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3 Diagnostiek van decubitus

  • T. Defloor
  • L. Schoonhoven

Samenvatting

Decubitusclassificatie is gebaseerd op de identificatie van de verschillende weefsellagen en de uitgebreidheid van de weefselschade.

Decubitus wordt geclassificeerd in vier graden: niet-wegdrukbare roodheid (graad 1), blaar of ontvelling (graad 2), oppervlakkige decubitus (graad 3) en diepe decubitus (graad 4). Wegdrukbare roodheid wordt hierbij niet beschouwd als decubitus.

Er bestaan twee observatiemethoden om een onderscheid te kunnen maken tussen wegdrukbare en niet-wegdrukbare roodheid: de vingerdrukmethode en het drukschijfje. Het transparante drukschijfje verdient de voorkeur.

Bij patiënten met een donkere huid moet om een graad 1 decubitus te kunnen onderscheiden, ter hoogte van het drukpunt gelet worden op blijvende rode, blauwe of paarse huidtinten gecombineerd met een wijziging in een of meerdere van de volgende kenmerken: gewijzigde huidtemperatuur, vaste of weke weefselconsistentie en pijn of jeuk. Decubitus correct kunnen classificeren vraagt training en ervaring. Een onderscheid maken met andere huidletsels is niet eenvoudig.

Literatuur

  1. Allcock N, Wharrad H, Nicolson A. Interpretation of pressure-sore prevalence. Journal of Advanced Nursing 1994;20(1):37–45.PubMedCrossRefGoogle Scholar
  2. Ankrom MA, Bennett RG, Sprigle S. Pressure-related deep tissue injury under intact skin and the current pressure ulcer staging systems. Advances in skin & wound care 2005;18:35–42.CrossRefGoogle Scholar
  3. Ayello EA. Assessment of pressure ulcer healing. Advances in Wound Care 1997;10(5):1–0.Google Scholar
  4. Bates-Jensen BM. The Pressure Sore Status Tool a few thousand assessments later. Advance in Wound Care 1997;10(5):65–73.Google Scholar
  5. Beeckman D, Boucqué H, Van Maele G, Defloor T. E-learning ter verbetering van de classificatie van decubitus: een onderzoek bij verpleegkundigen en studenten verpleegkunde. Master in de Verpleegkunde en Vroedkunde Gent: Universiteit Gent, 2006.Google Scholar
  6. Black J, Bahrestani M, Dorner B, Edsberg L, Langemo D, Taler G, Zulkowski K. Proposed staging system and deep tissue injury definitions with descriptions. In Saunders DA, Knapp S (eds). Charting the course for pressure ulcer prevention and treatment. 10th National NPUAP Biennial Conference & 20th Anniversary Celebration. San Antonio, TX, VS, 2007.Google Scholar
  7. Bliss MR. Hyperaemia. Journal of Tissue Viability 1998;8(4):4–13.PubMedCrossRefGoogle Scholar
  8. Bours GJ, Halfens RJ, Lubbers M, Haalboom JR. The development of a national registration form to measure the prevalence of pressure ulcers in The Netherlands. Ostomy/Wound Management 1999;45(11):28-33, 40.PubMedGoogle Scholar
  9. Buntinx F, Beckers H, De Keyser G, Flour M, Nissen G, Raskin T, De Vet H. Inter-observer variation in the assessment of skin ulceration. Journal of Wound Care 1996;5(4):166–70.PubMedGoogle Scholar
  10. Collier M. Blanching and non-blanching hyperaemia. Journal of Wound Care 1999;8:63–6.PubMedCrossRefGoogle Scholar
  11. Cuddigan J. Pressure ulcer classification: What do we have? What do we need? Advances in Wound Care 1997;10(5):13–15.PubMedGoogle Scholar
  12. David JA, Chapman RG, Chapman EJ, Lockett B. An investigation of the current methods used in nursing for the care of patients with established pressure sores. Guildford: Nursing Practice Research Unit, 1983.Google Scholar
  13. Dealey C, Lindholm C. Pressure ulcer classification. In Romanelli M, Clark M, Cherry G, Colin D, Defloor T, editors. Science and practice of pressure ulcer management. Berlijn: Springer, 2006:37–41.CrossRefGoogle Scholar
  14. Defloor T, Clark M, Witherow A, Colin D, Lindholm C, Schoonhoven L, Moore Z. EPUAP statement on prevalence and incidence monitoring of pressure ulcer occurence 2005. EPUAP Review 2005a;6(3):74–80.Google Scholar
  15. Defloor T, Herremans A, Grypdonck M, De Schuijmer J, Paquay L, Schoonhoven L, Van den Bossche K, Vanderwee K et al. Belgische Richtlijn voor decubituspreventie 2005. Gent: Story Scientia, 2005b.Google Scholar
  16. Defloor T, Schoonhoven L, Fletcher J, Furtado K, Heyman H, Lubbers M, Lyder C, Witherow A. Pressure ulcer classification. Differentiation between pressure ulcers and moisture lesions. EPUAP review 2005c;6(3):81–5.Google Scholar
  17. Defloor T, Schoonhoven L, Vanderwee K, Weststrate J, Myny D. Reliability of the European Pressure Ulcer Advisory Panel classification system. Journal of Advanced Nursing 2006;54(2):189–98.PubMedCrossRefGoogle Scholar
  18. Defloor T, Schoonhoven L. Inter-rater reliability of the EPUAP pressure ulcer classification system. Journal of Clinical Nursing 2004;13(8):952–9.PubMedCrossRefGoogle Scholar
  19. Laat EH de, Scholte op Reimer, WJ, Van Achterberg T. Pressure ulcers: diagnostics and interventions aimed at wound-related complaints: a review of the literature. Journal of Clinical Nursing 2005;14:464–72.PubMedCrossRefGoogle Scholar
  20. Derre B. Evolutie van beginnende decubitus op intensieve zorgen. Scriptie Medisch-sociale wetenschappen. Gent: Universiteit Gent, 1998.Google Scholar
  21. Ersser SJ, Getliffe K, Voegeli D, Regan S. A critical review of the inter-relationship between skin vulnerability and urinary incontinence and related nursing intervention. International Journal of Nursing Studies 2005;42:823–35.PubMedCrossRefGoogle Scholar
  22. European Pressure Ulcer Advisory Panel (EPUAP): www.epuap.org
  23. Fletcher J. Wound bed preparation and the TIME principles. Nurs Stand 2005;20(12):57–66.PubMedCrossRefGoogle Scholar
  24. Gray M, Ratliff C, Donovan A. Perineal skin care for the incontinent patient. Advances in skin & wound care 2002;15(4):170–8.CrossRefGoogle Scholar
  25. Haalboom JRE, Van Everdingen JJE, Cullum N. Incidence, prevalence, and classification. In: Parish LC, Witkowski JA, Crissey JT, editors. The decubitus ulcer in clinical practice. Berlijn: Springer, 1997:12–23.CrossRefGoogle Scholar
  26. Halfens RJG, Bours GJJW, Van Ast W. Relevance of the diagnosis ’stage 1 pressure ulcer’: an empirical study of the clinical course of stage 1 ulcers in acute care and long-term care hospital populations. Journal of Clinical Nursing 2001;10(6):748–57.PubMedCrossRefGoogle Scholar
  27. Healey F. The reliability and utility of pressure sore grading scales. Journal of Tissue Viability 1995;5(4):111–4.CrossRefGoogle Scholar
  28. Lowthian P. The classification and grading of pressure sores. Care – Science and Practice 1987;5:5–9.Google Scholar
  29. Maklebust J, Sieggreen M. Pressure ulcers: guidelines for prevention and nursing management. Pennsylvania: Springhouse Corporation, 1995.Google Scholar
  30. Maklebust J. Policy implications of using reverse staging to monitor pressure ulcer status. Advance in Woundcare 1997;10(5):32–5.Google Scholar
  31. Maklebust J. Pressure ulcers: etiology and prevention. Nursing Clinics of North America 1987;22(2):359–77.PubMedGoogle Scholar
  32. Michel CC, Gillot H. Microvascular mechanism in stasis and ischaemia. In: Bader DL (ed). Pressure sores: clinical practice and scientific approach. Londen: Mac Millan, 1992:153–63.Google Scholar
  33. Nixon J, Mc Gough A. The pathophysiology and aetiology of pressure ulcers. In Morison M (ed). The prevention and treatment of pressure ulcers. Edingburgh: Mosby, 2001:17–36.Google Scholar
  34. Nixon J, McElvenny D, Mason S, Brown J, Bond S. A sequential randomised controlled trial comparing a dry visco-elastic polymer pad and standard operating table mattress in the prevention of post-operative pressure sores. International Journal of Nursing Studies 1998;35(4):193–203.PubMedCrossRefGoogle Scholar
  35. Panel for the Prediction and Prevention of Pressure Ulcers in Adults. Pressure ulcers in adults: prediction and prevention. Clinical practice guideline number 3. Rockville: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, AHCPR Publication No. 92-0047, 1992.Google Scholar
  36. Parish LC, Witkowski JA, Crissey JT. The decubitus ulcer in clinical practice. Berlijn: Springer, 1997.CrossRefGoogle Scholar
  37. Pedley GE. Comparison of pressure ulcer grading scales: a study of clinical utility and inter-rater reliability. International Journal of Nursing Studies 2004;41(2):129–40.PubMedCrossRefGoogle Scholar
  38. Pel-Littel R. Betrouwbaarheid en validiteit van meetinstrumenten voor het meten van graad 1 decubitus. Maastricht: Universiteit Maastricht, 2003.Google Scholar
  39. Polit DF, Beck CT, Hungler BP. Essentials of nursing research. Methods, appraisal, and utilization. 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2001.Google Scholar
  40. Reid J, Morison M. Towards a consensus: classification of pressure sores. Journal of Wound Care 1994;3(3):157–60.Google Scholar
  41. Russell LJ, Reynolds TM. How accurate are pressure ulcer grades? An image-based survey of nurse performance. Journal of Tissue Viability 2001;11(2):67–75.PubMedCrossRefGoogle Scholar
  42. Schoonhoven L, Haalboom JRE, Bousema MT, Algra A, Grobbee DE, Grypdonck MH, Buskens E. Prospective cohort study of routine use of risk assessment scales for prediction of pressure ulcers. British Medical Journal 2002;325(7368):797–800.PubMedCentralPubMedCrossRefGoogle Scholar
  43. Shea JD. Pressure sores: classification and management. Clin Orthop Rel Res 1975;112:89–100.Google Scholar
  44. Smith DM. Pressure ulcers in the nursing home. Annals of Internal Medicine 1995;123(6):433–42.PubMedCrossRefGoogle Scholar
  45. Stotts NA. Assessing a patient with a pressure ulcer. In Morison MJ, editor. The prevention and treatment of pressure ulcers. Edingburgh: Mosby, 2001:99–115.Google Scholar
  46. Torrance C. Pressure sores aetiology, treatment and prevention. Beckenham: Croom Helm, 1983.Google Scholar
  47. Vanderwee K, Grypdonck M, Defloor T. Non-blanchable erythema as an indicator for the need for pressure ulcer prevention: a randomized-controlled trial. Journal of Clinical Nursing 2007;16:325–35.PubMedCrossRefGoogle Scholar
  48. Vanderwee K, Grypdonck MH, De Baquer B, Defloor T. The reliability of two observation methods of nonblanchable erythema, Grade 1 pressure ulcer. Applied Nursing Research 2006;19:156–62.PubMedCrossRefGoogle Scholar
  49. Vanderwee K. Het effect van drukreducerende maatregelen op het ontstaan van decubitus. Een bijdrage tot een evidence based verpleegkundige praktijkvoering. Proefschrift Doctor in de Sociale Gezondheidswetenschappen. Gent: Universiteit Gent, 2006.Google Scholar
  50. Witkowski JA, Parish LC. Histopathology of the decubitus ulcer. Journal of the American Academy of Dermatology 1982;6(6):1014–21.PubMedCrossRefGoogle Scholar
  51. Yarkony GM. Pressure ulcers: a review. Arch Phys Med Rehabil 1994;75:908–17.PubMedCrossRefGoogle Scholar
  52. Yarkony GM, Kirk PM, Carlson C, Roth EJ, Lovell L, Heinemann A, King R, Lee MY, Betts HB. Classification of pressure ulcers. Arch Dermatol 1990;126(9):1218–9.PubMedCrossRefGoogle Scholar

Copyright information

© Bohn Stafleu van Loghum, onderdeel van Springer Uitgeverij 2008

Authors and Affiliations

  • T. Defloor
    • 1
  • L. Schoonhoven
    • 2
  1. 1.Universiteit GentGent
  2. 2.UMC St RadboudNijmegen

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