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1、压疮护理 101 Pressure Wound Care 101,Sharon Lepper 护理学学士，注册护士， 伤口造口失禁护士 Sharon Lepper BSN RN WOCN,Copyright EHOB, 2010,EHOB产品由上海天呈“医流商城”全国代理， 招商加盟热线 ：021-51083677-869 手机：15900626542 谢秋亭 传真：51816400， 地址：上海市杨浦区翔殷路128号 国家大学科技园1号楼B座310室。,Copyright EHOB, 2010,2,预案能够使压疮发病率降低50% Protocols decrease incidence by
2、 50% 1,1. 书名：护理人员的培训影响老年住院病人的褥疮发生内科学文献1988; 148:2241- 2243.作者：Moody BL, Fanale JE, Thompson M. Vaillancourt D, Symonds G, Bonasoro C. Moody BL, Fanale JE, Thompson M. Vaillancourt D, Symonds G, Bonasoro C. Impact of staff education on pressure sore development in elderly hospitalized patients. Archi
3、ves of Internal Medicine. 1988; 148:2241-2243.,Copyright EHOB, 2010,Copyright EHOB, 2010,3,3,压疮的临床预案应解决以下方面： Clinical Protocols for Pressure Ulcers Should Address:,Cognition 认知,Mobilization & Ambulation 活动与步行,Nutrition and Hydration营养和水化,Moisture and Incontinence湿度和失禁,Medication Use药物治疗,Existing Pre
4、ssure Ulcers (Deep Tissue Injury)已生成的褥疮（深部组织损伤）,Contact with medical devices (i.e., braces, orthothics, cannulas, tubing), and/or any object in contact with the body接触医疗器械 （例如，支架、矫形器、插管、输液管）和/或任何与身体接触的物体）,Copyright EHOB, 2010,Copyright EHOB, 2010,4,4,4,ALL SUPPORT SURFACES SHOULD: 所有的支持表面应具备以下几点：,Re
5、distribute weight in a 3-dimensional manner. 以三维方式重新分配体重,Minimize pressure, shear and friction injury. 使压力、剪切力和摩擦损伤最小化,Assist in moisture and temperature control. 协助控制湿度和温度,Be easy to clean. 易于清洁,Aid in patient transferring and mobilization. 辅助患者的转移和活动,Be cost effective. 性价比高,为什么要遵循临床预案？ Why Follow
6、Protocols?,Copyright EHOB, 2010,Copyright EHOB, 2010,5,5,5,5,ALL LOWER EXTREMITY PROTOCOLS SHOULD: 所有的下肢预案都应具备：,Elevate heel (Dewedge). 提高足跟,Protect side of foot and ankle. 保护脚侧和脚踝,Neutralize weight of lower extremity (Delever). 冲减下肢重量,Maintain and promote circulation. 保持和促进血液循环,Address foot drop an
7、d lateral rotation of the ankle. 改善足下垂和踝关节外侧旋转,Allow access to the foot for inspection/treatment as well as range of motion techniques. 允许进到足部进行检查/治疗，以及各种运动技巧,Be lightweight 重量更轻,为什么要遵循临床预案？ Why Follow Protocols?,Copyright EHOB, 2010,Copyright EHOB, 2010,6,6,6,6,6,预防压疮的风险评估 Risk Assessment for Preve
8、ntion of Pressure Ulcers,Braden Scale布兰登量表 Sensory perception感官知觉 Moisture湿度 Activity灵便性 Mobility移动性 Nutrition营养 Friction and Shear摩擦和剪切力 Norton Scale 诺顿量表 Five criteria scale 五个标准量表,6,Copyright EHOB, 2010,Copyright EHOB, 2010,7,体内平衡Homeostasis,即使外部环境不断变化，但身体却能够维持相对稳定的内环境。 The bodys ability maintain
9、 the relatively stable internal conditions even though the outside world changes continuously.,Copyright EHOB, 2010,静态空气包含的科学知识 The Science Behind Static Air,Archimedes Principle:阿基米德原理 The buoyant force on an object in a fluid is equal to the weight of the fluid the object displaces (buoyancy law)
10、在液体中的物体的浮力，等于物体排开的液体的重量（浮力定律） Boyles Law: 博伊尔定律 A gas will compress proportionately to the amount of pressure exerted on it. If the temperature remains constant, the volume of a given mass of gas is inversely proportional to the absolute pressure.视施加在气体上的压力大小，气体会比例地压缩。如果温度保持恒定，一定量的气体的体积与其绝对压力成反比。 Ne
11、wtons Law：牛顿定律 For every action, there is a reaction。每个作用力，都有一个反作用力。 Pascals Principle:帕斯卡尔原理 A law stating that a confined liquid transmits pressure applied to it from an eternal source equally in all directions.在密闭容器内，施加于静止液体上的压强将以等值同时传到各点。,Copyright EHOB, 2010,Copyright EHOB, 2010,支持表面 Support Su
12、rface,一种用于压力再分配的专业设施，设计用于组织负荷、微气候、和/或其他治疗功能的管理（例如，床垫、集成床系统、床垫置换、覆盖罩，或坐垫，或坐垫外罩）。 A specialized device for pressure redistribution designed for management of tissue loads, micro-climate, and/or other therapeutic functions (i.e. mattresses, integrated bed system, mattress replacement, overlay, or seat
13、cushion, or seat cushion overlay). 国家褥疮咨询小组，版权2007 NPUAP Copyright2007 NPUAP， National Pressure Ulcer Advisor Panel,Copyright EHOB, 2010,Copyright EHOB, 2010,了解褥疮是如何与为何行成的 Understanding How and Why Pressure Wounds Form,Interaction of shear and force. The skeletal frame of the body pulls the body by
14、force of gravity downward. The soft tissue (skin and underlying tissue) is held in place by contact with the bed surface.剪切力和压力的相互作用。身体的骨架由于重力向下推压身体。软组织（皮肤和皮下组织）接触到床垫被挤压到。 Distortion of the blood vessels in the area being stretched create angulation of the tissue.拉伸部位的血管的变形引起组织形成骨突 Small vessel thro
15、mbosis occurs with constricture at the fascial level resulting in tissue death.由筋膜抽搐引起微小血管栓塞导致组织坏死。,Copyright EHOB, 2010,褥疮的阶段 Stages of Pressure Wounds,Understanding of anatomy了解解剖学 Recognizing layers of the skin识别皮肤层 Knowledge of staging system分期系统的认识 Wound classification伤口分类 Moisture湿度 Candidiasi
16、s念珠菌病 Neuropathic神经系统疾病 Uncertainty in accuracy 准确度的不确定性,Copyright EHOB, 2010,表皮层,真皮层,皮下组织,Copyright EHOB, 2010,在骨突出上面 Over a Bony Prominence,Copyright EHOB, 2010,Copyright EHOB, 2010,褥疮分级的历史 History of Staging,First record of pressure ulcer by Hippocrates in 400 BC 首次有关褥疮记载是由希波克拉底于公元前400年记录的 Earlie
17、st staging system by Guttman in 1955 首个褥疮分级法是由古特曼于1955年创立的 Shea developed the first well documented method in 1975 首个有具可查方法是由谢伊于1975年开发的 In 1988 the IAET (now WOCN) developed a four-level staging system 在1988年，国际造口治疗师协会（现为伤口造口失禁护理协会），开发了一种四级分期系统。 In 1989 NPUAP also developed a four-stage system 在198
18、9年，国家褥疮咨询小组，也开发了一种四期系统,Copyright EHOB, 2010,临床挑战与分期 Clinical Challenges with Staging,Understanding of anatomy了解解剖学 Recognizing layers of the skin识别皮肤层 Knowledge of staging system分期系统的认识 Wound classification伤口分类 Moisture湿度 Candidiasis念珠菌病 Neuropathic神经系统疾病 Uncertainty in accuracy 准确度的不确定性,Copyright E
19、HOB, 2010,表皮层,真皮层,皮下组织,Copyright EHOB, 2010,一期 Stage I,Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. 在完整的皮肤上的某一区域有不可变白的红斑，一般出现在骨性突出上。深色皮肤上可能不会看到变白的现象，其颜
20、色可能与周围皮肤颜色不同。,Copyright 2007 NPUAP,Copyright EHOB, 2010,表皮层,真皮层,皮下脂肪,肌肉组织,骨,Copyright EHOB, 2010,一期 描述 Stage I Description,The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. This may indicate “at risk” persons. 此区域与其周围皮肤组织相比，可能会有疼痛、硬实、柔软、发热或发凉的感觉。这有可能是预示患者“有发病的危险”
21、。,Copyright EHOB, 2010,Copyright EHOB, 2010,一期 Stage I,Copyright EHOB, 2010,Copyright EHOB, 2010,二期 Stage II,Partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink, wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. 真皮部分损失，呈现
22、出浅的开放性溃疡创面，带有红色、粉色创面，无腐肉。或者可以看到完整的或开口的/破裂的充血水泡。,Copyright 2007 NPUAP,Copyright EHOB, 2010,表皮层,真皮层,皮下脂肪,肌肉组织,骨,Copyright EHOB, 2010,Presents as a shiny or dry shallow ulcer without slough or bruising. 呈现出肿亮的或干的浅层褥疮，无腐肉或伤痕。 This stage should not be used to describe skin tears, tape burns, perineal der
23、matitis, maceration or excoriation. 这个阶段应该不会有皮肤撕裂、带烧伤、会阴疱疹、皮肤浸软或腐肉。,二期描述 Stage II Description,Copyright EHOB, 2010,Copyright EHOB, 2010,二期 Stage II,Sacrum骶骨,Heel脚跟,Heel脚跟,Copyright EHOB, 2010,Copyright EHOB, 2010,三期 Stage III,Full thickness tissue loss. Subcutaneous fat may be visible but bone, tend
24、on or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. 全层皮肤组织缺损。可以看到皮下脂肪层，但骨骼、肌腱及肌肉均不外露。可能会呈现腐肉，但不会隐蔽组织深度毁损。可能会出现侵蚀和槽形侵蚀。,Copyright EHOB, 2010,Copyright EHOB, 2010,三期 描述 Stage III Description,The depth of a stage III
25、pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast , areas of significant adiposity can develop extremely deep stage III pressure ulcers. 三期褥疮的深度依解剖学位置而变化。鼻梁、耳朵、枕骨部和踝骨部没有皮下组
26、织，这些部位发生三期褥疮会是浅层的。相反，脂肪过多的区域可以发展成非常深的三期褥疮。 Bone/tendon is not visible or directly palpable. 骨骼和肌腱不可见或不可直接接触到。,Copyright EHOB, 2010,Copyright EHOB, 2010,三期 Stage III,Copyright EHOB, 2010,Copyright EHOB, 2010,四期 Stage IV,Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar
27、may be present on some parts of the wound bed. Often include undermining and tunneling. 全层皮肤毁损，并带有骨骼、肌腱或肌肉的裸露。在创面某些区域可能会有腐肉和痂疮。通常会有侵蚀和槽形侵蚀。,Copyright 2007 NPUAP,Copyright EHOB, 2010,Copyright EHOB, 2010,四期描述 Stage IV Description,The depth of a stage IV pressure ulcer varies by anatomical location. T
28、he bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage IV ulcers can be shallow. 四期褥疮的深度依解剖学位置而变化。 鼻梁、耳朵、枕骨部和踝骨部没有皮下组织，这些部位发生的四期褥疮可能是浅层的。 Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule) making osteomyel
29、itis possible. 四期褥疮可扩及到肌肉和/或支撑结构（如，筋膜、肌腱或关节囊），有可能引发骨髓炎。 Exposed bone/tendon is visible or directly palpable. 裸露的骨骼/肌腱可见或可直接接触到。,Copyright EHOB, 2010,Copyright EHOB, 2010,四期 Stage IV,Copyright EHOB, 2010,Copyright EHOB, 2010,无法分期 Unstageable,Full thickness tissue loss in which the base of the ulcer i
30、s covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. 全层皮肤毁损，褥疮创面被腐肉覆盖（黄色、浅棕色、灰色、绿色或者是棕色腐肉）和/或创面有痂疮（浅棕色、棕色或黑色）,Copyright EHOB, 2010,Copyright EHOB, 2010,无法分期 Unstageable,Copyright EHOB, 2010,Copyright EHOB, 2010,深层组织损伤 Deep Tissue Injury,Purple
31、 or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. 紫色或栗色局部变色的完整皮肤或充血的水泡是由皮下组织受挤压和/或剪力造成的。,Copyright 2007 NPUAP,Copyright EHOB, 2010,Copyright EHOB, 2010,深层组织损伤描述 Deep Tissue Injury Description,The area may b
32、e preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. 局部皮肤的状况可能是，与其周围组织相比疼痛的、硬实的、柔软的、发热或发凉。 Deep tissue injury may be difficult to detect in individuals with dark skin tones. 在深肤色的患者身上，很难辨识出深层组织损伤。 Evolution may include a thin blister over a dark
33、wound bed. The wound may further evolve and become covered by thin eschar. 再进步发展可能会在深色创面上出现扁薄的水泡。若进一步发展，会在上层结一层薄痂疮。 Evolution may be rapid exposing additional layers of tissue even with optimal treatment. 再继续恶化的话，即便使用最佳的治疗方法，其它组织层也会迅速裸露。,Copyright EHOB, 2010,Copyright EHOB, 2010,深层组织损伤 Deep Tissue I
34、njury,Heel脚跟,Sacrum骶骨,Left Sacrum左骶部,Copyright EHOB, 2010,Copyright EHOB, 2010,32,深层组织损伤的临床后果 Clinical Ramifications of Deep Tissue Injury,Can develop as soon as 20 minutes in high risk patients 对高危患者，褥疮可以在短至20分钟开始,May take 3 to 7 days to be clinically recognized 可能要花3到7天来临床确诊,It is important to con
35、sider providing proper support surfaces from the time the patient arrives at the hospitaleven as they wait for admission 重要的考虑是，当患者到达医院后，应立即提供合适的支持表面，即使患者还在接诊处等候。,Copyright EHOB, 2010,Copyright EHOB, 2010,33,我该如何选择支持表面？ How do I choose Support Surfaces?,Copyright EHOB, 2010,Copyright EHOB, 2010,34,4
36、 inches of the support surface immediately adjacent to the body determines the bodys response to the support surface. 4英寸厚的支持表面直接接触身体，决定了身体对支持表面的反应。,Copyright EHOB, 2010,Copyright EHOB, 2010,35,Copyright EHOB, 2010,Copyright EHOB, 2010,36,为什么采用静态空气？ Why Static Air?,Volume of body sinks into static a
37、ir chamber compressing and displacing volume of air in chamber until pressure in chamber* is enough to support weight of body (Buoyancy Principle, Boyles Law and Newtons Third Law) in perpendicular, non-gradient fashion. (Pascals Principle) 身体的体积陷入静态空气室内，压缩并挤出气室内空气的体积，直到气室内的压力足以以垂直的、非梯度的方式支撑起身体的重量（根
38、据浮力原理、博伊尔定律，牛顿第三定律，和帕斯卡尔原理）。,*Intra-chamber pressure气室内压力,Copyright EHOB, 2010,Copyright EHOB, 2010,37,Static Air provides more complete support for your patients 静态空气给病人提供更加完整的支持,Static Air Dynamic Air Gel 静态空气 动态空气 凝胶体,Copyright EHOB, 2010,38,独立研究 Independent Research,EHOB公司利用CT扫描来演示软组织的变形 EHOB ut
39、ilizes CT Scans to illustrate soft tissue deformation.,Copyright EHOB, 2010,床板,4英寸厚泡沫,空气垫,39,独立研究 Independent Research,Placing the air overlay on the standard hospital bed = 19mmHG 将空气垫置于标准病床上= 19mmHG,Copyright EHOB, 2010,病床模拟 压力=19mmHg (3英寸高密度泡沫，空气垫和普通床。身穿衣服,Copyright EHOB, 2010,40,Copyright EHOB,
40、2010,Copyright EHOB, 2010,41,WHO 何人,By all caregivers and support staff 由所有护理人员和支持人员,WHEN 何时,On admission and through scheduled assessments throughout a patients stay and discharge入院时，通过有计划的评估，贯穿病人从住院到出院的整个期间。,WHY 何原因,Health-impaired people develop pressure ulcers 健康受损的人患褥疮,WHERE 何地,In all places an
41、d on all surfaces utilized throughout the Continuum of Care. 需要用到持续护理的所有地方和所有表面,为什么支持表面的选择如此重要？ Why is support surface selection so important?,Copyright EHOB, 2010,Copyright EHOB, 2010,15个不同床垫的临床/案例研究 15 Different Mattress Clinical/Case Studies,减少褥疮发病率倒计时“Count Down to Decreasing Pressure Ulcer Prev
42、alence”,Deanna Vargo，注册护士，护理学学士，CWS, FCCWS，美国俄亥俄州巴伯顿市民医院 Deanna Vargo, RN, BSN, CWS, FCCWS，Barberton Citizens Hospital, Barberton, Ohio,结论： 最终结果表明，在18个月内，医院获得性褥疮发生率从17.4%降到3%。在发生率降低的同时，降低了床铺租赁费，在全院医师的调查中发现，医师的满意度为100%。所有未来发生率研究表明，在过去连续三个季度的持续改进下，褥疮发生率降至1.7%。 Conclusion Final results showed 17.4% to
43、3% facility acquired pressure ulcer prevalence within 18 months. This prevalence rate was decreased while finding significant reduction in rental bed cost and 100% physician satisfaction within a hospital-wide physician survey. All future prevalence studies showed continued improvements with the pas
44、t three consecutive quarterly results at 1.7% facility acquired pressure ulcer prevalence.,Copyright EHOB, 2010,Copyright EHOB, 2010,43,空气床垫的优点 Overlay Advantages May be utilized during patient repositioning and transfers for caregiver ease 可用于重新安置病人和转移病人，减轻护理强度。 May be utilized on multiple surfaces
45、 (i.e. mattress, transfer cart, etc.) 可用于多种表面上（例如床垫上、运送车上等） May be used throughout the continuum of care (i.e. unit to unit, facility to facility, facility to home) 可用于持续护理的全过程（例如从科室到科室，从医院到医院，从医院到家里）,Copyright EHOB, 2010,Copyright EHOB, 2010,摩擦和剪切力损伤 Friction & Shearing Injury,Mechanical force of t
46、wo surfaces moving across each other 两个表面的机械力相互摩擦 Causes blisters or abrasions 造成水疱或擦伤 Mechanical force that happens when tissue attached to bone are pulled in one direction, and surface tissue remain stationary. Commonly occurs when head of bed is raised and patient slides downward. 当连接到骨骼的组织被外力朝着某
47、个方向拉动时，机械力就产生了，而表面组织却保持静止。这通常发生在床头被提升而病人朝下滑时。 Causes loss of skin surface in irregular pattern. 造成皮肤表面的不规则毁损 Can resemble pressure wounds. 导致类似压迫性创伤,Copyright EHOB, 2010,Copyright EHOB, 2010,Copyright EHOB, 2010,Copyright EHOB, 2010,46,46,46,46,46,46,46,脚跟褥疮 Heel Ulcers,Heel ulcers constitute 30% of
48、 all pressure ulcers in hospital settings. 脚跟褥疮占医院机构中所有褥疮病例的30%,The heel consistently ranks as the second most common location for pressure ulcers. 脚跟一直是第二位最常发生褥疮的部位,(在这些研究中发现Dekeyser, Dejarger, Meyst and Evers),(在这些研究中发现Barczak, Barnett, Childs, Bosley),Copyright EHOB, 2010,Copyright EHOB, 2010,47,
49、Foam泡沫,Static Air静态空气,Copyright EHOB, 2010,48,“髋骨骨折患者的脚跟褥疮预防” “Prevention of Heel Pressure Ulcers in Fractured Hip Patients”,I. Lena McCubbin shows heel pressure ulcers dropped from 5.6% to 0% and the after group also showed no sacral ulcers with the use of the Static Air. I. 利纳 麦克卡宾发现脚跟褥疮的发生率从 5.6%下降至 0%。使用静态空气后，以后的小组未见骶骨褥疮发生。,II. Only Statistically Significant Study - Peer Reviewed - Won the Blue Ribbon Award for best poster at the 2004 WOCN II.仅仅统计学上显著的研究 - 经同行评审 - 在2004年伤口造口失禁护理协会上获得了最高奖项，以最佳海报。,Copyright EHOB, 2010,Copyright EHOB, 2