压疮评估与治疗的进展详解

Pressure Ulcer Classifications 分级
Unstageable: Depth Unknown
Full 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. 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 fluctuance) eschar on the heels serves as ‘the body’s natural (biological) cover’ and should not be removed.
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 尽管临床小组作出最大的努力,但高风险的病人仍有压疮 发生
Pressure Ulcer Classifications 分级
Stage 3:Full Thickness Skin Loss 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 without undermining of adjacent tissue 三期压疮
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 是护理人员难以回避的临床问题！
What is a Pressure Ulcer? 压疮是什么?
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 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.
能力发生变化 Depression抑郁等情绪
Pressure Ulcer Classifications 分级
Stage 1: Nonblanchable Erythema Observable, pressure-related alteration of 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
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 some 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
Pressure Ulcer Classifications 分级
Stage 4:Full Thickness Tissue Loss 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
Primary 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)
Pressure Ulcer Classifications 分级
Stage 2:Partial Thickness Skin Loss Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater二期压疮
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。
除骨隆突受压部位外，Baidu Nhomakorabea应关注：
吸氧导管、经鼻导管、 气管插管及其固定支架、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）
Pressure Ulcers May Not be Preventable 有些压疮是难以避免的