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Anatomi &Anatomi & Fisilogi KulitFisilogi Kulit
SuriadiSuriadi
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Bagian Epidermis
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Kulit
-Tebal : 0.5 mm - > 5 mm 1 mm – 2 mm
-Epidermis : Corneum Lucidum Granulosum Spinosum Basale Dermis : Papiler Retikuler Hipodermis
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Epidermis
- Fungsi pelindung- Epithel skuamosa- P. darah (-)- Telapak tangan dan kaki
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Corneum
-Bentuk seperti tanduk-Rata / flat-Relatif tebal – terdapat sel mati-Soft keratin : # elastis
# melindungi sel hidup-Mudah abrasi dan diganti dengan sel baru
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Lucidum
-Rata-Sel mengandung protein = eleidin-Hanya di telapak tangan dan kaki-Cegah ultraviolet dan sinar matahari
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Spinosum
-Sel berbentuk polihedral ( multi muka )-Disebut “prikle cell”-Proses aktif sintersa protein – pembelahan sel-Sel dibentuk untuk mengganti sel diatasnya
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Granulosum
-Tebal 2-4 sel-Mengandung granul dan keratohyalin-Memicu proses keratinisasi ( sel mati)
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Basale
-1 lapis sel koluimnar/kuboid-Proses pembelahan sel
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Papilare
-Analogi dengan sub-epitel-Jar. Penunjang longgar-Terdapat serat kolagen-Bentuk seperti jari tangan-Terdapat kapiler dan ujung syaraf Meissner’s-Terdapat pola ornamen pada jempoll
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Retikulare
Bentuk seperti jalaJaringan penunjang padatTerdapat serat kolagenTerdapat pola sulkus = Garis Langer’sInsisi pada Garis Langer’s berpengaruh pada penyembuhan
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Penyembuhan lukaPenyembuhan luka
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Injury
Normal repairRegeneration
Excessive healing
Deficienthealing
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1. Fase inflamasi1. Fase inflamasiLuka jar. lunak Respons vaskuler
Respons seluler
Tujuan : stop perdarahan dan membersihkan luka
p.darah rusak
Tutup vaskuler Tutup endotel
KeluarkanSubst. vasokonstriksi
Kapiler vasokonstriksi
platelet
Proses hemostasis( 5 – 10 menit)
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Fase inflamasiFase inflamasiKapiler konstriksi
Permeabel vena meninggi
-Stim. S. sensoris-Loc. Refl. Action-Subst. Vasodilator hist,serot,sitokin
Kapilerdilatasi
* plasma masuk ke luka (eksudasi) oedema dan acidosis* migrasi lekosit /netrofil (fagositosis)• berlangsung 3 hari* netrofil diganti makrophag
Hist.
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Inflammation
Proliferation
Remodelling
Injury
Repair
0 5ds 20-30ds mos
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Phase 1: Inflammation
PDGFIGFTGF
EGF
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Phase 1: Inflammation
PDGFIGFTGF
EGF
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Phase 1: Inflammation
PDGFIGFTGF
EGF
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Phase 1: Inflammation
PDGFIGFTGF
EGF
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Fungsi makrophagFungsi makrophag1. Fagositosis2. Sintesa kolagen3. Bentuk jar. Granulasi + fibroblast4. Bentuk growth factor untuk re-epitelialisasi5. Bentuk kapiler baru = angiogenesis
Parameter fase inflamasi sukses dan berpindak ke fase proliferasi :luka bersih, tidak terdapat kuman / infeksiterbentuk makrophag dan fibroblast
Tanda klinis : eritema, hangat, oedema dan rasa sakit berlangsang sampai hari ke 3 atau ke 4
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Phase 1 : InflammationPhase 1 : Inflammation
Monocytes
PMNs
PDGF
IL-1, IL-6, TNFα
TGF 2,α,β
VEGF
Platelets
Macrophages
Fibroblasts
Maintaininflammation
Endothelial cell
FGF
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Platelet plugPlatelet plug Chemo-attractionChemo-attraction
PMNsPMNs MonocytesMonocytes LymphocytesLymphocytes
Phase 1: Inflammation
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Phase 2: Proliferation Epithelial cellsEpithelial cells
Migrate to the sides of edgesMigrate to the sides of edges Endothelial cellsEndothelial cells
AngiogenesisAngiogenesis FibroblastsFibroblasts
ECM formationECM formation
Granulation tissue
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2. Fase proliferasi2. Fase proliferasi1. Kegiata seluler ---- proliferasi sel2. Peran fibroblast >> --- * persiapan pembentukan struktur protein
untuk rekonstruksi jaringan * aktif bergerak dan mengeluarkan substansi
kolagen, elastin. hyaluronic acidfibronectin dan proteoglycans
3. Pembentukan jar. granulasi dari makrophag, p.darah dan fibroblast. Proses sintetik fibroblast disebut fibroplasia dengan respons :
proliferasi, migrasi, deposit jar. matriks dan kontraksi luka4. Angiogenesis ; proses pembetukan kapiler didalam luka
- Upaya respons untuk oksigenisasi dan nutrisi- 3 dan 4 merupakan proses yang ter-integrasi dan dipengaruhi oleh platelet dan makrophag yang mengeluarkan growth factor
5. Epitelialisasi- Fibroblast keluarkan KGF (Keratinocyte) - stimulasi mitosis sel epid.- Keratinasi mulai dari pinggir ketengah- Dengan sintesa kolagen, kwalitas dermis disempurnakan- Struktur fibroblast berubah menjadi myofibroblast -- kontraksi
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Phase 2: Proliferation
EFG FGF
PDGF
IGF
TGF
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Epithelialising woundEpithelialising wound
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Phase 3: Remodelling
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Which one of the wounds will Which one of the wounds will heal faster? heal faster?
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Which one of the wounds will Which one of the wounds will heal faster? heal faster?
The rate of healing depends on the largest diameter of a circle contained within the wound
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Normal Wound HealingNormal Wound Healing
0 5ds 30ds 100ds
Inflammation
Proliferation Re-modelling
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Impaired Wound Impaired Wound HealingHealing
0 5ds 30ds 100ds
Inflammation
Proliferation Re-modelling
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Impaired Wound Impaired Wound HealingHealing
Wound dependentWound dependent Host dependentHost dependent
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Impaired Wound HealingImpaired Wound Healing Wound dependentWound dependent
Local hypoxiaLocal hypoxia Hematoma/edemaHematoma/edema Increased bacterial loadIncreased bacterial load DesiccationDesiccation MacerationMaceration Foreign bodyForeign body Friction/shearFriction/shear
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Impaired Wound Impaired Wound HealingHealing
Host dependentHost dependent Underlying disease (DM, etc)Underlying disease (DM, etc)
AnemiaAnemia
Poor nutritional statusPoor nutritional status
HypoalbuminemiaHypoalbuminemia
MedicationsMedications
SepsisSepsis
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Injury
Regeneration
Deficienthealing
Chronic wounds
Excessive healing
Normal repair
FibrosisKeloids
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EB and Wound HealingEB and Wound Healing Persistent inflammatory activityPersistent inflammatory activity Polymicrobial colonizationPolymicrobial colonization Frequent infectionsFrequent infections Scar is more friable that intact skinScar is more friable that intact skin Poor nutritional statusPoor nutritional status Low hemoglobinLow hemoglobin
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““Preparing the wound bed”Preparing the wound bed” TTissueissue debridementdebridement IInfection/inflammationnfection/inflammation MMoisture balanceoisture balance EEdge effectdge effect
Sibbald et al. Ostomy and Wound Management Nov 2000 and Nov 2003
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Person with a Person with a Chronic UlcerChronic Ulcer
Treat the CauseTreat the Cause Patient Centered Patient Centered concernsconcerns
Local WoundLocal Wound
TTissue Debridement issue Debridement Persistent Persistent IInflammation / nflammation /
Superficial Superficial IInfectionnfection
MMoisture Balanceoisture Balance
Edge effect for non healing wounds- biologicals, adjunctive therapies, skin grafts etc.
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Luka - ( dalam dan luas )Luka - ( dalam dan luas )
Superfisial – batas epid.Superfisial – batas epid. Partial thicknessPartial thickness Full thickness – sampai fasiaFull thickness – sampai fasia Deep (dalam) – sampai ototDeep (dalam) – sampai otot
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3. Fase maturasi3. Fase maturasi- Mulai mg ke 3 sampai bulan ke 12- Sasaran : penyempurnaan jar. baru yang kuat dan bermutu- Perubahan fibroblast : * keluar dari jar. Granulas * kolagen + fibrin >>- Minggu ke 10 pembentukan jar. parut yang kuat
Kolagen dibentuk Kolagen dipecah (e. Kolagenase)
Kolagen muda Kolagen matang/kuat
Proses re-modelling
Proses keseimbangan
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Luka sembuhLuka sembuh
Pengertian :
Terciptanya kontinuitas lapisan kulit sertaadanya kekuatan jar. parut yang mampumelakukan fungsi / aktifitas yang normal
Outcome tergantung :
- kondisi biologik- lokasi luka- luas luka
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Konsep baruKonsep baru
Konsep dasar : penyembuhan luka
perawatan berbasis suasana lembab
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JustifikasiJustifikasi1. Fibrinolisis : fibrin cepat hilang pada suasana lembab
oleh netrofil dan sel endotel
2. Angiogenesisi : proses akan lebih terangsang pada suasana lembab
3. Infeksi : lebih rendah dibandingkan suasana kering ( 2.6 % vs 7.1 % )
4. Percepatan pembentukan sel aktif : invasi netrofi yang diikuti olehmakrophag, monosit dan limfosit ke daerah luka akan
berfungsilebih dini.
5. Pembentukan growth factor : lebih cepat pada suasana lembab* EGF, FGF dan Interleukin1 dikeluarkan oleh makrophaguntuk proses angiogenesis dan pembentukan str. Korneum* Platelet-derived Growth Factor (PDGF) dan TransformingGrowth Factor-beta (TGF-beta) dibentuk oleh platelet untukproses proliferasi fibroblast.
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The ways in which wounds healThe ways in which wounds healThree basic classifications exist:Three basic classifications exist:
Healing by primary intentionHealing by primary intentionTwo opposed surfaces of a clean, incised wound Two opposed surfaces of a clean, incised wound (no significant degree of tissue loss) are held (no significant degree of tissue loss) are held together. together. Healing takes place from the internal layers Healing takes place from the internal layers outwardsoutwardsHealing by secondary IntentionHealing by secondary IntentionIf there is significant tissue loss in the formation If there is significant tissue loss in the formation of thewound, healing will begin by the production of thewound, healing will begin by the production ofgranulation tissue wound base and walls.ofgranulation tissue wound base and walls.Delayed primary healingDelayed primary healing If there is high infection risk – patient is given antibiotics If there is high infection risk – patient is given antibiotics and closure is delayed for a few days e.g. bitesand closure is delayed for a few days e.g. bites
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Thank you