EVIDENCE BASED PRACTICE:

PERAWATAN LUKA MODERN

YANG AMAN DIMASA PANDEMI

Lucia Anik Purwaningsih

(Clinical Nurse Specialist Wound Ostomy Continence/ET)
Disampaikan pada acara :
Seminar Nasional Keperawatan 13-14 November 2021
 Sekilas Tentang Saya

• Name : Lucia Anik Purwaningsih

• Phone Number/ WA : +62 81 329786169
• email : elanie_la@yahoo.com
• Education :
• S2 Master of Nursing, (Twin Programme Khon Kaen University Thailand - UMY
Yogyakarta) 2014
• ET Nurse (WOCN), InETNEP (Indonesian Enterostomal Therapy Nurse Education
Program), Twin Programme Indonesia-Australia, Universitas Indonesia Jakarta, 2007
• Ners, Gadjah Mada University, Yogyakarta 2005
• S1 PSIK, Gadjah Mada University, Yogyakarta 2004
• D3 Keperawatan, Akper Depkes Mangkuyudan Yogyakarta, 1999
• Employment :
• Head Nurse, Burn Unit – ICU Bedah Jantung Sardjito General Hospital
• Wound Consultant Sardjito General Hospital
• Tim Ahli Luka Bakar RSUP Dr Sardjito Yogyakarta
• Lecturer S2 Keperawatan - S1 Keperawatan FKKMK Gadjah Mada University
• National Trainer of Indonesian Enterostomal Therapy Nurse Education Programe
(InETNEP-WOC(ET)N)
• Organization :
• Ketua DPW InWOCNA DI Yogyakarta
• Bidang Kredensial DPP InWOCNA
• Dewan Pakar DPW HIPMEBI DI Yogyakarta
• Professional Board InOA (Indonesian Ostomy Association) YKI – DI Yogyakarta
• Member of WCET (World Council of Enterostomal Therapy)
 Outline

Overview
Optimalisasi
Wound &Healing TIME
Penyembuhan Luka
Process
 OVERVIEW:
Sejarah Luka
Jenis luka
LUAS & PROSES
DALAM SEMBUH

• Superfisial • Primary
• Partial thickness • Secondary
• Full thickness • Tertiary

LUKA

WAKTU
SEMBUH
INTEGRITAS DERAJAT
KONTAMINASI

• Terbuka • Akut
• Bersih
• Tertutup • Kotor • Kronis

The Wound Man

 Sejarah Penanganan Luka

Bersihkan/Singkirkan benda
asing Tutup luka/pertemukan Luka Sembuh/menutup
tepi luka Balut/dressing

Tradisional Modern
1600 BC Abad 18 Abad 19 Mid 1980 Mid 1990
Linen strips Debridement Antiseptik gauze, lint, Moist hydrogels,
dibasahi oil Antibiotik plasters, Absorb hydrocolloids,
atau lemak bandages polyurethane alginates, synthetic HA
The Edwin Smith
Air, Susu cotton foams, foam,
papyrus dating from C uka, Wine, wool hydrocolloids silicone permeable
c.1600–1500 B.C., Minyak, cellulose adhesive films
Egypt. Madu, Resin synthetic silver, collagen
It was bought in 1862,
Wool Tulle
translated in 1906 by
H. Breasted,
 Evolution of the Wound Management
BC 1980 1980 2000 2000+

Traditional Advanced
Modern/Advanced
Gauze & Tape Moist Wound Healing Tissue Engineering
Moist&Wound
Chronic Acute Healing
Betadine Growth Factors
Chronic & Acute
Revanol, etc Antimicrobials
(Dry Wound Healing) (Winter) Enzymatics,NPWT
Louise Pasteure

)
 MENGAPA HARUS LEMBAB ?
• Fibrinolis : fibrin cepat hilang pada
suasana lembab oleh netrofil dan sel
endotel
• Angiogenesis : proses penyembuhan
akan lebih terangsang pada suasana
lembab

• Infeksi : lebih rendah dibandingkan

suasana kering ( 2.6 % vs 7.1 % )
Hucllin (1998,1993)semi-oclosive
menurunkan infeksi 50% vs balutan
tradisional
• Percepatan pembentukan sel aktif :
invasi netrofil yang diikuti oleh
makrophag, monosit dan limfosit ke
daerah luka akan berfungsi Lebih dini.
• Pembentukan growth factor : lebih cepat
pada suasana lembab
Epithelialisation of wound
occurs more rapidly if a moist wound
enviroment is maintained (Winter 1962,
Alvares 1988)

INDONESIAN WOUND OSTOMY CONTINENCE NURSE ASSOCIATION - Certified Basic Wound Care Nurse (CBWCN)
Modern/Advanced: Moist Wound Healing

Perawatan berbasis suasana lembab

The new concept on wound management

(Winter, 1971)
(dikelola berdasarkan kondisi WOUND BED/
WARNA DASAR luka)

Wound Bed Preparation

TIME
Healing
Process Acute vs. Chronic wound Healing:

1/3 of all patients with wounds experience a wound “Infection”

 Jenis dan Problem Luka

ULKUS
ULKUS
DIABET PROBLEM VARIKOSUM
JARINGAN
TRAUMA/ NEKROTIK/RUSAK
CRUSH
INJURY
DEHISENSI

PROBLEM PROBLEM
ULKUS
TEKAN
BAKTERIAL/ EKSUDAT
INFEKSI
DEGLOVING

LUKA
BAKAR

Courtesy : David S Perdanakusuma

 Gol Perawatan Luka

SE M BUH

Tidak ada jaringan

Tertutup epitel Tidak ada eksudat
nekrotik berlebih/lembab

Tidak infeksi

Tampilan bekas luka

Fungsi optimal Safety
baik
Cost effective Courtesy : David S Perdanakusuma
To promote optimal wound healing, one must have :

1. Knowledge of the skin and physiology of healing

and maintain wound environment
2. Good physical assessment skill (dasar utk
pemilihan cleansing dan dressing)
3. Understanding of wound cleansing agent
4. Understanding of wound care product and
pharmaceuticals (Selections of topycal
therapy)
(Bryant, 2007 ; Acute & chronic wound:Currennt Management
Concepts)
1.Acute VS Chronic Wound Healing
 MAINTAIN A PHYSIOLOGIC WOUND ENVIRONMENT
1. Adequat moisture level (not wet – not dry)
– Saline-moistened gauze cannot keep the wound continually moist
2. Maintain normal temperatur
• Lock (1979), body temperature (37°C) significant increase in mitotic activity
up to 108%
3. Bacterial balance
– Lawrence(1994), bacteria can penetrate up to 64 layer of gauze
4. Maintain normal pH
– When the skin is broken the wound tissue became alkaline wich
subsequently increase the risk bacterial invasion (Hermans,1990) and
impaired function of MMP´s (Amstrong,2002)
– pH low, various celluler functions may decline or stop
Semi-occlovise dressing; film, hydrocolloids, foam, alginate are able to
keep a wound moist, reduce wound infection, maintain to neutral pH and
normal temperature

INDONESIAN WOUND OSTOMY CONTINENCE NURSE ASSOCIATION - Certified Basic Wound Care Nurse (CBWCN)
Evidence-Based Wound Care : Moist Wound Healing

Advantage

- Provides a protective
- Prevents wound
barrier to external threats
desiccation
- Diminishes (mengurangi)
- Enhance cell migration fibrosis
- Promote angiogenesis
- Reduces dressing frequency
- Augment autolysis
- Enhance patient comfort
- Lesson risk for wound
- Better cosmetic appearance
infection
(healing and beauty)
- Improves thermoregulation - Saves nursing time
- Faster pH balance
- Cuts cost

Xakellis &Chrischilles(1992); Bohon et al(1996);Ovington (2000);Wiechula (2003);Van Rijswijk

(2004); Jones &Frnnie (2007); Brolmann et al (2013); Vloemans (2014)
INDONESIAN WOUND OSTOMY CONTINENCE NURSE ASSOCIATION - Certified Basic Wound Care Nurse (CBWCN)
 2

Asessmen

Diagnosis Luka
Kronik
CLINICAL PATHWAY ON WOUND

Akut
Preparasi bed luka
MANAGEMENT

(I) Kontrol (T) Pengelolaan jaringan non vital (M) Pengelolaan eksudat
bakteri

Antibiotik Debridement Produk Absorbtif

Luka telah terpreparasi

Penutupan luka

Primer Sekunder Graft Flap

Luka sembuh
Falanga V, 2004
PENGKAJIAN

Problem Warna Perm ukaan

Hitam Nekrotik BASAH
Nekrotik

Kuning Nekrotik
Bakterial/ Slough
Infeksi
C C MOIST
Kuning Hijau
Infeksi
Eksudat

Merah Granulasi
KERING

Pink Epitelialisasi
 Wound Bed Preparation
Three Pronged Attack

INDONESIAN WOUND OSTOMY CONTINENCE NURSE ASSOCIATION-CERTIFIED BASIC WOUND CARE NURSE (CBWCN)
 Persiapan Dasar Luka

The Principle of Wound Bed Preparation

(RYB)

Outcame :Viable Outcame: bacterial Outcame: Moisture Outcame:advancing

wound Bed (Red) balance,reduce infection balance epidermal margin

INDONESIAN WOUND OSTOMY CONTINENCE NURSE ASSOCIATION-CERTIFIED BASIC WOUND CARE NURSE (CBWCN)
PENGEMBANGAN
KONSEP TIME

TIMERS

2019 Atkin dkk

 Membuang Jaringan Non-
1 vital/Nekrotik
Debridement

Kontrol inflamasi/
2 Bakteri/Infeksi
Antiseptik/Antibiotik/Antibacterial/silver

3 Kontrol Eksudat (Moist) Absorb eksudat Keseimbangan

Kelembaban

4 Optimalisasi Tepi Luka/

Epitelialisasi
Memperkecil ukuran luka Periwound

Repair & Merangsang

5 Penyembuhan
akselerasi Penutupan luka Reparasi

6 Social-Perbaikan Kualitas
Hidup : Kehidupan Sosial
Edukasi Pemahaman Motivasi
 Langkah Menangani Luka
T I M E R S
Membuang Kontrol Kontrol Repair & Social-Perbaikan
Jaringan Non- inflamasi/ Eksudat Optimalisasi Tepi Merangsang Kualitas Hidup
vital/Nekrotik Bakteri/Infeksi (Moist) Luka/Epitelialisasi Penyemb uhan Sosial

Debridement Antiseptik Absorben Deb ridement/Eksisi HA

Antimikroba Dressing Periwound
Surgical Antibiotik Foam Hialuronic Acid Rencana
Enzymatic Perawatan
Autolytic Skingrafting Lanjut
Mechanical Edukasi Pasien/
Biological Keluarga
Pemahaman
Motivasi
Scar
Manag e ment

Mengelola Ukuran Luka Pasien Dapat

Luka Bersih Inflamasi, Mengecil Menutup Luka
Kelemb ab an Kembali Pada
Jaringan Non vital Infeksi Epitelialisasi Akselerasi
Lingkungan Kehidupan
dibuang Terkontrol Perbaikan Jaringan
Luka Sosialnya
 3. Cleansing agent
• Cairan non toksik
NORMAL SALINE
• Cairan antiseptik
• PHMB® sol/ gel
Hati – hati :
• Chlorhexidine
• Hydrogen Peroxide
• Chlorine
• Povidone Iodine
 Pencucian dan Penggantian balutan luka
paska operasi dari berbagai Jurnal
No Jurnal Tahun Isi jurnal
1. Prevention of Post-Operative Wound 2012 • Ganti balutan luka diperbolehkan 48 jam
Infection in setelah operasi
Accordance with Evidence Based Practice • Cairan pencuci luka sangat dirokemandasikan
(Archana Maurya, Seema Mendhe) menggunakan saline steril

2. Post-operative wound management
(Kaihan Yao, Lily Bae, Wei Ping Yew)
2013 • Usahakan luka tidak dibuka dan tidak
tersentuh selama 48 jam setelah operasi
• Cairan pencuci luka yang direkomendasikan
adalah saline steril atau air mengalir jika luka
terdapat pus

3. Prevention and 2018 • Luka di ganti balutan selama 24 jam-48 jam

Management of Surgical setelah operasi, karena luka akan re-
Wound Complications epitelisasi dalam 2 hingga 3 hari.
(Connie L. Harris, Janet Kuhnke, Jennifer, • Cairan pencuci luka yang paling baik
et.,al) menggunakan saline steril.
TEHNIK MENCUCI LUKA
— SWABBING /
MENGGOSOK LUKA
Harus GENTLE,
STOP menggosok jaringan
granulasi
atau sampai BERDARAH

— IRIGASI
Hati-hati terhadap tekanan
tinggi
Gunakan jarum no 18

- Buang jaringan nekrotik

dan benda-benda asing

- Jaringan nekrotik ---> baik

untuk pertumbuhan bakteri
4. PEMILIHAN DRESSING
/ BALUTAN

S
a LUKA LUKA
d BASAH MOIST KERING
e
a
s
u • Absorbent • Silicon dres
d
a Dressing • Transparent • Hidroaktif
i
i • Hidrofiber Dressing Gel
p • Calcium
R
r Alginate
S
o • Foam
d
S
u
a
k
r
d
y
j
a
i
n
t
g
o
Menyerap cairan Menjaga kelembaban Memberi kelembaban
…….????

Rawat luka

Luka Tutup luka

Pilih
Dressing
Algoritma Pemilihan Topikal Terapi Berdasar Warna Luka
Di RSUP DR.SARDJITO

Keep Silicon (Si-Aid®),Tulle gras,

RED :Jaringan Epitel
moist Transparant film

Keep Foam Silicon dressing, hidroloid

RED: Jaringan moist ca alginate (Askina sorb®)
Granulasi
Antiseptik PHMB, Antimikrobial dressing,
Yellow :Exudate, rongga absorb absorb dressing (alginate, foam), silver dressing

Hydroactive wound gel

Black: Avascular hidrasi Autolitic debridement (SSD)

PHMB, Antimicrobial dressing,

Infected control Silver dressing/SSD, Hidrofobik dressing
 Problem : Nekrotik Debridement
Warna : Hitam Kuning Rawat kering ke moist :
Permukaan : Kering Gel/Cream

Problem : Nekrotik Debridement

Warna : Kuning Slough Rawat basah ke moist :
Permukaan : Basah Absorben

Problem : - /terkontrol Penutupan Luka

Warna : Merah Granulasi Skin-grafting atau
Permukaan : Moist persekundam

Luka sembuh Scar Management

Tertutup Epitel

Courtesy : David S Perdanakusuma

NEW CONCEPT WOUND MANAGEMENT
LUKA

Problem Tanpa Problem

Preparasi Bed Luka

Jaringan Bakteri Eksudat

Debridement M OIST
• Cuci / irigasi Absortif Produk
- Surgical • Antibacterial
- Autolotic
- Mechanical
- Enzymatic
Luka
- Biological
Terpreparasi

Penutupan
Luka
• Jahit Primer
• Skin Grafting Epitelialisasi
• Flap (Sekunder)

Repair dan Stimulasi Penyembuhan

SEMBUH Penanganan
Parut
Suport - Kualitas Hidup/Sosial
Courtesy : David S Perdanakusuma
 Perkiraan Waktu Sembuh Luka

Wound Bed Preparation =……. Minggu

Proliferation Phase = 3 Minggu
Pembentukan Epidermis = 2 Minggu
+- 2 Minggu

= ...................
Wound Dressing Algoritma
 ALGORITME MANAJEMEN
LUKA

KRONIK KRONIK KRONIK KRONIK Kronik

AKUT HITAM, KERING KUNING, BASAH MERAH dengan cairan
Merah, basah Merah Muda
kuning kehijauan/Pus
(Nekrotik) (Slough) (Granulasi) (Epitelisasi)
(Infeksi)

Cleansing Cleansing
Anestesi Cleansing
Wound
Cleansing Wound Cleansing
Wound (PHMB) Wound Wound
lokal (PHMB) (NaCL) (NaCL)

Cleansing Kultur Moist

Debridement Debridemnet Moist dressing
wound Pus/Dasar luka dressing

Surgical, Silicon, Tulle grass,

Surgical,Autolisis
Debridement Autolisis, Silikon.Foam, non-
,Mekanik, Enzym, Debridement
non vital Biological
Mekanik, Enzym, Hidrokoloid, adherent,Transparan
Biological film
Surgical,
Absorb dressing, Autolisis,
Penutupan Hidroaktif Gel
Alginate Mekanik, Enzym,
luka (Primer)
Biological

Courtesy of Prof.DR.dr.David Perdanakusuma, SpBP (K)

Perawatan luka di masa pandemi

• Ketika melakukan perawatan luka dengan pasien

berarti kita sedang kontak erat dengan seseorang
berisiko bagi kita dan juga pasien
• Radius 1 meter , ≥ 15menit
• Sentuhan fisik
• Tindakan yang dapat membuat aerosol
 • Slow release action
• Absorb yang baik
Pertimbangan • Tidak lengket
pemilihan balutan luka • Menjaga kelembaban
dimasa Pandemi • Interaktif dalam waktu ‘lama’
(antimicrobial dressing)
‘Do no harm’ • Cara aplikasi sederhana
(persingkat waktu perawatan)
• APD sesuai analisis risiko minimal
level 2
 Alternatif topikal terapi
• Antiseptik
• Antibiotik
• Honey/madu
• Lidah buaya
• Saline 0,9 %
• Parafine-Vaseline impragnate gauze
Diperlukan penelitian lebih lanjut

INDONESIAN WOUND OSTOMY CONTINENCE NURSE ASSOCIATION-BASIC SERTIFIED WOUND CARE NURSE (BCWCN)
 Evaluation

• Wound toilet
• Debridement Depends on is requirement
• Change dressing

• Consider the painful dressing

Johnson (1988), traditional wound care practices of using frequent wet to dry dressing, it
actually lowers the wound surface temperature by 2- 5°C, with corresponden adverse
effect on mitotic activity
- Frequent undressing of wound significantly reduce wound temperature and delays
healing

INDONESIAN WOUND OSTOMY CONTINENCE NURSE ASSOCIATION - Certified Basic Wound Care Nure (CBWCN)
Key message

• Luka kering (dessicated) perlu hidrasi

• Luka bereksudat perlu absorpsi
• Luka nekrotik perlu debridement
• Luka terinfeksi perlu antimkrobial

Konsep penyembuhan luka terkini adalah kondisi lingkungan

lembab yang sesuai (mouisture balance)

INDONESIAN WOUND OSTOMY CONTINENCE NURSE ASSOCIATION - Certified Basic Wound Care Nurse (CBWCN)
Daftar pustaka
1. Sood, et al. 2014. Wound Dressing and Comparative Effectiveness Data. Advances in
Wound Care Journal, vvol 3, number 8. Wound Healing Society
2. Baranoski & Ayello. 2012. Wound Care Essensials Practice Principles. Lippincott
Williams & Wilkins: Philadelphia
3. Blackly P. 2004. Practical Stoma, Wound and Continence Management, Second Editon. Research Publication
Pty Ltd 27A Boronia Road, Vermont, Victoria, Australia
4. Bryant R & Nic D. 2007. Acut and Chronic Wounds, Current Management Conceps, Third Edition, Msby,
Inc un affiliateof Elsevier Inc. Philadelphia
5. Carville K, 1998. Wound Care Manual, Third Edition, Copyright Silver Chain Foundation, Sundercombe St.
Osborne Park, Western, Australia.
6. Dealy C, 2007, The Care of Wounds, A quide for Nurses, Third Edition, Blackwell Publishing Ltd, British,
USA, Australia, Hong Kong
7. Nixon J cit Marison MJ, Ovington LG, Wilkie K 2004, Chronic Wound Care, A Problem – Based
Learning, Approach chapter Pressure Ulcer, Copyright, Licencing Agency, 90 Tottenham Courd Road,
London
8. Suriadi, 2007. Perawatan luka ( Edisi 4 ), Jakarta, PT Sagung Seto
9. Abhishek Devare, Arun Bhatnagar, Analysis of etiology of loss of skin in lower limb and its
reconstructive options, International Surgery Journal, 2020
10. Amit Gefen, Karen Ousey, Safe and effective wound care during the COVID-19 pandemic.
JOURNAL OF WOUND CARE, 2020

INDONESIAN WOUND OSTOMY CONTINENCE NURSE ASSOCIATION - Certified Basic Wound Care Nurse (CBWCN)
TERIMA
KASIH