An example of an observation sheet for patients with bedsores. Nursing assessment sheet for the development and stage of pressure ulcers

No chronic diseases Physiological data 1. Condition of the skin and subcutaneous fat Skin color pallor Rashes No Severity of the subcutaneous fat layer BMI assessment overweight body Edema No localization 2. Respiration and circulation Frequency breathing movements 18 min. Cough: No Sputum: No Character of sputum if present: Addition: Characteristics of pulse: frequent, rhythmic, intense Blood pressure in peripheral arteries: 170/100 left hand 170/100 right hand 173/100 Addition 3. Digestion Appetite: reduced Swallowing: normal Flatulence (bloating): No Compliance with the prescribed diet No Addendum: 4.

IV. Recommended care plan for those at risk of developing pressure ulcers (in a bedridden patient)

in a sitting position – ischial tuberosities, shoulder blades, feet.

Risk factors development of bedsores

diseases with impaired tissue trophism, decreased sensitivity (diabetes mellitus, cardiovascular diseases);
neurological disorders (pain, paresis, paralysis);
elderly or senile age;
exhaustion or obesity;
urinary and/or fecal incontinence;
dehydration, malnutrition;
insufficient care: dry, damp, dirty skin, untidy bed and linen;
improper movement of the patient, pushing a bedpan under him, pulling out the sheet, applying plasters;
alcoholism, smoking;
taking medications (sedatives, steroids)

To identify a patient's risk of developing bedsores, the nurse uses specially designed tables using the Norton, Waterlow scale (see.

Nursing observation chart for patients with pressure ulcers. registration form No. 003-2/у

Change the patient’s position every 2 hours:¦Daily¦¦¦8 – 10 hours – “sitting” position;¦12 times¦¦¦10 – 12 hours – position “on the left side”;¦¦¦¦¦¦12 – 14 hours – position “on the right side";¦¦ ¦14 - 16 o'clock - "sitting" position;¦¦ ¦16 - 18 o'clock - Sims position;¦¦ ¦18 - 20 o'clock - "sitting" position;¦¦ ¦20 - 22 o'clock - "position" on the right side";¦¦ ¦22 - 24 hours - position "on the left side";¦¦ ¦0 - 2 hours - Sims position;¦¦ ¦2 - 4 hours - position "on the right side";¦¦ ¦4 - 6 hours - position “on the left side”; ¦¦ ¦6 - 8 hours - Sims position. ¦¦ ¦If the patient can be moved (or move independently with the help of auxiliary means) and in a chair ( wheelchair), he can ¦¦ ¦be in a sitting position and in bed¦¦ + + + ¦3. Washing contaminated areas of skin¦Daily¦ ¦¦1 time¦ + + + ¦4.

Nursing interventions for pressure ulcers

Attention

FULL NAME. patient 2. Department 3. Ward 4. Clinical diagnosis 5. Start of implementation of the care plan: date hour. min. 6. Completion of implementation of the care plan: date hour.
min. I. Patient’s consent to the proposed care plan The patient (full name) received an explanation regarding the care plan for the prevention of pressure ulcers; received information: about risk factors for the development of bedsores, the goals of preventive measures, the 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.

Nursing care for bedsores of varying severity

Provide high-quality hygienic care for the patient’s body: o at least three times a day (more often if necessary) wash or wipe the skin with warm water using soap and a terry towel; o use 10% camphor alcohol, antiseptics; o wash the patient after each urination and defecation; o for urinary incontinence, use diapers (change every 4 hours), for men - external urinals. 5. Monitor the condition of the bed and underwear: o exclude an uneven mattress or backboard; o do not use underwear with rough seams, buttons, fasteners, patches; o regularly straighten wrinkles on underwear and bed linen; o shake off crumbs after feeding the patient; o change soiled linen as it gets dirty.
6.

Nursing observation card for patient No. 1

In a supine position, it can occur on the shoulder blades, back of the head or heels. In a sitting position, it appears on the shoulder blades, feet and seat.
There are 4 main stages in the formation of bedsores:

At the first stage, the skin is not damaged. Redness appears, the affected area itself is hot.
In the second stage, you can notice the formation of small wounds and dead tissue of a yellowish tint.
The third stage is characterized by the loss of individual areas of skin, deep hematomas and damaged tissue around them are formed, muscles are difficult to palpate.
The fourth stage - the damage reaches the bones, the muscles are exposed. The depth of the lesion depends on the location and thickness of the skin.

The formation of bedsores can be caused by a disability in which a person cannot move. At stages 1 and 2, healing occurs from a week to several months.

Features of nursing care for seriously ill and immobile patients

Bed linen and clothing should be made from natural, breathable materials and should not contain hard seams, buttons or fasteners.
Adjust the sheets under the patient, try to avoid wrinkles or wrinkles in the bed, and clean up crumbs after eating.
Clothing should be appropriate for the room temperature to avoid excessive sweating.
Carry out hygiene procedures as often as possible.

Training relatives in self-care¦ ¦(specify the result)¦ + + ¦6. Amount of food eaten as a percentage:¦ ¦breakfast lunch afternoon dinner¦ + + ¦7.
Amount of protein in grams:¦ + +¦8. Liquids obtained:¦ ¦9 - 13 ppm13 - 18 ppm18 - 22 ppm¦ + + ¦9. Foam rubber pads are used under:¦ ¦(list)¦ + + ¦10. A massage was carried out around the areas once¦ + + ¦11. To maintain moderate humidity, the following were used:¦ ¦¦ + + ¦12. Remarks and comments:¦ ¦¦ Full name nurses involved in monitoring the patient: Signature: IV.

Recommended care plan for the risk of developing bedsores (in a bedridden patient) ¦Nursing interventions¦Multiplicity¦ + + + ¦1. Conducting a current assessment of the risk of developing¦Daily¦ ¦bedsores at least 1 time a day (in the morning) on a scale¦1 time¦ ¦Waterlow¦¦ + + + ¦2.

Nursing interventions at risk of developing pressure ulcers

Appendix No. 2 Approved by Order of the Ministry of Health Russian Federation dated April 17, 2002 N 123 Medical documentation Insert for the medical record of an inpatient patient N 003/uRegistration form N 003-2/u CARD OF NURSING OBSERVATION FOR PATIENTS WITH BEDSORES 1.

FULL NAME. patient 2. Department 3. Ward 4. Clinical diagnosis 5. Start of care plan: date hour. min. 6. Completion of implementation of the care plan: date hour.
min. I. Patient’s consent to the proposed care plan The patient (full name) received an explanation regarding the care plan for the prevention of pressure ulcers; received information: about risk factors for the development of bedsores, the goals of preventive measures, the 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.

Recommended care plan for bedridden patients at risk of developing pressure ulcers

Check the condition of your skin by examining it daily. For dryness, use moisturizing nourishing creams, especially in areas of possible future bedsores. Where the skin is especially sweaty, use drying powders.
Use protective creams. Do not massage in the area of protruding bone areas, as this may damage the integrity of the skin. 4. Keep your skin clean. Wash or dry your skin with warm water at least twice a day (more often if necessary). boiled water, especially carefully - places of possible formation of bedsores, using mild or liquid soap, 10% solution camphor alcohol, salicylic alcohol solution.

Info

At home, use a solution of vodka or a solution triple cologne, diluted with table vinegar. For urinary incontinence, you can use diapers for adult patients, changing them in a timely manner (at least every 4 hours).

Men can use external urinals. In case of fecal incontinence, wash patients in parallel with changing linen. Protect the patient's skin from abrasions, scratching, and irritating patches.

5. Monitor the condition of the patients’ bed linen and dowels (this can be done when the patient’s position changes): a) change wet, contaminated linen in a timely manner; b) do not use underwear that has rough seams, fasteners, or buttons on the side facing the patient; c) regularly straighten wrinkles in your linen; d) brush crumbs off the bed after every meal. 6.

Nursing process map for pressure ulcers sample filling

Bedsores”, approved by Order of the Ministry of Health of Russia dated April 17, 2002 N 123) (signature, full name), as certified by those present during the conversation (nurse signature) (witness signature) The patient did not agree (refuse) with the proposed care plan, in what he signed with his own hand (the patient’s signature) or signed for him (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.

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

Protocol No. 123 of the Ministry of Health aims to promote Newest technologies preventive measures and treatment of necrosis in people with a variety of diseases that lead to forced long-term stay in a motionless position.

Tasks of development and implementation of protocol No. 123

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

Introduction of innovative technologies for assessing the risk level of pressure ulcers, creation preventative plan, reducing the number of cases of bedsores and prevention infectious inflammation bedsores.

Early treatment of necrosis, based on the stage of its occurrence.

Improving the quality and reducing the cost of patient therapy, thanks to the introduction of resource-saving technologies.

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, according to estimates social workers, bedsores develop in approximately 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 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 the growth 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 there is also a need to resort to surgical intervention when late stages 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 when there is prolonged pressure or friction of the 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 soft fabrics under it are subject to movement. In this situation, there is a disruption in the blood supply to this area, and the skin is damaged.

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

Cachexia;
Anemia;
Lack of protein and vitamin C in food;
Dehydration;
Reduced blood pressure;
Enuresis/encopresis;
Pathologies of the nervous system;
Ischemia;
Thin skin;
Anxiety;
Confusion;
Coma;
Violation of hygiene rules;
Folded bed linen or patient's clothing;
Parts of a hospital bed;
Items for restraining the patient;
Injuries to the axial areas of the skeleton or internal organs;
Spinal cord injuries;
Use of cytostatics;
Violation of the rules for shifting the patient.
Old age;
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 pressure ulcers in those patients who are forced to stay long time in a fixed position.

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:

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

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:

Abundant blood supply to the skin, but its integrity is not compromised.
Peeling of the top layer of skin, the beginning of the necrotic process of the dermis and subcutaneous tissue.
Purulent discharge from the ulcer, necrotic changes cover the muscle tissue.
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 the person’s pain sensations are also taken into account.

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:

Reduced compression of bony protrusions;
Avoid friction and movement of tissues when moving the patient or when the position is incorrectly chosen for him;
Regular examination of the patient’s skin in a high-risk area;
Maintaining patient hygiene;
Properly selected diet;
Teaching the patient how to help himself when moving;
Training of relatives.

According to the protocol of the Order on pressure ulcers 123, preventive measures are necessary for seriously ill bedridden people who have 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

The patient is provided with a special bed, which must 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 nurse's mid-thigh.
This bed must have the ability to change height so that the patient can leave it independently.
It is necessary to choose the right mattress against bedsores. Place special foam rollers under your feet.
Bed linen must be cotton.
It is necessary to change the patient's position every two hours, including at night. After changing position, inspect the skin.
The patient should be moved carefully, lifting him above the bed.
Massage should be done only after applying a special moisturizer.
Wash the patient using liquid soap and dry the skin with blotting movements.
Use waterproof diapers and sheets.
Encourage the patient to move independently and teach this.
Provide training to loved ones.
Avoid overdrying or overmoistening the skin.
Monitor the patient’s bed, remove crumbs and folds.
Teach the patient to perform respiratory exercises and support him in this.

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 performing medical intervention, you need to take from the patient voluntary consent, in accordance with Article 32 “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 complete information about the goals of their prevention and all possible complications and risks.

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"

Page: 3 of 4

Interview conducted by 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 N 123)

___________________ (signature, full name),

what those present at the conversation attest to

The patient did not agree (refuse) with the proposed care plan, which he signed with his own hand _____________ (patient signature)

_________________ (signature, full name).

II. Sheet nursing assessment risk of development

and stages of bedsores

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)

III. Anti-decubitus measures registration sheet

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

End of care plan implementation: date ____ hour. ____ min. ___

FULL NAME. nurses involved in monitoring the patient:

bedsores (in a lying patient)

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

bedsores (in a patient who can sit)

BIBLIOGRAPHY TO OST 91500.11.0001-2002

Excerpts from the Industry Standard "Protocol for the management of patients. Pressure ulcers"

“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)

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 “Card nursing supervision 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. Vyalkov.

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

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

4. Clinical epidemiology, medical and social significance

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 (hydrocolloids, hydrogels, etc.) and medications (enzymes, anti-inflammatory drugs, agents that improve regeneration) products, instruments, and equipment. In some cases, surgical treatment of stage III-IV bedsores is required.

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.

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, prominence of the fibula, ischial tuberosity, elbow, heels.

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

1) 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

Preventive measures should be aimed at:

- observation of the skin over bony protrusions;

— teaching the patient self-help techniques for moving;

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, incl. care

Features of patient care

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 a low degree of risk, a foam mattress 10 cm thick may be sufficient. For a higher degree of risk, as well as for existing bedsores of different stages, other mattresses are needed. 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, incl. 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 are recorded in the registration sheet for anti-decubitus measures (convincing evidence B).

8. Do not allow the patient to lie directly on the greater trochanter in the lateral position.

9. 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 (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).

- inspect all skin at least once a day, and risk areas - with each movement;

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 the 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 N 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). The daily diet should be high enough in calories to maintain the patient’s ideal body weight.

The patient must have information about:

— the consequences of non-compliance with the entire prevention program, incl. decrease in quality of life.

The patient must be taught:

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

Additional information for relatives:

— features of placement in various positions;

- dietary and drinking regime;

— encouraging the patient to move independently every 2 hours;

- encouraging the patient to perform breathing exercises.

6.1.10 Additional information for patients and family members

Prevention is the best cure. To help us prevent you from developing bedsores, you should:

- consume a sufficient amount of liquid (at least 1.5 liters) in your food (the volume of liquid should be checked with your doctor) and at least 120 g of protein; 120 g of protein needs to be “gained” from various foods you love, both animal and plant origin.

- consume at least 500-1000 mg of ascorbic acid (vitamin C) per day;

- move around in bed, incl. 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;

- go 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, and the inner surface of the 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 lowest level (angle no more than 30 degrees). Raise the head of the head for 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;

— follow the rules for lifting and moving;

- 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.

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Industry standard OST 91500.11.0001-2002 "Protocol for the management of patients. Pressure ulcers" - Nursing observation card for patients with pressure ulcers

MINISTRY OF HEALTH OF THE RUSSIAN FEDERATION

ABOUT APPROVAL OF THE INDUSTRY STANDARD

"PROTOCOL FOR 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 the management of patients. Pressure sores" (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).

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

to the Order of the Russian Ministry of Health

SYSTEM OF STANDARDIZATION IN HEALTHCARE

PATIENT MANAGEMENT PROTOCOL. Bedsores (L.89)

Industry standard OST 91500.11.0001-2002 “Protocol for the management of patients. Pressure sores” was developed under the leadership of the First Deputy Minister of Health of the Russian Federation A.I. Vyalkova Moscow medical academy them. THEM. Sechenov Ministry of Health of the Russian Federation (P.A. Vorobyov, Z.V. Mukhina), Medical College No. 1 of the Moscow Health Committee (I.I. Tarnovskaya), Central Research Institute of Epidemiology of the Ministry of Health of the Russian Federation (N.A. Semina), Russian Academy of Postgraduate Education (E.P. Selkova), Institute of Surgery named after. A.V. Vishnevsky Russian Academy of Medical Sciences (A.M. Svetukhin, V.A. Mitish).

1 AREA OF USE

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 infection.

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 in the general structure nosocomial infections amounted to 7.5%.

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.

The duration of the patient's hospitalization increases, and there is a need for adequate dressings (hydrocolloids, hydrogels, etc.) and medications (enzymes, anti-inflammatory drugs, 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 makes it possible to prevent their development in patients at risk in more than 80% of cases.

5. GENERAL QUESTIONS

Pressure at bony prominences, friction, and shearing (shearing) forces lead to pressure ulcers. Prolonged (more than 1 - 2 hours) pressure action 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.

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

Industry standard "Protocol for patient management. Pressure ulcers"

“Patient management protocol. Bedsores" (OST 91500.11.0001-2002)

1 area of use

2. Purpose of development and implementation

3. Development and implementation tasks

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. Clinical epidemiology

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.

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.

5. General questions

Pressure at bony prominences, friction, and shearing (shearing) forces lead to pressure ulcers. Prolonged (more than 1-2 hours) pressure action 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.

Internal risk factors

- insufficient intake of protein, ascorbic acid

- urinary and/or fecal incontinence

– neurological disorders (sensory, motor)

- peripheral circulatory disorders

External risk factors

- poor hygiene care

- folds on bed and/or underwear

— means of fixing the patient

- injuries to the spine, pelvic bones, organs abdominal cavity

- damage spinal cord

- use of cytostatic drugs

- incorrect technique for moving the patient in bed

- extensive surgery lasting more than 2 hours.

Waterlow scale for assessing the risk of developing pressure ulcers

Skin nutritional disorders, such as terminal cachexia

control/via catheter

Chained to a chair

Not by mouth/ anorexia

Orthopedic - below the belt,

High doses of steroids

More than 2 hours on the table

The Waterlow scale scores are summed up and the risk level is determined using the following totals:

- no risk - 1-9 points,

— there is a risk — 10 points,

— high risk — 15 points,

- very high risk - 20 points.

In immobile patients, the risk of developing pressure ulcers should be assessed daily, even if during the initial examination the risk level was assessed at 1-9 points.

The results of the assessment are recorded in the nursing observation chart for the patient (see the appendix to the industry standard). Anti-decubitus measures begin immediately in accordance with the recommended plan.

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 area: auricle, thoracic spine (the most protruding part), sacrum, greater trochanter of the femur, prominence 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

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

Diagnosis of pressure ulcer infection is made by a doctor. The diagnosis is made based on examination data. The following criteria are used:

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 a hospital are recorded as nosocomial infections (Appendix 7).

In the case of a patient staying in a nursing home, when patients are served 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 the appendix to the industry standard).

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:

- reduction of 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);

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

— providing the patient with adequate food and drink;

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;

6. Characteristics of requirements

6.1. Patient model

01 Clinical situation

Patients with complete immobility with a Waterlow scale score of 10 or more

02 Group of diseases

Diseases of inflammatory, degenerative or toxic origin caused by severe damage to the central nervous system

03 Profile of the unit, institution

traumatology, neurology, neurosurgery, oncology, resuscitation, intensive care

04 Functional purpose of the department, institution

6.1.1. Criteria and signs 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. Medical care regulated by this industry standard is performed in a hospital setting. The functional purpose of medical care is prevention.

6.1.4. Medical assistance not related to patient care is not provided.

6.1.5. Drug therapy is not provided.

6.1.7. Requirements for patient care and ancillary procedures

Training loved ones to care for seriously ill patients

Skin care for a seriously ill patient

Caring for hair, nails, shaving a seriously ill patient

1 time every 10 days

Aid for defecation of seriously ill patients

Urination aid for a seriously ill patient

Moving a seriously ill patient in bed

Every day every 2 hours

Placing a seriously ill patient in bed

Preparing and changing bed linen for a seriously ill patient

Daily as needed

Benefit for changing linen and clothes for a seriously ill patient

Care of the perineum and external genitalia of seriously ill patients

Assessing the risk of developing pressure ulcers

Daily 3 times a day

Transportation of a seriously ill patient within an institution

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.

3. The choice of an anti-bedsore mattress depends on the degree of risk of developing bedsores and the patient’s body weight. For a low degree of risk, a foam mattress 10 cm thick may be sufficient. For a higher degree of risk, as well as for existing bedsores of different stages, other mattresses are needed. When placing the patient in a chair (chair - gurney), foam rubber pillows 10 cm thick are placed under the buttocks and behind the back.

Foam pads with a thickness of at least 3 cm are placed under the feet (convincing evidence B).

7. Move the patient carefully, avoiding friction and tissue displacement, lifting him above the bed, or using a back sheet.

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, gaskets);

— follow the rules of lifting and moving: avoid friction and tissue shift;

- examine all skin at least once a day, and risk areas

- with each movement;

- maintain proper nutrition and adequate fluid intake;

— correctly carry out hygiene procedures: eliminate friction.

14. Do not allow the skin to become overly moisturized or dry: if it is overly moisturized, dry it using powders without talc; if it is dry, moisturize with cream (convincing evidence C).

Recommended plans of care for bedridden and non-sitting patients at risk of developing pressure ulcers are provided in the appendix to the industry standard. Registration of anti-decubitus measures is carried out on a special form (see appendix to the industry standard).

6.1.8. The diet should contain at least 120 g of protein and 500-1000 mg of ascorbic acid per day (Strength of Evidence C). The daily diet should be high enough in calories to maintain the patient’s ideal body weight.

6.1.9. A necessary precondition for medical intervention is the informed voluntary consent of the citizen (32).

In cases where a citizen’s condition does not allow him to express his will, and medical intervention is urgent, the question of its implementation in the interests of the citizen is decided by a council, and if it is impossible to assemble a council, the attending (duty) doctor directly, with subsequent notification of officials of the Ministry of Defense.

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, incl. manipulations performed by the patient and/or his relatives;

The patient must be taught:

- 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;

- technique hygiene procedures;

- monitoring and maintaining moderate skin moisture;

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.

Data on informing the patient's consent are recorded on a special form (see the appendix to the industry standard).

6.1.10 Additional information for patients and family members

Memo for the patient

Prevention is the best cure.

To help us prevent you from developing bedsores, you should:

- consume a sufficient (at least 1.5 l) amount of liquid in food (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 various foods you love, both animal and plant origin.

“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

2. PURPOSE OF DEVELOPMENT AND IMPLEMENTATION

3. DEVELOPMENT AND IMPLEMENTATION TASKS

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.

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

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At the time of inclusion in the database, the document was not published

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 of pathologies associated with prolonged immobility.

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.

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.

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

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.

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.

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 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” 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 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, incl. care

Poor hygiene care

Folds in bedding and underwear

Bed rails

Patient restraints

Injuries of the spine, pelvic bones, abdominal organs

Use of cytostatics

Incorrect technique for moving the patient

The total number of stroke patients admitted to the department during the year is ___________.
The number of patients at risk of developing pressure ulcers according to the D. Waterlow scale is 10 or more points ___________.
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.

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

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

Change the patient's position every 2 hours:

8-10 hours - sitting position;
10-12 hours - position “on the left side”;
12-14 hours - position “on the right side”;
14-16 hours - sitting position;
16-18 hours - Sims position;
18-20 hours - sitting position;
0-2 hours - Sims position;
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 a 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 drafters 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 the capillaries is 30 mm. mercury column and, thus, it becomes clear that higher pressure from external factors leads to compression of the blood capillaries, which affects the insufficient supply of oxygen to the tissue.

FACTOR: EXPOSURE TIME

The longest exposure time 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. Increased risk the appearance of bedsores 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 local change the skin appears 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 on an individual basis, as well as immediately when 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 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:

Introduction of innovative technologies for assessing the risk level of pressure ulcers, creating a preventive plan, reducing the number of cases of pressure ulcers and preventing infectious inflammation of pressure ulcers.
Early treatment of necrosis, based on the stage of its occurrence.
Improving the quality and reducing the cost of patient therapy, thanks to the introduction of resource-saving technologies.
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

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.

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 in the final stages 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.

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.

Cachexia;
Anemia;
Lack of protein and vitamin C in food;
Dehydration;
Reduced blood pressure;
Enuresis/encopresis;
Pathologies of the nervous system;
Ischemia;
Thin skin;
Anxiety;
Confusion;
Coma;
Violation of hygiene rules;
Folded bed linen or patient's clothing;
Parts of a hospital bed;
Items for restraining the patient;
Injuries to the axial areas of the skeleton or internal organs;
Spinal cord injuries;
Use of cytostatics;
Violation of the rules for shifting the patient.
Old age;
Major surgery over two hours.

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:

Most often, necrotic changes occur near the ears, in the thoracic spine, sacrum, on the proximal thigh, in the area of the fibula, on the buttocks, in the elbow joint, and near the heel tuberosities.
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:

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

Protocol No. 123 proposes to consider infectious diseases that are consequences of the development of necrosis 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:

Reduced compression of bony protrusions;

Avoid friction and movement of tissues when moving the patient or when the position is incorrectly chosen for him;

Regular examination of the patient’s skin in a high-risk area;

Maintaining patient hygiene;

Properly selected diet;

Teaching the patient how to help himself when moving;

Training of relatives.

Patient model

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

The patient is provided with a special bed, which must 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 nurse's mid-thigh.

This bed must have the ability to change height so that the patient can leave it independently.

It is necessary to choose the right mattress against bedsores. Place special foam rollers under your feet.

Bed linen must be cotton.

It is necessary to change the patient's position every two hours, including at night. After changing position, inspect the skin.

The patient should be moved carefully, lifting him above the bed.

Massage should be done only after applying a special moisturizer.

Wash the patient using liquid soap and dry the skin with blotting movements.

Use waterproof diapers and sheets.

Encourage the patient to move independently and teach this.

Provide training to loved ones.

Avoid overdrying or overmoistening the skin.

Monitor the patient’s bed, remove crumbs and folds.

Teach the patient to perform respiratory exercises and support him in this.

Diet according to standard order

Informed voluntary consent protocol form

The bedsore standard requires treatment only at the will of the person. Before performing medical intervention, it is necessary to obtain 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.”

Abdominal hernias.

An abdominal hernia is an exit from the abdominal cavity of internal organs along with the peritoneum covering them through natural or acquired defects of the abdominal wall under the skin or into other cavities. There are external and internal, congenital and acquired, reducible and irreducible abdominal hernias. Classification: umbilical hernias, hernias of the white line of the abdomen, inguinal hernias, femoral hernias, diaphragmatic hernia, postoperative hernia (strangulation).

Strangulated hernia. Incarceration is compression of the contents of the hernia in the area of the hernial orifice. As a result of strangulation in the hernial contents, blood supply and innervation are stopped, blood stagnation and tissue necrosis develop. Symptoms: sudden pain in the hernia area, its enlargement, irreducibility, sharp tension and pain in the hernial protrusion. After some time, cramping pain in the abdomen, vomiting, retention of stool and gas. Tactics: For a strangulated hernia, thermal procedures, anesthesia, antispasmodics, and attempts at manual reduction are contraindicated. Emergency hospitalization to the surgical department on a stretcher in a position comfortable for the patient is indicated. In case of spontaneous reduction during transportation, emergency hospitalization for dynamic observation of the patient in the hospital is also indicated. Treatment: The main surgical method is herniotomy. Contraindications to surgical treatment are severe respiratory and cardiovascular failure, active tuberculosis, malignant tumors. For such patients, a bandage is recommended. Kinds surgical interventions: autohernioplasty (closure using the patient’s own tissues) and allohernioplasty (various synthetic grafts made of polypropylene).

Peritonitis.

Peritonitis is an inflammation of the peritoneum, accompanied by local and general symptoms diseases and minor disturbances in the activity of the most important organs and systems of the body. Types: primary, secondary, tertiary. Primary is an extremely rare form of peritonitis of hematogenous origin in which infection of the peritoneum occurs from an extraperitoneal source. Secondary is the most common form of abdominal infection and the main cause of abdominal sepsis in surgical patients. Tertiary - peritonitis without a source of infection, develops in patients in critical conditions with severe depletion of the body's defenses. By prevalence: local (less than two anatomical areas of the peritoneal cavity are affected), widespread (diffuse - the process covers from two to five anatomical areas of the peritoneal cavity, diffuse - more than five anatomical areas are affected). According to the nature of the contents of the abdominal cavity: serous-fibrinous, fibrinous-purulent, purulent, fecal, bile, hemorrhagic, chemical. Depending on the course of the process: no signs of sepsis, sepsis, severe sepsis (multiple organ failure). Clinic: gradually increasing severe pain in the abdomen (localized in the area of the source of peritonitis, then spreading throughout the abdomen), intoxication, pale face, pointed features, sunken eyes. Nausea, vomiting of gastric contents, then intestinal contents. Retention of gases and stool, increased body temperature, muscle tension in the anterior abdominal wall. Treatment: after removing the patient from anesthesia, place him in the Fowler position, parenteral nutrition for 3-4 days, infusion therapy as prescribed by the doctor, respiratory and physiotherapy, daily dressings and rinsing of the abdominal cavity through drains. During the operation, a probe is inserted into the stomach and intestines, which is removed on days 4-6.

Acute intestinal obstruction.

Acute intestinal obstruction is a disease that is characterized by partial or complete disruption of the movement of contents through the intestines. Types: dynamic - develops as a result of a violation of the contractility of the intestine of paralytic or spastic origin and in most cases is functional in nature, mechanical - with organic blockage of the intestine. Dynamic obstruction is a disorder of intestinal motility of various origins due to damage to its neuromuscular elements. Dynamic obstruction: (Clinic - constant bursting pain in the abdomen of a generalized nature, retention of stool and gases, pronounced moderate bloating, regurgitation and vomiting appear at more late stages diseases resulting from stasis and hypertension in the proximal gastrointestinal tract. Treatment: decompression of the proximal gastrointestinal tract using gastric or intestinal tubes, the use of pharmacological stimulants of intestinal motility (cerucal, proserin, pituitrin), administration vent pipe or the importance of a siphon tube and hypertensive enemas, correction of water-electrolyte balance, elimination of hypovolemia, elimination of hypoxia, maintaining cardiovascular activity, relieving pain and intestinal spasm.) Mechanical obstruction: (clinic - severe abdominal pain of a cramping nature, vomiting, stool retention and gases, bloating. Treatment: surgical)

Acute pancreatitis.

Acute pancreatitis is a pathological process in which swelling, autolysis and necrosis of pancreatic tissue develop with secondary inflammation of pancreatic tissue. Classification: edematous form and pancreatic necrosis (hemorrhagic, fatty, purulent). Complications: septic shock, multiple organ failure, abscess and phlegmon of the pancreas, bleeding, diffuse peritonitis, pancreatic false cyst. Clinic: the onset of the disease is acute, severe cutting pain in the epigastrium and left hypochondrium of a girdling nature, repeated vomiting that does not bring relief, dyspeptic symptoms, increased body temperature. Treatment: conservative, rest (Fowler's position), cold is applied to the pancreatic region, parenteral nutrition, anesthesia, anti-enzyme drugs (Gordox, Contrical), plasma, albumin, detoxification and antibiotic therapy, immunotherapy and desensitizing therapy are carried out for 2-3 days, Highly effective in the first 3-5 days of the disease are hormonal pancreatic blockers sandastotin and octreotide, gastric secretion blockers (famotidine, ranitidine, omeprazole), surgical treatment (laparotomy, drainage of the omental bursa around the pancreas, cholecystostomy, resection of the tail and body of the pancreas.

Acute cholecystitis.

Acute cholecystitis is inflammation of the gallbladder. Classification: calculous (with stones in gallbladder) and non-calculous (without stones). According to the clinical and morphological form: catarrhal, phlegmonous, gangrenous. Complications: acute pancreatitis, obstructive jaundice, secondary hepatitis, cholangitis, infiltrate, abdominal abscess, peritonitis. Clinic: hepatic colic (severe bursting pain in the right hypochondrium, radiating to the right supraclavicular region, scapula, right shoulder), frequent vomiting with an admixture of bile, stool and gas retention, increased body temperature to 38-39. Treatment: conservative - bed rest, table No. 5, position in bed with the head end elevated, in the first days cold on the right hypochondrium, parenteral nutrition, in case of uncontrollable vomiting, rinse the stomach, antibiotic therapy, detoxification therapy and desensitizing therapy, painkillers and antispasmodics. Surgical treatment: cholecystectomy.

Acute appendicitis

Acute appendicitis - nonspecific inflammation vermiform appendix cecum. Classification: acute and chronic. Clinic: cutting or pressing pain in the epigastric region spreading throughout the abdomen, after a few hours in the right iliac region, pain usually radiates to the right leg, nausea, vomiting, stool and gas retention, increased body temperature, weakness, malaise, pulse increases, muscle tension in the anterior abdominal wall. Complications: appendicular infiltrate. Treatment: surgical only - appendectomy.

Ambulance:

Prevention and treatment of bedsores: (order 123)

· Placing air-inflated circles

· Regularly change body position in bed every 1.5-2 hours

· Massage in the area of pressure

· Elimination of wrinkles in underwear and bed linen

· Replacing wet clothes with dry ones

· Removal of foreign bodies and other bed irregularities

· Therapeutic exercises and active regimen of the patient

· Effective irritants: ethyl, camphor, salicylic alcohols

· Careful care of the skin and mucous membranes, washing and wiping with an antiseptic solution, and the skin with a warm soapy solution, providing the patient with clean underwear.

Caring for a patient with a plaster cast:

· If the bandage is too tight, the patient experiences pain in the limbs, cyanosis, increased swelling, and numbness of the fingers. In this case, it is necessary to cut the bandage and temporarily strengthen it with a bandage

Care must be taken to ensure that the bandage does not become contaminated during urination and defecation.

· Keep the limb elevated and move the fingers

· Ensure that the plaster is dry

· Do not allow the patient to remove plaster cast on one's own

· Make sure that no crumbs get under the plaster cast.

Preparing the patient for abdominal ultrasound:

· Explain the process and purpose of the upcoming study and obtain his consent

· Eliminate foods from the diet 2-3 days before the test. causing gas formation(legumes, black bread, cabbage, milk)

· Strictly on an empty stomach

· Do not smoke, do not drink alcohol

First aid for acute delay urine:

·Use of reflex methods

· Catheterization with a soft catheter in women; in men, this procedure is performed by a doctor or urological nurse