ALERGI MAKANAN

oleh; Ariyanto Harsono, Anang Endaryanto

BATASAN
Alergi makanan adalah kumpulan gejala yang mengenai banyak organ dan sistem tubuh yang ditimbulkan oleh alergi terhadap bahan makanan. Alergi makanan di masyarakat merupakan istilah umum untuk menyatakan reaksi simpang terhadap makanan termasuk di dalamnya proses non-alergi yang sebenarnya lebih tepat disebut intoleransi. Intoleransi makanan merupakan reaksi terhadap makanan yang bukan reaksi imunologik, misalnya reaksi toksik, reaksi metabolik, dan reaksi indiosinkrasi.
PATOFISIOLOGI
Faktor yang berperan dalam alergi makanan :
• Imaturitas usus secara fungsional (misalnya dalam fungsi-fungsi : asam lambung, enzym-enzym usus, glycocalyx) maupun fungsi-fungsi imunologis (misalnya : IgA sekretorik) memudahkan penetrasi alergen makanan. Imaturitas juga mengurangi kemampuan usus mentoleransi makanan tertentu.
• Genetik berperan dalam alergi makanan. Sensitisasi alergen dini mulai janin sampai masa bayi dan sensitisasi ini dipengaruhi oleh kebiasaan dan norma kehidupan setempat.
• Faktor pencetus : faktor fisik (dingin, panas, hujan), faktor psikis (sedih, stress) atau beban latihan (lari, olah raga).
Alergen dalam makanan :
• Merupakan protein, glikoprotein atau polipeptida dengan besar molekul lebih dari 18.000 dalton, tahan panas dan tahan enzim proteolitik.
• Pada ikan diketahui allergen-M sebagai determinan. Pada telur ovomukoid merupakan alergen utama. Pada susu sapi betalaktoglobulin (BLG), alfalalaktalbumin (ALA), bovin serum albumin (BSA) dan bovin gama globulin (BGG) merupakan alergen utama dan BLG adalah alergen terkuat. Pada kacang tanah alergen terpenting adalah arachin, conarachin dan peanut-1. Pada udang dikenal allergen-1 dengan berat molekul 21.000 dalton dan Allergen-2 dengan berat molekul 200.000 dalton. Pada gandum yang merupakan alergen utama adalah: albumin, pseudoglobulin dan euglobulin
Terjadinya alergi makanan :
• Pada paparan awal, alergen dikenali oleh sel penyaji antigen untuk selanjutnya mengekspresikan pada sel-T. Sel-T tersensitisasi dan akan merangsang sel-B menghasilkan antibodi dari berbagai subtipe.
• Alergen yang intak diserap oleh usus dalam jumlah cukup banyak dan mencapai sel-sel pembentuk antibodi di dalam mukosa usus dan organ limfoid usus,yang pada anak atopi cenderung terbentuk IgE lebih banyak.Selanjutnya terjadi sensitisai sel mast pada saluran cerna, saluran nafas dan kulit. Kombinasi alergen dengan IgE pada sel mast bisa terjadi pada IgE yang telah melekat pada sel mast atau komplek IgE-Alergen terjadi ketika IgE masih belum melekat pada sel mast atau IgE yang telah melekat pada sel mast diaktifasi oleh pasangan non spesifik, akan menimbulkan degranulasi mediator. Pembuatan antibodi IgE dimulai sejak paparan awal dan berlanjut walaupun dilakukan diet eliminasi. Komplemen akan mulai mengalami aktivasi oleh kompleks antigen antibodi.
• Pada paparan selanjutnya mulai terjadi produksi sitokin oleh sel-T. Sitokin mempunyai berbagai efek terhadap berbagai sel terutama dalam menarik sel-sel radang misalnya netrofil dan eosinofil, sehingga menimbulkan reaksi peradangan. Aktifasi komplemen dan terjadinya komplek imun akan menarik netrofil.
• Gejala klinis yang timbul adalah hasil interaksi mediator, sitokin dan kerusakan jaringan yang ditimbulkannya.
• Bayi atopi juga mendapat sensitisasi melalui makanan alergenik yang terkandung dalam air susu ibu. Bayi-bayi dengan alergi awal terhadap satu makanan misalnya susu, juga mempunyai resiko yang tinggi untuk berkembang menjadi alergi terhadap makanan lain.

GEJALA KLINIK/Symptom
Gejala klinis alergi makanan biasanya mengenai berbagai organ sasaran seperti kulit, saluran nafas, saluran cerna, mata, telinga, saluran vaskuler. Organ sasaran bisa berpindah-pindah, gejala sering kali sudah dijumpai pada masa bayi. Makanan tertentu bisa menyebabkan gejala tertentu pada seseorang anak, tetapi pada anak lain bisa menimbulkan gejala lain. Pada seseorang makanan yang satu bisa mempunyai organ sasaran yang lain dengan makanan yang lain, misalnya udang menyebabkan urtikaria, sedangkan kacang tanah menyebabkan sesak nafas. Susu sapi bisa menimbulkan gejala alergi pada saluran nafas, saluran cerna, kulit dan anafilaksis. Bischop (1990) mendapatkan pada penderita yang alergi susu sapi : 40% dengan gejala asma, 21% eksema, 43% dengan rinitis. Peneliti lain mendapatkan gejala alergi susu sapi berupa : urtikaria, angionerotik udem, pucat, muntah, diare, eksema dan asma.

CARA PEMERIKSAAN/DIAGNOSIS
Diagnosis alergi makanan diperoleh dari anamnesa, pemeriksaan fisik, pemeriksaan laboratorium dan secara akademis dipastikan dengan ”Double Blind Placebo Controlled Food Challenge”. Secara klinis bisa dilakukan uji eliminasi dan provokasi terbuka ”Open Challenge”. Pertama-tama dilakukan eliminasi dengan makanan yang dikemukakan sendiri oleh penderita atau orangtuanya atau dari hasil uji kulit. Kalau tidak ada perbaikan maka dipakai regimem diet tertentu.

Diagnosis dengan diet eliminasi
Ada beberapa regimen diet yang bisa digunakan :
1. ”ELIMINATION DIET”: beberapa makanan harus dihindari yaitu Buah, Susu, Telur, Ikan dan Kacang, di Surabaya terkenal dengan singkatan BSTIK. Merupakan makanan-makanan yang banyak ditemukan sebagai penyebab gejala alergi, jadi makanan-makanan dengan indeks alergenisitas yang tinggi. Indeks ini mungkin lain untuk wilayah yang lain, sebagai contoh dengan DBPFC mendapatkan telur, kacang tanah, susu sapi, ikan, kedelai, gandum, ayam, babi, sapi dan kentang, sedangkan Bischop mendapatkan susu, telur, kedelai dan kacang.
2. ”MINIMAL DIET 1” (Modified Rowe’s diet 1): terdiri dari beberapa makanan dengan indeks alergenisitas yang rendah. Berbeda dengan ”elimination diet”, regimen ini terdiri dari beberapa bahan makanan yang diperbolehkan yaitu : air, beras, daging sapi, kelapa, kedelai, bayam, wortel, bawang, gula, garam dan susu formula kedelai. Bahan makanan lain tidak diperbolehkan.
3. ”MINIMAL DIET 2” (Modified Rowe’s Diet 2): Terdiri dari makanan-makanan dengan indeks alergenisitas rendah yang lain yang diperbolehkan, misalnya : air, kentang, daging kambing, kacang merah, buncis, kobis, bawang, formula hidrolisat kasein, bahan makanan yang lain tidak diperkenankan.
4. ”EGG and FISH FREE DIET”: diet ini menyingkirkan telur termasuk makanan-makanan yang dibuat dari telur dan semua ikan. Biasanya diberikan pada penderita-penderita dengan keluhan dengan keluhan utama urtikaria, angionerotik udem dan eksema.
5. ”HIS OWN’S DIET”: menyingkirkan makanan-makanan yang dikemukakan sendiri oleh penderitanya sebagai poenyebab gejala alergi.
Diet dilakukan selama 3 minggu, setelah itu dilakukan provokasi dengan 1 bahan makanan setiap minggu. Makanan yang menimbulkan gejala alergi pada provokasi ini dicatat. Disebut alergen kalau pada 3 kali provokasi menimbulkan gejala alergi. Waktunya tidak perlu berturut-turut. Jika dengan salah satu regimen diet tidak ada perbaikan padahal sudah dilakukan dengan benar, maka diberikan regimen yang lain. Sebelum memulai regimen yang baru, penderita diberi ”carnaval” selama seminggu, artinya selama 1 minggu itu semua makanan boleh dimakan (pesta). Maksudnya adalah memberi hadiah setelah 3 minggu diet dengan baik, dengan demikian ada semangat untuk menjalani diet berikunya. Selanjutnya diet yang berikutnya juga dilakukan selama 3 minggu sebelum dilakukan provokasi.
Periksaan Penunjang
• Uji kulit : sebagai pemerikasaan penyaring (misalnya dengan alergen hirup seperti tungau, kapuk, debu rumah, bulu kucing, tepung sari rumput, atau alergen makanan seperti susu, telur, kacang, ikan).
• Darah tepi : bila eosinofilia 5% atau 500/ml condong pada alergi. Hitung leukosit 5000/ml disertai neutropenia 3% sering ditemukan pada alergi makanan.
• IgE total dan spesifik: harga normal IgE total adalah 1000u/l sampai umur 20 tahun. Kadar IgE lebih dari 30u/ml pada umumnya menunjukkan bahwa penderita adalah atopi, atau mengalami infeksi parasit atau keadaan depresi imun seluler.

DIAGNOSA BANDING
• Gangguan saluran cerna dengan diare dan atau mual muntah, misalnya : stenosis pilorik, Hirschsprung, defisiensi enzim, galaktosemia, keganasan dengan obstruksi, cystic fibrosis, peptic disease dan sebagainya.
• Reaksi karena kontaminan dan bahan-bahan aditif, misalnya : bahan pewarna dan pengawet, sodium metabisulfite, monosodium glutamate, nitrit, tartrazine, toksin, fungi (aflatoxin), fish related (scombroid, ciguatera), bakteri (Salmonella, Escherichia coli, Shigella), virus (rotavirus, enterovirus), parasit (Giardia, Akis simplex), logam berat, pestisida, kafein, glycosidal alkaloid solanine, histamin (pada ikan), serotonin (pisang, tomat), triptamin (tomat), tiramin (keju) dan sebagainya.
• Reaksi psikologis.

PENATALAKSANAAN
Identifikasi alergen dan eliminasi :
• Diet eliminasi/provokasi adalah untuk diagnostik. Bila alergen telah diketemukan maka harus dihindari sebaik mungkin dan makanan-makanan yang tergolong hipoalergenik dipakai sebagai pengganti.
• Pada bayi dari keluarga atopik, disarankan menunda pemberian makanan makanan yang dikenal sebagai makanan alergenik utama, dengan cara :
o Eliminasi susu sapi sampai usia 1 tahun
o Eliminasi telur sampai usia 18-24 bulan
o Eliminasi kacang-kacangan dan ikan sampai usia 3 tahun
Pencegahan :
• Alergi tidak bisa disembuhkan, tapi dengan pencegahan yang efektif akan mengendalikan frekuensi dan intensitas serangan, penggunaan obat, jumlah hari absen sekolah, serta membantu memperbaiki kualitas hidup.
• Pemberian ASI sangat dianjurkan. Pada bayi yang melakukan eliminasi makanan dan mendapat ASI, maka ibu juga harus pantang makanan penyebab alergi. Dengan eliminasi sebelumnya, alergi susu sapi menghilang pada kebanyakan kasus pada umur 2 tahun. Untuk pengganti susu sapi dapat dipakai susu hidrolisat whey atau hidrolisat casein. Pilihan lain adalah susu formula kedelai, dengan harus tetap waspada terhadap kemungkinan alergi terhadap kedelai. Pada bayi yang menderita alergi makanan derajat berat yang telah menggunakan formula susu hipoalergenik, bila ingin melakukan diet provokasi dengan susu formula sapi, harus dilakukan dirumah sakit, karena jika gagal ada kemungkinan terjadi renjatan anafilaksis.
• Sayur mayur bisa dianjurkan sebagai pengganti buah, daging sapi atau kambing sebagai pengganti telur ayam dan ikan.
• Makan di restoran kurang aman dan dianjurkan selalu membaca label bahan-bahan makanan jika membeli makanan jadi.
• Desensitisasi pada alergi makanan tidak dilakukan sebab reaksinya hebat dan sedikit sekali bukti-bukti kerberhasilannya. Andaikata berhasil, selama desensitisasi penderita juga tetap harus menyingkirkan makanan penyebab serangan alergi itu.

Pengobatan
Bila diet tidak bisa dilaksanakan maka harus diberi farmakoterapi dengan obat-obatan seperti yang tersebut di bawah ini :
Kromolin, Nedokromil.
Dipakai terutama pada penderita dengan gejala asma dan rinitis alergika. Kromolin umumnya efektif pada alergi makanan dengan gejala Dermatitis Atopi yang disebabkan alergi makanan. Dosis kromolin untuk penderita asma berupa larutan 1% solution (20 mg/2mL) 2-4 kali/hari untuk nebulisasi atau berupa inhalasi dengan metered-dose inhaler 1,6 mg (800 µg/inhalasi) 2-4 kali/hari. Untuk rinitis alergik digunakan obat semprot 3-4 kali/hari yang mangandung kromolin 5.2 mg/semprot. Untuk konjungtivitis diberikan tetes mata 4% 4-6 x 1 tetes mata/hari. Nedokromil untuk nebulisasi tak ada. Yang ada berupa inhalasi dengan metered-dose inhaler dan dosis untuk asma adalah 3,5 mg (1,75 mg/inhalasi) 2-4 kali/hari. Untuk konjungtivitis diberikan tetes mata nedokromil 2% 4-6 x 1-2 tetes mata/hari.
Glukokortikoid.
Digunakan terutama bila ada gejala asma. Steroid oral pada asma akut digunakan pada yang gejala dan PEF nya makin hari makin memburuk, PEF yang kurang dari 60%, gangguan asma malam dan menetap pada pagi hari, lebih dari 4 kali perhari, dan memerlukan nebulizer serta bronkodilator parenteral darurat. menggunaan bronkodilator. Steroid oral yang dipakai adalah : metil prednisolon, prednisolon dan prednison. Prednison diberikan sebagai dosis awal adalah 1-2 mg/kg/hari dosis tunggal pagi hari sampai keadaan stabil kira-kira 4 hari kemudian diturunkan sampai 0,5 mg/kg/hari, dibagi 3-4 kali/hari dalam 4-10 hari. Steroid parenteral digunakan untuk penderita alergi makanan dengan gejala status asmatikus, preparat yang digunakan adalah metil prednisolon atau hidrokortison dengan dosis 4-10 mg/kg/dosis tiap 4-6 jam sampai kegawatan dilewati disusul rumatan prednison oral. Steroid hirupan digunakan bila ada gejala asma dan rinitis alergika.
Beta adrenergic agonist
Digunakan untuk relaksasi otot polos bronkus. Epinefrin subkutan bisa diberikan dengan dosis 0,01 mg/kg/dosis maksimum 0,3 mg/dosis.
Metil Xantin
Digunakan sebagai bronkodilator. Obat yang sering digunakan adalah aminofilin dan teofilin, dengan dosis awal 3-6/kg/dosis, lanjutan 2,5 mg/kg/dosis, 3-4 kali/24 jam.
Simpatomimetika
• Efedrin : 0,5 – 1,0 mg/kg/dosis, 3 kali/24 jam
• Orciprenalin : 0,3 – 0,5 mg/kg/dosis, 3-4 kali/24 jam
• Terbutalin : 0,075 mg/kg/dosis, 3-4 kali/24 jam
• Salbutamol : 0,1 – 0,15 mg/kg/dosis, 3-4 kali/24 jam
Leukotrien antagonis
LTC4 dan LTD4 menimbulkan bronkokonstriksi yang kuat pada manusia, sementara LTE4 dapat memacu masuknya eosinofil dan netrofil ke saluran nafas. Dapat digunakan pada penderita dengan asma persisten ringan. Namun pada penelitian dapat diberikan sebagai alternatif peningkatan dosis kortikosteroid inhalasi, posisi anti lekotrin mungkin dapat digunakan pada asma persisten sedang, bahkan pada asma berat yang selalu membutuhkan kortikosteroid sistemik, digunakan dalam kombinasi dengan xantin, beta-2-agonis dan steroid. Preparat yang sudah ada di Indonesia adalah Zafirlukast yang diberikan pada anak sebesar 20 mg/dosis 2 kali/24jam.
H1-Reseptor antagonis
H1 reseptor antagonis generasi kedua tidak ada efek samping CNS. Setirizin bisa digunakan pada anak mulai umur 1 tahun dan tidak ada efek samping kardiovaskular, dapat digunakan jangka lama. H1 reseptor antagonis generasi pertama efek antikolinergiknya dapat memperburuk gejala asma karena pengentalan mukus. Pada dosis tinggi efek samping pada CNS sangat membatasi penggunaanya dalam pengobatan asma. Beberapa penelitian membuktikan efektifitas. Difenhidramin diberikan dengan dosis 0,5 mg/kg/dosis, 3 kali/24 jam. CTM diberikan dengan dosis 0,09 mg/kg/dosis, 3-4 kali/24 jam. Setirizin, dosis pemberian sesuai usia anak adalah: 2-5 tahun: 2.5 mg/dosis,1 kali/hari; > 6 tahun : 5-10 mg/dosis,1 kali/hari. Loratadin, dosis pemberian sesuai usia anak adalah: 2-5 tahun : 2.5 mg/dosis,1 kali/hari; > 6 tahun : 10 mg/dosis,1 kali/hari. Feksofenadin, dosis pemberian sesuai usia anak adalah : 6-11 tahun : 30 mg/hari, 2 kali/hari; > 12 tahun : 60 mg/hari, 2 kali/hari atau 180 mg/hari, 4 kali/hari. Azelastine, dosis pemberian sesuai usia anak adalah: 5-11 tahun : 1 semprotan 2 kali/hari; > 12 tahun : 2 semprotan, 2 kali/hari. Pseudoephedrine, dosis pemberian sesuai usia anak adalah : 2-6 tahun : 15 mg/hari, 4 kali/hari; 6-12 tahun : 30 mg/hari, 4 kali/hari; > 12 tahun : 60 mg/hari 4 kali/hari. Ipratropium bromide 0.03% 2 semprotan, 2-3 kali/hari.

PROGNOSIS
Alergi makanan yang mulai pada usia 2 tahun mempunyai prognosis yang lebih baik karena ada kemungkinan kurang lebih 40% akan mengalami grow out. Anak yang mengalami alergi pada usia 15 tahun ke atas cenderung untuk menetap.
DAFTAR PUSTAKA
1. Sampson HA, Leung DYM. Adverse reaction to Foods. In: Behrman RE, Kliegman RM, Jenson HB (eds): Textbook of Pediatrics. 17th Ed Philadelphia, WB Saunders 2004. pp. 789-792.
2. Sampson HA. Food allergy. J Allergy Clin Immunol, 2004; 111 : S540-7.
3. American Academy of Pediatrics, Committee on Nutrition : Hypoallergenic infant formulas. Pediatrics 2000; 106 : 346-49.
4. Sicherer SH: Diagnosis and management of childhood food allergy. Curr Probl Pediatr 2001; 31 : 35-57.
5. Wahn U, Nickel R, Illi S, Lau S, Grubber C, Hamelmann E, 2004. Strategies for early prevention of allergic disorders. Clin Exp All Rev; 4 : 194-199.
http://ummusalma.wordpress.com/2007/02/17/alergi-makanan/

ASUHAN KEPERAWATAN PADA KLIEN DENGAN LUKA BAKAR (COMBUSTIO)

PENDAHULUAN
Luka bakar dapat mengakibatkan masalah yang kompleks yang dapat meluas melebihi kerusakan fisik yang terlihat pada jaringan yang terluka secara langsung. Masalah kompleks ini mempengaruhi semua sistem tubuh dan beberapa keadaan yang mengancam kehidupan. Dua puluh tahun lalu, seorang dengan luka bakar 50% dari luas permukaan tubuh dan mengalami komplikasi dari luka dan pengobatan dapat terjadi gangguan fungsional, hal ini mempunyai harapan hidup kurang dari 50%. Sekarang, seorang dewasa dengan luas luka bakar 75% mempunyai harapan hidup 50%. dan bukan merupakan hal yang luar biasa untuk memulangkanpasien dengan luka bakar 95% yang diselamatkan. Pengurangan waktu penyembuhan, antisipasi dan penanganan secara dini untuk mencegah komplikasi, pemeliharaan fungsi tubuh dalam perawatan luka dan tehnik rehabilitasi yang lebih efektif semuanya dapat meningkatkan rata-rata harapan hidup pada sejumlah klien dengan luka bakar serius.
Beberapa karakteristik luka bakar yang terjadi membutuhkan tindakan khusus yang berbeda. Karakteristik ini meliputi luasnya, penyebab(etiologi) dan anatomi luka bakar. Luka bakar yang melibatkan permukaan tubuh yang besar atau yang meluas ke jaringan yang lebih dalam, memerlukan tindakan yang lebih intensif daripada luka bakar yang lebih kecil dan superficial. Luka bakar yang disebabkan oleh cairan yang panas (scald burn) mempunyai perbedaan prognosis dan komplikasi dari pada luka bakar yang sama yang disebabkan oleh api atau paparan radiasi ionisasi. Luka bakar karena bahan kimia memerlukan pengobatan yang berbeda dibandingkan karena sengatan listrik (elektrik) atau persikan api. Luka bakar yang mengenai genetalia menyebabkan resiko nifeksi yang lebih besar daripada di tempat lain dengan ukuran yang sama. Luka bakar pada kaki atau tangan dapat mempengaruhi kemampuan fungsi kerja klien dan memerlukan tehnik pengobatan yang berbeda dari lokasi pada tubuh yang lain. Pengetahuan umum perawat tentang anatomi fisiologi kulit, patofisiologi luka bakar sangat diperlukan untuk mengenal perbedaan dan derajat luka bakar tertentu dan berguna untuk mengantisipasi harapan hidup serta terjadinya komplikasi multi organ yang menyertai.
Prognosis klien yang mengalami suatu luka bakar berhubungan langsung dengan lokasi dan ukuran luka bakar. Faktor lain seperti umur, status kesehatan sebelumnya dan inhalasi asap dapat mempengaruhi beratnya luka bakar dan pengaruh lain yang menyertai. Klien luka bakar sering mengalami kejadian bersamaan yang merugikan, seperti luka atau kematian anggota keluarga yang lain, kehilangan rumah dan lainnya. Klien luka bakar harus dirujuk untuk mendapatkan fasilitas perawatan yang lebih baik untuk menangani segera dan masalah jangka panjang yang menyertai pada luka bakar tertentu.

Definisi
Luka bakar adalah suatu trauma yang disebabkan oleh panas, arus listrik, bahan kimia dan petir yang mengenai kulit, mukosa dan jaringan yang lebih dalam (Irna Bedah RSUD Dr.Soetomo, 2001).

Etiologi
1. Luka Bakar Suhu Tinggi(Thermal Burn)
a. Gas
b. Cairan
c. Bahan padat (Solid)
2. Luka Bakar Bahan Kimia (hemical Burn)
3. Luka Bakar Sengatan Listrik (Electrical Burn)
4. Luka Bakar Radiasi (Radiasi Injury)

Fase Luka Bakar
A. Fase akut.
Disebut sebagai fase awal atau fase syok. Secara umum pada fase ini, seorang penderita akan berada dalam keadaan yang bersifat relatif life thretening. Dalam fase awal penderita akan mengalami ancaman gangguan airway (jalan nafas), brething (mekanisme bernafas), dan circulation (sirkulasi). Gnagguan airway tidak hanya dapat terjadi segera atau beberapa saat setelah terbakar, namun masih dapat terjadi obstruksi saluran pernafasan akibat cedera inhalasi dalam 48-72 jam pasca trauma. Cedera inhalasi adalah penyebab kematian utama penderiat pada fase akut.
Pada fase akut sering terjadi gangguan keseimbangan cairan dan elektrolit akibat cedera termal yang berdampak sistemik. Problema sirkulasi yang berawal dengan kondisi syok (terjadinya ketidakseimbangan antara paskan O2 dan tingkat kebutuhan respirasi sel dan jaringan) yang bersifat hipodinamik dapat berlanjut dengan keadaan hiperdinamik yang masih ditingkahi denagn problema instabilitas sirkulasi.

B. Fase sub akut.
Berlangsung setelah fase syok teratasi. Masalah yang terjadi adalah kerusakan atau kehilangan jaringan akibat kontak denga sumber panas. Luka yang terjadi menyebabkan:
1. Proses inflamasi dan infeksi.
2. Problempenuutpan luka dengan titik perhatian pada luka telanjang atau tidak berbaju epitel luas dan atau pada struktur atau organ – organ fungsional.
3. Keadaan hipermetabolisme.

C. Fase lanjut.
Fase lanjut akan berlangsung hingga terjadinya maturasi parut akibat luka dan pemulihan fungsi organ-organ fungsional. Problem yang muncul pada fase ini adalah penyulit berupa parut yang hipertropik, kleoid, gangguan pigmentasi, deformitas dan kontraktur.
1. Diagnosa Keperawatan
Sebagian klien luka bakar dapat terjadi Diagnosa Utama dan Diagnosa Tambahan selama menderita luka bakar (common and additional). Diagnosis yang lazim terjadi pada klien yang dirawat di rumah sakit yang menderila luka bakar lebih dari 25 % Total Body Surface Area adalah :
1. Penurunan Kardiak Output berhubungan dengan peningkatan permiabilitas kapiler.
2. Defisit Volume Cairan berhubungan dengan ketidak seimbangan elektrolit dan kehilangan volume plasma dari pembuluh darah.
3. Perubahan Perfusi Jaringan berhubungan dengan Penurunan Kardiak Output dan edema.
4. Ketidakefektifan Pola Nafas berhubungan dengan kesukaran bernafas (Respiratory Distress) dari trauma inhalasi, sumbatan (Obstruksi) jalan nafas dan pneumoni.
5. Perubahan Rasa Nyaman : Nyeri berhubungan dengan paparan ujung syaraf pada kulit yang rusak.
6. Gangguan Integritas Kulit berhubungan dengan luka bakar.
7. Potensial Infeksi berhubungan dengan gangguan integritas kulit.
8. Perubahan Nutrisi : Nutrisi Kurang dari Kebutuhan Tubuh berhubungan dengan peningkatan rata-rata metabolisme.
9. Gangguan Mobilitas Fisik berhubungan dengan luka bakar, scar dan kontraktur.
10. Gangguan Gambaran Tubuh (Body Image) berhubungan dengan perubahan penampilan fisik

Klien luka bakar mungkin dapat terjadi Diagnosa Resiko dari satu atau lebih Diagnosa keperawatan berikut :
1. Ketidakefektifan coping keluarga berhubungan dengan kehilangan rumah, keluarga atau yang lain.
2. Ketidakefektifan pertahanan coping individu berhubungan dengan situasi krisis.
3. Kecemasan berhubungan dengan ancaman kematian, situasi krisis dan kehilangan pengendalian.
4. Takut berhubungan dengan nyeri, prosedur terapi dan keadaan masa depan yang tidak diketahui.
5. Kelebihan cairan berhubungan dengan pemberian cairan intra vena yang terlalu banyak.
6. Kurangnya perawatan diri berhubungan dengan nyeri, kontraktur dan kehilangan fungsi pada ekstrimitas dan bagian tubuh lain.
7. Gangguan fungsi (disfungsi) seksual berhubungan dengan luka bakar perineum, genetalia, payudara, imobilisasi, kelelahan, depresi dan gangguan dalam gambaran diri (body image).
8. Gangguan pola tidur berhubungan dengan nyeri, cara pengobatan dan lingkungan yang gaduh.
9. Isolasi sosial berhubungan dengan cara pengobatan dan perubahan dalam penampilan fisik.
10. Perubahan eliminasi urine berhubungan dengan gagal ginjal dan terapi obat.
11. Kurangnya pengetahuan berhubungan dengan pengaruh luka bakar.

Marilynn E. Doenges dalam Nursing care plans, Guidelines for planning and documenting patient care mengemukakan beberapa Diagnosa keperawatan sebagai berikut :
1 Resiko tinggi bersihan jalan nafas tidak efektif berhubungan dengan obtruksi trakeabronkial;edema mukosa dan hilangnya kerja silia. Luka bakar daerah leher; kompresi jalan nafas thorak dan dada atau keterdatasan pengembangan dada.
2 Resiko tinggi kekurangan volume cairan berhubungan dengan Kehilangan cairan melalui rute abnormal. Peningkatan kebutuhan : status hypermetabolik, ketidak cukupan pemasukan. Kehilangan perdarahan.
3 Resiko kerusakan pertukaran gas berhubungan dengan cedera inhalasi asap atau sindrom kompartemen torakal sekunder terhadap luka bakar sirkumfisial dari dada atau leher.
4 Resiko tinggi infeksi berhubungan dengan Pertahanan primer tidak adekuat; kerusakan perlinduingan kulit; jaringan traumatik. Pertahanan sekunder tidak adekuat; penurunan Hb, penekanan respons inflamasi.
5 Nyeri berhubungan dengan Kerusakan kulit/jaringan; pembentukan edema. Manifulasi jaringan cidera contoh debridemen luka.
6 Resiko tinggi kerusakan perfusi jaringan, perubahan/disfungsi neurovaskuler perifer berhubungan dengan Penurunan/interupsi aliran darah arterial/vena, contoh luka bakar seputar ekstremitas dengan edema.
7 Perubahan nutrisi : Kurang dari kebutuhan tubuh berhubungan dengan status hipermetabolik (sebanyak 50 % - 60% lebih besar dari proporsi normal pada cedera berat) atau katabolisme protein.
8 Kerusakan mobilitas fisik berhubungan dengan gangguan neuromuskuler, nyeri/tak nyaman, penurunan kekuatan dan tahanan.
9 Kerusakan integritas kulit berhubungan dengan Trauma : kerusakan permukaan kulit karena destruksi lapisan kulit (parsial/luka bakar dalam).
10 Gangguan citra tubuh (penampilan peran) berhubungan dengan krisis situasi; kejadian traumatik peran klien tergantung, kecacatan dan nyeri.
11 Kurang pengetahuan tentang kondisi, prognosis dan kebutuhan pengobatan berhubungan dengan Salah interpretasi informasi Tidak mengenal sumber informasi.

DAFTAR PUSTAKA

Brunner and suddart. (1988). Textbook of Medical Surgical Nursing. Sixth Edition. J.B. Lippincott Campany. Philadelpia. Hal. 1293 – 1328.

Carolyn, M.H. et. al. (1990). Critical Care Nursing. Fifth Edition. J.B. Lippincott Campany. Philadelpia. Hal. 752 – 779.

Carpenito,J,L. (1999). Rencana Asuhan Dan Dokumentasi Keperawatan. Edisi 2 (terjemahan). PT EGC. Jakarta.

Djohansjah, M. (1991). Pengelolaan Luka Bakar. Airlangga University Press. Surabaya.

Doenges M.E. (1989). Nursing Care Plan. Guidlines for Planning Patient Care (2 nd ed ). F.A. Davis Company. Philadelpia.

Donna D.Ignatavicius dan Michael, J. Bayne. (1991). Medical Surgical Nursing. A Nursing Process Approach. W. B. Saunders Company. Philadelphia. Hal. 357 – 401.

Engram, Barbara. (1998). Rencana Asuhan Keperawatan Medikal Bedah. volume 2, (terjemahan). Penerbit Buku Kedokteran EGC. Jakarta.

Goodner, Brenda & Roth, S.L. (1995). Panduan Tindakan Keperawatan Klinik Praktis. Alih bahasa Ni Luh G. Yasmin Asih. PT EGC. Jakarta.

Guyton & Hall. (1997). Buku Ajar Fisiologi Kedokteran. Edisi 9. Penerbit Buku Kedoketran EGC. Jakarta

Hudak & Gallo. (1997). Keperawatan Kritis: Pendekatan Holistik. Volume I. Penerbit Buku Kedoketran EGC. Jakarta.

Instalasi Rawat Inap Bedah RSUD Dr. Soetomo Surabaya. (2001). Pendidikan Keperawatan Berkelanjutan (PKB V) Tema: Asuhan Keperawatan Luka Bakar Secara Paripurna. Instalasi Rawat Inap Bedah RSUD Dr. Soetomo. Surabaya.

Jane, B. (1993). Accident and Emergency Nursing. Balck wellScientific Peblications. London.

Long, Barbara C. (1996). Perawatan Medikal Bedah. Volume I. (terjemahan). Yayasan Ikatan Alumni Pendidikan Keperawatan Pajajaran. Bandung.

Marylin E. Doenges. (2000). Rencana Asuhan Keperawatan: Pedoman Untuk Perencanaan dan Pendokumentasian Perawatan Pasien Edisi 3. Penerbit Buku Kedoketran EGC. Jakarta.

R. Sjamsuhidajat, Wim De Jong. (1997). Buku Ajar Ilmu Bedah Edisi Revisi. Penerbit Buku Kedokteran EGC. Jakarta.

Senat Mahasiswa FK Unair. (1996). Diktat Kuliah Ilmu Bedah 1. Surabaya.

Sylvia A. Price. (1995). Patofisiologi: Konsep Klinis Proses-Proses Penyakit. Edisi 4 Buku 2. Penerbit Buku Kedokteran Egc, Jakarta

IBU

Engkau adalah wanita termegah,
yang berkorban tanpa lelah...
engkau adalah wanita terkasih,
yang tak kan pernah tersisih...
di sari batinku...
untuk selamanya...
dalam ada dan tiada...

IBU.......
Samudra cintamu,
Mengalir dalam tiap hela nafasku...
Do’a sucimu,
Mengiringi irama detak jantungku...
Kasih sayangmu,
Menghangatkan dingin jiwaku...

IBU......
Air matamu adalah mutiara syurga...
Air yang slalu mengalir,
Ketika ku lemah terbaring...
Air yang membuncah,
Ketika ku terkena musibah...

IBU.......
Diatas syurgaku kau tegap mulia...
Di kehidupanku kau adalah malaikat dunia,
Dari Tuhan...
untuk membimbingku mengenal-Nya....

IBU.......
Ijinkan ku berbakti padamu...
Setelah ku tunduk pada ALLOH, Tuhanku...
Setelah ku tunduk pada MUHAMMAD Rosulku...
Aku tunduk padamu IBU...

Ya ALLOH...
Tuhan yang menggenggam jiwa semua manusia...
Tuhan yang berkuasa atas yang nyata dan kasat mata...
Tuhan yang maha kaya atas apapun juga...
Tuhan yang pada-Mu segala puji tertuju...

Ya ALLOH...
Ampuni hamba yang tlah lama berslimut dosa...
Ampuni IBU hamba dan jadikan dia bidadari syurga...
Sayangi dan kasihi IBU hamba,
Melebihi kasih dan sayangnya pada hamba...

Ya ALLOH...
Tiada kesulitan bahkan kerugian secuilpun untuk-Mu,
Jika mengabulkan apa yang hamba minta...
Hamba mohon penuhilah doa hamba untuk IBU hamba...
AMIN........

22 desember 2008, hari IBU....

sebagai persembahan untuk Wanita yang mencintaiku,
menyeyangiku,
dalam senang dan sedih...
wanita yang slalu memberi inspirasi,
wanita yang slalu memotivasi,
wanita yang dengan doa dan pengorbanannya aku bisa seperti ini...
tapi tak pernah sekalipun aku membahagiakannya selain menjaga diriku tetap sehat agar dia bahagia...
aku akan berusaha membahagiakan nya....
dialah satu-satunya harapan yang membuatku tetap tegar menghadapi semua urusan...
dialah IBU....
takzimku pada mu IBU...

Menjaga Kesehatan Kulit

Kulit yang sehat akan membuat membuat orang terlihat lebih segar dan muda. Terutama bagi kaum perempuan yang ingin terlihat cantik dan awet muda, maka kesehatan kulit salah satu hal terpenting yang harus diperhatikan.

Jangan Merokok
Merokok akan merusak sirkulasi kecil dalam kulit, sehingga membuat kulit kelihatan kusam dan tidak cerah. Akan menambah keriput pada kulit, terutama pada kulit di sekitar mulut.

Diet Seimbang
Diet dengan makanan yang sehat secara seimbang, mengandung banyak sayuran dan buah untuk memenuhi kecukupan vitamin, mineral dan anti oksidan.

Olahraga
Olahraga yang teratur akan membuat kulit sehat dan berat badan yang ideal.

Tidur yang cukup
Tidur sangat diperlukan untuk memperbaiki sel-sel tubuh yang rusak, termasuk sel-sel kulit. Membuat kulit dan tubuh kembali segar.

Kurangi Konsumsi Alkohol
Konsumsi alkohol yang berlebihan juga dapat merusak hati.

Lindungi dari Sinar Matahari
Bahaya dari sinar matahari ialah sinar ultraviolet A yang dipancarkannya, yang dapat merusak jaringan kolagen kulit. Kulit akan menipis dan mudah untuk terjadi keriput.

Atasi Stres
Stres selain dapat merusak kesehatan, juga akan berpengaruh pada wajah dan bentuk tubuh anda. (cy)
http://www.resep.web.id/tips/menjaga-kesehatan-kulit.htm

PROFIL PERAWAT MASA KINI; BAK MEMAKAN BUAH SIMALAKAMA

Perawat kontemporer menuntut perawat yang memiliki pengetahuan dan ketram pilan dalam berbagai bidang. Dulu peran perawat inti adalah memberikan perawatan dan kenyamanan karena mereka menjalankan perawatan spesifik, tapi seka rang hal ini telah berubah. Peran perawat sudah menjadi lebih luas dengan penekanan pada peningkatan kesehatan dan pencegahan penyakit, juga memandang klien secara komprehensif. Pera wat masa kini menjalankan fungsi dalam kaitannya dengan berbagai peran pemberi kepe rawatan, pembuat keputusan klinik dan etika, pelindung dan advokat bagi klien, manajer kasus, rehabilitator, pembuat kenyamanan, komunikator dan pendidik.(Potter-Perry).
Statemen diatas sudah sebaiknya menjadi iktibar bagi kita-kader keperawatan tan ah air- untuk memahami tujuan kerja kita yang tidak sebatas melakukan technical saja tapi sudah menyentuh berbagai bidang.
Bak jauh panggang dengan api, di lapangan kita bisa melihat kondisi keseharian kerja perawat. Banyak ditemu kan laporan bahwa pe rawat dikenal sebagai sosok yang menakutkan, tidak tahu sopan-santun dalam menangani pasien dan berbagai ungkapan miring lainnya. Perawat yang notabene telah bekerja lebih banyak dari dokter karena 24 jam selalu bertemu dengan pa sien, juga harus menghadapi berbagai kepedihan seperti laporan tindakan pemukulan oleh keluarga pasien yang tidak puas dengan asuhan keperawatan yang diberikan, lalu gaji yang diberi kan juga dibawah standar. Ibarat memakan buah simalakama, perawat men jadi serba-salah dalam melakukan tindakan apapun.
Padahal, keperawatan sudah dianggap sebagai satu profesi, bukan lagi sejumlah ketrampilan khusus dan seorang perawat bukan hanya seorang yang dilatih dengan keah lian tertentu. Keperawatan adalah sebuah profesi. Profesi memiliki beberapa karakteristik utama seperti:
1 Adanya pendidikan lanjutan dari anggotanya, demikian pula landasan dasarnya
2 Mempunyai kerangka pengetahuan teoretis yang mengarah pada skill, kemampu an dan norma tertentu.
3. Memberikan pelayanan tertentu
4. Anggota suatu profesi memiliki otonomi untuk membuat keputusan dan mela kukan tindakan
5. Profesi sebagai satu kesatuan memiliki kode etik untuk melakukan praktik kepera watan.
Sudah jelas, keperawatan memiliki semua hal tersebut diatas. Akan tetapi, ki ni kita dihadapkan bahwa keperawatan hanya sebatas profesi, belum menyentuh aspek yang demikian lengkap seperti organisasi keperawatan di berbagai negara lainnya. Padahal, u sia keperawatan di Indonesia sudah sama tuanya dengan usia republik ini, wa lau dulu di kenal sebagai paramedis yang bertugas merawat korban perang disamping keberadaan dokter yang lebih dulu mujur dengan didirikannya STOVIA sebagai sekolah kedokteran pertama di Indonesia dengan CBZ (RS.CIPTO MANGUNKUSUMO saat ini-red) seba gai RS akademika-nya. Tapi bukan berarti dengan hal seperti itu membuat kita beralasan bahwa keperawatan di tanah air terus berada dalam ketertinggalan dan mematuhi sifat pe simisme. Sudah saatnya kita melakukan perubahan dan reformasi misi hingga visi 2010 menjadi kenyataan bagi kita selaku kader keperawatan Indonesia.
http://andibloggersejati.blogspot.com

Tips Merawat Kulit

Kulit merupakan bagian tubuh kita yang bersentuhan langsung dengan segala hal di luar tubuh, seperti misalnya cuaca, sinar matahari atau yang lainnya. Dan kulit kita merupakan hal pertama yang terlihat, saat kita mulai mengalami penuaan. Jadi sudah sewajarnya kita patut melakukan perawatan pada kulit. Berikut kami sampaikan beberapa tips perawatan kulit.

Perlindungan Terhadap Matahari - Matahari memiliki peran utama dalam merusak kulit. Anda perlu melindungi kulit dari matahari guna mencegah penuaan pada kulit. Matahari sangat berpengaruh dalam membuat kulit berkerut, kering, dan membuat warna kulit berubah; Penjarangan kulit, tekstur kulit, penipisan kulit serta penyakit kulit yang berhubungan dengan paparan sinar matahari dapat membuat kulit Anda nampak jauh lebih tua. Jadi, mulailah melindungi kulit dengan krem pelindung matahari.

Hindari Merokok - Tips ini terutama bagi kaum pria, karena populasi dari perokok terbesar di dunia adalah pria. Merokok bukan hanya menyebabkan kanker paru-paru, tapi juga dapat membuat kulit kusam dan berkerut. Menurut beberapa penelitian terdapat dugaan kuat kalau nikotin yang terkandung dalam rokok memiliki pengaruh yang sama layaknya elastin pada matahari.

Berolahraga - Sejalan dengan bertambahnya usia, sangatlah mustahil menyembunyikan tanda-tanda penuaan di balik kulit. Leher, pipi dan sudut mata merupakan bagian yang paling mudah terlihat saat usia bertambah tua. Demi memperbaiki penampilan kulit, kita mesti menyeimbangkan antara diet dan latihan secara teratur. Selain Anda juga harus rajin minum air putih, paling sedikit delapan hingga sepuluh gelas setiap hari.

Senyum Memiliki Manfaat Ajaib - Wajah kita cenderung menyesuaikan pada posisi dari ekspresi yang kita bawa sepanjang waktu. Jika Anda lebih sering cemberut atau marah-marah, kulit Anda-pun akan lebih cenderung cepat berkerut, terutama di area mata, garis dan sudut bibir atau garis-garis lain yang mengikuti ekspresi saat cemberut. Sebuah senyum dapat membuat keajaiban bagi kulit Anda dan membuat awet muda pula. Jadi untuk mengindari jadi cepat tua, yang perlu Anda lakukan hanya lebih banyak tersenyum.

Perawatan Kulit - Merawat kulit merupakan hal yang sangat penting. Anda harus segera mencuci wajah setiap kali sehabis keluar di bawah terik matahari. Menggosok kulit dengan peeling secara teratur, setidaknya seminggu 2 kali, akan membantu mengangkat sel-sel kulit mati dan kotoran yang menempel, sehingga kulit dapat lebih leluasa bernafas dan lebih cerah.

Posisi Tidur - Tidur dengan posisi telungkup dapat menyebabkan kerut. Selain itu hindari tidur dengan posisi tetap sepanjang malam, hal ini dapat menyebabkan kulit Anda kusut. Dan Anda perlu tidur setidaknya 8 jam setiap hari.
KapanLagi.com

Pregnant and Born/Hamil dan Lahir

Seperti hampir semua anak kecil di dunia, daku pernah bertanya-tanya, dari manakah datangnya seorang anak? Dan daku pernah mempunyai konsep yang amat sangat indah. Menurut pikiran daku yang waktu itu belum mengenal istilah pembuahan ataupun proses-proses kenikmatan yang mendahuluinya, anak dihasilkan dari pengharapan.

Like almost every child in this world, I was also questioning (wondering) where the babies come from. And I have a beautiful theory — from my innocent thought, which for sure at that time still don't know what the fertilization process is, or the pleasure activity preceding before it — a child comes from hope.

Saat sepasang suami-istri menikah, maka diberkatilah mereka. Mereka akan saling mengasihi dan berdoa bersama akan datangnya seorang anak. Oleh karena itu, tidak jarang kita akan mendengar perkataan, "Mereka masih menunggu datangnya seorang anak dalam kehidupan mereka." Bah, kenapa pakai kata-kata seperti itu? Kesannya terlalu saru. Sampai-sampai muncullah pemikiran bahwa seorang anak tiba-tiba 'diselipkan' begitu saja ke rahim seorang istri. Belakangan aku baru tahu kalau seorang anak itu bukan ditunggu kedatangannya, tapi 'diusahakan'.

When a man and a woman are blessed to become husband and wife, they shall love each other, and then pray together for a coming of a child. Because of that, we are often hear a lot of people say that the couple's hope of getting a child hasn't been granted yet — or they are still hoping (waiting) for a child to enter their life. Walae, why do we use those expression? It seems so ambiguous and made me think that a child can just be slipped into a woman's womb. Finally, I knew that a a child is not for us to wait but it is for us to work out... :)

Yah mungkin juga aku bisa berpikir seperti itu karena dulu belum tahu ada kasus yang istilahhnya 'hamil di luar nikah', 'kecelakaan' ataupun unwanted child. (Lah kalau memang anak didatangkan dengan doa, tentunya atas persetujuan Tuhan dong. Dengan kata lain yang bisa hamil itu cuma istri-istri dari pasangan yang diberkati di tempat ibadah secara agama dan direstui oleh seluruh sanak keluarga). Waktu itu juga sepertinya gelar MBA (Married By Accident) belum begitu populer.

Perhaps it was caused by my naive thinking, I didn't recognize a case of woman got pregnant out of wedlock, "accident" or even "unwanted child." If a child comes from a granted pray so it must comes from GOD's approval. Thus, all wives that are expecting baby is only the blessed ones from all churches, temples, mosque, etc. and must also blessed by the entire family — as at the time, when I was a kid — no such things as MBA (Married By Accident) or that phrase was not (too) popular.

Tapi aku pernah mendengar sebuah berita di televisi yang mengubah konsep 'anak datang dari doa'. Kalau tidak salah ingat, berita tersebut tentang seorang guru yang amat sangat genit dan sangat 'dekat dan akrab' dengan muridnya. (dekat dalam arti, Sangat... dekat sekali dalam makna denotasi)

My concept — a child comes form hope — suddenly changed when I was watching a local news on the TV. If I remembered correctly, it was about a flirty high school teacher, famous to be close to his student — close in the meaning 'too close' in a denotation meaning.

Nah kira-kira laporan yang dibacakan oleh narator (atau apalah namanya yang baca berita pas dikasih gambar) itu berbunyi, "Tersangka terkenal suka memegang-megang siswi. Ada yang pipinya dielus, bahkan ada yang hamil." Sudah bisa ditebak ada yang ada di pikiran daku waktu itu?

The news anchor (the person who read the story when you can see the illustration picture) was telling that the teacher loves to touch the girls. He loves to touch the cheek of the girls and even one of them gets pregnant... Can you guess how wild my imagination is when I heard that news?

"Oh... ternyata mengelus pipi bisa berefek samping hamil!!!" Pikiran daku tidak berhenti di sana, lalu aku mengambil satu kesimpulan teori: "Sentuhan seorang lelaki bisa meresap ke dalam kulit dan akhirnya tiba di perut? Membesar, membesar, dan akhirnya menjadi seorang bayi?" Bahaya bener... Pantesan orang-orang tua selalu bilang, "Ati-ati, jangan tidur sama lelaki!!" Wah, berarti pas tidur seranjang, sebelah-sebelahan, tiba-tiba tengah malam nanti ada 'sesuatu' yang tiba-tiba merayap keluar dari si jantan dan menyusup ke perut betina? Dan DUING!!! Mengembanglah perut sang betina. Tapi, belakangan (saat daku kira-kira udah SMA) tante daku malah bilang, "Tidur sama cowok itu gak papa. Asal bener tidur bareng ya. Kalau gak tidur, nah, itulah yang bahaya!" Hm... ada benarnya juga sih.

"Oh... so you can get pregnant if a man touch your cheek!!!" And my imagination didn't stop at that point. I concluded that a touch of a man can really go through into your skin and then turn up on your tummy. After that, it's getting bigger and bigger, and finally became a baby!! Wow... it's so dangerous... no wonder parents always says to their daughter, "Be careful, don't sleep with a man!!!" Wa... does it mean that if a man and a woman sleep side by side, then something will crawl slowly in the midnight from a man and will slip to a woman's tummy? And then, DUNG!!! The woman's tummy blows up. But, when I was in senior high school, my auntie said, "It's OK to sleep side by side with a man as long as you REALLY sleep!!! If you don't sleep... thus... IT IS DANGEROUS!!!". Hmm, it's quite true.

Oh iya, ngomong-ngomong. Kalau dilihat di komik ataupun di film kartun, ada yang menceritakan bahwa bayi itu didatangkan oleh burung besar! (entah jenis apa dan dari mana) Wah... kalau dipikir-pikir, aneh juga ya cerita ini, kira-kira masih ada anak kecil yang percaya gak ya? Soalnya menurut fakta, banyak hewan termasuk burung tentunya, terancam punah karena ekspansi wilayah yang dilakukan manusia ke habitat mereka di alam. Lalu di mana letak logikanya kalau pembawa kelahiran itu sendiri terancam punah sementara manusia malah semakin banyak? Yah, mungkin memang seharusnya cerita film kartun tidak boleh dianggap serius.

By the way, comics or cartoons are often tell us that a big bird (a type of crane?) will bring the babies... This story, according to me, is quite funny... do you think that many children still believe that? It's funny for me since, as you know, that a lot of animal, including birds are already in the rare category... almost gone because of human's expansion to their environment in the nature. So, where is the logical thinking, if the carrier itself are almost gone but human are getting more and more? Yeah, maybe that's way we may not consider cartoon movies so seriously.

Mari kita ke tahap selanjutnya, hal lahir melahirkan. Hm.. kayanya daku mengerti istilah 'caesar' terlebih dahulu daripada lahir alami. Kenapa bisa begitu? Gampang saja alasannya.

Let's move on to the next level... I think I understood Caesar operation as a delivery method earlier than the natural one... How could it be so? It was a very simple reason...

Setelah bayi tumbuh besar di dalam perut, ia perlu segera dikeluarkan sebelom perut ibunya meledak. Nah cara paling cepat adalah membuka perut ibu, mengeluarkan bayi, lalu kita tutup kembali. Hampir persis sama seperti cara kerja resleting. Bagaimana prosesnya secara lebih mendetail? Ah peduli amat sama tetek bengek proses 'caesar' itu. Toh dokter pasti punya obat bius kan? Tinggal suntik sana suntik sini, siaplah perut ibu dibelek tanpa rasa sakit.

My thinking was... after a baby grows in mum's tummy, he/she should be out of it before his/her mum's tummy explodes, so the easiest way is to open mum's tummy and then, close it up again. It almost looks like if we close up our zipper... How are the details of the process? Shall we care? No need, right? There are doctors to give the mummies a sleeping shots... shoot here... shoot there and mummy's tummy is ready to be opened without any pain.

Pada waktu masih SD, seorang teman menceritakan teorinya yang lebih ajaib lagi. Katanya, sebenarnya saat ibu hamil, isi perutnya adalah cairan. Lalu bagaimana cara melahirkan? Dengan penuh keyakinan dia berkata, "Melalui cara yang sama kaya kencing." "Heh? Kenapa bisa begitu? Kalau yang keluar cuma cairan, bayinya mana? Apa harus dibekukan sampai pada suhu 0°C? Pake cetakan kue?" "Denger dulu dong. Setelah semua cairan dikeluarkan, kempeslah perut si mama. Tugas dokter adalah memastikan agar cairan tersebut tertampung seluruhnya dengan baik. Jangan sampai ada yang tumpah! Nanti bisa-bisa bayinya cacat. Setelah ditampung, biarkan beberapa lama, lalu dengan sendirinya air kencing itu akan berubah menjadi seorang bayi!!!"

Another theory is come from my primary school's friend... and it is more imaginary than mine. He said that the pregnant mummy contains of a kind of liquid. If so, then how to deliver the baby? With full confidence, he said, "Using the same way like we go to urinate." "Huh? How come it is like that? If it's only liquid, so where is the baby? Do we have to freeze it in 0ºC and use a cake molder to shape the baby?" "Hey!!! Please hear it first!!! After all the liquid is out, of course mummy's tummy is smaller... then the doctor is supposed to make sure that he get all the liquid and there is no even one drop goes wasted, so the baby will be a healthy and complete baby. After that, the doctor shall keep the liquid for awhile... and then... abracadabra... By itself, the liquid turns to a baby!!!"

Heh? Kok gaya penjelasannya bahkan kaya di resep-resep masakan? (setelah matang, biarkan beberapa lama, lalu makanan siap dihidangkan). Mungkin juga teman daku itu berpikir kalau setelah cairan itu ditampung, lalu dimasukkan ke dalam inkubator. Jadi guna inkubator seperti guna oven pada pembuatan roti. Masukkan cairan, lalu cairan tersebut akan mengembang, sebagian menjadi daging, tulang, sebagian besar masih berupa cairan, yaitu darah. Mungkin teman daku itu terinspirasi untuk membandingkan antara inkubator ( yang bentuknya kotak) yang di rumah sakit dan oven (kotak juga!) yang ada di dapur.

The way she told me the theory sounded like told me about food recipes — after it's cooked, leave it for a while, then it's ready to be eaten... It might cross my friend's mind that after the doctor collects all the liquid, he will put it in an incubator. So the function of incubator is the same as the function of an oven when you make a bread. Put the liquid, let it blows up, a part of it will become flesh, bones, and the rest is still a liquid, i.e. blood. Maybe he was inspired by the form of an incubator in the hospital, which is square and the form of an oven (that's also square) in his mummy's kitchen.

http://www.kejut.com/lahir

What is in the future for stroke treatment?

Currently, studies are being done on additional drugs that dissolve clots. These drugs are administered either in the veins (like TPA) or directly into the clogged artery. The goal of these studies is to determine which stroke patients might benefit from this new and aggressive form of treatment.

New medications are also being tested that help slow the degeneration of the nerve cells that are deprived of oxygen during a stroke. These drugs are referred to as "neuroprotective" agents, an example of which is sipatrigine. Another example is chlormethiazole, which works by modifying the expression of genes within the brain. (Genes produce proteins that determine an individual's makeup.)

Finally, stem cells, which have the potential to develop into a variety of different organs, are being used to try to replace brain cells damaged by a previous stroke. In many academic medical centers, some of these experimental agents may be offered in the setting of a clinical trial. While new therapies for the treatment of patients after a stroke are on the horizon, they are not yet perfect and may not restore complete function to a stroke victim.

Stroke At A Glance

• Stroke is the sudden death of brain cells due to lack of oxygen.
  
  
• Stroke is caused by the blockage of blood flow or rupture of an artery to the brain.
  
  
• Sudden tingling, weakness, or paralysis on one side of the body or difficulty with balance, speaking, swallowing, or vision can be a symptom of a stroke.
  
  
• Any person suspected of having a stroke or TIA should present for emergency care immediately
  
  
• Clot-busting drugs like TPA can be used to reverse a stroke, but the time frame for their use is very narrow. Patients need to present for care as soon as possible so that TPA therapy can be considered.
  
  
• Stroke prevention involves minimizing risk factors, such as controlling high blood pressure, elevated cholesterol, tobacco abuse, and diabetes.

References: Johnston SC, Nguyen-Huynh MN, Schwarz ME, Fuller K, Williams CE, Josephson SA, Hankey GJ, Hart RG, Levine SR, Biller J, Brown RD Jr, Sacco RL, Kappelle LJ, Koudstaal PJ, Bogousslavsky J, Caplan LR, van Gijn J, Algra A, Rothwell PM, Adams HP, Albers GW.; "National Stroke Association guidelines for the management of transient ischemic attacks." Ann Neurol. 2006 Sep;60(3):301-13. "Primary prevention of ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council: cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: the American Academy of Neurology affirms the value of this guideline." Stroke. 2006 Jun;37(6):1583-633. Epub 2006 May 4. Liferidge AT, Brice JH, Overby BA, Evenson KR. "Ability of laypersons to use the Cincinnati Prehospital Stroke Scale." Prehosp Emerg Care. 2004 Oct-Dec:8(4):384-7.

http://www.medicinenet.com/stroke/page9.htm

What can be done to prevent a stroke?

Risk factor reduction

High blood pressure: The possibility of suffering a stroke can be markedly decreased by controlling the risk factors. The most important risk factor for stroke is high blood pressure. When a person's blood pressure is persistently too high, roughly greater than 130/85, the risk of a stroke increases in proportion to the degree by which the blood pressure is elevated. Controlling blood pressure in the normal range decreases the chances of a stroke.

Smoking: Another important risk factor is cigarette or other tobacco use. Cigarettes cause the carotid arteries to develop severe atherosclerosis, which can lead to their closure and block the blood flow to the brain. Atherosclerosis in general, including involvement of the arteries that supply blood to the heart, is accelerated by smoking. So, when an individual smokes, the main question becomes - which will occur first; a stroke, heart attack, or lung cancer?

Diabetes: Another risk factor for developing a stroke is diabetes mellitus. Diabetes causes the small vessels to close prematurely. When these blood vessels close in the brain, small (lacunar) strokes may occur. Good control of blood sugar is important in decreasing the risk of stroke in diabetic patients. An elevated level of blood cholesterol is also a risk factor for a stroke due to the eventual blockage of blood vessels (atherosclerosis). A healthy diet and medications can help normalize an elevated blood cholesterol level.

Blood thinner/warfarin: An irregular heart beat (atrial fibrillation in particular) is associated with an increased risk of an embolic stroke, in which the blood clot travels from the heart, through the bloodstream, and into the brain. Warfarin (Coumadin) is a blood "thinner" that prevents the blood from clotting. This medication is often used in patients with atrial fibrillation to decrease this risk. Warfarin is also sometimes used to prevent the recurrence of a stroke in other situations, such as with certain other heart conditions and conditions in which the blood has a tendency to clot on its own (hypercoagulable states). Patients taking warfarin need to have periodic blood checks to make sure that their current dose is producing the desired effect. Patients on warfarin also need to know that they are at increased risk for bleeding, either externally or internally.

Aspirin and other antiplatelet therapy: Many stroke patients who do not require warfarin can use another class of medicines called "antiplatelet" drugs to reduce their risk of suffering another stroke. These medicines reduce the tendency of the blood to clot (clog) in the arteries. As a side effect, patients on these medicines usually have a higher likelihood of bleeding, but this risk is less than when taking an anticoagulant like warfarin. The most commonly prescribed first-choice antiplatelet agent for preventing a stroke recurrence is aspirin. If the patient has an adverse reaction to aspirin or has a stroke despite being on aspirin, newer antiplatelet preparations can be used [clopidogrel (Plavix), dipyridamole (Persantine).

Carotid endarterectomy: In many cases, a person may suffer a TIA or a stroke that is caused by the narrowing or ulceration (sores) of the carotid arteries (the major arteries in the neck that supply blood to the brain). If left untreated, patients with these conditions have a high risk of experiencing a major stroke in the future. An operation that cleans out the carotid artery and restores normal blood flow is known as a carotid endarterectomy. This procedure has been shown to markedly reduce the incidence of a subsequent stroke. In patients who have a narrowed carotid artery, but no symptoms, this operation may be indicated in order to prevent the occurrence of a first stroke.

http://www.medicinenet.com/stroke/page8.htm

What complications can occur after a stroke?

A stroke can become worse despite an early arrival at the hospital and appropriate medical treatment. It is not unusual for a stroke and a heart attack to occur at the same time or in very close proximity to each other.

During the acute illness, swallowing may be affected. The weakness that affects the arm, leg, and side of the face can also impact the muscles of swallowing. A stroke that causes slurred speech seems to predispose the patient to abnormal swallowing mechanics. Should food and saliva enter the trachea instead of the esophagus when eating or swallowing, pneumonia or a lung infection can occur. Abnormal swallowing can also occur independently of slurred speech.

Because a stroke often results in immobility, blood clots can develop in a leg vein (deep vein thrombosis). This poses a risk for a clot to travel upwards to and lodge in the lungs - a potentially life-threatening situation (pulmonary embolism). There are a number of ways in which the treating physician can help prevent these leg vein clots. Prolonged immobility can also lead to pressure sores (a breakdown of the skin, called decubitus ulcers), which can be prevented by frequent repositioning of the patient by the nurse or other caretakers.

Stroke patients often have some problem with depression as part of the recovery process, which needs to be recognized and treated.

The prognosis following a stroke is related to the severity of the stroke and how much of the brain has been damaged. Some patients return to a near-normal condition with minimal awkwardness or speech defects. Many stroke patients are left with permanent problems such as hemiplegia (weakness on one side of the body), aphasia (difficulty or the inability to speak), or incontinence of the bowel and/or bladder. A significant number of persons become unconscious and die following a major stroke.

If a stroke has been massive or devastating to a person's ability to think or function, the family is left with some very difficult decisions. In these cases, it is sometimes advisable to limit further medical intervention. It is often appropriate for the doctor and the patient's family to discuss and implement orders to not resuscitate the patient in the case of a cardiac arrest, since the quality of life for the patient would be so poor. In many cases, this decision is made somewhat easier if the patient has made such a request when well.

http://www.medicinenet.com/stroke/page7.htm

What is the treatment of a stroke?

Tissue plasminogen activator (TPA)

There is opportunity to use alteplase (TPA) as a clot-buster drug to dissolve the blood clot that is causing the stroke. There is a narrow window of opportunity to use this drug. The earlier that it is given, the better the result and the less potential for the complication of bleeding into the brain.

Present American Heart Association guidelines recommend that if used, TPA must be given within three hours after the onset of symptoms. Normally, TPA is injected into a vein in he arm. The time frame for use can be extended to six hours if it is dripped directly into the blood vessel that is blocked. This is usually performed by an interventional radiologist, and not all hospitals have access to this technology.

For posterior circulation strokes that involve the vertebrobasilar system, the time frame for treatment with TPA may be extended even further to 18 hours.

Heparin and aspirin

Drugs to thin the blood (anticoagulation; for example, heparin) are also sometimes used in treating stroke patients in the hopes of improving the patient's recovery. It is unclear, however, whether the use of anticoagulation improves the outcome from the current stroke or simply helps to prevent subsequent strokes (see below). In certain patients, aspirin given after the onset of a stroke does have a small, but measurable effect on recovery. The treating doctor will determine the medications to be used based upon a patient's specific needs.

Managing other Medical Problems

Blood pressure and cholesterol control are key to prevention of future stroke events. In transient ischemic attacks, the patient may be discharged with medications even if the blood pressure and cholesterol levels are acceptable. In an acute stroke, blood pressure will be tightly controlled to prevent further damage.

In patients with diabetes, the blood sugar (glucose) level is often elevated after a stroke. Controlling the glucose level in these patients may minimize the size of a stroke. Finally, oxygen may administered to stroke patients when necessary.

Rehabilitation

When a patient is no longer acutely ill after a stroke, the healthcare staff focuses on maximizing the patient's functional abilities. This is most often done in an inpatient rehabilitation hospital or in a special area of a general hospital. Rehabilitation can also take place at a nursing facility.

The rehabilitation process can include some or all of the following:

1. speech therapy to relearn talking and swallowing;
   
   
2. occupational therapy to regain dexterity in the arms and hands;
   
3. physical therapy to improve strength and walking; and
   
   
4. family education to orient them in caring for their loved one at home and the challenges they will face.

The goal is for the patient to resume as many, if not all, of their pre-stroke activities and functions. Since a stroke involves the permanent loss of brain cells, a total return to the patient's pre-stroke status is unfortunately, not a realistic goal in many cases.

When a stroke patient is ready to go home, a nurse may come to the home for a period of time until the family is familiar with caring for the patient and the procedures for giving various medications. Physical therapy may continue at home. Eventually, the patient is usually left at home with one or more caregivers, who now find their lives have changed in major ways. Caring for the stroke patient at home may be easy or very nearly impossible. At times, it becomes apparent that the patient must be placed in a board and care home or a skilled nursing facility because adequate care cannot be given at home despite the good intentions of the family.

http://www.medicinenet.com/stroke/page6.htm

How is a stroke diagnosed?

A stroke is a medical emergency. Anyone suspected of having a stroke should be taken to a medical facility immediately for evaluation and treatment. Initially, the doctor takes a medical history from the patient if he/she is alert or others familiar with the patient if they are available, and performs a physical examination. If a person has been seeing a particular doctor, it would be ideal for that doctor to participate in the assessment. Previous knowledge of the patient can improve the accuracy of the evaluation. A neurologist, a doctor specializing in disorders of the nervous system and diseases of the brain, will often assist in the diagnosis and management of stroke patients.

Just because a person has slurred speech or weakness on one side of the body does not necessarily signal the occurrence of a stroke. There are many other possibilities that can be responsible for these symptoms. Other conditions that can mimic a stroke include:

• brain tumors,
  
  
• a brain abscess (a collection of pus in the brain caused by bacteria or a fungus),
  
  
• migraine headache,
  
  
• bleeding in the brain either spontaneously or from trauma,
  
  
• meningitis or encephalitis,
  
  
• an overdose of certain medications, or
  
  
• an imbalance of sodium, calcium, or glucose in the body can also cause changes in the nervous system that can mimic a stroke.

In the acute stroke evaluation, many things will occur at the same time. As the physician is taking the history and performing the physical examination, nursing staff will begin monitoring the patient's vital signs, getting blood tests, and performing an electrocardiogram (EKG or ECG).

Part of the physical examination that is becoming standardized is the use of a stroke scale. The American Heart Association has published a guide to the examination of the nervous system to help care providers determine the severity of a stroke and whether aggressive intervention may be warranted.

There is a narrow time frame to intervene in an acute stroke with medications to reverse the loss of blood supply to part of the brain (please see TPA below). The patient needs to be appropriately evaluated and stabilized before any clot-busting drugs can be potentially utilized.

Computerized tomography: In order to help determine the cause of a suspected stroke, a special x-ray test called a CT scan of the brain is often performed. A CT scan is used to look for bleeding or masses within the brain, a much different situation than stroke that is also treated differently.

MRI scan: Magnetic resonance imaging (MRI) uses magnetic waves rather than x-rays to image the brain. The MRI images are much more detailed than those from CT, but this is not a first line test in stroke. While a CT scan may be completed within a few minutes, an MRI may take more than an hour to complete. An MRI may be performed later in the course of patient care if finer details are required for further medical decision making. People with certain medical devices (for example, pacemakers) or other metals within their body, cannot be subjected to the powerful magnetic field of an MRI.

Other methods of MRI technology: An MRI scan can also be used to specifically view the blood vessels non-invasively (without using tubes or injections), a procedure called an MRA (magnetic resonance angiogram). Another MRI method called diffusion weighted imaging (DWI) is being offered in some medical centers. This technique can detect the area of abnormality minutes after the blood flow to a part of the brain has ceased, whereas a conventional MRI may not detect a stroke until up to six hours after it has started, and a CT scan sometimes cannot detect it until it is 12 to 24 hours old. Again, this is not a first line test in the evaluation of a stroke patient, when time is of the essence.

Computerized tomography with angiography: Using dye that is injected into a vein in the arm, images of the blood vessels in the brain can give information regarding aneurysms or arteriovenous malformations. As well, other abnormalities of brain blood flow may be evaluated. With increasingly sophisticated technology, CT angiography has supplanted conventional angiograms.

Conventional angiogram: An angiogram is another test that is sometimes used to view the blood vessels. A long catheter tube is inserted into an artery (usually in the groin area) and dye is injected while x-rays are simultaneously taken. While an angiogram delivers some of the most detailed images of the blood vessel anatomy, it is also an invasive procedure and is used only when absolutely necessary. For example, an angiogram is done after a hemorrhage when the precise source of bleeding needs to be identified. It also is sometimes performed to accurately evaluate the condition of a carotid artery when surgery to unblock that blood vessel is contemplated.

Carotid Doppler ultrasound: A carotid Doppler ultrasound is a non-invasive (without injections or placing tubes) method that uses sound waves to screen for narrowings and decreased blood flow in the carotid artery (the major artery in the neck that supplies blood to the brain).

Heart tests: Certain tests to evaluate heart function are often performed in stroke patients to search for the source of an embolism. An echocardiogram is a sound wave test that is done by placing a microphone device on the chest or down the esophagus (transesophageal echocardiogram) in order to view the heart chambers. A Holter monitor is similar to a regular electrocardiogram (EKG), but the electrode stickers remain on the chest for 24 hours or longer in order to identify a faulty heart rhythm.

Blood tests: Blood tests such as a sedimentation rate and C-reactive protein are done to look for signs of inflammation that can suggest inflamed arteries. Certain blood proteins that can increase the chance of stroke by thickening the blood are measured. These tests are performed to identify treatable causes of a stroke or to help prevent further injury. Screening blood tests looking for potential infection, anemia, kidney function, and electrolyte abnormalities may also be considered.

http://www.medicinenet.com/stroke/page5.htm

What should be done if you suspect you or someone else is having a stroke?

If any of the symptoms mentioned above suddenly appear, emergency medical attention should be sought. Therefore, the first action should be to call 911 (or whatever number activates the emergency medical response in your area). The family doctor and/or neurologist should also be contacted. However, the first priority is ensuring that the ambulance arrives as soon as possible.

• The affected person should lie flat to promote an optimal blood flow to the brain.
  
  
• If drowsiness, unresponsiveness, or nausea are present, the person should be placed in the rescue position on their side to prevent choking should vomiting occur.
  
  
• Although aspirin plays a major role in stroke prevention (see below), once the symptoms of a stroke begin, it is generally recommended that additional aspirin not be taken until the patient receives medical attention. If stroke is of the bleeding type, aspirin could theoretically make matters worse.

Cincinnati Prehospital Stroke Scale (CPSS)

According to a study by the University of North Carolina, three commands may be used to assess whether a person may be experiencing a stroke. Lay persons can command a potential stroke victim to:

1. Smile
   
   
2. Raise both arms
   
   
3. Speak a simple sentence

The three commands, known as the Cincinnati Prehospital Stroke Scale (CPSS), are used by health professionals as a simple first step in the assessment process for signs of stroke. If a person has trouble with any of these simple commands, emergency services (911) should be called immediately with a description of the situation, noting that you suspect the individual is having a stroke.

http://www.medicinenet.com/stroke/page4.htm

What is the impact of strokes?

In the United States, stroke is the third largest cause of death (behind heart disease and all forms of cancer). The cost of strokes is not just measured in the billions of dollars lost in work, hospitalization, and the care of survivors in nursing homes. The major cost or impact of a stroke is the loss of independence that occurs in 30% of the survivors. What was a self-sustaining and enjoyable lifestyle may lose most of its quality after a stroke and other family members can find themselves in a new role as caregivers.

What are stroke symptoms?

When brain cells are deprived of oxygen, they cease to perform their usual tasks. The symptoms that follow a stroke depend on the area of the brain that has been affected and the amount of brain tissue damage.

Small strokes may not cause any symptoms, but can still damage brain tissue. These strokes that do not cause symptoms are referred to as silent strokes. According to The U.S. National Institute of Neurological Disorders and Stroke (NINDS), these are the five major signs of stroke:

1. Sudden numbness or weakness of the face, arm or leg, especially on one side of the body. The loss of voluntary movement and/or sensation may be complete or partial. There may also be an associated tingling sensation in the affected area.

2. Sudden confusion or trouble speaking or understanding. Sometimes weakness in the muscles of the face can cause drooling.

3. Sudden trouble seeing in one or both eyes

4. Sudden trouble walking, dizziness, loss of balance or coordination

5. Sudden, severe headache with no known cause

http://www.medicinenet.com/stroke/page3.htm

What are the risk factors for stroke?

Overall, the most common risk factors for stroke are:

• high blood pressure,
  
  
• high cholesterol,
  
  
• smoking,
  
  
• diabetes and
  
  
• increasing age.

Heart rhythm disturbances like atrial fibrillation, patent foramen ovale, and heart valve disease can also be the cause.

When strokes occur in younger individuals (less than 50 years old), less common risk factors are considered including illicit drugs, such as cocaine or amphetamines, ruptured aneurysms, and inherited (genetic) predispositions to blood clotting.

An example of a genetic predisposition to stroke occurs in a rare condition called homocystinuria, in which there are excessive levels of the chemical homocystine in the body. Scientists are trying to determine whether the non-hereditary occurrence of high levels of homocystine at any age can predispose to stroke.

What is a transient ischemic attack (TIA)?

A transient ischemic attack (TIA) is a short-lived episode (less than 24 hours) of temporary impairment to the brain that is caused by a loss of blood supply. A TIA causes a loss of function in the area of the body that is controlled by the portion of the brain affected. The loss of blood supply to the brain is most often caused by a clot that spontaneously forms in a blood vessel within the brain (thrombosis). However, it can also result from a clot that forms elsewhere in the body, dislodges from that location, and travels to lodge in an artery of the brain (emboli). A spasm and, rarely, a bleed are other causes of a TIA. Many people refer to a TIA as a "mini-stroke."

Some TIAs develop slowly, while others develop rapidly. By definition, all TIAs resolve within 24 hours. Strokes take longer to resolve than TIAs, and with strokes, complete function may never return and reflect a more permanent and serious problem. Although most TIAs often last only a few minutes, all TIAs should be evaluated with the same urgency as a stroke in an effort to prevent recurrences and/or strokes. TIAs can occur once, multiple times, or precede a permanent stroke. A transient ischemic attack should be considered an emergency because there is no guarantee that the situation will resolve and function will return.

A TIA from a clot to the eye can cause temporary visual loss (amaurosis fugax), which is often described as the sensation of a curtain coming down. A TIA that involves the carotid artery (the largest blood vessel supplying the brain) can produce problems with movement or sensation on one side of the body, which is the side opposite to the actual blockage. An affected patient may experience paralysis of the arm, leg, and face, all on one side. Double vision, dizziness (vertigo), and loss of speech, understanding, and balance can also be symptoms depending on what part of the brain is lacking blood supply.

http://www.medicinenet.com/stroke/page2.htm

What is a stroke?

A stroke, or cerebrovascular accident (CVA), occurs when blood supply to part of the brain is disrupted, causing brain cells to die. When blood flow to the brain is impaired, oxygen and glucose cannot be delivered to the brain. Blood flow can be compromised by a variety of mechanisms.

Blockage of an artery

• Narrowing of the small arteries within the brain can cause a so-called lacunar stroke, (lacune=empty space). Blockage of a single arteriole can affect a tiny area of brain causing that tissue to die (infarct).
  
  
• Hardening of the arteries (atherosclerosis) leading to the brain. There are four major blood vessels that supply the brain with blood. The anterior circulation of the brain that controls most motor, activity, sensation, thought, speech, and emotion is supplied by the carotid arteries. The posterior circulation, which supplies the brainstem and the cerebellum, controlling the automatic parts of brain function and coordination, is supplied by the vertebrobasilar arteries.

If these arteries become narrow as a result of atherosclerosis, plaque or cholesterol, debris can break off and float downstream, clogging the blood supply to a part of the brain. As opposed to lacunar strokes, larger parts of the brain can lose blood supply, and this may produce more symptoms than a lacunar stroke.

• Embolism to the brain from the heart. In situations in which blood clots form within the heart, the potential exists for small clots to break off and travel (embolize) to the arteries in the brain and cause a stroke.

Rupture of an artery (hemorrhage)

• Cerebral hemorrhage (bleeding within the brain substance). The most common reason to have bleeding within the brain is uncontrolled high blood pressure. Other situations include aneurysms that leak or rupture or arteriovenous malformations (AVM) in which there is an abnormal collection of blood vessels that are fragile and can bleed.

What causes a stroke?

Blockage of an artery

The blockage of an artery in the brain by a clot (thrombosis) is the most common cause of a stroke. The part of the brain that is supplied by the clotted blood vessel is then deprived of blood and oxygen. As a result of the deprived blood and oxygen, the cells of that part of the brain die. Typically, a clot forms in a small blood vessel within the brain that has been previously narrowed due to a variety of risk factors including:

• high blood pressure (hypertension),
  
  
• high cholesterol,
  
  
• diabetes, and
  
  
• smoking.

Embolic stroke

Another type of stroke may occur when a blood clot or a piece of atherosclerotic plaque (cholesterol and calcium deposits on the wall of the inside of the heart or artery) breaks loose, travels through open arteries, and lodges in an artery of the brain. When this happens, the flow of oxygen-rich blood to the brain is blocked and a stroke occurs. This type of stroke is referred to as an embolic stroke. For example, a blood clot might originally form in the heart chamber as a result of an irregular heart rhythm, such as occurs in atrial fibrillation. Usually, these clots remain attached to the inner lining of the heart, but occasionally they can break off, travel through the blood stream, form a plug (embolism) in a brain artery, and cause a stroke. An embolism can also originate in a large artery (for example, the carotid artery, a major artery in the neck that supplies blood to the brain) and then travel downstream to clog a small artery within the brain.

Cerebral hemorrhage

A cerebral hemorrhage occurs when a blood vessel in the brain ruptures and bleeds into the surrounding brain tissue. A cerebral hemorrhage (bleeding in the brain) can cause a stroke by depriving blood and oxygen to parts of the brain. Blood is also very irritating to the brain and can cause swelling of brain tissue (cerebral edema). Edema and the accumulation of blood from a cerebral hemorrhage increases pressure within the skull and causes further damage by squeezing the brain against the bony skull.

Subarachnoid hemorrhage

In a subarachnoid hemorrhage, blood accumulates in the space beneath the arachnoid membrane that lines the brain. The blood originates from an abnormal blood vessel that leaks or ruptures. Often this is from an aneurysm (an abnormal ballooning out of the wall of the vessel). Subarachnoid hemorrhages usually cause a sudden, severe headache and stiff neck. If not recognized and treated, major neurological consequences, such as coma, and brain death will occur.

Vasculitis

Another rare cause of stroke is vasculitis, a condition in which the blood vessels become inflamed.

Migraine headache

There appears to be a very slight increased occurrence of stroke in people with migraine headache. The mechanism for migraine or vascular headaches includes narrowing of the brain blood vessels. Some migraine headache episodes can even mimic stroke with loss of function of one side of the body or vision or speech problems. Usually, the symptoms resolve as the headache resolves.

http://www.medicinenet.com/stroke/article.htm#tocas

How is end-organ damage assessed in the patient with high blood pressure?

Damage of organs fed by the circulatory system due to uncontrolled hypertension is called end-organ damage. As already mentioned, chronic high blood pressure can lead to an enlarged heart, kidney failure, brain or neurological damage, and changes in the retina at the back of the eyes. Examination of the eyes in patients with severe hypertension may reveal damage; narrowing of the small arteries, small hemorrhages (leaking of blood) in the retina, and swelling of the eye nerve. From the amount of damage, the doctor can gauge the severity of the hypertension.

People with high blood pressure have an increased stiffness, or resistance, in the peripheral arteries throughout the tissues of the body. This increased resistance causes the heart muscle to work harder to pump the blood through these blood vessels. The increased workload can put a strain on the heart, which can lead to heart abnormalities that are usually first seen as enlarged heart muscle. Enlargement of the heart can be evaluated by chest x-ray, electrocardiogram, and most accurately by echocardiography (an ultrasound examination of the heart). Echocardiography is especially useful in determining the thickness (enlargement) of the left side (the main pumping side) of the heart. Heart enlargement may be a forerunner of heart failure, coronary (heart) artery disease, and abnormal heart rate or rhythms (cardiac arrhythmias). Proper treatment of the high blood pressure and its complications can reverse some of these heart abnormalities.

Blood and urine tests may be helpful in detecting kidney abnormalities in people with high blood pressure. (Remember that kidney damage can be the cause or the result of hypertension.) Measuring the serum creatinine in a blood test can assess how well the kidneys are functioning. An elevated level of serum creatinine indicates damage to the kidney. In addition, the presence of protein in the urine (proteinuria) may reflect chronic kidney damage from hypertension, even if the kidney function (as represented by the blood creatinine level) is normal. Protein in the urine alone signals the risk of deterioration in kidney function if the blood pressure is not controlled. Even small amounts of protein (microalbuminuria) may be a signal of impending kidney failure and other vascular complications from uncontrolled hypertension. African American patients with poorly controlled hypertension are at a higher risk than Caucasians for most end-organ damage and particularly kidney damage.

Uncontrolled hypertension can cause strokes, which can lead to brain or neurological damage. The strokes are usually due to a hemorrhage (leaking blood) or a blood clot (thrombosis) of the blood vessels that supply blood to the brain. The patient's symptoms and signs (findings on physical examination) are evaluated to assess the neurological damage. A stroke can cause weakness, tingling, or paralysis of the arms or legs and difficulties with speech or vision. Multiple small strokes can lead to dementia (impaired intellectual capacity). The best prevention for this complication of hypertension or, for that matter, for any of the complications, is control of the blood pressure. Recent studies have also suggested the angiotensin receptor blocking drugs may offer an additional protective effect against strokes above and beyond control of blood pressure.

High Blood Pressure (Hypertension) At A Glance

• High blood pressure (hypertension) is designated as either essential (primary) hypertension or secondary hypertension and is defined as a consistently elevated blood pressure exceeding 140/90 mm Hg.
  
  
• In essential hypertension (95% of people with hypertension), no specific cause is found, while secondary hypertension (5% of people with hypertension) is caused by an abnormality somewhere in the body, such as in the kidney, adrenal gland, or aortic artery.
  
  
• Essential hypertension may run in some families and occurs more often in the African American population, although the genes for essential hypertension have not yet been identified.
  
  
• High salt intake, obesity, lack of regular exercise, excessive alcohol or coffee intake, and smoking may all adversely affect the outlook for the health of an individual with hypertension.
  
  
• High blood pressure is called "the silent killer" because it often causes no symptoms for many years, even decades, until it finally damages certain critical organs.
  
  
• Poorly controlled hypertension ultimately can cause damage to blood vessels in the eye, thickening of the heart muscle and heart attacks, hardening of the arteries (arteriosclerosis), kidney failure, and strokes.
  
  
• Heightened public awareness and screening of the population are necessary to detect hypertension early enough so it can be treated before critical organs are damaged.
  
  
• Lifestyle adjustments in diet and exercise and compliance with medication regimes are important factors in determining the outcome for people with hypertension.
  
  
• Several classes of anti-hypertensive medications are available, including ACE inhibitors, ARB drugs, beta-blockers, diuretics, calcium channel blockers, alpha-blockers, and peripheral vasodilators.
  
  
• Most anti-hypertensive medications can be used alone or in combination: some are used only in combination; some are preferred over others in certain specific medical situations; and some are not to be used (contraindicated) in other situations.
  
  
• The goal of therapy for hypertension is to bring the blood pressure down to 140/85 in the general population and to even lower levels in diabetics, African Americans, and people with certain chronic kidney diseases.
  
  
• Screening, diagnosing, treating, and controlling hypertension early in its course can significantly reduce the risk of developing strokes, heart attacks, or kidney failure.

http://www.medicinenet.com/high_blood_pressure/page8.htm

The metabolic syndrome and obesity

Genetic factors play a role in the constellation of findings that make up the "metabolic syndrome." Individuals with the metabolic syndrome have insulin resistance and a tendency to have type 2 diabetes mellitus (non-insulin-dependent diabetes).

Obesity, especially associated with a marked increase in abdominal girth, leads to high blood sugar (hyperglycemia), elevated blood lipids (fats), vascular inflammation, endothelial dysfunction (abnormal reactivity of the blood vessels), and hypertension all leading to premature atherosclerotic vascular disease. The American Obesity Association states the risk of developing hypertension is five to six times greater in obese Americans, age 20 to 45, compared to non-obese individuals of the same age. The American Journal of Clinical Nutrition reported in 2005 that waist size was a better predictor of a person's blood pressure than body mass index (BMI). Men should strive for a waist size of 35 inches or under and women 33 inches or under. The epidemic of obesity in the United States contributes to hypertension in children, adolescents, and adults.

What are the symptoms of high blood pressure?

Uncomplicated high blood pressure usually occurs without any symptoms (silently) and so hypertension has been labeled "the silent killer." It is called this because the disease can progress to finally develop any one or more of the several potentially fatal complications of hypertension such as heart attacks or strokes. Uncomplicated hypertension may be present and remain unnoticed for many years, or even decades. This happens when there are no symptoms, and those affected fail to undergo periodic blood pressure screening.

Some people with uncomplicated hypertension, however, may experience symptoms such as headache, dizziness, shortness of breath, and blurred vision. The presence of symptoms can be a good thing in that they can prompt people to consult a doctor for treatment and make them more compliant in taking their medications. Often, however, a person's first contact with a physician may be after significant damage to the end-organs has occurred. In many cases, a person visits or is brought to the doctor or an emergency room with a heart attack, stroke, kidney failure, or impaired vision (due to damage to the back part of the retina). Greater public awareness and frequent blood pressure screening may help to identify patients with undiagnosed high blood pressure before significant complications have developed.

About one out of every 100 (1%) people with hypertension is diagnosed with severe high blood pressure (accelerated or malignant hypertension) at their first visit to the doctor. In these patients, the diastolic blood pressure (the minimum pressure) exceeds 140 mm Hg! Affected persons often experience severe headache, nausea, visual symptoms, dizziness, and sometimes kidney failure. Malignant hypertension is a medical emergency and requires urgent treatment to prevent a stroke (brain damage).

http://www.medicinenet.com/high_blood_pressure/page7.htm

Adrenal gland tumors

Two rare types of tumors of the adrenal glands are less common, secondary causes of hypertension. The adrenal glands sit right on top of the kidneys. Both of these tumors produce excessive amounts of adrenal hormones that cause high blood pressure. These tumors can be diagnosed from blood tests, urine tests, and imaging studies of the adrenal glands. Surgery is often required to remove these tumors or the adrenal gland (adrenalectomy), which usually relieves the hypertension.

One of the types of adrenal tumors causes a condition that is called primary hyperaldosteronism because the tumor produces excessive amounts of the hormone aldosterone. In addition to the hypertension, this condition causes the loss of excessive amounts of potassium from the body into the urine, which results in a low level of potassium in the blood. Hyperaldosteronism is generally first suspected in a person with hypertension when low potassium is also found in the blood. (Also, certain rare genetic disorders affecting the hormones of the adrenal gland can cause secondary hypertension.)

The other type of adrenal tumor that can cause secondary hypertension is called a pheochromocytoma. This tumor produces excessive catecholamines, which include several adrenaline-related hormones. The diagnosis of a pheochromocytoma is suspected in individuals who have sudden and recurrent episodes of hypertension that are associated with flushing of the skin, rapid heart beating (palpitations), and sweating, in addition to the symptoms associated with high blood pressure.

Coarctation of the aorta

Coarctation of the aorta is a rare hereditary disorder that is one of the most common causes of hypertension in children. This condition is characterized by a narrowing of a segment of the aorta, the main large artery coming from the heart. The aorta delivers blood to the arteries that supply all of the body's organs, including the kidneys.

The narrowed segment (coarctation) of the aorta generally occurs above the renal arteries, which causes a reduced blood flow to the kidneys. This lack of blood to the kidneys prompts the renin-angiotensin-aldosterone hormonal system to elevate the blood pressure. Treatment of the coarctation is usually the surgical correction of the narrowed segment of the aorta. Sometimes, balloon angioplasty (as described above for renal artery stenosis) can be used to widen (dilate) the coarctation of the aorta.

http://www.medicinenet.com/high_blood_pressure/page6.htm