Check List Rawat Luka Gangren PSIK FIKES UMM_ps
2012
RAWAT LUKA GANGREN I.
KONSEP DASAR PRAKTIKUM 1. PENGKAJIAN LUKA a. Warna Luka: 1) Hitam: nekrosis (jaringan mati) 2) Slough: kuning padat (bukan cair) 3) Hijau/abu-abu/kuning: bernanah dan infeksi 4) Merah (permukaan seperti jelly): fase granulasi 5) Merah muda (permukaan lebih halus): fase ephitelisasi b. Bentuk dan Ukuran: panjang, lebar dan dalam. Pengukuran luka 2 dimensi (Pengukuran superfisial dapat dilakukan dengan alat seperti penggaris untuk mengukur panjang dan lebar luka. Jiplakan lingkaran (tracing of circumference) luka direkomendasikan dalam bentuk plastik transparan atau asetat sheet dan memakai spidol)
Pengukuran luka (Pengkajian kedalaman/undermining berbagai sinus tract internal memerlukan pendekatan tiga dimensi. Metode paling mudah adalah menggunakan instrumen berupa aplikator kapas lembab steril. Pengukuran tiga dimensi dilakukan dengan mengkaji panjang, lebar dan kedalaman luka, kemudian dengan menggunak kapas lidi steril, masukkan ke dalamluka dengan hati-hati untuk menilai ada tidaknya goa, dan mengukurnya mengikutiarah jarum jam. Bagian atas luka (jam 12) adalah titik kearah kepala pasien, sedangkan bagian bawah luka (jam 6) adalah titik kearah kaki pasien. Panjang dapat diukur dari ” jam 12 – jam 6 ”. Lebar dapat diukur dari sisi ke sisi atau dari ” jam 3 – jam 9).
c. Status Vaskuler: nadi, CRT (Capillary Refill Time), temperatur, edema. d. Infeksi dan nyeri: ukur skala nyeri dan pantau tanda-tanda infeksi. e. Exudate/cairan luka: Hal yang perlu dicatat tentang exudate adalah jenis, jumlah, warna, konsistensi dan bau. 1. Jenis Exudate Serous – cairan berwarna jernih. Hemoserous – cairan serous yang mewarna merah terang. Sanguenous – cairan berwarna darah kental/pekat. Purulent – kental mengandung nanah. 2. Jumlah: Kehilangan jumlah exudate luka berlebihan, seperti tampak pada luka bakar atau fistula dapat mengganggu keseimbangan cairan dan mengakibatkan gangguan elektrolit. Kulit sekitar luka juga cenderung maserasi jika tidak menggunkan balutan atau alat pengelolaan luka yang tepat. 3. Warna: ini berhubungan dengan jenis exudate namun juga menjadi indikator klinik yang baik dari jenis bakteri yang ada pada luka terinfeksi (contoh, pseudomonas aeruginosa yang berwarna hijau/kebiruan). 4. Konsistensi: ini berhubungan dengan jenis exudate, sangat bermakna pada luka yang edema dan fistula. 5. Bau: ini berhubungan dengan infeksi luka dan kontaminasi luka oleh cairan tubuh seperti faeces terlihat pada fistula. Bau mungkin juga berhubungan dengan proses autolisis jaringan nekrotik pada balutan oklusif (hidrocolloid).
Check List Rawat Luka Gangren PSIK FIKES UMM_ps f.
Stadium Luka: (Berdasarkan WAGNER ULCER STADIUM) No Gambar Luka 1
a) b) c) d) e)
2012
Keterangan Stadium 0 (Pre Ulcer) Skin is intact Redness of skin Calluses It can be prevented but also can be raises annually become next grade
2
a) Stadium 1 b) Superficial diabetic ulcer c) Superficial ulcer involving the full skin thickness but not underlying tissues
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a) Stadium 2 b) Deep ulceration c) Ulcer extension involving ligament, tendon, joint capsule or fascia with no abscess and osteomyelitis
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a) Stadium 3 b) Deep ulcer with abscess, osteomyelitis, or joint sepsis
5
a) Stadium 4 b) Gangrene localized to portion of forefoot or heel
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a) Stadium 5 b) Extensive gangrenous involvement of the entire foot
Adapted with permission from Wagner FW Jr. The diabetic foot. Orthopedics 1987;10:163–72
Check List Rawat Luka Gangren PSIK FIKES UMM_ps
2012
2. JENIS DRESSING Dressing yang digunakan dibagi menjadi: 1) Kasa : yang sering digunakan untuk rawat luka sederhana 2) Gabus: ukurannya tebal, sehingga baik untuk menyerap eksudat, contohnya : Allevyn Adhesive Dressings/cutisorb, suprasob P, flexipore 3) Silikon dressing : mencegah perlengketan langsung dengan kasa, contohnya supratul/cuticel 4) Hidrokoloid : absorben eksudat dengan teknologi serap, contohnya : duoderm extrathin/duoderm CGF, suprasob B 5) Hidrogel : gel yang berfungsi sebagai absorben dan melembabkan keadaan luka, contohnya : hidroactive gel 6) Hidrofiber : soft non-woven pad or ribbon dressings made from sodium carboxymethylcellulose fibers, the same absorbent material used in hydrocolloid dressings, contohnya : aquacel, kaltostat 7) Alginate : non-woven fibers derived from brown seaweeds In this case, the alginate product itself turns into a soft, non-adhesive gel when in contact with wound drainage. Alginates are used on wounds with a moderate to heavy level of wound drainage and can also control minor bleeding. Contohnya : aquacel Ag/Kaltostat Ag
No 1
2
MACAM-MACAM DRESSING : Gambar
Nama Duoderm Hidroactive gel
Duoderm extra thin
Manfaat
Indication : 1. Allows non-traumatic removal of secondary dressing without damaging new tissue 2. Filler for dry cavity wounds to provide a moist wound healing environment 3. Can be used to fill uneven or hard to reach areas 4. Clear and preservative-free 5. Aids autolytic debridement 6. Latex-free Contraindication : 1. In the presence of anaerobic infection, occlusive therapy is not recommended. 2. The control of blood glucose as well as appropriate pressure relief measures should be provided with diabetic foot ulcers 3. Do not use on individuals with a known sensitivity to the gel or its components Indication : 1. Thin polyurethane film provides a bacterial2 and viral3 barriera b when the dressing remains intact and without leakage 2. Film provides a waterproof barrier over the dressing 3. Can be removed without damaging newly formed tissue 4. Designed to reduce the risk of further skin breakdown due to friction by preventing contact with clothes/bed linen 5. Can be used on the body as a primary or secondary dressing 6. Can be used on skin tears and superficial wounds, dry to lightly exuding wounds, newly-formed tissue or skin at risk of further breakdown 7. This product does not contain latex. Contraindication: Do not use on individuals with a known sensitivity to the polyurethane film or its components
Check List Rawat Luka Gangren PSIK FIKES UMM_ps 3
Duoderm CGF
2012
Indication : 1. Thin polyurethane film provides a bacterial2 and viral3 barriera b when the dressing remains intact and without leakage 2. Film provides a waterproof barrier over the dressing 3. Can be removed without damaging newly formed tissue 4. Designed to reduce the risk of further skin breakdown due to friction by preventing contact with clothes/bed linen 5. Can be used on the body as a primary or secondary dressing 6. Can be used on skin for partial and full-thickness wounds with exudate 7. This product does not contain latex. Contraindication: Do not use on individuals with a known sensitivity to the polyurethane film or its components
DuoDERM® dressing is a hydrocolloid dressing that distinguishes it from other hydrocolloid dressings and a vapour-permeable outer film to provide an occlusive moist environment.
EASE OF APPLICATION
Translucent backing enhances dressing placement and initial monitoring of the woundc Are easy to use4, mould and can be cut to shapea to dress awkward areasc
Prior To Dressing
Applying A Dressing
Wash your hands, cleanse and rinse the wound then dry the surrounding skin
Removal
Warm the dressing Gently apply the Gently mould the between your hands centre part of the dressing into place dressing 30-60 seconds Remove the ´top´ white release paper Remove the being careful to ´bottom´ white Measure the wound minimise finger release paper whilst to select the contact with the rolling the dressing appropriate adhesive surface in place - but don´t dressing size, stretch it allowing a 3cm (1¼ Hold the adhesive inches) overlap on side of the dressing Repeat on the other intact skin around over the wound side and remove the the whole wound clear release paper Align with the centre of the wound
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Kaltostat
Gently lift one corner of the dressing Roll it away from the wound whilst holding the skin away Gently lift the other corners and pull upwards until the dressing completely peels off
Indication: Kaltostat is indicated as a primary dressing for the management of heavily exuding wounds including chronic wounds such as leg ulcers (venous arterial and diabetic), pressure sores, fungating carcinomas, and acute wounds such as donor sites, abrasions,
Check List Rawat Luka Gangren PSIK FIKES UMM_ps
2012
lacerations and post surgical wounds.
Contraindication: Known sensitivity to Kaltostat or its components.
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Aquacel
Indication: AQUACEL® dressing incorporating unique Hydrofiber® Technology is a sterile, white, fibrous dressing derived from 100% sodium carboxymethylcellulose. It is a primary, versatile dressing indicated for use on moderately and highly exuding chronic and acute wounds. Also available in ribbon form, with stichbonding for added strength.
Contraindication: Known sensitivity to Aquacel or its components.
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Aquacel Ag
Indication: 1.
2.
3.
4.
5. 6.
7.
8.
AQUACEL ® Ag Dressing is indicated for moderate to highly exuding wounds which are infected or at risk of infection. Releases ionic silver in a controlleda manner as wound exudate is absorbed into the dressing1,2,a May help protect periwound skin by helping reduce the risk of maceration 3,4,b May help minimise crossinfection during dressing removal5,b Is soft and conformable6 Supports wound healing by providing a moist wound healing environment7 AQUACEL ® Ag Dressing provides rapid and sustained antimicrobial activity in vitro.1,2,8 As demonstrated in in vitro testing, AQUACEL ® Ag Dressing provides sustained antimicrobial activity for up to 7 days.2
Contraindication: Known sensitivity to Aquacel Ag or its components.
How aquacel work? 1. Provides excellent absorption and retention capabilities for moderate to highly exuding wounds.2 2. Conforms to the wound surface to form an intimate contact.3,a 3. Helps reduce wound pain while the dressing is in situ and upon removal.4-7 4. Supports wound healing by providing a moist wound healing environment. 5. May help minimise cross-infection during dressing removal Why it was silver (Ag)? Silver is a proven antimicrobial in the management of infected wounds and wounds at risk of infection, when used in a protocol of care1-3. Proactive use of silver dressings "…can inhibit the progression of bacterial penetration and can be effective against MRSA and most other superficial pathogens." 4 How to apply aquacel/Aquacel Aq/Kaltostat
Check List Rawat Luka Gangren PSIK FIKES UMM_ps 7
2012
Lomatule/cuticle/supratule Indication: Indicated for use on superficial exuding wounds such as: firstand second-degree burns, cuts and abrasions, lacerations, radiation injuries, and donor and recipient skin graft sites.
Contraindication: Known sensitivity to cuticell or its components.
II.
TUJUAN PRAKTIKUM 1. TUJUAN UMUM. Setelah mengikuti praktikum berikut diharapkan mahasiswa dapat melakukan keterampilan dalam melakukan rawat luka gangrene dengna menggunakan modern dressing. 2. TUJUAN KHUSUS. Setelah melakukan praktikum berikut mahasiswa mampu : 1. Melakukan pengkajian terhadap luka 2. Menentukan dan melakukan penggantian dressing yang tepat 3. Melakukan rawat luka dengan prinsip steril yang tepat.
Check List Rawat Luka Gangren PSIK FIKES UMM_ps
2012
CHECK LIST NO 1
ASPEK YANG DINILAI
BOBOT
PERSIAPAN Mempersiapkan alat dengan meletakkan diatas meja bersih : 1. 1. Bak instrumen steril berisi : a. 2 pinset anatomi b. 1 pinset chirurgis c. 1 gunting lurus/lancip (tidak untuk nekrotomi) d. Kasa steril/deppers dalam kom steril e. 2 Cucing f. 1 Sarung tangan steril
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3
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
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2. Alat-alat yang tidak steril a. Gunting verban/plester b. Sarung tangan tidak steril c. Kapas d. Alkohol 70 % e. NaCl 0,9 % f. Bengkok berisi larutan klorin 0,5 % g. Bengkok kosong h. Perban i. Perlak j. Dressing : duoderm CGF, duoderm extra thin, duoderm hidroactive gell, kaltostat, aqua cell Ag, supratul k. Korentang Mempersiapkan lingkungan : 1. Menutup pintu/sketsel/selambu 2. Menjaga privasi pasien Mempersiapkan pasien : 1. Memperkenalkan diri = “Pak/Bu, nama saya...saya adalah perawat di sini” 2. Menanyakan kesedian di rawat = “Pak/Bu, saya hendak merawat luka anda, apakah bapak/ibu bersedia?” 3. Menjelaskan maksud dan tujuan : = “Pak/Bu tujuan dari merawat luka adalah mencegah.., ......, ....”. a. Mencegah infeksi b. Mempercepat penyembuhan c. Memberikan rasa nyaman PELAKSANAAN Cuci tangan Memasang perlak = “Pak/Bu permisi, saya memasang perlak” Mendekatkan bengkok dan membuka peralatan Memakai sarung tangan non steril Membuka luka dengan menggunting perban == “Pak/Bu permisi, saya melepas perbannya terlebih dahulu” Mengkaji kondisi luka (warna, bentuk dan ukuran, status vaskuler, stadium) Menetukan dressing yang tepat dan menyiapkan di bak instrumen steril Melepas sarung tangan Mengeluarkan cucing dan mengisi salah satu cucing dengan NaCl Memakai sarung tangan steril Mengambil pinset anatomi di tangan kanan dan pinset chirurgis di tangan kiri. Mengambil kassa steril dimasukkan dalam cucing. Memeras kassa kemudian di pindah ke cucing yang lain. Pinset chirurgis di taruh kembali di bak instrumen steril. Perhatikan pembagian tugas untuk tangan yang ke alat dan tangan ke pasien. Ambil kassa basah dengan pinset chirurgis, berikan ke pinset anatomis tanpa saling bersentuhan antar pinset. Bersihkan luka dengan kasa memakai pinset anatomi dari arah dalam keluar. Bila ada pus/nanah, tekan daerah sekitar luka agar pus keluar. Lakukan hingga bersih = “Pak/Bu, permisi ya” Kasa kotor dibuang di bengkok Ambil kassa kering dengan pinset chirurgis, berikan ke pinset anatomis tanpa
5
10
30
45
0
NILAI 1
2
Check List Rawat Luka Gangren PSIK FIKES UMM_ps
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saling bersentuhan antar pinset untuk mengeringkan luka. Kasa kotor dibuang di bengkok.
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Berikan dressing yang sudah dipilih pada luka
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Tutup dan bungkus luka dengan kassa dan perban
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Mengambil perlak = “Permisi Pak/Bu, saya mengambil perlak”. Mengembalikan klien pada posisi yang nyaman dan merapikan alat = “Rawat luka sudah selesai Pak/Bu. Bagaimana perasaan Bapak/Ibu? Semoga lekas sembuh. Terimakasih”. Melepas sarung tangan Dokumentasikan EVALUASI Luka bersih Pasien merasa nyaman Balutan rapi Komunikasi dengan pasien selama tindakan Tanggal Ujian : Penguji, Nilai = 1 x ..... + 2 x ..... x 100 = ........... x 100 2x =
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