Maintaining patient monitoring records. Nursing process map for pressure ulcers sample filling. To reduce skin friction on the supporting surface

“On approval of the industry standard

“Patient management protocol. Bedsores"

In order to ensure the quality of medical care for patients at risk of developing pressure ulcers, I ORDER:

1.1. Industry standard “Protocol for patient management. Bedsores" (OST 91500.11.0001-2002) (Appendix No. 1 to this order).

1.2. Registration form No. 003-2/у “Nursing observation card for patients with bedsores” (Appendix No. 2 to this order).

2. Entrust control over the implementation of this order to the First Deputy Minister A.I. Vyalkova.

Minister Yu.L. Shevchenko

Appendix No. 1 to the order

SYSTEM OF STANDARDIZATION IN HEALTHCARE

Patient management protocol.

1 AREA OF USE

The requirements of the industry standard apply to the provision of medical care to all patients who have risk factors for developing pressure ulcers, according to the risk factors, and who are treated in an inpatient setting.

2. PURPOSE OF DEVELOPMENT AND IMPLEMENTATION

3. DEVELOPMENT AND IMPLEMENTATION TASKS

1. Introduction of modern systems for assessing the risk of developing pressure ulcers, drawing up a prevention program, reducing the incidence of pressure ulcers and preventing pressure ulcer infections.

2. Timely treatment of bedsores depending on the stage of their development.

3. Improving the quality and reducing the cost of patient treatment due to the introduction of resource-saving technologies.

4. Improving the quality of life of patients at risk of developing bedsores.

4. CLINICAL EPIDEMIOLOGY, MEDICAL

According to English authors, in medical and preventive care institutions, bedsores develop in 15-20% of patients. According to a study conducted in the United States, about 17% of all hospitalized patients are at risk for developing pressure ulcers or already have them.

The estimated cost for treating pressure ulcers per patient ranges from $5,000 to $40,000. According to D. Waterlow, in the UK the cost of caring for patients with pressure ulcers is estimated at 200 million pounds sterling and increases by 11% annually as a result of treatment costs and increased length of hospitalization.

Inadequate anti-bedsore measures lead to a significant increase in direct medical costs associated with the subsequent treatment of resulting bedsores and their infection.

The duration of the patient's hospitalization increases, and there is a need for adequate dressings (hydrocalloid, hydrogels, etc.) and medicinal (enzymes, anti-inflammatory, regeneration-improving agents) products, instruments, and equipment. In some cases, surgical treatment of bedsores of stages III-IV is required.

Legislative framework of the Russian Federation

Free consultation

Federal legislation

ORDER of the Ministry of Health of the Russian Federation dated April 17, 2002 N 123 “ON APPROVAL OF THE INDUSTRY STANDARD “PROTOCOL FOR THE MANAGEMENT OF PATIENTS. BEDSORES"

In order to ensure the quality of medical care for patients at risk of developing pressure ulcers, I order:

1.1. Industry standard “Protocol for patient management. Bedsores" (OST 91500.11.0001-2002) (Appendix No. 1 to this order).

1.2. Registration form N 003-2/у “Nursing observation card for patients with bedsores” (Appendix No. 2 to this order).

Application
to the order
Ministry of Health of Russia
dated April 17, 2002 N 123

Introduction of modern methodology for the prevention and treatment of bedsores in patients with various types of pathologies associated with prolonged immobility.

1. Introduction of modern systems for assessing the risk of developing pressure ulcers, drawing up a prevention program, reducing the incidence of pressure ulcers and preventing pressure ulcer infection.

2. Timely treatment of bedsores depending on the stage of their development.

3. Improving the quality and reducing the cost of patient treatment due to the introduction of resource-saving technologies.

4. Improving the quality of life of patients at risk of developing bedsores.

There are practically no statistical data on the incidence of pressure ulcers in medical institutions of the Russian Federation. But, according to a study in the Stavropol Regional Clinical Hospital, designed for 810 beds, with 16 inpatient departments, for 1994-1998. 163 cases of pressure ulcers were registered (0.23%). All of them were complicated by infection, which accounted for 7.5% of the total structure of nosocomial infections.

In addition to the economic (direct medical and non-medical) costs associated with the treatment of pressure ulcers, it is necessary to take into account intangible costs: severe physical and mental suffering experienced by the patient.

Inadequate anti-bedsore measures lead to a significant increase in direct medical costs associated with the subsequent treatment of resulting bedsores and their infection.

The duration of the patient's hospitalization increases, and there is a need for adequate dressings (hydrocalloid, hydrogels, etc.) and medicinal (enzymes, anti-inflammatory, regeneration-improving agents) products, instruments, and equipment. In some cases, surgical treatment of stage III-IV bedsores is required.

All other costs associated with the treatment of bedsores also increase.

Adequate prevention of pressure ulcers makes it possible to prevent their development in patients at risk in more than 80% of cases.

Thus, adequate prevention of pressure ulcers will not only reduce the financial costs of treating pressure ulcers, but also improve the patient’s quality of life.

Pressure at bony prominences, friction, and shearing (shearing) forces lead to pressure ulcers. Long-term (more than 1-2 hours) pressure leads to vascular obstruction, compression of nerves and soft tissues. In the tissues above the bone protrusions, microcirculation and trophism are disrupted, hypoxia develops, followed by the development of bedsores.

Damage to soft tissue from friction occurs when the patient moves, when the skin is in close contact with a rough surface. Friction causes injury to both the skin and deeper soft tissues.

Shear damage occurs when the skin is immobile and deeper tissues are displaced. This leads to impaired microcirculation, ischemia and skin damage, most often against the background of additional risk factors for the development of bedsores (see appendices).

Risk factors for the development of pressure ulcers may be reversible (eg, dehydration, hypotension) or irreversible (eg, age), intrinsic or extrinsic.

123 order of the Ministry of Health

Sacrum – 36%
Buttocks – 21%
Heels – 25%
Dr. places 2-4%

GENERAL APPROACHES TO PREVENTION

Adequate prevention of pressure ulcers will ultimately lead to a reduction in direct medical costs associated with the treatment of pressure ulcers, direct (non-medical), indirect (indirect) and intangible (intangible) costs.

Adequate anti-bedsore measures must be carried out by nursing staff after special training.

Preventive measures should be aimed at:

Reducing pressure on bone tissue;

Prevention of friction and tissue shear when moving the patient or when positioning him incorrectly (“sliding” from pillows, “sitting” in a bed or on a chair);

Observation of the skin over bony prominences;

Keeping the skin clean and moderately moist (not too dry and not too wet);

Providing the patient with adequate food and drink;

Teaching the patient self-help techniques for mobility;

General approaches to the prevention of pressure ulcers are as follows:

Timely diagnosis of the risk of developing bedsores;

Timely start of implementation of the entire complex of preventive measures;

Adequate technique for performing simple medical services, incl. care

1. The total number of stroke patients admitted to the department during the year is ___________.
2. The number of patients at risk of developing pressure ulcers according to the D. Waterlow scale is 10 or more points ___________.
3. The number of patients who developed pressure ulcers ___________.

IN THE INSPECTION DEPARTMENT OF A REGIONAL (CITY) HOSPITAL

Sample: all patients receiving treatment in the department during the calendar year, but for at least 6 hours, with a risk of developing pressure ulcers of 10 points or more on the Waterlow scale, who do not have pressure ulcers at the time of meeting the industry standard.

4. The total number of patients who were in the department during the year (min. period of at least 6 hours) ___________.
5. The number of patients at risk of developing pressure ulcers on the Waterlow scale of 10 or more points __________.
6. Number of patients who developed pressure ulcers _______.



7. 8-10 o'clock - Fowler's position;
8. 14-16 hours - Fowler's position;
9. 18-20 hours - Fowler's position;
10. 20-22 hours - position “on the right side”;
11. 22-24 hours - position “on the left side”;
12. 2-4 hours - position “on the right side”;
13. 6-8 hours - Sims position

Change the patient's position every 2 hours:

14. 8-10 hours - sitting position;
15. 10-12 hours - position “on the left side”;
16. 12-14 hours - position “on the right side”;
17. 14-16 hours - sitting position;
18. 16-18 hours - Sims position;
19. 18-20 hours - sitting position;
20. 0-2 hours - Sims position;
21. 4-6 hours - position “on the left side”;

If the patient can be moved (or move independently with the help of assistive devices) and in a chair (wheelchair), he can be in a sitting position and in a bed).

Daily 12 times

"Expert Standard for the Prevention of Pressure Sores in Nursing."

Germany, April 2002

This Standard includes a detailed list of responsibilities and displays of integrity on the part of personnel. The compilers of the Standard emphasize that all statements, without exception, are based on existing national and foreign scientific literature and are thus scientifically sound.

SI Qualified nursing staff have current knowledge of the occurrence of pressure ulcers and can make a competent assessment of the risk of pressure ulcers. (from the Expert Standard for Pressure Ulcer Prevention)

Factors and causes of bedsores

(excerpts from German literature)

Based on studies that were published in 1930, we can call such a thing as a pressure limit, which, when increased over a certain time, leads to the formation of bedsores. This pressure limit is 30 millimeters of mercury, i.e. if the patient lies on a hard surface or sits in a chair that puts a lot of pressure on the tissue, bedsores appear. As a result of the examination, blood pressure in the capillaries is 30 mm. mercury column and, thus, it becomes clear that higher pressure from external factors leads to compression of the blood capillaries, which affects the insufficient supply of oxygen to the tissue.

FACTOR: EXPOSURE TIME

The longest exposure time was determined to be 2 hours. This time limit is based on the fact that tissue is guaranteed to die if there is no oxygen supply within 2 hours - a situation that is largely uncontrolled in clinical practice. Some authors suggest that the 2 hour period is determined historically and refer to Florence Nightingale (1820-1910), who described ulcers formed from bedsores. During the Crimean War, it took an estimated 2 hours in the infirmary to shift or move seriously wounded soldiers; Thus, the maximum exposure time was identified. In fact, this time is based on experimental studies conducted on animals, and is the basis for regularly turning the patient over in order to prevent the formation of bedsores.

FACTOR: MAIN DISEASES

A huge number of diseases lead to the formation of bedsores. This fact must be taken into account, since it is often argued that the formation of pressure ulcers results from insufficient professional care. Consequently, successful therapy of various underlying diseases is a prerequisite for effective prevention of the formation of ulcerative bedsores. An increased risk of pressure ulcers occurs:



FACTOR: SHEAR AND FRICTION

Mainly distinguished:

Shear forces: the patient slides down on the mattress;

Friction: formed, for example, as a result of the movement of the heels on the sheet.

The problem of increased shear forces occurs when the patient has dry skin.

As before, there are controversial discussions about the relationship between the formation of bedsores and urinary and fecal incontinence. The Expert Standard “Prevention of Pressure Sores in Nursing” clearly states that this relationship is not guaranteed. It is necessary to clearly distinguish between bedsores, on the one hand, and skin changes due to exposure to urine, on the other hand, even in cases where the local skin changes seem identical. Skin changes caused by urine represent damage to the skin layers and cellular structures. It is more correct to designate all kinds of lesions on the skin formed under the influence of urine as “dermatitis”, since due to swelling of the skin, infection can occur.

There are many studies that show that a lack of protein increases the risk of pressure ulcers, as does a lack of intracellular zinc.

A summary of the various factors shows that the occurrence of pressure ulcers is a multifactorial phenomenon. Considering all these factors, it becomes clear that, at least theoretically, it is possible to prevent the formation of bedsores, despite the fact that the possibilities of influencing the patient during care are different for everyone.







PI Care professionals determine the risk of pressure ulcers in all patients for whom such a risk cannot be excluded immediately at the beginning of the care contract and later on an individual basis, as well as immediately when there is a change in mobility, activity or pressure. Risk, among other things, is also determined using a standardized rating scale according to Braden, Waterlow or Norton.

SI There is a current systematic assessment of the threat of pressure ulcers.

(from the Expert Standard for Pressure Ulcer Prevention)

Until now, scientists and pragmatists in Germany argue over the issue of reliability, validity and validity for the use of scale assessment methods. This is also evidenced by the fact that the National Expert Standard names three acceptable rating scales, which we will consider.

Prevention of bedsores - order 123 of the Ministry of Health (protocol)



04/17/2002 The Ministry of Health of the Russian Federation issued order No. 123 On the approval of the industry standard “Protocol for the management of patients. Bedsores." This Order of the Ministry of Health No. 123 contains basic information about bedsores and necessary preventive measures.



Industry standard for pressure ulcers

Scope of application of the Order of the Ministry of Health No. 123

The provisions of this medical protocol of the Ministry of Health No. 123 are applicable to provide medical care to patients at risk of developing bedsores who are undergoing therapeutic treatment in hospitals.

The purpose of the development and implementation of Order of the Ministry of Health No. 123

Ministry of Health Protocol No. 123 aims to promote the latest technologies for preventive measures and treatment of necrosis in people with a variety of diseases that lead to a forced long stay in an immobile position.

Tasks of development and implementation of protocol No. 123

The main objectives of the Order of the Ministry of Health No. 123:

22. Introduction of innovative technologies for assessing the risk level of pressure ulcers, creating a preventive plan, reducing the number of cases of pressure ulcers and preventing infectious inflammation of pressure ulcers.
23. Early treatment of necrosis, based on the stage of its occurrence.
24. Improving the quality and reducing the cost of patient therapy, thanks to the introduction of resource-saving technologies.
25. Improving the quality of life of patients who are at risk of necrosis.

The main objective of the protocol is directly to prevent the occurrence of bedsores.

Clinical epidemiology, medical and social significance

Order No. 123 of the Ministry of Health also mentions statistics on the development of bedsores in patients. There are few statistical data on the incidence of this disease in patients undergoing treatment in hospitals in the Russian Federation.

Important! However, over 4 years, 153 cases of bedsores were registered in the Stavropol hospital for 800 patients. Moreover, each of them was complicated by infection.

In England, social workers estimate that about 1/5 of patients develop pressure ulcers. In America, the same number of patients are either at risk for necrosis or already have bedsores. Order No. 123 considers bedsores as an economic problem. The costs of treating bedsores that occur are estimated at disappointing figures. Every year the cost of caring for such patients increases by ten percent.

The order of the Ministry of Health also emphasizes the fact that in addition to the material costs of treating necrosis that occurs in patients, it is worth taking into account the severe moral and physical suffering of patients.

Improper treatment and prevention of bedsores provokes an increase in the necessary costs in medicine to eliminate necrosis and complications that arise. In addition, the patient is forced to stay longer in a hospital facility. Spending on special anti-bedsore medications, instruments, and equipment is increasing. Sometimes it also becomes necessary to resort to surgical intervention in the final stages of necrosis. There is a need to spend large amounts of money on other methods of treatment.



According to the Ministry of Health protocol No. 123, with correctly performed preventive measures, it is possible to avoid the occurrence of necrosis in most patients.

Important! In addition to reducing the cost of treating a patient, correct preventive actions can improve his quality of life.

General questions of Order of the Ministry of Health No. 123

Order No. 123 considers bedsores as necrotic tissue changes.

Bedsores occur when there is prolonged pressure or friction of the skin on a hard surface. In this case, the vessels become stenotic and the nerves in the compressed area are compressed, which disrupts tissue nutrition.

In addition, necrotic changes can develop due to shear, when the skin is motionless and the soft tissue underneath is subject to movement. In this situation, there is a disruption in the blood supply to this area, and the skin is damaged.

Risk factors

Order No. 123 defines bedsores as necrosis that forms as a result of reversible and irreversible causes.

26. Cachexia;
27. Anemia;
28. Lack of protein and vitamin C in food;
29. Dehydration;
30. Reduced blood pressure;
31. Enuresis/encopresis;
32. Pathologies of the nervous system;
33. Ischemia;
34. Thin skin;
35. Anxiety;
36. Confusion;
37. Coma;
38. Violation of hygiene rules;
39. Folded bed linen or patient's clothing;
40. Parts of a hospital bed;
41. Items for restraining the patient;
42. Injuries to the axial areas of the skeleton or internal organs;
43. Spinal cord injuries;
44. Use of cytostatics;
45. Violation of the rules for shifting the patient.
46. Old age;
47. Major surgery over two hours.

In order to determine how likely a patient is to develop necrosis, according to Order of the Ministry of Health No. 123 “Bedsores,” you need to use the Waterlow risk scale. With its help, scores are calculated based on many factors, including the patient’s physique, his gender and age, skin type and others.



The protocol requires daily calculation of the degree of threat of bedsore formation in those patients who are forced to remain in a fixed position for a long time.

The figure obtained after calculations must be entered into the protocol for the management of this disease and preventive measures must be started immediately.

Areas of development of pressure ulcers

Risk areas for necrosis may vary and depend on the position in which the patient remains for a long time.

Protocol No. 123 of the Ministry of Health identifies two groups of risk zones:

48. Most often, necrotic changes occur near the ears, in the thoracic spine, sacrum, on the proximal thigh, in the area of ​​the fibula, on the buttocks, in the elbow joint, and near the heel tuberosities.
49. Much less often, necrosis can affect the occipital and scapular regions, and the phalanges of the toes.



Clinical picture and diagnostic features

Ministry of Health Protocol No. 123 divides the development of pressure ulcers into several stages. Symptoms have their own characteristics at each stage of necrosis formation:

50. Abundant blood supply to the skin, but its integrity is not compromised.
51. Peeling of the top layer of skin, the beginning of the necrotic process of the dermis and subcutaneous tissue.
52. Purulent discharge from the ulcer, necrotic changes cover the muscle tissue.
53. Necrosis affects all tissues, an ulcer forms where areas of bone are visible.

The diagnosis of “bedsore” is made based on the results of an examination by a doctor. Laboratory findings on the composition of discharge from the ulcer and the person’s pain sensations are also taken into account.

Protocol No. 123 proposes to consider infectious diseases that are consequences of the development of necrosis as nosocomial infections.

Order of the Ministry of Health No. 123 requires that all data received be recorded in the nursing chart for monitoring and caring for the patient.

General approaches to the prevention of bedsores according to standard No. 123

Order of the Ministry of Health No. 123 implies that preventive actions are carried out by nurses after training.

Prevention goals, according to Ministry of Health protocol No. 123:

Patient model

According to the protocol of the Order on pressure ulcers 123, preventive measures are necessary for seriously ill bedridden people who have scored more than ten points on the Waterlow risk scale while staying in a hospital setting.

The bedsore protocol considers specifically those patients who are undergoing therapy in oncology, traumatology, neurology, neurosurgical and intensive care units.

The requirements of the order apply to diseases that result in immobility of the patient.

Features of patient care in protocol No. 123

Diet according to standard order

The protocol also recommends preventing bedsores with proper nutrition. Based on Ministry of Health Order No. 123, the patient’s menu should include at least 120 grams of protein and about one gram of vitamin C per day. Meals must contain a sufficient amount of calories.

Informed voluntary consent protocol form

The bedsore standard requires treatment only at the will of the person. Before performing medical intervention, it is necessary to obtain voluntary consent from the patient, in accordance with Article 32 of the “Fundamentals of the Legislation of the Russian Federation on the Protection of Citizens.”

If the patient’s well-being prevents him from expressing his opinion on this matter, and medical intervention is urgent, then the problem should be resolved by a council or the attending doctor. After this, he must notify the hospital staff about his actions.

Order of the Ministry of Health No. 123 prescribes the nature and sequence of implementation of preventive anti-bedsore actions to be agreed upon with the patient on paper, and, if impossible, with his relatives. The “Bedsores” standard also obliges to provide the patient with complete information about the goals of their prevention and all possible complications and risks.

MINISTRY OF HEALTH
RUSSIAN FEDERATION

On approval of the industry standard
"Protocol for patient management. Pressure ulcers"

_______________________________________________________________________________
The document does not require state registration by the Ministry of Justice of the Russian Federation
Letter of the Ministry of Justice of the Russian Federation dated 06/03/2002 N 07/5195-UD.
______________________________________________________________________________

In order to ensure the quality of medical care for patients at risk of developing pressure ulcers

I order:

1. Approve:

1.1. Industry standard "Protocol for the management of patients. Pressure sores" (OST 91500.11.0001-2002) (Appendix No. 1* to this order).
__________________
* See Appendix No. 1 at the link. - Database manufacturer's note.

1.2. Registration form N 003-2/у “Nursing observation card for patients with bedsores” (Appendix No. 2 to this order).

2. Entrust control over the implementation of this order to the First Deputy Minister A.I. Vyalkov.

Minister
Yu.L.Shevchenko

Appendix N 2. Registration form N 003-2/у "Nursing observation card for patients with pressure ulcers"

Appendix No. 2

APPROVED
by order of the Ministry
healthcare of the Russian Federation
dated April 17, 2002 N 123

Medical documentation
Insert for medical
inpatient card
N 003/у
Registration form N 003-2/у

"CARD OF NURSING OBSERVATION OF PATIENTS
WITH BEDSORES"

1. Full name patient

2. Branch

3. Chamber

4. Clinical diagnosis

5. Start of implementation of the care plan: date ____ hour. _____ min.

6. Completion of implementation of the care plan: date ____ hour._____ min.

I. Patient's consent to the proposed plan of care

Received an explanation of the pressure ulcer prevention care plan;

Received information:

about risk factors for the development of bedsores,

for the purposes of preventive measures,

consequences of non-compliance with the entire prevention program.

The patient was offered a care plan in accordance with the industry standard “Protocol for the management of patients. Bedsores”, approved by Order of the Ministry of Health of Russia dated April 17, 2002 N 123, and full explanations were given about the features of the diet.

The patient is informed of the need to follow the entire prevention program, regularly change position in bed, and perform breathing exercises.

The patient is informed that failure to comply with the recommendations of the nurse and doctor may be complicated by the development of bedsores.

The patient is notified of the outcome if the plan of care is not followed.

The patient had the opportunity to ask any questions he had regarding the plan of care and received answers to them.

The interview was conducted by nurse _____________ (nurse signature)

" __ " ______________ 20 __

The patient agreed with the proposed plan of care, which he signed with his own hand __________________ (patient signature) or signed for him (according to paragraph 6.1.9 of the industry standard “Protocol for the management of patients. Pressure sores”, approved by order of the Ministry of Health of Russia dated April 17, 2002 N 123)

___________________ (signature, full name),

what those present at the conversation attest to

_____________ (nurse signature)

_____________ (witness signature)

The patient did not agree (refuse) with the proposed care plan, for which he signed with his own hand __________________ (patient signature) or signed for him (according to paragraph 6.1.9 of the industry standard “Protocol for the management of patients. Pressure sores”, approved by order of the Ministry of Health of Russia dated April 17, 2002 N 123 )

____________________ (signature, full name).

II. Nursing assessment sheet for the development and stage of pressure ulcers

04/17/2002. This Order of the Ministry of Health No. 123 contains basic information about bedsores and necessary preventive measures.

Industry standard for pressure ulcers

Scope of application of the Order of the Ministry of Health No. 123

The provisions of this medical protocol of the Ministry of Health No. 123 are applicable to provide medical care to patients at risk of developing bedsores who are undergoing therapeutic treatment in hospitals.

The purpose of the development and implementation of Order of the Ministry of Health No. 123

Ministry of Health Protocol No. 123 aims to promote the latest technologies for preventive measures and treatment of necrosis in people with a variety of diseases that lead to a forced long stay in an immobile position.

Tasks of development and implementation of protocol No. 123

The main objectives of the Order of the Ministry of Health No. 123:

1. Introduction of innovative technologies for assessing the risk level of pressure ulcers, creating a preventive plan, reducing the number of cases of pressure ulcers and preventing infectious inflammation of pressure ulcers.
2. Early treatment of necrosis, based on the stage of its occurrence.
3. Improving the quality and reducing the cost of patient therapy, thanks to the introduction of resource-saving technologies.
4. Improving the quality of life of patients who are at risk of necrosis.

The main objective of the protocol is directly to prevent the occurrence of bedsores.

Clinical epidemiology, medical and social significance

Order No. 123 of the Ministry of Health also mentions statistics on the development of bedsores in patients. There are few statistical data on the incidence of this disease in patients undergoing treatment in hospitals in the Russian Federation.

Important! However, over 4 years, 153 cases of bedsores were registered in the Stavropol hospital for 800 patients. Moreover, each of them was complicated by infection.

In England, social workers estimate that about 1/5 of patients develop pressure ulcers. In America, the same number of patients are either at risk for necrosis or already have bedsores. Order No. 123 considers bedsores as an economic problem. The costs of treating bedsores that occur are estimated at disappointing figures. Every year the cost of caring for such patients increases by ten percent.

The order of the Ministry of Health also emphasizes the fact that in addition to the material costs of treating necrosis that occurs in patients, it is worth taking into account the severe moral and physical suffering of patients.

Improper treatment and prevention of bedsores provokes an increase in the necessary costs in medicine to eliminate necrosis and complications that arise. In addition, the patient is forced to stay longer in a hospital facility. Spending on special anti-bedsore medications, instruments, and equipment is increasing. Sometimes it also becomes necessary to resort to surgical intervention in the final stages of necrosis. There is a need to spend large amounts of money on other methods of treatment.

According to the Ministry of Health protocol No. 123, with correctly performed preventive measures, it is possible to avoid the occurrence of necrosis in most patients.

Important! In addition to reducing the cost of treating a patient, correct preventive actions can improve his quality of life.

General questions of Order of the Ministry of Health No. 123

Pathogenesis

Order No. 123 considers bedsores as necrotic tissue changes.

Bedsores occur when there is prolonged pressure or friction of the skin on a hard surface. In this case, the vessels become stenotic and the nerves in the compressed area are compressed, which disrupts tissue nutrition.

In addition, necrotic changes can develop due to shear, when the skin is motionless and the soft tissue underneath is subject to movement. In this situation, there is a disruption in the blood supply to this area, and the skin is damaged.

Risk factors

Order No. 123 defines bedsores as necrosis that forms as a result of reversible and irreversible causes.

In order to determine how likely a patient is to develop necrosis, according to Order of the Ministry of Health No. 123 “Bedsores,” you need to use the Waterlow risk scale. With its help, scores are calculated based on many factors, including the patient’s physique, his gender and age, skin type and others.

The protocol requires daily calculation of the degree of threat of bedsore formation in those patients who are forced to remain in a fixed position for a long time.

The figure obtained after calculations must be entered into the protocol for the management of this disease and preventive measures must be started immediately.

Areas of development of pressure ulcers

Risk areas for necrosis may vary and depend on the position in which the patient remains for a long time.

1. Most often, necrotic changes occur near the ears, in the thoracic spine, sacrum, on the proximal thigh, in the area of ​​the fibula, on the buttocks, in the elbow joint, and near the heel tuberosities.
2. Much less often, necrosis can affect the occipital and scapular regions, and the phalanges of the toes.

Clinical picture and diagnostic features

Ministry of Health Protocol No. 123 divides the development of pressure ulcers into several stages. Symptoms have their own characteristics at each stage of necrosis formation:

1. Abundant blood supply to the skin, but its integrity is not compromised.
2. Peeling of the top layer of skin, the beginning of the necrotic process of the dermis and subcutaneous tissue.
3. Purulent discharge from the ulcer, necrotic changes cover the muscle tissue.
4. Necrosis affects all tissues, an ulcer forms where areas of bone are visible.

The diagnosis of “bedsore” is made based on the results of an examination by a doctor. Laboratory findings on the composition of discharge from the ulcer and the person’s pain sensations are also taken into account.

Protocol No. 123 proposes to consider infectious diseases that are consequences of the development of necrosis as nosocomial infections.

Order of the Ministry of Health No. 123 requires that all data received be recorded in the nursing chart for monitoring and caring for the patient.

General approaches to the prevention of bedsores according to standard No. 123

Order of the Ministry of Health No. 123 implies that preventive actions are carried out by nurses after training.

Prevention goals, according to Ministry of Health protocol No. 123:

• Reduced compression of bony protrusions;
• Avoid friction and movement of tissues when moving the patient or when the position is incorrectly chosen for him;
• Regular examination of the patient’s skin in a high-risk area;
• Maintaining patient hygiene;
• Properly selected diet;
• Teaching the patient how to help himself when moving;
• Training of relatives.

Patient model

According to the protocol of the Order on pressure ulcers 123, preventive measures are necessary for seriously ill bedridden people who have scored more than ten points on the Waterlow risk scale while staying in a hospital setting.

The bedsore protocol considers specifically those patients who are undergoing therapy in oncology, traumatology, neurology, neurosurgical and intensive care units.

The requirements of the order apply to diseases that result in immobility of the patient.

Features of patient care in protocol No. 123

1. The patient is required to have handrails on both sides and a mechanism for raising the top of the bed. Its height should approximately correspond to the level of the nurse's mid-thigh.
2. This bed must have the ability to change height so that the patient can leave it independently.
3. It is necessary to choose the right mattress against bedsores. Place special foam rollers under your feet.
4. must be cotton.
5. It is necessary to change the patient's position every two hours, including at night. After changing position, inspect the skin.
6. The patient should be moved carefully, lifting him above the bed.
7. Massage should be done only after applying a special moisturizer.
8. Wash the patient using liquid soap and dry the skin with blotting movements.
9. Use waterproof diapers and sheets.
10. Encourage the patient to move independently and teach this.
11. Provide training to loved ones.
12. Avoid overdrying or overmoistening the skin.
13. Monitor the patient’s bed, remove crumbs and folds.
14. Teach the patient to perform respiratory exercises and support him in this.

Diet according to standard order

The protocol also recommends preventing bedsores with proper nutrition. Based on Ministry of Health Order No. 123, the patient’s menu should include at least 120 grams of protein and about one gram of vitamin C per day. Meals must contain a sufficient amount of calories.

Informed voluntary consent protocol form

The bedsore standard requires treatment only at the will of the person. Before performing medical intervention, it is necessary to obtain voluntary consent from the patient, in accordance with Article 32 of the “Fundamentals of the Legislation of the Russian Federation on the Protection of Citizens.”

If the patient’s well-being prevents him from expressing his opinion on this matter, and medical intervention is urgent, then the problem should be resolved by a council or the attending doctor. After this, he must notify the hospital staff about his actions.

Order of the Ministry of Health No. 123 prescribes the nature and sequence of implementation of preventive anti-bedsore actions to be agreed upon with the patient on paper, and, if impossible, with his relatives. The “Bedsores” standard also obliges to provide the patient with complete information about the goals of their prevention and all possible complications and risks.

Video

Abdominal hernias.

An abdominal hernia is an exit from the abdominal cavity of internal organs along with the peritoneum covering them through natural or acquired defects of the abdominal wall under the skin or into other cavities. There are external and internal, congenital and acquired, reducible and irreducible abdominal hernias. Classification: umbilical hernias, hernias of the white line of the abdomen, inguinal hernias, femoral hernias, diaphragmatic hernias, postoperative hernias (strangulation).

Strangulated hernia. Incarceration is compression of the contents of the hernia in the area of ​​the hernial orifice. As a result of strangulation in the hernial contents, blood supply and innervation are stopped, blood stagnation and tissue necrosis develop. Symptoms: sudden pain in the hernia area, its enlargement, irreducibility, sharp tension and pain in the hernial protrusion. After some time, cramping pain in the abdomen, vomiting, retention of stool and gas. Tactics: For a strangulated hernia, thermal procedures, anesthesia, antispasmodics, and attempts at manual reduction are contraindicated. Emergency hospitalization to the surgical department on a stretcher in a position comfortable for the patient is indicated. In case of spontaneous reduction during transportation, emergency hospitalization for dynamic observation of the patient in the hospital is also indicated. Treatment: The main surgical method is herniotomy. Contraindications to surgical treatment are severe respiratory and cardiovascular failure, active tuberculosis, malignant tumors. For such patients, a bandage is recommended. Types of surgical interventions: autohernioplasty (closure using the patient’s own tissues) and allohernioplasty (various synthetic grafts made of polypropylene).

Peritonitis.

Peritonitis is an inflammation of the peritoneum, accompanied by local and general symptoms of the disease and minor disruptions in the activity of the most important organs and systems of the body. Types: primary, secondary, tertiary. Primary is an extremely rare form of peritonitis of hematogenous origin in which infection of the peritoneum occurs from an extraperitoneal source. Secondary is the most common form of abdominal infection and the main cause of abdominal sepsis in surgical patients. Tertiary - peritonitis without a source of infection, develops in patients in critical conditions with severe depletion of the body's defenses. By prevalence: local (less than two anatomical areas of the peritoneal cavity are affected), widespread (diffuse - the process covers from two to five anatomical areas of the peritoneal cavity, diffuse - more than five anatomical areas are affected). According to the nature of the contents of the abdominal cavity: serous-fibrinous, fibrinous-purulent, purulent, fecal, bile, hemorrhagic, chemical. Depending on the course of the process: no signs of sepsis, sepsis, severe sepsis (multiple organ failure). Clinic: gradually increasing severe pain in the abdomen (localized in the area of ​​the source of peritonitis, then spreading throughout the abdomen), intoxication, pale face, pointed features, sunken eyes. Nausea, vomiting of gastric contents, then intestinal contents. Retention of gases and stool, increased body temperature, muscle tension in the anterior abdominal wall. Treatment: after removing the patient from anesthesia, place him in the Fowler's position, parenteral nutrition for 3-4 days, infusion therapy as prescribed by a doctor, breathing and physical therapy, daily dressings and lavage of the abdominal cavity through drains. During the operation, a probe is inserted into the stomach and intestines, which is removed on days 4-6.

Acute intestinal obstruction.

Acute intestinal obstruction is a disease that is characterized by partial or complete disruption of the movement of contents through the intestines. Types: dynamic - develops as a result of a violation of the contractility of the intestine of paralytic or spastic origin and in most cases is functional in nature, mechanical - with organic blockage of the intestine. Dynamic obstruction is a disorder of intestinal motility of various origins due to damage to its neuromuscular elements. Dynamic obstruction: (Clinic - constant bursting pain in the abdomen of a generalized nature, retention of stool and gases, moderate bloating, regurgitation and vomiting appear in the later stages of the disease as a result of stasis and hypertension in the proximal gastrointestinal tract. Treatment: decompression of the proximal gastrointestinal tract with using gastric or intestinal tubes, the use of pharmacological stimulants of intestinal motility (cerucal, proserin, pituitrin), the introduction of a gas outlet tube or the importance of a siphon tube and hypertensive enemas, correction of water and electrolyte balance, elimination of hypovolemia, elimination of hypoxia, maintaining cardiovascular activity, pain relief and intestinal spasm.) Mechanical obstruction: (clinic – severe abdominal pain of a cramping nature, vomiting, stool and gas retention, bloating. Treatment: surgical)

Acute pancreatitis.

Acute pancreatitis is a pathological process in which swelling, autolysis and necrosis of pancreatic tissue develop with secondary inflammation of pancreatic tissue. Classification: edematous form and pancreatic necrosis (hemorrhagic, fatty, purulent). Complications: septic shock, multiple organ failure, abscess and phlegmon of the pancreas, bleeding, diffuse peritonitis, pancreatic false cyst. Clinic: the onset of the disease is acute, severe cutting pain in the epigastrium and left hypochondrium of a girdling nature, repeated vomiting that does not bring relief, dyspeptic symptoms, increased body temperature. Treatment: conservative, rest (Fowler's position), cold is applied to the pancreatic region, parenteral nutrition, anesthesia, anti-enzyme drugs (Gordox, Contrical), plasma, albumin, detoxification and antibiotic therapy, immunotherapy and desensitizing therapy are carried out for 2-3 days, Highly effective in the first 3-5 days of the disease are hormonal pancreatic blockers sandastotin and octreotide, gastric secretion blockers (famotidine, ranitidine, omeprazole), surgical treatment (laparotomy, drainage of the omental bursa around the pancreas, cholecystostomy, resection of the tail and body of the pancreas.

Acute cholecystitis.

Acute cholecystitis is inflammation of the gallbladder. Classification: calculous (with stones in the gallbladder) and non-calculous (without stones). According to the clinical and morphological form: catarrhal, phlegmonous, gangrenous. Complications: acute pancreatitis, obstructive jaundice, secondary hepatitis, cholangitis, infiltration, abdominal abscess, peritonitis. Clinic: hepatic colic (severe bursting pain in the right hypochondrium, radiating to the right supraclavicular region, scapula, right shoulder), frequent vomiting mixed with bile, retention of stool and gases, increased body temperature to 38-39. Treatment: conservative - bed rest, table No. 5, position in bed with the head end elevated, in the first days cold on the right hypochondrium, parenteral nutrition, in case of uncontrollable vomiting, rinse the stomach, antibiotic therapy, detoxification therapy and desensitizing therapy, painkillers and antispasmodics. Surgical treatment: cholecystectomy.

Acute appendicitis

Acute appendicitis is a nonspecific inflammation of the appendix of the cecum. Classification: acute and chronic. Clinic: cutting or pressing pain in the epigastric region spreading throughout the abdomen, after a few hours in the right iliac region, pain usually radiates to the right leg, nausea, vomiting, stool and gas retention, increased body temperature, weakness, malaise, pulse increases, muscle tension in the anterior abdominal wall. Complications: appendicular infiltrate. Treatment: surgical only - appendectomy.

Ambulance:

Prevention and treatment of bedsores: (order 123)

· Placing air-inflated circles

· Regularly change body position in bed every 1.5-2 hours

· Massage in the area of ​​pressure

· Elimination of wrinkles in underwear and bed linen

· Replacing wet clothes with dry ones

· Removal of foreign bodies and other bed irregularities

· Therapeutic exercises and active regimen of the patient

· Effective irritants: ethyl, camphor, salicylic alcohols

· Careful care of the skin and mucous membranes, washing and wiping with an antiseptic solution, and the skin with a warm soapy solution, providing the patient with clean underwear.

Caring for a patient with a plaster cast:

· If the bandage is too tight, the patient experiences pain in the limbs, cyanosis, increased swelling, and numbness of the fingers. In this case, it is necessary to cut the bandage and temporarily strengthen it with a bandage

Care must be taken to ensure that the bandage does not become contaminated during urination and defecation.

· Keep the limb elevated and move the fingers

· Ensure that the plaster is dry

· Do not allow the patient to remove the plaster cast on their own

· Make sure that no crumbs get under the plaster cast.

Preparing the patient for abdominal ultrasound:

· Explain the process and purpose of the upcoming study and obtain his consent

· Eliminate gas-causing foods (legumes, brown bread, cabbage, milk) from the diet 2-3 days before the test.

· Strictly on an empty stomach

· Do not smoke, do not drink alcohol

First aid for acute urinary retention:

·Use of reflex methods

· Catheterization with a soft catheter in women; in men, this procedure is performed by a doctor or urological nurse

Instructions: Circle the number corresponding to the Waterlow scale.

Sum of points _____________

Risk: no, high, very high (underline)

Bedsores: yes, no (underline)

Stage: 1 2 3 4 (circle)

Agreed with the doctor___________________________

(doctor's signature)

Appendix 2

to the order of the Russian Ministry of Health

from 04/17/02 No. 123

Medical documentation

Insert for medical

inpatient card No. 003/у

Registration form No. 003–2/у

“NURSING CARE CARD

CARE FOR PATIENTS WITH BEDSORES"

1.Patient’s name_________________________________________________________

2. Department_______________________________________________________________

3. Chamber __________________________

4. Clinical diagnosis_______________________________________________

________________________________________________________________

5. Start of implementation of the care plan: date_________hour_______min____

6.Completion of implementation of the care plan: date______ hour______min_____

Patient's agreement to the proposed plan of care

Patient___________________________________________________________

Received an explanation of the bedsore prevention care plan; received information: about risk factors for the development of bedsores, the goals of preventive measures, the consequences of non-compliance with the entire prevention program.

The patient is offered a care plan in accordance with the industry standard “Patient Management Protocol. Bedsores”, approved by order of the Ministry of Health of Russia dated April 17, 2002 No. 123, full explanations were given about the features of the diet.

The patient is informed of the need to follow the entire prevention program, regularly change position in bed, and perform breathing exercises.

The patient is informed that failure to comply with the recommendations of the nurse and doctor may be complicated by the development of bedsores. The patient is notified of the outcome if the plan of care is not followed. The patient had the opportunity to ask any questions he had regarding the plan of care and received answers to them.

The interview was conducted by a nurse_________________________________

(nurse signature)

"__________" ___________20__________

The patient agreed with the proposed plan of care, which he signed with his own hand____________________

(patient signature)

Or signed for him in accordance with paragraph 6.1.9 of the OST “Protocol for the management of patients. Bedsores”, approved by order of the Ministry of Health of the Russian Federation dated April 17, 2002 No. 123___________ (signature, full name), as certified by those present during the conversation__________ ______________

(m/s signature) (witness signature)

The patient did not agree (refuse) with the proposed care plan, which he signed with his own hand__________________________

(patient signature)

Or signed for him in accordance with paragraph 6.1.9 of the OST “Protocol for the management of patients. Bedsores”, approved by order of the Ministry of Health of the Russian Federation dated April 17, 02. No. 123 _________________________

(signature full name)

Standard care plan for a patient at risk of developing pressure ulcers

(in a patient who can sit)

Standard care plan for pressure ulcer risk

(in a bedridden patient)