Mini case geriatric division in rehabilitation department

1. REHABILITATION OF HIP DISARTICULATION AND
TROMBOEKTOMY LEFT LOWER EXTREMITY DUE TO
ACUTE LIMB ISCHEMIC RUTHERFORD III WITH
GERIATRIC SYNDROME
Presented by:
Ika Ayu Paramita, dr.
Supervised By:
Dr.Med.Sc. Irma Ruslina Defi, dr. Sp.KFR
(K)
Istingadah Desiana., dr., Sp.KFR

2. IDENTITY
DATE OF EXAMINATION: 15TH NOVEMBER 2022
Name Mrs. KR
Gender Male
Date of Birth July, 6st 1938 (84 years old)
Religion Islam
Marital Status Married
Vocational Retired
Education Bachelor (Pendidikan Guru Agama)
Referral
Diagnosis
ALI Extermitas inferior bilateral Post hip disarticulation
dextra
Refered from Vascular Surgery Departement

3. HISTORY TAKING
(NOVEMBER 18TH 2022)
Chief complain: Can not move lower part of the
body

4. PRESENT ILLNESS
• The patient complaint unable to changing body position from supine to side lying and lying to sitting
since 3 weeks a go.
• November 3th 2020 patient felt pain (NRS 9) and weakness on both lower extremity. Complaints are
also accompanied by black discolouration on both lower extremity from knee until the feet, numbness,
and cold palpable. Due to his condition the patient was brought by the family to the Hasan Sadikin
Hospital.
• Patient admitted in Hasan Sadikin Hospital on 4th 2022 and he diagnose with acute limb ischemic
rutherford grade III. He is indicated to under gone hip disarticulation in right lower extremity and
tromboektomi at left lower extremity at November 5th 2022.
• Now patient complained of pain in the postoperative amputee wound (NRS 4). Amputee wound stil
produce blood and serous fluid. Pain also felt on his left extremity (NRS 5), pain is felt when patient leg
is bent or moved. Pain decresed when his leg in resting position (NRS 3).
• He still feels the amputated leg.
• He also complaint has multiple wound at his left extremity since 1 week a go that getting bigger
• Patient felt shortness of breath and easily fatique when do daily activity (eating, upper dressing,
bathing), changing body position, sitting with support more than 15 minute and talking more than 3
sentence.

5. PRESENT ILLNESS
• He complain hard to fall asleep at night. Patient wake up many times during the sleep and hard to fall
asleep again.
• He urinate using condom cathether. Patient defecate everyday and consistency of the stool is normal. He
defecate using diapers
• The patient complained of enlarged testicles since October 24th, 2022. The patient had received medication
treatment at ASM hospital.
• His food intake 3 times a day with composition ( 3 spoons of rice, 2 slice of vegetable, 1 slice protein) but
decrease of intake because patient felt tired when eating more than 3 spoons and felt bloating. Fluid intake
less than 1 liter/days
5

6. October 2022
Patient has
retensio urin and
admitted to ASM
hospital in
Cileunyi. Patient
hospitalized 7 days
November 3th 2022
Patient felt pain, muscle
weakness, and cold palpable in
both extremity
Admitt to RSHS
November 4th 2022
Operation hip disarticulation
Tromboektomi
TIMELINE
ADL independent
Mobilization indepent
ADL dependent

7. PAST MEDICAL CONDITION
•Hypertension (+) since 10th uncontrolled (2012)
•Heart disease (+) since 7th uncontrolled (2015)
• Kidney stone and stone removal operation 40th year a go (1982)
• Recureent kidney stones and Benign Prostate Hiperplasia (operation) at 2013
• Gallstones and removal operation 2019
• No lung TB
• Stroke (-)
•Diabetes Melitus (-)
COMORBIDITY
Hypertension
Cardiac heart failure
No history diabetes mellitus and allergic.

8. RECENT MEDICATION
• IVFD NaCl 0.9% 1500cc/24 jam
• Heparin 5000 IV
• Ceftriaxone IV 1x2gr
• Metronidazole IV 3x500mg
• Ketorolac 30mg 3x1 IV
• Omeprazole 40mg 2x1
• November 16th
• Merophenem 3x1gr IV
• Amikasin 1x1gr IV
• Bisoprolol 1x2,5mg IV
• Atorvastatin 1x40mg
• Ramipril 1x5mg PO
• Furosemid 1x60mg IV

9. HISTORY OF FUNCTIONAL ACTIVITY,
HABIT & NUTRITION
History of Physical Activity
Time Activity METs
05.00 – 05.30
05.30 – 06.30
Waking up, shalat
Gardening
1.3
2.5
06.30 – 07.00 Watching television
Take a bath
1.3
2.0
07.00 – 07.30 Breakfast 1.5
07.30 – 12.00
12.00 – 13.00
Cooking
Shalat
2.0
1.3
13.00 – 15.30 Lunch
Taking a nap
1.5
1
15.30 – 16.00 Shalat 1.3
17.45 – 18.15 Shalat 1.3
18.15 – 18.30 Take a bath 2.0
18.30 – 19.00
19.00 – 21.00
Dinner
Watching television
1.5
1.3
21.00 – 05.00 Sleep 1.0
Average 1.0 –
3.3
The patient’s functional activities were normal before
illness
The patient's daily activities are home maker (METS 2.0
– 3.3)

10. HISTORY OF FUNCTIONAL ACTIVITY,
HABIT & NUTRITION
Habit
The patient has history of smoking 2-3packs/day since 15 years old and stoped at 2015.

11. HISTORY OF FUNCTIONAL ACTIVITY,
HABIT & NUTRITION
History of Nutrition
Patient gets diet per oral with balance nutrition diet, 3x main food, 2x snacks. Total nergy
17373 kkal, protein 65,14 gr, fat 42 gr, karbohidrat 260,5gr

12. History of Psycho and Socioeconomic Status
SOCIAL CONDITION
• The patient lives in Bandung with his second children, his wife has passed away in 4 March
2015. They have 3 children that already married and 2 children lived separately (Subang
and Bandung).
• The main caregiver is his second child.
• His children are very supportive
FAMILY INCOME
•Patient has income from retirement allowance 3.000.000/month.
•Patient and family are a midlle economy status.
•Patients use JKN insurance.

13. History of Psycho and Socioeconomic Status
PSYCHOLOGICAL CONDITION
• Patient is a friendly and passionate person.
• He feels sad about his condition but still has motivation to do all medical treatment.
HOPE
Patient hopes he can walk with crutches

14. GENOGRAM
Tn K, 73y.o Ny F, 65 y.o
Caregiver
Patient
Living
together
Male
Female
Female die

15. FUNCTIONAL
STATUS
Before Hospitalization
ADL independent
Mobilization independent
Inpatient settings
He is able to sit with assistance and support.
ADL all dependent
Micturition using DC and defecation using diapers

16. PHYSICAL
EXAMINATION
.

17. GENERAL STATUS
- Consciousness : Compos Mentis
- Nutritional status
• Body weight : 40 kg
• Body height : 155 cm
• BMI : 16,6 kg/m2 (Severe underweight)
Vital sign
- Blood pressure : 125/81 mmHg
- Pulse Rate : 60 bpm
- Respiratory rate : 20x/min
- Temperature : 36,2 0 C
- SpO2 : 99%

18. GENERAL STATUS
Head : conjunctiva anemic (+/+), lymph node
enlargement (-)
Teeth Edentia on right upper and left lower
premolar teeth, caries dentis (+)
Neck : JVP is not elevated, enlargement of
lymph nodes (-)
Thorax
- Lung
: Symmetric shape and movement,
retraction (-), breathing pattern:
thoracoabdominal, Chest expansion 2/2/2
cm (limited)
Vesicular sound left = right, rhonchi (+/-),
wheezing (+/-),
secret (+/-), cough reflex (+), voluntary
cough ability effective (by impression).
- Cor Ictus cordis not seen, palpable at ICS V
midclavicular sinistra Upper border : ICS
II line midclavicular sinistra Right
border: ICS V midsternal line Left
border: ICS V, 1 cm anterior axillary line
sinistra Normal heart sound S1-S2
murmur (-), gallop (-), other additional
heart sound (-)
Abdomen : Distanded, Normal bowel sound, liver
and spleen are not palpable, tenderness
(-), scibala (-)
Genitourinary : Enlargedment scrotum +
Inflammation sign (-), tenderness
suprapubic (-), full blast (-)
Skin : Skin turgor normal, dry skin (+),
pressure injury gr 2 ar lateral side of
lower extremity

19. BODY FUNCTION

20. • MENTAL FUNCTION
Assessment Tools Items Result Normal Value Interpretation
MoCA-Ina 21/30 ≥26/30 No Cognitive
Impairment
Orientation 5/5 5/5
5/5 5/5
Registration 3/3 3/3
Attention and
calculation
5/5 5/5
Recall 0/2 3/3
Languange 2/2 2/2
1/1 1/1
3/3 3/3
1/1 1/1
1/1 1/1
1/1 1/1
Total 27 30

21. • EMOTIONAL FUNCTION
Assessment Tools Result Normal
Value
Interpretation
Geriatric Depression Scale 5 <4
Probable
Depression
Fatigue Severity Scale 55 <36 Severe Fatique
• SLEEP FUNCTION
Assessment Tools Result Normal
Value
Interpretation
Insomnia Severity Index 19 <8 Moderate Severe insomnia

22. • SENSORY FUNCTION AND PAIN
Function Items Result Description
Seeing function Visual acuity (using 6 m
Snellen chart)
Suspect presbyopia, cataract (+)
Hearing function Whispering test Normal
Tactile, Touch Light touch Can not be evaluated due to pain
Pinprick
Proprioceptive
function
Joint position sense Impaired on left side extremities
Kinaesthesia
Pain in body part Wound Amputee
Sound limb lower extremity
sinistra
NRS 4
NRS 5

23. • FUNCTION OF THE CARDIOVASCULAR SYSTEMS
Function Items Result Description
Heart functions Heart rate 60x/minute
Heart rhythm Regular
Contraction force of
ventricular muscles
Adequate pulse
Blood vessel functions Function of arteries ABI can not be evaluated, pulsed not
palpable
Function of capillaries CRT<2 sec
Function of veins JVP 5+2 cm H2O
Blood pressure
functions
135/81 mmHg

24. • FUNCTION OF THE RESPIRATORY SYSTEM
• SENSATION AND THE CARDIORESPIRATORY FUNCTION
Function Items Result Description
Respiratory
function
Respiratory rate 28-30x/minute
Respiratory rhythm Thoracoabdominal
Depth of respiration Chest expansion 2/2/2 cm
Respiratory
Muscle
Function
Respiratory muscle function Single Breath Count Test: 5
Dyspnea borg scale
Resting 3 moderate
after activity 7 very severe (eating, speaking)
Additional respiratory function Cough test: voluntary cough ability
effective (by impression)
Function Items Result Description
Cardiorespiratory
function
Oxygen saturation 99%
room air when resting
Exercise tolerance
function
General physical endurance Not tested
Aerobic capacity Cannot be evaluate
Fatigability Fatigue Severity Scale
55 (fatique)

25. • FUNCTION OF THE HEMATOLOGICAL AND
IMMUNOLOGICAL SYSTEMS
Function Items Result Description
Haematological
system functions
Production of blood Erytrocyte 3.31 mill/uL
Thrombocyte 370 thousand/uL
Oxygen-carrying functions of
the blood
Hemoglobin 9,6 g/dL
Immunological
system functions
Immune response Leucocyte 12,11 10^3/uL
Hypersensitivity reactions No data

26. • FUNCTION RELATED TO THE DIGESTIVE SYSTEM
Function Items Result Description
Defecation
Function
Elimination of feces Normal
Fecal consistency Bristol stool type 4
(Normal)
Frequency of defecation Every days
Fecal continence No incontinence
Weight maintenance functions MNA 18 (<17) – Risk of
Malnourished
Sensation
associated with
the digestive
system
Sensation of nausea No complain
Feeling bloated Yes
Sensation of abdominal cramp No complain

27. • FUNCTION RELATED TO METABOLISM AND
ENDOCRINE SYSTEM
Function Items Result Description
Water, mineral and
electrolyte balance function
Water Balance Input-output
Mineral Balance Not tested
Electrolyte Balance Laboratory
Natrium 140 mmol/L
Chloride 90 mmol/L
Potassium 4,3 mmol/L
Magnesium 2.0 mg/dL
Metabolic-endocrine Laboratory
Albumin 2.70 g/dL

28. GENITOURINARY FUNCTION
Function Items Result Description
URINARY FUNCTION
Urinary
filtratrion
function
Filtration of urine Ureum : 22.3 mg/dL
Creatinin : 0,65 mg/dL
Urinary
collection
function
Collection of urine Examination hasn't been
carried out
Urinary function Urination Spontaneous
Frequency of urination 5-6 x/24 h
Urinary continence No incontinence
Sensation
associated with
urinary function
Normal
28

29. STRUCTURE RELATED TO THE GENITOURINARY AND
REPRODUCTIVE SYSTEM
• Enlargement testis
• Fluid +
29

30. • NEUROMUSCULOSKELETAL AND MOVEMENT
RELATED FUNCTION
Functions of the Joints and Bones
Function Items Result Description
Mobility of joint
functions
Mobility of joint
functions
Normal
Stability of joint
functions
Stability of joint
functions
Normal
Mobility of bone
functions
Mobility of bone
functions
Normal

31. • NEUROMUSCULOSKELETAL AND MOVEMENT
RELATED FUNCTION (CONT-)
MUSCLE FUNCTIONS
Muscle power
functions
Fungsional/fungsional
Muscle tone functions Normotonus
Muscle endurance
functions
Cannot be evaluated

32. • NEUROMUSCULOSKELETAL AND MOVEMENT
RELATED FUNCTION (CONT-)
MOVEMENT FUNCTIONS
Motor reflex functions • Spasticity
• Physiological reflex :
• Pathological reflex
-
BPR ++/++
KPR ++/++
APR ++/++
Babinski -/-
Involuntary movement
reaction functions
Clonus Clonus ankle -/-

33. SCREENING SARCOPENIA
SCREENING FRAILTY
TOOLS Result Interpretation
SARC-F 8 (decrease in strength,
unable to walking, unable to
rise from a chair, unable climb
stair)
Suggestive of sarcopenia
SARC-Calf 18 (Calf circumference 33 cm) Suggestive of sarcopenia
AWGS Protocol Cannot be evaluated
TOOLS Result Interpretation
Fried Frailty Phenotype 3 (weight loss, fatigue, and low
physical activity)
Frailty
Frailty Index-40 18,75 Frailty
Clinical Frailty Scale Completely dependent, approaching the
end of life. Typically, they could not
recovered even from minor illness
Very Severely Frail

34. PALLIATIVE ASSESMENTS
TOOLS Result Detail Interpretation
Karnofsky performances
scale
40% Disabled, requires
special care and
assistance
Need caregiver
Palliative performance
scale
30% Total care, unable to do
any work, extensive
disease
Palliative Performance Index 3,5 Survival more than 6
weeks

35. GERIATRIC GIANT
ADA TIDAK ADA
Isolation √
Instability √
Impecunity √
Intellectual impairment √
Impairment of vision √
Impairment of hearing √
Immobility √
Infection √
Immune deficiency √
Inanition √
Insomnia √
Impaction √
Incontinency √
Iatrogenic √

36. Functions of the Skin
Function Items Result Description
Protective
functions of the
skin
Protective function of the skin Pressure injury grade II a.r
calf extremity sinistra
FUNCTIONS OF THE SKIN AND RELATED STRUCTURES

37. • GENITOURINARY AND REPRODUCTIVE FUNCTION
Function Items Result Description
URINARY FUNCTION
Urinary filtratrion function Filtration of urine Ureum : 22.3 mg/dL
Creatinin : 0.65 mg/dL
Urinary collection
function
Collection of urine -
Urinary function Urination Via Condom Catheter
Frequency of urination Cbe
Urinary continence No incotinence
Sensation associated
with urinary function
No complain of suprapubic pain

38. • FUNCTION OF THE SKIN AND RELATED STRUCTURE
Functions of the Skin
Function Items Result Description
Protective functions
of the skin
Protective function of the skin - Quality of the skin on the feet and
elbows: dry skin (+)
Repair function of the skin - -

39. BODY STRUCTURE

40. STRUCTURES OF THE CARDIOVASCULAR,
IMMUNOLOGICAL AND RESPIRATORY SYSTEMS
• STRUCTURES OF RESPIRATORY SYSTEMS
November, 18nd 2022 Interpretation
KESAN:
- Tidak tampak
bronkopneumonia/pneum
onia.
- Kardiomegali disertai
atherosclerosis aorta.

41. ECHO
• Dilated LA, eccentric LVH
• Reduced LV system function (LVEF 44%) with RWMA
• Mild MR, Mild TR, intermediate probable of PH
• LV Diastole dysfunction +
• None RV dysfunction
• No Sec, no thrombosis, no pericard effusion
Presentation title 41

42. SKIN AND RELATED STRUCTURES
Skin area ar hip
Interpretation
- Hip
disarticulation
- Discharged fluid,
blood.

43. SKIN AND RELATED STRUCTURES
Skin area ar left
lower extremity
Multiple pressure sore size with partial thickness loss of skin with
exposed dermis, ireguler, epidermolisis +, eksudat + minimal,
nekrotik +, slough +, granulasi -, pus +, epitelisasi -

44. ACTIVITIES AND
PARTICIPATION

45. • LEARNING & APPLYING KNOWLEDGE
Activity area Functional Result
Purposeful sensory
experiences
Able to receive & retain information
Basic learning Able to do basic learning
Applying knowledge Focusing attention Can repeat number sequence
Reading Able
Writing Able
Calculating Able
Solving problem Able
Making decision Able
• GENERAL TASKS & DEMANDS
Activity area Result
Undertaking a single task Not able due to immobilization
Carrying out daily routine Not able due to immobilization
Handling stress and other
psychological demands
Able, can accept changing conditions

46. • COMMUNICATION
Activity area Item Result
Receiving Messages Spoken messages Normal
Nonverbal messages
Written messages
Producing messages Speaking Normal
Nonverbal messages
Writing messages Normal
Conversation and use of
communication device
and techniques
Conversation Can participate in daily
conversation (sunda
language)
Discussion Adequate
Using telecommunication
devices
Able

47. • MOBILITY
Activity area Item Result
Changing
basic body
position
Lying down • Rolling side to side : Dependent supported by caregiver
Sitting • Sitting : Supported 90 degress, complaint fatique in 10 minute, Vital sign
normal
Standing Not able

48. • MOBILITY
Activity area Item Result
Maintaining a body position Maintaining a lying position Able
Maintaining a sitting position Able with trunk support
Maintaining a standing position Not able
Transferring oneself While lying Cbe
While sitting Able with trunk support
Lifting & carrying objects Able
Moving objects with lower
extremities
Pushing Cbe
Fine hand use Picking up Able
Grasping Able
Manipulating Able
releasing Able
pulling Not able
pushing Not able
Reaching
Turning/twisting
Able
Able

49. • WALKING & MOVING
• MOVING AROUND USING TRANSPORTATION
Activity area Item Result
Walking Short distances Not able
Long distances Not able
On different surfaces Not able
Around obstacles Not able
Moving around in different locations Within the home Not able
Outside the home Not able
Moving around using equipment Using wheelchair Not able
Activity area Item Result
Driving Driving a car Not able

50. SELF-CARE (USING BARTHEL INDEX)
Activity Item Result Score
Self-Care Feeding Needs cutting,
spreading butter,
etc, or requies
modified diet
5
Bathing Dependent 0
Dressing Dependent 0
Grooming Needs help
personal care
0
Bowel Continent 10
Bladder Continent 10
Toilet use Dependent 0
Transfers Unable no sitting
balance
0
Mobility Immobile or
<50yard
0
Stairs Unable 0
50

51. DOMESTIC LIFE
• HOUSEHOLD TASKS
Activity area Item Result
Acquisition of goods and
services
Shopping
Gathering daily necesities
0
0
Preparing meals Preparing simple meals 0
Doing housework Cleaning in the kitchen and
utensils
0
Cleaning living area 0
Using household
appliances
0
Storing daily necessities 0
Disposing of garbage 0
Lawton IADL Scale
0/8
Low function, dependent

52. • INTERPERSONAL INTERACTIONS AND RELATIONSHIPS
Participation Items Result
General interpersonal interactions His children are very supportive.
Particular
interpersonal
relationships
Informal social relationship The patient is friendly and passionate
person
Family relationship The patient still often communicate with
their relatives and occasionally ask for
opinions in making decisions
Intimate The patient's relationship with his
children is good

53. • MAJOR LIFE AREAS
• COMMUNITY, SOCIAL & CIVIC LIFE
Participation Item Result
Work and employment Retired From pensioun
Participation Items Result
Recreation and
leisure
Hobby Gardening Not able
Socializing The patient occasionally communicates
with friends and neighbors
Religion and
spirituality
The patient prays (shalat) 5
times a day
Able with supine position
Self-satisfaction Bad QoL
EQ5D: 3,3,3,3,3
EQ5D VAS 25 (0–100)

54. ENVIRONMENTAL
FACTORS

55. • PRODUCTS AND TECHNOLOGY
Products and technology Result
For personal use in daily living - Need decubitus bed, bed recling.
For personal indoor and
outdoor mobility and
transportation
- Requires wheelchair
For communication -

56. • SUPPORT & RELATIONSHIPS
Items Result
Immediate family - His children are supportive as caregivers.
Personal care provider and
personal assisctance
Plan to be assited by his children in turn

57. • SERVICES, SYSTEMS AND POLICIES
Items Items Result
General social
support service,
system and policies
General social support
services
Need help from local social services
Health Health services - Access from the house to the
highway is 200 m, the distance from
the health centre to the house is 2km
km, and the distance from the house
to the Hasan Sadikin Hospital is 80
km
- Already received rehabilitation
services during hospitalized
Health systems The patient use BPJS for health
insurance
Health policies BPJS policy system

58. RESUME & CASE ANALYSIS
Cannot move lower
extremity
Possible Cause Supporting Data
Respiratory
function
problem
 RR 28-30x/mnt, Saturation 95% RA
 Rhonki +/-, Wheezing +/-
 Single Breath Count Test: 5
 Chest expansion 2/2/2 cm
 Borg Dyspnea Scale very severe 7
 Ro Thorax Pneumonia
Pain  Wound amputee
 ALI ar left extremity
Mobilization
disturbance
 Hip disarticulation
 MMT lowe extremity sin non fungsional
 Enlarged testis
Pressure Injury  Acute Limb Ischemia

59. RESUME & CASE ANALYSIS
Cannot move lower
extremity
Malnurish  MNA 18
ADL  Barthel Index
Probable
Depression
 GDS 5
Frailty syndrome Immobility
MNA 18 (<17) – at risk of Malnourished
Sedentary lifestyle
Sarcopenia Low muscle mass, low muscle strength, low physical
activity
Cardiopulmonary
Endurance
Disturbance
• Fatique Severity Scale 55
• Low Physical activity

60. ASSESSMENT
Medical diagnosis
Clinical Diagnosis:
• Post Hip disarticulation dextra and tromboektomi lower extremity sinistra
• Geriatric syndrome (isolation, instability, immobility, infection, Inaniation, insomnia,
sarcopenia, frailty)

61. ASSESSMENT
Location Diagnosis :
• Musculoskeletal system
• Cardiovaskular system
• Urinary system
• Integument system
Etiological Diagnosis :
• Vascular occlusion
• CHF NHAY 2-3

62. FUNCTIONAL DIAGNOSIS
Body structure
● S410 Structure of Cardiovascular
system
● S710-799 Structure related to
movement
● S610 Structure of urinary system
● S898 Skin and related structures
Activities
d410 Changing basic body position
D415 Maintaining a body position
d420 Transfering oneself
d429 Changing and maintaining body
position
d430 Lifting and carrying objects
d435 Moving object with lower extremities
D460 Moving around in different location
d465 Moving around using equipment
d510 Washing oneself
d530 Toileting
d540 Dressing
D630-d639 household tasks
d710 General interpersonal interaction
D750 Informal socialrelatioship
D760 Family relationshop
D920 Recreation and leisure
Environment
E 115 Products and technology for personal use in daily living
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
65 yo
Passionate personality
Body Function
o Emotional function
● B270 Sensory function related to
other stimuli
● B430 Hematological system
function
● B440 Respiratory function
● B445 Respiratory muscle function
● B525 Defecation function
● B 545 Water, mineral and
electrolyte balance function
● B620 Urinary function
● B730 Muscle power function
● B750-b789 Movement function
● B810 Protective function of skin

63. PROGNOSIS
Quo Ad vitam : dubia ad bonam
Quo Ad sanationam : ad malam
Quo Ad Functionam :
• ADL self care independent (eating, grooming, dressing,
toileting, transfer same level assisted by caregiver)
• Indoor using wheelchair pushed by independent
• and Community Ambulation mandiri

64. DISCHARGE PLANNING
●Patient and caregiver understand about medical and
rehabilitation program
Patient understand about pacing technique and energy
conservation
Transfer same level dependent
Ambulation wheelchair wheeling dependent
ADL selfcare independent in sitting position (eating, grooming,
dressing)

65. GOALS
3 months 6 months
 The patient and family understand about medical and
rehabilitation problem, about sanationam and functional
prognosis
 No respiratory tract infection
 Pain decreased
 Wound healing and prevent new pressure injury
 Diagnoses enlargedment testis establish
 ADL self-care (eating, gromming, dressing) Independent in
sitting position
 Transfer same level dependent
 Mobilization indoor and community using wheelchair wheeling
by caregiver
 No impaction
 No musculoskeletal complication
 Quality of life increase with EQ5D 22211 and
EQVAS > 70%
 No depression


66. MEDICAL AND
REHABILITATION
PROBLEM REVIEW
AND MANAGEMENT

67. CGA Analysis
Medical Aspect Aspects of Nursing
Care
Aspects of Functional Psychosocioeconomic
Aspect
Environment Aspect
• HAP
• Hip disarticulation
dextra
• ALI ar extremitas
inferior sinistra post
tromboektomi
• Enlargement testis
• Multiple Pressure
injury
• CHF NYHA stage II-III
• Geriatric syndrome
(isolation, instability,
immobility, infection,
Inaniation, insomnia,
sarcopenia, frailty)
• Proper Bed
positioning
• Turning every 2
hour
• Wound dressing
everyday
• Breathing exercise
• PROM exercise
lower extremities
• AROM exercise
upper extremities
• Maintain Adequate
nutrition and
medication
• Skin assessment
regularly
• Respiratory
disturbance
• Pain
• Pressure injury gr III
• Mobilization
disturbance
• ADL disturbance
• Risk of Malnourished
• Geriatric syndrome
(isolation, instability,
immobility, infection,
Inaniation, insomnia,
sarcopenia, frailty)
• Probable
depression
• Passionate person
• No caregiver
burden
• Family support do
the medical
treatment
• No impecunity
• Need further
assessment about
patient’s house
condition
• Need further education
and training for
caregiver after
discharge from hospital

68. No Problem Clinical Target Obstacle Potention Program
1
Respiratory
Disturbance
 RR 28-30x/mnt,
Saturation 95% RA
 Rhonki +/-,
Wheezing +/-
 Single Breath
Count Test: 5
 Chest expansion
2/2/2 cm
 Borg Dyspnea Scale
very severe 7
 Ro Thorax
Pneumonia
- Respiratory
rate normal
- No Infection
of lung
- Immobility Proble
depression
Caregiver and
family support
- Relaxation breathing
- Education:
• Impact of inactivity and
benefits of exercise
programs
• Energy conservation
technique (6 P): Planning
(time management), Pacing
(breakdown activity),
Prioritizing (avoid useless
activity), Positioning &
Posture (control posture,
relaxation, breathing control),
Positive Attitude (asking for
help) and pacing technique
2 Pain  Pain on wound
amputee NRS 4
 ALI ar left
extremity NRS 5
- Pain decreased
(NRS 3-4)
• Immobility - Good family
support
- TENS a.r Proximal Lower
extremity sinsitra
- Relaxation breathing

69. No Problem Clinical Target Obstacle Potention Program
3 Mobilization - Muscle weakness :
motoric non fungsional
lower extremity sinistra
- Pain
- Enlarged testis
- Risk of malnurt
- Frailty
- Suspect sarcopenia
- Establish
diagnosis of
enlarged testis
from urology
- Transfer
dependent
- Indoor
ambulation
using
wheelchair
wheeling
independent
- Community,
using
wheelchair
pushed by
caregiver
- Caregiver
untrained
Good muscle
strength in upper
extremity
No joint stiffness
Caregiver
support
- Mobilization gradually :
Sitting up right with
support to without
support, out of bed.
- PROM Lower exercise
- AROM Upper extremity
- Plan to Isometric
strengthening exercise
when dyspnue resolved
Presentation title 69

70. No Problem Clinical Target Obstacle Potention Program
4 Pressure
Injury
Pressure injury
stage 2 ar left
extremity lateral
side
- Wound
healed
- No more
pressure
injury
- Immobility (total
dependent on
caregiver)
- Hb
- Hypoalbuminemia
- Risk of
Malnourished
- Inaniation
- Don’t have a
decubitus bed
Caregiver
support
No
impecunity
- Proper bed positioning
- Pressure relief per 2 hour
- Using bed sheet and
pants with soft and
smooth texture fabric.
- Planning using decubitus
bed when patient lying
- High protein dietary
intake
- Use emollient in dry skin
area twice daily
- Daily skin inspection

71. No Problem Clinical Target Obstacle Potention Program
5 Malnourished - MNA 18
- Albumin 2,70 g/dL
- Hemoglobin 9,6 g/dL
- MNA reach
minimum of
24 points.
- Albumin reach
minimum of
3.2 g/dL
- Hemoglobin
reach
minimum of
12 g/dL
- Cardiopulmon
ary endurance
disturbance
- Inaniation
No swallowing
disturbance
Caregiver
support
- Consult to nutritionist
- Education to patient
whats impact of
malnourished
- Motivated to high protein
diatery intake
6 ADL Barthel index 25 ADL fully
dependent,
except eating
Cardiopulmonary
endurance
disturbance
Good muscle
strength in
upper extremity
No joint stiffness
Caregiver
support
OT: Plan to ADL selfcare
training in sitting position
with energy conservatif

72. No Problem Clinical Target Obstacle Potention Program
7 Probable
Depression
GDS 5 No depression - Passionate person
Good family
support
Psychologist
- Counseling psychologist for
pyshicological and acceptance
medical condition
Social worker
- Assessment Socio-economic,
environment condition and
evaluate patients based on their
needs and limitation
8 Frailty Frailty phenotype 4 Physical Activity
increase - Innaniation
- Immobilization
Good muscle
strength in upper
extremity
No joint stiffness
AAROM upper extremity
Plan to ADL activity while sitting
9 Suggestive
sarcopenia
- SARC-F : 8
- SARC Calf 8
Increased
physical
performance
- Low physical
activity
- Low functional
capacity
- Limited mobility
- Decreased
appetite
- Refer to Clinical nutritionist for
higher protein diet
- Plan : Strengthening exercise
(isometric)

73. CASE
ANALYSIS

74. `
QOL
Decline
Man, 84 years old
Midle economy status
Probable Depression
Pneumonia
Artheriolsclerosis
Arterial plaque
rupture
Low flow stasis
Acute Limb Ischemia
Stage III bilateral
Hip
disarticulation
dextra
Chronic Heart
Failure
Endothelial
injury
Obstructive
Lung Disease
Phantom
sensation
Sensoric
Impairment
Imobilization
Pressure
Injury
Pain
Instability
ventilation,
difussion
Cardiopulmonary
endurance
disturbance
Easily fatigue
Mobilization
disturbance
ADL and iADL
disturbance
Psycological
disturbance
Isolation
Muscle
weakness
High risk of
fall
Decreased
Intake
Inaniation
Risk of
malnourished
Suggestive
Sarcopenia
Low muscle
performance
Frailty
Hipertension
Sound limb extremity
sinistra tromboektomi
Smoker
s
Anemia,
Hipoalbumin

75. THANK YOU

76. ATTACHMENTS

77. NO Pertanyaan Nilai
1 Apakah anda merasa bahwa saudara anda tersebut meminta pertolongan lebih
banyak dari yang dibutuhkan?
0 1 2 3 4
X
2 Apakah anda merasa kehabisan waktu untuk diri anda sendiri karena harus
merawat saudara anda tersebut?
X
3 Apakah anda merasa tertekan antara merawat saudara anda dan kewajiban lain
di dalam keluarga dan pekerjaan?
X
4 Apakah anda merasa malu dengan kelakuan saudara anda tersebut? X
5 Apakah anda merasa marah jika anda berada di dekat saudara anda tersebut? X
6 Apakah anda merasa saudara anda tersebut pada masa ini berpengaruh negatif
terhadap hubungan anda dengan anggota keluarga yang lain atau teman-teman?
X
7 Apakah anda khawatir tentang masa depan saudara anda tersebut? X
8 Apakah anda merasa saudara anda tersebut tergantung pada anda? X
9 Apakah anda merasa tegang bila anda berada di dekat saudara anda? X
10 Apakah anda merasa kesehatan anda terganggu karena mengurus saudara anda
tersebut?
X
11 Apakah merasa tidak punya cukup kebebasan/keleluasaan pribadi bagi anda
sendiri karena mengurus saudara anda tersebut?
X
12 Apakah anda merasa bahwa kehidupan sosial and terganggu karena anda
merawat/mengurus saudara anda tersebut?
X
13 Apakah anda merasa tidak nyaman bila teman-teman berkunjung karena anda
mengurus saudara anda tersebut?
X
14 Apakah anda merasa bahwa saudara anda tersebut kelihatannya mengharapkan
perhatian anda seolah-olah anda adalah satu-satunya orang yang dapat
diharapkan?
X
15 Apakah anda merasa tidak punya cukup uang untuk merawat saudara anda
dengan kondisi keuangan anda?
X
16 Apakah anda merasa tidak mampu merawat saudara anda tersebut lebih lama
lagi?
X
17 Apakah anda merasa kehilangan kendali terhadap kehidupan anda sejak saudara
anda sakit?
X
18 Apakah anda mengharapkan dapat mengalihkan perawatan saudara anda tersebut
kepada orang lain saja?
X
19 Apakah anda merasa tidak tahu harus berbuat apalagi terhadap saudara anda? X
20 Apakah anda merasa harus berbuat lebih banyak lagi untuk saudara anda? X
Attachment 1 – Zarit Burden
Total Score = 11 (No burden)
Attachment 1 – Zarit Burden

78. Attachment 3 – Geriatric Depression Scale
NO PERTANYAAN
1 APAKAH ANDA SEBENARNYA PUAS DENGAN KEHIDUPAN
ANDA?
YA
2 APAKAH ANDA TELAH MENINGGALKAN BANYAK
KEGIATAN DAN MINAT/KESENANGAN ANDA
YA
3 APAKAH ANDA MERASA KEHIDUPAN ANDA KOSONG? YA
4 APAKAH ANDA SERING MERASA BOSAN? YA
5 APAKAH ANADA MEMPUNYAI SEMANGAT YANG BAIK
SETIAP SAAT?
TIDAK
6 APAKAH ANDA MERASA TAKUT SESUATU YANG BURUK
AKAN TERJADI PADAANDA?
YA
7 APAKAH ANDA MERASA BAHAGIA UNTUK SEBAGIAN
BESAR HIDUP ANDA?
YA
8 APAKAH ANDA MERASA SERING TIDAK BERDAYA? TIDAK
9 APAKAH ANDA LEBIH SERING DIRUMAH DARIPADA PERGI
KELUAR DAN MENGERJAKAN SESUATU HAL YANG BARU?
YA
10 APAKAH ANDA MERASA MEMPUNYAI BANYAK MASALAH
DENGAN DAYA INGAT ANDA DIBANDINGKAN
KEBANYAKAN ORANG ?
TIDAK
11 APAKAH ANDA PIKIR BAHWA KEHIDUPAN ANDA
SEKARANG MENYENANGKAN?
TIDAK
12 APAKAH ANDA MERASA TIDAK BERHARGA SEPERTI
PERASAAN ANDA SAAT INI?
YA
13 APAKAH ANDA MERASA PENUH SEMANGAT? TIDAK
14 APAKAH ANDA MERASA BAHWA KEADAAN ANDA TIDAK
ADA HARAPAN?
TIDAK
15 APAKAH ANDA PIKIR BAHWA ORANG LAIN, LEBIH BAIK
KEADAANNYA DARIPADAANDA?
YA
*) SETIAP JAWABAN YANG SESUAI
MEMPUNYAI SKOR “1 “ ( SATU ) :
SKOR 5-9: KEMUNGKINAN DEPRESI
SKOR 10 ATAU LEBIH : DEPRESI
Total score = 6

79. Attachment 4 – Fatigue Severity Score
No Selama seminggu terakhir, saya
merasa bahwa
Sangat Tidak Setuju – Sangat
Setuju
1 2 3 4 5 6 7
1 Motivasi saya lebih rendah saat saya
lelah
X
2 Gerak badan membuat saya lelah X
3 Saya mudah lelah X
4 Kelelahan mempengaruhi fungsi fisik
saya
X
5 Kelelahan sering menyebabkan
masalah bagi saya
X
6 Kelelahan saya menghambat fungsi
fisik saya terus menerus
X
7 Kelelahan mengganggu pelaksanaan
tugas dan tanggung jawab tertentu
X
8 Kelelahan merupakan salah satu dari
tiga gejala yang paling membuat saya
tidak bisa melakukan apa-apa
X
9 Kelelahan mengganggu pekerjaan,
keluarga, atau kehidupan sosial saya
X
Total Skor 55
Total score 55 (<36) : suggests the patient may not be suffering from fatigue

80. INSOMNIA SEVERITY INDEX
Presentation title 80
19

81. Attachment 6 – Mini
Nutritional Assessment 1
0
0
2
3
0
2
0
3
0
0
1
1
0.5
1
0.5
1
1
1.0
0
4.5
5.5
10
TOTAL 12

82. Attachment 9 – SARC-F
Total : 8
Attachment 10 – SARC-CalF
Total = 8

83. Attachment 11 – Fried Frailty Phenotype
Result: 3 (Frailty)
Attachment 13 – Clinical Frailty Scale

84. Attachment 12 – Frailty Index-40
Total score: 18,75 (Frailty)

85. Attachment 14 – Karnofsky Performance Scale Attachment 15 – Palliative Performance Scale

86. Presentation title 86
3.5

87. Attachment 17 – LAWTON -
BRODY INSTRUMENTAL
ACTIVITIES OF DAILY
LIVING SCALE (I.A.D.L.)
Result : 0/8 (Low Function,
Dependent)

88. RISK OF FALL
RISK LEVEL : LOW RISK
0
15
0
20
0
0

89. PENGKAJIAN KUALITAS HIDUP (EQ 5D)
No Kategori Skala Skor pasien
1 Mobilitas
3
Saya tidak mempunyai masalah untuk berjalan 1
Saya ada masalah untuk berjalan 2
Saya hanya mampu berbaring 3
2 Perawatan diri sendiri
3
Saya tidak mempunyai kesulitan dalam perawatan diri sendiri 1
Saya mengalami kesulitan untuk membasuh badan, mandi atau berpakaian 2
Saya tidak mampu membasuh badan, mandi atau berpakaian sendiri 3
3 Aktivitas sehari-hari
3
Saya tidak mempunyai kesulitan dalam melaksanakan kegiatan sehari-hari saya 1
Saya mempunyai keterbatasan dalam melaksanakan kegiatan sehari-hari 2
Saya tak mampu melaksanakan kegiatan sehari-hari 3
4 Rasa nyeri/rasa tak nyaman
3
Saya tidak mempunyai keluhan rasa nyeri atau rasa tak nyaman 1
Saya sering merasakan agak nyeri/agak kurang nyaman 2
Saya menderita karena keluhan rasa nyeri atau tidak nyaman 3
5 Rasa cemas/depresi
1
Saya tidak merasa cemas/gelisah atau depresi (jiwa tertekan) 1
Saya kadang merasa agak cemas atau depresi 2
Saya merasa sangat cemas atau sangat depresi 3
13

90. Bagian kedua EQ-5D (VAS)
Pasien diminta untuk menggambarkan kondisi kesehatannya
pada skala 0 -100 (0 jika sangat buruk dan 100 jika sangat
baik)
Misal : pasien menunjuk angka 35, maka tingkat kesehatan
yang dirasakan 50% (VAS 50%)
PENGKAJIAN KUALITAS HIDUP (EQ 5D)