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ASUHAN KEPERAWATAN LUKA

ASUHAN KEPERAWATAN LUKA. SEPTRIANI R. //////WWAARRNNINNGG\\\ GRAPHIC CONTENT AHEAD THE FOLLOWING IMAGES MAY SHOCK OR DISTURB SOME VIEWERS. By Nancy & Morgan. ASSESSMENT. Kondisi pengkajian : Tindakan? Observasi perdarahan Observasi Kondisi klien. ASSESSMENT. Identifikasi pasien

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ASUHAN KEPERAWATAN LUKA

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  1. ASUHAN KEPERAWATAN LUKA SEPTRIANI R

  2. //////WWAARRNNINNGG\\\\\\\GRAPHIC CONTENT AHEADTHE FOLLOWING IMAGES MAY SHOCK ORDISTURB SOME VIEWERS By Nancy & Morgan

  3. ASSESSMENT • Kondisi pengkajian : Tindakan? • Observasi perdarahan • Observasi Kondisi klien

  4. ASSESSMENT • Identifikasi pasien • Pemeriksaan Fisik • Pemeriksaan Diagnostik • Faktor-faktor penyembuhan luka • 11 Pola Gordon

  5. PATIENT ASSESSMENT • Medical History immunosupresi?AB? • Other Dissease DM ? Gangguan Imun? • Inadequate nutrition Kadar protein? • Psychological problems • Lifestyle

  6. WOUND ASSESSMENT • Perfusion • Cause: determine etiology • Wound characteristic : • Location • Size (length x width x depth) • Exudate • Pain • Condition of surrounding skin • Odor • Infections

  7. LOCATION

  8. Measuring Length

  9. Measuring Width • Side to side

  10. Measuring Depth

  11. Exudate • Serosa : Bening cairan berisi plasma • Purulen : cairan warna kuning, hijau, coklat kemerahan atau coklat • Sanguinosa : perdarahan aktif • Serosasanguinosa : warna pucat merah, berair, campuran serosa dengan sanguionosa

  12. Serosa

  13. Purulen

  14. Sanguinosa

  15. PAIN

  16. Condition of surrounding skin • Color (erythema, white, blue) • Texture • Skin temperature (warm, cool) • Integrity of the surrounding skin

  17. Infection

  18. Diagnosa • Kerusakan integritas kulit • Nyeri akut • Hambatan mobilitas fisik • Harga diri rendah

  19. Intervensi • Dx.kep  rencanaasuhankep tujuan & hasilygdiharapkan  rencanaterapi yang akandiberikan • Pembuatanrencanatindakankepsesuaikandngkondisidarurat/stabil • Tujuanutamaperawatanluka : • M’cegahinfeksi • M’ningkatkanp’nyembuhanluka • K’nyamanandll

  20. Dx. 1 Tujuan pnulisan SMART “ stelahdilakukan tx.kep slma …x…jam dihrapkanintegritaskulitdptmeningkat “ Kriteriahasil : • Tepiluka sling b’dekatan • Luka bersih • Tidak terjadi infeksi Intervensi : ONEC

  21. Implementasi • Sesuai intervensi • Pertolongan pd luka : • PembersihanLuka • Perlindunganterhadapluka

  22. Evaluasi • SOAP Datang • SOAP Pulang • Berdasarkan diagnosa

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