ASUHAN

KEPERAWATAN PASIEN
DENGAN LUKA
CERTIFIED WOUND CARE CLINICIAN
ASSOCIATE PROGRAM
 Certified Wound Care Clinician Associate

Tujuan Pembelajaran

TPU TPK
Peserta mampu melakukan Peserta mampu:
pengkajian luka.
1. Melakukan pengkajian luka
2. Menentukan derajat luka
3. Memahami faktor penghambat
penyembuhan luka
4. Melakukan Pendokumentasian
luka
PENGKAJIAN LUKA
Certified Wound Care Clinician Associate

Monitoring – Observation - Inspection

Daily monitoring of a
patient skin, observation the
dressing, especially if dressing stay
in place for several days

Dokumentasi:
Subjective – Tidak ada keluhan –
nyaman saat beraktifitas
Objective - Balutan tampak bersih
dan kering, kulit sekitar balutan
tenang, tidak tampak tanda-tanda
kemerahan
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Jenis Luka

AKUT KRONIK
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Assessment

● Wound Etiology
Holistic
● Duration of the wound / Wound age
Assessment
● Factor that impede healing

● Location
● Stage
● Wound base
● Type of tissue
● Dimension
Wound ● Exudates
Assessment ● Odor
● Wound edge
● Periwound skin
● sign of infection
● wound pain
Certified Wound Care Clinician Associate

Assessment: Etiology

Will drive intervention choise and strategies

Venous Ulcer Pressure Injury
(tx/compression bandage) (tx/relief pressure)

Courtesy: Wocare Center

Certified Wound Care Clinician Associate

Assessment: Etiology

Types of Skin Damage

Mechanical pressure, shear, friction, stripping

incontinence, drainage, harsh solutions, improper use
Chemical of products
Vascular arterial, venous, diabetic
Infectious Candidiasis, impetigo, herpes Allergic
Miscellaneous radiation, thermal
Certified Wound Care Clinician Associate

Assessment: Duration/Wound Age

The age of the

wound is Guidelines
for chronic wound has not
improve, 2 – 4 weeks
recommend biopsy
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Factor That Impede Healing

▪ Comorbid condition
▪ Malignancies, diabetics, etc
▪ Medications
▪ chemotherapy, corticosteroid
▪ Decrease oxygenation and
tissue perfusion
▪ Alteration in nutrition and
hydration
▪ Psychosocial barriers
▪ Family factors, financial, etc
Certified Wound Care Clinician Associate

Wound Assessment

1.Location Stage Wound base

2.(Letak Luka) ( 1- 4 ) (Dasar luka / RYB)

Type of tissue Dimension Exudates

(Epitelisasi –
( Pengukuran luka ) (Cairan luka)
granulasi – slough)

Odor Wound edge Per wound skin

(Bau tidak sedap) (Tepi luka) (Kulit sekitar luka)

Sign of
infection Wound pain
(Nyeri)
(Tanda infeksi)
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Wound Location

Menentukan
LETAK LUKA atau
LOKASI LUKA pada
GAMBAR
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Stadium Luka I - IV
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Stadium Luka I - IV

Stage III
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Warna Dasar Luka

RED YELLOW BLACK

RYB
Kemudahan sistem yang diperkenalkan adalah bersifat
konsisten dan mudah dimengerti serta tepat guna dalam
pemilihan balutan

Courtesy by Anton Yun,CWCC

Certified Wound Care Clinician Associate

Pengukuran Luka

Panjang x lebar x Ada tidaknya undermining / goa,

yang diukur sesuai dengan arah
kedalaman jarum jam.

Head
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Digambar
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Dokumentasi

FOTO DENGAN MENGGUNAKAN TANGGAL

(NAMA / MR / USIA / TANGGAL / PERAWATAN KE)

Co: TN A / 01.121017 / 55TH / 15-10-17 / I

Certified Wound Care Clinician Associate

TAKE PHOTOGRAPH
•Gunakan pencahayaan yang cukup
•Pastikan permukaan luka yang akan difoto terlihat dengan jelas
•Gunakan jarak yang konsisten antara luka dan kamera
•Tulis pada label meliputi: identitas pasien, lokasi luka, dan
tanggal pengambilan foto (kecuali apabila tercantum tanggal
pada kamera)
•Gunakan kamera yang dapat memiliki fasilitas untuk
memperbesar/memperkecil gambar dan atau macro future jika
memungkinkan agar dapat mengambil foto close up (35 mm
pada lensa kamera agar tidak terbentuk bayangan pada
gambar).
Cara Pengambilan foto luka agar maksimal (Bates Jansen, 2012)
Certified Wound Care Clinician Associate

SAMPLE PHOTOGRAPH
Certified Wound Care Clinician Associate

UNDERMINING

ALAT: Mandrin, spidol marker

CARA: Masukkan mandrin ke dalam goa dengan hati-hati – kemudian ulir mandrin
searah dengan jarum jam, beri tanda dengan spidol – lakukan hingga goa berakhir.
Kemudian tentukan jarak kedalaman goa yang paling panjang.
DOKUMENTASI : Goa berada di jam XX hingga jam YY, terpanjang ZZ cm
Certified Wound Care Clinician Associate

UNDERMINING
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CARA PENDOKUMENTASIAN UNDERMINING

12
undermining
undermining m
2,1 c
2,3 cm

09 WOUND 03

1,6
cm
undermining

06

Undermining di jam 12 – 02 ukuran 2,1 cm

di jam 04 – 06 ukuran 1,6 cm
di jam 08.30 – 11.30 ukuran 2,3 cm
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WOUND MEASUREMENT
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PERIWOUND SKIN

KULIT DISEKITAR LUKA:

✔ Gatal
✔ Maserasi
✔ Odema
✔ Hiperpigmentasi

Courtesy by Anton Yun, CWCC in USA

Certified Wound Care Clinician Associate

WOUND EDGE

TEPI LUKA
Umumnya tepi luka akan dipenuhi
oleh jaringan epitel, berwarna
merah muda.

Kegagalan penutupan terjadi jika

tepi luka :
• Edema
• Nekrosis / callus
• Infeksi
Certified Wound Care Clinician Associate

CAIRAN LUKA

Blood Inflammation

Chronic wound fluid Product of infection

Certified Wound Care Clinician Associate

BAU TIDAK SEDAP / ODOR

Foul odors from wounds result from the metabolic by-products of anaerobic and certain
gram negative organisms. Deeper infection (e.g. cellulitis, necrotizing infections) are not
necessary for significant odor generation. Wound odor, also referred to as malodor, is
typically the result of necrotic tissue or bacterial colonization in the wound bed.

Assessment:
Very strongOdor is evident on entering the room (6–10 feet or 2–3 meters from the
patient) with the dressing intact.
Strong Odor is evident on entering the room (6–10 feet or 2–3 meters from the
patient) with the dressing removed.
Moderate Odor is evident at close proximity to the patient when the dressing is intact.
Slight Odor is evident at close proximity to the patient when the dressing is removed.
No odor No odor is evident, even at the patient’s bedside with the dressing removed.
From: Haughton and Young (1995)
Certified Wound Care Clinician Associate

TANDA INFEKSI

▪ Proses inflamasi / peradangan yang

memanjang : kemerahan, odema,
nyeri, panas
▪ Exudatives, purulent
▪ Berbau tidak sedap
▪ Hasil kultur infeksi
Certified Wound Care Clinician Associate

BIO BURDEN
•Adanya kuman diluka
meningkatkan beban (burden)
dari lukanya sehingga
menghambat
penyembuhan luka: LUKA
KRONIK

•Klasifikasi:
• Kontaminasi
• Kolonisasi
• Kritikal kolonisasi
• Infeksi
Certified Wound Care Clinician Associate

WOUND PAIN

An unpleasant sensory
and emotional
experience with tissue
damage

Hypnonursing management :
pain relief
Certified Wound Care Clinician Associate

CARA PENGAMBILAN KULTUR

1. Siapkan alat pengambilan kultur dan balutan

2. Cuci tangan
3. Buka balutan luka lama
4. Cuci luka dengan larutan normal saline
JANGAN antiseptik
5. Keringkan dengan kasa steril
6. Tunggu sampai eksudat keluar
7. Lakukan pengambilan sampel kultur dengan
mengusap zig zag sebanyak 10 kali usapan
yang mewakili seluruh area luka
8. Sampel dikirim ke lab, jika tertunda
pengiriman harus disimpan dalam almari es / “Contoh alat swab dan
suhu dingin tabung pengambilan
kultur pada luka”
Certified Wound Care Clinician Associate

KULTUR

Wound swab with zig zag motion

Certified Wound Care Clinician Associate

PENULISAN DOKUMENTASI ASKEP

•ASSESMENT •TUJUAN – KRITERIA HASIL

•DIAGNOSA KEPERAWATAN : •RENCANA KEPERAWATAN
•Disturbed Body Image (TIME)
•Deficient Knowledge Related •IMPLEMENTASI
To Wound Care KEPERAWATAN
•Impaired Tissue Integrity •EVALUASI
•Risk For Impaired Skin
Integrity
•Risk For Infection
Certified Wound Care Clinician Associate
DOKUMENTASI
PENGKAJIAN:
• Ps. Datang pukul 10.00. Secara keseluruhan
kondisi pasien relatif kurang baik, gelisah,
nyeri pada luka saat disentuh. BP : 150/100
mmHg, GDS 528, antibiotik sistemik dari
dokter masih dilanjutkan.
• Kami temukan : Luka DM, akral perifer kiri
dan kanan dingin, sianosis, pucat, alopecia,
tipis dan kering.
• Luka di KAKI, ½ luas plantar8X6 , exudat
minimal purulent dan malodour. Warna
dasar luka 80% MERAH 20 % KUNING ,
STAGE II Tanda infeksi (+).
• SCORE NILAI = 37 - PREDIKSI HEAL = 8 MG
PLAN= TIME
Prosedur:
• Mencuci dengan anticeptic solution
• Evakuasi eksudat dan bau
• (T) Debridemang dengan Autolysis
debridemang
• (I) kontrol infeksi dengan pemberian
antibiotik dan nutrisi dg kolagen fish 10 gr/day
• (M) Dressing moist dengan Metcovazin,
calcium alginate
• (E) Menghindari maserasi pda tepi luka,
perencanaan ganti balutan @ 2 hari sekali
• Penatalaksanaan sistemik dalam pemberian
antibiotik dengan pasca hasil kultur terlampir
(Jika Ada)
• IMPLEMENTASI= 3M
Certified Wound Care Clinician Associate

DOKUMENTASI
Lampiran:

Foto luka dengan menggunakan penggaris

Certified Wound Care Clinician Associate

KESIMPULAN

Pengkajian secara holistik (Etiology, usia luka, dan faktor

yang menghambat penyembuhan luka) sangat memfasilitasi
perawat dalam melakukan pengkajian luka.

WINNERS Scale – membantu Prediksi proses

penyembuhan luka

Pendokumentasian dilakukan untuk memfasilitasi

komunikasi antar perawat, meningkatkan pelayanan yang baik
dan profesionalisme, serta memenuhi standar legal.
Certified Wound Care Clinician Associate

REFERENCES

Bryant, R (2016). Acute and Chronic Wounds. (3nd ed.). St Louis :

Mosby Year Book
Carvile, K. (2012). Wound Care Manual. (6th ed.). Perth, WA : Silver
Chain Foundation.
Doughty, Beckley D, McNichol, Lauwerie L (2016). Wound, Ostomy
and Continence Nurse Society core curriculum. Wound management.
Philaedelphia : Wolters Kluwe
 WORKSHOP
PENGKAJIAN LUKA
Certified Wound Care Clinician Associate

Kaji menggunakan WINNERS scale

Certified Wound Care Clinician Associate

NILAI PREDIKSI

55 : X = 12 : N

55 = Nilai Score Tertinggi Rentang Sakit

12 = Prediksi Waktu Penyembuhan Luka
X = SCORE NILAI
N = HASIL PREDIKSI WAKTU

36 : 55 = 12 : N
N = 36 X 12 / 55
= 7,8
= 8 MINGGU

Prediksi proses
penyembuhan luka = 8 Mg.
Certified Wound Care Clinician Associate

CASE REPORT

CASE REPORT : 01.31.2008 - 03.31.2008 (TOTAL : 8 MINGGU)

Certified Wound Care Clinician Associate

WORKSHOP KELOMPOK
•Peserta dibagi dalam kelompok
•Kelompok di bagikan panthom dan perlengkapan
pengkajian luka
•Disiapkan kertas lembar balik dan spidol untuk menyiapkan
presentasi
•Peserta melakukan pengkajian dalam kelompok selama 15
menit
•Masing – masing kelompok mempresentasikan hasil kerja
•Pembimbing menanyakan kepada peserta tentang hasil
diskusi kelompok