壓瘡分期課件

1、壓瘡定義壓瘡 :是身體局部組織長期受壓、血液循環(huán)障礙，組織營養(yǎng)缺乏，致使皮膚失去正常功能而至皮膚及軟組織的破損和壞死。其損傷程度由持續(xù)性皮膚表面紅損、皮膚潰瘍以至到更深層組織壞死，可能由局部而至多處不同程度的損傷。（NPUAP1989）壓瘡分期的歷史1980年，國際造口治療師協(xié)會（IAET）發(fā)展了4度分級系統(tǒng) 1989年NPUAP發(fā)展了與IAET相似的4級系統(tǒng)期壓瘡定義為不會變白的紅斑、完整的皮膚，預示皮膚潰瘍損傷 期壓瘡定義為全皮層的喪失，伴有廣泛的破壞、組織壞死或危及肌肉、骨或支撐結(jié)構(gòu)，潛行和竇道也可出現(xiàn)壓瘡分期的歷史（1989NPUAP） 壓瘡分期的歷史1997年NPUAP修正了期壓瘡定

2、義：一種可見的與壓力相關(guān)的完整皮膚的改變，與鄰近或相對的身體區(qū)域相比包括一種或下面多種的變化：皮膚溫度的改變（熱或冷）、皮膚組織質(zhì)地改變（硬或潮濕）、感覺改變（疼痛、癢），其在淺色皮膚上表現(xiàn)為局部持續(xù)發(fā)紅，而在深色皮膚上表現(xiàn)為持續(xù)的紅色、蘭色、或紫色。NPUAP2007更新壓瘡定義A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination w

3、ith shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. (2007,National Presser Ulcer Advisory Panel)美國壓瘡咨詢小組壓瘡是皮膚或潛在組織由於壓力，或者複合剪切力或摩擦力而導致的損傷，常發(fā)生在骨隆突處的局限性損傷。很多與壓瘡有關(guān)或混雜的因素的重要性仍有待說明。（

4、2007, NPUAP）Pressure Ulcer Stages Revised by NPUAPFebruary 2007 - The National Pressure Ulcer Advisory Panel has redefined the definition of a pressure ulcer and the stages of pressure ulcers, including the original 4 stages and adding 2 stages on deep tissue injury and unstageable pressure ulcers.

5、This work is the culmination of over 5 years of work beginning with the identification of deep tissue injury in 2001. 2007-2月修正了壓瘡的定義和分期，在原來4期的基礎(chǔ)上增加了2個期，并對各期進行了進一步的描述。 期壓瘡:皮膚仍保持完整,但由于壓力的作用,出現(xiàn)了以下一種或一種以上的改變。深色的皮膚可能沒有明顯的蒼白變化，但它的顏色可能與周圍皮膚不同。皮膚溫度改變(過冷或過熱)皮膚組織質(zhì)地改變(發(fā)硬或潮濕)感覺改變(疼痛發(fā)癢)Stage II:Further descript

6、ion:Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. *Bruising indicates suspected deep tissue injury進一步描述：表現(xiàn)爲有光澤的或乾燥的表淺潰瘍，沒有組織脫落或擦傷，這個階段不能描述爲皮膚撕裂、膠帶損傷、會陰皮炎、浸漬或表皮脫落。

7、*青腫表示可疑的深部組織損傷II期壓瘡: 以部分皮層喪失為特征,涉及表皮層和真皮層,表現(xiàn)為擦傷水皰水皰破潰后形成淺的潰瘍表完整的水皰分離的表皮層表皮真皮表皮的分離與破裂 水皰破裂這是II期壓瘡嗎？Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include underm

8、ining and tunneling. 失去全層皮膚組織，除了骨、肌腱或肌肉尚未暴露，皮下脂肪可以看得見。組織脫落也可以表現(xiàn)出來，但是組織脫落的深度不太明確。可能包括皮下剝離和瘻道。Stage III: Further description: The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers c

9、an be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.進一步描述：第期壓瘡的深度隨解剖位置的不同而變化。鼻梁、耳朵、枕骨部和踝部沒有皮下組織，因此第期潰瘍可能是表淺的。相比之下，脂肪明顯過多的區(qū)域第期壓瘡可能就非常深。骨腱是看不見的或不可以直接觸及。表皮或真皮全部受損，穿入皮下組織，但尚未穿透筋膜及肌肉層。Stage IV: Fu

10、ll thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.失去全層皮膚組織伴骨、肌腱或肌肉外露。組織脫落或焦痂可能出現(xiàn)在創(chuàng)傷部位的某些部分。通常包括皮下剝離和瘻道。Stage IV:Further description: The depth of a stage IV pressure ulcer varies by an

11、atomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is vis

12、ible or directly palpable.進一步描述：第期壓瘡的深度隨解剖位置的不同而變化。鼻梁、耳朵、枕部和踝部沒有皮下組織，所以潰瘍比較表淺。第期潰瘍可延伸至肌肉和（或）支撐結(jié)構(gòu)（例如：筋膜、肌腱或關(guān)節(jié)囊），可導致骨髓炎?？梢钥匆娀蛑苯佑|摸到外露的骨或肌腱。 Suspected Deep Tissue Injury（可疑的深部組織損傷） Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue f

13、rom pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. 潛在的軟組織受壓力或剪切力的損害，可導致完整的皮膚一些局限的區(qū)域色素改變?nèi)缱仙蚝旨t色，或?qū)е鲁溲乃?。與周圍的組織相比，這些區(qū)域的軟組織之前可能有疼痛、堅硬、成糊狀、潮濕、發(fā)熱或冰冷。Suspected Deep Tissue Injury（可疑的深部組織損傷）Further description

14、: Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.進一步

15、描述：在膚色較深部位，深部組織損傷可能難以檢測出。損傷在厚壁的水皰覆蓋創(chuàng)面可能進一步發(fā)展更爲甚，這個創(chuàng)傷部位可能進一步發(fā)展，形成薄的焦痂覆蓋，這時即使輔以最適合的治療，病變可迅速發(fā)展，暴露多層皮下組織。Example of Deep Tissue Injury of the Sacrum.Example of Deep Tissue Injury of the Heel.Differential Diagnostics與挫傷、血腫、特發(fā)性的壞疽、肛旁膿腫要鑒別.DTI的特征：通常DTI發(fā)生在骨隆突處，有一個較長時間固定于一個體位的病史；這些傷口惡化很快。足跟部是DTI出現(xiàn)的常見部位。DTI高危

16、人群：IC：急診照護：長期護理晚期臨終病人Unstageable:Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.Unstageable:Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow,

17、 tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.Unstageable:不可分期階段Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.不可分期階段：失去全層皮膚組織，潰瘍的底部被傷口床的腐痂（包括黃色、黃褐色、灰色、綠色和褐色）和（或）痂皮（黃褐色、褐色或黑色）覆蓋。Unstageable:不可分期階段Further description:Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, ca