Penilaian Dan Perawatan Luka Terkini
July 2, 2019 | Author: Koernia Swa Oetomo, Dr., dr., SpB.FINACS.Fics(K) TRAUMA. | Category: N/A
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Makalah ini berisi tentang Penilaian dan Perawatan Luka Terkini oleh Dr. dr. Koernia Swa Oetomo, SpB, FINACS. FICS(K)Tra...
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PENILAIAN DAN PERAWATAN LUKA TERKINI
Oleh: Ricky Wibowo
Pembimbing : Dr.dr. Koernia Swa Oetomo Sp. B FINACS.FICS (K) Trauma
PROGRAM PENDIDIKAN DOKTER SPESIALIS – 1 ILMU BEDAH FAKULTAS KEDOKTERAN UNIVERSITAS AIRLANGGA – RSUD RSUD Dr. SOETOMO S UR AB AY A 2 01 4
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DAFTAR ISI
1. Daftar Isi......................................... Isi.............................................................. ........................................... ........................................i ..................i 2. Pendahuluan.................................... Pendahuluan.................................................... ...................................... ............................................1 ......................1 3. Tujuan........................................ Tujuan........................................................ ...................................... ........................................... ............................2 .......2 4. Penilaian Luka.......................... Luka..................................................... ................................................. ........................................3 ..................3 5. Pencucian Luka........................... Luka...................................................... ..................................................... ....................................11 ..........11 6. Debridement Luka........................ Luka.............................................. ................................................. .......................................13 ............13 7. Penilaian dan Peraawatan pada Luka Infeksi................... Infe ksi............................................17 .........................17 8. Manajemen Nyeri pada Luka.......................... Luka...................................................... ..........................................22 ..............22 9. Perawatan Dasar Luka Luka Lanjutan................................... Lanjutan......................................................... ............................25 ......25 10. Daftar Pustaka........................................... Pustaka........................................................... ...................................... ................................28 ..........28
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PENILAIAN DAN PERAWATAN LUKA TERKINI
PENDAHULUAN
Persiapan dasar luka mencakup faktor holistik dan pendekatan sistematik dalam perawatan luka. Konsep perawatan luka mencakup penilaian dan manajemen yang tepat berdasar penyebab baik lokal ataupun sistematik faktorfaktor yang dapat menundda penyembuhan luka. Mempersiapkan dasar luka yang baik secara langsung juga mengarah pada penilaian dan perawatan pada luka itu sendiri. Proses penyembuhan Luka 1. Homeostasis
Pada luka, pendarahan yang terjadi harus segera dirawat dan harus segera tertangani dalam 24 jam pertama. 2. Inflamasi
Proses normal pada luka yang bersifat akut dan bisa bersifat patologis pada luka kronis. 3. Proliferasi
Tahap dimulainya proses perbaikan karena disintegrasi sebelumnya. Fibroplasia meliputi pembentukan jaringan fibroplast dan kolagen, angiogenesis, dan reepitelisasi. 4. Remodelling
Proses membentuk kulit yang fisiologis meskipun tensil strength strength tak sekuat jaringan sebelumnya (kecuali tulang) dan proses dapat berjalan hingga 3 bulan. Faktor-faktor yang berpengaruh terhadap penyembuhan luka
Faktor-faktor yang berpengaruh terhadap penyembuhan luka :
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Aliran Darah
Menilai aliran darah pada luka merupakan hal sangat penting dalam hal prognosis terutama luka luka pada ekstremitas inferior. Bila aliran darah pada luka dinilai buruk, perawatan luka dengan kasa basah/lembab menjadi kontraindikasi. Antiseptik topical untuk mengeringkan luka dan mencegah invasi bakteri direkomendasikan dalam hal ini. Faktor Host
Faktor resiko dan komorbid yang ada dapat menyebabkan penyembuhan luka tertunda seperti :
Obat-obatan imunosupresi ( corticosteroid, kemoterapi)
Edema sekitar luka (luka kronis)
Hipoalbumin.
Dibawah
30
g/L
sudah
dinyatakan
memperlambat
penyembuhan luka, dibawah 20g/L luka akan susah sembuh bahkan takkan pernah sembuh( terutama pada ulkus dekubitus).
Anemia, bila Hb dibawah 100g/L akan memperlambat penyembuhan luka. Bila Hb dibawah 70-80 g/L luka takkan ta kkan pernah sembuh.
Penyakit atau pengobatan yang dapat menekan sistem imun seperti rheumatoid arthritis, penyakit gangguan vaskular dan kolagen ( lupus, scleroderma, dermatomyositis), dan pengobatan radiasi atau kemoterapi.
TUJUAN
Secara umum bertujuan untuk memperbaiki/ mempertahankan kondisi pasien. Perawatan Perawata n luka itu sendiri se ndiri bertujuan mencegah me ncegah kerusakan lebih lanjut dan komplikasinya, mengontrol nyeri dan memperbaiki kualitas hidup.
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PENILAIAN LUKA
Parameter umum yang digunakan meliputi riwayat luka, lokasi, ukuran termasuk ada tidaknya tunneling , , derajat kerusakan jaringan, penampakan dasar luka, eksudat, batas luka dan kulit sekitar luka. Penilaian luka secara berkala bertujuan memonitor me monitor penyembuhan luka l uka serta manajemen terapi sudah tepat atau belum. Dokumentasi luka diperlukan untuk mengetahui progres dari terapi serta kelanjutan dalam perawatan berikutnya.
Riwayat Luka
Informasi yang perlu digali :
Luka/ulkus sebelumnya, perawatan yang sudah diberikan sebelumnya dan respon terapi yang didapatkan.
Lama terjadinya luka
Program terapi yang sudah dilakukan saat ini dan sebelum datang ke RS.
Lokasi Luka
Mencari
lokasi
luka
dengan
menggunakan
diagram
badan
atau
dokumentasi deskripsi anatomi luka.
Ukuran Luka
Berkurang atau bertambahnya area luka ( surface area/raw surface) surface) atau kedalaman luka
Pengukuran luka menggunakan penggaris disposabel untuk mengukur panjang dan lebar luka Penngunaan cairan asetat untuk mengetahui batas lingkaran luka.
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Gambar 1. Mengukur panjang dan lebar luka
Mengukur kedalaman luka dengan probe steril atau cotton aplikator steril. Probe diletakkan pada dasar luka paling dalam kemudian gunakan jari dengan memakai sarung tangan steril untuk mengetahui kedalaman luka yang kemudian diukur dengan penggaris.
Menilai adanya tunneling pada luka yang dalam. Dengan probe steril dimasukkan
hingga
terdapat
tahanan.
Penilaian
tunneling
didokumentasikan dalam bentuk arah (dalam bentuk jam) dan ukuran
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(dalam
bentuk
sentimeter)
Gambar 2. Mengukur kedalaman luka.
Penilaian kedalaman luka dan tunneling perlu dilakukan karena ruang kosong dapat menimbulkan pembentukan abses, kematian jaringan, dan rasa tidak nyaman pada pasien sehingga perlu dilakukan eksisi atau packing atau packing segera. Bahan penutup luka dipilih berdasar pada jumlah drainase, penambahan ukuran kedalaman luka dan tunneling .
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Gambar 3. Menilai dan mengukur tunneling atau undermining . Derajat kerusakan Luka
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Beberapa jenis penampakan Dasar Luka
Jaringan nekrotik hitam (Eschar )
Jaringan non viabel konsistensi bisa lembut, lembab atau padat dan kering.
Gambar 4. Jaringan nekrotik hitam ( eschar )
Jaringan nekrotik kuning ( slough )
Jaringan non viabel bisa padat atau lembut. Bila padat kemungkinan terdapat jaringan tendon atau ligamen dan sebaiknya tidak di debridemen.
Gambar 5. Jaringan kuning ( slough ). ).
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Gambar 6. Jaringan granulasi.
Jaringan hipergranulasi
Biasanya merah cerah, rapuh, dan keluar hingga diliuar batas luka. Debridemen diperlukan untuk merangsang reepitelisasi.
Gambar 7. Jaringan hipergranulasi. hipergranulasi.
Jaringan merah muda, ungu (epithelial)
Jaringan viabel yang rapuh. Biasanya mulai tampak pada batas dari luka
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gambar 8. Jaringan epithelial
Persentase jaringan pada dasar luka
Jumlah dari tiap jenis jaringan pada luka (hitam, kuning, merah) dapat dipresentasikan dalam persentase. Eksudat Eksudat Luka L uka
Eksudat luka dinilai berdasar :
Kuantitas/jumlah : Dokumentasi dari frekwensi pergantian kasa dapat
membantu menilai jumlah eksudat yang dihasilkan.
Warna
: jernih, sanguinus, sa nguinus, purulen atau kombinasi semuanya
(serosanguinus)
Bau
: ada/tidaknya bau yang dihasilkan
Jumlah eksudat yang banyak harus diperhatikan kemungkinan kolonisasi bakteri yang masif dan kemungkinan besar dapat berkembang menjadi sepsis. Tepi luka dan kondisi kulit disekitarnya
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Gambar 9. Callus hiperkeratotik pada plantar pedis.
Maserasi
Kelembaban yang berlebihan terjadi bila pembalutan luka tidak adekuat menyerap eksudat dan atau ketika terdapat edema tungkai, peningkatan tekanan atau infeksi.
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Gambar 11. Jaringan kemerahan kemerahan (erythema).
Indurasi
Pengerasan atau penebalan jaringan berhubungan dengan proses inflamasi, infeksi, atau penumpukan darah.
Edema
Dapat mengindikasikan terdapat infeksi atau tekanan pada jaringan setempat proses trauma.
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Larutan Antiseptik topikal seperti povidon iodine hanya digunakan pada luka yang sulit sembuh atau pada luka dimana resiko terjadi infeksi lebih besar daripada stimulasi penyembuhan luka itu sendiri. Metode Pencucian Luka
Gunakan tekanan yang cukup saat irigasi larutan agar pada proses pencucian luka tidak ti dak ikut i kut merusak dasar luka. Irigasi luka yang aman dan efektif e fektif serta aman bertekanan sekitar 4-15 pounds 4-15 pounds per square inch (psi) inch (psi) . Metode 1
Irigasi luka dengan spuit 30cc dan jarum ukuran 18-20 G dan tempatkan jarak 4-6 cm dari dasar luka. Masker dan kacamata google google serta gaun operasi disarankan digunakan sebagai universal precaution terhadap precaution terhadap cipratan dari larutan irigasi. Metode ini bertekanan sekitar 15 psi dan digunakan pada luka:
Bereksudat banyak
Mengandung slough Mengandung slough atau atau eschar .
Luka terinfeksi Terdapat tunneling
undermining
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Metode 4
Basahi dan kompres luka dengan kasa yang dibasahi dengan saline hingga lembab
Bisa dilakukan setelah irigasi dan ditujukan untuk menutup luka setelah membersihkan dan membuang semua debris pada luka.
DEBRIDEMENT DEBRIDEMENT LUKA
Pembuangan jaringan nekrotik dan material asing melalui suatu proses yang dinamakan debridement dan salah satu faktor terpenting dalam manajemen penyembuhan luka terutama kronis. kronis. Dengan adanya jaringan nekrotik pada dasar luka maka:
Meningkatkan resiko infeksi dan konsentrasi bakteri dengan memberikan media untuk pertumbuhan bakteri.
Meningkatkan demand metabolik tubuh untuk mengeluarkan jaringan nekrotik.
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Tak ada jaringan nekrotik pada dasar luka.
Tujuan untuk mempertahankan dari status luka, dan untuk kenyamanan pasien.
Bila terdapata gangren kering dan atau aliran darah yang tak adekuat.
Bila ekstremitas inferior tak teraba nadinya atau memiliki ankle brachial index index yang abnormal. Segera lakukan penanganan khusus untuk ulkus arterial dan ulkus gangren diabetikum.
Penilaian vaskuler direkomendasikan untuk ulkus pada ekstermitas inferior untuk menyingkirkan kemungkinan aliran darah yang adekuat di daerah tersebut. Teknik debridement dinilai berdasar sedikit invasif (irigasi sederhana) hingga yang paling invasif ( tajam/surgikal debridement).
Jenis debridement : autolitik, enzimatik, surgikal dan mekanikal.
Beberapa teknik debridement dapat digunakan untuk mengambil jaringan nekrotik dari luka.
Teknik debridement selektif termasuk autolitik, enzimatik, dan surgikal untuk pengambilan jaringan nekrotik saja.
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Menggunakan bebat (hidrocoloid, hidrogel, lapisan transparan) untuk menjaga luka tetap lembab.
Debridement Debridement Enzimatik
Berguna untuk membuang jaringan nekrotik dimana debridement surgikal tak bisa dilakukan.
Menggunakan enzim proteolitik untuk meluluhkan jaringan nekrotik.
Lebih lamban dan lebih tak agresif dibanding debridement surgikal.
Resep diperlukan untuk memperoleh obat-obatan jenis ini.
Dapat menghasilkan banyak eksudat, iritasi lokal l okal pada sekitar kulit dan kemungkinan terjadinya infeksi.
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Debridement Debridement mekanikal mekanikal (non-selektif) Kompres dengan kasa basah
Kasa dibasahi dengan salin dan di taruh dipermukaan luka hingga kering
Bila kasa sudah kering segera diganti kasa yang baru
Jaringan debris yang lengket pada kasa harus segera dibuang./
Ganti kasa basah 2-4 kali perhari.
Bila jaringan nekrotik hilang, segera hentikan metode ini.
Metode ini sangat nyeri, harus pengawasan ketat, dan mahal.
Irigasi Luka
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PENILAIAN DAN PERAWATAN PADA LUKA YANG TERINFEKSI
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Gambar 13. Luka yang terlalu luas memicu resiko infeksi lebih tinggi.
Infeksi : kolonisasi bakteri hingga ke sirkulasi sistemik menimbulkan
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Tabel 1. Faktor resiko lokal dan faktor resiko sistemik terjadinya kolonisasi atau infeksi. Diambil dari : Sibbald R G.et al, 2003.
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Tanda dan gejala klinis kolonisasi kritis dan infeksi pada luka kronis.
Selain pemeriksaan klinis, swab bakteri atau kultur, pemeriksaan laboratorium dan radiologi digunakan untuk diagnosis dan perawatan dari luka infeksi.
Untuk memperoleh spesimen kultur bila luka menunjukkan tanda dan gejala klinis infeksi atau apabila luka tak pernah membaik meskipun
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Osteomyelitis
Resiko terjadinya osteomyelitis bergantung secara langsung dengan kedalaman luka dan hubungannya antara kulit dan tulang. Osteomyelitis bisa tampak normal pada foto x-ray.
Bila ulkus telah menyentuh tulang atau bila dicurigai infeksi pada
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Dokumentasi
pada status progresivitas perkembangan manajemen
nyeri. Jenis dari nyeri pada luka
Berdasar etiologi dibagi menjadi neuropatik dan nosiseptif dan berdasar durasi dibagi menjadi akut dan kronik.
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Manajemen nyeri pada luka
Beri waktu jeda untuk istirahat bila setiap tindakan yang kita lakukan menimbulkan nyeri yang sudah terlalu hebat.
Obat-obat topikal yang dapat menimbulkan nyeri dihindari.
Atasi penyebab dari nyeri (bebat tekan yang terlalu keras, dan lain-
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