off area/ulcerBedridden turn and reposition every 1-2 hours（每隔12小時給病人翻身）Chair or wheelchair: teach to shift every 15 minutes or nurse reposition and shift points of pressure every 1 hour Make a written schedule and keep it visible/document Use positioning pillow【軟枕】 & wedges【支架】 to raise Pressure Ulcer off support surface.,30 Degree Lateral Position【壓力分布：30度側(cè)臥】,Pressure distribution,Optimize【優(yōu)化】 the Environment,Debride necrotic tissue【清除壞死組織】Clean woundApply topical wound care (fill dead space)Eliminate excess moisture【滲液】Check for Signs of Infection,Enhance human immunity,Correct Underlying Problems【糾正潛在的病因】 diarrhea Urinary Incontinence【小便失禁】Assess and Manage PainProvide Attention to Nutritional Status， Link between pressure ulcer and malnutrition,nutritional assessment,Provide Adequate dietary intake to prevent malnutrition (may need supplementation)Provide nutrients to support healing【愈合】,Provide Education,1、 Patient and Family need to understand cause、 contributing factors 、prevention measures 、 Significance of Nutrition 2、Give Resource Information at bedside 3、Education of family, patient, caregiver, nurse etc is the key to prevention and successful management of existing pressure ulcer.,PREVENTION,Superior Care!Keen Observation!Prompt Reporting!,Prevention is more important than treatment!,Risk Population,TheObesity,Malnourished patients,The old,Neurological diseases,Patients with fever,Patients receiving cast immobilization,Patients with edema,People with pain,Incontinence,Patients with use of sedatives(鎮(zhèn)靜藥）,Avoid long-term compression,Avoid friction force, shearing force,Protect the patients skin,Promote skin blood circulation,Enhance the body nutrition,Health education,Preventive measures,Avoid long-term compression,Reduce pressure: Turn bed residents every 2 hours. Even a 15 degree turn helps to relieve pressure on skin surface. Use a written turning schedule so that others know in which direction the resident is to go.,Avoid long-term compression,Position correctly! Use pillows to support joints Avoid skin touching skin Check to make sure no body part is hitting a wall or railing Remember! Check positioning in the chairs. Chairs too small or residents that lean to one side may have pressure.,Microsoft OfficeXP2002,Avoid Shearing & Friction,Use lifter sheet(升降板) to move resident up in bedUse assistance of over bed trapeze（吊架）Keep HOB 30 degrees or lower to avoid slipping down in bedCup heels & elbows during ROM exercisesDont drag heels over sheets when using lifts.,PrintShop2005,Protect the patients skin,Check every 2 hours for incontinence. Feces, urine and even soap are abrasive to the skin due to a ph imbalance.,Clean, Rinse and thoroughly Dry skin after each incontinent episode.,Moisturize skin with lotion to prevent dry skin.Use lotion over bony prominences but do not massage reddened areas as it may cause more damage to underlying tissueUse special barrier creams as ordered,Microsoft OutlookXP2002,Protect the patients skin,Enhance the body nutrition,What is Needed?,Elderly need at least 1200 calories/dayProtein- for repair & regrowthCarbohydrates & Fats-tissue maintenance & energy sourceVitamins- promote wound healing,Protein,Best Sources: eggs milk cheese yogurt,Printshop2005,Carb sources Whole grains(五谷雜糧) Cereal（谷類） RiceUnsaturated fats（不飽和脂肪） Olive oil（橄欖油） Canola oil（菜籽油） Safflower oil（紅花油）,Vitamin C- for collagen (膠原)formation Good S