35例住院患者皮肤撕裂伤临床特点及护理对策

Clinical characteristics and nursing strategies of 35 inpatients with skin tears

目的：分析住院患者皮肤撕裂伤的临床特点，探讨相应的护理对策。方法制定资料收集表，回顾性分析35例皮肤撕裂伤患者的年龄、性别、基础疾病、营养状态、发生科室、部位及严重度分级、活动能力、意识状态及护理措施等资料，采用描述性统计分析结果。结果35例撕裂伤患者男性占57.1％（20/35）），平均年龄（68.5±0.8）岁，其中≥65岁占74.3％（26/35）。撕裂伤特点包括撕裂伤部位：双下肢和躯干部最多，各占28.6％（10/35），双上肢占14.3％（5/35），双手和双足各占11.4％（4/35），头面部最少，占5.7％（2/35）。皮肤撕裂伤严重度：3级最多，占42.9％（15/35），其次为2b级占25.6％（9/35），1b级占14.3％（5/35），1a级和2a级各占8.6％（3/35）。临床相关特点：活动能力轻度受限占51.4％（18/35），非常受限28.6％（10/35），不受限14.3％（5/35），完全受限5.7％（2/35）。意识状态：清醒占80％（28/35），不清醒占20％（7/35）。采取了预防护理措施者仅占20％（7/35）。结论住院患者皮肤撕裂伤以移动能力轻度受限、意识清醒和老年患者居多，预防措施落实率很低。建议加强护士培训，提高预防意识，对有皮肤撕裂伤危险的患者列入重点预防并提高预防措施落实率。

Objective To analyze the clinical characteristics of inpatients with skin tears and to explore corresponding nursing strategies. Methods A data collection form was developed to collect data of the 35 patients with skin tears by retrospective analysis, including their age, gender, underlying diseases, nutritional status, department, location and severity level, activity ability, consciousness level and nursing measures, with the results analyzed by descriptive statistics.Results Out of the 35 patients, male accounted for 57.1% （20/35）, with average age of （68.5±0.8） years old, and 74.3% （26/35） equal to or above 65 years old. Characteristics of skin tears （ with locations included）： lower extremities and trunk were the most, both accounted for 28. 6% （10/35）, followed by upper limbs, accounting for 14.3% （5/35）, hands and feet, both accounting for 11. 4% （4/35）, and the least of head and face, accounting for 5.7% （2/35）. Severity of skin tears： Grade-3 was the most, accounting for 42. 9% （ 15/35 ） , followed by Grade-2b, accounting for 25.6% （9/35）, Grade-1b, accounting for 14.3% （5/35）, and Grade-1a and Grade-2a, both accounting for 8. 6% （ 3/35 ） . Clinical characteristics： those with activity slightly limited accounted for 51. 4% （18/35）, followed by those with activity very much limited, accounting for 28.6% （10/35）, with no limitation, accounting for 14. 3% （ 5/35 ） , and completely limited, accounting for 5. 7% （ 2/35 ） . Consciousness level：Conscious patients accounted for 80% （28/35）, and unconscious ones 20% （7/35）. Preventive nursing measures were taken only by 20% （7/35）.Conclusions The majority of inpatients with skin tears are with slight limitation of activity, conscious minds, and old age. Implementation rate of preventive measures is very low. It is advised to strengthen training of nurses, improve awareness of prevention, pay more attention to patients with high risk of skin tears and improve the implementation rate of preventive measures.