Perawatan Luka

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.

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- 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)

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The inflammatory phase (Initiated immediately after injury and last 3-6 days

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Injury /damage Cells

Blood Clot

Uniting the wound edges

Histamine

Vasodilation Permeability

Neutrophils& Monocytes

Oedema& Engorgement

0-3 days

Dry

-Dilated blood vessels-Microcirculation slow down

The Regenerative (Proliferative) phase

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Blood vessels near the edge of the wound become porous

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

Traps other blood cells & damaged blood vesselsBegin to regenerate within the wound margins

Allowing excess moisture to escape

Macrophage activity

Formation& multiplication of fibroblasts

migrate along fibrin threads

- Laying down of a ground substance- Beginning the synthesis of collagen fibers (granulation tissue )

Stimulates

Which

This fibrous networkR

esultin

g

Begins 2-3 days of injuryLasting up to 2-3 weeks

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

Description and Characteristics

Cause Type

Open wound; painful Sharp instrument eg. Knife Incision

Close wound, skin appears ecchymotic (bruised) because of damaged blood vessels

Blow from a blunt instrument Contusion

Open wound; involving the skin ; painful

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

Abrasion

Open wound; can be intentional or unintentional

Penetration of the skin and, often the underlying tissues from a sharp instrument

Puncture

Open wound; edges are often jagged

Tissues torn apart, often from accidents (eg, machinery)

Laceration

Open wound; usually accidental ( bullet or metal fragments)

Penetration of the skin and the underlying tissues

Penetrating wound

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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 cont’d (Altmeire 1997, Ayliffe & Lowbury 1992, NAS 1996)

Contaminated: fresh traumatic wound dari sumber yang relatif bersih. Acute non-purulent 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

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Partial Thickness Full Thickness

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/DisordersA. DiabetesB. Respiratory disordersC. Blood disorders

3. Smoking4. Nutrition and build

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Risk Factors Which Increase Patient Susceptibility to infection cont’d (Manley.K, Bellman. L,2000)

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

Cytotoxic drugs2. Kerusakan integritas jaringan3. 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.25

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 ExudateMostly serumWatery, clear of cellsE.g., fluid in a blister

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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.

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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R=Red Y=Yellow B= Black

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.Location2.ukuran3.Keadaan jaringan4.Exudate/Drainage5.kondisi sekitar luka6.Pain7.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 + serumluka + pusluka + 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 Tidak Steril Alat Steril

Gunting pembalut PlasterBengkok/ kantong plastikPembalut Alkohol 70 %Betadine 10 %Bensin/ AsetonObat antiseptic/ desinfektan NaCl 0,9 %

Pincet anatomi 1Pinchet chirurgie 1Gunting Luka (Lurus)Kapas LidiKasa SterilKasa Penekan (deppers)Mangkok / kom Kecil

Prosedur PelaksanaanJelaskan 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 sterilPlester 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 Tidak Steril Alat Steril

Gunting pembalut PlasterBengkok/ kantong plastikPembalut Alkohol 70 %Betadine 2 %H2O2, savlon Bensin/ AsetonObat antiseptic/ desinfektan NaCl 0,9 %

Pincet anatomi 1Pinchet chirurgie 2Gunting Luka (Lurus dan bengkok)

Kapas LidiKasa SterilKasa Penekan (deppers)

Sarung TanganMangkok / kom Kecil 2

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.

Hal-hal yang perlu diperhatikan• 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