A.

Format Laporan Akhir

1. Pengkajian
a. Identitas Pasien
Nama : Ny. A
Umur : 52 Th
Jenis Kelamin : Perempuan
Agama : Islam
Alamat : Jl. Martadinata, Gg Miri No.2
b. Alasan Masuk Rs
c. Pasien mengatakan dia menderita diabetes dan kakinya luka kecil
awalnya dan lama kelamaan luka tersebut menyebar dan menjadi besar
lalu pasien khawatir terhadap lukanya dan pasien memutuskan untuk
pergi ke klinik.
d. Kunjungan Ke
Pusat Perawatan Luka dan Kaki Diabetik Kitamura Pontianak
e. Tipe Luka
Gangren Basah
Kunjungan ke 1

Pada tanggal 27 Desember 2021, dari luka Ny. A didapatkan data :

Ukuran luka : P : 5 CM X L 4,5 CM, Granulasi 15%, Slough 15%, Epitelisasi 15%,
Maceration 5%
MUNGS
Maceration : 5%
Undermining :-
Necrotic tissue :-
Granulation : 15%
Syamptons :-
2. Intervensi
a. Cleansing
Cuci luka dengan cairan Ozone/NaCL, diberikan sabun antiseptik
diusap menggunakan kasa atau cuttisoft hingga berbusa. Usap dari
daerah luka menuju luar luka. Kemudian bila dengan NaCL lalu
keringkn menggunakan tissu.
b. Debridement
Menggunakan teknik mekanikal
c. Dressing
Primary dressin : Alginate untuk menjaga kondisi luka tetap moist
( lembab )besert berikan madu
Secondary dressing : Kasaa

The Assessment Tool for Diabetic Wound MUNGS

No Score ITEMS Skor
Date Date Date Date
M Maceration
0 None
1 Thin at the edge and/or maceration
≤2 cm from the wound edge
2 >2 cm from the wound edge and/or
expanded
U Undermining/tunnelling/sinus
0 None
1 <3 cm
2 >3 cm
N Necrotic tissue type (black, white,
yellow, grey, brown, green)
0 None
 1 Soft slought and with ≥ 1 colour
2 Necrotic; with spongy, soft and
coloured skin
3 Necrotic; hard, spongy or moist tissue
and skin with ≥ 1 colour
4 Necrotic; dry, hard, black and/or
brownish
G Granulation tissue
0 Skin intact
1 Ful granulation
2 Granulation of 50 % to <100%
3 Granulation of <50%
4 No granulation
S Other wound-related signs or
symptoms
Wound edge : Around the skin 0 None
wound:
o Red ring
1 One or
o Hyperkeratonic o Hyperpigmentation
two
o Unattached o Induration
o Undefined o Hypopigmentation 2 Three to
o Crust o Eryhema around live
o Pale the wound
3 More
o Damage o Oedema
than five
o Epibole o Purple
o Rolled/lining o Lesion
Wound infection or Granulation :
inflammation :
o Fragile granulation
o Pain o Bright red
o Pus o Hypergranulation
o Odour o Senescent
o Faver o Pale
o Rising o Blackish
o Temperature/warm o Trauma
o Tissue compatible
with a biofilm
o Ischemia

Total score

Signature

kunjungan ke 2

Pada tanggal 29 Desember 2021, dari luka Ny. A didapatkan data :

Ukuran luka : 5 CM X L 4,5 CM, Granulasi 10%, Slough 15%, Epitelisasi 5%, Maceration
5%
MUNGS
Maceration : 5%
Undermining :-
Necrotic tissue :-
Granulation : 10%
Syamptons :-

2. Intervensi
a. Cleansing
Cuci luka dengan cairan Ozone/NaCL, diberikan sabun antiseptik
diusap menggunakan kasa atau cuttisoft hingga berbusa. Usap dari
daerah luka menuju luar luka. Kemudian bila dengan NaCL lalu
keringkn menggunakan tissu.
b. Debridement
Menggunakan teknik mekanikal
c. Dressing
Primary dressin : Alginate untuk menjaga kondisi luka tetap moist
( lembab )besert berikan madu
Secondary dressing : Kasaa

The Assessment Tool for Diabetic Wound MUNGS

No Score ITEMS Skor
Date Date Date Date
M Maceration
0 None
1 Thin at the edge and/or maceration
≤2 cm from the wound edge
2 >2 cm from the wound edge and/or
expanded
U Undermining/tunnelling/sinus
0 None
1 <3 cm
2 >3 cm
N Necrotic tissue type (black, white,
 yellow, grey, brown, green)
0 None
1 Soft slought and with ≥ 1 colour
2 Necrotic; with spongy, soft and
coloured skin
3 Necrotic; hard, spongy or moist tissue
and skin with ≥ 1 colour
4 Necrotic; dry, hard, black and/or
brownish
G Granulation tissue
0 Skin intact
1 Ful granulation
2 Granulation of 50 % to <100%
3 Granulation of <50%
4 No granulation
S Other wound-related signs or
symptoms
Wound edge : Around the skin 0 None
wound:
o Red ring
1 One or
o Hyperkeratonic o Hyperpigmentation
two
o Unattached o Induration
o Undefined o Hypopigmentation 2 Three to
o Crust o Eryhema around live
o Pale the wound
3 More
o Damage o Oedema
than five
o Epibole o Purple
o Rolled/lining o Lesion
Wound infection or Granulation :
inflammation :
o Fragile granulation
o Pain o Bright red
o Pus o Hypergranulation
o Odour o Senescent
o Faver o Pale
o Rising o Blackish
o Temperature/warm o Trauma
o Tissue compatible
with a biofilm
o Ischemia

Total score

Signature

Hari ke 3

Pada tanggal 31 Desember 2021, dari luka Ny. A didapatkan data :

Ukuran luka : P : 5 CM X L 5 CM, Granulasi 10%, Slough 10%, Epitelisasi 20%
MUNGS
Maceration :-
Undermining :-
Necrotic tissue :-
Granulation : 10%
Syamptons :-
2. Intervensi
a. Cleansing
Cuci luka dengan cairan Ozone/NaCL, diberikan sabun antiseptik
diusap menggunakan kasa atau cuttisoft hingga berbusa. Usap dari
daerah luka menuju luar luka. Kemudian bila dengan NaCL lalu
keringkn menggunakan tissu.
b. Debridement
Menggunakan teknik mekanikal
c. Dressing
Primary dressin : Alginate untuk menjaga kondisi luka tetap moist
( lembab )besert berikan madu
Secondary dressing : Kasaa

The Assessment Tool for Diabetic Wound MUNGS

No Score ITEMS Skor
Date Date Date Date
M Maceration
0 None
1 Thin at the edge and/or maceration
≤2 cm from the wound edge
2 >2 cm from the wound edge and/or
expanded
U Undermining/tunnelling/sinus
0 None
1 <3 cm
2 >3 cm
N Necrotic tissue type (black, white,
yellow, grey, brown, green)
 0 None
1 Soft slought and with ≥ 1 colour
2 Necrotic; with spongy, soft and
coloured skin
3 Necrotic; hard, spongy or moist tissue
and skin with ≥ 1 colour
4 Necrotic; dry, hard, black and/or
brownish
G Granulation tissue
0 Skin intact
1 Ful granulation
2 Granulation of 50 % to <100%
3 Granulation of <50%
4 No granulation
S Other wound-related signs or
symptoms
Wound edge : Around the skin 0 None
wound:
o Red ring
1 One or
o Hyperkeratonic o Hyperpigmentation
two
o Unattached o Induration
o Undefined o Hypopigmentation 2 Three to
o Crust o Eryhema around live
o Pale the wound
3 More
o Damage o Oedema
than five
o Epibole o Purple
o Rolled/lining o Lesion
Wound infection or Granulation :
inflammation :
o Fragile granulation
o Pain o Bright red
o Pus o Hypergranulation
o Odour o Senescent
o Faver o Pale
o Rising o Blackish
o Temperature/warm o Trauma
o Tissue compatible
with a biofilm
o Ischemia

Total score

Signature