A BOY 16 YEARS OLD WITH GRADE IV

DECUBITUS ULCER

By:
Peter Darmaatmaja Setiabudi G99162143

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

Patient Identity
Name : An. F
Age : 16 y.o
Gender : Male
Religion : Islam
Occupation : Student
Address : Kampung Laut, Cilacap
Admision : 14 Oktober 2017
Examination : 2 November 2017
Medical Record : 01384XXX
ANAMNESIS

Chief Complaint

The wound on the left and right

buttocks, and right hip
ANAMNESIS
(alloanamnesis)
Present illness
His family complaint about wound that extends in his
buttocks and hip.
ANAMNESIS
Present illness
The patient was admitted on October 14, 2017. The
patient was. In June 2017, the patient performed the
act of left leg amputation and education to bed rest
for long time. Currently the patient complains of
wound in the right hips, right and left buttock. His
mother tell that her child often feels uncomfortable,
holds his buttocks, and itching in the left buttocks,
but his mother thinks that it didnt matter of course.
His mother said that all along for the wound care
using regular coconut oil done every day, and his
mother explained the wound was dry.
ANAMNESIS
Present illness
However, since hospitalization in RSDM, his
mother no longer applied coconut oil ointment on
the wound of the patient. During hospitalization,
the patient was only lying on a bed because of
pain in his legs and couldnt stand or walk. His
mother told me that since hospitalization the
wounded in the buttocks is getting bigger, the
patient was in pain and fever. The wound also
began to arise in the right buttocks and right hips
that are sore.
ANAMNESIS
Present illness
Patients have no history of diabetes mellitus and
hypertension. His mother told that her child is
currently decreasing appetite, bitter when eating
and weight loss.
 History Formerly Disease

History of Allergy / Asthma : denied

History of Hypertension : denied
History of Diabetes Mellitus : denied
History of Heart Disease : denied
Anamnesis
Previous Disease
History

- History like illness : denied

- Hospitalization history ; on RS Dr. Soeharso 3
days, on RSDM perform to left leg amputation
Anamnesis
Family History

- Same illness : (-)

Anamnesis
A history of the patient's habits

patient is difficult to eat, currently the patient gets

the liquid and soft diet.
Anamnesis
Social Economic History

patients is a student, currently treated with

financing the BPJS.
Physical Examination
General status

GCS, E4V5M6, composmentis,

moderate pain

Vital Sign

BP : 120/80 mmHg
HR : 94x/minute
RR : 20x/minute
t : 38oC
Physical Examination
Head
mesocephal
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 (-)

Extremity

Left cruris post amputation

Extremity coldness : (-)
Oedem : (-)
Physical Examination
Right trochanter major region
Inspection ; the onset is chronic
wound, the type is press ulcus, basic
wound is granulation tissue, the size is
7 x 7 x 0,5 cm, the depth is muscle,
stinky wound, the border edges is
firm, regular, no inflammation sign
Palpation ; tenderness (+)
Physical Examination
Right glutea region
Inspection ; the onset is chronic
wound, the type is press ulcus, basic
wound is epithelial tissue and slough,
the size is 8 x 7 x 1 cm, the depth is
muscle, stinky wound, the border
edges is firm, regular, no inflammation
sign, necrotic (+)
Palpation ; tenderness (+)
Physical Examination
Left glutea region
Inspection ; the onset is chronic
wound, the type is press ulcus, basic
wound is granulation tissue, the first
wound size is 8 x 8 x 0,5 cm, the
second wound size is 7 x 6 x 0,5 cm
the depth is muscle, stinky wound, the
border edges is firm, irregular, no
inflammation sign, necrotic tissue(-)
Palpation ; tenderness (+)
 Assessment I

Decubitus ulcer grade IV

 Planning I

1. Inf. RL 20 tpm
2. Blood examination
3. Medication
4. The right-left-leaning every 2
hours
5. Decubitus bed
6. Inj. Ceftriaxon 2g/24 jam
 Blood Examination (RSDM, 1 November 2017)
Pemeriksaan Hasil Satuan Rujukan
DARAH RUTIN
Hemoglobin 8.4 g/dl 14.0 17.5
Hematokrit 25 % 33 45
Leukosit 0.3 ribu/ul 4.5 14.5
Trombosit 117 ribu/ul 150 450
Eritrosit 3.12 ribu/ul 4.50 5.90
Index Eritrosit
MCV 80.8 /um 80.0 96.0
MCH 26.9 pg 28.0 33.0
MCHC 33.3 g/dl 33.0 36.0
RDW 13.0 % 11.6 14.6
MPV 8.8 fl 7.2 11.1
PDW 8 % 25 - 65
Hitung Jenis
Eosinofil 2.00 % 0.00 4.00
Basofil 0.00 % 0.00 1.00
Neutrofil 57.00 % 29.00 72.00
Limfosit 37.00 % 33.00 48.00
Monosit 4.00 % 0.00 6.00
 Assessment II

Decubitus ulcer grade IV

 Planning I

1. Transfusion PRC 1 Kolf

2. Kurvalap medication
3. Consultation to Plastic Surgery
and Reconstruction pro
debridement
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