1、压疮护理 101 Pressure Wound Care 101Sharon Lepper 护理学学士，注册护士，护理学学士，注册护士，伤口造口失禁护士伤口造口失禁护士 Sharon Lepper BSN RN WOCN Copyright EHOB,2019EHOB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,20192预案能够使压疮发病率降低预案能够使压疮发病率降低50%Protocols decr
2、ease incidence by 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.1.Moody BL,Fanale JE,Thompson M.Vaillancourt D,Symonds G,Bonasoro C.Impact of staff education on pressure sore development in elderly hospitalized patients.Arc
3、hives of Internal Medicine.1988;148:2241-2243.Copyright EHOB,2019Copyright EHOB,20193压疮的临床预案应解决以下方面：压疮的临床预案应解决以下方面：Clinical Protocols for Pressure Ulcers Should Address:Cognition 认知认知Mobilization&Ambulation 活动与步行活动与步行 Nutrition and Hydration营养和水化营养和水化 Moisture and Incontinence湿度和失禁湿度和失禁 Medication U
4、se药物治疗药物治疗 Existing Pressure Ulcers(Deep Tissue Injury)已生成的褥疮（深部已生成的褥疮（深部组织损伤）组织损伤）Contact with medical devices(i.e.,braces,orthothics,cannulas,tubing),and/or any object in contact with the body接触医疗器械接触医疗器械（例如，支架（例如，支架、矫形器、插管、输液管）和、矫形器、插管、输液管）和/或任何与身体接触的物体）或任何与身体接触的物体）Copyright EHOB,2019Copyright EH
5、OB,201944ALL SUPPORT SURFACES SHOULD:所有的支持表面应具备以下几点：所有的支持表面应具备以下几点：Redistribute 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
6、.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？为什么要遵循临床预案？Why Follow Protocols?Copyright EHOB,2019Copyright EHOB,201955ALL LOWER EXTREMITY PROTOCOLS SHOULD:所有的下肢预案都应具备：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 Main
7、tain and promote circulation.保持和促进血液循环 Address foot drop and 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？为什么要遵循临床预案？Why Follow Protocols?Copyright EHOB,2019Copyri
8、ght EHOB,2019666预防压疮的风险评估预防压疮的风险评估 Risk Assessment for Prevention 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6Copyright EHOB,2019Copyright EHOB,20197体内平衡体内平衡Homeostasis即使外部环境
9、不断变化，但身体却能够维持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。相对稳定的内环境。The bodys ability maintain the relatively stable internal conditions even though the outside world changes continuously.Copyright EHOB,2019静态空气包含的科学知识静态空气包含的科学知识The Science Behind Static Air Archimedes Principle:阿基米德原理阿基米德原理 The buoyant force on an o
10、bject in a fluid is equal to the weight of thefluid the object displaces(buoyancy law)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 prop
11、ortional 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。Newtons Law：牛顿定律牛顿定律 For every action,there is a reaction。每个作用力，都有一个反作用力。Pascals Principle:帕斯卡尔原理帕斯卡尔原理A law stating that a confined liquid transmits pressure applied to it from an eternalsource equally in all direct
12、ions.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,2019Copyright EHOB,2019 支持表面Support Surface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 functio
13、ns(i.e.mattresses,integrated bed system,mattress replacement,overlay,or seat cushion,or seat cushion overlay).国家褥疮咨询小组，版权2019 NPUAP Copyright2019 NPUAP，National Pressure Ulcer Advisor PanelCopyright EHOB,2019Copyright EHOB,2019了解褥疮是如何与为何行成的了解褥疮是如何与为何行成的 Understanding How and Why Pressure Wounds Form
14、 uInteraction of shear and force.The skeletal frame of the body pulls the body by 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。uDistortion of the blood vessels in the area being
15、 stretched create angulation of the tissue.拉伸部位的血管的变形引起组织形成骨突 uSmall vessel thrombosis 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,2019褥疮的阶段褥疮的阶段Stages of Pressure Wounds Understanding of anatomy了解解剖学 Recognizing layers of the skin识别皮肤层
16、Knowledge of staging system分期系统的认识 Wound classification伤口分类 Moisture湿度湿度 Candidiasis念珠菌病念珠菌病 Neuropathic神经系统疾病神经系统疾病 Uncertainty in accuracy 准确度的不确定性 Copyright EHOB,2019表皮层真皮层皮下组织Copyright EHOB,2019在骨突出上面在骨突出上面 Over a Bony ProminenceCopyright EHOB,2019Copyright EHOB,2019褥疮分级的历史褥疮分级的历史History of Stag
17、ingFirst 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首次有关褥疮记载是由希波克拉底于公元前400年记录的年记录的Earliest staging system by Guttman in 1955 首个褥疮分级法是由古特曼于首个褥疮分级法是由古特曼于1955年创立的年创立的Shea developed the first well documented method in 1975 首个有具可查方法是由谢伊于首个有具可查方法是由谢伊于1975年开发的年开发的In 1988 the IAET(
18、now WOCN)developed a four-level staging system 在在1988年，国际造口治疗师协会（现为伤口造口失禁护理年，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。协会），开发了一种四级分期系统。In 1989 NPUAP also developed a four-stage system 在在1989年，国家褥疮咨询小组，也开发了一种四期系统年，国家褥疮咨询小组，也开发了一种四期系统 Copyright EHOB,2019临床挑战与分期临床挑战与分期 Clinical Challenges with Staging Unders
19、tanding 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湿度湿度 Candidiasis念珠菌病念珠菌病 Neuropathic神经系统疾病神经系统疾病 Uncertainty in accuracy 准确度的不确定性 Copyright EHOB,2019表皮层真皮层皮下组织Copyright EHOB,2019一期一期 Stage IIntact skin with non-blanchabl
20、e 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，其颜色可能与周围皮肤颜色不同。现象，其颜色可能与周围皮肤颜色不同。Copyright 2
21、019 NPUAPCopyright EHOB,2019表皮层真皮层皮下脂肪肌肉组织骨Copyright EHOB,2019一期一期 描述描述 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”。Copyright EHOB,2019Copyright EHOB,2019
22、一期 Stage ICopyright EHOB,2019Copyright EHOB,2019二期二期Stage IIPartial 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，呈现出浅的开放性溃疡创面，带有红色、真皮部分损失，呈现出浅的开放性溃疡创面，带有红色、粉色创面，粉色创面，无腐肉
23、无腐肉。或者可以看到。或者可以看到完整的或开口的完整的或开口的/破裂破裂的充血水泡的充血水泡。Copyright 2019 NPUAPCopyright EHOB,2019表皮层真皮层皮下脂肪肌肉组织骨Copyright EHOB,2019Presents 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 dermatitis,macerat
24、ion 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。二期描述二期描述 Stage II DescriptionCopyright EHOB,2019Copyright EHOB,2019二期二期Stage IISacrum骶骨骶骨Heel脚跟脚跟Heel脚跟脚跟Copyright EHOB,2019Copyright EHOB,2019三期三期 Stage IIIFull thickness tissue loss.Subcutaneous fat may be visible but bone,tendon or muscle are not
25、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,2019Copyright EHOB,2019三期三期 描述描述Stage III Description The depth of a stage III pressure ulcer varies by a
26、natomical 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
27、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,2019Copyright EHOB,2019三期三期 Stage IIICopyright EHOB,2019Copyright EHOB,2019四期四期 Stage IVFull thickness tissue loss with exposed bone,tendon or muscle.Slough or eschar may be present on some parts of the wound be
28、d.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 2019 NPUAPCopyright EHOB,2019Copyright EHOB,2019四期描述 Stage IV Description The depth of a stage IV pressure ulcer varies by anatomical location.The bridge of the nose,ear,occiput and malleolus do no
29、t 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 osteomyelitis 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 b
30、one/tendon is visible or directly palpable.裸露的骨骼/肌腱可见或可直接接触到。Copyright EHOB,2019Copyright EHOB,2019四期Stage IVCopyright EHOB,2019Copyright EHOB,2019无法分期无法分期UnstageableFull thickness tissue loss in which the base of the ulcer is covered by slough(yellow,tan,gray,green or brown)and/or eschar(tan,brown
31、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,2019Copyright EHOB,2019无法分期无法分期UnstageableCopyright EHOB,2019Copyright EHOB,2019深层组织损伤深层组织损伤Deep Tissue InjuryPurple or maroon localized area of discolored intact skin or blood-filled blister due to dama
32、ge 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 2019 NPUAPCopyright EHOB,2019Copyright EHOB,2019深层组织损伤描述深层组织损伤描述 Deep Tissue Injury Description The area may be preceded by tissue that is painful,firm,mushy,boggy,warmer or cooler as compared to
33、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 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
34、。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,2019Copyright EHOB,2019深层组织损伤深层组织损伤Deep Tissue InjuryHeel脚跟脚跟Sacrum骶骨骶骨 Left Sacrum左骶部左骶部 Copyright EHOB,2019Copyright EHOB,201932深层组织损伤的临床后果深层组织损
35、伤的临床后果 Clinical Ramifications of Deep Tissue InjuryCan develop as soon as 20 minutes in high risk patients对高危患者，褥疮可以在短至对高危患者，褥疮可以在短至20分钟开始分钟开始May take 3 to 7 days to be clinically recognized可能要花可能要花3到到7天来临床确诊天来临床确诊It is important to consider providing proper support surfaces from the time the patien
36、t 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。的支持表面，即使患者还在接诊处等候。Copyright EHOB,2019Copyright EHOB,201933我该如何选择支持表面？我该如何选择支持表面？How do I choose Support Surfaces?Copyright EHOB,2019Copyright EHOB,2019344 inches of the support sur
37、face immediately adjacent to the body determines the bodys response to the support surface.4 4英寸厚的支持表面英寸厚的支持表面直接接触身体直接接触身体，决定，决定了身体对支持表面的反应。了身体对支持表面的反应。Copyright EHOB,2019Copyright EHOB,201935Copyright EHOB,2019Copyright EHOB,201936为什么采用静态空气？为什么采用静态空气？Why Static Air?Volume of body sinks into static
38、air 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
39、的、非梯度的方的体积，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式支撑起身体的重量（根据浮力原理、博伊尔定律，牛顿第三（根据浮力原理、博伊尔定律，牛顿第三定律，和帕斯卡尔原理）定律，和帕斯卡尔原理）。*Intra-chamber pressure气室内压力 Copyright EHOB,2019Copyright EHOB,201937Static 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 Copyrigh
40、t EHOB,201938 独立研究独立研究 Independent ResearchEHOB公司利用CT扫描来演示软组织的变形EHOB utilizes CT Scans to illustrate soft tissue deformation.Copyright EHOB,2019床板床板4英寸厚泡沫英寸厚泡沫空气垫空气垫39独立研究独立研究 Independent Research Placing the air overlay on the standard hospital bed=19mmHG 将空气垫置于标准病床上将空气垫置于标准病床上=19mmHGCopyright EHOB
41、,2019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,201940Copyright EHOB,2019Copyright EHOB,201941WHO何人何人 By all caregivers and support staff 由所有护理人员和支持人员护理人员和支持人员 WHEN何时何时 On admission and through scheduled assessments throughout a patients stay and discharge入院时，通过有计划的入院时，通过有计划的评估，贯穿病人从住院到出院的整个
42、期间。评估，贯穿病人从住院到出院的整个期间。WHY何原因何原因 Health-impaired people develop pressure ulcers健康受损的人患褥疮健康受损的人患褥疮 WHERE何地何地 In all places and on all surfaces utilized throughoutthe Continuum of Care.需要用到持续护理的所有地方和所有表面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？为什么支持表面的选择如此重要？Why is support surface selection so important?Copyr
43、ight EHOB,2019Copyright EHOB,201915个不同床个不同床垫垫的的临临床床/案例研究案例研究15 Different Mattress Clinical/Case Studies减少褥疮发病率倒计时减少褥疮发病率倒计时“Count Down to Decreasing Pressure Ulcer Prevalence”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：结
44、论：最终结果表明，在最终结果表明，在18个月内，医院获得性褥疮个月内，医院获得性褥疮发生率从发生率从17.4%降到降到3%。在发生率降低的同时。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，降低了床铺租赁费，在全院医师的调查中发现，医师的满意度为现，医师的满意度为100%。所有未来发生率研。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，究表明，在过去连续三个季度的持续改进下，褥疮发生率降至褥疮发生率降至1.7%。ConclusionFinal results showed 17.4%to 3%facility acquired pressure ulcer preval
45、ence 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 past three consecutive quarterly results at 1.7%
46、facility acquired pressure ulcer prevalence.Copyright EHOB,2019Copyright EHOB,201943 空气床垫的优点空气床垫的优点 Overlay AdvantagesMay 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。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(i.e.mattress,transfer ca
47、rt,etc.)可用于多种表面上（例如床垫上、运送车上等）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）到医院，从医院到家里）Copyright EHOB,2019Copyright EHOB,2019摩擦和剪切力损伤 Friction&Shearing Injury Mechanic
48、al force of two 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
49、骼的组织被外力朝着某个方向拉动时，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,2019Copyright EHOB,2019Copyright EHOB,2019Copyright EHOB,20194646464646脚跟褥疮脚跟褥疮 Heel UlcersHeel ulcers constitute 30%of all press
50、ure ulcers in hospital settings.脚跟褥疮占医院机构中所有褥疮病例的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,2019Copyright EHO
