pressure sore 사례 연구(수정중)

[이영호]

1. 77세 여성 7월 14일 내원 

   o/s 3개월 전 심장 수술 후 입원

   c/c 욕창 (2.5cm*4cm 의 원형) rt sacrum

   National Pressure Ulcer Advisory Panel 3단계, 근력 저하 (도수 근력평가 2-)  

2. 치 료

  7월 14일 이후 매일 화침 치료(7월 22일 현재 8회 시행)

현재 새살이 돋아나고 크기는 2cm*3cm 의 원형 크기로 회복됨.

3. 관련 내용

 가. Pressure ulcers(bed sore, pressure sore)

Pressure ulcers, also known as decubitus ulcers or bedsores, are localized injuries to the skin and/or underlying tissue that usually occur over a bony prominence as a result of pressure, or pressure in combination with shear and/or friction. The most common sites are the skin overlying the sacrum, coccyx, heels or the hips, but other sites such as theelbows, knees, ankles or the back of the cranium can be affected.

Pressure ulcers occur due to pressure applied to soft tissue resulting in completely or partially obstructed blood flow to the soft tissue. Shear is also a cause, as it can pull on blood vessels that feed the skin. Pressure ulcers most commonly develop in individuals who are not moving about, such as being bedridden or are confined to a wheelchair. It is widely believed that other factors can influence the tolerance of skin for pressure and shear, thereby increasing the risk of pressure ulcer development. These factors are protein-calorie malnutrition, microclimate (skin wetness caused by sweating or incontinence), diseases that reduce blood flow to the skin, such as arteriosclerosis, or diseases that reduce the sensation in the skin, such as paralysis or neuropathy. The healing of pressure ulcers may be slowed by the age of the person, medical conditions (such as arteriosclerosis, diabetes or infection), smoking or medications such as anti-inflammatory drugs.

Although often prevented and treatable if detected early, pressure ulcers can be very difficult to prevent in critically ill people, frail elders, wheelchair users (especially where spinal injury is involved) and terminally ill individuals. Primary prevention is to redistribute pressure by regularly turning the person. The benefit of turning to avoid further sores is well documented since at least the 19th century. In addition to turning and re-positioning the person in the bed or wheelchair, eating a balanced diet with adequate protein and keeping the skin free from exposure to urine and stool is very important.

The rate of pressure ulcers in hospital settings is high, but improvements are being made. They resulted in 29,000 deaths in 2013 up from 14,000 deaths in 1990.^[1]

Classification[edit]

The definitions of the four pressure ulcer stages are revised periodically by the National Pressure Ulcer Advisor Panel (NPUAP)^[2] in the United States and the European Pressure Ulcer Advisor Panel (EPUAP) in Europe.^[3] Briefly, they are as follows:

• Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area differs in characteristics such as thickness and temperature as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate "at risk" persons (a heralding sign of risk).

• Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. 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.

• 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 undermining and tunneling. The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

• Stage IV: Full 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. The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) 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 likely to occur. Exposed bone/tendon is visible or directly palpable. In 2012, the NPUAP stated that pressure ulcers with exposed cartilage are also classified as a stage IV.

• Unstageable: Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels is normally protective and should not be removed.

• Suspected Deep Tissue Injury: A purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from 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. A 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.

Healing time is prolonged for higher stage ulcers. While about 75% of Stage II ulcers heal within eight weeks, only 62% of Stage IV pressure ulcers ever heal, and only 52% heal within one year. It is important to note that pressure ulcers do not regress in stage as they heal. A pressure ulcer that is becoming shallower with healing is described in terms of its original deepest depth (e.g., healing Stage II pressure ulcer).

Classification of ulcers.

  Epidermis

  Dermis

  Subcutaneous tissue

  Muscle

  Bone

  Skin inflammation

  Blister

  Necrosis

  Fibrin 

- 출처 : wikipedia

나. 욕창의 치료 원리

- 침 치료로 미세손상(micro injury)을 입혀 피부의(표피) 줄기세포 분열을 촉진

- 섬유아세포(fibroblast)는 진피층에 존재하는 세포로 콜라겐섬유, 탄력섬유, GAGs, 각종 효소를 생산하는 데 피부가 상처를 입으면 이러한 재생 능력이 극적으로 증가함.

- 표피, 진피, 피하지방층의 이해 : http://cafe.daum.net/panicbird/RbZD/37

[문형철]

굿잡.. 20케이스만 잡아서 논문으로 써보자 ㅎㅎㅎ

[paul97]

명확한 근거가 제시되니.. 치료받는 사람 입장에서는 마음이 든든하겠습니다 !!