压疮分期

null 压疮定义 压疮定义 压疮 :是身体局部组织长期受压、血液循环障碍，组织营养缺乏，致使皮肤失去正常功能而至皮肤及软组织的破损和坏死。其损伤程度由持续性皮肤面红损、皮肤溃疡以至到更深层组织坏死，可能由局部而至多处不同程度的损伤。（NPUAP1989）压疮分期的历史压疮分期的历史 1980年，国际造口治疗师协会（IAET）发展了4度分级系统 1989年NPUAP发展了与IAET相似的4级系统 Ⅰ期压疮定义为不会变白的红斑、完整的皮肤，预示皮肤溃疡损伤 ⅳ期压疮定义为全皮层的丧失，，伴有广泛的破坏、组织坏死或危及肌肉、骨或支撑结构，潜行和窦道也可出现 压疮分期的历史（1989NPUAP）压疮分期的历史（1989NPUAP） 压疮分期的历史压疮分期的历史 1997年NPUAP修正了Ⅰ期压疮定义：一种可见的与压力相关的完整皮肤的改变，与邻近或相对的身体区域相比包括一种或下面多种的变化：皮肤温度的改变（热或冷）、皮肤组织质地改变（硬或潮湿）、感觉改变（疼痛、痒），其在浅色皮肤上表现为局部持续发红，而在深色皮肤上表现为持续的红色、兰色、或紫色。 NPUAP2007更新压疮定义NPUAP2007更新压疮定义 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 with 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)美国压疮咨询小组 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，常發生在骨隆突處的局限性損傷。很多與壓瘡有關或混雜的因素的重要性仍有待說明。（2007, NPUAP） Pressure Ulcer Stages Revised by NPUAP Pressure Ulcer Stages Revised by NPUAP February 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. This work is the culmination of over 5 years of work beginning with the identification of deep tissue injury in 2001. 2007-2月修正了压疮的定义和分期，在原来4期的基础上增加了2个期，并对各期进行了进一步的描述。 Ⅰ期压疮:皮肤仍保持完整,但由于压力的作用,出现了以下一种或一种以上的改变。深色的皮肤可能没有明显的苍白变化，但它的颜色可能与周围皮肤不同。 Ⅰ期压疮:皮肤仍保持完整,但由于压力的作用,出现了以下一种或一种以上的改变。深色的皮肤可能没有明显的苍白变化，但它的颜色可能与周围皮肤不同。 皮肤温度改变(过冷或过热) 皮肤组织质地改变(发硬或潮湿) 感觉改变(疼痛\发痒) Stage II:Stage II:Further description: 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。 *青腫表示可疑的深部組織損傷 II期压疮: 以部分皮层丧失为特征,涉及表皮层和真皮层,表现为擦伤\水疱\水疱破溃后形成浅的溃疡表II期压疮: 以部分皮层丧失为特征,涉及表皮层和真皮层,表现为擦伤\水疱\水疱破溃后形成浅的溃疡表完整的水疱分离的表皮层表皮 真皮 表皮的分离与破裂 水疱破裂 null这是II期压疮吗？Stage III: 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. 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: 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 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. 進一步描述： 第Ⅲ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Ⅲ期潰瘍可能是表淺的。相比之下，脂肪明顯過多的區域第Ⅲ期壓瘡可能就非常深。骨腱是看不見的或不可以直接觸及。 表皮或真皮全部受损，穿入皮下组织，但尚未穿透筋膜及肌肉层。表皮或真皮全部受损，穿入皮下组织，但尚未穿透筋膜及肌肉层。Stage IV: 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. 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在創傷部位的某些部分。通常包括皮下剝離和瘻道。 Stage IV:Stage IV:Further description: The depth of a stage IV pressure ulcer varies by anatomical 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 visible or directly palpable. 進一步描述： 第Ⅳ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Ⅳ期潰瘍可延伸至肌肉和（或）支撐結構（例如：筋膜、肌腱或關節囊），可導致骨髓炎。可以看見或直接觸摸到外露的骨或肌腱。 Suspected Deep Tissue Injury（可疑的深部組織損傷） 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 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. 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域色素改變如紫色或褐紅色，或導致充血的水皰。與周圍的組織相比，這些區域的軟組織之前可能有疼痛、堅硬、成糊狀、潮濕、發熱或冰冷。 Suspected Deep Tissue Injury（可疑的深部組織損傷）Suspected Deep Tissue Injury（可疑的深部組織損傷） Further description: 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面可能 進一步發展更爲甚，這個創傷部位可能進一步發展， 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.Example of Deep Tissue Injury of the Heel.Differential Diagnostics Differential Diagnostics 与挫伤、血肿、特发性的坏疽、肛旁脓肿要鉴别. DTI的特征： 通常DTI发生在骨隆突处，有一个较长时间固定于一个体位的病史；这些伤口恶化很快。足跟部是DTI出现的常见部位。 DTI高危人群： IC： 急诊照护： 长期护理 晚期临终病人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, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Unstageable:不可分期阶段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, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Unstageable:不可分期阶段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:不可分期阶段Unstageable:不可分期阶段Further description: 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 serves as "the body's natural (biological) cover" and should not be removed. 進一步描述： 只有足夠的腐痂或痂皮剝落，才能確定真正的深度和分期。踝部的焦痂是穩定的（乾燥的，粘附牢固的，完整且無紅斑或波動的）可以作爲身體自然的（或生物學的）屏障，不應移除。 压疮是一个难以回避的临床问!压疮是一个难以回避的临床问题!