美国医师协会压疮指南.ppt

AMDAClinicalPracticeGuideline(CPG)forPressureUlcers美国医师协会压疮临床实践指南,ForMedicalDirectorsandAttendingPhysicians适合于卫生主管和主治医师,WhatisaPressureUlcer?压疮是什么?,Anyskinlesionusuallyoverabonyprominencecausedbyunrelievedpressureresultingindamagetounderlyingtissue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。,PressureUlcersMayNotbePreventable有些压疮是难以避免的,Aggressivemeasurescanreducebutnoteliminatetheincidenceofpressureulcers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；Candevelopdespitebesteffortsofclinicalteaminhighriskpatients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Everyeffortshouldbemadetopreventpressureulcers要通过任何方式的努力来预防压疮；Asystematicapproachtorecognizeandmanagepressureulcersisneeded需要用系统化的管理方法来识别和管理压疮。,FactorsAffectingPressureUlcerDevelopment促成压疮发生的四大直接因素,Pressure压力Shearing剪切力Friction摩擦力Moisture潮湿,AMDAPressureUlcerCPGSteps压疮临床实践指南包括：,Recognition识别Assessment/RootCauseAnalysis评估和分析根本原因Treatment治疗Monitoring监护,PressureUlcersCPGRecognition压疮识别,Documentanyhistoryofpressureulcersinthemedicalrecord在病历中记录压疮的全部历史资料；Thoroughlyexamineallskinsurfacesonadmission入院时仔细全面检查病人的皮肤；Identifyallprimaryriskfactors识别所有基本的风险因素,PressureUlcersCPGRecognition压疮识别,Distinguishtypesofulcers辨别溃疡的类型Vascularinsufficiency/ischemia(venousstasisandarterialischemiculcers)血管机能不全/局部缺血（静脉淤滞和动脉缺血性溃疡）Neuropathic神经性的Pressure压力性的,PressureUlcersCPGRecognition压疮识别,Primaryriskfactorsfordevelopmentofpressureulcersare:形成压疮的原发危险因素：Impaired/decreasedmobility活动性受到限制或者减少Co-morbidconditions,e.g.,diabetesmellitus糖尿病等合并症Urinaryorfecalincontinence失禁Undernutrition,malnutrition,&hydrationdeficits营养不良、脱水Impaireddiffuseorlocalizedbloodflow血流灌注受限或者局部淤血Drugssuchassteroidsthatmayaffectwoundhealing类固淳药品的使用影响伤口康复；Historyofahealedpressureulcer压疮痊愈的经历Residentrefusalofsomeaspectsofcare&treatment居民拒绝给予局部的护理和治疗Intrinsicrisksduetoaging老龄化为固有的危险因素,PressureUlcersCPGRecognition压疮识别,MajorRiskFactorsforDevelopingPressureUlcers发生压疮的主要因素Alterationsinsensationorresponsetocomfort对舒适与否的感觉反应能力发生变化Degenerativeneurologicaldisease退化性神经疾病Cerebrovasculardisease脑血管疾病Centralnervoussystem(CNS)injury中枢神经系统受损伤Depression抑郁等情绪,PressureUlcersCPGRecognition压疮识别,MajorRiskFactorsforDevelopingPressureUlcers形成压疮的主要危险因素Causesofimpaired/decreasedmobility活动性受限或减少Neurologicdisease/injury神经疾病/神经损伤Fractures骨折Pain疼痛Restraints受到束缚,PressureUlcersCPGRecognition压疮识别ComorbidConditionsThatMayAffectUlcerHealing多种可能影响压疮康复的身体状况,Malnutritionanddehydration营养和水合作用Diabetesmellitus糖尿病End-stagerenaldisease晚期肾脏疾病Thyroiddisease甲状腺疾病Congestiveheartfailure充血性心力衰竭PeripheralVascularDisease外周血管疾病,Vasculitis/othercollagenvasculardisorders血管炎和其他胶原血管疾病Immunedeficiencystates免疫缺陷状态Malignancies恶性肿瘤COPD慢性阻塞性肺病Depressionandpsychosis精神状态抑郁Drugsthataffecthealing药物影响康复Contracturesatmajorjoints关节处大范围的挛缩,PressureUlcersCPGAssessment压疮评估,PressureUlcerClassifications分级Stage1:Observable,pressure-relatedalterationofintactskin,includingchangesinskintemperature,tissueconsistency,sensation,and/ordefinedareaofpersistentrednessinlightskin(red,blueorpurplehuesindarkskin)一期压疮Stage2:Partialthicknessskinlossinvolvingepidermis,dermis,orboth.Theulcerissuperficialandpresentsclinicallyasanabrasion,blister,orshallowcrater二期压疮,PressureUlcersCPGAssessment压疮评估,PressureUlcerClassificationscontinuedStage3:Fullthicknessskinlossinvolvingdamageto,ornecrosisof,subcutaneoustissuethatmayextenddownto,butnotthrough,fascia.Theulcerpresentsclinicallyasadeepcraterwithorwithoutunderminingofadjacenttissue三期压疮Stage4:Fullthicknessskinlosswithextensivedestruction,tissuenecrosisordamagetomuscle,bone,orsupportingstructures(e.g.,tendon,jointcapsule).Underminingandsinustractsalsomaybeassociated四期压疮,PressureUlcersCPGAssessment压疮评估,EthicalIssuesToConsider对伦理的考虑ReviewAdvanceDirectives检查病人预先的医嘱Identifychoicesthatlimitthescope,intensity,durationandselectionofvariouswound-relatedoradjunctivetreatments选择治疗作用区域、强烈程度和持续时间最小化的治疗，配合相应的伤口治疗和辅助治疗方式。,PressureUlcersCPGAssessment压疮评估,Aneffectiveassessmentincludes有效的评估包括：Defineandinterpretfactorsaffectingtreatmentandwoundhealingsuchasphysical,functionalandpsychosocialfactors定义和解释关于治疗和伤口康复的影响因素，例如身体的，功能的和心理方面的因素。Defineprognosisidentifyrealisticgoals解释预测识别现实的各个目标Identifymanagementpriorities识别需要处理的优先项目。,PressureUlcersCPGAssessment压疮评估,Certainclinicalfindingsmayhavepriority确定临床所见现象能够治疗的优先顺序。Addresssystemicandlife-threateningissues标明对系统或生命有威胁的问题；Stage3and4ulcers三期、四期压疮Significantpain明显疼痛的疮口Fluidandelectrolyteabnormalities渗出物或电解质异常Nutritionaldeficits营养不足Needforsurgicalinterventiontoremovenecrotictissue需要通过外科手术来清理掉坏死组织。Soft-tissueinfection软组织感染。,FactorsThatAffectPUWoundHealing影响压疮伤口康复的因素包括：,PUWoundhealingisacomplexmultifactorialprocess压疮的康复是一个复杂的、多因素的、缓慢的过程！,SoftTissueInfection软组织感染,SystemicIllness系统性疾病,Osteomyelitis骨髓炎,WoundEnvironment伤口周边环境,Pressure压力,Oxygen氧供能力,Perfusion灌注状况,SystemicHealingAbility组织的复原能力,Compliance组织顺应性,Edema浮肿,Nutrition营养状况,压疮导致病人疼痛，感染甚至危及病人生命，治疗昂贵且漫长！压疮的关键工作在于预防！,LEANMASSErosion(catabolism)ofmuscleproteinVisceralproteinforglucoseproduction肌肌肉蛋白腐化（分解代谢），内脏蛋白利用葡萄糖,ENERGYPRODUCTIONMainlyfromglucoseandaminoacids能量生产主要来自于葡萄糖和氨基酸,Amarkedincreaseinenergydemandsandleanbodymasslossinitiatedbythestressresponse压力应激反应的标志是病人对能量的需求明显增加、消瘦、以及体重丢失。,AminoAcids氨基酸,PhotoscourtesyofR.H.Demling,MD.,TheCatabolicResponsetoawound(ActivationoftheStressResponse伤口的分解代谢反应（压力刺激反应),Netproteinloss纯粹的蛋白质丢失,TheNonhealingChronicWoundFailuretoHealby12Weeks慢性伤口需要12周的时间才能愈合,Catabolism分解代谢,Catabolism分解代谢,Anabolism合成代谢,Anabolism合成代谢,Energy能量,ProteinSynthesis蛋白质合成,EnergyStore能量储存,ProteinStore蛋白质储存,Macronutrients大量营养物质,Energy,EnergyStore能量储存,ProteinStore蛋白质储存,Macronutrients大量营养物质,ProteinSynthesis蛋白质合成,TheNonhealingWound坏死阶段的伤口,TheHealingWound康复阶段的伤口,Filling填充,Woundcontraction伤口收缩,Densecollagenscar细密的胶原结疤,Neutrophils嗜中性白细胞,O2,CourtesyofR.H.Demling,MD.,PressureUlcersCPGTreatment压疮治疗,Woundpreventionplan伤口预防方案Woundtreatmentplan伤口治疗方案,PressureUlcersCPGTreatment压疮治疗,Preventivemeasures预防措施Maintainpersonalhygiene保持个人卫生Assureadequatenutrition保证适当的营养Manageurinary/fecalincontinence正确处理失禁病人的护理Repositionandhavepatientshiftweight更换体位,转移病人受压部位Avoidmessagingreddenedareas避免出现变红的区域Preventcontractures预防挛缩,Positiontoalleviatepressureoverbonyprominences体位更换缓解骨突出处的压力Usepositioningdevices使用减压性的体位垫装置Maintainlowestheadelevation保持最低的头部高度Useliftingdevices使用可以提升病人的转移装置,PressureUlcersCPGTreatment压疮治疗,PreventiveMeasures预防措施ImportantPointsonPositioningandSupportSurfaces关于体位和支撑面的要点Useapressure-reducingmattress使用减压防护垫Avoidplacingpatientontrochantersordirectlyonwound避免病人骨隆突处和伤口处直接受压Mattressoptionsfoam,airloss,water,gel,alternatingairorviscoelastic选择适当的垫子海绵、气垫、水垫、凝胶、交换充气垫、粘弹性防护垫Pressurerelievingdevices(e.g.viscoelasticmattress)whereindicated危险部位使用分散压力的装置（例如：粘弹性ACTION防护垫）,PressureUlcersCPGTreatment压疮治疗,PreventiveMeasures预防措施AssuringadequateNutritionandHydration保证营养和水分Watchforanorexiainpatientswithasuddenchangeinintake对于食欲缺乏的病人要改变营养摄入方式Undernourishedpatientscaloric/protein/hydrationtargets:营养不足的病人热量、蛋白质、补水作用的目标：30-35calories/kg/day1-1.5g/kg/dayprotein30ml/kg/dayfluidExceptforadailymultivitamin,othervitaminandmineralsupplementsarenotneededunlessdeficienciesareconfirmed除了日常补充多种维生素之外，其他的维生素和矿物质是不需要额外补充的，除非是临床证实需要补充的。,PressureUlcersCPGTreatment压疮治疗,PreventiveMeasuresAStepWiseApproachtoNutritionalInterventioninPatientswithWounds预防措施对于有压疮伤口的病人选用营养干预是一个明智的方法Level1Approximatelywithinfirstweekafterwoundonset第一阶段大约在伤口开始后的第一周内Level2FollowingcompletionofLevel1assessment第一阶段治疗后进行第二阶段治疗Level3Approximatelywithin2weeksofimplementingLevel2第二阶段治疗后两周内进行第三阶段的治疗.Source:AMDAPressureUlcerTherapyCompanionClinicalPracticeGuideline,PressureUlcersCPGTreatment压疮治疗,WoundCare伤口护理Principlesofwounddressings:伤口敷裹的原则：Protectwoundbedfromfurthertrauma,contaminationordrying避免伤口创面进一步的受到创伤或者污染或者过于干燥Promoteremovalofnecrotictissueandexudate加速坏死组织和渗出物的移除Provideamoisthealingenvironmentsupportiveofregenerationandgrowthofgranulationtissue.提供湿润的愈合环境来利于恢复和肉芽组织生长Woundcharacteristicschangeasthewoundevolves.随着伤口的发展，伤口的特性不断发生改变。Tailordressingsprimarilytowoundcharacteristics,notwoundstage选择适应伤口特性的敷料，而不是适应伤口的阶段。,PressureUlcersCPGTreatment压疮治疗,WoundCareTeamsPossibleRoles合理的角色伤口护理团队Helpguidecarebystayingabreastofdevelopmentsinthefield利用该领域的发展结果来帮助指导护理工作Evaluatenewproductsforformulary评估规定的新产品Provideconsultationfordifficultwounds提供不同类型伤口的咨询Helpselectappropriatesupportsurfacesforcomplexpatients帮助病人选择适当的支撑装置Trainnewstaff训练新的医护人员Providecontinuingeducationforexistingstaff提供目前医护人员的持续教育Performwoundcare执行伤口护理,PressureUlcersCPGTreatment压疮治疗,WoundCareIntactSkin伤口护理完整的皮肤Stage1PressureUlcersmayheraldamoreextensivewound一期压疮或许已经预示更大面积的损伤Protectinvolvedareafromfurtherinjuryfrompressureorshearingforces预防相关区域遭受压力和剪切力的进一步损伤Nodressingrequired没有包扎伤口的必要Monitorfrequentlyforchanges频繁的监测伤口变化,PressureUlcersCPG:Treatment压疮治疗,WoundCareCleanWoundBase清洁伤口的基底部Stage2orhealingStage3orStage4wound二期或者处于康复阶段的三期四期压疮Dressingshouldkeepulcerbedcontinuallymoistbutthesurroundingskindry敷料要保证创面的湿润但是周围要保证干的Choosedressingbasedonsituation根据伤口的情形来选择包扎方式Fillwounddeadspacewithlooselypackeddressingmaterial伤口的死腔要用疏松的敷料来填充,PressureUlcersCPG:Treatment压疮治疗,WoundCareEscharorWoundBasewithAdherentNecroticTissue伤口焦痂或者伤口出现附着的坏死组织Additionaltreatmentsareindicatedinwoundscoveredbyescharorwithsurfacenecrosisofsubcutaneoustissue(withoutunderminingadjacenttissue)伤口的附助治疗指明了：表面焦痂的伤口以及皮下组织坏死的伤口Typesofdebridementusedtoremoveescharandsurfacenecrosis用于移除焦痂和皮下坏死组织的各种清创术Sharpsurgicaldebridement剧烈的外科清创术Mechanical机械的Enzymaticagents采用酶因子的Autolytic自溶的Sterilebiological(maggot)无菌的生物学方法Dontusetopicalantibioticsroutinely不要例行公事地使用局部抗生素,PressureUlcersCPG:Treatment压疮治疗性处理,WoundCareExtensiveSubcutaneousTissueDamage广泛的皮下组织损伤Stage4(someStage3)pressureulcersarecharacterizedbyfullthicknessskinlosswithextensivetissuenecrosis,underminingandsinustracts四期压疮（包括部分3期压疮）深部出现大面积的组织坏死，窦道状坏疽；Treatmentmayrequireextensivesurgicaldebridement治疗需要较大面积的外科清疮术；Alldevitalizedtissueremoved去除所有的坏死组织Underminedareasshouldbeexploredandunroofed深部损伤要去除表层才能准确界定。,PressureUlcersCPG:Treatment压疮治疗性处理,WoundCareCategoriesofProductsUsedinWoundCare用于伤口护理的产品分类Hydrocolloids水胶体Alginate藻酸盐等Foams泡沫等WoundFillers伤口填充物CompositeDressings合成敷料,PressureUlcersCPG:Treatment压疮治疗性处理,WoundCareOngoingManagement持续的管理1.Cleanseateachdressingchange清洁伤口更换敷料2.Debrideeschar,asneeded如果有需要的话要清创焦痂3.Evaluate/treatforinfection评定和处理感染4.Employfacilityinfectioncontrol利用多种设施达到感染控制,PressureUlcersCPG:Treatment压疮治疗性处理,WoundCareOngoingManagement(continued)持续处理5.Re-evaluateco-existingmedicalconditions再次评定病人身体状况方面的医疗条件6.Prescribepaincontrolmeasures处方建议采用控制疼痛的措施7.Addresspsychosocialissues,depression,andpossibleisolation病人的心理状态，可能孤独和抑郁。,PressureUlcersCPGTreatment压疮治疗性处理,WoundCareAlternativestoNon-Responders伤口护理-针对没有反应的患者供选方案Forcleanwoundsnotrespondingtoappropriatetreatmentconsider:为没有反应的患者清洁伤口提供适当的治疗：Topicalantibioticointments/solutionsfor2weektrial局部提供的抗生素，尝试两周；Progresstoasupportsurfacethatoffersfurtherprotection改进支撑体的质地，提供更深入的保护；Consideracourseofelectrotherapy考虑给予电疗治疗；Considertransfertoanothersiteforsurgicaldebridement/repair,mgt.ofsystemiccomplications,comfort/painmgt.,andspecializeddiagnosticstudies考虑外科清疮术/修复术，全身性的合并症，舒适/疼痛，对特殊的指针进行研究。,PressureUlcersCPGMonitoring压疮监测,Regularweeklyevaluationstoassesshealing(basedonestablishedAssessmentGuides)tomonitorsuccessofthetreatmentregimen基于已经确立的评估指南，每周对伤口的康复程度进行评定以监测相应治疗方式所取得的治疗效果；Follow-updiagnostictestingandconsultation跟随诊断测试和会诊,Documentpatientresponsetotreatment证明病人治疗的反应Monitorandadjusttreatmentasindicated监测指征调整治疗方案Recognizeandmanagecomplications识别和处理合并症,PressureUlcersCPG:Monit