Nursing process map for pressure ulcers sample filling. Legislative framework of the Russian Federation Order 123 prevention of bedsores registration of medical history

INDUSTRY STANDARD

Standardization system in healthcare of the Russian Federation

Patient management protocol. Bedsores (L.89)

1 area of ​​use

1 area of ​​use

Industry standard requirements apply to implementation medical care all patients who have risk factors for developing pressure ulcers, according to the risk factors, and who are being treated in an inpatient setting.

2. Purpose of development and implementation

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

3. Development and implementation tasks

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

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, 163 cases of pressure ulcers (0.23%) were registered in 1994-1998. All of them were complicated by infection, which 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.

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

Inadequate anti-bedsore measures lead to a significant increase in direct medical costs associated with the subsequent treatment of resulting bedsores and their infection. The duration of the patient's hospitalization increases, and there is a need for adequate dressings (hydrocalloid, hydrogels, etc.) and medicinal (enzymes, anti-inflammatory, agents that improve regeneration) products, instruments, and equipment. In some cases it is required surgery bedsores of stages III-IV.

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

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

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

5. General questions

Pathogenesis

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

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

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

Risk factors

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

Internal risk factors

Reversible

Irreversible

Exhaustion

Senile age

Limited mobility

Anemia

Insufficient protein intake ascorbic acid

Dehydration

Hypotension

Urinary and/or fecal incontinence

Neurological disorders (sensory, motor)

Reversible

Irreversible

Peripheral circulation disorder

Thin skin

Anxiety

Confusion

External risk factors

Reversible

Irreversible

Poor hygiene care

Major surgery

Folds in bedding and/or underwear

lasting more than 2 hours

Bed rails

Patient restraints

Injuries of the spine, pelvic bones, abdominal organs

Spinal cord injuries

Use of cytostatic drugs

Incorrect technique for moving the patient in bed

Waterlow scale for assessing the risk of developing pressure ulcers

Body type:
body weight relative to height

Floor
Age, years

Special risk factors

Average

healthy

Skin nutritional disorders, such as terminal cachexia

Above average

Cigarette

Obesity

Below the average

Edema

Sticky (fever)

75-81
more than 81

Heart failure

Peripheral vascular diseases

Color change

Cracks, stains

Incontinence

Mobility

Neurological disorders

Full control/via catheter

for example, diabetes,

Restless, fussy

multiple sclerosis, stroke,

Feeding tube/liquids only

motor/sensory, paraplegia

Periodic

Apathetic

Not by mouth/anorexia

Through catheter/fecal incontinence

Limited mobility

Stool and urine

Inert

Chained to a chair

Major surgery/trauma

Orthopedic - below the belt, spine;

More than 2 hours on the table

Drug therapy

Cytostatic drugs

Prevention of bedsores

Bedsore– necrosis (necrosis of the skin) with the subcutaneous fat layer and other soft tissues, developing as a result prolonged compression and local circulatory disorders.

Factors in the development of bedsores

  • compression
  • friction
  • bias
  • immobility
  • fever
  • anemia
  • malnutrition
  • reduced body weight
  • spinal cord injury

Localization of bedsores: back of the head, shoulder blades, sacrum, elbows, heels.

Stages of bedsore formation

  1. paleness of the skin, which is replaced by hyperemia, cyanosis
  2. damage to the epidermis, manifests itself as a bubble against the background of erythema
  3. damage to the entire thickness of the skin
  4. destruction of the skin down to the bones

Prevention of bedsores

Bedsores are easier to prevent than to treat!

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

To prevent bedsores, the following requirements must be strictly observed:

1. To reduce the degree and duration of compression skin:

  • every 2 hours, change the patient’s position in bed, turn him over (Fowler’s, Sims’ position), while simultaneously wiping the skin with a 10% solution camphor alcohol;
  • to reduce pressure on the sacrum, the head end of the bed should be raised no more than 45 degrees;
  • when the patient is in bed, special circles are used, which are placed under the sacrum, heel tubercles, elbows, and back of the head to avoid contact of these protrusions with the supporting surface;
  • The most effective is the use of special anti-decubitus mattresses.

If a wheelchair is used, its seat must be wide enough to allow the patient to turn.

2. To reduce skin friction on the supporting surface:

  • the sheets must be stretched, dry, without wrinkles, scars, crumbs;
  • it is necessary to care for the skin of the perineum (keep it dry);
  • promptly identify and treat scratches and other damage to the skin.

3. Nutritious food with sufficient protein, vitamins and fluid content

  • Liquid – at least 1.5 liters (the volume of liquid should be checked with the doctor).
  • Proteins - at least 10 g (cottage cheese, meat, fish, buckwheat, semolina, rice, green peas).
  • Ascorbic acid (vitamin C) – at least 500-1000 mg per day.

Modern medications for the treatment of bedsores: Panthenol - aerosol, Solcoseryl - gel and ointment, Levosin, Deoxykol

Risk factors

  • Cachexia;
  • Anemia;
  • Dehydration;
  • Enuresis/encopresis;
  • Pathologies of the nervous system;
  • Ischemia;
  • Thin skin;
  • Anxiety;
  • Confusion;
  • Coma;
  • Violation of hygiene rules;
  • Parts of a hospital bed;
  • Spinal cord injuries;
  • Use of cytostatics;
  • Old age;

Areas of development of pressure ulcers

  • Maintaining patient hygiene;
  • Properly selected diet;
  • Training of relatives.

Patient model

Diet according to standard order

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 Ministry of Health No. 123 contains basic information about bedsores and necessary preventive measures.

Industry standard for pressure ulcers

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

The provisions of this medical protocol Ministry of Health No. 123 is applicable to provide medical care to patients at risk of developing bedsores that 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 therapy of necrosis in people with a variety of diseases that lead to a forced long 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:

  1. 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.
  2. Early treatment of necrosis, based on the stage of its occurrence.
  3. Improving the quality and reducing the cost of patient therapy, thanks to the introduction of resource-saving technologies.
  4. 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 hospital facility. Spending on special anti-bedsore medications, instruments, and equipment is increasing. Sometimes it also becomes necessary to resort to surgical intervention at 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.

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;
  • 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 for a long time stays sick.

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

  1. Most often, necrotic changes occur near the ears, in thoracic region spinal column, sacral region, on the proximal thigh, in the area of ​​the small tibia, on the buttocks, in elbow joint, near the heel tubercles.
  2. 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:

  1. Abundant blood supply to the skin, but its integrity is not compromised.
  2. Peeling of the top layer of 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 forms where areas of bone are visible.

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

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

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

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

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

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

  • 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

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

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

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

Diet according to standard order

The protocol also recommends preventing bedsores using 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. Meals must contain a sufficient amount of 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 full information about the goals of their prevention and all possible complications and risks.

Order 123 bedsores

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

Extract from the order

GENERAL APPROACHES TO PREVENTION

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

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

Preventive measures should be aimed at:

Reducing pressure on bone tissue;

Prevention of friction and tissue shear when moving the patient or when positioning him incorrectly (“sliding” 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

Order April 17, 2002 No. 123

Extract from the order

  • Bad 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

Order April 17, 2002 No. 123

Extract from the order

  • Exhaustion or overweight body
  • Limited mobility
  • Anemia
  • Insufficient intake of protein, vitamin C
  • Urinary or fecal incontinence
  • Neurological disorders
  • Peripheral circulation disorder
  • Thin skin
  • Anxiety
  • Confusion

Norton scale

The most important thing in preventing the formation of bedsores is to identify the risk of developing this complication. For this purpose, many rating scales have been proposed, including:

  • Norton scale (1962);
  • Waterlow scale (1985);
  • Braden (1987) scale;
  • Medley scale (1991) and others.

The Norton scale, due to its simplicity and speed of risk assessment, has become the most popular among nursing staff everywhere.

Order April 17, 2002 No. 123

Extract from the order

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.

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

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

Order April 17, 2002 No. 123

Extract from the order

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

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

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

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

IN THE INSPECTION DEPARTMENT OF A REGIONAL (CITY) HOSPITAL

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

THE ASSESSMENT IS CARRIED OUT ON THE FOLLOWING POSITIONS:

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

Order April 17, 2002 No. 123

  • 8-10 o'clock - Fowler's position;
  • 14-16 hours - Fowler's position;
  • 16-18 hours - Sims position;
  • 18-20 hours - Fowler's position;
  • 0-2 hours - Sims position;
  • 6-8 hours - Sims position

Daily 12 times

Order April 17, 2002 No. 123

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;
  • 20-22 hours - 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 moved independently with assistance) aids) and in the chair ( wheelchair), he can be in a sitting position and in bed).

Daily 12 times

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

Germany, April 2002

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

SI Qualified nursing staff have current knowledge of the occurrence of pressure ulcers and can make a competent assessment of the risk of pressure ulcers.

Factors and causes of bedsores

(excerpts from German literature)

Based on studies that were published in 1930, we can call such a thing as a pressure limit, which, when increased over a certain time, leads to the formation of bedsores. This pressure limit is 30 millimeters of mercury, i.e. if the patient lies on a hard surface or sits in a chair that puts a lot of pressure on the tissue, bedsores appear. As a result of the examination blood pressure in capillaries is 30 mm. mercury column and, thus, it becomes clear that more high pressure from the outside external factors leads to compression of blood capillaries, which affects insufficient income oxygen into 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 revealed maximum time impact. 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 result of the formation of bedsores is insufficient professional care. Hence, successful therapy 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 the local skin changes seem identical. Skin changes caused by urine represent damage to the skin layers and cellular structures. It is more correct to designate all kinds of lesions on the skin formed under the influence of urine as “dermatitis”, since due to swelling of the skin, infection can occur.

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

Summary 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.

(from the Expert Standard for Pressure Ulcer Prevention)

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.

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Chronic diseases no Physiological data 1. Condition of the skin and subcutaneous fat Skin color pallor Rashes No Intensity of the subcutaneous fat layer BMI assessment overweight 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 Arterial pressure on 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 for developing pressure ulcers

  • 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 no less than three times per day (more often if necessary) wash or wipe the skin 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 the body 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 supine position may 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 pressure ulcers:

  1. At the first stage, the skin is not damaged. Redness appears, the affected area itself is hot.
  2. In the second stage, you can notice the formation of small wounds and dead tissue of a yellowish tint.
  3. The third stage is characterized by the loss of individual areas of the skin, deep hematomas and damaged tissue around them are formed, the muscles are difficult to palpate.
  4. 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.
  • Conduct hygiene procedures as often as possible.
    • It is necessary to monitor your body temperature, as this also leads to unwanted wetting. Diabetes, chronic diseases or unstable work of cardio-vascular system increase the risk of developing hematomas.
    Caring for the patient's skin The use of certain drugs or steroids leads to deterioration of the skin condition in the same way as lack of nutrition.

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 N 2 Approved by Order of the Ministry of Health of the Russian Federation dated April 17, 2002 N 123 Medical documentation Insert to 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 soft or liquid soap, 10% camphor alcohol solution, 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 laundry; 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.

"Map nursing supervision for patients with bedsores"() 1. 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. ___ 1. Patient’s consent to the proposed care plan Patient ____________________________________________________________ (full name) received clarification regarding the care plan for the prevention of pressure ulcers; AND ABOUT). II. Sheet nursing assessment risk of development and stage of pressure ulcers

Name

Body mass

Special factors
risk

Incontinence

Mobility

Neurological
disorders

Extensive
operational
intervention
below the waist/
injury

More than 2 hours
on the table 5

Medicinal
therapy
Instructions: Circle the number corresponding to the Waterlow scale. Sum of points ________ Risk: no, yes, high, very high (underline as appropriate) Bedsores: yes, no (underline as appropriate) Stage 1 2 3 4 Agreed with the doctor ____________________________ (doctor’s signature) Start of implementation of the care plan: date ___________ hour. ____ min. _____ End of care plan implementation: date ________ hour. ____ min. _____

1. In the morning, Waterlow scale __________ points

2. Change of position, bed condition (enter)

8-10 o'clock position -

10-12 o'clock position -

12-14 o'clock position -

14-16 o'clock position -

16-18 o'clock position -

18-20 o'clock position -

20-22 o'clock position -

22-24 o'clock position -

0-2 o'clock position -

2-4 o'clock position -

4-6 o'clock position -

6-8 o'clock position -

3. Clinical procedures:

shower bath washing

4. Teaching the patient self-care (indicate the result)

5. Training relatives in self-care (specify the result)

Amount of food eaten as a percentage:

breakfast _____% lunch _____% afternoon snack _____% dinner _____%

7. Amount of protein in grams:

8. Liquid obtained:

9-13 hours _____ ml 13-18 hours _____ ml 18-22 hours _____ ml

9. Foam pads are used for: (list)

10. Massage was performed about ___________________ areas __________________ times

11. To maintain moderate humidity, the following were used:

12. Notes and comments:
FULL NAME. nurses involved in monitoring the patient: Signature: ___________________________________________

at risk of developing bedsores (in a lying patient)

Nursing interventions

Multiplicity

1. Conducting a current assessment of the risk of developing bedsores at least once a day (in the morning) according to the Waterlow scale

1 time daily

2. Change the patient’s position every 2 hours:

Daily 12 times

8-10 o'clock - Fowler's position;

10-12 hours - position “on the left side”;

12-14 o'clock - position "on the right side";

14-16 hours - Fowler's position;

16-18 hours - Sims position;

18-20 hours - Fowler's position;

20-22 hours - 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

1 time daily

Daily 12 times

According to an individual program

6. Determination of the amount of food eaten (the amount of protein is at least 120 g, ascorbic acid 500-1000 mg per day)

Daily 4 times

7. Ensuring the consumption of at least 1.5 liters of fluid per day:

from 9.00-13.00 - 700 ml;
from 13.00-18.00 - 500 ml;
from 18.00-22.00 - 300 ml

During the day

8. Use of foam pads in risk areas, eliminating pressure on the skin

During the day

9. For incontinence:
- feces - changing diapers immediately after defecation, followed by careful hygiene procedures

During the day

10. If pain intensifies, consult a doctor

During the day

11. Teach and encourage the patient to change position in bed (pressure points) using bars, grab bars, and other devices.

During the day

12. Massage the skin near risk areas

Daily 4 times

13. Patient education breathing exercises and encouraging him to carry them out

During the day

14. Monitor skin moisture and maintain moderate humidity

During the day

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

at risk of developing bedsores (in a patient who can sit)

Nursing interventions

Multiplicity

1. Conduct current assessment risk of developing bedsores at least 1 time a day (in the morning) according to the Waterlow scale

1 time daily

2. Change the patient’s position every 2 hours:
8-10 hours - sitting position;
10-12 hours - position “on the left side”;
12-14 o'clock - position "on the right side";
14-16 hours - sitting position;
16-18 hours - Sims position;
18-20 hours - sitting position;
20-22 hours - 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 assistive devices) and in a chair (wheelchair), he can be in a sitting position and in a bed

Daily 12 times

3. Washing contaminated skin areas

1 time daily

4. Checking the condition of the bed when changing position (every 2 hours)

Daily 12 times

5. Teaching the patient’s relatives the technique of correct movement (lifting above the bed)

According to an individual program

6. Teaching the patient to move independently in bed using a lifting device

According to an individual program

7. Teaching the patient how to safely independently move from bed to chair using other means

According to an individual program

8. Determination of the amount of food eaten (the amount of protein is at least 120 g, ascorbic acid 500-1000 mg per day)

Daily 4 times

9. Ensure consumption of at least 1.5 liters of fluid per day:
from 9.00-13.00 - 700 ml;
from 13.00-18.00 - 500 ml;
from 18.00-22.00 - 300 ml

During the day

10. Use foam pads that eliminate pressure on the skin under risk areas, incl. with the patient in a “sitting” position (under the feet).

During the day

11. For incontinence:

Urine - change diapers every 4 hours;

Stool - changing diapers immediately after defecation followed by a gentle hygienic procedure

During the day

12. If pain intensifies, consult a doctor

During the day

13. Teach and encourage the patient to change position in bed (pressure points) using bars, grab bars, and other devices.

During the day

14. Massage the skin near risk areas

Cardiology department Ward 6

Full name Chernyshev Sergey Prokopyevich

Gender m Age ( full years) 67

Permanent place of residence: Chistopol, Akademika K. 7-14

Place of work disabled group 3

Sent to hospital for emergency indications: No,

Type of transportation: can go

Height 160 Weight 70 BMI 27.34

Allergy No

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

Medical diagnosis Angina pectoris

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

Identifying risk factors

3. Nature of nutrition: fractional, complete

4. Bad habits

Smoking: No

Alcohol consumption: No

Physiological data

Skin color pallor

No rashes

Edema No localization

2. Breathing and circulation

Respiratory rate 18 min.

Cough: No

Sputum: No

Addition:

Characteristics of pulse: frequent, rhythmic, intense

Blood pressure on peripheral arteries: 170/100

left hand 170/100 right hand 173/100

Addition

3. Digestion

Appetite: reduced

Swallowing: normal

Compliance with the prescribed diet No

Addition:

Urination: free

Frequency of urination: day 8 at night 2

Incontinence: No

Addition:

Bowel function:

Regularity/frequency: 2

The chair is decorated

Addition:

5. Physical activity

Dependency: partial

Walking aids are used: Yes

What kind of devices are used: cane

Does it need help? medical worker Yes

Addition:

6. Sleep, rest

Night sleep duration 7

Duration nap 2

Body temperature at the time of examination was 36.5

Addition:

Addition:

Addition:

Is there a risk of falling: No

Addition:

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

10. Priority problem(s): dyspnea on exertion

11. Potential problems development of myocardial infarction


PATIENT CARE PLAN

Patient's name

Patient problems

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

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

A set of exercises for angina pectoris

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

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

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

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

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

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

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

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

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

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

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

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

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

The following exercises are performed while sitting on a chair.

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

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

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

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

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


3.2. Nursing observation card for patient No. 2

Medical organization Central District Hospital

Cardiology department Ward 11

Full name Yarullin Marat Fatykhovich

Gender and Age (full years) 68

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

Place of work, group 3 disabled

Who refers the patient self-referral

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

Type of transportation: on a gurney,

Height 170 Weight 80 BMI 27

Allergies: No

Source of information (underline): patient, family,

Medical diagnosis Hypertonic disease

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

Identifying risk factors

1. Work and rest mode does not work

2. Living conditions live in favorable conditions

3. The nature of nutrition is fractional, not complete

4. Bad habits

Smoking: No

Alcohol consumption: No

5. Industrial hazards none

6. No chronic diseases

Physiological data

1. Condition of the skin and subcutaneous fat

Physiological skin color

No rashes

The nature of the rash.

Expressiveness of the subcutaneous fat layer

BMI assessment overweight

Swelling No

Addition

2. Breathing and circulation

Respiratory rate 16 min.

Cough: No

Sputum: No

Character of sputum, if present:

Addition:

Characteristics of pulse filled

Blood pressure in peripheral arteries:

left hand 160/70 right hand 160/70

Addition

3. Digestion

Appetite: not changed,

Swallowing: normal,

Flatulence (bloating): No

Compliance with the prescribed diet: No

Addition:

4. Physiological functions

Operation Bladder:

Urination: free,

Frequency of urination: day 7 at night 2

Incontinence: No

Addition:

Bowel function:

Regularity/frequency:

The chair is decorated

Addition:

5. Physical activity

Dependency: none,

Walking aids used: No

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

Do you need help from a medical professional? No

Addition:

6. Sleep, rest

Duration of night sleep 8

Daytime sleep duration 1

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

7. Ability to support normal temperature body

Body temperature at the time of examination

Addition:

8. Ability to maintain safety

Are there visual impairments: No

Addition:

Are there hearing impairments: No

Addition:

Is there a risk of falling: No

Addition:

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

10. Priority issue(s) headache

11. Potential problems risk of complications


PATIENT CARE PLAN

Patient's name Yarullin Marat Fatykhovich

Patient problems

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

The goal is long-term, the deadline is full recovery for discharge

Sheet additional research 1