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Pressure ulcers

Yunita Sari

Pressure ulcer

Pressure ulcers

Pressure ulcers

Kegagalan perawat ???

Definisi pressure ulcer


Pressure ulcer adalah kerusakan jaringan yang terlokalisir yang disebabkan karena adanya kompressi jaringan yang lunak diatas tulang yang menonjol (bony prominence) dan adanya tekanan dari luar dalam jangka waktu yang lama. Kompressi jaringan akan menyebabkan gangguan pada suplai darah pada daerah yang tertekan. Apabila ini berlangsung lama, hal ini dapat menyebabkan insufisiensi aliran darah, anoksia atau iskemi jaringan dan akhirnya dapat mengakibatkan kematian sel

Stadium pressure ulcer (NPUAP 2007)


http://www.npuap.org/

Stadium pressure ulcer (NPUAP 2007)


Stadium 1 Kulit yang masih utuh, dengan erithema yang menetap, biasanya terletak diatas bony prominence. Mungkin disertai dengan perubahan warna kulit, hangat, edema, keras, atau nyeri

Stadium 2 Hilangnya sebagian lapisan kulit dermis. Cirinya adalah luka terbuka dengan dasar luka berwarna merah pink. atau blister yang berisi cairan bening yang masih utuh/pecah Tidak sama dengan dermatitis karena inkontinensia, maserasi, atau luka karena plester

Pressure ulcers (NPUAP, 2007)


Stadium Tiga Hilangnya lapisan kulit secara lengkap, meliputi kerusakan atau nekrosis dari jaringan subkutan atau lebih dalam, tapi tidak sampai pada fascia, otot, dan tulang. Kadang terdapat kantong luka (underminning) Stadium Empat Hilangnya lapisan kulit secara lengkap dengan kerusakan yang luas, nekrosis jaringan, kerusakan pada otot, tulang atau tendon. Seringkali terdapat kantong luka

Concept of Pressure Ulcer Development


1. Develop from superficial to deep tissue (Top-down theory)
(NPUAP, 2007)

Stage I

Stage II

Stage III

Stage IV

2. Develop from Bottom to superficial (Bottom-Up theory)


(NPUAP, 2007)

Deep tissue injury


Tipe yang unik dari luka tekan (Black, 2007) PU berkembang dari jaringan bagian dalam seperti fascia dan otot walapun tanpa adanya adanya kerusakan pada permukaan kulit. Dikarakteristikan dengan warna ungu Hot topic diantara klinisi dan researchers Dimasukan dalam definisi NPUAP tahun 2007

mekanismenya masih dalam penelitian, teori terbaru


adalah karena prolonged hypoxia (Gawlitta, 2007; Sari Y, 2008; 2012)

Sari Y, Nagase T, Minematsu T et al. Hypoxia is involved in deep tissue injury. Wounds 2010 Feb;22(2).

Characteristic of Deep Tissue Injury


Berdeteriorasi secara cepat menjadi luka tekan yang parah walau dengan perawatan yang optimum (Black, 2007)

Sulit untuk dideteksi pada stadium awal


Belum ada pencegahannya di clinical setting Most cases : Unavoidable/ tak terhindarkan

Patients undergo surgery, protracted unconsciousness


(Ankrom, 2005; Black, 2003; 2007)

Sari Y, Nakagami G, Kinoshita A et al. Changes in serum and exudate creatine phosphokinase (CPK) Concentrations as an indicator of deep tissue injury: a pilot study. International Wound Journal. Int Wound J. 2008 Dec;5(5):674-80.

History of Deep Tissue Injury Classification


1975 2001 2007 2009 Shea/
Society for Healthcare Epidemiology of America

Closed Pressure Ulcer NPUAP draft definition NPUAP Suspected Deep Tissue Injury EPUAP-NPUAP International Guideline

Finally, DTI is included into staging system by NPUAP


http://www.npuap.org/pr2.htm

Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or bloodfilled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.

Pictures of DTI
Kejadian DTI sering disebabkan karena immobilisasi dalam jangka waktu yang lama, misalnya karena periode operasi yang panjang. Penyebab lainnya adalah seringnya pasien mengalami tenaga yang merobek (shear).

Source : (Aoi et.al, jpurnal of plastic reconstructive surgery, 2010)\

Deep Tissue Injury (Clinical case)


Stage I PU Deep Tissue Injury

The Need to include DTI into staging system


Considering the imporatance of DTI deterioration, the clinicians and researchers in wound care strongly suggest to include deep tissue injury into staging system

Unstageable
Unstageable/ Unclassified

Kerusakan jaringan atau hilangnya


jaringan dimana kedalamannya tidak dapat diketahui karena tertutup oleh slough (kuning, hijau, atau coklat), atau eschar

(sawo matang, kecoklatan, hitam) di dasar


luka Sampai slough/eschar di hilangkan, kedalamannya tidak dapat ditentukan, tp biasanya merupakan stadium 3/4

Termasuk kategori apa

Faktor resiko luka tekan

Memprediksi Faktor resiko luka tekan


1. Norton Scale 2. Braden scale 3. Braden Q scale

Memprediksi faktor resiko untuk pressure ulcers

Japanese WOCN conference.2011

Interpretasi nilai braden scale Skor yang tertinggi 23, terendah 6 Resiko rendah : 15-18 Resiko menengah : 13-14 Resiko tinggi : 10-12 Resiko sangat tinggi : < 9

Guideline pencegahan luka tekan (international guideline by NPUAP)


http://www.npuap.org/wpcontent/uploads/2012/03/Final_Quick_Prevention_for_web_2010.pdf

Level of Evidence

Skin Care
1. Ensure that a complete skin assessment is part of the risk assessment screening policy in place in all health care settings. (Strength of Evidence = C)
2. Whenever possible, do not turn the individual onto a body surface that is still reddened from a previous episode of pressure loading. (Strength of Evidence = C) 3. Do not use massage for pressure ulcer prevention (Strength of Evidence = B) 4. Do not vigorously rub skin that is at risk for pressure ulceration.(Strength of Evidence = C) 5. Use skin emollients to hydrate dry skin in order to reduce risk of skin damage. (Strength of Evidence = B) 6. Protect the skin from exposure to excessive moisture with a barrier product in order to reduce the risk of pressure damage. (Strength of Evidence = C)

Nutrition
1. Screen and assess the nutritional status of every individual at risk of pressure ulcers in each health care setting

2. Offer high-protein mixed oral nutritional supplements and/or tube feeding, in addition to the usual diet, to individuals with nutritional risk and pressure ulcer risk because of acute or chronic diseases, or following a surgical intervention. (Strength of Evidence = A) 3. Offer high-protein mixed oral nutritional supplements and/or tube feeding, in addition to the usual diet, to individuals with nutritional risk Quick Reference Guide Prevention and pressure ulcer risk because of acute or chronic diseases, or following a surgical intervention. (Strength of Evidence = A)

Positioning
1. Repositioning should be undertaken using the 30-degree tilted sidelying position (alternately, right side, back, left side) or the prone position if the individual can tolerate this and her/his medical condition allows. Avoid postures that increase pressure, such as the 90-degree side-lying position, (Strength of Evidence = C) 2. If sitting in bed is necessary, avoid head-of-bed elevation and a slouched position that places pressure and shear on the sacrum and coccyx. (Strength of Evidence = C) 3. Use transfer aids to reduce friction and shear. Lift dont drag the individual while repositioning. (Strength of Evidence = C)

Support Surface
1. Use higher-specification foam mattresses rather than standard hospital foam mattresses for all individuals assessed as being at risk for pressure ulcer development. (Strength of Evidence = A)
2. . Ensure that the heels are free of the surface of the bed. (Strength of Evidence = C) 3. . Use a pillow under the calves so that heels are elevated (i.e., floating).

4. Ensure that the heels are free of the surface of the bed.
5. Do not use small-cell alternating-pressure air mattresses or overlays. (Strength of Evidence = C)

Memonitor perkembangan luka tekan

PSST ( Pressure Sore Status Tool ) SWHT ( Sussman Wound Healing Tool ) PUSH ( Pressure Ulcer Scale for Healing )

DESIGN
PUHP (The Japanese Pressure Ulcer Healing Process )

Inovasi dalam perawatan luka tekan oleh perawat

Deteksi dengan thermografi Pembuatan alat untuk mengetahui tekanan antar muka Kasur anti dekubitus

Ultrasonografi untuk deteksi deep tissue injury


Vibrasi untuk mempercepat penyembuhan luka tekan

Inovasi dalam perawatan luka tekan yang Membawa perubahan di rumah sakit

Deteksi dini kemungkinan infeksi dengan thermography


Nakagami G et.al. Predicting delayed pressure ulcer healing using thermography: a prospective cohort study. J Wound Care. 2010 Nov;19(11):465-6, 468, 470

Delayed healing disebabkan karena inflamasi yang memanjang

Namun, tidak dapat diidentifikasi secara visual pada stadium awal Bila temperatur dasar luka > tepi luka = cenderung lama Bila temperatur dasar luka < tepi luka = luka akan sembuh

Alat untuk mengukur tekanan antar muka


Sugama J et al. Reliability and validity of a multi-pad pressure evaluator for pressure ulcer management. J Tissue Viability 2002;12(4):148-53.

Mengukur tekanan antar muka (interface pressure) antara matras dan badan Untuk mengetahui resiko terkena luka tekan Digunakan sebagai standar perawatan luka tekan di jepang Menurut penelitian Suriadi et.al (2006), pengukuran tekanan antar muka sangat diperlukan pada pasien di ICU
Suriadi et.al A new instrument for predicting pressure ulcer risk in an intensive care unit. J Tissue Viability. 2006 Aug;16(3):21-6.

(video)

Kasur untuk menurunkan resiko luka tekan


Sanada H et al. Randomised controlled trial to evaluate a new double-layer aircell overlay for elderly patients requiring head elevation. J Tissue Viability 2003; 13(3):112-18.

Changing the air cell shape to a double layer from a single layer at this site. A randomised controlled trial was undertaken to evaluate the effectiveness of this product . The pressure ulcer incidence rate was 3.4% in the patients using double-layer mattress, 19.2% in those nursed on the single layer and 37.0% of those using the standard mattress.

Ultrasound untuk memprediksi deep tissue injury


Noriyuki et.al Ultrasound Assessment of Deep Tissue Injury in Pressure Ulcers: Possible Prediction of Pressure Ulcer Progression. Journal of plastic surgery. 2009

Tidak ada metode yang dapat digunakan untuk mendeteksi DTI pada fase awal
Dapat digunakan untuk mendeteksi DTI yang akan menjadi parah

Vibration therapy
Vibration of 47 Hz (our research group) - Animal study by using ear mouse

Vibration improve the blood flow of skin microcirculation (Nakagami, 2007)


Vibration improve deterioration of DTI (Sari Y, 2012) -Clinical study Accelerate healing of very superficial pressure ulcer (Arashi M, 2010)

Vibrasi pada penderita diabetes


Pasien 1

Pasien 2

(Syabariyyah, 2012)

Case study for Adjunctive Use of Noncontact Low-Frequency Ultrasound for Treatment of Suspected Deep Tissue Injury:
J Wound Ostomy Continence Nurs. 2011 Jul-Aug;38(4):394-403. Adjunctive use of noncontact low-frequency ultrasound for treatment of suspected deep tissue injury: a case series. Jeremy Honaker, RN, BSN, CWOCN

Patients have been treated with : repositioning schedule assistive repositioning turning devices; ointment twice Daily with optional soft-silicone bordered foam; appropriate support surfaces including static-air overlay** on ICU beds; dietetic consultation; heel-offloading boots; and institutional Braden Scale Prevention Policy.

Often did not prevent DTI Deterioration

Case study for Adjunctive Use of Noncontact Low-Frequency Ultrasound for Treatment of Suspected Deep Tissue Injury:

NPWT/VAC
Terapi populer dan andalan Memberikan tekanan negatif pada luka Mekanisme : Mengeluarkan eksudat dari luka Peningkatan aliran darah Mengurangi edema Meningkatkan jaringan granulasi Meningkatkan mekanikal force yg dpt merapatkan tepi2 luka

Thank You

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