两分钟掌握压疮预防要点 Pressure Injury Prevention Points

1. 考虑患者卧床不起和长期坐位为导致压疮的因素。

Consider bedfast and chairfast individuals to be at risk for development of pressure injury.

2. 使用风险评估表，如Braden评分表，尽快确认患者压疮的风险因素（入院8小时内）

Use a structured risk assessment, such as the Braden Scale, to identify individuals at risk for pressure injury as soon as possible (but within 8 hours after admission).

3. 完善以下这些额外的风险因素的评估：

Refine the assessment by including these additional risk factors:

a. 脆弱的皮肤

Fragile skin

b. 现有的任何分期的压疮，包括已经愈合和闭合的溃疡

Existing pressure injury of any stage, including those ulcers that have healed or are closed

c. 因血管疾病、糖尿病或使用烟草导致的四肢血液循环障碍

Impairments in blood flow to the extremities from vascular disease, diabetes or tobacco use

d. 因压力导致的身体部位的疼痛

Pain in areas of the body exposed to pressure

4. 定期或有情况变化时重新评估风险。定期评估的频率基于以下水平：

Repeat the risk assessment at regular intervals and with any change in condition. Base the frequency of regular assessments on acuity levels:

a. 急症照护——每次交接班

Acute care ---- Every shift

b. 家庭护理——每次护士到访

Home care --- At every nurse visit

5. 制定一个护理计划，基于每一个风险因素，而不仅仅是风险评估的总分。例如，风险源于不能移动，解决翻身、改变体位和支撑表面的问题；如果因营养失调导致的风险，就考虑解决这些问题。

Develop a plan of care based on the areas of risk, rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning, repositioning, and the support surface. If the risk is from malnutrition, address those problems.

1. 入院时尽快检查所有的皮肤（入院8小时内）

Inspect all of the skin upon admission as soon as possible (but within 8 hours).

2. 每班至少检查一次皮肤有无压疮的迹象，特别是指压不变白红斑

Inspect the skin at least daily for signs of pressure injury, especially non-blanchable erythema.

3. 评估压力点，如骶骨、尾骨、脚踝、坐骨、粗隆、肘部和医疗设备

Assess pressure points, such as the sacrum, coccyx, buttocks, heels, ischium, trochanters, elbows and beneath medical devices.

4. 当检查黑色素沉着的皮肤时，寻找肤色的改变、肤温的变化和皮肤组织与相邻皮肤的一致性的对比。湿润皮肤可以帮助识别肤色的变化。

When inspecting darkly pigmented skin, look for changes in skin tone, skin temperature and tissue consistency compared to adjacent skin.

5. 在尿失禁后马上清洁皮肤。

Cleanse the skin promptly after episodes of incontinence.

6. 使用中性的清洁液清洁皮肤。

Use skin cleansers that are PH balanced for the skin.

7. 每天在干燥的皮肤上使用保湿霜。

Use skin moisturizers on dry skin.

8. 避免按压红斑或压疮的区域。

Avoid positioning an individual on an area of erythema or pressure injury.

1. 考虑个体住院因素导致的营养不良和疾病所致的营养失调或因诊断测试所需的禁食。

Consider hospitalized individuals to be at risk for under nutrition and malnutrition from their illness or being NPO for diagnostic testing.

2. 使用一个有效、可靠的筛查工具来确定营养不良的风险，如迷你营养评估表。

Use a valid and reliable screening tool to determine risk of malnutrition, such as Mini Nutrition Assessment.

3. 参考注册营养师和营养学家对于患者因营养不良导致压疮的风险评估。

Refer all individuals at risk for pressure injury from malnutrition to a registered dietitian / nutritionist.

4. 协助患者在进餐时增加口服摄入量。

Assist the individual at mealtimes to increase oral intake.

5. 鼓励患者摄入足够的液体和均衡膳食来减少压疮的风险。

Encourage all individuals at risk for pressure injury to consume adequate fluids and a balanced diet.

6. 定期评估体重的改变。

Assess weight changes over time.

7. 评估口腔、肠内和肠外摄入量的充足性。

Assess the adequacy of oral, enteral and parenteral intake.

8. 在口服给药和两餐之间补充营养素，除非有禁忌。

Provide nutrition supplements between meals and with oral medications, unless contraindicated.

1. 翻身和改变体位来减少压疮的风险，除非由于疾病或医学治疗的禁忌。

Turn and reposition all individuals at risk for pressure injury, unless contraindicated due to medical condition or medical treatments.

2. 基于支承表面的使用、皮肤的压力耐受性和个人的偏好来选择一个翻身的频率。

Choose a frequency for turning based on the support surface in use, the tolerance of skin for pressure and the individual’s preferences.

3. 为保证不间断的睡眠，考虑在夜晚延长翻身的时间。

Consider lengthening the turning schedule during the night to allow for uninterrupted sleep.

4. 呈30度角侧躺在床上，并用手来确认骶骨是否离开床面。

Turn the individual into a 30-degree side lying position, and use your hand to determine if the sacrum is off the bed.

5. 避免使身体损伤区域受压。

Avoid positioning the individual on body areas with pressure injury.

6. 确保脚踝离开床面。

Ensure that the heels are free from the bed.

7. 患者的体位要考虑其活动度、暴露的剪切力、肌肤水分、灌注量、体型和体重。

Consider the level of immobility, exposure to shear, skin moisture, perfusion, body size and weight of the individual when choosing a support surface.

8. 患者处于任何体位都要经常翻身。

Continue to reposition an individual when placed on any support surface.

9. 当失禁时使用可吸收的纸尿垫。

Use a breathable incontinence pad when using microclimate management surfaces.

10. 当患者坐在椅子或轮椅上时使用可均衡承重的椅垫。

Use a pressure redistributing chair cushion for individuals sitting in chairs or wheelchairs.

11. 虚弱或不能自行移动的患者在轮椅上需每小时改变体位。

Reposition weak or immobile individuals in chairs hourly.

12. 若患者不能移动或床头角度超过30度时，需在骶骨处贴聚氨酯泡沫敷料。

If the individual cannot be moved or is positioned with the head of the bed elevated over 30-degree, place a polyurethane foam dressing on the sacrum.

13. 在脚踝处使用脚圈或贴聚氨酯泡沫辅料以降低脚踝压疮的高风险性。

Use heel offloading devices or polyurethane foam dressing on individuals at high-risk for heel ulcers.

14. 在医疗设备下贴泡沫或透气性的敷料。

Place thin foam or breathable dressing under medical devices.

1. 告知患者及其家属关于压疮的风险因素。

Teach the individual and family about risk for pressure injury.

2. 鼓励患者和家属参与减少风险。

Engage individual and family in risk reduction interventions.