Chapter14. 상처간호(3) - 욕창간호

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[기본간호학] Chapter14. 상처간호(3) - 욕창간호  기본간호학 / Nursing Science

2013/09/14 21:03

http://blog.naver.com/cmn0422/130176173627

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Chapter 14. 상처간호(2)

14.1 상처간호

14.2 욕창간호

14.2 욕창간호

1. 욕창이란

- 욕창(Bed sore, Pressure Sore, Decubitus ulcer)

: 특정한 부위에 지속적인 압력이 가해져 순환장애로 인해 조직이 손상

: 압력 + 마찰에 의함

- 욕창의 단계

1단계	■ Non-blanchable erythema ■ 홍반(redness) 있으나 피부손상 없음(iintact) ■ 압력을 제거해도 일정 시간 지속됨 ■ (지속 시간에 대한 기준은 의견이 분분함)
2단계	■ Partial thickness ■ 표피+진피 부분적 피부상실, 표재성 궤양 ■ 찰과상(abrasion) 또는 수포(blister)가 있을 수 있음
3단계	■ Full thickness skin loss ■ 피하지방까지 손상, 괴사를 보임 ■ 광범위한 손상으로 깊은 궤양을 보임
4단계	■ Full thickness tissue loss ■ 근육, 뼈, 지지조직까지 완전한 조직 손상 및 괴사

- 호발부위

-

 

(특히, sacrum, coccyx, heels and the hips) 

- 발생요인

원인

위험요인

① 압력 Pressure applied to soft tissue resulting in completely or partially obstructed blood flow to the soft tissue. ② 응전력(shearing), 마찰(friction) a force created when the skin of a patient stays in one place as the deep fascia and skeletal muscle slide down with gravity. It can cause the pinching off of blood vessels which may lead to ischemia. ③ 소기후(Microclimate) the temperature and moisture of the skin in contact with the surface of the bed or wheelchair. - Moisture: Over time, excess moisture may cause the bonds between epithelial cells to weaken, thus resulting in the maceration of the epidermis. - Temperature: The cutaneous metabolic demand rises by 13% for every 1°C rise in cutaneous temperature. When supply can't meet demand, ischemia then occurs.

① 영양부족 및 빈혈 ② 연령 ③ 습기 ④ 체온 ⑤ 피부감각 부재 ⑥ 운동능력 부족 ⑦ 혈압 및 혈관질환 ⑧ 비만

2. 욕창간호과정

- 욕창의 사정:

Braden scale for predicting pressure ulcer risk

(일부 책에서는 16점 이하 욕창발생 고위험군으로 분류)

- 욕창의 예방★

Pressure Ulcer Prevention

Quick Reference Guide

the European Pressure Ulcer Advisory Panel (EPUAP),

American National Pressure Ulcer Advisory Panel (NPUAP) (2009)

① Nutrition for Pressure Ulcer Prevention

■ a minimum of 30-35 kcal per kg body weight per day, with 1.25-1.5g/kg/day protein and 1ml of fluid intake per kcal per day.

② Repositioning for the Prevention of Pressure Ulcers

■ Repositioning Frequency should be influenced by the support surface used.

■ Use the 30-degree tilted side-lying position (alternately, right side, back, left side) or the prone position if the individual can tolerate this and her/his medical condition allows.

■ Avoid postures that increase pressure, such as the 90-degree side-lying position, or the semi-recumbent position.

③ Support Surfaces

■ Using higher-specification foam mattresses rather than standard hospital foam mattresses for all individuals at risk for pressure ulcer development.

(아마도 이런 거?)

■ When high-risk patients cannot be repositioned manually, active support surfaces(overlay, mattress) are needed, as they can change their load-distribution properties.

■ Ensure that the heels are free of the surface of the bed by elevating the heel completely. The knee should be in slight flexion. Hyperextension of the knee may cause obstruction of the popliteal vein, and this could predispose an individual to deep vein thrombosis.

(다양한 기구를 사용할 수 있음)

■ Use a pressure-redistributing seat cushion for individuals sitting in a chair whose mobility is reduced and who are thus at risk of pressure ulcer development. Otherwise limit the time of being sitting on a chair.

① 2-3시간마다 체위변경

② 압박부위 지지(mattress, 베개 등 사용)

③ 올바른 신체선열, 족저굴곡이나 무릎 과신전 등 방지

④ 영양공급을 적절히 할 것. 특히 고단백, 수분공급

⑤ 압력 받는 부위에 마사지를 제공

⑥ 피부를 건조하게 유지할 것(습한 피부는 epithelial cells을 약하게 함)

※ Dressing Types

Film Dressing(Tega-derm film)

Foam Dressing(Mepilex)

Hydro-colloid dressing(Duo-derm)

Hydrogel dressing

Calcium alginate dressing

Hydrofiber dressing

-  

- 욕창의 치료

■ 상처 치료의 기본: 손상부위를 습윤 상태로 유지하고 주변 조직은 건조하게 유지하는 것

	Determining the cause	Treating the wound
Stage 1	■ The skin in a grade 1 pressure ulcer is not broken but it requires protection and monitoring. ■ At this stage it will not be known how deep the pressure damage is and regular monitoring is essential. ■ The cause of the pressure ulcer should be identified and stopped. ■ For example, if the cause is direct pressure then either ensure that the patient’s position is changed more frequently or ‘step-up’ the pressure relief, e.g. move the patient from a static foam mattress to an alternating pressure mattress.	■ A grade 1 pressure ulcer is a wound, therefore a wound assessment tool or care plan should be commenced. ■ Wound dressings for a grade 1 pressure ulcer should be simple and offer protection without risking any further skin damage, especially if the patient is sliding down the bed or chair causing the dressing to ‘ruck’. ■ A film dressing or a thin hydrocolloid would be appropriate to protect the wound area. The slippery nature of these dressings may reduce further friction or shearing if these factors are involved.
Stage 2	■ If the pressure ulcer is circular, this is often an indication that direct pressure is the cause. In this case ensure that the patient’s position is changed more frequently or ‘step-up’ the level of pressure relief. ■ If the pressure ulcer is not uniform and is more widespread, then shearing or friction may be the cause. If this is the case, ensure that the patient is positioned so that they do not slide down the bed or chair and that appropriate manual handling techniques and equipment are used to ensure that the skin is protected. ■ Direct pressure, shearing and friction may all be involved in the development of a pressure ulcer.	■ Commence with a wound assessment tool or a care plan. ■ A grade 2 pressure ulcer is a superficial wound. If the wound has slough on the wound bed, debridement may be necessary. There are many dressings that aid debridement, for example, hydrogels or hydrocolloids. ■ If protection is necessary as well as the promotion of a moist wound healing environment, a hydrocolloid or foam may be appropriate. Hydrofibres and alginates are also possible dressing choices, but there must be sufficient exudate to enable the dressing to change to a softer gel-like form. ■ Dressing some areas may be a challenge and many dressings are available in sacral and heel shapes to help with these difficult areas. ■ It is essential in the treatment of all pressure ulcers that the skin around the wound(the peri-wound skin) is protected and maintained if further breakdown or deterioration is to be avoided.

※ Protecting the peri-wound skin

Factors which affect the peri-wound skin	Treatment options
Urine and faeces if the patient is incontinent	Using continence products, Use a gentle emollient(moisturizer) to wash the skin and dry gently, without rubbing, to prevent the skin from becoming dry and cracked Use a barrier film or barrier cream, such as Cavilon after cleansing the skin.
Exudate on the peri-wound skin	Cleanse with either tap water or sterile saline. Apply a protector to the wound edge such as Cavilon, zinc and castor oil or Sudocrem. The chosen dressing must be effective at absorbing and holding on to the exudate.
Dressings with adhesive borders	Use a barrier film or cream before applying an adhesive dressing to form a barrier between the skin and the adhesivewhen it is removed and ensure that all dressings are removed according to the manufacturer’s instructions.
Maceration is caused when the peri-wound skin absorbs too much moisture, the tissues become boggy, white and friable	Ensure the chosen dressing has the ability to absorb the exudate levels and be able to hold on to the exudate effectively and not allow it to spread out, potentially damaging the peri-wound skin. Ensure that the dressing is changed frequently enough to prevent maceration from occurring. Protect the peri-wound skin with a barrier cream or film.

Stage 3	■ It is at this stage that the nurse must consider why the wound is getting deeper. There are many reasons for this: ● The full extent of the initial pressure damage is now showing. ● The damaging factors(pressure, shear or friction) are continuing. Check that the pressure relief is appropriate and effective. This includes both equipment and the repositioning of the patient ● The dressings are not managing the exudate levels and the wound is getting bigger or deeper due to the destructive nature of chronic exudate ● The pressure ulcer may be infected ● The patient has a poor ability to heal, which may be due to poor circulation, inadequate nutrition, low haemoglobin levels or the presence of disease such as diabetes mellitus. ■ Therefore, if the wound is not healing or progressing it is necessary to investigate further.	● As these pressure ulcers are substantially deep in many cases, the absorbency levels of the dressings may need to be increased. ● Many absorbent dressings can be used in combination to increase the overall absorbency. ● Always check that the absorbency is effective enough and that maceration is not occurring. If this is occurring, increase the dressing absorbency levels or the frequency of dressing changes. ● If conventional dressings cannot manage the exudate, topical negative pressure therapy could be considered.
Stage 4	● The steps outlined for determining the cause of grade 3 pressure ulcers should be followed. ● It is essential to establish if or why the wound is deteriorating, or if the depth of the wound is due to the initial pressure damage.	● Again, the steps outlined under the treatment of grade 3 pressure ulcers should be followed. ● If there is bone exposed, consider infection in the bone(osteomyelitis). This can be identified using an X-ray or a magnetic resonance imaging(MRI) scan and is usually treatable with antibiotic therapy. In this case, antibiotics should be prescribed.

- 괴사조직제거(Debridement) 방법

 ① 생리식염수 거즈(Wet-to-dry dressing)

 ② 효소제제: Elase ointment, Travase(Sutilains ointment)

 ③ 월풀목욕

 ④ 수술: 일차봉합, 피부이식, myocutaneous flaps 등

 

(Barrier cream and film)