压疮分期及其护理进展.PDF

特别策划 压疮规范化管理 Special Planning 压疮分期及其护理进展 周玉洁 杨美玲 张洪君 洪涛 张军 朴莹 [ 摘 要] 本文介绍压疮的分期、压疮的评估以及压疮发生后的处理方法。对国内外相关研究的分析表明：美国压疮专家咨 询组 2007年更新的压疮分期是目前全球使用最广泛的压疮分期系统之一；可应用视觉模拟评分表、面部等级评分表等工具评 估成年压疮患者的疼痛程度；使用压疮愈合计分表评价压疮的愈合效果具有很好的信度、效度和内部一致性；应用生理盐水或 饮用水定期清洗伤口；根据患者的病情、坏死组织的类型、性质和部位、治疗目标、可利用的资源及患者意愿选择适宜的清创 方式；敷料的选择应基于伤口床的情况、伤口周围皮肤情况以及患者的护理目标。 [ 关键词 ] 压疮分期；护理评估；伤口处理 [中图分类号] R47 [DOI] 10.3969/j.issn.1672-1756.2014.07.004 Recent progress of pressure ulcer staging and nursing / ZHOU Yujie, YANG Meiling, ZHANG Hongjun, et al. // Department of General Surgery, Peking University Third Hospital, Beijing, 100191 China /// Chinese Nursing Management-2014,14(7): 683-686 [Abstract] This paper introduced pressure ulcer staging, nursing assessment and wound care of pressure ulcer. Based on the analysis of related studies, we found that the pressure ulcer staging developed by National Pressure Ulcer Advisory Panel in 2007 was one of the most widely used systems in the world. Adult pressure ulcer patients’ pain could be assessed by Visual Analogue Scale, Face pain Scale and some other scales. Pressure ulcer scale for healing had good reliability and validity. Wound should be cleaned with normal saline or water regularly. Debridement methods should be chosen according to patient’s condition, necrotic tissue type, wound site, treatment goals, available resources and patient’s preference. Selection of dressing must be based on the wound condition, skin surrounding the wound and nursing goals. [Key words] pressure ulcer staging; nursing assessment; wound care 压疮是皮肤或皮下组织的局限性损 查，结果显示美国压疮现患率为 9.2