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Page 1: 3M Health Care Business Wound Care Overview & SSI Prevention · PDF file3M Health Care Business Wound Care Overview & SSI Prevention ... (Produk&SOP) Moist wound healing ... PERAWATAN

© 3M 2011. All Rights Reserved.

3M Health Care Business

Wound Care Overview & SSI Prevention Moist Wound Healing Management

Dudung Jafar Sidik, CWCC Professional Service, Skin & Wound Care Division

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Pengertian Luka:

� Suatu gangguan dari kondisi normal pada kulit (Taylor, 1997).

� A break in the skin or other body tissues caused by injury or surgical incision/cut (National Cancer Institute)

� Kerusakan kontinyuitas kulit, mukosa membran dan tulang atau organ tubuh lain (Kozier, 1995).

Luka adalah terputusnya kontinuitas suatu jaringan oleh karena adanya cedera /

pembedahan

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Menurut waktu penyembuhan :

Luka Akut:

� Masa penyembuhan sesuai dengan konsep penyembuhanyang telah disepakati.

� Misalnya: luka Trauma, operasi (bersih)

Luka kronis:

� Mengalami kegagalan dalam proses penyembuhan, dapatkarena faktor eksogen dan endogen (vascular compromise, chronic inflammation, or repetitive insults to the tissue)

� Tidak sembuh lebih dari 3 bulan

� Decubitus, Gangren dan Vena ulcer

(Mustoe:2006, Moreo:2005)

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Luka Bakar???

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Penanganan Luka Bakar

Pemberian Cairan:

� Total cairan = 4cc x berat badan x luas luka bakar

� Rumus Baxter: Berikan 50% dari total cairan dalam 8 jam pertama, dan sisanya dalam 16 jam berikutnya

Penanganan Luka

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Wound Care Outcome

Luka Kronik

� Decubitus

� Vascular Ulcer

� Diabetic Ulcer

ILO/SSI Tidak terjadi

� Safety (Produk&SOP)

� Moist wound

healing

� Cost

Effectiveness

Meminimalkan efeksamping

# amputasi

Luka Akut

� Post operasi

� Kecelakaan

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Mekanisme Terjadinya Luka :

� Luka insisi (Incised wounds) Terjadi karena teriris oleh instrumen yang tajam/pembedahan.

� Luka memar (Contusion Wound) Terjadi akibat benturan oleh suatu tekanan dan dikarakteristikkan oleh cedera pada jaringanlunak, perdarahan dan bengkak.

� Luka lecet (Abraded Wound),Terjadi akibat kulit bergesekan dengan benda lain yang biasanya dengan benda yang tidaktajam.

� Luka tusuk (Punctured Wound) Terjadi akibat adanya benda, seperti peluru atau pisau yang masuk kedalam kulit dengandiameter yang kecil.

� Luka tembus (Penetrating Wound) Luka yang menembus organ tubuh biasanya pada bagian awal luka masuk diameternya keciltetapi pada bagian ujung biasanya lukanya akan melebar.

� Luka gores (Lacerated Wound) Terjadi akibat benda yang tajam seperti oleh kaca atau oleh kawat.

� Luka Bakar (Combustio)

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Skin: Structure

� Epidermis� Multilayered squamous epithelium (five layers)

� Thin, avascular and waterproof

� Resident skin flora

� Dermis� Complex network of connective tissue

� Structural support

� Vascular, nerve and lymphatic supply

� Sebum (lipids), sweat (thermoregulation)

� Subcutaneous tissue� Water and fat storage

� Insulator and mechanical shock absorber

� Muscle� Composed of contractile cells or fibers which results to

movement of an organ or part of the body

� Peritoneum� Membrane covering the internal organs and lining the

abdominal cavity

Epidermis

Dermis

Subcutaneous

Muscle

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Prinsip Perawatan Luka

LUKA BASAH

LUKA KERING

MOIST

Autolysis agent + Transparent

semi permeable

Transparent Dressing with or without adherent Pad

Slough, Kuning Hijau Granulasi, Epitelisasi Nekrotik Hitam

Autolysis agent + Transparent

semi permeable

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Perawatan Luka

Acute

� Post Operasi

� Mempertahankan aseptic technique

� Antiseptic??

Chronic

� Manajemen Cairan / exudate

� Manajement jaringan necrotik

� Supporting new tissue growth

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Luka Kronik

Asesment/pengkajianmenentukan kpnpenyembuhanPersentasi jaringan(merah, kuning, hitam), kedalaman, posisi goadan exudate

PencucianSabun cair dan air rebusan daun jambu(kesat)

Nekrotomipertumbuhan jaringanbarua. Banyak: metode tajamb. Autolisis agent

Tentukan regimen dressing melindungiHydrogel, hydrocoloid, spon, antimicrobial (silver), transparan dressing

Menutup luka

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Chronic Wound Care Overview

� Pressure Ulcer

� Diabetic Ulcer

� Vascular Ulcer

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Pressure Ulcer

Etilogi:

Tekanan pada pembuluh darah > tekanan alirah darah dlm pembuluh

� shear

� friction forces

� Moisture

� duration of pressure.

� intensity of pressure.

� ability of tissue to tolerate pressure (tissue tolerance)

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Comonly body parts presured

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Berdasarkan kedalaman:

1. Stadium I (Superfisial /Non-Blanching Erithema) : Lapisan epidermis kulit

2. Stadium II (Partial Thickness): Lapisan epidermis + bagian atas dari dermis. Seperti abrasi, blister atau lubang yang dangkal.

3. Stadium III (Full Thickness): Lapisan epidermis + dermis (tidak mengenai otot).

4. Stadium IV (Full Thickness)Telah mencapai lapisan otot, tendon dan tulang dengan adanyadestruksi/kerusakan yang luas.

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Wound Stage

Lapisan Epidermis Lapisan Epidermis + Dermis atas

Lapisan Epidermis + Dermis

Lapisan Epidermis + Dermis+otot+tulang

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Contoh Kasus

Goa, lokasi? Kedalaman?

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Contoh kasus

� Dressing yang diperlukan

Merah = ± 25% Kuning = ± 70% Hitam = 5%

Primer:Nekrotomi = HydrogelPenyerap exudate = alginate / alginate with silver

Secondary Transparent Dressing

� Tentukan Prosentase

� Cuci Luka

Sabun Cair + air rebusan jambubiji (kesat)

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Tentukan jenis dressing

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Vascular / Leg Ulcer

Venous Ulcer: vein valvular incompetence and causing reflux (reverse flow) of blood.

Arterial ulcers are the result of reduced blood flow to the legs. The most common cause of this is atherosclerosis.

Mix

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Venous Ulcer

False4 Layers Bandages3 Layers BandagesNo BandageBandage layer

Possible Calcified Vessel

Venous UlcerMixedArterial Venous Ulcer

Arterial UlcerType of wound

> 1.2> 0.90.7 – 0.80.5 – 0.7< 0.5Score Index

� 3M Cast padding or orthopedic wool

� Crepe bandage,

� Elastic bandage and

� Coban or Cohesive bandage.

� Perawatan Luka – Dressing

� Kompresi: 4 layers bandages

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Pengukuran score Index

Pengukuran tek didorsalis pedis

Pemasangan lapisanterakhir: adhesive bandage 3MCoban

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Cancer Wound???

• Tujuan: Palliative Therapy

Manajemen Exudate

Dapat menjalankan aktivitas (Maj. Bau)

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Compiled From: SHEA, APIC, CDC Recommendations Guidelines, 1999

Impact of Surgical Site Infections/SSIFrequent

� An Estimated 2.6 Percent of Nearly 30 Million Operations Are Complicated by Surgical Site Infections (SSI’s) Each Year.

� Infection Rates, up to 11 Percent, Are Reported for Certain Types of Operations.

Costly

� SSI’s Cost U.S. Hospitals in Excess of $1.5 Billion Annually

Potentially Deadly

� Direct Cause of 20,000 Deaths Annually

� Contribute to Additional 70,000 Death

Preventable

� 40 percent to 60 percent of SSI’s are preventable

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� SSIs occur in 2%-5% of patients undergoing inpatient surgery in the US.

� Approximately 500,000 SSIs occur each year.

� Each SSI is associated to ~7-10 additional post-operative hospital days.

� Patients with an SSI have a 2-11 times higher risk of death, compared with operative patients without an SSI.

� 2001, CDC: 500.000 kasus SSI dan meninggal langsungdihubungkan dengan SSI sebanyak 10. 000

� SSI are believed to account for up to $10 billion annually in healthcare expenditures.

SHEA/IDSA Practice Recommendation. Strategies to Prevent SSI in Acute Care Hospitals, Oct. 2008

Impact of SSI

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HAIs in Indonesia

Perdalin Jaya dan RS Sulianti Saroso di 11 rumah sakit di Jakarta pada 2003, Suara Karya On Line, 2009.

IADP / CR-BSI 26,4 %

ISK 15,1 %

VAP 24,5 %

SSI/ILO 32,1%

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Konsep Pelayanan Kesehatan

Terdiri dari 6 aspek

� Safety

� Effectiveness

� Timeliness

� Efficiency

� Equity

� Patient awareness.

IOM (1999) dan National Health Service

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� Mengkoordinasikan dengan bagian manajemen resiko dalam investigasi pasien yang klaim dengan infeksi nosokomial.

� Sebagai penghubung antara staf keperawatan, dokter dan petugas kesehatan lainnya yang berhubungan dengan pengendalian infeksi

� Mengajukan kebutuhan peralatan dalam usaha pengendalianinfeksi nosokomial kepada bagian administrasi dan komitepengendalian infeksi nosokomial.

5.Management and communication

Job Analysis ICP (Infection Control Professional)

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Definisi dan Klasifikasi SSI

� Denifinisi:

a. infeksi pada luka operasi / organ/ruang yang terjadidalam 30 hari paska operasi

b. Apabila terdapat implant Dalam kurun 1 tahun.

� Sumber bakteri pada ILO dapat berasal dari: a. Pasienb. Dokter & Team c. Lingkungan (termasuk instrumentasi).

The National Nosocomial Surveillance Infection (NNIS)

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Faktor Resiko SSI

Usia Perokok Obesitas

DiabetesPenyakit / infeksiLamanya Operasi

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SKIN

SUBCUTANEOUS

TISSUE

DEEP SOFT TISSUE

(FASCIA &MUSCLE)

ORGAN

Superficial Incisional SSI

Deep IncisionalSSI

Organ /Space SSI

Superficial Incisional SSI

KlasifikasiKlasifikasi Surgical Site Infection (SSI)Surgical Site Infection (SSI)

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Klasifikasi SSI/ILO

Superficial Deep Space/organ

� Ditemukan kumandari cairan atautanda dari jaringansuperfisial

� Terdapat minimal satu dari tanda-tanda inflammasi

� Dehidensi dari fasiaatau dibebaskanoleh ahli bedahkarena ada tandainflammasi.

� Ditemukannyaadanya abses padareoperasi, PA atauradiologis.

� Keluar cairanpurulen dari drain organ dalam

� Ditemukan abses

� Didapat isolasibakteri dari organ dalam

Dinyatakan oleh dokter yang merawat

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Prinsip Pencegahan ILO:

Dilakukan pada tahap pra, intra dan post operatif :

1. Mengurangi resiko infeksi dari pasien.

2. Mencegah transmisi mo (petugas, lingkungan, instrument & pasien)

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Faktor terjadinya SSI

� Pre operasi:

a. Persiapan pasien (infeksi,diabet, merokok, etc)

b. Mandi/Cukur

c. AB profilaksis 30 menit sebelum insisi

d. Surgical Scrub

e. Skin antiseptic dan incise drape

� Intra Operasi

a. Persyaratan kamar bedah, instrument

b. Lamanya Operasi

� Post Operasi:

Perawatan luka (aseptik)

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BAGAIMANA MELAKUKAN

PERAWATAN LUKA UNTUK

MENCEGAHAN SSI ?

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Patient’s skin

Theater personnel

Instruments

Adjacent area Floor

Ventilation

Wound

Theater air

Body, incisionand wound drapes

Watertightclothing

Gloves

Clothing

Masks

Mouthhands

Body

Sumber Kontaminasi Luka

Courtesy of Dr. Patrick Parks, 3M St. Paul

Wound Care

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� Mandikan pasien dengan zat antiseptik malam hari sebelum hari operasi (Kategori II)

� Cuci dan bersihkan lokasi pembedahan dan sekitarnya untuk menghilangkan kontaminasi sebelum mengadakan persiapan kulit dengan anti septik (Kategori II)

Mandi & Kebersihan Daerah Operasi

Pencegahan Infeksi Luka Operasi ( Rekomendasi CDC 1999)

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Wound Closure: Metode Penutupan Luka

Suture dan staples

� Invasive – increased physical and tissue trauma during placement and removal

� High probability of infection

� Causes undesirable cosmetic pattern on the skin

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Benefits

Lower potential for infection

� Non-invasive ( does not produce pathway for pathogens to follow after in place)

� Decrease incidence of tissue inflammatory response

• Skin Closure tape are made from hypoallergenic latex-free material

• Non-invasive placement (surrounding tissue is not punctured)

• No foreign body under the skin

• No tissue trauma on removal (sutures and staples may disrupt or tear the healing tissue of the wound)

• Can be removed, reapplied during healing process without causing tissue trauma

Four days later, taped wounds displayed the least infection followed by stapled wounds and the sutured wounds.(Lennihan R. and Mackereth M. “A comparison of staples and nylon slosure in varicose vein surgery” Vascular Surgery 9:200, 1975).

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Plester pengganti benang jahitan

� Penutupan luka bersih, misalnya luka post op.

� Penutupan luka dengan infeksi dimanakeadaan infeksi sudah teratasi

� Luka tanpa disertai edema (bengkak)/tarikan

� Setelah penggunaan jahitan di bagian dalam

� Dapat juga digunakan bersama benang jahitan

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Dressing

KERUSAKAN JARINGAN /

KULIT

DRESSING

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Perawatan Insisi Setelah Operasi :

� Lindungi dengan dressing steril selama24-48 jam pasca operasi

� Cuci tangan sebelum dan Setelahmengganti dressing dan gunakan tekniksteril

� Pertahankan kelembaban luka: pilihdressing yang tepat

� Tidak ada rekomendasi mengenai perlunya menutup luka operasi yang sudah dijahit lebih dari 48 jam ataupun kapan waktu yang tepat untuk mulai di perbolehkan mandi dengan luka tanpa tutup

CDC Guidelines for Prevention of SSI, 1999.

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6 LANGKAH MELAKUKAN HAND RUB

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Syarat Dressing Ideal

Dapat mempertahankankondisi moist lembab

Bryant R. and Nix D. Acute and Chronic Wound Current Management Concepts, 3rd Edition, 2007

Dapat mencegahmasuknyamikroorganisme

Tidak merusakjaringan yang barutumbuh danmenimbukan rasa sakit pada saatdilepas.

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1. Mencegah Masuknya MO: Gunakan Semi-occlusivedressingsa. Reduce wound infections by more than 50% compared gauze

Joseph Lister (1827-1912) mengemukakan teori

mengenai infeksi yang disebabkan oleh adanya

kontaminan pada luka terbuka.

b. Cost-effective if used appropriately.

� Tujuan Program PPI

*Hutchinson J. Prevalence of wound infection under occlusive dressings, a collective survey of reported research, Wounds 1:123, 1989)

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� HemostasisPhase

� InflammationPhase

� Proliferation Phase

� Remodeling Phase

Type of Cells involved

Platelets

NeutrophilsMacrophages

MacrophagesKeratinocytes

Endothelial cellsFibroblasts

Fibroblasts

Injury HoursHours DaysDays WeeksWeeks YearsYears

2. Tidak merusak sel jaringan baru

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Kasa menyebabkan rekat pada permukaan lukaPasien sakit dan mengganggu penyembuhan

Fibers stick on the wound

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G. Winter’s publication – 1962

3. Mempertahankan Kelembaban Luka

Hinman C. and Maibach H. Efect of air exposure and cclusion on experimental human skin wounds. Nature 200, 377-378 (Oct. 26, 1963)

Moist Moist

Wound Healing Wound Healing MacerationMacerationDesiccationDesiccation

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Dry vs. Moist Wound Healing

� Cells move below the wound bed to find a moist area

� Formation of a dry, firmly adhering scab

� Repair process takes place under a protective scab.

� Firm crust of coagulated blood is the body’s own wound cover protecting the wound against external contaminants.

Kasa dan Plester

DRY WOUND HEALING

Semi Occlusive Dressing

MOIST WOUND HEALING

� Cell can grow, divide and migrate at an increased rate to optimize the formation of new tissue

� Epithelial cells require moisture to move from the wound edges to re-epithelialize or close the wound

� Wound exudate serves as a transport medium for:

� Enzymes, growth factors and hormones

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Dressing harus mempunyai sifatSemipermeable

Klasifikasi Dressing

� Transparent Adhesive Film

� Kain Plester lebar dengan bantalan

� Transparan Adhesive Film denganbantalan

O2

1. Dapat menahan masuknya MO

2. Memungkinkan O2 masuk

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Terapi Hyperbaric

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Dressing Selection for Wound Solution

Luka Bersih / post op tanpaexudate/cairan

Luka Bersih / post op

dengan sedikitsisa cairan

Luka kotor / post op banyakexudat / cairan

Transparan tanpa pad Transparan dengan pad Kain lebar dg Pad

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Plester kain lebar

Untuk luka yang panjang

Terbuat dari kain (polyester), pada:

a. Daerah banyak pergerakannya

b. Daerah lekukan

c. Daerah Kepala

d. Perdarahan

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Prosedur perawatan luka post operasi

� Prinsip: mempertahankan aseptik teknik

a. Hand rub

b. Sarung tangan

� Bersihkan dengan NaCl keringkan

� Iodine?

� Sofratule?

a. Tidak lengket: tidak perlu

b. Anti microbial: sesuaikan dg SOP rumah sakit

� Tutup dengan dressing

a. Exudate banyak, mis kasus acute: Soft cloth with pad

b. Tidak ada cairan/exudate: Semi occlusive Tegaderm pad

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Cost Analisa: Kasa+Plester VS Transparent Dressing

Persiapan

� Memotong, mengemas dan pengemas

� Mengantarkan dan mengambil ke CSSD

Pengemasan

� Tempat kasa

� Pengemas

Proses Sterilisasi;

� Air dan Listrik

Paramater jaminan sterilisasi

� External,internal dan BI

Penggantian Dressing

� Kasa diganti tiap 2 hari sekali

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Penggunaan Plester Kain Lebar

Plester kain lebar tidakdirekomendasikan untukdipotong-potong menjadi ukuranseperti plester untuk fiksasiselang infus/alat kesehatan yang lain

Penggunaannya untuk merawatluka agar optimal dalammemfiksasi kasa sehingga dibuatukurannya lebar.

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Kesimpulan:

Faktor ILO/SSI

� Hand Hygiene

� Teknik Perawatan Luka

� Jenis Transparant Dressing dapat mendukung penyebuhan lukadengan mempertahankan kondisi MOIST

Pertanyaan:

[email protected]

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