Comprehensive decipher pressure ulcer (Pressure Ulcear)

(one) PU definition

Pressure ulcer is Pressure Ulcear, is called PU (below to replace with PU), also calledThe bedsore or presses the sore.PU refersBecause the local organization the long time bearing creates the blood circulation to bond, the local soft tissue lacks the blood, the oxygen deficit, the fester and necrosis。

(two) PU graduation

According to the clinical manifestation, presses the sore to be possible to divide into three issues:

I red spot time: After bodily local long-term bearing, local blood circulation bad, the bearing spot organization lacks the blood, the oxygen deficit, the arterial bifurcation reactivity expands, causes to assume the hyperemia shape local, local skin performance for red spot as well as mild dropsy. If the bearing situation continues to exist, the skin presents the blue purple.

II wheal time: The blood capillary permeability adds, presents the wheal locally which the size varies. Dermis and Subcutaneous tissue also further swelling, the skin blushes, the hyperemia, the organization induration is more obvious.

III ulcer time

•Shallow ulcer time: Ulcer table is shallow, the depth does not surpass the skin entire level. Clinical manifestation for ulcer boundary ataxia, base base pale (blood supply barrier), Granulation tissue growth bad. Also the detectable injured area boundary has thick and the hard Scar tissue forms.

•Depth ulcer time: The shallow ulcer to the deep level development, implicates the fascia, the muscle even the skeleton. The clinical manifestation presents the black necrosis shape for the injured area; If has the bacterial infection concurrently, the injured area secretion common unusual smell, assumes the purulent.

International stage division National Pressure Ulcer Advisory Panel (1989) standard graduation

•Stage 1: Skin integrity, in the bearing blushes under the area finger to press, the skin color has not bleached.

•Stage 2: The skin loses the epidermis or the dermis, Cheng Biaoqian the ulcer. (blister, abrasion and so on)

•Stage 3: Wound intrusion Subcutaneous tissue, but not yet encroaches upon the myo- membrane. (volcano shape wound)

•Stage 4: Wound necrosis to muscle level, skeleton, tendon and so on

Rests on the international pressure sore Advisory commission (NPUAP)2007 year to press the sore frame work method to increase two by stages:

Suspects in-depth damage time:The hypodermic soft tissue the pressure and/or the shearing force damage, the skin color turns locally the purple or the brown purple red; The epidermis integrated or presents the hyperemia the blister.

May not by stages:Complete skin level tissue breakage, but ulcer basis by the yellow, the sepia, the gray, the green either the brown slough cover and/or has the sepia, brown or black Eschar in ulcer base.

(three) PUPrevention

(1) skin examination and turning over: Skin examination at least each class of one time. The turning over decides according to the skin bearing situation.

(2) regular clean skin。

(3) avoids the skin which the environmental factor causes being dry.

(4) avoids splashing the immediate contact, avoids splashing carries on the massage.

(5) avoids the skin contact feces and urine as far as possible, the wound percolate and the sweat.

(6) improves the nutrition。

(7) like enhances patient's mobility and the activity possibility existence, should establish the recovery treatment in its entire course of treatment

The content, must hold their existing activity level to the majority patients.

(8) like patient condition permission, and does not have the contraindication, should cause the angle reduction as far as possible which the head raises, and reduces the time as far as possible which the head raises.

(9) correct moving and changes the patient.

(four) PUVarious times nursing countermeasure

ⅠTime: The turning over, avoids once again the bearing, endures the massage. Available match skin Run.

ⅡTime: Extracts in the blister under the aseptic technique to infiltrate the fluid, trims off the blister skin, the surface spurts Bei Fuji, covers with the aseptic gauze. If the wheal is small, but does not need

Cuts the blister skin, with the gauze compression wrap then, reduces seeps out.

ⅢTime -ⅣTime: Creates processing clear, trades the medicine on time. Available against bedsore placard membrane.

Suspects in-depth damage time:①Reduced pressure②Does not have the blood blister, black hard posts with ulcer or posts transparently, promotion extravasated blood absorption, softened induration. Has the blood blister, the black soft aseptic technique incision drainage, the use infiltrates the fluid absorption to post the cover safeguarding, the promotion cicatrization.

May not by stages:The reduced pressure, creates clear.

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