2010年3月31日 星期三

壓瘡定量評估方法。SS

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2010/3/31

衛生署豐原醫院 外科

游朝慶

Sessing Scale(SS)

    在1995年,Ferrell及Sessing等人發展了Sessing Scale工具,用來評估壓瘡的癒合過程。其為一7分系統(0到6分),此工具評估五個項目包括傷口,滲液,臭味,壞死組織及周邊皮膚,每一項目最高6分,最低為0分,0代表正常,6代表最差。總分是以各項目中最高分數的那一項分數為其總分。分數減少表示傷口有進步1,2

 

0

1

2

3

4

5

6

skin at examination site傷口處

Normal正常

intact but pale or reddened完整但蒼白或發紅

edges and center filled in 傷口已長滿

filling with slough 傷口被腐肉填滿

moderate granulation tissue中等肉芽組織

minimal granulation tissue 少量肉芽組織

ulcer with no granulation tissue無肉芽組織

Drainage滲液

none

Slight少

Moderate中量

abundant 大量

purulent 有膿

   

Odor臭味

none

slight 輕微

moderate 中等

strong 強烈

foul 惡臭

   

Necrosis壞死組織

none

minimal 少量

mild to moderate 中量

abundant 大量

     

surrounding skin周邊皮膚

normal

slightly swollen 輕微浮腫

red or discolored發紅或變色

broken 破損

     

其又分為6個時期stage,如下,以各項目符合最嚴重的那一時期為其時期3

stage

Description

0

Normal skin but at risk正常

1

Skin completely closed 皮膚完整但有紅斑或褪色

May lack pigmentation or be reddened

2

Wound edge and center are filled in傷口被填滿,周邊組織無發紅

Surrounding tissue are intact and not reddened

3

Wound bed filled with granulating tissue傷口床填滿肉芽組織

Slough present有一些乾掉的分泌物

Free of necrotic tissue無壞死組織

Minimal drainage and odor滲液或臭味很少

4

Moderate to minimal granulating tissue中度或少量肉芽組織

Slough and minimal necrotizing tissue有少量壞死組織

Moderate drainage and odor中量滲液或臭味

5

Presence of heavy drainage and odor, Escher, and slough

Surrounding skin reddened or discolored

6

Breaks in skin around primary ulcer傷口旁皮膚有破損,有膿瘍,

Purulent drainage, foul odor, necrotic tissue and/or eschar惡臭

May have sepsis symptoms壞死組織及痂皮,或敗血症狀

1. Ferrell BA, Artinian BM, Sessing D. The sessing scale for assessment of pressure ulcer healing. J Am Geriatr Soc. 1995;43(1):37–40.

2. Ferrel, B.A. The Sessing Scale for measurement of pressure ulcer healing. Advances in Wound Care, 1997, 10(5): 78–90.

3. Moya Morison, The prevention and treatment of pressure ulcers , Mosby; 1 edition (December 15, 2000) , p102

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