A.

Identitas klien
Nama : Tn. F

Jenis kelamin : Laki-laki

Usia : 53 thn

Alamat : Jl Putri Candramidi Gg Silka Jaya No 2

Perkerjaan : Swasta

Agama : Islam

Tanggal pengkajian : 16 Desember 2020

B. Alasan masuk RS
Klien mengatakan lukanya akibat dari garukkan

C. Kunjungan ke
Klien mengatakan hari ini tanggal 16 Desember 2020 kunjungan yang ke empat kali di klinik
kitamura.

D. Tipe luka
Diabetes Mellitus ( Trauma )

E. Wound bed

F. Ukuran luka
Pada tanggal 16-12-2020 : P : 5 cm L : 2 cm

G. Wound score ( MUNGS )

Wound score (MUNGS)
16 Deseber 2020

No Score ITEMS Skor

M Maceration 0

0 None
 1 Thin at the adge and/ or maceration ≤ 2 cm from the wound adge

2 >2 cm cm from the wound adge

U Undermining / tunnelling/ sinus 0

0 None

1 ≤ 3 cm

2 < 3cm

N Necrotic tissue type ( black, white, yellow, grey, brown, green

0 None

1 Soft slough and with ≤ 1 colour

2 Necrotis: with spongy, soft and colored skin

3 Necrotis: hard, spongy or moist tissue and skin ≥ 1colour

4 Necrotis: dry, hard, black, and / or brownish

G Gralation tissue 4

0 Skin intact

1 Full granulation

2 Granulation of 50% to < 100%

3 Granulation <50%

4 No granulation

S Other wound-releted signs or symptoms 4

0 None Wound edge Around the skin wound

 Red ring  Hyperpigmentation
1 One or two
 Hyperkeratonic  Induration
2 Tree tp five  Unattached  Hypopingmentation
 Undefined   Erytema araund the wound
3 More then  Crust  Oedema 
five  Pale   Purple
Wound infektion or  Damage  Lesion 
inflamation  Epibole
 Rolled/lining Granulation
 Pain
 Pus  Fragile granulation
 Odour  Bright red
 Rising temperature/  Hypergranulation
warm  Senescent
 Pale
 Blackish
 Trauma
 Tissue complatible with a
biofilm
 Ischemia

Total : 8

Wound score (MUNGS)

18 Desember 2020

No Score ITEMS Skor

M Maceration 0

0 None

1 Thin at the adge and/ or maceration ≤ 2 cm from the wound adge

2 >2 cm cm from the wound adge

U Undermining / tunnelling/ sinus 0

0 None

1 ≤ 3 cm

2 < 3cm

N Necrotic tissue type ( black, white, yellow, grey, brown, green 0

 0 None

1 Soft slough and with ≤ 1 colour

2 Necrotis: with spongy, soft and colored skin

3 Necrotis: hard, spongy or moist tissue and skin ≥ 1colour

4 Necrotis: dry, hard, black, and / or brownish

G Gralation tissue 4

0 Skin intact

1 Full granulation

2 Granulation of 50% to < 100%

3 Granulation <50%

4 No granulation

S Other wound-releted signs or symptoms 2

0 None Wound edge Around the skin wound

 Red ring  Hyperpigmentation
1 One or two
 Hyperkeratonic  Induration
2 Tree tp five  Unattached  Hypopingmentation
 Undefined   Erytema araund the wound
3 More then  Crust  Oedema
five  Pale   Purple
 Damage  Lesion
Wound infektion or
 Epibole
inflamation  Rolled/lining Granulation
 Pain
 Pus  Fragile granulation
 Odour  Bright red
 Rising temperature/  Hypergranulation
warm  Senescent
 Pale
 Blackish
 Trauma
 Tissue complatible with a
biofilm
 Ischemia

Total : 6
H. Intervensi
1. Cleansing
Kaki klien dicuci dengan airl NacL, teknik pencucian luka dengan di guyur
menggunakan NacL dan air ozon dengan mempertahankan teknik steril, lalu disabun
dengan menggunakan kasa steril dan sabun lalu dikeringkan.

2. Debridement
a. Tanggal 16 Desember 2020
Menggunakan teknik debridement mechanical dan surgical
b. Tanggal 18 Desember 2020
Menggunakan teknik debridement mechanical

3. Dressing
a. Primary
Dressing yang digunakan adalah dressing madu campuran
b. Secondary
Kemudian luka ditutup menggunakan pad steril
c. Tersier
Luka di tutup menggunakan hypafix

Grafik luka
pada Tn.F
9

0
16-Dec-20 18-Dec-20 20-Dec-20