1、AMDA Clinical Practice Guideline(CPG) for Pressure Ulcers 美国医师协会压疮临床实践指南,For Medical Directors and Attending Physicians 适合于卫生主管和主治医师,What is a Pressure Ulcer? 压疮是什么?,Any skin lesion usually over a bony prominence caused by unrelieved pressure resulting in damage to underlying tissue 皮肤损伤_通常发生在骨隆突处_是
2、压力和/或剪力、摩擦力对皮下组织损伤的结果。,Pressure Ulcers May Not be Preventable 有些压疮是难以避免的,Aggressive measures can reduce but not eliminate the incidence of pressure ulcers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； Can develop despite best efforts of clinical team in high risk patients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 Every effort shou
3、ld be made to prevent pressure ulcers要通过任何方式的努力来预防压疮； A systematic approach to recognize and manage pressure ulcers is needed需要用系统化的管理方法来识别和管理压疮。,Factors Affecting Pressure Ulcer Development 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,AMDA Pressure Ulcer CPG Steps压疮临床实践指南包括：,Recognit
4、ion识别 Assessment/Root Cause Analysis评估和分析根本原因 Treatment治疗 Monitoring监护,Pressure Ulcers CPG Recognition压疮识别,Document any history of pressure ulcers in the medical record在病历中记录压疮的全部历史资料； Thoroughly examine all skin surfaces on admission入院时仔细全面检查病人的皮肤； Identify all primary risk factors识别所有基本的风险因素,Press
5、ure Ulcers CPG Recognition压疮识别,Distinguish types of ulcers辨别溃疡的类型 Vascular insufficiency/ischemia (venous stasis and arterial ischemic ulcers)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,Pressure Ulcers CPG Recognition压疮识别,Primary risk factors for development of pressure ulcers are:形成压疮的原
6、发危险因素： Impaired/decreased mobility活动性受到限制或者减少 Co-morbid conditions, e.g., diabetes mellitus糖尿病等合并症 Urinary or fecal incontinence失禁 Undernutrition, malnutrition, & hydration deficits营养不良、脱水 Impaired diffuse or localized blood flow血流灌注受限或者局部淤血 Drugs such as steroids that may affect wound healing类固淳药品的
7、使用影响伤口康复； History of a healed pressure ulcer压疮痊愈的经历 Resident refusal of some aspects of care & treatment居民拒绝给予局部的护理和治疗 Intrinsic risks due to aging老龄化为固有的危险因素,Pressure Ulcers CPG Recognition压疮识别,Major Risk Factors for Developing Pressure Ulcers发生压疮的主要因素 Alterations in sensation or response to comfor
8、t对舒适与否的感觉反应能力发生变化 Degenerative neurological disease退化性神经疾病 Cerebrovascular disease脑血管疾病 Central nervous system (CNS) injury中枢神经系统受损伤 Depression抑郁等情绪,Pressure Ulcers CPG Recognition压疮识别,Major Risk Factors for Developing Pressure Ulcers形成压疮的主要危险因素 Causes of impaired/decreased mobility活动性受限或减少 Neurolog
9、ic disease/ injury神经疾病/神经损伤 Fractures骨折 Pain疼痛 Restraints受到束缚,Pressure Ulcers CPG Recognition压疮识别 Comorbid Conditions That May Affect Ulcer Healing 多种可能影响压疮康复的身体状况,Malnutrition and dehydration营养和水合作用 Diabetes mellitus糖尿病 End-stage renal disease晚期肾脏疾病 Thyroid disease甲状腺疾病 Congestive heart failure充血性心
10、力衰竭 Peripheral Vascular Disease外周血管疾病,Vasculitis/other collagen vascular disorders 血管炎和其他胶原血管疾病 Immune deficiency states免疫缺陷状态 Malignancies恶性肿瘤 COPD 慢性阻塞性肺病 Depression and psychosis精神状态抑郁 Drugs that affect healing药物影响康复 Contractures at major joints关节处大范围的挛缩,Pressure Ulcers CPG Assessment压疮评估,Pressur
11、e Ulcer Classifications 分级 Stage 1: Observable, pressure-related alteration of intact skin, including changes in skin temperature, tissue consistency, sensation, and/or defined area of persistent redness in light skin (red, blue or purple hues in dark skin) 一期压疮 Stage 2: Partial thickness skin loss
12、involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater二期压疮,Pressure Ulcers CPG Assessment压疮评估,Pressure Ulcer Classifications continued Stage 3: Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue
13、 that may extend down to, but not through, fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue 三期压疮 Stage 4: Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures (e.g., tendon, joint
14、 capsule). Undermining and sinus tracts also may be associated四期压疮,Pressure Ulcers CPG Assessment压疮评估,Ethical Issues To Consider对伦理的考虑 Review Advance Directives检查病人预先的医嘱 Identify choices that limit the scope, intensity, duration and selection of various wound-related or adjunctive treatments选择治疗作用区域
15、、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。,Pressure Ulcers CPG Assessment压疮评估,An effective assessment includes有效的评估包括： Define and interpret factors affecting treatment and wound healing such as physical, functional and psychosocial factors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。 Define prognosis identify real
16、istic goals解释预测识别现实的各个目标 Identify management priorities识别需要处理的优先项目。,Pressure Ulcers CPG Assessment压疮评估,Certain clinical findings may have priority 确定临床所见现象能够治疗的优先顺序。 Address systemic and life-threatening issues 标明对系统或生命有威胁的问题； Stage 3 and 4 ulcers 三期、四期压疮 Significant pain 明显疼痛的疮口 Fluid and electroly
17、te abnormalities渗出物或电解质异常 Nutritional deficits营养不足 Need for surgical intervention to remove necrotic tissue需要通过外科手术来清理掉坏死组织。 Soft-tissue infection软组织感染。,Factors That Affect PU Wound Healing 影响压疮伤口康复的因素包括：,PU Wound healing is a complex multifactorial process 压疮的康复是一个 复杂的、多因素的、 缓慢的过程！,Soft Tissue Infe
18、ction 软组织感染,Systemic Illness 系统性疾病,Osteomyelitis 骨髓炎,Wound Environment 伤口周边环境,Pressure 压力,Oxygen 氧供能力,Perfusion 灌注状况,Systemic Healing Ability 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！,LEAN MASS Erosion (catabolism) of muscle protein Visceral protein f
19、or glucose production肌肌肉蛋白腐化（分解代谢），内脏蛋白利用葡萄糖,ENERGY PRODUCTION Mainly from glucose and amino acids能量生产主要来自于葡萄糖和氨基酸,A marked increase in energy demands and lean body mass loss initiated by the stress response 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。,Amino Acids氨基酸,Photos courtesy of R.H. Demling, MD.,The Ca
20、tabolic Response to a wound (Activation of the Stress Response 伤口的分解代谢反应（压力刺激反应),Net protein loss纯粹的蛋白质丢失,The Nonhealing Chronic Wound Failure to Heal by 12 Weeks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,Protein Synthesis 蛋白质合成,Energy Store能量储存,Prot
21、ein Store蛋白质储存,Macronutrients 大量营养物质,Energy,Energy Store能量储存,Protein Store蛋白质储存,Macronutrients 大量营养物质,Protein Synthesis 蛋白质合成,The Nonhealing Wound 坏死阶段的伤口,The Healing Wound 康复阶段的伤口,Filling 填充,Wound contraction 伤口收缩,Dense collagen scar细密的胶原结疤,Neutrophils 嗜中性白细胞,O2,Courtesy of R.H. Demling, MD.,Pressu
22、re Ulcers CPG Treatment压疮治疗,Wound prevention plan伤口预防方案 Wound treatment plan 伤口治疗方案,Pressure Ulcers CPG Treatment 压疮治疗,Preventive measures预防措施 Maintain personal hygiene保持个人卫生 Assure adequate nutrition 保证适当的营养 Manage urinary/fecal incontinence正确处理失禁病人的护理 Reposition and have patient shift weight 更换体位,
23、转移病人受压部位 Avoid messaging reddened areas避免出现变红的区域 Prevent contractures 预防挛缩,Position to alleviate pressure over bony prominences 体位更换缓解骨突出处的压力 Use positioning devices使用减压性的体位垫装置 Maintain lowest head elevation 保持最低的头部高度 Use lifting devices使用可以提升病人的转移装置,Pressure Ulcers CPG Treatment压疮治疗,Preventive Meas
24、ures预防措施 Important Points on Positioning and Support Surfaces 关于体位和支撑面的要点 Use a pressure-reducing mattress 使用减压防护垫 Avoid placing patient on trochanters or directly on wound避免病人骨隆突处和伤口处直接受压 Mattress options foam, air loss, water, gel, alternating air or viscoelastic 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 Pr
25、essure relieving devices (e.g. viscoelastic mattress) where indicated 危险部位使用分散压力的装置（例如：粘弹性ACTION防护垫）,Pressure Ulcers CPG Treatment压疮治疗,Preventive Measures预防措施 Assuring adequate Nutrition and Hydration 保证营养和水分 Watch for anorexia in patients with a sudden change in intake对于食欲缺乏的病人要改变营养摄入方式 Undernouris
26、hed patients caloric/protein/hydration targets:营养不足的病人热量、蛋白质、补水作用的目标： 30-35 calories/kg/day 1-1.5 g/kg/day protein 30 ml/kg/day fluid Except for a daily multivitamin, other vitamin and mineral supplements are not needed unless deficiencies are confirmed 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
27、。,Pressure Ulcers CPG Treatment压疮治疗,Preventive Measures A Step Wise Approach to Nutritional Intervention in Patients with Wounds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Level 1 Approximately within first week after wound onset第一阶段大约在伤口开始后的第一周内 Level 2 Following completion of Level 1 assessment第一阶段治疗后进行第二阶段治疗 Lev
28、el 3 Approximately within 2 weeks of implementing Level 2第二阶段治疗后两周内进行第三阶段的治疗.Source: AMDA Pressure Ulcer Therapy Companion Clinical Practice Guideline,Pressure Ulcers CPG Treatment压疮治疗,Wound Care伤口护理 Principles of wound dressings:伤口敷裹的原则： Protect wound bed from further trauma, contamination or dryin
29、g避免伤口创面进一步的受到创伤或者污染或者过于干燥 Promote removal of necrotic tissue and exudate加速坏死组织和渗出物的移除 Provide a moist healing environment supportive of regeneration and growth of granulation tissue. 提供湿润的愈合环境来利于恢复和肉芽组织生长 Wound characteristics change as the wound evolves.随着伤口的发展，伤口的特性不断发生改变。 Tailor dressings primari
30、ly to wound characteristics, not wound stage选择适应伤口特性的敷料，而不是适应伤口的阶段。,Pressure Ulcers CPG Treatment压疮治疗,Wound Care Teams Possible Roles合理的角色伤口护理团队Help guide care by staying abreast of developments in the field利用该领域的发展结果来帮助指导护理工作 Evaluate new products for formulary评估规定的新产品 Provide consultation for diff
31、icult wounds提供不同类型伤口的咨询 Help select appropriate support surfaces for complex patients帮助病人选择适当的支撑装置 Train new staff训练新的医护人员 Provide continuing education for existing staff提供目前医护人员的持续教育 Perform wound care执行伤口护理,Pressure Ulcers CPG Treatment压疮治疗,Wound Care Intact Skin 伤口护理完整的皮肤 Stage 1 Pressure Ulcers
32、may herald a more extensive wound一期压疮或许已经预示更大面积的损伤 Protect involved area from further injury from pressure or shearing forces预防相关区域遭受压力和剪切力的进一步损伤 No dressing required没有包扎伤口的必要 Monitor frequently for changes频繁的监测伤口变化,Pressure Ulcers CPG: Treatment压疮治疗,Wound Care Clean Wound Base清洁伤口的基底部 Stage 2 or he
33、aling Stage 3 or Stage 4 wound 二期或者处于康复阶段的三期四期压疮 Dressing should keep ulcer bed continually moist but the surrounding skin dry敷料要保证创面的湿润但是周围要保证干的 Choose dressing based on situation根据伤口的情形来选择包扎方式 Fill wound dead space with loosely packed dressing material伤口的死腔要用疏松的敷料来填充,Pressure Ulcers CPG: Treatment
34、压疮治疗,Wound Care Eschar or Wound Base with Adherent Necrotic Tissue伤口焦痂或者伤口出现附着的坏死组织Additional treatments are indicated in wounds covered by eschar or with surface necrosis of subcutaneous tissue (without undermining adjacent tissue) 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 Types of debridement used to remove e
35、schar and surface necrosis用于移除焦痂和皮下坏死组织的各种清创术 Sharp surgical debridement剧烈的外科清创术 Mechanical机械的 Enzymatic agents采用酶因子的 Autolytic 自溶的 Sterile biological (maggot)无菌的生物学方法 Dont use topical antibiotics routinely 不要例行公事地使用局部抗生素,Pressure Ulcers CPG: Treatment压疮治疗性处理,Wound Care Extensive Subcutaneous Tissue
36、 Damage广泛的皮下组织损伤Stage 4 (some Stage 3) pressure ulcers are characterized by full thickness skin loss with extensive tissue necrosis, undermining and sinus tracts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； Treatment may require extensive surgical debridement治疗需要较大面积的外科清疮术； All devitalized tissue removed去除所有的坏死
37、组织 Undermined areas should be explored and unroofed深部损伤要去除表层才能准确界定。,Pressure Ulcers CPG: Treatment压疮治疗性处理,Wound Care Categories of Products Used in Wound Care用于伤口护理的产品分类 Hydrocolloids水胶体 Alginate藻酸盐等 Foams泡沫等 Wound Fillers 伤口填充物 Composite Dressings合成敷料,Pressure Ulcers CPG: Treatment压疮治疗性处理,Wound Car
38、e Ongoing Management 持续的管理 1. Cleanse at each dressing change清洁伤口更换敷料 2. Debride eschar, as needed如果有需要的话要清创焦痂 3. Evaluate/treat for infection评定和处理感染 4. Employ facility infection control利用多种设施达到感染控制,Pressure Ulcers CPG: Treatment压疮治疗性处理,Wound Care Ongoing Management (continued)持续处理 5. Re-evaluate co
39、-existing medical conditions再次评定病人身体状况方面的医疗条件 6. Prescribe pain control measures处方建议采用控制疼痛的措施 7. Address psychosocial issues, depression, and possible isolation病人的心理状态，可能孤独和抑郁。,Pressure Ulcers CPG Treatment压疮治疗性处理,Wound Care Alternatives to Non-Responders 伤口护理-针对没有反应的患者供选方案For clean wounds not respo
40、nding to appropriate treatment consider:为没有反应的患者清洁伤口提供适当的治疗： Topical antibiotic ointments/solutions for 2 week trial局部提供的抗生素，尝试两周； Progress to a support surface that offers further protection 改进支撑体的质地，提供更深入的保护； Consider a course of electrotherapy 考虑给予电疗治疗； Consider transfer to another site for surgi
41、cal debridement/repair, mgt. of systemic complications, comfort/pain mgt., and specialized diagnostic studies 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。,Pressure Ulcers CPG Monitoring压疮监测,Regular weekly evaluations to assess healing (based on established Assessment Guides) to monitor success of the treat
42、ment regimen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-up diagnostic testing and consultation 跟随诊断测试和会诊,Document patient response to treatment证明病人治疗的反应 Monitor and adjust treatment as indicated监测指征调整治疗方案 Recognize and manage complications识别和处理合并症,Pressure Ulcers CPG: Monitoring压疮监测,Pressure
43、Ulcers CPG Monitoring压疮监测,Decide Whether To Change Treatment As Wound Heals 根据伤口愈合状况决定是否改变治疗方式 Dressing types敷料的类型 Debridement options清创术的选择 Nutritional program营养补充程序 Support surface options选择表面支撑体,Pressure Ulcers and Quality Improvement 压疮管理和护理质量的改进,Goals of system to prevent and manage pressure ul
44、cer预防和治疗压疮的系统目标Wound improvement/healing 伤口改善/愈合 Prevent additional skin breakdown防止进一步的皮肤损伤； Prevent decline in overall condition 预防全身性衰弱； Pain reduction 减少疼痛,Pressure Ulcers and Quality Improvement 压疮管理和护理质量的改进,Tips for risk management related to pressure ulcers与压疮治疗有关危险因素管理体系 Clear and consistent
45、 documentation in the chart清楚的连贯性的图解； Clearly defined roles and responsibilities清楚确定相应的角色和任务； Effective communication between shifts and disciplines多学科之间有效沟通； Communication with families与家庭建立沟通机制； Document unavoidable factors that prevent healing or lead to worsening of pressure sores记录引起压疮进一步恶化或者阻碍
46、压疮康复的难免性因素； Policies and QA measures to ensure quality care通过相应政策和质量管理措施来保证护理工作的品质。,Summary概述,Pressure ulcers continue to challenge nursing facilities在各个护理机构压疮是持续存在的难题 Some ulcers are unavoidable, many develop prior in hospitals有一些压疮是难于避免的，有一些压疮是在病人入院前已经产生了的。 There is a need to maintain processes and systems to address prevention, recognition, and treatment that maximize the patients comfort, dignity and quality of life需要一系列的程序包括：预防、识别和治疗措施，最大程度的让病人舒适、感受到尊重和拥有更好的生活质量。,
