PERAWATAN LUKA

FITHRI KURNIATI

SISTEM INTEGUMEN

FUNCTIONS OF THE SKIN

Regulates body temperature. Prevents loss of essential body fluids, and penetration of toxic substances. Protection of the body from harmful effects of the sun and radiation. Excretes toxic substances with sweat ( waste removal). Mechanical support. Immunological function mediated by Langerhans cells. Sensory organ for touch, heat, cold, socio-sexual and emotional sensations. Vitamin D synthesis from its precursors under the effect of sunlight and introversion of steroids.
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DEFINISI LUKA
Luka adalah hilang atau rusaknya sebagian jaringan tubuh yang disebabkan oleh trauma benda tajam atau tumpul, perubahan suhu, zat kimia, ledakan, sengatan listrik atau gigitan hewan[ R. Sjamsu Hidayat, 1997]. Menurut Koiner dan Taylan luka adalah terganggunya (disruption) integritas normal dari kulit dan jaringan di bawahnya yang terjadi secara tiba-tiba atau disengaja, tertutup atau terbuka, bersih atau terkontaminasi, superficial atau dalam.

Wound-definitions
(Manley, Bellman, 2000)

- A loss of continuity of the skin or mucous membrane which may involve soft tissues, muscles, bone and other anatomical structure.
- Any disruption to layers of the skin and underlying tissues due to multiple causes including trauma, surgery, or a specific disease state.

PHASES OF WOUND HEALING

= regeneration (renewal) of tissue.

A. The inflammatory phase (3-6 days)

B. The regenerative (Proliferative) phase (day 4-day21)

C. The maturation (Remodeling) phase (day 21- 1 or 2
yrs)
(Manley, Bellman, 2000)

PROSES PENYEMBUHAN LUKA

Fase Inflamasi

Fase Proliferasi

Fase Penyudahan

Pembuluh darah terputus, menyebabkan Pendarahan dan tubuh berusaha untuk menghentikannya. (sejak terjadi luka sampai hari ke lima)

q Penyerapan

Terjadi proliferasi fibroplast (menautkan tepi luka)

kembali jaringan berlebih. q Pengerutan sesuai gaya gravitasi. q Perupaan kembali jaringan yg baru. q Biasanya 3 6 bulan.

The inflammatory phase

(Initiated immediately after injury and last 3-6 days

Injury /damage Cells

Histamine Blood Clot Dry

Vasodilation Permeability

Uniting the wound edges Neutrophils& Monocytes -Dilated blood vessels -Microcirculation slow down
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Oedema& Engorgement 0-3 days

The Regenerative (Proliferative) phase

Blood vessels near the edge of the wound become porous
Allowing excess moisture to escape
Begins 2-3 days of injury Lasting up to 2-3 weeks

- Resultant tissue filling is referred To as granulation tissue - process of wound contraction begins

Macrophage activity
Stimulates Formation& multiplication of fibroblasts Which
Resulting

Traps other blood cells & damaged blood vessels Begin to regenerate within the wound margins This fibrous network

- Laying down of a ground

substance - Beginning the synthesis of collagen fibers (granulation tissue )
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migrate along fibrin threads

The Maturative phase

Dimulai pada hr ke 21 dpt memanjang hingga 6 bulan bahkan hingga 1- 2 th pasca injury. Fibroblasts terus mensintesa collagen Serat2 kolagen membentuk struktur yang mature The scar/jaringan parut menjadi lebih tipis, kurang elastis, dan memutih

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KLASIFIKASI PENYEMBUHAN LUKA

Penyembuhan Primer luka diusahakan bertaut, biasanya dengan bantuan jahitan.
Penyembuhan Sekunder Penyembuhan luka tanpa ada bantuan dari luar (mengandalkan antibodi)

Factors affecting wound healing

Developmental consideration/Age Nutrition Life-style Medication Infection Wound perfusion

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KLASIFIKASI LUKA
Tindakan Thd Luka
Luka disengaja (Intentional Traumatis)

Luka tidak disengaja (Unintentional Traumatis)

Integritas Luka
Luka tertutup

Luka terbuka

Mekanisme Luka
Luka memar

Luka incisi

Luka abrasi

Types of Wound (Hahn,Olsen,Tomaselli, Goldberg ,2004)

Type
Incision Contusion

Cause
Sharp instrument eg. Knife Blow from a blunt instrument

Description and Characteristics

Open wound; painful Close wound, skin appears ecchymotic (bruised) because of damaged blood vessels Open wound; involving the skin ; painful

Abrasion

Surface scrape, either unintentional (eg, scraped knee from fall) or intentional (eg, dermal abrasion to remove pockmarks)

Puncture

Penetration of the skin and, often the underlying tissues from a sharp instrument
Tissues torn apart, often from accidents (eg, machinery) Penetration of the skin and the underlying tissues

Open wound; can be intentional or unintentional

Open wound; edges are often jagged Open wound; usually accidental ( bullet or14 metal fragments)

Laceration Penetrating wound

Classification of surgical wounds according to the degree of contamination Clean wounds: non- traumatic, uninfected wounds where is no inflammation encountered and no break in technique has occurred. Clean-contaminated: A viscus is entered but without spillage of contents. This category included non- traumatic wounds where a minor break in technique has occurred.
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Classification of surgical wounds contd

(Altmeire 1997, Ayliffe & Lowbury 1992, NAS 1996)

Contaminated: fresh traumatic wound dari sumber yang relatif bersih. Acute nonpurulent inflammation mungkin dijumpai Dirty or infected : Old traumatic wounds from a dirty source, with delayed treatment, devitalised tissue, clinical infection, faecal contamination or a foreign body.
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Classification of wounds berdasarkan kedalamannya

I.
Partial-thickness: Confined to the skin,
the dermis and epidermis.

II. Full-thickness : Involve the dermis,

epidermis, subcutaneous tissue, and possibly muscle and bone Partial Thickness Full Thickness

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Decubitus ulcer

Gunshot wound

Stab wound

Lacerating wound

KOMPLIKASI SPESIFIK ADANYA LUKA

Hemorrhage (Perdarahan)
Meningkaynya nadi, meningkatnya pernafasan, Menurunnya tekanan darah, lemah, pasien mengeluh kehausan.

Infeksi
luka memerah, bengkak, nyeri, jaringan sekitar mengeras, leukosit meningkat.

Dehiscene
(tepi sulit/tidak dapat menyatu)

Eviceration
(menonjolnya organ-organ tubuh bagian dalam ke arah luar melalui incisi)

Risk Factors Which Increase Patient Susceptibility to infection

(Manley.K, Bellman. L,2000)

A- Intrinsic risk factors: 1. Extremes age: Defined as Children aged 1

year and under, and people aged 65 years and over.

2. Underling Conditions/Disorders
A. Diabetes B. Respiratory disorders C. Blood disorders

3. Smoking 4. Nutrition and build

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Risk Factors Which Increase Patient Susceptibility to infection contd

(Manley.K, Bellman. L,2000)

B- Extrinsic risk factors: 1. Drug therapy as a risk factor: e.g.

Cytotoxic drugs 2. Kerusakan integritas jaringan 3. Adanya benda asing

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S&S of Presence of Infection

Wound is swollen. Wound is deep red in color. Wound feels hot on palpation. Drainage is increased and possibly purulent. Foul odor may be noted. Wound edges may be separated with dehiscence present.
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TYPES OF WOUND DRAINAGE

1. Serous-clean, watery 2. Purulent- thick, yellow, green, tan or brown. 3. Serosanguineous-pale, red, watery mixture of serous and sanguineous. 4. Sanguineous- bright red, indicative of active bleeding.

Types of Wound Drainage (cairan luka)

Exudate is material, such as fluid and cells, that has escaped from blood vessels during the inflammatory process and deposited in or on tissue surfaces. The Nature and amount of exudate vary according to: Tissue involved, Intensity and duration of the inflammation, and the presence of microorganisms. 1. Serous Exudate Mostly serum Watery, clear of cells E.g., fluid in a blister 27

2.

A purulent Exudate pus It consists of leukocytes, liquefied dead tissue debris, dead and living bacteria. The Process of pus formation = suppuration, and the bacteria that produce pus = pyogenic bacteria. Purulent exudate vary in color, some acquiring tinges of blue, green, or yellow. The color may depend on the causative organism.

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3.

A sanguineous (hemorrhagic) Exudate It consists of large amount or blood cells, indicating damage to capillaries that is very severe enouagh to allow the escape of RBCs from plasma This type of exudate is frequently seen in open wounds. Nurses often need to distinguish whether the exudate is dark or bright. Bright indicate fresh blood, whereas dark exudate denotes older bleeding.

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The RYB color code (Stotts,1999)

This concept is based on the color of the open wound rather than the depth or size of the wound.

R=Red

Y=Yellow

B= Black

On this scheme, the goal of wound care is to protect ( cover) red, cleanse yellow, and debride black. The RYB code can be applied to any wound allowed to heal by secondary intention.
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Red wounds
Usually in the late regeneration phase of tissue repair (ie, developing granulation tissue) and are clean and uniformly pink in appearance
They need to be protected to avoid disturbance to regenerating tissue. Examples are superficial wounds, skin donor sites, and partial- thickness or second degree burns.

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 Cara melindungi red wounds:

Dibersihkan dengan lembut dan hati-hati Hindari penggunaan kasa, dan balutan kering Applying a topical antimicrobial agent.

Appling a transparent film or hydrocolloid dressing.

Changing the dressing as infrequently as possible.

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Yellow wounds
Characterized primarily by liquid to semiliquid slough that is often accompanied by purulent drainage. The nurse cleanses yellow wounds to absorb drainage and remove nonviable tissue. Methods used may include . Applying wet-to-wet dressing; irrigating the wound; using absorbent dressing material such as impregnated nonadherent, hydrogel dressing, or other exudate absorbers; and consulting with the physician about the need for a topical antimicrobial to minimize bacterial growth.
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Black Wound
Covered with thick necrotic tissue or Eschar. e.g.. third degree burns and gangrenous ulcer. Required debridement . When the eschar is removed, the wound is treated as yellow, then red.
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Wound assessment (Hahn,Olsen,Tomaselli,

Goldberg ,2004)

What to assess?
1.Location 2.ukuran 3.Keadaan jaringan 4.Exudate/Drainage 5.kondisi sekitar luka 6.Pain 7.Swelling/pembengkakan

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Nursing Diagnoses
Risk for Impaired Skin Integrity Impaired Skin Integrity Impaired Tissue Integrity Risk for Infection Pain

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TINDAKAN KEPERAWATAN TERHADAP LUKA

Perawatan Luka Bersih Perawatan Luka Kotor

Ciri ciri : luka + serum luka + pus luka + nekrose

Purposes of wound dressing

1. Melindungi luka dari truama mekanis 2. Melindungi luka dari kontaminasi kuman 3. Mempertahankan kelembban luka 4. To provide thermal insulation 5. menyerap drainage and /or debride a wound

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6. Mencegah perdarahan (when applied as a pressure dressing or with elastic bandages). 7. Mengimobilisasi sisi luka sehingga menfasilitas proses penyembuhan dan menjegah injury.
8. Memberi kenyamanan psikologis

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Guidelines for cleaning wounds

1. Gunakan larutan fisologis seperti isotonic saline or
lactated ringer solution.

2. Jika memungkinkan hangatkan larutan sesuai

suhu tubuh

3. Jika luka sangat kotor lakukan rawat luka sesering

mungkin

4. Jika luka bersih, has little exudate , and

menunjukkan healthy granulation tissue , hindari penggantian dan perawatan luka yg terlalu sering
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5. Pertimbauntuk membersihkan
permukaan luka yg noninfected dgn cara mengirigasi (mencuci/mengguyur) irrigating dgn normal saline dari pada mengusapnya secara mekanik 6. Untuk mempertahankan kelembaban, tidak usah mengeringkan luka setalh emmbersihkannya
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Topics for Home Care Teaching

Supplies Infection prevention Wound healing Appearance of the skin/recent changes Activity/mobility Nutrition Pain Elimination
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Perawatan Luka Bersih

Tujuan :
Mencegah timbulnya infeksi. Observasi perkembangan luka. Mengabsorbsi drainase. Meningkatkan kenyamanan fisik dan psikologis.

Indikasi :
Luka bersih tak terkontaminasi dan luka steril. Balutan kotor dan basah akibat eksternal ada rembesan/ eksudat. Ingin mengkaji keadaan luka. Mempercepat debredemen jaringan nekrotik.

Prosedur Perawatan Luka Bersih

1. Menyiapkan alat 2. Menyiapkan pasien Perkenalkan diri Jelaskan tujuan Jelaskan prosedur perawatan pada pasien Persetujuan pasien 3. Tekhnis pelaksanaan

PERALATAN
Alat Steril
Pincet

Alat Tidak Steril

Gunting Plaster Bengkok/

anatomi 1 Pinchet chirurgie 1 Gunting Luka (Lurus) Kapas Lidi Kasa Steril Kasa Penekan (deppers) Mangkok / kom Kecil

pembalut kantong plastik

Pembalut
Alkohol

70 % Betadine 10 % Bensin/ Aseton Obat antiseptic/ desinfektan NaCl 0,9 %

Prosedur Pelaksanaan
Jelaskan prosedur perawatan pada pasien. Tempatkan alat yang sesuai. Cuci tangan. Buka pembalut dan buang pada tempatnya. Bila balutan lengket pada bekas luka, lepas dengan larutan steril atau NaCl. Bersihkan bekas plester dengan bensin/aseton (bila tidak kontra indikasi), arah dari dalam ke luar. Desinfektan sekitar luka dengan alkohol 70%.

Buanglah kapas kotor pada tempatnya dan pincet kotor tempatkan pada bengkok dengan larutan desinfektan. Bersihkan luka dengan NaCl 0,9 % dan keringkan. Olesi luka dengan betadine 2 % (sesuai advis dari dokter) dan tutup luka dengan kasa steril Plester verban atau kasa. Rapikan pasien. Alat bereskan dan cuci tangan. Catat kondisi dan perkembangan luka.

Perawatan Luka Kotor (decubitus)

Definisi :
Luka + Serum Luka + Pus Luka + Nekrose

Tujuan :
Mempercepat penyembuhan luka. Mencegah meluasnya infeksi. Mengurangi gangguan rasa nyaman bagi pasien maupun orang lain.

Prosedur Perawatan Luka Kotor (decubitus) 1. Menyiapkan alat 2. Menyiapkan pasien Perkenalkan diri Jelaskan tujuan Jelaskan prosedur perawatan pada pasien Persetujuan pasien 3. Tekhnis pelaksanaan

PERALATAN
Alat Steril
Pincet

Alat Tidak Steril

Gunting Plaster Bengkok/

anatomi 1 Pinchet chirurgie 2 Gunting Luka (Lurus dan bengkok) Kapas Lidi Kasa Steril Kasa Penekan (deppers) Sarung Tangan Mangkok / kom Kecil 2

pembalut kantong plastik

Pembalut
Alkohol

70 % Betadine 2 % H2O2, savlon Bensin/ Aseton Obat antiseptic/ desinfektan NaCl 0,9 %

Prosedur Pelaksanaan
Jelaskan prosedur perawatan pada pasien. Tempatkan alat yang sesuai. Cuci tangan dan gunakan sarung tangan (mengurangi transmisi pathogen yang berasal dari darah). Sarung tangan digunakan saat memegang bahan berair dari cairan tubuh. Buka pembalut dan buang pada tempatnya serta kajilah luka becubitus yang ada. Bersihkan bekas plester dengan bensin/aseton (bila tidak kontra indikasi), arah dari dalam ke luar. Desinfektan sekitar luka dengan alkohol 70%.

Buanglah kapas kotor pada tempatnya dan pincet kotor tempatkan pada bengkok dengan larutan desinfektan. Bersihkan luka dengan H2O2 / savlon. Bersihkan luka dengan NaCl 0,9 % dan keringkan. Olesi luka dengan betadine 2 % (sesuai advis dari dokter) dan tutup luka dengan kasa steril. Plester verban atau kasa. Rapikan pasien. Alat bereskan dan cuci tangan. Catat kondisi dan perkembangan luka.

 Cermat dalam menjaga kesterilan. Peka terhadap privasi pasien. Saat melepas atau memasang balutan, perhatikan tidak merubah posisi drain atau menarik luka. Alat pelindung mata harus dipakai bila terdapat resiko kontaminasi okuler seperti cipratan mata. dsb

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