3. Identity
Nama Mrs E
Medical Record 0002054405
Age 67 Years
Address Kebonwaru
Marital status Married
Tribes Sundanese
Religion Moslem
Occupation Housewife
Education Elementary school
Referred by Plastic surgery
Referral diagnosis Multiple pressure injury grade IV
with squele stroke
Dexterity Right handed
Caregiver 1st , 3 rd and her husband
Health insurance BPJS
4. HISTORY TAKING
Chief complaint : Pain in whole body
Present Ilness
• The patient complained of pain in the buttocks (NRS 7-8) when moving or sitting, the pain was
reduced when the patient was lying down and lying on the side. The wound on the buttocks was found by
her son since January 2022, with a diameter of 5 cm. The patient's wound was treated by her husband wit
h herbal medicine, but the wound was getting bigger and worsened.
• Prior to the injury, in 2016 the patient had a stroke with symptoms of weakness on the left side of
the body. The patient was treated at St. Yusuf Hospital for 1 week. The patient continued therapy at home
with alternative medicine but the condition didn’t improve. Patient can still do ADL self-care independen
tly. 9 months later the family noticed that the right side of the patient's body became weak and could not
be moved. But at that time patient was not taken to the hospital and the family chose to treat her at home.
patient' ADL is fully dependent in bed. She use diapers, and the main caregiver for the patient is her
husband. The patient continues to take anti-hypertensive drugs but not regularly.
• The patient also complained of stiffness in all of her joints (NRS 7-8), especially when moved and
disappeared when not moved. The patient can eat in a lying position with head up 30 degrees without cho
cking. Every day the patient eats less and less. The patient never finished 1 portion of her food. There are
no sleep disturbances.
5. Add some text to the title slide
Past Medical Condition
History of family ilness & Allergic
Hypertension (+) uncontrolled, Storke (+), Dyslipidemia (-) uncontrolled, DM(-)
Fall history: (-)
Infection (-), immune deficiency (-)
Hypertension +, Stroke +, DM(-)
History of allergic : No
6. TIMELINE
July 2016
She feels headaches and
the first time the doctor said
she got hypertension
August 2016
The first time she got a Stroke
attack (hemiparesis sinistra)
and was hospitalized for 1
week
August 2016 – June 2022
Homecare with the primary care
giver is her husband
ADL self care
partial dependent
ADL self care
Full- dependent
7. History of Psycho and Socioeconomic Status
SOCIAL CONDITION
The patient has 3 children, currently living with her
husband. The patient's house is on 2 floors with the rooms on
the 2nd floor. Since being sick, the patient has been sleeping in
the family room on the 1st floor. Child No. 3, the patient,
often comes to accompany her.
FAMILY INCOME
The patient's current income
from child number 3 per month is
2 million rupiahs but since the
patient is sick, the patient's child does
not work so the income
from relatives is uncertain
PSYCHOLOGICAL CONDITION
A patient is a quiet person who never
complains and spends more time at home
with his family
HOBBY
No hobby
HOPE
She hopes the injury is resolved an
d no pain anymore.
8. History of Functional Abilities
No Activity Function After August 2016
1 Bowel 2
2 Bladder 1
3 Grooming 0
4 Toileting 0
5 Eating 0
6 Changing basic position from supine to sitting 0
7 Moving, walking 0
8 Dressing 0
9 Up-down stairs 0
10 Bathing 0
Total 3
Very severe Disability
ADL
Very severe disability
9. IADL
No Activity Function Before illness After illness
August 2016
1 Using telephone 1 0
2 Shopping 1 0
3 Preparation Food 1 0
4 House keeping 1 0
5 Laundry 1 0
6 Mode of transportation 1 0
7 Responsibility of own medications 1 0
8 Ability to handle fiances 1 0
Total Score 8 0
High function, indep
endent
Low function,
dependent
18. PENILAIAN RISIKO JATUH LANSIA
No Risiko Skala
1 Gangguan gaya berjalan (diseret, menghentak, berayun) 4
2 Pusing atau pingsan pada posisi tegak 3
3 Kebingungan setiap saat (contoh: pasien yang mengalami demensia) 3
4 Nokturia/Inkontinen 3
5 Kebingungan intermiten (contoh pasien yang mengalami delirium/Acute confusional state) 2
6 Kelemahan umum 2
7 Obat-obat berisiko tinggi (diuretik, narkotik, sedatif, antipsikotik, laksatif, vasodilator, antiaritm
ia, antihipertensi, obat hipoglikemik, antidepresan, neuroleptik, NSAID)
2
8 Riwayat jatuh dalam 2 bulan terakhir 2
9 Osteoporosis 1
10 Gangguan pendengaran dan/atau penglihatan 1
11 Usia 70 tahun ke atas 1
Tingkat risiko :
• Risiko rendah bila skor 1-3 : Lakukan intervensi risiko rendah
• Risiko tinggi bila skor ≥ 4 : Lakukan intervensi risiko tinggi
23. Comprehensive Geriatric ASSESTMENT
Total Score Detail Impression
1 EQ5D
EQ VAS
2,2,3,1,1
50 (0-100)
Problems in mobility, ADL and daily activity Bad QoL
2 ADL (Barthel Index) 3/20 Difficulty in all aspect Very severe disability
3 IADL Lawton 0/8 all impaired Low function, depend
ent
4 Frailty Index-40 13 (<0,08) - Frailty
5 SARC-F Cbe ( <4 ) - Cannot be evaluated
6 EWGSOP BIAASM: cbe
Chair Stand: cbe
Hand Grip : cbe
ASM cbe + low muscle strength + low physical pe
rformance
Suspect Sarcopenia
7 Fried Frailty Fenotipe 5/5 5 out of 5 phenotypic criteria (reduce grip
strength, low physical activity, slowed walking
speed, fatigue)
Frailty
8 Clinical Frailty Scale 8 ( <5 ) Need help in all activities Severe Frail
24. Total Score Detail Impression
9 BBS (Berg Balance Scale) cbe/56 - Cannot be evaluated
10 Mini Best Test cbe/28 - Cannot be evaluated
11 Mini Nutritional Assessment 20 ( <24) Malnutrition
12 Geriatric Depression Scale 11 ( < 5) Depression
13 GUSS 20/20 Indirect swallowing test=5
Direct swallowing test= 15
Normal
14 MOCA INA Basic cbe/30 Patient cannot use her hand Cannot be evaluated
15 Risk of Fall in elderly 5 (<4) - High concern risk of fall
16 Zarit burden scale 13/ 88 Little or no burden
17 MMSE 19/24 Mild cognition impairment Atensi and calculation,
language
18 Karnofsky performance scale 40/100% Severely disabled Requires special care and
assistance
19 Palliative performance scale 30/100% Totally bed bound
25. Pemeriksaan Penunjang
Klinis: Congestive cardiac failure, (CCF)
Thoraks AP
Foto asimetris, inspirasi cukup.
Skeletal dan soft tissue yang tervisualisasi dalam batas normal
Trakea di tengah
Cor membesar ke lateral kiri dengan apex tertanam pada diafragm
a, pinggang jantung normal. Kalsifikasi aorta (-).
Sinuses dan diafragma dalam batas normal
Pulmo:
- Hili dalam batas normal
- Corakan bronkovaskuler bertambah
- Tidak tampak perbercakan/ perselubungan di kedua lapang paru.
- Kranialisasi (-)
KESAN :
- Roentgenologis pulmo dalam batas normal.
- Kardiomegali
28. Resume
Women, 68 yo, housewife, with lower economic status, was diagnose multiple pressure injury grade IV
after squele Stroke infark in chronic phase:
From history taking and physical exams at July 6th 2022:
• The patient was unable to do all her ADL and IADL due to squele stroke from July 2016 because her
weakness in all extremities.
• Patient didn’t want to do the exercise at home since the first time she got stroke, she only lying on the
bed and all her activity in the bed.
• She don’t have any close friend to motivated her, her siblings whereabout is unknown.
• The condition getting worse because her family didn’t accepts the medical treatment.
• Since stroke, she more quite and never complain about her condition.
• She urinate and defecated in the diapers and She still could feel the sensation and hold her urination.
• She has hypertention as risk factor of the stroke.
• Patient has sarcopenia and frailty.
• Patient has depression.
• Patient hopes want to free of pain and can do her ADL independently.
29. Diagnose
Medical diagnosis
Multiple pressure injury grade 4 at regio sacrum, deep tissue injury regio calcaneus sinistra,
grade unstageable regio pedis sinistra (lateral aspect )
Stroke infark chronic phase
Hipertention
Geriatric Syndrome (Immobility, Isolation)
Frailty
Sarcopenia
30. Mobilization and ADL disturbance ec Chronic pain due to Multiple pressure injury grade IV and muskuloscelatal problem +
Stroke infark chronic phase with risk factor Hypertention, and Geriatric Syndrome
(Immobility, Isolation, Impecunity,inanition,infection)
Body structure and function
B280 sensation of pain
B2802 pain in multiple body part
B730 Sensory function
B260 proprioceptive function
B420 Blood pressure functions
B7306 Power of all muscle of the body
B1301 Motivation
B1302 Appetite
S810 Structures of areas of the skin
B5350 sensation of nausea
B530 weight maintanace functions
B7356 tone of all muscle of the body
S110 structure of brain
S540 structure of intestine
S898 skin and related structure, other specified
Activities
d429 Changing and maintaining body position
D5500 indicating need for eating
D5600 indicationg need for drinking
Environment
E 120 Products and technology for personal indoor and outdoor mobility and transportation
e310 Immediate family
e355 Health professionals
e580 Health services, systems and policies
Personal factors
67 yo
Housewifw
31. Geriatric Giants
Positive in patient :
Immobility, Instability, Isolation, Infection, Immune deficiency, Impecunity,
Inanition, frailty, sarcopenia.
Negative in patient :
Intellectual impairment, Impairment of hearing, impairment of vision, Inco
ntinency, , Impaction
32. PROBLEM LIST
MEDICAL PROBLEM
• Depression
• Multiple pressure injury grade 4 at regio sacrum,
deep tissue injury regio calcaneus sinistra, grade
unstageable regio pedis sinistra (lateral aspect )
• Chronic Pain
• Stroke infark chronic phase
• Hipertention
• Geriatric Syndrome (Immobility, Instability, Isolation,
Infection, Immune deficiency, Impecunity,
• Inanition, frailty, sarcopenia)
• Frailty
• Sarcopenia
REHABILITATION PROBLEM
•Immobilization impact (Multiple pressure injury )
•ADL disturbance
•Mobilization disturbance
•At risk of malnutrition
•At risk of pneumonia
•At risk of sepsis
•Bad Quality of life
33. Prognosis
• Ad vitam : dubia ad malam
The risk of mortality was higher because psychosocial problems, immobilization and infection
• Ad sanationam : dubia ad malam
Malnutrition, improper wound care + immobilization, psychosocial problems and pain trigger high infectio
n recurrence
• Ad Functionam :
ADL self care and IADL dependent by caregiver
Mobilization with wheelchair wheeling by caregiver
Resolve Psychosocial problems as a one of main problems.
34. DISCHARGE PLANNING
Room :
room preparation with adequate ventilation, sufficient lighting, decubitus mattress, oxygen, using
pillow to support the patient
Caregivers:
knowing how to take care of a patient’s especially for wound care,
taught how to mobilize the patient in bed (proper positioning)
being taught how to measure the patient's vital signs, and
knowing when to go to the hospital,
caregivers take turns alternately
35. long term goal:
1. Her family understand patient condition and the importance of medical treat
ment for this patient.
2. The family understand about her prognostic
3. Patient can live with chronic pain
Short term goal (one month):
1. Psycological problem resolved (Patient can accept and understand her condition)
2. The wound not getting worse,
3. No new pressure injury in new side of the body
4. Prevent infection (community acquired pneumonia, UTI)
5. Patient can side lying without pain follow by sitting with support
6. Buying TENS for daily use at home
7. Reduced pain when exercise or mobilization using TENS.
36. CGA Analysis
Medical Aspect Aspects of Nursing
Care
Aspects of Functional Psychosocial Aspec
t
Environment Aspect
• Chronic pain due t
o Multiple pressure
injury grade IV
• Stroke infark chroni
c phase with risk fa
ctor Hypertention
• Geriatric Syndrome
(Immobility, Isolatio
n, Impecunity,inanit
ion, infection)
• Frailty
• Sarcopenia
• Education careg
iver for wound
care
• Chronic pain
• ADL and IADL distur
bance
• Mobilization disturb
ance
• At risk of malnutritio
n
• Quality of life
• Susp cardiopulmonal
endurance
• Consult to Psyc
olog
•Two floor house, patient sl
eep at 1st floor
•The door is narrow, difficul
ty for bed mobilization
•Light and ventilation is not
-adequate
•Access to main road 200
meter
• Access to puskesmas 1 k
m and 7 km to RSHS
37. Assessment of Medical Rehabilitation Problems
Problem Clinical Goal Detention Potention Program
1.Pain - Screaming
when the
body
- move
- Pain
decreased
•Malnutrition
•Infection
•Multiple pres
sure injury gra
de 4
- No caregiv
er burden
• Analgesic patch
• TENS
• Move and exercise the patient 1
hours after the drug is given
• Physiotherapy:
1. Gentle stretching on all extremi
ties
2. Immobil
ization im
pact (Mult
iple press
ure injury
)
- Multiple p
ressure inj
ury
-no infection
-No new pres
sure injury in
new side of t
he body
-the wound i
s not getting
wider
• Caregivers
(husband)
don't belie
ve in medic
al treatme
nt
• Wounds re
quire speci
al care
- Good Supp
ort from her
daughter
• Turning every 1 hours
• Wound care
• Operation If the conditions possi
ble
• Decubitus matras
• Nutrision : high protein
38. Problem Clinical Goal Detention Potention Program
2. ADL &
IADL
- ADL and IAD
L all severe d
ependent car
e giver
- Motorik non-
fungsional in
upper and
lower
extremity
- ADL and IA
DL all depe
ndent
- Low econom
ic condition
- No caregiver burden
- Good in cognition
- ADL and IADL all by caregiv
er
Psicologic
al proble
m
-depression and
axiety
- Patient can
understand
and accept
her conditio
n
- The depress
ion resolve
d
- No big family
(patient sibli
ngs) and frie
nds support
- Still have motivation
- Her daughter suppo
r for medical treatm
ent and mental supp
ort
• Psicological conseling
for patient and family
• Home modification
• Plan to family meetin
g
39. Problem Clinical Goal Detention Potention Program
5. Sarcopenia - Muscle mass c
be (N: > 5,7 Kg
/m2)
- Hand grip stre
ngth 14 kg (N:
> 18Kg)
- SARC-Calf : 15
No Sarcopenia Risk of malnutriti
on
MMT fun
ctional
- Strengthening exercis
e (exercise testing first
)
- Aerobic exercise
- Refer to Clinical nutriti
onist for higher protei
n diet
Problem Clinical Goal Detention Potention Program
5. Sarcopenia - Muscle mass c
be (N: > 5,7 Kg
/m2)
- Hand grip stre
ngth 14 kg (N:
> 18Kg)
- SARC-Calf : 15
No Sarcopenia Risk of malnutriti
on
MMT fun
ctional
- Strengthening exercis
e (exercise testing first
)
- Aerobic exercise
- Refer to Clinical nutriti
onist for higher protei
n diet
Problem Clinical Goal Detention Potention Program
5. Sarcopenia - Muscle mass cb
e (N: > 5,7 Kg/m
2)
- Hand grip streng
th cbe (N: > 18K
g)
- SARC-Calf : cbe
No Sarcopenia Risk of malnutriti
on
- - Refer to Clinical nutriti
onist for higher protei
n diet
Problem Clinical Goal Detention Potention Program
6. Frailty Frailty phenotype
5
Physical Activity i
ncrease,
Pre-frail
Pain Cognition
function is
good
- Mobilization In sitting
position.
