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Konsep

MOISTURE
BALANCE
PADA PERAWATAN LUKA
common misconceptions within your practice
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n CLINICAL NURSE – WOUND OSTOMY AND


CONTINENCE NURSE

n  Tercatat menjadi bagian dari kegiatan kesehatan dunia di


World Council of Enterostomal Therapy, Asian Wound Care
Association, Europian Wound Management Association,
International Wound Practice Research Alliance, PAN Pacific
Pressure Injury, Malaysian Wound Profesional Association dan
lainnya.

n  WIDASARI PRAKOSO n  WIDASARI SRI GITARJA n  WIDASARI SRI GITARJA WIDA.ME


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n SINCE…

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n  Mendirikan WOCARE CENTER sejak tahun 2007 , Selama 10 tahun berkiprah
dalam upaya pengembangan profesionalisme keperawatan di
Indonesia dengan memprakarsai berdirinya lebih dari 500 praktik mandiri keperawatan
yang tersebar di seluruh Indonesia, baik di RS, homecare dan pelayanan kesehatan lain.
Bersama TIM WINNERS mengentaskan keilmuan WOC dengan Jumlah lulusan mencapai lebih
dari 10.000 wound care clinician.
WOCARE Center
ET / WOC-Nurse

WOUND OSTOMY CONTINENCE

Enterostomal Therapy Nurse Education Program


The WINNERS
Wocare for Indonesian Nurses
Mapping of Indonesian ETNEP
Outline
1.  INTEGUMENT DAN PERLUKAAN
2.  MYTH or MITOS, 5!
3.  KONSEP LEMBAB PADA
PERAWATAN LUKA
Integument -
PERLUKAAN
PHYSIOLOGY AND FUNCTIONS
INTEGUMENT

10
LAPISAN – LAPISAN
KULIT
•  First “Skin
Immune System
(SIS)” Keeping other

Skin
harmful chemicals and
pathogens out
•  Protect from UV light

function • 

• 
Vitamin D
synthesization
Keeping water in the
body
•  Skin pigmentation
•  First sensory
Epidermis
Perlindungan tubuh
oleh epidermis yang utama
adalah oleh stratum
corneum, dengan
mempertahankan air dalam
tubuh dan mempertahankan
benda asing tetap diluar
tubuh
MASALAH PADA INTEGUMEN : PER- LUKA -AN

DEFINITION
as a break in the
A wound is defined
continuity of the skin (Schultz et al. 2003).
Wounds can be broadly classified as acute or chronic.
BACKGROUND
Acute wounds usually heal in an ordered, timely fashion
(Falanga 2002, Schultz et al. 2003).
Chronic wounds are associated with at least one co-
morbidity (Olin et al. 1999, Oien et al. 2000). These co-morbidities
are frequently hypertension, diabetes, cardio-vascular disease, and
neurological disorders.
PERLUKAAN ? Bagaimana cara merawatnya 15
Myth or
MITOS, 5!
SEPUTAR PERAWATAN LUKA
common misconceptions within your practice
Myth #1: Wet-to-dry dressings are cheaper to use.

Balutan dengan KASA lebih murah.


Not only is wet-to-dry substandard care (as we discuss in
Wet-to-Dry Dressings: Why Not?), it’s not even cost-effective.
Here’s the math: The daily cost of care for a foam dressing is only $3.55. The daily
cost of wet-to-dry is $12.26. Why the big difference?
1.  Wet-to-dry dressings require frequent changes, and each dressing change
causes a drop in wound temperature. In order for a wound to heal, it should be
close to normal body temperature. So if there is a 2⁰ C drop in temperature, this
will slow or stop healing, and it can take up to four hours for that wound to warm
up and get back to get back to normal healing temperature. As we always say,
“When the temperature drops, the healing stops.”
2.  Out of all the different dressings out there,
foam keeps the wound bed the warmest. And foam dressings can remain in
place from 3 to 7 days, decreasing costs, labor and drops in temperature. As
always, with any dressing application, follow the manufacturer’s instructions on
proper usage.
Myth #2: Bleeding in a chronic wound is a sign of healing.

Jika BERDARAH artinya LUKA BAGUS


“Oh, it’s bleeding! That’s good!”
No, that’s not normal or acceptable. Sanguineous (bloody)
exudate serves as a clue to bedside clinicians that you need to go in and
investigate what is causing the bleeding. Start by looking for:
§  malignancy or trauma on the site
§  high bio burden?
§  a dressing that sticks to the wound and causes bleeding upon
removal
By putting on our detective hats and looking at the clues the wound is giving us,
we can identify issues sooner rather than later.
Myth #3: Erythema is a sure sign of wound infection.

KEMERAHAN di sekitar luka adalah INFEKSI


Erythema in the periwound is one of the classic signs of
local infection, but it’s not enough to label it as infected.
You need to see at least three signs and symptoms. Here are some additional signs
and symptoms to consider:
§  Foul odor
§  Increasing pain in the wound
§  Heat in the periwound
§  Purulent drainage
§  Edema
If you see at least three of these signs, it means you have local infection and need to
immediately treat the wound topically, before it moves into a systemic infection.
Myth #4: Oral or IV antibiotics are indicated for all infected
wounds.

SEMUA luka yang infeksi harus menggunakan AB


Administer oral or IV antibiotics only if infection extends beyond the wound margin,
indicating a systemic infection. In other words, you need to see signs and symptoms
such as fever, an elevated white blood cell count, or red streaks emanating from the
wound.
Oral antibiotics are simply not the most effective treatment for local infections. Many
chronic wounds have impaired blood flow, which can compromise the delivery of oral
antibiotics to that wound. Meanwhile, the unnecessary use of
antibiotics leads to the development of antibiotic-resistant
strains of bacteria.
So make sure you have first identified if this is a local or
systematic infection. If systematic, then you should treat with
oral/IV antibiotics.

Presentation Title Here


Myth #5: Clinicians are not responsible if a physician orders 
inappropriate treatment. 

HARUS RESEP DOKTER


“I did it because the doctor ordered it.”
We hear this excuse all the time! Would you administer improper heart medication
to a patient if you knew it was wrong? You have to think of wound care the same
way. It’s our responsibility to uphold the standards of care. If physicians are
unaware of the guidelines and policies, we need to educate them.

Saying that the doctor wrote it and you merely followed orders is not going to
protect you legally, and it’s certainly not in the best interest of your patient.
Always practice the current standard of care – no excuses!
What myths do you battle?
While these are some of the most common myths in wound care, we know there are more. 22
Bagaimana cara MENGATASINYA?
What are some of the common misconceptions
within your practice, and how to you deal with them?
Have you been in a situation where you had to help educate
physicians or colleagues?
Proses Penyembuhan Luka
11.01.2017 – 14.03.2017, Wound healed in 10 weeks
Kronik

11.01.2017 30.01.2017 25.02.2017 14.03.2017


Pertama kali pasien datang Kondisi luka pada perawatan Kondisi luka hari ke 10 Perawatan ke 14 (empat
dengan keluhan nyeri pada ke 5 (lima) dengan (sepuluh). Luka tampak lebih belas). Luka sudah menutup.
tumit kaki, tidak dapat menggunakan occlusive tenang dan keluhan sudah
Total perawatan dengan
berjalan. Keadaan ini sudah dressing. berkurang.
konsep lembab membutuhkan
berlangsung selama 2 minggu
Tetap dengan menggunakan waktu sekurangnya 10
dan hanya ditutup kasa
perawatan modern. minggu.
iodine.
MOISTURE
Balance
PADA PERAWATAN LUKA
How Much Wound Moisture is Needed? 25

TERNYATA BUKAN HAL YANG MUDAH UNTUK


MENETAPKAN BALUTAN LEMBAB APA YANG AKAN DITARUH DI
there is no easy way to LUKA AGAR KESEIMBANGANNYA TERJAGA.
determine exactly how much However, there are some signs you can watch for that can help you
moisture is needed for wound determine when a wound is too dry or too wet- the trick is
healing getting just the right amount of moisture without
overdoing it.
MOISTURE balance
Moist wound healing is the practice of keeping a wound in an
optimally moist environment in order to promote faster healing.
Moist? vs. Dry?
What level of moisture is enough? 27

20% 50% 80%

Dry Moisture Balance Hypermoist


if the wound bed is too Moist wound healing is If the wound exudate
dry this will prevent the practice of keeping level is too high it will
epithelial cell a wound in an cause maceration and
movement across the optimally moist damage to the
wound and delay environment in order surrounding skin and
healing. to promote faster wound bed,
healing.
MOIST WOUND HEALING 28
1962 – 1970 – 1980
In the 1962, British researcher George D. Winter
described the benefits of moist wound healing . His
research demonstrated that moist
environments optimize healing of wounds.
In the 1970s and 80s, moist wound healing became a

During the late 1980s and 90s, the field of moist


wound dressings was thoroughly researched and many
new wound dressing products were
developed such as hydrogels, foams and
alginates. Increasingly, wound dressings began to be
seen as not just protective measures, but active parts
of the healing process.
Experiment study 29
DR. George D Winter

creating multiple small


1962 conducted study by
partial thickness wounds on the backs of pigs.
•  Portion of the wounds were allowed to dry out
and form scabs,
•  while others were covered with a polymer film.

Results: Wounds that had been covered by polymer film,


epithelialized twice as quickly as the wounds exposed to air.
Winter’s theory 30
Teori Pak Winter
Winter postulated that epithelial cells in dry wounds have to
negotiate the scab, consuming energy and time,
whereas in moist wounds they migrate freely across a
moist, vascular wound surface.
Winter’s theory has been supported by other studies in
addition other studies provided evidence that,
•  a moist environment can accelerate
the inflammatory response,
•  leading to faster cell proliferation and
•  wound healing in deeper dermal
wounds.
Epidermis Function 31
Menggunakan Balutan Occlusive
The principle of moist wound healing mimics the
function of the epidermis.
Our body is mainly composed of water, and the natural
environment of a cell is moist; therefore, a dry cell is a
dead cell.
The diagram below demonstrates the benefits of moist wound
healing from use of an occlusive dressing.
Assessment and Monitoring
it is crucial that careful management of the wound moisture level is carried out. 32

Dressing Selection Status of Exudate


Through doing this in practice, it allows A simple and easy method in doing this is to
decisions to be made on dressing document at each dressing change
selection and the frequency of dressing the interaction between the dressing
change, and it also helps guide practice in in place and the exudate level.
noticing the signs or risks of wound deterioration.
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Moisture Balance
Here are some of the benefits of moist wound
healing:

1. Wound Healing Takes Less Time: When


the body creates a scab or eschar, that requires
time and energy. Additional energy is required to
break down the scab after the wound is healed. In
a moist wound healing environment, the body
is able to focus on healing the wound rather
than protecting it, and wounds heal faster.

17.01.17 – 01.02.17 2 weeks


3
4
2. Keratinocyte Cells Function More
Easily: Keratinocytes, a major component of the
epidermis, have several critical roles in wound healing. The
cross-talk between keratinocytes and the other types of
cells involved in wound healing is crucial for effective
closure of the wound. In dry wounds, keratinocytes
must burrow underneath the wound bed in order to find a
moist area to move forward. In a moist wound healing
environment, keratinocytes can easily travel across
the wound surface more quickly and easily.

3. Autolytic Debridement is Facilitated: Moist


environments trap endogenous proteolytic enzymes in the
wound. This allows those enzymes to more efficiently
perform autolytic debridement to break down
necrotic tissue. Along with speeding healing, moist
wound environments allow for the body’s natural process
of healing to work more effectively.
3
5

4. Decreases Incidence of Wound Infection: A


moist wound environment reduces the possibility of
infection by creating a hypoxic environment in the
wound bed which promotes angiogenesis, decreases
the pH, and makes the wound area inhospitable to
bacteria.

5. Preserves Growth Factors in Wound


Fluid: Growth factors are natural proteins which
control key cellular activities during the tissue repair
process. Moist wound healing allows the growth factors to
be preserved on the wound bed to repair tissues more
quickly.
3
6

6. Stimulates Collagen Synthesis: Moist wound


healing promotes production of collagen by the
fibroblasts. Since collagen is the basis of the new tissue
that will heal the wound, this increased production helps
the body lay down the matrix for new tissue more quickly
so that the cells necessary for healing are attracted.

7. Reduces Pain: Another benefit of moist wound


treatment is that there is reduced pain. With less pain,
there is also a reduced stress response and less fatigue
in patients which also aids in the healing process.
Decreased pain can also lead to better patient mobility,
which improves circulation, oxygenation, and allows
for better healing.

8. Reduces Scarring: Moist wound treatment, by


promoting the growth and movement of new
cells and ensuring that proteins for closing the wound are
efficient, causes reduced inflammation, promotes more
even skin formation and therefore reduces scarring.
SUMMARY

Wound care clinics can help


chronic wounds heal better and faster
— and save limbs and save lives.

“A good wound clinic should have the


technology and equipment to treatment
and evaluate wounds and help them heal better
and faster, to provide a better quality of life for
patients,
Wound clinics have the capacity to STOP
AMPUTATION, save limbs and save lives.”
Indonesian Wound
Care Clinician
Association
GROUP ALUMNI WOCARE
UNTUK INDONESIA
Indonesian ETNEP
1st !OS – INTERNATIONAL OSTOMY SCIENTIFIC Meeting
KOLABORASI ANTAR DISIPLIN KEILMUAN – WORKSHOP2 TERKINI TENTANG PERAWATAN LUKA – NETWORKING
DENGAN ASIA – KEGIATAN KEPERAWATAN DIBERBAGAI MODEL SETTING TEMPAT ATAU KEDARURATAN –
PSIKOSOSIAL, ETC
References
•  Bryant, R (2016). Acute and Chronic Wounds. (3nd ed.). St Louis : Mosby Year Book
•  Carvile, K. (2012). Wound Care Manual. (6th ed.). Perth, WA : Silver Chain Foundation.
•  Doughty, Beckley D, McNichol, Lauwerie L (2016). Wound, Ostomy and Continence Nurse
Society core curriculum. Wound management. Philaedelphia : Wolters Kluwe
•  J. Bryan, RN Moist wound healing: a concept that changed our practice, Journal of Wound
Care, VOL 13, NO 6, June 2004
•  Wayne, P.A., Krasner, D., et al.(1996) Chronic Wound Care: A Clinical Source Book for
Health Care Professionals 245-252. HMP Comm.
•  Baranoski S, Ayello EA, Langemo DK (2008) Wound assessment. In Baranoski S, Ayello EA
(Eds) Wound Care Essentials: Practice Principles.
•  Parnham A (2002) Moist wound healing: does the theory apply to chronic wounds? Journal of
Wound Care. 11, 4, 143-146.

Thank You!
Any Questions?