压疮评估与治疗的进展详解课件

1、压疮评估与治疗的进展Based on AMDA Clinical Practice Guideline(CPG) for Pressure Ulcers 美国医师协会2015年10月压疮临床实践指南 消化内科 邓忠越压疮评估与治疗的进展Based on AMDA Clinic压疮是护理人员难以回避的临床问题！压疮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。What is a Pressure Ulcer?压疮是什么?A pressure ulcer is localized 除骨隆突受压部位外，还应关注：吸氧导管、经鼻导管、气管插

3、管及其固定支架、血氧饱和度无创面罩、连续加压装置、夹板、支架尿管等与皮肤接触的相关部位（C）除骨隆突受压部位外，还应关注：Pressure Ulcers May Not be Preventable有些压疮是难以避免的Aggressive 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；Can develop despite best efforts of clinical team in high risk patients 尽管临床小组作出

4、最大的努力,但高风险的病人仍有压疮发生Pressure Ulcers May Not be PrePrimary risk factors for development of pressure ulcers are形成压疮的原发危险因素Impaired/decreased mobility活动性受到限制或者减少 (Neurologic disease/ injury/Fractures/Pain/Restraints)Drugs such as steroids that may affect wound healing类固淳药品的使用影响伤口康复；Resident refusal of s

5、ome aspects of care & treatment患者拒绝给予局部的护理和治疗Intrinsic risks due to aging老龄化为固有的危险因素Alterations in sensation or response to comfort对舒适与否的感觉反应能力发生变化 Depression抑郁等情绪Primary risk factors for develPressure Ulcer Classifications 分级 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) 一期压疮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二期压疮Pressure Ulcer Classifications 分级 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 三期压疮 Pressure Ulcer Classifications 分级 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四期压疮Pressure Ulcer Classifications 分级 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 分级 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 分级 Suspected Deep Tissue InjurPressure Ulcer Classifications 分级II期III期IV期不可分期I期可疑深部组织受损P

13、ressure Ulcer ClassificationsFactors 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Systemic Illness系统性疾病Osteomyelitis骨髓炎Wound Environment伤口周边环境 Pressure压力Oxygen氧供能力Perfusion灌注状况SystemicHealing Ability组织

14、的复原能力Compliance组织顺应性Edema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！Factors That Affect PU Wound HMalnutrition and dehydration营养失调和脱水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 colla

15、gen vascular disorders 血管炎和其他胶原血管疾病Immune deficiency 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关节挛缩Comorbid Conditions That May Affect Ulcer Healing 多种可能影响压疮康复的身体状况Malnutrition and dehydration营The Nonhealing Chron

16、ic 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 Catabolism分解代谢 Anabolism合成代谢 Anabolism合成代谢Energy能量Protein Synthesis蛋白质合成EnergyStore能量储存ProteinStore蛋白质储存Macronutrients大量营养物质EnergyEnergyStore能量储存ProteinStore蛋白质储存Macronutrients大量营养物质Protein Synthesis蛋白质合成The Nonhealing Wound坏死阶段的伤口Th

17、e Healing Wound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.The Nonhealing Chronic WoundFPreventive Measures A Step Wise Approach to Nutritional Intervention in Patients with Wounds预防措施对于有压疮伤口的病人选用营养干预是一个明智的方法Assuring adequate Nutrition

18、 and Hydration 保证营养和水分 Watch 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式Undernourished patients caloric/protein/hydration targets 营养不足的病人热量、蛋白质、补水作用的目标：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，除非是临床证实需要补充的。Preventive Measures A Step WPreventive measures预防措施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 s

20、hift weight 更换体位,转移病人受压部位Avoid 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 Preventive measures预防措施MaintPreventiv

21、e measures预防措施Preventive measures预防措施Wound Care伤口护理Principles of wound dressings:伤口敷裹的原则：Protect 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Promote removal of necrotic tissue and exudate促进坏死组织和渗出物的移除Provide a moist healing environment supportive of regeneration and

22、 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Wound characteristics change as the wound evolves.随着伤口的发展，伤口的特性不断发生改变。Tailor 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。Wound Care伤口护理Principles of woPressure Ulcers CPG Treatment压疮治疗Wound Care Intact Skin伤口

23、护理完整的皮肤Stage 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Protect 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No dressing required没有包扎伤口的必要Monitor frequently for changes频繁的监测伤口变化Pressure Ulcers CPG TreatmentPressure Ulcers CPG: Treatme

24、nt压疮治疗Wound Care Clean Wound Base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 Dressing 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Choose dressing based on situation根据伤口的情形来选择包扎方式Fill wound dead space with loosely packed dressing ma

25、terial伤口的死腔要用疏松的敷料来填充Pressure Ulcers CPG: TreatmentPressure Ulcers CPG: Treatment压疮治疗Wound Care Extensive Subcutaneous Tissue Damage广泛的皮下组织损伤Stage 4 (some Stage 3) pressure ulcers are characterized by full thickness skin loss with extensive tissue necrosis, undermining and sinus tracts四期压疮（包括部分3期压疮）

26、深部出现大面积的组织坏死，窦道状坏疽；Treatment may require extensive surgical debridement治疗需要较大面积的外科清疮术；All devitalized tissue removed去除所有的坏死组织Undermined areas should be explored and unroofed深部损伤要去除表层才能准确界定。Pressure Ulcers CPG: TreatmentPressure Ulcers CPG Treatment压疮治疗性处理Wound Care Alternatives to Non-Responders伤口护理

27、-针对没有反应的患者供选方案For clean wounds not responding to appropriate treatment consider:为效果不好的患者清洁伤口提供适当的治疗：Topical antibiotic ointments/solutions for 2 week trial局部提供的抗生素，尝试两周；Progress to a support surface that offers further protection 改进支撑体的质地，提供更深入的保护；Consider a course of electrotherapy 考虑给予电疗治疗；Conside

28、r transfer to another site for surgical debridement/repair, mgt. of systemic complications, 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。Pressure Ulcers CPG Treatment压Pressure Ulcers CPG: Treatment压疮治疗Wound Care Ongoing Management 持续的管理1. Cleanse at each

29、 dressing change清洁伤口更换敷料2. Debride eschar, 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 measures处方建议采用控制疼痛的措施7. Address psychosocial issues, depressio

30、n, and possible isolation病人的心理状态，可能孤独和抑郁。Pressure Ulcers CPG: TreatmentWound Classifications 伤口分类和敷料选择 1988年由美国学杂志从欧州引进了创面RYB分类方法。RYB方法将期或延期愈合的开放创面（包括急性和慢性创面）分为红、黄、黑及混合型。红色创面可能处于创面愈合 过程中的炎性期、增生期或成熟期。黄色创面是感染创面或含有纤维蛋白的腐痂，无愈合的倾向 。黑色创面含有坏死组织，同样无愈合倾向。混合伤口：有不同颜色的组织，以百分比来描素各种颜色所占的比例。 此分类方法的优点在于根据创面愈合过程的不同时

31、期分类，利于医护人员提供治疗 Wound Classifications 伤口分类和敷料肉芽期 纤维母细胞移行，肉芽组织形成上皮形成期 创面逐渐缩小/上皮化清创期（炎性反应期）肉芽期 纤维母细胞移行，肉芽组织形成上皮形成期 判别伤口的类型：以伤口受伤的原因伤口的位置伤口的大小及深度渗出液：量、性质、颜色及气味伤口外观（基底）伤口周围皮肤情况疼痛伤口有无感染Wound evaluation判别伤口的类型：以伤口受伤的原因Wound evaluati一、判别伤口的类型： 评估伤口发生的原因：如电击伤、机械伤、温度伤、化学伤、放射性或血管性病变等二、伤口的位置：记录伤口在解剖区域相关的位置，如骶尾部

32、、肩部等。各种不同类型的伤口好发于身体不同的部位评估伤口是在固定部位还是伸展部位、皮肤皱褶处、骨隆突处、关节部位三、伤口的大小及深度1.表面的测量：测量表面最宽最长处，以头坐标，纵轴为长，横为宽2.深度的测量 3.伤口的范围：4.评估创面：坏死组织、结痂、肉芽组织约占伤口的多少百分比5.伤口潜行的测量：指伤口皮肤边缘与伤口床之间的袋状空穴。通常外表可见伤口边缘内卷。 （1）测量方法：同伤口深度测量方法，沿伤口四周边缘逐一测量。 （2）记录方法：用顺时针方向记录，如潜行6-7点3厘米。6.窦道的测量：周围皮肤与伤口床之间形成的纵形腔隙。能探到腔隙的底部或盲端。 方法：同伤口深度测量方法7.瘘管：

33、探测时无盲端，伤口表面与脏器相通Wound evaluation长宽一、判别伤口的类型：Wound evaluation长宽四、渗出液：量、性质、颜色及气味渗出液量的评估：无渗出：24小时更换的纱布不潮湿、是干燥的少量渗出：24小时渗出量少于5毫升，每天更换纱布不超过1块中等量渗出：24小时渗出量在5-10毫升，每天至少需要1块纱布，但不超3块。大量渗出：24小时渗出量超过10毫升，每天需要3块或更多的纱布。渗液的颜色：澄清：通常被认为是正常，注意葡萄球菌感染或来自泌尿道或淋巴道浑浊、粘稠：提示炎症反应或感染，渗液含有白细胞和细菌粉红色或红色：提示毛细血管损伤绿色：提示细菌感染，如绿脓杆菌黄色

34、或褐色：伤口出现腐肉或由泌尿道/肠瘘的渗出物Wound evaluation四、渗出液：量、性质、颜色及气味Wound evaluati五、伤口外观肉芽：肉芽组织是指小血管及结缔组织増生逐渐填满伤口。 健康：牛肉样鲜红柔软发亮 血流不足：淡红色、淡白或白灰色腐肉：松散，呈黄色，失去活力坏死：棕色或黑色，失去活力上皮化：出现上皮细胞，呈粉红色感染：皮肤周围红、肿、热、痛解剖结构暴露：骨、筋膜、血管、神经 Wound evaluation五、伤口外观Wound evaluation六、伤口周围皮肤情况水肿：伤口表皮增生：伤口周围的组织硬度：愈合嵴：周围皮肤浸渍、过敏七、疼痛八、伤口感染局部症状全身

35、症状 Wound evaluation六、伤口周围皮肤情况Wound evaluationPressure Ulcers CPG: Treatment压疮治疗Wound Care Categories of Products Used in Wound Care用于伤口护理的产品分类Hydrocolloids水胶体Alginate藻酸盐等Foams泡沫等Wound Fillers 伤口填充物Composite Dressings合成敷料Pressure Ulcers CPG: Treatment如何正确的选择敷料？根据渗出量选择敷料的吸收能力根据创面大小选择敷料尺寸根据创面深度选择辅助敷料种类

36、根据局部创面决定是否减压引流或加压包扎根据创面位置选择敷料的形状、薄厚根据皮肤耐受性选择敷料的粘性强度如何正确的选择敷料？根据渗出量选择敷料的吸收能力传统纱布传统纱布油纱优点：粘性低，不伤肉芽保湿顺应性好可剪裁缺点：不能吸收渗液，易浸渍可渗透细菌需要外敷料固定油纱优点：薄膜敷料一般作为辅助敷料使用薄膜敷料一般作为辅助敷料使用水凝胶敷料主要用于干燥结痂或有腐烂组织的伤口、腔洞及窦道伤口水凝胶敷料水胶体敷料水胶体敷料藻酸盐敷料用于各类大量渗出性伤口藻酸盐敷料用于各类大量渗出性伤口银离子敷料用于严重污染伤口、感染伤口银离子敷料用于严重污染伤口、感染伤口溃疡贴 适用于轻至中度渗液的压疮，下肢溃疡，供皮

37、区，小面积烧伤以及其他透明贴 适用于轻度，浅表压疮和下肢溃疡的上皮成熟期，供皮区，术后伤口擦伤等减压贴 内层为水胶体成分，促进溃疡伤口愈合，外加聚乙烯泡沫圈，分解局部压力作用糊剂 作为填充剂，主要用于深度伤口和腔隙的伤口，预防伤口坍塌，加快肉芽生长，增加吸收渗液能力粉剂 用于浅表且渗液较多的伤口，增加渗液的吸收能力，加快上皮生长，延长水胶体敷料的使用时间溃疡贴（一）干性愈合理论 18世纪后期至20世纪中叶，伤口干性愈合理论盛行。该理论认为，伤口愈合需干燥环境，有大气氧的参与可以促进伤口愈合，因而透气的敷料才能使伤口获得足够氧气，以供细胞生长的各种生化反应所需。 其缺点是伤口愈合环境差，结痂造成伤口疼痛，更换敷料时损伤创面，愈合速度慢，不能隔绝细菌的侵入，易造成痂下脓肿。（二）湿性愈合理论 1958年，有学者首先发理被保持完整的水疱