„Dobór opatrunku specjalistycznego zależy od etiologii i stanu klinicznego rany, stanu ogólnego pacjenta oraz zdolności do regeneracji organizmu. W procesie leczenia oceniamy ranę według strategii TIMERS, MOIST oraz wielu skal oceny rany” – zaznaczyła w rozmowie z Forum Leczenia Ran specjalistka leczenia ran, mgr Anna Mirosz, członek zarządu Stowarzyszenia Naukowego Leczenia Ran.
Forum Leczenia Ran, Natalia Janus: Jakie czynniki powinniśmy wziąć jeszcze pod uwagę, w doborze odpowiedniego opatrunku?
Anna Mirosz: Wśród kluczowych czynników w indywidualnej ocenie rany i odpowiednim dopasowaniu do niej opatrunku będą również rozmiar, głębokość i umiejscowienie rany, ilość wysięku lub jego brak, obecność zakażenia w ranie, przetoki, kieszenie, martwica sucha/ rozpływna, włóknik czy ziarnina w dnie rany. Ponadto istotny jest również stan skóry wokół rany oraz faza gojenia, ponieważ do każdej z nich przeznaczony jest inny rodzaj opatrunku.
Przykładowo, do ran zakażonych z dużym wysiękiem zastosowany opatrunek powinien pochłonąć wysięk i zatrzymać go w swojej strukturze. Powinien także posiadać właściwości antybakteryjne. Rany głębokie natomiast powinny być wypełnione opatrunkiem do ¾ wysokości, a następnie pokryte opatrunkiem wtórnym. Zastosowany opatrunek powinien wspierać procesy naprawcze, które zachodzą w ranie. Priorytetem będzie również leczenie choroby, która miała wpływ na powstanie rany bądź zaburzenie procesu jej gojenia.
Od jakich czynników zależy to, jaki opatrunek sprawdzi się najlepiej ?
Aby dobrać opatrunek do danej rany trudno gojącej się konieczne jest poznanie etiologii danej rany. Można powiedzieć, że stan rany decyduje o doborze opatrunku, ale musimy pamiętać o przyczynach powstania rany i zastosowaniu metod wspierających działanie opatrunku. Jeśli zastosujemy najlepszy opatrunek na owrzodzenie w przebiegu przewlekłej niewydolności żylnej, bez zastosowania kompresjoterapii, będziemy mieli małe szanse na zamknięcie się takiego owrzodzenia.
Ponadto jeśli w leczeniu owrzodzenia cukrzycowego w przebiegu neuropatii nie zastosujemy odciążenia miejsca z raną, również nie możemy liczyć na pozytywne efekty terapii. Pamiętajmy również, iż w przypadku owrzodzenia w przebiegu niedokrwienia kończyny, priorytetem jest udrożnienie tętnic, a w przypadku owrzodzenia odleżynowego – odciążenie i leczenie żywieniowe. Prowadząc taką ranę stosujemy różne opatrunki, w zależności od obecnego stanu rany.
Jakie powikłania mogą świadczyć o niewłaściwie dobranym opatrunku?
– Aby proces gojenia rany przebiegał prawidłowo, opatrunek powinien zostać dobrany również w zależności od fazy gojenia. Istotny jest również odpowiedni czas zmiany opatrunku, ponieważ zarówno zbyt częste, jak i zbyt rzadkie zmiany będą opóźniały proces gojenia.
Zastosowanie nawet najlepszego opatrunku specjalistycznego w leczeniu ran, niezgodnego jednak ze stanem rany opóźnia lub całkowicie zatrzymuje postęp gojenia. Dodatkowo może doprowadzić do maceracji skóry wokół i powiększenia się rany.
Jak zatem wybrać ten najlepszy?
Na polskim rynku jest kilkaset rodzajów opatrunków przeznaczonych do ran trudno gojących, ale to od nas, personelu medycznego i od naszej wiedzy zależy ich indywidualny dobór do danej rany i fazy gojenia. Błędem jest zabezpieczenie rany suchej, bez wysięku – opatrunkiem chłonnym z zawartością srebra, rany w stanie zapalnym z dużym wysiękiem – opatrunkiem hydrokoloidowym czy rany głębokiej – opatrunkiem wierzchnim, bez wypełnienia rany.
Powiedziała Pani o odpowiednim czasie zmiany opatrunku. Odpowiedni, czyli jaki?
– Opatrunek należy zmieniać tak często jak jest to konieczne i tak rzadko jak jest to możliwe, zawsze indywidualnie. Informacja podana przez producenta, iż opatrunek może pozostać na ranie np. do 7 dni, nie oznacza, że powinniśmy pozostawić go na tyle dni bez kontroli. Niekiedy stan rany wymaga zmiany opatrunku już po 24 godzinach.
Jak natomiast rozpoznać, że dany opatrunek nie goi rany? Kiedy powinniśmy zdecydować się na zastosowanie innego opatrunku?
– Jeżeli w ciągu 2 tygodni od zastosowania opatrunku specjalistycznego nie zauważyliśmy poprawy bądź doszło do pogorszenia stanu rany to fakt ten powinien nas zaniepokoić. Niekiedy niepowodzenie w procesie gojenia ma związek z brakiem bądź nieodpowiednim oczyszczaniem rany, nieumiejętną zmianą opatrunku, zbyt długim utrzymaniem opatrunku na ranie lub zaniedbaniem higienicznym. Należy wówczas dokonać oceny postępowania i jeśli to nie przyniesie poprawy, zmienić rodzaj opatrunku.
Jakie są cechy idealnego opatrunku ? W jakim czasie powinien on wygoić ranę ?
– Współczesna technologia opatrunków opiera się na zasadzie stworzenia i utrzymywania wilgotnego środowiska rany. Opatrunki specjalistyczne pełnią dwie podstawowe funkcje, zapewniają skuteczną, zewnętrzną ochronę rany oraz warunkują fizjologiczny przebieg procesu gojenia. Obie te funkcje są od siebie uzależnione i tylko ich wzajemne oddziaływanie zapewnia wysoką skuteczność.
Cechy idealnego opatrunku, opisane w 1979 r. przez T. D. Turnera, na którym opieramy się obecnie to:
- utrzymuje odpowiednią wilgotność w ranie;
- utrzymuje odpowiednią temperaturę w ranie;
- umożliwia prawidłową wymianę gazową;
- pochłania wysięk i zatrzymuje go w swojej strukturze;
- pochłania nieprzyjemny zapach z rany;
- chroni skórę wokół rany przed maceracją;
- zapewnia odpowiednie ph w ranie;
- chroni przed infekcją z zewnątrz;
- nie powoduje bólu podczas utrzymania i zmiany ;
- nie uszkadza nowych tkanek podczas zmiany opatrunku;
- skutecznie usuwa elementy martwicze;
- wypełnia ranę i nie pozostawia pustych przestrzeni;
- stabilnie utrzymuje się w miejscu założenia;
- nie wymaga zbyt częstych zmian;
- wspiera procesy gojenia na każdym etapie
- jest łatwy w użyciu;
- jest nietoksyczny i niealergizujący;
- ma różne kształty, co umożliwia dostosowanie do takich miejsc jak pięta, łokieć czy kość ogonowa.
Niektóre rany goją się kilka tygodni, niektóre kilkanaście miesięcy. Od czego zależy ten czas?
– Czas gojenia zależy od leczenia ogólnego choroby, chorób przewlekłych współistniejących, ogólnego stanu pacjenta oraz doboru odpowiedniego opatrunku. Czas gojenia jest indywidualny i często bywa tak, że duża, głęboka rana np. odleżynowa po zastosowaniu odciążenia, leczenia ogólnego, włączając odpowiednie żywienie wygoi się szybciej niż niewielkie owrzodzenie goleni w przebiegu niewydolności żylnej, podczas którego nie zastosowano kompresjoterapii.
13 kwietnia mgr Anna Mirosz poprowadzi bezpłatny webinar pt. „Rana trudna do wygojenia – co zrobić, aby skrócić czas gojenia? Praktyczne wskazówki”. Aby wziąć udział w wydarzeniu, należy się zarejestrować. Serdecznie zapraszamy.
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