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SCALE – trudno gojące się rany u kresu życia pacjenta

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SCALE (Skin Changes At Life’s End) to rodzaj trudno gojących się ran pojawiających się u kresu życia. Mimo stosowania odpowiedniej pielęgnacji i prawidłowego leczenia, trudno jest doprowadzić do zagojenia się zmiany. Wpływ ma na to szybko postępujące niedokrwienie u pacjentów będących w stanie agonalnym i znaczne osłabienie funkcji skóry.

Pod koniec życia wiele narządów w ciele człowieka zaczyna tracić swoją funkcję, aż w końcu dochodzi do ich całkowitego obumarcia. Podobne zmiany obejmują również skórę – która wraz z końcem życia traci swoje zdolności regeneracyjne.

Odleżyny najczęstszą zmianą skórną zwiastującą śmierć pacjenta

W ostatnich miesiącach i tygodniach życia dochodzi do zaburzeń procesów homeostazy organizmu, dlatego znacznie obniża się perfuzja tkanek, co doprowadza do niewydolności wielonarządowej. Organizm zaczyna tracić również zdolność do utrzymywania prawidłowej temperatury ciała czy regulowania cukru we krwi. Pod koniec życia krew w organizmie człowieka w większym stopniu zużywana jest przez inne organy, takie jak serce czy mózg, by utrzymać organizm przy życiu. W związku z tym mniejsza ilość krwi trafia do skóry, co oznacza także niższe natlenienie tkanek i brak zdolności wykorzystania kluczowych składników odżywczych i innych czynników niezbędnych do utrzymania normalnego funkcjonowania skóry. U kresu życia skóra staje się niewydolna, traci więc swoje właściwości, zaczyna słabnąć i być podatna na uszkodzenia.

Gdy funkcje skóry zaczynają zanikać, nawet w wyniku niewielkiego skaleczenia, pacjenci podatni są na wystąpienie powikłań, takich jak: infekcja, krwotok, zgorzel, owrzodzenie. Najczęstszym rodzajem rany u kresu życia są natomiast odleżyny, których etiologia jest inna niż ucisk, a główną przyczyną zmian jest hipoperfuzja i niedokrwienie. Odleżyny pojawiające się u kresu życia często nie goją się prawidłowo i pogarszają się wraz ze zbliżającą się śmiercią. U pacjentów agonalnych odleżyny najczęściej pojawiają się w dolnym odcinku pleców. W praktyce klinicznej wyróżniono również specyficzne odmiany odleżyn pojawiających się u kresu życia – odleżynę Kennedy’ego  lub odleżynę typu TB-TTI.

Czynniki ryzyka i objawy związane ze SCALE

Czynniki ryzyka wpływające na rozwój ran u kresu życia, oprócz postępującego niedokrwienia i niewydolności narządów, dotyczą m.in.:

  • inkontynencji – problemu nietrzymania moczu lub kału;
  • ograniczenia sprawności ruchowej;
  • upośledzonego układu odporności;
  • niedożywienia i odwodnienia.

Ponadto na rozwój niegojących się ran u kresu życia wpływają choroby współistniejące (np. nowotwór) czy przyjmowanie niektórych leków.

Objawy ran u kresu życia obejmują m.in. obniżoną miejscową temperaturę, przebarwienia, martwicę skóry, utratę integralności skóry. Zmniejszona perfuzja tkanek, która jest głównym czynnikiem ryzyka powstania ran i uszkodzeń, objawia się najczęściej w dystalnych częściach ciała, które mają jedno zaopatrzenie w krew (kapilary), czyli palców u rąk i nóg, a także obejmuje uszy czy nos. Zaburzenie to manifestuje się m.in. ciemnym rumieniem, plamistym odbarwieniem czy miejscową niską temperaturą.

Jak podjąć decyzję o wdrożeniu leczenia?

Zmianom skórnym pojawiającym się u kresu życia często nie można zapobiec. Utrata funkcji niektórych narządów niejednokrotnie jest nieunikniona. Rany mogą rozwijać się nawet przy zapewnieniu najlepszej możliwej pielęgnacji i metod leczenia.  W miarę możliwości u kresu życia pacjenta należy jednak zadbać o jego komfort. Przed podjęciem decyzji o wdrożeniu leczenia, często agresywnego ze względu na postępujący stan rany, należy wziąć pod uwagę jak wpłynie to na pacjenta. Leczenie często wiąże się z bólem i może pogarszać jakość ostatnich dni życia chorego.

W podjęciu decyzji o wdrożeniu leczenia, w praktyce klinicznej, stosowana jest także ocena rany pod względem:

  • możliwości wyleczenia (w oczekiwanej długości życia pacjenta);
  • utrzymywania rany pod kontrolą;
  • niemożliwości wyleczenia (rana paliatywna).

Leczenie ran u kresu życia może polegać na prewencji (zapobieganiu rozwinięciu się rany), wdrożeniu leczenia, utrzymaniu stanu rany (niedoprowadzanie do pogorszenia), łagodzeniu dolegliwości współistniejących z raną (poprawa komfortu życia pacjenta). Pod uwagę brane są zawsze preferencje pacjenta – czyli jego chęć do podjęcia leczenia.

Źródła:

woundsource.com

R. G. Sibbald, D. L. Krasner, J. Lutz „SCALE: Skin Changes At Life’s End: Final Consensus Statement: October 1, 2009”, Clinical Management Extra, 2010

R. Beldon, „Skin changes at life’s end (SCALE): a consensus document”, Wounds UK, 2010, Vol 3. No. 1

 

Przeczytaj także: Jak rozpoznać i ocenić ranę? Część II – odleżyny [ZDJĘCIA]

Biblioteka Faktów

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

Odleżyny u pacjentów w terminalnej fazie choroby

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