icu基础护理原则浅谈压疮预防及措施（ICU basic nursing principle -- prevention and measure of pressure sore）

1、icu基础护理原则浅谈压疮预防及措施（ICU basic nursing principle - prevention and measure of pressure sore）ICU principles of basic careICU treated in critically ill patients, the implementation of the 24h special care system, high standards of patients and nursing level based nursing quality, basic nursing is an impo

2、rtant part of clinical nursing, basic nursing quality is not only closely related to the rehabilitation of patients, but also reflects the overall level of nursing hospital.As ICU nurses, it is an important link to ensure the quality of basic nursing care for critical patients and gradually improve

3、the basic nursing care.The basic nursing quality management should follow the principle of ICU is: (1) system: clear quality standards of basic nursing; (2) to evaluate clinical signs, take the foundation: individualized nursing interventions; (3) continuity: the implementation of nursing order syst

4、em, the effect of maintaining the high quality of nursing care; (4) continuous quality improvement: continuous assessment of the effect of basic nursing mistakes, preventive measures etc.Prevention and nursing progress of bedsore in critically ill patients with ICUAlso known as pressure ulcers, pres

5、sure ulcers, clinically known as bedsores, Chinese medicine called a sore, refers to the local organization pressed for a long time, the blood circulation disorder, continuous local ischemia and hypoxia, malnutrition and soft tissue necrosis and ulceration1. For many years, the incidence of pressure

6、 sore has been one of the important indexes to evaluate the level of hospital nursing. ICU is a place where critical patients congregate, and the incidence of pressure sores is higher than that in general wards. According to statistics, the incidence of pressure ulcers in ICU patients is lowest, abo

7、ut 4%, up to 51%2. Foreign patients and their families because of pressure ulcers sue for compensation cases are increasing 3 in Holland, more than 1% health care funding for prevention and cure of the pressure ulcer or pressure sore caused by the payment due to hospitalization expenses; bedsore tre

8、atment costs the United States approximately $1 billion per year 4. The prevention and treatment of pressure sore is the focus and difficulty of ICU nursing work. Pressure ulcer not only increases the patients pain and financial burden, but also wastes medical resources, delays the rehabilitation of

9、 diseases and prolongs the hospitalization time. It is the common aspiration of the nursing profession to identify the risk factors of bedsore timely so as to take preventive measures in time, to prevent and treat pressure ulcers effectively, and to avoid the waste of medical resources. Through sear

10、ching a large amount of literature, the author summarized the causes and preventive nursing measures of ICU prone patients with pressure sores.1 pressure sore risk factors1.1 external factors 1.1.1 pressure almost all ICU patients had to stay in bed, and the body with a variety of therapeutic monito

11、ring of pipeline and wire, many patients because of disease and treatment also had to be protective constraint, which limits the patients body movement and posture change, is likely to cause some parts of the body, such as the occipital double elbow, sacral, heel and lateral malleolus and other part

12、s of long-term pressure. Pressure is the most important factor in the formation of pressure ulcers, normal skin capillary pressure of 24kPa, up to 4h 4.67kPa under pressure or changing pressure even if 25.3kPa 1H will not have any organization change, but if the pressure of the 9.3kPa for 2h may cau

13、se irreversible changes in 5 cells. Supine position,The body pressure at the right heel, head, caudal, left and right shoulder blades is 4.27kPa (32mmHg), especially the right heel exceeds 9.33kPa (70mmHg) 6, which suggests that the pressure should be reduced at intervals.1.1.2 friction and shear IC

14、U patients due to sedation, use of artificial airway and gastrointestinal nutrition, often need to take the position of head bent leg. The head is raised by more than 30 degrees. In order to prevent the patient from slipping while bending his legs, the sacral and heel parts are affected by friction

15、and shearing force.1.1.3 humid environment, in a humid environment, the risk of pressure sores in patients increases by 5 times 7. Fecal incontinence or diarrhea, exudation from wound secretions, sweating caused by fever, and excessive humidity in the ward can make the skin moist. Urine and feces al

16、so act as a stimulus to the skin. According to statistics, the incidence of pressure sores in incontinent patients is 5.5 times that of patients in general 7. Dampness can weaken the barrier of the stratum corneum of the skin, make the harmful substance easy to invade, and be beneficial to the bacte

17、rial reproduction, and the protective ability of the skin itself to the mechanical function such as friction is also decreased. Skin impregnation and skin wrinkles are also causes of pressure sores, and thisSome of these factors are common in ICU patients.1.2 internal factors1.2.1 sensory dysfunctio

18、n, most ICU patients have sensory disturbances, mainly because of the use of sedatives or the patients conscious disturbance. Feeling low ability can cause skin damage on the compression sensitivity decreased, the decrease or loss of self protection, cannot change or control the position, the skin t

19、issue metabolism denervation changes, the main anti tension component synthesis of collagen in the skin will be reduced, so that the skin becomes not resistant to friction and damage 8.1.2.2 ICU there are many malnourished patients during hypermetabolic state, resulting in malnutrition, which is com

20、mon in severe trauma, burns, septic shock and postoperative patients. The high metabolic state causes negative nitrogen balance, then thinning of the subcutaneous tissue, more prominent bone formation, and more difficult wound healing. Low levels of plasma proteins can cause skin edema. This further

21、 threatens the nutritional supply of the skin and makes it more susceptible to damage. Holmes and other 7 studies found that 75% of patients with plasma albumin levels below 35g/L had pressure ulcers, whereas in patients with higher plasma albumin levels, the incidence of pressure ulcers was only 16

22、%. Anemia and malnutrition effects on the healing of patients with pressure sores and wounds, one of the main risk factors of pressure ulcers also, hematocrit, hemoglobin 0.36 120g/L has good screening effect of 7 in predicting the occurrence of pressure ulcers. In patients with malnutrition, subcut

23、aneous fat decreases, the skins tolerance to external pressure decreases, and the skin is vulnerable to damage. Therefore, improving the nutritional status of patients is very important to prevent the occurrence of pressure sores.1.2.3 tissue hypoxia, many ICU patients have circulatory dysfunction,

24、and mechanical ventilation treatment, these will reduce the oxygen supply of the tissue. The use of many special drugs, such as certain vasoactive drugs, can cause hypoxia in the skin tissue. Norepinephrine, for example, can cause peripheral vasoconstriction, reduce peripheral tissue perfusion and c

25、apillary blood flow, and further reduce the oxygen supply of the skin tissue. In addition,Interstitial edema also reduces capillary blood flow and affects the oxygen supply of the skin, 9.1.2.4 stress clinical discovery, early injury patients with early pressure sores incidence rate is high, 10. Und

26、er stress, the hormone release in large quantities, the central nervous system and neuroendocrine conduction system disorder, accompanied by insulin resistance and glucose and lipid metabolism disorders, internal homeostasis was destroyed, the compressive ability of the tissue decreased.1.3 patients

27、 at high risk, such as old age, paralysis, paralysis, coma, malnutrition, incontinence, and patients with stents or plaster. In addition, 11 reported after Luna high APACHE score, the change of body temperature, cycle instability was significantly related to high risk of renal dysfunction, metabolic

28、 acidosis, electrolyte disturbance and other factors are pressure ulcers, especially hypotension more alarming. 2 pressure sore risk factors evaluationThe prevention and treatment of pressure sore - straight is a difficult problem for clinical medical personnel. It is a key step to prevent bedsore b

29、y applying pressure sore risk factor scale (RAS) to assess the patients condition. Clinically recognized and commonly used pressure ulcer risk factors assessment scales include Anderson scoring scale, Waterlow score scale, Nortoni5F subscales, Bradeni scale, Cubbin and Jackson scales, etc. The Unite

30、d States pressure ulcer prevention guidelines recommend using Norton and Braden2 scales, especially Braden assessment scale is considered to be the ideal pressure RAS, the sensitivity and specificity are balanced using Braden assessment scale interventions for high-risk patients, the incidence of pr

31、essure sores decreased 50%60%12, has been applied in the world the majority of medical institutions. The Braden scale contains 6 major risk factors known as pressure sores, namely, sensation, activity, humidity, movement, nutrition, friction and shear force. These 6 aspects in addition to the fricti

32、on and shear for 13, the score was 14 points, each factor is divided into 4 grade scores, total scores of 623, the risk score less pressure is high, 18 points for the diagnosis value of pressure ulcer risk.1518 points suggest mild risk, 1314 points suggest moderate risk, 1012 points suggest high ris

33、k, 9 points belowTips are highly dangerous. Braden assessment in clinical application in elderly patients and ICU (ICU) patients, perioperative and surgical patients can make accurate fracture risk assessment of 13, to take corresponding nursing measures, reasonable utilization of nursing human reso

34、urces, with the scientific method of preventing ulcer. In addition to the external evaluation when the patient is admitted, also stressed that after admission in regularly or at any time, with the progress in the treatment of implementation or the course of admission does not exist or potential risk

35、 factors will produce and perform at any time, the evaluation can help find problems in time, take positive measures to curb the risk of pressure ulcer. The establishment of pressure ulcer grade three monitoring network management, timely reporting, and do well in oral or written communication with

36、patients and their families, to improve the cognition and compliance of patients and their families have effect on the pressure sores nursing, nurse patient communication and better protection of the law.3 prevention and nursing of bedsore3.1 decompression, 3.1.1 decompression, intermittent decompre

37、ssion is the key to effective prevention of pressure sores. Turn back at least 1 times every 1 to 2H. Avoid pulling, pulling, pulling, pushing and pushing when turning over,On the basis of hemiplegia patients in routine preventive nursing of pressure sore, take over circular supine 14, i.e. supine p

38、osition (2 2.5h) - contralateral position (2 2.5h) - patient side (1 1.5h) - supine position (2 2.5h) cycle. In turn the traditional nursing, 90 degree lateral turn over to see, but recent studies have found that the average body side 30 degrees or 60 degrees when the good parts of the pressure ulce

39、r was significantly less than the supine or lateral 90 degrees, 30 degrees lateral pressure is less than 4.27kPa6. Choosing proper position is the first measure to prevent bedsore when turning over. In the semi recumbent position, the head of the bed is raised 45 degrees, the patient is most likely

40、to slide, increasing the caudal shear force, forming pressure sores, so it is advisable to use 8 5 to 30 degrees. To establish a turnover card, Braden score, 7 score, cervical fracture and condition limit, patients must use the air cushion bed 8. Soft pillow is a good decompression device, heel shou

41、ld not use cotton ring, because cotton ring is not flexible, long-term use is compressed, lose the prevention of pressure sores, but cause partial pressure sore 15.3.1.2 commonly used tool 6 decompression decompression Liu Guangwei reports all appliances such as air mattress, water mattress, silicon

42、e mattress can produce massage effect; a new type of automatic turning bed and bed sideways to improve the material and structure of the bed to disperse the back skin pressure to prevent bedsore; make the ideal program-controlled massage bed body pressure is less than 4kPa, is a kind of ideal mattre

43、ss. Local support tools to prevent pressure sores Wang Yulin 15 reported a small cool liquid cushion pad, three liters of water, infusion bags, compound tea pad, pad, the pad negative semen cassiae. In order to reduce the pressure, the air cushion is the best, followed by water cushion, gel pad and

44、foam plastic mat. The temperature is the lowest, the cushion is the second, and the cushion and the foam pad are higher than 16. It is recommended to use pressure reducing products according to temperature and humidity.3.2 nutritional support malnutrition is the internal cause of pressure sores, and

45、 can affect the healing of pressure sores. Protein is essential for tissue repair, and vitamins promote wound healing. Should be based on the nutritional status of patients targeted for nutritional supply, given high protein, adequate heat, high vitamin diet, in order to increase the body resistance

46、 and tissue repair capacity.In addition, the appropriate supplement of zinc sulfate and other minerals can promote the healing of pressure sores 17. If the pressure ulcer of grade IV is not cured for a long time, intravenous infusion of compound amino acids and anti infection therapy can be done. In

47、 patients with hypoproteinemia, intravenous infusion of plasma and Human Albumin can increase the plasma colloid osmotic pressure and improve the blood circulation of the skin. The total parenteral nutrition (TPN) can be used to treat those who can not eat, so as to ensure the daily supply of variou

48、s nutrients and to meet the metabolic needs of the body.3.3 avoid damp stimulation, use diaper or urine receiver for incontinence, keep perineum and skin clean and dry. Use catheter with catheter instead of anal canal for frequent diarrhea and fecal incontinence. Methods: according to the selection

49、of the appropriate type of tracheal catheter, endotracheal tube coated with paraffin oil in patients after anus, and inflated, external disposable laparoscopic protective sleeve, which can effectively protect the perianal skin and reduce the nursing workload. There are also reports of using Johnson

50、0B tampons stuffed into the anus to prevent fecal spills, replacing 34h 1 times per 18.After the above treatment and with drug treatment, the fecal incontinence control, so as to reduce the waste of perianal skin irritation, keep the perianal skin clean and dry; the wound secretion more or sweating

51、patients, timely cleaning the wound dry skin, clothes and sheets should be replaced, often remove debris, keep the bed clean clothing, dry and smooth without wrinkles.3.4 part processing3.4.1 a wound wound compression skin flush, induration, should be based on the change of position, can use the hyd

52、rocolloid dressings (ulcer paste, transparent paste), not massage, because soft tissue compression red is a protective response to normal skin, relieve pressure after a 30 40min will not fade, the formation of pressure ulcer, such as redness, that soft tissue injury, massage will aggravate the damag

53、e degree. Postmortem examination showed that the local tissue that had been massaged showed maceration and degeneration without any massage, 19. Transparent dressing can effectively reduce the patients skin pressure, make local skin more smooth, wear-resistant, so as to reduce the local skin stress,

54、 shear stress and friction, can effectively eliminate the 20 caused by the pressure sore. Usage: according to the local compression area, choose transparent paste, which is slightly larger than the partial pressure skin. After the local skin is washed, it will be put on a transparent paste, gently p

55、ressed by hand, so that the transparent paste and the skin firmly affixed to it, and try to keep the local dry. In addition, many hospitals are still using the gas ring, which is not advisable, because inflatable gas ring will be the skin venous reflux compression blocking, is not conducive to the c

56、entral part of the skin blood circulation.3.4.2 two stage wound has no damage or less infiltration in the two stage. Hydrocolloid dressing can be used, and the dressing interval is 2 to 7d. The wound is damaged or more fluid, and hydrocolloid dressing / alginate dressing can be used. Local skin full

57、-thickness rupture, but not involving subcutaneous tissue or local ulcer tissue red TODAY, NURSE, May, 2011, No.5 embellish and necrotic tissue is not long, can clean the wound surface. Research has shown that water washing is better than scrubbing 21. Can promote granulation tissue growth, accelera

58、te healing, when the exudate exudate wound edge, replace the guard.3.4.3 three or four stage complete debridement, remove necrotic tissue, cut scab and cut drainage, change dressing interval 24h, if not cut scab, use water gel and hydrocolloid dressing, autolysis debridement. The thick scab is then

59、used after the blade is scratched and the dressing interval is between 3 and 4D. The tendon and periosteum are exposed and protected by water gel, and surgery is performed if necessary.3.4.4 refractory ulcers can be treated with hyperbaric oxygen.The selection principles of 22 3.4.5 absorption capacity of wound dressing according to the exudation amount of dressing