春暉居家護理所

~傷口護理~ Wound CARE

※傷口護理原則 ： / ※Wound nursing principle:

1. 傷口周圍保持乾燥。 / around the wound keep dry.

2. 傷口需維持適當的濕度。 / The wound needs to maintain appropriate moisture.

3. 無菌技術更換敷料 。 / When you change the dressing must be below asepsis technique.

4. 隨著傷口的進展選擇不同的敷料 。 / You can choose a different dressing according to the progress of wound.

5. 傷口護理並不需要根據標準常規進行更換的次數。 The wound nursing doesn't need the number of times that carries on changing according to the standard normal regulations.

※標準傷口護理步驟 ： / ※Standard wound nursing step:

1. 生理食鹽水清洗傷口 。 Apply normal saline cleans a wound.

2. 優碘環形擦拭傷口 。 The iodine solution annulus form wipes a wound.

3. 30 秒後將優碘擦拭淨 。Clean the better-iodine after 30 second.

P.S.優碘殘留在非感染性傷口，會抑制組織生長及造成皮膚色素沉著。 / P.S. IF iodine solution remaining the wound , will repress tissue growth and make skin pigment calm and steady.

※共同護理： / ※Common nursing:

1. 提供適當的營養。 / Provide an appropriate nutrition.

2. 避免傷口的壓迫 . / Avoid the stress of wound.

3. 尾骨傷口盡量不包尿布-可使用2條看護墊，交叉將臀部包起，保持傷口的周圍乾燥。 / The sacrum wound as far as possible doesn't wrap a diaper-can use 2 and nurse pad, cross and start to wrap hip, keep the surroundings aridity of the wound.

4. 床單拉平 . / The bed sheet evens up.

※傷口各期數之換藥法一 / ※The method of change dressing.  

1. 第一期一 / Stage Ⅰ

表徵 ：發紅不退-若發生在腹股溝，擦乾後用氧化鋅薄薄擦在腹股溝，再將乾紗打散墊在腹股溝。其他部位一用乳液輕輕拍打發紅皮膚，勿用甘油等收斂性油劑。 / Sign: If the redness doesn't disappear, use zinc oxide apply this area, spread a dry gauze in the groin. The other parts use bodylotion apply , don't use glycerine oil etc.

2. 第二期一 / Stage Ⅱ

表徵 :：潰蕩至真皮層或起水泡 . Sign: The ulcer goes to a dermis layer or rises bubble.

處理方法 :a. 大水泡一直徑超過 5mm.: 傷口標準消毒法後，由居家護理師處理刺破傷口，之後覆蓋Sofra-tulle及乾紗布。 / Treatment: a: Big bubble over 5mm-After stander change wound dressing, by yours home care nursing sting break a wound, Then cover Sofra-tulle and dry gauze.

b.小水泡-直徑2-3mm，水泡不需刺破，一標準消毒後覆蓋乾紗布即可。 / b. Small bubble-diameter 2-3 mms, the bubble doesn't need to stab to break, After standard disinfects, thenYou can cover dry gauze .

3.第三期- / Stage Ⅲ-

表徵 :有不規則的深凹傷口，疼痛感，有黃色傷口一標準消毒後 /

     用生理食鹽水沾濕紗布打鬆輕塞入深凹傷口，一日換藥2~4次。只要傷口滲液成淡黃色且多時，即換藥。 / A irregular deeply cave wound、yellow color wound and feel pain. After stander wound care, put the wet gauge (with normal saline) loosen and lightly into a deeply cave wound , change medicine 2~4 times one day. Change medicine when the gauge become yellow color

4.第四期 - / Stage Ⅳ

表徵 ：有潛行深度傷口，黑色傷口，需由居家護理師或返診整型外科清創。                                                     / Sign: Got a depth wound, black wound, need home care nurse or visit plastic doctor .

※3、4期黃＆黑痂傷口清創法--- / 3 and 4 stage wound got black scar wound debridment method----

◎    燙傷藥膏Flamazine薄薄塗於傷口上(需先標準傷口消毒法)，上面再覆蓋乾紗固定。 / Flamazine thin Be drawn to a wound( First need a standard wound care method), then cover the dry gauge.

◎    Y jelly 塗在傷口上，覆蓋O-P site，一日一次。 / Apply K-Y jelly on the wound,then cover O-P site, one times per day.

1. 3-M 及comfeel公司之去痂皮軟膏也可使用，但價格昂貴。 / 3-M and comfeel company it have ointment can also use, but the price is expensive.