新编护理学基础-病人的清洁和卫生2.pptVIP

病人的清洁卫生(二) 中国医科大学护理学院 吕岩 Cleanliness and hygiene（二） Skin Care Assessing 1.Nursing History 2.Physical Assessment Diagnosing 1.Knowledge Deficit 2.Self-Esteem Disturbance Planning Implementing 1.General Guidelines for Skin Care 2.Bathing Nursing History Skin Care Practices--incorporate the client’s needs and preferences and determine necessary learning needs. Self-Care Abilities--determine the amount of nursing assistance and the kind of bath. Past or Current Skin Problems--alert the nurse to specific nursing interventions or referrals the client may require. Physical assessment 压 疮 （Pressure sores） Etiology of Pressure Ulcers 易 患 人 群 神经系统疾病者 老年人 肥胖者 身体衰弱、营养不佳者 水肿病人 疼痛病人 石膏固定病人 大、小便失禁病人 发热病人 使用镇静剂的病人 易 患 部 位 骨隆突处 仰卧 侧卧位 俯卧位 坐位 皮肤皱褶处 有石膏包裹或有压迫的地方 Supine Position Side-lying Position Prone Position Sitting Position Stages of Pressure Ulcer Formation 瘀血红润期 炎性浸润期 浅度溃疡期 深度溃疡期 深度溃疡期 Pressure Ulcers Nursing Process Assessing Assessment of Skin Integrity Assessment of Pressure Ulcer Assessment of Skin Integrity Nursing History Physical Assessment Risk Assessment Tools Risk Assessment Tools Norton 量表 营养评估表 Anderson危险指标记分法 Assessment of Pressure Ulcers 压疮的位置 压疮的范围 (长度, 宽度, 深度) 压疮的分期 伤口基底部的颜色和坏死或结痂的位置 伤口周围的情况 周围皮肤的完整性 感染的临床征象 Diagnosing Impaired Skin Integrity Risk for Infection Pain Body Image Disturbance Anxiety Planning For maintaining intact skin Inspect at regular intervals Keep skin clean, dry, and moisturized Provide appropriate pressure-relieving devices and measures For promoting wound healing Advocate wound nutrition Document wound assessment at regular intervals Apply appropriate wound treatments and dressing Implementing Preventing Pressure Ulcers Treating Pressure Ulcers Preventing pressure ulcers 避免局部组织长期受压 避免摩擦力和剪切力 保护病人的皮肤 背部按摩护理 增进病人营养 鼓励病人活动 Supine Position Side-lying Position Prone Position Sitting Position Treating Pressure Ulcers 清创 换药 控制感染 其它方法 Braden Scale for Predicting Pressure Sore Norton’s Pressure A