FORMAT LAPORAN KASUS

A. DATA DEMOGRAFI

Nama :
Jenis kelamin :
Usia :
Alamat :
Pekerjaan :
Pendidikan :
Riwayat diabetes :
Riwayat luka :
Tanggal pengkajian :
B. PENGKAJIAN
1. Riwayat Penyakit dan Luka
a. Riwayat penyakit :
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b. Riwayat Luka :
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2. Pemeriksaan laboratorium

Pemeriksaan laboratorium , tanggal

Jenis pemeriksaan Hasil Nilai normal

3. Pemberian terapi
Obat oral
No Nama obat
1
2
3
4
5
 4. Pemeriksaan Kaki (sesuai format pengkajian kaki klinik)

LOWER LIMB VASCULAR ASSESSMENT

ABPI Right Angkle: 110 Brachial: 50 left Angkle: 110 Brachial Indax:50
Indax: 0,4 index : 0,4

Int. Claudication: No Rest Pain: No Int. Claudication: Yes Rest Pain: Yes

Oedema: yes Warm: no Oedema: No Warm: no

Diabetes Amputation: no, Diabetes Amputation: no,
PERIPHERAL SENSORI ASSESSMENT
RIGHT LEFT
Monofilament test: normal (0) Monofilament test:abnormal (0)
Temperature perception: abnormal (1) Temperature perception: normal (0)
FOOT WOUNDS
RIGH LEFT
Foot Ulcer Yes No Foot Ulcer
FOOT DEFORMITY
RIGH LEFT
Bunion Yes No Bunion Yes No
Clow toes Yes No Clow toes Yes No
SKIN AND NAIL CONDITION
RIGHT LEFT
Skin dry Yes No Skin dry Yes No
Plantar callous Yes No Plantar callous Yes No
Ingrowing nail Yes No Ingrowing nail Yes No
Thickened nail Yes No Thickened nail Yes No
Nail onychomycosis Yes No Nail onychomycosis Yes No
Corn Yes No Corn Yes No
Fissure Yes No Fissure yes No
FOOTWEAR ASSESSMENT
RIGHT LEFT
Foot wear: good fit Yes No Foot wear: good fit Yes No
Foot wear: good shape Yes No Foot wear: good shape Yes No
Foot wear: lace/volcro Yes No Foot wear: lace/volcro Yes No
Not too loose/too tight Yes No Not too loose/too tight Yes No
(square box toe- not Yes No (square box toe- not yes No
pointed) pointed)
(slip on not appropriate) Yes No (slip on not appropriate) Yes no
C. WOUND PROGRESS

1) Tanggal : ......................................................
Foto kaki depan Foto kaki belakang

 Wound Bed: .................................................................................................................

 Wound Edge :...............................................................................................................
 Wound Care:
a) Cleansing : ............................................................................................................
b) Debridement: ........................................................................................................
c) Wound dressing : ..................................................................................................
d) Wound score (MUNGS) : ....................................................................................
No Score ITEMS Skor
M Maceration
0 None
1 Thin at the adge and/ or maceration ≤ 2 cm from the wound
adge
2 >2 cm cm from the wound adge and / or expanded
U Undermining / tunnelling/ sinus
0 None
1 ≤ 3 cm
2 < 3cm
N Necrotic tissue type ( black, white, yellow, grey, brown, green
0 None
1 Soft slough and with ≤ 1 colour
2 Necrotis: with spongy, soft and colored skin
3 Necrotis: hard, spongy or moist tissue and skin ≥ 1colour
4 Necrotis: dry, hard, black, and / or brownish
G Granulation tissue
0 Skin intact
1 Full granulation
2 Granulation of 50% to < 100%
3 Granulation <50%
4 No granulation
S Other wound-releted signs or symptoms
 0 None Wound edge Around the skin
 Red ring wound
 Hyperkeratonic  Hyperpigmentation
 Unattached  Induration
 Undefined  Hypopingmentation
 Crust (1)  Erytema araund the
1 One or two  Pale wound
2 Tree tp five  Damage  Oedema
3 More then  Epibole  Purple
five  Rolled/lining  Lesion
Wound infektion or  Bulla
inflamation Granulation
 Pain  Fragile granulation
 Pus  Bright red
 Odour  Hypergranulation
 Rising temperature/  Senescent
warm  Pale
 Blackish
 Trauma
 Tissue complatible
with a biofilm
 Ischemia

Total

e) Penjelasan (mengubungkan wound bed dengan wound care)

 Tahapcleansing
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 Tahap debridement :
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 Tahap Dressing :
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D. PEMBAHASAN

(Menjelaskan wound progres yang didalamnya menjelaskan fakta, teori dan opini)

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E. KESIMPULAN

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F. REFERENSI