A WOMAN 55 YEARS OLD WITH GRADE II

DECUBITUS ULCER GLUTEA DEXTRA REGION

By:
Rusmita Hardinasari G9915038
Salicha Oktamila A G99161

Supervised by :
dr. Amru Sungkar, Sp. B, Sp. BP-RE
ANAMNESIS

Patient Identity
Name : Ms. S
Age : 55 y.o
Gender : Female
Religion : Islam
Occupation : Farmer
Address : Selogiri, Wonogiri
Admision : 13 Mei 2017
Examination : 17 Juli 2017
Medical Record : 01316XXX
ANAMNESIS

Chief Complaint

The wound on the buttocks

ANAMNESIS

Chief Complaint

The wound on the buttocks

ANAMNESIS
Present illness
 3 Month before admisson, patients complained
left limbs is weakly. Complaints begin with pain in
the lower leg especially when walking. This pain
is progressive, until patient didn’t walk.
 Patient was taken to RSUD Wonogiri and treated
for a week but this condition is bad until decrease
of consciousness, then patient referred to IGD
RSDM because suspicious of bleeding in brain
caused by stroke.
ANAMNESIS
Present illness
 The patient is treated by the neurosurgeon
departemnet and performed emergency surgery in
the brain.
 The patient was admitted on May 13, 2017. Because
this condition, the patient just laying in the bed and
didn’t anythyng activity. Then her family complaint
about wound that extends in her buttocks. After
examination by the treating physician, then the
patient is consulted to the Plastic Surgery
departement with a diagnosis of ulcer decubitus in
gluteus region.
 History Formerly Disease

History of Allergy / Asthma : denied

History of Hypertension : (+) 10 years ago, did
not control routine
History of Diabetes Mellitus : denied
History of Heart Disease : denied
Anamnesis
Previous Disease
History

- History like illness : (+) stroke 5 years ago

- History Hypertension : (+) 10 years ago, did
not control routine
- History of Diabetes Mellitus : (-)
- Allergic history : (-)
Anamnesis
Family History

- Same illness : (-)

Anamnesis
A history of the patient's habits

 Eating 3 times a day with rice, vegetables, and side

dishes such as tempe, tofu, fish, or chicken.
Decreased appetite since after patients sick.
Anamnesis
Social Economic History

 patients is the farmer, lived with her husband and is

currently treated with financing the BPJS.
Physical Examination
General status

• GCS, E2VXM2, sickly being,

turned on NGT to support
food

Vital Sign

• BP : 130/70 mmHg
• HR : 84x/menit
• RR : 20x/menit
• t : 36,9oC
Physical Examination
Head
• mesocephal, lession (+) is hacted post
craniotomy
Eyes
• Anemic conjunctiva(-/-), icteric sclera (-/-),
pupil, isokor (3mm/3mm), light reflex (+/+),
hematom periorbita (-/-)
Ear
• mucous (-), blood (-), mastoid pain (-),
Tragus pain(-)
Nose
• asymetric nose (-, mucus (-), blood (-)
Mouth
• bleeding gum (-), lession (-), wet mucosa (+),
unstable maxilla (-), unstable mandibula (-),
cleft palate (-), clef t lip (-), cleft alveolar (-)
Physical Examination
Neck

• thyroid enlargement (-), lymphonode

enlargement (-), pain (-), JVP increase (-)

Thorax

• normochest, symetric, symetric respiration

movement

Heart

• Inspection : ictus cordis is not

visible.
• Palpation : ictus cordis normal.
• Percusion : heart border normal
• Auscultation : heart sound normal, regular,
abnormal sound (-)
Physical Examination
Pulmo

• Inspection : movement of hemithorax

symetric dextra sinistra
• Palpation : fremitus tactil symetric dextra
sinistra
• Percusion : sonor/sonor.
• Auscultation : vesicular (+/+) normal,
additional sound(-/-)

Abdomen

• Inspection : distended (-)

• Auscultation : Bowel Sound (+) normal
• Percusion : tympanic.
• Palpation : pain (-), defance muscular (-)
Physical Examination
Genitourinaria

• urination normal, hematuria (-), pyuria(-),

dissuria (-)

Musculoskeletal

• Normal

Extremity

• Extremity coldness : (-)

• Oedem : (-)
Physical Examination

LOCALIS
STATUS

• Inspeksi : tampak ulkus

dekubitus grade III
dengan ukuran 8 x 4 x 0.5
cm, tepi iireguler, dasar
luka terlihat fascia otot,
pus (+), jaringan nekrotik
(+)
• Palpasi : nyeri tekan sulit
dievaluasi
 Assessment I

Ulkus dekubitus grade III

regio sacrum
 Planning I

1. Blood examination
2. Medication
3.The right-left-leaning every 2
hours
4.Decubitus bed
5. Inj. Ceftriaxon 2g/24 jam
 Blood Examination (RSDM, 13 Juni 2017)

Pemeriksaan Hasil Satuan Rujukan

DARAH RUTIN
Hemoglobin 11.6 g/dL 10.5 – 12.9
Hematokrit 34 % 33 – 41
Leukosit 13.6 ribu/µl 5.5 – 17,0
Trombosit 425 ribu/µl 150 – 450
Eritrosit 4.58 juta/µl 4,10 – 5,30
KIMIA KLINIK
SGOT 25 u/dl <31
SGPT 32 u/dl <34
Albumin 2.2 g/dl 3.5-5.2
Creatinine 0.1 mg/dl 0.6-1.1
Ureum 10 mg/dl <50
ELEKTROLIT
Natrium darah 135 mmol/L 136-145
Kalium darah 3.5 mmol/L 3.3-5.1
Chloride darah 103 mmol/L 98-106
 Assessment II

Ulkus dekubitus grade III

regio sacrum
 Planning I

1. Medication for prepare surgical

operation (debridement)
2. Pro Closing defect
Decubitus Ulcer
DEFINITION

Dekubitus ulcer is an area of limited cellular necrosis. In

General, the decubitus ulcer marked with a wound with
tissue necrosis that occurs in response to pressure from
outside
ETIOLOGY

 The main caused of pressure sore is the pressure

which causes ischemia.
RISK FACTOR

Uncontrolled Neurovascular
Old age
diabetes disease

Spinal
Malnutrition Trauma
damage
Pathomechanical Ulcus Decubitus

 Long pressure
 Surface pressure
 Glide
 Friction
 Immobilizationan
Pathophisiology
 Risk Factor
 Fever, anemia, infection, ischemic,
hypoxemia, hypotension, malnutritio,
spinal cord trauma, neurologic disease,
thin, old age and high metabolism.
 During aging, cell regeneration in the skin
becomes slower so the skin will be thin.

 The content of collagen in the changing skin

causes skin elasticity is reduced so it is
susceptible to deformation and damage.

 The declining ability of the cardiovascular system

and the incompetent arteriovenosus system leads
to a progressive decrease in skin perfusion.
 A number of diseases that cause decubitus ulcers such as DM that

exhibit peripheral cardiovascular insufficiency and decreased

cardiovascular function as in the respiratory system cause blood

oxygenation rates in the skin to decrease. Low nutrition and

anemia slow down the healing process in decubitus ulcers.

 Hipoalbuminemia that facilitates the occurrence of decubitus and

decrease healing dekubitus, on the contrary if there is dekubitus

will cause blood albumin levels decreased.

 In malnourished people, decubitus ulcers are more easily formed

than normal people.

Classification
Grade 1 Grade 2
Classification
Grade 3 Grade 4
Diagnostic
 Culture and urine analysis
 Fecal Culture
This examination is necessary in the presence of
incontinent alvi to see Clostridium difficile
leucocytes and toxins when pseudomembranous
colitis occurs.
 Biopsy
An important biopsy on a wound state that does
not improve with intensive treatment or in a
chronic decubitus ulcer to see if there is a
process leading to malignancy. In addition,
biopsy aims to look at the types of bacteria that
infect decubitus ulcers.
Diagnostic
 Blood Investigation
To see the inflammatory reaction that occurs
should be examined white blood cells and the
rate of sedimentation of blood.
 State of Nutrition
Things to check for are albumin levels,
prealbumin levels, transferrin levels, and serum
protein levels,
 Radiologist
Radiological examination to see the presence of
bone damage due to osteomyelitis. Examination
can be done with X-rays, bone scans or MRI.
Therapy
 Management of decubitus ulcers with nonmedicament

includes dietary regulation and medical rehabilitation.

 Giving a diet high in calories, protein, vitamins and

minerals will improve the nutritional status of decubitus

ulcer patients. Increased nutritional status of this patient

will improve the patient's immune system so as to

accelerate the healing ulcer dekubitus.

 The medical rehabilitation therapies given for the healing of

decubitus ulcers are by infrared radiation, short wave

diathermy.
Therapy

• Maintain cleanness in ulcers and

surrounding areas
• Compresses, washing, rinsing,
drying and topical ingredients such
as 0.9% NaCl solution, 3% H202
solution and 0.9% NaCl, plasma
solution and Burowi solution and
other antiseptic solutions.
Therapy

 Resolving infections
It needs culture check and resistance test.
Systemic antibiotics may be given if the
patient has sepsis and cellulitis.
Cleaned several times daily with an
antiseptic solution such as a 3% H 2 O 2
solution, 1% povidone iodine, 0.5% zinc
sulfate. Ultraviolet radiation (especially
UVB) has a bactericidal effect.
Therapy
• Stimulate and help the formation of granulation and
epithelial tissue.
• To accelerate the formation of granulation and
epithelial tissue in decubitus ulcers so as to speed
healing can be given:
• Topical materials for example:
2% salicylic salicy ointment, zinc preparation (ZnO,
ZnSO4).
• Hyperbaric Oxygen; In addition to having
bacteriostatic effects on a number of bacteria, also
have a proliferative epithelial effect, increase
granulation tissue and improve vascular state
Therapy
• Surgical action
Surgical action aims to clean ulcers and
accelerate ulcer healing and closure, especially
decubitus grade III & IV ulcers and hence
frequent skin tanning, myocutaneous flap, skin
graft and other interventions on ulcers.
Complication
 Complications often occur in stages 3 and
4, although it can also be in superficial
ulcers. Complications that may occur
include infection (often multibacterial,
either aerobic or anerobic), involvement
of bone and joint tissue such as
periostitis, osteitis, osteomyelitis, septic
arthritis, septicemia, anemia,
hypoalbuminemia, even death