53 降低神經外科手術患者壓瘡發生率之方案 張昭惠陳惠玲 * 陳香祺 壓瘡一直是醫療院所普遍存在的問題之一, 國內外文獻均指出, 每年需支付相當大的醫療費用於治療壓瘡患者身上, 而手術引起的壓瘡佔 12 66%, 其中神經外科患者因手術時間長, 更易形成壓瘡 本 專案小組統計手術室 2004 年 5 月至 8 月各科壓瘡發生比率, 其中以神經外科最高為 9.5%, 經分析發現 : 同仁對壓瘡的認知及預防方法不一, 故針對問題提出改善對策, 制定壓瘡防護標準 增設壓瘡危險因 子評估 建立護理品質追蹤改善制度 安排在職教育 設計棉捲做特殊防護 並施行個別輔導後, 神經外科手術患者壓瘡發生率由 9.5% 降至 7%, 不僅達到良好的成效, 並增加手術醫療團隊對預防壓 瘡之共識, 進而提升手術照護品質 手術 壓瘡 預防 前 12 66% Beckrich & Aronovitch, 1999 Scott Leaper Clark Kelly 2001 25 1.6Young, Evans, & Davis, 2003 8,000 70,000 1998 Waterlow 1998 95% 2004 5 8 8,392 85 18918 9.5 = 100 言 手術過程壓瘡發生原因分析 24 14 10.8 * 95 8 30 96 5 10 96 9 13 81362 386 07 3468151 706
54 Lowering the Incidence of Pressure Sores 表一神經外科手術患者壓瘡基本資料 N = 18 n % 性別 10 56 8 44 年齡 15 40 4 22 41 60 7 39 61 7 39 術中體溫 > 36 5 28 36 13 72 Braden Scale 值 18 10 56 < 18 8 44 急診手術 8 44 10 56 使用溫毯 18 100 0 0 眼皮黏貼紙膠 18 100 0 0 使用懸吊帶 18 100 0 0 慢性疾病 11 61 7 39 營養狀況 4g/dl 6 33 < 4g/dl 12 67 13g/dl 10 56 < 13g/dl 8 44 38 10 56 < 38 8 44 60mmHg 6 33 < 60mmHg 12 67 BMI < 18.5 或 > 24 5 28 13 72 術前皮膚乾燥 薄 水腫 4 22 14 78 手術時間超過 4 小時 18 100 0 0 手術臥位 8 44 10 56 BMI = Body Mass Index. 2004 5 8 189 18 35 2004 5 8 18 70 表二神經外科手術患者壓瘡發生部位之比率 N = 35 圖一神經外科平均手術時間 1 2 3 4 n % 7 2 0 0 9 28 2 5 0 0 7 20 2 4 0 0 6 17 1 3 1 0 5 14 2 1 0 0 3 8 1 1 0 0 2 5 2 0 0 0 2 5 1 0 0 0 1 3 18 16 1 0 35 100
55 圖二壓瘡發生率高之特性要因圖 表三神經外科手術患者壓瘡發生原因比率 N = 70 n % 4 18 26 1 8 11 2 7 10 3 6 9 4 6 9 4 5 7 5 5 7 5 5 7 5 4 6 6 3 4 7 3 4 7 70 100 手術與壓瘡形成之相關性 Bergstrom, Braden, Kemp, Champagne, & Ruby, 1998 12.73g/dl 38 Albumin 4.0g/dl Lewicki, Mion, Splane, Samstag, & Secic, 1997 MeEwen, 1996 4 4 Hoshowsky & Schramm, 1994 Aronovitch 1999 7 13.2 Sanada 1997 Armstrong & Bortz, 2001 2002 60mmHg
56 Lowering the Incidence of Pressure Sores 醫護人員對壓瘡預防之重要性 2001 63 Hoshowsky Schramm 1994 2006 2006 2006 2002 解決辦法與決策 9.5% 8.1% 2004 9 1 2005 4 30 一 計劃期 (2004 年 9 月 1 日 ~2004 年 10 月 31 日 ) ㈠ 2004 9 12 66 15 9.5 15 = 1.4 9.5 8.1 9.5 1.4 = 8.1 ㈡ Braden Scale 18 BMI < 18.5 > 24 30 4 OP site ㈢ 2004 10 ㈣ 2004 10 二 執行期 (2004 年 11 月 1 日 ~2004 年 12 月 31 日 ) ㈠ 2004 11 1
57 表四神經外科手術患者壓瘡發生部位專案實施前後比較 n = 35 2004 7 10 n = 22 2005 1 4 1 2 3 4 1 2 3 4 7 2 0 0 9 4 1 0 0 5 2 5 0 0 7 1 4 0 0 5 2 4 0 0 6 0 0 0 0 0 1 4 0 0 5 1 1 0 0 2 2 0 1 0 3 2 0 0 0 2 1 1 0 0 2 1 1 0 0 2 2 0 0 0 2 2 0 0 0 2 1 0 0 0 1 0 0 0 0 0 9 0 0 0 9 2 2 0 0 4 18 16 1 0 35 13 9 0 0 22 > 4 > 60 4.0g/dl < 13g/dl Braden Scale < 18 ㈡ 2004 11 1 ㈢ 2004 117 30 8 00 7 30 8 30 ㈣ 2004 11 三 評值期(2005 年 1 月 1 日 ~2005 年 4 月 30 日 ) 2005 1 4 結果評值 2005 1 4 221 16 7 22 13 9 9.5 7 6 = 9.5% 7% 9.5% = 26.3% = 7% 9.5% 8.1% 9.5% 100% = 179% 結論 9.5 7
58 Lowering the Incidence of Pressure Sores 阻力 限制及建議 30 15 20 10 參考文獻 2006 53 5 44 51 1998 15 1 42 49 2001 10 67 80 2006 17 1 11 21 2006 17 2 42 49 2002 19 1 9 20 Armstrong, D., & Bortz, P. (2001). An integrated review of pressure relief in surgical patients. AORN Journal, 73(3), 645 674. Aronovitch, S. (1999). Intraoperatively acquired pressure ulcer prevalence: A national study. Wound Ostomy Continence Nurses, 26(3), 130 136. Beckrich, K., & Aronovitch, S. A. (1999). Hospital-acquired pressure ulcer: A comparison of coasts in medical and surgical patients. Nursing Ecomomics, 17(5), 263 271. Bergstrom, N., Braden, B. J., Kemp, M., Champagne, M., & Ruby, E. (1998). Predicting pressure ulcer risk: A multisite study of the predicting validity of the Braden Scale. Nursing Research, 47(5), 261 269. Hoshowsky, V., & Schramm, C. (1994). Intraoperative pressure sore prevention: An analysis of bedding materials. Research Nurses Health, 17(5), 333 339. Lewicki, L., Mion, L., Splane, K., Samstag, D., & Secic, M. (1997). Patient risk factors for pressure ulcers during car-
59 diac surgery. AORN Journal, 65(5), 933 942. McEwen, D. R. (1996). Intraoperative positing of surgical patient. AORN Journal, 63(6), 1059 1079. Sanada, H. (1997). The role of skin blood flow on pressure ulcer development during surgery. Advance Skin Wound Care, 10(6), 29 34. Scott, E. M., Leaper, D. J., Clark, M., & Kelly, P. J. (2001). Effects of warming therapy on pressure ulcers in surgical patients. AORN Journal, 73(5), 921 938. Waterlow, J. (1998). Prevention is cheaper than cure. Nursing Times, 84(25), 69 70. Young, Z. F., Evans, A., & Davis, J. (2003). Nosocomial pressure ulcer prevention. Journal of Nursing Administration, 33(7/8), 380 383. 附件一手術室患者壓瘡事件發生報告表 Supine Prone Lithotomy Jack Knife R t Lateral L t Lateral Sitting Trendelenburg (Action Pad) 80 0.7 ± 10% 70 0.6 ± 10% Endo EKG < 4hrs Tourniquet mmhg 30 1. Kg cm 2. 3. HbHct albumin mg/dl(<3.5 mg/dl) 4. 5. DM PAOD H/T 6. 60mmHg
60 Lowering the Incidence of Pressure Sores Program for Lowering the Incidence of Pressure Sores in Neurosurgical Patients Chau-Hui Chang Hui-Ling Chen * Hsiang-Chi Chen Abstract: Pressure sores are one of the well known problems that occur in hospitals. As the literature on the subject indicates, a lot of money is expended in managing this problem every year, and 12 66% of pressure sores are caused during surgery. Patients who undergo neurosurgical procedures are susceptible to pressure sores because of lengthy operations. We collected data on patients with pressure sores who underwent surgery between May 2004 and August 2004, and found that the incidence of pressure sore in neurosurgical patients was 9.5, which was the highest among all surgical patients. This project was developed to solve the problem of pressure sores by setting up standard preventive procedures, a nursing follow up system and continuing education courses, and utilizing cotton rolls to pad sites of pressure sores. The incidence of pressure sore in neurosurgical patients was reduced from 9.5% to 7% after the improvement project was carried out. The more concerned nurses are about pressure sores, the better the quality of operative nursing care. Key Words: operation, pressure sore, prevention. RN, BSN, Department of Nursing, Kaohsiung Veterans General Hospital; *RN, BSL. Received: August 30, 2006 Revised: May 10, 2007 Accepted: September 13, 2007 Address correspondence to: Hsiang-Chi Chen, No. 386, Da-Chung 1st. Rd., Kaohsiung 81362, Taiwan, ROC. Tel: 886(7)346-8151 ext. 706; E-mail: apple880605@yahoo.com.tw