Chapter 5 Assisting Clients With Hygiene Section 6 Prevention and Care of Pressure Ulcers

案例1 张老太太，74岁，上海人，随着年龄的增大，有轻微的痴呆，两个月前不慎摔了一跤后在家卧床，两周前患者臀部开始破溃，日渐消瘦，同时还伴有发烧。

案例2 患者赵某，男，82岁，2004年发生脑梗塞，留有不能言语及左侧肢体瘫痪等后遗症，长期卧床，出现左小腿压疮半年余 患者左小腿踝上方IV期压疮，4cm x 4cm x 1cm大小，基底部全部呈黑色，渗液少，伤口清创后见肌腱外露达2cm

contents Contributing Factors to Pressure Ulcers Formation Prediction and Prevention of Pressure Ulcers Treating and nursing pressure ulcer

Economic consequences of pressure ulcers Frequency: 3-14%,2-25%(nursing home) 85.7% paraplegia 58% pressure ulcer ＞ 65y Economic consequences: Days in hospital increase Cost of heath care increase: $4,000-40,000

压疮带来的社会经济影响 住院时间延长 医疗费用增加 死亡率增加 身体精神负担增加 照顾负担：人力时间增加 预防1.83英镑/天，治疗3.91英镑/天 难治性压疮已成为截瘫病人的直接死亡原因之一，约占截瘫病人的7%-8%（2002，US） 老年护理院的病人，有压疮的老年人较无压疮的老年人死亡率增加4倍，如患有难治性压疮，其死亡率将增加6倍。 压疮是皮肤出现的最严重的并发症，在临床病人中非常常见，美国的一项研究显示，39.5%的康复治疗的截瘫与四肢瘫病人至少有一个部位发生压疮，而日本的一项大规模的调查显示85.7%截瘫病人曾患压疮，其中17.9%的患者患有难治性压疮 。 压疮一旦发生，治疗比较困难，有时还会引起严重的后果，甚至死亡。有研究发现，老年护理院的病人，有压疮的老年人较无压疮的老年人死亡率增加4倍，如患有难治性压疮，其死亡率将增加6倍。因此，临床应加强护理，降低压疮的发生率。

我国卫生部在等级医院评审和质量年检查中也已将压疮作为衡量护理质量的标准之一，将发生压疮视为未提供一个符合标准的护理行为的证据。

压疮是临床难以回避的问题！

Pressure ulcer decubitus ulcer, and bedsore Concept: pressure sore, a localized area of tissue lesion and necrosis that tends to develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period, blood circulation is obstructed, and local tissue is ischemic.

Contributing Factors to Pressure Ulcers Formation Factor of pressure Pressure Friction Shearing force Moisture irritation to the Skin Nutritional Status Age Fever (infection) Orthopedic Devices

压疮发生的原因 压力因素 垂直压力 摩擦力 剪切力

垂直性压力                                               　　毛细血管的内压32mmHg是压疮形成的极限。

压疮产生方程式 = × 压力的强弱 时间 压疮产生

Lindan等报告 卧位 承重部位 KPa mmHg 仰卧位 骶、臀、足跟、枕 5.3~8.0 40~60 俯卧位 膝、胸 6.7 50 坐位 坐骨结节 10 75 毛细血管压16-32mmHg

压力 (KPa/mmHg) 持续时间 组织损伤 9.33/70 1~2h 局部缺血 2h 不可逆损伤 32/240 间歇性缓解 轻微变换

摩擦力 由两层相互接触的表面发生相对移动时产生的 摩擦力作用于皮肤，易损害皮肤的角质层

剪切力 由于骨骼及深层组织的重力作用向下滑行，而皮肤及表层组织由于摩擦力的缘故仍停留在原位，使两层组织产生相对性移位而引起的 两层组织间发生剪切力时，血管被拉长、扭曲、撕裂而发生深层组织坏死 剪切力是由压力和摩擦力相加而成，与体位有密切关系 图5-10 剪切力形成图

Factor of pressure Pressure Shearing force Friction 垂直 压力 剪切力 摩擦力

Moisture irritation to the Skin urinary and fecal incontinence wound drainage sweat

Nutritional Status Malnutrition Cachexia Obesity Dehydration Edema Protein malnutrition Protein- energy malnutrition Cachexia Obesity Dehydration Edema

Age Gerontologic nursing practices for the client with impaired skin integrity ★Older adult’s skin is less tolerant to pressure, friction, and shearing force because of decreased elasticity due to normal aging. ★The older adult has decreased number of sweat glands, leaving the skin dry and less tolerant to shear and friction. ★Impaired skin integrity is a high risk to older adult; it is among the five most common nursing diagnoses for older adult clients in long-term care facilities.

★Dermis of the older adult’s skin is thinner due to the normal absence of subcutaneous fat, therefore making the older adult more susceptible to skin breakdown. ★After the age of 50 epidermal cell renewal reduces by one third, and as a result wound healing is approximately 50% slower than a 35-year-old adult. ★In the presence of chronic coronary or peripheral vascular diseases circulation to the extremities is reduced.

Fever (infection) increase the body’s metabolic rate diaphoresis increasing the needs of the cells for oxygen Make hypoxemic tissue more susceptible to ischemic injury diaphoresis increased skin moisture irritation

Orthopedic Devices plaster, bandage, splint, retractor reduce mobility of the client or of an extremity friction pressure

Prediction and Prevention of Pressure Ulcers Assessment Patients With High Risk of Pressure Ulcers Predicting Pressure Ulcers Risk Common Pressure Ulcer Sites Preventative interventions

Patients With High Risk of Pressure Ulcers! Clients with the neural diseases Old people Obesity Debilitated and malnutrition Edema Pain orthopedic devices urinary and fecal incontinence fever quietive therapy

Predicting Pressure Ulcers Risk predictive instruments the Braden Scale the Norton Scale Waterlow Scale Anderson Scale Jackson Scale Cubbin Scale the Gosnell and Knoll instruments

Halfens等在荷兰对该量表的信度和效度进行了多中心的前瞻性研究，结果表明Braden量表是一个可信的量表，具有足够的灵敏度和特异度 应用压疮危险因素评估量表是预防压疮关键性的一步，是有效护理干预的一部分——Bergstrom N, Braden BJ, Nursing Clin North Am, 1995

the Braden Scale Items/points 4 3 2 1 Activity Mobility   Mobility Friction and shear  Sensory perception Moisture Nutrition Walks frequently  No limitations Not at all No impairment Rarely moist Excellent Walks occasionally Slightly limited  No apparent problem Slightly limited Occasionally moist Adequate Chairfast Very limited Potential problem Very moist Probably inadequate Bedfast Completely immobile Problem Completely limited Constantly moist Very poor

诊断界值 Bergstrom等1988年进行了大样本的多中心研究，确定诊断界值为18分，≤18分提示有发生压疮的可能性 6项累计总分≤11分，预示有压疮发生高度危险；总分12-14分为中度危险；15-18分为轻度危险；>18分认为无压疮发生危险 Pang等在香港以亚洲人为对象进行研究，结果也表明18分时最佳的诊断界值。其中15-18分提示轻度危险，13-14分提示中度危险，10-12分以下提示高度危险，9分以下提示极度危险

量表的评估周期 入院时立即进行 所有病人都需要做评估 当病人情况有变化时评估，然后每星期进行评估 康复病人或老人院老人可每星期作评估，为期4星期，然后每3个月再进行评估 观察所有受压部分骨隆突处的皮肤状况

the Norton Scale Items/points 4 3 2 1 Mental condition Nutrition condition Mobility Activity Incontinence Circulation    Temperature  Medications Alert Good Full Ambulatory Absent Capillary promptly 36.6-37.2℃  Not Apathetic Fair Slightly limited Walks with help Urine incontinence Capillary slowly 37.2-37.7℃  Administering sedatives Confused Poor Very limited Chair-bound Fecal incontinence Edema slightly 37.7-38.3℃  steroidal drugs Stupor Very poor Immobile Bedfast Double E moderate or serious ＞38.3℃  Double use

神经内科评分法 ——蒋琪霞、韦静90s ≥19分时，需将病人列入压疮发生高危组 4 蒋琪霞、韦静在上世纪90年代初综合国内外各家论点，结合我国人种特点及神经内科瘫痪病人特点，制定的压疮相关因素评估表。7项相关因素评分范围7-28分，对100例神经内科瘫痪病人研究后认为：若各相关因素累计得分≥19分时，需将病人列入压疮发生高危组，加强防护措施。同时研究发现：各相关因素的排列顺序为：排泄状况、营养状况、体型、瘫痪状况、卧床时间、年龄、意识状况，与压疮发生呈直线正相关。 ≥19分时，需将病人列入压疮发生高危组 各相关因素的排列顺序为：排泄状况、营养状况、体型、瘫痪状况、卧床时间、年龄、意识状况，与压疮发生呈直线正相关

Common Pressure Ulcer Sites bony prominences

1965年Indan等通过研究报告了人在坐和卧位时压迫点的分布，仰卧时，枕骨粗隆、骶尾部、足跟是压迫最重的部位，压力范围5. 3～8 1965年Indan等通过研究报告了人在坐和卧位时压迫点的分布，仰卧时，枕骨粗隆、骶尾部、足跟是压迫最重的部位，压力范围5.3～8.0kPa(40～60mmHg)。 俯卧时膝部和胸部受到的压力接近6.7kPa(50mmHg) 坐位时,集中到坐骨结节的压力高达10kPa(75mmHg)。

supine position 枕部 骶尾部 肩胛部 足跟部 肘部 脊椎 spine carina Occipital scapula heel sacrum elbow

Lateral position 踝部 髋部 内髁与 外 髁 肘部 肩峰 耳部 Medial, lateral malleolus ear 外 髁 肘部 肩峰 耳部 Medial, lateral malleolus ear medial,lateral knee shoulder anterior iliac crest elbow

Prone position 肩峰 足趾 膝 部 面颊和 生殖器 耳 廓 （男性） （女性） 乳房 cheek (ear) shoulder breast(female) genitals(male) iliac crest, knee breast(female) 肩峰 面颊和 耳 廓 足趾 膝 部 生殖器 （男性） 乳房 （女性） cheek (ear) shoulder knee toes Genitals (male) Breast (female) iliac crest

Sitting position shoulder elbow sacrum ischium tuber sole

Preventative interventions

Preventative interventions Avoid pressure on local tissues for prolonged period Reduce shear and friction Protect skin of patients (Hygiene and skin care) Stimulating blood circulation of skin Provide adequate nutrition Health education

Avoid pressure on local tissues for prolonged period Turn the patients periodically (every 2 hours or 30 minutes necessarily) Protect bony prominence and support interspace Use the devices right, such as plaster, bandage, splint, retractor     

Avoid pressure on local tissues in prolonged period 翻身 Avoid pressure on local tissues in prolonged period Turn the patients periodically 2h，30min Protect bony prominence and support interspace Use the devices right 支被架 气垫床褥

Devices used to prevent or treat pressure ulcers Devices to support pressure areas Flotation pads are pliable pads with a consistency like body fat, which disperse pressure over a larger area. Pillows and bridging techniques lift the pressure site off the mattress and separate two points of pressure. Devices to aid in turning a client A Guttman bed rotates the client from prone to supine positions and from side to side. Kinetic therapy continuously rotates the client 270 degrees every 3 minutes.

Devices to minimize or equalize pressure Alternating air mattresses made of polyvinyl air cells are attached to a pump that inflates and deflates them every 3-7 seconds, alternating pressure points. Water mattresses disperse and evenly distribute the client’s body weight. High and low air loss bed allow deformation of bed surface to the body contours, thereby reducing tissue pressure below capillary closure. These beds also eliminate shear and friction and reduce moisture. 软枕、支被架、气垫褥、水褥、羊皮褥：分散压力、消除剪切力和摩擦力，防止潮湿 对于水肿和肥胖患者，气垫圈使局部血液循环受阻，造成静脉充血与水肿同时妨碍汗液蒸发而刺激皮肤，不宜使用。

Reduce shear and friction For bedridden clients, elevated the head of the bed to no more than 30 degrees. 30min clients must be positioned, transferred, and turned correctly. lifting rather than dragging bedpan 抬空足跟，使用踝和足跟保护垫，肘护垫 使用保护性敷料：使用3M透明敷贴/水胶体敷料

Protect skin of patients keep the client’s skin and bedsheet clean and dry Clean,not soap ; daub ointments, Urine, stool, wound drainage;Vaseline or zinc oxide Incontinence; diaper 保持患者皮肤和床单清洁干燥 禁用肥皂、酒精清洁用品，可使用爽身粉 大小便失禁，清洁皮肤，涂凡士林软膏，润滑皮肤 过度清洁皮肤 酒精等擦拭皮肤 独自搬动危重患者

预防潮湿 潮湿较干燥的皮肤发生压疮的几率高出5倍 使用尿套/大便收集袋 必要时留置导尿 吸水性尿布/尿垫的使用,尽量避免使用尿不湿，以免霉菌感染 皮肤保护膜/粉的使用

预防潮湿的误区 使用烤灯等使皮肤干燥， 组织细胞代谢及需氧量增加进而造成细胞缺血甚至坏死 涂抹凡士林、氧化锌膏等油性剂，无透气性、亦无呼吸功能，其水分蒸发量维持在一个较低水平上，远低于正常皮肤的水分蒸发量，导致皮肤浸渍。

健康皮肤的护理 美国卫生保健政策和研究机构（AHCPR）推荐预防压疮皮肤护理指导原则 有压疮风险病人每天常规皮肤检查，尤其骨隆突处 使用中性温和的洗液，用温水 皮肤过于干燥，可使用润肤露 需要时洗澡既保持清洁和舒适 环境：保持湿度大于40度 不要将滑石粉拍到皮肤皱褶处 避免防止或减少大小便失禁对周围皮肤的浸渍 避免按摩骨隆突部位

Stimulating blood circulation of skin range-of-motion,ROM Warm water bath in bed: see disc Check and massage skin Local tissue massage back rub: see disc ROM练习：对长期卧床的患者，应每日进行主动或被动的全范围关节运动练习，以维持关节的活动性和肌肉张力，促进肢体的血液循环，减少压疮发生 温水擦浴 局部按摩与背部按摩

Provide adequate nutrition receive sufficient protein, vitamins (A, C, B1, B 5), and zinc

改善营养 AHCPR指南指出：白蛋白＜35g/L,总淋巴细胞1.8×10 9/L或体重减少超过15%，即可认为存在明显的营养不良，加强饮食补充尤其是丰富蛋白质摄入可明显减少压疮。 增进全身营养 合理的膳食，必要时鼻饲或静脉 对易出现压疮的患者应给予高蛋白、高热量、高维生素的饮食，保证正氮平衡，促进创面愈合 维生素A促进组织修复和创口愈合

Health education Educate clients and care givers regarding pressure ulcer prevention

Treating and nursing pressure ulcer

Stages of Pressure Ulcer Stage I :nonblanchable erythema of intact skin, the heralding lesion of skin ulceration Stage Ⅱ: Partial thickness skin loss involves damage or necrosis of epidermis, dermis, or both Stage Ⅲ: Full thickness skin loss involves damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia Stage Ⅳ: Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structure such as tendon or joint capsule

瘀血红润期（hyperemia, nonblanchable erythema ） heralding lesion. temporary circulation lesion Manifestation: Redness(lightly skin) Red blue,purple hues (darker skin) Redness, swollenness, heat, and pain nonblanchable erythema指压不变白的红肿、局部有热感，症状不明显 国际NPUAP/EPUAP压疮分级系统

炎性浸润期(ischemic,inflamation ) epidermis, dermis, or both Gore,ischemic, readness and swollenness enlarged；color: purple, not change with pressed；superficial abrasion, blister or shallow crater 特点：表皮红肿、水疱，浅层真皮组织坏死，皮肤损伤，此时极易破溃，显露出潮湿红润的创面。 国际分级：真皮层部分缺损

浅度溃疡期 (superficial ulceration) subcutaneous tissue(superficial tissue) Blister is torn, infection, ichor,necrosis and ulcer 特点：进一步溃烂，皮肤损伤，筋膜剥离 国际分级：全皮层缺损，有腐肉，但未涉及深部组织，如骨骼肌腱未暴露

坏死溃疡期 (Necrotic ulceration) Deep dermis, muscle, bone, tendon or joint capsule Necrosis turn blue, ichor, septicopyaemia

Treating pressure ulcer Supportive or systemic measures ： providing adequate nutrition Protein status Hemoglobin Controlling infection ： Body substance isolation and good hand washing technique Local care of the wound

Local care of the wound Stage I Principle: eliminating risk factors or contributing factors to pressure ulcers increasing turning frequency, avoiding local tissue pressed long term, improving circulation, keeping bed linen clean, smooth, dry without oddment, reducing friction and shearing force, avoiding excretion and moisture stimulating to skin, increasing nutrition and enhancing immunity and so on. Moist dressing Toast light Ban massage

Stage Ⅱ Principle:protecting skin and preventing infection preventive measure followed intensify care of blister Small untorn blister: big blister: see disc draw out liquid in blister with sterile injector , unnecessarily scissoring pellicle, and then sterilize the surface and cover it with sterile dressings. ultraviolet or infrared treatment.

Stage Ⅲ Principle: keeping cleanliness of the ulcer area Eliminate pressure,keep clean physical therapy: Goosenecked light Moisture-retentive dressings transparent films, hydrocolloid dressing, and hydrogels 新鲜的鸡蛋内膜、纤维蛋白膜、骨胶原膜等贴于创面

Stage Ⅳ Principle: keeping cleanliness of the ulcer area, debriding necrotic tissue, keeping drainage smoothly, promoting acestoma growing

Stage Ⅳ Preventive measures Clean and rinse ulcer area: see disc with sterilized normal saline or 1:5000 Furacilin solution, then covered with sterilized Vaseline gauze or dressings. Metronidazole dressing or be daubed with Sulfapyridine Argentums or Furacilin. cleansed with 3% Hydrogen Peroxide solution for deep ulcer. keeping drainage smoothly oxygen therapy Surgery: debride necrotic tissue, skin grafting and skin flap Chinese traditional medicine 冲洗创面，保持引流通畅： 去除坏死组织： 空气隔绝后持续吹氧疗法：利用纯氧抑制厌氧菌生长。5-6L/min,bid,15min/次 中草药治疗：采用清热解毒、活血化瘀、去腐生肌、收敛作用 直流电中草药离子导入疗法：通过汗腺管导入药物；镇痛；扩血管，改善循环 大面积深达骨骼的压疮，植皮修补缺损组织

伤口湿润环境愈合理论的诞生 1962年，英国动物学家Winter用聚乙烯膜覆盖猪的伤口，其上皮化率增快了1倍，湿润且具有通透性的伤口敷料应用后所形成的湿润环境表皮细胞能更好地繁衍、移生、爬行，从而加速了伤口愈合过程 1972年，Robee教授通过实验再次证实了清洁无结痂的湿润伤口其上皮细胞移行、增生的速度比结痂的伤口要快得多，由此，湿性疗法的观点开始被临床广泛接受 20世纪90年代初，Knighton也发现应用封闭敷料密闭伤口后，伤口基底床保持湿润状态且形成低氧环境，在此综合作用下刺激毛细血管生长和再生，成为肉芽组织生长的基础

概念 湿性治疗 创面治疗 是指用药液、药膏，湿性敷料作用于创面，保持创面的湿润，促进创口的愈合 是利用湿性伤口愈合的原理，使得伤口在止血、清除坏死组织以后，存于湿润的环境中，在不结痂的状态中促进肉芽组织的形成以及生长，最终使得伤口恢复正常

常用新型敷料的品种 水胶体敷料：吸收渗液、溶解坏死组织、减轻疼痛和瘢痕形成 藻酸盐敷料：止血、吸收、溶解 水凝胶敷料：溶解、填充窦道及腔隙类伤口，保护骨膜、肌腱等，防止坏死 泡沫类敷料：提供湿性环境、保护创面，促进肉芽组织生长，吸收大量渗液 银离子敷料：提供抗菌环境，保持湿性环境

Key term Pressure ulcer, pressure sore, decubitus ulcer, and bedsore Contributing Factors to Pressure Ulcers Formation Pressure Friction Shearing force Moisture incontinence

Malnutrition obesity Cachexia Dehydration Edema hypoxemic ischemic Orthopedic Devices

plaster, bandage, splint, retractor hypoalbuminemia Mobility Activity Apathetic Bedfast Occipital bone, scapula, spine carina, elbow, iliac crest, sacrum, heel

ear, shoulder, elbow, anterior iliac crest, trochanter, medial knee, lateral knee, medial malleolus, lateral malleolus cheek (chin), ear, shoulder, breast(female), genitals(male), iliac crest, knee, toes ischium tuber, shoulder, elbow, sacrum, sole bony prominence

nonblanchable erythema Partial thickness skin loss Full thickness skin loss Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle,

septicopyemia, blister transparent films, hydrocolloid dressing, and hydrogels debride Sulfapyridine Argentums eschar and slough skin grafting

Objectives Concept of pressure ulcer Contributing Factors to Pressure Ulcers Formation Patients With High Risk of Pressure Ulcers Predicting Pressure Ulcers Risk Common Pressure Ulcer Sites

Preventative interventions Stages of Pressure Ulcer and its manifestation Treating pressure ulcer

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