Jak ważny jest dobór właściwego opatrunku do rany? [CASE STUDY]
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Jak ważny jest dobór właściwego opatrunku do rany? [CASE STUDY]

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Na proces gojenia ran trudno gojących, w tym ostrych wpływa wiele czynników. Do najważniejszych należą aspekty związane ze strategią TIME, czyli prawidłowe oczyszczanie łożyska rany, kontrola obciążenia mikrobiologicznego, wilgotne zarządzanie oraz wsparcie naskórkowania. Strategia TIME realizowana jest głównie dzięki właściwemu doborowi opatrunków specjalistycznych, które wspierają proces gojenia i skracają czas terapii. Temat ten został dokładnie omówiony przez mgr Urszulę Jakubowską, pielęgniarkę specjalizującą się w leczeniu ran, podczas warsztatów „Leczenie Ran – Perspektywa Praktyka”.

 

Case study – krok po kroku

Pacjent: mężczyzna, ok. 70 lat, bez chorób współistniejących

Podczas swojego wystąpienia mgr Urszula Jakubowska przedstawiła przypadek 70-letniego mężczyzny, który zwrócił się do niej o pomoc w 18. dniu po upuszczeniu na stopę ciężkiego (ok. 100 kg) przedmiotu. Pacjent doznał wieloodłamowego złamania kości stopy prawej i powstania ogromnego krwiaka, który przez prawie 3 tygodnie nie został w żaden sposób zaopatrzony.

Złamanie kości śródstopia zostało zaopatrzone na 3 tygodnie butem gipsowym zamkniętym. Pacjent usłyszał również informację: „Ma pan krwiaka, który będzie się powoli otwierał, przez ok. pół roku. Przez ten czas wygnije, wypadnie i dopiero zacznie się goić.”

Właściwe leczenie krwiaka i zaistniałych zmian rozpoczęte zostało przez specjalistkę natychmiast, niestety dopiero po 18 dniach od urazu.

– Podczas pierwszej wizyty, po zdjęciu opatrunku, który składał się jedynie z kompresu (zdjęcie nr 1) i maści ze srebrem, po bardzo dokładnym umyciu powierzchni przodostopia, zauważyłam obrzęknięte palce stóp i zmianę martwiczą, koloru żółtego i czarnego. Balotująca powierzchnia tego krwiaka była dość ruchoma, niezbyt bolesna. Po dokładnej ocenie i zbadaniu tętna na tętnicy grzbietowej podjęłam decyzję o uwolnieniu krwiaka. Ważne jest ze na skutek urazu nie doszło do przerwania ciągłości skóry. Dzięki temu krwiak nie uległ nadkażeniu.

Jak należy przeprowadzić ewakuację krwiaka?

Jak zaznaczyła specjalistka, decyzja o ewakuacji krwiaka powinna zostać podjęta już przez specjalistów, którzy zajmowali się pacjentem bezpośrednio po zdjęciu gipsowego buta. Dodała również, iż bardzo istotnym działaniem, które należy wykonać przed nacięciem skóry i ewakuacją krwiaka jest dokładna dezynfekcja pola preparatem zgodnym z procedurami np. przemycie pola preparatem jodowym na bazie wody.

– Po zastosowaniu tego preparatu skóra jest żółta (widać to na zdjęciu powyżej). Po dokładnym przemyciu powierzchni skóry, dokonałam nacięć tylko w tych miejscach, gdzie widoczna była czarna martwica.

Przemycie i nacięcie w miejscach czarnej martwicy, co dalej?

Specjalistka dodała, iż po otwarciu tej zmiany, wyglądała ona na bardzo głęboką. Sterylne narzędzie chirurgiczne „weszło” w tę ranę na kilka centymetrów. Wówczas zaczęła wypływać skrzepnięta, galaretowata treść – krew, która przez cały czas od urazu się tam utrzymywała.

– Kolejnym działaniem, które przeprowadziłam było bardzo dokładne wypłukanie rany poprzez wstrzyknięcie strzykawką roztworu soli fizjologicznej. W miarę możliwości wypłukałam ranę z pozostałości po skrzepniętej krwi, a w ramach antyseptyki zastosowałam przymoczki z roztworu do płukania ran Granudacyn, które pozwoliły na zoptymalizowanie środowiska w ranie i pozbycie się drobnoustrojów.

Uwolnienie krwiaka, dokładne wypłukanie loży, przymoczki – teraz czas na dobór odpowiedniego opatrunku

Jak podkreśliła specjalistka, kolejną niezwykle istotną czynnością był dobór odpowiedniego opatrunku. Dodała, iż musiała wziąć pod uwagę fakt, iż rana jest okrągła w środku, ma powierzchnię dolną, boczną, dlatego ważne, aby wypełnić całą jej przestrzeń. Istotne było nie tylko to jaki opatrunek zastosować, ale w jaki sposób ułożyć go w ranie, żeby zadziałał na całą powierzchnię i wspierał kolejne etapy gojenia. W takiej sytuacji ważne jest by opatrunek chłonął i zatrzymywał wysięk – niedopuszczalna jest kumulacja wysięku w ranie głębokiej.

Czy wysięk to coś złego?

Urszula Jakubowska dodała, że sam wysięk z rany jest czynnikiem pozytywnym i fizjologicznym. Pod warunkiem, że jego ilość jest umiarkowana, potrzebna do utrzymywania wilgotnego środowiska, dzięki któremu funkcje naprawcze w ranie będą zachodziły we właściwy sposób. Inaczej jest, jeżeli tego wysięku będzie za dużo i nie będzie on odpowiednio zagospodarowany. Nadmiar wysięku prowadzi do maceracji tkanki wokół rany czy nawet powiększenia rany.

– Po wnikliwej ocenie rany, zdecydowałam, iż na ten moment najbardziej właściwym opatrunkiem będzie opatrunek Exufiber Ag+. Dodatkowo zabezpieczyłam ranę opatrunkiem wierzchnim, który będzie chronił ranę przed urazami oraz utrzymywał w niej przyjazne środowisko. Był to miękki opatrunek z pianki poliuretanowej z siarczanem srebra i węglem aktywowanym Mepilex Ag.

Specjalistka: „Na kolejną wizytę zaprosiłam pacjenta za trzy dni”

– Powyższe zdjęcia pokazują, jak rana zmieniła się w ciągu ośmiu dni. Biorąc pod uwagę czas, jest to ogromny postęp. Na pierwszym zdjęciu powyżej widać dokładnie dno rany wyściełane (oczywiście po oczyszczeniu) ziarniną. Palce i przestrzenie międzypalcowe zabezpieczyłam i oddzieliłam kompresem. Skórę zabezpieczyłam maścią na bazie cynku. Zaaplikowałam do rany opatrunek włóknisty do wypełnień Exufiber Ag+ z siarczanem srebra.

Urszula Jakubowska zwróciła uwagę, iż zastosowany opatrunek jest niezwykle skuteczny i bezpieczny w stosowaniu do rany kanałowej, co zapewnia jego jednolita struktura. W momencie żelowania zmienia się w swoistą zwartą galaretkę. Struktura ta jest spójna i łatwa do wyjęcia. Na warsztatach obejrzeć można, jak specjalistka usuwa ten opatrunek w jednym kawałku z łożyska rany. Po jego usunięciu widać postępujące procesy autooczyszczania i demarkacji reszty martwych tkanek.

„Po wypłukaniu widać było dokładnie, iż rana wypełniła się żywą, aktywną ziarniną…”

– Co równie ważne, w procesie opieki nad raną ważne jest też działanie antyseptyczne, czyli wypłukanie, eradykacja i przygotowanie powierzchni do założenia opatrunku. Tym właściwym preparatem jest podchloryn, ponieważ jest bezpieczny, a jednocześnie działa biobójczo na szerokie spektrum drobnoustrojów.

Kolejne zdjęcia prezentują ranę w 20. dobie od urazu

Opatrunek był zmieniany co trzy dni. Zastosowanie właściwego opatrunku, dociętego i włożonego w ranę, pozwoliło na znaczne zmniejszenie łożyska rany i spłycenie loży po krwiaku. W celu ściągnięcia brzegów stosowano taśmy.

– Opatrunek wykonany z stabilnej i zbitej struktury z włókien alkoholu poliwinylowego zapewnia dużą możliwość absorbcji i retencji. W momencie kontaktu z wysiękiem żeluje strukturę i ściąga go. Zawarty w opatrunku siarczan srebra działa bójczo już po 30 minutach, a w badaniach in vivo działa również przeciwbiofilmowo. Sprawdza się doskonale w użyciu do ran kanałowych, głębokich, jak również płaskich.

Mepilex Ag zastosowany jako opatrunek wtórny

Specjalistka zaznaczyła, iż drugą pozycją, która w leczeniu tego pacjenta bardzo się sprawdziła, był opatrunek Mepilex Ag. Produkt ten zabezpieczył ranę, utrzymał wilgotne środowisko oraz pozwolił uniknąć maceracji skóry wokół rany. Siarczan srebra zawarty w produkcie spowodował, że nie doszło do rozwinięcia się infekcji wewnętrznej, a węgiel aktywny zniwelował przykry zapach.

Terapia trwała dość krótko, ok. dwóch miesięcy. Ostatnie zdjęcie pokazuje bardzo ładnie wynaskórkowaną i wypielęgnowaną skórę. Ostatecznie brzegi rany bardzo ładnie zamknęły się. Skóra  smarowana była maścią natłuszczającą, a na świeżo wynaskórkowaną ranę aplikowano ochronnie Mepilex Em – cienką piankę z warstwą kontaktową z silikonu.

 

Artykuł powstał we współpracy z firmą Mölnlycke.

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