团 体 标 准 T/SXNA003 -2021 器械相关压力性损伤护理规范 Nursing standard of device related pressure injuries 2021-12-17发布 2021-12-31实施 陕西省护理学会 发布 ICS 11.020 C10 全国团体标准信息平台 2 目 录 前 言 ................................ ................................ ................................ ................................ ................................ .....3 1 范围 ................................ ................................ ................................ ................................ ................................ .....4 2 规范性引用文件 ................................ ................................ ................................ ................................ .............. 4 3 术语和定义 ................................ ................................ ................................ ................................ ....................... 4 4 器械相关压力性损伤 的风险因素 ................................ ................................ ................................ .............. 5 4.1高危人群与好发部位 ................................ ................................ ................................ .............................. 5 4.2与医疗器械相关的因素 ................................ ................................ ................................ ......................... 5 4.3与患者相关危险因素 ................................ ................................ ................................ .............................. 6 5 评估 ................................ ................................ ................................ ................................ ................................ .....6 5.1风险评估 ................................ ................................ ................................ ................................ ..................... 6 5.2创面评估 ................................ ................................ ................................ ................................ ..................... 6 5.3压力性损伤愈合评估 ................................ ................................ ................................ .............................. 6 6 预防 ................................ ................................ ................................ ................................ ................................ .....7 6.1选择适合的医疗器械和（或）防护用具 ................................ ................................ ......................... 7 6.2器械重置及停用 ................................ ................................ ................................ ................................ .......7 6.3器械受压局部及周围皮肤护理 ................................ ................................ ................................ ............ 7 6.4使用预防性敷料 ................................ ................................ ................................ ................................ .......8 6.5加强教育与管理 ................................ ................................ ................................ ................................ .......8 7 护理措施 ................................ ................................ ................................ ................................ ............................ 8 附 录 A（规范性附录） 压力性损伤分期及非手术治疗护理要点 ................................ ................. 10 附 录 B（资料性附录） ICU MDRPI 风险评估量表 ................................ ................................ ............ 14 附 录 C（资料性附录） 压力性损伤愈合评估表 — PUSH测评表 ................................ ............... 15 附 录 D（规范性附录） 敷料粘贴步骤 ................................ ................................ ................................ ... 16 附 录 E（规范性附录） 交班制度流程 ................................ ................................ ................................ .... 17 参考文献 ................................ ................................ ................................ ................................ .............................. 18 全国团体标准信息平台 3 前 言 本标准按照 GB/T1.1给出的