Ikram Bauk M.Kep, RN.

, WOC(ET)N
WOUND OSTOMY CONTINENCE

Enterostomal Therapy Nurse Education Program

 The WINNERS
Wocare for Indonesian Nurses
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INTRODUCTION

7 STEP DISASTER WOUND CARE NURSING MANAGEMENT

CASE STORIES : DISASTER WOUND MANAGEMENT

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JOGJAKARTA, 2006
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MAJOR DEPRESSION INFECTION

SALAH SATUNYA BERHUBUNGAN PENANGANAN AWAL KEJADIAN
DENGAN KEHILANGAN TUBUH LUKA YANG KURANG TEPAT
MENGAKIBATKAN KEGAGALAN
PROSES PENYEMBUHAN LUKA DI
WOUNDS FASE INFLAMASI
CRUSH SYNDROME
INFEKSI DAN KEMATIAN JARINGAN YANG CHRONIC WOUND
TERJADI DAN MAKIN MELUAS
MENYEBABKAN JARINGAN DAN ORGAN PERBURUKAN
LUKA MENGALAMI
PENUNGJANG LAINNYA MENJADI TIDAK HINGGA KEMATIAN JARINGAN
BERFUNGSI MENGAKIBATKAN YANG DITANDAI DENGAN HILANGNYA
FUNGSI
AMPUTASI HINGGA MENINGGAL DUNIA
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Depresion Crush syndrome Chronic wound Infection

COMPLICATION IN WOUND MANAGEMENT

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WOUND PROBLEM

Burn (Luka Bakar) Pain/Nyeri Dressing Not Available

Delay Healing (Gagal Sembuh) Infection Lack of Knowledge

Bleeding (Perdarahan) Amputation Wound Clinician Not

available
Wet to dry Concept (Membalut Frakture
dengan Kasa Basah/Kering)

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Burn Delay Healing BLEEDING INFECTION

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Lack of
AMPUTASI FRAKTUR Wet to DRAY
Kowledge

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Wound Healing
Assesment
Process

Wound
Clinician
Knowledge
DRESSING WBP (TIME)concept

Infection Process and Management

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Triangle of
WOUND
Assesment
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TISSUE INFLAMATION
MANAGEMENT CONTROL

TIME

MOISTURE
EPITELIAL EDGE
BALANCE
 TISSUE MANAGEMENT
Autolitic
Debridemen
t
DEBRIDEMENT
CSWD
Enzym
atic

Kimiawi

Maggot

Surgica
l
Buang Jaringan Mati Sampai Ketemu Sampai Terjadi
Dasarnya Merah Proses Granulasi
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INFLAMATION
CONTROL
Cuci luka pakai sabun baby,NACL, AIR
BERSIH, ANTISEPTIC yg tidak TOXIC

TOPICAL ANTI
BACTERIAL Kultur Kuman

KOLABORASI antibiotic
oral

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At local level bacteria colonise all chronic wounds; the most
commonly reported are Staphyloccocus aureus and
Pseudomonas aeruginosa two renowned biofilm
formers.
93.5%
52.2 %
Position Document. Management of Biofilm. Wounds International 2016
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WAJIB ada di BENCANA

Dihydrochloride PHMB
NON TOXIC Non TOXIC

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MOISTURE BALANCE 4
Menempatkan BALUTAN yang menciptakan LEMBAB yg SEIMBANG

NEKROTIC/KERING PROLIFERASI/GRANULASI
LEMBAB/BASAH : LEMBAB DAN MENYERAB :

HYDROGEL, ZINC CREAM, MADU, HYDROCOLOID, ALOEVERA ZINC CREAM, ALGINATE, FOAM, HYDROCOLOID, MADU

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EPITELIAL EDGE 5

PELIHARA EPTEL/ BERSIHKAN TEPI LUKA dari callus, jaringan fibrotic,

tepinya harus menyatu dengan dasar luka, perhatikan tepi yang rolling
kedasar luka,
Nutrisi harus baik sehingga granulasi naik sesuai dengan waktunya.

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Modern wound care

Evidence based on wound

management

Old wound care

Traditional wound care
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Foam /Gamgee/
Alginate Zinc Cream Gauze Crepe Bandage
PLESTER PUTIH

WAJIB ada disuatu BENCANA

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Tidak EBP Sehingga luka - luka yang harus dirawat sembuh dengan baik MESKIPUN
DALAM SITUASI BENCANA/DARURAT akibatnya menjadi KRONIK, DAN INFEKSI SERTA
AMPUTASI DAN BAHKAN KEMATIAN KARENA SEPSIS

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UPDATE TEORI & KEBIJAKAN

SKILL PEMERINTAH & OP

PRAKTISI DAN
MODERN DRESSING
DOSEN WAJIB
WAJIB ADA DI RS dan
UPDATE PERAWATAN
PUSKESMAS
LUKA

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Change before you have to!
The world is keep changing. Don’t stay here.
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Moisture Balance
Here are some of the benefits of moist wound
healing:

1. Wound Healing Takes Less

Time: When the body creates a scab or eschar,
that requires time and energy. Additional energy
is required to break down the scab after the
wound is healed. In a moist wound healing
environment, the body is able to focus on
healing the wound rather than protecting it, and
wounds heal faster.

( 17.01.2017 – 25.01.2017 )
17.01.17 – 01.02.17 2 weeks
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3. Autolytic Debridement is Facilitated: Moist

environments trap endogenous proteolytic enzymes in the
wound. This allows those enzymes to more efficiently
perform autolytic debridement to break down
necrotic tissue. Along with speeding healing, moist
wound environments allow for the body’s natural process
of healing to work more effectively.
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5. Preserves Growth Factors in Wound Fluid:

Growth factors are natural proteins which control key
cellular activities during the tissue repair process.
Moist wound healing allows the growth factors to be
preserved on the wound bed to repair tissues more
quickly.
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7. Reduces Pain: Another benefit of moist wound

treatment is that there is reduced pain. With less pain, there
is also a reduced stress response and less fatigue in
patients which also aids in the healing process. Decreased
pain can also lead to better patient mobility, which
improves circulation, oxygenation, and allows for better
healing.

8. Reduces Scarring: Moist wound treatment, by

promoting the growth and movement of new
cells and ensuring that proteins for closing the wound are
efficient, causes reduced inflammation, promotes more even
skin formation and therefore reduces scarring.
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DISASTER WOUND CARE NURSING MANAGEMENT

A ABC
CLEAR AND MANAGEMENT

B BASE LINE WOUND ASSESSMENT

LOCATION; ETIOLOGY; MEASUREMENT; WOUND BASE;
STADIUM; EXUDATE; ODOR AND PAIN

C CLEANSING
IRIGATION; SPRAY
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DISASTER WOUND CARE NURSING MANAGEMENT

DRESSING &
D DOCUMENTATION
EVIDENCE BASE DRESSING INTO PRACTICE AND E-TECH
DOCUMENTATION

EVALUATION &
E TRANSFER
SOAP DAN SISTEM RUJUKAN

F FOLLOW UP CARE
SETELAH 48 – 72 JAM PERTAMA PASCA PERAWATAN
LUKA DENGAN BALUTAN LUKA
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Ps. Ditemukan Selasa, pukul 10.00.

ABC clear; Secara keseluruhan
kondisi pasien relatif tenang. Nyeri pada
luka saat disentuh.

BASE Assessment : Luka di KAKI, ½ luas plantar 8X6 ,

exudat minimal serosa. Warna dasar luka 80% MERAH 20 %
KUNING , STAGE II. Tidak berbau. Nyeri +5
Cleanse dg PHMB;
Dressing moist dg Zinc cream, calcium alginate
Evaluasi KU jika nyeri tidak berkurang – transfer Hospital
Rencana Follow up: Kamis (3 days)
KEMUDAHAN DALAM SISTEM
INFORMASI DOKUMENTASI/REPPORT –
EVALUASI/ RUJUKAN/ TRANSFER –
FOLLOW UP CARE DAN GET
COLABORATION
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GET COLABORATION AND MULTIDICIPLINE 2

OTHERS SURGEON
NUTRITIONIST, FISIOTHERAPY;
NURSES; PSIKOLOGIST;

G
LABORATORIUM MEDICAL DOCTOR

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In parking area
The condition after earthquake was slightly in normal condition
The National Disaster Mitigation Agency
(BNPB) will collaborate with local government to
anticipated the first condition, such as health division.

HEALTH DIVISION immediately collaborate with all

health provider including WOUND CARE TEAM
 coordinator

Co-coordinator

Indonesian Wound Care Clinician in Clinician out Clinician

Clinician Association Hospital Hospital transfer
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Review the events of
PRIOR day
Present any ISSUES
UPDATE everyone on the
anticipated such as
Transfers option
Incoming volunteers and
their background
Major Political issues
GREEN TRIAGE
Indonesian Project:

The members of the Wound

Management in Disaster Settings
Consensus Meeting was
development and dissemination
of the Wound Care in
Disaster Settings guidelines
has been supported by
Indonesian Wound Care
Clinician Association and other
disciplines
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Palu dan
donggala
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DISASTER SITUASION IN LOMBOK 4
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OTHER DISASTER SITUASION IN
LOMBOK
OTHER DISASTER SITUASION IN
LOMBOK
SUMMARY

Wound care clinics can help

chronic wounds heal better and faster —
and save limbs and save lives.

“A good wound clinic should have the

technology and equipment to treatment
and evaluate wounds and help them heal better
and faster, to provide a better quality of life for
patients,
Wound clinics have the capacity to STOP
AMPUTATION, save limbs and save lives.”
 REFERENCES

1. http://www.pubpdf.com/pub/21131698/Disaster-management-triage-based-wound-care-and-patient-safety-
reflections-on-practice-following-an-Earthquake

2. Prasit WuthisuthimethaweeSamuel J. LindquistNicola SandlerOrnella ClavisiStephanie KorinDavid Watters

Russell L. Gruen; Wound Management in Disaster Settings. World Journal of Surgery
April 2015, Volume 39, Issue 4, pp 842–853

3. Carolina Prevaldi, Ciro Paolillo, Carlo Locatelli, Giorgio Ricci, Fausto Catena, Luca Ansaloni, and
Gianfranco Cervellin; Management of traumatic wounds in the Emergency Department: position
paper from the Academy of Emergency Medicine and Care (AcEMC) and the World Society of
Emergency Surgery (WSES). World J Emerg Surg. 2016; 11: 30.

4. Bret A. Nicks,1 Elizabeth A. Ayello, Kevin Woo, Diane Nitzki-George,and R. Gary Sibbald; Acute wound
management: revisiting the approach to assessment, irrigation, and closure considerations. Int J
Emerg Med. 2010 Dec; 3(4): 399–407.

5. Bryant A, Ruth, et.al. Acute and Chronic Wounds: Current Management Concepts. 5th Ed.
Philadelphia: Mosbi Elsevier (2016),
6. Carville, Kerlyn. Wound Care Manual. 5rd Ed. Western Australia: Silver Chain Foundation (2013)
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LUKA BAKAR 1
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LUKA BAKAR 2

Kasa NACL +
Btehadine Next Visit Visit ke 2 (hari ke 6) Visit ke 3 (hari ke 9)
Modern Dressing: 3 hari pasca Perawatan Proliferasi dan Maturasi Proces
Modern Dressing:
Cuci Luka NACL; pembentukan
AUTOLISIS Debridement EPITELISASI
Zinc Cream Plus Dressing :
Gamgee/Kasa
Zinc Cream + Kasa +
Crepe bandage

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TERIMAKASIH