NOMOR:

LEMBAR PENGKAJIAN LUKA / LUKA

NAMA :
TEKAN UMUR :
WOUND/PRESSURE ULCER ASSESSMENT TOLL ALAMAT:

Tanggal / Date :..............................................................................................................

Diagnosa :..............................................................................................................
Riwayat alergi dressing :.............................................................................................................

1. SKETSA LUKA LOKASI LUKA/LUKA TEKAN

(Wound/pressure ulcer location)

Panjang.....cm,lebar......cm,dalam.....cm

2. ETIOLOGI LUKA (Wound etiologi)

o Bedah(surgery)
o Trauma
o Tekanan (pressure)
o Lainnya (other)
Note:........................................................................................................................ .............................
3. GAMBARAN KLINIS LUKA (cllinical appereance)
o Nekrotik/hitam
o Slough /kuning
o Granulasi /pink menyala
o epithelisasi
4. KEADAAN KULIT SEKITAR LUKA( surrounding skin)
o Baik (intact)
o Maserasi(maceration)
o Edema (Oedema)
o Kering(dry)
5. NYERI/Pain (skala 0-10)
o Nilai:....................................................................................................................... ......................
6. EKSUDAT(exudate)
o Tidak ada
o Ada
Note:........................................................................................................................ ...........................

7. TIPE EKSUDAT (Type Exudate)

o Serouse
o Hemoserosa
o Darah
o Pus
8. BAU (odour)
o Tidak
o Sedikit
o Sangat
9. LABORATORIUM (swab culture)
o Ya/yes
o Tidak/No
Tanggal/date:................................................................................................................ ................
Hasil:.............................................................................................................................................
10. PENANGANAN LUKA SEBELUMNYA (previous management)
......................................................................................................................................................................
.....................................................................................................................................................................
11. PENGGUNAAN ANALGETIK
o Ya/Yes
o Tidak/No
Note:........................................................................................................................ ............................
12. JENIS DRESSING YANG DIGUNAKAN (Type of Dressing)
o Gauze
o Hidrocolloid
o Film
o Hidofiber
o Tulle grass
o Foam
o Hidroactive gel
o Lain-lain
Note:........................................................................................................................ ............................
13. TINDAKAN DAN RENCANA PERAWATAN SELANJUTNYA (Nursing intervention and plan)
......................................................................................................................................................................
......................................................................................................................................................................
....................................................................................................................................................................

Foto Luka :
Paraf Petugas

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