We lose about a gram of skin cells every day because of skin friction on clothes and hygiene activities are carried out every day like a shower. Pressure sores can occur at any stage of life, but this is a particular problem in the elderly. Khsusnya in clients with immobility. Decubitus comes from the Latin meaning lay decumbree defined as an injury caused by the position of the patient that has not changed in a period of more than 6 hours. Decubitus is local tissue necrosis that tends to occur when soft tissue pressed between the bony external surface for a prolonged period. Local tissue microcirculation disturbances and resulting tissue hypoxia. Networks get oxygen and nutrients and dispose of waste products through the blood. Some of the factors that interfere with this process will affect the metabolism of cells by reducing or eliminating the circulation of tissue that causes tissue ischemia.
Tissue ischemia is the lack of blood locally or decreased blood flow due to mechanical obstruction). Decreased blood flow causes the body becomes pale area. Pale reddish color seen when a light-skinned patients. Pale does not occur in patients with darker skin pigment. Tissue damage occurs when the capillary pressure is large enough and close the capillary.
Someone who is not im-car lying in bed for weeks without any pressure sores due to change positions several times an hour. Replacement of this position, even a shift, it is enough to replace parts of the body in contact with the base of the bed.
While im-mobility almost caused decubitus if it lasts long. Ulcers caused ganggual local blood flow, as well as the general state of the patient.
Decubitus is damage / death of tissue under the skin to skin, even through the muscle to the bone due to the emphasis on a continuous area, resulting in local blood circulation disorders. Although all parts of the body has pressure sores, the bottom of the tubuhlah a particularly high risk and in need of attention particular periodicals. Common areas decubitus is a bony ridge above and not covered by sub-cutaneous fat enough, such as the sacrum area, an area the greater trochanter and the anterior superior spine ischiadica, heel and elbow area.
Decubitus is a serious matter, with morbidity and mortality in elderly patients. Country-developed countries, the percentage of occurrence of decubitus reached about 11% and occurs within the first two weeks of the treatment. Old age has a great potential for decubitus occurs because the skin changes associated with aging include:
• Reduced subcutaneous fat tissue
• Reduced network of collagen and elastin
• Decreased efficiency of collateral capillaries in the skin so the skin becomes thinner and fragile.
TYPE decubitus ulcers
Based on the time required for the healing of decubitus ulcers and a temperature difference of ulcer with surrounding skin, pressure sores can be divided into three;
1. Normal type
Having different temperatures to below 2.5 ° C less than the surrounding skin and will heal in about 6 weeks of treatment. Ulcers This is because local tissue ischemia due to pressure, but the flow of blood and blood vessels is actually good.
2. Type arterioskelerosis
Having a temperature difference of less than 1oC between the ulcer with surrounding skin. This situation indicates impaired blood flow due to vascular disease (arterisklerotik) perperan participate in addition to the factor of pressure sores. With treatment, the ulcer is expected to heal within 16 weeks.
3. Type of terminal
Occurred in patients who will die and will not recover.
Pathophysiology occurrence of pressure sores
Capillary pressure in the area ranged from 16 mmHg-33 mmHg. Skin will remain intact because the blood circulation awake, when the pressure of him still around those limits. But for example when a patient immobil / spikes to her bed and lay passively on a foam mattress the pressure sacrum area will reach 60-70 mmHg and 30-45 mmHg reach the heel area.
The pressure will rise and if continued ischemic region occurred nokrosis skin tissue. Animal experiments found that total blockage in the capillary was reversible when less than 2 hours. A person who is forced to lie for weeks will not have to replace position dakubitus for several times perjammnya. In addition to the pressure, there are some additional mechanical factors that may facilitate the occurrence of pressure sores;
• Factors such as skin teregangnya slid downward movement in patients with a half-reclining position
• Factors akiab folded skin friction is very thin body with bed linen, so as if the skin "left" of the area of the body.
Factors teragannya skin from the body with the power sliding base where he lay would lead to local tissue ischemia. This situation occurs when the patient immobil, not lying flat on your back, but in the semi-sitting position. There is a tendency of the body to slide down, let alone wet condition.
Often this is prevented by giving penhalang, such as pillows or small / wood beams on both feet. This effort is just akian prevent movement of the skin, which is now fixed from the base, but the skeleton remains cederung forward. The result is an emphasis stripes / stretching on the subcutaneous tissue-secant will tergunting in certain places, and will be closing arterioles and small arteries from too stretched and even torn. Power cut is called Shering Forces.
In addition shering forces, the movement of the body above the base where he lay, with a fixation on the surface of the pad skin will cause skin folds (skin folding). Mainly occurs in patients with thin skin sagging. Skin folds that occur can attract / confuse (distortion) and closing blood vessels. In addition to the direct effects of ischemia of the above factors, it still must be considered edotil damage, platelet accumulation and edema. All inidapat cause necrosis jarigan caused more disruption of capillary blood flow. Damage to blood vessels menyebabkn endotil also easily damaged when exposed to trauma.
Factors body itself (intrinsic factors) also contribute to the occurrence of pressure sores among others;
• During aging, skin cell regeneration becomes slower so that the skin will be thinner (tortora & anagnostakos, 1990)
• The content of collagen in the skin that change causes reduced skin elasticity thus susceptible to deformation and damage.
• The ability of the cardiovascular system are decreased and less competent arteriovenosus system causes a progressive decrease in skin perfusion.
• A number of diseases such as diabetes that show cause cardiovascular insufficiency and decreased peripheral cardiovascular function such as the respiratory system causing blood oxygenation levels in the skin decreases.
• Nutritional status, underweight or overweight opposite
• Hypoalbuminemia that facilitate healing of pressure sores and decubitus memperjelek, otherwise if there are sores akam causes decreased blood albumin levels
• Neurologic Diseases, diseases that damage the blood vessels, as well as facilitate and meperjelek decubitus
• The state of hydration / body fluids need to be assessed carefully.
• Cleanliness of the bed,
• weaving tools matted and dirty, or medical equipment that causes sufferers fixed to a certain attitude also facilitate the occurrence of pressure sores.
• Sit bad
• Improper position
• Change the position of the less
CLINICAL APPEARANCE OF decubitus
Clinical performance characteristics of pressure sores can be divided as follows;
Grade I reaction of inflammation is limited to the epidermis, appears as an area of redness / erythema induration or abrasions.
Grade II reactions deeper to reach all layers of the dermis to the subcutaneous weak, it appears as shallow ulcers, degan clear edge and changes in skin pigment color.
Grade III ulcers become deeper, covering the subcutaneous fat tissue and resound, adjacent to the fascia of the muscles. It's starting to get an infection with the smell of necrotic tissue.
Degree IV Expansion ulcer penetrates the muscle, so it looked bone at the base of the ulcer which can cause infection in the bones or joints.
Given the pathophysiology of decubitus is an emphasis on bony areas, harusla mind that damage tissue beneath a vast experience of pressure sores is lelih ulkusnya.
Management of decubitus begins with vigilance to prevent pressure sores by knowing the high risk patients with pressure sores, for example in patients who immobil and konfusio.
Attempts to meremalkan the decubitus, among others, by using the Norton scoring system. Scores below 14 indicate a higher risk for the occurrence of pressure sores. In evaluating these scores can be patient progress
Next action adalan keep the skin in particular patients with bathing every day. Once dry it well and then rubbed with lotion, especially in the skin for bumps bone. Should be given massase for blood circulation, all excreta / secretary should be cleaned with caution agari not cause blisters on the skin of the patient.
Further action is useful both for prevention and after the occurrence of pressure sores are:
1. Improving the health status of patients;
general; repair and maintain the patient's general condition, such as anemia resolved, corrected hypoalbuminemia, and hidarasi nutirisi sufficient, vitamins (vitamin C) and minerals (Zn) were added.
special; trying to overcome / mengoabati diseases that exist in people, such as diabetes.
2. Reduce / equalize the pressure factor that interferes with blood flow;
a. Over as / than recline / sleep alternating least every two hours long. The objection to this approach is the reliance on nurses sometimes are lacking, and sometimes annoying people break even painful.
b. Special mattresses for more memambagi average compression occurs in the patient's body, for example; mattress with air bubbles press up and down, water mattresses water temperature can be set. (Objection advanced tools are expensive, care must sendir well and can ruasak)
c. Stretch the skin and skin folds that cause local blood circulation is interrupted, reduced, among others;
• Maintain the position of the patient, if laid flat on the bed, or already enables the chair to sit down.
• Support beams legs, small pillows weeks to hold the patient's body, "donut" to heel,
• Outside the country often used sheepskin with fur is soft and thick as the base of the patient's body.
Bagitu looking skin hiperemis the patient's body, khsusnya in places that often occur decubitus, all-usahan business is done with more care to improve the ischemia that occurs, because once there is damage jaringa healing effort will be more complicated.
When it happens decubitus, specify the stage and medical measures to adjust what is encountered:
1. Decubitus degree I
With the inflammatory reaction is limited to the epidermis;
skin redness carefully cleaned with warm water and soap, lotion given,
then dimassase 2-3 times / day.
2. Grade II decubitus
Where have occurred shallow ulcer;
Wound care should pay attention to the terms of aseptic and antiseptic.
The area concerned is swiped with ice and blown with warm air alternately to stimulate circulation.
May be given a topical ointment, perhaps also to stimulate the growth of young tissue / granulation,
Replacement bandage and ointment is not too often because it can even damage tissue growth expected.
3. Degrees III decubitus
With the ulcer is deep, resound through the pack muscles and often already existing infection;
Keep the wound clean and always disusahakan exudate can flow out.
Balut is not too thick and otherwise transparent so permeable to masukknya air / oxygen and evaporation.
Humidity injury kept wet, as it will facilitate the regeneration of skin cells.
If the wound is dirty can be washed with physiological saline solution.
Systemic antibiotics may be necessary.
4. Degree IV decubitus
With the expansion of the ulcer to the bottom of the bone and are often accompanied the necrotic tissue;
All the above steps still do and necrotic tissue should be cleaned adal, sebaba will deter pertumbuhgan tissue / epithelialization.
Some enzyme preparations try awarded for this effort, with the goal of reducing bleeding, compared to surgery which is also an alternative. After necrotic tissue removed danluka clean, natural wound healing can be expected.
Some businesses accelerate is among others to provide oxygenation to the injured area,
Action with ultrasono to open blockages of blood vessels and to the local skin transplantation.
Degree IV decubitus mortality can reach 40%.
NORTON FOR MEASURING RISK SCORE pressure sores.
The risk of pressure sores if the total score ≤ 14
2. National pressure Ulcer Advisory panel (NPUAP), 1989 dalam Potter & perry, 2005
3. Perry & Potter, 1999. Buku Ajar Fundamental Of Nursing Vol.2. Jakarta : EGC
4. Luka dan Perawatannya (Ismail S.Kep, Ns, M.Kes), Manajemen Luka (Moya J. Morison, 2003).
5. Doenges, Marilynn E. 2000. Rencana Keperawatan : Pedoman Perencanaan dan Pendokumentasian Perawatan Pasien. Jakarta : EGC.