PLC – professional learning center 2017

CBWT
Certified Basic Wound Therapy
In 1995, a horse-riding accident
transformed Christopher Reeve from an
actor indelibly identified with Superman
into a quadriplegic and an outspoken
advocate for the disabled. Ten years
later, Reeve's death from complications
of a bedsore called attention to one of
the most serious problems facing people
with disabilities.
 Luka Tekan Kegagalan perawat

 (Florence Nightingale, 1861) :

 “Nursing could prevent them”

 (Jean Martin Charcot, 1825-1893) :

 “Doctors could do nothing about pressure
ulcer”
 Department of Health (DoH, 1993) : “Pressure
ulcer should be considered a key indicator of
the quality of care provided by the hospital”
 Culley 1998 : “There is a much greater
awareness that all healthcare professionals
need to be involved in pressure ulcer
prevention”

Tissue Viability Society

European Pressure Ulcer Advisory Panel
PRESSURE ULCER
Pressure sore
Pressure area
Bedsore
Decubitus
 Luka tekan
DEFINISI
Kerusakan jaringan kulit
akibat adanya penekanan
(pressure), lipatan (shear),
gesekan (friction) antara
jaringan lunak tipis
dengan daerah tulang
yang menonjol pada
permukaan yang keras,
dalam jangka waktu yang
panjang dan terus
menerus (tempat tidur /
kursi roda)
 PRESSURE
Cellular response
Vessel occlusion To pressure
Tissue hypoxia

Pallor

Relief of pressure Persistence pressure

Pressure ulcer
Reactive Tissue
hyperemia Perfusion ischemia
worsens
Tissues
Hypoxia become Capillaries Metabolic wastes
Resolves edematous leak because of accumulate
increased
permeability
Resolution Increased
Protein
Accumulation
In interstitial space
 Pressure Shear

Penyebab lain pada luka tekan :

microclimate (kelembaban dan
temperature)
pada tubuh dan area yang kotak
dengan tubuh
 Gangguan mobilitas

Tekanan Gangguan aktivitas

Gangguan sensori
persepsi

Kejadian lembab
luka tekan Faktor
ekstrinik Gesekan
Lipatan
Toleransi Nutrisi
jaringan
Demograpic
Faktor Oksigenasi
instrinsik
Temperatur kulit
Penyakit
kronik
 Category/Stage I: Nonblanchable Erythema Category/Stage IV: Full Thickness Tissue Loss

Category/Stage II: Partial Thickness Skin Loss Unstageable: Depth Unknown

Category/Stage III: Full Thickness Skin Loss Suspected Deep Tissue Injury: Depth Unknown
 Tentukan faktor risiko dengan : Braden scale, Norton scale,
Gosnell scale, dll
 Hilangkan atau kurangi faktor risikonya : TEKANAN
 Edukasi ke klien & keluarga tentang risikonya
 Tingkatkan aktivitas dan mobilisasi : buat jadwal reposisi
 Gunakan prosedur mengangkat dan menggeser dengan
benar
 Tingkatkan status nutrisi
 Perhatikan kebersihan kulit
 Manajemen inkontinensia
 Gunakan bahan pelindung tubuh yang halus atau matres /
cushion yg mengurangi penekanan
SENSORY 1. Completely 2. Very Limited : 3. Slightly 4. No
PERCEPTION : limited : Responds only limited : respond impairment
Respond to unresponsive to painful stimuli but can’t
pressure- communicate
discomfort
MOISTURE : 1. Constantly 2. Very moist 3. Occasionally 4. Rarely
Degree to moist moist moist
moisture expose
ACTIVITY : 1. Bedfast 2. Chairfast 3. Walks 4. Walks
Degree of occasionally frequently
physical activity
MOBILITY : 1. Completely 2. Very limited 3. Slightly 4.No
Ability to change immobile limited limitation
& control position
NUTRITION : 1. Very poor 2. Probably 3. Adequate 4.
Usual food intake inadequate Excellent
pattern
FRICTION : 1. Problem 2. Potential 3. No apparent
Degree of need problem problem
assistance in
moving
 Pada skala braden bila didapatkan
rentang skor nilai > 18, maka pasien
tidak beresiko mengalami luka
tekan, tetapi bila skor nilai ≤18,
maka pasien mengalami resiko
terjadi luka tekan.
Lifting dan
reposisi yang
benar dan baik
Menjaga
kebersihan
Buat jadwal
mobilisasi
 • Pengkajian kulit
• Kebersihan kulit
• Pertahankan kelembaban kulit
Skin Care • Pertahankan temperatur kulit yang stabil
• Optimalkan status nutrisi

• Jadwal mobilisasi
Mechanical • Hindari gesekan dan lipatan
loading & • Kurangi penekanan pada tumit
support • Tingkatkan kegiatan dan mobilisasi
surface • Gunakan “support rurface” yang sesuai
 Reposition the individual in such a way that pressure is
relieved or redistributed: When choosing a particular position
for the individual, it is important to assess whether the pressure is
actually relieved or redistributed.
 Avoid positioning the individual on bony prominences with
existing non-blanchable erythema: If an individual is positioned
directly onto bony prominences with pre-existing non-blanchable
erythema, the pressure and/or shearing forces sustained will
further occlude blood supply to the skin, thereby worsening the
damage and resulting in more severe pressure ulceration.
 Avoid subjecting the skin to pressure and shear forces.
 Lift — don’t drag
 Use a split leg sling mechanical lift when available to transfer an
individual into a wheelchair or bedside chair when the individual needs
total assistance to transfer.
 Do not leave moving and handling equipment under the individual after
use, unless the equipment is specifically designed for this purpose.
 Use the 30° tilted side-lying position
25
Mattress Replacement System Integrated Bed

Air Fluidized Therapy Seat Cushion

 Immersion: Envelopment
:
Depth of penetration into surface Contact area of level of immersion
Poor Envelopment Conventional Surface Fluid Support

Design choices to optimize can include:

• Conformable, stretchy surface materials
• Bladderdesign (horizontal or vertical shape)
• Fluidsupport (air fluidized)
Design choices to optimize
can include:
• Powered, multi-zone surface to adjust
to separate body areas
• Surface algorithms tuned to adjust by
body weight and when HOB raised
SURFACE DESIGN FOR SHEAR
AND FRICTION MANAGEMENT

Key is to have surface or frame

absorb shear rather than the
body
•As the patient head is raised, or they Surface anti-shear liner: eases sliding between surface
are pulled up in bed, shear forces may
cause tissue distortion, like the red box
•Goal is to have surface/bed frame
absorb shear not tissue, like pink box

Design choices to optimize

include:
•Layers that slide readily over one
another
•Materials that deform easily with
minimal “push-back” on skin
•Algorithms that automatically reposition
to relieve shear
 SURFACE DESIGN FOR MICROCLIMATE: MANAGING HEAT AND HUMIDITY OF THE SKIN

Rate that heat and humidity

are trapped in or pass through
the surface determines amount
of accumulation.

— Flowing relatively close to skin so heat and H2O pass

readily from skin to airstream
— Flowing at a relatively high rate so it can remove heat and

H2O that reaches airstream rapidly and prevents

warming in mattress
— Relatively cool or dry so the airstream will absorb a large
quantity of heat and H2O and carry it away for ejection
 Tentukan etiology /
faktor penyebab
 Kontrol faktor yang
mempengaruhi
penyembuhan luka
(sumber tekanan)
 Pemilihan topikal terapi
yang tepat
 Buat perencanaan untuk
mempertahankan proses
penyembuhan : nutrisi
dan mobilisasi
 0 1 2 3 4 5 Sub-score

LENGTH X 0 < 0.3 0.3 – 0.6 0.7 – 1.1 – 2.0 2.1 – 3.0
WIDTH 1.0

(in cm2)
6 7 8 9 10 >
24.0
3.1 – 4.0 4.1 – 8.0 8.1 – 12.1 –
12.0 24.0
0 1 2 3 Sub-score
EXUDATE
AMOUNT
None Light Moderate Heavy
0 1 2 3 4 Sub-score
TISSUE
TYPE Epithelial Granulation Necrotic
Closed Slough
Tissue Tissue Tissue
TOTAL
SCORE
Pressure Ulcer Healing Chart
To monitor trends in PUSH Scores over time
(Use a separate page for each pressure ulcer)

Pressure Ulcer Healing Record

Date

Length x
Width

Exudate
Amount

Tissue Type

PUSH Total
Score
 Luka dengan kedalaman
Unstageable
stadium 4
Aplikasi dressing merangsang granulasi
Aplikasi SECONDARY dressing merangsang granulasi
 Bryant AR, Nix DP, et al. Acute & chronic wounds current management concepts.
2007. 3rd ed. Philadelphia: Mosby elsevier. p. 48-39.
 Carville K. Wound care manual. 2007. 5th ed. Western Australia: Silver Chain
Nursing Association. p. 12-8.
 Jurnal Ilmiah Keperawatan STIKES Hang Tuah Surabaya Volume 3 Nomer
2/April 2012
 National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory
Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of
Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed.). Cambridge
Media: Perth, Australia; 2014.
 Linnman M. The science of support surface: nomenclature, design for
performance, selection.
 Call E, Black J. Using devices for pressure ulcer prevention and treatment. 2016.
Weber State University, Salt Lake City.
 Australian Wound Management Association. Pan Pacific Clinical Practice
Guideline for the Prevention and Management of Pressure Injury. Cambridge
Media Osborne Park, WA: 2012.
Kunjungi website
kami
www.perawatanluka.com;
www.klinikmoist.com;
www.stopamputasi.com