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Cleanliness and hygiene （二）

Cleanliness and hygiene （二）. 压 疮 （ Pressure sores ）. 身体局部组织长期受压，血液循环障碍，局部持续缺血、缺氧、营养不良而致的软组织溃烂和坏死。 来源于拉丁文 Decub 褥疮 bed sores 压力性溃疡 pressure ulcers 营养性溃疡. Mechanism of Pressure Ulcers. Mechanism. Mechanism. Outer factors. Inner factor. Blood Circulation smoking spasm

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Cleanliness and hygiene （二）

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  1. Cleanliness and hygiene（二）

  2. 压 疮（Pressure sores） 身体局部组织长期受压，血液循环障碍，局部持续缺血、缺氧、营养不良而致的软组织溃烂和坏死。 来源于拉丁文 Decub 褥疮 bed sores 压力性溃疡 pressure ulcers 营养性溃疡

  3. Mechanism of Pressure Ulcers

  4. Mechanism

  5. Mechanism Outer factors Inner factor Blood Circulation smoking spasm Age Nutrition Anaemia Movement & Sensation Mechanics Factor pressure friction shearing force Trauma & Infection Temperature Moisture Pressure ulcer

  6. Mechanism-Pressure Landis 2.7Kpa Mclennan 2.1-4.3Kpa (体积描记器) Disdule 9.3Kpa 2h 肌肉：500mmHg 4h 皮肤：800mmHg 8h 200mmHg 16h

  7. Mechanism-Pressure 压力梯度

  8. Mechanism-Shearing Force N f G 剪切力（Shearing force) 因两层组织相邻表面间的滑行，产生进行性地相对移动所引起的，是由摩擦力与压力相加而成，与体位有密切关系。

  9. Risk Factors

  10. 患神经系统疾病者 老年人 肥胖者 身体衰弱、营养不佳者 水肿病人 疼痛病人 石膏固定病人 大小便失禁病人 发热病人 使用镇静剂的病人 Susceptible People（易患人群）

  11. Susceptible Sites（易患部位） • 缺乏脂肪组织保护、无肌肉包裹或肌层较薄的骨隆突处及受压部位 supine position side-lying position prone position sitting position • 皮肤皱褶处 • 石膏包裹或受压处

  12. Supine Position

  13. Side-lying Position （髋部）

  14. Prone Position

  15. Sitting Position

  16. Stages of Pressure Ulcer Formation

  17. 瘀血红润期 StageⅠ Ⅰ期：具有超过30分钟不消退的红斑，皮肤完整

  18. 炎性浸润期 Stage Ⅱ Ⅱ期：损害累及表皮或真皮受损

  19. 浅度溃疡期 Stage Ⅲ Ⅲ期：损害涉及皮肤全层及皮下脂肪组织

  20. 深度溃疡期 Stage Ⅳ Ⅳ期：深层组织（肌肉、骨骼、关节）受损

  21. 深度溃疡期 Stage Ⅳ

  22. Pressure Ulcers &Nursing Process

  23. Assessing • Assessment of Skin Integrity • Assessment of Pressure Ulcer

  24. Assessment of Skin Integrity • Nursing History • Physical Assessment • Risk Assessment Tools

  25. Braden Scale for Predicting Pressure Sore Norton’s Pressure Area Risk Assessment Form Scale Anderson Scale Risk Assessment Tools

  26. Braden 量表 总分：6-23分 总分↓ 危险性↑ 轻度危险：15-18分 中度危险：13-14分 高度危险：10-12分 极度危险：9分以下

  27. Norton 量表 总分：5-20分 15-18分：5％ 14分以下：32％ 12分下（高危组）：48％（2周） 营养评估量表

  28. 营养评估表 25-28分：不易患压疮 19-25分：较易患压疮 ≤18分：极易患压疮

  29. Anderson危险指标记分法 记分≥3分，发生压疮的危险性极高

  30. Assessment of Pressure Ulcers • Location of the lesion • Size of lesion (length, width, depth) • Stage of the ulcer • Color of the wound bed and location of necrosis or eschar • Condition of the wound margins • Integrity of surrounding skin • Clinical signs of infection

  31. 头 长 宽 脚

  32. 记录 • 骶尾部Ⅲ压疮，大小6×6cm，伤口基底部80％黄色腐肉，有大量血水样渗出液，无味，伤口周围皮肤红肿，有触痛。

  33. Diagnosing • Impaired Skin Integrity • Risk for Infection • Pain • Body Image Disturbance • Anxiety

  34. Planning For maintaining intact skin • Inspect at regular intervals • Keep skin clean, dry, and moisturized • Provide appropriate pressure-relieving devices and measures For promoting wound healing • Advocate wound nutrition • Document wound assessment at regular intervals • Apply appropriate wound treatments and dressing

  35. Implementing • Preventing Pressure Ulcers • Treating Pressure Ulcers

  36. Preventing pressure ulcers • Protecting the Skin from External Mechanical Forces Turning the client periodically *body Mechanics Supporting surface*Doughnut Avoiding Friction and Shearing Force • Hygiene and Skin care • Stimulate Blood Circulation of Skin *Massage Heat lamps • Providing Nutrition • Teaching Clients and Families about Prevention

  37. Supine Position

  38. Side-lying Position · · ·

  39. Prone Position

  40. Sitting Position

  41. Sapphire 1100 ORTHODERM CONVERTIBL Air Prism Sapphire 800 Sapphire 475

  42. Thera-Turn 1000 Prodigy Mattress Overlay Comfort Turn Roho Dry Flotation Mattress Overlay Tru - Turn

  43. MAXIFLOAT L SERIES NATURE SLEEP 700 MAXIFLOAT D SERIES 436 PRESSURE REDUCTION MATTRESS MAXIFLOAT E SERIES

  44. Low Air Loss Mattress

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