Wound Care

Management

CHRONIC INFECTED ACUTE MODERN

WOUND WOUND WOUND DRESSING
Lets Start
to Create a Change
 13.466 ISLANDS AND 34 PROVINCIES AND
236.641.326 PEOPLE AND 2.380 HOSPITAL
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Management

1. Anatomi Fisiologi
Our 2. Proses Penyembuhan Luka

Topics 3. Pengkajian Luka

4. Wound Care Management
for Today 5. Balutan Luka
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5 STRATEGIC PLAN FOR HEALING

PAHAM
PAHAMANATOMI DAN PAHAMPROSES PAHAMFAKTORYANG PAHAM MEMILIH DAN
MELAKUKANPENGKAJIAN
FISIOLOGYKULIT PENYEMBUHANLUKA MEMPENGARUHI LUKA CARAMEMBALUT LUKA
DAN EVALUASILUKA
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ANATOMI KULIT
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Management

KULIT NORMAL
Organ terbesar: 15 % BB dewasa
Fungsi utama sebagai pelindung
Ketebalan 0,5-6 mm
1 inch kulit terdiri dari: 650 kelenjar
keringat, 20 pembuluh darah, 60 rb
melanosit dan ribuan ujung syaraf
tepi.
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1. Epidermis

Lapisan Kulit
2. Dermis

3. Hipodermis
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Management

EPIDERMIS
Lapisan paling luar dari kulit (epitel)
• Tidak ada pembuluh darah, nutrisi &
difusi dari dermis
• Variasi ketebatan: 0,4 – 0,6 mm
• Memiliki 5 stratum / jenjang
• Epidermis dan dermis dibatasi oleh
basement membrane zone (BMZ)
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KERATINIZATION

Perlindungan tubuh oleh epidermis

yang utama adalah oleh stratum
corneum, dengan mempertahankan
air dalam tubuh dan
mempertahankan benda asing
tetap diluar tubuh.
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DERMIS
• Lapisan kedua dari kulit,
ketebalan 2-4 mm
• Terdiri dari jaringan ikat /
connective tissue
• Sel utama : fibroblast
penghasil protein utama :
colagen & elastin
• Memiliki banyak pembuluh
darah & sel syaraf
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Management

HIPODERMIS
Atau superficial facia

• Jaringan utama : jaringan lemak &

subdermal flexus
• pembuluh darah & jaringan ikat.
• Fungsi : penjaga organ
dibawahnya, mengurangi benturan
saat bergerak, penyimpan jaringan
lemak.
• Jaringan lemak memiliki fungsi
menghangatkan tubuh (regulasi
suhu tubuh).
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FISIOLOGIS KULIT
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MAJOR FUCTIONS
• Protection
• Sensation
• Sintesa Vitamin D
• Thermoregulation
• Excretion
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Balutan sebagai PROTEKSI

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Balutan sebagai PROTEKSI

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FAKTOR PERUBAH  Penuaan (Aging)

KARAKTER KULIT  UVR

 Hidrasi
 Sabun
 Nutrisi
 Obat - obatan
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PROSES
PENYEMBUHAN LUKA
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Wound Neglected
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Luka adalah diskontinuitas

jaringan lunak (kulit), karena
trauma.
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Management

Primary Closure  dilakukan debridement dan

necrotomi, dijahit langsung.

PRIMARY HEALING (PENYEMBUHAN PRIMER)

Wound Care
Management

Spontaneus Closure = Secondary wound closure = dilakukan

debridement, necrotomi kemudian dibiarkan sembuh sendiri.

SECONDARY HEALING (PENYEMBUHAN SEKUNDER)

Wound Care
Management

Delayed primary closure = Dilakukan debridement, necrotomi  dibiarkan

saja. Beberapa hari kemudian (3 – 4 hari) baru dijahit / ditautkan.

DELAYED PRIMARY HEALING (PENYEMBUHAN PRIMER TERTUNDA)

= TERTIARY HEALING
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Schematic
Diagram of the
Phases of Wound
Healing
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UNDERSTANDING WOUND HEALING PROCESS

INFLAMATION PROLIFERATION MATURATION

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PEMBENTUKAN
JARINGAN EPITHEL
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UNDERSTANDING MOISTURE BALANCE

CONCEPT
• George D Winter (1962):
proved that wounds that were kept moist,
healed better than those that were exposed to the
air.

THE FATHER OF MOIST

WOUND HEALING
Wound Care
Management
Justifikasi
1. Fibrinolisis : fibrin cepat hilang pada suasana lembab oleh netrofil dan sel endotel
2. Angiogenesisi : proses akan lebih terangsang pada suasana lembab
3. Infeksi : lebih rendah dibandingkan suasana kering ( 2.6 % vs 7.1 % )
4. Percepatan pembentukan sel aktif : invasi netrofi yang diikuti oleh makrophag,
monosit dan limfosit ke daerah luka akan berfungsi lebih dini.
5. Pembentukan growth factor : lebih cepat pada suasana lembab
 EGF, FGF dan Interleukin1 dikeluarkan oleh makrophag untuk proses
angiogenesis dan pembentukan str. Korneum
 Platelet-derived Growth Factor (PDGF) dan Transforming
 Growth Factor-beta (TGF-beta) dibentuk oleh platelet untuk proses proliferasi
fibroblast.
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Management

Luka yang dirawat lembab akan terjadi proses autolysis debridement

Wound Care
Management

Luka dibalut sedemikian rupa sehingga tetap dipertahankan

dalam situasi lingkungan luka LEMBAB
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Mempertahankan suasana LEMBAB pada luka

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Luka TERAWAT dan TERTUTUP, mencegah kontaminasi dari

lingkungan luar dan tampilan lebih menarik
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SEMBUH, perawatan dengan cara melindungi lapisan EPIDERMIS

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Perawatan Konsep Lembab

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CASE STUDY : DFU HEALING 3 WEEK

Dok. Wocare clinic

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PENGKAJIAN
LUKA
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JENIS LUKA

AKUT KRONIK
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BIOBURDEN
Adanya kuman diluka meningkatkan beban
(burden) dari lukanya sehingga menghambat
penyembuhan luka: LUKA KRONIK

Klasifikasi:
• Kontaminasi
• Kolonisasi
• Kritikal kolonisasi
• Infeksi
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LIHAT LUKA !

Holistic assessment
Etiology
USIA LUKA
Faktor yang menghambat penyembuhan
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Wound assessment
 Location
 Stage
 RYB
 Type of tissue
 Pengukuran luka
 Cairan luka
 Odor
 Wound edge
 Periwound skin
 Tanda infeksi
 wound pain
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LOKASI
LUKA
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WOUNG STAGE (STADIUM LUKA)

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Stage Berapa Sajakah Ini?

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RYB
Red – Yellow - Black
Menilai DASAR LUKA dengan mudah untuk
percepatan KESEMBUHAN LUKA

Courtesy from Ahmad-GOCARE

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Contoh Diagram Warna Dasar Luka

Red: ……% | Yellow: ……% | Black: …...%

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UKURAN LUKA / DIMENSI

 Panjang X lebar X kedalaman
 Ada tidaknya undermining / goa

*) goa/undermining diukur sesuai dengan arah

jarum jam
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Cara Menggambar
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CAIRAN LUKA

Blood Inflammation

Chronic wound fluid Product of infection

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KAJI TANDA INFEKSI ?

 Proses inflamasi / peradangan yang
memanjang : kemerahan, odema,
nyeri, panas
 LUKA KRONIK
 Eksudatif, berwarna seroanginosa,
 berbau tidak sedap
 Hasil kultur infeksi
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DOKUMENTASI FOTO
Wound Care
Management
Pengkajian:
•Ps. Datang pukul 10.00. Secara
keseluruhan kondisi pasien relatif
kurang baik, gelisah, nyeri pada luka
saat disentuh. BP : 150/100 mmHg,
GDS 528, antibiotik sistemik dari
dokter masih dilanjutkan.
•Kami temukan : Luka DM, akral perifer
kiri dan kanan dingin, sianosis, pucat,
alopecia, tipis dan kering.
•Luka di KAKI, ½ luas plantar8X6 ,
exudat minimal purulent dan
malodour. Warna dasar luka 80%
MERAH 20 % KUNING , STAGE II Tanda
infeksi (+).
DOKUMENTASI
Management : TIME
Procedur:
• Pencucian dengan anticeptic solution
• Evakuasi eksudat dan bau
• (T) Debridemang: CSWD (Conservative Sharp Wound Debridement) dan kombinasi
dengan Autolysis debridemang
• (I) kontrol infeksi dg pemberian antibiotik dan nutrisi dg kolagen fish 10 gr/day
• (M) dressing moist dg Metcovazin, calcium alginate, hydrocolloid thin
• (E) menghindari maserasi pda tepi luka, perencanaan ganti balutan @ 2 hari sekali
Anjuran:
• Mohon bantuan sejawat dalam penatalaksanaan sistemik dalam pemberian antibiotik
pasca hasil kultur terlampir.
• Dan pemberian anti nyeri
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WOUND CARE
MANAGEMENT
Wound Care
Management

PEDIATRIC WOUND NEGLECTED

BURN ABSES PERIANAL
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Management

Problems in Conventional Wound Care

In-Effective cost
Patient cost
Hospital cost
Nursing care cost

Takes time: 3 x /day changing

wound dressing

Wounds not really healed or

healed over time
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New Concept in Wound Care

Dressing change every 3 days

Moist Wound Healing Painless dressing change Cost effective
or more
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CHRONIC WOUND
• ISFAILED TO PROGRESS OR RESPOND TO TREATMENT OVER THE
NORMAL EXPECTED OF HEALING TIME FRAME (4 WEEKS) AND BECOME “STUCK” IN THE
INFLAMATORY PHASE . Clinical Guidelines (Nursing)- Royal Children hospital Melbourne

• GENERALLY WOUND DOESN’T START TO HEAL WITHIN 4 WEEKS OR HASN’T

HEALED WITHIN 8 WEEKS

• IS MEAN DELAY WOUND HEALING PROCESS

• THIS IS A SPECIAL CONDITION THAT WE HAVE TO DEAL WITH DIFFICULTIES OF

INTERNAL AND EXTERNAL PROBLEMS

• AND WE MUST TREAT THE WOUND WITH AN EVIDENCE BASE PRACTICES

Wound Care
Management

LUKA KRONIK
• Vaskular Status ?
• Nutritional Status ?
• Glycemic Control ?
• Debridment ?
• Appropriate Dressing ?
• Appropriate Off Loading ?
• Resolution Of Infection ?

Courtesy by Ahmad-gocare
Wound Care
Management

PRINSIP MANAJEMEN LUKA

• Kontrol & hilangkan penyebabnya
• Pressure, shear, friction, moisture, neurophathy
• Ciptakan dukungan sistemik
• Nutrisi & cairan, edema, GDS
• Ciptakan & pertahankan lingkungan luka
• Cegah infeksi, kebersihan luka, jaringan mati, lembab,
dll
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Working Toward CHRONIC WOUND

Projects Worked On HEALED 80% MATURATION

PHASE
2 WEEKS

PROLIFERATION
PHASE
3 - 6 WEEKS
WOUND BED
PREPARATION
2 – 4 WEEKS

Time Spent ON 12 WEEKS

2009. EVIDENCE PRACTISE BASE ON WINNERS SCALE THAT ADOPTED FROM BETES JANSEN SCALE
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WOUND BED PREPARATION

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UNDERSTANDING WOUND BED PREPARATION

TISSUE INFLAMATION
MANAGEMENT CONTROL

TIME
MOISTURE EPITELIAL EDGE
BALANCE

(Falanga, 2004)
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Management

Hilangkan jaringan mati & benda asing

T
• SAFE Debridemang:
• Surgical
• CSWD: tanpa nyeri & berdarah
• Enzymatic: hewan / herbal (enzim proteolitik)
• Autolytic: Moisture balance
• Mechanical: kasa basah kering, hydroterapi, swab
Tissue • Chemical: Hydrogen peroxide, iodine cadexomer
management • Bilogical: maggot
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Autolytic Debridement
Wound Care
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• Cairan pencuci

I
• Dressing yg tepat (topikal antimicrobial &
antiseptik)
• Sistemik therapy (jika perlu)

Inflammation /
Infection Control
Wound Care
Management

Cairan pencuci luka

• Efektif cara mencuci
• Swab
• Tekanan
• Irigasi
• Pilih cairan yang tepat
• Air & sabun/normal salin/air hangat
• PHMB
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Management

Pertahankan lingkungan lembab yg seimbang

pada luka. (winter, 1962)

M
• Manajemen:
• Dressing yg tepat, luka kering vs luka
basah
• Kompresi ??

Moisture Balance
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Moisture Balance
Wound Care
Management

Tepi luka yg baik?

E
• Manajemen:
• Pencucian adekuat
• Penipisan tepi luka
• Moisture balance dressing

Epithelial edge
advancement
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Epithelial edge advancement

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BALUTAN LUKA
(DRESSING)
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Management

CONVENTIONAL DRESSING EVIDENCE BASE DRESSING

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Management

DRESSING PROCESS

AUTOLYSISDEBRI
MEMPERTAHANK DMENT :
MEMBUANG MEMPERCEPAT
ANLEMBAB/
JARINGAN MATI, PROSESPENYEMB
MOISTURE BENDA ASING YANG U- HAN LUKA
BALANCE TIDAK DIBUTUHKAN
TUBUH
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CARA MEMBALUT LUKA

BALUTAN
BALUTAN SEKUNDER
BALUTAN PRIMER
LUKA
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Management

HYDROGEL HYDROCOLLOID

CMC = CARBOXYLMETYL CELULOSA

BALUTAN DARI GETAH POHON
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Management

CALCIUM

ALGINATE
BALUTAN DARI RUMPUT LAUT
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Management

ZINK CREAM

CHITOSAN
BALUTAN DARI TITRASI NANO
PROTEIN KULIT UDANG
 Pesantren
Wound Care Luka
Indonesia:
Management
Wound Care Management

FOAM

Disponsori oleh:
Wound Care
Management

SILVER
Wound Care
Management

Transparent
Film
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Management

NURSE
PRESCRIPTION
(NOTA ORDER  on/)
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CASE STUDY:
USED NPWT
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Discussion:
What we have learnt
today?
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Bagaimana Perasaanmu Jika Bisa

Menyembuhkan Luka?
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Think about
CARING with LOVE
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Management

Describing 5 Levels Of Nursing Competency As:

Level 1 :Novice
Level 2 : Advanced Beginner
Level 3 :Competent
Level 4 : Proficient
Level 5 : Expert
Wound Care
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Wound Care
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The world is changed by examples,

Not by opinions
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Terimakasih
Wound Care
Management

Referensi:

• Bryant, R (2016). Acute and Chronic Wounds. (3nd ed.). St Louis : Mosby Year Book
• Carvile, K. (2012). Wound Care Manual. (6th ed.). Perth, WA : Silver Chain Foundation.
• Doughty, Beckley D, McNichol, Lauwerie L (2016). Wound, Ostomy and Continence
Nurse Society core curriculum. Wound management. Philaedelphia : Wolters Kluwe
• Smeltzer SC, Bare BG, et al. Brunner & Suddarth’s texbook of medical surgical nursing.
1996. 8th ed. Philadelphia: Lippincott-Raven publishers. p. 1491-1477
• Dealey C. The care of wound: a guide for nurses. 2005. 3rd ed. UK: Blackwell
Publishing Ltd. p.10-1