BAB IV

SISTEM INTEGUMEN

A. Kompetensi Utama
Mampu melakukan pengkajian pasien dengan gangguan sistem imunologi

B. Unit Kompetensi
1. Mampu melakukan wawancara pasien dengan gangguan sistem imunologi
2. Mampu melakukan pemeriksaan fisik pasien dengan gangguan sistem imunologi
3. Mampu mengidentifikasi data abnormal pemeriksaan fisik sistem imunologi
C. Tinjauan Teori
Anatomi fisiologi kulit :
a. Hair
Rambut adalah protein produk akhir yang tidak hidup yang di temukan pada semua
permukaan kulit kecuali pada telapak tangan dan kaki. Setiap folikel rambut berfungsi
sebagai unit independen dan melalui tahap-tahap perkembangan yang intermiten. Rambut
melindungi kulit dari sengatan matahari hawa dingin.
b. Epidermis
Epidermis adalah lapisan kulit terluar yang tipis dan berjenjang yang berhubungan langsung
dengan lingkungan luar. Berfungsi untuk melindungi tubuh dari berbagai zat kimia yang
terdapat di luar tubuh dan melindungi tubuh dari sinar UV dan bakteri.
c. Sebaceous gland
Kelenjar minyak di temukan di seluruh kulit kecuali pada telapak tangan dan kaki serta
paling banyak pada wajah, kulit kepala, punggung atas dan dada. Sebum memiliki fungsi
lubrikasi dan aktifitas bakterisidal. Androgen bertanggung jawab bagi perkembangan
kelenjar sebaseus. Androgen inutero menyebabkan acne neonatal. Setelah pubertas produksi
sebum dapat menyebabkan acne pada remaja.
d. Dermis
Lapisan jaringan padat dibawah epidermis, membentuk sebagian besar substansi dan struktur
pada kulit.
e. Sweat porn
Tempat keluarnya keringat yang merupakan sisa metabolisme yang terdiri atas sebagai unsur
yang tidak dibutuhkan lagi oleh tubuh.
f. Arrector pili muscle
Adalah otot polos yang menempel pada folikel rambut. Ketika otot ber interaksi rambut
menjadi tegak.
g. Eccrine sweat gland
Adalah memproduksi keringat dan berperan penting dalam termoregulasi. Kelenjar ini
ditemukan pada keseluruhan kulit keculi pada tepi vermilion( tautan antara area merah jambu
pada bibir dengan kulit di sekitarnya), telinga, bantalan kuku, gland penis, dan labia minora.
Mereka lebih banyak pada telapak tangan, telapak kaki, dahi dan aksila.
h. Hair follicle
Akar rambut terdapat otot polos. Penegak rambut, dan ujung saraf indra perasa nyeri. Udara
dingin akan membuat otot-otot ini berkontraksi dan mengakibatkan rambut akan berdiri.
Adanya saraf-saraf perasa mengakibatkan rasa nyeri apabila rambut di cabut.
i. Nerve
Untuk menghantarkan suatu rangsangan. Seperti panas, dingin, nyeri dll.
j. Papilla
Untuk menerima nutrisi dari follicle.
k. Subcutaneous tissue
Untuk mengatur suhu tubuh dan juga melindungi organ dalam dan tulang. Berfungsi
berperan dalam pigmentasi.
l. Artiole
Arteri yang mengandung kapiler.
m. Venule
Pembuluh darah kecil yang mengumpulkan darah dan mengangkutnya ke pembuluh darah
besar untuk transportasi ke jantung.
D. Prosedur Pratikum
WAWANCARA SPESIFIK UNTUK PASIEN DENGAN GANGGUAN INTEGUMEN
Apakah yang anda tanyakan kepada pasien untuk menggali riwayat kesehatan pasien dengan
kelainan kulit?
a. Keluhan saat masuk rumah sakit
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b. Riwayat kesehatan lalu

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c. Riwayat kesehatan keluarga

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 d. Riwayat lain
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PEMERIKSAAN FISIK :

PENGKAJIAN SISTEM HASIL PENGKAJIAN

Integumen Inspeksi:
Area Lesi:

Persentase Luka Bakar:

Karakteristik Luka Akut:

a. .................................................................................................
b. .................................................................................................
c. .................................................................................................
d. .................................................................................................
e. .................................................................................................

Karakteristik Luka Kronik:

a. .................................................................................................
b. .................................................................................................
c. .................................................................................................
d. .................................................................................................
e. .................................................................................................
f. .................................................................................................
g. .................................................................................................
h. .................................................................................................
 Derajat luka:
Derajat I :
Derajat II:
Derajat III:
Derajat IV:

Palpasi:
Tekstur:

Tumor:

Panas:

PEMERIKSAAN DIAGNOSTIK DAN PENUNJANG GANGGUAN

INTEGUMEN
A. Pemeriksaan laboratorium
Tujuan :
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Indikasi:
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Interpretasi hasil abnormal:

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PROSEDUR PERAWATAN LUKA DAN TINDAKAN

PERAWATAN LUKA STOMA
Pertanyaan:
Jelaskan indikasi pembuatan stoma :
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A. Alat dan Bahan

1. Pinset anatomis 2
2. Pinset sirurgis 1
3. Kom kecil 1
4. Bak instrumen sedang 1
5. Korentang 1
6. Cairan NaCl 0,9% secukupnya
7. Sarung tangan bersih 2 pasang
8. Kassa steril 8 buah
9. Topikal dressing/ zalp
10. Kantong stoma
11. Perlak dan alas perlak
12. Bengkok 2
13. Kapas alkohol secukupnya
14. Kom sedang berisi air hangat
15. Kapas sedang 6 buah

B. Prosedur Tindakan
PROSEDUR HASIL PRAKTIKUM
1. Persiapan pasien: Jelaskan tanda dan gejala iritasi kulit akibat feses.
a. Jelaskan prosedur
.......................................................................................
tindakan perawatan
luka stoma pada .......................................................................................
pasien
.......................................................................................
b. Siapkan alat
perawatan luka stoma .......................................................................................
.......................................................................................
2. Prosedur Tindakan
a. Cuci tangan sebelum .......................................................................................
tindakan
Bagaimana karakteristik feses yang diobservasi saat
b. Jaga privasi pasien mengganti kantong stoma?
c. Dekatkan alat
.......................................................................................
d. Pasang perlak dan
alas perlak .......................................................................................
e. Pasang sarung tangan
.......................................................................................
f. Buka kantong stoma,
jika sulit melepas .......................................................................................
tepian kantong stoma,
.......................................................................................
gunakan kapas
alkohol .......................................................................................
g. Bersihkan stoma
.......................................................................................
dengan air hangat dan
kapas
h. Lepaskan sarung
tangan, siapkan alat
steril
i. Bersihkan sekitar luka
dengan kassa NaCl
j. Keringkan sekitar
luka
k. Oles luka dan
sekitarnya dengan
Zalp / topikal
l. Pasang kantong stoma
baru
m. Bereskan alat
n. Cuci tangan
PERAWATAN GANGREN
Pertanyaan:
apakah yang dimaksud luka gangren?
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Mengapa bisa terjadi luka gangren?
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Alat dan Bahan
1. Sarung tangan bersih 1 pasang
2. Sarung tangan steril 1 pasang
3. Bak instrumen sedang 1
4. Kom kecil 1
5. Korentang 1
6. Bengkok 1
7. Kassa steril 10
8. Kassa gulung
9. Perlak dan alas perlak
10. Plester dan gunting plester
11. Waskom sedang
A. Prosedur Tindakan
PROSEDUR HASIL PRAKTIKUM
1. Persiapan pasien: Apakah yang menjadi karakteristik luka gangren?
a. Jelaskan prosedur
.......................................................................................
tindakan perawatan
luka gangren pada .......................................................................................
pasien
.......................................................................................
b. Siapkan alat
perawatan luka .......................................................................................
gangren
.......................................................................................
c. Pasang penopang kaki
.......................................................................................
2. Prosedur Tindakan
.......................................................................................
a. Cuci tangan sebelum
tindakan .......................................................................................
b. Jaga privasi pasien
Apakah luka gangren term,asuk luka akut atau luka
c. Dekatkan alat
d. Pasang penopang kronik? Jelaskan alasannya
kaki*
.......................................................................................
e. Pasang perlak dan
alas perlak .......................................................................................
f. Pasang waskom
.......................................................................................
sedang di bawah kaki
g. Pasang sarung tangan .......................................................................................
bersih
.......................................................................................
h. Buka balutan lama
i. Irigasi luka dengan .......................................................................................
cairan NaCl
.......................................................................................
j. Siapkan alat
perawatan luka .......................................................................................
k. Pasang sarung tangan
.......................................................................................
steril
l. Bersihkan luka .......................................................................................
gangren
menggunakan NaCl
m. Keringkan luka
n. Tutup luka dengan
kassa steril dan kassa
gulung
o. Bereskan alat
p. Cuci tangan

* jika lokasi luka di telapak kaki

MELAKUKAN NEKROTOMI
Pertanyaan:
Apakah yang dimaksud dengan nekrotomi?
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Apakah indikasi melakukan tindakan nekrotomi?
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A. Alat dan Bahan
1. Sarung tangan steril 1 pasang
2. Bak instrumen kecil 1
3. Kom kecil 1
4. Korentang 1
5. Bengkok 1
6. Kassa steril 5
7. Gunting jaringan 1
8. Pinset sirurgis 1
9. Pinset anatomis 1
10. Perlak dan alas perlak
11. Plester dan gunting plester
12. Korentang 1
13. Cairan NaCl 0,9% secukupnya

B. Prosedur Tindakan
PROSEDUR HASIL PRAKTIKUM
1. Persiapan pasien: Jelaskan ciri-ciri jaringan yang mati?
 a. Jelaskan prosedur .......................................................................................
tindakan nekrotomi
.......................................................................................
pada pasien
b. Siapkan alat .......................................................................................
nekrotomi
.......................................................................................
2. Prosedur Tindakan .......................................................................................
a. Cuci tangan sebelum
.......................................................................................
tindakan
b. Jaga privasi pasien .......................................................................................
c. Dekatkan alat
Jelaskan macam-macam debridemant!
d. Pasang perlak dan
alas perlak .......................................................................................
e. Pasang sarung tangan
.......................................................................................
steril
f. Buka balutan lama, .......................................................................................
bersihkan luka
.......................................................................................
g. Lakukan pemotongan
jaringan mati .......................................................................................
menggunakan pinset
.......................................................................................
sirurgis dan gunting
jaringan .......................................................................................
h. Perhatikan: dalam
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melakukan
nekrotomi, pilih .......................................................................................
jaringan mati dan
.......................................................................................
jangan sampai
membuat luka baru.
i. Bersihkan luka
kembali
j. Keringkan luka
k. Tutup dengan kassa
steril
l. Bereskan alat
m. Cuci tangan

Kasus I:

Seorang laki-laki berusia 35 tahun. Lima jam sebelum masuk RS saat sedang memasak
gorengan untuk jualan kompor gas yang digunakan tiba tiba meledak mengenai tubuhnya.
Setelah kejadian langsung dibawa ke RS. Setelah 3 jam di UGD dilakukan penanganan
dengan diinfus dan perawatan luka. Keluhan Utama pasien mengeluh Nyeri, nyeri terasa
panas dan perih, skala nyeri 9, nyeri di rasakan terus menerus. Hasil pemeriksaan fisik :
Luas luka bakar 45% (Dada, tangan kiri dan kanan, paha kiri/kanan), Warna dasar luka
Merah, Kedalaman luka dermis, Terdapat edema sekitar luka, Mengeluarkan cairan serous,
Tidak tampak pertumbuhan jaringan, Suhu sekitar luka teraba dingin.
1. Buatlah patofisiologi terkait kasus diatas?
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2. Buatlah diagnosa keperawatan yang mungkin muncul pada kasus diatas?

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3. Buatlah tujuan keperawatan berdasarkan (NOC) dan rencana keperawatan berdasarkan

(NIC)
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PENGKAJIAN LUKA
A. LUKA BAKAR
Apakah yang menyebabkan luka bakar?
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Estimasi persentasi luka bakar: menggunakan Total Body Surface Area dari Wallace
Rule of Nine. Isi estimasi persentasi luka bakar pada kotak yang disediakan pada
setiap area pada gambar di bawah ini!
B. MANAJEMEN TIME
Manajemen TIME adalah suatu metoda yang digunakan dalam mempersiapkan
dasar luka (wound bed preparation). Persiapan dasar luka penting untuk
memfasilitasi terjadinya epitelisasi dan pertumbuhan jaringan yang baru.
1. T : Tissue (ada debris atau jaringan nekrotik)
2. I : Inflamation or Infection (luka terdapat tanda infeksi atau tidak)
3. M : Moisture balance (keseimbangan kelembaban, tidak kering area
sekitar luka)
4. E : Edges (tepi luka, adagoa/undermining tidak, tepi luka jelas, tidak
edem)
TUGAS:
Kaji Luka menggunakan metoda TIME berdasarkan gambar yang anda lihat!
Hasil Praktikum:
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C. PRESSURE SORE/LUKA TEKAN

Pertanyaan:
Apakah faktor resiko terjadinya luka tekan?
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Kaji resiko luka tekan menggunakan format:
1. NPUAP
0 1 2 3 4 5 Sub
0 < 0,3 0,3-0,6 0,7-1,0 1,1-2,0 2,1-3,0 Score
Panjang x lebar
6 7 8 9 10
(cm2)
3,1-4,0 4,1-8,0 8,1- 12,1- >24,0
12,0 24,0
0 1 2 3 Sub
Jumlah Eksudat
None Light Moderate Heavy Score
0 1 2 3 4 Sub
Closed Epithelia Granulation Slough Necrotic Score
Tipe Jaringan
l Tissue Tissue
Tissue
Total

2. Skala Braden
Skor
Sensori Persepsi 1 tidak merasakan 2 sangat terbatas 3 gangguan 4 Tanpa gangguan
sama sekali ringan

Kelembaban 1 kelembaban 2 sangat lembab 3 kadang-kadang 4 kelembapan

konstan/selalu lembab normal
basah

Aktivitas 1 Bedrest 2 menggunakan 3 kadang2 4 berjalan lebih

kursi roda berjalan sering

Mobilitas 1 Imobilitas/tidak 2 sangat terbatas 3 mobilitas 4 tanpa gangguan

bisa bergerak sedikit
terganggu

Status Nutrisi 1 Sangat jelek, 2 kemungkinan tidak 3 Adequate, 4 Excellent, intake

IMT sangat adekuat, IMT intake sangat baik,
kurang atau kurang atau mencukupi , IMT normal
obesitas overweigt IMT normal

Gesekan 1 ada masalah 2 masalah potensial 3 tidak ada

(Friction) masalah

Total Score