6 Key Factors in Treating a Diabetic Wound

TOPNURSE~By 2030, it is estimated that more than 550 million people around the world will have diabetes. Approximately 25% of these diabetic patients will develop foot ulcers during their lifetime, which often require advanced diabetic wound treatment to prevent complications. To help achieve the optimal healing environment and protect against problems, there are six key factors to consider when treating diabetic wounds.

1. Wound Assessment

Diabetic wounds fall into three categories: neuropathic, ischemic, and neuroischemic. Knowing the distinct features of each wound category is essential to identifying wound progression, infection, and healing. Failure to properly identify the type of wound that exists can lead to an ineffective diabetic wound treatment plan, causing long-term complications or amputation.

2. Tissue Debridement

Wound debridement, or the removal of necrotic tissue from a wound, will reduce pressure, stimulate wound healing, allow for the inspection of underlying tissue, help with secretion or wound drainage, and optimize a wound dressing’s effectiveness. Clinicians typically recommend sharp debridement by scalpel or scissors, but there are other tissue-removal treatments they may recommend, including larval, autolytic, and ultrasonic.

Only an experienced practitioner who knows which section of the tissue to remove without damaging blood vessels, nerves, or tendons should perform a debridement procedure. Understanding the importance of debridement to your diabetic wound treatment plan is often essential with advanced diabetic wounds.

3. Infection Control

Infections are the top concern in any diabetic wound treatment plan. Due to the high morbidity and mortality rates associated with diabetic wounds, more aggressive forms of infection control are necessary. Both oral and topical antibiotics are recommended for all diabetic wound treatment patients who show signs of infection, even mild ones. Topical antimicrobials can reduce bacteria, protect against further contamination, and prevent the spread of infection deeper into the wound. Typical wound dressings used in treating diabetic wounds are those impregnated with antimicrobial agents to help fight infection. Clinicians often prescribe advanced wound care dressings that include silver, iodine, medical-grade honey, or polyhexamethylene biguanide (PHMB) which work to enhance healing by keeping your wound moist.

4. Moisture Balance

Choosing the optimal dressing for a diabetic wound is essential to successful wound healing. The proper wound dressing will help maintain a balanced moisture environment (not too wet or too dry) and allow the wound to drain and heal properly. The location of the wound will also be taken into consideration by your clinician when they choose a dressing. While each wound needs to be assessed properly, some common dressings that can be used for diabetic wounds include alginates, hydrocolloids, and films.

5. Pressure Offloading

For most diabetic wound treatment plans for patients suffering from foot or leg ulcers, pressure reduction or offloading is a key factor in preventing complications. A non-removable total contact cast (TCC) redistributes pressure evenly throughout the lower leg and can reduce healing times. However, TCC is not always the best choice, especially for infected wounds, so other removable offloading devices may be used including removable cast walkers, Scotchcast boots, or healing sandals.

The most common problem with healing when using removable devices is that some patients do not wear them properly, which can delay wound healing. In these cases, studies have found that patients with removable offloading devices only wear them less than 30% of the day. If you have questions about how to utilize offloading devices, speak with your doctor.

6. Underlying Factors

A diabetes wound patient must be treated holistically in order to identify underlying issues and reduce risk factors that are causing wounds in the first place. Achieving control of diabetes is difficult but essential, especially concerning blood glucose levels, proper nutrition, high blood pressure, and smoking cessation. Other factors, such as proper footwear and adequate blood supply to extremities, need to be assessed. No matter the level of injury, a clinician specializing in this field should prescribe a diabetic wound treatment plan.

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How does diabetes affect wound healing?

Diabetes can cause wounds to heal more slowly. This raises the risk that someone with diabetes will develop infections and other complications.

A person who manages their diabetes well can improve wound healing and reduce the chances of developing a serious infection.

Diabetes and wound healing

Those with diabetes may find that different types of wounds are slow to heal.

TOPNURSE~Minor wounds, cuts, and burns are a part of life, but for people with diabetes, they can cause serious health issues.

Many people with diabetes develop wounds that are slow to heal or never heal. Wounds that do not heal well can become infected.

An infection can spread locally, to surrounding tissue and bone, or to further away areas of the body. In some cases, they may even be fatal.

Diabetic foot ulcers affect 15 percent of people with diabetes. These are painful sores that can ultimately lead to foot amputation.

Even when a wound does not become infected, it can affect a person's health and quality of life. Cuts or injuries on the feet or legs can make it difficult to walk or exercise without pain.

Keeping diabetes under control can reduce the risk of slow-healing wounds and complications, including foot ulcers.

A 2013 study found a clear correlation between blood glucose and wound healing. People undergoing surgery for chronic diabetes wounds were more likely to fully heal if their blood glucose was well-controlled at the time of surgery.

Why does diabetes affect wound healing?

Diabetes makes it more difficult for the body to manage blood glucose levels. When blood glucose remains chronically high, it impairs the function of white blood cells, resulting in an inability to fight bacteria.

Diabetes, particularly if uncontrolled, is also associated with poor circulation. As circulation slows, red blood cells move more slowly. This makes it more difficult for the body to deliver nutrients to wounds. As a result, the injuries heal slowly, or may not heal at all.

Nerve damage is another factor affecting wound healing. Uncontrolled blood glucose can damage the body's nerves, which means that people with diabetes may sustain trauma to their feet more easily without being aware that they are injured. This can prevent them from seeking treatment, allowing a wound to become even worse.

Impaired sweating, dry and cracked skin, toenail infections, and foot deformities are more commonly found in people with diabetes, increasing the risk of a bacterial infection.

Research is consistently uncovering other ways that diabetes affects wound healing, including:

• weakened production of hormones associated with growth and healing
• decreased production and repair of new blood vessels
• weakened skin barrier
• decreased collagen production

Complications

People who exhibit poor wound healing due to circulatory and neurological effects of diabetes may have other complications as well. These include heart disease, kidney disease, and eye problems.

A wound left untreated may become infected, and the infection may spread locally to muscle and bone. This is called osteomyelitis.

If the infection spreads into the bloodstream, it is called sepsis and can be life-threatening. Deep infections may sometimes become severe and require amputation.

Prevention

Maintaining good foot hygiene by washing and moisturizing daily may help to promote wound healing.

Strategies that can prevent slow-healing wounds due to diabetes include managing blood glucose, proper foot care, and treating wounds promptly.

Proper foot care includes:

• washing feet daily
• patting dry and applying moisturizing lotion
• avoiding walking barefoot
• carefully trimming toenails
• wearing comfortable shoes
• inspecting feet and looking inside shoes daily
• having a doctor check feet at each visit

People with diabetes should carefully monitor their wounds. While it is normal for diabetic wounds to heal slowly, it is not normal for them to remain open for several weeks, to spread or ooze, or to be extremely painful.

People with well-managed diabetes are less likely to suffer from serious wounds that do not heal.

People with type 1 diabetes must take insulin for life. Those with type 2 diabetes have more options for controlling their blood glucose, including several anti-diabetic drugs and insulin.

Both types of diabetes benefit from a carb-controlled diet. In the case of type 2 diabetes, lifestyle interventions, such as diet, exercise, and weight loss, may substantially improve blood sugars and may even allow a person to manage their diabetes without medication.

Outlook

A wound that does not heal can quickly become life-threatening. A positive outlook for slow-healing wounds depends on receiving prompt treatment.

People with diabetes should immediately contact a doctor when they develop serious or painful wounds, or if a wound appears infected, causes a fever, or does not heal after several days.

A combination of aggressive antibiotic treatment, cleaning the wound, surgical treatment to remove dead tissue, and better glucose control can help. If the wound does not respond to treatment, such as with a severe or extensive diabetic foot ulcer, amputation may be necessary.

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What is a Diabetic Foot Ulcer?

What is a Diabetic Foot Ulcer?

TOPNURSE~A diabetic foot ulcer is an open sore or wound that occurs in approximately 15 percent of patients with diabetes and is commonly located on the bottom of the foot. Of those who develop a foot ulcer, 6 percent will be hospitalized due to infection or other ulcer-related complication.

Diabetes is the leading cause of non-traumatic lower extremity amputations in the United States, and approximately 14-24 percent of patients with diabetes who develop a foot ulcer will require an amputation. Foot ulceration precedes 85 percent of diabetes-related amputations. Research has shown, however, that development of a foot ulcer is preventable.  

Causes

Anyone who has diabetes can develop a foot ulcer. Native Americans, African Americans, Hispanics, and older men are more likely to develop ulcers. People who use insulin are at higher risk of developing a foot ulcer, as are patients with diabetes-related kidney, eye, and heart disease. Being overweight and using alcohol and tobacco also play a role in the development of foot ulcers.  

Ulcers form due to a combination of factors, such as lack of feeling in the foot, poor circulation, foot deformities, irritation (such as friction or pressure), and trauma, as well as duration of diabetes. Patients who have diabetes for many years can develop neuropathy, a reduced or complete lack of ability to feel pain in the feet due to nerve damage caused by elevated blood glucose levels over time. The nerve damage often can occur without pain, and one may not even be aware of the problem. Your podiatrist can test feet for neuropathy with a simple, painless tool called a monofilament.

Vascular disease can complicate a foot ulcer, reducing the body's ability to heal and increasing the risk for an infection. Elevations in blood glucose can reduce the body's ability to fight off a potential infection and also slow healing. 

Symptoms

Because many people who develop foot ulcers have lost the ability to feel pain, pain is not a common symptom. Many times, the first thing you may notice is some drainage on your socks. Redness and swelling may also be associated with the ulceration and, if it has progressed significantly, odor may be present.

When to Visit a Podiatrist

Once an ulcer is noticed, seek podiatric medical care immediately. Foot ulcers in patients with diabetes should be treated to reduce the risk of infection and amputation, improve function and quality of life, and reduce health-care costs.

Diagnosis and Treatment

The primary goal in the treatment of foot ulcers is to obtain healing as soon as possible. The faster the healing, the less chance for an infection.

There are several key factors in the appropriate treatment of a diabetic foot ulcer:

• Prevention of infection
• Taking the pressure off the area, called “off-loading”
• Removing dead skin and tissue, called “debridement”
• Applying medication or dressings to the ulcer
• Managing blood glucose and other health problems

Not all ulcers are infected; however, if your podiatrist diagnoses an infection, a treatment program of antibiotics, wound care, and possibly hospitalization will be necessary.

To keep an ulcer from becoming infected, it is important to:

• keep blood glucose levels under tight control;
• keep the ulcer clean and bandaged;
• cleanse the wound daily, using a wound dressing or bandage; and
• avoid walking barefoot.

For optimum healing, ulcers, especially those on the bottom of the foot, must be “off-loaded.”  You may be asked to wear special footgear, or a brace, specialized castings, or use a wheelchair or crutches.  These devices will reduce the pressure and irritation to the area with the ulcer and help to speed the healing process.

The science of wound care has advanced significantly over the past ten years. The old thought of “let the air get at it” is now known to be harmful to healing. We know that wounds and ulcers heal faster, with a lower risk of infection, if they are kept covered and moist. The use of full-strength betadine, hydrogen peroxide, whirlpools, and soaking are not recommended, as these practices could lead to further complications.

Appropriate wound management includes the use of dressings and topically-applied medications. Products range from normal saline to growth factors, ulcer dressings, and skin substitutes that have been shown to be highly effective in healing foot ulcers.

For a wound to heal, there must be adequate circulation to the ulcerated area. Your podiatrist can determine circulation levels with noninvasive tests. 

Tightly controlling blood glucose is of the utmost importance during the treatment of a diabetic foot ulcer. Working closely with a medical doctor or endocrinologist to control blood glucose will enhance healing and reduce the risk of complications.

Surgical Options: A majority of non-infected foot ulcers are treated without surgery; however, if this treatment method fails, surgical management may be appropriate. Examples of surgical care to remove pressure on the affected area include shaving or excision of bone(s) and the correction of various deformities, such as hammertoes, bunions, or bony “bumps.”

Healing time depends on a variety of factors, such as wound size and location, pressure on the wound from walking or standing, swelling, circulation, blood glucose levels, wound care, and what is being applied to the wound. Healing may occur within weeks or require several months.

Prevention

The best way to treat a diabetic foot ulcer is to prevent its development in the first place. Recommended guidelines include seeing a podiatrist on a regular basis. Your podiatrist can determine if you are at high risk for developing a foot ulcer and implement strategies for prevention.

You are at high risk if you have or do the following:

• Neuropathy
• Poor circulation
• A foot deformity (e.g., bunion, hammer toe)
• Wear inappropriate shoes
• Uncontrolled blood sugar
• History of a previous foot ulceration

Reducing additional risk factors, such as smoking, drinking alcohol, high cholesterol, and elevated blood glucose, are important in prevention and treatment of a diabetic foot ulcer. Wearing the appropriate shoes and socks will go a long way in reducing risks. Your podiatrist can provide guidance in selecting the proper shoes.

Learning how to check your feet is crucial so that you can find a potential problem as early as possible. Inspect your feet every day—especially the sole and between the toes—for cuts, bruises, cracks, blisters, redness, ulcers, and any sign of abnormality. Each time you visit a health-care provider, remove your shoes and socks so your feet can be examined. Any problems that are discovered should be reported to your podiatrist as soon as possible; no matter how simple they may seem to you. 

The key to successful wound healing is regular podiatric medical care to ensure the following “gold standard” of care:

• Lowering blood sugar
• Appropriate debridement of wounds
• Treating any infection
• Reducing friction and pressure
• Restoring adequate blood flow

Additional information is available from the American Diabetes Association.

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What’s the Connection Between Diabetes and Wound Healing?

How diabetes affects your body

TOPNURSE~Diabetes is a result of your body’s inability to produce or use insulin. Insulin is a hormone that allows your body to turn glucose, or sugar, into energy. If your body has difficulty metabolizing glucose, it can lead to high blood sugar levels. This can affect your body’s ability to heal wounds.

In people with diabetes, wounds tend to heal more slowly and progress more quickly, so it’s important to know what to look out for.

Although cuts, grazes, scratches, and blisters can occur anywhere on the body, the feet are one of the most common places of injury. A small wound on the foot can quickly develop into a foot ulcer.

Foot ulcers can become serious if left untreated. Between 14 and 24 percent of people who have diabetes and develop an ulcer will end up having a lower limb amputation.

For this reason, it’s crucial that you do regular self-checks and closely monitor any wounds closely. Catching wounds early is the only way to reduce your risk of complications.

Keep reading to learn more about the healing process, ways to speed the healing process along, and how to improve your body’s healing powers long-term.

Why wound healing is slow

When you have diabetes, a number of factors can affect your body’s ability to heal wounds.

High blood sugar levels

Your blood sugar level is the main factor in how quickly your wound will heal.

When your blood sugar level is higher than normal, it:

• prevents nutrients and oxygen from energizing cells
• prevents your immune system from functioning efficiently
• increases inflammation in the body’s cells

These effects slow down wound healing.

Neuropathy

Peripheral neuropathy can also result from having blood sugar levels that are consistently higher than normal. Over time, damage occurs to the nerves and vessels. This can cause the affected areas to lose sensation.

Neuropathy is particularly common in the hands and feet. When it happens, you may not be able to feel wounds when they occur. This is one major reason why foot wounds tend to be more common in people with diabetes.

Poor circulation

People with diabetes are twice as likely to develop peripheral vascular disease, a condition of poor circulation. Peripheral vascular disease causes your blood vessels to narrow, which reduces blood flow to the limbs. The condition also affects red blood cells’ ability to pass through the vessels easily. And a higher-than-normal blood glucose level increases the thickness of blood, affecting the body’s blood flow even more.

Immune system deficiency

Many people who have diabetes also have problems with immune system activation. The number of immune fighter cells sent to heal wounds, and their ability to take action, is often reduced. If your immune system can’t function properly, wound healing is slower and your risk of infection is higher.

Infection

If your immune system isn’t functioning at its best, your body may struggle to fight off bacteria that cause infection.

Higher-than-normal blood sugar levels also increase the possibility of infection. This is because bacteria thrive on the extra sugar that’s available in the bloodstream. High blood sugar levels can also prevent immune cells from being able to fight off invading bacteria.

If your infection is untreated and left to spread, it can lead to complications such as gangrene or sepsis.

What can happen if wounds are left untreated

Wounds present a real cause for concern. If they’re not carefully monitored, they can quickly progress into an infection or more serious complication.

The most serious concern is amputation. People with diabetes are 15 times more likely to have amputations as a result of foot wounds or ulcers. Here’s why this happens and what you can do to prevent it.

How to help the healing process along

To help the healing process along, follow these tips:

Do regular self-checks. Catching wounds early is the key to avoiding infections and complications. Make sure you do daily self-checks and look for new wounds, especially on your feet. Don’t forget to check in between and under your toes.

Remove dead tissue. Necrosis (dead cells) and excess tissue often occur with diabetic wounds. This can promote bacteria and toxins and increase wound infection. It can also prevent you from being able to inspect the underlying tissue. Your doctor will often help you with the removal process.

Keep dressings fresh. Regularly changing dressings can help reduce bacteria and maintain appropriate moisture levels in the wound. Doctors often recommend special wound care dressings.

Keep pressure off the area. Pressure can cause wear and tear that damages the skin and leads to a deeper wound or ulcer.

When to see your doctor

If you’re dealing with a foot wound, consider wearing white socks during the healing process. This will make it easier to see blood or other signs of drainage on your socks.

See your doctor if you experience any of the following:

• tingling
• burning
• loss of sensation
• persistent pain
• swelling

You should also see your doctor if your symptoms worsen or last longer than a week.

Any break in the skin of your feet is cause for concern, so if you’re unsure about the wound, see your doctor. They can identify the wound and advise you on how best to care for it. The faster you get the appropriate treatment, the more likely you are to prevent complications.

How to promote long-term health and healing

There are a few things you can do to boost your immune system and aid in wound healing.

Eat a healthy diet. Diet has a direct influence on blood sugar levels, so maintaining proper nutrition is key. If you can consistently maintain healthy glucose levels, you’re more likely to avoid wounds and heal faster should a wound occur.

People with diabetes can often maintain better blood sugar control by avoiding processed carbohydrates, added sugars, and fast food. It also helps to increase your intake of fiber, fruits, vegetables, and legumes. Good nutrition provides what your body needs for faster wound healing, such as vitamin C, zinc, and protein.

Stay active. Exercise helps improve insulin sensitivity. This helps sugar in the bloodstream enter your cells more efficiently, which promotes healing and health.

Quit smoking. Smoking decreases your cells’ ability to carry oxygen. Smoking also disrupts the immune system and increases your risk of vascular disease.

Consider honey. Some research shows honey to be an effective alternative dressing for diabetic foot ulcer wound healing.

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The Benefits of Moist Wound Healing

TOPNURSE~Moist wound healing is the practice of keeping a wound in an optimally moist environment in order to promote faster healing. Research has shown that moist wound healing is three to five times quicker than the healing of wounds that are allowed to dry out.

British researcher George D. Winter described the benefits of moist wound healing in the 1960s. His research demonstrated that moist environments optimize healing of wounds. In the 1970s and 80s, moist wound healing became a standard practice. During the late 1980s and 90s, the field of moist wound dressings was thoroughly researched and many new wound dressing products were developed such as hydrogels, foams and alginates. Increasingly, wound dressings began to be seen as not just protective measures, but active parts of the healing process.

What are the Benefits of Moist Wound Healing?

Before the theory of moist wound healing was developed, dressings were used primarily to absorb fluid, protect the wound from injury and limit exposure to infections. The natural scab on the wound was considered to be a normal part of the healing process. However, moist healing theory discovered that by preventing the body from developing a scab, wounds could not only be healed faster, but also better. Here are some of the benefits of moist wound healing:

Wound Healing Takes Less Time: When the body creates a scab or eschar, that requires time and energy. Additional energy is required to break down the scab after the wound is healed. In a moist wound healing environment, the body is able to focus on healing the wound rather than protecting it, and wounds heal faster.

Keratinocyte Cells Function More Easily: Keratinocytes, a major component of the epidermis, have several critical roles in wound healing. The cross-talk between keratinocytes and the other types of cells involved in wound healing is crucial for effective closure of the wound. In dry wounds, keratinocytes must burrow underneath the wound bed in order to find a moist area to move forward. In a moist wound healing environment, keratinocytes can easily travel across the wound surface more quickly and easily.

Autolytic Debridement is Facilitated: Moist environments trap endogenous proteolytic enzymes in the wound. This allows those enzymes to more efficiently perform autolytic debridement to break down necrotic tissue. Along with speeding healing, moist wound environments allow for the body’s natural process of healing to work more effectively.

Decreases Incidence of Wound Infection: A moist wound environment reduces the possibility of infection by creating a hypoxic environment in the wound bed which promotes angiogenesis, decreases the pH, and makes the wound area inhospitable to bacteria.

Preserves Growth Factors in Wound Fluid: Growth factors are natural proteins which control key cellular activities during the tissue repair process. Moist wound healing allows the growth factors to be preserved on the wound bed to repair tissues more quickly.

Stimulates Collagen Synthesis: Moist wound healing promotes production of collagen by the fibroblasts. Since collagen is the basis of the new tissue that will heal the wound, this increased production helps the body lay down the matrix for new tissue more quickly so that the cells necessary for healing are attracted.

Reduces Pain: Another benefit of moist wound treatment is that there is reduced pain. With less pain, there is also a reduced stress response and less fatigue in patients which also aids in the healing process. Decreased pain can also lead to better patient mobility, which improves circulation, oxygenation, and allows for better healing.

Reduces Scarring: Moist wound treatment, by promoting the growth and movement of new cells and ensuring that proteins for closing the wound are efficient, causes reduced inflammation, promotes more even skin formation and therefore reduces scarring.

The Importance of Moist Wound Healing

For the best wound care outcome and the quickest healing process, moist wound healing is the best choice. Today's wound care dressings have moisture management properties to fulfill all of the functions of the passive dressings of earlier times, but also promote faster healing, reduce pain, encourage vapor transmission, promote autolytic debridement, and also act as a bacterial barrier.

Source

https://www.woundsource.com

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Clearing The Air About Moist Vs. Dry Wound Healing

TOPNURSE~In the beginning, long before Johnson met Johnson and Band-Aids were invented, primitive men and women suffered minor cuts and abrasions and probably left them uncovered to heal. After all, the bleeding had stopped, a scab eventually formed and experience had taught them that their skin would heal in a week or two. So there was no great rush to find a use for those puffy, cottony, soft, white plants growing in the fields just yet.

In those early days of discovery, the scab and the blister were considered nature's miracle wound coverings. The scab became our partial and temporary exoskeleton and the blister was the human equivalent of bubble wrap, both protecting the wounds and encouraging the healing process. A scab is the body's natural wound covering. As long as the site is kept moist, the scab will not inhibit the healing process. At that time, keeping scabs and blisters intact seemed like the keys to wound healing.

Drastic Wounds Call for Drastic Measures

But as time marched on and people suffered larger wounds (such as those that might be acquired while trying to take down a wild boar without decent weaponry), a need arose to stop excessive bleeding and further injury with some kind of wound covering. Trial and error most likely proved that palm leaves worked and poison ivy did not.

It wasn't until around 1500 BC that ancient Egyptians and Greeks started using lint, animal grease and honey as topical wound treatments. They had discovered that the lint provided a fibrous base that promoted wound site closure, the animal grease provided a barrier to environmental pathogens, and the honey served as an antibiotic agent.

What they may not have realized at the time was that their treatment method accelerated the wound healing process by promoting a moist wound bed.

What Is Moist Wound Healing?

There are two main components to moist wound healing: 1) Do not use disinfectants over the wound and 2) Keep the wound moist. The first component, not using disinfectants, makes sense because disinfectants such as iodine, sodium hypochlorite and hydrogen peroxide are toxic to cells and should never be applied over a wound surface. We don't want to kill cells; we want to encourage them to live and proliferate.

The second component refers to the fact that lacerations, abrasions, crush injuries and burns heal faster and with less scarring when treatment involves promoting a moist wound bed.

The proof that moist wounds heal faster than dry wounds came back in 1962, thanks to Dr. George D. Winter and his landmark paper, "Formation Of The Scab And The Rate Of Epithelialization Of Superficial Wounds In The Skin Of The Young Domestic Pig"1. His research showed that, contrary to the conventional wisdom at the time that wounds should be allowed to dry out and form scabs to promote healing, wounds instead heal faster if kept moist. Winter's work began the evolution of modern wound dressings that promote moist wound healing.

Specifically, cell growth needs moisture and the main goal of moist wound therapy is to create and maintain these optimal moist conditions. Cells can grow, divide and migrate at an increased rate to enhance the formation of new tissue. During this phase of wound healing, an aqueous medium with several nutrients and vitamins is essential for cell metabolism and growth.

The Role of Exudate in Wound Healing

In this environment, the wound exudate, the moisture that naturally seeps out from a wound site, serves as a transport vehicle for a variety of bioactive molecules such as enzymes, growth factors and hormones. The different cells in the wound area communicate with each other via these mediators, ensuring that the healing processes proceed in a coordinated manner.

Wound exudate also provides the different cells of the immune system with an ideal medium to destroy invading pathogens such as bacteria, foreign bodies and necrotic tissues, diminishing the rate of infection.

Moist wound healing inhibits the formation of a solid, impenetrable scab, which tends to block the epithelial cells from spreading horizontally through the thin layer of wound exudate and across the wound bed. The wound is then able to close quickly. In addition, pain is significantly reduced when wounds are covered with an occlusive dressing. At first, there were concerns that the presence of moisture in wounds would increase the risk of clinical infection, but that has been shown not to be the case.

To summarize, treating topical wounds is broken down into the following components:

• Cleaning the wound in order to remove dead tissue and debris
• Dressing the wound to promote a moist wound bed and to prevent reinjuring the site
• Determining the frequency of dressing changes
• Reevaluation to measure the rate of healing

Following this protocol provides:

• Up to 50% faster wound healing than dry wound healing
• A lower rate of infection
• No need of systemic antibiotics
• Painless removal of the dressing without damaging newly formed tissue
• Less scarring and better cosmetic results

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Perawatan Luka Lembab (Moist), Modern, dan Terkini

Perawatan Luka Lembab (Moist), Modern, dan Terkini

TOPNURSE~Metode perawatan luka berkembang seiring dengan perkembangan ilmu pengetahuan dan teknologi, termasuk konsep perawatan luka lembab (moist). Hal ini ditandai dengan munculnya bahan-bahan perawatan luka modern yang telah dirancang sesuai dengan karakteristik luka, sehingga proses penyembuhan luka maksimal.

Pada awalnya para ahli berpendapat bahwa penyembuhan luka akan sangat baik bila luka dibiarkan tetap kering . Mereka berpikir bahwa infeksi bakteri dapat dicegah apabila seluruh cairan yang keluar dari luka terserap oleh pembalutnya. Akibatnya sebagian besar luka dibalut oleh bahan kapas pada kondisi kering. Penelitian yang dilakukan Winter (1962) tentang keadaan lingkungan yang optimal untuk penyembuhan luka menjadi dasar diketahuinya konsep “Moist Wound Healing” (Morrison, 2004).

Perawatan Luka Lembab (Moist Wound Healing)

”Moist Wound Healing” adalah metode untuk mempertahankan kelembaban luka dengan menggunakan balutan penahan kelembaban, sehingga penyembuhan luka dan pertumbuhan jaringan dapat terjadi secara alami. Munculnya konsep “Moist Wound Healing” disertai dengan teknologi yang mendukung, hal tersebut menjadi dasar munculnya pembalut luka modern (Mutiara, 2009).

Penggunaan dan pemilihan produk-produk perawatan luka yang kurang sesuai akan menyebabkan proses inflamasi yang memanjang dan kurangnya suplai oksigen di tempat luka. Hal-hal tersebut akan memperpanjang waktu penyembuhan luka. Luka yang lama sembuh disertai dengan penurunan daya tahan tubuh pasien membuat luka semakin rentan untuk terpajan mikroorganisme yang menyebabkan infeksi (Morrison, 2004).

Mempertahankan Kelembapan

Untuk itu dikembangkan suatu metode perawatan luka dengan cara mempertahankan isolasi lingkungan luka agar tetap lembab dengan menggunakan balutan penahan kelembaban, yang dikenal dengan moist wound healing. Metode ini secara klinis memiliki keuntungan akan meningkatkan proliferasi dan migrasi dari sel-sel epitel disekitar lapisan air yang tipis, mengurangi resiko timbulnya jaringan parut dan lain-lain, disamping beberapa keunggulan metode ini dibandingkan dengan kondisi luka yang kering adalah meningkatkan epitelisasi 30- 50%, meningkatkan sintesa kolagen sebanyak 50%, rata-rata re-epitelisasi dengan kelembaban 2-5 kali lebih cepat serta dapat mengurangi kehilangan cairan dari atas permukaan luka (Tarigan, 2007).

Manfaat perawatan luka lembab

1. Luka tidak diijinkan mengering, yang mengakibatkan penyembuhan luka terus menerus 24 jam sehari, balutan ini mendukung lingkungan yang lembab.
2. Kelebihan eksudat akan dipindah. Eksudat diserap ke dalam balutan primer dan sekunder
3. Kontak antara luka dan cairan luka tetap terjaga. Berarti pasien bisa mendapatkan keuntungan dari keseimbangan normal. Faktor penyembuhan selama setiap fase penyembuhan luka.
4. Meningkatkan fungsi optimal sel dan protease yang bertanggung jawab untuk penyembuhan. Perkiraan sel meregenerasi dua kali lebih cepat, penyembuhan lembab dibanding penyembuhan kering
5. Meningkatkan penyembuhan lebih cepat dengan tingkat infeksi yang lebih rendah. Lukanya dilindungi oleh balutan yang kuat yang mana mencegah infeksi dari luar.
6. Lebih nyaman untuk pasien daripada dressing tradisional. Menjaga ujung saraf terhidrasi dalam luka mengurangi rasa sakit.
7. Perubahan perban lebih sedikit diperlukan. Pembalutan bisa dibiarkan di luka selama 3 sampai 5 hari tergantung kondisi luka.
8. Bekas luka berkurang dan lebih baik. Serat kolagen berkoordinasi lebih lurus.
9. Penurunan biaya untuk perawatan luka total. Penurunan jumlah balutan, kebutuhan obat penenang dan menurunkan total biaya bahan perban.

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Luka Bakar

Luka Bakar

TOPNURSE~Luka bakar dan luka akibat benda panas berkaitan dengan risiko tinggi kematian pada anak. Yang bertahan hidup, akan menderita cacat dan trauma psikis sebagai akibat rasa sakit dan perawatan yang lama di rumah sakit.

Penilaian

Luka bakar dapat terjadi pada sebagian lapisan kulit atau lebih dalam. Luka bakar yang dalam (full-thickness) berarti seluruh ketebalan kulit pasien mengalami kerusakan dan tidak akan terjadi regenerasi kulit.

Tanyakan dua hal berikut:

• Sedalam apakah luka bakar tersebut?
  • Luka bakar dalam, berwarna hitam/putih dan biasanya kering, tidak terasa dan tidak memucat bila ditekan.
  • Luka-bakar-sebagian, berwarna merah muda atau merah, melepuh atau berair dan nyeri.
• Seberapa luas tubuh pasien yang terbakar?
  • Gunakan bagan luas permukaan tubuh berdasarkan umur berikut ini.
  • Sebagai pilihan lain, gunakan telapak tangan pasien untuk memperkirakan luas luka bakar. Telapak tangan pasien berukuran kira-kira 1% dari total permukaan tubuhnya.

Bagan perkiraan persentase permukaan tubuh yang terbakar

Perkirakan total daerah yang terbakar dengan menjumlahkan persentase permukaan tubuh yang terkena seperti yang ditunjukkan dalam gambar (lihat tabel untuk daerah A–F yang berubah sesuai dengan umur pasien).

Tatalaksana

• Rawat inap semua pasien dengan luka bakar >10% permukaan tubuh; yang meliputi wajah, tangan, kaki, perineum, melewati sendi; luka bakar yang melingkar dan yang tidak bisa berobat jalan.
• Periksa apakah pasien mengalami cedera saluran respiratorik karena menghirup asap (napas mengorok, bulu hidung terbakar),
  • Luka bakar wajah yang berat atau trauma inhalasi mungkin memerlukan intubasi, trakeostomi
  • Jika terdapat bukti ada distres pernapasan, beri oksigen .
• Resusitasi cairan (diperlukan untuk luka bakar permukaan tubuh > 10%). Gunakan larutan Ringer laktat dengan glukosa 5%, larutan garam normal dengan glukosa 5%, atau setengah garam normal dengan glukosa 5%.
  • 24 jam pertama: hitung kebutuhan cairan dengan menambahkan cairan dari kebutuhan cairan rumatan dan kebutuhan cairan resusitasi (4 ml/kgBB untuk setiap 1% permukaan tubuh yang terbakar)
    • Berikan ½ dari total kebutuhan cairan dalam waktu 8 jam pertama, dan sisanya 16 jam berikutnya.
      Contoh: untuk pasien dengan berat badan 20 kg dengan luka bakar 25%
      Total cairan dalam waktu 24 jam pertama
      = (60 ml/jam x 24 jam) + 4 ml x 20kg x 25% luka bakar
      = 1440 ml + 2000 ml
      = 3440 ml (1720 ml selama 8 jam pertama)
  • 24 jam kedua: berikan ½ hingga ¾ cairan yang diperlukan selama hari pertama
  • Awasi pasien dengan ketat selama resusitasi (denyut nadi, frekuensi napas, tekanan darah dan jumlah air seni)
  • Transfusi darah mungkin diberikan untuk memperbaiki anemia atau pada luka-bakar yang dalam untuk mengganti kehilangan darah.
• Mencegah Infeksi
  • Jika kulit masih utuh, bersihkan dengan larutan antiseptik secara perlahan tanpa merobeknya.
  • Jika kulit tidak utuh, hati-hati bersihkan luka bakar. Kulit yang melepuh harus dikempiskan dan kulit yang mati dibuang.
  • Berikan antibiotik topikal/antiseptik (ada beberapa pilihan bergantung ketersediaan obat: peraknitrat, perak-sulfadiazin, gentian violet, povidon dan bahkan buah pepaya tumbuk). Antiseptik pilihan adalah perak-sulfadiazin karena dapat menembus bagian kulit yang sudah mati. Bersihkan dan balut luka setiap hari.
  • Luka bakar kecil atau yang terjadi pada daerah yang sulit untuk ditutup dapat dibiarkan terbuka serta dijaga agar tetap kering dan bersih.
• Obati bila terjadi infeksi sekunder
  • Jika jelas terjadi infeksi lokal (nanah, bau busuk, selulitis), kompres jaringan bernanah dengan kasa lembap, lakukan nekrotomi, obati dengan amoksisilin oral (15 mg/kgBB/dosis 3 kali sehari), dan kloksasilin (25 mg/kgBB/dosis 4 kali sehari). Jika dicurigai terdapat septisemia gunakan gentamisin (7.5 mg/kgBB IV/IM sekali sehari) ditambah kloksasilin (25–50 mg/kgBB/dosis IV/IM 4 kali sehari). Jika dicurigai terjadi infeksi di bawah keropeng, buang keropeng tersebut .
• Menangani rasa sakit
  • Pastikan penanganan rasa sakit yang diberikan kepada pasien adekuattermasuk perlakuan sebelum prosedur penanganan, seperti mengganti balutan.
  • Beri parasetamol oral (10–15 mg/kgBB setiap 6 jam) atau analgesik narkotik IV (IM menyakitkan), seperti morfin sulfat (0.05–0,1 mg/kg BB IV setiap 2–4 jam) jika sangat sakit.
• Periksa status imunisasi tetanus
  • Bila belum diimunisasi, beri ATS atau immunoglobulin tetanus (jika ada)
  • Bila sudah diimunisasi, beri ulangan imunisasi TT (Tetanus Toksoid) jika sudah waktunya.
• Nutrisi
  • Bila mungkin mulai beri makan segera dalam waktu 24 jam pertama.
  • Anak harus mendapat diet tinggi kalori yang mengandung cukup protein, vitamin dan suplemen zat besi.
  • Anak dengan luka bakar luas membutuhkan 1.5 kali kalori normal dan 2-3 kali kebutuhan protein normal.

Kontraktur luka bakar

​Luka bakar yang melewati permukaan fleksor anggota tubuh dapat mengalami kontraktur, walaupun telah mendapatkan penanganan yang terbaik (hampir selalu terjadi pada penanganan yang buruk).

• Cegah kontraktur dengan mobilisasi pasif atau dengan membidai permukaan fleksor Balutan dapat menggunakan gips. Balutan ini harus dipakai pada waktu pasien tidur.

Fisioterapi dan rehabilitasi

• Harus dimulai sedini mungkin dan berlanjut selama proses perawatan luka bakar.
• Jika pasien dirawat-inap dalam jangka waktu yang cukup lama, sediakan mainan untuk pasien dan beri semangat untuk tetap bermain.

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