|
| Treatment of Pressure Ulcers |
压疮的治疗 |
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. |
各种局部作用药物已用于治疗压疮。有些药物（如收敛剂、碱性皂制品）已证明是有害的，有些药物，如酶、抗菌剂、氧化剂和聚糖酐珠等，却是有益的。
选用何种药物取决于溃疡的深度。较深的溃疡使用酶剂效果可能更好。
压疮的局部治疗还包括使用各种敷料。包扎敷料即是一组销售很广的敷料，它在压疮治疗中的应用已越来越广泛。敷料（包括透明敷料、水胶体敷料和水凝胶）既可与局部作用药物合用，也可单用。 |
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 |
潜在的护理诊断皮肤完整性受损。
用品：洗涤盆、肥皂、水、清洁剂或处方局部搽剂、指定敷料、护肤剂、棉签（棉头涂药器）、低敏胶布或胶布敷料贴和一次性无菌手套、测量设备等。 |
| Steps and Rationale |
步骤及说明 |
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。
＊ 养活血源性病原体的传播。操作受体液污染用品里应戴手套。2. 关上房门或拉上床边布帘。
* 维护病人隐私。
3. 病人体位舒适，褥疮性溃疡部位及周围皮肤易于处理。
* 体位应便于溃疡及周围皮肤的清理。 |
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. 评估压疮及周围皮肤，确定压疮分期。
a. 注意溃疡周围皮肤的颜色、湿度及外观。
* 皮肤情况可指示组织损害进展情况，残留水分会浸软皮肤。 |
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. 测量各层溃疡直径。
* 提供疮面大小的客观参数，以此决定选用何种敷料，表面面积=长（L）×宽（Ｗ）。
c. 使用无菌棉签或其他允许测量疮面深度的仪器测量压疮深度。
* 深度测量对决定疮口容积很重要。虽然表面积在溃疡一期和二期也能充分代表组织丢失情况，但在深度三至四期，疮面容积能更充分地反映组织丢失情况。 |
| Volume = 2（L x D） + 2 （W x D） + （L + D） |
容积＝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. 测量受外缘组织坏死损害的皮肤的深度。用无菌棉签轻轻探查皮缘下面。
* 潜行损害代表下方组织的丢失程度大于皮肤。表明组织坏死进一步发展。 |
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. 用温水和肥皂轻轻洗涤溃疡周围的皮肤。用水彻底冲洗。
* 清洁皮肤表面减少居留细菌数量。肥皂可能刺激皮肤。
6. 用毛巾轻轻拍打皮肤，使其彻底干燥。
* 水分会浸软皮肤层。 |
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. 带无菌手套。
* 在清洁、测量及应用敷料时，必须坚持无菌操作。（在考虑使用干净或无菌手套时，应核对各医院的相关规定。）
8. 用生理盐水或清洗剂彻底清理溃疡。
* 清洁疮面吸附材料的碎片。之前所敷的酶可能要先浸软后才能清除。 |
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. 较深溃疡可用冲洗注射器清洗。
b. 也可通过淋浴用手提淋浴器清洗。
c. 可用水（漩涡）疗法协助进行疮面清洗及清创术。
9. 按处方使用局部作用药剂。：
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，将少量酶软膏涂于手掌。
* 没有必要涂太厚的软膏。薄层软膏吸收更好，效果佳。过量药物可能刺激周围皮肤。只在坏死部位使用。
b. 用手掌轻快按磨手掌里的药物，使之软化。
* 更容易将软膏敷于溃疡处。
c. 在溃疡坏死部位均匀地涂上薄薄一层软膏。不要将酶涂在周围皮肤上。
* 正确分布软膏可确保效果，酶可致周围皮肤出现烧灼感、感觉异常和皮炎等 |
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. 用生理盐水弄湿纱布敷料，直接敷于溃疡处。
* 保护疮面，保持溃疡面水分，缩短愈合所需时间。皮肤细胞在潮湿环境中生存。
e. 用一片干纱布覆盖湿纱布，胶布固定。
* 防止细菌进入湿敷料 |
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. |
抗菌剂：f. 深层溃疡：将抗菌膏涂在带手套的优势手上，然后将之涂进溃疡及其周围。（如该部位已被感染，应避免污染扩散）
* 抗菌膏可轻微刺激组织；必须完全覆盖疮面，以有效控制细菌生长。
g. 将无菌纱布垫覆于溃疡处，胶布固定。
* 保护溃疡，防止翻身或变换体位时药膏脱落。 |
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. 药距离溃疡部位约1英寸（2.5cm）, 在疮面轻轻洒上一层直径为5mm的药粉。
* 不溶性药粉层用于吸收疮面渗出液。
i. 用纱布敷料包扎溃疡。
* 固定药物，保护疮面。 |
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. |
水胶体珠/膏：j. 用水胶体珠或膏充填溃疡缺陷至约一半深度。
* 水胶体珠或膏有助于疮面漏液吸收。引流疮面处理最好用水胶体珠颗粒。
k. 覆盖水胶体敷料，敷料面应大于疮面边缘1至1.5英寸。
* 敷料保留疮面水分，留置时间可达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. |
水凝胶药剂：l. 用无菌敷料器或手套将水凝胶涂于溃疡面。
* 保持疮面湿度，同时吸收过多漏液。也可充当局部作用药剂的载体。
m. 在凝胶上覆盖干燥的软纱布，并盖住整个溃疡。
* 使水凝胶贴于疮面。水凝胶属吸附剂。 |
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 |
藻酸钙：n. 用敷料器或手套将藻酸钙包裹疮面。
* 保持疮面湿度，同时吸收过多漏液。
o. 在藻酸盐上覆盖干燥的纱布、泡沫或水胶体。
* 使藻酸盐贴于疮面。 |
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. 重新置放病人体位，不要压迫溃疡部位，保持舒适。
* 避免敷料意外脱落。
11. 除去手套，处理污染用品。洗手。
* 防止微生物传播。
12. 在护理薄上记录溃疡外观及治疗情况（所用局部作用药剂型号、所用敷料、及病人反应。
* 基线观察结果及后续检查揭示愈合进展情况。提供护理证明。
13. 溃疡外观恶化应向主管护士或医生报告。
* 恶化可能表明需要采取其他治疗。 |
| 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. |
护士注意事项：早期溃疡边缘往往是不规则的。一段时间后疮缘变得光滑圆整。如疮面大，用冲洗注射器加普通无菌水冲洗会有所帮助。 |
| Teaching ConsiderationsAll individuals participating in client's wound care should be taught the correct method to administer ulcer care. |
病人宣教：应教育所有参与病人疮面护理的人员正确实施溃疡护理法。 |
| Geriatric ConsiderationsMedicare regulations limit reimbursement for some types of pressure relief equipment used for Stages 3, 4, and 5 pressure ulcers. |
老人：老年医疗保险制度法规对某些第3、4和5期压疮减压仪器使用费用的损失补偿有限制。 |
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. |
外观描述一期：红斑不发白，皮肤完整，或软柔或硬化；红斑边缘通常不规则。
二期：部分皮肤层丢失累及表皮和/或真皮。浅表性溃疡。 临床表现为擦伤、水泡、或浅表溃疡龛（火山口状溃疡）。 |
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：全层皮肤丢失，包括皮下组织损伤或坏死，可深及筋膜。溃疡临床表现为溃疡龛，伴或无相邻皮肤剥离。
四期：全层皮肤丢失伴广泛性损害或坏死，穿过皮下层深入肌、骨。溃疡边缘“翻卷”进入凹陷处，形成一坚硬的纤维环。 |
| 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：损伤被一硬膜层覆盖，该硬膜层可能牢固地附着于溃疡基。在焦痂脱落或手术去除前难以确定其分期。 |
| Treatment of Pressure Ulcers |
压疮的治疗 |
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. |
各种局部作用药物已用于治疗压疮。有些药物（如收敛剂、碱性皂制品）已证明是有害的，有些药物，如酶、抗菌剂、氧化剂和聚糖酐珠等，却是有益的。
选用何种药物取决于溃疡的深度。较深的溃疡使用酶剂效果可能更好。
压疮的局部治疗还包括使用各种敷料。包扎敷料即是一组销售很广的敷料，它在压疮治疗中的应用已越来越广泛。敷料（包括透明敷料、水胶体敷料和水凝胶）既可与局部作用药物合用，也可单用。 |
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 |
潜在的护理诊断皮肤完整性受损。
用品：洗涤盆、肥皂、水、清洁剂或处方局部搽剂、指定敷料、护肤剂、棉签（棉头涂药器）、低敏胶布或胶布敷料贴和一次性无菌手套、测量设备等。 |
| Steps and Rationale |
步骤及说明 |
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。
＊ 养活血源性病原体的传播。操作受体液污染用品里应戴手套。2. 关上房门或拉上床边布帘。
* 维护病人隐私。
3. 病人体位舒适，褥疮性溃疡部位及周围皮肤易于处理。
* 体位应便于溃疡及周围皮肤的清理。 |
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. 评估压疮及周围皮肤，确定压疮分期。
a. 注意溃疡周围皮肤的颜色、湿度及外观。
* 皮肤情况可指示组织损害进展情况，残留水分会浸软皮肤。 |
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. 测量各层溃疡直径。
* 提供疮面大小的客观参数，以此决定选用何种敷料，表面面积=长（L）×宽（Ｗ）。
c. 使用无菌棉签或其他允许测量疮面深度的仪器测量压疮深度。
* 深度测量对决定疮口容积很重要。虽然表面积在溃疡一期和二期也能充分代表组织丢失情况，但在深度三至四期，疮面容积能更充分地反映组织丢失情况。 |
| Volume = 2（L x D） + 2 （W x D） + （L + D） |
容积＝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. 测量受外缘组织坏死损害的皮肤的深度。用无菌棉签轻轻探查皮缘下面。
* 潜行损害代表下方组织的丢失程度大于皮肤。表明组织坏死进一步发展。 |
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. 用温水和肥皂轻轻洗涤溃疡周围的皮肤。用水彻底冲洗。
* 清洁皮肤表面减少居留细菌数量。肥皂可能刺激皮肤。
6. 用毛巾轻轻拍打皮肤，使其彻底干燥。
* 水分会浸软皮肤层。 |
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. 带无菌手套。
* 在清洁、测量及应用敷料时，必须坚持无菌操作。（在考虑使用干净或无菌手套时，应核对各医院的相关规定。）
8. 用生理盐水或清洗剂彻底清理溃疡。
* 清洁疮面吸附材料的碎片。之前所敷的酶可能要先浸软后才能清除。 |
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. 较深溃疡可用冲洗注射器清洗。
b. 也可通过淋浴用手提淋浴器清洗。
c. 可用水（漩涡）疗法协助进行疮面清洗及清创术。
9. 按处方使用局部作用药剂。：
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，将少量酶软膏涂于手掌。
* 没有必要涂太厚的软膏。薄层软膏吸收更好，效果佳。过量药物可能刺激周围皮肤。只在坏死部位使用。
b. 用手掌轻快按磨手掌里的药物，使之软化。
* 更容易将软膏敷于溃疡处。
c. 在溃疡坏死部位均匀地涂上薄薄一层软膏。不要将酶涂在周围皮肤上。
* 正确分布软膏可确保效果，酶可致周围皮肤出现烧灼感、感觉异常和皮炎等 |
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. 用生理盐水弄湿纱布敷料，直接敷于溃疡处。
* 保护疮面，保持溃疡面水分，缩短愈合所需时间。皮肤细胞在潮湿环境中生存。
e. 用一片干纱布覆盖湿纱布，胶布固定。
* 防止细菌进入湿敷料 |
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. |
抗菌剂：f. 深层溃疡：将抗菌膏涂在带手套的优势手上，然后将之涂进溃疡及其周围。（如该部位已被感染，应避免污染扩散）
* 抗菌膏可轻微刺激组织；必须完全覆盖疮面，以有效控制细菌生长。
g. 将无菌纱布垫覆于溃疡处，胶布固定。
* 保护溃疡，防止翻身或变换体位时药膏脱落。 |
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. 药距离溃疡部位约1英寸（2.5cm）, 在疮面轻轻洒上一层直径为5mm的药粉。
* 不溶性药粉层用于吸收疮面渗出液。
i. 用纱布敷料包扎溃疡。
* 固定药物，保护疮面。 |
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. |
水胶体珠/膏：j. 用水胶体珠或膏充填溃疡缺陷至约一半深度。
* 水胶体珠或膏有助于疮面漏液吸收。引流疮面处理最好用水胶体珠颗粒。
k. 覆盖水胶体敷料，敷料面应大于疮面边缘1至1.5英寸。
* 敷料保留疮面水分，留置时间可达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. |
水凝胶药剂：l. 用无菌敷料器或手套将水凝胶涂于溃疡面。
* 保持疮面湿度，同时吸收过多漏液。也可充当局部作用药剂的载体。
m. 在凝胶上覆盖干燥的软纱布，并盖住整个溃疡。
* 使水凝胶贴于疮面。水凝胶属吸附剂。 |
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 |
藻酸钙：n. 用敷料器或手套将藻酸钙包裹疮面。
* 保持疮面湿度，同时吸收过多漏液。
o. 在藻酸盐上覆盖干燥的纱布、泡沫或水胶体。
* 使藻酸盐贴于疮面。 |
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. 重新置放病人体位，不要压迫溃疡部位，保持舒适。
* 避免敷料意外脱落。
11. 除去手套，处理污染用品。洗手。
* 防止微生物传播。
12. 在护理薄上记录溃疡外观及治疗情况（所用局部作用药剂型号、所用敷料、及病人反应。
* 基线观察结果及后续检查揭示愈合进展情况。提供护理证明。
13. 溃疡外观恶化应向主管护士或医生报告。
* 恶化可能表明需要采取其他治疗。 |
| 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. |
护士注意事项：早期溃疡边缘往往是不规则的。一段时间后疮缘变得光滑圆整。如疮面大，用冲洗注射器加普通无菌水冲洗会有所帮助。 |
| Teaching ConsiderationsAll individuals participating in client's wound care should be taught the correct method to administer ulcer care. |
病人宣教：应教育所有参与病人疮面护理的人员正确实施溃疡护理法。 |
| Geriatric ConsiderationsMedicare regulations limit reimbursement for some types of pressure relief equipment used for Stages 3, 4, and 5 pressure ulcers. |
老人：老年医疗保险制度法规对某些第3、4和5期压疮减压仪器使用费用的损失补偿有限制。 |
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. |
外观描述一期：红斑不发白，皮肤完整，或软柔或硬化；红斑边缘通常不规则。
二期：部分皮肤层丢失累及表皮和/或真皮。浅表性溃疡。 临床表现为擦伤、水泡、或浅表溃疡龛（火山口状溃疡）。 |
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：全层皮肤丢失，包括皮下组织损伤或坏死，可深及筋膜。溃疡临床表现为溃疡龛，伴或无相邻皮肤剥离。
四期：全层皮肤丢失伴广泛性损害或坏死，穿过皮下层深入肌、骨。溃疡边缘“翻卷”进入凹陷处，形成一坚硬的纤维环。 |
| 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：损伤被一硬膜层覆盖，该硬膜层可能牢固地附着于溃疡基。在焦痂脱落或手术去除前难以确定其分期。 |
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