WOUND MANAGEMENT

FAKRUL ARDIANSYAH
 ANATOMI KULIT

1. Epidermis
2. Dermis
3. Subkutis
 EPIDERMIS
Epidermis has cells called melanocytes containing
melanin, which gives skin its colour.
Lapisan Epidermis
a. stratum corneum: no nucleus and are essentially dead
cells. They are constantly worn away and replaced by
new cells moving to the surface.
b. stratum lucidum: protoplasm becomes replaced with
keratin
c. stratum granulosum: produces the precursor to keratin
d. stratum spinosum: contains bundles of keratin laments
e. stratum basale : it is constantly producing new cells by
cell division, The deepest layer, taking about seven
weeks to reach the surface
 DERMIS
Dermis is composed of connective tissue, both
collagen and elastic bres.
Dermis can be found blood vessels, lymph
vessels, sensory nerve endings, sweat and
sebaceous glands and hair follicles
 Fungsi Kulit

1. Pelindung atau proteksi

2. Penerima rangsang
3. Pengatur panas atau thermoregulasi
4. Pengeluaran (ekskresi)
5. menyimpan lemak di dalam kelenjar lemak
 LUKA
Terputusnya kontinuitas jaringan karena
cedera atau pembedahan.
 Klasifikasi Luka
Klasifikasi berdasarkan struktur lapisan kulit:
1. superfisial, yang melibatkan lapisan
epidermis;
2. partial thickness, yang melibatkan
lapisan epidermis dan dermis;
3. full thickness yang melibatkan epidermis,
dermis, lapisan lemak, fascia, dan
bahkan sampai ke tulang
 Klasifikasi Luka
Onset & duration: Acute & Chronic wounds
Type of wound closure: Primary, Secondary, & Tertiary
intention
1. Penyembuhan primer (healing by primary intention)
Tepi luka bisa menyatu kembali, permukaan bersih,
tidak ada jaringan yang hilang. Biasanya terjadi setelah
suatu insisi. Penyembuhan luka berlangsung dari
internal ke eksternal.
2. Penyembuhan sekunder (healing by secondary
intention) Sebagian jaringan hilang, proses
penyembuhan berlangsung mulai dari pembentukan
jaringan granulasi di dasar luka dan sekitarnya.
3. Delayed primary healing (tertiary healing)
Penyembuhan luka berlangsung lambat, sering disertai
infeksi, diperlukan penutupan luka secara manual.
FISIOLOGI PENYEMBUHAN LUKA
PENYEMBUHAN LUKA
 APA PENYEBAB LUKA KRONIK???
A. Underlying pathology
B. Prolonged inflammatory phase
C. Low level of growth factors
D. Host condition
E. Denervation
Apa penyebab penyembuhan luka
terlambat???
 Bagaimana upaya proses
penyembuhan luka normal??
 Pengkajian Holistik
1. Etiologi
2. Durasi luka
3. Pengkajian luka
4. Faktor yang mempengaruhi penyembuhan luka:
a. Kondisi penyakit lain
b. Medikasi
c. Gangguan akses layanan
d. Infeksi
e. Luka tekan
f. Penurunan perfusi oksigen jaringan
g. Gangguan nutrisi dan cairan
h. psikososial
 Pengkajian Luka
1. Anatomic location of wound
2. Extent of tissue loss
3. Characteristics of wound base
4. Type of tissue
5. Percentage of wound containing each type of
tissue observed
6. Dimension of wound in cm (length, width,
dept, tunneling, undermining)
 Pengkajian Luka
7. Exudate (amount, type)
8. Odor
9. Wound edges
10. Periwound skin
11. Presence or absence of local signs of
infection
12. Wound pain
 Type of Tissue

Necrotic Tissue that has died and has

therefore lost its physical properties &
biological activity
 Type of Tissue
Soft, moist, avascular (necrotic/devitalized)
tissue; may be white, yellow, or green; may
be loose or firmly adherent
 Type of Tissue
Granulation Tissue Pink/ red moist tissue
comprised of new blood vessels, connective
tissue, fibroblasts, & inflammatory cells, fills
an open wound when it starts to heal;
typically appears deep pink or red; surface is
granular
 Type of Tissue
Ephitelial
Regenerated epidermis across the wound
surface; pink and dry in color
 Mengukur Panjang, Lebar dan
Kedalaman
Length
is measured by placing the ruler at the point
of greatest length (or head-to-toe)
 Mengukur Panjang, Lebar dan
Kedalaman
Width
is measured by placing the ruler at the point of
greatest width (or side to side)
 Mengukur Panjang, Lebar dan
Kedalaman
Depth
The most common method of obtaining
wound depth is by inserting a cotton-tipped
applicator into the wound bed & placing a
mark on the applicator at the level of the skin
 Measuring Tunneling
A Tunnel
is a channel that extends from any part of the
wound through subcutaneous tissue or muscle

Undermining & tunneling can be documented by

measuring depth & noting the location using the
clock method, the top of wound (12 oclock
position) would point toward the pts head,
whereas the bottom of the wound (6 oclock
position) would point towards the feet
Tunneling
 Mengukur Undermining
Undermining
is tissue destruction that occurs under intact
skin around the wound perimeter
 EKSUDAT
Cairan luka yang diberkontribusi dalam proses
penyembuhan luka
Karakteristik eksudat yang dikaji meliputi
jumlah , tipe dan bau
Type : clear, serosanguineous, sunguineous,
purulen
 Bau
Odor can be described as absent, faint,
moderate, or strong.
The type of dressing used can affect wound
odor as well as hygiene & the presence of
nonviable tissue
 Wound Edge
The edge of wound should be assessed as an
integral part of wound evaluation.
Wound edge give information regarding
epithelialization, chronicity, and even etiology
Periwound Area/ Surrounding Skin
Color (erythema, white, blue)
Texture (moist, dry, indurated, macerated)
Skin temperature (warm, cool)
Integrity of the surrounding skin
 Bacterial Burden
The extent of bioburden is classified as contamination,
colonization, critical colonization, & infection
Clinical Signs & Symptoms of Chronic Wound Infection:
a. New/ increased slough
b. Drainage excess, change in color/ consistency
c. Poor granulation tissue
d. Redness, warmth around the wound
e. Sudden high glucose in patient with diabetes - Pain or
tenderness
f. Unusual odor
g. Increased wound size/new areas of breakdown
 Wound Pain

Wound pain can indicate infection or

deterioration as well as inappropriate or
inadequate treatment choices.
Pain should be measured regularly & frequently
with a validate pain assessment scale
Pain assessment requires a pain history & the
qualification of the severity of the pain for the
verbal as well as the non verbal or cognitively
impaired patient.
 Prinsip Manajemen Luka
1. Kontrol faktor penyebab
2. Tingkatkan support sistemik dalam
menurunkan potensial kofaktor
3. Mempertahankan fisiologis lingkungan lokal
luka (level kelembaban. Temperatur normal.
Keseimbangan bakteri dan pH).
 Wound Bed Preparation
T for tissue: non-viable or deficient
I for infection/inflammation
M for moisture imbalance
E for edge, which is not advancing or
undermining
 T=Tissue
Remove non-viable tissue Debriding the wound
1. Autolytic debridement which is moisture
retentive & allows the lysis of necrotic tissue by
ones own white cells & enzymes
2. Chemical-enzyme or other chemical removes
necrotic tissue
3. Mechanical-physical pulling away of necrotic
tissue with dressing removal
4. Surgical/sharp- removal of necrotic tissue with a
scalpel.
 I= Infection (or Inflammation)
Management
1. Removal of devitalized tissue which is often
the focus of the microbial burden
2. Systemic antibiotics
3. Topical antimicrobials Need to keep in mind
overuse of antibiotics can increase likelihood
of bacterial resistance Most chronic wounds
have a number of organisms present but not
have clinical infection-bioburden
 M=Moisture
Balance between moist wound healing and
preventing maceration of periwound.
Maintaining moisture in the wound bed: moist
wound healing allows for epithelial migration &
more rapid closure
Dressings for:
1. Maintaining moisture in wound bed
2. Adding or restoring moisture
3. Removing or pulling moisture, in the form of
drainage, from the wound bed
 E=Edge
The final stage of wound healing is
epithelialisation, which is the active division,
migration, and maturation of epidermal cells
from the wound margin across the open wound
The wound bed must be full of well vascularised
granulation ----- the proliferating epidermal cells
to migrate, adequate oxygen and nutrients to
support epidermal regeneration.
There needs to be a rich source of viable
epidermal cells which can undergo repeated cell
division particularly at the edge of the wound
the epidermal margin fails to migrate
Hypoxia
Infection
Desiccation
Dressing trauma
Hyperkeratosis
Callus at the wound margin
Pembersihan Luka
 Bagaimana memilih balutan luka?
Choose based on TIME
Need for tissue debridement
Infection or inflammation present
How moist is the wound
Are there healthy wound edges
Prinsip Alasan Pemilihan Balutan Luka
To produce rapid healing
To remove or contain odour,
To reduce pain,
To prevent or combat infection,
To contain exudate,
To cause minimum distress or disturbance to the
patient,
To hide or cover a wound for cosmetic reasons.
A combination of two or more of the above
 Seleksi Balutan
The choice of dressing or treatment regimen
may be influenced by many different factors,
these can be divided into different principal
interrelated groups :
- wound,
- Product,
- or patient related,
- Economic factors
 Teknologi Perawatan Luka
Hyperbaric Oxygenation
Efek HO pada penyembuhan luka
1. Meningkatkan oksigenisasi jaringan
2. Meningkatkan metabolisme sel
3. Meningkatkan deposit collagen
4. Meningkatkan neoangiogenesis
5. Meningkatkan migrasi sel epitel
6. Menurunkan edema jaringan lokal
7. Meningkatkan ke efektifan antibiotik
Negative-Pressure Wound Therapy
NPWT membantu penyembuhan luka melalui
evakuasi cairan luka, menstimulasi
pembentukan jaringan granulasi, menurunkan
bacterial burden, & mempertahankan
lingkungan lembab.
Ultraviolet Light
Merubah fungsi sel, meningkatkan
permeabilitas dinding sel melalui perubahan
bentuk protein, menstimulasi produksi zat-zat
kimia seperti prostaglandin & arachidonic
acid, meningkatkan produksi adenosine
triphosphate (ATP)
Ultrasound
Menggunakan gelombang suara lebih besar dari 20.000
Hertz, Efek Ultrasound pada penyembuhan luka:
Menstimulasi pergerakan cairan di dalam dan antar sel
Menstimulasi wound debridement
Menstimulasi respon inflamasi pada luka
Menstimulasi sirkulasi lokal
Meningkatkan permeabilitas membran sel, macrophage
activity, sintesa protein & angiogenesis
TERIMAKASIH