PRAKTIK KEPERAWATAN MANDIRI

Karya
Gang Swadaya 1 No. 09 Kec. Parindu Kab. Sanggau
Care
PENGKAJIAN LUKA DIABETES : MUNGS
Nama Pasien : …………………...

Tanggal : …………………… MR : ………..

Tanggal :
No Nilai
PENGKAJIAN
Nilai
M Maceration
0 Tidak ada
1 Tipis di tepi luka dan atau ≤ 2 cm dari tepi luka
2 > 2 cm from wound edge and or expand
U Undermining/Tunneling/sinus
0 None
1 ≤ 3 cm
2 > 3 cm
N Necrotic tissue type (black, white, yellow, gray, brawn, green)
0 None
1 Soft Slough and have ≥ 1 colors
2 Necrotic with combination; spongy, soft and have ≥ 1 colors
3 Necrotic with combination ; hard, spongy, or moist and have ≥ 1 colors
4 Dry Necrotic, hard, black and or brownish
G Granulation tissue
0 Skin intact
1 Full granulation (100%)
2 Granulation 50 % to < 100%
3 Granulation < 50%
4 No granulation
S Other Signs or Symptoms in wound
Wound edge: Around skin wound: 0 None
□ red ring □ hyperpigmentation 1 One or two
□ hyperkeratonic □ induration 2 Three to five
□ unattached □ hypopigmentation 3 More than five
□ undefined, □ erythema around the wound
□ crust □ edema
□ pale □ purple
□ damage, □ lesion
□ epibole Problem in granulation:
□ rolled/lining □ fragile granulation
Wound infection or □ brigh red
inflammation: □ hypergranulation,
□ pain □ senescent,
□ pus □ pale
□ odor □ blackish
□ fever □ trauma
□ rising □ tissue compatible with biofilm
temperature/warm
Total score