Case Presentation

Plastic Surgery

A 55th Years Old Woman with Pressure Sore

Grade IV on the Sacrum Region

By:
Dorothy Eugene Nindya
G99142129
Supervisor:
Amru Sungkar, dr.,Sp.B,Sp. BP-RE

Patient Identity

Name

:Mrs. S,

Age

Address

Medical record : 013446xx

: 55th years old

: Bangunsari, Karanganyar

Chief Complain: Wound at the buttocks

was
Patient
Present
consulted
by
neurology
department

Illness:
wound at

the lower
back

appeared
since
3month ago

it was
getting
bigger

made the
patient feel
pain

History of hospital treatment: (+)

Motorcycle accident was

Nutrition History
He always eats food three times a day.

He eats with rice, vegetables and tempe, tofu,

egg, and eats meat rarely.

Social Economy History

The patient is a 47th years old male, lives at home with his
wife and 1 son

Before this illness, he worked with his wife selling food

Now, he treated in hospital with BPJS facility.

PHYSICAL EXAMINATION
Primary Survey

Airway: inserted with tracheostomy tube

Breathing: spontaneous, thoracoabdominal with respiration rate 22x/minute

Circulation: Heart Rate 88x/minutes, blood pressure 130/80 mmHg

Disability: GCS E2V1M2, light reflex (+/+), isokor(3mm/3mm)

Exposure: temperature 36.7o C, lesion (+)

Localized Status

Sacrum Region

Inspection: ulcer (size 7 x 5 x 1

cm), necrotic tissue (+), pus (+)

Palpation: tenderness (+)

Assesment I
Pressure

Sore grade IV on the sacrum region

Planning I
Laboratory blood
test

Wound management

Repositioning per 2
hours

Using Decubitus bed

Blood Test (November 28th , 2016)

Examination

Result

Normal Range

HEMATOLOGI ROUTINE
Hb
HCT
AL
AT
AE

9.6
33
17.6
711
4.24

g/dl

13.5-17.5

33-45

103/l

4.5 11.0

103/l

150 450

106/l

4.5 -5.9

HEMOSTASIS
PT

13.7

Second

10.0 15.0

APTT

27.4

Second

20.0 40.0

INR

1.070

Supporting
Examination

Examination

Result

Normal Range

Sodium

124

Mmol/L

136-145

Potassium

3.4

Mmol/L

3.3-5.1

Chloride

96

Mmol/L

98-106

Albumin

3.4

g/dl

3.5-5.2

Blood sugar

132

Mg/dl

60-140

Creatinin

0.3

Mg/dl

0.2-1.3

Ureum

19

Mg/dl

<50

Assesment II

Pressure Sore grade IV on the sacrum region

Planning II

Wound management

Repositioning per 2 hours

Decubitus Bed

Diet 1800kkal/day and 50

gr protein/day

LITERATURE

REVIEW

Definition

Pressure Sore : damage caused to the skin due to compression or

irritation of time at a location where there are bony, causing
obstructed blood flow that can occur local ischemia and necrosis

(Crowe T & Brockbank C,2009).

Predilection

(Wong H, et.al,2015).

(Grey et.al,2006).

MORBIDITY AND MORTALITY

(Kumar A, Mahal R,2014).

ETIOLOGY

The main caused of pressure sore is the pressure which

causes ischemia.

(Garber SL, Rintala DH ,2003).

RISK FACTORS

(Apostolopoulou E, et.al ,2014)

PATHOPHYSIOLOGY

(Grey et.al,2006).

PATHOGENESIS

(Grey et.al,2006).

SYMPTOMS
NPUAP classified pressure sore into four grades.
GRADE I

GRADE I
limited to the epidermis
and dermis with erythema
of the skin

can be cured in 5-10 days.

(Dharmarajan T.S, Ugalino J.T ,2002)

GRADE II

GRADE II

extending into adipose

tissue

visible erythema and

induration

can be cured in 10-15 days

(Dharmarajan T.S, Ugalino J.T ,2002)

GRADE III

GRADE III

extending to the
subcutaneous fat layer
and muscle

usually heal in 3-8 weeks

(Dharmarajan T.S, Ugalino J.T ,2002)

GRADE IV

GRADE IV
ulceration and necrosis
extends the fascia,
muscles, bones and joints

can occur or osteomyelitis

and septic arthritis

can be recovered in 3-6

months.
(Dharmarajan T.S, Ugalino J.T ,2002)

EXAMINATION

(Niezgoda JA, et.al,2006)

TREATMENT
Things to consider when treat pressure sore:

(Riordan J, Voegeli D,2009)

Pressure sore treatment can be divided as:

(Riordan J, Voegeli D,2009)

Nonsurgical Treatment

(Riordan J, Voegeli D,2009)

Nonsurgical Treatment

(Riordan J, Voegeli D,2009)

Maintaining a clean state

(Riordan J, Voegeli D,2009)

Lowering and overcome the infection

(Riordan J, Voegeli D,2009)

Stimulate and help the granulation tissue formation

and epithelialization

(Riordan J, Voegeli D,2009)

SURGICAL TREATMENT
Lifting of necrotic tissue

(Riordan J, Voegeli D,2009)

Lifting of necrotic tissue

Biological debridement

Sharp debridement

Ultrasound assisted
debridement

(Riordan J, Voegeli D,2009)

Surgery

(Riordan J, Voegeli D,2009)

Surgery

(Riordan J, Voegeli D,2009)

Specific Areas -ischial

the gluteal thigh flap

a fasciocutaneous flap
based on the
descending branch of
the inferior gluteal
artery

the inferior gluteus

maximus
myocutaneous flap
(Mostafa,2012)

Specific Areas-sacral
Gluteus maximus
musculocutaneous
flap

Superior gluteal
artery island
flap

V-Y gluteus
maximus flap

Gluteal rotation
flap

(Diaz et all,2013)

Specific Areas-trochanteric

Tensor Fascia Lata (TFL)

musculocutaneous flap

anterolateral thigh flap

(Diaz et all,2013)

Prevention

(Diaz et all,2013)

REFERENCE

Crowe T & Brockbank C (2009). Nutrition therapy in the prevention and treatment of pressure ulcers. School of
Exercise and Nutrition Sciences Deakin University: 17(2)

Wong H, et.al (2015). Efficacy of a pressure-sensing mattress cover system for reducing interface pressure: study
protocol for a randomized controlled trial. Department of Clinical Neurosciences Foothills Hospital(16): 434

Apostolopoulou E, et.al (2014). Pressure ulcer incidence and risk factors in ventilated intensive care patients. Health
Science Journal. 8(3): 333-337

Ausili, et.al (2013). Treatment of pressure sores in spina bifida patients with calcium alginate and foam dressings.
European Review for Medical and Pharmacological Sciences (17): 1642-1647

Aust MP (2011). Pressure Ulcus Prevention. American Journal of Critical Care : 20: 376

Bluestein D, Javaheri A (2008). Pressure Ulcers: Prevention, Evaluation, and Management. American Academy of
Family Physicians 78(10): 1186-1194

Ciliers G, Kotze J (2014). Pressure Ulcers: Surgical Intervention. Wound Healing Southern Africa 7 (2): 45-52

Chen K, Chang K (2010). Reconstruction of Ischial Pressure Sore. JTSP 19 (2): 128-136

Chester H, Bogie K (2007). The Prevention and Treatment of Pressure Ulcers.

Converse JM. Reconstructive plastic surgery. Second ed. WB Saunders, 1977; 1596-1635.

Cox J (2011). Predictors of Pressure Ulcers in Adult Critical Care Patient. American Journal of Critical Care: 20(5)

Anders J, et.al (2010). Decubitus Ulcers: Pathophysiology and Primary Prevention. Deutsches rzteblatt
International. 107(21): 37182

Dharmarajan T.S, Ugalino J.T (2002). Pressure Ulcers: Clinical Features and Management. Hospital Physician: 64-71

Diaz S, Li X (2013). Update in the Surgical Management of Decubitus Ulcers. Anaplastology 2 (3)

Dozsa C (2014). Results of A Decubitus Prevention and Wound Care Project. Value in Health 17 : A323A68

Garber SL, Rintala DH (2003). Presure Ulcers in Veteran with Spinal Cord Injury: A Retrospective Study. Journal of
Rehabilitations Research and Develpment: 433

Hunter IA, Davies J (2014). Managing pressure sores. Wound management surgery : 32(9) : 472-476

Keast D, Parslow N (2006). Best Practice Recommendations for the Prevention and Treatment of Pressure Ulcers.
Wound Care Canada 4 (1): 31-43

Kulma A, et.al (2012). The Effects of Newly Developed Linen Dressings on Decubitus Ulcers. Journal of Palliative
Medicine 15(2): 146-149

Kumar A, Mahal R (2014). Pressure ulcer risk factors: There is no higher priority than prevention. IOSR Journal of
Nursing and Health Science 3(3): 22-25

Niezgoda JA, et.al (2006). The Effective Management of Pressure Ulcers. Advances in Skin & Wound Care 19(1): 3-14

Rappl L, Hamm R (2009). Pathophisiology, Prevention, and Treatment of Pressure Ulcers.

Riordan J, Voegeli D (2009). Preventions and Treatment of Pressure Ulcers. British Journal of Nursing 18(20): 21-27

Takahashi M, Black J (2010). Pressure Ulcer Prevention : Pressure, Shear, Friction, and Microclimate in Context.
International Review

Wentworth K (2013). Diagnosis, Management, and Prevention of Pressure Ulcers. Hospital Medicine Clinics 2(2):
274:291

Angelis B, Lucarini L (2012). Combined Use of Super-Oxidised Solution with Negative Pressure of Pressure Ulcers.
International Wound Journal 10 (3): 36-339

Thank You