預防手術後壓瘡照護流程之發展

The Development of a Care Protocol for Postoperative Pressure Sore Prevention

10.6224/JN.62.6.98

黃玉玲(Yu-Ling Huang)；林慧玲(Hui-Ling Lin)；王方(Fang Wang)；吳淑芳(Vivienne Shu-Fang Wu)

壓瘡 ； 手術後壓瘡 ； 臨床照護 ； pressure ulcer ； postoperative pressure sore care ； clinical care

護理雜誌

62卷6期（2015 / 12 / 01）

98 - 104

繁體中文

壓瘡是長時間手術後常見的合併症，手術後發生壓瘡容易造成病患疼痛、增加感染機率與延長住院天數，並增加護理照顧時數與醫療成本。因此，如何維持手術病患皮膚完整性是手術室護理人員的職責，也是護理照顧品質的表現。目前國外已有發展手術病患專用之壓瘡危險評估及手術室預防壓瘡的臨床照護流程，但國內較少有這方面的文獻，故引發筆者彙整國內外相關文獻，合併考量國內醫院目前手術後壓瘡的現況，發展出預防手術後壓瘡照護流程，藉以提供臨床醫護人員在面臨手術後壓瘡之參考。本照護流程內容包含手術後壓瘡的風險評估、手術後壓瘡相關危險因素之預防措施及特殊手術臥位之保護措施等。期許此份照護流程能運用於手術全期照護，並有效預防手術後壓瘡的發生，以提升手術全期照護品質。

Pressure sores are a common complication caused by long periods of bed rest following major surgery. These sores may increase patient postoperative pain, increase the risk of infections, lengthen the period of hospitalization, and increase the duration and costs of nursing care. Therefore, maintaining the skin integrity of surgical patients is an important responsibility for operating room nurses and an indicator of nursing care quality. While pressure-sore risk assessment tools and interoperative strategies are available and used in foreign countries, there has been little related research conducted in Taiwan. After examining the relevant literature and considering the current postoperative pressure sore situation in Taiwan, the author developed a postoperative pressure sore care protocol as a reference for clinical staff. Protocol procedures include major breakthrough developments in areas such as post-survey risk assessment for pressure ulcers, pressure ulcer prevention strategies that take surgery-related risk factors into consideration, extra care and protection measures for surgical supine patients, and post-pressure sores. The developed postoperative pressure sore protocol may be incorporated into surgical care procedures during the post-surgical care period in order to effectively prevent the occurrence of post-surgery pressure ulcers. Furthermore, the developed protocol offers the potential to improve and strengthen the quality of surgical care in terms of both healthcare and post-surgical care.

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