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隼尚
7 years ago
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1 壓瘡及其分期壓瘡是皮膚及其下方軟組織局部破損通常位於骨隆突部位上損傷時可呈現為完整皮膚或潰瘍甚至會疼痛壓瘡是由於持續受壓或剪力所引致而軟組織對壓力及剪力的耐受性亦會受到微氣候營養血液循環合併症及軟組織狀況的影響定義圖例第1期壓瘡: 紅斑期完整的皮膚上出現受壓後不會褪色的紅斑但在深膚色的患者上可能會看不到變化在肉眼可見的癥狀前可消失的紅斑感覺異常皮溫變化及皮膚硬腫都可能首先出現然而皮膚顏色的變化並不包括紫色或栗子色因為這代表著深層組織受損第2期壓瘡部分真皮層缺損部分皮膚缺損並有真皮層露出伴有粉紅或紅色的創面濕潤或許有完整或破掉的漿液水皰但不會看到脂肪或更深層的組織肉芽組織腐肉及焦痂在這階段也不會出現這些破損通常由於不良微氣候及剪力造成骨盆皮膚及腳跟的壓瘡這時期的缺損不應被用來描述與潮濕相關的皮膚破損如尿布疹對磨疹醫療貼布引致的皮膚破損或創傷引致的傷口(皮膚撕裂燙傷或擦傷) 第3期壓瘡: 全層皮膚缺損全層皮膚缺損並可看到脂肪組織通常會出現肉芽組織及捲邊亦可能有壞死組織或焦痂傷口深度在不同部位會不一樣如皮下脂肪較多的部位傷口也會較深此外也可能會出現潛行性傷口及隧道同時筋膜肌肉肌腱韌帶軟骨或骨頭尚未暴露若腐肉或焦痂覆蓋著整個傷口這時便應介定為無法分期的壓瘡第4期壓瘡: 全層皮膚及組織缺損全層皮膚及組織缺損並會露出筋膜肌肉肌腱韌帶軟骨或骨頭亦可能有壞死組織或焦痂捲邊潛行性傷口及隧道通常也會出現傷口深度在不同部位會不一樣若腐肉或焦痂覆蓋著整個傷口這時便應介定為無法分期的壓瘡無法分期的壓瘡全層皮膚及組織缺損被覆蓋雖然全層皮膚及組織缺損但整個傷口被壞死組織或焦痂所覆蓋導致其破損的程度無法被介定假如腐肉或焦痂被移除將可揭示為第3期或第4期壓瘡在缺血的肢體或腳後跟上的穩定焦痂(乾爽黏緊完整而沒有發紅或波動感) 不應被軟化或移除深層組織的壓瘡:持續不會褪色的深紅栗子色或紫色斑塊完整或破損皮膚出現局部持續不會褪色的深紅栗子色或紫色斑塊或表皮分離後呈現出暗黑色的創面或充滿血的水皰在這皮膚顏色轉變前通常會出現疼痛及皮溫變化膚色較黑的患者會展現出不同皮膚顏色的變化此時期的壓瘡是由於骨頭與肌肉的界面承受高壓力或持續受壓並伴隨著剪力所導致此傷口可迅速演變以揭示皮膚組織破損的實際程度或可能在沒有皮膚組織的缺損下回復正常假如看見壞死組織皮下組織肉芽組織筋膜肌肉或其他底層結構組織表示已惡化成為全層的壓瘡 (如無法分期第3期或第4期) 切勿使用深層組織的壓瘡來形容血管性創傷性神經性或皮膚性的病變黏膜的損傷黏膜上的損傷是由於在黏膜附近曾使用醫療用品所引致此類傷口不適用於任何壓瘡的分期

2 PRESSURE INJURY AND STAGES A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense pressure, prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Definition Schematic Drawing STAGE 1 PRESSURE INJURY: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. STAGE 2 PRESSURE INJURY: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). STAGE 3 PRESSURE INJURY: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. STAGE 4 PRESSURE INJURY: Full-thickness loss of skin and tissue Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. UNSTAGEABLE PRESSURE INJURY: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on an ischemic limb or the heel(s) should not be softened or removed. DEEP TISSUE PRESSURE INJURY: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. MUCOSAL MEMBRANE PRESSURE INJURY Mucosal membrane pressure injury is found on mucous membranes with a history of a medical device in use at the location of the injury. These ulcers cannot be staged.

3 WHO IS AT RISK OF PRESSURE INJURY? When you sit in a chair or lie in bed, not moving for some time, you may notice that your skin feels uncomfortable or even painful. When this happens, you change your position to stop that uncomfortable feeling. Many people are unable to take this simple step of changing position. They may be ill, be calmed (with medicine) during a surgical operation or unable to notice the uncomfortable skin feeling. Skin is fed by our blood supply. If we stay in one position too long without moving, blood can no longer get to the skin at the parts of our body where we sit or lie down. When this happens the skin can die and a wound develops. These wounds were once called bed sores (from not moving enough in bed) or decubitus ulcers. Today health workers call these pressure injuries. A pressure injury that has an open sore on the skin is called an ulcer, it may be close to the skin surface or deep down to the bone. Causes: Sadly pressure injuries are very common and many people may know of a family member or friend who has had a pressure injury. Pressure It occurs between the body parts, especially the bony prominences and the supporting surface. Pressure damage may occur if not relieved regularly. Shear It occurs when the person slides down in a sitting position or being dragged along a surface during repositioning. It affects mainly deep tissues. The tissues attached to the bone are pulled in one direction while the surface tissues remain stationary. Friction It occurs with repeated rubbing between body parts and the supporting surface resulting in abrasion of epidermis that increases the potential for deeper tissue damage. Microclimate Tissue damage would occur more quickly when skin surface temperature is raised. Excessive skin moisture would also upsurge the likelihood of skin damage. Risk Factors: Impaired sensation A person s awareness to change position / make postural adjustment to relieve pressure will be affected by the poor perception of pain and discomfort of his / her body parts Age Degenerative changes in skin, nerve and vessel wall associates with advanced age make the tissue more susceptible to damage Immobility People are at risk of developing pressure sores if they have difficulty moving and are unable to easily change position while seated or in bed. Immobility may be due to: poor health, generalized weakness, paralysis, coma, injury that requires bed rest or wheelchair use, etc. Chronic illness Diseases (such as diabetes mellitus, stroke, heart or lung diseases, anaemia, etc.) affect tissue perfusion, oxygenation and tissue repair potentials Malnutrition It compromised the person s tissue health, healing potential, immunity to infection and general well-being. Loss of fat and muscles results in less cushioning between bones and supporting surface Moisture Excess moisture from incontinence, perspiration or wound exudates may soften the epidermis making it more susceptible to damage by friction

4 誰有患壓瘡的風險? 當你坐在椅子上或躺在床上並維持靜止狀態一段時間, 你可能發覺皮膚會產生不舒服的感覺, 甚至痛楚此時, 你會移動身體來消除這不舒服的感覺這小小的動作看似簡單, 但有些人連這一下轉身的動作也做不到包括病重的被麻醉的或因種種原因未能對不舒服或痛楚產生感覺的人可知道皮膚的養份是由血液提供如果身體長期處於同一姿勢而缺乏移動, 血液將不能供應至被壓著的部位這樣皮膚就會朽壞而形成一個傷口, 這類傷口稱為壓瘡輕微的壓瘡通常位處於貼緊皮膚表面, 嚴重的可深入至骨骼遺憾的是壓瘡在今天並不罕見可能你身邊的朋友甚至家人都曾受壓瘡之苦成因 : 壓力骨隆突部位與承托面 ( 如床褥坐椅 ) 接觸受壓而未能定時得到舒緩剪力摩擦力當病人坐姿不穩而下滑, 或協助其移動轉換體位臥姿時方法不正確, 可引致皮膚及深層組織受損皮膚重複與承托面摩擦而受損高危因素 : 微氣候皮膚表面溫度上升會加快附近組織損壞, 造成破損而皮膚過分濕濡亦會令皮膚破損的機會增加感知減弱未能感覺受壓而自行轉換姿勢衰老退化長者的皮膚神經血管壁較脆弱, 容易受損行動不便任何妨礙轉換體位的情況都會增加壓瘡形成的機會行動不便通常是源於 : 健康欠佳, 全身乏力, 四肢癱瘓, 陷入昏迷, 或由於傷患以致需長時間臥床或倚靠輪椅潮濕患有慢性病大小便出汗產生的水份令皮膚表層軟化, 如糖尿病中風心臟病貧血等, 令血液未能有效地輸送到皮膚, 增加患壓瘡之風險營養不良缺乏蛋白質令身體組織修補減慢脂肪和肌肉的流失令骨與承托面缺乏緩衝使其容易受損

5 HOW COULD PRESSURE INJURIES BE PREVENTED? If you are at risk to develop pressure injuries, then your doctor, nurse and carer will join hands in taking steps to prevent pressure injuries from happening. Focusing on causative factors and risk factors, here are some suggested preventive measures: Change position regularly (every 2 4 hours) to relieve pressure Shift weight frequently when in sitting position, do not sit for more than 2 hours each time Use of pressure redistributing devices such as pressure redistributing mattresses, seat cushions, etc. Pressure point Maintain proper sitting posture with adequate support to avoid shearing Protect skin from friction. Keep bed sheets clean, dry and wrinkle-free Do not drag the person during repositioning / transfer to avoid friction and shearing force Keep skin clean and dry : Change soiled napkin, bed sheets and clothes as soon as possible. Clean and dry perineal area thoroughly. Apply protective / barrier cream as needed Maintain a well-balanced diet Ensure adequate fluid intake Encourage daily active / passive range-of-motion exercise Perform skin inspection daily. If early signs of pressure injury are present, take immediate measures to avoid further damage to the area (e.g.: increase the frequency of turning)

6 怎麼可以預防壓瘡? 如果你被評定為壓瘡的高危人士, 醫護人員和你的照顧者應採取預防措施防止壓瘡形成針對各項引致壓瘡的成因及高危因素, 我們建議以下的預防措施 : 協助不能自助的人士按時 ( 每 2 至 4 小時 ) 轉換體位以減少身體某一部位連續受壓的時間每小時轉換坐姿, 坐椅時間每次不多於 2 小時常見的受壓位置使用減壓用品保護受壓部位, 如減壓床褥坐墊等保持良好坐姿, 以防身體下滑產生剪力減少皮膚受摩擦, 保持床舖清潔, 平滑, 無碎屑移動病人時應避免拖拉, 以減低摩擦力和剪力, 防止皮膚受損保持皮膚衛生乾爽 : 及時更換尿片和沾濕的衣物和床單至於失禁人士, 有需要時可塗上皮膚保護劑 ; 若皮膚乾燥, 可塗上適量潤膚劑均衡飲食, 攝取足夠營養及水份, 增強身體抵抗力鼓勵及協助病人多作肢體活動每天檢查皮膚狀況若發現有初期壓瘡徵狀, 應及早採取措施 ( 如增加轉換坐臥姿的頻密度, 避免受損部位繼續受壓 )

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