手术室压疮风险评估的最佳证据总结

Evidence Summary of risk assessment of pressure injury among surgical patients

目的总结手术患者压疮风险评估的最佳证据。方法计算机检索国内外循证资源数据库及文献数据库关于手术患者压疮风险评估的所有指南、证据总结、最佳实践、系统评价及专家共识等,检索时限为建库至2018年6月。由3名研究者对检索到的文献进行评价和资料提取,对符合质量标准的文献进行证据提取。结果共纳入8篇文献,其中临床指南5篇、证据总结3篇。经过评价,总结得出12条手术患者压疮评估的证据:专业医护人员参与评估高危人群,评估包括疼痛、主诉及皮肤检查;使用有效、可靠的专业评估工具,结合临床判断,识别压疮危险因素(如灌注、氧合、体温升高、年老);手术患者要考虑到手术患者的风险因素包括术前制动时间长短、手术持续时间、术中低血压事件次数增多、术中低体温、术后翌日活动能力降低等;压疮评估包括内源性因素和外源性因素;根据患者的病情特点需要尽可能地重复进行风险评估;每次风险评估时,都要进行全面的皮肤检查,以评价完好的皮肤是否有任何变化;每次皮肤评估的内容:皮温、皮肤颜色改变、有无水肿、受压组织相对于周围组织硬度的改变、皮肤湿度改变、皮肤的完整性;检查医疗器械下面和周围的皮肤至少每天2次,查看周围组织有无压力相关损伤的迹象;评估并记录压疮特征,包括部位、分类/分期、大小、组织类型、颜色、伤口周围情况、创缘、窦道、瘘管、渗出、气味;对医疗专业人员就如何使用国际NPUAP/EPUAP压疮分期体系进行培训;对医疗专业人员就如何进行准确而可靠的风险评估进行教育;考虑使用计算机决策支持系统或多元化策略,以促进压疮评估和记录的质量改进。结论医疗机构应加强对护理人员进行压疮评估及规范记录的培训,强化危险意识,对手术患者进行动态、专业的压疮危险因素评估,及时预警压疮的发生,从而保障患者的安全。由于最佳证据随着研究的推陈出新而持续更新,使用证据者需根据所在医院的临床环境、医院特点,选择性应用证据。

Objective To summarize the best evidence of risk assessment of pressure injury among surgical patients. Methods We searched JBI Library、Cochrane Library、NGC、SIGN、PubMed、CNKI, CBM, etc., to collect documents including guidelines, evidence summaries, best practice information sheets, systematic reviews and expert consensus. Three researchers independently reviewed studies and extracted data from the publications meeting inclusion criteria. Results 8 publications were recruited, including 5 clinical guidelines and 3 evidence summaries. Finally,12 items of best evidence were summarized, as follows. Health care professionals should involve in assessing of patients who are at risk of developing pressure ulcers, including pain related to pressure ulcers, complaints and skin inspections. Use a valid/reliable risk assessment tool in conjunction with the identifcation of additional risk factors (e.g., perfusion and oxygenation, increased body temperature, and advanced age), along with clinical judgment. Consider additional risk factors specific to individuals undergoing surgery including: duration of time immobilized before surgery, length of surgery, increased hypotensive episodes during surgery, low core temperature during surgery;and reduced mobility on day one postoperatively. Assess for intrinsic/extrinsic risk factors. Undertake a reassessment if there is any significant change in the individual′s condition. Include a comprehensive skin assessment as part of every risk assessment to evaluate any alterations to intact skin. Undertake a comprehensive skin assessment that includes skin temperature, color, edema, change in tissue consistency in relation to surrounding tissue, skin moisture, and skin integrity. Inspect the skin under and around medical devices at least twice daily for the signs of pressure related injury on the surrounding tissue. Assess and document physical characteristics including: location, category/stage, size, tissue types, color, periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor. Staff education should be a core component of any quality improvement project aimed to improve the accuracy of pressure injury classification and quality of documentation. Health professionals should receive education regarding the prevention, assessment and management of pressure injury. The use of multi-component strategies or a computerized clinical decision support can be considered in quality improvement initiatives for improving pressure injury classification and documentation. Conclusions Medical institutions should strengthen training of nursing staff, especially pressure ulcer assessment and standardization of nursing records. It is also needed to raise awareness of relevant risks. Nursing staff should perform risk assessment dynamically and professionally, in order to timely identify the occurrence of pressure injuries to and ensure patients′ safety. Since best evidence would be updated along with research project, researchers should selectively apply evidence based on clinical settings and hospital conditions.