Turkiye Klinikleri Journal of Nursing Sciences

.: REVIEW
Örnek Görseller Eşliğinde Basınç Yarası Evrelendirme ve Koruyucu Bakım Davranışları: Geleneksel Derleme
Pressure Injury Staging and Preventive Care Behaviors with Sample Photographs: Traditional Compilation
Zeynep KAPTANa , Sevil PAMUK CEBECİb
aEskişehir Osmangazi Üniversitesi Sağlık Bilimleri Enstitüsü, Hemşirelik Bölümü, Hemşirelik Esasları AD, Eskişehir, Türkiye
bEskişehir Osmangazi Üniversitesi Sağlık Bilimleri Fakültesi, Hemşirelik Bölümü, Hemşirelik Esasları AD, Eskişehir, Türkiye
Turkiye Klinikleri J Nurs Sci. 2024;16(3):930-42
doi: 10.5336/nurses.2024-101414
Article Language: TR
Full Text
ÖZET
 Basınç yarası, deri ve deri altındaki dokularda basınç, friksiyon, yırtılma ve benzeri etkenlerin yol açtığı lokal doku zedelenmesidir. Günümüzde, bilim ve teknolojideki ilerlemelere rağmen basınç yaraları hâlâ önemli bir sorun olarak karşımıza çıkmaktadır. Özellikle yoğun bakımlarda, palyatif bakım merkezlerinde yaşam sonu bakım alan hastalar ile immobil hastalarda basınç yarası örneklerine daha sık rastlanmaktadır. Basınç yarası sıklıkla sakrum, koksiks, iskiyal tuberositler, büyük trokanter, dirsekler, diz kapağı çevresi, topuklar, skapulalar, krista iliyaka, lateral ve mediyal bölgelerde meydana gelmektedir. Özellikle kemik çıkıntılarının bulunduğu alanlarda gelişebilen basınç yaraları; hasta sırt üstü pozisyonda ise sakrum, koksiks, oksipital, skapula ve topuklarda, sürekli lateral pozisyonda yatan hastalarda ise omuz başları, trokanter, diz kapağı çevresi ve ayak bileklerinde, oturur pozisyonda ise gluteal bölümde ve skapulada daha sık görülmektedir. ABD'de en yaygın kabul gören sınıflandırma sistemi Amerikan Ulusal Basınç Yaralanması Danışma Paneli sistemine göre basınç yaraları ''Evre 1, Evre 2, Evre 3, Evre 4, Evrelendirilemeyen Evre, Şüpheli Derin Doku Hasarı, Tıbbi Cihazlarla İlişkili Basınç Yaralanması, Mukozal Membran Basınç Yaralanması'' olarak sınıflandırılmıştır. Kullanılan bu sınıflandırma sistemi, basınç yaralarının ciddiyetini ve tedavi seçeneklerini değerlendirmede klinik uygulamada önemli bir rol oynamaktadır. Basınç yarası önlenebilir bir durum olmasına rağmen önlenemediği ve oluşması durumunda; hastaların hastanede yatış süreleri uzamakta, morbidite ve mortalite oranları yükselmekte, bakım veren profesyonellerin iş yükü ve bakımının maliyeti artmakta, ikincil enfeksiyon riski gelişebilmekte ve komplikasyonlardan kaynaklanan ölümler de artmaya yol açabilmektedir. Bu nedenlerle özellikle hastalara 24 saat bakım veren hemşirelerin ve diğer sağlık profesyonellerinin basınç yarası hakkında bilgi ve bilinç farkındalığının artırılmasına ihtiyaç vardır. Makale basınç yarasını tanıma, evrelendirme hakkında görseller eşliğinde bilgi vermek ve basınç yarasından koruyucu bakım davranışlarına değinmek amacıyla yazılmıştır.

Anahtar Kelimeler: Basınç yarası; yara evrelendirme; sınıflama; koruyucu bakım; hemşirelik
ABSTRACT
 Pressure injury is a local tissue damage occurring in the skin and underlying tissues due to factors such as pressure, friction, shear, and similar influences. Despite advancements in science and technology, pressure injurys continue to pose a significant problem. Instances of pressure injurys are more frequently encountered, especially in intensive care units, palliative care centers, and in patients receiving end-of-life care, as well as in immobilized patients. Pressure injury often occur in the sacrum, coccyx, ischial tuberosities, greater trochanters, elbows, heels, scapulae, cristae, lateral and medial regions. Pressure injury, which can develop especially in areas where bone protrusions are present; It is more common in the sacrum, coccyx, occipital, scapula and heels if the patient is in the supine position, in the shoulder heads, thorachanter, kneecap area and ankles in patients who always lie in the lateral position, and in the gluteal part and scapula in the sitting position. According to the National Pressure Injury Advisory Panel system, the most widely accepted classification system in the USA, pressure injury are classified as Stage 1, Stage 2, Stage 3, Stage 4, Unstageable Pressure Injury, Suspected Deep Tissue Injury, Medical Device-Related Pressure Injury, Mucous Membrane Pressure Injury''. This classification system used plays an important role in clinical practice in assessing the severity of pressure injury and treatment options. While pressure injury are a preventable condition, their occurrence leads to prolonged hospital stays, increased morbidity and mortality rates, heightened workload and care costs for healthcare professionals, potential development of secondary infections, and a rise in deaths attributed to complications. Therefore, there is a need to enhance the knowledge and awareness of pressure injury, particularly among nurses providing 24-hour care and other healthcare professionals. This article aims to provide information, accompanied by visuals, about recognizing and staging pressure injury, and discusses preventive care behaviors related to pressure injury.

Keywords: Pressure injury; wound staging; classification; preventive care; nursing
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-Proclamation, advertisement, announcement, libelous expressions are used against natural person or legal identity,

-During various attacks to the website,

-Disruption of the website because of a virus.

Written, visual and audible materials of the website, including the code and the software are under protection by legal legislation.

Without the written consent of Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. the information on the website cannot be downloaded, changed, reproduced, copied, republished, posted or distributed.

All rights of the software and the design of the website belong to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. will be pleased to hear your comments about our terms of use. Please share the subjects you think may enrich our website or if there is any problem regarding our website.

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