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(2) eritema mengelilingi luka

(3) keluarnya nanah

(4) Limfangitis

(5) jaringan nekrotik

c) Palpasi

(1) denyut nadi menuju cedera

(2) fleksi/ekstensi terhadap resistensi jika keterlibatan bersama

(3) area kelembutan

(4) sensasi di sekitarnya dan jauh dari cedera

 Diagnostic procedure
a) CBC dengan deferensial : jika ada infeksi
b) Sampel residu air liur (penyeka)
c) Kepekaan terhadap luka yang sensitif
d) Radioterapi pada luka
(1) Adanya benda asing
(2) Cedera pada tulang
 Analisa data
a. Gangguan integritas kulit
b. Resiko infeksi
c. Nyeri
d. kegelisahan/ketakutan
e. pengetahuan yang kurang
 Planning and and implementation/interventions
a. Menetapkan akses IV untuk pemberian cairan / obat kristaloid
1) Siapkan forlassist dengan intervensi medis
2) Place affected part in position of comfort
3) Cleanse wound throughly with mild antiseptic soap and irrigate
extensively with normal saline solution
a) Consider taking photographs before cleaning if njury associated
with crime
b) Assist with collection and maintenance of physical and forensic
evidence as indicated
4) Bantu debridemen luka, sesuai kebutuhan
5) Membantu menutup luka, jika diperlukan, delayed closure is preferred
6) Oleskan pembalut yang sesuai
7) Membantu selama dirumah sakit
b. Administer pharmacologic therapy as ordered
1) Membantu administrasi anestesi lokal atau regional
2) Antibiotik
3) Analgesik non-narkotika
4)Narkotikaa
5) Imunisasi tetanus
c. Educated patient and significant others
1) Instruksi perawatan luka khusus berdasarkan situasi
2) Ganti pembalut, seperti yang ditunjukkan
3) Tanda infeksi dan komplikasi lain
4) Minum obat antibiotik seperti yang diperintahkan
5) Kembali atau jadwalkan janji temu untuk perawatan selanjutnya

4. expected outcomes/evaluation (see appendix B)

a. fungsi neurovaskular dan neuromuskuler pada area cedera

b. pereda sakit

H. Wound complications

Uncomplicated lokalized infections and abscesses are treated in the emergency.


Infections associated with body jewelry/piercings often require removal of the object.
experiencing major systemic infections are admitted to the hospital for general support and
treatment

1. Assessment
a. Subjective data collection
1) History of present injury/chief complaint
a) Circumstances of recent injury/wound/body piercing
b) Characteristicsof common wound-related infections
(1) Staphylococcus infections
(a) Staphylococcus aureus (gram-positive bacteria)
(b) Associated with most skin infections
(c) Usually localized abscesses in superficial subcutaneous
tissues
(d) Infection may become systemic
(e) Community-associated methicillin-resistant S. aureus
(MRSA)
(2) Pasteurellosis
(a) Pasteurella multocida
(b) Necrotizing infection associated with animal bites,
especially
(c) Progresses to cellulitis, osteomyelitis, sinusitis, pleuritis
(3) Cat-scratch fever
(a) Origin possibly Afipia felos, or Bartonella henselae
(b) Associated with cat or dog scratches
(c) Regional or local lymphadenitis,fever, self-limiting
(4) Wound botulism
(a) Anaerobic Clostridium botulinum
(b) Associated with crush injuries or major trauma
(c) Incubation period 4 to 14 days
(d) Symptoms
(i) Weakness
(ii) Blurred vision
(iii) Difficulty speaking/swallowing
(iv) Dry mucous membranes
(v) Dilated fixed pupils
(vi) Progressive muscular paralysis
(5) Gas gangrene
(a) Anaerobic Clostridium perfringens
(b) History of intestinal or gallbladder surgery or minor
trauma to old scar containing spores
(c) Incubation period 1 day to 6 weeks
(d) Symptoms
(i) Rapidly developing tense, hard edema, leading
to
(ii) Thrombosis of local vessels
(iii) Soft tissue crepitus (hydrogen sulfide and carbon
dioxide in tissues).