Ulcer压疮的定义

ZinaWhiteRNCWOCN1PressureUlcer压疮ZinaWhiteRNCWOCNZinaWhiteRNCWOCN2Topics目录PressureUlcer压疮的定义RiskFactors&Causes压疮发生的危险因素和病因ASSESSMENT评估评估Staging压疮分期Management压疮处理ZinaWhiteRNCWOCN3PressureUlcer压疮LESIONCAUSEDBYUnrelievedpressure未被释放的压力RESULTINGINDAMAGEOFUNDERLYINGTISSUE由于无法释放的压力而引起的皮肤破溃，继而引起下层的组织的坏死ZinaWhiteRNCWOCN4RiskFactors危险因素：Pressure压力Friction摩擦力Shear剪切力Moisture潮湿Immobility制动Inactivity丧失知觉Malnutrition营养不良FecalandUrinaryIncontinence大小便失禁ZinaWhiteRNCWOCN5Shear剪切力ZinaWhiteRNCWOCN6EffectsofShear剪切力引起的后果Shear剪切力:forcesofgravitywithfriction由地心吸引力而引起的摩擦Undermining破坏:ZinaWhiteRNCWOCN7Pathophysiology病理学Softtissueiscompressedbetweenbonyprominenceandexternalsurfaceforaprolongedperiodoftime.软组织长期受压于骨骼隆突与外部硬面之间1.Unrelievedpressure未被释放的压力2.Vesselscompress血管受压3.Can’tdeliverOxygenandNutrition无法输送氧气和营养4.Ulcerforms形成溃疡ZinaWhiteRNCWOCN8CommonSites易发部位Mostcommon常见:Coccyx尾部,Sacrum骶骨部,Heels足跟部Reason病因:lesssofttissueispresentbetweentheboneandskin这些部位的骨骼和皮肤间的软组织较少ZinaWhiteRNCWOCN9MorePressureUlcerSites常见褥疮部位ZinaWhiteRNCWOCN10CapillaryPressure毛细血管压NormalPressures正常值：ArterialCapillary动脉毛细血管压:30-40mmHgMidCapillary中间毛细血管压:25mmHgVenousCapillar：静脉毛细血管压:10-14mmHgNeed17mmHgtoFunction；需17mmHg才能活动；CapillaryClosingPressure毛细血管闭合压:17-32mmHgZinaWhiteRNCWOCN11AnatomyofSkin皮肤解剖学ZinaWhiteRNCWOCN12ASSESSMENT评估ASSESSMENT评估-Initial-StartingPoint最初－开始LookatEntirePerson观察病人整体情况TeamEffort小组协作ReASSESSMENT再评估-Atleastweekly至少每周一次Re-evalTx:planifdeterioration再评估：如果恶化，需列出方案MayneedtoChangePlan(MD)可能改变方案（医生）MonitorProgress监测进展ZinaWhiteRNCWOCN13StageI（I期）Non-Blanchingerythema(redness)红斑（发红）不热烫、Effects结果:EpidermisandDermis表皮和真皮损伤Darkskin:warmth,edema,skinhardened.皮肤颜色变深处：温热、肿胀、皮肤变硬ZinaWhiteRNCWOCN14StageII（II期）PartialThickness部分皮层破损Effects症状：epidermis&dermis表皮和真皮破损Superficial浅表的表现:Abrasion磨损Blister水泡Shallowcrater较浅的腔洞Medianhealingrange8.7to38days愈合时间平均8.7至38天ZinaWhiteRNCWOCN15StageIII（III期）FullThickness全皮层破损Epidermis,Dermis,Subcutaneousdowntobutnotthroughfascia.表皮、真皮及皮下组织，但未损及肌腱Presents:deepcrater(worw/o)Undermining较深的腔洞伴有坏死ZinaWhiteRNCWOCN16StageIV（IV期）FullThickness全层皮肤破损Extensivedestruction,tissuenecrosis,ordamagetomuscleorboneorsupportingstructure(tendon,jointcapsule)Underminingandsinustract.更大范围的破损、组织坏死、在肌肉、骨骼或支撑结构（肌腱、关节处）产生破坏并形成窦道或腔洞MedianhealingtimeforStageIIIandIVis69daysIII、IV期褥疮的愈合期平均为69天ZinaWhiteRNCWOCN17HelpfulTips（小窍门）1.OnlyStagePressureUlcer对压疮进行分期2.Pleasedon’treversestage:(downstage)anulcercan’thealfromaStageIVtoaStageIIbecausethereisalreadyextensivedamage.不要忽视压疮的分期，不可能指望IV期的压疮直接就愈合至II期，因为IV期的压疮破损是非常严重的3.Whenescharispresenttheulcercannotbestageduntiltheescharisremoved若伤口有焦痂出现，需除痂才能对溃疡进行正确分期4.Vigorousmassageisnotrecommendedforreddenedskin.(Itmaystimulateundesirablebloodflowandcausefurtherdamagetofragiletissue).不建议对红润皮肤进行按摩（由此可能刺激过度的血流并对易碎组织产生破坏）ZinaWhiteRNCWOCN18ZinaWhiteRNCWOCN19Management（褥疮处理）RelieveorEliminatetheSource（缓解并减除压力源）OptimizetheEnvironment（优化伤口愈合环境）SupporttheHost（提高人体免疫力）ProvideEducation（提供教育）ZinaWhiteRNCWOCN20RelieveoreliminatethePressuresource（缓解或移除压力源）Keeppressureoffarea/ulcer（防止局部/溃疡处产生压力）Bedriddenturnandrepositionevery1-2hours（每隔1－2小时给病人翻身）Chairorwheelchair:teachtoshiftevery15minutesornurserepositionandshiftpointsofpressureevery1hour（当病人坐在椅子或轮椅上时：让病人每个15分钟换体位，或每隔1小时由护士帮助换位和转换支撑点的压力）Makeawrittenscheduleandkeepitvisible/document（写下翻身等的时间安排，并放在显眼处）Usepositioningdevices(pillow&wedges)toraisePressureUlceroffsupportsurface.使用定位器材（软枕或支架）将褥疮处和支撑区格开Avoiddonut-typedevicescausetheycausemorepressure.（避免使用环状器材，因为这将产生更多的压力）ZinaWhiteRNCWOCN21RelieveoreliminatethePressuresource（缓解或移除压力源）Pressuredistribution:30DegreeLateralPosition压力分布：30度侧卧ZinaWhiteRNCWOCN22OptimizetheEnvironment（优化伤口愈合环境）Debridenecrotictissue清除坏死组织Cleansewound清洁伤口Applytopicalwoundcare(filldeadspace)应用局部伤口处理的敷料（填充死腔）EliminateMoisture吸收多余的渗液CheckforSignsofInfection在出现伤口感染征兆时，进行细菌培养ZinaWhiteRNCWOCN23OptimizetheEnvironment（优化伤口愈合环境）WoundContamination(伤口污染）:Unavoidablestatethepresenceofbacteriaonthewoundsurfacewithoutproliferation.在创面始终有细菌存在，但细菌不增殖WoundColonization（伤口细菌严重定殖）:Boththepresenceandproliferationofthebacterialorganisms,whichmayinvadenecrotictissue.Colonizationelicitsnoresponsefromthehost.细菌出现且大量增殖，并入侵坏死组织，引起宿主没有响应Infection（感染）:Representstheinvasionofthebacteriaintohealthytissueswheretheycontinuetoproliferateandelicitareactionfromthehost(e.g.,erythema,pain,warmth,swelling,andchangesinexudateandodor).细菌继续增殖，并引起宿主的反应(如：红、肿、热、痛，及渗液大量出血和有恶臭等）ZinaWhiteRNCWOCN24SupporttheHost（支持宿主提高免疫力）CorrectUnderlyingProblems（纠正潜在的病因）Diarrhea（腹泻）UrinaryIncontinence（小便失禁）AssessandManagePain（评估并做疼痛处理）ProvideAttentiontoNutritionalStatus（对营养状况引起足够重视）LinkbetweenPressureUlcerandMalnutrition（将压疮和营养不良联系起来）Goal:IstoEnsureDietcontainsNutrientsAdequatetoSupportHealing（目的：保证病人吸取足够的营养来支持伤口的愈合）ZinaWhiteRNCWOCN25SupporttheHost（支持宿主提高免疫力）NutritionalASSESSMENT病人营养状况的评估ScreenforDeficiencies（营养不足筛检）ProvideAdequatedietaryintaketopreventmalnutrition(mayneedsupplementation)（提供足够的饮食摄入量来预防营养不良－需额外补充营养）Providenutrientstosupporthealing（为伤口愈合提供营养）ZinaWhiteRNCWOCN26Provi