涉外护理英语unit7ManagingWound.ppt

涉外 护理英语,Unit 7 Managing Wound,对外经济贸易大学出版社,Assessing the wound Discussing the wound management Asking for advice on wound care Using a Wound Assessment Chart Giving an oral report of the case,Unit7 Managing Wound,伤 口 护 理,评估伤口 讨论伤口管理 征询伤口护理的意见 使用伤口评估单 口头汇报病人病情,Description,Basic wound care involves protecting the surrounding skin, wound cleansing, debridement, and the application of topical treatment, appropriate dressing, bandages and tapes to prevent wound complications and promote of wound healing.,翻译,单元描述,基本的伤口护理是指保护周围皮肤、清洗伤口、清除坏死组织、选用适当的敷料、绷带和引流条来进行局部治疗以预防伤口并发症并促进伤口愈合。,Work Description,A wound care nurse is a nurse who specializes in wound management. Wound care nurses work with a patients medical team to monitor a variety of wounds and their healing process, and they also care directly for the patient, promoting healthy and rapid healing of a wide variety of wounds. Chronic wounds such as bedsores, ulcers, and abscesses are often an important part of wound care nursing. Wound care nurses can also care for ostomy sites, as well as the areas around feeding tubes, ports, and recent surgeries. Most wound care nurses work in a hospital setting, treating patients who require acute care, although some travel as home health consultants, or work in nursing homes and other residential facilities.,翻译,The first task of a wound care nurse is to assess a wound, determining the depth of the wound and taking note of any developing issues, such as signs of infection. Then, the nurse develops a treatment plan, which often starts with debridement of the wound to clean out dead tissue and any foreign material. In the long-term care of the wound, the nurse regularly cleans and inspects the wound, re-bandages it if necessary, and keeps an eye on the wounds progress. Wound care nurses may need to consult with doctors to discuss the need for antibiotics, surgical drains, or surgical debridement in the case of serious wounds. They also work with other patient caregivers to educate them about wound care and handling the patients case. For example, for an elderly person with bed sores, regular rotation of the patient and the use of specialized pillows to relieve pressure on the sores may be an important part of patient care.,单元工作任务描述,伤口护理护士是专门处理伤口的护士。伤口护理护士是患者医疗团队的一员，监控各种伤口及其愈合过程，他们也直接护理患者，促进各种伤口健康快速地愈合。 慢性伤口如压疮、溃疡和脓肿等常见伤口是伤口护理的重要部分。伤口护理护士也可以进行造瘘口护理、鼻饲管、输液港和近期手术部位周围皮肤护理。虽然伤口护理护士可担任家庭健康顾问或在养老院及其他社区医疗机构工作，但大部分在医院工作，处理需要紧急理护的患者。,伤口护理护士的第一个任务就是评估伤口，确定伤口的深度，并记录伤口进展情况，如感染的迹象。第二个任务是制定治疗计划，它通常从伤口的清创开始，清除坏死组织和异物。需要长期护理的伤口，护士须定期清洗和检查，必要时要重新包扎伤口，并密切观察伤口进展。 如伤口伤势严重，伤口护理护士可能需要与医生商量讨论是否需要抗生素、外科引流管或者外科清创术。他们也教育其他患者照顾者如何护理伤口和处理患者病情，例如，指导护理一个有压疮的老年患者，定期给患者翻身和使用专用枕头来缓解对压疮的压力是非常重要的。,Description,Initial assessment of the wound involves classification (including the absence of sinus tracts, undermining or tunneling), site, dimensions (length, width and depth), appearance of the wound bed (including color and the presence or absence of necrotic tissue, slough, granulation tissue and epithelialisation), exudates, odour, the surrounding skin, clinical signs of wound infection, and pain at wound site. Reassessment of the wound should be done at least once a week. However, if the condition of the patient or the wound deteriorates, the treatment plan should be re-evaluated as soon as any evidence of deterioration is noted.,Task 1 Assessing the wound,翻译,任务描述,伤口的初步评估包括分类（是否有窦道、伤口坑洞）、部位、大小（长、宽和深度）；伤口床的外观（包括颜色、是否有坏死组织、腐肉、肉芽组织和外皮形成）；渗出液、气味；周围皮肤；伤口感染的临床迹象和伤口部位的疼痛程度。每周至少要对伤口重新评估一次。然而，如果患者的病情或伤口恶化，治疗计划应该重新评估。,Related Information,Classification of wounds Generally, wounds can be classified as acute, chronic, or postoperative. Acute wounds refer to traumatic wounds such as abrasions, cuts, lacerations and burns. They usually respond rapidly to treatment and tend to heal without complications. Chronic wounds are described as wounds secondary intention and being of long duration or frequent recurrence. Chronic wounds can develop at any time from an acute wound, because of an undetected persisting infection or inadequate initial management. In most cases, chronic wounds represent the final stage of progressive tissue destruction, caused by venous, arterial or metabolic vascular disorders, pressure sores, radiation damage or tumors. Postoperative wounds are intentional acute wounds. Usually the wound edges are held in approximation by sutures, clips or tape, and heal rapidly by primary intention. However, some surgical wounds are left open to heal by secondary intention, often to allow drainage of infected material.,翻译,相关信息,伤口的分类 一般来说，伤口分为急性伤口、慢性伤口或者术后伤口。急性伤口是指诸如擦伤、割伤、撕裂伤和烧伤等创伤性伤口。这些伤口对治疗反应迅速，愈合快没有并发症。慢性伤口被描述为伤口的二期愈合，持续时间长或频繁复发。因持续感染未被发现或初次处理不当，急性伤口随时可发展为慢性伤口。大多数情况下，这是由静脉、动脉或者代谢性血管疾病、压疮、放射性损伤或者肿瘤引起。术后伤口是人为的急性伤口。伤口边缘通常用线缝合、回形针或胶带包围，会按预想的迅速愈合。然而，有些手术伤口是开放的，通过二期愈合而快速愈合，通常要引流感染性物质。,Appearance of the wound bed The appearance of wound bed is an indication of the phase it has reached on the continuum of healing and any complication that may be present. A black wound indicates a necrotic wound, often with hard eschar present. This dehydrated, dead tissue will delay healing and needs to be removed to provide a healing environment. Krasner (1995) describes two types of yellow woundsthose that are infected and those that contain fibrous slough. Infected wounds are characterised by yellow, light green or cream-coloured exudate, comprising bacteria, cellular debris and leucocytes. Fibrous slough is usually yellow, cream-coloured or white. It often appears soft and stringy, and may stick to the wound bed. As slough provides an excellent medium for bacterial proliferation, it needs to be removed to optimise the healing process. A red wound indicates the presence of granulation tissue. Granulation tissue may appear deep pink or red in colour and is moist with raised “granules”. These are delicate loops of capillaries, which are easily damaged. A granulating wound is a healthy, healing wound and maintaining an optimum healing environment is therefore essential. A pink wound represents an epithelialising wound. Epithelial tissue migrates from the wound margins and undamaged hair follicles, and moves over the wound surface once granulation is level with surrounding skin.,翻译,伤口床的外观 伤口床的外观可以显示伤口愈合的各个连续阶段，也可显示是否存在并发症。 黑色的伤口表明伤口组织坏死，通常伴有硬焦痂。这种脱水、坏死的组织会延迟愈合，需要被清除以形成愈合环境。克莱斯勒（1995）描述了两种类型的黄色伤口一种是受感染的黄色伤口，一种是包含纤维腐肉的黄色伤口。感染的伤口其特点是有黄色、浅绿色或者是米色分泌物，由细菌、细胞碎片和白细胞组成。纤维腐肉通常呈黄色、奶油色或者米色的，质柔软、粘稠，会粘到伤口床。因为腐肉为细菌增殖提供了良好的介质，需要去除腐肉以优化愈合过程。红色的伤口表明肉芽组织形成。肉芽组织的颜色可能表现为粉色或红色，是凸起的粒状组织，柔软湿润。凸起的颗粒组织毛细血管十分脆弱，很容易被损伤。形成了肉芽的伤口是健康的、即将愈合的伤口，因此维护最佳愈合环境十分必要。粉色的伤口代表着上皮伤口。一旦肉芽组织与周围皮肤平齐，上皮组织就从伤口边缘和未损坏的毛囊迁移过来，跨过伤口表面。,Exudate,翻译,分泌物,伤口渗出物的量在不同的愈合阶段是不同的。一般来说，随着伤口愈合，渗出物产生减少。虽然慢性伤口，如压疮，存在某种渗出物，但正常的肉芽组织相对干燥。因此，伤口渗出物量的突然增加可能预示着感染，这是因为底层毛细血管扩张是炎症反应的一部分，尤其是让白细胞迁移到感染源。毛细血管渗透性增加也让大量血浆渗漏。除了评估渗出物的量，也要确定它的外观。渗出物可出现流血、浆液、血清或脓，颜色或清澈，或呈粉色、浅绿色、深红色、红黄色或者绿色。然而，健康的愈合伤口，渗出物正常表现为浅黄色。用来形容渗出物量的术语有大量的、中量的和少量的，但是这种描述不精确，是一种主观的评估。渗出物的颜色、稠密度、脓性和气味是用来定义伤口状况的其他特征，而这些特征都没有客观的测量标准。,Discussion of the nursing topic,1. What can be collected when assessing the wound initially? Initial assessment of the wound involves classification (including the absence of sinus tracts, undermining or tunnelling), site, dimensions (length, width and depth), appearance of the wound bed (including color and the presence or absence of necrotic tissue, slough, granulation tissue and epithelialisation), exudates, odour, the surrounding skin, clinical signs of wound,2. When can the wound be reassessed? Reassessment of the wound should be done at least once a week. Howerver, if the condition of the patient or the wound deteriorates, the treatment plan should be re-valuated as soon as any evidence of deterioration is noted.,3. Can you describe a wound that you know? Open: a. Looks infected as it has pus in the wound. It looks red and sore. b. Looks black and uneven around the edges with yellowish material in the middle. c. Looks like it has dead tissue around the edges. It looks blackened and not healed. d. Looks red and dry.,Common questions used for describing a wound,1. Is the wound closed? Or are there any areas along the wound that are open? 2. Are the sutures/staples in or out? 3. Is there drainage from the wound? 4. Are the wound edges well-approximated?,5. Is the wound “dehisced”? How much of it? 6. Is there “healthy granulation tissue in the wound bed”? 7. Is there “fibrinous material within the wound bed? 8. Is the skin surrounding the wound necrotic? 9. Is the dressing saturated?,Practice of the task,(Marilyn, the ward nurse, is handing over some patients to Susie, and talking about the patients wounds.) Marilyn: OK, lets start on Mrs. Chad in Bed 17. She is a 67-year-old lady with Type 2 diabetes for 33 years and poor mobility on her own, er, with eight cats. She had hypertension, diabetic retinopathy, peripheral neuropathy and arterial disease. She was admitted via Casualty with a discolored ischaemic left leg. On the medical aspect of her left foot was an infected, necrotic wound. This was Stage 5 foot. She was confused and dehydrated. Susie: Right. Fortunately, she was taken to hospital for a treatment. What has been done for her?,翻译,Marilyn: Four weeks ago when admitted to hospital, she was given IV fluids. She underwent vascular investigation, which revealed tibial disease. She underwent popliteal posterior tibial bypass, with amputation of left first toe and debridement of surrounding non-viable tissue. Yesterday, she commenced VAC therapy. But after one month in bed, Mrs. Chad developed a pressure ulcer on her sacrum. After the visit, the doctor ordered wound care of gauze moistened with normal saline twice a day. The wound was assessed as a Stage II pressure sore with enough depth to need packing. The wound measured 3 centimeters (cm) long, 2 cm wide and 1.5 cm deep. The wound bed was 100 percent red granulation tissue. There was a moderate amount of serous drainage. The wound edges were intact. There were symptoms of infection. Susie: All right, he will be arranged to reassess the wound, is that right?,Marilyn: Yes, thats right. OK, lets move on to Bed 18, Mrs. Jane Evens. She is 67 years old, lives with her husband in a one-story home in a small Midwestern community. She has been a smoker, although she hasnt smoked in the last 10 years and has recently retired from a packaging company where she worked, for the past 10 years, standing on an assembly line. Jane is not a diabetic. Jane has been admitted to hospital for a surgery for a ruptured diverticular abscess and a colostomy. She has had the ulcer for several years, and it has always embarrassed her. She usually wore slacks to hide it even during the summer. In the past, Jane treated the ulcer with various creams and antibiotic ointments and a bandage. It has gotten smaller. Susie: Right. But, it seems that it doesnt work well. Marilyn: Mm, her lower leg and foot reveal a moderate amount of edema. Jane complains that if she elevated her leg at night when she watched television, the swelling decreased. She does not have any leg pain. There is red discoloration of the skin above her ankle, prominent,superficial leg veins, distention of the veins on the medial aspect of the foot, a hardened, indurated texture to the skin, and dry, flaky skin. The ulcer is a full thickness wound on the medial aspect of the lower leg, measuring 6.0 cm long by 4.0 cm wide and approximately 1.0 cm deep. The wound edges are irregular and have a white discoloration. The wound bed is approximately 75% red, granular tissue and 25% yellow, fibrinous slough. Susie: Er, what has been done for her? Marilyn: The gauze dressing was applied the day before. It is saturated with tannish colored drainage. The wound has no odor. A foam dressing was chosen to cover the wound to absorb the wound exudate at the wound edges. In addition, a compression wrap was applied after obtaining a measurement of the leg circumference 2, 6, and 10 inches above the ankle. The measurements provided a reference point for the expected decrease in the edema with the use of compression. Susie: All right, I will look into the wound and see if its OK.,任务案例,（病房护士玛丽莲正在对苏茜交接患者，并讨论患者的伤口。） 玛丽莲： 好的，让我们从17床查德太太开始，这位老太太67岁，患有2型糖尿病33年，自主活动能力差，呃，养了8只猫。有高血压、糖尿病视网膜病、周围神经病变和心血管疾病等。在不同愈合阶段，伤口渗出物的量有差异。一般来说，随着伤口的愈合，渗出物会逐渐减少。虽然慢性伤口，如压疮，会出现分泌物，但周围正常的肉芽组织相对干燥。因此，伤口渗出物量的突然增加表明可能有感染，这是因为皮下毛细血管扩张是炎症反应的一种表现，尤其是白细胞侵入到感染源。毛细血管通透性增加也让大量血浆外渗。除了评估渗出物的量，也要确定渗出物的外观。渗出物可以是鲜血、浆液、血清或脓，颜色或清澈，或呈粉色、浅绿色、深红色、红黄色或者绿色。然而，健康的愈合伤口，渗出物颜色呈现黄色。用来形容渗出物量的术语有大量、中量和少量，但是这些描述不精确，是一种主观评估。广泛用于描述伤口状态的其他特征有渗出物的颜色、粘稠度、气味以及是否有脓性变化，但这些特征都没有客观的测量方式。 苏茜： 好的。幸运的是，因左腿缺血而经急诊收入病房。左脚伤口感染、坏死，处于糖尿病足五期。查得太太意识不清且脱水。,玛丽莲： 四周前，入院时，给予了静脉输液治疗。经血管造影检查，显示有胫骨病。她做过腘胫后旁路手术，切除了左边第一根趾头，消除了周围非活体组织。昨天，她开始了封闭负压引流术VAC治疗。但是卧床一周后，查德太太的骶骨的形成了压疮。医生查房后，指示用浸有生理盐水的纱布进行伤口护理，每日两次。伤口被评估为压疮II期，伤口足够深需要填料。伤口有3 cm长、2 cm宽和1.5 cm深。伤口床是100%的鲜红肉芽组织，有中等量的引流液。伤口边缘不完整，有感染的症状。 苏茜： 好的，要安排重新评估伤口，是吗？ 玛丽莲： 是的。好的，让我们移到18床，简埃文斯太太，67岁，和丈夫住在中西部小区社的平房里。她有吸烟史，但近十年没有吸了，最近刚从一家包装公司退休，过去十年里，一直在装配线站着工作。简不是糖尿病患者，因憩室脓肿破裂和结肠造口手术而入院。她患溃疡几年了，这个病总是让她很窘迫。甚至夏季，她也要经常穿宽松的长裤隐藏。过去，简用过各种药膏、抗生素软膏和绷带处理溃疡。伤口已经变小了。 苏茜： 是的，但是，似乎没什么效果。,玛丽莲： 嗯，她的小腿和脚有中度水肿。简说，如果晚上看电视时抬高腿，肿胀就减轻了。腿一点儿也不痛。脚踝的皮肤上有红色斑点，病足的腿部静脉突出、静脉扩张、浅皮肤纹理硬化、皮肤干燥、脱落。这个溃疡是小腿内侧完全厚的伤口，测量有6厘米长、4厘米宽和几乎1厘米深。伤口边缘不规则且有白色的变色。伤口床是大约75%的红色粒状组织和25%的黄色纤维腐肉。 苏茜： 呃，采取什么措施了吗？ 玛丽莲： 头天用的纱布敷料，已被浅棕色的引流物浸润。伤口没有气味。选用了泡沫状敷料覆盖伤口以吸收伤口边缘处的分泌物。另外，脚踝之上的腿围测量为2、6、10英寸，使用了压力包扎。这个测量值为使用压缩扎后的水肿减少提供了一个参考值。 苏茜： 好的，我会检查伤口，看看情况。,A. Read the conversation and answer the following questions.,1. What brought Mrs. Chad to hospital? She was admitted via Casualty with a discolored ischaemic left leg. 2. What did she undergo? She underwent vascular investigation, which revealed tibial disease. 3. How long has she been in hospital? Four weeks.,4. Is Jane a diabetic? No, she is not a diabetic 5. What operation has she had? She has had a surgery for a ruptured diverticular abscess and a colostomy. 6. How did Jane treat her ulcer in the past? Jane treated the ulcer with various creams and antibiotic ointments and a bandage.,B. Use the words in the box to fill in the blanks.,1. Mrs. Smith has an area of , or dead issue on her right lower leg. There are blackened areas or on the upper wound. These areas should be debrided surgically right away. necrosis; eschar 2. Mr. Hill has in his left lower leg. The wound is showing a sign of drying out, or . There is a lot of skin flaking off his leg. cellulitis; desiccation,3. The skin surrounding Mr. Harleys leg wound is red and warm to touch. The is a sign of infection and was conformed by a wound sent to the lab 2 days ago. inlammation; swab 4. The yellowish or dead fibrous issue on the inner part of the Birds wound will have to be softened before or removal of the tissue. slough; debridement,C. Fill in the missing information about Mr. Jay Joseph and Mrs. Jane Evens in the chart according to the conversation above when necessary.,D. Create a conversation between two nurses assessing the wound according to the following paragraph. If possible, try to use similar or different words that have the same meaning when describing the wound.,Mrs. Lee comes to the clinic. She has Type 2 diabetes and cannot feel her lower extremities. Yesterday morning she noted a wound on the left outer ankle. She reports increased swelling over the past 3 days and a generalized throbbing pain with a deeper pain in the left posterior calf. The wound is warm to touch when compared with adjacent tissue and painful. The wound is covered with tan leathery necrotic tissue and the area measures 5.3 cm x 3.1 cm x 0.0 cm. The periwound area is a non-tender white colored thick skin tissue. The peri-wound tissue is erythematous, edematous, indurated, and the proximal portion of total affected area is covered by loose skin that appears to have been a fluid filled blister that has spontaneously unroofed (measures 1.0 cm x 3.8 cm).,Description,Wound management is the evaluation, treatment, and prevention of open injuries. Wounds can be caused by injury, chronic health conditions, or surgery. Proper evaluation and treatment of wounds is extremely important to minimize the risk of uncontrolled bleeding, infection, and other serious complications.,Task 2 Discussing wound Management,翻译,任务描述,伤口管理是对开放性损伤的评估、治疗和预防。伤口由外伤、慢性病或者手术引起。对伤口恰当的评估和治疗对于减少未知流血、感染和其他严重并发症等危险极为重要。,Related Information,Wound bed preparation Wound bed preparation is an essential factor in the management of wounds. Initially, a careful assessment of the type of wound is made and then appropriate treatment is selected. Before healing can commence, it is important to prepare the base of the wound by ensuring that there is a good blood supply to the area, removing any dead tissue, clearing infection and establishing an optimal moisture balance in the wound. The assessment of blood circulation is done using a Doppler (ultrasound) test that uses high-frequency sound waves to measure and assess the flow of blood in blood vessels, tissues and organs. Faint or absent sounds may indicate constricted or obstructed blood flow. Its also important to decrease the high bacterial load by controlling inflammation or infection. In addition, its necessary to create moisture balance in the wound environment, so that the wound is neither too dry nor too moist. Studies show that wounds will not heal if there are certain barriers to healing present. The first barrier to healing is the presence of necrotic tissuein other words, dead tissue. The necrotic tissue stops healthy tissue from growing, so its important to remove any dead tissue from the wound. After necrosis, the second barrier to good healing is high bacterial load, or a high level of infection which is carried by the tissues. Its therefore important that any infections are treated before effective wound care can start. Finally, imbalance of moisture levels in the wound bed also stops the healing process. Wounds with excessive exudatesthat is, wounds which are too moist and also wounds which have excessi