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PRAKTIK KLINIK PERAWATAN LUKAMAHASISWA SEMESTER VIII
PROGRAM STUDI PENDIDIKAN NERSSTIKes PATRIA HUSADA BLITAR
2016
FORMAT PENGKAJIAN LUKA
Identitas
Nama : Umur :Tanggal MRS : No. RM :Jam MRS : Diagnosa Masuk :
TT
V Vital Sign: TD: S: N: RR:Kesadaran: CM Apatis Somnolen Sopor
Pen
gkaj
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Um
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FAKTOR PENGHAMBAT PENYEMBUHAN LUKA
Immobilisasi Vaskularisasi Kurang Infeksi Luka
Diabetes Keganasan Kurang Nutrisi
Anemia Edema Lainnya: .............................Catatan:
PENGOBATAN YANG BERPENGARUH PADA PENYEMBUHAN LUKA
Steroid Immunisuppressan Kemoterapi
Antibiotik NSAID Lainya:..............................Catatan:
STATUS NUTRISI
Baik NGT
Sedang Suplemen Nutrisi
Jelek TPNCatatan:
BERAT BADAN DIBANDINGKAN TINGGI BADAN
Dibawah Normal Normal Diatas Normal
Kekurangan BB:...........................Kg Kelebihan BB:.......................KgCatatan:
ALERGI OBAT
Ya Tidak
Jika Ya, sebutkan..................................................
TIPE LUKA
Luka Tekan
Luka Operasi
Luka Diabetik
Lainnya, Spesifikasi.................................
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Um
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Loc
atio
n
Beri Tanda "X" dan Nomor Pada Masing-Masing Luka Pada Gambar di Bawah
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Lu
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Nomor Luka
Tanggal Pengkajian
Stadium Luka
Analgesik Sebelum Dressing Ya/Tidak Ya/Tidak Ya/Tidak Ya/Tidak Ya/Tidak
Ukuran Luka
Panjang (cm/mm)
Lebar (cm/mm)
Dalam (cm/mm)
Warna Dasar Luka
Granulasi (Merah) % % % %
Slough (Kuning/Hijau) % % % %
Nekrose (Hitam) % % % %
Epitelisasi (Pink) % % % %
Hipergranulasi (Merah) % % % %
Eksudat
1: Kering
2: Moist
3: Sedikit
4: Sedang
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Lu
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5: Banyak
Catatan:P
engk
ajia
n L
uk
a
Odor/ Bau Ya/Tidak Ya/Tidak Ya/Tidak Ya/Tidak Ya/Tidak
Wound Edge/ Tepi Luka1: Samar, tidak jelas terlihat
2: Batas tepi terlihat menyatu dengan dasar luka
3: Jelas, tidak menyatu dengan dasar luka
4: Jelas, tidak menyatu dengan dasar luka, tebal
5: Jelas, fibrotik, parut tebal hiperkeratonik
Warna Kulit Sekitar Luka1: Pink/ Normal 2: Merah terang jika ditekan3: Putih/Pucat/Hipopgmentasi4: Merah gelap/ Abu-abu5: Hitam/ Hiperpigmentasi
Undermining/ Goa1: Tidak Ada
2: Goa < 2 cm di area manapun3: Goa 2 - 4 cm < 50 % pinggir luka4: Goa 2 - 4 cm > 50 % pingir luka5: Goa > 4 cm di area manapun
Catatan:
Tipe Eksudat/ Drainage1: Tidak ada2: Bloody
3: Serosanguineuous
4: Serous5: Purulent
Jaringan Yang Edema1: No Swelling/ Edema2: Non pitting edema < 4 cm disekitar luka3: Non pitting edema > 4 cm disekitar luka4: Pitting edema < 4 cm disekitar luka
Jaringan Granulasi1: Kulit utuh/ stage 1
2: Terang 100% Jaringan Granulasi
3: Terang 50% Jaringan Granulasi4: Granulasi 25 %
5: Tdk ada Jaringan GranulasiEpitelisasi
1: 100% epitelisasi
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2: 75% - 100% epitelisasi
3: 50% - 75% epitelisasi4: 25% - 50% epitelisasi5: < 25% epitelisasi
Catatan:
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Lu
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Nyeri Skala Nyeri 1 - 10
Penatalaksanaan
Antimikrobial
1: Povidon Iodine/ Bethadine2: Hydrogel3: Lainnya:
Cairan Pembersih & Irigasi Luka
1: Produk Pembersih Khusus2: Normal Saline3: Cairan Sabun4: Lainnya:
Dressing
1: Calcium Alginate2: Collagen3: Balutan Kassa Kering4: Balutan Kassa Lembab5: Hydrogel 6: Kassa Hydrogel 7:Hydrogel Sheet Dressing
8: Hydrocolloid Dressing9: Transparent Film Dressing10: Lainnya:
Debridement
1: Autolitytic2: Enzymatic3: Mechanical4: Sharp
5: Surgical
Catatan:
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Lu
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Harapan klien terhadap lukanya
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Pemeriksaan Diagnostik
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Hasil Laboratorium
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...........................................................................................................................................................................................................Intervensi Tim Kesehatan Lain (dokter, dll)
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...........................................................................................................................................................................................................Intervensi Keperawatan
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PRAKTIK KLINIK PERAWATAN LUKAMAHASISWA SEMESTER VIII
PROGRAM STUDI PENDIDIKAN NERSSTIKes PATRIA HUSADA BLITAR
2016
FORMAT PENGKAJIAN LUKA(L/P)
Coma
FAKTOR PENGHAMBAT PENYEMBUHAN LUKA
Kurang Nutrisi
Lainnya: .............................
PENGOBATAN YANG BERPENGARUH PADA PENYEMBUHAN LUKA
Lainya:..............................
STATUS NUTRISI
BERAT BADAN DIBANDINGKAN TINGGI BADAN
Diatas Normal
ALERGI OBAT
TIPE LUKA
1
Ya/Tidak Ya/Tidak
Ukuran Luka
Warna Dasar Luka
% %
% %
% %
% %
% %
Eksudat
2
Ya/Tidak Ya/Tidak
Wound Edge/ Tepi Luka
Warna Kulit Sekitar Luka
Undermining/ Goa
Tipe Eksudat/ Drainage
Jaringan Yang Edema
Jaringan Granulasi
3
Nyeri
Penatalaksanaan
Antimikrobial
Cairan Pembersih & Irigasi Luka
Dressing
Debridement
4
5
