Asuhan Keperawatan pada Kerusakan integritas Kulit

Dina Dewi S L I 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)

Time since the surgical injury Drain: type, location,
pattency.

Size (cm)
Location Suture:
Type of suturing Amount of suture

Dressing

Exudate: type,
amount, color.

Wound Assessment

Laboratory test: HB, WBC, Albumin, PaO2

Wound Edges:
Color of incision Collagen deposition Epithelial resurfacing

Surrounding Skin:
Color, Moisture, Hygiene Temperature, sensation Blister, edema

ASSESSMENT OF WOUND (SECONDARY OR TERTIARY INTENTION)

Time since the surgical or injury Dressing Size Depth Location

Sign of Infection

Odor or
Exudates Laboratory test:
HB, WBC, etc Albumin, PaO2

Wound Assessment

Wound Edges

Surrounding Skin:
Color, Moisture, Hygiene Suppleness, edema, temperature, sensation Maceration, scar

Wound bed:
Red, Pink Yellow, Black

Wound healing modes

Characteristic First intention Second intention Third intention

Wound edges
Infection Granulation tissue Scar tissue Healing time Expample

Approximate d
Absent Small mount Small Fast Surgical incision

Not Initially not approximated approximated

Often present Often present Large mount Very large Very slow Infected wound Large mount Large Slow Separated incision

Luka Kronis
Dekubitus Ulcer Diabetic Ulcer Venous Ulcer Ulcer Of Carsinoma

Diagnosa Keperawatan
Kerusakan interitas kulit dpt berhungan 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 : 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