Patient management protocol. Bedsores. Nursing process map for bedsores sample filling How to choose an anti-bedsore mattress - detailed video

INDUSTRY STANDARD

Standardization system in healthcare 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 infections.

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, for 1994-1998, 163 cases of pressure ulcers (0.23%) were registered. 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 due to the action additional factors risk of developing bedsores (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 intake of protein and 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, organs abdominal cavity
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

MINISTRY OF HEALTH
RUSSIAN FEDERATION

On approval of the industry standard
"Protocol for patient management. Pressure ulcers"

_______________________________________________________________________________
The document does not require state registration by the Ministry of Justice of the Russian Federation
Letter of the Ministry of Justice of the Russian Federation dated 06/03/2002 N 07/5195-UD.
______________________________________________________________________________

In order to ensure the quality of medical care for patients at risk of developing pressure ulcers

I order:

1. Approve:

1.1. Industry standard "Protocol for the management of patients. Pressure sores" (OST 91500.11.0001-2002) (Appendix No. 1* to this order).
__________________
* See Appendix No. 1 at the link. - Database manufacturer's note.

1.2. Registration form N 003-2/у "Card nursing supervision for patients with bedsores" (Appendix No. 2 to this order).

2. Entrust control over the implementation of this order to the First Deputy Minister A.I. Vyalkov.

Minister
Yu.L.Shevchenko

Appendix N 2. Registration form N 003-2/у "Nursing observation card for patients with bedsores"

Appendix No. 2

APPROVED
by order of the Ministry
healthcare of the Russian Federation
dated April 17, 2002 N 123

Medical documentation
Insert for medical
inpatient card
N 003/у
Registration form N 003-2/у

"CARD OF NURSING OBSERVATION OF PATIENTS
WITH BEDSORES"

1. Full name patient

2. Branch

3. Chamber

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 plan of care

Received an explanation of the bedsore prevention care plan;

Received information:

about risk factors for the development of bedsores,

for the purposes of preventive measures,

consequences of non-compliance with the entire prevention program.

The patient was offered a care plan in accordance with 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, and full explanations were given about the features of the diet.

The patient is informed of the need to follow the entire prevention program, regularly change position in bed, and perform breathing exercises.

The patient is informed that failure to comply with the recommendations of the nurse and doctor may be complicated by the development of bedsores.

The patient is notified of the outcome if the plan of care is not followed.

The patient had the opportunity to ask any questions he had regarding the plan of care and received answers to them.

The interview was conducted by nurse _____________ (nurse signature)

" __ " ______________ 20 __

The patient agreed with the proposed plan of care, which he signed with his own hand __________________ (patient signature) or signed for him (according to paragraph 6.1.9 of the industry standard “Protocol for the management of patients. Pressure sores”, approved by order of the Ministry of Health of Russia dated April 17, 2002 N 123)

___________________ (signature, full name),

what those present at the conversation attest to

_____________ (nurse signature)

_____________ (witness signature)

The patient did not agree (refuse) with the proposed care plan, for which he signed with his own hand __________________ (patient signature) or signed for him (according to paragraph 6.1.9 of the industry standard “Protocol for the management of patients. Pressure sores”, approved by order of the Ministry of Health of Russia dated April 17, 2002 N 123 )

____________________ (signature, full name).

II. Nursing assessment sheet for the development and stage of pressure ulcers

Name
Body mass
Special risk factors
Incontinence
Mobility
Neurological disorders
Major surgery below the belt/trauma					More than 2 hours per table 5
Drug therapy

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

Color skin pallor

No rashes

Edema No localization

2. Breathing and circulation

Frequency breathing movements 18 min.

Cough: No

Sputum: No

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

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. Chronic diseases none

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 body

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 (sleep disorder, interrupted sleep, drowsiness during the day, 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 complete recovery by discharge

Sheet additional research 1

Abdominal hernias.

Abdominal hernia - exit from the abdominal cavity internal organs together with the peritoneum covering them through natural or acquired defects abdominal wall under the skin or into other cavities. There are external and internal, congenital and acquired, reducible and irreducible abdominal hernias. Classification: umbilical hernias, hernia of the white line of the abdomen, inguinal hernias, femoral hernia, diaphragmatic hernia, postoperative hernias(infringement).

Strangulated hernia. Incarceration is compression of the contents of the hernia in the area of ​​the hernial orifice. As a result of strangulation in the hernial contents, blood supply and innervation are stopped, blood stagnation and tissue necrosis develop. Symptoms: sudden pain in the hernia area, its enlargement, irreducibility, sharp tension and pain in the hernial protrusion. Over time cramping pain in the abdomen, vomiting, stool and gas retention. Tactics: When strangulated hernia contraindicated thermal procedures, pain relief, antispasmodics, attempt at manual reduction. Emergency hospitalization is indicated surgery department on a stretcher in a position comfortable for the patient. In case of spontaneous reduction during transportation, emergency hospitalization is also indicated for dynamic observation patient in hospital. Treatment: The main surgical method is herniotomy. Contraindications to surgical treatment are severe respiratory and cardiovascular failure, active tuberculosis, malignant tumors. For such patients, a bandage is recommended. Kinds surgical interventions: autohernioplasty (closure using the patient’s own tissues) and allohernioplasty (various synthetic grafts made of polypropylene).

Peritonitis.

Peritonitis is an inflammation of the peritoneum, accompanied by local and general symptoms illnesses and minor impairments the most important organs and body systems. Types: primary, secondary, tertiary. Primary is an extremely rare form of peritonitis of hematogenous origin in which infection of the peritoneum occurs from an extraperitoneal source. Secondary – the most common form abdominal infection and the main cause of abdominal sepsis in surgical patients. Tertiary - peritonitis without a source of infection, develops in patients in critical conditions with severe depletion of the body's defenses. By prevalence: local (less than two anatomical areas of the peritoneal cavity are affected), widespread (diffuse - the process covers from two to five anatomical areas of the peritoneal cavity, diffuse - more than five anatomical areas are affected). According to the nature of the contents of the abdominal cavity: serous-fibrinous, fibrinous-purulent, purulent, fecal, bile, hemorrhagic, chemical. Depending on the course of the process: no signs of sepsis, sepsis, severe sepsis (multiple organ failure). Clinic: gradually increasing severe pain in the abdomen (localized in the area of ​​the source of peritonitis, then spreading throughout the abdomen), intoxication, pale face, pointed features, sunken eyes. Nausea, vomiting of gastric contents, then intestinal contents. Retention of gases and stool, increased body temperature, muscle tension in the anterior abdominal wall. Treatment: after removing the patient from anesthesia, place him in the Fowler position, parenteral nutrition for 3-4 days, infusion therapy as prescribed by a doctor, respiratory and physiotherapy, daily dressings and rinsing of the abdominal cavity through drains. During the operation, a probe is inserted into the stomach and intestines, which is removed on days 4-6.

Acute intestinal obstruction.

Acute intestinal obstruction is a disease characterized by partial or complete violation movement of contents through the intestines. Types: dynamic - develops as a result of a violation of the contractility of the intestine of paralytic or spastic origin and in most cases is functional in nature, mechanical - with organic blockage of the intestine. Dynamic obstruction is a disorder of intestinal motility of various origins due to damage to its neuromuscular elements. Dynamic obstruction: (Clinic - constant bursting pain in the abdomen of a generalized nature, retention of stool and gases, pronounced moderate bloating, regurgitation and vomiting appear at more late stages diseases resulting from stasis and hypertension in the proximal gastrointestinal tract. Treatment: decompression of the proximal parts of the gastrointestinal tract using gastric or intestinal tubes, the use of pharmacological stimulants of intestinal motility (cerucal, proserin, pituitrin), the introduction of a gas outlet tube or the value of a siphon tube and hypertensive enemas, correction of water-electrolyte balance, elimination of hypovolemia, elimination of hypoxia, maintenance cardiovascular activity, pain relief and intestinal spasm.) Mechanical obstruction: (clinic – severe pain cramping in the abdomen, vomiting, retention of stool and gas, bloating. Treatment: surgical)

Acute pancreatitis.

Acute pancreatitis is a pathological process in which swelling, autolysis and necrosis of pancreatic tissue develop with secondary inflammation of pancreatic tissue. Classification: edematous form and pancreatic necrosis (hemorrhagic, fatty, purulent). Complications: septic shock, multiple organ failure, abscess and phlegmon of the pancreas, bleeding, diffuse peritonitis, false cyst pancreas. Clinic: the onset of the disease is acute, severe cutting pains in the epigastrium and left hypochondrium of a girdling nature, repeated vomiting that does not bring relief, dyspeptic symptoms, increased body temperature. Treatment: conservative, rest (Fowler's position), cold is applied to the pancreas area, carried out for 2-3 days parenteral nutrition, pain relief, antienzyme drugs (Gordox, Contrical), plasma, albumin, detoxification and antibiotic therapy, immunotherapy and desensitizing therapy, highly effective in the first 3-5 days of the disease hormonal blockers pancreas sandastotin and octreotide, gastric secretion blockers (famotidine, ranitidine, omeprazole), surgical treatment (laparotomy, drainage of the omental bursa around the pancreas, cholecystostomy, resection of the tail and body of the pancreas.

Acute cholecystitis.

Acute cholecystitis is inflammation of the gallbladder. Classification: calculous (with stones in gallbladder) and non-calculous (without stones). According to the clinical and morphological form: catarrhal, phlegmonous, gangrenous. Complications: acute pancreatitis, obstructive jaundice, secondary hepatitis, cholangitis, infiltration, abdominal abscess, peritonitis. Clinic: hepatic colic (severe bursting pain in the right hypochondrium, radiating to the right supraclavicular region, scapula, right shoulder), frequent vomiting with an admixture of bile, stool and gas retention, increased body temperature to 38-39. Treatment: conservative – bed rest, table No. 5, position in bed with the head end elevated, in the first days cold on the right hypochondrium, parenteral nutrition, in case of uncontrollable vomiting, rinse the stomach, antibiotic therapy, detoxification therapy and desensitizing therapy, painkillers and antispasmodics. Surgical treatment: cholecystectomy.

Acute appendicitis

Acute appendicitis - nonspecific inflammation vermiform appendix of the cecum. Classification: acute and chronic. Clinic: cutting or pressing pain in the epigastric region with distribution throughout the abdomen, after a few hours in the right iliac region, pain usually radiates to right leg, nausea, vomiting, retention of stool and gases, increased body temperature, weakness, malaise, increased pulse rate, muscle tension in the anterior abdominal wall. Complications: appendicular infiltrate. Treatment: surgical only - appendectomy.

Ambulance:

Prevention and treatment of bedsores: (order 123)

· Placing air-inflated circles

· Regularly change body position in bed every 1.5-2 hours

· Massage in the area of ​​pressure

· Elimination of body folds, bed linen

· Replacement wet laundry for dry

· Removal foreign bodies and other bed irregularities

· Physiotherapy and active mode of the patient

· Effective irritants: ethyl, camphor, salicylic alcohols

· Careful care of the skin and mucous membranes, washing and wiping with an antiseptic solution, and the skin with a warm soapy solution, providing the patient with clean underwear.

Caring for a patient with a plaster cast:

· If the bandage is too tight, the patient experiences pain in the limbs, cyanosis, increased swelling, and numbness of the fingers. In this case, it is necessary to cut the bandage and temporarily strengthen it with a bandage

Care must be taken to ensure that the bandage does not become contaminated during urination and defecation.

· Keep the limb elevated and move the fingers

· Ensure that the plaster is dry

· Do not allow the patient to remove plaster cast on one's own

· Make sure that no crumbs get under the plaster cast.

Preparing the patient for abdominal ultrasound:

· Explain the process and purpose of the upcoming study and obtain his consent

· Eliminate foods from the diet 2-3 days before the test. causing gas formation(legumes, black bread, cabbage, milk)

· Strictly on an empty stomach

· Do not smoke, do not drink alcohol

First aid for acute urinary retention:

·Use of reflex methods

· Catheterization with a soft catheter in women; in men, this procedure is performed by a doctor or urological nurse