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MAKALAH JURNAL

Penggunaan Chlorhexidine Gluconate dalam Pelaksanaan Oral Care pada Pasien yang Menggunakan Ventilator untuk Pencega an Ventilator Acquired Pneumonia !VAP"

Di ruang ICU RSUP DR. M. Djamil Padang

OLEH:

NURUL FATIA TISRI YOLANDARI ZIL FADILAH REZI MA ALDI

PRA!TE! PROFESI PEMINATAN !EPERA ATAN "A AT DARURAT FA!ULTAS !EPERA ATAN UNI#ERSITAS ANDALAS $%&'

#A# $ P%N&AHULUAN '( Latar #elakang Pn(um)nia a*i+a, -(n,ila,)r .Ventilator Associated Pneumonia / #AP/ did(0ini1i*an 1(+agai 2n(um)nia n)1)*)mial 2ada 2a1i(n 3ang m(ngguna*an -(n,ila,)r .d(ngan ,a+ung (nd),ra*(al a,au ,ra*()1,)mi/ 1(lama l(+i4 dari '5 jam. Ventilator Associated Pneumonia m(ru2a*an *)m2li*a1i di 1(+an3a* $56 dari 2a1i(n 3ang m(n(rima -(n,ila1i m(*ani*. In1id(n #AP m(ning*a, 1(iring d(ngan 2(ning*a,an dura1i 2(nggunaan -(n,ila1i m(*ani*. E1,ima1i in1id(n adala4 1(+(1ar 76 2(r 4ari 1(lama 8 4ari 2(r,ama9 $6 2(r 4ari 1(lama :;&% 4ari9 dan &6 2(r 4ari 1(,(la4 &% 4ari. M(ngurangi ang*a *(jadian ,(rjadin3a 2n(um)ni 3ang dida2a, dari ruma4 1a*i, ,(ru1 m(njadi ,an,angan ,(r4ada2 *(1(lama,an 2a1i(n di 2(la3anan *(1(4a,an. Ang*a 2n(um)ni 1(+an3a* '<6 dari 1(mua in0(*1i 3ang dida2a, di ruma4 1a*i, dida2a, di ruma4 1a*i,9 2ada uru,an *(dua in0(*1i m(lalui 1aluran 2(r*(mi4an. #(n,ila,)r; a11)=ia,(d 2n(um)nia .#AP/ ,(rjadi 1(+agai a*i+a, dari 2(radangan 2aru 1(,(la4 in,u+a1i. Pr)1(1 m(*ani* dari in,u+a1i m(njadi 2(ng4alang an,ara )r)0aring dan ,ra*(a9 3ang m(m0a1ili,a1i ma1u*n3a +a*,(ri *( 2aru;2aru .Zurm(4l39 $%&7/. M(1*i2un in,(r-(n1i +(ru2a 2(ndidi*an *(1(4a,an mulu, m(m+an,u dalam m(ngurangi *(jadian #AP. Hal ini m(ru2a*an ,inda*an in,(r-(n1i 3ang (0(*,i09 namun ,ida* 1(lalu di2ra*,(**an 1(=ara *)n1i1,(n. P(ra>a, 1(+agai 2(m+(ri 2(ra>a,an u,ama di ICU ruma4 1a*i,9 +(lum m(la*u*an in,(r-(n1i 2(ra>a,an mulu, d(ngan (0(*,i0. ?(+(ra2a 2(n(li,ian m(n3a,a*an +a4>a *(+an3a*an 2(ra>a, 2(r=a3a +a4>a 2(ra>a,an mulu, 4an3a 1(+agai u*uran *(n3amanan +agi 2a1i(n .Zurm(4l39 $%&7/. #AP +(r4u+ungan d(ngan ,inggin3a ang*a *(jadian *(ma,ian dan *(1a*i,an 2ada 2a1i(n d(ngan -(n,ila1i m(*ani*. Ru,ini,a1 oral care m(nunju**an dam2a* lang1ung 2ada 2(nurunan ang*a *(jadian #AP. ?(rda1ar*an 4a1il 2(n(li,ian Zurm(4l3 .$%&7/9 m(nunju**an adan3a 2(nurunan 3ang 1igni0i*an 2ada ang*a *(jadian #AP. P(n(li,ian ,(r1(+u, dila*1ana*an d(ngan m(la*u*an oral care m(ngguna*an chlorhexidine gluconate solution %9&$6. Oral care ,(r1(+u, dila*u*an d(ngan 0r(*u(n1i m(ngg)1)* gigi 1(,ia2 ' jam dan 1>a++ing 1(,ia2 &$ jam. ?(rda1ar*an la,ar +(la*ang di a,a1 2(nuli1 ,(r,ari* un,u* m(m+a4a1 ,(n,ang in)-a1i )ral =ar( 3ang m(ngguna*an clorhexidine gluconate *(2ada 2(ra>a, *4u1u1n3a 2(ra>a, di ruangan ICU RSUP Dr. M. Djamil Padang. D(ngan +(r,am+a4n3a

2(ng(,a4uan 2(ra>a, ,(n,ang )ral =ar(9 di4ara2*an da2a, m(ngurangi ang*a *(jadian #AP. )( *u+uan a( *u+uan Umum M(ng(,a4ui ,(n,ang oral care m(ngguna*an chlorhexidine gluconate ,( *u+uan K usus a/ M(ng(,a4ui ,(n,ang #AP +/ M(ng(,a4ui 2(n,ingn3a oral care m(ngguna*an chlorhexidine gluconate

#A# $$ *$NJAUAN PU-*AKA

A( Ventilator Associated Pneumonia !VAP" '( &e.inisi #AP adala4 2n(um)nia 3ang m(ru2a*an in0(*1i n)1)*)mial 3ang ,(rjadi 1(,(la4 '5 jam 2ada 2a1i(n d(ngan +an,uan -(n,ila1i m(*ani* +ai* i,u m(lalui 2i2a (nd),ra*(a mau2un 2i2a ,ra*()1,)mi. ?(rda1ar*an American college of chestphysicians, #AP adala4 1ua,u *(adaan dimana ,(rda2a, gam+aran in0il,ra, +aru dan m(n(,a2 2ada 0),) ,)ra*. S(lain i,u #AP di1(r,ai )l(4 ,anda lain 3ai,u9di,(mu*ann3a mi*r))rgani1m( 3ang 1ama 4a1il +ia*an dara4 a,au 2l(ura d(ngan mi*r))rgani1m( 3ang di,(mu*an di 12u,um mau2un a2rira1i ,ra*(a9 *a-i,a1i 2ada 0),) ,)ra*9 g(jala 2n(um)nia a,au ,(da2a, dua dari ,iga g(jala +(ri*u, 3ai,u d(mam9 l(u*)1i,)1i1 dan 1(*r(, 2urul(n. !)m2li*a1i 3ang =u*u2 1(riu1 3ang mun=ul a*i+a, #AP9 1(2(r,i A=u,( R(12ira,)r3 Di1,r(11 S3ndr)m( .ARDS/. Hal ini di1(+a+*an 1(+agian *ar(na ,(r,undan3a 2(m+(rian ,(ra2i an,i+i),i* 3ang 1(1uai9 dan 1(+agian *ar(na 2)2ula1i 3ang 1anga, +(r+(da . 2a1i(n a=u,( r(12ira,)r3 di1,r(11 13ndr)m( .ARDS/9 +(r+agai -aria1i dalam ,(ra2i m(di1 1(1uai (m2iri1 2ada $ 4ari 2(r,ama 2(m+(rian -(n,ila1i m(*ani*9 dan 2a1i(n ICU m(di1 dan +(da4 / )( %tiologi Ting*a, *(ma,ian 3ang l(+i4 ,inggi 2ada #AP di1(+a+*an adan3a *)l)ni1a1i +a*,(ri 2ada 2aru. Mi*r))rgani1m( 2(n3(+a+ ,(rjadin3a #AP an,ara lain Staphylococcus aureus, Pseudomonas aeruginosa, Acinetobacter sp, dan Maltophilia stenotrophomonas. ?a*,(ri 2(n3(+a+ #AP dig)l)ng*an m(njadi 7 *(l)m2)* +(rda1ar*an )n1(, a,au laman3a 2)la *uman9 an,ara lain: a. ?a*,(ri 2ada *(l)m2)* & d(ngan )n1(, dini adala4 haemophilus influenza, moraxella, staphylococcus aureus, cattarrhalis streptococcus pneumoniae, *uman gram n(ga,i0 . E1=4(ri=4ia =)li9 !l(+1i(lla 1229 Pr),(u1 1229 En,(r)+a=,(r 122 /9 1(r,a methicillin sensitive staphylococcus aureus M!!A". +. ?a*,(ri 2ada *(l)m2)* $ d(ngan )n1(, lam+a, adala4 +a*,(ri 2(n3(+a+

*(l)m2)* & di,am+a4 L(gi)n(lla 2n(um)24ilia9 *uman ana(r)+9 dan M(,4i=illin r(1i1,an S,a243l)=)==u1 aur(u1 .MRSA/. =. ?a*,(ri 2ada *(l)m2)* 7 adala4 Pseudomonas aeruginosa, Acinetobacter spp, dan M#!A. /( 0aktor Resiko Fa*,)r 3ang da2a, m(ning*a,*an ri1i*) ,(rjadin3a #AP adala4 2(ma*aian in,u+a1i 2ada 2a1i(n. Tinda*an in,u+a1i m(m2(rmuda4 ma1u*n3a *uman dan m(n3(+a+*an *)n,amina1i ujung 2i2a (nd),ra*(al 2ada 2(nd(ri,a d(ngan 2)1i1i ,(rl(n,ang. S(lain i,u ,(rjadin3a #AP da2a, di1(+a+*an )l(4 +(r+agai 0a*,)r 1(2(r,i 2)1i1i 2a1i(n 3ang da,ar9 ma*r) a12ira1i lam+ung9 dan 2(ng4i1a2an l(ndir 1am2ai ,ra*(a. 1( &iagnosis Diagn)1i1 #AP da2a, di,(ga**an +(rda1ar*an 7 *)m2)n(n ,anda in0(*1i 1i1,(mi* 3ai,u d(mam l(+i4 dari 7597%C9 ,a*i*ardi9 dan l(u*)1i,)1i1 l(+i4 dari &$ @ &%ABml di1(r,ai gam+aran in0il,ra, +aru a,au2un 2(r+uru*an di 0),) ,)ra*1 1(r,a 2(n(muan +a*,(ri 2(n3(+a+ in0(*1i 2aru. T)rr(1 d**. m(n3a,a*an +a4>a diagn)1i1 #AP m(li2u,i ,anda;,anda in0il,ra, +aru mau2un 2r)gr(1i0 2ada 0),) ,)ra* di1(r,ai g(jala d(mam9 l(u*)1i,)1i1 mau2un l(u*)2(ni dan 1(=r(, 2urul(n 2( Pencega an P(n=(ga4an 3ang +(r*ai,an d(ngan 2(nurunan in1id(n1i #AP 1ala4 1a,un3a adala4 d(ngan m(njaga *(+(r1i4an mulu,. Tinda*an 3ang da2a, dila*u*an un,nu* m(njaga *(+(r1i4an mulu, adala4 d(ngan )ral =ar( 3ang dila*u*an )l(4 2(ra>a, 1(+agai 1ala4 1a,u +agian dari 2(m+(rian 2(la3anan *(1(4a,an. #( Oral Care Menggunakan Chlorhexidine gluconate '( Pengertian Oral Care Oral care adala4 ,inda*an m(m+(r1i4*an dan m(n3(gar*an mulu,9 gigi9 dan gu1i. Oral care d(ngan 2(nggunaan an,i+i),i* a,au2un an,i1(2,i= di4ara2*an da2a, m(nurun*an 2(r,um+u4an +a*,(ri di )r)0aring9 1(4ingga in1id(n ,(rjadin3a #AP m(nurun.

)( Man.aat Chlorhexidine gluconate S(ja* di2(r*(nal*an9 +(r+agai n(gara mulai m(ngguna*an chlorhexidine glu=)na,( 1(+agai an,i1(2,i= di ruma4 1a*i,. $hlorhexidine gluconate di2a*ai 1(+agai di1in0(*,an 2ada *uli, 1(+(lum )2(ra1i9 =u=i ,angan 1(+(lum )2(ra1i dan juga 1(+agai di1in0(*,an ala,;ala, *(d)*,(ran ,(ru,ama ala,;ala, )2(ra1i. O+a, ini m(ru2a*an 1ala4 1a,u an,i1(2,i* 2ada )2(ra1i 3ang ,(ru,ama +an3a* digina*an di *(d)*,(ran gigi. ?(r1i0a, +a*,(ri)1,a,i* un,u* *uman gram;n(ga,i09 ragi9 jamur9 2r),)C)a9 alga9 dan -iru19 1(r,a 1anga, 1(n1i,i0 2ada +(+(ra2a 12(1i(1 *uman 1(2(r,i pseudomonasspp, proteus spp, haemophilus spp, diptheroid spp, dan actinomyces spp. A*an ,(,a2i ada juga +(+(ra2a *uman gram;n(ga,i0 3ang r(1i1,(n ,(r4ada2 chlorhexidine gluconate. $hlorhexidine gluconate ,(,a2 (0(*,i0 >alau2un ada 1a+un9 nana4 dan dara4. Ind(*1 ,(ra2(u,i* )+a, ini 1anga, ,inggi d(ngan ,)*1i1i,a1 3ang =u*u2 r(nda4. Pada 2(nggunaan +(rulang dan jang*a lama da2a, m(n3(+a+*an d(rma,i,i1 *)n,a* dan 0),)1(n1i,i-i,a1. P(nggunaann3a 1(+agai d(n,al g(l dan )+a, *umur da2a, m(ngu+a4 >arna lida4 dan gigi. $hlorhexidine gluconate 2ada 2H 0i1i)l)gi1 da2a, m(ngi*a, +a*,(ri di2(rmu*aan r)ngga mulu,9 di1(+a+*an adan3a in,(ra*1i an,ara mua,an 2)1i,i0 dan m)l(*ul;m)l(*ul $hlorhexidine gluconate d(ngan dinding 1(l +a*,(ri 3ang m(n3(+a+*an ,(rjadin3a 2(n(,ra1i *(dalam 1i,)2la1ma dan 2ada a*4irn3a m(n3(+a+*an *(ma,ian mi*r))rgani1m(. S,r(2,)*)*u1 ,(r,(n,u da2a, ,(ri*a, )l(4 $hlorhexidine gluconate 2ada m(dia 2)li1a*arida diluar 1(l9 1(4ingga da2a, m(ning*a,*an 1(n1i0i,a1 1,r(2,)*)*u1 dalam r)ngga mulu, ,(r4ada2 $hlorhexidine gluconate. S(+agai an,i1(2,i=9 chlorhexidine gluconate da2a, m(la>an a*,i-i,a1 2(r*(m+angan mi*r))rgani1m( gram 2)1i,i09 1(2(r,i Methicillin%resistant !taphylococcus aureus .MRSA/ dan Vancomisin%resistant &nterococcus .#RE/. A*an ,(,a2i dalam m(la>an mi*r))rgani1m( gram n(ga,i09 (0(*,i-i,a1 chlorhexidine gluconate m(njadi *urang )2,imal.

#A# $$$ P%M#AHA-AN Di ruang ICU 2(ra>a, m(ngguna*an =airan H$O$ & 6 un,u* )ral =ar(. !H$O$/ .Hidr)g(n 2(r)*1ida/ adala4 =airan +(ning d(ngan 1i0a, )*1ida1i 3ang *ua, dan m(ru2a*an ag(n 2(mu,i4 3ang *ua, 3ang diguna*an 1(+agai di1in0(*,an .Sa4(lian9 $%&%/. !(gunaan dari H$O$ adala4 1(+agai +a4an 2(mu,i4 *(r,a1 dan ,(*1,il9 di1in*(*1i contact lenses9 dan 1(+agai 2(mu,i4 gigi. H$O$ 3ang di*)n1um1i 1(=ara )ral da2a, m(nga*i+a,*an iri,a1i 1aluran 2(n=(rnaan9 (r)1i dan 2(r0)ra1i ga1,r)in,(1,inal. S(dang*an 2(nggunaan H$O$ 2ada in,ra-(na da2a, m(n3(+a+*an 2(radangan 2(m+ulu4 dara49 g(l(m+ung di 2(m+ulu4 dara4 dan +(r2),(n1i r(a*1i al(rgi 3ang m(ngan=am n3a>a .Sa4(lian9 $%&%/. Hal ini di+u*,i*an )l(4 2(n(li,ian T)m+(1 and "allu=i .$%%:/ 3ang m(n3a,a*an +a4>a 43dr)g(n 2(r)@id( ,ida* dir(*)m(nda1i*an un,u* )ral =ar( *ar(na da2a, rm(n3(+a+*an iri,a1i 2ada mu*)1a mulu,. Ada +(+(ra2a j(ni1 =airan 3ang da2a, diguna*an un,u* oral care 1ala4 1a,un3a chlorhexidine gluconate. $hlorhexidine gluconate adala4 =airan 3ang di2a*ai 1(+agai di1in0(*,an 2ada *uli, 1(+(lum )2(ra1i9 =u=i ,angan 1(+(lum )2(ra1i dan juga 1(+agai di1in0(*,an ala,;ala, *(d)*,(ran ,(ru,ama ala,;ala, )2(ra1i. O+a, ini m(ru2a*an 1ala4 1a,u an,i1(2,i* 2ada )2(ra1i 3ang ,(ru,ama +an3a* diguna*an di *(d)*,(ran gigi. ?(r1i0a, +a*,(ri)1,a,i* un,u* *uman gram;n(ga,i09 ragi9 jamur9 2r),)C)a9 alga9 dan -iru19 1(r,a 1anga, 1(n1i,i0 2ada +(+(ra2a 12(1i(1 *uman 1(2(r,i pseudomonas spp, proteus spp, haemophilus spp, diptheroid spp, dan actinomyces spp. P(nggunaan chlorhexidine gluconate 1anga, (0(*,i0 1(+agai an,i+a*,(ri9 ,ida* m(ngiri,a1i mu*)1a mulu,9 dan da2a, m(n=(ga4 2n(um)ni 2ada 2a1i(n d(ngan -(n,ila1i m(*ani* . (+MD9 $%&%/. M(nuru, 2(n(li,ian idjia1,u,i .$%%7/ $hlorhexidine gluconate m(m2un3ai (0(* an,i+a*,(ri 2aling +ai* di+anding*an d(ngan H$O$. !(l(+i4an u,ama chlorhexidine gluconate di+anding*an d(ngan )+a, *umur *(+an3a*an lainn3a adala4 2(rl(*a,ann3a d(ngan 1u+1,an1i .jaringan r)ngga mulu,/. I*a,ann3a +ai* d(ngan jaringan luna* mau2un *(ra1 2ada mulu, m(n3(+a+*an (0(* chlorhexidine gluconate +(r,a4an dalam jang*a >a*,u 3ang lama 1(,(la4 diguna*an. Dumla4 +a*,(ri dalam 1ali-a 1(=ara 2(rla4an +(r*urang m(n=a2ai an,ara &%;$%6 di+anding*an jumla4 a>al 1(+(lum 2(ma*aian dan ,(,a2 +(r,a4an 1(lama < 4ingga &$ jam .Nar(1>ari9 $%&%/. $hlorhexidine gluconate m(mili*i ,ing*a, an,i+a*,(ri9 an,i-iru1 dan a*,i-i,a1 an,i jamur 3ang ,inggi9 1(r,a 4am2ir +(+a1 dari (0(* 1am2ing. $hlorhexidine gluconate 2ada 2H

0i1i)l)gi1 da2a, m(ngi*a, +a*,(ri di2(rmu*aan r)ngga mulu,9 di1(+a+*an adan3a in,(ra*1i an,ara mua,an 2)1i,i0 dan m)l(*ul;m)l(*ul $hlorhexidine gluconate d(ngan dinding 1(l +a*,(ri 3ang m(n3(+a+*an ,(rjadin3a 2(n(,ra1i *(dalam 1i,)2la1ma dan 2ada a*4irn3a m(n3(+a+*an *(ma,ian mi*r))rgani1m( .Pil(ggi (, al9 $%&&/. ?(+(ra2a 2(n(li,ian ,(la4 m(m+u*,i*an +a4>a chlorhexidine gluconate 1anga, (0(*,i0 un,u* m(nurun*an ang*a *(jadian #AP dian,aran3a 2(n(li,ian dari Zurm(4l3 .$%&7/ 3ang m(n3a,a*an +a4>a ,(rda2a, 2(nurunan ang*a *(jadian #AP 1(+(1ar :$986 1(,(la4 m(la*1ana*an oral care m(ngguna*an chlorhexidine gluconate. Ha1il 2(n(li,ian C4l(+i=*i dan Sa0dar .$%%</9 m(n3a,a*an +a4>a chlorhexidine gluconate 1anga, +(rman0aa, dalam m(n=(ga4 #AP.

#A# $V P%NU*UP '( Kesimpulan P(nggunaan chlorhexidine gluconate 1anga, (0(*,i0 1(+agai an,i+a*,(ri9 ,ida* m(ngiri,a1i mu*)1a mulu,9 dan da2a, m(n=(ga4 2n(um)ni 2ada 2a1i(n d(ngan -(n,ila1i m(*ani*. $hlorhexidine gluconate m(m2un3ai (0(* an,i+a*,(ri 2aling +ai* di+anding*an d(ngan H$O$. ?(+(ra2a 2(n(li,ian ,(la4 m(m+u*,i*an +a4>a 2(nggunaan chlorhexidine gluconate un,u* oral care da2a, m(nurun*an ang*a *(jadian #AP. )( -aran D(ngan adan3a ,ran10(r ilmu 3ang dila*u*an )l(4 ma4a1i1>a Fa*ul,a1 !(2(ra>a,an UNAND9 di4ara2*an 2(ra>a, di ruang ICU RSUP DR. M. Djamil Padang da2a, m(ngguna*an =airan chlorhexidine gluconate dalam 2(la*1anaan oral care d(ngan ,ujuan un,u* m(ngurangi *(jadian #AP.

&A0*AR PU-*AKA Nar(1>ari. $%&%. Perbedaan &fe'tivitas Obat (umur $hlorhexidine )anpa Al'ohol *ibanding'an *engan $hlorhexidine +eral'ohol *alam Menurun'an (uantitas (oloni +a'teri #ongga Mulut. Dia*1(1 ,anggal 8 F(+ruari $%&' dari 4,,2:BB(2rin,1.un1.a=.idB&%&8<B&B&7::A%A%5$%&%%8$'&.2d0 Pil(ggi (, al. $%&&. Prevention Of Ventilator%Associated Pneumonia, Mortality And All ,ntensive $are -nit Ac.uired ,nfections +y )opically Applied Antimicrobial Or Antiseptic Agents/ A Meta%Analysis Of #andomized $ontrolled )rials ,n ,ntensive $are -nits. Dia*1(1 ,anggal 8 F(+ruari $%&' dari 4,,2:BB>>>.n=+i.nlm.ni4.g)-B2u+m(dB$&<%$A': Sa4(lian. $%&%. 0ydrogen Peroxide 01o1 +enefit And !ide &ffects, Practical !uggestions On -sed And #evie2 Of Oral, ,nternal -se. Dia*1(1 2ada ,anggal 8 F(+ruari $%&' dari 4,,2:BB>>>.ra31a4(lian.=)mB43dr)g(n2(r)@id(.4,ml T)m+(1 dan "allu==i. $%%:. )he &ffects Of 0ydrogen Peroxide #inses On )he 3ormal Oral Mucosa. Dia*1(1 2ada ,anggal 8 F(+ruari $%&' dari 4,,2:BB>>>.n=+i.nlm.ni4.g)-B2u+m(d >(+MD. $%&%. *rugs 4 Medications % $hlorhexidine 5luconate Mucous Membrane. Dia*1(1 ,anggal 8 F(+ruari $%&' dari 4,,2:BB>>>.>(+md.=)mBdrug1Bdrug;878:; C4l)r4(@idin(E"lu=)na,(EMu=)u1EM(m+ran(.a12@F drugidG878:Hdrugnam(GC4l)r4(@idin(E"lu=)na,(EMu=)u1EM(m+ran( idjia1,u,i. $%%7. &fe'tivitas 01o1 67, 3aocl 1,87 *an $hlorhexidine 5luconate 9,17 )erhadap Mi'roorganisme !aluran A'ar 5igi 3e'rose. Dia*1(1 ,anggal 8 F(+ruari $%&' dari 4,,2:BB>>>.in0)li,+ang.ri1,(*.g).idBind(@.242FlGidHg)GdHiG7'A