Keast David H, Bowering C Keith, Evans A Wayne, Mackean Gerald L, Burrows Catherine, D'Souza Lincoln
Department of Family Medicine, University of Western Ontario, London, Ontario, Canada.
Wound Repair Regen. 2004 May-Jun;12(3 Suppl):S1-17. doi: 10.1111/j.1067-1927.2004.0123S1.x.
The effective management of nonhealing wounds is based on a complete patient history, a detailed initial assessment of the wound, and an analysis of probable causative factors. This information is used to individualize a management strategy to the underlying pathophysiology preventing healing and to implement appropriate wound interventions. Regular reassessment of progress toward healing and appropriate modification of the intervention are also necessary. Accurate and clinically relevant wound assessment is an important clinical tool, but this process remains a substantial challenge. Wound assessment terminology is nonuniform, many questions surrounding wound assessment remain unanswered, agreement has yet to be reached on the key wound parameters to measure in clinical practice, and the accuracy and reliability of available wound assessment techniques vary. This article, which resulted from a meeting of wound healing experts in June 2003, reviews clinically useful wound measurement approaches, provides an overview of the principles and practice of chronic wound assessment geared to a clinical audience, and introduces a simple mnemonic, MEASURE. MEASURE encapsulates key wound parameters that should be addressed in the assessment and management of chronic wounds: Measure (length, width, depth, and area), Exudate (quantity and quality), Appearance (wound bed, including tissue type and amount), Suffering (pain type and level), Undermining (presence or absence), Reevaluate (monitoring of all parameters regularly), and Edge (condition of edge and surrounding skin). This article also provides some preliminary recommendations targeted to developing best practice guidelines for wound assessment.
难愈合伤口的有效管理基于完整的患者病史、对伤口的详细初始评估以及对可能致病因素的分析。这些信息用于根据潜在的病理生理机制制定个性化的管理策略，以促进愈合，并实施适当的伤口干预措施。定期重新评估愈合进展并对干预措施进行适当调整也很有必要。准确且与临床相关的伤口评估是一项重要的临床工具，但这一过程仍然是一项重大挑战。伤口评估术语不统一，围绕伤口评估仍有许多问题未得到解答，在临床实践中应测量的关键伤口参数尚未达成共识，现有伤口评估技术的准确性和可靠性也各不相同。本文源自2003年6月伤口愈合专家会议，回顾了临床上有用的伤口测量方法，为临床受众概述了慢性伤口评估的原则和实践，并介绍了一个简单的记忆方法MEASURE。MEASURE概括了慢性伤口评估和管理中应涉及的关键伤口参数：测量（长度、宽度、深度和面积）、渗出物（数量和质量）、外观（伤口床，包括组织类型和数量）、痛苦（疼痛类型和程度）、潜行（有无）、重新评估（定期监测所有参数）以及边缘（边缘和周围皮肤状况）。本文还针对制定伤口评估的最佳实践指南提出了一些初步建议。
