Order 123 prevention of bedsores basic provisions. Propagation of protocol requirements

Active Edition from 17.04.2002

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

Order

In order to ensure quality medical care patients at risk development of bedsores I order:

1. Approve:

1.1. Industry standard "Protocol for the management of patients. Bedsores" (OST 91500.11.0001-2002) (Appendix N 1 to this order).

1.2. Accounting form N 003-2 / y "Card nursing care for patients with bedsores" (Appendix N 2 to this order).

2. To impose control over the implementation of this order on the First Deputy Minister A.I. Vyalkov.

Minister.
Yu.L. SHEVCHENKO

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

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 risk factors, and are treated in a hospital.

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

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

2. Timely treatment 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 bedsores in medical institutions of the Russian Federation are practically absent. But, according to a study in the Stavropol Territory clinical hospital, designed for 810 beds, with 16 inpatient departments, for 1994-1998. 163 cases of bedsores (0.23%) were registered. All of them were complicated by infection, which in the general structure nosocomial infections amounted to 7.5%.

According to English authors, bedsores are formed in 15-20% of patients in medical and preventive care institutions. 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 to treat pressure ulcers per patient is between $5,000 and $40,000. According to D. Waterlow, in the UK, the cost of caring for patients with bedsores is estimated at 200 million pounds and increases by 11% annually as a result of treatment costs and an increase in the duration of hospitalization.

In addition to the economic (direct medical and non-medical) costs associated with the treatment of bedsores, non-material costs must also be taken into account: severe physical and moral suffering experienced by the patient.

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

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

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

Adequate prevention of bedsores can prevent their development in patients at risk in more than 80% of cases.

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

PATHOGENESIS

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

Friction damage to soft tissues occurs when the patient is moved, when the skin is in close contact with a rough surface. Friction causes injury to both the skin and deeper soft tissues.

Shear injury occurs when the skin is immobile, and there is a displacement of tissues lying deeper. This leads to impaired microcirculation, ischemia and skin damage, most often against the background of additional risk factors for pressure ulcers (see appendices).

RISK FACTORS

Risk factors for developing pressure ulcers can be reversible (eg, dehydration, hypotension) or irreversible (eg, age), intrinsic or extrinsic.

Internal factors risk

External risk factors

Waterlow scale for assessing the risk of developing pressure ulcers

Waterlow scores are summed up, and the degree of risk is determined by the following total values:

In immobile patients, pressure ulcer risk assessment should be performed daily, even if initial examination the degree of risk was estimated at 1-9 points.

The results of the assessment are recorded in the nursing care card for the patient (see Appendix No. 2). Anti-decubitus measures begin immediately in accordance with the recommended plan.

PLACES OF APPEARANCE OF DEDUCULES

Depending on the position of the patient (on the back, on the side, sitting in a chair), the pressure points change. The drawings (see item 03) show the most and least vulnerable areas of the patient's skin.

Most often in the area: auricle, thoracic spine (most protruding section), sacrum, greater trochanter femur, there is little protrusion tibia, ischial tuberosity, elbow, heels.

Less common in the area: the back of the head, mastoid process, acromial process of the scapula, spine of the scapula, lateral condyle, toes.

CLINICAL PICTURE AND FEATURES OF DIAGNOSIS

The clinical picture is different at different stages of development of bedsores:

Stage 1: persistent hyperemia of the skin, which does not disappear after the cessation of pressure; the skin is not broken.

Stage 2: persistent hyperemia of the skin; detachment of the epidermis; superficial (shallow) breach of integrity skin(necrosis) with spread to the subcutaneous tissue.

Stage 3: destruction (necrosis) of the skin up to the muscle layer with penetration into the muscle; can 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.

A pressure sore infection is diagnosed by a doctor. The diagnosis is made on the basis of examination data. The following criteria are used for this:

1) purulent discharge;

2) pain, swelling of the edges of the wound.

The diagnosis is confirmed bacteriologically when the microorganism is isolated from cultures of fluid samples obtained by smear or puncture from the edges of the wound.

Confirmation of the existing complication of "decubitus infection" bacteriologically should be carried out in all patients suffering from agranulocytosis, even in the absence of external signs inflammation (pain, swelling of the edges of the wound, purulent discharge).

Bedsore infections that develop in a hospital are recorded as nosocomial infections.

If the patient is at home nursing care, in patient care nursing staff services of mercy, data on the location, size, stage of bedsores are recorded only in the nursing care card for patients with bedsores "(see Appendix N 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-decubitus measures should be performed by nursing staff after special training.

Preventive measures should be aimed at:

Reducing the pressure on bone tissues;

Prevention of friction and shearing of tissues during the movement of the patient or in case of improper placement ("sliding" from pillows, "sitting" position in bed or on a chair);

Observation of the skin over bony prominences;

Maintaining cleanliness of the skin and its moderate moisture (not too dry and not too wet);

Patient care adequate nutrition and drink:

Teaching the patient self-help techniques for moving:

Education of loved ones.

General approaches to prevent bedsores are as follows:

Timely diagnosis of the risk of developing bedsores,

Timely start of the entire complex preventive measures,

Adequate technique for performing simple medical services, incl. care.

* not shown

IN THE DEPARTMENT OF NEUROLOGY OF THE REGIONAL (CITY) HOSPITAL

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

1. Total patients with stroke admitted to the department during the year ________________.

2. The number of patients at risk of developing pressure ulcers on the D. Waterlow scale of 10 or more points ________________.

3. Number of patients who developed bedsores ___________ .

IN THE REANIMATION DEPARTMENT OF THE REGIONAL (CITY) HOSPITAL

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

EVALUATION IS CARRIED OUT ON THE FOLLOWING POSITIONS:

1. The total number of patients who were 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 ___________.

The patient is informed about the need to comply with the entire prevention program, regularly change position in bed, and perform breathing exercises.

The patient is notified of the outcome in case of refusal to complete the care plan.

The patient had the opportunity to ask any questions of interest to him regarding the care plan and received answers to them.

The interview was conducted by a nurse __________________ (signature of a nurse)

"___" ___________ 20___

The patient agreed with the proposed plan of care, in which he signed with his own hand _____________________________ (signature of the patient) or signed for it (according to paragraph 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 04.17.02 N 123) _____________________ (signature, Full name), which is certified by those present at the conversation

On the website "Zakonbase" you will find the ORDER of the Ministry of Health of the Russian Federation dated April 17, 2002 N 123 "ON APPROVAL OF THE INDUSTRY STANDARD "PROTOCOL OF MANAGEMENT OF PATIENTS. DECUCUSPERS" in fresh and full version in which all changes and amendments have been made. This guarantees the relevance and reliability of the information.

At the same time, download the ORDER of the Ministry of Health of the Russian Federation of April 17, 2002 N 123 "ON APPROVAL OF THE INDUSTRY STANDARD "PROTOCOL OF MANAGEMENT OF PATIENTS. Bedsores" can be completely free, both in full and in separate chapters.

It was approved back in 2002. Such protocols are being developed by the Ministry of Health for effective treatment almost all diseases. They are very important - they help to competently organize the treatment process, coordinate the actions of medical personnel.

A similar order of the Ministry of Health also simplifies the work of a doctor when compiling therapeutic plan. There is no need to draw up a treatment algorithm every time using proven methods. The protocol for the management of bedsores, the order (No. 123), which was developed by the Ministry of Health, helps to properly organize and prevent prevention work - this is an important area in the work of any modern medical facility.

What are bedsores and how dangerous are they?

A bedsore is a damage to the skin and subcutaneous fat, which occurs as a result of prolonged compression. The disease is often diagnosed in bedridden patients, and in advanced cases can lead to complications such as sepsis, the need for limb amputation, and death. The treatment of this, at first glance, a simple disease, is not simple, and in some cases drags on for many months. The new protocol of the Ministry of Health helps to provide more adequate treatment.

Prevention of bedsores order 123 is complex, and requires medical workers lots of time and expertise. It is important to properly organize (in accordance with the order of the Ministry of Health), select the right means care, think over his diet - all these points are clearly spelled out in order 123.

Decubitus Management Protocol 123 - Basics

The new protocol for the management of bedsores (123) is mandatory for the category of people who inevitably fall into the risk group for this disease and are being treated in a medical facility.

Why was Protocol 123 of the Ministry of Health created?

The pressure ulcer treatment protocol was developed with several important goals in mind.

1. The use of a progressive methodology for assessing the available options for the formation of bedsores.
2. Drawing up an effective algorithm for effective prevention.
3. regulates the standards for the treatment of bedsores depending on the stage of the process.
4. Stabilization of the quality of life of patients.
5. Informing relatives about the algorithm for caring for a person with an already diagnosed bedsore.

As a result, order 123 of the Ministry of Health should help reduce the incidence or recurrence of the inflammatory process.

Medical and social significance of order 123

By applying the new protocol for bedsores, doctors have managed to achieve a significant reduction in the incidence of this disease. The data are relative, since the Ministry of Health practically did not conduct statistical records before this order. The order is also important for reducing the cost of therapy.

For reference. The average cost of treating this disease can reach up to $40,000 and continues to increase every year.

Be sure to take into account the severe emotional suffering that the patient necessarily experiences. Despite the fact that statistics on this pathology has been kept in the Ministry of Health for a relatively short time, it can be said with confidence that Order 123 made it possible to significantly improve preventive measures. Now more than 80% of patients manage to prevent the development of the disease and, accordingly, its severe complications.

Risk factors for the development of pathology

Order 123 (protocol for the management of patients with bedsores), adopted by the Ministry of Health, allows you to most fully take into account all the prerequisites for the development of this disease.

The protocol for the prevention of bedsores also contains a special Waterlow scale. It allows you to evaluate all the prerequisites for the formation of pathology in points. This will show very well how intensively preventive measures should be organized. The final values ​​in the scale (in points) are interpreted as follows:

• up to 9 b. - there is no risk of disease;
• 10 b. – moderate risk;
• 15 b. - high risk the appearance of inflammation;
• 20 b. - a very high risk of developing pathology, the patient requires maximum attention and active prevention.

Standard 123 of the protocol for the management of patients with bedsores, developed by the Ministry of Health, provides for daily examinations of bedridden patients in a hospital. This must be done even if the degree of risk is minimal or completely absent. All examination data are recorded in the patient's medical history - it is also filled in in accordance with Order 123 of the Ministry of Health.

Clinical picture of the disease

Order 123 of the Ministry of Health contains data on all clinical manifestations this pathology. It is customary to distinguish four stages of the course of this pathology.

1. Redness of the skin. It may be different intensity. Distinctive feature such hyperemia is the fact that it does not go away after the termination of the action annoying factor(eg pressure). At the same time, the integrity of the skin is not violated.
2. Intense hyperemia in the affected area. There is a detachment of the epidermis, vesicles or sores at the site of the lesion. The patient may complain of pain in the area of ​​the pressure sore.
3. There is intense necrosis. It affects not only the skin - it almost always penetrates into muscle tissue. Discharges from a wound of various character are often observed.
4. At this stage, necrosis actively spreads to the entire skin and muscle layer tendons and bones are exposed. Discharge from the wound of a purulent nature, with a sharp unpleasant odor.

The standard protocol for the management of patients with bedsores of the Ministry of Health (123) clearly defines the main diagnostic points. Along with the obligatory presence of pain and swelling at the site of the lesion, as well as purulent discharge, a laboratory research. After a smear or puncture of the wound, the material is sent for bacteriological research. This will help to subsequently appoint an effective antibacterial drug. The Ministry of Health pays great attention to diagnostics, which determines correct appointment treatment.

Ministry of Health Prevention Standard

The Ministry of Health is well aware of how much prevention is needed, and great attention has been paid to this. The industry standard protocol for the management of pressure ulcers clearly defines adequate preventive measures that must be used in hospitals. These include:

• reduction of skin tension at the location of physiological bone protrusions;
• prevention of friction of the human skin during its movement (or involuntary slipping);
• constant monitoring and assessment of the condition of the skin;
• organization of permanent and high-quality hygiene procedures;
• with adequate protein and fiber content.

The management of bedsores according to standard 123 also provides for the obligation of health workers to teach the patient's loved ones the basics of proper care. After a person is discharged from the hospital, this moment becomes the main one in the prevention of bedsores. New order The protocol for the management of patients with bedsores contains all the basic requirements for the methods of correct care.

Algorithm for competent care of a person with bedsores

OST 123 (pressure sores) of the Ministry of Health contains all the main provisions that give the patient's relatives an idea about proper care. Several highlights should be noted.

Pays a lot of attention to the patient's diet. It should be of moderate calorie content, since it is undesirable for a bedridden patient to gain excess weight. Order of the Ministry of Health of the Russian Federation 123 on the prevention of pressure sores says that the patient must receive the recommended doses of ascorbic acid. The dose is up to 1000 mg / day. Studies have shown that taking vitamin C significantly reduces the risk of developing this disease and reduces the incidence of complications.

Video

MINISTRY OF HEALTH
RUSSIAN FEDERATION

About approval of the industry standard
"Protocol of management of patients. Bedsores"

_______________________________________________________________________________
The document does not need state registration by the Ministry of Justice of the Russian Federation
Letter of the Ministry of Justice of the Russian Federation dated 03.06.2002 N 07/5195-YUD.
______________________________________________________________________________

To ensure the quality of care for patients at risk of pressure ulcers

I order:

1. Approve:

1.1. Industry standard "Protocol for the management of patients. Bedsores" (OST 91500.11.0001-2002) (Appendix N 1 * to this order).
__________________
* Appendix N 1, see the link. - Database manufacturer's note.

1.2. Accounting form N 003-2 / y "Map of nursing care for patients with bedsores" (Appendix N 2 to this order).

2. To impose control over the implementation of this order on the First Deputy Minister A.I. Vyalkov.

Minister
Yu.L. Shevchenko

Appendix N 2

Appendix No. 2

APPROVED
by order of the Ministry
healthcare of the Russian Federation
dated April 17, 2002 N 123

Medical documentation
Insert for medical
inpatient card
N 003/y
Accounting form N 003-2 / y

"CARD OF NURSING SUPERVISION FOR PATIENTS
WITH DECUCUSPERS"

1. Full name patient

2. Branch

3. Chamber

4. Clinical diagnosis

5. Start of implementation of the care plan: date ____ hour. _____ min.

6. Completion of the implementation of the care plan: date ____ hour._____ min.

I. Patient Consent to the Proposed Plan of Care

Received clarification about the plan of care for the prevention of pressure ulcers;

Got information:

about risk factors for pressure sores,

for preventive measures,

consequences of non-compliance with the entire prevention program.

The patient was offered a plan of care in accordance with the industry standard "Protocol for the management of patients. Bedsores", approved by order of the Ministry of Health of Russia dated April 17, 2002 N 123, full explanations were given about the features of the diet.

The patient is informed about the need to comply with the entire prevention program, regularly change position in bed, and perform breathing exercises.

The patient is informed that non-compliance with the recommendations of the nurse and doctor may be complicated by the development of bedsores.

The patient is notified of the outcome in case of refusal to complete the care plan.

The patient had the opportunity to ask any questions of interest to him regarding the care plan and received answers to them.

Interviewed by nurse _____________ (signature of the nurse)

"__" ______________ 20 __

The patient agreed with the proposed plan of care, in which he signed with his own hand __________________ (patient's signature) or signed for it (according to paragraph 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 N 123)

___________________ (signature, full name),

what those present at the conversation testify

_____________ (signature of the nurse)

_____________ (witness's signature)

The patient did not agree (refused) with the proposed care plan, which he signed with his own hand __________________ (patient's signature) 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 N 123 )

____________________ (signature, full name).

II. Nursing Risk Assessment Sheet for Development and Staging of Pressure Ulcers

Scope 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 the provision of medical care to patients at risk of pressure ulcers who are undergoing therapeutic treatment in hospitals.

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

Protocol of the Ministry of Health No. 123 aims to promote Newest technologies preventive measures and therapy of necrosis in people with a variety of diseases, leading to a forced long stay in an immobile position.

Tasks for the development and implementation of Protocol No. 123

The main tasks of the order of the Ministry of Health No. 123:

1. The introduction of innovative technologies for assessing the level of risk of pressure ulcers, the creation preventive plan, reducing the number of cases with formed bedsores and preventing infectious inflammation bedsores.
2. Early therapy of necrosis, based on the stage of their occurrence.
3. Improving the quality and reducing the cost of therapy for patients, thanks to the introduction of technologies that save resources.
4. Improving the quality of life of patients who are at risk of necrosis.

As the main task, the protocol considers directly the prevention of the occurrence of bedsores.

Clinical epidemiology, medical and social significance

The order of the Ministry of Health No. 123 also mentions the statistics of 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 in the Stavropol hospital, 153 cases of pressure sores were registered per 800 patients. Moreover, each of them was complicated by infection.

In England, according to social workers, bedsores develop in about 1/5 of patients. 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 cost of treating pressure sores that have arisen is estimated at disappointing figures. Every year, the cost of caring for such patients is growing by ten percent.

The order of the Ministry of Health also emphasizes the fact that in addition to material expenses for the treatment of emerging necrosis in patients, it is worth considering the severe moral and physical suffering of patients.

Improper treatment and prevention of bedsores provokes growth necessary costs in medicine to eliminate necrosis and complications that have arisen. In addition, the patient is forced to stay longer in the hospital. Spending on special anti-decubitus medicines, tools, equipment is increasing. Sometimes it is also necessary to resort to surgical intervention at final stages development of necrosis. There is a need to spend large amounts of money on other methods of treatment.

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

Important! Proper preventive actions allow, in addition to reducing the cost of treating a patient, to improve his quality of life.

General issues of the order of the Ministry of Health No. 123

Pathogenesis

Order No. 123 considers bedsores as necrotic tissue changes.

Bedsores occur with prolonged pressure or friction of the skin on a hard surface. At the same time, the vessels are stenotic and the nerves in the squeezed area are compressed, which disrupts tissue nutrition.

In addition, necrotic changes can develop due to shearing, when the skin is immobile, and soft tissues under it are subject to movement. In this situation, there is a failure in the blood supply to this area, the skin is damaged.

Risk factors

Order No. 123 puts forward bedsores as necrosis, formed as a result of reversible and irreversible causes.

In order to determine how likely a patient is to develop necrosis, according to the Order of the Ministry of Health No. 123 "Decubituses", you need to use the Waterloo risk scale. With its help, points are calculated based on many factors, including the patient's physique, gender and age, skin type, and others.

The protocol prescribes to calculate daily the degree of threat of pressure ulcers in those patients who are forced to stay long time in a fixed position.

The figure obtained after the calculations must be entered into the protocol for managing this disease and immediately begin preventive measures.

Areas of development of bedsores

Risk areas for necrosis may be different and depend on the posture in which long time the patient stays.

1. Most often, necrotic changes occur near the ears, in the thoracic spine, sacral region, on the proximal part of the thigh, in the region of the fibula, on the buttocks, in elbow joint, near the heel tubercles.
2. Much less often, necrosis can affect the occipital and scapular regions, the phalanges of the toes.

Clinical picture and diagnostic features

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

1. Abundant blood filling of the skin, but their integrity is not violated.
2. Exfoliation of the upper layer of the skin, the beginning of the necrotic process of the dermis and subcutaneous tissue.
3. Purulent discharge from the ulcer, necrotic changes cover the muscle tissue.
4. Necrosis affects all tissues, an ulcer is formed, where parts of the bone are visible.

The diagnosis of "decubitus" is made based on the results of the examination by the doctor. Also taken into account are laboratory findings on the composition of discharge from the ulcer and pain person.

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

Order of the Ministry of Health No. 123 prescribes to record all received data in sister map monitoring and patient care.

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.

The goals of prevention, according to the protocol of the Ministry of Health No. 123:

• Reduced compression of bony prominences;
• To prevent friction and movement of tissues at the time of moving the patient or with an incorrectly chosen position for him;
• Regular examination of the skin of a patient in a high-risk area;
• Compliance with patient hygiene;
• Properly selected diet;
• Teaching the patient how to help himself when moving;
• Relatives training.

Patient Model

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

The protocol for bedsores is considered specifically for those patients who are undergoing therapy in oncological, traumatological, neurological, 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

1. The patient is supposed to have handrails on both sides and a mechanism for raising the top of the bed. Its height should approximately correspond to the level of the mid-thigh of the nurse.
2. This bed should have the ability to change height so that the patient can leave it on his own.
3. It is necessary to choose the right mattress against bedsores. Place special foam rollers under the feet.
4. must be cotton.
5. It is necessary to change the position of the patient every two hours, including at night. After changing the posture, inspect the skin.
6. Move the patient carefully, lifting him off the bed.
7. Massage should be done only after applying a special moisturizer.
8. Wash the patient with liquid soap, dry the skin with wet movements.
9. Use waterproof diapers and sheets.
10. Encourage the independent movement of the patient, teach this.
11. Provide training to loved ones.
12. Avoid overdrying or waterlogging of the skin.
13. Monitor the patient's bed, remove crumbs, folds.
14. Teach the patient to perform respiratory exercises, support in this.

Diet according to the standard of the order

The protocol also recommends preventing pressure sores through proper nutrition. Based on the data of the order of the Ministry of Health No. 123, the menu for the patient should include at least 120 grams of protein and about one gram of vitamin C per day. Dishes must contain enough calories.

Protocol Informed Consent Form

The pressure sore standard requires treatment only at the will of the person. Before performing medical intervention, you need to take from the patient voluntary consent, according to 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 that, he must notify the hospital staff about his actions.

Order of the Ministry of Health No. 123 prescribes the nature and sequence of preventive anti-decubitus actions to be coordinated with the patient on paper, if not possible, with his relatives. The "Decubituses" standard also obliges to provide the patient with full information about the goals of their prevention and all possible complications and risks.

Video

Order of the Ministry of Health of the Russian Federation of 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 of June 3, 2002 N 07/5195-YUD, this order does not need 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 bedsores, I order:
1. Approve:
1.1. Industry Standard Case Management Protocol. Pressure sores (OST 91500.11.0001-2002) (Appendix N 1 to this order).
1.2. Accounting form N 003-2 / y Nursing observation card for patients with bedsores (Appendix N 2 to this order).
2. To impose control over the implementation of this order on the First Deputy Minister A.I. Vyalkov.

Minister Yu.L.Shevchenko

Industry standard OST 91500.11.0001-2002
System of standardization in healthcare of the Russian Federation
Patient management protocol. Pressure sores (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 risk factors, and are treated in a hospital.

2 Purpose of design and implementation

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

3 Development and implementation tasks

1. The 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 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 and social significance

Statistical data on the incidence of bedsores in medical institutions of the Russian Federation are 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 bedsores (0.23%) were registered. All of them were complicated by infection, which accounted for 7.5% of the total structure of nosocomial infections.
According to English authors, bedsores are formed in 15-20% of patients in medical and preventive care institutions. 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 to treat pressure ulcers per patient is between $5,000 and $40,000. According to D. Waterlow, in the UK, the cost of caring for patients with bedsores is estimated at 200 million pounds and increases by 11% annually as a result of treatment costs and an increase in the duration of hospitalization.
In addition to the economic (direct medical and non-medical) costs associated with the treatment of bedsores, non-material costs must also be taken into account: severe physical and moral suffering experienced by the patient.
Inadequate anti-decubitus measures lead to a significant increase in direct medical costs associated with the subsequent treatment of pressure ulcers and their infection. The duration of the patient's hospitalization is increasing, there is a need for adequate dressings (hydrocalloids, hydrogels, etc.) and medicinal (enzymes, anti-inflammatory, regeneration-improving agents) agents, tools, and equipment. In some cases, surgical treatment of bedsores III-IV stages is required.
All other costs associated with the treatment of bedsores also increase.
Adequate prevention of bedsores can prevent their development in patients at risk in more than 80% of cases.
Thus, adequate prevention of bedsores will not only reduce the financial costs of treating pressure ulcers, but also improve the patient's quality of life.

5 General issues

Pathogenesis

Pressure at bony prominences, friction, and shearing (shearing) forces lead to pressure sores. Prolonged (more than 1-2 hours) action of pressure leads to vascular obstruction, compression of nerves and soft tissues. In the tissues above the bone protrusions, microcirculation and trophism are disturbed, hypoxia develops, followed by the development of bedsores.
Friction damage to soft tissues occurs when the patient is moved, when the skin is in close contact with a rough surface. Friction causes injury to both the skin and deeper soft tissues.
Shear injury occurs when the skin is immobile, and there is a displacement of tissues lying deeper. This leads to impaired microcirculation, ischemia and skin damage, most often in the presence of additional risk factors for pressure ulcers (see appendices).

Risk factors

Risk factors for developing pressure ulcers can be reversible (eg, dehydration, hypotension) or irreversible (eg, age), intrinsic or extrinsic.
Internal risk factors

External risk factors

Locations of bedsores

Depending on the position of the patient (on the back, on the side, sitting in a chair), the pressure points change. The drawings (see item 03) show the most and least vulnerable areas of the patient's skin.
Most often in the area: auricle, thoracic spine (the most protruding section), sacrum, greater trochanter of the femur, protrusion of the fibula, ischial tuberosity, elbow, heels.
Less common in the region: occiput, mastoid process, acromial 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 bedsores:
Stage 1: persistent hyperemia of the skin, which does not disappear after the cessation of pressure; 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) with spread to the subcutaneous tissue.
Stage 3: destruction (necrosis) of the skin up to the muscle layer with penetration into the muscle; there may be fluid 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.
A pressure sore infection is diagnosed by a doctor. The diagnosis is made on the basis of examination data. The following criteria are used for this:
1) purulent discharge;


Bacteriological confirmation of the existing complication of "decubitus infection" should be carried out in all patients suffering from agranulocytosis, even in the absence of external signs of inflammation (pain, swelling of the wound edges, purulent discharge).
Bedsore infections that develop in a hospital are recorded as nosocomial infections.
In the case of a patient staying in a nursing home, when patients are served by nursing personnel of the mercy services, data on the location, size, stage of pressure ulcers are recorded only in the nursing observation card for patients with pressure ulcers ”(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-decubitus measures should be performed by nursing staff after special training.

Preventive measures should be aimed at:
- reduction of pressure on bone tissue;
- prevention of friction and shearing of tissues during the movement of the patient or in case of improper placement (“sliding” from pillows, “sitting” position in bed or on a chair);
- observation of the skin over bony prominences;
- keeping the skin clean and its moderate moisture (not too dry and not too wet);
- providing the patient with adequate food and drink;
- training the patient in self-help techniques for moving;
- education of relatives.
General approaches to preventing pressure ulcers are as follows:
- timely diagnosis the risk of developing bedsores,
- timely start of the implementation of the entire complex of preventive measures,
- adequate technique for performing simple medical services, including care.

6 Specification of requirements

6.1 Patient model

6.1.1 Criteria and features that define the patient model

The industry standard may include patients with 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 inability of the patient to independently move along the plane and change the position of the body in space without special equipment or assistance.

6.1.2 Propagation of protocol requirements

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

6.1.3 Medical care condition

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

The functional purpose of medical services is prevention.

6.1.4 Characteristics of the algorithms and features of the provision 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 medicines

Medical 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. Placement of the patient on a functional bed (in a hospital setting). There should be handrails on both sides and a device to raise the head of the bed. The patient should not be placed on a bed with armored mesh or with old spring mattresses. The height of the bed should be at the mid-thigh level of the caregiver.
2. The patient being transferred or moving into a chair should be on a bed with a variable height, allowing him to independently, with the help of other improvised means, move out of bed.
3. The choice of anti-decubitus mattress depends on the degree of risk of developing pressure ulcers and the patient's body weight. At low risk, a 10 cm thick foam mattress may be sufficient. high degree risk, as well as with existing bedsores different stages need other mattresses. When placing the patient in a chair (wheelchair), foam rubber pillows, 10 cm thick, are placed under the buttocks and behind the back. Foam rubber pads, at least 3 cm thick, are placed under the feet (convincing evidence B).
4. Bed linen - cotton. The blanket is light.
5. Under the vulnerable areas, it is necessary to place rollers and foam rubber pillows.
6. Change body position every 2 hours, including at night, according to the schedule: Fowler's low position, "on the side" position, Sims' position, "on the stomach" position (as agreed with the doctor). Fowler's position should coincide with the meal time. At each movement - inspect areas of risk. The results of the examination - write down in the registration sheet of anti-decubitus measures (convincing evidence B).
7. Move the patient carefully, eliminating friction and tissue shift, lifting him above the bed, or using a bed sheet.
8. Do not allow the patient to lie directly on big skewer hips.
9. Do not expose risk areas to friction. Massage of the whole body, including near risk areas (within a radius of at least 5 cm from the bony prominence), should be performed after abundant application of a nourishing (moisturizing) cream to the skin (strong evidence B).
10. Wash the skin without friction and bar soap, use liquid soap. Dry the skin thoroughly after washing with blotting motions (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 the fulcrum. Encourage him to change position: turn around using the bed rails, pull himself up.
13. Teach relatives and other caregivers to reduce the risk of pressure tissue damage:
Regularly change the position of the body;
use devices that reduce pressure (pillows, foam rubber, gaskets);
observe the rules of lifting and moving: exclude friction and shear of tissues;
Examine the entire skin at least 1 time per day, and risk areas - with each movement;
carry out proper nutrition and adequate fluid intake;
Properly carry out hygiene procedures: eliminate friction.
14. Avoid excessive moisturizing or dryness of the skin: in case of excessive moisture, dry using powders without talc, in case of dryness, moisten with cream (strength of evidence C).
15. Constantly maintain a comfortable bed condition: shake off crumbs, straighten wrinkles.
16. Educate the patient breathing exercises and encourage him to do them every 2 hours.

Recommended care plans for the risk of developing bedsores in a 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 Requirements for dietary prescriptions 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 prerequisite for medical intervention is the informed voluntary consent of a 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 (Bulletin of the SND and the Armed Forces of the Russian Federation of August 19, 1993, No. 33, Art. 1318).
In cases where the condition of a citizen 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 convene a council, the directly attending (duty) doctor with subsequent notification officials medical institution.
The plan for the implementation of anti-decubitus measures is discussed and agreed with the patient in writing and, if necessary, with his relatives.

The patient should be informed about:

risk factors for the development of bedsores;
- the purpose of all preventive measures;
- the need to complete 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 quality of life.

The patient must be educated:

The technique of changing the position of the body on a plane using aids(handrails of the bed, armrests of the chair, devices for lifting the patient);
- breathing exercises.

Additional Information for relatives:

Places of formation of bedsores;
- moving technique;
- features of accommodation in various provisions;
- dietary and drinking regimen;
- technique of hygienic procedures;
- observation and maintenance of moderate skin moisture;
- stimulating the patient to move independently every 2 hours;
- stimulating the patient to perform breathing exercises.
Note: The training of the patient and / or his relatives must be accompanied by a demonstration and comments on the drawings from paragraph 10 of OST 91500.11.0001-2002.
Data 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

Reminder for the patient

Prevention - the best treatment. To help us prevent you from getting pressure sores, you should:
Eat a sufficient (at least 1.5 l.) amount of liquid (the amount of liquid should be checked with a doctor) and at least 120 g of protein; 120 g of protein you need to "dial" from different foods you love, both animal and plant origin. For example, 10 g of protein is found in:

Protein is also found in plant foods. So, 100 g of the product contains a different amount of protein:

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

Reminder for relatives

At each movement, any deterioration or change in condition, regularly examine the skin in the region of the sacrum, heels, ankles, shoulder blades, elbows, occiput, greater trochanter of the femur, inner surface knee joints.
Do not expose vulnerable areas of the body to friction. Wash affected areas at least once a day if necessary. usual rules personal hygiene, as well as urinary incontinence, heavy sweating. Use mild and liquid soap. Make sure that detergent washed off, dry the area of ​​skin. If the skin is too dry, use a moisturizer. Wash your skin with warm water.
Use barrier creams if indicated.
Do not massage in the area of ​​protruding 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 permission of the doctor). The types of provisions depend on the disease and the condition of the particular patient. Discuss this with your doctor.
Change the position of the patient 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 a case (instead of cotton-gauze and rubber circles) to reduce pressure on the skin.
Release pressure on areas of broken skin. Use the appropriate tools.
Lower the head of the bed to the most low level(angle not more than 30 gr.). Raise the headboard a short time to perform any manipulation.
Do not allow the patient to lie directly on the greater trochanter in the lateral position.
Avoid continuous sitting in a chair or wheelchair. Remind you to change position every hour, independently change the position of the body, pull yourself up, examine vulnerable areas of the skin. Advise him to relieve pressure on the buttocks every 15 minutes: lean forward, to the side, rise, leaning on the arms of the chair.
Reduce the risk of tissue damage from pressure:
Regularly change the position of the body;
use devices that reduce body pressure;
Observe the rules for lifting and moving;
Examine the skin at least 1 time per day;
Eat proper nutrition and adequate fluid intake.
Monitor the quality and quantity of food and fluids, including for urinary incontinence.
Maximize the activity of your ward. 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 during protocol execution and termination of protocol requirements

The requirements of the protocol cease to apply in the absence of the risk of developing pressure ulcers on 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 presentation of the protocol

8 Monitoring

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

In the department of neurology of the regional (city) hospital

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

1. Total number of stroke patients admitted to the department during the year ________________.
2. The number of patients at risk of developing pressure ulcers on the D. Waterlow scale 10 or more points ________________.
3. Number of patients who developed bedsores ________________.

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

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

The assessment is carried out on the following positions:

1. The total number of patients who were 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. 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 assessment and documentation side effects and development of complications

A pressure sore infection is diagnosed by a doctor. The diagnosis is made on the basis of examination data. The following criteria are used for this:
1) purulent discharge;
2) pain, swelling of the edges of the wound.
The diagnosis is confirmed bacteriologically when the microorganism is isolated from cultures of fluid samples obtained by smear or puncture from the edges of the wound.
Bacteriological confirmation of the existing complication of "bedsore infection" should be carried out in all patients suffering from agranulocytosis, even in the absence of external signs of inflammation (pain, swelling of the wound edges, purulent discharge).
Bedsore infections that develop in a hospital are recorded as nosocomial infections.

8.4 How to exclude a patient from monitoring

There is no procedure for exclusion of a patient from monitoring.

8.5 Interim assessment and amendments to this standard

Assessment of the implementation of OST 91500.11.0001-2002 is carried out 2 times a year based on the results of the analysis of information obtained during monitoring.
Amendments to OST 91500.11.0001-2002 are carried out in case of receipt of information:
a) the presence in this industry standard of requirements that cause damage patient health,
b) upon receipt of convincing evidence of the need for changes mandatory requirements 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 the prescribed manner.

8.6 Parameters for assessing the quality of life during the implementation of the protocol

The parameters for assessing the quality of life when fulfilling OST 91500.11.0001-2002 are not provided.

8.7 Estimating the cost of the protocol and the cost 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, annual comparison of statistical data on the frequency of pressure sores development indicators is carried out.

8.9 How to generate a report

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

Application 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/y
Account form No. 003-2/u

"Nursing care card for patients with bedsores"

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

I. Patient Consent to the Proposed Plan of Care

Patient_______________________________________________________
(FULL NAME)
Received clarification about the plan of care for the prevention of pressure ulcers; received information about: risk factors for pressure ulcers,
for preventive measures,
consequences of non-compliance with the entire prevention program.
The patient was 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 about the need to comply with the entire prevention program, regularly change position in bed, and perform breathing exercises.
The patient is informed that non-compliance with the recommendations of the nurse and doctor may be complicated by the development of bedsores.
The patient is notified of the outcome in case of refusal to complete the care plan.
The patient had the opportunity to ask any questions of interest to him regarding the care plan and received answers to them.

Interviewed by nurse _________________ (nurse's signature)

"____" _______________ 20__

The patient agreed with the proposed plan of care, in which he signed with his own hand _________________________ (signature of the patient)
or signed for it (according to paragraph 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 testify
___________________ (signature of the nurse)
___________________ (witness's signature)
The patient did not agree (refused) with the plan of the proposed care, which he signed with his own hand _____________________________ (signature of the patient)
or signed for it (according to paragraph 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. Sheet nursing assessment risk of development and stage of bedsores

Instructions: circle the number corresponding to the points on 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 ____________________________________________
(physician's signature)

III. Registration sheet for anti-decubitus measures

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

FULL NAME. nurses involved in patient care:
Signature:

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