1、压疮护理 101 Pressure Wound Care 101 Sharon Lepper 护理学学士，注册护士，护理学学士，注册护士，伤口造口失禁护士伤口造口失禁护士 Sharon Lepper BSN RN WOCN Copyright EHOB,2022 EHOB产品由上海天呈“医流商城全国代理，招商加盟热线：021-51083677-869 ：15900626542 谢秋亭 ：51816400，地址：上海市杨浦区翔殷路128号 国家大学科技园1号楼B座310室。Copyright EHOB,2022 2 预案能够使压疮发病率降低预案能够使压疮发病率降低50%Protocols dec
2、rease incidence by 50%1 1.书名：?护理人员的培训影响老年住院病人的褥疮发生?内科学文献1988;148:2241-2243.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.Archi
3、ves of Internal Medicine.1988;148:2241-2243.Copyright EHOB,2022 Copyright EHOB,2022 3 3 压疮的临床预案应解决以下方面：压疮的临床预案应解决以下方面：Clinical Protocols for Pressure Ulcers Should Address:Cognition 认知认知 Mobilization&Ambulation 活动与步行活动与步行 Nutrition and Hydration营养和水化营养和水化 Moisture and Incontinence湿度和失禁湿度和失禁 Medicati
4、on Use药物治疗药物治疗 Existing Pressure Ulcers(Deep Tissue Injury)已生成的褥已生成的褥疮疮深部深部组织损组织损伤伤 Contact with medical devices(i.e.,braces,orthothics,cannulas,tubing),and/or any object in contact with the body接触医接触医疗疗器械器械 例如，支架、例如，支架、矫矫形器形器、插管、插管、输输液管和液管和/或任何与身体接触的物体或任何与身体接触的物体 Copyright EHOB,2022 Copyright EHOB,
5、2022 4 4 4 ALL SUPPORT SURFACES SHOULD:所有的支持外表所有的支持外表应应具具备备以下几点：以下几点：Redistribute weight in a 3-dimensional manner.以三维方式重新分配体重 Minimize pressure,shear and friction injury.使压力、剪切力和摩擦损伤最小化 Assist in moisture and temperature control.协助控制湿度和温度 Be easy to clean.易于清洁 Aid in patient transferring and mobili
6、zation.辅助患者的转移和活动 Be cost effective.性价比高 为什么要遵循临床预案？为什么要遵循临床预案？Why Follow Protocols Copyright EHOB,2022 Copyright EHOB,2022 5 5 5 5 ALL LOWER EXTREMITY PROTOCOLS SHOULD:所有的下肢预案都应具备：所有的下肢预案都应具备：Elevate heel(Dewedge).提高足跟 Protect side of foot and ankle.保护脚侧和脚踝 Neutralize weight of lower extremity(Dele
7、ver).冲减下肢重量 Maintain and promote circulation.保持和促进血液循环 Address foot drop and lateral rotation of the ankle.改善足下垂和踝关节外侧旋转 Allow access to the foot for inspection/treatment as well as range of motion techniques.允许进到足部进行检查/治疗，以及各种运动技巧 Be lightweight 重量更轻 为什么要遵循临床预案？为什么要遵循临床预案？Why Follow Protocols Copyr
8、ight EHOB,2022 Copyright EHOB,2022 6 6 6 6 6 预防压疮的风险评估预防压疮的风险评估 Risk Assessment for Prevention of Pressure Ulcers Braden Scale布兰登量表 Sensory perception感官知觉 Moisture湿度 Activity灵便性 Mobility移动性 Nutrition营养 Friction and Shear摩擦和剪切力 Norton Scale 诺顿量表 Five criteria scale 五个标准量表 6 Copyright EHOB,2022 Copyri
9、ght EHOB,2022 7 体内平衡体内平衡Homeostasis 即使外部环境不断变化，但身体却能够维持即使外部环境不断变化，但身体却能够维持相对稳定的内环境。相对稳定的内环境。The bodys ability maintain the relatively stable internal conditions even though the outside world changes continuously.Copyright EHOB,2022 静态空气包含的科学知识静态空气包含的科学知识 The Science Behind Static Air Archimedes Prin
10、ciple:阿基米德原理阿基米德原理 The buoyant force on an object in a fluid is equal to the weight of the fluid the object displaces(buoyancy law)在液体中的物体的浮力，等于物体排开的液体的重量浮力定律在液体中的物体的浮力，等于物体排开的液体的重量浮力定律 Boyles Law:博伊博伊尔尔定律定律 A gas will compress proportionately to the amount of pressure exerted on it.If the temperatu
11、re remains constant,the volume of a given mass of gas is inversely proportional to the absolute pressure.视视施加在气体上的施加在气体上的压压力大小，气体会比例地力大小，气体会比例地压缩压缩。如果温度保持恒定，一定量的气体的体。如果温度保持恒定，一定量的气体的体积积与其与其绝对压绝对压力成反比。力成反比。Newtons Law：牛：牛顿顿定律定律 For every action,there is a reaction。每个作用力，都有一个反作用力。每个作用力，都有一个反作用力。Pascal
12、s Principle:帕斯卡帕斯卡尔尔原理原理 A law stating that a confined liquid transmits pressure applied to it from an eternal source equally in all directions.在密在密闭闭容器内，施加于静止液体上的容器内，施加于静止液体上的压强压强将以等将以等值值同同时时传传到各点。到各点。Copyright EHOB,2022 Copyright EHOB,2022 支持外表 Support Surface 一种用于压力再分配的专业设施，设计用于组织负荷、微气候、和/或其他治疗功能
13、的管理例如，床垫、集成床系统、床垫置换、覆盖罩，或坐垫，或坐垫外罩。A specialized 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).国家褥疮咨询小组，版权2022 NPUAP
14、 Copyright2022 NPUAP，National Pressure Ulcer Advisor Panel Copyright EHOB,2022 Copyright EHOB,2022 了解褥疮是如何与为何行成的了解褥疮是如何与为何行成的 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
15、and underlying tissue)is held in place by contact with the bed surface.剪切力和压力的相互作用。身体的骨架由于重力向下推压身体。软组织皮肤和皮下组织接触到床垫被挤压到。Distortion of the blood vessels in the area being stretched create angulation of the tissue.拉伸部位的血管的变形引起组织形成骨突 Small vessel thrombosis occurs with constricture at the fascial level
16、resulting in tissue death.由筋膜抽搐引起微小血管栓塞导致组织坏死。DTI-SACRUMCopyright EHOB,2022 褥疮的阶段褥疮的阶段 Stages of Pressure Wounds Understanding of anatomy了解解剖学 Recognizing layers of the skin识别皮肤层 Knowledge of staging system分期系统的认识 Wound classification伤口分类 Moisture湿度湿度 Candidiasis念珠菌病念珠菌病 Neuropathic神经系统疾病神经系统疾病 Uncertainty in accuracy 准确度的不确定性 Copyright EHOB,2022 表皮层 真皮层 皮下组织 Copyright EHOB,2022 在骨突出上面在骨突出上面 Over a Bony Prominence Copyright EHOB,2022 Copyright EHOB,2022 褥疮分级的历史褥疮分级的历史 History of Staging First re
