WOUND CARE MANAGEMENT

Pesantren Ramadhan 2017

PEDIATRIC WOUND NEGLECTED
 BURN  ABSES PERIANAL
 In-Effective cost
Patient cost
Hospital cost
Nursing care cost

Takes time: 3 x /day

changing wound dressing

Wounds not really healed

or healed over time

Problems in Conventional Wound Care

 New Concept in Wound Care
 Moist Wound
Healing
 Dressing change
every 3 days or
more
 Painless dressing
change
 Cost effective
 CHRONIC WOUND
• IS FAILED TO PROGRESS OR RESPOND TO TREATMENT OVER
THE NORMAL EXPECTED OF HEALING TIME FRAME (4 WEEKS) AND BECOME “STUCK” IN THE
INFLAMATORY PHASE . Clinical Guidelines (Nursing)- Royal Children hospital Melbourne

• GENERALLY WOUND DOESN’T START TO HEAL WITHIN 4 WEEKS

OR HASN’T HEALED WITHIN 8 WEEKS

• IS MEAN DELAY WOUND HEALING PROCESS

• THIS IS A SPECIAL CONDITION THAT WE HAVE TO DEAL WITH DIFFICULTIES
OF INTERNAL AND EXTERNAL PROBLEMS

• AND WE MUST TREAT THE WOUND WITH AN EVIDENCE BASE

PRACTICES
LUKA KRONIK
• VASKULAR STATUS ?
• NUTRITIONAL
STATUS ?
• GLYCEMIC CONTROL ?
• DEBRIDMENT ?
• APPROPRIATE
DRESSING ?
• APPROPRIATE OFF
LOADING ?
• RESOLUTION OF
INFECTION ?
Courtesy by Ahmad-gocare
 PERAWATAN LUKA KRONIS

 PENGKAJIAN LUKA  MEMBUAT PERENCANAAN

 TUJUAN PERAWATAN : LUKA SEMBUH
 19.11.2013  23.11.2013
PRINSIP MANAJEMEN LUKA
 Kontrol & hilangkan penyebabnya
 Pressure, shear, friction, moisture, neurophathy

 Ciptakan dukungan sistemik

 Nutrisi & cairan, edema, GDS

 Ciptakan & pertahankan lingkungan luka

 Cegah infeksi, kebersihan luka, jaringan mati, lembab, dll
 Working Toward CHRONIC WOUND
Projects Worked On HEALED 80%

MATURATION
PHASE
2 WEEKS

PROLIFERATION
PHASE
3 - 6 WEEKS
WOUND BED
PREPARATION
2 – 4 WEEKS

Time Spent ON 12 WEEKS

2009.
EVIDENCE PRACTISE BASE ON WINNERS SCALE THAT ADOPTED FROM BETES
JANSEN SCALE
STANDART PERAWATAN LUKA

3 M:
MENCUCI LUKA
MEMBUANG JARINGAN MATI
MEMILIH TOPIKAL THERAPY
 MENCUCI LUKA
 Tujuan : menurunkan jumlah
bakteri dan membersihkan dari
sisa balutan lama dan hasil
autolisis debridment
 mempersiapkan luka sebelum
dibalut
 Psikologis : bersih dan nyaman

 Hati hati terhadap pemakaian

antiseptik
 Cairan pencuci luka

 Efektif cara mencuci

 Swab
 Tekanan
 Irigasi
 Pilih cairan yang tepat
 Air & sabun/normal salin/air hangat
 PHMB
 Penyabunan dan pencucian
Tehnik pencucian dapat dengan cara Pemilihan cairan pencuci yg tepat.
Penggunaan cairan pencuci fisiologis.
perendaman atau irigasi
 M EMBUANG JARINGAN MATI
PERSIAPAN DASAR LUKA (wound bed preparation)

Debridement /
Debridemang : Necrosis:
Membuang jaringan Kematian sel yang
nekrosis dari permukaan disebabkan oleh penurunan
luka proses enzymatic tubuh
 PERSIAPAN DASAR LUKA
MENGHILANGKAN faktor
yang menghambat penyembuhan luka

MEMPERSIAPKAN DASAR
LUKA dengan secara maximal untuk
dapat menggunakan advanced product

Sehingga PROSES
PENYEMBUHAN AKAN
BERLANGSUNG CEPAT

04.12.2013
14.12.2013
WOUND BED PREPARATION
UNDERSTANDING WOUND BED PREPARATION

TISSUE INFLAMATION
MANAGEMENT CONTROL

TIME
MOISTURE
EPITELIAL EDGE
BALANCE
(Falanga, 2004)
 T: Tissue management

 Hilangkan jaringan mati & benda asing

SAFE Debridemang:
 Surgical
 CSWD: tanpa nyeri & berdarah
 Enzymatic: hewan / herbal (enzim proteolitik)
Autolytic: Moisture balance
 Mechanical: kasa basah kering, hydroterapi, swab
 Chemical: Hydrogen peroxide, iodine cadexomer
 Bilogical: maggot
Autolytic Debridement
 I : Inflammation &
Infection control

 Cairan pencuci
 Dressing yg tepat (topikal antimicrobial & antiseptik)
 Sistemik therapy (jika perlu)
 M: Moisture Balance

 Pertahankan lembab yg seimbang (winter, 1962)

 Manajemen:
 Dressing yg tepat, luka kering vs luka basah
 Kompresi ??
Moisture Balance
E: Epithelial edge advancement

 Tepi luka yg baik?

 Manajemen:
 Pencucian adekuat
 Penipisan tepi luka
 Moisture balance dressing
Epithelial edge advancement
 VIDEO