Nursing process map for pressure ulcers sample filling. Application

“On approval of the industry standard

“Patient management protocol. Bedsores"

In order to ensure the quality of medical care for patients at risk of developing pressure ulcers, I ORDER:

1.1. Industry standard “Protocol for patient management. Bedsores" (OST 91500.11.0001-2002) (Appendix No. 1 to this order).

1.2. Registration form No. 003-2/у “Nursing observation card for patients with bedsores” (Appendix No. 2 to this order).

2. Entrust control over the implementation of this order to the First Deputy Minister A.I. Vyalkova.

Minister Yu.L. Shevchenko

Appendix No. 1 to the order

SYSTEM OF STANDARDIZATION IN HEALTHCARE

Patient management protocol.

1 AREA OF USE

The requirements of the industry standard apply to the provision of medical care to all patients who have risk factors for developing pressure ulcers, according to the risk factors, and who are treated in an inpatient setting.

2. PURPOSE OF DEVELOPMENT AND IMPLEMENTATION

3. DEVELOPMENT AND IMPLEMENTATION TASKS

1. Introduction modern systems assessing the risk of developing pressure ulcers, developing a prevention program, reducing the incidence of pressure ulcers and preventing pressure ulcer infection.

2. Timely treatment of bedsores depending on the stage of their development.

3. Improving the quality and reducing the cost of patient treatment due to the introduction of resource-saving technologies.

4. Improving the quality of life of patients at risk of developing bedsores.

4. CLINICAL EPIDEMIOLOGY, MEDICAL

According to English authors, in medical and preventive care institutions, bedsores develop in 15-20% of patients. According to a study conducted in the United States, about 17% of all hospitalized patients are at risk for developing pressure ulcers or already have them.

The estimated cost for treating pressure ulcers per patient ranges from $5,000 to $40,000. According to D. Waterlow, in the UK the cost of caring for patients with pressure ulcers is estimated at 200 million pounds sterling and increases by 11% annually as a result of treatment costs and increased length of hospitalization.

Inadequate anti-bedsore measures lead to a significant increase in direct medical costs associated with the subsequent treatment of resulting bedsores and their infection.

The duration of the patient's hospitalization increases, and there is a need for adequate dressings (hydrocalloid, hydrogels, etc.) and medicinal (enzymes, anti-inflammatory, regeneration-improving agents) products, instruments, and equipment. In some cases, surgical treatment of bedsores of stages III-IV is required.

Legislative framework of the Russian Federation

Free consultation

Federal legislation

ORDER of the Ministry of Health of the Russian Federation dated April 17, 2002 N 123 “ON APPROVAL OF THE INDUSTRY STANDARD “PROTOCOL FOR THE MANAGEMENT OF PATIENTS. BEDSORES"

In order to ensure the quality of medical care for patients at risk of developing pressure ulcers, I order:

1.1. Industry standard “Protocol for patient management. Bedsores" (OST 91500.11.0001-2002) (Appendix No. 1 to this order).

1.2. Registration form N 003-2/у “Nursing observation card for patients with bedsores” (Appendix No. 2 to this order).

Application
to the order
Ministry of Health of Russia
dated April 17, 2002 N 123

Introduction of modern methodology for the prevention and treatment of bedsores in patients with various types pathologies associated with prolonged immobility.

1. Introduction of modern systems for assessing the risk of developing pressure ulcers, drawing up a prevention program, reducing the incidence of pressure ulcers and preventing pressure ulcer infections.

2. Timely treatment of bedsores depending on the stage of their development.

3. Improving the quality and reducing the cost of patient treatment due to the introduction of resource-saving technologies.

4. Improving the quality of life of patients at risk of developing bedsores.

Statistical data on the incidence of pressure ulcers in medical institutions Russian Federation practically absent. But, according to a study in the Stavropol regional clinical hospital, designed for 810 beds, with 16 inpatient departments, for 1994-1998. 163 cases of pressure ulcers were registered (0.23%). All of them were complicated by infection, which accounted for 7.5% of the total structure of nosocomial infections.

In addition to the economic (direct medical and non-medical) costs associated with the treatment of pressure ulcers, it is necessary to take into account intangible costs: severe physical and mental suffering experienced by the patient.

Inadequate anti-bedsore measures lead to a significant increase in direct medical costs associated with the subsequent treatment of resulting bedsores and their infection.

The duration of the patient's hospitalization increases, and there is a need for adequate dressings (hydrocalloid, hydrogels, etc.) and medicinal (enzymes, anti-inflammatory, regeneration-improving agents) products, instruments, and equipment. In some cases, surgical treatment of stage III-IV bedsores is required.

All other costs associated with the treatment of bedsores also increase.

Adequate prevention of pressure ulcers makes it possible to prevent their development in patients at risk in more than 80% of cases.

Thus, adequate prevention of pressure ulcers will not only reduce the financial costs of treating pressure ulcers, but also improve the patient’s quality of life.

Pressure at bony prominences, friction, and shearing (shearing) forces lead to pressure ulcers. Long-term (more than 1-2 hours) pressure leads to vascular obstruction, compression of nerves and soft tissues. In the tissues above the bone protrusions, microcirculation and trophism are disrupted, hypoxia develops, followed by the development of bedsores.

Damage to soft tissue from friction occurs when the patient moves, when the skin is in close contact with a rough surface. Friction causes injury to both the skin and deeper soft tissues.

Shear damage occurs when the skin is immobile and deeper tissues are displaced. This leads to impaired microcirculation, ischemia and skin damage, most often against the background of additional risk factors for the development of bedsores (see appendices).

Risk factors for the development of pressure ulcers may be reversible (eg, dehydration, hypotension) or irreversible (eg, age), intrinsic or extrinsic.

123 order of the Ministry of Health

Sacrum – 36%
Buttocks – 21%
Heels – 25%
Dr. places 2-4%

GENERAL APPROACHES TO PREVENTION

Adequate prevention of pressure ulcers will ultimately lead to a reduction in direct medical costs associated with the treatment of pressure ulcers, direct (non-medical), indirect (indirect) and intangible (intangible) costs.

Adequate anti-decubitus measures must be carried out nursing staff after special training.

Preventive measures should be aimed at:

Reducing pressure on bone tissue;

Prevention of friction and tissue shear when moving the patient or when positioning him incorrectly (“sliding” from pillows, “sitting” in a bed or on a chair);

Observation of the skin over bony prominences;

Keeping the skin clean and moderately moist (not too dry and not too wet);

Providing the patient with adequate food and drink;

Teaching the patient self-help techniques for mobility;

General approaches Prevention of bedsores boils down to the following:

Timely diagnosis of the risk of developing bedsores;

Timely start of implementation of the entire complex of preventive measures;

Adequate technique for performing simple medical services, incl. care

1. Total patients with stroke hospitalized in the department during the year ___________.
2. The number of patients at risk of developing pressure ulcers according to the D. Waterlow scale is 10 or more points ___________.
3. The number of patients who developed pressure ulcers ___________.

IN THE INSPECTION DEPARTMENT OF A REGIONAL (CITY) HOSPITAL

Sample: all patients receiving treatment in the department during the calendar year, but for at least 6 hours, with a risk of developing pressure ulcers of 10 points or more on the Waterlow scale, who do not have pressure ulcers at the time of meeting the industry standard.

4. The total number of patients who were in the department during the year (min. period of at least 6 hours) ___________.
5. The number of patients at risk of developing pressure ulcers on the Waterlow scale of 10 or more points __________.
6. Number of patients who developed pressure ulcers _______.



7. 8-10 o'clock - Fowler's position;
8. 14-16 hours - Fowler's position;
9. 18-20 hours - Fowler's position;
10. 20-22 hours - position “on the right side”;
11. 22-24 hours - position “on the left side”;
12. 2-4 hours - position “on the right side”;
13. 6-8 hours - Sims position

Change the patient's position every 2 hours:

14. 8-10 hours - sitting position;
15. 10-12 hours - position “on the left side”;
16. 12-14 hours - position “on the right side”;
17. 14-16 hours - sitting position;
18. 16-18 hours - Sims position;
19. 18-20 hours - sitting position;
20. 0-2 hours - Sims position;
21. 4-6 hours - position “on the left side”;

If the patient can be moved (or move independently with the help of assistive devices) and in a chair ( wheelchair), he can be in a sitting position and in bed).

Daily 12 times

"Expert Standard for the Prevention of Pressure Sores in Nursing."

Germany, April 2002

This Standard includes a detailed list of responsibilities and displays of integrity on the part of personnel. The compilers of the Standard emphasize that all statements, without exception, are based on existing national and foreign scientific literature and are thus scientifically sound.

SI Qualified nursing staff have current knowledge of the occurrence of pressure ulcers and can make a competent assessment of the risk of pressure ulcers. (from the Expert Standard for Pressure Ulcer Prevention)

Factors and causes of bedsores

(excerpts from German literature)

Based on studies that were published in 1930, we can call such a thing as a pressure limit, which, when increased over a certain time, leads to the formation of bedsores. This pressure limit is 30 millimeters of mercury, i.e. if the patient lies on a hard surface or sits in a chair that puts a lot of pressure on the tissue, bedsores appear. As a result of the examination blood pressure in capillaries is 30 mm. mercury column and, thus, it becomes clear that more high pressure from the outside external factors leads to compression of blood capillaries, which affects the insufficient supply of oxygen to the tissue.

FACTOR: EXPOSURE TIME

Like the most long time exposure was determined to be 2 hours. This time limit is based on the fact that tissue is guaranteed to die if there is no oxygen supply within 2 hours - a situation that clinical practice practically uncontrolled. Some authors suggest that the 2 hour period is determined historically and refer to Florence Nightingale (1820-1910), who described ulcers formed from bedsores. During the Crimean War, it took an estimated 2 hours in the infirmary to shift or move seriously wounded soldiers; Thus, the maximum exposure time was identified. In fact, this time is based on experimental studies conducted on animals, and is the basis for regularly turning the patient over in order to prevent the formation of bedsores.

FACTOR: MAIN DISEASES

A huge number of diseases lead to the formation of bedsores. This fact must be taken into account, since it is often argued that the formation of pressure ulcers results from insufficient professional care. Consequently, successful therapy of various underlying diseases is a prerequisite for effective prevention of the formation of ulcerative bedsores. An increased risk of pressure ulcers occurs:



FACTOR: SHEAR AND FRICTION

Mainly distinguished:

Shear forces: the patient slides down on the mattress;

Friction: formed, for example, as a result of the movement of the heels on the sheet.

The problem of increased shear forces occurs when the patient has dry skin.

As before, there are controversial discussions about the relationship between the formation of bedsores and urinary and fecal incontinence. The Expert Standard “Prevention of Pressure Sores in Nursing” clearly states that this relationship is not guaranteed. It is necessary to clearly distinguish between bedsores, on the one hand, and skin changes due to exposure to urine, on the other hand, even in cases where the local skin changes seem identical. Skin changes caused by urine represent damage to the skin layers and cellular structures. It is more correct to designate all kinds of lesions on the skin formed under the influence of urine as “dermatitis”, since due to swelling of the skin, infection can occur.

There are many studies that show that a lack of protein increases the risk of pressure ulcers, as does a lack of intracellular zinc.

A summary of the various factors shows that the occurrence of pressure ulcers is a multifactorial phenomenon. Considering all these factors, it becomes clear that, at least theoretically, it is possible to prevent the formation of bedsores, despite the fact that the possibilities of influencing the patient during care are different for everyone.







PI Care professionals determine the risk of pressure ulcers in all patients for whom such a risk cannot be excluded immediately at the beginning of the care contract and later in individually, as well as immediately if there is a change in mobility, activity or pressure. Risk, among other things, is also determined using a standardized rating scale according to Braden, Waterlow or Norton.

SI There is a current systematic assessment of the threat of pressure ulcers.

(from the Expert Standard for Pressure Ulcer Prevention)

Until now, scientists and pragmatists in Germany argue over the issue of reliability, validity and validity for the use of scale assessment methods. This is also evidenced by the fact that the National Expert Standard names three acceptable rating scales, which we will consider.

Prevention of bedsores - order 123 of the Ministry of Health (protocol)



04/17/2002 The Ministry of Health of the Russian Federation issued order No. 123 On the approval of the industry standard “Protocol for the management of patients. Bedsores." This Order of the Ministry of Health No. 123 contains basic information about bedsores and necessary preventive measures.



Industry standard for pressure ulcers

Scope of application of the Order of the Ministry of Health No. 123

The provisions of this medical protocol of the Ministry of Health No. 123 are applicable to provide medical care to patients at risk of developing bedsores who are undergoing therapeutic treatment in hospitals.

The purpose of the development and implementation of Order of the Ministry of Health No. 123

Ministry of Health Protocol No. 123 aims to promote the latest technologies for preventive measures and treatment of necrosis in people with a variety of diseases that lead to a forced long stay in an immobile position.

Tasks of development and implementation of protocol No. 123

The main objectives of the Order of the Ministry of Health No. 123:

22. Introduction of innovative technologies for assessing the risk level of pressure ulcers, creation preventive plan, reducing the number of cases of bedsores and preventing infectious inflammation of bedsores.
23. Early treatment of necrosis, based on the stage of its occurrence.
24. Improving the quality and reducing the cost of patient therapy, thanks to the introduction of resource-saving technologies.
25. Improving the quality of life of patients who are at risk of necrosis.

The main objective of the protocol is directly to prevent the occurrence of bedsores.

Clinical epidemiology, medical and social significance

Order No. 123 of the Ministry of Health also mentions statistics on the development of bedsores in patients. There are few statistical data on the incidence of this disease in patients undergoing treatment in hospitals in the Russian Federation.

Important! However, over 4 years, 153 cases of bedsores were registered in the Stavropol hospital for 800 patients. Moreover, each of them was complicated by infection.

In England, social workers estimate that about 1/5 of patients develop pressure ulcers. In America, the same number of patients are either at risk for necrosis or already have bedsores. Order No. 123 considers bedsores as an economic problem. The costs of treating bedsores that occur are estimated at disappointing figures. Every year the cost of caring for such patients increases by ten percent.

The order of the Ministry of Health also emphasizes the fact that in addition to the material costs of treating necrosis that occurs in patients, it is worth taking into account the severe moral and physical suffering of patients.

Improper treatment and prevention of bedsores provokes an increase in the necessary costs in medicine to eliminate necrosis and complications that arise. In addition, the patient is forced to stay longer in a hospital facility. Spending on special anti-bedsore medications, instruments, and equipment is increasing. Sometimes it also becomes necessary to resort to surgical intervention at the last stages of development of necrosis. There is a need to spend large amounts of money on other methods of treatment.



According to the Ministry of Health protocol No. 123, with correctly performed preventive measures, it is possible to avoid the occurrence of necrosis in most patients.

Important! In addition to reducing the cost of treating a patient, correct preventive actions can improve his quality of life.

General questions of Order of the Ministry of Health No. 123

Order No. 123 considers bedsores as necrotic tissue changes.

Bedsores occur due to prolonged pressure or friction skin on a hard surface. In this case, the vessels become stenotic and the nerves in the compressed area are compressed, which disrupts tissue nutrition.

In addition, necrotic changes can develop due to shear, when the skin is motionless and the soft tissue underneath is subject to movement. In this situation, there is a disruption in the blood supply to this area, and the skin is damaged.

Risk factors

Order No. 123 defines bedsores as necrosis that forms as a result of reversible and irreversible causes.

26. Cachexia;
27. Anemia;
28. Lack of protein and vitamin C in food;
29. Dehydration;
30. Reduced blood pressure;
31. Enuresis/encopresis;
32. Pathologies of the nervous system;
33. Ischemia;
34. Thin skin;
35. Anxiety;
36. Confusion;
37. Coma;
38. Violation of hygiene rules;
39. Folded bed linen or patient's clothing;
40. Parts of a hospital bed;
41. Items for restraining the patient;
42. Injuries to the axial areas of the skeleton or internal organs;
43. Spinal cord injuries;
44. Use of cytostatics;
45. Violation of the rules for shifting the patient.
46. Old age;
47. Large surgery for more than two hours.

In order to determine how likely a patient is to develop necrosis, according to Order of the Ministry of Health No. 123 “Bedsores,” you need to use the Waterlow risk scale. With its help, scores are calculated based on many factors, including the patient’s physique, his gender and age, skin type and others.



The protocol requires daily calculation of the degree of threat of bedsore formation in those patients who are forced to remain in a fixed position for a long time.

The figure obtained after calculations must be entered into the protocol for the management of this disease and preventive measures must be started immediately.

Areas of development of pressure ulcers

Risk areas for necrosis may vary and depend on the position in which the patient remains for a long time.

Protocol No. 123 of the Ministry of Health identifies two groups of risk zones:

48. Most often, necrotic changes occur near the ears, in the thoracic spine, sacral region, on the proximal thigh, in the area of ​​the small tibia, on the buttocks, in the elbow joint, near the heel tubercles.
49. Much less often, necrosis can affect the occipital and scapular regions, and the phalanges of the toes.



Clinical picture and diagnostic features

Ministry of Health Protocol No. 123 divides the development of pressure ulcers into several stages. Symptoms have their own characteristics at each stage of necrosis formation:

50. Abundant blood supply to the skin, but its integrity is not compromised.
51. Peeling of the top layer of skin, the beginning of the necrotic process of the dermis and subcutaneous tissue.
52. Purulent discharge from the ulcer, necrotic changes cover the muscle tissue.
53. Necrosis affects all tissues, an ulcer forms where areas of bone are visible.

The diagnosis of “bedsore” is made based on the results of an examination by a doctor. Laboratory findings on the composition of discharge from the ulcer and painful sensations person.

Protocol No. 123 proposes to consider infectious diseases, which are consequences of the development of necrosis, such as nosocomial infections.

Order of the Ministry of Health No. 123 requires that all data received be recorded in the nursing chart for monitoring and caring for the patient.

General approaches to the prevention of bedsores according to standard No. 123

Order of the Ministry of Health No. 123 implies that preventive actions are carried out by nurses after training.

Prevention goals, according to Ministry of Health protocol No. 123:

Patient model

According to the protocol of the Order on pressure ulcers 123, preventive measures are necessary for seriously ill patients bedridden people who scored more than ten points on the Waterlow risk scale while staying in a hospital setting.

The bedsore protocol considers specifically those patients who are undergoing therapy in oncology, traumatology, neurology, neurosurgical and intensive care units.

The requirements of the order apply to diseases that result in immobility of the patient.

Features of patient care in protocol No. 123

Diet according to standard order

The protocol also recommends preventing bedsores with proper nutrition. Based on Ministry of Health Order No. 123, the patient’s menu should include at least 120 grams of protein and about one gram of vitamin C per day. Dishes must contain sufficient quantity calories.

Informed voluntary consent protocol form

The bedsore standard requires treatment only at the will of the person. Before producing medical intervention, you need to take voluntary consent from the patient, in accordance with Article 32 of the “Fundamentals of the legislation of the Russian Federation on the protection of citizens.”

If the patient’s well-being prevents him from expressing his opinion on this matter, and medical intervention is urgent, then the problem should be resolved by a council or the attending doctor. After this, he must notify the hospital staff about his actions.

Order of the Ministry of Health No. 123 prescribes the nature and sequence of implementation of preventive anti-bedsore actions to be agreed upon with the patient on paper, and, if impossible, with his relatives. The “Bedsores” standard also obliges to provide the patient with full information about the goals of their prevention and all possible complications and risks.

Cardiology department Ward 6

Full name Chernyshev Sergey Prokopyevich

Gender m Age ( full years) 67

Permanent place residence: Chistopol, Academician K. 7-14

Place of work disabled group 3

Sent to hospital for emergency indications: No,

Type of transportation: can go

Height 160 Weight 70 BMI 27.34

Allergy No

Source of information: patient, family, medical documents, staff

Medical diagnosis Angina pectoris

The patient's complaints at the time of supervision were pain in the heart area, shortness of breath with physical activity

Identifying risk factors

3. Nature of nutrition: fractional, complete

4. Bad habits

Smoking: No

Alcohol consumption: No

Physiological data

Skin color pallor

No rashes

Edema No localization

2. Breathing and circulation

Respiratory rate 18 min.

Cough: No

Sputum: No

Addition:

Characteristics of pulse: frequent, rhythmic, intense

Blood pressure on peripheral arteries: 170/100

left hand 170/100 right hand 173/100

Addition

3. Digestion

Appetite: reduced

Swallowing: normal

Compliance with the prescribed diet No

Addition:

Urination: free

Frequency of urination: day 8 at night 2

Incontinence: No

Addition:

Bowel function:

Regularity/frequency: 2

The chair is decorated

Addition:

5. Physical activity

Dependency: partial

Walking aids are used: Yes

What kind of devices are used: cane

Does it need help? medical worker Yes

Addition:

6. Sleep, rest

Night sleep duration 7

Duration nap 2

Body temperature at the time of examination was 36.5

Addition:

Addition:

Addition:

Is there a risk of falling: No

Addition:

9. The patient’s existing (present) problems: pain in the heart area, shortness of breath during exercise

10. Priority problem(s): dyspnea on exertion

11. Potential problems development of myocardial infarction

PATIENT CARE PLAN

Patient's name

Patient problems

The goal is short-term, the deadline is pain in the heart area is relieved within 3 days

The goal is long-term, the deadline is the absence of complications.

A set of exercises for angina pectoris

Sitting on a chair, bend your knees at a right angle and place them shoulder-width apart, hands on your knees. Deep breathing 2-3 times. The exhalation is lengthened.

Clench and unclench your fingers into a fist 8-10 times. Breathing is voluntary. The pace is average.

Bend your knees at a right angle and place them shoulder-width apart; hands on the belt.

Alternately bend and straighten your legs ankle joints 8-10 times. Breathing is voluntary. The pace is average.

Bend your knees at a right angle and place them shoulder-width apart, hands on your waist. Raise your arms up to the sides, bend over - inhale, return to the starting position - exhale, 2-3 times. The pace is slow.

Sitting on the edge of a chair, bend your knees at a right angle and place them shoulder-width apart, lower your arms. Alternately 2-3 times place your leg on the knee of the other leg - exhale, return to the starting position - inhale. You can support the shin with runes. The pace is slow.

Bend your knees at a right angle and place them shoulder-width apart, hands on your waist. Alternately, move your arms back and make circular movements with them 2-3 times. When abducting and raising the arm - inhale, returning to the starting position - exhale. The pace is slow.

After this, get up, walk slowly for 4 minutes, stop, take 2-3 deep breaths and exhales.

Further exercises are done in a standing position.
Place your feet shoulder-width apart and hold the back of the chair with your hands. Half squat - exhale, return to the starting position - inhale. Repeat 3-4 times. The pace is slow.

Place your feet shoulder-width apart and lower your arms. Then pull them forward and spread them apart - inhale. Lower your arms - exhale, 2-3 times, the pace is slow.

Feet together, hands holding onto the back of the chair. Alternately move your leg to the side 2-3 times. Breathing is voluntary. The pace is slow.

Place your feet shoulder-width apart, place your fingers on your shoulders. Circular movements in the shoulder joints; repeat 2-3 times in each direction. The pace is slow. Breathing is voluntary.

Place your legs together, hands on your waist. Deep breathing 2-3 times.

The following exercises are performed while sitting on a chair.

Bend your knees at a right angle and place them shoulder-width apart, lower your arms. Alternately stretch your leg forward. Raise your arms to the sides - inhale. Return to the starting position - exhale, 3-4 times. The pace is slow.

Sitting on a chair, bend your knees at a right angle and place them shoulder-width apart. Fingers to shoulders. Raising your elbows to the sides - inhale, return to the starting position - exhale, 3-4 times. The pace is slow.

Sitting on a chair, bend your knees at a right angle and place them shoulder-width apart, place your hands on your knees. Simultaneously bend and straighten your legs at the ankle joints, 3-4 times. The pace is slow. Breathing is voluntary.

Sitting on a chair, put your legs together, put your hands on your belt. Alternately move your arms to the sides - inhale, return to the starting position - exhale. 2-3 times. The pace is slow.

Sitting on a chair, place your legs together and place your hands on your hips. Deep breathing 2-3 times.

3.2. Nursing observation card for patient No. 2

Medical organization Central District Hospital

Cardiology department Ward 11

Full name Yarullin Marat Fatykhovich

Gender and Age (full years) 68

Permanent place of residence: s. Kargali, st. Prohodnaya 9a

Place of work, group 3 disabled

Who refers the patient self-referral

Sent to the hospital for emergency reasons: yes, 3 hours after illness;

Type of transportation: on a gurney,

Height 170 Weight 80 BMI 27

Allergies: No

Source of information (underline): patient, family,

Medical diagnosis Hypertonic disease

The patient's complaints at the time of supervision were headaches, dizziness, shortness of breath that worsened when walking

Identifying risk factors

1. Work and rest mode does not work

2. Living conditions live in favorable conditions

3. The nature of nutrition is fractional, not complete

4. Bad habits

Smoking: No

Alcohol consumption: No

5. There are no industrial hazards

6. No chronic diseases

Physiological data

1. Condition of the skin and subcutaneous fat

Physiological skin color

No rashes

The nature of the rash.

Expressiveness of the subcutaneous fat layer

BMI assessment overweight

Swelling No

Addition

2. Breathing and circulation

Respiratory rate 16 min.

Cough: No

Sputum: No

Character of sputum, if present:

Addition:

Characteristics of pulse filled

Blood pressure in peripheral arteries:

left hand 160/70 right hand 160/70

Addition

3. Digestion

Appetite: not changed,

Swallowing: normal,

Flatulence (bloating): No

Compliance with the prescribed diet: No

Addition:

4. Physiological functions

Operation Bladder:

Urination: free,

Frequency of urination: day 7 at night 2

Incontinence: No

Addition:

Bowel function:

Regularity/frequency:

The chair is decorated

Addition:

5. Physical activity

Dependency: none,

Walking aids used: No

What kind of devices are used: crutches, cane, walker, handrails (underline)

Do you need help from a medical professional? No

Addition:

6. Sleep, rest

Duration of night sleep 8

Daytime sleep duration 1

Addition (difficulty falling asleep, interrupted sleep, daytime sleepiness, insomnia at night):

7. Ability to maintain normal body temperature

Body temperature at the time of examination

Addition:

8. Ability to maintain safety

Are there visual impairments: No

Addition:

Are there hearing impairments: No

Addition:

Is there a risk of falling: No

Addition:

9. The patient’s existing (present) problems: headache, dizziness, shortness of breath that worsens when walking

10. Priority problem(s) headache

11. Potential problems risk of complications

PATIENT CARE PLAN

Patient's name Yarullin Marat Fatykhovich

Patient problems

The goal is short-term, the deadline is that the headache will stop within 3 days.

The goal is long-term, the deadline is complete recovery by discharge

Additional research sheet 1

Order of the Ministry of Health of the Russian Federation dated April 17, 2002 N 123 On approval of the industry standard. Patient management protocol. Bedsores

According to the conclusion of the Ministry of Justice of the Russian Federation dated June 3, 2002 N 07/5195-UD, this order does not require state registration (information published in the Bulletin of the Ministry of Justice of the Russian Federation, 2002, N 8)

In order to ensure the quality of medical care for patients at risk of developing pressure ulcers, I order:
1. Approve:
1.1. Industry standard Patient management protocol. Bedsores (OST 91500.11.0001-2002) (Appendix No. 1 to this order).
1.2. Registration form N 003-2/у Card of nursing observation of patients with bedsores (Appendix No. 2 to this order).
2. Entrust control over the implementation of this order to the First Deputy Minister A.I. Vyalkov.

Minister Yu.L. Shevchenko

Industry standard OST 91500.11.0001-2002
Standardization system in healthcare of the Russian Federation
Patient management protocol. Bedsores (L.89)

1 area of ​​use

The requirements of the industry standard apply to the provision of medical care to all patients who have risk factors for developing pressure ulcers, according to the risk factors, and who are treated in an inpatient setting.

2 Purpose of development and implementation

Introduction of modern methodology for the prevention and treatment of bedsores in patients with various types of pathologies associated with prolonged immobility.

3 Development and implementation tasks

1. Introduction of modern systems for assessing the risk of developing pressure ulcers, drawing up a prevention program, reducing the incidence of pressure ulcers and preventing pressure ulcer infections.
2. Timely treatment of bedsores depending on the stage of their development.
3. Improving the quality and reducing the cost of patient treatment due to the introduction of resource-saving technologies.
4. Improving the quality of life of patients at risk of developing bedsores.

4 Clinical epidemiology, medical and social significance

There are practically no statistical data on the incidence of pressure ulcers in medical institutions of the Russian Federation. But, according to a study in the Stavropol Regional Clinical Hospital, designed for 810 beds, with 16 inpatient departments, for 1994-1998. 163 cases of pressure ulcers were registered (0.23%). All of them were complicated by infection, which accounted for 7.5% of the total structure of nosocomial infections.
According to English authors, in medical and preventive care institutions, bedsores develop in 15-20% of patients. According to a study conducted in the United States, about 17% of all hospitalized patients are at risk for developing pressure ulcers or already have them.
The estimated cost for treating pressure ulcers per patient ranges from $5,000 to $40,000. According to D. Waterlow, in the UK the cost of caring for patients with pressure ulcers is estimated at 200 million pounds sterling and increases by 11% annually as a result of treatment costs and increased length of hospitalization.
In addition to the economic (direct medical and non-medical) costs associated with the treatment of pressure ulcers, it is necessary to take into account intangible costs: severe physical and mental suffering experienced by the patient.
Inadequate anti-bedsore measures lead to a significant increase in direct medical costs associated with the subsequent treatment of resulting bedsores and their infection. The duration of the patient's hospitalization increases, and there is a need for adequate dressings (hydrocalloid, hydrogels, etc.) and medicinal (enzymes, anti-inflammatory, agents that improve regeneration) products, instruments, and equipment. In some cases, surgical treatment of stage III-IV bedsores is required.
All other costs associated with the treatment of bedsores also increase.
Adequate prevention of pressure ulcers can prevent their development in patients at risk in more than 80% of cases.
Thus, adequate prevention of pressure ulcers will not only reduce the financial costs of treating pressure ulcers, but also improve the patient’s quality of life.

5 General questions

Pathogenesis

Pressure at bony prominences, friction, and shearing (shearing) forces lead to pressure ulcers. Long-term (more than 1-2 hours) pressure leads to vascular obstruction, compression of nerves and soft tissues. In the tissues above the bone protrusions, microcirculation and trophism are disrupted, hypoxia develops, followed by the development of bedsores.
Damage to soft tissue from friction occurs when the patient moves, when the skin is in close contact with a rough surface. Friction causes injury to both the skin and deeper soft tissues.
Shear damage occurs when the skin is immobile and deeper tissues are displaced. This leads to impaired microcirculation, ischemia and skin damage, most often against the background of additional risk factors for the development of pressure ulcers (see appendices).

Risk factors

Risk factors for the development of pressure ulcers may be reversible (eg, dehydration, hypotension) or irreversible (eg, age), intrinsic or extrinsic.
Internal risk factors

External risk factors

Places where bedsores appear

Depending on the patient's position (on his back, on his side, sitting in a chair), the pressure points change. The pictures (see paragraph 03) show the most and least vulnerable areas of the patient’s skin.
Most often in the area: auricle, thoracic spine (the most prominent part), sacrum, greater trochanter of the femur, protrusion of the fibula, ischial tuberosity, elbow, heels.
Less commonly in the area: occiput, mastoid process, acromion process of the scapula, spine of the scapula, lateral condyle, toes.

Clinical picture and diagnostic features

The clinical picture is different at different stages of development of pressure ulcers:
Stage 1: persistent skin hyperemia that does not go away after the pressure stops; the skin is not damaged.
Stage 2: persistent skin hyperemia; epidermal detachment; superficial (shallow) violation of the integrity of the skin (necrosis) spreading to the subcutaneous tissue.
Stage 3: destruction (necrosis) of the skin down to the muscle layer with penetration into the muscle; There may be liquid discharge from the wound.
Stage 4: damage (necrosis) of all soft tissues; the presence of a cavity in which tendons and/or bone formations are visible.
Diagnosis of pressure ulcer infection is made by a doctor. The diagnosis is made based on examination data. The following criteria are used:
1) purulent discharge;


Confirmation of the existing complication of “bedsore infection” bacteriologically should be carried out in all patients suffering from agranulocytosis, even in the absence external signs inflammation (pain, swelling of the wound edges, purulent discharge).
Pressure ulcer infections that develop in a hospital are recorded as nosocomial infections.
If the patient stays at home nursing care, when serving patients by nursing staff of compassionate services, data on the location, size, and stage of bedsores are recorded only in the nursing observation card for patients with bedsores” (see Appendix No. 2).

General approaches to prevention

Adequate prevention of pressure ulcers will ultimately lead to a reduction in direct medical costs associated with the treatment of pressure ulcers, direct (non-medical), indirect (indirect) and intangible (intangible) costs.
Adequate anti-bedsore measures must be carried out by nursing staff after special training.

Preventive measures should be aimed at:
- reducing pressure on bone tissue;
- prevention of friction and tissue shear when moving the patient or when positioning him incorrectly (“sliding” off pillows, sitting in a bed or on a chair);
- observation of the skin over bony protrusions;
- keeping the skin clean and moderately moist (not too dry and not too wet);
- providing the patient with adequate food and drink;
- teaching the patient self-help techniques for moving;
- training loved ones.
General approaches to the prevention of pressure ulcers are as follows:
- timely diagnosis of the risk of developing bedsores,
- timely start of implementation of the entire complex of preventive measures,
- adequate technique for performing simple medical services, including nursing care.

6 Characteristics of requirements

6.1 Patient model

6.1.1 Criteria and features defining the patient model

The industry standard may include patients who have a risk of developing bedsores of more than 10 points on the Waterlow scale, suffering from diseases caused by severe damage to the central nervous system of inflammatory, degenerative or toxic origin, accompanied by complete immobility: the patient’s inability to independently move along a plane and change the position of the body in space without special devices or outside help.

6.1.2 Propagation of protocol requirements

Diseases leading to immobility: damage to the spinal cord due to spinal trauma, tumor growth, metastases in the spine with dysfunction of the underlying parts of the spinal cord, infections with impaired control of urination and/or defecation, etc.

6.1.3 Condition for providing medical care

Medical care regulated by this industry standard is performed in a hospital setting.

The functional purpose of medical services is prevention.

6.1.4 Characteristics of algorithms and features of medical care

Medical assistance not related to patient care is not provided.

6.1.5 Characteristics of algorithms and features of the use of medications

Drug therapy is not provided.

6.1.6 Requirements for the regime of work, rest, treatment or rehabilitation

6.1.7 Requirements for patient care and ancillary procedures

Features of patient care

1. Placing the patient on a functional bed (in a hospital setting). There should be handrails on both sides and a device for raising the head of the bed. The patient should not be placed on a bed with armored mesh or old spring mattresses. The height of the bed should be at the height of the caregiver's mid-thighs.
2. The patient being moved or moved into a chair must be on a bed with a variable height that allows him to move out of the bed independently, using other available means.
3. The choice of an anti-bedsore mattress depends on the degree of risk of developing bedsores and the patient’s body weight. For low risk situations, a 10 cm thick foam mattress may be sufficient. For more high degree risk, as well as for existing bedsores different stages need other mattresses. When placing the patient in a chair (wheelchair), foam rubber pads with a thickness of 10 cm are placed under the buttocks and behind the back. Foam rubber pads with a thickness of at least 3 cm are placed under the feet (convincing evidence B).
4. Bed linen – cotton. The blanket is light.
5. It is necessary to place bolsters and foam cushions under vulnerable areas.
6. Change body position every 2 hours, including at night, according to the schedule: low Fowler position, side position, Sims position, prone position (in agreement with the doctor). Fowler's position should coincide with meal times. Every time you move, inspect risk areas. The results of the inspection should be recorded on the registration sheet for anti-decubitus measures (convincing evidence B).
7. Move the patient carefully, avoiding friction and tissue displacement, lifting him above the bed, or using a back sheet.
8. Do not allow the patient to lie directly on the side big skewer hips.
9. Do not expose areas at risk to friction. Massage of the whole body, including near risk areas (within a radius of at least 5 cm from the bony protrusion) should be carried out after generous application of nourishing (moisturizing) cream to the skin (convincing evidence B).
10. Wash the skin without rubbing and bar soap, use liquid soap. Dry the skin thoroughly after washing using a blotting motion (Strength of Evidence C).
11. Use waterproof diapers and diapers that reduce excessive moisture.
12. Maximize the patient’s activity: teach him self-help to reduce pressure on support points. Encourage him to change position: turn around using the bed rails, pull himself up.
13. Teach family and other caregivers how to reduce the risk of tissue damage from pressure:
· regularly change body position;
· use devices that reduce pressure (pillows, foam rubber, pads);
· follow the rules of lifting and moving: avoid friction and tissue shear;
· examine all skin at least once a day, and risk areas - with each movement;
· carry out proper nutrition and adequate fluid intake;
· carry out hygiene procedures correctly: avoid friction.
14. Avoid over-moisturizing or drying the skin: if it is excessively moisturized, dry it using powders without talc; if it is dry, moisturize with cream (convincing evidence C).
15. Constantly maintain a comfortable state of the bed: shake off crumbs, straighten folds.
16. Teach the patient breathing exercises and encourage him to do them every 2 hours.

Recommended care plans for those at risk of developing pressure ulcers bedridden patient and a patient who can sit are given in Appendix No. 2. Registration of anti-decubitus measures is carried out on a special form (see Appendix No. 2 to the order of the Ministry of Health of Russia dated April 17, 2002 No. 123).

6.1.8 Dietary requirements and restrictions

The diet should contain at least 120 g of protein and 500-1000 mg of ascorbic acid per day (Strength of Evidence C). Daily ration must be sufficient in calories to maintain the patient's ideal body weight.

6.1.9 Informed consent form

A necessary precondition for medical intervention is the informed voluntary consent of the citizen in accordance with Article 32 of the “Fundamentals of the Legislation of the Russian Federation on the Protection of Citizens” dated July 22, 1993, No. 5487-1 (Gazette of the SND and the Armed Forces of the Russian Federation, August 19, 1993, No. 33, Art. 1318).
In cases where a citizen’s condition does not allow him to express his will, and medical intervention is urgent, the issue of its implementation in the interests of the citizen is decided by a council, and if it is impossible to assemble a council, by the attending (duty) doctor directly, with subsequent notification officials medical and preventive institution.
The plan for implementing anti-bedsore measures is discussed and agreed upon with the patient in in writing, and, if necessary, with his loved ones.

The patient must have information about:

Risk factors for the development of bedsores;
- the purposes of all preventive measures;
- the need to implement the entire prevention program, including manipulations performed by the patient and/or his relatives;
- the consequences of non-compliance with the entire prevention program, including a decrease in the level of quality of life.

The patient must be taught:

The technique of changing the position of the body on a plane with the help of auxiliary means (bed rails, chair armrests, devices for lifting the patient);
- breathing exercise technique.

Additional Information for relatives:

Places of formation of bedsores;
- moving technique;
- features of placement in various positions;
- dietary and drinking regime;
- hygiene procedures technique;
- monitoring and maintaining moderate skin moisture;
- encouraging the patient to move independently every 2 hours;
- encouraging the patient to perform breathing exercises.
Note: Education of the patient and/or his relatives must be accompanied by a demonstration and comments on the drawings from clause 10 of OST 91500.11.0001-2002.
Information about informed consent patients are registered on a special form (see Appendix 2 to the order of the Ministry of Health of Russia dated April 17, 2002 No. 123).

6.1.10 Additional information for patients and family members

Memo for the patient

Prevention is the best treatment. To help us prevent you from developing bedsores, you should:
· consume a sufficient amount of liquid (at least 1.5 liters) (the volume of liquid should be checked with a doctor) and at least 120 g of protein; 120 g of protein needs to be “gained” from different foods you love, both animal and plant origin. For example, 10 g of protein is contained in:

Protein is also found in foods of plant origin. So, 100 g of product contains different amounts of protein:

· consume at least 500-1000 mg of ascorbic acid (vitamin C) per day;
· move in bed, including from bed to chair, eliminating friction; use aids;
· use an anti-bedsore mattress and/or chair cushion;
· try to find a comfortable position in bed, but do not increase pressure on vulnerable areas (bone protrusions);
· change your position in bed every 1-2 hours, or more often if you can sit up;
· walk if you can; do exercises by bending and straightening your arms and legs;
· do 10 breathing exercises every hour: deep, slow breath in through your mouth, exhale through your nose;
· take an active part in your care;
· Ask the nurse questions if you have any problems.

Memo for relatives

With each movement, any deterioration or change in condition, regularly inspect the skin in the area of ​​the sacrum, heels, ankles, shoulder blades, elbows, back of the head, greater trochanter of the femur, inner surface knee joints.
Do not expose vulnerable areas of the body to friction. Wash vulnerable areas at least once a day if you need to maintain normal personal hygiene rules, as well as if you have urinary incontinence, heavy sweating. Use mild and liquid soap. Make sure the detergent is rinsed off and dry the area. If your skin is too dry, use a moisturizer. Wash your skin with warm water.
Use barrier creams if indicated.
Avoid massaging the area of ​​prominent bony protrusions.
Change the patient's position every 2 hours (even at night): Fowler's position; Sims position; "on the left side"; "on the right side"; “on the stomach” (with the doctor’s permission). The types of positions depend on the disease and condition of the individual patient. Discuss this with your doctor.
Change the patient's position by lifting him off the bed.
Check the condition of the bed (folds, crumbs, etc.).
Avoid skin contact with the hard part of the bed.
Use foam rubber in the case (instead of cotton-gauze and rubber circles) to reduce pressure on the skin.
Relieve pressure on areas where skin integrity is compromised. Use appropriate equipment.
Lower the head of the bed to the most low level(angle no more than 30 degrees). Raise the head of the head a short time to perform any manipulations.
Do not allow the patient to lie directly on the greater trochanter in the lateral decubitus position.
Avoid continuous sitting in a chair or wheelchair. Remind them to change position every hour, change their body position independently, pull themselves up, and examine vulnerable areas of the skin. Advise him to relieve pressure on the buttocks every 15 minutes: lean forward, to the side, or rise, leaning on the arms of the chair.
Reduce the risk of tissue damage due to pressure:
· change your body position regularly;
· use devices that reduce body pressure;
· Observe lifting and moving rules;
· examine your skin at least once a day;
· Maintain proper nutrition and adequate fluid intake.
Monitor the quality and quantity of food and fluids, including urinary incontinence.
Expand the activity of your ward as much as possible. If he can walk, encourage him to take a walk every hour.
Use waterproof diapers, diapers (for men - external urinals) for incontinence.

6.1.11 Rules for changing requirements when implementing the protocol and termination of protocol requirements

The protocol requirements cease to apply if there is no risk of developing pressure ulcers according to the Waterlow scale.

6.1.12 Possible outcomes and their characteristics

6.1.13 Cost characteristics

Cost characteristics are determined in accordance with the requirements of regulatory documents.

Graphical, schematic and tabular representation of the protocol

8 Monitoring

8.1 Criteria and methodology for monitoring and evaluating the effectiveness of the protocol

In the neurology department of the regional (city) hospital

Sample: all stroke patients treated in the department during a calendar year who are at risk of developing pressure ulcers of 10 or more Waterlow scale points and who do not have pressure ulcers at the time the industry standard is met.

1. The total number of stroke patients hospitalized in the department during the year ________________.
2. The number of patients with a risk of developing pressure ulcers according to the D. Waterlow scale of 10 or more points ________________.
3. Number of patients who developed bedsores ________________.

In the intensive care unit of a regional (city) hospital

Sample: all patients receiving treatment in the department during the calendar year, but for at least 6 hours, with a risk of developing pressure ulcers of 10 points or more on the Waterlow scale, who do not have pressure ulcers at the time of meeting the industry standard.

The assessment is carried out according to the following positions:

1. The total number of patients in the department during the year (minimum period of at least 6 hours)________________.
2. The number of patients with a risk of developing pressure ulcers on the Waterlow scale of 10 or more points ________________.
3. The number of patients who developed bedsores __________.

8.2 Principles of randomization

The principles of randomization are not provided for in OST 91500.11.0001-2002.

8.3 Procedure for assessing and documenting side effects and complications

Diagnosis of pressure ulcer infection is made by a doctor. The diagnosis is made based on examination data. The following criteria are used:
1) purulent discharge;
2) pain, swelling of the edges of the wound.
The diagnosis is confirmed bacteriologically by isolating the microorganism in cultures of fluid samples obtained by smear or puncture from the edges of the wound.
Confirmation of the existing complication of “bedsore infection” bacteriologically should be carried out in all patients suffering from agranulocytosis, even in the absence of external signs of inflammation (pain, swelling of the edges of the wound, purulent discharge).
Pressure ulcer infections that develop in the hospital are recorded as nosocomial infections.

8.4 Procedure for excluding a patient from monitoring

There is no procedure for excluding a patient from monitoring.

8.5 Interim evaluation and modification of this standard

Assessment of the implementation of OST 91500.11.0001-2002 is carried out 2 times a year based on the results of analysis of information obtained during monitoring.
Amendments to OST 91500.11.0001-2002 are carried out if information is received:
a) the presence of requirements in this industry standard that cause damage patient health,
b) upon receipt of convincing evidence of the need for changes to the mandatory requirements of the industry standard.
Changes to this standard are prepared by the development team. Amendments to this industry standard are carried out by the Russian Ministry of Health in accordance with the established procedure.

8.6 Parameters for assessing quality of life when performing the protocol

Parameters for assessing quality of life when performing OST 91500.11.0001-2002 are not provided.

8.7 Estimation of the cost of implementing the protocol and the price of quality

Clinical and economic analysis is carried out in accordance with the requirements of regulatory documents.

8.8 Comparison of results

When monitoring OST 91500.11.0001-2002, statistical data on the frequency of pressure ulcer development indicators is annually compared.

8.9 Report generation procedure

The annual report on monitoring results includes quantitative results obtained during the development of medical records, and their qualitative analysis, conclusions, and proposals for updating the industry standard.
The report is submitted to the working group of this industry standard. The report materials are stored in the Laboratory of Standardization Problems in Healthcare of the Institute of Healthcare Management of the Moscow medical academy them. THEM. Sechenov Ministry of Health of Russia in the form of text printed on paper, CD in the archive of the above-mentioned Laboratory.
The results of the report may be published publicly.

Appendix No. 2
Approved by order of the Ministry of Health of the Russian Federation

from "17" 04.2002
№ 123
Medical documentation
Insert for medical
inpatient card No. 003/у
Registration form No. 003-2/у

“Nursing observation card for patients with pressure ulcers”

1. FULL NAME. patient
2. Branch
3. Ward
4. Clinical diagnosis
5. End of implementation of the care plan: date ______ hour.________ min. _____

I. Patient's consent to the proposed plan of care

Patient_______________________________________________________
(FULL NAME)
received an explanation of the pressure ulcer prevention care plan; received information: about risk factors for the development of bedsores,
for the purposes of preventive measures,
consequences of non-compliance with the entire prevention program.
The patient is offered a care plan in accordance with the industry standard “Patient Management Protocol. Bedsores”, approved by order of the Ministry of Health of Russia dated April 17, 2002 No. 123, full explanations were given about the features of the diet.
The patient is informed of the need to follow the entire prevention program, regularly change position in bed, and perform breathing exercises.
The patient is informed that failure to comply with the recommendations of the nurse and doctor may be complicated by the development of bedsores.
The patient is notified of the outcome if the plan of care is not followed.
The patient had the opportunity to ask any questions he had regarding the plan of care and received answers to them.

The interview was conducted by a nurse _________________ (nurse signature)

"____"_______________20__

The patient agreed with the proposed plan of care, which he signed with his own hand _________________________ (signature of the patient)
or signed for it (according to clause 6.1.9 of the industry standard “Protocol for the management of patients. Bedsores”, approved by order of the Ministry of Health of Russia dated April 17, 2002 No. 123)
___________________________ (signature, full name),
what those present at the conversation attest to
___________________ (nurse signature)
___________________(witness signature)
The patient did not agree (refuse) with the proposed care plan, for which he signed with his own hand _________________________ (signature of the patient)
or signed for it (according to clause 6.1.9 of the industry standard “Protocol for the management of patients. Bedsores” approved by order of the Ministry of Health of Russia dated April 17, 2002 No. 123)
____________________________ (signature, full name).

II. Nursing assessment sheet for the development and stage of pressure ulcers

Instructions: Circle the number corresponding to the Waterlow scale.

Total points ____________
Risk: no, yes, high, very high (underline as appropriate)
Bedsores: yes, no (underline as appropriate)
Stage 1 2 3 4

Agreed with the doctor _____________________________________________________
(doctor's signature)

III. Anti-decubitus measures registration sheet

Start of implementation of the care plan: date ______ hour.________ minutes. _____
End of implementation of the care plan: date ______ hour.________ min. _____

FULL NAME. nurses involved in monitoring the patient:
Signature:

The choice of position and their alternation may vary depending on the disease and condition of the patient.

Prevention of bedsores

BEDSORES is an area of ​​necrotic tissue that occurs in patients with impaired skin sensitivity as a result of physical compression (squeezing), friction and displacement, as well as prolonged moisture and infection, or a combination of these factors. Individual predisposition can also be the cause of bedsores.

Stages of development of bedsores :

Stage 1 : persistent hyperemia of the skin that does not go away after the pressure stops: the skin is not broken.

Stage 2 : persistent hyperemia of the skin: detachment of the epidermis: superficial (shallow) violation of the integrity of the skin (necrosis) spreading to the subcutaneous tissue.

Stage 3 : destruction (necrosis) of the skin down to the muscle layer with penetration into the muscle: there may be liquid discharge from the wound.

Stage 4 : damage (necrosis) of all soft tissues: the presence of a cavity in which tendons and/or bone formations are visible.

Diagnosis of a skin infection is made by a doctor based on examination data. Pressure ulcer infections that develop in a hospital are recorded as hospital-acquired infections.

Places where bedsores appear .

Depending on the patient's position (on his back, on his side, sitting in a chair), the pressure points change.

Most often in the region: auricle, thoracic spine (the most protruding part), sacrum, greater trochanter of the femur, protrusion of the fibula, ischial tuberosity, elbow, heels.

Less commonly in the area: occiput, mastoid process, acromion process of the scapula, spine of the scapula, lateral condyle, toes.

Basic principles of patient care

with the risk of developing bedsores.

Ministry of Health of the Russian Federation "PROTOCOL FOR MANAGEMENT OF PATIENTS. Bedsores"

Placing the patient on a functional bed (in a hospital setting) with handrails and a device for raising the head of the bed.

To transfer to the chair, the patient must be on a bed with variable height.

Availability of an anti-decubitus mattress or foam mattress at least 10 cm thick. Place bolsters and foam cushions with a thickness of at least 3 cm under vulnerable areas.

Bed linen is cotton. The blanket is light.

Change body position every 2 hours, incl. and at night.

Whenever moving, inspect risk areas; record the results in the registration sheet for anti-decubitus measures.

Move it carefully, avoiding friction and shifting of tissues, lifting it above the bed, or using a back sheet.

Do not expose areas at risk to friction. Full body massage, incl. near risk areas (within a radius of at least 5 cm from the bony protrusion) should be carried out after generous application of nourishing (moisturizing) cream to the skin.

Wash the skin without rubbing, using liquid soap.

Dry the skin thoroughly after washing using blotting movements.

Use waterproof diapers and diapers that reduce excessive moisture.

In patients with involuntary urination and defecation, immediately provide hygienic care and change bed linen.

Maximize the patient's self-help activities to reduce pressure on support points.

Teach relatives and caregivers measures to prevent bedsores.

Avoid over-moisturizing or drying the skin: if it is excessively moisturized, dry it using powders without talc; if it is dry, moisturize with cream.

Constantly maintain a comfortable state of the bed: shake off crumbs, straighten folds.

Teach the patient breathing exercises and encourage him to do them every 2 hours.

The diet should be high enough in calories to maintain the patient’s ideal body weight, contain at least 120 g of protein and 500-1000 mg of ascorbic acid per day, and a sufficient amount of liquid (up to 1.5 l), unless there are contraindications.

Note:

pH-neutral liquid soap and single-use care products are used.