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Proces leczenia odleżyn jest długotrwały i obarczony ryzykiem powikłań. Z tego powodu terapia musi mieć charakter zindywidualizowany i kompleksowy, a jednym z jej ważnych elementów są specjalistyczne opatrunki. Według jakich kryteriów należy je dobierać?
Odleżyny są istotnym problemem opieki zdrowotnej występującym na całym świecie. Owrzodzenia odleżynowe zaliczane są do ran trudno gojących się/przewlekłych. Największym ryzykiem ich wystąpienia obarczeni są pacjenci unieruchomieni, zarówno hospitalizowani, objęci opieką długoterminową i hospicyjną, jak i przebywający w swoich domach i w domach pomocy społecznej. Problem ten dotyczy osób w różnym wieku, ale najbardziej narażeni są ludzie starsi i niedożywieni. Statystyki wskazują, że w Polsce aż 3–17 % pacjentów hospitalizowanych i 17–28% objętych opieką domową cierpi z powodu odleżyn.
Jak wskazują eksperci, efektywność terapii odleżyn zależy od wielu czynników, a jednym z nich jest prawidłowa opieka nad raną i dobór odpowiedniego sposobu prowadzenia leczenia miejscowego: stosowania opatrunków specjalistycznych, częstotliwości ich zmiany, doboru opatrunku w zależności od stanu rany. Organizacja European Pressure Ulcer Advisory Panel opracowała wytyczne dotyczące tej kwestii.
Zasady doboru skutecznego opatrunku na odleżyny
Ocena stanu rany
Dobór skutecznego opatrunku na odleżyny zależy w pierwszej kolejności od uwzględnienia indywidualnych potrzeb pacjenta i obrazu klinicznego leczonej rany. Niezbędnym etapem procesu leczenia jest ocena stanu odleżyny. Należy w niej określić: rozmiar, głębokość i umiejscowienie, stan skóry wokół odleżyny oraz brzegów rany (występowanie zaczerwienienia, maceracji, zasinień, zszarzenia tkanek), stan tkanki na dnie rany (obecność martwicy, ziarniny), obecność, ilość, rodzaj, konsystencję wysięku, występowanie drążących tuneli i kieszeni (postępowanie według strategii TIME).
Przy ocenie stanu rany pomocna jest opracowana przez EPUAP czterostopniowa klasyfikacja odleżyn. Inne narzędzia przydatne do oceny stanu odleżyn to pięciostopniowa skala Torrance’a oraz klasyfikacja odleżyn wg Seilera.
Właściwości opatrunku
Nowoczesne, specjalistyczne opatrunki dostosowane do leczenia ran przewlekłych, w tym owrzodzeń odleżynowych, muszą charakteryzować się ściśle określonymi właściwościami.
Powinny być łatwe w użyciu, nietoksyczne, niealergizujące, utrzymywać odpowiednią temperaturę i wilgotność rany, umożliwiać wymianę gazową, skutecznie usuwać elementy martwicze, nie przyklejać się do rany i jej brzegów, nie wymagać częstych zmian i przede wszystkim nie powodować bólu w trakcie utrzymania i podczas zmiany opatrunku.
Przy doborze opatrunku należy także uwzględnić optymalną częstotliwość wymiany opatrunku. Jeśli zmiany będą zbyt częste, spowoduje to wydłużenie procesu gojenia i podrażnienie tkanek, będzie się to także wiązało z obniżeniem komfortu pacjenta.
Opatrunek powinien zapewniać ochronę mechaniczną i przeciwko drobnoustrojom. Oznacza to, że opatrunek powinien wypełniać dno rany bez pozostawiania wolnych przestrzeni, gdyż powoduje to namnażanie się bakterii. Każda przetoka, tunel, kieszeń powinny być wypełnione opatrunkiem w postaci sączka, tak aby odprowadzały wysięk z rany na zewnątrz.
Stała kontrola rany
Efektywność doboru opatrunku na odleżyny jest uzależniona od stałej, regularnej kontroli stanu rany i jej oczyszczania. W wytycznych EPUAP wskazano, że przy każdej zmianie opatrunku należy uważnie analizować stan rany w celu zaobserwowania postępów lub powikłań
w procesie gojenia.
Wszelkie zaobserwowane zmiany w stanie odleżyny powinny być brane pod uwagę przy doborze stosowanego opatrunku. W przypadku poprawy stanu odleżyny (zmniejszenia rozmiaru i głębokości, ograniczenia ilości wysięku, poprawy jakości tkanek w dnie rany) należy zmienić rodzaj opatrunku na taki, który będzie odpowiadał nowej sytuacji miejscowej. Podobna sytuacja zachodzi w przypadku, kiedy podczas oceny stanu rany zostaną zaobserwowane oznaki rozwijającej się infekcji.
Przeciwdziałanie infekcjom
Zaobserwowanie objawów infekcji – takich jak nasilone zaczerwienienie lub inne zmiany w kolorze tkanek, stwardnienie tkanek, wystąpienie lub nasilenie już istniejących dolegliwości bólowych, zwiększona miejscowo temperatura, zwiększenie ilości wysięku (np. wystąpienie ropy lub krwi), powiększenie rozmiaru owrzodzenia odleżynowego, wystąpienie tuneli lub kieszeni w łożysku rany, zwiększenie ilości tkanki martwiczej, nieprzyjemny zapach – powinno stanowić sygnał do zmiany opatrunku na taki, który będzie wykazywał właściwości przeciwdrobnoustrojowe.
W wytycznych NPUAP w przypadku wystąpienia krytycznej kolonizacji lub zakażenia odleżyny zaleca się stosowanie opatrunków zawierających srebro. Przykładem takiego opatrunku jest Atrauman® Ag firmy HARTMANN.
Atrauman® Ag wykazuje wysoką skuteczność przeciwbakteryjną przeciwko licznym bakteriom gram-dodatnim i gram-ujemnym, w tym szczepowi Staphylococcus aureus opornemu na metycylinę, z drugiej zaś strony charakteryzuje się niską cytotoksycznością, zachowując przy życiu 90% komórek – ludzkich keratynocytów linii HaCaT, co oceniane było w modelu doświadczalnym i potwierdzone w obserwacji klinicznej.[*]
Atrauman® Ag charakteryzuje się także pozostałymi pożądanymi dla opatrunku dedykowanego odleżynom właściwościami: nie przykleja się do rany, dzięki czemu jego zmiany przebiegają bezboleśnie oraz nie zatrzymuje wysięku w środowisku rany. Ponadto może pozostać na ranie do 7 dni, co zapewnia optymalną częstotliwość wymiany opatrunku. Bardzo dobrze sprawdza się w ranach tunelowych, z kieszeniami i głębokich, gdyż można go ciąć na paski i umieszczać w tych miejscach. Wymaga opatrunku wtórnego Zetuvit® Plus, który można zmieniać co 3 dni w zależności od ilości wysięku. Należy pamiętać, że zmiana opatrunku pierwotnego następuje wraz z opatrunkiem wtórnym; decyduje okres zmian opatrunku z krótszym czasem pozostawania na ranie.
Holistyczna opieka nad pacjentem, dobranie odpowiednich opatrunków do leczenia miejscowego ran przewlekłych, w tym odleżynowych, skutkuje poprawą jakości życia pacjentów.
Źródła:
- Bazaliński, P. Więch, B. Barańska, M. Kózka, Wybrane miejscowe problemy gojenia się rany odleżynowej – opis przypadków, „Pielęgniarstwo w Anestezjologii i Intensywnej Opiece” 2017, 3(3): 165-170.
- National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014.
- [*] Ziegler K, Görl R, Effing J, Ellermann J, Mappes M, Otten S, Kapp H, Zoellner P, Spaeth D, Smola H: Reduced cellular toxicity of a new silver-containing antimicrobial dressing and clinical performance in non-healing wounds. Skin Pharmacol Physiol 2006; 19: 140-146.
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