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Jak wyglądają procedury pielęgnacyjne w zależności od rodzaju ran typu MASD?

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Długotrwała ekspozycja skóry na wilgoć może skutkować maceracją, rozwojem stanów zapalnych i powstaniem rozległych ran podatnych na zakażenia. Procedury pielęgnacyjne różnią się w zależności od rodzaju i przyczyny urazu.

Na uszkodzenia skóry wskutek długotrwałego kontaktu z wilgocią (ang. moisture-associated skin damage, MASD) szczególnie narażeni są pacjenci hospitalizowani. Rozróżnia się cztery rodzaje schorzeń skórnych typu MASD: zapalenie skóry związane z nietrzymaniem moczu lub kału, wyprzenie skórne, zapalenie skóry wokół stomii i zapalenie skóry wokół rany.

Przed wdrożeniem procedur pielęgnacyjnych należy przeprowadzić ocenę pacjenta. W zależności od stanu chorego i przyczyny urazu zaleca się różne metody pielęgnacji.

Ocena stanu pacjenta z uszkodzeniami skóry typu MASD

Ocena ogólna

Podczas analizy stanu pacjenta bierze się pod uwagę jego mobilność, sprawność zwieraczy, odżywienie, alergie oraz występujące w przeszłości problemy skórne i rany. By ustalić ryzyko uszkodzeń skóry, stosuje się skalę Norton i skalę Braden.

Należy również ocenić stopień samodzielności pacjenta oraz zaangażowanie jego bliskich w proces leczenia. Pozwala to opracować właściwy schemat procedur dotyczących pielęgnacji skóry i toalety chorego.

Ocena skóry

Podczas analizy stanu skóry pacjenta stosuje się ocenę wizualną. Pod uwagę bierze się zmiany w pigmentacji, ewentualne zmiany patologiczne oraz uszkodzenia. W trakcie badania palpacyjnego ocenia się natomiast wilgotność, temperaturę oraz obrzęki i stwardnienia naskórka. Przeprowadza się również badanie różnicujące w kierunku odleżyn. Działania te umożliwiają określenie typu i rozległości uszkodzenia oraz wykrycie ewentualnych zakażeń i stanów zapalnych.

Procedury pielęgnacyjne w przypadku MASD

Procedury uniwersalne  

Niektóre z działań pielęgnacyjnych wykonuje się niezależnie od typu MASD. Procedury te obejmują:

Utrzymanie skóry w czystości

Podstawą pielęgnacji jest utrzymanie skóry w czystości. W tym celu stosuje się łagodne preparaty o pH wynoszącym około 5,5. Nie należy używać tradycyjnych mydeł – zawierają zasady i kwasy tłuszczowe, które podwyższają pH. Skutkuje to podrażnieniem kwaśnej powłoki hydrolipidowej skóry, która staje się wówczas podatna na uszkodzenia.

Zabezpieczenie skóry przed dalszymi urazami

By zabezpieczyć skórę przed dalszymi uszkodzeniami, stosuje się preparaty barierowe np. na bazie wazeliny, które chronią przed działaniem nadmiernej wilgoci. Podczas pielęgnacji powinno się ponadto zadbać o utrzymanie prawidłowego stopnia nawilżenia i elastyczności skóry.

Kontrola skóry w kierunku zakażeń

Procedury pielęgnacyjne obejmują regularną kontrolę skóry w kierunku ewentualnych zakażeń. W przypadku ich wystąpienia wdraża się leczenie przeciwgrzybicze lub przeciwbakteryjne. Zaleca się stosowanie preparatów miejscowych w postaci proszku lub pudru. W trakcie toalety pacjentów rekomenduje się używanie jednorazowych misek i myjek w celu zminimalizowania ryzyka zakażenia krzyżowego.

Procedury w przypadku zapalenia skóry związanego z nietrzymaniem moczu lub kału

Chorym zaleca się m.in. używanie pieluchomajtek. Należy jednak zwrócić szczególną uwagę na zapewnienie dostatecznej cyrkulacji powietrza. Jeżeli zachodzi taka konieczność, pacjentowi zakłada się cewnik do pęcherza moczowego lub do systemu odprowadzania stolca. Wówczas codziennie należy ocenić zasadność utrzymywania cewnika w pęcherzu moczowym.

Procedury w przypadku wyprzenia zapalnego skóry

W przypadku wyprzenia zapalnego skóry powinno się unikać produktów, w których składzie znajdują się m.in.: glukonian chlorheksydyny, alkohol lub substancje zapachowe. Środki te mogą zostać wchłonięte przez podrażnione tkanki, co spowoduje głębsze uszkodzenia.

Podczas osuszania zmienionego chorobowo obszaru nie należy pocierać skóry. Zaleca się delikatne osuszanie ręcznikami jednorazowymi.

By zminimalizować ryzyko dalszej maceracji lub podrażnień objętej stanem zapalnym powierzchni, stosuje się roślinne maści i kremy ochronne. Nie powinno się używać preparatów w postaci talku lub pudru, ponieważ ulegają zbryleniu i powodują nadmierne nawilżenie.

Procedury w przypadku zapalenia skóry związanego z wilgocią wokół rany

Podstawą procesu pielęgnacyjnego w przypadku zapalenia skóry spowodowanego wilgocią wokół rany jest właściwy dobór opatrunku w zależności od nasilenia wysięku. Zaleca się stosowanie opatrunków specjalistycznych separujących nadmierny wysięk. Jednocześnie niewskazane są opatrunki o działaniu okluzyjnym.

W przypadku uwidocznionej kości oszacowuje się ryzyko zapalenia kości i szpiku. Przeprowadza się także konsultację ze specjalistą.

Procedury w przypadku okołostomijnego zapalenia skóry

Jeżeli do uszkodzenia doszło w związku ze stomią, procedury pielęgnacyjne prowadzi się w porozumieniu z pielęgniarką stomijną.

Aby zapobiec przeciekaniu treści jelitowej ze stomii, pacjent powinien nosić luźną odzież i zrezygnować z pasków, by ograniczyć ucisk w okolicy stomii. Do pielęgnacji skóry wokół stomii nie powinno się używać tłustych kremów i maści. Tego typu środki utrudniają przyklejenie sprzętu stomijnego do skóry, co może skutkować podciekaniem.

Skórę powinno się osuszać przed założeniem kolejnego worka lub płytki. Zaleca się także regularną kontrolę wielkości i kształtu otworu w płytce – zbyt duży otwór może spowodować podciekanie skóry wydalinami. Warto zastosować również specjalistyczne pasty uszczelniające, które minimalizują ryzyko kontaktu skóry z treścią jelitową.

Źródła: S. Kempa, D. Klich, M. Sopata, „Uszkodzenia skóry związane z wilgocią”, w: „Leczenie Ran”, 2016;13(1):9–13.

E. Szkiler, „MASD i MARSI – zaburzenia integralności skóry, różnicowanie, objawy i postępowanie”, w: „Pielęgniarstwo w Anestezjologii i Intensywnej Opiece”, 2021;7(1):35–44.

 

Przeczytaj także:

Rany powstałe w wyniku maceracji skóry – rodzaje

Biblioteka Faktów

Przeczytaj bezpłatnie pokrewny artykuł w czasopiśmie „Pielęgniarstwo w Anestezjologii i Intensywnej Opiece”:

Postępowanie z ranami u pacjentów objętych opieką paliatywną, zgodnie ze strategią higieny rany

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