56例慢性伤口的标准化评估及管理

Standardized assessment and management of 56-cases chronic wounds

本文总结了标准化伤口评估方法在56例慢性伤口护理中使用的经验。重点介绍标准化评估工具,包括伤口初诊评估单、伤口评估及处理单、长海伤口测量尺、长海痛尺。伤口评估的频率为每周至少一次,伤口变化时增加评估次数,实行评估的首诊负责制,做好评估的交接管理,保障伤口护理人员资质,确保评估的一致性、完整性。标准化评估可以提高伤口评估的正确程度,准确、全面的评估对伤口护理具有指导意义。通过评估了解伤口局部的情况、患者全身系统问题、伤口致病原因,选择合适的敷料和伤口治疗方法,促进慢性伤口愈合。

Nursing practice experiences in 56 cases with chronic wound were concluded using standardized wound assessment. Assessment tools were highlighted including initial assessment tool, evaluation and processing orders, Changhai Wound Measuring Ruler and Changhai Pain Feet. Insistency and integrity of assessment process was guaranteed by qualified nursing staff, timely assessment frequency at least once a week, increasing assessment times when wound changed, implementing first consultation system and strict handover system. Personal qualification ought to be strictly regulated, to ensuring assessment consistency and completeness. The standardized assessment have guiding significance for wound care.The local wound condition, patients’ overall dysfunction and possible reasons for causing disease were identified by evaluation of wound. Suitable wound dressing and targeted wound treatment were selected. Multi-discipline cooperation, specialties in wound assessment deserves to be recommended to have better treatment effect and facilitate chronic wound healing.