2010年3月31日 星期三

壓瘡定性評估方法。Shea

2010/3/31

衛生署豐原醫院 外科

游朝慶

    自從1989,美國國家壓瘡諮詢委員會(National Pres sure Ulcer Advisory Panel (NPUAP))與AHCPR發表壓瘡評估系統以來,此工具已成為全世界最廣為使用的壓瘡評估工具之一(Maklebust & Margolis, 1995),此工具也於2007年2月更新為最新版。

    根據NPUAP, 1989的定義,壓瘡是骨頭突出處,因受到重壓或剪力或摩擦而導致皮膚及其下方組織的局部受損。

    歷史上有許多壓瘡的分期系統被發展出來,最早見於文獻的是1955年由Guttman所發展的,於1975年,Darrell Shea,一位在邁阿密大學的骨外科醫師基於病理學的觀察,及組織傷害的深度,發展出第一套有充分證據支持的壓瘡分期系統,他依據軟組織的傷害來定義每一期,此系統由數字分為四期(grade),I到IV以及一種封閉的壓瘡(closed pressure ulcer,其就如目前所稱呼的深層組織傷害deep tissue injury),Grade I是急性發炎反應,而Grade IV是指傷及筋膜及嚴重的侵蝕undermining。各種分類系統也於1959 被Campbell,於1976被Barton,及在1981,1985被Daniel,Priest和Wheatley三人,及1990被Yarkony-kirk 所發展出來,然而Shea的系統直到1980年代末期都一直是美國最廣為使用的系統。

    實際上,Shea classification一共分為五期:

Examination of the Sore

Grade

acute inflammatory reaction involving all soft tissue layers of the skin with erythema of skin; moist irregular partial thickness ulceration limited to the epidermis exposing the underlying dermis may be present

紅斑及破皮,如NPUAP stage I&II

I

acute inflammatory reaction involving all soft tissue layers with a full thickness skin ulcer involving the dermis; may extend to but not go into the underlying subcutaneous fat

吃到皮下脂肪,如NPUAP stage III

II

ulcer extensively involving the subcutaneous fat with undermining of the skin and limited by deep fascia; often necrotic, infected and foul-smelling; patient may be toxic with systemic symptoms

在fascia上方有潛行性傷口,在NPUAP分類上還是stage III

III

ulcer has penetrated the deep fascia; extensive soft tissue spread, osteomyelitis and/or septic and dislocated joints; patient usually highly toxic

穿過fascia,如NPUAP stage IV

IV

large cavity draining through a relatively small sinus, typically overlying a bony prominence; with/without muscle and bone involvement

口小洞大,如同現在NPUAP 的DTI stage

closed

    有人說,Shea的分類比較偏向臨床,哪一個時期適合用哪一種治療,如下表,而NPUAP的分類比較適合護理人員用在預防壓瘡的發生(褥瘡,Wikipedia)

Grade

Treatment

I

local wound care

II

local wound care

III

surgical debridement

IV

radical surgery

closed

surgery with wide excision

參考資料

http://www.medal.org/visitor/www%5CActive%5Cch21%5Cch21.01%5Cch21.01.08.aspx

Shea JD. Pressure ulcers. Clin Orthopedics Related Research. 1975; 112: 89-100.

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