DELAYED WOUND HEALING :

Problem and Management

Lucia Anik
Disampaikan Pada Acara Seminar Nasional Keperawatan:
The 1stAnniversary INWOCNA DIY– JAWA TENGAH
“Evidence Based Practice On Wound, Stoma and Continence Care”
Dalam Mendukung Praktek Keperawatan Mandiri
Semarang, July 22th 2018
 Kenapa luka tidak
Kunjung sembuh ???
To promote optimal wound healing, one must have :

• Knowledge of the skin and physiology of healing

• Good physical assessment skill/triangle assessment (dasar utk
pemilihan cleansing agent dan dressing)
• Understanding of wound cleansing agent
• Understanding of wound care product and pharmaceuticals
(Selections of topical therapy)
(Bryant, 2007 ; Acute & chronic wound: Current Management Concepts)
 Underlying comorbid
• Vascular disease
• Infection
• Diabetes or other metabolic disorder
• Immunosuppression
• Unrelieved pressure
• Radiation injury
• malnutrition
 How the wound becomes chronic
The reason is that that body’s ability to deal with damage is
overwhelmed by factors as repeated trauma, continued pressure,
ischemia or illness

(crovetti et al., 2004)

 General Clinical Appearance
• Bad granulation
• Exudative/hyper moist
• Necrotic tissue (Demarcation)
• •Sensibility disturbance
• •Deformity of surrounding structure
“Burdens within the
wound include exudate, bacteria, and
necrotic/cellular debris.”
 HOW TO CARE......???
The Principles :

• Wound bed preparation ( TIME Principle) RED

• Wound healing Wound care (Based on wound bed RYB)

 Wound Bed Preparation
• The TIME principle as applied to management of wound
Tissue non-viable Infection or Moisture imbalance Edge of wound
Or deficent inflamation non advancing /undermined

Debridement Antimicrobial Absorb dressing

Antisepetic Elevation/Vaccum Biological agent
Compression Adjuvant therapies
skin graft, VAC, PRP
debridement

RED
Falanga,2004
Triangle wound assessment
 ALGORITME MANAGEMENT LUKA

KRONIK KRONIK KRONIK KRONIK Kronik

AKUT HITAM, KERING KUNING, BASAH
MERAH dengan kuning
Merah, basah Merah Muda
kehijauan/Pus
(Nekrotik) (Slough) (Infeksi)
(Granulasi) (Epitelisasi)

Cleansing Cleansing
Anestesi Cleansing
Wound
Cleansing Wound Cleansing
Wound PHMB Wound
lokal PHMB PHMB Wound

Cleansing Kultur Pus/Dasar

Debridement Debridement Moist dressing Moist dressing
wound luka

Surgical,Autolisis,M Surgical, Autolisis, Foam, Tulle grass, non-

Debridement
ekanik, Enzym, Mekanik, Enzym, Debridement Hidrokoloid, adherent,Transparan
non vital Biological film
Biological Silikon

Surgical, Autolisis,
Penutupan Absorb dressing,
Hidroaktif Gel Mekanik, Enzym,
Alginate
luka (Primer) Biological

Courtesy of Prof.DR.dr.David Perdanakusuma, SpBP (K)

 Algoritma Pemilihan Topikal Terapi Berdasar Warna Luka

RED PINK : Jaringan Epitelisasi Transparant film, tulle, extra thin J

E
N
W I
O RED: Jaringan Granulasi Hidrocolloid, Foam dressing S
U
N PHMB, Ca ALGINATE, FOAM DRESSING, D
D HIDROFIBER, R
Yellow : Slough, EXudate, E
ANTIMIKROBIAL DRESSING
B Rongga S
E S
D I
Black/yellow:avascular Hydroactive gel: burnazin,
N
askina gel, duoderm gel G
PHMB, Antimicrobial dressing;
Infected
Acticoat
sorbach, Aquacel, Calgitrol,
Kasus
• Anak perempuan 14 tahun dengan
diagnosis severe SLE keluhan utama
kaki bengkak dan bernanah dengan
jaringan nekrotik, demam suhu
40°C, Procalcitonin 39,17 ng/ml,
kultur luka Pseudomonas Sp dan
Eschericia Coli.
 Date/Tgl 26/12/16 1 2
Pengkajian luka/triangle assessment
Jenis luka Kronis Kronis
lokasi R. Pedis Sakrum
ukuran P:7, L:5 P:4,L3
1 derajat luka ungradeable III

dasar luka Y, B R, Y
Exudate High Minimal
Odour / bau + +
Pain / nyeri VAS:7 VAS:3
tepi luka Edema ++ Epitel
Surrounding skin Kemerahan, lembab
bersisik

Infection (culture) Pseudomona E.Coli

2 20/12 2 s
(photograph)
Assessed by
Aplikasi
• Pada regio pedis :
• Wound cleansing dengan NaCl, kompres dgn PHMB (antiseptik)
• Beri wound gel® ( utk autolisis debridement ) tidak nyeri
• Tutup luka dengan Antimikrobial dressing, tidak lengket, aborbs
eksudate
• Ganti balutan jika sudah jenuh/ basah (menurunkan trauma pada
anak)

Tanggal 28-12-2016
Hasil
• Setelah 4 kali wound care tampak
jaringan berwarna merah (Red)
granulasi dan epitelisasi pada tepi
luka,
• Tidak ada bengkak dan demam
• Procalcitonin 0,8 ng/ml.
 Perkembangan luka

Saat kontrol
20/2/2016

26/12/2016

4/1/17

12/1/17

Tanggal 16/1/2017 pasien disiapkan u/

tindakan PRP rawat jalan
15/1/2017
 Pasien Guillain Barre Syndrome dengan pressure ulcer
Pencucian luka dengan PHMB solution, warna dasar luka merah kekuningan (slough) topical
dressing menggunakan antimicrobial silver untuk mengontrol infeksi, tutup dengan foam absorb
dressing untuk mempertahankan kelembaban
 References
1. Bryan Ruth A,2007.Acute & ChronIC Wounds:Current Management Concepts.Third Edition.Mosby..Elsevier
2. Lansdown Alan BG Silver: New technology and wound healing in the skin Journal of Wound Care 2002
11/4,125-130.
3. Graham-Field Grafco Lumex Medical Products Inc.(Packaging of Product
4. Lyon CC Smith AJ Abdominal Stomas and their skin disorders. An atlas of Diagnosis and Management
Martin Dunitz Ltd 2001. London (Pages 186-187)
5. Journal of Wound Care A glossary of common terms in wound care March Vol 9,no 3 2000.Page 139
6. Blackley P.1998 Practical Stoma Wound and Continence Management Research Publications Pty
Ltd.Victoria.
7. Bray www.bray.co.uk Toughened silver nitrate caustics in medicine1997
8. Hampton & Bryant1992 Ostomies and Continent Diversions Mosby Year Book page113
9. Lyon C.C., Smith AJ, Griffiths, Beck MH & MacDonald RH. Papular over-granulation with bowel
metaplasia:a distinct irritant reaction affecting abdominal stomas. 2000 British Association of Dermatology
143 (Suppl57)42-85
10. Ozaki H. & Ohki S, Iwamoto M, Miura E, Anazawa S & Omura Y.2002 Clinical Challenges. Diagnosis,
management and care of stomas and mucosal transplantation. WCET Journal Vol22 No3.
11. Lansdown Alan BG Silver: New technology and wound healing in the skin Journal of Wound Care 2002
11/5,1-5
12. Dunford. C Hypergranulation Journal of Wound Care Nov, Vol 8 No 10 1999
13. Rollins H. Hypergranulation tissue at gastrostomy sites. Journal of Wound Care March Vol 9, No3 2000
14. Carville Keryln 2007 Wound Care manual pg121 &91
15. Wright JB, Lam K, Burrell RE. Wound management in an era of increasing bacterial antibiotic resistance: A
role for topical silver treatment. American Journal of Infection Control Vol 26 No 6 pages 572-577
Thank You
CP: 081329786169