– Błędy popełnione podczas udzielania pierwszej pomocy mogą mieć ogromny wpływ na dalsze losy pacjenta oraz pomyślne zakończenie leczenia – zaznaczyła w rozmowie z Forum Leczenia Ran pielęgniarka koordynująca w Małopolskim Centrum Leczenia i Rehabilitacji Oparzeń oraz Chirurgii Plastycznej i Replantacyjnej, członek komisji rewizyjnej Stowarzyszenia Naukowego Leczenia Ran mgr Beata Śpiewak.
Forum Leczenia Ran, Natalia Janus: Jak długo zajmuje się Pani leczeniem ran oparzeniowych?
Beata Śpiewak: – Na Oddziale Oparzeń pracuję 24 lata, od 17 lat jestem pielęgniarka oddziałową, a od 2015 r. pielęgniarką koordynującą w MCOP. W swojej pracy spotykam się z głębokimi i rozległymi ranami oparzeniowymi IIa, IIb i III stopnia. Są to urazy obejmujące rozległe powierzchnie ciała. Oprócz tego, że trafiają do nas pacjenci prosto z miejsca wypadku (np. wybuch gazu, pożar, porażenie prądem, oparzenia chemiczne), przyjmujemy również pacjentów leczonych dotychczas w innych szpitalach czy środowisku domowym. Są to tzw. oparzenia zastarzałe.
Co wpływa na gojenie ran oparzeniowych?
– Wpływ ma wiele czynników, m.in. wiek pacjenta, choroby współistniejące, rodzaj urazu, czas działania czynnika parzącego oraz sposób udzielenie pierwszej pomocy medycznej, czyli z tzw. Złotej Godziny. O wynikach leczenia ran oparzeniowych decydują pierwsze godziny po wypadku. Błędy popełnione podczas udzielania pierwszej pomocy, mogą mieć ogromny wpływ na dalsze losy pacjenta oraz pomyślne zakończenie leczenia. Dlatego należy pamiętać o chłodzeniu rany (tylko 15 min.), leczeniu przeciwbólowym, jałowym zabezpieczeniu rany, wdrożeniu resuscytacji płynowej i transporcie pacjenta do Ośrodka Oparzeniowego.
A jakim procedurom zostaje poddany pacjent już w Ośrodku?
– W przebiegu leczenia chorego oparzonego niezwykle istotne jest również leczenie ogólne choroby oparzeniowej (leczenie wstrząsu oparzeniowego), chirurgiczne opracowanie rany oparzeniowej, stosowanie opatrunków specjalistycznych oraz wdrożenie procedur żywienia dojelitowego, pozajelitowego, stosowanie hemofiltracji ciągłej, HBO, rehabilitacji, zapewnienie pomocy psychologa oraz zapobieganie i leczenie zakażeń.
Oprócz odpowiednich procedur, w takich Ośrodkach Oparzeniowych, jak m.in. MCOP szczególnie ważne jest również stosowanie międzynarodowych standardów w leczeniu oparzeń. Jak to wygląda w praktyce?
– MCOP jest znakomicie przygotowane do leczenie pacjentów oparzonych z rozległymi i głębokimi ranami. Boksy na IT zapewniają pacjentom odpowiednie środowisko mikrobiologiczne do leczenia ran. Nadzór nad zakażeniami szpitalnymi uchodzi obecnie za najważniejszy wskaźnik opieki medycznej.
Dlaczego jest on tak ważny?
– Wystąpienie zakażenia szpitalnego jest istotnym zagrożeniem w procesie leczenia i pielęgnacji pacjenta z urazem oparzeniowym. Oprócz tego, że wpływa ono na pogorszenie przebiegu choroby oparzeniowej i zwiększa liczbę występujących powikłań, to również wydłuża czas hospitalizacji i zwiększa koszty leczenia.
Więc jak sobie radzicie, aby minimalizować to ryzyko?
– W naszym ośrodku wprowadzono szereg procedur profilaktyki zakażeń szpitalnych. Pacjenci z rozległymi ranami oparzeniowymi leżą w pojedynczych boksach, w których powietrze jest filtrowane przez filtry Hepa oraz wspomagane nadciśnieniem, zapewniającym prawidłowy obieg powietrza (wymiana powietrza następuje 15 razy na godzinę). Dzięki automatycznemu otwieraniu i zamykaniu drzwi do boksu, nie dochodzi do wymiany powietrza miedzy boksem a korytarzem. W boksach, całej IT oraz bloku operacyjnym woda jest czysta mikrobiologicznie. Dla każdego pacjenta stosujemy również jałową pościel.
Jak do tych procedur przygotowany jest Zespół?
– Aby zapobiegać zakażeniom krzyżowym, na Intensywnej Terapii do każdego pacjenta na boksie, na dyżurze przypisana jest jedna pielęgniarka, która przed wejściem do boksu musi wyposażyć się w fartuch ochronny, maskę i czapkę oraz zdezynfekować ręce. Wszystkie procedury muszą być wykonywane w sposób jałowy. Dużym osiągnieciem zespołu i organizacji pracy w MCOP jest to, że każda zmiana opatrunku odbywa sią na bloku operacyjnym, czyli dzięki nawiewom laminarnym w warunkach jałowych.
– Dzięki wprowadzeniu gotowych sterylnych zestawów do takich procedur, jak zakładanie i pielęgnacja CVP, odsysanie i nebulizacja w systemie zamkniętym, dekontaminacja pacjenta oparzonego czy dekontaminacja sprzętu medycznego, niewątpliwie zmniejszamy ryzyko zakażenia ran u tej grupy pacjentów. Ponadto pobieramy wymazy ze sprzętu, badamy czystość mikrobiologiczną wody, pobieramy wymazy z rąk personelu pracującego oraz okresowo kontrolujemy personel na nosicielstwo w kierunku MRSA. Systematycznie odbywają się również szkolenia z dezynfekcji rąk prowadzone przez pielęgniarkę epidemiologiczną.
Gojenie rozległych i głębokich oparzeń wymaga czasu. O jakich technikach leczenia możemy mówić w przypadku takich ran?
– W MCOP stosujemy nowoczesne metody leczenia ran oparzeniowych, m.in. leczenie chirurgiczne, które obejmuje takie zabiegi jak: nacięcia odbarczające, wycięcie tkanki martwiczej, przeszczepy skóry własnej siatkowe, lite i pełnej grubości. Pobieramy skórę pacjenta do hodowli keratynocytów, komórek mezenchymalnych izolowanych z tkanki podskórnej tłuszczowej. W leczeniu ran oparzeniowych stosujemy także Integrę, specjalistyczne opatrunki srebrowe, podciśnieniowe leczenia ran – Vac oraz Komorę HBO.
Czy u tej grupy pacjentów stosuje się antybiotyki?
– Prowadzenie antybiotykoterapii jest ścisłe powiązane w wynikami badań mikrobiologicznych. Antybiotyki celowane stosowane są na podstawie analizy wymazu z rany, badania krwi i wydzieliny z drzewa oskrzelowego.
Czy Ci pacjenci cierpią? Czy te rany oparzeniowe są wyjątkowo bolesne?
– Pacjenci na naszym oddziale wymagają stosowania leków przeciwbólowych, które otrzymują we wlewach przez pompy strzykawkowe. U chorych oparzonych nie wymagających stałego podawania leków, stosujemy leczenie przeciwbólowe wg zaleceń lekarza lub PCA. Ból oceniamy na podstawie skali WAS i wówczas podajemy leki.
Pod czyją opieką przebywa podczas pobytu na oddziale pacjent i jakie powikłania mogą wystąpić w tym czasie?
– Leczenie chorego oparzonego wymaga ścisłej współpracy zespołu terapeutycznego, w którego skład wchodzą: chirurg plastyk, anestezjolog, zespół pielęgniarski, rehabilitant, psycholog, mikrobiolog oraz zespół żywieniowy. Wśród powikłań najczęściej spotykamy się z pogłębieniem rany oparzeniowej w wyniku zakażenia, odleżynami, obrzękami czy zaburzeniami metabolicznymi. W przypadku oparzeń elektrycznych dochodzi również do późnych krwotoków. Ta grupa pacjentów narażona jest szczególnie również na zapalenie płuc, a co się z tym wiąże, przedłużającą się wentylację mechaniczną. U chorych oparzonych może pojawić się również depresja, wynikająca z długiego okresu hospitalizacji czy braku kontaktu z rodziną.
Jak rozumiem, to nie koniec problemów, które pojawiają się u chorych oparzonych?
– Niestety nie, na naszym oddziale pacjenci cierpią również na takie dolegliwości, jak zespół stresu pourazowego PTSD, zapalenie pęcherzyka żółciowego, zapalenie mięśnia serowego, krwawienie z przewodu pokarmowego czy niewydolność wielonarządowa ARDS. Niekiedy dochodzi także do sepsy oraz zgonu pacjenta.
Czy zapadł Pani w pamięć jakiś szczególny przypadek oparzenia, konkretni pacjenci?
– Wielu pacjentów pozostało w mojej pamięci, zarówno tych, co przeżyli oraz tych, którzy odeszli po ciężkiej chorobie. Z uwagi na zazwyczaj długi czas pobytu pacjenta na Oddziale, nasze relacje są bliskie. Do tej pory mam kontakt z pacjentem, który piętnaście lat temu przeżył ciężkie oparzenie 80% cpc. Doskonale pamiętam też 30-letniego pacjenta po oparzeniu prądem elektrycznym, który długo walczył o życie, nie poddawał się, ale niestety zmarł. Wtedy wszystkie płakałyśmy.
Takie momenty muszą być obciążające psychicznie dla personelu medycznego?
– Oczywiście, ale pamiętam również pacjentkę bezdomną, młoda kobietę, która straciła rodzinę, dziecko. Dzięki nawiązaniu dobrej relacji z pielęgniarkami i pomocy psychologa, po wyjściu ze szpitala przeszła terapię, znalazła pracę, wynajęła mieszkanie i odzyskała relacje z dzieckiem. Była szczęśliwa i podziękowała, że znalazła w nas wsparcie.
Jak rozumiem, takie sytuacje motywują do działania?
– Personel medyczny jest świadkiem walki o życie wielu pacjentów, dlatego jest to ogromne szczęście, że w obecnych czasach i dostępie do nowoczesnych metod leczenia oparzeń można uratować tak wiele osób przed śmiercią. Chorzy oparzeni ze względu na osłabienie odporności i długi okres pobytu w szpitalu są szczególnie narażeni na zakażenia szpitalne. Dlatego tak ważne jest zaangażowanie i świadome postępowanie w czynnościach pielęgnacyjnych u tej grupy pacjentów.
Przeczytaj także:
- „W leczeniu ran drobnoustroje są wciąż dwa kroki przed nami” – wywiad z prof. Marzenną Bartoszewicz
- „Pielęgniarki to przyszłość leczenia ran w Polsce” – wywiad z Anną Mirosz
- „Pielęgniarka w leczeniu ran musi mieć głos w dyskusji i być partnerem w działaniu” – wywiad z Zuzanną Konrady
- „Medycyna to schody ruchome, które jadą w dół. Musimy walczyć, żeby się na nich utrzymać” – rozmowa z dr. n. med. Grzegorzem Krasowskim
- W leczeniu ran potrzebujemy telemedycyny i rozszerzenia kompetencji pielęgniarek – wywiad z prof. Tomaszem Banasiewiczem
- Rany trudno gojące się izolują bardziej niż kwarantanna – wywiad z dr hab. n. med. Markiem Kucharzewskim
- SNLR: stanowisko dot. postępowania z raną podczas epidemii COVID-19
- Stowarzyszenie Naukowe Leczenia Ran – nowe aktywności i konferencje o leczeniu ran
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