2010年3月29日 星期一

壓瘡定量評估方法。SWHT


2010/3/29
衛生署豐原醫院 外科
游朝慶

Sussman Wound Healing Tool (SWHT)

Sussman Wound Healing Tool於1997由Sussman及Swanson等人發展出來,用來當作壓瘡在經過一段時間治療後的預測及追蹤工具,Carrie Sussman,一位物理治療師,一位位於加州洛杉磯Sussman Physical Therapy, Inc. 及Wound Care Management Services公司的總裁,也是一位知名的傷口治療專家。他是美國NPUAP裡面第一個物理治療師成員,目前則為NPUAP的副會長。SWHT這個工具是採用急性傷口癒合模式其中的10個描述傷口的項目(例如有無壞死組織,有無瘀血,且只需回答有或無)以及11個需要測量傷口的項目(如深度,位置,傷口癒合時期)組合而成。其使用相當簡當,且也容易去追蹤使用
Sussman Wound Healing Tool (SWHT)
Wound Assessment Form
Circle week of care: B 1 2 3 4 5 6 7 8 9 10 11
SWHT
Variable
Tissue Attribute Attribute Definition Rating Relationship to Healing Score
1 Hemorrhage
瘀血
Purple ecchymosis of wound tissue or surrounding skin Present or absent Not Good 0
2 Maceration
浸潤
Softening of a tissue by soaking until the connective tissue fibers are soft and friable Present or absent Not Good 0
3 Undermining
口袋或隧道
Includes both undermining and tunneling Present or absent Not Good 0
4 Erythema
發紅
Reddening or darkening of the skin compared to surrounding skin; usually accompanied by heat Present or absent Not Good 0
5 Necrosis
有slough,eschar壞死組織
All types of necrotic tissue, including eschar and slough Present or absent Not Good 1
6 Adherence at wound edge
傷口周圍和傷口床有連續(無落差)
Continuity of wound edge and the base of the wound Present or absent Good 0
7 Granulation
(Fibroplasia —
Significant
reduction
Reduction
in depth)
Pink/red granulation tissue filling in the wound bed, reducing wound depth
肉芽組織,長肉使傷口變淺
Present or absent Good 1
8 Appearance of
contraction
(reduce size)
有無傷口收縮
First measurement of the wound drawing together, resulting in reduction in wound open surface area Present or absent Good 1
9 Sustained contraction
(more reduced size)傷口有無持續收縮
Continued drawing together of wound edge, measured by reduced wound open surface area Present or absent Good 0
10 Epithelialization有新皮或疤痕形成 Appearance and continuation of resurfacing with new skin or scar at the wound edges or surface Present or absent Good 1

Measures and extent (Depth & undermined)測量傷口深度及口袋深度
Depth/location score Undermining/location score other Letter
11 General depth>0.2cm 1 16 underm@12:00>0.2cm 0 location RT
12 depth@12:00>0.2cm 0 17 underm@3:00>0.2cm 0 Wound healing phase P
13 depth@3:00>0.2cm 0 18 underm@6:00>0.2cm 0 Total”not goog” 1
14 depth@6:00>0.2cm 1 19 underm@9:00>0.2cm 0 Total”goog” 3
15 depth@9:00>0.2cm 1

Key:present=1, abscent=0, location choice: upper body(UB), coccyx(C), trochanter(T) ,ischial(I), heel(H) and foor(F), add right or left(R or L), wound healing phase: imflammation(I), proliferation(P), epithelialization(E), remodeling (R)

參考資料
Sussman C, Swanson G. Utility of the Sussman Wound Healing Tool in predicting wound healing outcomes in physical therapy. Adv Wound Care. 1997;10(5):74–77.

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