压力性损伤
原因
预防
评估 临床表现
护理
PRESSURE INJURY: A PRESSURE INJURY IS LOCALIZED DAMAGE TO THE SKIN AND/OR UNDERLYING SOFT TISSUE USUALLY OVER A BONY PROMINENCE OR RELATED TO A MEDICAL OR OTHER DEVICE. THE INJURY CAN PRESENT AS INTACT SKIN OR AN OPEN ULCER AND MAY BE PAINFUL. THE INJURY OCCURS AS A RESULT OF INTENSE AND/OR PROLONGED PRESSURE OR PRESSURE IN COMBINATION WITH SHEAR. THE TOLERANCE OF SOFT TISSUE FOR PRESSURE AND SHEAR MAY ALSO BE AFFECTED BY MICROCLIMATE, NUTRITION, PERFUSION, CO-MORBIDITIES AND CONDITION OF THE SOFT TISSUE.
压力性损伤的预防和护理
定义更新的背景和意义：
2016年4月8日至9日，在芝加哥举行的400多名专业人士的会议上，展示了最新的 分级定义。使用一种一致的格式，来自弗吉尼亚大学的MIKEL GRAY博士通过一个 互动的讨论和投票过程，引导了临时的任务小组和会议参与者对最新的定义达成 一致。在会议期间，参与者还通过照片验证了新的术语。 美国压疮委员会NPUAP在压力损伤分级系统中使用“压力性损伤”取代了“压力 性溃疡”。术语的变化更准确地描述了对完整的和溃疡性皮肤的压力性损伤。在 先前的分级系统阶段1和深层组织损伤描述了受伤的完整皮肤，而其他阶段则描 述了开放性溃疡。这导致了混淆，因为每个阶段的定义都被认为是“压力性溃疡 ”。 除了术语的变化外，阿拉伯数字现在被用在各个阶段的名称中，而不是罗马数字 。“疑似”一词已从深层组织损伤诊断标签中移除。在会议上达成的附加压力伤 害定义包括医疗器械相关的压力损伤和粘膜压力损伤。
1 压力性损伤发生的原因：
垂直压力
主
要
剪切力
因Hale Waihona Puke 素摩擦力力学因素
局部潮湿或 排泄物刺激
营养状况
矫形器械 使用不当
体温升高
年龄
IN ADDITION TO THE CHANGE IN TERMINOLOGY, ARABIC NUMBERS ARE NOW USED IN THE NAMES OF THE STAGES INSTEAD OF ROMAN NUMERALS. THE TERM “SUSPECTED” HAS BEEN REMOVED FROM THE DEEP TISSUE INJURY DIAGNOSTIC LABEL. ADDITIONAL PRESSURE INJURY DEFINITIONS AGREED UPON AT THE MEETING INCLUDED MEDICAL DEVICE RELATED PRESSURE INJURY AND MUCOSAL MEMBRANE PRESSURE INJURY.
THE UPDATED STAGING DEFINITIONS WERE PRESENTED AT A MEETING OF OVER 400 PROFESSIONALS HELD IN CHICAGO ON APRIL 8-9, 2016. USING A CONSENSUS FORMAT, DR. MIKEL GRAY FROM THE UNIVERSITY OF VIRGINIA ADEPTLY GUIDED THE STAGING TASK FORCE AND MEETING PARTICIPANTS TO CONSENSUS ON THE UPDATED DEFINITIONS THROUGH AN INTERACTIVE DISCUSSION AND VOTING PROCESS. DURING THE MEETING, THE PARTICIPANTS ALSO VALIDATED THE NEW TERMINOLOGY USING PHOTOGRAPHS.
学习内容：
最新压力性损伤{压疮}定义： 是发生皮肤和/或潜在皮下 软组织的局限性损伤，通常 发生在骨隆突处或与医疗或 其他医疗设备有关的损伤。 该压力性损伤可表现为局部 组织受损但表皮完整或开放 性溃疡并可能伴有疼痛。剧 烈和（或）长期的压力或压 力联合剪切力可导致压力性 损伤出现。皮下软组织对压 力和剪切力的耐受性受环境、 营养、灌注、合并症和软组 织的条件的影响。
THE TERM “PRESSURE INJURY” REPLACES “PRESSURE ULCER” IN THE NATIONAL PRESSURE ULCER ADVISORY PANEL PRESSURE INJURY STAGING SYSTEMACCORDING TO THE NPUAP. THE CHANGE IN TERMINOLOGY MORE ACCURATELY DESCRIBES PRESSURE INJURIES TO BOTH INTACT AND ULCERATED SKIN. IN THE PREVIOUS STAGING SYSTEM STAGE 1 AND DEEP TISSUE INJURY DESCRIBED INJURED INTACT SKIN, WHILE THE OTHER STAGES DESCRIBED OPEN ULCERS. THIS LED TO CONFUSION BECAUSE THE DEFINITIONS FOR EACH OF THE STAGES REFERRED TO THE INJURIES AS “PRESSURE ULCERS”.