Decubitus ulcers is the destruction or death of the tissue under the skin to the skin even through the muscle to the bone, due to the emphasis on an area basis constantly - constantly causing disruption of blood circulation.Decubitus ulcers are ulcers caused due to intense pressure by the weight on the bed.Decubitus wound was necrosis of the soft tissue between the bones bulges and solid surfaces, most commonly due to immobilization.
Etiologya) Pressureb) Humidityc) Friction
PathophysiologyPressure immobilization time will result in pressure sores, if one part of the body is on a gradient (the difference between the two pressure points). Deeper tissue near the bone, especially muscle tissue with a good blood supply will shift towards lower gradient, while the skin is maintained at the contact surface by increasing friction with the presence of moisture, this condition causes blood vessels stretch and angggulasi (micro circulation) in blood and tissue shear forces experienced in, this will be the ischemia and necrosis before continuing to the skin.
Clinical Manifestations and Complicationsa) The initial injury is a reddish mark which does not disappear when pressed thumb.b) In more severe injuries encountered skin ulcers.c) May present pain and signs of systemic inflammation, including fever and increased white blood cell count.d) infection can occur as a result of weakness and hospitalization is prolonged even on a small ulcer.
Diagnostic Examinationa) Culture: artificial microorganism growth or cell - the cell network.b) Serum Albumin: The main protein in plasma and other serous fluid.
Medical managementa) Changing the position of the patient is bed rest.b) Eliminate pressure on reddened skin and a clean bandage placement and thin when it is shaped decubitus ulcers.c) Systemic: broad spectrum antibiotics, such as: Amoxilin 4x500 mg for 15-30 days. Siklosperm 1-2 grams for 3-10 days. Topical: antibiotic ointment such as kloramphenikol 2 grams.
Nursing Management1.Pengkajiana) The activity / restSigns: decreased strength, endurance, range limitations gerak.pada area of pain disorders such as muscular buds change.b) CirculationSigns: hypoxia, decreased peripheral pulse distal extremity injuries, general peripheral vasoconstriction with loss of pulse, white and cold, tissue edema formation.c) EliminationSigns: decreased urine output is the absence of the emergency phase, the color may be reddish black, if so, identify potentially damage the muscle.d) food / fluidSigns: general tissue edema, anorexia, nausea and vomiting.e) NeurosensoriSymptoms: area numb / tinglingf) RespiratorySymptoms: decreased function of the spinal cord, cord edema, neurological damage, paralysis of respiratory and abdominal muscles.g) Integrity egoSymptoms: family problems, work, finances, disability.Signs: anxiety, crying, dependence, self mmenarik, angry.h) SecuritySigns: a fracture due to the location (fall, accident, tetanik muscle contraction, until the electric shock).
2.Diagnosa Nursing1) Damage to tissue integrity related to mechanical tissue destruction secondary to pressure, friction and faction.2) Damage to physical mobility related to limitation of movement required, the status of which is conditioned, loss of motor control due to changes in mental status.3) Changes in nutrition less than body requirements related to inability of oral intake.4) High risk of infection associated with decubitus basic exposure, suppression of inflammatory responses.5) High risk for ineffective management of therapeutic regimen related to insufficient knowledge of the etiology, prevention, treatment and care at home.
3.Intervensi and Implementation1) Damage to tissue integrity related to mechanical tissue destruction secondary to pressure, friction and faction.- Apply principles of prevention of decubitus sores.R: the precautionary principle decubitus sores, covers reduce or rotate the pressure of the soft tissue.- Set posis patients as comfortable as possible.R: minimizing the occurrence of pressure sores affected tissue.- Wrap the wound with a bandage that retains moisture on the wound environment.R: moist wound healing can accelerate.
2) Damage to physical mobility related to limitation of movement required, the status of which is conditioned, loss of motor control due to changes in mental status.- Support the mobilization of a higher level.R: regular motion consistent relieving pressure on bone protrusions.- Assist / encourage self care / hygiene, such as bathing.R: increased muscle strength and circulation, increase patient control of health improvement in the situation and the environment.- Pay particular attention to the skin.R: research shows that skin is very susceptible to damage due to the weight concentration.
3) Changes in nutrition less than body requirements related to inability of oral intake.- Give preformance eat small amounts, often and in a warm state.R: help prevent gastric distension / discomfort and increase intake, increase appetite.- Help oral hygiene before meals.R: oral / clean equipment increased appetite good.- Maintain strict calorie.R: precise guidelines for the proper calorie intake.
4) High risk of infection associated with decubitus basic exposure, suppression of inflammatory responses.- Use the proper technique for changing a bandage.R: good technique reduces the entry of pathogenic microorganisms into the wound. Measure signs - vital signs.R: an increase in body temperature, tachycardia showed the presence of sepsis.- Use sterile gloves every bandage change.R: every ulcers contaminated by different microorganisms, these measures can prevent infection.- Wash the wound with 0.9% NaCl solution.R: Can get rid of dead tissue on the surface of the skin and reducing microorganisms.- Give the antibiotic medication as indicated.R: decubitus ulcers pilihanpada useful antibiotics against gram-negative organisms and gram positive.
5) High risk for ineffective management of therapeutic regimen related to insufficient knowledge of the etiology, prevention, treatment and care at home.- Encourage measures to prevent decubitus sores.R: injury prevention is easier than treatment of pressure sores.- Encourage measures to treat decubitus sores.R: This specific instructions to help patients and families learn to improve healing and prevent infection.
4. Evaluation1) Patients can prevent and identify factors causing decubitus sores; shows the progress of healing.2) patients had skin without neritema and not pale.3) The patient showed an increase in body weight and muscle mass.4) Leather will not teritasi due exposure to fecal or urine drainage.5) Demonstrate effective learning outcomes for the purpose of repatriation and patient care at home.
REFERENCESCapernito, Linda Juall. , 1999. Plans and Documentation Nursing Diagnosis: Nursing Diagnosis and Collaborative Problems Ed.2. Jakarta: EGC.Doenges, Marilynn E. In 2000. Nursing Plans: Guidelines for Planning and Documenting Patient Care. Jakarta: EGC.Nurachman, Elly. , 2001. Nutrition In Nursing. Jakarta: Sagung Seto.
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