The first section pressure sore evaluation system
I. Definition
Pressure sore refers to the soft tissue injury, such as ulceration and necrosis, caused by local persistent ischemia, hypoxia and malnutrition due to long-term compression of local tissues and blood circulation disorder. The most basic and important factor that causes pressure ulcers is stress, so at present, pressure ulcers tend to be renamed as "pressure ulcers or pressure ulcers".
Second, the prone parts
Pressure sores mostly occur in the compression of bony protuberance, lack of adipose tissue protection, no muscle wrapping or thin muscle layer, which is closely related to lying position.
Supine position: common in occipital tuberosity, scapula, elbow, sacrococcygeal, heel, especially sacrococcygeal.
When lying on the side: it is common in auricle, acromion, ribs, hip bone, femoral rotor, medial and lateral of knee joint and medial and lateral of ankle joint.
Prone position: prone on cheeks, auricle, acromion, female breast, rib protrusion, male genitalia, anterior superior iliac spine, knees and toes.
When sitting: it mostly occurs in ischial tubercle, scapula, heel and so on.
Third, high-risk groups.
The high-risk groups prone to pressure ulcers include: ① the elderly or obese; 2. Patients with emaciation, malnutrition, anemia and diabetes; ③ Coma patients taking sedatives; ④ Patients with paralysis, edema, fever or pain; ⑤ Incontinence patients; ⑥ Those whose activities are limited due to medical care measures (such as braking, plaster fixation, surgery, traction, etc.). ).
Fourth, risk factors.
The risk factors of pressure ulcer include: ① limited activity; (2) elevated body temperature; (3) change of consciousness or sensory disturbance; ④ Application of orthopedic instruments; ⑤ Malnutrition or disorder of water metabolism; ⑥ Drug influence; ⑦ The skin is stimulated by water; ⑧ The whole body lacks oxygen.
Five, pressure sore staging
1, stagnation and redness (1)
It's the early stage of pressure ulcers. Local skin compression, temporary blood circulation disorder, manifested as redness, heat, numbness or tenderness. There is no damage to the skin surface at this stage.
2. Inflammatory infiltration stage (second stage)
The red and swollen parts are continuously compressed, the blood circulation is not improved, the venous return is blocked, and local venous congestion occurs. The compressed part is purplish red, with induration under the skin. Edema thins the skin and can form blisters. After the blister burst, a moist and ruddy wound surface can be seen, and the patient has pain.
3. Superficial ulcer stage (stage III)
Epidermal blisters gradually expand, and there is yellow exudate on the dermal wound. After infection, the epidermis is covered with pus, which leads to superficial tissue necrosis and ulcer.
4. Necrotic ulcer stage
For the severe stage of pressure sore, necrotic tissue turns black, purulent secretion increases, and the smell is unpleasant; The infection spread to the surrounding and deep tissues, invading the dermis and muscle layer, reaching the bone; Severe cases can cause septicemia or septicemia, endangering patients' lives.
Six, pressure sore wound assessment
Evaluation content:
1. Wound size: (length× width) You can measure the length of the wound from head to toe and the width from left to right with a ruler.
2. Depth: Put sterile hemostatic forceps directly into the deepest part of the wound, and measure the distance between the starting point of hemostatic forceps and the skin surface to hemostatic forceps's head.
3. Stealth depth: When measuring, put the sterile hemostatic forceps directly at the deepest place that hemostatic forceps can reach along the knife edge, and measure the distance between the starting point of hemostatic forceps and the skin surface to hemostatic forceps's head.
4. Histomorphology: black scab, yellow carrion, red granulation tissue, epidermal hyperplasia, hard around wound tissue.
5, exudate: pink bloody, yellow clear, yellow pus, yellow-green pus or brown, smell: tasteless, smelly.
6. Skin or tissue around the wound: normal, white, pink, crimson, purple and black.
The prevention system of pressure sore in the second quarter
After evaluating the patients with pressure sore evaluation form, the following preventive measures should be taken for patients with pressure sore risk factors:
1, protect the skin and avoid local pressure for a long time.
Establish a turn-over card to encourage and assist patients to turn over within Q2h; Protect the carina and support the body gap; Avoid dragging, pulling and pushing when patients turn over and carry, and prevent skin damage; For patients who stay in bed for a long time, the bedside should be raised < 30 to reduce the occurrence of shear force. For patients who use plaster, splint and traction, the padding should be flat and soft.
2. Keep the patient's skin clean and avoid local irritation.
Timely remove the patient's urine, feces, sweat and other body excreta and secretions, avoid using soap and alcohol products to clean the skin, and keep the bed unit clean, dry and flat.
3, promote skin blood circulation
Warm water bath and proper massage can be used to avoid massage at the protruding parts of bones and redness of skin, so as not to aggravate skin damage.
4. Improve the nutritional status of the body.
For patients whose condition permits, encourage them to eat a diet with high protein, high vitamins and high zinc, and assist parenteral nutrition when necessary.
5. Health education
Carry out publicity and education on the prevention of pressure ulcers for family members and patients, and improve patients' compliance behavior.
6. For patients with high-risk pressure ulcers, pressure ulcers should be reported, registered and followed up as required.
Section III Pressure Ulcer Reporting System
First, pressure ulcers report indications:
1. No pressure ulcer occurred, but the risk factor score reached the report score (see pressure ulcer occurrence report/high-risk warning for details).
2, pressure ulcers outside the hospital.
3, pressure ulcers are inevitable
4, pressure ulcers in hospital
Second, the pressure sore prevention and prediction process and responsibilities
1. Nurses should carefully hand over and carefully evaluate patients' skin condition when accepting patients who are admitted to hospital, transferred to other hospitals and after operation, and patients who are critically ill, unable to take care of themselves and need intensive care.
2. When patients are found to have pressure ulcers or high-risk pressure ulcers, the Pressure Ulcer Occurrence/High-risk Early Warning Report should be filled in within 24 hours after the patients are admitted to hospital, transferred to hospital or have pressure ulcers, and the head nurse should report it to the nursing department in time after evaluating and signing. In case of holidays, report to the night shift for ward rounds.
3. Record the patient's current skin or skin lesions in detail, such as location, scope, degree and depth. (Patients transferred to other hospitals and undergoing major surgery should be accompanied by nurses to confirm their signatures) and wound treatment methods.
2, take appropriate nursing measures and make corresponding records.
(1) Keep the bed unit clean, dry and flat;
(2) Keep the skin clean and dry;
(3) implement local decompression measures such as turning over and hip lifting, and establish a turning-over card (if the patient or his family refuses to cooperate with turning over or massage, the nurse should make corresponding records); The roll-over record should reflect Q2h roll-over, massage or hip lifting.
(4) properly handle the wound.
(5) For patients with inevitable skin pressure ulcers in the hospital, such as severe hypoproteinemia, forced posture, advanced cancer, etc. There is no risk of pressure ulcers when admitted to hospital, and effective preventive measures are actively taken to avoid pressure ulcers as much as possible.
3, completes the skin condition succession.
(1) Recording frequency The skin condition of Grade I nursing and critically ill patients is recorded with the frequency of patient's writing shift, while the skin condition of Grade II and III patients is recorded at least 1 time per week. If patients with grade ⅰ, ⅱ and ⅲ have dressing changes, they should write in time.
(2) Record the present situation of skin or the location, scope, degree, depth and treatment of skin lesions.
4. Register the prognosis of pressure sore in the pressure sore follow-up table in time, and indicate the date, skin condition or patient's whereabouts of pressure sore, and notify the head nurse; Patients with pressure ulcers should also be informed of the head of the pressure ulcer management team.
5. Those who fail to report in time shall be punished according to the relevant regulations of the nursing department for individuals, head nurses and departments.
The fourth quarter pressure sore follow-up system
First, the hospital pressure sore management team
1. Make an assessment within one working day (except holidays) after receiving the early warning report of pressure ulcer occurrence/high risk. The evaluation contents include:
(1) For patients with pressure ulcers, evaluate the degree of skin lesions according to the prediction record; For those predictors of pressure ulcers that are considered inevitable, the integrity of their skin should be evaluated;
(2) To evaluate the feasibility and implementation of measures to prevent and treat pressure ulcers;
(3) record of evaluation of prevention and treatment measures for pressure ulcers;
(4) Pressure sore record.
2. Patients with pressure ulcers are followed up 1-2 times a week. Follow-up measures should be taken:
(1) to guide wound treatment and correctly record the follow-up record of pressure ulcers.
(2) Evaluate the implementation of preventive measures.
(3) After the wound is healed, fill in the outcome on the pressure sore follow-up record; If follow-up is needed, it will be handed over to the head nurse for follow-up.
3. Statistics and analysis of hospital pressure ulcers (in months, seasons and years respectively).
Second, the head nurse
Patients who were predicted to be at high risk of pressure ulcers were followed up 1-2 times a week. Follow-up should be:
1. Evaluate the patient's skin integrity, the implementation of measures, the writing of nursing records and the results of pressure ulcers. Fill in the pressure ulcer follow-up record form in time and submit it to the nursing department.
2, when the patient's condition improved, change one's major, discharge or death, according to the nursing unit pressure sore registration record content truthfully fill in the pressure sore follow-up record form and submit it to the nursing department.
3. In case of pressure sore, immediately supervise and take corresponding measures, and record the implementation. At the same time, fill in the early warning report of pressure ulcer occurrence/high risk, report it to the nursing department, and call the hospital pressure ulcer management team.
The fifth section pressure sore treatment and nursing standards
First, diagnose:
1, blood stasis and ruddy phase
The blood stasis and ruddy period is also called stage I pressure sore. Temporary blood circulation disorder occurs in the compressed part, and local skin appears redness, swelling, heat, numbness or tenderness. After the pressure was released for 30 minutes, the skin color could not return to normal.
2. Inflammatory infiltration stage
Inflammatory infiltration stage is also called stage ⅱ pressure sore. If we continue to press the red and swollen parts, the blood circulation will not be improved, the venous return will be blocked, and the local veins will be congested, indicating that the local redness will infiltrate, expand and harden; The skin color turns purple and does not fade when pressed; Blisters often form on the epidermis, which is very painful.
3. Superficial ulcer stage
Epidermal blisters burst, revealing moist and ruddy wounds with yellow exudate flowing out; After infection, the surface is covered with pus, causing superficial tissue necrosis, forming ulcers and aggravating pain.
4. Necrotic ulcer stage
It is the severe stage of pressure sore, with black necrotic tissue, increased purulent secretion and foul smell; The infection spread to the surrounding and deep tissues, invading the dermis and muscle layer, reaching the bone; Severe cases can cause septicemia or septicemia, endangering patients' lives.
Second, the treatment:
Principle: local treatment is the main treatment, supplemented by systemic treatment.
1, systemic therapy: active treatment of primary disease, increased nutrition, systemic anti-infection treatment.
2, local treatment:
(1) Blood stasis blocking redness: remove risk factors and avoid the aggravation of pressure ulcers. Wet and hot compress and local massage can be used, but the massage intensity should be gentle to prevent new skin damage. Vaseline gauze can be used to protect the wound for patients with blood stasis that is difficult to recover for too long. Hydrocolloid dressing can be used to treat and protect wounds, but it must be used on the premise that the skin is fully clean, because it is easy to cause the environment to be too humid and lead to new skin damage.
(2) Inflammation and infiltration stage: Protecting skin and preventing infection are the key treatments at this stage.
1) Reduce friction, prevent bubbles from bursting, and promote bubbles to absorb themselves; Large blisters can be pumped out with a sterile syringe, and then the local skin can be disinfected and wrapped with a sterile dressing.
2) When the wound is not infected, vaseline gauze can be used to cover the wound; Hydrocolloid dressing can also be used when the wound is not too wet or oozing, but it is necessary to strengthen the observation of oozing and infection of the wound. Once there is too much exudation or infection, it should be stopped immediately to prevent the wound from deepening or infection from spreading due to too much exudation.
3) When the wound is infected, vaseline gauze mixed with silver sulfadiazine ointment can be used to cover the wound. When silver sulfadiazine is used, there will be protein-like exudation (seemingly purulent exudation, but odorless) on the wound surface. At this time, the interaction between drugs and wounds is a normal reaction.
(3) Superficial ulcer stage: clean the wound and promote healing.
1) After cleaning the wound with normal saline cotton ball, use vaseline gauze, chlortetracycline ointment and tannic acid ointment to promote wound healing and prevent infection.
2) In the case of no infection, hydrocolloid dressing can be used when the wound is not too wet or oozing, but the observation of oozing and infection of the wound should be strengthened. Once there is too much exudation or infection, it should be stopped immediately to prevent the wound from deepening or infection from spreading due to too much exudation.
3) When the wound is infected, it should be cleaned with normal saline cotton ball, treated with local antibacterial drugs and externally applied with sulfadiazine silver cream. When silver sulfadiazine is applied to the wound, there will be protein-like exudation (seemingly purulent exudation, but odorless). At this time, the result of the interaction between the drug and the wound is a normal reaction.
4) Necrotic ulcer stage: remove necrotic tissue and promote granulation tissue growth. The wound can be cleaned with normal saline or 1: 2000 chlorhexidine solution, and then treated with sulfadiazine silver cream. For patients with deep ulcer and poor drainage, 3% hydrogen peroxide solution should be used for washing and dressing change. Secretions from infected wounds should be collected for bacterial and drug sensitivity tests, and drugs should be selected according to the results. Some traditional Chinese medicine preparations (Changpi ointment) can also be used to treat pressure ulcers. For a large area of pressure sore reaching the bone, doctors should cooperate with doctors to remove necrotic tissue and repair the defective tissue by skin grafting, so as to shorten the course of pressure sore and relieve the pain of patients. Pay special attention not to advocate the use of drugs that dissolve necrotic tissue without antibacterial effect to prevent infection from deepening the wound or spreading.
Third, nursing:
1, Nutrition Guidance: Good nutrition is an important condition for wound healing, so we should have a balanced diet and increase the intake of protein, vitamins and trace elements. For long-term malnutrition, bedridden or seriously ill patients, adequate nutrition should be given to supplement high-protein foods such as lean meat; High vitamin diet such as tomato, eggplant and red dates; Those who can't eat are given nasal feeding or supportive therapy under the guidance of nutritionists.
2. Keep the correct posture: increase the number of laps to avoid excessive local pressure. The forced posture taken due to illness should be changed every half an hour to two hours to reduce the time of skin pressure.
3, avoid local skin irritation: underwear is soft and breathable, and it is kept clean and dry; Sheets should be neat and level, without wrinkles and debris; Those who have incontinence, vomiting or sweating should be scrubbed clean in time and change clothes and sheets; Users of diapers must keep diapers clean and dry, and change them in time.
4. Standardized operation: When using the toilet, you should choose a toilet that is not damaged. Don't use it forcibly. If necessary, pad the edge of the toilet with soft paper or cloth to prevent scratching the skin; When turning over, move lightly to avoid scratching your skin. Correctly implement massage (see the chapter on prevention and nursing of pressure sore in the routine nursing operation rules for the prevention of pressure sore).
5, according to the doctor's advice to implement anti-infection treatment, prevent sepsis.
6. Strengthen psychological nursing guidance, encourage patients to establish confidence and turn over frequently.
7. Health education: explain the progress law, clinical manifestations and treatment and nursing points of pressure ulcers to patients and their families, so that they can pay attention to and participate in the early care of pressure ulcers and actively cooperate with the treatment.
Notice on high-risk early warning report of pressure ulcer
In order to strengthen the basic nursing of hospitalized patients and reduce the occurrence of inevitable pressure ulcers in the hospital, the following provisions are made:
1, through the risk assessment of patients who may have pressure ulcers in the hospital before they occur, put forward effective preventive measures and implement them.
2, at the same time, fill in the pressure ulcer occurrence/high-risk early warning report and report it to the nursing department.
3, the nursing department to track, for patients who still have hospital pressure ulcers after taking various measures, the pressure ulcer management team will discuss and decide whether hospital pressure ulcers will inevitably occur.
4. Failure to fill in the early warning report on the occurrence/high risk of pressure ulcers is regarded as failure to effectively prevent it. If pressure sores occur in hospitals, they are all regarded as avoidable pressure sores in hospitals, which are characterized as nursing defects.
Supplementary notice:
If the operation is expected to last more than four hours, the default is a pressure sore risk warning.
Responsibilities of pressure sore management team
1. Organize a survey on the knowledge of pressure ulcers among nurses in the whole hospital, and hold lectures on prevention and treatment of pressure ulcers.
2. Organize the confirmation of inevitable pressure ulcers: For a few inevitable pressure ulcers that still occur after the department announces the high-risk warning of pressure ulcers and takes corresponding preventive and nursing measures, the pressure ulcer management team will check the patients within 24 hours based on the principle of seeking truth from facts, confirm whether they are inevitable pressure ulcers, and propose further preventive measures. If necessary, take photos of the wound and keep the data, and actively carry out teaching and research related to pressure ulcers.
3, responsible for organizing departments to apply for hospitalization, hospitalization complex refractory pressure sore nursing consultation, make full use of the advantages of hospital nursing human resources and material resources, and give feasible guidance to clinical departments.
4, 65438+ 0-2 times a week to check the high-risk early warning patients with pressure ulcers, which plays a guiding, supervising and promoting role.
5. Assist the nursing department to actively promote effective nursing methods for pressure ulcers, such as the application of new dressings for pressure ulcers.
Early warning report of pressure ulcer occurrence/high risk
date month year
Department name, gender, age, bed number and hospitalization number
The date of admission □ occurred in the department □ was brought to the department by other departments ().
□ Out-of-hospital bring □ Inevitable occurrence □ High-risk warning
clinical diagnosis
Assessment of basic conditions of risk factors for pressure ulcers (two or more of the following conditions must be met to declare pressure ulcers):
□ 1, forced posture is strictly limited to turning over□ 8, and vital signs are unstable.
□2, coma □ 9, old age or over 70 years old.
□3, heart failure□10, nutritional deficiency
□4, respiratory failure□11,extreme dyspnea
□5, hemiplegia □ 12, high edema
□6, metabolic disorder□13, urinary incontinence
□7, pelvic fracture□14, sensory disturbance
Braden score: (Please tick the appropriate score)
Note: 15- 18 is slightly dangerous; 13- 14 points of moderate risk; 10- 12 is highly dangerous; A score below 9 is extremely dangerous.
If the score is ≤ 12, fill in the high warning.
Feeling wet, activity mode, activity ability, nutritional friction/shear force
1 completely restricted.
Very limited.
3 Mild restriction
4 Unlimited 1 continuous humidity
2 Humidity
Sometimes the weather is wet.
4 humidity is very low 1 bed rest
Two chairs
Take an occasional walk
4 move freely 1 can't move at all.
2 serious restrictions
3 Mild restriction
Four hasn't changed. 1 very bad.
2 may not be enough
Three is enough.
4 Very good. 1 There is a problem.
2 potential problems
There is no obvious problem.
Brief introduction of disease:
Pressure sore situation:
1 location: 1) sacrococcygeal 2) hip 3) spine 4) scapula 5) elbow 6) knee 7) lateral ankle.
8) Heel 9) Pillow 10) Ear 1 1) Other
2 Pressure sore area (cm):
3 classification:
Wound condition: 1 redness, 2 oozing blood (blisters), 3 ulcer, 4 suppuration, 5 necrosis, 6 malodor and 7 others.
Take measures:
□ Turn over regularly □ Use air cushion bed □ Local air bag □ Change dressing (times/day) □ Auxiliary drugs ()
□ Use film pasting
□ Other methods
Reporter head nurse
Note: the department is responsible for filling out the report form in duplicate: one keeps the records of the department and the other reports to the nursing department (both forms are kept for one year).
Pressure ulcer follow-up table
Department name, gender, age, bed number and hospitalization number
Braden score of clinical diagnosis time of pressure ulcer
Re-evaluation of the follow-up time of pressure ulcers Braden score will inevitably lead to pressure ulcers: □ Yes □ No.
Staging of pressure sore: □ blood red □ inflammatory infiltration □ superficial ulcer □ necrotic ulcer □ suspected necrosis □ not staged.
Wound surface condition: □ redness and discoloration □ redness and swelling □ oozing blood (blisters) □ festering □ suppurating.
Evaluation of wound surface: location
Area (length/width/depth)
Nursing measures taken:
□ Turn over regularly □ Use air cushion bed □ Local air bag □ Change dressing (times/day)
□ Auxiliary drugs ()
□ Use film pasting
□ Other methods
Guiding opinions:
Interviewer: Date
Results:
Author: Date
Note: the follow-up form is in duplicate, one for the department and one for the nursing department; Follow-up is the head nurse of the department or the member of the department pressure sore management team. The follow-up organized by the nursing department shall be filled in by the nursing department or the members of the hospital pressure sore management team and returned to the department. Report the results of terminating the follow-up.