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Pressure ulcer care in critically ill patients and progress of: Yen Chun Key words pressure ulcer care in critically ill patients

Over the past decade, domestic and international pressure ulcers in critically ill patients awareness and prevention has much in common, but the occurrence of pressure ulcers and prevention point of view there are some key differences. Lack of nursing resources, and often occurs in patients with pressure ulcers only take care measures, rather than the use of nursing process to identify and solve patient problems. How according to China's situation and to promote the prevention of pressure ulcers in critically ill patients is urgent to resolve the validity of a topic, critically ill patients in critical condition, combined with prolonged bed rest, prone to pressure sores [1]. To better address the scientific attitude and approach the problem of pressure sore prevention, especially to some of these points are summarized below.

1 awareness of pressure sore

first called bedsores pressure sores, comes from the Latin In fact, pressure sores often occur in long-lying or sitting position (such as wheelchairs) patients, and not just caused by the lie. Pressure sores caused by the most basic, the most important factor is the pressure caused by local tissue ischemia and hypoxia, so called

local tissue pressure sores is pressure on the body too long, or long-term physical and chemical stimulation of neurotrophic factors in disorders and blood circulation, local tissue ischemia and malnutrition continue to cause loss of normal function of the skin, caused by defects and destruction. Pressure sore is a common clinical complication, not the original disease, which most of the primary disease because of other very good care without causing damage. In the event of pressure ulcers, not only to patients suffering tremendous physiological and psychological and economic pressure, will increase the workload of nurses, a serious secondary infection can be life-threatening sepsis guidelines. Most ulcers are preventable, but not all. Such as serious negative nitrogen balance in critically ill patients, malnutrition, tissue repair after injury itself a lot more difficult to acute cerebral hemorrhage in critically ill patients need to strictly limit the stand, using existing nursing means difficult to prevent the occurrence of pressure sores, resulting in inevitable pressure sore [2]. Can not put all the pressure ulcers were attributed to improper care. Pressure ulcers in critically ill patients the quality of care can be a direct response to a department, a hospital management level and professional standard of care [3]. Critically ill hospital patients are at high risk of pressure ulcers occur.

1.1 compression on the critical condition of the patients will be given to a variety of treatment and monitoring equipment and treatment, the treatment of pipes and wires may limit the detection of patients with physical activity and body position changes so that the patient activity decreased, resulting in the patient long-term pressure on the skin. Pressure sores caused not only by the vertical pressure, can also be caused by friction and shear force, usually 2 to 3 kinds of force due to combined action.

1.1.1 Vertical stress-induced pressure sores main reason is that local tissue by the continuous vertical pressure, Cinsdule proposed that in the 9.3kPa pressure for 2 hours or more, could cause irreversible cellular changes, suggesting that each there is the need to relieve stress from time to time [4].

1.1.2 the role of friction on the skin friction, easy to damage the skin, the stratum corneum.

1.1.3 supine shear stress in critically ill patients, such as raising the body down the bed, there is a parallel between the skin and bed friction, coupled with the vertical direction gravity of skin, resulting in shear force have caused local skin blood circulation disorder and pressure ulcers occur.

1.2 wet in wet conditions the risk of patients developed pressure ulcers increased 5-fold [2].

1.3 age, the incidence was positively correlated with age. Patients aged over 50 compared with a high incidence of patients under the age of 50 from 7 to 8 times [5].

1.4 Nutrition hematocrit and hemoglobin of less than 0.36 less than 120g / l cut point is a better test [6], the incidence of pressure sores has a good selection predict.

1.5 smokers smoking the risk of pressure ulcers was significantly increased. Heel pressure ulcers non-smokers smokers 4 times [7], smoking and the incidence of pressure sores and severity were positively correlated.

1.6 unconsciousness cognitive function than those who place a clear risk of pressure ulcers was significantly increased.

1.7 Long-term use of sedative drugs in critically ill patients, steroids and the activity led to decreased body resistance is pressure ulcer risk factors.

1.8 skin, high fever and body temperature is closely related to pressure ulcers, according to unconscious patients reported occurred within 20 hours, pressure ulcers: pressure sores occur on average body temperature of patients was no greater than 38.5 ℃ pressure sores than the average body temperature of patients 37.5 ℃ [8]. Some studies have shown: 1 degree rise in body temperature, metabolic rate increased by 10%, so high temperature is pressure ulcer risk factors.

1.9 weight obesity weight loss than those of the high probability of occurrence of pressure ulcers [9], but obesity, adipose tissue blood supply critically ill patients and difficulty in relatively small, easily drag when turning in bed, resulting in pressure the occurrence of sores. Has been demonstrated, the role of time pressure and stress the size of a parabolic relationship, greater pressure on both the time required for pressure sore pressure is relatively small short [10].

2 pressure ulcer care in critically ill patients

2.1 correct assessment of critically ill patients

the positive assessment of the patient as a key step in prevention of pressure ulcers, pressure ulcers occur to the patient's risk factors for the qualitative and quantitative comprehensive analysis, commonly used pressure ulcer Braden score, has been in the medical world institutions widely used.

2.2 Pressure relief devices of various applications

2.2.1 to avoid prolonged pressure and friction of local organizations

turning the patient every 2h 1 shot back, for edema, numbness and other critically ill patients need to increase turn around times. Roll 30 degrees to take measures to prevent pressure sores, when the body side and the bed 30 degrees, there is conducive to human bone protruding parts scattered pressure and blood flow, can reduce the risk of pressure ulcers [11] to avoid damage to the skin stratum corneum, to prevent Slide the patient's body.

2.2.2-separated-type air ring can make the body part floating at the median of the skin does not touch the balloon.

2.2.3 electric air bed pressure sore prevention alternately charge and discharge through the air way, changing the pressure points in critically ill patients, reducing local compression time.

2.2.4 cool liquid cushion against pressure sores using the cool liquid cushion, the use of pad fluid flow, reduction of local pressure, reduce the local temperature, reducing oxygen consumption. Traditionally used for prevention of pressure sores has not advocate the use of heat lamp, heat lamp to increase the local skin temperature, increased pressure sore susceptibility.

2.3 focuses on the prevention of pressure ulcers in critically ill patients to minor activities, daily full range of joint movement should be carried out in order to maintain joint mobility and muscle tension, promote the body's blood circulation, reduce pressure ulcer. Guide effective deep breathing, increased mental and physical comfort guide and assist both upper active rotation, flexion, extension and other activities to help lower limb passive hip, knee and ankle flexion for relevant, extension, transfer, and other passive activities, action should be slowly starting to relax, each second twenty minutes.

2.4 care to keep clean sheets clean, flat, dry, clean skin daily with warm water and strong detergents to disable irritating.

2.5 daily ward ventilation environmental management, reduce mobility, ground, desktop wipe with disinfectant.

2.6 diet reduced elasticity of the skin care and malnutrition, increased incidence of pressure ulcers, delayed wound healing and disease prognosis, and decreased immunity. According to the specific circumstances of the patients adjust diet, nutrition support.

2.7 treatment and protection of wound

2.7.1 first detection of the ulcer size, location, stage and appearance (granulation tissue, necrosis, scab, carrion, exudative), then The wounds were debrided choose different methods of debridement, with 37 ℃ The warm salt water rinse the wound to remove necrotic tissue and foreign bodies, reducing the infection to promote healing.

2.7.2 did not break the blisters on after sterilization with sterile gauze protecting large blisters, bubbles collected after disinfection liquid, and then coated with ointment, sterile gauze protection. The higher number of wound exudate on the larger, according to gauze wet conditions, and appropriately increase the number of dressing change.

2.7.3 exudate on the wound pus pus many more wounds, Xiadian rubber single, top-down repeatedly washed with saline to clean wounds. Rinse thoroughly than cotton scrub, scrub overcome the wound with sterile cotton balls easy to damage the granulation tissue, cotton fiber is easy to stay in the foreign body reaction caused by the wound, healing of tissue defects [12].

2.7.4 wound scab and scab pus under pressure ulcer care first washed with normal saline and exudate pus, and then sterile saline soaked gauze in the wound site, so that soften dry scab. From the callus surface side of the fractional removal of necrotic tissue, and then normal saline will be sprayed evenly bFGF in the wound, the increase in infrared radiation 15min 2 times a day.

2.7.5 Wound oxygen covering the wound with a plastic bag, fasten the bag through a small hole to oxygen, the oxygen flow rate 5 ~ 6L/min, every 15min, 2 times a day. More wounds on the secretions, the first debridement and then oxygen, put the bottle in the wet 75% ethanol, the oxygen through the humidifier bottle with a portion of ethanol, inhibit bacterial growth and reduce the discharge and speed up wound healing. Oxygen therapy is the use of pure oxygen, anaerobic bacteria inhibit the growth of the wound to improve wound tissue oxygen supply, improving local tissue metabolism.

2.7.6 Baby Nappy cream with plastic wrap and use a lot of studies have shown that moist wound environment more conducive to the formation of epithelial cells, so that the wounds without scarring process in general and natural healing, and healed faster than dry environment, 10 times faster [13]. This method is sealed a wound moist therapy, pressure sores in the skin can be treated with baby Nappy cream create a moist environment, apply plastic wrap to form a closed environment, controlling the evaporation of water vapor, liquid and efficient isolation bacterial invasion, quickly create a moist environment conducive to wound healing. Meanwhile, the pressure ulcer moist environment, can reduce the adhesion of plastic wrap and wound in the replacement of plastic wrap will not damage new granulation tissue and epithelial tissue, the wound will reduce the pain [13].

2.7.7 Vaseline to reduce friction of the skin, the role of the protective film on the skin to form a closed inks [14], to reduce local skin friction and abrasion of the opportunity to avoid the sweat, urine, stool Blood and other direct contact with the skin.

2.8 pressure ulcers physical therapy and drug application

2.8.1 wet packing pressure ulcer

1962 Nyan Win to Dr demonstrate the use of wound dressings over exposed to moisture in the air near the natural healing significantly faster wound healing [15] to reduce inflammation and lower crust to form the risk of infection to relieve pain.

2.8.2 egg membrane covering debrided coverage with the egg membrane, its formation close to the wound, the egg membrane coverage to 1 cm beyond the wound [5].

2.8.3 Iodine is a new broad-spectrum, highly efficient, non-toxic topical disinfectant, so that tissue dehydration, and promote wound dry, dilation of blood vessels, promote blood circulation, softening and dissipation induration [16] , no stimulation of the mucosa, non-corrosive, applied to the local surface can form a protective film to protect the wound and surrounding skin to prevent bacteria directly into the wound and promote wound healing.

2.8.4 wound infection, around the red, swollen, hot, pain, exudate and more, smell, peripheral leukocytosis, wound bacterial culture and sensitivity to do experiments, directed by your doctor use of antibiotics or the use of silver ions or nano-silver antimicrobial dressing.

2.8.5 Insulin treatment of pressure ulcers combined 654-2 increase glucose utilization of insulin to promote protein synthesis and increase microvascular perfusion 654-2 to relieve spasm, analgesic effect and humid, conducive to wound the formation of epithelial cells, promote granulation tissue growth and wound healing. Therefore the mixture of insulin ,654-2 after wet compress on the wound, you can improve local circulation and promote wound tissue glucose uptake and utilization, and promote protein synthesis, reduce pain, accelerate tissue growth, reduce pressure ulcer healing time [17 ].

2.8.6 Insulin Combined with pressure ulcers found that phenytoin treatment success fibroblast growth factor insulin-like effects, can promote the growth of fibroblasts and collagen synthesis [18]. Phenytoin can significantly increase the local collagen deposition and wound angiogenesis, wound macrophages to increase the number and function of the effective promotion of granulation tissue and accelerate wound healing.

2.8 condition observation

observing closely and accurately record changes, each time when the wound dressing to assess and modify the plan to develop and improve the quality of care.

2.9 Nurses should increase their sense of responsibility to strengthen accountability, increase awareness of the dangers of pressure ulcers, reducing errors caused by the nursing pressure ulcer. Studies have shown that nursing focuses on identifying risk factors and timely, accurate prediction of risk, so take appropriate care measures.

2.9.1 build turning the key card in the prevention of pressure ulcers to enhance care management,Shoes, pay attention to basic care, bedside stand hanging cards, turn over after the recording time, posture and skin conditions.

2.9.2 ward nurse visits, observation of patients with skin conditions, turn over the card of checking the accuracy and reasonableness of the measures to ensure the use of bedridden patients turn over cards are implemented.

2.9.3 cards using the stand, so that patients and their families to understand the methods and importance of skin care, play a supervisory role of nursing, so that patients receive full care and effective management.

2.10 psychological care of patients sympathy, understanding and care,Vibram Five Fingers, to establish the confidence to overcome the disease to reduce pressure and friction to inform patients, with treatment and care. Psychological qualities of nurses training, attention to psychological care of the

3 Summary

sores in critically ill patients is reduced by the activity and functional impairment caused great harm of a potential complication of the rapid process of its formation, the treatment process is very long. Therefore, effective nursing intervention, strict implementation of bedside shift relief systems to eliminate the occurrence of pressure ulcers, reducing pain. Also, psychological care for patients, health education, helping patients build confidence, with treatment and a speedy recovery, so that the quality of care is guaranteed.

References

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[15] Moues CM, van den Bemd GJ, Heule F, et al.Comparing conventional gauze therapy to vacuum-assisted closure wound therapy.J Plast Reconstr Aesthet Surg ,2007,60:672-681.

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