Advertisement

5 Wondzorg bij patiënten met decubitus

  • H.E.W. de Laat
  • P.H.M. Spauwen
  • C.J.M. van der Vleuten

Samenvatting

Wondgenezing is al decennialang een belangrijk aandachtsgebied in de praktijk, het onderwijs en het wetenschappelijk onderzoek van behandelaars van wonden en zorgverleners die zich met wonden bezighouden. Er is veel bekend over het genezingsproces, met name over dat van acute wonden. De normale reactie van verwond weefsel is een in de tijd geordend reparatieproces dat uiteindelijk resulteert in blijvend herstel van de anatomie en functie van het aangedane weefsel. Dit proces is niet eenvoudig en rechtlijnig, maar is een complex en levendig samenspel tussen cellen onderling en tussen cellen en de matrix buiten de cellen, onder invloed van vele stoffen, zoals mineralen enzymen en vitamines.[1,2]

In dit proces kan iets misgaan, waardoor de genezing wordt vertraagd of helemaal stopt. Er ontstaat een chronische wond. Decubitus is zo’n wond. Er zijn vier theorieën over de gevolgen van (te) langdurige druk en/of wrijfkrachten in de weefsels:

  • lokale ischemie van de weefsels;

  • verstoring van het metabole evenwicht;

  • reperfusieschade;

  • onherstelbare vervorming van cellen.[3]

Decubitus is niet per definitie een chronische wond. Een belangrijk kenmerk van een chronische wond is dat deze zonder behandeling niet binnen twee tot vier weken geneest.[2] Een graad 2 decubitus, waarbij de huid ontveld is, kan nog langs de natuurlijke weg genezen door intensivering van preventieve maatregelen. Een graad 3 of 4 decubitus valt doorgaans onder de chronische wonden. Op basis van een goede probleemanalyse, aanvullend onderzoek, een behandelplan en regelmatige evaluatie kan de chronische decubituswond tot genezen worden gebracht.

Supplementary material

Literatuur

  1. 1.
    Robson MC. The pathophysiology of chronic wounds. In: Téot L, Banwell PE, Ziegler UE, editors. Surgery in wounds. Berlijn: Springer-Verlag, 2004:29–40.CrossRefGoogle Scholar
  2. 2.
    Tredget EE, Medina A, Haik J. The pathophysiology of acute wounds. In: Téot L, Banwell PE, Ziegler UE, editors. Surgery in wounds. Berlijn: Springer-Verlag, 2004:3–28.CrossRefGoogle Scholar
  3. 3.
    Laat E de. Critical pressure: pressure ulcer care in critically ill patients and hospitalised patients at large. Nijmegen: Radboud University Nijmegen, Medical Centre, 2006.Google Scholar
  4. 4.
    Harding KG, Morris HL, Patel GK. Science, medicine, and the future: Healing chronic wounds. BMJ 2002 Jan 19;324(7330):160–3.PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Brown EJ. Phagocytosis. Bioessays 1995 Feb;17(2):109–17.PubMedCrossRefGoogle Scholar
  6. 6.
    Beele H, De Win M. Theorie. In: Wit-Gele Kruis Vlaanderen, editor. Handboek wondzorg. 1e ed. Maarssen: Elsevier gezondheidszorg, 2004:15–48.Google Scholar
  7. 7.
    Medina A, Scott PG, Ghahary A, Tredget EE. Pathophysiology of chronic nonhealing wounds. J Burn Care Rehabil 2005 Jul;26(4):306–19.PubMedCrossRefGoogle Scholar
  8. 8.
    Penhallow K. A review of studies that examine the impact of infection on the normal wound-healing process. J Wound Care 2005 Mar;14(3):123–6.PubMedCrossRefGoogle Scholar
  9. 9.
    Ovington L. Bacterial toxins and wound healing. Ostomy Wound Manage 2003 Jul;49(7A Suppl):8–12.PubMedGoogle Scholar
  10. 10.
    Cutting KF. The causes and prevention of maceration of the skin. J Wound Care 1999 Apr;8(4):200–1.PubMedCrossRefGoogle Scholar
  11. 11.
    Phillips SJ. Physiology of wound healing and surgical wound care. ASAIO J 2000 Nov;46(6):S2–S5.CrossRefGoogle Scholar
  12. 12.
    Williams DT, Harding K. Healing responses of skin and muscle in critical illness. Critical Care Medicine 2003 Aug;31(8):S547–S557.CrossRefGoogle Scholar
  13. 13.
    Tibbs MK. Wound healing following radiation therapy: a review. Radiother Oncol 1997 Feb;42(2):99–106.PubMedCrossRefGoogle Scholar
  14. 14.
    Laat EH de, Scholte op Reimer WJ, Achterberg T van. Pressure ulcers: diagnostics and interventions aimed at wound-related complaints: a review of the literature. J Clin Nurs 2005 Apr;14(4):464–72.PubMedCrossRefGoogle Scholar
  15. 15.
    Gardner SE, Frantz RA, Doebbeling BN. The validity of the clinical signs and symptoms used to identify localized chronic wound infection. Wound Repair Regen 2001 May;9(3):178–86.PubMedCrossRefGoogle Scholar
  16. 16.
    Freeman K, Smyth C, Dallam L, Jackson B. Pain measurement scales: A comparison of the visual analogue and faces rating scales in measuring pressure ulcer pain. J Wound Ostomy Continence Nurs 2001 Nov;28(6):290–6.PubMedGoogle Scholar
  17. 17.
    Harvey C. Wound healing. Orthop Nurs 2005 Mar;24(2):143–57.PubMedCrossRefGoogle Scholar
  18. 18.
    Thomas DR. Age-related changes in wound healing. Drugs Aging 2001;18(8):607–20.PubMedCrossRefGoogle Scholar
  19. 19.
    Thomas TA, Taylor SM, Crane MM, Cornett WR, Langan EM, III, Snyder BA, et al. An analysis of limb-threatening lower extremity wound complications after 1090 consecutive coronary artery bypass procedures. Vasc Med 1999;4(2):83–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Arnold M, Barbul A. Nutrition and wound healing. Plast Reconstr Surg 2006 Jun;117(7 Suppl):42S–58S.CrossRefGoogle Scholar
  21. 21.
    Posthauer ME. Hydration: an essential nutrient. Adv Skin Wound Care 2005 Jan;18(1):32–3.PubMedCrossRefGoogle Scholar
  22. 22.
    Rush JW, Denniss SG, Graham DA. Vascular nitric oxide and oxidative stress: determinants of endothelial adaptations to cardiovascular disease and to physical activity. Can J Appl Physiol 2005 Aug;30(4):442–74.PubMedCrossRefGoogle Scholar
  23. 23.
    Towler J. Cigarette smoking and its effects on wound healing. J Wound Care 2000 Mar;9(3):100–4.PubMedCrossRefGoogle Scholar
  24. 24.
    Rantala A, Lehtonen OP, Niinikoski J. Alcohol abuse: a risk factor for surgical wound infections? Am J Infect Control 1997 Oct;25(5):381–6.PubMedCrossRefGoogle Scholar
  25. 25.
    Schryvers OI, Stranc MF, Nance PW. Surgical treatment of pressure ulcers: 20-year experience. Arch Phys Med Rehabil 2000 Dec;81(12):1556–62.PubMedCrossRefGoogle Scholar
  26. 26.
    Karukonda SR, Flynn TC, Boh EE, McBurney EI, Russo GG, Millikan LE. The effects of drugs on wound healing – part 1. Int J Dermatol 2000 Apr;39(4):250–7.PubMedCrossRefGoogle Scholar
  27. 27.
    Karukonda SR, Flynn TC, Boh EE, McBurney EI, Russo GG, Millikan LE. The effects of drugs on wound healing – part II. Specific classes of drugs and their effect on healing wounds. Int J Dermatol 2000 May;39(5):321–33.PubMedCrossRefGoogle Scholar
  28. 28.
    Wicke C, Halliday B, Allen D, Roche NS, Scheuenstuhl H, Spencer MM, et al. Effects of steroids and retinoids on wound healing. Arch Surg 2000 Nov;135(11):1265–70.PubMedCrossRefGoogle Scholar
  29. 29.
    Buhaescu I, Izzedine H, Covic A. Sirolimus – challenging current perspectives. Ther Drug Monit 2006 Oct;28(5):577–84.PubMedCrossRefGoogle Scholar
  30. 30.
    Kwaliteitsinstituut voor de gezondheidszorg CBO. Conceptrichtlijn Tweede Herziening Decubitus. Utrecht: Kwaliteitsinstituut voor de gezondheidszorg CBO, 2002, 21 februari.Google Scholar
  31. 31.
    European Pressure Ulcer Advisory Panel (EPUAP). Guidelines on treatment of pressure ulcers. EPUAP Review 1999;1(2):31–3.Google Scholar
  32. 32.
    Bates-Jensen B. New pressure ulcer status tool. Decubitus 1990 Aug;3(3):14–5.PubMedGoogle Scholar
  33. 33.
    Bates-Jensen BM. The Pressure Sore Status Tool a few thousand assessments later. Adv Wound Care 1997 Sep;10(5):65–73.PubMedGoogle Scholar
  34. 34.
    Reintjes P, Hoog W de, Boogaard M van den, Laat E de. Scoren op genezing. Beoordelen van een decubituswond. Nursing 2005 Apr;11(4):26–9.Google Scholar
  35. 35.
    Edwards R, Harding KG. Bacteria and wound healing. Curr Opin Infect Dis 2004 Apr;17(2):91–6.PubMedCrossRefGoogle Scholar
  36. 36.
    Gardner SE, Frantz RA, Troia C, Eastman S, MacDonald M, Buresh K, et al. A tool to assess clinical signs and symptoms of localized infection in chronic wounds: development and reliability. Ostomy Wound Manage 2001 Jan;47(1):40–7.PubMedGoogle Scholar
  37. 37.
    Sibbald RG, Chapman P, Contreras-Ruiz J. The role of bacteria in pressure ulcer. In: Romanelli M, Cherry G, Colin D, Defloor T, editors. Science and practice of pressure ulcer management Londen: Springer-Verlag, 2006:139–62.CrossRefGoogle Scholar
  38. 38.
    Cunningham SC, Napolitano LM. Necrotizing soft tissue infection from decubitus ulcer after spinal cord injury. Spine 2004 Apr 15;29(8):E172–E174.CrossRefGoogle Scholar
  39. 39.
    Chan JW, Virgo KS, Johnson FE. Hemipelvectomy for severe decubitus ulcers in patients with previous spinal cord injury. Am J Surg 2003 Jan;185(1):69–73.PubMedCrossRefGoogle Scholar
  40. 40.
    Llewelyn M, Cohen J. Diagnosis of infection in sepsis. Intensive Care Med 2001;27 Suppl 1:S10–S32.PubMedGoogle Scholar
  41. 41.
    Volanakis JE. Human C-reactive protein: expression, structure, and function. Mol Immunol 2001 Aug;38(2-3):189–97.PubMedCrossRefGoogle Scholar
  42. 42.
    Hirshberg J, Rees RS, Marchant B, Dean S. Osteomyelitis related to pressure ulcers: the cost of neglect. Adv Skin Wound Care 2000 Jan;13(1):25–9.PubMedGoogle Scholar
  43. 43.
    Horch RE. Osteomyelitis. In: Téot L, Banwell PE, Ziegler UE, editors. Surgery in wounds. Heidelberg: Springer-Verlag, 2004:272–81.CrossRefGoogle Scholar
  44. 44.
    Han H, Lewis Jr VL, Wiedrich TA, Patel PK. The value of Jamshidi core needle bone biopsy in predicting postoperative osteomyelitis in grade IV pressure ulcer patients. Plast Reconstr Surg 2002 Jul;110(1):118–22.PubMedCrossRefGoogle Scholar
  45. 45.
    Stotts NA, Rodeheaver GT, Thomas DR, Frantz RA, Bartolucci AA, Sussman C, et al. An instrument to measure healing in pressure ulcers: development and validation of the pressure ulcer scale for healing (PUSH). J Gerontol A Biol Sci Med Sci 2001 Dec;56(12):M795–M799.CrossRefGoogle Scholar
  46. 46.
    Thomas DR, Rodeheaver GT, Bartolucci AA, Franz RA, Sussman C, Ferrell BA et al. Pressure ulcer scale for healing: derivation and validation of the PUSH tool. The PUSH Task Force. Adv Wound Care 1997 Sep;10(5):96–101.PubMedGoogle Scholar
  47. 47.
    Ayello EA. Cleansing and cleansers. In: Téot L, Banwell PE, Ziegler UE, editors. Surgery in wounds. Berlijn: Springer-Verlag, 2004:3–28.Google Scholar
  48. 48.
    Ovington L. Wound management: cleansing agents and dressings. In: Morison MJ, editor. The prevention and treatment of pressure ulcers. Londen: Mosby, 2001:135–54.Google Scholar
  49. 49.
    Moscati RM, Mayrose J, Reardon RF, Janicke DM, Jehle DV. A multicenter comparison of tap water versus sterile saline for wound irrigation. Acad Emerg Med 2007 May;14(5):404–9.PubMedCrossRefGoogle Scholar
  50. 50.
    European Pressure Ulcer Advisory Panel. Nutritional Guidelines for Pressure Ulcer Prevention and Treatment (http://www.epuap.org/) (laatst geraadpleegd op 14 februari 2006), 2005.
  51. 51.
    Cameron S, Leaper D. Tissue viability. Antiseptic toxicity in open wounds. Nurs Times 1988 Jun 22;84(25):77–9.PubMedGoogle Scholar
  52. 52.
    Mahaffey PJ. Something old, something new in wound dressings. BMJ 2006 Apr 15;332(7546):91–6.CrossRefGoogle Scholar
  53. 53.
    Bellingeri A, Hofman D. Debridement of pressure ulcers. In: Romanelli M, Clarc M, Cherry G, Colin D, Defloor T, eds. Science and practice of pressure ulcer management. Londen: Springer-Verlag, 2006:129–37.CrossRefGoogle Scholar
  54. 54.
    Rees JE. Where have all the bubbles gone? An ode to Hydrogen peroxide, the champagne of all wound cleaners. Accid Emerg Nurs 2003 Apr;11(2):82–4.PubMedCrossRefGoogle Scholar
  55. 55.
    Henley N, Carlson DA, Kaehr DM, Clements B. Air embolism associated with irrigation of external fixator pin sites with hydrogen peroxide. A report of two cases. J Bone Joint Surg Am 2004 Apr;86-A(4):821–2.PubMedGoogle Scholar
  56. 56.
    Milner SM. Acetic acid to treat Pseudomonas aeruginosa in superficial wounds and burns. Lancet 1992 Jul 4;340(8810):6–1.CrossRefGoogle Scholar
  57. 57.
    Sloss JM, Cumberland N, Milner SM. Acetic acid used for the elimination of Pseudomonas aeruginosa from burn and soft tissue wounds. J R Army Med Corps 1993 Jun;139(2):49–51.PubMedCrossRefGoogle Scholar
  58. 58.
    Zhou LH, Nahm WK, Badiavas E, Yufit T, Falanga V. Slow release iodine preparation and wound healing: in vitro effects consistent with lack of in vivo toxicity in human chronic wounds. Br J Dermatol 2002 Mar;146(3):365–74.PubMedCrossRefGoogle Scholar
  59. 59.
    Ohtani T, Mizuashi M, Ito Y, Aiba S. Cadexomer as well as cadexomer iodine induces the production of proinflammatory cytokines and vascular endothelial growth factor by human macrophages. Exp Dermatol 2007 Apr;16(4):318–23.PubMedCrossRefGoogle Scholar
  60. 60.
    Hoeksema H. Brandwonden. In: Wit-Gele Kruis Vlaanderen, editor. Handboek wondzorg. 1e ed. Maarssen: Elsevier gezondheidszorg, 2004:171–216.Google Scholar
  61. 61.
    Cooper R, Molan P. The use of honey as an antiseptic in managing Pseudomonas infection. J Wound Care 1999 Apr;8(4):161–4.PubMedCrossRefGoogle Scholar
  62. 62.
    Beele H. Wondafdekking. In: Wit-Gele Kruis Vlaanderen, editor. Handboek wondzorg. 1e ed. Maarssen: Elsevier gezondheidszorg, 2004:71–103.Google Scholar
  63. 63.
    Marazzi M, Stefani A, Chiaratti A, Ordanini MN, Falcone L, Rapisarda V. Effect of enzymatic debridement with collagenase on acute and chronic hard-to-heal wounds. J Wound Care 2006 May;15(5):222–7.PubMedCrossRefGoogle Scholar
  64. 64.
    Mumcuoglu KY. Clinical applications for maggots in wound care. Am J Clin Dermatol 2001;2(4):219–27.PubMedCrossRefGoogle Scholar
  65. 65.
    Sherman RA, Wyle F, Vulpe M. Maggot therapy for treating pressure ulcers in spinal cord injury patients. J Spinal Cord Med 1995 Apr;18(2):71–4.PubMedGoogle Scholar
  66. 66.
    Sherman RA. Maggot versus conservative debridement therapy for the treatment of pressure ulcers. Wound Repair Regen 2002 Jul;10(4):208–14.PubMedCrossRefGoogle Scholar
  67. 67.
    Rijswijk L van. Ingredient-based wound dressing classification: a paradigm that is passe and in need of replacement. J Wound Care 2006 Jan;15(1):11–4.PubMedCrossRefGoogle Scholar
  68. 68.
    Greene AK, Puder M, Roy R, Arsenault D, Kwei S, Moses MA, et al. Microdeformational wound therapy: effects on angiogenesis and matrix metalloproteinases in chronic wounds of 3 debilitated patients. Ann Plast Surg 2006 Apr;56(4):418–22.PubMedCrossRefGoogle Scholar
  69. 69.
    Kamolz LP, Andel H, Haslik W, Winter W, Meissl G, Frey M. Use of subatmospheric pressure therapy to prevent burn wound progression in human: first experiences. Burns 2004 May;30(3):253–8.PubMedCrossRefGoogle Scholar
  70. 70.
    Moues CM, Vos MC, Bemd GJ van den, Stijnen T, Hovius SE. Bacterial load in relation to vacuum-assisted closure wound therapy: a prospective randomized trial. Wound Repair Regen 2004 Jan;12(1):11–7.PubMedCrossRefGoogle Scholar
  71. 71.
    Ricci E, Calvicchioli A, Romanelli M. Conservative management of pressure ulcers. In: Romanelli M, Clark M, Cherry G, Colin D, Defloor T, editors. Science and practice of pressure ulcer management. Londen: Springer-Verlag, 2006:111–8.CrossRefGoogle Scholar
  72. 72.
    Armstrong DG, Lavery LA. Negative pressure wound therapy after partial diabetic foot amputation: a multicentre, randomised controlled trial. Lancet 2005 Nov 12;366(9498):1704–10.PubMedCrossRefGoogle Scholar
  73. 73.
    Eginton MT, Brown KR, Seabrook GR, Towne JB, Cambria RA. A prospective randomized evaluation of negative-pressure wound dressings for diabetic foot wounds. Ann Vasc Surg 2003 Nov;17(6):645–9.PubMedCrossRefGoogle Scholar
  74. 74.
    Ford CN, Reinhard ER, Yeh D, Syrek D, Las MA de, Bergman SB, et al. Interim analysis of a prospective, randomized trial of vacuum-assisted closure versus the healthpoint system in the management of pressure ulcers. Ann Plast Surg 2002 Jul;49(1):55–61.PubMedCrossRefGoogle Scholar
  75. 75.
    Gottrup F, Jorgensen B, Karlsmark T, Sibbald RG, Rimdeika R, Harding K, et al. Less pain with Biatain-Ibu: initial findings from a randomised, controlled, double-blind clinical investigation on painful venous leg ulcers. Int Wound J 2007 Apr;4 Suppl 1:24–34.PubMedCrossRefGoogle Scholar
  76. 76.
    Spindler J. Wondenboek. Leiden: Woundcare Consultant Society, 2001.Google Scholar
  77. 77.
    Hinman CD, Maibach H. Effect of air exposure and occlusion on experimental human skin wounds. Nature 1963 Oct 26;200:377–8.CrossRefGoogle Scholar
  78. 78.
    Winter GD. Formation of the scab and the rate of epithelization of superficial wounds in the skin of the young domestic pig. Nature 1962 Jan 20;193:293–4.CrossRefGoogle Scholar
  79. 79.
    Dyson M, Young SR, Hart J, Lynch JA, Lang S. Comparison of the effects of moist and dry conditions on the process of angiogenesis during dermal repair. J Invest Dermatol 1992 Dec;99(6):729–33.PubMedCrossRefGoogle Scholar
  80. 80.
    Young SR, Dyson M, Hickman R, Lang S, Osborn C. Comparison of the effects of semi-occlusive polyurethane dressings and hydrocolloid dressings on dermal repair: 1. Cellular changes. J Invest Dermatol 1991 Sep;97(3):586–92.PubMedCrossRefGoogle Scholar
  81. 81.
    Mekkes JR. (www.huidziekten.nl; www.huidziekten.nl/woundcare/keuzetabel/amckeuzetabel.htm) 2007. Laatst geraadpleegd op 2 juli 2007.

Copyright information

© Bohn Stafleu van Loghum, onderdeel van Springer Uitgeverij 2008

Authors and Affiliations

  • H.E.W. de Laat
    • 1
  • P.H.M. Spauwen
    • 1
  • C.J.M. van der Vleuten
    • 1
  1. 1.UMC St RadboudNijmegen

Personalised recommendations