1、AMDA Clinical Practice Guideline(CPG)for Pressure Ulcers美国医师协会压疮临床实践指南美国医师协会压疮临床实践指南For Medical Directors and Attending Physicians适合于卫生主管和主治医师适合于卫生主管和主治医师第1页，共40页。What is a Pressure Ulcer?压疮是什么压疮是什么?nAny skin lesion usually over a bony prominence caused by unrelieved pressure resulting in damage to
2、underlying tissuen皮肤损伤_通常发生在骨隆突处_是压力和/或剪力、摩擦力对皮下组织损伤的结果。第2页，共40页。Pressure Ulcers May Not be Preventable有些压疮是难以避免的有些压疮是难以避免的nAggressive measures can reduce but not eliminate the incidence of pressure ulcers积极的预防措施能够降低压疮的发生率，但并不能彻底消灭压疮；nCan develop despite best efforts of clinical team in high risk pa
3、tients尽管临床小组作出最大的努力,但高风险的病人仍有压疮发生nEvery effort should be made to prevent pressure ulcers要通过任何方式的努力来预防压疮；nA systematic approach to recognize and manage pressure ulcers is needed需要用系统化的管理方法来识别和管理压疮。第3页，共40页。Factors Affecting Pressure Ulcer Development促成压疮发生的四大直接因素促成压疮发生的四大直接因素 nPressure压力nShearing剪切力n
4、Friction摩擦力nMoisture潮湿第4页，共40页。AMDA Pressure Ulcer CPG Steps压疮临床实践指南包括：压疮临床实践指南包括：nRecognition识别nAssessment/Root Cause Analysis评估和分析根本原因nTreatment治疗nMonitoring监护第5页，共40页。Pressure Ulcers CPGRecognition压疮识别压疮识别nDocument any history of pressure ulcers in the medical record在病历中记录压疮的全部历史资料；nThoroughly ex
5、amine all skin surfaces on admission入院时仔细全面检查病人的皮肤；nIdentify all primary risk factors识别所有基本的风险因素第6页，共40页。Pressure Ulcers CPG Recognition压疮识别压疮识别Distinguish types of ulcers辨别溃疡辨别溃疡的类型的类型 nVascular insufficiency/ischemia(venous stasis and arterial ischemic ulcers)血管机能不全/局部缺血（静脉淤滞和动脉缺血性溃疡）nNeuropathic
6、神经性的nPressure压力性的第7页，共40页。Pressure Ulcers CPG Recognition压疮识别压疮识别Primary risk factors for development of pressure ulcers are:形成压疮的原发危险因素：nImpaired/decreased mobility活动性受到限制或者减少nCo-morbid conditions,e.g.,diabetes mellitus糖尿病等合并症nUrinary or fecal incontinence失禁nUndernutrition,malnutrition,&hydration d
7、eficits营养不良、脱水nImpaired diffuse or localized blood flow血流灌注受限或者局部淤血nDrugs such as steroids that may affect wound healing类固淳药品的使用影响伤口康复；nHistory of a healed pressure ulcer压疮痊愈的经历nResident refusal of some aspects of care&treatment居民拒绝给予局部的护理和治疗nIntrinsic risks due to aging老龄化为固有的危险因素第8页，共40页。Pressure
8、Ulcers CPG Recognition压疮识别压疮识别Major Risk Factors for Developing Pressure Ulcers发生压疮的主要因素发生压疮的主要因素nAlterations in sensation or response to comfort对舒适与否的感觉反应能力发生变化 nDegenerative neurological disease退化性神经疾病nCerebrovascular disease脑血管疾病nCentral nervous system(CNS)injury中枢神经系统受损伤nDepression抑郁等情绪第9页，共40页。
9、Pressure Ulcers CPG Recognition压疮识别压疮识别Major Risk Factors for Developing Pressure Ulcers形成压疮的主要危险因素形成压疮的主要危险因素Causes of impaired/decreased mobility活动性受限或减活动性受限或减少少nNeurologic disease/injury神经疾病/神经损伤nFractures骨折nPain疼痛nRestraints受到束缚第10页，共40页。Pressure Ulcers CPG Recognition压疮压疮识别识别 Comorbid Condition
10、s That May Affect Ulcer Healing 多种可能影响压疮康复的身体状况多种可能影响压疮康复的身体状况Malnutrition and dehydration营养和水合作用Diabetes mellitus糖尿病End-stage renal disease晚期肾脏疾病Thyroid disease甲状腺疾病Congestive heart failure充血性心力衰竭Peripheral Vascular Disease外周血管疾病Vasculitis/other collagen vascular disorders 血管炎和其他胶原血管疾病Immune defici
11、ency states免疫缺陷状态Malignancies恶性肿瘤COPD 慢性阻塞性肺病Depression and psychosis精神状态抑郁Drugs that affect healing药物影响康复Contractures at major joints关节处大范围的挛缩第11页，共40页。Pressure Ulcers CPG Assessment压疮评估压疮评估Pressure Ulcer Classifications 分级分级 nStage 1:Observable,pressure-related alteration of intact skin,including
12、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)一期压疮nStage 2:Partial thickness skin loss involving epidermis,dermis,or both.The ulcer is superficial and presents clinically as an abrasion,blister,or
13、 shallow crater二期压疮第12页，共40页。Pressure Ulcers CPG Assessment压疮评估压疮评估Pressure Ulcer Classifications continuednStage 3:Full thickness skin loss involving damage to,or necrosis of,subcutaneous tissue that may extend down to,but not through,fascia.The ulcer presents clinically as a deep crater with or wi
14、thout undermining of adjacent tissue 三期压疮 nStage 4:Full thickness skin loss with extensive destruction,tissue necrosis or damage to muscle,bone,or supporting structures(e.g.,tendon,joint capsule).Undermining and sinus tracts also may be associated四期压疮第13页，共40页。Pressure Ulcers CPG Assessment压疮评估压疮评估E
15、thical Issues To Consider对伦理的考虑对伦理的考虑 nReview Advance Directives检查病人预先的医嘱nIdentify choices that limit the scope,intensity,duration and selection of various wound-related or adjunctive treatments选择治疗作用区域、强烈程度和持续时间最小化的治疗，配合相应的伤口治疗和辅助治疗方式。第14页，共40页。Pressure Ulcers CPG Assessment压疮评估压疮评估An effective ass
16、essment includes有效的评估包括：有效的评估包括：nDefine and interpret factors affecting treatment and wound healing such as physical,functional and psychosocial factors定义和解释关于治疗和伤口康复的影响因素，例如身体的，功能的和心理方面的因素。nDefine prognosis identify realistic goals解释预测识别现实的各个目标nIdentify management priorities识别需要处理的优先项目。第15页，共40页。Pr
17、essure Ulcers CPG Assessment压疮评估压疮评估Certain clinical findings may have priority 确定临床所见现象能够治疗的优先顺序。nAddress systemic and life-threatening issues 标明对系统或生命有威胁的问题；nStage 3 and 4 ulcers 三期、四期压疮nSignificant pain 明显疼痛的疮口nFluid and electrolyte abnormalities渗出物或电解质异常nNutritional deficits营养不足nNeed for surgica
18、l intervention to remove necrotic tissue需要通过外科手术来清理掉坏死组织。nSoft-tissue infection软组织感染。第16页，共40页。Factors That Affect PU Wound Healing 影响压疮伤口康复的因素包括：PU Wound healing is a complex multifactorial process压疮的康复是一个复杂的、多因素的、缓慢的过程！Soft Tissue Infection软组织感染软组织感染Systemic Illness系统性疾病系统性疾病Osteomyelitis骨髓炎骨髓炎Wou
19、nd Environment伤口周边环境伤口周边环境 Pressure压力压力Oxygen氧供能力氧供能力Perfusion灌注状况灌注状况SystemicHealing Ability组织的复原能力组织的复原能力Compliance组织顺应性组织顺应性Edema浮肿浮肿Nutrition营养状况压疮导致病人疼痛，感染甚至危及病人生命，治疗昂贵且漫长！压疮的关键工作在于预防！第17页，共40页。LEAN MASSErosion(catabolism)of muscle proteinVisceral protein for glucose production肌肌肉蛋白腐化（分解代谢），内脏蛋
20、白利用葡萄糖ENERGY PRODUCTIONMainly from glucose and amino acids能量生产主要来自于葡萄糖和氨基酸A marked increase in energy demands and lean body mass loss initiated by the stress response 压力应激反应的标志是病人对能量的需求明显增加、消瘦、以及体重丢失。Amino Acids氨基酸Photos courtesy of R.H.Demling,MD.The Catabolic Response to a wound(Activation of the
21、Stress Response伤口的分解代谢反应（压力刺激反应)Net protein loss纯粹的蛋白质丢失第18页，共40页。The Nonhealing Chronic WoundFailure to Heal by 12 Weeks慢性伤口需要12周的时间才能愈合 Catabolism分解代谢分解代谢 Catabolism分解代谢 Anabolism合成代谢 Anabolism合成代谢合成代谢Energy能量Protein Synthesis蛋白质合成EnergyStore能量储存能量储存ProteinStore蛋白质储存蛋白质储存Macronutrients大量营养物质大量营养物质
22、EnergyEnergyStore能量储存能量储存ProteinStore蛋白质储存蛋白质储存Macronutrients大量营养物质大量营养物质Protein Synthesis蛋白质合成The Nonhealing Wound坏死阶段的伤口坏死阶段的伤口The Healing Wound康复阶段的伤口康复阶段的伤口Filling填充Wound contraction伤口收缩Densecollagenscar细密的胶原结疤Neutrophils嗜中性白细胞O2Courtesy of R.H.Demling,MD.第19页，共40页。Pressure Ulcers CPGTreatment压疮
23、治疗压疮治疗nWound prevention plan伤口预防方案nWound treatment plan 伤口治疗方案第20页，共40页。Pressure Ulcers CPGTreatment 压疮治疗压疮治疗Preventive measures预防措预防措施施Maintain personal hygiene保持个人卫生Assure adequate nutrition 保证适当的营养Manage urinary/fecal incontinence正确处理失禁病人的护理 Reposition and have patient shift weight 更换体位,转移病人受压部位A
24、void messaging reddened areas避免出现变红的区域 Prevent contractures 预防挛缩Position to alleviate pressure over bony prominences 体位更换缓解骨突出处的压力Use positioning devices使用减压性的体位垫装置Maintain lowest head elevation 保持最低的头部高度Use lifting devices使用可以提升病人的转移装置 第21页，共40页。Pressure Ulcers CPG Treatment压疮治疗压疮治疗Preventive Measu
25、res预防措施预防措施Important Points on Positioning and Support Surfaces 关于体位和支撑面的要点nUse a pressure-reducing mattress 使用减压防护垫nAvoid placing patient on trochanters or directly on wound避免病人骨隆突处和伤口处直接受压nMattress options foam,air loss,water,gel,alternating air or viscoelastic 选择适当的垫子海绵、气垫、水垫、凝胶、交换充气垫、粘弹性防护垫nPres
26、sure relieving devices(e.g.viscoelastic mattress)where indicated 危险部位使用分散压力的装置（例如：粘弹性ACTION防护垫）第22页，共40页。Pressure Ulcers CPG Treatment压疮治疗压疮治疗Preventive Measures预防措施预防措施 nAssuring adequate Nutrition and Hydration 保证营养和水分 nWatch for anorexia in patients with a sudden change in intake对于食欲缺乏的病人要改变营养摄入方
27、式nUndernourished patients caloric/protein/hydration targets:营养不足的病人热量、蛋白质、补水作用的目标：n30-35 calories/kg/dayn1-1.5 g/kg/day proteinn30 ml/kg/day fluidnExcept for a daily multivitamin,other vitamin and mineral supplements are not needed unless deficiencies are confirmed 除了日常补充多种维生素之外，其他的维生素和矿物质是不需要额外补充的，
28、除非是临床证实需要补充的。第23页，共40页。Pressure Ulcers CPG Treatment压疮治疗压疮治疗Preventive Measures A Step Wise Approach to Nutritional Intervention in Patients with Wounds预防措施预防措施对于有压疮对于有压疮伤口的病人选用营养干预是一个明智的方法伤口的病人选用营养干预是一个明智的方法nLevel 1 Approximately within first week after wound onset第一阶段大约在伤口开始后的第一周内nLevel 2 Followin
29、g completion of Level 1 assessment第一阶段治疗后进行第二阶段治疗nLevel 3 Approximately within 2 weeks of implementing Level 2第二阶段治疗后两周内进行第三阶段的治疗.Source:AMDA Pressure Ulcer Therapy Companion Clinical Practice Guideline 第24页，共40页。Pressure Ulcers CPG Treatment压疮治疗压疮治疗Wound Care伤口护理伤口护理Principles of wound dressings:伤口
30、敷裹的原则：nProtect wound bed from further trauma,contamination or drying避免伤口创面进一步的受到创伤或者污染或者过于干燥nPromote removal of necrotic tissue and exudate加速坏死组织和渗出物的移除nProvide a moist healing environment supportive of regeneration and growth of granulation tissue.提供湿润的愈合环境来利于恢复和肉芽组织生长nWound characteristics change
31、as the wound evolves.随着伤口的发展，伤口的特性不断发生改变。nTailor dressings primarily to wound characteristics,not wound stage选择适应伤口特性的敷料，而不是适应伤口的阶段。第25页，共40页。Pressure Ulcers CPG Treatment压疮治疗压疮治疗Wound Care Teams Possible Roles合理的角色合理的角色伤口护理团队伤口护理团队nHelp guide care by staying abreast of developments in the field利用该领
32、域的发展结果来帮助指导护理工作nEvaluate new products for formulary评估规定的新产品nProvide consultation for difficult wounds提供不同类型伤口的咨询nHelp select appropriate support surfaces for complex patients帮助病人选择适当的支撑装置nTrain new staff训练新的医护人员nProvide continuing education for existing staff提供目前医护人员的持续教育nPerform wound care执行伤口护理第26
33、页，共40页。Pressure Ulcers CPG Treatment压疮治疗压疮治疗Wound Care Intact Skin伤口护理伤口护理完整的皮肤完整的皮肤nStage 1 Pressure Ulcers may herald a more extensive wound一期压疮或许已经预示更大面积的损伤nProtect involved area from further injury from pressure or shearing forces预防相关区域遭受压力和剪切力的进一步损伤nNo dressing required没有包扎伤口的必要nMonitor frequen
34、tly for changes频繁的监测伤口变化第27页，共40页。Pressure Ulcers CPG:Treatment压疮治疗压疮治疗Wound Care Clean Wound Base清洁伤口的基底部清洁伤口的基底部Stage 2 or healing Stage 3 or Stage 4 wound 二期或者处于康复阶段的三期四期压疮 nDressing should keep ulcer bed continually moist but the surrounding skin dry敷料要保证创面的湿润但是周围要保证干的nChoose dressing based on s
35、ituation根据伤口的情形来选择包扎方式nFill wound dead space with loosely packed dressing material伤口的死腔要用疏松的敷料来填充第28页，共40页。Pressure Ulcers CPG:Treatment压疮治疗压疮治疗Wound Care Eschar or Wound Base with Adherent Necrotic Tissue伤口焦痂或者伤口出现附着的坏死组织伤口焦痂或者伤口出现附着的坏死组织nAdditional treatments are indicated in wounds covered by esc
36、har or with surface necrosis of subcutaneous tissue(without undermining adjacent tissue)伤口的附助治疗指明了：表面焦痂的伤口以及皮下组织坏死的伤口nTypes of debridement used to remove eschar and surface necrosis用于移除焦痂和皮下坏死组织的各种清创术nSharp surgical debridement剧烈的外科清创术nMechanical机械的nEnzymatic agents采用酶因子的nAutolytic 自溶的nSterile biolo
37、gical(maggot)无菌的生物学方法nDont use topical antibiotics routinely 不要例行公事地使用局部抗生素 第29页，共40页。Pressure Ulcers CPG:Treatment压疮治疗性处理压疮治疗性处理Wound Care Extensive Subcutaneous Tissue Damage广泛广泛的皮下组织损伤的皮下组织损伤nStage 4(some Stage 3)pressure ulcers are characterized by full thickness skin loss with extensive tissue
38、necrosis,undermining and sinus tracts四期压疮（包括部分3期压疮）深部出现大面积的组织坏死，窦道状坏疽；nTreatment may require extensive surgical debridement治疗需要较大面积的外科清疮术；nAll devitalized tissue removed去除所有的坏死组织nUndermined areas should be explored and unroofed深部损伤要去除表层才能准确界定。第30页，共40页。Pressure Ulcers CPG:Treatment压疮治疗性处理压疮治疗性处理Woun
39、d Care Categories of Products Used in Wound Care用于用于伤口护理的产品分类伤口护理的产品分类nHydrocolloids水胶体nAlginate藻酸盐等nFoams泡沫等nWound Fillers 伤口填充物nComposite Dressings合成敷料第31页，共40页。Pressure Ulcers CPG:Treatment压疮治疗性处理压疮治疗性处理Wound Care Ongoing Management 持续的管理持续的管理1.Cleanse at each dressing change清洁伤口更换敷料2.Debride esc
40、har,as needed如果有需要的话要清创焦痂3.Evaluate/treat for infection评定和处理感染4.Employ facility infection control利用多种设施达到感染控制第32页，共40页。Pressure Ulcers CPG:Treatment压疮治疗性处理压疮治疗性处理Wound Care Ongoing Management(continued)持持续处理续处理5.Re-evaluate co-existing medical conditions再次评定病人身体状况方面的医疗条件6.Prescribe pain control meas
41、ures处方建议采用控制疼痛的措施7.Address psychosocial issues,depression,and possible isolation病人的心理状态，可能孤独和抑郁。第33页，共40页。Pressure Ulcers CPG Treatment压疮治疗性处理压疮治疗性处理Wound Care Alternatives to Non-Responders伤口护理伤口护理-针对没有反应的患者供选方案针对没有反应的患者供选方案nFor clean wounds not responding to appropriate treatment consider:为没有反应的患者
42、清洁伤口提供适当的治疗：nTopical antibiotic ointments/solutions for 2 week trial局部提供的抗生素，尝试两周；nProgress to a support surface that offers further protection 改进支撑体的质地，提供更深入的保护；nConsider a course of electrotherapy 考虑给予电疗治疗；nConsider transfer to another site for surgical debridement/repair,mgt.of systemic complicat
43、ions,comfort/pain mgt.,and specialized diagnostic studies 考虑外科清疮术/修复术，全身性的合并症，舒适/疼痛，对特殊的指针进行研究。第34页，共40页。Pressure Ulcers CPG Monitoring压疮监测压疮监测nRegular weekly evaluations to assess healing(based on established Assessment Guides)to monitor success of the treatment regimen基于已经确立的评估指南，每周对伤口的康复程度进行评定以监测
44、相应治疗方式所取得的治疗效果；nFollow-up diagnostic testing and consultation 跟随诊断测试和会诊第35页，共40页。nDocument patient response to treatment证明病人治疗的反应nMonitor and adjust treatment as indicated监测指征调整治疗方案nRecognize and manage complications识别和处理合并症Pressure Ulcers CPG:Monitoring压疮监测压疮监测第36页，共40页。Pressure Ulcers CPG Monitori
45、ng压疮监测压疮监测Decide Whether To Change Treatment As Wound Heals 根据伤口愈合状况决定是否改变治疗方式nDressing types敷料的类型nDebridement options清创术的选择nNutritional program营养补充程序nSupport surface options选择表面支撑体第37页，共40页。Pressure Ulcers and Quality Improvement压疮管理和护理质量的改进压疮管理和护理质量的改进Goals of system to prevent and manage pressure
46、 ulcer预防和治疗压疮的系统目标预防和治疗压疮的系统目标nWound improvement/healing 伤口改善/愈合nPrevent additional skin breakdown防止进一步的皮肤损伤；nPrevent decline in overall condition 预防全身性衰弱；nPain reduction 减少疼痛 第38页，共40页。Pressure Ulcers and Quality Improvement压疮管理和护理质量的改进压疮管理和护理质量的改进Tips for risk management related to pressure ulcers
47、与与压疮治疗有关危险因素管理体系压疮治疗有关危险因素管理体系nClear and consistent documentation in the chart清楚的连贯性的图解；nClearly defined roles and responsibilities清楚确定相应的角色和任务；nEffective communication between shifts and disciplines多学科之间有效沟通；nCommunication with families与家庭建立沟通机制；nDocument unavoidable factors that prevent healing or
48、 lead to worsening of pressure sores记录引起压疮进一步恶化或者阻碍压疮康复的难免性因素；nPolicies and QA measures to ensure quality care通过相应政策和质量管理措施来保证护理工作的品质。第39页，共40页。Summary概述概述nPressure ulcers continue to challenge nursing facilities在各个护理机构压疮是持续存在的难题nSome ulcers are unavoidable,many develop prior in hospitals有一些压疮是难于避免的，有一些压疮是在病人入院前已经产生了的。nThere is a need to maintain processes and systems to address prevention,recognition,and treatment that maximize the patients comfort,dignity and quality of life需要一系列的程序包括：预防、识别和治疗措施，最大程度的让病人舒适、感受到尊重和拥有更好的生活质量。第40页，共40页。
