| Treatment of Pressure Ulcers | 壓瘡的治療 |
| Various topical agents have been used in treating pressure ulcers. Some of these agents （e.g., astringents, alkaline soap products） have proven harmful. Beneficial agents include enzymes, antiseptics, oxidizing agents, and dry dextranomer beads. The agent of choice depends on the depth of the ulcer. Deeper ulcers may derive greater benefit from enzyme application. Local treatment of pressure ulcers also includes using various dressings. The occlusive dressings are a group of dressings that are widely marketed and are being used with increasing frequency to treat pressure ulcers. These dressings （including transparent dressings, hydrocolloid dressings, and hydrogels） may be used in combination with topical agents or by themselves. | 各種局部作用藥物已用于治療壓瘡。有些藥物（如收斂劑、堿性皂制品）已證明是有害的，有些藥物，如酶、抗菌劑、氧化劑和聚糖酐珠等，卻是有益的。 選用何種藥物取決于潰瘍的深度。較深的潰瘍使用酶劑效果可能更好。 壓瘡的局部治療還包括使用各種敷料。包扎敷料即是一組銷售很廣的敷料，它在壓瘡治療中的應用已越來越廣泛。敷料（包括透明敷料、水膠體敷料和水凝膠）既可與局部作用藥物合用，也可單用?！?/td> |
| Potential Nursing DiagnosesImpaired skin integrity EquipmentWash basin, soap, water, cleansing agent or prescribed topical agents, ordered dressings, skin protectant, cotton-tipped applicators, hypoallergenic tape or adhesive dressing sheet （Hypofix）, disposable and sterile gloves, measuring device | 潛在的護理診斷皮膚完整性受損。 用品：洗滌盆、肥皂、水、清潔劑或處方局部搽劑、指定敷料、護膚劑、棉簽（棉頭涂藥器）、低敏膠布或膠布敷料貼和一次性無菌手套、測量設備等?！?/td> |
| Steps and Rationale | 步驟及說明 |
| 1. Wash hands and don gloves. * Reduces transmission of blood-borne pathogens. Gloves should be worn when handling items soiled by body fluids. 2. Close room door or bedside curtains. * Maintains client's privacy. 3. Position client comfortably with area of decubitus ulcer and surrounding skin easily accessible. * Area should be accessible for cleansing of ulcer and surrounding skin. | 1. 洗手，戴手套。 ＊ 養(yǎng)活血源性病原體的傳播。操作受體液污染用品里應戴手套。2. 關上房門或拉上床邊布簾。 * 維護病人隱私。 3. 病人體位舒適，褥瘡性潰瘍部位及周圍皮膚易于處理。 * 體位應便于潰瘍及周圍皮膚的清理。 |
| 4. Assess pressure ulcer and surrounding skin to determine ulcer stage. a. Note color, moisture, and appearance of skin around ulcer. * Skin condition may indicate progressive tissue damage. Retained moisture causes maceration. | 4. 評估壓瘡及周圍皮膚，確定壓瘡分期。 a. 注意潰瘍周圍皮膚的顏色、濕度及外觀。 * 皮膚情況可指示組織損害進展情況，殘留水分會浸軟皮膚。 |
| b. Measure two perpendicular diameters. * Provides an objective measure of wound size. May determine type of dressing chosen. Surface area = length （L） x width （W）. c. Measure depth of pressure ulcer using a sterile cotton-tipped applicator or other device that will allow a measurement of wound depth. * Depth measure is important for determining wound volume. Although surface area adequately represents tissue loss in stage 1 and 2 ulcers, volume more adequately represents tissue loss in the deeper stage 3 through 4 wounds. | b. 測量各層潰瘍直徑。 * 提供瘡面大小的客觀參數，以此決定選用何種敷料，表面面積=長（L）×寬（Ｗ）。 c. 使用無菌棉簽或其他允許測量瘡面深度的儀器測量壓瘡深度。 * 深度測量對決定瘡口容積很重要。雖然表面積在潰瘍一期和二期也能充分代表組織丟失情況，但在深度三至四期，瘡面容積能更充分地反映組織丟失情況?！?/td> |
| Volume = 2（L x D） 2 （W x D） （L D） | 容積＝2（Ｌ×Ｄ）＋2（Ｗ×Ｄ）＋（Ｌ＋Ｄ） |
| d. Measure depth （D） of skin undermined by lateral tissue necrosis. Use a sterile cotton-tipped applicator and gently probe under skin edges. * Undermining represents the loss of underlying tissues to a greater extent than that of the skin. Undermining may indicate progressive tissue necrosis. | d. 測量受外緣組織壞死損害的皮膚的深度。用無菌棉簽輕輕探查皮緣下面。 * 潛行損害代表下方組織的丟失程度大于皮膚。表明組織壞死進一步發(fā)展?！?/td> |
| 5. Wash skin surrounding ulcer gently with warm water and soap. Rinse area thoroughly with water. * Cleansing of skin surface reduces number of resident bacteria. Soap can be irritating to skin. 6. Gently dry skin thoroughly by patting lightly with towel. * Retained moisture causes maceration of skin layers. | 5. 用溫水和肥皂輕輕洗滌潰瘍周圍的皮膚。用水徹底沖洗。 * 清潔皮膚表面減少居留細菌數量。肥皂可能刺激皮膚。 6. 用毛巾輕輕拍打皮膚，使其徹底干燥。 * 水分會浸軟皮膚層?！?/td> |
| 7. Apply sterile gloves. * Aseptic technique must be maintained during cleansing, measuring, and application of dressings. （Check institutional policy regarding use of clean or sterile gloves.） 8. Cleanse ulcer thoroughly with normal saline or cleansing agent. * Removes debris of digested material from wound. Previously applied enzymes may require soaking for removal. | 7. 帶無菌手套。 * 在清潔、測量及應用敷料時，必須堅持無菌操作。（在考慮使用干凈或無菌手套時，應核對各醫(yī)院的相關規(guī)定。） 8. 用生理鹽水或清洗劑徹底清理潰瘍。 * 清潔瘡面吸附材料的碎片。之前所敷的酶可能要先浸軟后才能清除?！?/td> |
| a. Use irrigating syringe for deep ulcers. b. Cleansing may be accomplished in the shower with a hand-held shower head. c. Whirlpool treatments may be used to assist with wound cleansing and debridement. 9. Apply topical agents, if prescribed: Enzymes | a. 較深潰瘍可用沖洗注射器清洗。 b. 也可通過淋浴用手提淋浴器清洗。 c. 可用水（漩渦）療法協(xié)助進行瘡面清洗及清創(chuàng)術。 9. 按處方使用局部作用藥劑。： 酶： |
| l Keeping gloves sterile, place small amount of enzyme ointment in palm of hand. * It is not necessary to apply thick layer of ointment. A thin layer absorbs and acts more effectively. Excess medication can irritate surrounding skin. Apply only to necrotic areas. l Soften medication by rubbing briskly in palm of hand. * Makes ointment easier to apply to ulcer. l Apply thin, even layer of ointment over necrotic areas of ulcer. Do not apply enzyme to surrounding skin. * Proper distribution of ointment ensures effective action. Enzyme can cause burning, paresthesia, and dermatitis to surrounding skin. | a. 手套消毒，將少量酶軟膏涂于手掌。 * 沒有必要涂太厚的軟膏。薄層軟膏吸收更好，效果佳。過量藥物可能刺激周圍皮膚。只在壞死部位使用。 b. 用手掌輕快按磨手掌里的藥物，使之軟化。 * 更容易將軟膏敷于潰瘍處。 c. 在潰瘍壞死部位均勻地涂上薄薄一層軟膏。不要將酶涂在周圍皮膚上。 * 正確分布軟膏可確保效果，酶可致周圍皮膚出現燒灼感、感覺異常和皮炎等 |
| l Moisten gauze dressing in saline and apply directly over ulcer. * Protects wound. Keeping ulcer surface moist reduces time needed for healing. Skin cells normally live in moist environment. l Cover moistened gauze with single piece of dry gauze and tape securely in place. * Prevents bacteria from entering moist dressing. | d. 用生理鹽水弄濕紗布敷料，直接敷于潰瘍處。 * 保護瘡面，保持潰瘍面水分，縮短愈合所需時間。皮膚細胞在潮濕環(huán)境中生存。 e. 用一片干紗布覆蓋濕紗布，膠布固定。 * 防止細菌進入濕敷料 |
| Antisepticsl Deep ulcers: apply antiseptic ointment to dominant gloved hand and spread ointment in and around ulcer. （Avoid spread of contamination if area is infected.） * Antiseptic ointment causes minimal tissue irritation. All surfaces of wound must be covered to effectively control bacterial growth. l Apply sterile gauze pad over ulcer and tape securely in place. * Protects ulcer and prevents removal of ointment during turning or repositioning. | 抗菌劑：f. 深層潰瘍：將抗菌膏涂在帶手套的優(yōu)勢手上，然后將之涂進潰瘍及其周圍。（如該部位已被感染，應避免污染擴散） * 抗菌膏可輕微刺激組織；必須完全覆蓋瘡面，以有效控制細菌生長。 g. 將無菌紗布墊覆于潰瘍處，膠布固定。 * 保護潰瘍，防止翻身或變換體位時藥膏脫落?！?/td> |
| Dextranomer Beadsl Hold container of beads approximately I inch （2.5 cm） above ulcer site and lightly sprinkle 5 mm-diameter layer over wound. * Layer of insoluble powder is needed to absorb wound exudate. l Apply gauze dressing over ulcer. * Holds beads in place and protects wound. | 聚糖酐珠：h. 藥距離潰瘍部位約1英寸（2.5cm）, 在瘡面輕輕灑上一層直徑為5mm的藥粉。 * 不溶性藥粉層用于吸收瘡面滲出液。 i. 用紗布敷料包扎潰瘍。 * 固定藥物，保護瘡面?！?/td> |
| Hydrocolloid Beads/Pastel Fill ulcer defect to approximately half of the total depth with hydrocolloid beads or paste. * Hydrocolloid beads/paste will assist in absorbing wound drainage. Highly draining wounds are best treated with hydrocolloid beads/granules. l Cover with hydrocolloid dressing; extend dressing 1 to 1 1/2 inches beyond edges of wound. * Dressing maintains wound humidity. May be left in place up to 7 days. | 水膠體珠/膏：j. 用水膠體珠或膏充填潰瘍缺陷至約一半深度。 * 水膠體珠或膏有助于瘡面漏液吸收。引流瘡面處理最好用水膠體珠顆粒。 k. 覆蓋水膠體敷料，敷料面應大于瘡面邊緣1至1.5英寸。 * 敷料保留瘡面水分，留置時間可達7天。 |
| Hydrogel Agentsl Cover surface of ulcer with hydrogel using sterile applicator or gloved hand. * Maintains wound humidity while absorbing excess drainage. May be used as a carrier for topical agents. l Apply dry, fluffy gauze over gel to completely cover ulcer. * Holds hydrogel against wound surface, is absorbent. | 水凝膠藥劑：l. 用無菌敷料器或手套將水凝膠涂于潰瘍面。 * 保持瘡面濕度，同時吸收過多漏液。也可充當局部作用藥劑的載體。 m. 在凝膠上覆蓋干燥的軟紗布，并蓋住整個潰瘍。 * 使水凝膠貼于瘡面。水凝膠屬吸附劑。 |
| Calcium Alginatesl Pack wound with alginate using applicator or gloved hand. * Maintains wound humidity while absorbing excess drainage. l Apply dry gauze, foam, or hydrocolloid over alginate. * Holds alginate against wound surface | 藻酸鈣：n. 用敷料器或手套將藻酸鈣包裹瘡面。 * 保持瘡面濕度，同時吸收過多漏液。 o. 在藻酸鹽上覆蓋干燥的紗布、泡沫或水膠體。 * 使藻酸鹽貼于瘡面?！?/td> |
| 10. Reposition client comfortably off pressure ulcer. * Avoids accidental removal of dressings. 11. Remove gloves and dispose of soiled supplies. Wash hands. * Prevents transmission of microorganisms. 12. Record appearance of ulcer and treatment （type of topical agent used, dressing applied, and client's response） in nurse's notes. * Baseline observations and subsequent inspections reveal progress of healing. Documents care. 13. Report any deterioration in ulcer's appearance to nurse in charge or physician. * Deterioration of condition may indicate need for additional therapy. | 10. 重新置放病人體位，不要壓迫潰瘍部位，保持舒適。 * 避免敷料意外脫落。 11. 除去手套，處理污染用品。洗手。 * 防止微生物傳播。 12. 在護理薄上記錄潰瘍外觀及治療情況（所用局部作用藥劑型號、所用敷料、及病人反應。 * 基線觀察結果及后續(xù)檢查揭示愈合進展情況。提供護理證明。 13. 潰瘍外觀惡化應向主管護士或醫(yī)生報告。 * 惡化可能表明需要采取其他治療?！?/td> |
| Nurse AlertEarly ulcers tend to have irregular borders; with time, borders become smooth and rounded. If wound is large, irrigating with plain sterile water from an irrigating syringe may be helpful. | 護士注意事項：早期潰瘍邊緣往往是不規(guī)則的。一段時間后瘡緣變得光滑圓整。如瘡面大，用沖洗注射器加普通無菌水沖洗會有所幫助?！?/td> |
| Teaching ConsiderationsAll individuals participating in client's wound care should be taught the correct method to administer ulcer care. | 病人宣教：應教育所有參與病人瘡面護理的人員正確實施潰瘍護理法?！?/td> |
| Geriatric ConsiderationsMedicare regulations limit reimbursement for some types of pressure relief equipment used for Stages 3, 4, and 5 pressure ulcers. | 老人：老年醫(yī)療保險制度法規(guī)對某些第3、4和5期壓瘡減壓儀器使用費用的損失補償有限制?！?/td> |
| Description of AppearanceStage I: Nonblanchable erythema of the intact skin; may be soft or indurated; edge is usually irregular. Stage II: Partial-thickness skin loss involves epidermis and/or dermis. Ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. | 外觀描述一期：紅斑不發(fā)白，皮膚完整，或軟柔或硬化；紅斑邊緣通常不規(guī)則。 二期：部分皮膚層丟失累及表皮和/或真皮。淺表性潰瘍。 臨床表現為擦傷、水泡、或淺表潰瘍龕（火山口狀潰瘍）?！?/td> |
| Stage III: Full-thickness skin loss involves damage or necrosis of subcutaneous tissue that may extend to the fascia. Ulcer presents clinically as a deep crater, with or without undermining of adjacent skin. Stage IV: Full-thickness skin loss occurs with extensive destruction or necrosis through subcutaneous layers into muscle and bone. Ulcer edge appears to "roll over" into the defect and is a tough fibrinous ring. | 三期：全層皮膚丟失，包括皮下組織損傷或壞死，可深及筋膜。潰瘍臨床表現為潰瘍龕，伴或無相鄰皮膚剝離。 四期：全層皮膚丟失伴廣泛性損害或壞死，穿過皮下層深入肌、骨。潰瘍邊緣“翻卷”進入凹陷處，形成一堅硬的纖維環(huán)?！?/td> |
| Stage V: Lesion is covered by a tough membranous layer that may be rigidly adherent to the ulcer base. Stage is difficult to determine until eschar has sloughed or has been surgically removed. | 五期：損傷被一硬膜層覆蓋，該硬膜層可能牢固地附著于潰瘍基。在焦痂脫落或手術去除前難以確定其分期?！?/td> |
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