压疮治疗规范宋军芳ppt课件.pptx
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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
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