PreventionandCareofPressureUlcerLearningObjectivesDiscussthereasonswhypeopledeveloppressureulcer.Definethetermpressureulcer.IdentifystagesofpressureulcerListpreventivemeasures.Explainhowtocarepressureulcer.

Whatisapressureulcer(壓力性潰瘍)?

Pressureulcerisdefinedasanylesioncausedbyunrelievedpressurethatresultsindamagetounderlyingtissue.Pressureulcerisadamageareaofskinwhichoccurswhen,overtime,pressurereducesorcutsoffthebloodsupplytoaparticularpartofthebody.Oldname:decubitusulcer,bedsore(褥瘡)

Newname:pressuresore(壓瘡),

pressureulcer(壓力性潰瘍)ThechangeofthetermArepressureulcersserious?

Theycanbeserious,dependingonhowmuchtheskinandtissueshavebeendamaged.Milddamage

onlycausestheskintobediscoloredandfeelwarmerthanthesurroundingskin.Deepulcer

godownintothemuscle,oreventothebone(osteomyelitis（骨髓炎）,evendeath).Howpressureulcerarecaused

1.Pressure（壓力）

Ex.sittingorlyinginonepositionfortoolong2.Friction（摩擦力）

Ex.slidingupanddownthebed3.Shearing（剪切力）

Ex.patient’sskinstickstothesheetsonthebedbuthis/herbodyslidesdownthebed.Wherethepressureulceraremostlikelytodeveloppressureulceraremostlikelytodeveloponthebodywheretheboneisclosetotheskinsurface.

pressureulceraremostlikelytodeveloponthepartsofbodythattaketheweight.AreasatriskofpressuredamageSupinepositionPronePositionLateralpositionSittingpositionAssessmentWhoiseasilytogetpressureulcerAdvancedAgeImmobilityIncontinencefeverUsinganorthopedicdeviceMalnutritionanddehydrationDiseasesanddisordersMedications,particularlysedatives（鎮靜劑）Whogetspressureulcer?Anyonewhositsorliesinonepositionfora

longtimemightgetpressureulcer.TheNortonScaleforRiskAssessmentofPressureUlcerItems4321PhysicalconditionGoodFairPoorVerypoorMentalstateAlertApatheticConfused

StuporousActivityAmbulatoryWalkswithhelpChair-boundBedfastMobilityFullSlightlylimitedVerylimitedImmobileIncontinenceAbsentOccasionalUsuallyDoubleMedicationsNotadministeringAdministeringAdministeringDouble

sedativesandsedativesnon-steroidaluse

non-steroidal(類固醇)drugs

drugsTherearefourstagesofapressureulcer

Damage：

Limitedtothetoptwolayersofskin（epidermallayer表皮anddermallayer真皮）.

Appearance:Theskinisnotbrokenandtherednessdoesnotturnwhitewhentouched.

Stage1Damage:Extendsbeyondthetoptwolayersoftheskintothefatlayer.Appearance:Theskinisslightlybroken,andhasanabrasion(擦傷),blister（水泡）orsmallcrater（凹陷）.Stage2

Damage：

Extendsthroughallthesuperficiallayersoftheskin,downtothemuscle.

Appearance:Anulcerandadeepcraterareformed.Stage3

Damage：

Includesdestructionofallsofttissueandthebone.Appearance:Abiganddeepulcerisformed,fillswithpus（膿）andnecrosistissue（壞死組織）.Stage4PreventionavoidingprolongedpressurechangingpositionregularlyPreventionmeasuresRelievingpressureSkinCareImprovingcirculationGooddietHealtheducationRelievingpressureChangeposition

Changepositionatleasteverytwohours;SupportsurfaceUsespecialmattresses

whichcontainfoam,air,gel,orwatercanrelievepressure.

Putpillowsorcushionsundertheback,elbow,betweenkneesandankles.Avoidingfrictionandshearing

Avoidtodragpatientswhenhelpingthemtomove.Checkroughthingsinclothesorinpocketscouldcausefriction.KeepbedcleanandsmoothedoutDon’traisetheheadofbedmorethan30degrees

SkinCareInspecttheskin

Checkanyrednessorbreaksintheskin.Keeptheskinclean

Skinshouldbecleanedassoonasitissoiled.Avoidskininjury

Avoidrub,scratchorcutskin;checkthatslippers,shoesandclothesarenottootight.

Minimizemoisture

Changebedfrequentlyandkeepitcleananddry;Usecontinenceaids,likepads,diapers,orcatheterizing;Placealayerofcottonclothingunderorthopedicdeviceuser.ImprovecirculationTakeabathorshower

Forcomfort,cleanlinessandcirculation;Usewarm(nothot)waterandamildsoap.Encouragemobility

Walkingandmovingcanincreasebloodflow.GooddietCalories,protein,andironisimportantthatwillhelpmaintainhealthyskin.Vitaminandmineralsupplementsarenecessarytokeephealthyskin.

Ifpatientsareunabletoeatanormaldietgivenutritionalsupplementsthroughintravenousdrip（IV靜脈輸液）.

HealtheducationTeachingpatientsandtheirfamilies

Givetheminformation(cause,riskfactors,commonsites,manifestation,preventionandtreatment)aboutpressureulcer.Howtocareapressureulcer

Apressureulcerlikesaniceberg.Stage1

AvoidanyriskfactorsRelievepressureevery1hour.Keepuprightpositionwhensittinginawheelchair.Avoidanypressure,friction,shearingandmoisture.Physiotherapy（理療）:

hotlamp（烤燈）

infra-redlamp（紅外線燈）

hotmoistcompress（濕熱敷）Stage2

Protectthewound,preventinfectionKeeppressureulcerdryandfreefrompressure.Dealwithbigblisters.ContinueallStage1measures.Stage3

freefrompressure,controlinfectionCleantheulcerwithsalineorhydrogendioxidesolution.Applyasteriledressingandrenewitdaily.Keepulceroutofpressure.Stage4

Cleannecrosis,promotegranulationgrowingRequiredebridement(清創術)ormoreextensivesurgerytokeepulcerfreefromdeadtissue.Cleanwithhydrogendioxidesolution.Maketheulcerexposed,dryandfreefrompressure.SUMMARIES

Thebestwaytopreventapressureulceristoavoidprolongedpressureandchangepositionfrequently.preventionPreventionmeasuresRelievingpressureSkinCareImprovecirculationGooddietHealtheducationCareapressureulcer1.Relievepressure.2.Keepuprightposition.3.Avoildanypressure,friction,shearingandmoisture.4.Physiotherapy.1.Keeppressureulcerdryandfreefrompressure.2.Dealwithbigblistersstages1stages2

1.Cleantheulcer.2.Applyadressingandrenewed.3.Keepulceroutofpressure

1.Requiredebridementorsurgery.2.Cleantheulcer.3.Maketheulcerexposed,dryandfreefrompressure.stages3stages4Dividedclassinto3groupsGroup1Activity1TodayyouhavebeenallocatedtocareforMrsMoore.Sheisa79-year-oldoverweightwomanwhohasbeenadmittedwithpneumonia.Youhaveobservedherbackskinbecomingred.Firstly,fromthisinformation,identifyherriskfactorsofpressuresore.Thenwritedowncareplanandimplementthem.Finally,placeabedpantoMrsMoore.