Download ppt-yufitriana-amir

Ns. Yufitriana Amir., MSc., PhD., FISQua
Dosen ilmu keperawatan Universitas Riau
[email protected]
Agenda
 Pengkategorian ulkus dekubitus berdasarkan internasional guideline
 Simulasi penghitungan prevalensi dan insiden ulkus dekubitus
Istirahat melihat video: STOP PRESSURE ULCERS
 Skala Braden: aplikasi di rumah sakit dan di penelitian
 Pencegahan ulkus dekubitus: simple namun terlupakan
Pressure ulcers
Pain, unpleasant
Low quality of life
Treatment for the
main disease and
pressure ulcer
Increase
hospital costs
Wound
infection care
Longer wound care
Expensive Health
Care Problem
Prolongs
hospital stay
Burden health care
expenditure
The quality of pressure ulcer care
should be as high as possible
Especially
PRESSURE ULCER PREVENTION
simple namun terlupakan
Pressure ulcer preventive measures
Structural quality indicators at wards
66 wards
• More than half of the wards had discharge planning, PU care
documentation, and nursing team discussions.
• Almost half of the wards had multi-disciplinary discussions and PU
risk assessment
• A quarter of the wards had PU wound care nurses and used PU
mattresses
• Only one ward had a patient information leaflet
Structural quality indicators at institutions
• 4 hospitals registered the number of nosocomial PU patients
• 3 hospitals had admission and discharge planning, and a PU contact
person
• 2 hospitals had information leaflets and used PU mattresses
• 1 hospital had a PU guideline and refresher course
• None had a PU prevention committee
ulkus dekubitus
RISK FACTORS AND RISK ASSESSMENT
 Structured Risk Assessment
 Risk Factor Assessment
 Risk Assessment Tools
Skala Braden
1. Persepsi sensori
2. Kelembaban
3. Aktifitas
4. Mobilitas
5. Nutrisi
6. Pergesekan dan pergeseran
diskusi
SKIN AND TISSUE ASSESSMENT
 Skin Assessment Policy Recommendations
 Conducting Skin and Tissue Assessment
PREVENTIVE SKIN CARE
 Avoid positioning the individual on an area of erythema whenever possible.
 Keep the skin clean and dry
 Do not massage or vigorously rub skin that is at risk of pressure ulcers
 Develop and implement an individualized continence management plan
 Protect the skin from exposure to excessive moisture with a barrier product in
order to reduce the risk of pressure damage
 Consider using a skin moisturizer to hydrate dry skin in order to reduce risk
of skin damage
 Do not use dimethyl sulfoxide (DMSO) cream for the prevention of pressure
ulcers
EMERGING THERAPIES FOR PREVENTION
OF PRESSURE ULCERS
 Microclimate Control
 Prophylactic Dressings
 Fabrics and Textiles
 Electrical Stimulation of the Muscles for Prevention of Pressure Ulcers
PREVENTION & TREATMENT
OF PRESSURE ULCERS
NUTRITION IN PRESSURE ULCER
PREVENTION AND TREATMENT
 Nutrition Screening
 Nutrition Assessment
 Care Planning
 Energy Intake
 Protein Intake
 Hydration
 Vitamins and Minerals
REPOSITIONING AND EARLY
MOBILIZATION
 General Repositioning for All Individuals
 Repositioning Frequency
 Repositioning Techniques
 Repositioning Individuals in Bed
 Prone Position
 Repositioning Seated Individuals
 Positioning Devices
 Mobilization
 Repositioning Documentation
REPOSITIONING TO PREVENT AND
TREAT HEEL PRESSURE ULCERS
General Recommendations
Repositioning for Preventing Heel Pressure Ulcers
 Ensure that the heels are free of the surface of the bed
 The knee should be in slight (5° to 10°) flexion
 Avoid areas of high pressure, especially under the Achilles tendon.
 Use a foam cushion under the full length of the calves to elevate heels.
 Apply heel suspension devices according to the manufacturer’s
instructions.
 Remove the heel suspension device periodically to assess skin integrity.
SUPPORT SURFACES
 General Recommendations for Mattress and Bed Support Surfaces
 Mattress and Bed Support Surfaces for Pressure Ulcer Prevention
 General Recommendations on Seating Support Surfaces
 Seating Support Surfaces to Prevent Pressure Ulcers
MEDICAL DEVICE RELATED PRESSURE
ULCERS
 Risk for Medical Device Related Pressure Ulcers
 Recommendations for Assessment of the Skin and Medical Device
 Recommendations for Prevention of Medical Device Related Pressure
Ulcers
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