Asuhan Keperawatan pada Kerusakan integritas Kulit

Heri K (kelas K3LN)Jur.Kep FK-UNIBRAW

Pengkajian Integritas Kulit Pengkajian Umum

Riwayat Kesehatan Pengkajian Fisik Diagnostik tes : WBC, Albumin, Radiologi

Pengkajian Fokus Karakteristik : Lokasi, Ukuran, Warna, Kulit

sekitar luka, Drainase, Temperatur, nyeri, penutupan luka,

Faktor yang terkait : tk. Kontaminasi, nutrisi, sosial ekonomi,

Type luka berikut ini dikelompokkan dlm luka akut:

Luka post operatif (surgical incision)

Dermatological incision

Amputation stump Laceration Abrasion

Donor site Scald (luka karena air

mendidih) Partial thickness burn (luka

bakar stadium I atau II superficial)

ASSESSMENT OF WOUND (PRIMARY INTENTION)

Laboratory test:

• HB, WBC,

• Albumin, PaO2

•Time since the surgical injury•Dressing

Drain: type, location, pattency.Exudate: type, amount, color.

Surrounding Skin:

• Color, Moisture, Hygiene

• Temperature, sensation

• Blister, edema

Wound Edges:

Color of incision

Collagen deposition

Epithelial resurfacing

Size (cm)Location

WoundAssessment

Suture:

Type of suturing

Amount of suture

ASSESSMENT OF WOUND (SECONDARY OR TERTIARY INTENTION)

Laboratory test:

• HB, WBC, etc• Albumin, PaO2

Size

Depth

Location

Wound bed:

• Red, Pink

• Yellow, Black

Surrounding Skin:

• Color, Moisture, Hygiene

• Suppleness, edema, temperature, sensation

• Maceration, scar

Sign of Infection

Odor or

Exudates

Wound Edges

Wound Assessmen

t

Time since the surgical or injury

Dressing

Wound healing types

Characteristic First intention Second intention Third intention

Wound edges

Approximated

Not approximated

Initially not approximated

Infection Absent Often present Often present

Granulation tissue

Small mount Large mount Large mount

Scar tissue Small Very large Large

Healing time

Fast Very slow Slow

Expample Surgical incision

Infected wound

Separated incision

Luka Kronis

Dekubitus UlcerDiabetic UlcerVenous UlcerUlcer Of Carsinoma

Diagnosa Keperawatan Kerusakan interitas kulit b.d Tindakan

invasi thd struktur tubuh, gang. Permukaan kulit, gang. Jaringan kulit :dpt berhubungan dengan faktor2 :* Eksternal : kelembaban, substansi kimia, pengobatan,immobilisasi, radiasi* Internal : gang. Turgor kulit, gang. Sirkulasi, gang. Sensasi, penonjolan tulang.

Tujuan

Memperlihatkan perbaikan pada integritas jaringan : temperatur, elastisitas, hidrasi, pigmentasi, dan warna kulit, tidak ada lesi jaringan, kulit intak.

Memperlihatkan penyembuhan luka primary intention : penyambungan kulit/jaringan, perbaikan drainase, perbaikan eritema,

Tujuan

Memperlihatkan penyembuhan luka, secondary intention : dasar luka, drainase purulen atau bau luka, maserasi/ blister pada kulit, nekrosis, sloughing, tunneling, undermining, eritema kulit sekitar luka, luas luka

Intervensi

Pengkajian luka operasi Inspeksi luka insisi : kemerahan, edema, tanda

dehiscence atau evisceration. Inspeksi luka pada setiap penggantian balutan Evaluasi penggunaan balutan

Edukasi Beritahu ttg menjaga luka operasi : tanda dan

gejala infeksi, menjaga luka tetap kering, meminimalkan stressor pd area insisi.

Kolaborasi : Konsultasi dietation Konsultasi enterostoma nurs

Pembersihan Luka Irigasi Luka

Primary Dressing

Secondary Dressing

Why “moist wound care”

• Insufficient moisture in exposed wound tissues causes desiccation and cell death, and prevents epithelial migration and matrix deposition

• Excessive moisture due to exudate inhibits cell proliferation and breaks down matrix components

• Moisture balance in the wound bed is maintained by appropriate choice of dressings

Why not wet to dry?

Although normal saline is isotonic, as it evaporates from the dressing, it becomes hypertonic and tissue fluid is drawn into the dressing Blood and proteins eventually accumulate

on dressing surface and dressing dries out completely

Has to be applied at least three times a day

Wound with clean granular base

Objectives: Protect & keep moistTreatments:

Hydrocolloid Hydrogel Secondary dressing Vacuum assisted closure (VAC) device Wet to damp saline (Temporarily)