CAJ | 학술논문

本文介绍压疮的分期、压疮的评估以及压疮发生后的处理方法。对国内外相关研究的分析表明：美国压疮专家咨询组2007年更新的压疮分期是目前全球使用最广泛的压疮分期系统之一；可应用视觉模拟评分表、面部等级评分表等工具评估成年压疮患者的疼痛程度；使用压疮愈合计分表评价压疮的愈合效果具有很好的信度、效度和内部一致性；应用生理盐水或饮用水定期清洗伤口；根据患者的病情、坏死组织的类型、性质和部位、治疗目标、可利用的资源及患者意愿选择适宜的清创方式；敷料的选择应基于伤口床的情况、伤口周围皮肤情况以及患者的护理目标。
본문개소압창적분기、압창적평고이급압창발생후적처리방법。대국내외상관연구적분석표명：미국압창전가자순조2007년경신적압창분기시목전전구사용최엄범적압창분기계통지일；가응용시각모의평분표、면부등급평분표등공구평고성년압창환자적동통정도；사용압창유합계분표평개압창적유합효과구유흔호적신도、효도화내부일치성；응용생리염수혹음용수정기청세상구；근거환자적병정、배사조직적류형、성질화부위、치료목표、가이용적자원급환자의원선택괄의적청창방식；부료적선택응기우상구상적정황、상구주위피부정황이급환자적호리목표。
This paper introduced pressure ulcer staging, nursing assessment and wound care of pressure ulcer. Based on the analysis of related studies, we found that the pressure ulcer staging developed by National Pressure Ulcer Advisory Panel in 2007 was one of the most widely used systems in the world. Adult pressure ulcer patients’ pain could be assessed by Visual Analogue Scale, Face pain Scale and some other scales. Pressure ulcer scale for healing had good reliability and validity. Wound should be cleaned with normal saline or water regularly. Debridement methods should be chosen according to patient’s condition, necrotic tissue type, wound site, treatment goals, available resources and patient’s preference. Selection of dressing must be based on the wound condition, skin surrounding the wound and nursing goals.