1、壓瘡護理 101 Pressure Wound Care 101Sharon Lepper 護理學學士，注冊護士， 傷口造口失禁護士 Sharon Lepper BSN RN WOCN Copyright EHOB, 2019EHOB產品由上海天呈“醫流商城”全國代理，招商加盟熱線 869手機謝秋亭傳真：51816400， 地址：上海市楊浦區翔殷路128號 國家大學科技園1號樓B座310室。 Copyright EHOB, 20192預案能夠使壓瘡發病率降低50%Protocols decrease incidence by 50% 1 1

2、. 書名：護理人員的培訓影響老年住院病人的褥瘡發生內科學文獻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. Archives of In

3、ternal Medicine. 1988; 148:2241-2243.Copyright EHOB, 2019Copyright EHOB, 201933壓瘡的臨床預案應解決以下方面： Clinical Protocols for Pressure Ulcers Should Address:Cognition 認知Mobilization & Ambulation 活動與步行 Nutrition and Hydration營養和水化 Moisture and Incontinence濕度和失禁 Medication Use藥物治療 Existing Pressure Ulcers (De

4、ep Tissue Injury)已生成的褥瘡（深部組織損傷）Contact with medical devices (i.e., braces, orthothics, cannulas, tubing), and/or any object in contact with the body接觸醫療器械 （例如，支架、矯形器、插管、輸液管）和/或任何與身體接觸的物體）Copyright EHOB, 2019Copyright EHOB, 2019444ALL SUPPORT SURFACES SHOULD: 所有的支持表面應具備以下幾點：Redistribute weight in a 3

5、-dimensional manner.以三維方式重新分配體重Minimize pressure, shear and friction injury.使壓力、剪切力和摩擦損傷最小化Assist in moisture and temperature control. 協助控制濕度和溫度Be easy to clean.易于清潔Aid in patient transferring and mobilization.輔助患者的轉移和活動Be cost effective. 性價比高 為什么要遵循臨床預案？ Why Follow Protocols?Copyright EHOB, 2019Cop

6、yright EHOB, 20195555ALL LOWER EXTREMITY PROTOCOLS SHOULD:所有的下肢預案都應具備： Elevate heel (Dewedge).提高足跟 Protect side of foot and ankle. 保護腳側和腳踝Neutralize weight of lower extremity (Delever).沖減下肢重量 Maintain and promote circulation. 保持和促進血液循環 Address foot drop and lateral rotation of the ankle.改善足下垂和踝關節外側旋

7、轉Allow access to the foot for inspection/treatment as well as range of motion techniques. 允許進到足部進行檢查/治療，以及各種運動技巧Be lightweight重量更輕為什么要遵循臨床預案？Why Follow Protocols?Copyright EHOB, 2019Copyright EHOB, 201966666預防壓瘡的風險評估 Risk Assessment for Prevention of Pressure UlcersBraden Scale布蘭登量表Sensory perceptio

8、n感官知覺Moisture濕度Activity靈便性Mobility移動性Nutrition營養Friction and Shear摩擦和剪切力 Norton Scale 諾頓量表Five criteria scale 五個標準量表6Copyright EHOB, 2019Copyright EHOB, 20197體內平衡Homeostasis即使外部環境不斷變化，但身體卻能夠維持相對穩定的內環境。The bodys ability maintain the relatively stable internal conditions even though the outside world

9、changes continuously.Copyright EHOB, 2019靜態空氣包含的科學知識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 thefluid the object displaces (buoyancy law)在液體中的物體的浮力，等于物體排開的液體的重量（浮力定律）Boyles Law: 博伊爾定律 A gas will compress proportiona

10、tely 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.視施加在氣體上的壓力大小，氣體會比例地壓縮。如果溫度保持恒定，一定量的氣體的體積與其絕對壓力成反比。 Newtons Law：牛頓定律 For every action, there is a reaction。每個作用力，都有一個反作用力。 Pascals Pr

11、inciple:帕斯卡爾原理A law stating that a confined liquid transmits pressure applied to it from an eternalsource equally in all directions.在密閉容器內，施加于靜止液體上的壓強將以等值同時傳到各點。 Copyright EHOB, 2019Copyright EHOB, 2019 支持表面Support Surface一種用于壓力再分配的專業設施，設計用于組織負荷、微氣候、和/或其他治療功能的管理（例如，床墊、集成床系統、床墊置換、覆蓋罩，或坐墊，或坐墊外罩）。A spe

12、cialized 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 cushion, or seat cushion overlay).國家褥瘡咨詢小組，版權2019 NPUAP Copyright2019 NPUAP， National

13、 Pressure Ulcer Advisor PanelCopyright EHOB, 2019Copyright EHOB, 2019了解褥瘡是如何與為何行成的 Understanding How and Why Pressure Wounds Form Interaction of shear and force. The skeletal frame of the body pulls the body by force of gravity downward. The soft tissue (skin and underlying tissue) is held in place

14、by contact with the bed surface.剪切力和壓力的相互作用。身體的骨架由于重力向下推壓身體。軟組織（皮膚和皮下組織）接觸到床墊被擠壓到。 Distortion of the blood vessels in the area being stretched create angulation of the tissue.拉伸部位的血管的變形引起組織形成骨突 Small vessel thrombosis occurs with constricture at the fascial level resulting in tissue death.由筋膜抽搐引起微小血

15、管栓塞導致組織壞死。Copyright EHOB, 2019褥瘡的階段Stages of Pressure WoundsUnderstanding of anatomy了解解剖學 Recognizing layers of the skin識別皮膚層 Knowledge of staging system分期系統的認識 Wound classification傷口分類 Moisture濕度 Candidiasis念珠菌病 Neuropathic神經系統疾病 Uncertainty in accuracy 準確度的不確定性 Copyright EHOB, 2019表皮層真皮層皮下組織Copyri

16、ght EHOB, 2019在骨突出上面 Over a Bony ProminenceCopyright EHOB, 2019Copyright EHOB, 2019褥瘡分級的歷史History of StagingFirst record of pressure ulcer by Hippocrates in 400 BC 首次有關褥瘡記載是由希波克拉底于公元前400年記錄的Earliest staging system by Guttman in 1955 首個褥瘡分級法是由古特曼于1955年創立的Shea developed the first well documented metho

17、d in 1975 首個有具可查方法是由謝伊于1975年開發的In 1988 the IAET (now WOCN) developed a four-level staging system 在1988年，國際造口治療師協會（現為傷口造口失禁護理協會），開發了一種四級分期系統。 In 1989 NPUAP also developed a four-stage system 在1989年，國家褥瘡咨詢小組，也開發了一種四期系統 Copyright EHOB, 2019臨床挑戰與分期 Clinical Challenges with StagingUnderstanding of anatom

18、y了解解剖學 Recognizing layers of the skin識別皮膚層 Knowledge of staging system分期系統的認識 Wound classification傷口分類 Moisture濕度 Candidiasis念珠菌病 Neuropathic神經系統疾病 Uncertainty in accuracy 準確度的不確定性 Copyright EHOB, 2019表皮層真皮層皮下組織Copyright EHOB, 2019一期 Stage IIntact skin with non-blanchable redness of a localized area

19、 usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.在完整的皮膚上的某一區域有不可變白的紅斑，一般出現在骨性突出上。深色皮膚上可能不會看到變白的現象，其顏色可能與周圍皮膚顏色不同。 Copyright 2019 NPUAPCopyright EHOB, 2019表皮層真皮層皮下脂肪肌肉組織骨Copyright EHOB, 2019一期 描述 Stage I Description

20、The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. This may indicate “at risk” persons. 此區域與其周圍皮膚組織相比，可能會有疼痛、硬實、柔軟、發熱或發涼的感覺。這有可能是預示患者“有發病的危險” 。 Copyright EHOB, 2019Copyright EHOB, 2019一期 Stage ICopyright EHOB, 2019Copyright EHOB, 2019二期Stage IIPartial thickness los

21、s 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.真皮部分損失，呈現出淺的開放性潰瘍創面，帶有紅色、粉色創面，無腐肉。或者可以看到完整的或開口的/破裂的充血水泡。 Copyright 2019 NPUAPCopyright EHOB, 2019表皮層真皮層皮下脂肪肌肉組織骨Copyright EHOB, 2019Presents

22、 as a shiny or dry shallow ulcer without slough or bruising.呈現出腫亮的或干的淺層褥瘡，無腐肉或傷痕。 This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.這個階段應該不會有皮膚撕裂、帶燒傷、會陰皰疹、皮膚浸軟或腐肉。 二期描述 Stage II DescriptionCopyright EHOB, 2019Copyright EHOB, 2019二期Stage

23、IISacrum骶骨Heel腳跟Heel腳跟Copyright EHOB, 2019Copyright EHOB, 2019三期 Stage IIIFull thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.全層皮膚組織缺損。可以看到皮下

24、脂肪層，但骨骼、肌腱及肌肉均不外露。可能會呈現腐肉，但不會隱蔽組織深度毀損。可能會出現侵蝕和槽形侵蝕。 Copyright EHOB, 2019Copyright EHOB, 2019三期 描述Stage III Description The depth of a stage III 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

25、 shallow. In contrast , areas of significant adiposity can develop extremely deep stage III pressure ulcers. 三期褥瘡的深度依解剖學位置而變化。鼻梁、耳朵、枕骨部和踝骨部沒有皮下組織，這些部位發生三期褥瘡會是淺層的。相反，脂肪過多的區域可以發展成非常深的三期褥瘡。 Bone/tendon is not visible or directly palpable. 骨骼和肌腱不可見或不可直接接觸到。 Copyright EHOB, 2019Copyright EHOB, 2019三期 Sta

26、ge IIICopyright EHOB, 2019Copyright EHOB, 2019四期 Stage IVFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.全層皮膚毀損，并帶有骨骼、肌腱或肌肉的裸露。在創面某些區域可能會有腐肉和痂瘡。通常會有侵蝕和槽形侵蝕。Copyright 2019 NPUAPCopy

27、right 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 not have subcutaneous tissue and stage IV ulcers can be shallow. 四期褥瘡的深度依解剖學位置而變化。 鼻梁、耳朵、枕骨部和踝骨部沒有皮下組織，這些部位發生的四期褥瘡

28、可能是淺層的。 Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule) making osteomyelitis possible. 四期褥瘡可擴及到肌肉和/或支撐結構（如，筋膜、肌腱或關節囊），有可能引發骨髓炎。 Exposed bone/tendon is visible or directly palpable. 裸露的骨骼/肌腱可見或可直接接觸到。 Copyright EHOB, 2019Copyright EHOB, 201

29、9四期Stage IVCopyright EHOB, 2019Copyright EHOB, 2019無法分期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 or black) in the wound bed.全層皮膚毀損，褥瘡創面被腐肉覆蓋（黃色、淺棕色、灰色、綠色或者是棕色腐肉）和/或創面有痂瘡（淺棕色、棕色或黑色） Copyright

30、 EHOB, 2019Copyright EHOB, 2019無法分期UnstageableCopyright EHOB, 2019Copyright EHOB, 2019深層組織損傷Deep Tissue InjuryPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.紫色或栗色局部變色的完整皮膚或充血的水泡是由皮下組織受擠壓和/或剪力造成的。 Co

31、pyright 2019 NPUAPCopyright EHOB, 2019Copyright EHOB, 2019深層組織損傷描述 Deep Tissue Injury Description The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. 局部皮膚的狀況可能是，與其周圍組織相比疼痛的、硬實的、柔軟的、發熱或發涼。 Deep tissue injury may be difficult to dete

32、ct in individuals with dark skin tones. 在深膚色的患者身上，很難辨識出深層組織損傷。 Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. 再進步發展可能會在深色創面上出現扁薄的水泡。若進一步發展，會在上層結一層薄痂瘡。 Evolution may be rapid exposing additional layers of tissue even with op

33、timal treatment. 再繼續惡化的話，即便使用最佳的治療方法，其它組織層也會迅速裸露。 Copyright EHOB, 2019Copyright EHOB, 2019深層組織損傷Deep Tissue InjuryHeel腳跟Sacrum骶骨 Left Sacrum左骶部 Copyright EHOB, 2019Copyright EHOB, 201932深層組織損傷的臨床后果 Clinical Ramifications of Deep Tissue InjuryCan develop as soon as 20 minutes in high risk patients對高危

34、患者，褥瘡可以在短至20分鐘開始May take 3 to 7 days to be clinically recognized可能要花3到7天來臨床確診It is important to consider providing proper support surfaces from the time the patient arrives at the hospitaleven as they wait for admission重要的考慮是，當患者到達醫院后，應立即提供合適的支持表面，即使患者還在接診處等候。 Copyright EHOB, 2019Copyright EHOB, 201

35、933我該如何選擇支持表面？How do I choose Support Surfaces? Copyright EHOB, 2019Copyright EHOB, 2019344 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觸身體，決定了身體對支持表面的反應。 Copyright EHOB, 2019Copyright EHOB, 201935Copyright EHOB, 201

36、9Copyright EHOB, 201936為什么采用靜態空氣？ Why Static Air?Volume of body sinks into static 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 fashi

37、on. (Pascals Principle) 身體的體積陷入靜態空氣室內，壓縮并擠出氣室內空氣的體積，直到氣室內的壓力足以以垂直的、非梯度的方式支撐起身體的重量（根據浮力原理、博伊爾定律，牛頓第三定律，和帕斯卡爾原理）。 *Intra-chamber pressure氣室內壓力 Copyright EHOB, 2019Copyright EHOB, 201937Static Air provides more complete support for your patients靜態空氣給病人提供更加完整的支持Static Air Dynamic Air Gel靜態空氣 動態空氣 凝膠體 Co

38、pyright EHOB, 201938 獨立研究 Independent ResearchEHOB公司利用CT掃描來演示軟組織的變形EHOB utilizes CT Scans to illustrate soft tissue deformation. Copyright EHOB, 2019床板4英寸厚泡沫空氣墊39獨立研究 Independent Research Placing the air overlay on the standard hospital bed = 19mmHG 將空氣墊置于標準病床上= 19mmHGCopyright EHOB, 2019病床模擬壓力=19mm

39、Hg(3英寸高密度泡沫，空氣墊和普通床。身穿衣服 Copyright EHOB, 201940Copyright EHOB, 2019Copyright EHOB, 201941WHO何人 By all caregivers and support staff 由所有護理人員和支持人員 WHEN何時 On admission and through scheduled assessments throughout a patients stay and discharge入院時，通過有計劃的評估，貫穿病人從住院到出院的整個期間。 WHY何原因 Health-impaired people de

40、velop pressure ulcers健康受損的人患褥瘡 WHERE何地 In all places and on all surfaces utilized throughoutthe Continuum of Care.需要用到持續護理的所有地方和所有表面 為什么支持表面的選擇如此重要？ Why is support surface selection so important?Copyright EHOB, 2019Copyright EHOB, 201915個不同床墊的臨床/案例研究15 Different Mattress Clinical/Case Studies減少褥瘡發病率

41、倒計時“Count Down to Decreasing Pressure Ulcer Prevalence”Deanna Vargo，注冊護士，護理學學士，CWS, FCCWS，美國俄亥俄州巴伯頓市民醫院 Deanna Vargo, RN, BSN, CWS, FCCWS，Barberton Citizens Hospital, Barberton, Ohio 結論：最終結果表明，在18個月內，醫院獲得性褥瘡發生率從17.4%降到3%。在發生率降低的同時，降低了床鋪租賃費，在全院醫師的調查中發現，醫師的滿意度為100%。所有未來發生率研究表明，在過去連續三個季度的持續改進下，褥瘡發生率降至1

42、.7%。 ConclusionFinal results showed 17.4% to 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 studi

43、es showed continued improvements with the past three consecutive quarterly results at 1.7% facility acquired pressure ulcer prevalence.Copyright EHOB, 2019Copyright EHOB, 201943 空氣床墊的優點 Overlay AdvantagesMay be utilized during patient repositioning and transfers for caregiver ease可用于重新安置病人和轉移病人，減輕護理

44、強度。 May be utilized on multiple surfaces (i.e. mattress, transfer cart, etc.)可用于多種表面上（例如床墊上、運送車上等） May be used throughout the continuum of care (i.e. unit to unit, facility to facility, facility to home)可用于持續護理的全過程（例如從科室到科室，從醫院到醫院，從醫院到家里） Copyright EHOB, 2019Copyright EHOB, 2019摩擦和剪切力損傷 Friction & S

45、hearing Injury Mechanical force of two surfaces moving across each other 兩個表面的機械力相互摩擦 Causes blisters or abrasions 造成水皰或擦傷 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 pati

46、ent slides downward. 當連接到骨骼的組織被外力朝著某個方向拉動時，機械力就產生了，而表面組織卻保持靜止。這通常發生在床頭被提升而病人朝下滑時。 Causes loss of skin surface in irregular pattern. 造成皮膚表面的不規則毀損 Can resemble pressure wounds. 導致類似壓迫性創傷 Copyright EHOB, 2019Copyright EHOB, 2019Copyright EHOB, 2019Copyright EHOB, 201946464646464646腳跟褥瘡 Heel UlcersHeel ulcers constitute 30% of all pressure