1、压疮的治疗规范宋宋军芳军芳This paper mainly introduces the design of an intelligent temperature control system which realizes the function of temperature measurement and control by using single bus digital temperature sensor DS18B20 and single chip microcomputer.The core components of the system are AT89C51 micr
2、ocontroller and DS18B20 temperature sensor.课堂目标课堂目标温习：压疮概念温习：压疮概念掌握压疮分期的临床特点掌握压疮分期的临床特点掌握掌握、期压疮治疗的具体期压疮治疗的具体 措施措施了解压疮的病理生理了解压疮的病理生理This paper mainly introduces the design of an intelligent temperature control system which realizes the function of temperature measurement and control by using single b
3、us digital temperature sensor DS18B20 and single chip microcomputer.The core components of the system are AT89C51 microcontroller and DS18B20 temperature sensor.主主 要要 内内 容容压疮概念压疮概念压压疮临床现状疮临床现状压压疮的病理生理疮的病理生理压疮压疮分期分期压压疮治疗疮治疗This paper mainly introduces the design of an intelligent temperature control
4、system which realizes the function of temperature measurement and control by using single bus digital temperature sensor DS18B20 and single chip microcomputer.The core components of the system are AT89C51 microcontroller and DS18B20 temperature sensor.压压 疮疮 概概 念念国际NPUAP-EPUAP压疮定义 压疮是指皮肤或/和皮下组织的局 部损伤
5、，通常位于骨突出部位。这种损伤一般是由压力或者压力 联合剪切力引起的。一些相关或不易区分的因素也与压疮有关，而这些因素的意义还有待进一步阐明。This paper mainly introduces the design of an intelligent temperature control system which realizes the function of temperature measurement and control by using single bus digital temperature sensor DS18B20 and single chip microc
6、omputer.The core components of the system are AT89C51 microcontroller and DS18B20 temperature sensor.压压 疮疮 概概 念念首先首先：明确了压疮发生的主：明确了压疮发生的主要原因：压力、剪切力、摩要原因：压力、剪切力、摩擦力的单独和联合作用擦力的单独和联合作用其次其次：明确了压疮好发部位，：明确了压疮好发部位，即即“骨隆突处的皮肤和皮下骨隆突处的皮肤和皮下组织组织”有助于有助于临床护临床护士采取压疮预士采取压疮预防措施，即防措施，即减减少少压力、避免压力、避免摩擦力和剪切摩擦力和剪切力对皮肤力对
7、皮肤造成造成的损伤的损伤有助于临床护有助于临床护士对压疮好发士对压疮好发部位进行重点部位进行重点预防和观察预防和观察第三第三：明确了损伤的性质为：明确了损伤的性质为局限性损伤局限性损伤第四第四：指出很多相关因素及：指出很多相关因素及压疮的危险因素压疮的危险因素有助于临床有助于临床护护士将压疮与散士将压疮与散在性胶带撕脱在性胶带撕脱伤、失禁相关伤、失禁相关性皮炎等进行性皮炎等进行鉴别鉴别说明压疮是一说明压疮是一个多因素综合个多因素综合作用作用This paper mainly introduces the design of an intelligent temperature control
8、system which realizes the function of temperature measurement and control by using single bus digital temperature sensor DS18B20 and single chip microcomputer.The core components of the system are AT89C51 microcontroller and DS18B20 temperature sensor.压压疮临床疮临床现状现状压疮压疮发生率发生率(国外有关资料统计国外有关资料统计)住院老年人，发生
9、率为住院老年人，发生率为10102525。发生压。发生压疮的老年患者较无压疮的老年患者死亡率增加疮的老年患者较无压疮的老年患者死亡率增加了了6 6倍。倍。住院病人中住院病人中度以上压疮，发生率度以上压疮，发生率3%3%12%12%。神经疾病患者的发生率为神经疾病患者的发生率为30%30%6 60%0%压疮病人的护理量增加压疮病人的护理量增加50%50%压疮发生率是临床评价护压疮发生率是临床评价护理质量的指标之一理质量的指标之一This paper mainly introduces the design of an intelligent temperature control system
10、which realizes the function of temperature measurement and control by using single bus digital temperature sensor DS18B20 and single chip microcomputer.The core components of the system are AT89C51 microcontroller and DS18B20 temperature sensor.高高 危危 患患 者者神经系统病人：自主活动受限，长期卧床，身体局神经系统病人：自主活动受限，长期卧床，身体局
11、 部组织长时间受压部组织长时间受压老年人：年龄老年人：年龄7070岁。岁。肥胖肥胖者：加大了承受部位的压力者：加大了承受部位的压力身体身体衰弱、营养不佳者：受压处缺乏保护衰弱、营养不佳者：受压处缺乏保护水肿水肿病人：降低了皮肤抵抗力病人：降低了皮肤抵抗力疼痛病人：处于强迫体位，活动减少疼痛病人：处于强迫体位，活动减少大小便大小便失禁病人：皮肤经常受到污物、潮湿的刺激失禁病人：皮肤经常受到污物、潮湿的刺激发热的病人：排汗增多发热的病人：排汗增多强迫强迫体位严格限制翻身体位严格限制翻身This paper mainly introduces the design of an intelligent
12、 temperature control system which realizes the function of temperature measurement and control by using single bus digital temperature sensor DS18B20 and single chip microcomputer.The core components of the system are AT89C51 microcontroller and DS18B20 temperature sensor.压压疮临床疮临床现状现状压疮压疮临床问题临床问题美国每
13、年用于压疮管理的费用约美国每年用于压疮管理的费用约110110亿美元亿美元单个压疮治疗成本约单个压疮治疗成本约500-500-70007000美元美元普通大众对于压疮的认识非普通大众对于压疮的认识非常薄弱常薄弱This paper mainly introduces the design of an intelligent temperature control system which realizes the function of temperature measurement and control by using single bus digital temperature sen
14、sor DS18B20 and single chip microcomputer.The core components of the system are AT89C51 microcontroller and DS18B20 temperature sensor.压疮临床现状压疮临床现状压力性压力性 溃疡溃疡护士的知识和态度护士的知识和态度压疮低估、预测压疮低估、预测结果不准确结果不准确评估不到位不能正确识别压疮专业知识欠缺特殊床垫使用特殊床垫使用 不及时不及时预防预防措施不一致措施不一致 未按照危险评估使用缺乏个体化压疮预防措施未完全按照实践指南采取措施认识不够This paper m
15、ainly introduces the design of an intelligent temperature control system which realizes the function of temperature measurement and control by using single bus digital temperature sensor DS18B20 and single chip microcomputer.The core components of the system are AT89C51 microcontroller and DS18B20 t
16、emperature sensor.压压疮的病理生理疮的病理生理压力压力血管闭塞血管闭塞组组织织灌灌注注不不良良组组织织缺缺血血问题解决问题解决 组织缺组织缺氧改善氧改善反反应应性性充充血血压力性溃疡压力性溃疡压力持续存在压力持续存在压力解除压力解除苍苍 白白组织缺氧组织缺氧组织水肿组织水肿增加蛋白组织增加蛋白组织间隙再积累间隙再积累渗透性增加，渗透性增加，引起毛细血管引起毛细血管漏漏代代谢谢废废物物积积累累This paper mainly introduces the design of an intelligent temperature control system which rea
17、lizes the function of temperature measurement and control by using single bus digital temperature sensor DS18B20 and single chip microcomputer.The core components of the system are AT89C51 microcontroller and DS18B20 temperature sensor.压疮的分期压疮的分期This paper mainly introduces the design of an intellig
18、ent temperature control system which realizes the function of temperature measurement and control by using single bus digital temperature sensor DS18B20 and single chip microcomputer.The core components of the system are AT89C51 microcontroller and DS18B20 temperature sensor.压疮的规范治疗压疮的规范治疗确定确定分期分期明确
19、引起压明确引起压疮的原因，疮的原因，排除危险因排除危险因素素评估评估根据根据评估评估给予给予护理护理措施措施摩擦力摩擦力剪切力剪切力感知觉感知觉全身营全身营养状况养状况体温体温123This paper mainly introduces the design of an intelligent temperature control system which realizes the function of temperature measurement and control by using single bus digital temperature sensor DS18B20 an
20、d single chip microcomputer.The core components of the system are AT89C51 microcontroller and DS18B20 temperature sensor.压疮的规范治疗压疮的规范治疗-确定分确定分期期压疮分期分期压疮各期描述各期描述图片片对照照期期皮肤完整、发红，与周围皮肤界限清楚，压之不退色 II 期期部分表皮缺损，皮肤表浅溃疡，基底红，无结痂，也可为完整或破溃的血泡。期期全层皮肤缺失，但肌肉、肌腱和骨骼尚未暴露，可有结痂、皮下隧道。IV 期期全层皮肤缺失伴有肌肉、肌腱和骨骼的暴露，常有结痂和皮下隧道。可
21、可疑疑深深部部组织损伤由于压力或剪力造成皮下软组织损伤引起的局部皮肤颜色的改变（如变紫、变红），但皮肤完整。不不可可分期分期全层皮肤缺失但溃疡基底部覆有腐痂和（或）痂皮。This paper mainly introduces the design of an intelligent temperature control system which realizes the function of temperature measurement and control by using single bus digital temperature sensor DS18B20 and sing
22、le chip microcomputer.The core components of the system are AT89C51 microcontroller and DS18B20 temperature sensor.压疮的规范治疗压疮的规范治疗-确定分确定分期期皮肤完整：皮肤完整：对于对于I I期压疮和怀疑有期压疮和怀疑有深深部部组织组织损伤的深肤色患者损伤的深肤色患者，单纯，单纯采用视采用视诊诊难以难以检查到检查到。当。当皮肤完整的情况下，皮肤完整的情况下，可可通过通过评估皮温、皮肤颜色评估皮温、皮肤颜色、组织硬度、组织硬度（尤其是柔软尤其是柔软或坚硬或坚硬）及疼痛，来）及疼痛
23、，来区分区分正常正常皮肤与受损皮肤。（证据皮肤与受损皮肤。（证据强度强度=B=B）This paper mainly introduces the design of an intelligent temperature control system which realizes the function of temperature measurement and control by using single bus digital temperature sensor DS18B20 and single chip microcomputer.The core components of
24、 the system are AT89C51 microcontroller and DS18B20 temperature sensor.压疮的规范治疗压疮的规范治疗-确定分确定分期期开放性开放性压疮：压疮：对深肤色患者难以对深肤色患者难以判断判断由由蜂窝织炎造成的炎性红肿和深部蜂窝织炎造成的炎性红肿和深部组织组织损伤损伤。当压疮表现为开放性时（。当压疮表现为开放性时（特别是特别是IIII、IIIIII、IVIV期压疮和不可分期压疮期压疮和不可分期压疮），），可可通过评估皮肤的热度、柔软度、疼痛通过评估皮肤的热度、柔软度、疼痛或或者者组织硬度的变化，来确定炎症的程度组织硬度的变化，来确定炎
25、症的程度和和可能可能的蜂窝织炎和的蜂窝织炎和/或潜行。（证据或潜行。（证据强度强度=C C）This paper mainly introduces the design of an intelligent temperature control system which realizes the function of temperature measurement and control by using single bus digital temperature sensor DS18B20 and single chip microcomputer.The core componen
26、ts of the system are AT89C51 microcontroller and DS18B20 temperature sensor.压疮的规范治疗压疮的规范治疗-治疗治疗期压疮处理原则：期压疮处理原则：加强防护措施加强防护措施解除局部受解除局部受压压改善局部血运改善局部血运去除危险去除危险因素因素加强营养摄入加强营养摄入避免压疮进展避免压疮进展This paper mainly introduces the design of an intelligent temperature control system which realizes the function of t
27、emperature measurement and control by using single bus digital temperature sensor DS18B20 and single chip microcomputer.The core components of the system are AT89C51 microcontroller and DS18B20 temperature sensor.压疮的规范治疗压疮的规范治疗-治疗治疗期期压疮处理具体压疮处理具体措施措施1 1、为为患者摆放体位时，压疮部位不能患者摆放体位时，压疮部位不能作为作为 直接受力面。直接受力面
28、。2 2、使用减压装置，抬高局部（、使用减压装置，抬高局部（通过将下肢通过将下肢放放 在枕头在枕头上使足跟不接触床面，或者通过上使足跟不接触床面，或者通过使使 用减压用减压装置将足跟悬空，来减轻患装置将足跟悬空，来减轻患I I期压期压疮疮 患者患者的足跟压力。（证据强度的足跟压力。（证据强度=B=B）3 3、使用透明敷料或薄的水胶体敷料以减轻、使用透明敷料或薄的水胶体敷料以减轻 摩擦。（摩擦。（710710天或敷料自然脱落天或敷料自然脱落）This paper mainly introduces the design of an intelligent temperature control
29、system which realizes the function of temperature measurement and control by using single bus digital temperature sensor DS18B20 and single chip microcomputer.The core components of the system are AT89C51 microcontroller and DS18B20 temperature sensor.双重粘性双重粘性具亲水性，吸收伤口渗液具亲水性，吸收伤口渗液形成潮湿的伤口愈合环境形成潮湿的伤口
30、愈合环境促进促进上皮化和胶原蛋白合成上皮化和胶原蛋白合成加速新加速新微血管增生微血管增生防菌抑菌防菌抑菌水胶体水胶体敷料敷料This paper mainly introduces the design of an intelligent temperature control system which realizes the function of temperature measurement and control by using single bus digital temperature sensor DS18B20 and single chip microcomputer.T
31、he core components of the system are AT89C51 microcontroller and DS18B20 temperature sensor.压疮的规范治疗压疮的规范治疗-治疗治疗期压疮处理原则：防止水疱破裂防止水疱破裂保护保护创面创面预防感染预防感染This paper mainly introduces the design of an intelligent temperature control system which realizes the function of temperature measurement and control b
32、y using single bus digital temperature sensor DS18B20 and single chip microcomputer.The core components of the system are AT89C51 microcontroller and DS18B20 temperature sensor.压疮的规范治疗压疮的规范治疗-治疗治疗期期压疮处理具体压疮处理具体措施措施1 1、小水疱：、小水疱：（直径5mm）未破的小水疱要减少和避免摩擦，防止破裂感染。未破的小水疱要减少和避免摩擦，防止破裂感染。生理盐水清洁伤口，纱布轻轻擦干；生理盐水清洁
33、伤口，纱布轻轻擦干；粘水胶体敷料，约粘水胶体敷料，约5-75-7天水疱吸收天水疱吸收后将后将敷料敷料撕去撕去；如果出现渗液增多、水疱增大需及时更换其他如果出现渗液增多、水疱增大需及时更换其他敷敷 料料。This paper mainly introduces the design of an intelligent temperature control system which realizes the function of temperature measurement and control by using single bus digital temperature sensor
34、DS18B20 and single chip microcomputer.The core components of the system are AT89C51 microcontroller and DS18B20 temperature sensor.压疮的规范治疗压疮的规范治疗-治疗治疗期压疮处理具体措施2、大水疱：大水疱：（直径5mm）】使用碘伏消毒伤口，在水疱的边缘用注射器抽出疱内使用碘伏消毒伤口，在水疱的边缘用注射器抽出疱内液体液体 或或用针头刺破水疱；用针头刺破水疱；用无菌纱布或棉签挤压干净水疱内的液体；用无菌纱布或棉签挤压干净水疱内的液体；粘贴粘贴透气性透气性薄薄膜膜敷料
35、，水疱吸收后才将敷料撕除；敷料，水疱吸收后才将敷料撕除；每天观察，如水疱又出现，不要每天观察，如水疱又出现，不要更换更换薄薄膜膜敷料，按照伤敷料，按照伤口消毒标准敷料外层，在敷料外层，水疱的边缘用注射器抽口消毒标准敷料外层，在敷料外层，水疱的边缘用注射器抽出疱内液体或用针头刺破水疱，用无菌棉签挤压干净水疱内出疱内液体或用针头刺破水疱，用无菌棉签挤压干净水疱内的液体或用无菌纱布吸干水疱内渗液，最后剪小块的液体或用无菌纱布吸干水疱内渗液，最后剪小块的的薄膜薄膜敷敷料料将穿刺点封紧，直至水疱完全吸收后才将敷料撕除；将穿刺点封紧，直至水疱完全吸收后才将敷料撕除；如渗液多，敷料已经松动脱落，可更换新如渗
36、液多，敷料已经松动脱落，可更换新的的薄膜薄膜敷料敷料。This paper mainly introduces the design of an intelligent temperature control system which realizes the function of temperature measurement and control by using single bus digital temperature sensor DS18B20 and single chip microcomputer.The core components of the system ar
37、e AT89C51 microcontroller and DS18B20 temperature sensor.压疮的规范治疗压疮的规范治疗-治疗治疗期期压疮处理具体压疮处理具体措施措施3 3、真皮真皮层层受损受损用用生理盐水清洗伤口及周围皮肤，以去除生理盐水清洗伤口及周围皮肤，以去除残残 留留在伤口上的表皮破损的组织；在伤口上的表皮破损的组织；使用碘伏消毒周围皮肤，待使用碘伏消毒周围皮肤，待干；干；创面可涂湿润创面可涂湿润 烧伤膏，去腐生肌。烧伤膏，去腐生肌。创面创面渗液少时可选用水胶体敷料，创面渗渗液少时可选用水胶体敷料，创面渗液液 多时多时使用高吸收的敷料如泡沫敷料；使用高吸收的敷料如
38、泡沫敷料；换药换药间隔根据伤口的渗液情况确定换药次数。间隔根据伤口的渗液情况确定换药次数。This paper mainly introduces the design of an intelligent temperature control system which realizes the function of temperature measurement and control by using single bus digital temperature sensor DS18B20 and single chip microcomputer.The core component
39、s of the system are AT89C51 microcontroller and DS18B20 temperature sensor.压疮的规范治疗压疮的规范治疗-治疗治疗/期压疮处理原则：期压疮处理原则：清洁创面清洁创面去除坏死去除坏死组织，促进肉芽组织生长组织，促进肉芽组织生长保护创面及周围皮肤，控制感染保护创面及周围皮肤，控制感染建立建立愈合的环境愈合的环境根据伤口的特点选择和更换敷料根据伤口的特点选择和更换敷料病人宣教病人宣教This paper mainly introduces the design of an intelligent temperature con
40、trol system which realizes the function of temperature measurement and control by using single bus digital temperature sensor DS18B20 and single chip microcomputer.The core components of the system are AT89C51 microcontroller and DS18B20 temperature sensor.压疮的规范治疗压疮的规范治疗-治疗治疗/期压疮具体措施：期压疮具体措施：黑色期黑色期：
41、机械清创或外科清创或自容清创机械清创或外科清创或自容清创 后充分引流（藻酸后充分引流（藻酸盐盐、脂质、脂质水胶水胶 体）体）+高吸收性敷料外敷。高吸收性敷料外敷。换药换药间隔：间隔：1212天天黄色黄色期期：清创，水凝胶清创，水凝胶/水胶体糊剂、藻水胶体糊剂、藻 酸盐类敷料酸盐类敷料+高吸收敷料或水高吸收敷料或水胶胶 体敷料或纱布外敷体敷料或纱布外敷换药换药间隔：间隔：2323天天This paper mainly introduces the design of an intelligent temperature control system which realizes the func
42、tion of temperature measurement and control by using single bus digital temperature sensor DS18B20 and single chip microcomputer.The core components of the system are AT89C51 microcontroller and DS18B20 temperature sensor.压疮的规范治疗压疮的规范治疗-治疗治疗/期压疮具体措施：期压疮具体措施：红色期红色期：水胶体糊剂水胶体糊剂+高吸收性敷料或水高吸收性敷料或水 胶体敷料外敷。
43、胶体敷料外敷。换药换药时间：时间：3535天天窦道（潜行）窦道（潜行）：渗出液多渗出液多者用藻酸盐填充条者用藻酸盐填充条+高吸收高吸收 性敷料或纱布外敷性敷料或纱布外敷 渗出液少渗出液少者用水胶体糊剂者用水胶体糊剂+吸收性敷吸收性敷料料 或纱布外敷或纱布外敷This paper mainly introduces the design of an intelligent temperature control system which realizes the function of temperature measurement and control by using single bus
44、 digital temperature sensor DS18B20 and single chip microcomputer.The core components of the system are AT89C51 microcontroller and DS18B20 temperature sensor.压疮的规范治疗压疮的规范治疗-治疗治疗不可分期处理原则：清清创是最基本的处理原则创是最基本的处理原则足跟足跟部稳定的干痂予保留部稳定的干痂予保留This paper mainly introduces the design of an intelligent temperature
45、 control system which realizes the function of temperature measurement and control by using single bus digital temperature sensor DS18B20 and single chip microcomputer.The core components of the system are AT89C51 microcontroller and DS18B20 temperature sensor.压疮的规范治疗压疮的规范治疗-治疗治疗可疑深部组织损伤：谨慎处理，不能被表象所
46、迷惑谨慎处理，不能被表象所迷惑取得取得患者和家属的同意患者和家属的同意严禁强烈和快速的清创严禁强烈和快速的清创早期可用水胶体敷料，使表皮软化早期可用水胶体敷料，使表皮软化This paper mainly introduces the design of an intelligent temperature control system which realizes the function of temperature measurement and control by using single bus digital temperature sensor DS18B20 and sing
47、le chip microcomputer.The core components of the system are AT89C51 microcontroller and DS18B20 temperature sensor.压疮的规范治疗压疮的规范治疗-治疗治疗综合处理综合处理1 1、经常评估患者，向患者及家属做健康教育及、经常评估患者，向患者及家属做健康教育及 心理护理，使其主动参与护理心理护理，使其主动参与护理;2 2、减压减压护理：正确使用气垫床、海绵垫、软枕护理：正确使用气垫床、海绵垫、软枕 头、翻身垫等；头、翻身垫等；3 3、建立翻身卡，定时、建立翻身卡，定时翻身翻身，间歇解除
48、身体部位，间歇解除身体部位 的压力，是预防和治疗压疮最有效的措施；的压力，是预防和治疗压疮最有效的措施；4 4、掌握、掌握翻身翻身技巧，避免拖、拉、拽等动作；技巧，避免拖、拉、拽等动作；5 5、加强、加强营养营养，改善全身状况，改善全身状况。This paper mainly introduces the design of an intelligent temperature control system which realizes the function of temperature measurement and control by using single bus digital
49、 temperature sensor DS18B20 and single chip microcomputer.The core components of the system are AT89C51 microcontroller and DS18B20 temperature sensor.压疮的规范治疗压疮的规范治疗-治疗治疗气垫床气垫床1 1、使用的气垫床达到一定压力后，垫面的微型、使用的气垫床达到一定压力后，垫面的微型 喷气孔可均匀的向外排气，改善患者体下喷气孔可均匀的向外排气，改善患者体下的的 空气循环。空气循环。关注充气不良。关注充气不良。2 2、避免使用环状设备以及充气手
50、套。、避免使用环状设备以及充气手套。3 3、足跟保护设备应把足跟完全抬起，将重力分、足跟保护设备应把足跟完全抬起，将重力分 散在腿部腓肠肌而不是跟腱上，膝关节应散在腿部腓肠肌而不是跟腱上，膝关节应轻轻 微弯曲。如果过伸微弯曲。如果过伸 导致腘静脉阻塞导致腘静脉阻塞 形成深静脉血栓。形成深静脉血栓。This paper mainly introduces the design of an intelligent temperature control system which realizes the function of temperature measurement and control
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