KONSEP LEMBAB DALAM PERAWATAN LUKA

Konsep atau prinsip lembab dalam perawatan  luka saat ini menjadi paradigma baru dalam konteks perawatan luka Penelitian Winter pada tahun 1962 menunjukkan bahwa penggunaan occlusive dressing meningkatkan proses penyembuhan dua kali lipat dibandingkan dengan membiarkan luka tetap terbuka. Hinman dan Maibach melaporkan hasil yang sama pada sembilan orang sukarelawan.

KEUNTUNGAN KONSEP LEMBAB

Beberapa studi telah menunjukkan bahwa lingkungan lembab  mempercepat proses epitelisasi dan untuk menciptakan lingkungan lembab dapat dilakukan dengan menggunanakan balutan semi occlusive, full occulisive dan impermeable dressing. (Schulitz, et al. 2005). Menurut Haimowitz, Julia.E., 1997, ada beberapa keuntungan prinsip moisture dalam perawatan luka, diantaranya:

• Mencegah luka menjadi kering dan keras. 
• Meningkatkan laju epitelisasi.
• Menjagah pembentukan jaringan eschar
• Meningkatkan pembentukan jaringan dermis. 
• Mengontrol inflamasi dan memberikan tampilan yang lebih kosmetis.
• Mempercepat proses autolysis debridement. 
• Dapat menurunkan kejadian infeksi. 
• Cost effective. 
• Mempertahankan gradient voltase normal. 
• Mempertahankan aktifitas neutrofil. 
• Menurunkan nyeri. 
• Memberikan keuntungan psikologis. 
• Mudah digunakan.

Ada banyak cara yang bisa digunakan untuk menciptakan kondisi lembab pada luka.Berikut beberapa contoh dressing yang bisa menjadi pilihan

KASA dan Normal Saline

Cara konvensional dan terkenal adalah menggunakan kasa yang dilembabkan dengan NaCL, cara ini bisa menciptakan suasana lembab tapi tidak dapat bertahan dalam jangka waktu yang lama sebaliknya cara ini bisa menimbulkan nyeri (pada beberapa pasien) saat pergantian balutan ketika kasa telah mengering.

TRANSPARANT FILMS DRESSING

Film dressing terbuat dari polyurethane memiliki sifat tipis, transparent, dan merekat. Transparan film memungkinkan transmisi uap air, oxygen dan karbondioksida namun tidak memiliki sifat absorben sehingga tidak tepat digunakan pada luka dengan eksudat. Umumnya digunakan untuk balutan intravena dan fiksasi kateter. Keistimewaan film dressing karena hanya merekat pada daerah yang kering sehingga tidak berpotensi mengganggu dasar luka (wound bed), meskipun demikian perlu hati-hati saat menggunakan dalam fase epitelisasi sebab aplikasi film dressing bisa melepaskan epitel-epitel yang masih muda. Contoh Film; Op-Site (Smith and Nephew)., Polyskin (Kendall Healthcare).

HYDROGELS

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Hydrogels merupakan polymer dengan kandungan air 90-95 % dan memiliki sifat semi transparan dan nonadherent (Hest, CT. 1995., Jeter, KF &Tintle, TE. 1991). Di pasaran hydrogel tersedia dalam bentuk pasta dan lembaran (sheet). Bentuk lembaran sangat comformable sehingga bisa mengikuti tekstur luka dan dapat mengabsorbsi eksudat dalam jumlah sedikit atau sedang. Karena sifatnya yang tidak lengket maka tidak menimbulkan nyeri saat pergantian balutan namun sifat ini pula yang mengharuskan hydrogel didampingi oleh balutan sekunder. Contoh Hydrogels; Nu-Gel (Johnson & Johnson Medical, Inc)., Hypergel (Molnlyncke), dan Intrasite Gel (Smith and Nephew).

HYDROCOLLOIDS

Hydrocolloid sebenarnya sudah digunakan secara luas sejak tahun 1982 (Haimowitz, Julia.E., 1997) dan risetnya sudah dimulai sejak tahun 1970an, jadi istilah modern dressing sebenarnya kurang tepat.

Beberapa wound expert menyatakan bahwa hydrocolloid merupakan balutan yang hampir memenuhi semua kriteria balutan ideal. Hydrocolloid memiliki sifat impermeable terhadap cairan dan oksigen, mengandung polyurethane, adherent (merekat) namun tidak menimbulkan nyeri. Kemampuan hydrocolloid dalam menyerap kelembaban yang berlebih membuatnya menjadi dressing favorit pilihan pemirsa…eh maaf, perawat. Sama halnya dengan hydrogel, hydrocolloid juga tersedia dalam kemasan pasta atau lembaran dan salah satu kelebihan hydrocolloid adalah kemampuannya untuk bertahan pada luka hingga tujuah hari, dengan demikian akan menurunkan nursing time. Contoh Hydrocolloid; DuoDerm (Convatec), Tegasorb (3M health Care), dan Comfeel (Coloplast).

FOAM

Foam dressing juga tersusun oleh polyurethane dan sangat comformable, permeable, non adherent  serta mudah diaplikasikan pada luka. Foam memiliki kapasitas yang tinggi utnuk mengabsorbsi eksudat. Foam juga mampu menyerap kelebihan kelembaban sehingga mengurangi resiko maserasi selain itu juga tidak menimbulkan nyeri dan trauma pada jaringan luka saat penggantian. 
Contoh foam antara lain Allevyn (Smith and Nephew)., Hydrasorb (Convatec) dan Cutinova (Beirsdeorf-Jobst, Inc).

Namun apapun jenis balutannya yang paling menentukan adalah keterampilan dan kemampuan perawat dalam mengambil keputusan klinis. Sebuah balutan mungkin cocok bagi satu pasien namun bisa jadi tidak tepat pada pasien yang berbeda dengan jenis luka yang sama.

REFERENSI:

1. Winter, GD. Formation of the scab and the rate of epithelialization of superficial wounds in the skin of the youn domestic pig. Nature. 1962; 193:293-294.

2. Schulitz, Gregory., Mozingo, David., Romanelli, Marco., Claxton, Karl. (2005) Wound healing and TIME; new concepts and scientific applications. Wound Repair and regeneration. 13(4):S1-S11.

3.  Haimowitz, JE., Margolis, DM. (1997) Moist wound healing. In: Krasner D, Kane, D. Chronic Wound Care, second edition. Wayne, PA. Health Management Publications, Inc., pp49-56

4.  Hinman, CD., Maibach, H. Effect of air exposure and occlusion on ecperimental human skin wound. Nature 1963; 200:377-378

PERUBAHAN POSISI UNTUK MENCEGAH DECUBITUS

Reposisi merupakan modalitas penting dalam pencegahan decubitus. Dalam kondis normal ketidaknyamanan dan rasa nyeri menstimulasi individu untuk melakukan perubahan posisi. Namun dalam beberapa kondisi medis individu bisa merasakan ketidaknyaman dan sensasi nyeri tersebut tapi tidak mampu melakukan perubahan posisi secara mandiri. Kegagalan dalam melakukan perubahan posisi berdampak pada memanjangnya durasi tekanan terhadap jaringan yang mengarah pada ischemic dan berakhir pada nekrosis jaringan.

Menurut EPUAP-NPUAP 2009 tujuan utama reposisi adalah mendistribusikan tekanan baik dalam posisi duduk atau berbaring serta memberikan kenyamanan pada pasien. Namun menurut hemat penulis sebenarnya tujuan ini kurang tepat. Ketika pasien berbaring dalam posisi supinasi maka tekanan terbesar berada pada daerah sacrum, kemudian ketika kita melakukan reposisi, misalnya pasien dimiringkan ke lateral kanan maka sebenarnya kita tidak mendistribusikan tekanan tapi memindahkan tekanan dari daerah sacrum ke daerah trochanter kanan.

Kalau begitu apa tujuan perubahan posisi?

Ada banyak manfaat yang bisa dirasakan oleh pasien terutama jaringan yang tertekan lama, anatara lain:

1. Memberikan kesempatan kepada daerah yang tertekan untuk reperfusi.

2. Memungkinkan evaporasi pada daerah yang tertekan sehingga suhu kulit daerah yang tertekan bisa diturunkan.

3. Menghindari akumulasi kelembaban antara kulit pasien dan permukaan tempat tidur.

4.  Bagi perawat reposisibisa digunakan untuk menginspeksi kulit yang tertekan sekaligus melakukan skin care yang diperlukan.

Berapa kali sebaiknya pasien yang beresiko decubitus untuk direposisi?

Berapa lama frekuensi yang terbaik untuk perubahan posisi masih belum diketahui dan kurangnya bukti-bukti riset yang menunjang (Moore & Cowman, 2009; Pieper, 2007) namun Cochrane review menyatakan bahwa durasi dua jam dalam satu posisi merupakan durasi maksimal yang direkomendasikan pada pasien dengan kapasitas sirkulasi yang normal (Moore & Cowman, 2009)

Terlepas dari polemik berapa jam frekuensi perubahan posisi, ada beberapa hal yang perlu diperhatikan dalam memutuskan berapa lama pasien sebaiknya direposisi, salah satunya adalah kondisi pasien secara umum, jangan sampai perubahan posisi justru memperburuk kondisi klinis pasien. Sebagai contoh pada pasien dengan  gangguan respirasi dan sirkulasi perubahan posisi yang sering mungkin akan berdampak pada status hemodinamik pasien oleh karena itu intensitas reposisi perlu mempertimbangkan stabilitas pasien.

Pada pasien yang menggunakan kasur anti decubitus masih perlukah dilakukan reposisi?

Perlu diketahui bahwa tidak ada kasur anti decubitus (support surface) yang benar-benar efektif mencegah decubitus. Oleh karena itu meskipun pasien telah menggunakan kasur anti decubitus perubahan posisi tetap diperlukan. Bedanya adalah durasi perubahan posisi antara pasien yang menggunakan kasur anti decuitus dan matras biasa. Deflor et al (2005) menemukan bahwa perubahan posisi setiap 4 jam pada visco-elastic foam matrass menurunkan resiko decubitus bila dibandingkan reposisi setiap 2-3 jam pada pasien yang menggunakan matrass biasa.

Pada dasarnya perubahan posisi bagian dari kebutuhan dasar manusia dan  Allah SWT telah mengisyaratkan perubahan posisi dalam Surah Ash-Habul Kahfi sebagai modalitas dalam pencegahan decubitus. Cuma sayangnya ada beberapa pasien yang tidak memiliki kemampuan untuk bergerak bebas secara mandiri. Oleh karena itu membantu pasien yang beresiko mengalami decubitus merupakan panggilan suara hati yang hanya bisa dilakukan oleh jiwa-jiwa yang amanah. Ayo ners show that you care…

KARAKTERISTIK EKSUDAT

Pada postingan sebelumnya kita telah mendiskusikan bahwa balutan lama jangan lansung dibuang. Sebab keberadaan eksudat bisa menjadi sumber informasi mengenai proses penyembuhan luka dan efektifitas perawatan luka yang telah diberikan.

Eksudat dapat dibaca melalui warna, konsistensi dan bau. tabel berikut menunjukkan interpretasi dari karakteristik eksudat.

WARNA EKSUDAT
Karakteristik	Kemungkinan Penyebab
Jernih, kuning jernih.	Serous exudate, sering dianggap sebagai eksudat normal, namun kadang-kadang dapat berhubungan dengan infeksi bakteri (staphylococcus aureus) atau adanya cairan dari tractus urinarius atau fistula limfatik.
Berkabut, seperti susu atau krim Cloudy, milky or creamy	Dapat mengindikasikan keberadaan fibrin (respon inflamasi) atau infkesi (eksudat yang purulent yang mengandung leukosit dan bakteri).
Pink atau merah	Berhubungan dengan keberadaan eritrosit dan mengindikasikan adanya kerusakan kapiler (sanguineous or haemorrhagic exudate).
Hijau	Dapat mengindikasikan adanya infeksi bakteri, seperti; Pseudomonas aeruginosa.
Kuning atau coklat	Dapat mengindikasikan keberadaan slough atau substansi yang berasal dari fistula gastrointestinal atau urinary.
Abu-abu atau biru	Berhubungan dengan penggunaan balutan yang mengandung silver.
KONSISTENSI EKSUDAT
Karakteristik	Kemungkinan Penyebab
Kental (High viscosity) High viscosity (thick, sometimes sticky)	Tinggi kandungan protein, berhubungan dengan Infeksi. Proses inflamasi Material nekrotik. Fistula enteric. Residu dari beberapa jenis balutan atau topical terapi.
Encer (Low viscosity). Low viscosity (thin, ‘runny’)	Rendah kandungan protein, berhubungan dengan: Penyakit vena atau penyakit jantung congestif. Malnutrisi.  Urinary, limfatik, atau fistula pada persendian.
BAU EKSUDAT
Karakteristik	Kemungkinan Penyebab
Bau tidak sedap	Pertumbuhan bakteri atau infeksi. Nekrotik jaringan. Fistula atau sinus enteric atau urinary.
**NB Beberapa balutan seperti hydrocolloid dapat menghasilkan bau.

Dibutuhkan empati yang mendalam bagi perawat, agar bisa memahami pesan yang disampaikan oleh eksudat.

References:

1.        World Union of Wound Healing Societies (WUWHS). Principles of best practice: Wound exudate and the role of dressing. A consensus document.London: MEP Ltd. 2007

PEMBALUT WANITA, ALTERNATIF BALUTAN LUKA

Produksi eksudat yang terjadi terus menerus tentunya akan menunda dan memperpanjang proses penyembuhan luka atau delayed healing. Produksi eksudat yang berlebihan akan mengganggu kenyaman pasien, menyita waktu perawat (nursing time) dan tingginya biaya perawatan Oleh karena itu manajemen eksudat langkah yang menentukan dalam keberhasilan perawatan luka.

Tidak Ada Rotan Akarpun Jadi

Salah satu tujuan dalam manajemen eksudat adalah mengabsorbsi. Saat ini beragam jenis modern dressing telah tersedia sebagai absorben eksudat seperti foam dressing dan VAC Therapy. Sayangnya terbatasnya ketersediaan absorben dressing dan mahalnya harga membuat penangana eksudat masih bersifat konvensional. Untuk itu alternatife dressing dibutuhkan sebagai pengganti dalam konteks cost effective.

EVIDENCE BASED

Alqahtani and Lalonde (2006) melaporkan bahwa dari 20 balutan steril dua diantaranya mengandung bakteri (coagulase-negative staphylococcus dan nonhemolytic streptococcus) secara mengejutkan dari 20 pembalut wanita hanya satu yang mengandung bakteri (coagulase-negative staphylococcus). Masih menurut Mas Alqahtani, dari segi biaya (cost effective), penggunaan balutan steril dengan ukuran 20 cm x 5 cm untuk perawatan luka selama satu bulan ternyata menghabiskan $ 16.50 sedangkan dengan menggunakan pembalut wanita hanya menghabiskan $ 2.43. Untuk kita di Indonesia foam dressing bisa kita dapatkan dengan kisaran harga Rp. 70.000 di apotik tertentu sedangkan pembalut wanita bisa kita dapatkan dimana saja dengan harga Rp. 500 per piece.

Tapi pembalut wanita tidak steril

Stootts., et al (1997) menemukan bahwa tidak ada perbedaan signifikan rata-rata masa penyembuhan antara luka yang dirawat dengan menggunakan prinsip steril dan bersih bahkan menggunakan prinsip bersih dapat menurunkan biaya secara signifikan dibandingkan kelompok pasien yang dirawat dengan prinsip steril. Lawson., et al (2003) menambahkan bahwa 9 (0.84%) dari 1.070 pasien yang dirawat dengan menggunakan prinsip steril mengalami surgical site infection sedangkan pada kelompok pasien yang dirawat dengan prinsip bersih insidens surgical site infection sebesar 0.83 % dari 983 pasien. Temuan ini sekali lagi membuktikan bahwa tidak ada perbedaan antara prinsip perawatan luka steril dan bersih.

Meskipun penelitian diatas masih bersifat case report, clinical study, dan observational study, namun sudah bisa kita kategorikan evidence level C. artinya pembalut wanita bisa menjadi alternative dressing dalam perawatan luka, terutama untuk mengatasi produksi eksudat yang berlebihan. Terutama apabila kita diperhadapkan pada kondisi tidak adanya modern dressing atau lemahnya daya beli pasien. Buat sejawat yang biasa terjun ke lokasi bencana, jangan lupa bawa pembalut wanita…..

Baca Juga:

• Wound Cleaning, Clean Up Our Minds
• Sterile Versus Non Sterile Clean Dressing
• Does Sterile or Non Sterile Technique Makes A Difference in Healing by Secondary Intention

References

1.        Barber LA. Clean technique or sterile technique? Let’s take a moment to think. J Wound Ostomy Continence Nurs 2002;29:29-32.

2.        Perelman VS, Francis GJ, Rutledge T, Foote J, Martino F, Dranitsaris G. Sterile versus nonsterile gloves for repair of uncomplicated lacerations in the emergency department: A randomized controlled trial. Ann Emerg Med 2004;43:362-70.

3.        Stotts NA, Barbour S, Griggs K, et al. Sterile versus clean technique in postoperative wound care of patients with open surgical wounds: A pilot study. J Wound Ostomy Continence Nurs 1997;24:10-8.

4.        Lawson C, Juliano L, Ratliff CR. Does sterile or nonsterile technique make a difference in wounds healing by secondary intention? Ostomy Wound Manage 2003;49:56-8,60.

Sterile versus nonsterile clean dressings

Moraya Alqahtani, MBBS¹ and Donald H Lalonde, MD BSc MSc FRCSC²

¹ Plastic Surgery, Dalhousie University, Halifax, Nova Scotia

² St John Regional Hospital, St John, New Brunswick

Correspondence and reprints: Dr Moraya Alqahtani, 67 Keyworth Lane, Halifax, Nova Scotia B3P 2T6. Telephone 902-446-5388, fax 902-446-5388, e-mail malqahtani@dal.ca

Abstract

 

BACKGROUND

Many patients cannot afford sterile dressings. In St John, New Brunswick, clean dressings have been used instead of sterile dressings for years, with no apparent ill effects. No previous studies have compared the sterility and cost of clean versus sterile dressing materials.

 

OBJECTIVES

The goals of the present study were to answer the following questions: how much more sterile are sterile dressings than clean dressings; and how much does this extra sterility cost?

METHODS

Sterility and cost of sterile gauze, panty liners, sanitary napkins, diapers and Coban tape (3M, USA) were compared. Samples, 2 cm × 2 cm in size, were cut out of each material under aseptic conditions, and delivered to the microbiology laboratory in sterile urine containers. The samples were then cultured and organisms were identified using conventional means.

 

RESULTS

The cost for one month, using one 20 cm × 5 cm wound dressing daily, was calculated and compared with panty liners ($2.43), sanitary napkins ($5.55), diapers ($9.39) and Coban tape ($0.66), which were much cheaper than sterile dressings ($16.50). How sterile were the dressings? None of the 20 sanitary napkins grew bacteria, one of the 20 panty liners grew bacteria (coagulase-negative Staphylococcus), two of 20 sterile dressings grew bacteria (one coagulase-negative Staphylococcus and one nonhemolytic Streptococcus), 15 of 20 diapers grew bacteria (all bacillus) and two of five Coban rolls grew bacteria (one bacillus and one coagulase-negative Staphylococcus). read more

 

Source:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2539027/

Does Sterile or Nonsterile Technique Make a Difference in Wounds Healing by Secondary Intention?

VOLUME: 49

Issue Number: 

4

author: 

Carol Lawson, RN, BSN; Lynn Juliano, RN, BSN; and Catherine R. Ratliff, PhD, GNP, CWOCN, CS

 

In the spring of 1998, nursing staff on two surgical units at a major medical center noticed inconsistencies in the care of open surgical wounds. Some nurses used sterile while others employed a clean dressing change technique. Because the nursing staff felt that existing wound care literature did not support the selection of one technique over another, they wanted to establish their own consistent guidelines based on infection rates and costs. Surgical site infections for wounds healing by secondary intention for more than 5,000 patients during the previous 15 months on the two surgical units showed a 1.2% wound infection rate. Because the surgical site infection rate was low, the nursing staff wanted to know if the infection rate would remain low if everyone practiced clean technique in order to provide a more consistent cost-effective practice.

Literature Review

The clean-versus-sterile technique debate has been waged among clinicians for years with no consensus of opinion. The terms "sterile" and "clean" have many different meanings among healthcare providers.^1,2 Sterile technique involves methods to reduce exposure to micro-organisms, including hand washing, and using a sterile field, instruments, gloves, and sterile dressing. Sterile dressing change may be defined as the replacement of the wound dressing using sterile technique and supplies. Clean technique involves employing methods to reduce the overall number of micro-organisms. Clean technique involves hand washing, preparing a clean field, and using clean gloves and instruments. Clean dressing change may be defined as the replacement of the wound dressing using clean technique and supplies. When considering which technique to use, the major concern is reducing the infection risk to the patient. Universal precautions should be the most essential component regardless of the technique used.

In 1993, Stotts et al³ surveyed members of the Wound Ostomy Continence Nurses Society regarding wound care practices. Of the 240 members who returned the surveys, 51% reported using sterile technique and 43% reported using nonsterile technique. However, these percentages varied widely when type of wound and setting were taken into consideration. Sterile technique was performed more frequently in the acute care facilities. Also, with the exception of immunosuppression, risk factors such as impaired perfusion were not deemed sufficient to warrant the use of sterile technique.

Wounds healing by secondary intention require dressings to provide a moist environment, debride necrotic tissue, absorb exudate, and protect the wound from trauma and contamination. In preparing patients for hospital discharge, respondents reported that 90% of patients with open wounds were taught to perform nonsterile technique regardless of the method used during hospitalizations. Consistency between what patients and caregivers are taught and actual practice during hospitalization is important in reinforcing home care instructions.

In 1997, the Nursing Consortium for Research and Practice⁴ surveyed 743 staff nurses from five healthcare agencies in San Francisco, Calif. regarding glove use. Sixty-one percent of respondents (n = 427) indicated that their choice of sterile or nonsterile gloves varied. Sterile gloves were chosen more often than nonsterile gloves for packing wounds and for dressing purulent wounds, tunneling wounds, and exposed orthopedic wounds. Clean gloves were generally used for dressing changes over intact surgical wounds and pressure ulcers. Acute care nurses indicated they were likely to use sterile gloves about 80% of the time (n = 544). Technique choices among staff nurses were based on the educational level of the provider and perception of the infection risk to the patient. A scientific foundation for wound care practice choices was not evident.

Despite the lack of specific evidenced-based research to support this practice, nurses are traditionally taught to use sterile techniques when caring for surgical wounds. Recent studies examining the effect of bacterial bioburden on healing suggest that clean technique may not have a substantial effect on the rate of healing or increase the rate of infection.⁵ Specifically, in a controlled clinical pilot study involving 30 patients undergoing gastrointestinal surgery, Stotts et al⁵ compared clean to sterile dressing change techniques. The principle variables for this study were cost and wound healing rate; secondary variables addressed wound infection, wound perfusion, nutrition, and immunologic status. Subjects were randomly assigned to clean and sterile wound dressing changes three times per day and monitored for 3 to 9 days. Wound healing rates did not vary between the clean and sterile groups, but the cost associated with dressing changes using clean technique was significantly less than the costs of using sterile technique (P < 0.05). However, generalization of these findings are limited by the small study sample size and short study duration.

Two studies examined contamination of boxes containing nonsterile gloves. Sadowski et al⁶ obtained cultures from glove boxes (n = 32) in patients' rooms to investigate the infection risk of using nonsterile gloves in 13 burn patients. Although cultures of the wound exudate of 11 of 13 patients (85%) showed evidence of Staphylococcus aureus, the patients and not the gloves proved to be the sources of contamination. Rossoff et al⁷ looked at 29 boxes of nonsterile gloves from patient rooms and also found contamination of the gloves but with a low bacterial bioburden. The clean glove boxes in this study were located directly outside the hospital rooms.

Purpose and Methodology

The purpose of this study was to determine differences in infection rates and costs of using sterile versus clean dressing change technique in the management of open surgical wounds.

A nonexperimental, longitudinal study design was used to monitor the infection rates and supply usage on two acute care surgical units at a major medical center for 3 months before and 3 months after implementation of nonsterile wound care for all patients with open surgical wounds. The two acute care units in the study comprise patients from the services of digestive health, trauma, transplant, general surgery, and urology. The sample included all hospitalized adult patients with one or more open surgical wounds healing by secondary intention who were receiving dressing changes three times per day with normal saline. The study was approved by the hospital's institutional review board.

Infection control tracks all hospital-acquired infections, including surgical site infections, through the documentation of culture results. This practice was not changed during the study period. Quarterly unit data of these rates are provided to the managers of the units for monitoring purposes. Managers also receive monthly cost reports of supply usage for their units for budgetary monitoring purposes. Before starting the second 3-month phase of the study, all registered nurses working on the two units were instructed in the clean wound care procedure (see Table 1). The nurses typically rotate between the two units based on clinical need. Descriptive statistics were used to describe the infection rates and supply costs for the study period.

Results

Three months before the change in wound care procedures, nine surgical site infections were recorded in 1,070 admissions to the two surgical units (rate .84%). During the next 3 months, following the change in procedures, eight surgical site infections were detected out of 963 admissions to the two units for a rate of .83%. The difference in wound infection rates 3 months before and after the change in protocol was not statistically significant.

Following a change in wound care procedures, when the need for sterile supplies was eliminated (staff no longer used sterile gloves, scissors, or bowls) the surgical units' supply budget decreased by $380. For the two acute care nursing units involved in the study, this could mean saving approximately $1,520 per year. Additionally, two nurses timed the two different dressings techniques and determined that approximately 10 minutes is needed to perform nonsterile wound care; whereas, sterile wound care takes approximately 13 minutes to complete. This means almost 10 minutes (three wound changes times 3 minutes) of a nurse's day could be spent carrying out other responsibilities.

Discussion

This study has several limitations. First, the number of surgical site infections is based on the documentation of a positive wound culture. Because cultures may not have been performed on all infected wounds, the number of wound infections may be underreported. Second, knowing the exact number of open surgical wounds that were seen during the study period rather than just the number of patients admitted during the study period would have provided a more accurate comparison of open wounds and exactly how many became infected. Third, the sample size is small, making it difficult to generalize these findings to other settings and patient populations. Prospective, randomized controlled studies on sterile-versus-clean technique need to be conducted and replicated to practice evidenced-based care. In this practice setting, surgical site infection rates on the open surgical wounds were monitored for a year following the study with no measurable increase in infection rates. Because the change in wound care procedures does not appear to jeopardize outcomes, policies and procedures have been implemented to reflect the standardization of clean technique for open surgical wounds to save costs and nursing time while maintaining consistency for patient teaching of wound care following discharge.

Conclusion

With the dramatic increases in healthcare costs, healthcare providers must examine their practices to ensure the delivery of high quality, cost-effective, care. In this study, using clean technique when changing dressings for surgical wounds healing by secondary intention did not increase wound infection rates and saved time and money. - OWM

References: 

1. Faller NA. A survey exploring the ET nursing art of wound care: factors associated with clean versus sterile technique. Amherst, Mass.: University of Massachusetts, Doctoral Dissertation, 1997.
2. Gray M, Doughty D. Clean versus sterile technique when changing wound dressings. JWOCN. 2001;28:125-128.
3. Stotts NA, Barbour S, Slaughter R, Wipke-Tevis D. Wound care practices in the United States. Ostomy/Wound Management. 1993;39(3):53-70.
4. Wise LC, Hoffman J, Grant L, Bostrum J. Nursing wound care survey: Sterile and nonsterile glove choice. JWOCN. 1997;24:144-50.
5. Stotts NA, Barbour S, Griggs K, et al. Sterile versus clean technique in postoperative wound care of patients with open surgical wounds: a pilot study. JWOCN. 1997;24(1):10-18.
6. Sadowski DA, Pohlman S, Maley MP, Warden GD. Use of nonsterile gloves for routine noninvasive procedures in thermally injured patients. Journal of Burn Care and Rehab. 1988;9(6):613-615.
7. Rossoff LJ, Lam S, Hilton E, Borenstein M, Isenberg HD. Is the use of boxed gloves in an intensive care unit safe? Am J Med. 1993;94(6):602-607.

 

source:http://www.o-wm.com/article/1544

KONSEP DASAR LUKA INFEKSI

Saldy Yusuf, S.Kep.Ns.ETN

Griya Afiat Makassar

Infeksi adalah kolonalisasi yang dilakukan oleh spesies asing terhadap organisme inang, dan bersifat paling membahayakan inang. Organisme penginfeksi, atau patogen, menggunakan sarana yang dimiliki inang untuk dapat memperbanyak diri, yang pada akhirnya merugikan inang. Patogen mengganggu fungsi normal inang dan dapat berakibat pada luka kronik, gangrene, kehilangan organ tubuh, dan bahkan kematian. Respons inang terhadap infeksi disebut peradangan. Secara umum, patogen umumnya dikategorikan sebagai organisme mikroskopik, walaupun sebenarnya definisinya lebih luas, mencakupbakteri, parasit, fungi, virus, prion, dan viroid. (http://id.wikipedia.org/wiki/Infeksi).

Beberapa jenis mikroorganisme (terutama bakteri) dapat berkembang biak, menyerang  hingga merusak jaringan sehingga menyebabkan ‘delayed healing’ yang akan kadang-kadang dapat pula menyebabkan penyakit sistemik. Kemampuan bakteri untuk menghasilkan efek yang merusak dipengaruhi oleh:

• Kemampuan system imunitas pasien untuk menyerang bakteri (host resistence).
• Jumlah bakteri pada luka, semakin banyak bakteri akan semakin beresiko. 
• Jenis bakteri pada luka. Beberapa bakteri memiliki kemampuan besar (virulensi) dibanding jenis lain dan dapat menyebabkan penyakit walaupun masih dalam jumlah yang sedikit. read more...

KONSEP DASAR LUKA

Saldy Yusuf, S.Kep.Ns.ETN

Griya Afiat Makassar

A. PENDAHULUAN

Seseorang yang menderita luka akan merasakan adanya ketidaksempurnaan yang pada akhirnya cenderung untuk mengalami gangguan fisik dan emosional (Hyland.  1994).  Sehingga  tidak  dapat  dipungkiri  bahwa  luka  akan mempengaruhi kualitas hidup seseorang. Sebagai contoh, pasien dengan luka kanker dengan eksudat yang banyak dan sangat berbau tentunya bukan hanya menjadi gangguan kesehatan bagi klien akan tetapi juga akan mempengaruhi gangguan interaksi pasien.

Menurut Schipper (1996) ada empat domain kualitas hidup yang bisa terkena dampak dari luka yaitu: Fungsi fisik dan pekerjaan, fungsi psikologis, interaksi sosial, sensasi somatik dan dampak finansial. Jadi kalau kita menggunakan model berpikir ESQ (berpikir melingkar) maka perawatan luka butuh pendekatan yang kompleks kita tidak hanya melihat lokasi  luka, mencium bau luka, mengganti balutan luka tapi lebih dari itu ada faktor-faktor lain yang harus diperhatikan dengan seksama.read more...

GAGAL KULIT

Istilah “Gagal Jantung” dan “Gagal Ginjal” tidak asing lagi di telinga kita sebagai praktisi di bidang kesehatan. Tapi pernahkan kita mendengar istilah “Gagal Kulit”?. Ya…”Gagal Kulit” atau “Skin Failure” merupakan istilah yang relatif baru dan masih terasa asing di telinga kita. Hal ini disebabkan kita jarang memandang kulit sebagai sebuah organ dan bagian integral dari system tubuh.

Padahal kulit merupakan system organ tubuh yang terbesar yang sangat beresiko untuk mengalami kerusakan baik akibat injury eksternal maupun injury internal. Seperti halnya miokardium, dapat mengalami ischemic hinggal infark akibat gangguan suplay oksigen. Kulit dapat mengalami kerusakan hingga kematian akibat gangguan suplay oksigen seperti adanya peningkatan interface pressure lebih dari 32 mmHg dapat menyebabkan decubitus.

Sayangnya, berdasarkan hasil kongres organ-organ internal tubuh kita yang dihadiri oleh Jantung, ginjal, hati, kulit. Sayangnya kulit kaki tidak dapat hadir karena mengalami leg ulcer, kulit bokong pun tidak bisa datang karena mengalami decubitus, apalagi kulit tangan baru saja kena luka bakar akiabt ledakan tabung gas 3 Kg, hehehe…

Kongres dipimpin oleh Mr. Otak dan menyepakati sebuah consensus yang berbunyi “Kepada seluruh organ-organ tubuh dengan ini dinyatakan bahwa apabila terjadi gangguan hemodinamik dalam bentuk apapun, maka suplay darah harus diutamakan ke otak, hati, dan ginjal” Kulit walaupun sebagai organ yang terbesar dan terluas namun memiliki suara minoritas akhirnya kalah. Oleh karena itu sejak saat itulah manakala terjadi ggn sirkulasi darah seperti penurunan cardiac output maka alirah darah ke kulit akan dikurangi karena dianggap organ yang ‘tidak penting”!.

DELAYED WOUND HEALING

Siapapun pasti tidak senang dengan isitilah “flight delayed” atau penerbangan ditunda tidak sesuai jadwal. Itulah yang saya alami sepulang Kongres InETNA tahun lalu. Padahal tidak sempat foto bareng dengan fans hanya gara-gara mengejar jadwal. Perut lapar, mata ngantuk menjadi kombinasi yang kuat untuk marah. Untungnya bisa masuk ‘Lion King’ makan dan minum gratis sehingga bisa menurunkan adrenalin.

Bagaimana dengan luka??? Luka juga kadang mengalami delayed baik disengaja maupun tidak, disadari atau tidak. Luka akut dalam keadaan normal akan sembuh dalam 2 minggu. Apabila sudah 14 hari belum ada tanda-tanda kesembuhan (epitelisasi) maka luka sudah dianggap mengalami “delayed wound healing”.

Apa yang menyebabkan luka bisa mengalami delay. Banyak factor seperti yang telah diposting di factor-faktor yang mempengaruhi proses penyembuhan luka. Secara umum ada dua factor yaitu factor lokal dan factor umum.

Oleh karena itu sebagai perawat (kalau memang mau professional) dalam perawatan luka hendaknya tidak hanya melakukan buka-tutup. Artinya perawatan luka hanya sebatas mengganti balutan lama dengan balutan baru. Namun sebaliknya harus menjadi “detektif” saat merawat luka, buka mata, psang telinga, buka hidung (tidak usah pakai masker), amati respon pasien verbal dan non verbal.

Satu contoh sederhana, seperti yang dikemukakan oleh Dr. Suriadi (2009) bahwa sebelum kita membuka balutan lama, perhatikan dulu wajah pasien. Wajah pasien menggambarkan bagaiman ekspresi luka dalam proses penyembuhannya. Secara in vitro betul!, saya mengamati wajah pasien memang berbanding lurus dengan kemajuan proses penyembuhan luka.

Merawat luka bukan hanya sekedar mengganti perban, tapi bagaimana kita bisa me’manage’ luka pasien, membaca masalah luka, dan mengambil keputusan yang tepat agar luka tidak mengalami ‘delayed wound healing’.

Dressings: cutting and application guide

Abstract

Wounds in some areas of the body are particularly difficult to dress, despite the wide range of dressing products available. This paper aims to set out some generic principles that may assist when dressing wounds in awkward areas.

Introduction

It is widely documented that patients with chronic wounds identify problems such as malodour, dressing leakage and pain as high on their list of priorities[1]. If these are not dealt with the patient may withdraw from social contact and become isolated because of embarrassment or curb their activities for fear of dressing leakage.

Despite the existence of a huge range of dressing products in a wide variety of shapes and sizes, dressing wounds in some anatomical areas continues to be a challenge for many clinicians. Although dressing manufacturers have designed products to cope with the curves and uneven textures of living human anatomy, these are usually limited to one or two sizes. However, it is possible to adapt these ready-made products.

Identifying patient needs

The first step in ensuring a good dressing fit is a thorough, holistic assessment of the patient. This must consider factors such as how the patient's lifestyle impacts on the dressing. For example, if the patient is an otherwise fit and healthy child it is likely that the dressing will be subjected to considerable wear and tear and this should be considered during selection. In addition, the patient may see other objectives as a priority over wound healing and meeting these is vital in obtaining concordance.

Previous dressings used should be reviewed and any problems that occurred considered. An example of this would be a dressing that always leaked from, or failed to stick at, one particular edge.read more

Australia Ciptakan Kulit Pengganti Untuk Luka Bakar

Peneliti asal Australia berusaha menciptakan kulit pengganti yang hidup dengan ketebalan penuh untuk korban luka bakar dan berharap dapat memulai penelitian dengan percobaan pada binatang pada tahun ini.

"Penelitian sedang dilakukan untuk mereproduksi kulit yang berfungsi untuk transplantasi di dalam laboratorium dan bisa mengubah hidup bagi yang mengalami luka bakar serius," ujar jurubicara Sydney Burns Foundation.

Korban luka bakar saat ini masih diobati dengan cangkok kulit, potongan kulit korban yang diambil dari bagian yang tidak terluka, atau dengan lembaran kulit tipis yang ditumbuhkan di laboratorium dengan sel kulit korban.

Namun laboratorium hanya bisa menumbuhkan epidermis, lapisan luar kulit, dan itu tidak bisa meregang, berkeringat, tumbuh rambut, atau memiliki perasaan atau gerakan yang normal.

Para peneliti di Sydney Burns Foundation, kolaborasi antara Universitas Sydney dan Rumah Sakit Concord, mengharapkan bisa melewati problem tersebut dengan mengembangkan kulit hidup dengan ketebalan penuh untuk dicangkokkan pada korban luka bakar.

Dosen Universitas Sydney Profesor Peter Maitz mengatakan tes secara ekstensif telah dilakukan guna memperoleh data untuk percobaan pada binatang pada masa mendatang.

"Luka bakar merupakan salah satu trauma yang paling berat dan melumpuhkan yang bisa dialami oleh seseorang," kata Maitz.

"Meskipun perawatan intensif dan luka bakar modern telah menyelamatkan banyak jiwa, masih ada jurang pemisah yang lebar antara memperoleh keselamatan dan kualitas hidup yang sebenarnya setelah luka bakar berat," tambahnya.

Ketika berbicara untuk stasiun televisi ABC pada bulan lalu, Maitz mengatakan bila luka bakar sampai meliputi seluruh lapisan kulit, dokter seringkali hanya bisa mencangkoknya dengan lapisan yang tipis, tipis saja.

"Walau bisa menutup luka, itu tetap tidak memiliki kelenturan. Kulit tidak bisa berkeringat, tidak bisa mengatur suhu, tidak bisa melakukan metabolisme atau memproduksi apapun. Ini semua adalah fungsi kulit normal," kata Maitz.

Walau nyawa korban luka bakar biasanya bisa diselamatkan di rumah sakit, tergantung pada dokter bedah plastik-lah untuk membuat hidup mereka pantas untuk dijalani.

"Sebab, bila orang tersebut meninggalkan rumah sakit dan memiliki luka besar sehingga ia tidak bisa bebas bergerak, tidak bisa menggunakan tangan, tidak bisa makan dengan benar, tidak bisa membersihkan diri sendiri, yang perlu ditanyakan adalah apa kita telah gagal menolong pasien kita?" ujar Maitz. source

JOURNAL REVIEW; Cost Of Healing Pressure Ulcer

Xakellis, George C.; Frantz, Rita

Abstract

The reported costs of treating pressure ulcers have varied widely from study to study. Previous studies have focused on single health care settings and computed only the costs occurring while the patient was a resident in that facility. The purpose of this study was to assess the cost of managing pressure ulcers from their initial occurrence in long-term care through their natural history, including hospital treatment ot complications. The 30 patients in this year-long study developed 45 ulcers. The mean length ot treatment for an ulcer was 116 days (SD = 127). The mean cost ot treatment, including long-term care and hospital costs, was $2.731 per ulcer (SD = 12.184); excluding hospital costs, the mean cost of treatment was $489 per ulcer (SD = 629). The mean cost of treatment per patient was $4,647 (SD = 15,102); excluding hospital costs, the mean treatment cost was $1,284 per patient (SD = 1,380). Eighty percent of the total cost of pressure ulcer treatment was generated by the 4% of patients who required hospitalization lor their pressure ulcers. In the absence of complications, pressure ulcers can be treated successfully and cost-effectively in long-term care.read more

JOURNAL REVIEW; Cost Of Pressure Ulcer Prevention in Long Term care

Xakellis GC, Frantz R, Lewis A.

John Deere Health Care, Moline, Illinois 61265, USA.

OBJECTIVE: To describe the total cost of pressure ulcer prevention, component costs of each intervention, and the relationship of costs to subjects' risk level. DESIGN: 3-month cohort trial. SETTING: A 600-bed, state-supported, long-term care facility. PATIENTS: A total of 539 war veterans, 83% of whom were male; mean age was 73 years. MAIN OUTCOME MEASURES: Cost to facility for using each of four preventive interventions: turning, pressure-reducing mattresses, chair cushions, miscellaneous preventive devices. RESULTS: Sixty-eight percent of subjects received a preventive intervention. Total 3-month facility cost of prevention was $132,114, and 97% of the cost was consumed by 30% of the subjects. Turning was the most expensive component, accounting for $99,567. The daily cost of turning for subjects who received it was $8.83 +/- 1.66. Cost increased with subject risk level. Low cost devices were instituted for lower risk subjects, whereas high cost interventions (turning) were reserved for the highest risk subjects. CONCLUSIONS: This long-term care facility expended substantial resources on prevention, and most resources (97%) were expended on less than half (30%) of subjects. Turning was, by far, the most expensive intervention, and the nursing staff reserved it for highest risk subjects. Strategies that substitute moderately priced mattresses for frequent turning may decrease the cost of prevention, as long as mattress cost is less than the daily turning costs it replaces. Future research to define the optimum combinations of preventive interventions for patients of various risk levels is needed. read more

Assessment and management of venous leg ulcers.

Assessment and management of venous leg ulcers.

Smith & Nephew - Treatment Options for Leg Ulcers

Smith & Nephew - Treatment Options for Leg Ulcers

Compression bandaging in the treatment of venous leg ulcers

Compression bandaging in the treatment of venous leg ulcers

FOUR LAYER BANDAGINGFOR VENOUS ULCER

PANKAJ PATEL
Vascular Surgeon, Lilavati Hospital, Mumbai 400 050.

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INTRODUCTION
The successful management of venous leg ulcers represents a significant clinical problem and a major drain on limited financial resources. Research has shown that majority of the ulcers can be induced to heal by the application of adequate levels of sustained graduated compression, although this technique is contraindicated for the treatment of ischaemic ulcers.

Bandages vary greatly in their ability to provide sustained compression due to differences in their structure and the content of elastomeric yarns. Other factors such as limb circumference and shape will also have an important influence on the pressure produced beneath the compression bandage.

EPIDEMIOLOGY
Leg ulcers are a chronic condition and these incur a significant financial implication on the patients. These ulcers can be caused by number of physiological or biochemical disorders either individually in combination, but the majority, approximately 70% are associated with venous disease.

The prevalence of active venous ulcers in the United Kingdom is around 1.5/10,000 of the adult population, although the number of people who develop at least one episode of ulceration may be 3-4 times greater than this. The prevalence of venous ulcerations increases with age and is more common in women than in men.

HISTORY

Bandages have a history stretching back thousand of years to the time of the ancient Egyptians, who used simple woven fabrics, often coated with adhesives, resins, and other medicaments as dressing for a wound healing. Like some of the bandages used today, these were made from non-extensible fabric and probably required considerable skill on the part of the user to ensure correct application.

In the 17th century, Pierre Dionis who was surgeon-in-ordinary to the queen of France and to the Empress Maria Theresa of Austria recommended the use of rigid lace-up stockings made from coarse linen or dog skin to apply compression in the treatment of leg ulcers. The bandages available at that time were not suitable for the application of sustained, controlled compression because of their inelastic nature. It was not until the middle of 19th century that the first elasticated bandages containing natural rubber were manufactured. In 1878, Calendar published a letter in the Lancet, which described the use of these materials in the management of varicose veins.

ANATOMY AND PHYSIOLOGY OF VENOUS SYSTEM OF THE LEG

The veins of the leg are divided into superficial and deep systems. The deep veins, which come together to form the popliteal and femoral veins lie within the fascia and are responsible for the venous return from the leg muscle. Also within the fascia, the soleus and gastrocnemius muscles have dilated valveless sinusoids, which fill with blood when the leg is at rest. Together these deep vascular structures, have a combined volume of about 100 to140 ml comparable to that of one of the ventricles of the heart.

The long saphenous vein which runs along the medial side of the vein from foot to groin and the short saphenous vein which runs at the back of the calf, from foot to knee are the major vessels of the superficial venous system. These vessels lie outside the fascia and are responsible for the venous return from the skin and subcutaneous fat.

The two systems are joined by communicating veins, sometimes called perforators as they perforate the deep fascia. The perforators, like the other veins in the leg, contain valves that permit the flow of blood in one direction only, from the outer or superficial system inwards to the deep veins. The venous pressure at the ankle of the subject who is lying supine is around 10 mm Hg, but on standing this will rise by about 80 mm Hg, due to an increase in hydrostatic pressure.

During walking, as the foot is dorsiflexed, the contraction of the calf muscle compresses the deep veins and soleal sinuses to the point at which they become almost totally collapsed, producing pressures of upto 250 mm Hg and emptying them of blood. As the foot is plantar flexed, the pressure in the veins falls, the proximal valves close, and the veins are refilled by blood passing through the perforators from the superficial system. During this cycle, in a normal leg, the distal valves of the deep veins and the valves of the perforators will ensure that the expelled blood can go only in one direction i.e. upwards, back to the heart.

The pumping action of the calf muscle causes the hydrostatic venous pressure in the ankle region to gradually fall until it reaches a steady state, usually about 30 mm Hg in the deep veins and 40 mm Hg in the superficial veins. If the subject then stands still, the pressure in both systems will slowly return to a stable value of about 90 mm Hg, a process that usually takes about 20-30 seconds.

THE EFFECT OF DAMAGE TO THE VENOUS SYSTEM

Blockage or damage to venous system will cause disruption to normal blood flow, which may manifest itself in a number of different ways according to the site and extent of the damage. If the valves in the superficial system are affected, venous return will be impaired and blood may accumulate in the veins causing them to become distended leading to the formation of varicosities (varicose veins).

If the function of the perforator valves is impaired the action of the calf muscle pump will tend to cause blood to flow in the reverse direction into the superficial system increasing the possibility of damage to the superficial vessels.

Following deep vein thrombosis that results in complete or partial obstruction of a deep vein, the unrelieved pressure produced by the calf muscle pump on the perforator valves may cause these to become incompetent. If this occurs, there will be a large rise in the pressure in the superficial system which may force proteins and red cells out of the capillaries and into the surrounding tissue, Here, the red cells break down releasing red pigments which causes staining of the skin called lipodermatosclerosis, an early indicator of ulcer formation.

DIAGNOSIS OF VENOUS ULCERATION

Ulcer characteristics - Its location is most often around the medial malleolus (gaiter area). The ulcer base is usually pink with healthy granulation tissue with an irregular border. There is usually a copious exudate from the ulcer. Pain is usually not present but may occur if the superficial nerves are exposed. The surrounding skin is pigmented with lipodermatosclerotic changes. The limb is usually swollen thereby making peripheral pulses difficult to palpate.

Investigation-

1. Hand held Doppler
2. Colour Doppler scan
3. Ankle-brachial index
4. Venous plethysmography
5. Venogram?

Treatment -

1. Compression Bandaging
2. Corrective Venous Surgery
3. Maintenance treatment

EXTERNAL COMPRESSION

For patients with venous disease, the application of graduated external compression can help to minimise or reverse the skin and vascular changes described previously, by forcing fluid from the interstitial spaces back into the vascular and lymphatic compartments. As the pressure within the veins of a standing subject is largely hydrostatic, it follows that the level of external pressure which is necessary to counteract this effect will reduce progressively up the leg, as the hydrostatic head is effectively reduced. For this reason it is usual to ensure that external compression is applied in a graduated fashion, with the highest pressure at the ankle.

FACTORS WHICH DETERMINE SUB-BANDAGE PRESSURE

The pressure developed beneath any bandage is governed by the tension in the fabric, the radius of curvature of the limb and the number of layers applied. Applying a bandage with a 50% overlap produces 2 layers of fabric which generates a pressure twice that produced by a single layer. Sub bandage pressure can be calculated using a simple formula derived from the Laplace equation as follows:

P = (TN x 4630)/CW where)

P = Pressure in mm Hg

T = Bandage tension in kgf

C = Circumference of the limb in cms.

W = Bandage width in cms

N = No. of layers applied

Sub-bandage pressure is therefore directly proportional to bandage tension but inversely proportion to the radius of curvature of the limb to which it is applied. This means, therefore, that a bandage applied with constant tension to a limb of normal proportions will automatically produce graduated compression with the highest pressure at the ankle. This pressure will gradually up the leg as the circumference increases.

Effects of compression

Graduated compression has shown to
1.Increase blood velocity in the deep veins
2.Reduce oedema and therefore reduce the pressure differential between the capillaries and the tissues.
3.Reduce distension of superficial veins and reverse venous hypertension
4.Improve the healing rate of chronic venous ulcers.

Sarin. S. in his recent research has indicated that external compression restores valve function in a proportion of superficial and deep veins by decreasing vein diameter and therefore improving overall venous function. The full physiological effect of compression is still not fully understood and required further research.

Stemmer demonstrated theoretically that 40 mm Hg pressure at the ankle was required to reverse chronic venous hypertension. The 4 layer bandage system was developed to apply 40 mm Hg pressure at the ankle graduated to 17 mm Hg pressure at the knee using bandages of different properties.

DRESSING
It is claimed that dressings influence ulcer healing. Following extensive randomised control studies, involving different dressing types usedconjunction with the 4 layer bandage, it was found that dressings had little influence on ulcer healing. Therefore, in the majority of ulcers a simple non-adherent dressing is used. Viz. Sofratule, Adaptic, lnadine, etc. It is very important to choose a dressing that will not aggravate the patient’s ulcer or surrounding skin.

BANDAGES
All bandages used are 10 cms in width and should be applied from the base of the toes to the knee joint.
Layer 1 - Orthopaedic wool such as Velband or Softban. This is used to absorb exudate and redistribute pressure around the ankle, protecting the bony prominences from excessive pressure. It also fills in the troughs behind the malleoli where little pressure is exerted. The bandage is applied without tension in a loose spiral.

Layer 2 - Cotton crepe bandage. This is arguably the least effective layer in the combination. Its function is to increase absorbency and to smooth the orthopaedic wool layer, thereby preserving the elastic energy of the main compression layers. The cotton crepe bandage is also applied in a spiral.

Layer 3 - Elasticated crepe bandage. This is a highly elastic, conformable compression bandage. It is applied at mid stretch in a figure of 8 with a 50% overlap. This weaves a mean pressure of 17 mm Hg on ankles measuring 18-25 cms.

Layer 4 - Coban. This is a light weight, elastic, cohesive bandage. When applied at mid stretch with 50% overlap to an ankle measuring 15-25 mm, it gives an ankle pressure of 23 mm Hg. Coban maintains the 4 layers in place until removal and adds durability to the system.

The combined pressure of these bandages is 40 mm Hg at the ankle graduated to 17 mm Hg pressure at the knee. This system has been further developed to accommodate differing limb circumferences. As the limb circumferences is variable, and may decrease considerably in the first few weeks, owing to a reduction of oedema following application of compression, the measurement of ankle should be repeated at frequent intervals.

Each limb must be assessed carefully and individually before applying compression and the bandager must be aware of potential problems that each limb may present, In particular, very thin legs need extra padding to prevent excessive pressure over the bony prominences and the tendinous area over the dorsum of the foot, which may cause pressure necrosis. This extra padding can be achieved in a variety of ways, e.g., by pleating the orthopaedic wool layers, thus protecting the tibial crest.

Conversely, a large or oedematous limb will need a stronger elastic bandage to achieve adequate compression. In ankles measuring more than 25 cms, a stronger elasticated crepe bandage is used in place of dynaflex to achieve 40 mm Hg pressure.

Ulcer lying behind the malleoli may not receive adequate compression. A pressure pad is placed over the primary dressing to apply direct pressure to the ulcer bed. Many chronic leg ulcer patients who have been bandaged for long periods of time are immobile and loose a proportion of their calf muscle bulk. Effective graduated compression relies on the natural gradient of the leg, which is decreased in these patients. This is simply rectified by padding the calf area and thus redefining the shape of the leg.

HAZARDS OF COMPRESSION BANDAGING
* Arterial disease is a contra indication. Patient with an ABI of less than 0.8 should not receive full compression. Application of compression to a limb with poor circulation may lead to pressure necrosis and may even necessitate amputation.

* Compression can cause pressure necrosis in absence of arterial disease in patients with narrow ankles and thin calves. Excessive pressure may beapplied over bony prominences and the malleoli.

* Compression should be used with caution for patient with rheumatoid arthritis or diabetes mellitus, as these patients are susceptible to microvessel disease. Application of compression can cause further occlusion of these vessels and result in pressure necrosis.

* Patients with oedema secondary to heart failure should not receive compressions to reduce oedema as this may produce a sudden increase in venous return, which may further exacerbate the heart failure.

VENOUS SURGERY
Following healing of venous ulcer, the underlying cause should be corrected surgically if possible viz; varicose veins surgery, subfascial endoscopic perforator ligation, deep venous valve repair.

MAINTENANCE TREATMENT
This is the most important treatment modality that prevents recurrence of ulceration. A class II compression stockings should be worn life long.

CONCLUSION
Sustained compression of over 40 mm Hg achieved with a 4 layer bandage results in rapid healing of chronic venous ulcers that have failed to heal in many months of compression at lower pressures with more conventional bandages.

SUMBER:
http://www.bhj.org/journal/2001_4304_oct/sp_487.htm