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PLC – professional learning center 2017 CBWT Certified Basic Wound Therapy
PLC – professional learning center 2017
PLC – professional learning center 2017

PLC professional learning center 2017

PLC – professional learning center 2017 CBWT Certified Basic Wound Therapy
PLC – professional learning center 2017 CBWT Certified Basic Wound Therapy
PLC – professional learning center 2017 CBWT Certified Basic Wound Therapy

CBWT

Certified Basic Wound Therapy

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

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.

In 1995, a horse-riding accident transformed Christopher Reeve from an actor indelibly identified with Superman into
Luka Tekan Kegagalan perawat  (Florence Nightingale, 1861) :  “Nursing could prevent them”  (Jean

Luka Tekan

Luka Tekan Kegagalan perawat  (Florence Nightingale, 1861) :  “Nursing could prevent them”  (Jean

Kegagalan perawat

(Florence Nightingale, 1861) :

“Nursing could prevent them”

(Jean Martin Charcot, 1825-1893) :

“Doctors could do nothing about pressure ulcer”

Luka Tekan Kegagalan perawat  (Florence Nightingale, 1861) :  “Nursing could prevent them”  (Jean
 Department of Health (DoH , 1993) : “Pressure ulcer should be considered a key indicator

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”

 Department of Health (DoH , 1993) : “Pressure ulcer should be considered a key indicator

Tissue Viability Society

European Pressure Ulcer Advisory Panel

 Department of Health (DoH , 1993) : “Pressure ulcer should be considered a key indicator
 PRESSURE ULCER  Pressure sore  Pressure area  Bedsore  Decubitus  Luka tekan

PRESSURE ULCER Pressure sore Pressure area Bedsore Decubitus

  • Luka tekan

 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

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)

DEFINISI Kerusakan jaringan kulit akibat adanya penekanan (pressure), lipatan (shear), gesekan (friction) antara jaringan lunak tipis

PRESSURE

Vessel occlusion

Tissue hypoxia

Pallor

Cellular response

To pressure

PRESSURE Vessel occlusion Tissue hypoxia Pallor Cellular response To pressure Relief of pressure Reactive hyperemia Hypoxia

Relief of pressure

Reactive

hyperemia

Hypoxia

Resolves

Resolution

Persistence pressure

Tissue

ischemia

PRESSURE Vessel occlusion Tissue hypoxia Pallor Cellular response To pressure Relief of pressure Reactive hyperemia Hypoxia

Pressure ulcer

PRESSURE Vessel occlusion Tissue hypoxia Pallor Cellular response To pressure Relief of pressure Reactive hyperemia Hypoxia

Tissues

Perfusion

worsens

become

edematous

Capillaries leak because of

PRESSURE Vessel occlusion Tissue hypoxia Pallor Cellular response To pressure Relief of pressure Reactive hyperemia Hypoxia

Metabolic wastes

accumulate

increased

permeability

Increased

Protein

Accumulation

In interstitial space

PRESSURE Vessel occlusion Tissue hypoxia Pallor Cellular response To pressure Relief of pressure Reactive hyperemia Hypoxia
Pressure
Pressure
Shear
Shear
Pressure Shear Penyebab lain pada luka tekan : microclimate (kelembaban dan temperature) pada tubuh dan area

Penyebab lain pada luka tekan :

microclimate (kelembaban dan

temperature) pada tubuh dan area yang kotak

dengan tubuh

Pressure Shear Penyebab lain pada luka tekan : microclimate (kelembaban dan temperature) pada tubuh dan area

Kejadian luka tekan

Tekanan

Kejadian luka tekan Tekanan Gangguan mobilitas Gangguan aktivitas Gangguan sensori persepsi Toleransi jaringan Faktor ekstrinik lembab

Gangguan mobilitas

Gangguan aktivitas Gangguan sensori

persepsi

Toleransi

jaringan

Faktor

ekstrinik

Kejadian luka tekan Tekanan Gangguan mobilitas Gangguan aktivitas Gangguan sensori persepsi Toleransi jaringan Faktor ekstrinik lembab

lembab

Gesekan

Lipatan

Faktor

instrinsik

Nutrisi

Demograpic

Oksigenasi

Temperatur kulit Penyakit

kronik

Kejadian luka tekan Tekanan Gangguan mobilitas Gangguan aktivitas Gangguan sensori persepsi Toleransi jaringan Faktor ekstrinik lembab
Category/Stage I: Nonblanchable Erythema Category/Stage II: Partial Thickness Skin Loss Category/Stage III: Full Thickness Skin Loss
Category/Stage I: Nonblanchable Erythema Category/Stage II: Partial Thickness Skin Loss Category/Stage III: Full Thickness Skin Loss

Category/Stage I: Nonblanchable Erythema

Category/Stage I: Nonblanchable Erythema Category/Stage II: Partial Thickness Skin Loss Category/Stage III: Full Thickness Skin Loss
Category/Stage I: Nonblanchable Erythema Category/Stage II: Partial Thickness Skin Loss Category/Stage III: Full Thickness Skin Loss

Category/Stage II: Partial Thickness Skin Loss

Category/Stage I: Nonblanchable Erythema Category/Stage II: Partial Thickness Skin Loss Category/Stage III: Full Thickness Skin Loss
Category/Stage I: Nonblanchable Erythema Category/Stage II: Partial Thickness Skin Loss Category/Stage III: Full Thickness Skin Loss

Category/Stage III: Full Thickness Skin Loss

Category/Stage I: Nonblanchable Erythema Category/Stage II: Partial Thickness Skin Loss Category/Stage III: Full Thickness Skin Loss
Category/Stage I: Nonblanchable Erythema Category/Stage II: Partial Thickness Skin Loss Category/Stage III: Full Thickness Skin Loss

Category/Stage IV: Full Thickness Tissue Loss

Category/Stage I: Nonblanchable Erythema Category/Stage II: Partial Thickness Skin Loss Category/Stage III: Full Thickness Skin Loss
Category/Stage I: Nonblanchable Erythema Category/Stage II: Partial Thickness Skin Loss Category/Stage III: Full Thickness Skin Loss

Unstageable: Depth Unknown

Category/Stage I: Nonblanchable Erythema Category/Stage II: Partial Thickness Skin Loss Category/Stage III: Full Thickness Skin Loss
Category/Stage I: Nonblanchable Erythema Category/Stage II: Partial Thickness Skin Loss Category/Stage III: Full Thickness Skin Loss

Suspected Deep Tissue Injury: Depth Unknown

Category/Stage I: Nonblanchable Erythema Category/Stage II: Partial Thickness Skin Loss Category/Stage III: Full Thickness Skin Loss
Category/Stage I: Nonblanchable Erythema Category/Stage II: Partial Thickness Skin Loss Category/Stage III: Full Thickness Skin Loss
 Tentukan faktor risiko dengan : Braden scale, Norton scale, Gosnell scale, dll  Hilangkan atau
 Tentukan faktor risiko dengan : Braden scale, Norton scale, Gosnell scale, dll  Hilangkan atau
  • 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

 Tentukan faktor risiko dengan : Braden scale, Norton scale, Gosnell scale, dll  Hilangkan atau
SENSORY 1. Completely 2. Very Limited : 3. Slightly 4. No PERCEPTION : limited : Responds
SENSORY 1. Completely 2. Very Limited : 3. Slightly 4. No PERCEPTION : limited : Responds
SENSORY 1. Completely 2. Very Limited : 3. Slightly 4. No PERCEPTION : limited : Responds
SENSORY
1.
Completely
2.
Very Limited :
3.
Slightly
4.
No
PERCEPTION :
limited :
Responds only
to painful stimuli
limited : respond
impairment
Respond to
unresponsive
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
immobile
limited
limitation
Ability to change
& control position
NUTRITION :
1.
Very poor
2.
Probably
3. Adequate
4.
inadequate
Excellent
Usual food intake
pattern
FRICTION :
1.
Problem
2. Potential
3.
No apparent
problem
problem
Degree of need
assistance in
moving
Pada skala braden bila didapatkan rentang skor nilai > 18, maka pasien tidak beresiko mengalami luka
Pada skala braden bila didapatkan rentang skor nilai > 18, maka pasien tidak beresiko mengalami luka
Pada skala braden bila didapatkan rentang skor nilai > 18, maka pasien tidak beresiko mengalami luka

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.

Pada skala braden bila didapatkan rentang skor nilai > 18, maka pasien tidak beresiko mengalami luka
 Lifting dan reposisi yang benar dan baik  Menjaga kebersihan  Buat jadwal mobilisasi

Lifting dan reposisi yang

benar dan baik

Menjaga

kebersihan

Buat jadwal mobilisasi

 Lifting dan reposisi yang benar dan baik  Menjaga kebersihan  Buat jadwal mobilisasi
 Lifting dan reposisi yang benar dan baik  Menjaga kebersihan  Buat jadwal mobilisasi
 Lifting dan reposisi yang benar dan baik  Menjaga kebersihan  Buat jadwal mobilisasi
Skin Care Mechanical loading & support surface • Pengkajian kulit • Kebersihan kulit • Pertahankan kelembaban

Skin Care

Mechanical

loading &

support

surface

• Pengkajian kulit • Kebersihan kulit • Pertahankan kelembaban kulit • Pertahankan temperatur kulit yang stabil
• Pengkajian kulit
• Kebersihan kulit
• Pertahankan kelembaban kulit
• Pertahankan temperatur kulit yang stabil
• Optimalkan status nutrisi
• Jadwal mobilisasi • Hindari gesekan dan lipatan • Kurangi penekanan pada tumit • Tingkatkan kegiatan
• Jadwal mobilisasi
• Hindari gesekan dan lipatan
• Kurangi penekanan pada tumit
• Tingkatkan kegiatan dan mobilisasi
• Gunakan “support rurface” yang sesuai
 Reposition the individual in such a way that pressure is relieved or redistributed: When choosing
  • 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

  •  Reposition the individual in such a way that pressure is relieved or redistributed: When choosing
    25
    25
    25
    25
    25
    25
    Mattress Replacement System Integrated Bed Air Fluidized Therapy Seat Cushion
    Mattress Replacement System Integrated Bed Air Fluidized Therapy Seat Cushion
    Mattress Replacement System Integrated Bed Air Fluidized Therapy Seat Cushion
    Mattress Replacement System
    Integrated Bed
    Air Fluidized Therapy
    Seat Cushion

    Immersion:

    Depth of penetration into surface

    Immersion: Depth of penetration into surface Design choices to optimize can include : • Powered, multi-zone
    Immersion: Depth of penetration into surface Design choices to optimize can include : • Powered, multi-zone
    Immersion: Depth of penetration into surface Design choices to optimize can include : • Powered, multi-zone
    Immersion: Depth of penetration into surface Design choices to optimize can include : • Powered, multi-zone

    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

    Envelopment:

    Contact area of level of immersion

    Poor Envelopment

    Conventional Surface

    Fluid Support

    Immersion: Depth of penetration into surface Design choices to optimize can include : • Powered, multi-zone
    Immersion: Depth of penetration into surface Design choices to optimize can include : • Powered, multi-zone

    Design choices to optimize can include:

    Conformable, stretchy surface materials

    Bladderdesign (horizontal or vertical shape)

    Fluidsupport (air fluidized)

    Immersion: Depth of penetration into surface Design choices to optimize can include : • Powered, multi-zone

    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 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 anti-shear liner: eases sliding between surface
    Surface anti-shear liner: eases sliding between surface

    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.

    SURFACE DESIGN FOR MICROCLIMATE: MANAGING HEAT AND HUMIDITY OF THE SKIN Rate that heat and humidity

    Flowing relatively close to skin so heat and H 2 O pass

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

    H 2 O that reaches warming in mattress

    airstream rapidly and prevents

    Relatively cool or dry so the airstream will absorb a large quantity of heat and H 2 O and carry it away for ejection

    SURFACE DESIGN FOR MICROCLIMATE: MANAGING HEAT AND HUMIDITY OF THE SKIN Rate that heat and humidity
     Tentukan etiology / faktor penyebab  Kontrol faktor yang mempengaruhi penyembuhan luka (sumber tekanan) 
     Tentukan etiology / faktor penyebab  Kontrol faktor yang mempengaruhi penyembuhan luka (sumber tekanan) 
     Tentukan etiology / faktor penyebab  Kontrol faktor yang mempengaruhi penyembuhan luka (sumber tekanan) 
    • 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

     Tentukan etiology / faktor penyebab  Kontrol faktor yang mempengaruhi penyembuhan luka (sumber tekanan) 
    0 1 2 3 4 5 Sub-score LENGTH X 0 < 0.3 0.3 – 0.6 0.7
    0 1 2 3 4 5 Sub-score LENGTH X 0 < 0.3 0.3 – 0.6 0.7
    0 1 2 3 4 5 Sub-score LENGTH X 0 < 0.3 0.3 – 0.6 0.7
    0 1 2 3 4 5 Sub-score LENGTH X 0 < 0.3 0.3 – 0.6 0.7
     

    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

     

    6

    7

    8

    9

    10 >

    (in cm 2 )

    24.0

    3.1 4.0

    4.1 8.0

    8.1

    12.1

    12.0

    24.0

    EXUDATE

    0

    1

    2

    3

       

    Sub-score

    AMOUNT

    None

    Light

    Moderate

    Heavy

    TISSUE

    0

    1

    2

    3

    4

     

    Sub-score

    TYPE

    Closed

    Epithelial

    Granulation

    Slough

    Necrotic

    Tissue

    Tissue

    Tissue

     

    TOTAL

    SCORE

    0 1 2 3 4 5 Sub-score LENGTH X 0 < 0.3 0.3 – 0.6 0.7

    Pressure Ulcer Healing Chart

    To monitor trends in PUSH Scores over time

    (Use a separate page for each pressure ulcer)

    Pressure Ulcer Healing Chart To monitor trends in PUSH Scores over time (Use a separate page
    Pressure Ulcer Healing Chart To monitor trends in PUSH Scores over time (Use a separate page
    Pressure Ulcer Healing Record Date Length x Width Exudate Amount Tissue Type PUSH Total Score
    Pressure Ulcer Healing Record
    Date
    Length x
    Width
    Exudate
    Amount
    Tissue Type
    PUSH Total
    Score
    Luka dengan kedalaman stadium 4

    Unstageable

    Luka dengan kedalaman stadium 4

    Luka dengan kedalaman

    stadium 4

    Luka dengan kedalaman stadium 4

    Aplikasi dressing merangsang granulasi

    Aplikasi dressing merangsang granulasi

    Aplikasi SECONDARY dressing merangsang granulasi

    Aplikasi SECONDARY dressing merangsang granulasi
    Aplikasi SECONDARY dressing merangsang granulasi
    Aplikasi SECONDARY dressing merangsang granulasi
    Aplikasi SECONDARY dressing merangsang granulasi
     Bryant AR, Nix DP, et al. Acute & chronic wounds current management concepts. 2007. ed.
     Bryant AR, Nix DP, et al. Acute & chronic wounds current management concepts. 2007. ed.
    • Bryant AR, Nix DP, et al. Acute & chronic wounds current management concepts. 2007. 3 rd

    ed. Philadelphia: Mosby elsevier. p. 48-39.

    • Carville K. Wound care manual. 2007. 5 th 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.

     Bryant AR, Nix DP, et al. Acute & chronic wounds current management concepts. 2007. ed.
    Kunjungi website kami www.perawatanluka.com; www.klinikmoist.com; www.stopamputasi.com
    Kunjungi website kami www.perawatanluka.com; www.klinikmoist.com; www.stopamputasi.com

    Kunjungi website

    kami

    www.perawatanluka.com;

    www.klinikmoist.com;

    www.stopamputasi.com

    Kunjungi website kami www.perawatanluka.com; www.klinikmoist.com; www.stopamputasi.com
    Kunjungi website kami www.perawatanluka.com; www.klinikmoist.com; www.stopamputasi.com
    Kunjungi website kami www.perawatanluka.com; www.klinikmoist.com; www.stopamputasi.com
    Kunjungi website kami www.perawatanluka.com; www.klinikmoist.com; www.stopamputasi.com