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.
- Any disruption to layers of the skin and underlying tissues due to multiple causes including trauma, surgery, or a specific disease state.

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PHASES OF WOUND HEALING = regeneration (renewal) of tissue. The inflammatory phase (3-6 days) B. The maturation (Remodeling) phase (day 21. The regenerative (Proliferative) phase (day 4-day21) C. Bellman.1 or 2 yrs) (Manley. 2000) 6 . A.

q Biasanya 3 – 6 bulan.PROSES PENYEMBUHAN LUKA Fase Inflamasi Fase Proliferasi Fase Penyudahan Pembuluh darah terputus. q Pengerutan sesuai gaya gravitasi. . q Perupaan kembali jaringan yg baru. (sejak terjadi luka sampai hari ke – lima) q Penyerapan Terjadi proliferasi fibroplast (menautkan tepi luka) kembali jaringan berlebih. menyebabkan Pendarahan dan tubuh berusaha untuk menghentikannya.

The inflammatory phase (Initiated immediately after injury and last 3-6 days Injury /damage Cells Histamine Blood Clot Dry Vasodilation Permeability Uniting the wound edges Neutrophils& Monocytes -Dilated blood vessels -Microcirculation slow down 8 Oedema& Engorgement 0-3 days .

Beginning the synthesis of collagen fibers (granulation tissue ) 9 migrate along fibrin threads .Laying down of a ground substance .Resultant tissue filling is referred To as granulation tissue .The Regenerative (Proliferative) phase Blood vessels near the edge of the wound become porous Allowing excess moisture to escape Begins 2-3 days of injury Lasting up to 2-3 weeks .process of wound contraction begins Macrophage activity Stimulates Formation& multiplication of fibroblasts Which Resulting Traps other blood cells & damaged blood vessels Begin to regenerate within the wound margins This fibrous network .

The Maturative phase • Dimulai pada hr ke 21 dpt memanjang hingga 6 bulan bahkan hingga 1. kurang elastis.2 th pasca injury. dan memutih 10 . • Fibroblasts terus mensintesa collagen • Serat2 kolagen membentuk struktur yang mature • The scar/jaringan parut menjadi lebih tipis.

• Penyembuhan Sekunder Penyembuhan luka tanpa ada bantuan dari luar (mengandalkan antibodi) . biasanya dengan bantuan jahitan.KLASIFIKASI PENYEMBUHAN LUKA • Penyembuhan Primer luka diusahakan bertaut.

Factors affecting wound healing Developmental consideration/Age Nutrition Life-style Medication Infection Wound perfusion 12 .

KLASIFIKASI LUKA Tindakan Thd Luka Luka disengaja (Intentional Traumatis) Luka tidak disengaja (Unintentional Traumatis) Integritas Luka Luka tertutup Luka terbuka Mekanisme Luka Luka memar Luka incisi Luka abrasi .

can be intentional or unintentional Open wound. Goldberg . often the underlying tissues from a sharp instrument Tissues torn apart. machinery) Penetration of the skin and the underlying tissues Open wound. dermal abrasion to remove pockmarks) Puncture Penetration of the skin and.Olsen. involving the skin . edges are often jagged Open wound. scraped knee from fall) or intentional (eg.Tomaselli. skin appears ecchymotic (bruised) because of damaged blood vessels Open wound. often from accidents (eg. usually accidental ( bullet or14 metal fragments) Laceration Penetrating wound . Knife Blow from a blunt instrument Description and Characteristics Open wound.2004) Type Incision Contusion Cause Sharp instrument eg.Types of Wound (Hahn. either unintentional (eg. painful Abrasion Surface scrape. painful Close wound.

Clean-contaminated: A viscus is entered but without spillage of contents. 15 . This category included non. uninfected wounds where is no inflammation encountered and no break in technique has occurred.traumatic wounds where a minor break in technique has occurred.traumatic.Classification of surgical wounds according to the degree of contamination Clean wounds: non.

clinical infection. 16 . with delayed treatment. Acute nonpurulent inflammation mungkin dijumpai Dirty or infected : Old traumatic wounds from a dirty source. faecal contamination or a foreign body.Classification of surgical wounds cont’d (Altmeire 1997. NAS 1996) Contaminated: fresh traumatic wound dari sumber yang relatif bersih. devitalised tissue. Ayliffe & Lowbury 1992.

Classification of wounds berdasarkan kedalamannya I. subcutaneous tissue. Partial-thickness: Confined to the skin. the dermis and epidermis. epidermis. and possibly muscle and bone Partial Thickness Full Thickness 17 . II. Full-thickness : Involve the dermis.

Decubitus ulcer .

Gunshot wound .

Stab wound .

Lacerating wound .

• Dehiscene (tepi sulit/tidak dapat menyatu) • Eviceration (menonjolnya organ-organ tubuh bagian dalam ke arah luar melalui incisi) . bengkak. lemah. • Infeksi luka memerah. jaringan sekitar mengeras.KOMPLIKASI SPESIFIK ADANYA LUKA • Hemorrhage (Perdarahan) Meningkaynya nadi. meningkatnya pernafasan. Menurunnya tekanan darah. nyeri. pasien mengeluh kehausan. leukosit meningkat.

L. Bellman. Underling Conditions/Disorders A.Risk Factors Which Increase Patient Susceptibility to infection (Manley. Extremes age: Defined as “ Children aged 1 year and under.K. 2. and people aged 65 years and over’.Intrinsic risk factors: 1. Nutrition and build 23 . Diabetes B. Respiratory disorders C. Blood disorders 3. Smoking 4.2000) A.

g.2000) B. Bellman. Drug therapy as a risk factor: e.Risk Factors Which Increase Patient Susceptibility to infection cont’d (Manley. Cytotoxic drugs 2. Adanya benda asing 24 . Kerusakan integritas jaringan 3. L.K.Extrinsic risk factors: 1.

Drainage is increased and possibly purulent. • Wound edges may be separated with dehiscence present. Wound feels hot on palpation. Wound is deep red in color. 25 .S&S of Presence of Infection • • • • Wound is swollen. • Foul odor may be noted.

Serous-clean. indicative of active bleeding. Sanguineous. Serosanguineous-pale.bright red. yellow. . Purulent. red. green. watery mixture of serous and sanguineous. watery 2. 3. 4.TYPES OF WOUND DRAINAGE 1. tan or brown.thick.

such as fluid and cells. fluid in a blister 27 . Intensity and duration of the inflammation. Serous Exudate Mostly serum Watery.. clear of cells E. The Nature and amount of exudate vary according to: Tissue involved. 1. and the presence of microorganisms. that has escaped from blood vessels during the inflammatory process and deposited in or on tissue surfaces.g.Types of Wound Drainage (cairan luka) Exudate is material.

or yellow. 28 . liquefied dead tissue debris. Purulent exudate vary in color. The Process of pus formation = suppuration. green. dead and living bacteria. some acquiring tinges of blue.2.     A purulent Exudate pus It consists of leukocytes. and the bacteria that produce pus = pyogenic bacteria. The color may depend on the causative organism.

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. Bright indicate fresh blood.3. 29 . Nurses often need to distinguish whether the exudate is dark or bright. whereas dark exudate denotes older bleeding.    A sanguineous (hemorrhagic) Exudate It consists of large amount or blood cells.

 The RYB code can be applied to any wound allowed to heal by secondary intention. 30 .1999) • This concept is based on the color of the open wound rather than the depth or size of the wound.The RYB color code (Stotts. R=Red Y=Yellow B= Black  On this scheme. and debride black. cleanse yellow. the goal of wound care is to protect ( cover) red.

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.thickness or second – degree burns. 31 .Red wounds • Usually in the late regeneration phase of tissue repair (ie. skin donor sites. and partial.

32 . Appling a transparent film or hydrocolloid dressing. Changing the dressing as infrequently as possible.• Cara melindungi red wounds: Dibersihkan dengan lembut dan hati-hati Hindari penggunaan kasa. dan balutan kering Applying a topical antimicrobial agent.

using absorbent dressing material such as impregnated nonadherent. or other exudate absorbers. irrigating the wound. and consulting with the physician about the need for a topical antimicrobial to minimize bacterial growth. • The nurse cleanses yellow wounds to absorb drainage and remove nonviable tissue. Methods used may include .Yellow wounds • Characterized primarily by liquid to semiliquid ”slough” that is often accompanied by purulent drainage. hydrogel dressing. – Applying wet-to-wet dressing. 33 .

g. the wound is treated as yellow. then red. • When the eschar is removed. 34 . third degree burns and gangrenous ulcer. • Required debridement ..Black Wound • Covered with thick necrotic tissue or Eschar. • e.

Swelling/pembengkakan 35 .Pain 7.Olsen.Location 2.Tomaselli.Exudate/Drainage 5. Goldberg .Keadaan jaringan 4.2004) What to assess? 1.kondisi sekitar luka 6.ukuran 3.Wound assessment (Hahn.

Nursing Diagnoses – Risk for Impaired Skin Integrity – Impaired Skin Integrity – Impaired Tissue Integrity – Risk for Infection – Pain 36 .

TINDAKAN KEPERAWATAN TERHADAP LUKA • Perawatan Luka Bersih • Perawatan Luka Kotor Ciri – ciri : luka + serum luka + pus luka + nekrose .

Melindungi luka dari kontaminasi kuman 3. Mempertahankan kelembban luka 4.Purposes of wound dressing 1. To provide thermal insulation 5. menyerap drainage and /or debride a wound 38 . Melindungi luka dari truama mekanis 2.

6. Memberi kenyamanan psikologis 39 . 7. Mencegah perdarahan (when applied as a pressure dressing or with elastic bandages). 8. Mengimobilisasi sisi luka sehingga menfasilitas proses penyembuhan dan menjegah injury.

Guidelines for cleaning wounds 1. Gunakan larutan fisologis seperti isotonic saline or lactated ringer solution. Jika memungkinkan hangatkan larutan sesuai suhu tubuh 3. has little exudate . Jika luka sangat kotor lakukan rawat luka sesering mungkin 4. 2. Jika luka bersih. and menunjukkan healthy granulation tissue . hindari penggantian dan perawatan luka yg terlalu sering 40 .

tidak usah mengeringkan luka setalh emmbersihkannya 41 . Pertimbauntuk membersihkan permukaan luka yg noninfected dgn cara mengirigasi (mencuci/mengguyur) irrigating dgn normal saline dari pada mengusapnya secara mekanik 6. Untuk mempertahankan kelembaban.5.

Topics for Home Care Teaching • • • • • • • • Supplies Infection prevention Wound healing Appearance of the skin/recent changes Activity/mobility Nutrition Pain Elimination 42 .

Meningkatkan kenyamanan fisik dan psikologis. • Mempercepat debredemen jaringan nekrotik. . • Ingin mengkaji keadaan luka. Indikasi : • Luka bersih tak terkontaminasi dan luka steril.Perawatan Luka Bersih Tujuan : • • • • Mencegah timbulnya infeksi. • Balutan kotor dan basah akibat eksternal ada rembesan/ eksudat. Mengabsorbsi drainase. Observasi perkembangan luka.

Prosedur Perawatan Luka Bersih 1. Menyiapkan alat 2. Tekhnis pelaksanaan . Menyiapkan pasien – Perkenalkan diri – Jelaskan tujuan – Jelaskan prosedur perawatan pada pasien – Persetujuan pasien 3.

9 % .PERALATAN Alat Steril Pincet Alat Tidak Steril Gunting Plaster Bengkok/ anatomi 1 Pinchet chirurgie 1 Gunting Luka (Lurus) Kapas Lidi Kasa Steril Kasa Penekan (deppers) Mangkok / kom Kecil pembalut kantong plastik Pembalut Alkohol 70 % Betadine 10 % Bensin/ Aseton Obat antiseptic/ desinfektan NaCl 0.

Prosedur Pelaksanaan Jelaskan prosedur perawatan pada pasien. Desinfektan sekitar luka dengan alkohol 70%. arah dari dalam ke luar. Buka pembalut dan buang pada tempatnya. Bila balutan lengket pada bekas luka. Tempatkan alat yang sesuai. lepas dengan larutan steril atau NaCl. . Cuci tangan. Bersihkan bekas plester dengan bensin/aseton (bila tidak kontra indikasi).

Catat kondisi dan perkembangan luka.Buanglah kapas kotor pada tempatnya dan pincet kotor tempatkan pada bengkok dengan larutan desinfektan. Rapikan pasien. Alat bereskan dan cuci tangan.9 % dan keringkan. . Olesi luka dengan betadine 2 % (sesuai advis dari dokter) dan tutup luka dengan kasa steril Plester verban atau kasa. Bersihkan luka dengan NaCl 0.

• Mengurangi gangguan rasa nyaman bagi pasien maupun orang lain.Perawatan Luka Kotor (decubitus) Definisi : • Luka + Serum • Luka + Pus • Luka + Nekrose Tujuan : • Mempercepat penyembuhan luka. . • Mencegah meluasnya infeksi.

Menyiapkan alat 2.Prosedur Perawatan Luka Kotor (decubitus) 1. Menyiapkan pasien  Perkenalkan diri  Jelaskan tujuan  Jelaskan prosedur perawatan pada pasien  Persetujuan pasien 3. Tekhnis pelaksanaan .

9 % . savlon Bensin/ Aseton Obat antiseptic/ desinfektan NaCl 0.PERALATAN Alat Steril Pincet Alat Tidak Steril Gunting Plaster Bengkok/ anatomi 1 Pinchet chirurgie 2 Gunting Luka (Lurus dan bengkok) Kapas Lidi Kasa Steril Kasa Penekan (deppers) Sarung Tangan Mangkok / kom Kecil 2 pembalut kantong plastik Pembalut Alkohol 70 % Betadine 2 % H2O2.

Bersihkan bekas plester dengan bensin/aseton (bila tidak kontra indikasi). Desinfektan sekitar luka dengan alkohol 70%. Cuci tangan dan gunakan sarung tangan (mengurangi transmisi pathogen yang berasal dari darah). . Tempatkan alat yang sesuai. Sarung tangan digunakan saat memegang bahan berair dari cairan tubuh. arah dari dalam ke luar. Buka pembalut dan buang pada tempatnya serta kajilah luka becubitus yang ada.Prosedur Pelaksanaan Jelaskan prosedur perawatan pada pasien.

Rapikan pasien. Bersihkan luka dengan H2O2 / savlon.9 % dan keringkan.Buanglah kapas kotor pada tempatnya dan pincet kotor tempatkan pada bengkok dengan larutan desinfektan. Olesi luka dengan betadine 2 % (sesuai advis dari dokter) dan tutup luka dengan kasa steril. Plester verban atau kasa. Bersihkan luka dengan NaCl 0. Alat bereskan dan cuci tangan. Catat kondisi dan perkembangan luka. .

• Saat melepas atau memasang balutan. • Peka terhadap privasi pasien. • Alat pelindung mata harus dipakai bila terdapat resiko kontaminasi okuler seperti cipratan mata. • dsb Hal-hal yang perlu diperhatikan .• Cermat dalam menjaga kesterilan. perhatikan tidak merubah posisi drain atau menarik luka.

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