压疮分期及其护理进展  

Recent progress of pressure ulcer staging and nursing

作　　者：周玉洁[1] 杨美玲[2] 张洪君[2] 洪涛[3] 张军[4] 朴莹[4] 

机构地区：[1]北京大学第三医院普通外科,100191 [2]北京大学第三医院护理部,100191 [3]广东省人民医院 [4]中国医科大学第一附属医院

出　　处：《中国护理管理》2014年第7期683-686,共4页Chinese Nursing Management

摘　　要：本文介绍压疮的分期、压疮的评估以及压疮发生后的处理方法。对国内外相关研究的分析表明:美国压疮专家咨询组2007年更新的压疮分期是目前全球使用最广泛的压疮分期系统之一;可应用视觉模拟评分表、面部等级评分表等工具评估成年压疮患者的疼痛程度;使用压疮愈合计分表评价压疮的愈合效果具有很好的信度、效度和内部一致性;应用生理盐水或饮用水定期清洗伤口;根据患者的病情、坏死组织的类型、性质和部位、治疗目标、可利用的资源及患者意愿选择适宜的清创方式;敷料的选择应基于伤口床的情况、伤口周围皮肤情况以及患者的护理目标。This paper introduced pressure ulcer staging, nursing assessment and wound care of pressure ulcer. Based on the analysis of related studies, we found that the pressure ulcer staging developed by National Pressure Ulcer Advisory Panel in 2007 was one of the most widely used systems in the world. Adult pressure ulcer patients＇ pain could be assessed by Visual Analogue Scale, Face pain Scale and some other scales. Pressure ulcer scale for healing had good reliability and validity. Wound should be cleaned with normal saline or water regularly. Debridement methods should be chosen according to patient＇s condition, necrotic tissue type, wound site, treatment goals, available resources and patient＇s preference. Selection of dressing must be based on the wound condition, skin surrounding the wound and nursing goals.

关 键 词：压疮分期 护理评估 伤口处理 

分 类 号：R47[医药卫生—护理学]