壓瘡定量評估方法。SS

Technorati 的標籤：壓瘡定量評估方法

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