ASKEP KLIEN DENGAN

ULKUS DIABETIKUM
Pengertian
• salah satu bentuk komplikasi kronik DM yang
berupa luka terbuka pada permukaan kulit yang
dapat disertai adanya kematian jaringan
setempat (nekrosis)
Klasifikasi
Menurut Wagner
• Grade 0 : Tidak ada lesi terbuka, kulit masih utuh disertai
pembentukan kalus
• Grade 1 : Ulkus superfisial terbatas pada kulit
• Grade 2 : Ulkus dalam dan menembus tendon dan tulang
• Grade 3 : Abses dalam, dengan atau tanpa osteomielitis
• Grade 4 : Gangren pada bagian distal kaki dengan atau
tanpa selullitus
• Grade 5 : Gangren seluruh kaki atau sebagian tungkai
bawah.
Patofisiologi
Sensory ataxia is both a symptom and a
sign in neurology. It is a form of ataxia (loss
of coordination) caused not by cerebellar
dysfunction but by loss of sensory input
into the control of movement.
• Charcot  refers to progressive degeneration of a weight bearing joint, a process
marked by bony destruction, bone resorption, and eventual deformity due to loss of
sensation
• The clinical presentation varies depending on the stage of the disease from mild
swelling to severe swelling and moderate deformity. Inflammation, erythema, pain
and increased skin temperature (3–7 degrees Celsius) around the joint may be
noticeable on examination. X-rays may reveal bone resorption and degenerative
changes in the joint.
• Two primary theories have been advanced: Neurotrauma: Loss of peripheral
sensation and proprioception leads to repetitive microtrauma to the joint in question;
this damage goes unnoticed by the neuropathic patient, and the resultant
inflammatory resorption of traumatized bone renders that region weak and
susceptible to further trauma. In addition, poor fine motor control generates
unnatural pressure on certain joints, leading to additional microtrauma.
• Neurovascular: Neuropathic patients have dysregulated autonomic nervous system
reflexes, and de-sensitized joints receive significantly greater blood flow. The
resulting hyperemia leads to increased osteoclastic resorption of bone, and this, in
concert with mechanical stress, leads to bony destruction.
•
A 68-year-old diabetic female on dialysis presented with a chronic
right heel ulcer (3.4 cm X 3.1 cm) of greater than 3 months
duration. Photograph of the wound after thorough wound bed
preparation over the course of 2 weeks.
• Diabetic cheiroarthropathy is a cutaneous condition
characterized by thickened skin and limited joint mobility
of the hands and fingers, leading to flexion contractures
Penatalaksanaan
• Kontrol metabolik, ex: mengontrol kadar gula darah
• Kontrol vaskular, ex: bedah vaskular rekonstruktif,
antiplatlet
• Kontrol Infeksi, ex: antibiotik
• Kontrol luka, ex: perawatan luka
• Kontrol tekanan/mekanik, mengurangi tekanan pada
telapak kaki, ex: total non-weight bearing, sepatu
yang dimodifikasi (half shoe, wedge shoe), alat
penyanggah tubuh seperti cruthes dan walker
• Kontrol edukasi, ex: pendkes self care, foot care
Framework for Practice
Pengkajian Luka dengan BWAT (BATES-
JENSEN WOUND ASSESSMENT TOOL)
• menggambarkan status keparahan luka.
• Semakin tinggi nilai yang dihasilkan maka semakin parah
luka
• 13 item pengkajian di dalamnya, yaitu : Size, Depth,
Edges, Undermining, Necrotic Tissue Type, Necrotic
Tissue Amount, Exudate Type, Exudate Amount, Skin
Color Surrounding Wound, Peripheral Tissue Edema,
Pheriperal Tissue Induration, Granulation Tissue, dan
Epithelialisation
Perbedaan ulkus neuropati dan vaskular
Interpretasi dari nilai ABI
Nilai ABI Interpretasi

>1,3 Kompresi arteri minimal

0,9 – 1,3 Normal

0,7 – 0,89 Oklusi minimal

0,40 - 0,60 Oklusi sedang

< 0,40 Oklusi berat

 PENILAIAN ULKUS KAKI DIABETIK

• ANAMNESIS  aktivitas, sepatu yang digunakan,

pembentukan kalus, nyeri, deformitas, durasi menderita DM,
dll
• PX FISIK  deskripsi karakter ulkus  ukuran, kedalaman,
bau, bentuk, lokasi, eksudat, edema
• Px penunjang  Gula darah, Rontgen pedis
Penilaian klinis ulkus dan deformitas kaki diabetik
Diagnosa keperawatan
• Kerusakan integritas kulit
• Kerusakan integritas jaringan
• Risiko kerusakan integritas kulit
• Risiko kerusakan integritas jaringan
• Risiko infeksi
• Ketidakefektifan perfusi jaringan perifer
• Risiko ketidakstabilan kadar glukosa darah
Impaired tissue integrity
Suggested NOC Labels
• Tissue Integrity: Skin and Mucous Membranes
• Wound Healing: Secondary Intention

Client Outcomes
• Reports any altered sensation or pain at site of tissue impairment
• Demonstrates understanding of plan to heal tissue and prevent
injury
• Describes measures to protect and heal the tissue, including
wound care
• Wound decreases in size and has increased granulation tissue

Suggested NIC Labels

• Skin Surveillance
• Wound Care
integritas jaringan: kulit dan membrane mukosa
1.gangguan eksterm
2.berat
3.sedang
4.ringan
5.tidak ada gangguan
Indikator 1 2 3 4 5
Suhu, elastisitas, hidrasi dan sensasi
Perfusi jaringan
Keutuhan kulit
Eritema kulit sekitar
Luka berbau busuk
Granulasi
Pembentukan jaringan parut
Penyusutan luka
Nursing Interventions
• Assess site of impaired tissue integrity and determine etiology
• Determine size and depth of wound
• Monitor site of impaired tissue integrity at least once daily for color
changes, redness, swelling, warmth, pain, or other signs of
infection
• Identify a plan for debridement if necrotic tissue (eschar or slough)
is present and if consistent with overall client management goals
• Select a topical treatment that maintains a moist wound-healing
environment that is balanced with the need to absorb exudate and
fill dead space
• Assess client's nutritional status; refer for a nutritional consultation
and/or institute dietary supplements
Impaired Skin integrity
• Altered epidermis and/or dermis
Defining Characteristics:
• Invasion of body structures;
• destruction of skin layers (dermis);
• disruption of skin surface (epidermis)
Related Factors:
• Altered metabolic state; altered circulation; altered
sensation;
• Ineffective Tissue perfusion related to weakening /
decrease in blood flow to the area of gangrene due to obstruction of
blood vessels.
• Goal: maintain peripheral circulation remained normal.

Expected outcomes:
• Palpable peripheral pulses were strong and regular.
• The color of the skin around the wound; not pale / cyanosis
• The skin around the wound felt warm.
• Edema does not occur and the wound is not getting worse.
• Sensory and motor improves.
• Interventions:
1. Instruct the patient to mobilize.
Rational: the mobilization improves blood circulation.
2. Teach about the factors that can increase blood flow: Elevate the
patient's leg is slightly lower than the heart (elevation position at rest),
avoid crossing legs, avoid tight bandage, avoid the use of cushions,
behind the knees and so on.
Rational: increase blood flow back so there is no edema.
3. Teach about the modification of risk factors such as:
Avoid high-cholesterol diet, relaxation techniques, stop smoking, and
drug use vasoconstriction.
Rational: high cholesterol can accelerate the onset of atherosclerosis,
smoking can cause vasoconstriction of blood vessels, relaxation to
reduce the effects of stress.
4. Cooperation with other health care team in the delivery of
vasodilators, checks blood sugar regularly and oxygen therapy.
Rational: vasodilator administration will increase the dilation of blood
vessels and tissue perfusion can be improved, while the regular blood
sugar checks can track the progress and state of the patient.
Knowledge Deficit related to Diabetic Foot Ulcers
• Nursing Diagnosis : Knowledge Deficit about the disease process, diet, care, and treatment related to a
lack of information.
Goal: The patient receive clear and accurate information about the disease.
Expected outcomes:
The patient know about the disease, diet, care and treatment and may explain the return if asked.
The patient can perform self-care based on the knowledge acquired.

Interventions:
1. Assess the level of knowledge of the patient / family about the disease of diabetes and gangrene.
Rationale: To provide information to patients / families, nurses need to know the extent to which
information or knowledge that is known to the patient / family.

2. Assess the patient's educational background.

Rationale: In order for nurses to provide explanations by using words and phrases that can understand
the patient as the patient's level of education.

3. Explain the process of disease, diet, care and treatment in patients with language and words that are
easy to understand.
Rationale: In order information can be received easily and precisely so as to avoid misunderstandings.

4. Explain the procedure to be performed, the benefits to the patient and the patient engage in it.
Rationale: With the explanations and participate directly in the action taken, the patient will be more
cooperative and reduced anxiety.

5. Use pictures to give an explanation (if there is / possible).

Rational: images may help to remember the explanation has been given.