PATIENT ASSESSMENT AND EVALUATION OF HEALINGfikes.ummgl.ac.id/downlot.php?file=Pengkajian...
Transcript of PATIENT ASSESSMENT AND EVALUATION OF HEALINGfikes.ummgl.ac.id/downlot.php?file=Pengkajian...
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WOUND ASSESSMENT Konsep Dasar Keperawatan Luka
Adi Subrata, M.Kep
SI Ilmu Keperawatan FIKES UMMGL 2015
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5 Basic Skills of Wound Caring
1. Anfis integumentum
2. Memahami 3 tahapan
proses penyembuhan
luka (inflamasi,
proliferasi dan maturasi)
3. Pengkajian luka
4. Cleansing Luka
5. Memilih topikal terapi
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Kelenjar
minyak
Urat saraf
Folikel rambut Vena Arteri Akar
rambut
Serabut saraf
sensor
Kelenjar
keringat
Penerima
sensor
Batang rambut
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5 MAIN OBJECTIVES 1. Mendapatkan informasi yang relevan
tentang pasien dan luka
2. Memonitor proses penyembuhan luka
3. Menentukan program perawatan luka
pada pasien
4. Mengevaluasi keberhasilan perawatan
5. Memudahkan perawat untuk
mensistematiskan intervensi yang
dimulai dari pengkajian
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Efek GULA DARAH TINGGI A. Neuropati sensorik (baal, kurang
peka terhadap stimulan invasif)
B. Neuropati motorik (kelemahan
otot, atropi)
C. Neuropati otonom (kaki kering et
causa defisit fungsi kelenjar
keringat)
D. Disfungsi Sel darah putih
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Gambaran Luka Kronis
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MONITORING – OBSERVATION – INSPECTION
Daily monitoring of a
patient skin,
observation the
dressing, especially if
dressing stay in place
for several days
Documentation :
Dressing dry and intact,
surrounding skin within
normal limits
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HOLISTIC ASSESSMENT
1. Identitas, RPS, RPD
2. Etiology
3. Duration of the wound / age
4. Factor that impede healing
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1. ETIOLOGY. Ex:Dekubitus/ulkus DM
Kerusakan jaringan kulit akibat adanya penekanan antara jaringan lunak dengan daerah
tulang yang menonjol pada support surface yang keras, dalam jangka waktu yang
panjang dan terus menerus
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ETIOLOGY : LUKA DIABETIKUM
Penyebab kejadian : kombinasi dari gangguan vaskular, peripheral neuropathy dan peningkatan faktor resiko infeksi pada penderita
Luka kronis yang sulit proses penyembuhannya
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2. Duration of wound
The age of the
wound
Guidelines for
pressure ulcer and
arterial wounds that
has not improve, 2 –
4 weeks recommend
biopsy
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3. Factor that impede healing Comorbid condition
(malignancies, diabetics, etc)
Medications
(chemotherapy, corticosteroid)
Decreasse oxygeation and tissue perfussion
Alteration in nutrition and hydration
Psychosocial barriers
(Family factors, financial, etc)
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Wound Location
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Betes Jensen Wound Assessment
1. Ukuran luka
2. Kedalaman luka
3. Tepi luka
4. GOA
5. Tepi jaringan nekrosis
6. Jumlah jaringan nekrosis
7. Tipe Eksudat
8. Jumlah eksudat
9. Warna kulit sekitar luka
10. Jaringan edema
11. Pengerasan jaringan tepi
12. Jaringan granulasi
13. Jaringan epitelisasi
Bates-Jensen Wound
Assessment Tool.pdf
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(1)Ukuran dan (2)kedalaman luka
Pengkajian 2 dimensi (Panjang x lebar)
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Metode WOUND TRACING
Menggunakan plastic transparan
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DIGITAL WOUND IMAGING (Aranz Medical Silhoutte Mobile)
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Pengukuran luka 3D
Panjang x lebar x kedalaman
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Pengukuran kedalaman luka
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(3)Tepi luka • Tepi luka yang baik adalah halus,
tipis dan lunak.
• Tepi luka yang tebal harus
ditipiskan, yang kasar harus
dihaluskan, yang kotor harus
dibersihkan dan yang keras harus
dilunakkan.
• Luka akan mengalami
penyembuhan yang optimal jika
sekitar luka utuh, tidak bengkak,
tidak kemerahan, tidak nyeri, tidak
mengeras, tidak sianosis.
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(4)GOA/cavity/undermining/sinus
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Mengkaji GOA
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(5)Tipe jaringan nekrosis
• Wajib dihilangkan
• Kerusakan
jaringan sebagai
efek defisit
oksigen
• Jenis: Slough,
black necrosis
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Maggot Debridement Therapy
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Maggot Debridement Therapy
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Raynaud Phenomenon
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Raynaud PHENOMENON in LUPUS
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(6)Jumlah jaringan nekrosis
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(7)Tipe eksudat
Eksudatcairan hasil
reaksi inflamasi
ekstravaskular dengan
berat jenis tinggi (diatas
1.020) dan seringkali
mengandung air, elektrolit,
nutrient, mediator
inflamasi, trombosit, enzim
pencerna protein, growth
factor
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Tipe eksudat
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Tipe eksudat
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Tipe eksudat
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(8)Jumlah eksudat
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Kategori jumlah eksudat
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Warna kulit
sekitar luka
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(9)Warna kulit
sekitar luka
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KULIT SEKITAR LUKA / PERIWOUND SKIN
a. Gatal
b. Maserasi (Kulit terus menerus dalam keadaan basah. Kulit menjadi lebih lunak, berubah warna menjadi putih, dan dapat dengan mudah terinfeksi oleh bakteri dan jamur)
c. Peripheral edema
d. hiperpigmentasi
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(10)Jaringan edema
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Faktor pencetus edema pada luka kronis
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Faktor pencetus edema pada luka kronis
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(11)Pengerasan tepi luka
Pengerasan tepi luka adalah
permasalahan tersendiri saat
pengkajian luka karena jika hal
tersebut dibiarkan luka ketika
sembuh akan menjadi
hipergranulasi.
Maka dari itu solusinya bisa
dengan dilunakkan terlebih
dahulu kemudian bisa
dilakukan cutting pada area
yang berlebih
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Pengerasan tepi luka
Kegagalan penutupan terjadi jika tepi luka :
a. Peripheral Edema
b. Nekrosis
c. infeksi
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Pengkategorian “wound induration”
1 = Tidak ada
2= Pengerasan < 2 cm di sebagian
kecil sekitar luka
3= Pengerasan 2-4 cm menyebar <
50% di tepi luka
4= Pengerasan 2-4 cm menyebar >
50% di tepi luka
5= Pengerasan > 4 cm di seluruh
tepi luka
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“wound induration”
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(12)Jaringan granulasi
SKORING
1= kulit utuh atau stage 1
2= terang 100 % jaringan granulasi
3= terang 50 % jaringan granulasi
4= granulasi 25 %
5= tidak ada jaringan granulasi
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Jaringan Granulasi Jaringan granulasi adalah
jaringan fibrosa yang terbentuk dari
bekuan darah sebagai bagian dari
proses penyembuhan luka
Ciri: berwarna merah, lembab,
lembut jika disentuh, dan memiliki
penampilan yang bergelombang
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Jaringan Granulasi Pembentukan granulasi berfungsi
a. untuk menyuplai vitamin,
mineral, glukosa, dan asam amino
ke fibroblas
b. Untuk memaksimalkan
pembentukan kolagen
c. Untuk membebaskan jaringan
dari nekrosis, benda asing, dan
infeksi sehingga mempercepat
penyembuhan
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Warna dasar luka
a. Red : granulasi (merah cerah) /
epitelisasi (merah muda)
b.Yellow : Kuning, lembek menempel di
area kulit sebagai dampak kematian
bakteri di area luka. Sifat avaskuler,
KKI (kontaminasi, kolonisasi, infeksi)
c. Black : Hitam, keras, wajib
dihilangkan, KKI.
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(13)Jaringan epitelisasi
1 =100 % epitelisasi
2 = 75 % - 100 % epitelisasi
3 = 50 % - 75% epitelisasi
4 = 25 % - 50 % epitelisasi
5 = < 25 % epitelisasi
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Epitelisasi (Fase Proliferasi) Fibroblas mengeluarkan
“keratinocyte growth factor
(KGF) yang berperan dalam
stimulasi mitosis sel epidermal.
Keratinisasi akan dimulai
dari pinggir luka dan akhirnya
membentuk barrier yang
menutupi permukaan luka
Ciri: warna merah muda, mulai
terjadi penutupan luka
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BAU TIDAK SEDAP / ODOR Bau dapat disebabkan
oleh adanya kumpulan bakteri yang menghasilkan protein
Apocrine sweat glands (kaki, ca mamae, ketiak)
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CA MAMAE
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CA CERVIX
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CA CERVIX
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TANDA INFEKSI ?
Proses inflamasi / peradangan yang memanjang : kemerahan (rubor), odema (tumor), nyeri (dolor), panas (kalor), functio laesa (defisit fungsi organ)
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Cara Pengambilan Kultur
a. Siapkan alat pengambilan kultur dan balutan
b. Cuci tangan
c. Buka balutan luka lama
d. Cuci luka dengan larutan normal saline JANGAN antiseptik
e. Keringkan dengan kasa steril
f. Tunggu sampai eksudat keluar
g. Lakukan pengambilan sampel kultur dengan mengusap zig zag sebanyak 10 kali usapan yang mewakili seluruh area luka
h. Sampel dikirim ke lab, jika tertunda pengiriman harus disimpan dalam almari es / suhu dingin
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Cara Pengambilan Kultur
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Pengambilan Kultur
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Pengambilan Kultur
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WOUND PAIN An unpleasant
sensory and emotional experience with tissue damage
Hypnonursing management : pain relief
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Wong Baker FACES
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