Dekubitus Ulcer

8/17/2019 Dekubitus Ulcer

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1.1. Marlon SoselisaMarlon Soselisa 201083034201083034

2.2. Jurika Kakisina Jurika Kakisina 200983021200983021

3.3. Milka MargaretaMilka Margareta 200983047200983047

4.4.

Yohanes F. SimanjuntakYohanes F. Simanjuntak

200983039200983039

5.5. Nurul Fajriah AfiatunnisaNurul Fajriah Afiatunnisa 201083045201083045

DERMATOVENEROLOGY DEPARTMENT

MEDICAL FACULTY

HASANUDDIN UNIVERSITY


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Name : Yos Welyam Ratu Gender : Male

D.O.B : 5 December 1983 Age : 32 years old Medical Record : 734715

Marrital Status : Married Religion : Christian Admision Date : 28 November 2015

PATIENT IDENTITYPATIENT IDENTITY


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Anamnesis :(Autoanamnesis)

Chief complaint :wound on buttocks area

Further Anamnesis:

Patient, man, 32 y.o consulted from internal department with

decubitus wound on his buttock since 3 months ago. Firstly, it was just a small wound seems the shape of pin’s head, then within 2months it grew wider every time he wore trousers. The patientcomplain the pain on it. The patient had went to the Surgeon, hewas given the medicine for five days however nothing changed.Next, He was hospitalized in RS Samarinda for 14 days, there wasimprovement, then he continued to be hospitalized in RS WSMakassar to continue the treatment. Lay on the back was hard forhim, so by changing the position (turn the body left to right or

vice versa) when laying on the bed made him feel easier.

HISTORY TAKINGHISTORY TAKING


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General condition : Moderate illness / Compos Mentis Vital signBlood pressure : 110/70 mmHgPulse : 84 x/mRespiratory Rate : 24 x/mTemperature : 36,5 °C

Height : 167 cm Weight : 50 kg BMI : 17,9

PHYSICAL EXAMINATION


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Head :no abnormality

Eyes :anemic conjunctiva (+), icteric sclera (-)

ENT:no abnormality

Thorax :

Pulmo- Inspection : symetris dextra et sinistra Palpation: no significant finding Percussion: sonor Auscultation: vesiculer

CORCOR:: Inspection : ictus cordis (+)Inspection : ictus cordis (+) Palpation: thrill (-)Palpation: thrill (-) Percussion: deafPercussion: deaf

Auscultation: S1/S2 regulerAuscultation: S1/S2 reguler


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Abdomen:Abdomen: Inspection : flatInspection : flat Palpation: tenderness(-)Palpation: tenderness(-) Percussion: tympaniPercussion: tympani

Auscultation: peristaltic (+) normalAuscultation: peristaltic (+) normal

GenitalsGenitals::CatheterizedCatheterized

EExtremitiesxtremities:: No abnormalityNo abnormality


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LocationLocation :: Regio gluteus dextra et sinistra,Regio gluteus dextra et sinistra,

scrotumscrotum EfflorescenceEfflorescence:: Ulcus, pus, erosion, excoriationUlcus, pus, erosion, excoriation

DERMATOLOGICAL STATUSDERMATOLOGICAL STATUS


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Hematology

RBC : 2,55 4,0 – 6,0 x 106 / mm3

HGB : 8,7 12,0 – 16,0 g/dL

HCT : 25,5 37,0 – 48,0 %

MCV : 100 80-97 µm3MCH : 34,1 26,5-33,5 Pg

MCHC : 34,1 31,5-35,0 g/dL

PLT : 228 150-400 x 103 / mm3

WBC : 2,28 4,0 – 10,0 x 103 / mm3

PT : 10,7 10-14 detik

aPTT : 22,6 22,0-30,0 detik

LABORATORYLABORATORY


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Chemistry

Blood glucose: 103 140 mg/dL

Ureum : 16 10-50 mg/dL

Creatinin : 0,60 M (


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Decubitus ulcerDecubitus ulcer B20B20

Chronic hepatitis CChronic hepatitis C AnemiaAnemia Electrolyte imbalanceElectrolyte imbalance

ASSESSMENTASSESSMENT


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PATIENT’S FOTOPATIENT’S FOTODAY 1

01 -12-2015


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01 -12-2015


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03 -12-2015


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03 -12-2015


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Dermato therapy :Dermato therapy : Cefixime tab 100 mg/12Cefixime tab 100 mg/12hh/oral/oral Fuson cream (Fuson cream (fusidic acid 2%)fusidic acid 2%)apply after compressapply after compress NaCl 0,9% compress 3x/day, 10 minutesNaCl 0,9% compress 3x/day, 10 minutes

Internal department therapy :Internal department therapy : IVFD Asering/D5% 1:1 28 tpmIVFD Asering/D5% 1:1 28 tpm Maxiliv 0-1-1Maxiliv 0-1-1 (alpha lipoic acid) Liver protector(alpha lipoic acid) Liver protector KSR 2x1 tabKSR 2x1 tab

Cotrimoxazole 960 mg 2x1Cotrimoxazole 960 mg 2x1 Novalgin 1 ampule/8Novalgin 1 ampule/8 hh/IV/IV Ceftazidime 1 vial/12Ceftazidime 1 vial/12hh/IV/IV PRC transfusion 2 bagsPRC transfusion 2 bags

CD4CD4++

countcount

TKTP dietTKTP diet

THERAPYTHERAPY


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Pyoderma gangrenosumPyoderma gangrenosum

Ecthyma gangrenosumEcthyma gangrenosum

DIFFERENTIALDIFFERENTIAL

DIAGNOSISDIAGNOSIS


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Patient, man, 32 y.o consulted from internal department with decubituswound on his buttock since 3 months ago. Firstly, it was just a small woundseems the shape of pin’s head, then within 2 months it grew wider everytime he wore trousers. The patient complain the pain on it. The patient wasdiagnosed with B20 and had been treated using ARV since 5 years ago and

stopped by 6 months ago. He was narcotics user (syringe) approximately 10years ago. Patient was moderate illness, compos mentis. vital signs are normal, BMI:underweight. General status : anemic conjunctiva (+). Dermatology status:location ategio gluteus dextra et sinistra, scrotuegio gluteus dextra et sinistra, scrotum with efflorescence um with efflorescence ulcus,lcus,

pus, erosion, excoriationpus, erosion, excoriation.. From laboratory data : anemia, liver function abnormality, electrolyteFrom laboratory data : anemia, liver function abnormality, electrolyteimbalance, chronic hepatitis Cimbalance, chronic hepatitis C

Therapy :Therapy :Cefixime tab 100 mg/12Cefixime tab 100 mg/12hh/oral/oral,,Fuson cream (Fuson cream (fusidic acid 2%)fusidic acid 2%)

apply after compressapply after compress,,NaCl 0,9% compress 3x/day, 10 minutesNaCl 0,9% compress 3x/day, 10 minutes

RESUMERESUME


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DECUBITUS ULCERDECUBITUS ULCER


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DEFINITIONDEFINITION

A decubitus ulcer is a localized injury to the skin orA decubitus ulcer is a localized injury to the skin orunderlying tissue, usually over a bony prominence,underlying tissue, usually over a bony prominence,

that is a result of pressure or of pressure or combinedthat is a result of pressure or of pressure or combinedwith sher or frictionwith sher or friction


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EPIDEMIOLOGYEPIDEMIOLOGY

It’s estimated that between 1,5 and 3 million peoplein the US have decubitus ulcers.

Most predevelop during the first few weeks ofMost predevelop during the first few weeks of

hospitalization.hospitalization. More common in the elderly, especially those overMore common in the elderly, especially those overthe age of 70the age of 70

The majority of pressure ulcers occur on the lowerThe majority of pressure ulcers occur on the lower

part of the body, 65% in the pelvic area and 30% opart of the body, 65% in the pelvic area and 30% othe lower limbsthe lower limbs


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RISK FACTORSRISK FACTORS

Comorbid conditionsComorbid conditions Drug that may effect ulcer healing (e.g steroids)Drug that may effect ulcer healing (e.g steroids)

History of a healed stage III or IV decubitus ulcerHistory of a healed stage III or IV decubitus ulcer Impaired diffuse or localized blood flowImpaired diffuse or localized blood flow Impaired or decreased mobility and functional abilityImpaired or decreased mobility and functional ability Increase in friction or shearIncrease in friction or shear

Moderate to severe cognitive impairmentModerate to severe cognitive impairment Undernutrition, malnutrition, and hydration deficitsUndernutrition, malnutrition, and hydration deficits


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ETIOLOGY & PATHOGENESISETIOLOGY & PATHOGENESIS

The main etiologic factors contributing to decubitusThe main etiologic factors contributing to decubitusulcer development include pressure, shearing forces,ulcer development include pressure, shearing forces,

friction, and moisture.friction, and moisture. Pressure or force per unit area is considered to be thePressure or force per unit area is considered to be themost important factor in decubitus ulcer formation.most important factor in decubitus ulcer formation.Normal tissue pressure : 12-32 mmHg. Pressures higherNormal tissue pressure : 12-32 mmHg. Pressures higher

than this upper limit can compromise tissue circulationthan this upper limit can compromise tissue circulationand oxygenation.and oxygenation.


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Pressure ulcer stage III complicated by fecalPressure ulcer stage III complicated by fecalincontinence (left) and IV (right)incontinence (left) and IV (right)


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CLINICAL FINDINGSCLINICAL FINDINGS

HistoryHistory

Should assess the following risk factors: mobility, activityShould assess the following risk factors: mobility, activitylevel, nutritional status, mentalevel, nutritional status, mentall status,status,incontinence/moisture conditions, general physicalincontinence/moisture conditions, general physicalcondition, skin appcondition, skin appearanceearance, medication use, friction &, medication use, friction &shear, weight, age, predisposing disease & prolongedshear, weight, age, predisposing disease & prolongedpressure.pressure.


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Cutaneus lesionCutaneus lesion


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Related physical findingsRelated physical findings Tenderness, erytTenderness, erythhema,ema,ooedema, & warmth ofedema, & warmth ofsurrounding skin, exudate, & foul odorsurrounding skin, exudate, & foul odor symptoms &symptoms &

signs of infection.signs of infection. Fever & declining mental or physical status shouldFever & declining mental or physical status shouldraise suspicion of bacteremia or osteomyelitis.raise suspicion of bacteremia or osteomyelitis.

Spasticity secondary to inflammation & infection maySpasticity secondary to inflammation & infection maytrigger muscle contractures & joint deformity that cantrigger muscle contractures & joint deformity that canlimit motion.limit motion.

Weakness & sign of anemia & dehydration can beWeakness & sign of anemia & dehydration can befound secondary to profound loss of fluid & protein.found secondary to profound loss of fluid & protein.


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Lab tests :Lab tests :Anemia, leukocytosis, hypoproteinemia,Anemia, leukocytosis, hypoproteinemia,hypoalbuminemia, elevated ESR, or reduced serumhypoalbuminemia, elevated ESR, or reduced serumiron levels may be presentiron levels may be present

Special tests : biopsy and imaging studies.Special tests : biopsy and imaging studies. Plain radiographsPlain radiographs identify ectopic bone, air in theidentify ectopic bone, air in theulcer cavity, & sclerotic or destructive changes in theulcer cavity, & sclerotic or destructive changes in theunderlying bony prominenceunderlying bony prominence

CT scanningCT scanning determine the extent of adetermine the extent of adecubitusdecubitus ulcer & its anatomic relation to surrounding structureulcer & its anatomic relation to surrounding structure..

MRIMRI determining the depth & extent of soft-tissuedetermining the depth & extent of soft-tissueinvolvement underlying decubitus ulcers.involvement underlying decubitus ulcers.


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COMPLICATIONCOMPLICATION

Local infectionsLocal infections BacteremiaBacteremia OsteomyelitisOsteomyelitis

MalignanciesMalignancies Necrotizing fasciitisNecrotizing fasciitis MyonecrosisMyonecrosis Metabolic alterations: hypercalcemia, hypoproteinMetabolic alterations: hypercalcemia, hypoprotein--emia, anemiaemia, anemia

DeathDeath


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TREATMENTTREATMENT

Use of basic support surfaces, repositioning the patient,Use of basic support surfaces, repositioning the patient,optimizing nutritional status, & moisturizing sacral skinoptimizing nutritional status, & moisturizing sacral skinwith expectations of some improvement within 2 weeks.with expectations of some improvement within 2 weeks.

Relief of pressure, shear, & frictional forcesRelief of pressure, shear, & frictional forcesWound management: cleansing, debridement, dressingWound management: cleansing, debridement, dressingproductsproductsBacterial colonization & infection managementBacterial colonization & infection management::

Systemic ab therapy if there is bacteremia, cellulitis,Systemic ab therapy if there is bacteremia, cellulitis,osteomyelitisosteomyelitisTopical ab toTopical ab to prevent/treat wound infection, reduce bacterial load or odor & sign of inflammation


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TREATMENTTREATMENT

Pain managementPain management Muscle relaxants & physical & occupational therapyMuscle relaxants & physical & occupational therapy ↓ muscle spasm in the area of ulcer.↓ muscle spasm in the area of ulcer.

TENSTENS Topical anestheticsTopical anesthetics Non-opioid analgesicsNon-opioid analgesics first line systemic therapyfirst line systemic therapy

SSurgery for deep ulcer, grade 3 or 4, with flaps or skinurgery for deep ulcer, grade 3 or 4, with flaps or skingraft.graft.


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PREVENTIONPREVENTION


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DISCUSSIONDISCUSSION


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Documents

Dekubitus Ulcer