壓瘡評(píng)估與治療的進(jìn)展詳解課件

1、壓瘡評(píng)估與治療的進(jìn)展Based on AMDA Clinical Practice Guideline(CPG) for Pressure Ulcers 美國(guó)醫(yī)師協(xié)會(huì)2015年10月壓瘡臨床實(shí)踐指南 消化內(nèi)科 鄧忠越壓瘡評(píng)估與治療的進(jìn)展Based on AMDA Clinic壓瘡是護(hù)理人員難以回避的臨床問(wèn)題！壓瘡A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure

2、in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated.皮膚損傷通常發(fā)生在骨隆突處是壓力和/或剪力、摩擦力對(duì)皮下組織損傷的結(jié)果。What is a Pressure Ulcer?壓瘡是什么?A pressure ulcer is localized 除骨隆突受壓部位外，還應(yīng)關(guān)注：吸氧導(dǎo)管、經(jīng)鼻導(dǎo)管、氣管插

3、管及其固定支架、血氧飽和度無(wú)創(chuàng)面罩、連續(xù)加壓裝置、夾板、支架尿管等與皮膚接觸的相關(guān)部位（C）除骨隆突受壓部位外，還應(yīng)關(guān)注：Pressure Ulcers May Not be Preventable有些壓瘡是難以避免的Aggressive measures can reduce but not eliminate the incidence of pressure ulcers 積極的預(yù)防措施能夠降低壓瘡的發(fā)生率，但并不能徹底消滅壓瘡；Can develop despite best efforts of clinical team in high risk patients 盡管臨床小組作出

4、最大的努力,但高風(fēng)險(xiǎn)的病人仍有壓瘡發(fā)生Pressure Ulcers May Not be PrePrimary risk factors for development of pressure ulcers are形成壓瘡的原發(fā)危險(xiǎn)因素Impaired/decreased mobility活動(dòng)性受到限制或者減少 (Neurologic disease/ injury/Fractures/Pain/Restraints)Drugs such as steroids that may affect wound healing類(lèi)固淳藥品的使用影響傷口康復(fù)；Resident refusal of s

5、ome aspects of care & treatment患者拒絕給予局部的護(hù)理和治療Intrinsic risks due to aging老齡化為固有的危險(xiǎn)因素Alterations in sensation or response to comfort對(duì)舒適與否的感覺(jué)反應(yīng)能力發(fā)生變化 Depression抑郁等情緒Primary risk factors for develPressure Ulcer Classifications 分級(jí) Stage 1: Nonblanchable Erythema Observable, pressure-related alteration o

6、f intact skin, including changes in skin temperature, tissue consistency, sensation, and/or defined area of persistent redness in light skin (red, blue or purple hues in dark skin) 一期壓瘡Pressure Ulcer ClassificationsStage 2:Partial Thickness Skin Loss Partial thickness skin loss involving epidermis,

7、dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater二期壓瘡Pressure Ulcer Classifications 分級(jí) Stage 2:Partial Thickness Skin Stage 3:Full Thickness Skin Loss Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may

8、 extend down to, but not through fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue 三期壓瘡 Pressure Ulcer Classifications 分級(jí) Stage 3:Full Thickness Skin Stage 4:Full Thickness Tissue Loss Full thickness skin loss with extensive destruction, tissue nec

9、rosis or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be associated四期壓瘡Pressure Ulcer Classifications 分級(jí) Stage 4:Full Thickness TisUnstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered

10、by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluc

11、tuance) eschar on the heels serves as the bodys natural (biological) cover and should not be removed. Pressure Ulcer Classifications 分級(jí) Unstageable: Depth Unknown Pr Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to d

12、amage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Pressure Ulcer Classifications 分級(jí) Suspected Deep Tissue InjurPressure Ulcer Classifications 分級(jí)II期III期IV期不可分期I期可疑深部組織受損P

13、ressure Ulcer ClassificationsFactors That Affect PU Wound Healing 影響壓瘡傷口康復(fù)的因素包括：PU Wound healing is a complex multifactorial process壓瘡的康復(fù)是一個(gè)復(fù)雜的、多因素的、緩慢的過(guò)程！Soft Tissue Infection軟組織感染Systemic Illness系統(tǒng)性疾病Osteomyelitis骨髓炎Wound Environment傷口周邊環(huán)境 Pressure壓力Oxygen氧供能力Perfusion灌注狀況SystemicHealing Ability組織

14、的復(fù)原能力Compliance組織順應(yīng)性Edema浮腫Nutrition營(yíng)養(yǎng)狀況壓瘡導(dǎo)致病人疼痛，感染甚至危及病人生命，治療昂貴且漫長(zhǎng)！壓瘡的關(guān)鍵工作在于預(yù)防！Factors That Affect PU Wound HMalnutrition and dehydration營(yíng)養(yǎng)失調(diào)和脫水Diabetes mellitus糖尿病End-stage renal disease晚期腎臟疾病Thyroid disease甲狀腺疾病Congestive heart failure充血性心力衰竭Peripheral Vascular Disease外周血管疾病Vasculitis/other colla

15、gen vascular disorders 血管炎和其他膠原血管疾病Immune deficiency states免疫缺陷狀態(tài)Malignancies惡性腫瘤COPD 慢性阻塞性肺病Depression and psychosis精神狀態(tài)抑郁Drugs that affect healing藥物影響康復(fù)Contractures at major joints關(guān)節(jié)攣縮Comorbid Conditions That May Affect Ulcer Healing 多種可能影響壓瘡康復(fù)的身體狀況Malnutrition and dehydration營(yíng)The Nonhealing Chron

16、ic WoundFailure to Heal by 12 Weeks慢性傷口需要12周的時(shí)間才能愈合 Catabolism分解代謝 Catabolism分解代謝 Anabolism合成代謝 Anabolism合成代謝Energy能量Protein Synthesis蛋白質(zhì)合成EnergyStore能量?jī)?chǔ)存ProteinStore蛋白質(zhì)儲(chǔ)存Macronutrients大量營(yíng)養(yǎng)物質(zhì)EnergyEnergyStore能量?jī)?chǔ)存ProteinStore蛋白質(zhì)儲(chǔ)存Macronutrients大量營(yíng)養(yǎng)物質(zhì)Protein Synthesis蛋白質(zhì)合成The Nonhealing Wound壞死階段的傷口Th

17、e Healing Wound康復(fù)階段的傷口Filling填充Wound contraction傷口收縮Densecollagenscar細(xì)密的膠原結(jié)疤N(yùn)eutrophils嗜中性白細(xì)胞O2Courtesy of R.H. Demling, MD.The Nonhealing Chronic WoundFPreventive Measures A Step Wise Approach to Nutritional Intervention in Patients with Wounds預(yù)防措施對(duì)于有壓瘡傷口的病人選用營(yíng)養(yǎng)干預(yù)是一個(gè)明智的方法Assuring adequate Nutrition

18、 and Hydration 保證營(yíng)養(yǎng)和水分 Watch for anorexia in patients with a sudden change in intake 對(duì)于食欲缺乏的病人要改變營(yíng)養(yǎng)攝入方式Undernourished patients caloric/protein/hydration targets 營(yíng)養(yǎng)不足的病人熱量、蛋白質(zhì)、補(bǔ)水作用的目標(biāo)：30-35 calories/kg/day1-1.5 g/kg/day protein30 ml/kg/day fluidExcept for a daily multivitamin, other vitamin and miner

19、al supplements are not needed unless deficiencies are confirmed 除了日常補(bǔ)充多種維生素之外，其他的維生素和礦物質(zhì)是不需要額外補(bǔ)充的，除非是臨床證實(shí)需要補(bǔ)充的。Preventive Measures A Step WPreventive measures預(yù)防措施Maintain personal hygiene保持個(gè)人衛(wèi)生Assure adequate nutrition 保證適當(dāng)?shù)臓I(yíng)養(yǎng)Manage urinary/fecal incontinence正確處理失禁病人的護(hù)理 Reposition and have patient s

20、hift weight 更換體位,轉(zhuǎn)移病人受壓部位Avoid messaging reddened areas避免出現(xiàn)變紅的區(qū)域 Prevent contractures 預(yù)防攣縮Position to alleviate pressure over bony prominences 體位更換緩解骨突出處的壓力Use positioning devices使用減壓性的體位墊裝置Maintain lowest head elevation 保持最低的頭部高度Use lifting devices使用可以提升病人的轉(zhuǎn)移裝置 Preventive measures預(yù)防措施MaintPreventiv

21、e measures預(yù)防措施Preventive measures預(yù)防措施Wound Care傷口護(hù)理Principles of wound dressings:傷口敷裹的原則：Protect wound bed from further trauma, contamination or drying避免傷口創(chuàng)面進(jìn)一步的受到創(chuàng)傷或者污染或者過(guò)于干燥Promote removal of necrotic tissue and exudate促進(jìn)壞死組織和滲出物的移除Provide a moist healing environment supportive of regeneration and

22、 growth of granulation tissue. 提供濕潤(rùn)的愈合環(huán)境來(lái)利于恢復(fù)和肉芽組織生長(zhǎng)Wound characteristics change as the wound evolves.隨著傷口的發(fā)展，傷口的特性不斷發(fā)生改變。Tailor dressings primarily to wound characteristics, not wound stage選擇適應(yīng)傷口特性的敷料，而不是適應(yīng)傷口的階段。Wound Care傷口護(hù)理Principles of woPressure Ulcers CPG Treatment壓瘡治療Wound Care Intact Skin傷口

23、護(hù)理完整的皮膚Stage 1 Pressure Ulcers may herald a more extensive wound一期壓瘡或許已經(jīng)預(yù)示更大面積的損傷Protect involved area from further injury from pressure or shearing forces預(yù)防相關(guān)區(qū)域遭受壓力和剪切力的進(jìn)一步損傷No dressing required沒(méi)有包扎傷口的必要Monitor frequently for changes頻繁的監(jiān)測(cè)傷口變化Pressure Ulcers CPG TreatmentPressure Ulcers CPG: Treatme

24、nt壓瘡治療Wound Care Clean Wound Base清潔傷口的基底部Stage 2 or healing Stage 3 or Stage 4 wound 二期或者處于康復(fù)階段的三期四期壓瘡 Dressing should keep ulcer bed continually moist but the surrounding skin dry敷料要保證創(chuàng)面的濕潤(rùn)但是周?chē)ＷC干的Choose dressing based on situation根據(jù)傷口的情形來(lái)選擇包扎方式Fill wound dead space with loosely packed dressing ma

25、terial傷口的死腔要用疏松的敷料來(lái)填充Pressure Ulcers CPG: TreatmentPressure Ulcers CPG: Treatment壓瘡治療Wound Care Extensive Subcutaneous Tissue Damage廣泛的皮下組織損傷Stage 4 (some Stage 3) pressure ulcers are characterized by full thickness skin loss with extensive tissue necrosis, undermining and sinus tracts四期壓瘡（包括部分3期壓瘡）

26、深部出現(xiàn)大面積的組織壞死，竇道狀壞疽；Treatment may require extensive surgical debridement治療需要較大面積的外科清瘡術(shù)；All devitalized tissue removed去除所有的壞死組織Undermined areas should be explored and unroofed深部損傷要去除表層才能準(zhǔn)確界定。Pressure Ulcers CPG: TreatmentPressure Ulcers CPG Treatment壓瘡治療性處理Wound Care Alternatives to Non-Responders傷口護(hù)理

27、-針對(duì)沒(méi)有反應(yīng)的患者供選方案For clean wounds not responding to appropriate treatment consider:為效果不好的患者清潔傷口提供適當(dāng)?shù)闹委煟篢opical antibiotic ointments/solutions for 2 week trial局部提供的抗生素，嘗試兩周；Progress to a support surface that offers further protection 改進(jìn)支撐體的質(zhì)地，提供更深入的保護(hù)；Consider a course of electrotherapy 考慮給予電療治療；Conside

28、r transfer to another site for surgical debridement/repair, mgt. of systemic complications, comfort/pain mgt., and specialized diagnostic studies 考慮外科清瘡術(shù)/修復(fù)術(shù)，全身性的合并癥，舒適/疼痛，對(duì)特殊的指針進(jìn)行研究。Pressure Ulcers CPG Treatment壓Pressure Ulcers CPG: Treatment壓瘡治療Wound Care Ongoing Management 持續(xù)的管理1. Cleanse at each

29、 dressing change清潔傷口更換敷料2. Debride eschar, as needed如果有需要的話(huà)要清創(chuàng)焦痂3. Evaluate/treat for infection評(píng)定和處理感染4. Employ facility infection control利用多種設(shè)施達(dá)到感染控制5. Re-evaluate co-existing medical conditions再次評(píng)定病人身體狀況方面的醫(yī)療條件6. Prescribe pain control measures處方建議采用控制疼痛的措施7. Address psychosocial issues, depressio

30、n, and possible isolation病人的心理狀態(tài)，可能孤獨(dú)和抑郁。Pressure Ulcers CPG: TreatmentWound Classifications 傷口分類(lèi)和敷料選擇 1988年由美國(guó)學(xué)雜志從歐州引進(jìn)了創(chuàng)面RYB分類(lèi)方法。RYB方法將期或延期愈合的開(kāi)放創(chuàng)面（包括急性和慢性創(chuàng)面）分為紅、黃、黑及混合型。紅色創(chuàng)面可能處于創(chuàng)面愈合 過(guò)程中的炎性期、增生期或成熟期。黃色創(chuàng)面是感染創(chuàng)面或含有纖維蛋白的腐痂，無(wú)愈合的傾向 。黑色創(chuàng)面含有壞死組織，同樣無(wú)愈合傾向?；旌蟼冢河胁煌伾慕M織，以百分比來(lái)描素各種顏色所占的比例。 此分類(lèi)方法的優(yōu)點(diǎn)在于根據(jù)創(chuàng)面愈合過(guò)程的不同時(shí)

31、期分類(lèi)，利于醫(yī)護(hù)人員提供治療 Wound Classifications 傷口分類(lèi)和敷料肉芽期 纖維母細(xì)胞移行，肉芽組織形成上皮形成期 創(chuàng)面逐漸縮小/上皮化清創(chuàng)期（炎性反應(yīng)期）肉芽期 纖維母細(xì)胞移行，肉芽組織形成上皮形成期 判別傷口的類(lèi)型：以傷口受傷的原因傷口的位置傷口的大小及深度滲出液：量、性質(zhì)、顏色及氣味傷口外觀(guān)（基底）傷口周?chē)つw情況疼痛傷口有無(wú)感染W(wǎng)ound evaluation判別傷口的類(lèi)型：以傷口受傷的原因Wound evaluati一、判別傷口的類(lèi)型： 評(píng)估傷口發(fā)生的原因：如電擊傷、機(jī)械傷、溫度傷、化學(xué)傷、放射性或血管性病變等二、傷口的位置：記錄傷口在解剖區(qū)域相關(guān)的位置，如骶尾部

32、、肩部等。各種不同類(lèi)型的傷口好發(fā)于身體不同的部位評(píng)估傷口是在固定部位還是伸展部位、皮膚皺褶處、骨隆突處、關(guān)節(jié)部位三、傷口的大小及深度1.表面的測(cè)量：測(cè)量表面最寬最長(zhǎng)處，以頭坐標(biāo)，縱軸為長(zhǎng)，橫為寬2.深度的測(cè)量 3.傷口的范圍：4.評(píng)估創(chuàng)面：壞死組織、結(jié)痂、肉芽組織約占傷口的多少百分比5.傷口潛行的測(cè)量：指?jìng)谄つw邊緣與傷口床之間的袋狀空穴。通常外表可見(jiàn)傷口邊緣內(nèi)卷。 （1）測(cè)量方法：同傷口深度測(cè)量方法，沿傷口四周邊緣逐一測(cè)量。 （2）記錄方法：用順時(shí)針?lè)较蛴涗洠鐫撔?-7點(diǎn)3厘米。6.竇道的測(cè)量：周?chē)つw與傷口床之間形成的縱形腔隙。能探到腔隙的底部或盲端。 方法：同傷口深度測(cè)量方法7.瘺管：

33、探測(cè)時(shí)無(wú)盲端，傷口表面與臟器相通Wound evaluation長(zhǎng)寬一、判別傷口的類(lèi)型：Wound evaluation長(zhǎng)寬四、滲出液：量、性質(zhì)、顏色及氣味滲出液量的評(píng)估：無(wú)滲出：24小時(shí)更換的紗布不潮濕、是干燥的少量滲出：24小時(shí)滲出量少于5毫升，每天更換紗布不超過(guò)1塊中等量滲出：24小時(shí)滲出量在5-10毫升，每天至少需要1塊紗布，但不超3塊。大量滲出：24小時(shí)滲出量超過(guò)10毫升，每天需要3塊或更多的紗布。滲液的顏色：澄清：通常被認(rèn)為是正常，注意葡萄球菌感染或來(lái)自泌尿道或淋巴道渾濁、粘稠：提示炎癥反應(yīng)或感染，滲液含有白細(xì)胞和細(xì)菌粉紅色或紅色：提示毛細(xì)血管損傷綠色：提示細(xì)菌感染，如綠膿桿菌黃色

34、或褐色：傷口出現(xiàn)腐肉或由泌尿道/腸瘺的滲出物Wound evaluation四、滲出液：量、性質(zhì)、顏色及氣味Wound evaluati五、傷口外觀(guān)肉芽：肉芽組織是指小血管及結(jié)締組織増生逐漸填滿(mǎn)傷口。 健康：牛肉樣鮮紅柔軟發(fā)亮 血流不足：淡紅色、淡白或白灰色腐肉：松散，呈黃色，失去活力壞死：棕色或黑色，失去活力上皮化：出現(xiàn)上皮細(xì)胞，呈粉紅色感染：皮膚周?chē)t、腫、熱、痛解剖結(jié)構(gòu)暴露：骨、筋膜、血管、神經(jīng) Wound evaluation五、傷口外觀(guān)Wound evaluation六、傷口周?chē)つw情況水腫：傷口表皮增生：傷口周?chē)慕M織硬度：愈合嵴：周?chē)つw浸漬、過(guò)敏七、疼痛八、傷口感染局部癥狀全身

35、癥狀 Wound evaluation六、傷口周?chē)つw情況Wound evaluationPressure Ulcers CPG: Treatment壓瘡治療Wound Care Categories of Products Used in Wound Care用于傷口護(hù)理的產(chǎn)品分類(lèi)Hydrocolloids水膠體Alginate藻酸鹽等Foams泡沫等Wound Fillers 傷口填充物Composite Dressings合成敷料Pressure Ulcers CPG: Treatment如何正確的選擇敷料？根據(jù)滲出量選擇敷料的吸收能力根據(jù)創(chuàng)面大小選擇敷料尺寸根據(jù)創(chuàng)面深度選擇輔助敷料種類(lèi)

36、根據(jù)局部創(chuàng)面決定是否減壓引流或加壓包扎根據(jù)創(chuàng)面位置選擇敷料的形狀、薄厚根據(jù)皮膚耐受性選擇敷料的粘性強(qiáng)度如何正確的選擇敷料？根據(jù)滲出量選擇敷料的吸收能力傳統(tǒng)紗布傳統(tǒng)紗布油紗優(yōu)點(diǎn)：粘性低，不傷肉芽保濕順應(yīng)性好可剪裁缺點(diǎn)：不能吸收滲液，易浸漬可滲透細(xì)菌需要外敷料固定油紗優(yōu)點(diǎn)：薄膜敷料一般作為輔助敷料使用薄膜敷料一般作為輔助敷料使用水凝膠敷料主要用于干燥結(jié)痂或有腐爛組織的傷口、腔洞及竇道傷口水凝膠敷料水膠體敷料水膠體敷料藻酸鹽敷料用于各類(lèi)大量滲出性傷口藻酸鹽敷料用于各類(lèi)大量滲出性傷口銀離子敷料用于嚴(yán)重污染傷口、感染傷口銀離子敷料用于嚴(yán)重污染傷口、感染傷口潰瘍貼 適用于輕至中度滲液的壓瘡，下肢潰瘍，供皮

37、區(qū)，小面積燒傷以及其他透明貼 適用于輕度，淺表壓瘡和下肢潰瘍的上皮成熟期，供皮區(qū)，術(shù)后傷口擦傷等減壓貼 內(nèi)層為水膠體成分，促進(jìn)潰瘍傷口愈合，外加聚乙烯泡沫圈，分解局部壓力作用糊劑 作為填充劑，主要用于深度傷口和腔隙的傷口，預(yù)防傷口坍塌，加快肉芽生長(zhǎng)，增加吸收滲液能力粉劑 用于淺表且滲液較多的傷口，增加滲液的吸收能力，加快上皮生長(zhǎng)，延長(zhǎng)水膠體敷料的使用時(shí)間潰瘍貼（一）干性愈合理論 18世紀(jì)后期至20世紀(jì)中葉，傷口干性愈合理論盛行。該理論認(rèn)為，傷口愈合需干燥環(huán)境，有大氣氧的參與可以促進(jìn)傷口愈合，因而透氣的敷料才能使傷口獲得足夠氧氣，以供細(xì)胞生長(zhǎng)的各種生化反應(yīng)所需。 其缺點(diǎn)是傷口愈合環(huán)境差，結(jié)痂造成傷口疼痛，更換敷料時(shí)損傷創(chuàng)面，愈合速度慢，不能隔絕細(xì)菌的侵入，易造成痂下膿腫。（二）濕性愈合理論 1958年，有學(xué)者首先發(fā)理被保持完整的水皰