Obok slidera Odleżyny Pielęgnacja

Odleżyny – jak je rozpoznać i zapobiegać we wczesnych stadiach? Wywiad z ekspertką

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Pierwsze objawy tworzenia się odleżyny to m.in. zaczerwienienie skóry, ból i wrażliwość na dotyk. Wczesne rozpoznanie tworzącej się odleżyny pozwala uniknąć długotrwałego leczenia i poważnych powikłań. Mgr Beata Marciszewska, specjalistka pielęgniarstwa chirurgicznego, mówi w rozmowie z Forum Leczenia Ran o tym, jakie działania należy podjąć, kiedy rozwija się odleżyna.

– Z mojego doświadczenia zawodowego wynika, że opiekunowie zbyt późno reagują na problem odleżyn. Bardzo często jadę do pacjenta, który według relacji rodziny ma „coś” na pośladkach, a okazuje się, że jest to odleżyna IV stopnia wymagająca już interwencji chirurgicznej. Konieczna jest edukacja rodzin i opiekunów już na etapie wczesnoszpitalnym lub w momencie pojawienia się choroby – mówi w rozmowie z Forum Leczenia Ran mgr Beata Marciszewska, specjalistka pielęgniarstwa chirurgicznego.

Jakie są pierwsze objawy odleżyn?

Odleżyna jest uszkodzeniem skóry, tkanki podskórnej, mięśniowej, a niekiedy kostnej. W wyniku długotrwałego ucisku na naczynia krwionośne dochodzi do zahamowania lub ograniczenia krążenia krwi, a w konsekwencji – do powstania martwicy i wytworzenia odleżyn. Owrzodzenie powstaje najczęściej w okolicach, w których skóra pokrywa wyniosłości kostne, takich jak: okolice kości krzyżowej, guz kulszowy, masyw krętacza większego i kości piętowych, okolice stawu kolanowego, kostka przyśrodkowa i boczna, wyrostek kolczysty kręgosłupa i okolica potyliczna.

Pierwszym objawem powstawania odleżyn, jak wyjaśnia Beata Marciszewska, jest zazwyczaj zaczerwienienie skóry. Rumieniowi może towarzyszyć ból, zwiększenie wrażliwości na dotyk, obrzęk bądź stwardnienie tkanki.

Odleżyny bolą. Z mojego doświadczenia wynika, że owrzodzenie boli na każdym etapie rozwoju. Pacjent przytomny, bez neuropatii, może zgłosić uczucie pieczenia, ucisku, bólu i podwyższonej ciepłoty w miejscu tworzenia się odleżyny – wyjaśnia Beata Marciszewska.

Wyróżnia się pięć stopni rozwoju odleżyny:

  • zaczerwienienie blednące pod uciskiem;
  • zaczerwienienie nieblednące pod uciskiem – mogą występować powierzchniowe uszkodzenia naskórka, pęcherze i ból;
  • rana powierzchowna nieobejmująca tkanek podskórnych – rana otoczona jest obrzękiem i rumieniem, a jej dno wypełnia czerwona ziarnina lub żółte masy rozpadających się tkanek;
  • rana obejmująca skórę i tkanki podskórne – dno rany może pokrywać czarna martwica;
  • rana obejmująca powięź, mięśnie, stawy i kości – ranę wypełniają czarnobrązowe masy rozpadających się tkanek.

W pierwszym stadium skóra nie jest uszkodzona, a zaczerwienienie pojawia się zazwyczaj nad wypukłością kostną. Miejsce może być bolesne, twarde lub miękkie, cieplejsze lub chłodniejsze od sąsiedniej tkanki. W okolicy kulszowej odleżynom mogą towarzyszyć wczesne oznaki, takie jak niewielkie podwyższenie temperatury, niewielkie zgrubienie, zaczerwienienie lub obrzmienie.

Pierwsze oznaki odleżyn – jakie działania podjąć?

– W momencie pojawienia się pierwszych objawów odleżyn konieczne jest wprowadzenie szeregu działań mających na celu niedopuszczenie do pogorszenia powstałej odleżyny oraz zapobieganie powstawaniu nowych – wskazuje Beata Marciszewska.

Już w przypadku zdiagnozowania pierwszego stopnia rozwoju odleżyn pacjentowi należy zapewnić odpowiednią profilaktykę obejmującą:

  1. Repozycjonowanie:

  • systematyczna zmiana pozycji pacjenta co 2-3 godziny, zgodnie z ustalonym wcześniej harmonogramem obracania;
  • delikatny masaż miejsca narażonego na odleżynę w momencie zmiany pozycji;
  • wprowadzenie rehabilitacji przyłóżkowej i biernych ćwiczeń.

– Podstawą w zapobieganiu odleżyn jest ciągła zmiana pozycji ciała pacjenta. Układanie pacjenta na bokach, brzuchu, plecach co około 2-3 godziny. Jako przykład podam przypadek pacjenta z odleżyną pierwszego stopnia na kości krzyżowej. W tym przypadku należy unikać leżenia na wznak, zalecaną jest pozycja siedząca (jeśli stan ogólny pacjenta na to pozwala), jednak trzeba  pamiętać aby siedząc także odciążyć miejsce występowania odleżyny. W momencie pionizacji ciała zachodzi inne ukrwienie pośladków, co niweluje ucisk – podkreśla Beata Marciszewska.

  1. Sprzęt przeciwodleżynowy:

  • łóżko rehabilitacyjne ze specjalistycznym materacem przeciwodleżynowym zmiennociśnieniowym, w celu odciążenia ciała pacjenta i wspomagania krążenia;
  • poduszki zmniejszające ucisk (nie zaleca się poduszek w kształcie pierścienia, ponieważ zaburzają przepływ krwi);
  • piankowe wyściółki.
  1. Pielęgnację:

  • utrzymywanie skóry czystej i suchej;
  • pielęgnacja skóry preparatami natłuszczającymi z zawartością pantenolu, allantoiny oraz witamin A, E, F, które wykazują działanie łagodzące podrażnienia i zabezpieczają skórę przed rozwojem odleżyny;
  • stosowanie piżam i bielizny wyłącznie z naturalnych tkanin, które przepuszczają powietrze i nie powodują otarć;
  • dieta bogata w białko, witaminy, minerały i właściwą ilość płynów.

– Na etapie pierwszego stopnia rozwoju schorzenia stosować można dostępne na rynku płyny, kremy i maści natłuszczające, jednak tylko w tych przypadkach, gdzie nie doszło do przerwania ciągłości skóry. W momencie, kiedy powstał pęcherz surowiczy, miejscowe stosowanie maści nie jest wskazane. Należy wtedy zastosować wysokospecjalistyczne opatrunki przeciwodleżynowe – informuje Beata Marciszewska.

Kto jest narażony na powstawanie odleżyn?

Czynnikami, które wpływają na powstawanie schorzenia są:

  • bezruch (np. unieruchomienie w opatrunku gipsowym, długotrwałe unieruchomienie w czasie operacji),
  • wilgoć (związana np. nietrzymaniem moczu, stolca, wzmożona potliwość skóry),
  • uszkodzenia skóry (otarcia, zadrapania, obrzęki),
  • procesy chorobowe prowadzące do niedotlenienia tkanek (uszkodzenie naczyń krwionośnych, anemia, niskie ciśnienie krwi),
  • zaburzenia odżywiania,
  • utrata bądź osłabienie odczuwania bólu,
  • cukrzyca i niewydolność nerek,
  • miażdżyca,
  • zaawansowana faza choroby nowotworowej,
  • neuropatie powodujące zaburzenia czucia i zaburzenia czynności zwieraczy.

– Najczęściej na powstawanie odleżyn narażeni są pacjenci leżący. Obrażenie może jednak dotykać też osoby chodzące. Miałam przypadek pacjentki całkowicie sprawnej, która miała odleżynę na pięcie. Schorzenie było już w trzecim stopniu, gdy zgłosiła się do mnie na wizytę. Pacjentka cierpiała na cukrzycę 2 stopnia i polineuropatię – opisuje Beata Marciszewska.

Ocenie ryzyka powstawania odleżyn służą m.in skale: Norton, Waterlow lub Douglas (zobacz: Skale oceny ryzyka wystąpienia odleżyn).

Źródła:

K. Cierzniakowska, A. Łabuńska, M. T. Szewczyk, A. Popow, A. Jawień, Analiza wybranych czynników wpływających na rozwój odleżyn, Leczenie Ran 2010;7, (3-4), str. 71 – 77

B. Rewerska, G. Sianos, J. Kowalik, Z. Kopański, A. Skura-Madziała, W. Ptak, Patofizjologia, profilaktyka i leczenie odleżyn, Journal of public health, nursing and medical rescue, No.2/2011, str. 14-18

M. Kucharzewski, E. Szkiler, G. Krasowski, M. Bartoszewicz, T. Banasiewicz i wsp., Algorytmy i wytyczne postępowania terapeutycznego w ranach trudno gojących się, Forum Leczenia Ran, 2020;1(3), str. 95-116

Przeczytaj także: Powstała nowa metoda leczenia zakażeń C. difficile

 

mgr Beata Marciszewska, specjalistka pielęgniarstwa chirurgicznego

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