MZ/T 132-2019Pressure ulcer prevention for senior care organization (English PDF)

3.1 Evaluation objects and parts

3.1.1 The service object of the elderly care institution shall be included in the evaluation object as long as it meets any of the following.

-Bedridden, unable to turn over independently or unable to be an active author;

-Advanced disease;

-Wasting or edema, severe malnutrition;

-People with impaired consciousness and restricted autonomy;

-Postoperative or fixed medical measures, restricted body position or mobility;

--Patients with sensory impairment or dysfunction caused by chronic diseases;

-Incontinence, local dampness;

-Elderly people with slow response and difficulty in autonomous movement;

-Fever.

3.1.2 Prone areas include compression, lack of adipose tissue protection, and skeletal eminence. The following areas should be evaluated.

-骶 tail;

-Anteroposterior spines;

-Costal margin protrusions;

--Hip;

-At the spinal body;

-Scapular region;

-Occipital tuberosity;

-Pinna;

-Elbows;

-Medial and lateral knee joints;

-Medial and lateral ankles;

-Heel area;

--toe;

-The big toe joint protrusion.

3.2 Evaluation requirements

3.2.1 The assessment should be performed on the day when the service object enters the elderly care institution, and follow-up observation should be conducted within 7 days.

3.2.2 If any one of the conditions in 3.1.1 occurs, the pressure ulcer risk level assessment shall be performed, see Appendix A.

3.2.3 During the fever period, a risk level shall be increased based on the evaluation score.

3.2.4 The relevant third party should be notified in writing when there is a risk of pressure ulcers.

4.1 Changing body position

When the risk of pressure ulcers is assessed as low-risk and high-risk, the position should be changed. The requirements are as follows.

-Autonomous change, supervise, remind, and encourage bedridden clients to change their positions frequently to reduce the pressure on skeletal protuberances;

--Passive change, to help clients who do not have the ability to stand up, turn over at least once every 2 hours;

-The service object using the wheelchair should change its posture once every 0.5h;

-When turning over and moving, avoid dragging, pulling, pushing, etc. to prevent scratching the skin.

4.2 Aid protection

When the pressure ulcer risk assessment is moderate to high risk or above, assistive devices should be used, the requirements are as follows.

-When lying down, you can use anti-pressure ulcer mattresses, roll-over auxiliary pads and other assistive devices. Place soft cushions (pillows) in the body space to reduce skeletal muscle Pressure at the protrusion-When sitting, can be equipped with auxiliary cushions, soft cushions placed in the body space;

-You can use the protective frame according to the doctor's order, use the protective frame to raise the quilt and blanket to avoid local pressure;

-The position should be changed according to the provisions of the use of assistive devices, and replaced immediately after soaking.

4.3 Cleaning

During service.

-The beds should be kept dry, level and free of debris;

-The skin of all parts of the body should be kept dry;

-Bathing and wiping bath, the skin should be wiped clean after bathing;

-Clients who are not suitable for bathing, such as surgery, trauma, and disturbance of consciousness, should arrange scrubbing baths;

-Apply force evenly when wiping to avoid rubbing the skin;

-When the clothing is wet with wound secretions, it should be changed immediately;

--Dinner, incontinence, vomiting, sweating, etc., should be wiped clean immediately, changing diapers and quilts with wet; warm water should be used Wash and dry the perineum;

-Use a non-destructive toilet to avoid hard plugs and deadlifts; soft paper or cloth pads should be placed on the edge of the bedpan;

-The client should be prevented from lying directly on the rubber sheet or plastic cloth.

4.4 Nutrition intake

Clients should be provided with meals that enhance their resistance and tissue repair capacity, and encourage and help them to eat.

4.5 Primary disease treatment

The client should be arranged to seek medical treatment, treat the primary disease, return to the clinic on time, give medicine on time, and help complete the rehabilitation course.

4.6 Psychological support

Clients should be provided with psychological counselling.

4.7 Health education

The clients and their families should be informed about the prevention of pressure ulcers.

5.1 Inspection

5.1.1 Inspections should be carried out simultaneously during daily care.

5.1.2 The inspection contents should include whether the skin is dry and intact, whether it is damaged, whether the color is changed, whether the diaper cover is dry and flat.

5.1.3 At the time of handover, the clients of each level of high risk of pressure ulcer should be inspected together to confirm the occurrence of pressure ulcers.

5.2 Record

5.2.1 Records should include.

--Pressure ulcer screening records of the service objects of the elderly care institutions;

-Record of pressure ulcer risk assessment;

-Written record of the outcome of those at high risk of pressure ulcers;

-Handover inspection and turn over records;

-Records of preventive measures taken at high risk of pressure ulcers;

-Written records of the use of assistive devices and drugs.

5.2.2 Records should be included in the client's health file.

5.3 Training

5.3.1 The knowledge of pressure ulcer prevention should be included in the pre-job training content of the elderly care workers.

5.3.2 Elderly care institutions shall carry out no less than one thematic training on pressure ulcer prevention every year.

Appendix A

(Informative appendix)

Table A.1 Risk assessment form for pressure ulcers

Living area bed number name gender age Evaluation Content Score Fully restricted and unresponsive to painful stimuli. 1 Very restricted to respond to painful stimuli, but cannot be expressed in words, but can only be expressed by moaning, restlessness. 2 Slightly restricted Responds to instructional language, but can't always express discomfort in words, or feel pain or discomfort in some limbs Impaired ability.

No damage Responds to prescriptive language, no feeling impaired. 4 Persistent Wetness Every time you move or flip, you always see your skin wet with secretions and urine. 1 Very wet sheets are changed at least every shift due to frequent moisture. 2 Occasionally wet The skin is occasionally wet, and the sheets are changed about once a day. 3 Rarely wet skin is usually dry, and the sheets are changed at regular times. 4 Bedridden is limited to bed. 1 Wheelchairs are not allowed to walk. You must use chairs or wheelchairs. 2 Support walking occasionally during the day, but the distance is very short. 3 You can move freely and walk often. 4 Being completely restricted with the help of others can change body position. 1 Severe restriction can occasionally change the position of the body or limbs, but not independently. 2 Mild restriction is only a slight change in the position of the body or extremities. It can be moved frequently and independently. 3 Unrestricted can be changed at will. 4 Very poor never eaten a full meal, or fasted and/or drank a liquid-free diet. 1 it may be inadequate after each meal, occasional meals or small liquid diets or tube feeding diets. 2 sufficient Most meals can be eaten, but meals are often added; they cannot be eaten by mouth.

Dividing nutritional needs.

Good meals are basically normal. 4 Problem Assistance is required to move. The skin and the surface of the sheets are not fully supported when moving.

Swipe down.

Potential problems are laborious to move, maintain good posture most of the time, and occasionally slide down. 2 does not exist problem can move independently in bed or chair and maintain good posture. 3 Evaluation score Evaluator's Signature. Evaluation Date.

Table note. The highest evaluation score is 23 points and the lowest is 6 points. The higher the assessment score, the higher the risk of hypotension. Evaluation score <=9 is classified as extremely high risk, and 10-12 is classified as high risk

13-14 are classified as moderate high risk, and 15-18 are classified as low high risk. Low-risk and high-risk risks should be evaluated once a week; the higher the risk, the shorter the evaluation cycle.

references

[1] World Health Organization, translated by Dong Jingwu, tenth revised edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) Second edition Chinese text, People's Medical Publishing House, 2015