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
Wound
Assessment
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
Assessment
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 Ulcer
Diabetic Ulcer
Venous Ulcer
Ulcer 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 moist
Treatments:
Hydrocolloid
Hydrogel
Secondary dressing
Vacuum assisted closure (VAC) device
Wet to damp saline (Temporarily)