2012109 pressure ulcer

7/18/2019 2012109 Pressure Ulcer

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Yunita Sari

Pressure ulcers



Pressure ulcer



Pressure ulcers

Pressure ulcers Kegagalan perawat ???



Definisi pressure ulcer

• Pressure ulcer adalah kerusakan jaringan yang terlokalisir yang disebabkankarena adanya kompressi jaringan yang lunak diatas tulang yang menonjol(bony prominence ) dan adanya tekanan dari luar dalam jangka waktu yanglama.

Kompressi jaringan akan menyebabkan gangguan pada suplai darah pada

daerah yang tertekan. Apabila ini berlangsung lama, hal ini dapatmenyebabkan insufisiensi aliran darah, anoksia atau iskemi jaringan danakhirnya dapat mengakibatkan kematian sel



Stadium pressure ulcer (NPUAP 2007)http://www.npuap.org/

http://www.npuap.org/

http://www.npuap.org/



Stadium pressure ulcer (NPUAP 2007)

Stadium 1

Kulit yang masih utuh, dengan erithema yangmenetap, biasanya terletak diatas bony prominence .Mungkin disertai dengan perubahan warna kulit,hangat, edema, keras, atau nyeri

Stadium 2Hilangnya sebagian lapisan kulit dermis . Cirinyaadalah luka terbuka dengan dasar luka berwarnamerah pink. atau blister yang berisi cairan beningyang masih utuh/pecah

Tidak sama dengan dermatitis karenainkontinensia, maserasi, atau luka karena plester



Pressure ulcers (NPUAP, 2007)Stadium TigaHilangnya lapisan kulit secara lengkap,

meliputi kerusakan atau nekrosis darijaringan subkutan atau lebih dalam,tapi tidak sampai pada fascia, otot,dan tulang . Kadang terdapat kantongluka (underminning)

Stadium EmpatHilangnya lapisan kulit secaralengkap dengan kerusakan yangluas, nekrosis jaringan, kerusakan

pada otot, tulang atau tendon .Seringkali terdapat kantong luka



Stage I Stage II Stage III Stage IV

Concept of Pressure Ulcer Development1. Develop from superficial to deep tissue ( Top-down theory )

(NPUAP, 2007)

2. Develop from Bottom to superficial ( Bottom-Up theory )(NPUAP, 2007)



Deep tissue injury• Tipe yang unik dari luka tekan (Black, 2007)

• PU berkembang dari jaringan bagian dalam seperti fascia

dan otot walapun tanpa adanya adanya kerusakan pada

permukaan kulit.

• Dikarakteristikan dengan warna ungu

• “Hot topic ” diantara klinisi dan researchers• Dimasukan dalam definisi NPUAP tahun 2007

• mekanismenya masih dalam penelitian , teori terbaru

adalah karena prolonged hypoxia (Gawlitta, 2007; Sari Y,

2008; 2012)

Sari Y , Nagase T, Minematsu T et al. Hypoxia is involved

in deep tissue injury . Wounds 2010 Feb;22(2).



Characteristic of Deep Tissue Injury

• Berdeteriorasi secara cepat menjadi luka tekan yang parah walau dengan

perawatan yang optimum (Black, 2007)

• Sulit untuk dideteksi pada stadium awal

• Belum ada pencegahannya di clinical setting

• Most cases : Unavoidable/ tak terhindarkan

Patients undergo surgery, protracted unconsciousness

(Ankrom, 2005; Black, 2003; 2007)

Sari Y , Nakagami G, Kinoshita A et al. Changes in serum and exudatecreatine phosphokinase (CPK) Concentrations as an indicator of deeptissue injury : a pilot study. International Wound Journal. Int Wound J.2008 Dec;5(5):674-80.



History of Deep Tissue Injury Classification

• 1975 Shea/ Society for Healthcare Epidemiology of America

Closed Pressure Ulcer

• 2001 NPUAP draft definition

• 2007 NPUAP

Suspected Deep Tissue Injury• 2009 EPUAP-NPUAP International Guideline



Finally, DTI is included into staging system by NPUAP

Suspected Deep Tissue Injury :Purple or maroon localized areaof discolored intact skin or blood-filled blister due to damage ofunderlying soft tissue frompressure and/or shear. The areamay be preceded by tissue that ispainful, firm, mushy, boggy,warmer or cooler as compared toadjacent tissue.

Deep tissue injury may be difficult to detect in individuals with dark skin tones.Evolution may include a thin blister over a dark wound bed. The wound mayfurther evolve and become covered by thin eschar. Evolution may be rapidexposing additional layers of tissue even with optimal treatment.

http://www.npuap.org/pr2.htm





Pictures of DTI

Source : (Aoi et.al, jpurnal of plastic reconstructive surgery, 2010)\

• Kejadian DTI sering disebabkan karena immobilisasi dalam jangka waktu yanglama, misalnya karena periode operasi yang panjang. Penyebab lainnya adalah

seringnya pasien mengalami tenaga yang merobek ( shear ).



Deep Tissue Injury (Clinical case)

Stage I PU Deep Tissue Injury



The Need to include DTI into staging system

Considering the imporatance of DTI deterioration, the cliniciansand researchers in wound care strongly suggest to include deep tissue injury

into staging system



Unstageable

• Unstageable/ Unclassified

• Kerusakan jaringan atau hilangnya

jaringan dimana kedalamannya tidak dapat

diketahui karena tertutup oleh slough

(kuning, hijau, atau coklat), atau eschar(sawo matang, kecoklatan, hitam) di dasar

luka

• Sampai slough/eschar di hilangkan,kedalamannya tidak dapat ditentukan, tp

biasanya merupakan stadium 3/4



Termasuk kategori apa



Faktor resiko luka tekan



Memprediksi Faktor resiko luka tekan

1. Norton Scale

2. Braden scale

3. Braden Q scale



Memprediksi faktor resiko untuk pressure ulcers



Japanese WOCN conference.2011



• Skor yang tertinggi 23, terendah 6

• Resiko rendah : 15-18

• Resiko menengah : 13-14

• Resiko tinggi : 10-12

• Resiko sangat tinggi : < 9

Interpretasi nilai braden scale

G id li h l k k



Guideline pencegahan luka tekan(international guideline by NPUAP)

http://www.npuap.org/wp-content/uploads/2012/03/Final_Quick_Prevention_for_web_2010.pdf



Level of Evidence

Ski C



1. Ensure that a complete skin assessment is part of the risk assessmentscreening policy in place in all health care settings. (Strength of

Evidence = C)

2. Whenever possible, do not turn the individual onto a body surface that isstill reddened from a previous episode of pressure loading. (Strength ofEvidence = C)

3. Do not use massage for pressure ulcer prevention (Strength of Evidence =B)

4. Do not vigorously rub skin that is at risk for pressure ulceration.(Strengthof Evidence = C)

5. Use skin emollients to hydrate dry skin in order to reduce risk of skindamage. (Strength of Evidence = B)

6. Protect the skin from exposure to excessive moisture with a barrierproduct in order to reduce the risk of pressure damage. (Strength ofEvidence = C)

Skin Care

N t iti



1. Screen and assess the nutritional status of every individual at risk ofpressure ulcers in each health care setting

2. Offer high-protein mixed oral nutritional supplements and/or tubefeeding, in addition to the usual diet, to individuals with nutritional riskand pressure ulcer risk because of acute or chronic diseases, orfollowing a surgical intervention. (Strength of Evidence = A)

3. Offer high-protein mixed oral nutritional supplements and/or tubefeeding, in addition to the usual diet, to individuals with nutritional risk

Quick Reference Guide Prevention and pressure ulcer risk because ofacute or chronic diseases, or following a surgical intervention. (Strengthof Evidence = A)

Nutrition

P i i i



Positioning

1. Repositioning should be undertaken using the30-degree tilted sidelying position (alternately, rightside, back, left side) or the prone position if theindividual can tolerate this and her/his medicalcondition allows. Avoid postures that increasepressure, such as the 90-degree side-lying position,(Strength of Evidence = C)

2. If sitting in bed is necessary, avoid head-of-bedelevation and a slouched position that places pressureand shear on the sacrum and coccyx. (Strength ofEvidence = C)

3. Use transfer aids to reduce friction and shear. Lift — don’t drag — the individual while repositioning.(Strength of Evidence = C)

S t S f



Support Surface

1. Use higher-specification foam mattresses rather than standardhospital foam mattresses for all individuals assessed as being atrisk for pressure ulcer development. (Strength of Evidence = A)

2. . Ensure that the heels are free of the surface of the bed. (Strengthof Evidence = C)

3. . Use a pillow under the calves so that heels are elevated (i.e.,“floating”).

4. Ensure that the heels are free of the surface of the bed.

5. Do not use small-cell alternating-pressure air mattresses or overlays.(Strength of Evidence = C)



• PSST ( Pressure Sore Status Tool )

• SWHT ( Sussman Wound Healing Tool )

• PUSH ( Pressure Ulcer Scale for Healing )

• DESIGN• PUHP ( The Japanese Pressure Ulcer Healing Process )

Memonitor perkembangan luka tekan



Inovasi dalam perawatan luka tekan oleh perawat



• Deteksi dengan thermografi

• Pembuatan alat untuk mengetahui tekanan antar muka

• Kasur anti dekubitus

• Ultrasonografi untuk deteksi deep tissue injury• Vibrasi untuk mempercepat penyembuhan luka tekan

Inovasi dalam perawatan luka tekan oleh perawat



Inovasi dalam perawatan luka tekan yangMembawa perubahan di rumah sakit

Deteksi dini kemungkinan infeksi dengan thermography



• Delayed healing disebabkan karena inflamasi yang memanjang

• Namun, tidak dapat diidentifikasi secara visual pada stadium awal

• Bila temperatur dasar luka > tepi luka = cenderung lama

• Bila temperatur dasar luka < tepi luka = luka akan sembuh

Deteksi dini kemungkinan infeksi dengan thermographyNakagami G et.al. Predicting delayed pressure ulcer healing using thermography: a prospectivecohort study. J Wound Care. 2010 Nov;19(11):465-6, 468, 470

Alat untuk mengukur tekanan antar muka



Alat untuk mengukur tekanan antar muka

Sugama J et al. Reliability and validity of a multi-pad pressure evaluatorfor pressure ulcer management. J Tissue Viability 2002;12(4):148-53.

• Mengukur tekanan antar muka (interface pressure) antara matras dan badan• Untuk mengetahui resiko terkena luka tekan

• Digunakan sebagai standar perawatan luka tekan di jepang• Menurut penelitian Suriadi et.al (2006), pengukuran tekanan antar mukasangat diperlukan pada pasien di ICU

Suriadi et.al A new instrument for predicting pressure ulcer risk in anintensive care unit. J Tissue Viability. 2006 Aug;16(3):21-6.



(video)

Kasur untuk menurunkan resiko luka tekan

http://localhost/var/www/apps/conversion/tmp/scratch_1/Lecture%20UMY/2009082501%E3%82%BB%E3%83%AB%E4%BD%93%E5%9C%A7%E6%B8%AC%E5%AE%9A.MOV





Kasur untuk menurunkan resiko luka tekanSanada H et al. Randomised controlled trial to evaluate a new double-layer air-cell overlay for elderly patients requiring head elevation. J Tissue Viability2003; 13(3):112-18.

• Changing the air cell shape to a double layer from a single layer atthis site.

• A randomised controlled trial was undertaken to evaluate theeffectiveness of this product .• The pressure ulcer incidence rate was 3.4% in the patients using

double-layer mattress, 19.2% in those nursed on the single layer and37.0% of those using the standard mattress.

Ultrasound untuk memprediksi deep tissue injury



Ultrasound untuk memprediksi deep tissue injuryNoriyuki et.al Ultrasound Assessment of Deep Tissue Injury in Pressure Ulcers: PossiblePrediction of Pressure Ulcer Progression. Journal of plastic surgery. 2009



• Tidak ada metode yang dapat digunakan untuk mendeteksi DTI pada fase awal

• Dapat digunakan untuk mendeteksi DTI yang akan menjadi parah

Vibration therapy



Vibration therapy

Vibration of 47 Hz (our research group)

- Animal study by using ear mouseVibration improve the blood flow of skin

microcirculation (Nakagami, 2007)

Vibration improve deterioration of DTI

(Sari Y, 2012)-Clinical study

Accelerate healing of very superficialpressure ulcer (Arashi M, 2010)

Vib i d d it di b t



Vibrasi pada penderita diabetes

(Syabariyyah, 2012)

Pasien 1

Pasien 2

Case study for Adjunctive Use of Noncontact Low-Frequency Ultrasound



for Treatment of Suspected Deep Tissue Injury:

Patients have been treated with :• repositioning schedule• assistive repositioning turning

devices;• ointment† twice • Daily with optional soft-silicone

bordered• foam;‡ appropriate support surfaces

• including static-air overlay** on ICUbeds; dietetic consultation;heel-offloading

• boots; and institutional Braden• Scale Prevention Policy.

Often did not prevent DTIDeterioration

J Wound Ostomy Continence Nurs. 2011 Jul-Aug;38(4):394-403.Adjunctive use of noncontact low-frequency ultrasound for treatment ofsuspected deep tissue injury: a case series.Jeremy Honaker, RN, BSN, CWOCN

Case study for Adjunctive Use of Noncontact Low-Frequency Ultrasoundf f d



for Treatment of Suspected Deep Tissue Injury:

NPWT/VAC



NPWT/VAC

• Terapi populer dan andalan• Memberikan tekanan negatif pada luka• Mekanisme :

• Mengeluarkan eksudat dari luka• Peningkatan aliran darah• Mengurangi edema• Meningkatkan jaringan granulasi• Meningkatkan mekanikal force yg dpt merapatkan tepi2

luka



Thank You

2012109 pressure ulcer

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