Decubitus Ulcer Wound Care - Refrat

7/25/2019 Decubitus Ulcer Wound Care - Refrat

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DECU

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PLASTIK

Disusun oleh:Hera Amalia Utami G99!"#$%I&ha Dith'ana G99!(

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DEFINITION

A 0ressure ul&er is an' lesion &ause.*' unrelie7e. 0ressure- usuall'o7er a *on' 0rominen&e- thatresults in .ama+e to un.erl'in+

tissue/Pressure ulcer an.pressure sore

decubitus ulcers an. bed sores

8Dharmaraan-"##"


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ULCERS

Intrinsic

Limited

mobility

Spinal cordinjury

Cerebrovascularaccident

Progressive neurologic

disordersPain

Fractures etc

Poornutritio

n

!nore"ia

De#ydration

Dietary restriction etc

Comorbidites

Diabetes melitus

Depression or psyc#osis

$alignanciesCongesti% #eart %ailureetc

!gings&in

Loss o% elasticity

Decreased cutaneous blood'o(

C#anges in dermal

p)

Loss o% subcutaneous %atetc

*luestein +,,


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E"trinsic

Pressure %romany #ard

sur%ace

Friction %rompatient.s

inability tomove (ell in

bed

S#ear %rominvoluntary

musclemovements

$oisture

*o(el orbladder

incontinence

E"cessiveperspiration

/ound drainage

RIS3 5ACTORS 5OR )RESSUREULCERS

*luestein +,,-


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!nders+,0,

)ATO)H;SIOLOG;


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SCORINGNO1TONP1ESS21E2LCE1SCO1E

*1!DENSC!LE


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INTE1P1ET!TION

Lo< Ris, : =1"#4o.erate Ris,: 1(

Hi+h Ris,: > #


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*1!DEN SC!LE

SensoryPerception

03Complete

ly limited

+3 4eryLimited

53Slig#tly

Limited

63 NoLimited

$oisture

03Constantly moist

+3 4erymoist

53Occasionally moist

63 1arely$oist

!ctivity

03*ed%ast

+3C#air%ast

53 /al&sOccasion

ally

63 /al&sFre7uentl

y

$obility

03Complete

lyImmobile

+3 4eryLimited

53Slisg#tlyLimited

63 NoLimited

Nutrition

03 4erypoor

+3Probablyinade7ua

te

53!de7uate

63E"cellent

Friction8 S#ear

03Problem

+3PotentialProblem

53 No!pparentProblem


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CL!SSIFIC!TION

9Dia: +,05;


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NP2!P ST!ected area may di>er %romsurrounding area

T#e a>ected tissue may be pain%ul?rm so%t or (armer or coolercompared(it# adjacent tisuue

Stage I

*luestein +,,-


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Partial@t#ic&ness loss o% dermisappearing as s#allo(

Open ulcer (it# a red pin& (oundbed

/it#out sloug# $ay also appear as an intact or

openAruptured serum@?lled blister

Stag

e II


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Full t#ic&ness tissue loss Subcutaneous %at may be visible *one tendon or muscle is not

e"posed Sloug# mau be present

$ay include undermining andtunneling

Stag

e III


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Full t#ic&ness tissue loss (it# e"posedbone tendon or muscle

Sloug# or esc#ar may be present onsome partso% t#e (ound bed

O%ten included undermining and

tunneling

Stage

I4


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*luestein +,,-


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)artmann +,,-


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!nders+,0,


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9Dia: +,05;


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CO44ON SITES O5 DECUBITUS ULCER5OR4ATION

The ris, is +reatest at those sites-ho


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T)ECO$$ONEST

P1ESS21ESO1ELOC!LIS!TIONS

)artmann +,,-


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CO$PLIC!TIONS Deat# #as been reported occur during

acute #ospitali:ation in B o% pstient(#o develop a pressure ulcer

compared (it# 0 o% at ris& patients(it#out pressure ulcer3 9T#omas +,,0;

Increasedmortality

rate

Osteomyelitis is a %re7uentcomplication o% pressure ulcersreported in 5- o% patients (it#

in%ected pressure ulcers3 9T#omas +,,0;

Osteomyeliti

s *acteremia %rom pressure ulcers is

uncommon but probably underestimated3T#e incidence o% bacteremia %rom pressureulcers is about 03 per 0,,,, #ospitaldisc#arges3 Sepsis is a serious conse7uence

o% pressure ulcers and a %re7uent cause o%deat#3 9T#omas +,,0;

Sepsis

Spinal subdural abscess 9SS!; represents aloculated in%ection bet(een t#e outermost layer o%t#e meninges t#e dura and t#e arac#noid3 T#eclose pro"imity o% ulcers to t#e sacral dural sacand ?lum terminale can provide direct anatomical

connection to t#e subdural space3 92soltseva+,05;

Spinalsubdural

abscess


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)artmann +,,-


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)artmann +,,


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$!N!


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T#e prevention strategies commonly used includeregular ris& assessment use o% special pressurerelieving support sur%aces regular repositioning andturning local s&in care and nutrition support3

Prevention

In t#e initial assessment t#e ulcer is evaluatedaccording to locali:ation stage si:e 9lengt#breadt# dept#; poc&et %ormation undermininge"udate 'o( etc3

!ssess t#e Pressure 2lcer

$oisture macerates and injures s&in3 Sources o%moisture include s(eat (ound drainage urine and%eces3 Several studies indicated t#at incontinenceincreases t#e ris& o% pressure ulcer development

Provide


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T#e di>erent positioning tec#ni7ues re7uiret#e combined use o% static and dynamic aids3

! r#yt#m o% t(o #ours is prescribed as t#etime interval%or repositioning3

1elieve Pressure FrictionS#ear

)artmann +,,-


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)artmann +,,-


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/ound cleansing

C#emical 9en:ymatic;debridement $ec#anical debridement !utolytic debridement

9compared (it# t#e above; *iological debridement

maggot debridement

Debridement

Ontario )ealt# Tec#nology !ssessmentSeries +,,G


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Dressing

)artmann +,,-


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)ydrot#erapy Electrot#erapy Electromagnetic t#erapy LLL t#erapy 2ltrasound t#erapy Negative pressure t#erapy

!djunctive p#ysical t#erapies



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Protein supplement Hinc supplement

!scorbic acid supplement $ulti@nutrient supplements

Nutrition t#erapy



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Surgical closure o% pressure ulcers resultsin more rapid resolution o% t#e (ound3 T#ec#ie% problems are t#at t#e ulcers%re7uently recur and many %rail patientscannot tolerate t#e procedure3

Surgical $anagement



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)artmann +,,-


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T)!NI

=O2

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Decubitus Ulcer Wound Care - Refrat