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一例IV期压力性损伤患者的护理体会——康复医学科

发布时间：2018-12-28 21:10:51

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Cerebral infarction is a commom clinical disease .it is found in the elderly ,and the risk is one of the fatal disease,also there is no effective cure. Patients with cerebral infarction are often associated with hemiplegia and multiple complications,and a common complication is pressure ulcer.

脑梗死是临床常见疾病，多见于中、老年人，病情凶险，是重要致死疾病之一，目前缺乏有效的治疗方法。脑梗死患者多伴偏瘫并造成多种并发症，压疮就是常见并发症的一种。

As we know,the incidence of pressure ulcer in general hospital is 2%~14%, combined with the senile patients with basic diseases, poor body condition, patients recover slowly, a serious threat to the patients' health and affect their quality of life, so in nursing work, the pressure ulcers has been regarded as care difficulties.The treatment and nursing experience of the patients are reported as follows：

综合性医院的院内压疮发生率为２％～１４％，加之中老年患者基础疾病多，身体条件差，患者恢复慢，严重威胁着患者健康和影响其生活质量，所以在护理工作中，一直被视为护理难点。现将该患者压疮治疗和护理体会汇报如下：

My department once treated a long stay in bed and hemiplegia patients with stage IV pressure ulcers, by combining the patient's condition, economic condition, and combined with the human, financial and material resources and other conditions of the ward, select the appropriate treatment, pressure ulcers healed in the end.

我们科室曾经收治一例长期卧床且偏瘫的IV期压疮患者，通过结合患者的病情、经济条件，同时结合病房的人力、财力、物力等条件，选择合适的治疗方法，压疮最终愈合。

Illness situation :The patient Wan**,male, 80 years old,his right limb was weak for six years and was admitted to our department on October 10.2016, He was conscious,Temperature is 38.6degress;The pulse is 80 times per minute ; Breathing in 20 times per minute ;Blood pressure is 136/80ｍｍＨｇ(Millimetre of mercury). The IV pressure ulcer on the right side was 6cm(centimeter )long and 5cm wide. with75% yellow carrion cover and a large number of solutions.

病例介绍:患者王某，男，８0 岁，因右侧肢体乏力六年于2016年10月10日收住康复科，患者入院时神清，Ｔ：３６.8℃，Ｐ：８０次／ｍｉｎ，Ｒ：２０次／ｍｉｎ，ＢＰ：１36／８０ｍｍＨｇ。右侧背部可见一块大小6ｃｍ ×5cmIV期压疮，表面有75%黄色腐肉覆盖，大量渗液，有恶臭味。

Previous history：

The patient has a history of hypertension for more than 10 years, a history of cerebral infarction for 6 years, and years of slow support and emphysema

既往史：高血压史10余年，脑梗史6年，慢支及肺气肿多年

Laboratory inspection:

Albumin: 36.2g/l(kilogram per litre);Percent of neutrophils is 84.6%;Hemoglobin is 92 g/l(kilogram per litre)

实验室检查：白蛋白36.2g/l、中性粒细胞百分比84.6%，血红蛋白：92g/l。

Physical examination:

the right limb is not active; the left limb is visible,and the muscle strength of the body is not matched;the seat balance is 0;the daily life ability score is 5 points.

体格检查：右侧肢体无活动，左侧肢体可见活动，四肢肌力检查不配合。坐位平衡0级，日常生活能力评分5分。

There are many methods of treating pressure ulcer and various kinds of drugs in clinic, the selection of appropriate treatment and nursing measures can promote the recovery of pressure ulces，In combination with the patient's condition its treatment is divided into several aspects：

1: The physiological saline, hydrogen peroxide wash, debridemen。

2：Wound use dressing

3：Relieve the pressure on the skin

4: Treatment a variety of complications that delay the healing of pressure ulcer, such as nutrient deficiency and infection.

5: Infrared irradiation

临床上治疗压疮的方法和药物种类繁多，选择合适的治疗和护理措施可促进压疮的痊愈。结合患者的病情其治疗主要分为以下几个方面

1.生理盐水、双氧水清洗，清创。

2.创面使用敷料。

3.缓减皮肤表面的压力。

4.治疗可能延迟愈合的各种并发症状，如营养缺乏及感染等。

5.使用红外线照射。

How to evaluate the wound properly is a key step in wound care.According to the specific situation of the patient's wound and the patient's own situation, select the suitable dressing and the replacement measures.

如何正确评估伤口是伤口护理的一步也是关键的一步。根据患者伤口的具体情况及患者的自身情况选择合适的敷料及换药措施。

Wet healing is beneficial to the dissolution of necrotic tissue and fibrinolysis.But it is also very important for the management of seepage.Not always "wet" is beneficial to the wound.According to the theory of moist wound healing, the use of new type of dressing in anti-infection, absorb the drainage, promote epithelial crawling, alleviate pain on obvious effect, absorption and healing of wound solutions, relationship is very important.

湿性愈合有利于坏死组织及纤维蛋白溶解从而达到清创的效果。但是对于渗液的管理也是十分的重要。不是一味的“湿性”对于伤口是有利的。根据伤口湿性愈合理论，使用新型敷料在抗感染，吸收渗液，促进上皮爬行，减轻疼痛上效果明显，对创面的渗液吸收和愈合关系至关重要。

Keeping local skin clean and time interval is the key to preventing infection. Pay attention to local skin evaluation.Whole-body support and patient compliance are important.It can be effective to treat pressure ulcers by following the principle of TIME replacement.

TIME principle: remove necrotic tissue, control infection, maintain the balance of wound moisture, and correct cell function.This principle should always run through wound management.

保持局部皮肤清洁和换药间隔时间是预防感染的关键，注意局部皮肤评估。全身支持和病人的依从性很重要。遵守TIME换药原则进行有效换药可以有效治疗压疮。TIME原则：清除坏死组织，控制感染，保持创面湿度平衡，矫正细胞的功能。这一原则应始终贯穿伤口管理。

Hydrogel dressing to soften the rotten meat, but may also affect the wound drainage balance, use the class should be correct when dressing wounds of patient evaluation and make the wound is not due to the humid environment by dipping, increase the number of dressing change, increase the burden of patients.

水凝胶敷料有利于软化腐肉，但也会影响伤口的渗液平衡，使用该类敷料时应当正确评估患者的伤口情况，使伤口不因湿润的环境而受到浸渍，增加敷料更换的次数，加重患者的负担

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一例IV期压力性损伤患者的护理体会——康复医学科

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