PRESSURE ULCER

Prevention & Management

WOCARE CLINIC
 STORY

In 1995, a horse-riding accident transformed

Christopher Reeve from an actor indelibly
identified with Superman into a quadriplegic
and an outspoken advocate for the disabled. Ten
years later, Reeve's death from
complications of a bedsore called attention
to one of the most serious problems facing
people with disabilities.
 OLD AWARENESS

Luka Tekan Kegagalan perawat

 (Florence Nightingale, 1861) :

 “Nursing could prevent them”

 (Jean Martin Charcot, 1825-1893) :

 “Doctors could do nothing about pressure ulcer”
 NOWDAYS

 Department of Health (DoH, 1993) : “Pressure ulcer

should be considered a key indicator of the quality of
care provided by the hospital”
 Culley 1998 : “There is a much greater awareness that all
healthcare professionals need to be involved in
pressure ulcer prevention”

Tissue Viability Society

European Pressure Ulcer Advisory Panel
 SINONIM

 PRESSURE ULCER
 Pressure sore
 Pressure area
 Bedsore
 Decubitus

 Luka tekan
 PRESSURE ULCER

DEFINISI
Kerusakan jaringan
kulit akibat adanya
penekanan antara
jaringan lunak tipis
dengan daerah tulang
yang menonjol pada
permukaan yang keras,
dalam jangka waktu
yang panjang dan terus
menerus (tempat tidur /
kursi roda)
AWMA
PENYEBAB & LOKASI
 PRESSURE
Cellular response
Vessel occlusion
To pressure
Tissue hypoxia

Pallor

Relief of pressure Persistence pressure

Pressure ulcer
Reactive Tissue
hyperemia Perfusion ischemia
worsens
Tissues
Hypoxia become Capillaries Metabolic wastes
Resolves edematous leak because of accumulate
increased
permeability
Resolution Increased
Protein
Accumulation
In interstitial space
 PREDISPOSISI

 Instrinsik
 Intensitas tekanan
 Lamanya tekanan

 Toleransi jaringan

 Ekstrinsik
 Usia

 Status Nutrisi & Kesehatan

 Status kulit

 Mobilisasi
 INTENSITAS
TEKANAN

• LAMANYA TEKANAN
 TOLERANSI JARINGAN

 SHEAR
 Posisi semi fowler
 FRICTION
 Saat mobilisasi pasien dan melakukan
hygiene
 PRESSURE
 Penekanan pd satu area
 MOISTURE
 Terutama dengan inkontinensia
 Diaphoresis
 Cairan luka yang tidak tertampung
 Usia : Lansia
Faktor lain
 Status Nutrisi : Malnutrisi
 Status Kesehatan :
Imobilisasi, kelumpuhan,
Neurophaty
 Status kulit : Kering
 PREVENTIVE PROTOCOLS
 Tentukan faktor risiko dengan : Braden scale, Norton scale, Gosnell
scale, dll
 Hilangkan atau kurangi faktor risikonya : TEKANAN
 Edukasi ke klien & keluarga tentang risikonya
 Tingkatkan aktivitas dan mobilisasi : buat jadwal reposisi
 Gunakan prosedur mengangkat dan menggeser dengan benar
 Tingkatkan status nutrisi
 Perhatikan kebersihan kulit
 Manajemen inkontinensia
 Gunakan bahan pelindung tubuh yang halus atau matres / cushion yg
mengurangi penekanan
 BRADEN SCALE
Patient’s name: ……………… Evaluator’s name: ………………. Assessment date:………………

SENSORY 1. Completely 2. Very Limited : 3. Slightly limited 4. No

PERCEPTION : limited : Responds only to : respond but impairment
Respond to unresponsive painful stimuli can’t
pressure- communicate
discomfort
MOISTURE : 1. Constantly 2. Very moist 3. Occasionally 4. Rarely
Degree to moisture moist moist moist
expose

ACTIVITY : 1. Bedfast 2. Chairfast 3. Walks 4. Walks

Degree of physical occasionally frequently
activity
MOBILITY : 1. Completely 2. Very limited 3. Slightly limited 4.No
Ability to change & immobile limitation
control position

NUTRITION : 1. Very poor 2. Probably 3. Adequate 4. Excellent

Usual food intake inadequate
pattern

FRICTION : 1. Problem 2. Potential 3. No apparent

Degree of need problem problem
assistance in
moving
 KUALITAS SERVICES

 Lifting dan reposisi

yang benar dan baik
 Menjaga kebersihan
 Buat jadwal
mobilisasi
 SKALA
PREVENTION