壓瘡定量評估方法。SWHT－傷口大師

2010/3/29

衛生署豐原醫院外科

游朝慶

Sussman Wound Healing Tool （SWHT）

Sussman Wound Healing Tool於1997由Sussman及Swanson等人發展出來，用來當作壓瘡在經過一段時間治療後的預測及追蹤工具，Carrie Sussman，一位物理治療師，一位位於加州洛杉磯Sussman Physical Therapy, Inc. 及Wound Care Management Services公司的總裁，也是一位知名的傷口治療專家。他是美國NPUAP裡面第一個物理治療師成員，目前則為NPUAP的副會長。SWHT這個工具是採用急性傷口癒合模式其中的10個描述傷口的項目（例如有無壞死組織，有無瘀血，且只需回答有或無）以及11個需要測量傷口的項目（如深度，位置，傷口癒合時期）組合而成。其使用相當簡當，且也容易去追蹤使用

Sussman Wound Healing Tool (SWHT)

Wound Assessment Form

Circle week of care: B 1 2 3 4 5 6 7 8 9 10 11

SWHT Variable	Tissue Attribute	Attribute Definition	Rating	Relationship to Healing	Score
1	Hemorrhage 瘀血	Purple ecchymosis of wound tissue or surrounding skin	Present or absent	Not Good	0
2	Maceration 浸潤	Softening of a tissue by soaking until the connective tissue fibers are soft and friable	Present or absent	Not Good	0
3	Undermining 口袋或隧道	Includes both undermining and tunneling	Present or absent	Not Good	0
4	Erythema 發紅	Reddening or darkening of the skin compared to surrounding skin; usually accompanied by heat	Present or absent	Not Good	0
5	Necrosis 有slough,eschar壞死組織	All types of necrotic tissue, including eschar and slough	Present or absent	Not Good	1
6	Adherence at wound edge 傷口周圍和傷口床有連續（無落差）	Continuity of wound edge and the base of the wound	Present or absent	Good	0
7	Granulation (Fibroplasia — Significant reduction Reduction in depth)	Pink/red granulation tissue filling in the wound bed, reducing wound depth 肉芽組織，長肉使傷口變淺	Present or absent	Good	1
8	Appearance of contraction (reduce size) 有無傷口收縮	First measurement of the wound drawing together, resulting in reduction in wound open surface area	Present or absent	Good	1
9	Sustained contraction (more reduced size)傷口有無持續收縮	Continued drawing together of wound edge, measured by reduced wound open surface area	Present or absent	Good	0
10	Epithelialization有新皮或疤痕形成	Appearance and continuation of resurfacing with new skin or scar at the wound edges or surface	Present or absent	Good	1

Measures and extent (Depth & undermined)測量傷口深度及口袋深度

	Depth/location	score		Undermining/location	score	other	Letter
11	General depth>0.2cm	1	16	underm@12:00>0.2cm	0	location	RT
12	depth@12:00>0.2cm	0	17	underm@3:00>0.2cm	0	Wound healing phase	P
13	depth@3:00>0.2cm	0	18	underm@6:00>0.2cm	0	Total”not goog”	1
14	depth@6:00>0.2cm	1	19	underm@9:00>0.2cm	0	Total”goog”	3
15	depth@9:00>0.2cm	1

Key:present=1, abscent=0, location choice: upper body(UB), coccyx(C), trochanter(T) ,ischial(I), heel(H) and foor(F), add right or left(R or L), wound healing phase: imflammation(I), proliferation(P), epithelialization(E), remodeling (R)

參考資料

Sussman C, Swanson G. Utility of the Sussman Wound Healing Tool in predicting wound healing outcomes in physical therapy. Adv Wound Care. 1997;10(5):74–77.