坏死性皮下感染，试试这个方法！

2019-03-25 张海红中华现代护理杂志

xujie.L

医生/

坏死性筋膜炎又称坏死性皮下感染，由需氧菌和厌氧菌混合感染所致的以皮下深筋膜及深筋膜周围脂肪组织的坏死性蜂窝织炎，在累及的血管内形成血栓，引起相应部位的皮肤、皮下组织及筋膜组织的坏死，感染灶沿着深筋膜组织扩散。

定义

坏死性筋膜炎又称坏死性皮下感染，由需氧菌和厌氧菌混合感染所致的以皮下深筋膜及深筋膜周围脂肪组织的坏死性蜂窝织炎，在累及的血管内形成血栓，引起相应部位的皮肤、皮下组织及筋膜组织的坏死，感染灶沿着深筋膜组织扩散。

特点：发病急，进展快，病死率高

错觉：皮肤外观常正常

病例介绍

患者女性81岁，主因"发现会阴脓肿10天"收入我科

入院体征：T 36.5℃；BP 164/93mmHg；住院期间最高体温39℃

10天前发现会阴脓肿，当地医院就诊，给予抗炎治疗，效果不佳，脓肿自行破溃，破溃面可见黄色脓性分泌物流出。

既往史：左侧乳腺切除术后40年；高血压病1年，最高压达200/110mmHg；间断头晕10个月

医疗报销：河北省新农合，家庭经济条件一般

诊断：坏死性筋膜炎、脓毒血症、会阴脓肿、左侧腹股沟脓肿、左侧腹壁脓肿、皮肤软组织感染、高血压病3级极高危......

全身评估-全身感染指征

全身评估-专科检查：

左侧会阴大阴唇、左侧腹股沟区及左侧腹壁局部、可见大片皮肤红肿，大阴唇局部伴皮肤溃疡，见脓白色脓液体流出。左腹股沟局部皮肤发黑、血性水泡形成。皮温升高，质地变硬，压痛触痛阳性，可触及波动感。

创面评估及手术处理

清创引流术后当日的伤口

伤口评估：

伤口大小：左侧会阴大阴唇、左侧腹股沟区及左侧腹壁间隔切开9处，切口约1.5cm，间距约6-8cm，切口间橡皮条挂线，总长度约45cm

伤口周围：大片红肿

手术处理：

1、脓肿切开引流

2、双氧水、生理盐水、新洁尔灭、稀释碘伏盐水反复冲洗创口及皮下组织间隙

3、皮下间隙放置银离子油纱引流渗液

4、于左腹壁皮肤最低点放置潘氏引流管一根

第1次换药评估及护理

评估：

护理目标：清除坏死组织，控制感染

第2次换药评估及护理

护理目标：控制感染有效管理渗液

第3次换药评估及护理

评估：

换药的目标：

1 清除坏死组织

2 减少换药次数

3 控制感染

创面护理的步骤

1、保守锐器清创+拆除腹股沟处5个橡皮条

2、拔除外科引流管

3、改用不带冲洗装置的负压引流，接墙壁负压0.02-0.03Kpa，确保贴膜密闭性

4、其余步骤同第1次

第4次换药评估及护理

评估：

换药的目标：闭合潜腔，促进肉芽生长

创面护理的步骤

1 保守锐器清除潜腔内的坏死组织

2 去除剩余的橡皮条

3 大阴唇局部涂银离子凝胶抑菌

4 放置负压引流管至合适位置

5 将无菌透明敷料贴敷于伤口上方，保持密闭性

6 调节负压至合适大小

其余步骤同前

第5次换药评估及护理

评估：

目标：闭合潜腔，促进肉芽生长

措施：

1 局部使用奥布卡因凝胶止痛

2 大阴唇上1/2填塞黑海绵，大阴唇下1/2创口局部涂银离子凝胶，腹壁小创口及潜腔填塞藻酸盐，其余创面填塞黑海绵

3 持续负压吸引

第6、7、8次换药评估及护理

评估：

第6、7次换药间隔6-7天，方法同前，引流通畅，渗液量减少

第8次换药的目标：闭合潜腔，促进肉芽生长

创面护理的步骤：

1 奥布卡因凝胶局部止痛

2 保守清除潜腔内少量的坏死组织

3 潜腔内局部涂少量银离子凝胶抑菌

4 藻酸盐填充伤口床及潜腔，外敷棉垫加压包扎

第9次换药评估及护理

评估：

目标：促进窦道闭合，出院管理

措施：

1 创面及窦道填塞藻酸盐敷料

2 髂前窦道填塞银离子纱布

3 外敷棉垫加压包扎

伤口愈合的全过程

疼痛变化曲线

健康教育

1.关注血糖

2.控制血压

3.重视饮食护理：补充VC、高蛋白、高热量、高维生素、蔬菜、水果

4.功能锻炼：患者髋部陈旧性骨折，加强下肢活动，防血栓

创面护理体会

1.精心的心理护理是创面护理成功的前提

2.充分镇痛是降低高危高龄患者换药风险的第一关

3.早期大胆尝试使用负压引流技术是快速彻底引流渗液的有效手段

4.定期冲洗负压装置是使消毒液深达各潜腔，进而控制感染、防止堵管的良方

5.负压治疗换药周期长，减轻患者换药之苦

6.保持创面持续有效负压是引流成功的关键

7.护士密切的病情观察是确保有效负压的不可或缺的环节

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2020-03-08 yuhaisheng_ibp_32061711

#皮下感染#

46 0
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2019-05-19 贪吃蛇大王

好

73 0
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2019-04-09 贪吃蛇大王

好好学习天天向上

76 0
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2019-04-05 贪吃蛇大王

谢谢分享

77 0
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2019-04-03 贪吃蛇大王

天天学习，谢谢分享

82 0
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createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/SrJSCPdKL0Ph25Lw3vlAkeSOJFyrKYpcmFTYHMla6icH6ibZ0zJHcbe2C5icyicow70stGsTm2efwfR6OibjYZD9N5A/132, createdBy=ff5a2004026, createdName=贪吃蛇大王, createdTime=Fri Apr 05 05:55:23 CST 2019, time=2019-04-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=364040, encodeId=eb7336404096, content=天天学习，谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=82, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/SrJSCPdKL0Ph25Lw3vlAkeSOJFyrKYpcmFTYHMla6icH6ibZ0zJHcbe2C5icyicow70stGsTm2efwfR6OibjYZD9N5A/132, createdBy=ff5a2004026, createdName=贪吃蛇大王, createdTime=Wed Apr 03 06:48:37 CST 2019, time=2019-04-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=363893, encodeId=2497363893e9, content=谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/SrJSCPdKL0Ph25Lw3vlAkeSOJFyrKYpcmFTYHMla6icH6ibZ0zJHcbe2C5icyicow70stGsTm2efwfR6OibjYZD9N5A/132, createdBy=ff5a2004026, createdName=贪吃蛇大王, createdTime=Mon Apr 01 06:26:39 CST 2019, time=2019-04-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=363677, encodeId=bdfe3636e7c0, content=谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/SrJSCPdKL0Ph25Lw3vlAkeSOJFyrKYpcmFTYHMla6icH6ibZ0zJHcbe2C5icyicow70stGsTm2efwfR6OibjYZD9N5A/132, createdBy=ff5a2004026, createdName=贪吃蛇大王, createdTime=Thu Mar 28 07:11:27 CST 2019, time=2019-03-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=363666, encodeId=0e08363666de, content=谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=22, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://thirdwx.qlogo.cn/mmopen/vi_32/DYAIOgq83eqYPFHuMA3bhYQrHvycmum7IJoCsLK0FP6X56Eoj9PZAECDke8zLCKxZZvk9q7B6rZmPuFgN5YCfw/132, createdBy=00912551888, createdName=12543c13m83暂无昵称, createdTime=Thu Mar 28 01:26:09 CST 2019, time=2019-03-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1362940, encodeId=72ee1362940c0, content=<a href='/topic/show?id=b723414321c' target=_blank style='color:#2F92EE;'>#坏死#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=21, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=41432, encryptionId=b723414321c, topicName=坏死)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c0e3195, createdName=millore, createdTime=Tue Mar 26 17:31:00 CST 2019, time=2019-03-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=363549, encodeId=812b363549c6, content=好好学习天天向上, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/SrJSCPdKL0Ph25Lw3vlAkeSOJFyrKYpcmFTYHMla6icH6ibZ0zJHcbe2C5icyicow70stGsTm2efwfR6OibjYZD9N5A/132, createdBy=ff5a2004026, createdName=贪吃蛇大王, createdTime=Tue Mar 26 05:28:37 CST 2019, time=2019-03-26, status=1, ipAttribution=)]
2019-04-01 贪吃蛇大王

谢谢分享

65 0
[GetPortalCommentsPageByObjectIdResponse(id=2054137, encodeId=1f63205413ef6, content=<a href='/topic/show?id=d4a9e192590' target=_blank style='color:#2F92EE;'>#皮下感染#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=71925, encryptionId=d4a9e192590, topicName=皮下感染)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=bb182500058, createdName=yuhaisheng_ibp_32061711, createdTime=Sun Mar 08 15:31:00 CST 2020, time=2020-03-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=366450, encodeId=28a0366450a5, content=好, beContent=null, objectType=article, channel=null, level=null, likeNumber=73, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/SrJSCPdKL0Ph25Lw3vlAkeSOJFyrKYpcmFTYHMla6icH6ibZ0zJHcbe2C5icyicow70stGsTm2efwfR6OibjYZD9N5A/132, 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createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/SrJSCPdKL0Ph25Lw3vlAkeSOJFyrKYpcmFTYHMla6icH6ibZ0zJHcbe2C5icyicow70stGsTm2efwfR6OibjYZD9N5A/132, createdBy=ff5a2004026, createdName=贪吃蛇大王, createdTime=Fri Apr 05 05:55:23 CST 2019, time=2019-04-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=364040, encodeId=eb7336404096, content=天天学习，谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=82, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/SrJSCPdKL0Ph25Lw3vlAkeSOJFyrKYpcmFTYHMla6icH6ibZ0zJHcbe2C5icyicow70stGsTm2efwfR6OibjYZD9N5A/132, createdBy=ff5a2004026, createdName=贪吃蛇大王, createdTime=Wed Apr 03 06:48:37 CST 2019, time=2019-04-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=363893, encodeId=2497363893e9, content=谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, 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content=谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=22, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://thirdwx.qlogo.cn/mmopen/vi_32/DYAIOgq83eqYPFHuMA3bhYQrHvycmum7IJoCsLK0FP6X56Eoj9PZAECDke8zLCKxZZvk9q7B6rZmPuFgN5YCfw/132, createdBy=00912551888, createdName=12543c13m83暂无昵称, createdTime=Thu Mar 28 01:26:09 CST 2019, time=2019-03-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1362940, encodeId=72ee1362940c0, content=<a href='/topic/show?id=b723414321c' target=_blank style='color:#2F92EE;'>#坏死#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=21, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=41432, encryptionId=b723414321c, topicName=坏死)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c0e3195, createdName=millore, createdTime=Tue Mar 26 17:31:00 CST 2019, time=2019-03-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=363549, encodeId=812b363549c6, content=好好学习天天向上, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/SrJSCPdKL0Ph25Lw3vlAkeSOJFyrKYpcmFTYHMla6icH6ibZ0zJHcbe2C5icyicow70stGsTm2efwfR6OibjYZD9N5A/132, createdBy=ff5a2004026, createdName=贪吃蛇大王, createdTime=Tue Mar 26 05:28:37 CST 2019, time=2019-03-26, status=1, ipAttribution=)]
2019-03-28 贪吃蛇大王

谢谢分享

24 0
[GetPortalCommentsPageByObjectIdResponse(id=2054137, encodeId=1f63205413ef6, content=<a href='/topic/show?id=d4a9e192590' target=_blank style='color:#2F92EE;'>#皮下感染#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=71925, encryptionId=d4a9e192590, topicName=皮下感染)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=bb182500058, createdName=yuhaisheng_ibp_32061711, createdTime=Sun Mar 08 15:31:00 CST 2020, time=2020-03-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=366450, encodeId=28a0366450a5, content=好, beContent=null, objectType=article, channel=null, level=null, likeNumber=73, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/SrJSCPdKL0Ph25Lw3vlAkeSOJFyrKYpcmFTYHMla6icH6ibZ0zJHcbe2C5icyicow70stGsTm2efwfR6OibjYZD9N5A/132, 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status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=363549, encodeId=812b363549c6, content=好好学习天天向上, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/SrJSCPdKL0Ph25Lw3vlAkeSOJFyrKYpcmFTYHMla6icH6ibZ0zJHcbe2C5icyicow70stGsTm2efwfR6OibjYZD9N5A/132, createdBy=ff5a2004026, createdName=贪吃蛇大王, createdTime=Tue Mar 26 05:28:37 CST 2019, time=2019-03-26, status=1, ipAttribution=)]
2019-03-28 12543c13m83暂无昵称

谢谢分享

22 0
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createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/SrJSCPdKL0Ph25Lw3vlAkeSOJFyrKYpcmFTYHMla6icH6ibZ0zJHcbe2C5icyicow70stGsTm2efwfR6OibjYZD9N5A/132, createdBy=ff5a2004026, createdName=贪吃蛇大王, createdTime=Fri Apr 05 05:55:23 CST 2019, time=2019-04-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=364040, encodeId=eb7336404096, content=天天学习，谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=82, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/SrJSCPdKL0Ph25Lw3vlAkeSOJFyrKYpcmFTYHMla6icH6ibZ0zJHcbe2C5icyicow70stGsTm2efwfR6OibjYZD9N5A/132, createdBy=ff5a2004026, createdName=贪吃蛇大王, createdTime=Wed Apr 03 06:48:37 CST 2019, time=2019-04-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=363893, encodeId=2497363893e9, content=谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/SrJSCPdKL0Ph25Lw3vlAkeSOJFyrKYpcmFTYHMla6icH6ibZ0zJHcbe2C5icyicow70stGsTm2efwfR6OibjYZD9N5A/132, createdBy=ff5a2004026, createdName=贪吃蛇大王, createdTime=Mon Apr 01 06:26:39 CST 2019, time=2019-04-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=363677, encodeId=bdfe3636e7c0, content=谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/SrJSCPdKL0Ph25Lw3vlAkeSOJFyrKYpcmFTYHMla6icH6ibZ0zJHcbe2C5icyicow70stGsTm2efwfR6OibjYZD9N5A/132, createdBy=ff5a2004026, createdName=贪吃蛇大王, createdTime=Thu Mar 28 07:11:27 CST 2019, time=2019-03-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=363666, encodeId=0e08363666de, content=谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=22, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://thirdwx.qlogo.cn/mmopen/vi_32/DYAIOgq83eqYPFHuMA3bhYQrHvycmum7IJoCsLK0FP6X56Eoj9PZAECDke8zLCKxZZvk9q7B6rZmPuFgN5YCfw/132, createdBy=00912551888, createdName=12543c13m83暂无昵称, createdTime=Thu Mar 28 01:26:09 CST 2019, time=2019-03-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1362940, encodeId=72ee1362940c0, content=<a href='/topic/show?id=b723414321c' target=_blank style='color:#2F92EE;'>#坏死#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=21, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=41432, encryptionId=b723414321c, topicName=坏死)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c0e3195, createdName=millore, createdTime=Tue Mar 26 17:31:00 CST 2019, time=2019-03-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=363549, encodeId=812b363549c6, content=好好学习天天向上, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/SrJSCPdKL0Ph25Lw3vlAkeSOJFyrKYpcmFTYHMla6icH6ibZ0zJHcbe2C5icyicow70stGsTm2efwfR6OibjYZD9N5A/132, createdBy=ff5a2004026, createdName=贪吃蛇大王, createdTime=Tue Mar 26 05:28:37 CST 2019, time=2019-03-26, status=1, ipAttribution=)]
2019-03-26 millore

#坏死#

21 0
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createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/SrJSCPdKL0Ph25Lw3vlAkeSOJFyrKYpcmFTYHMla6icH6ibZ0zJHcbe2C5icyicow70stGsTm2efwfR6OibjYZD9N5A/132, createdBy=ff5a2004026, createdName=贪吃蛇大王, createdTime=Fri Apr 05 05:55:23 CST 2019, time=2019-04-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=364040, encodeId=eb7336404096, content=天天学习，谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=82, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/SrJSCPdKL0Ph25Lw3vlAkeSOJFyrKYpcmFTYHMla6icH6ibZ0zJHcbe2C5icyicow70stGsTm2efwfR6OibjYZD9N5A/132, createdBy=ff5a2004026, createdName=贪吃蛇大王, createdTime=Wed Apr 03 06:48:37 CST 2019, time=2019-04-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=363893, encodeId=2497363893e9, content=谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, 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status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=363549, encodeId=812b363549c6, content=好好学习天天向上, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/SrJSCPdKL0Ph25Lw3vlAkeSOJFyrKYpcmFTYHMla6icH6ibZ0zJHcbe2C5icyicow70stGsTm2efwfR6OibjYZD9N5A/132, createdBy=ff5a2004026, createdName=贪吃蛇大王, createdTime=Tue Mar 26 05:28:37 CST 2019, time=2019-03-26, status=1, ipAttribution=)]
2019-03-26 贪吃蛇大王

好好学习天天向上

26 0

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坏死性皮下感染，试试这个方法！

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