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03 Pengkajian Luka

The document provides guidance on patient assessment and evaluation of wound healing. It discusses key areas to monitor such as the dressing and surrounding skin. A holistic assessment should examine the wound etiology, duration, and factors that could impede healing. The wound should also be assessed in terms of its location, stage, base, tissue type, dimensions, exudate, odor, edges, surrounding skin, signs of infection, and level of pain. Taking cultures appropriately is also outlined. The overall document offers a framework for conducting a thorough wound evaluation.

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RajaRafian
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91 views30 pages

03 Pengkajian Luka

The document provides guidance on patient assessment and evaluation of wound healing. It discusses key areas to monitor such as the dressing and surrounding skin. A holistic assessment should examine the wound etiology, duration, and factors that could impede healing. The wound should also be assessed in terms of its location, stage, base, tissue type, dimensions, exudate, odor, edges, surrounding skin, signs of infection, and level of pain. Taking cultures appropriately is also outlined. The overall document offers a framework for conducting a thorough wound evaluation.

Uploaded by

RajaRafian
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPSX, PDF, TXT or read online on Scribd
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PATIENT ASSESSMENT

AND EVALUATION OF
HEALING
MONITORING – OBSERVATION – INSPECTION
 Daily monitoring of a
patient skin,
observation the
dressing, especially if
dressing stay in place
for several days
 Documentation :
 Dressing dry and intact,
surrounding skin within
normal limits
ASSESSMENT
 Holistic assessment  Wound assessment
 Etiology  Location
 Stage
 Wound base
 Duration of the  Type of tissue
wound / age  Dimention
 Exudates
 Factor that impede  Odor
healing  Wound edge
 Periwound skin
 sign of infection
 wound pain
1. Etiology
 Will drive
intervention choise
and strategies
 Venous hypertention
/ venous ulcer =
compression bandage
 Pressure ulcer =
relief pressure
Types of Skin Damage / etiology
 Mechanical: pressure, shear, friction, stripping
 Chemical: incontinence, drainage, harsh
solutions, improper use of products
 Vascular: arterial, venous, diabetic
 Infectious: Candidiasis, impetigo, herpes
 Allergic
 Miscellaneous: radiation, thermal
ETIOLOGY : LUKA TEKAN
 KERUSAKAN JARINGAN KULIT AKIBAT ADANYA PENEKANAN ANTARA
JARINGAN LUNAK DENGAN DAERAH TULANG YANG MENONJOL PADA
SUPPORT SURFACE YANG KERAS, DALAM JANGKA WAKTU YANG
PANJANG DAN TERUS MENERUS
ETIOLOGY : LUKA DIABETIKUM

 Penyebab kejadian : multifaktor, yaitu kombinasi dari


gangguan vaskular, peripheral neuropathy dan
peningkatan faktor resiko infeksi pada penderita

 Luka kronis yang sulit proses penyembuhannya


2. Duration of wound
 The age of the
wound
 Guidelines for
pressure ulcer and
arterial wounds that
has not improve, 2 –
4 weeks recommend
biopsy
3. Factor that impede healing
 Comorbid condition
 malignancies, diabetics,
etc
 Medications
 chemotherapy,
corticosteroid
 Decreasse oxygeation
and tissue perfussion
 Alteration in nutrition
and hydration
 Psychosocial barriers
 Family factors, financial,
etc
Wound assessment
 Location ( LETAK LUKA )
 Stage ( 1- 4 )
 Wound base ( DASAR LUKA : RYB )
 Type of tissue ( EPITELISASI – GRANULASI – SLOUGH )
 Dimention ( PENGUKURAN LUKA )
 Exudates ( CAIRAN LUKA )
 Odor ( BAU TIDAK SEDAP )
 Wound edge ( TEPI LUKA )
 Periwound skin ( KULIT SEKITAR LUKA )
 sign of infection ( TANDA INFEKSI )
 wound pain ( NYERI )
Location
STADIUM LUKA
STAGE 1- 4
WARNA DASAR LUKA
/ WOUND BASE
 Red – Yellow – Black /
RYB

 Kemudahan sistem yang


diperkenalkan adalah
bersifat konsisten dan
mudah dimengerti serta
tepat guna dalam pemilihan
balutan
TYPE OF TISSUE
PENGUKURAN LUKA /
DIMENTION

 Panjang X lebar
X kedalaman

 Ada tidaknya
undermining / goa,
yang diukur sesuai
dengan arah jarum
jam.
Di gambar
UNDERMINING
KULIT SEKITAR LUKA
/ PERIWOUND SKIN
 Gatal
 Maserasi
 Odema
 hiperpigmentasi
TEPI LUKA / WOUND EDGE
 Umumnya tepi luka
akan dipenuhi oleh
jaringan epitel,
berwarna merah muda

 Kegagalan penutupan
terjadi jika tepi luka :
 Edema
 Nekrosis / callus
 infeksi
CAIRAN LUKA - What is it?

Blood Inflammation

Chronic wound fluid Product of infection


BAU TIDAK SEDAP / ODOR
 Bau dapat disebabkan
oleh adanya kumpulan
bakteri yang
menghasilkan protein

 Apocrine sweat glands

 atau Beberapa cairan


luka dapat
menimbulkan bau
TANDA INFEKSI ?

 Proses inflamasi /
peradangan yang
memanjang :
kemerahan, odema,
nyeri, panas
 LUKA KRONIK

 Eksudatif, berwarna
seroanginosa,

 berbau tidak sedap


 Hasil kultur infeksi
Cara Pengambilan Kultur

 Siapkan alat pengambilan kultur dan balutan


 Cuci tangan
 Buka balutan luka lama
 Cuci luka dengan larutan normal saline JANGAN
antiseptik
 Keringkan dengan kasa steril
 Tunggu sampai eksudat keluar
 Lakukan pengambilan sampel kultur dengan
mengusap zig zag sebanyak 10 kali usapan
yang mewakili seluruh area luka
 Sampel dikirim ke lab, jika tertunda pengiriman harus
disimpan dalam almari es / suhu dingin
Cara Pengambilan Kultur
WOUND PAIN
 An unpleasant
sensory and
emotional
experience with
tissue damage
 Hypnonursing
management : pain
relief
SOAL
SOAL

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