Rabu, 26 November 2008

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 0ÂșC 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

Sabtu, 15 November 2008

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.
  1. Sudden confusion or trouble speaking or understanding. Sometimes weakness in the muscles of the face can cause drooling.
  1. Sudden trouble seeing in one or both eyes
  1. Sudden trouble walking, dizziness, loss of balance or coordination
  1. 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:

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

What are the causes of secondary high blood pressure?

As mentioned previously, 5% of people with hypertension have what is called secondary hypertension. This means that the hypertension in these individuals is secondary to (caused by) a specific disorder of a particular organ or blood vessel, such as the kidney, adrenal gland, or aortic artery.

Renal (kidney) hypertension

Diseases of the kidneys can cause secondary hypertension. This type of secondary hypertension is called renal hypertension because it is caused by a problem in the kidneys. One important cause of renal hypertension is narrowing (stenosis) of the artery that supplies blood to the kidneys (renal artery). In younger individuals, usually women, the narrowing is caused by a thickening of the muscular wall of the arteries going to the kidney (fibromuscular hyperplasia). In older individuals, the narrowing generally is due to hard, fat-containing (atherosclerotic) plaques that are blocking the renal artery.

How does narrowing of the renal artery cause hypertension? First, the narrowed renal artery impairs the circulation of blood to the affected kidney. This deprivation of blood then stimulates the kidney to produce the hormones, renin and angiotensin. These hormones, along with aldosterone from the adrenal gland, cause a constriction and increased stiffness (resistance) in the peripheral arteries throughout the body, which results in high blood pressure.

Renal hypertension is usually first suspected when high blood pressure is found in a young individual or a new onset of high blood pressure is discovered in an older person. Screening for renal artery narrowing then may include renal isotope (radioactive) imaging, ultrasonographic (sound wave) imaging, or magnetic resonance imaging (MRI) of the renal arteries. The purpose of these tests is to determine whether there is a restricted blood flow to the kidney and whether angioplasty (removal of the restriction in the renal arteries) is likely to be beneficial. However, if the ultrasonic assessment indicates a high resistive index within the kidney (high resistance to blood flow), angioplasty may not improve the blood pressure because chronic damage in the kidney from long-standing hypertension already exists. If any of these tests are abnormal or the doctor's suspicion of renal artery narrowing is high enough, renal angiography (an x-ray study in which dye is injected into the renal artery) is done. Angiography is the ultimate test to actually visualize the narrowed renal artery.

A narrowing of the renal artery may be treated by balloon angioplasty. In this procedure, the physician threads a long narrow tube (catheter) into the renal artery. Once the catheter is there, the renal artery is widened by inflating a balloon at the end of the catheter and placing a permanent stent (a device that stretches the narrowing) in the artery at the site of the narrowing. This procedure usually results in an improved blood flow to the kidneys and lower blood pressure. Moreover, the procedure also preserves the function of the kidney that was partially deprived of its normal blood supply. Only rarely is surgery needed these days to open up the narrowing of the renal artery.

Any of the other types of chronic kidney disease that reduces the function of the kidneys can also cause hypertension due to hormonal disturbances and/or retention of salt.

It is important to remember that not only can kidney disease cause hypertension, but hypertension can also cause kidney disease. Therefore, all patients with high blood pressure should be evaluated for the presence of kidney disease so they can be treated appropriately.

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

Borderline high blood pressure

Borderline hypertension is defined as mildly elevated blood pressure higher than 140/90 mm Hg at some times, and lower than that at other times. As in the case of white coat hypertension, patients with borderline hypertension need to have their blood pressure taken on several occasions and their end-organ damage assessed in order to establish whether their hypertension is significant.

People with borderline hypertension may have a tendency as they get older to develop more sustained or higher elevations of blood pressure. They have a modestly increased risk of developing heart-related (cardiovascular) disease. Therefore, even if the hypertension does not appear to be significant initially, people with borderline hypertension should have continuing follow-up of their blood pressure and monitoring for the complications of hypertension.

If, during the follow-up of a patient with borderline hypertension, the blood pressure becomes persistently higher than 140/ 90 mm Hg, an anti-hypertensive medication is usually started. Even if the diastolic pressure remains at a borderline level (usually under 90 mm Hg, yet persistently above 85) treatment may be started in certain circumstances.

What causes high blood pressure?

Two forms of high blood pressure have been described: essential (or primary) hypertension and secondary hypertension. Essential hypertension is a far more common condition and accounts for 95% of hypertension. The cause of essential hypertension is multifactorial, that is, there are several factors whose combined effects produce hypertension. In secondary hypertension, which accounts for 5% of hypertension, the high blood pressure is secondary to (caused by) a specific abnormality in one of the organs or systems of the body. (Secondary hypertension is discussed further in a separate section later.)

Essential hypertension affects approximately 72 million Americans, yet its basic causes or underlying defects are not always known. Nevertheless, certain associations have been recognized in people with essential hypertension. For example, essential hypertension develops only in groups or societies that have a fairly high intake of salt, exceeding 5.8 grams daily. Salt intake may be a particularly important factor in relation to essential hypertension in several situations, and excess salt may be involved in the hypertension that is associated with advancing age, African American background, obesity, hereditary (genetic) susceptibility, and kidney failure (renal insufficiency). The Institute of Medicine of the National Academies recommends healthy 19 to 50-year-old adults consume only 3.8 grams of salt to replace the average amount lost daily through perspiration and to achieve a diet that provides sufficient amounts of other essential nutrients.

Genetic factors are thought to play a prominent role in the development of essential hypertension. However, the genes for hypertension have not yet been identified. (Genes are tiny portions of chromosomes that produce the proteins that determine the characteristics of individuals.) The current research in this area is focused on the genetic factors that affect the renin-angiotensin-aldosterone system. This system helps to regulate blood pressure by controlling salt balance and the tone (state of elasticity) of the arteries.

Approximately 30% of cases of essential hypertension are attributable to genetic factors. For example, in the United States, the incidence of high blood pressure is greater among African Americans than among Caucasians or Asians. Also, in individuals who have one or two parents with hypertension, high blood pressure is twice as common as in the general population. Rarely, certain unusual genetic disorders affecting the hormones of the adrenal glands may lead to hypertension. (These identified genetic disorders are considered secondary hypertension.)

The vast majority of patients with essential hypertension have in common a particular abnormality of the arteries: an increased resistance (stiffness or lack of elasticity) in the tiny arteries that are most distant from the heart (peripheral arteries or arterioles). The arterioles supply oxygen-containing blood and nutrients to all of the tissues of the body. The arterioles are connected by capillaries in the tissues to the veins (the venous system), which returns the blood to the heart and lungs. Just what makes the peripheral arteries become stiff is not known. Yet, this increased peripheral arteriolar stiffness is present in those individuals whose essential hypertension is associated with genetic factors, obesity, lack of exercise, overuse of salt, and aging. Inflammation also may play a role in hypertension since a predictor of the development of hypertension is the presence of an elevated C reactive protein level (a blood test marker of inflammation) in some individuals.

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

Isolated systolic high blood pressure

Remember that the systolic blood pressure is the top number in the blood pressure reading and represents the pressure in the arteries as the heart contracts and pumps blood into the arteries. A systolic blood pressure that is persistently higher than 140 mm Hg is usually considered elevated, especially when associated with an elevated diastolic pressure (over 90).

Isolated systolic hypertension, however, is defined as a systolic pressure that is above 140 mm Hg with a diastolic pressure that still is below 90. This disorder primarily affects older people and is characterized by an increased (wide) pulse pressure. The pulse pressure is the difference between the systolic and diastolic blood pressures. An elevation of the systolic pressure without an elevation of the diastolic pressure, as in isolated systolic hypertension, therefore, increases the pulse pressure. Stiffening of the arteries contributes to this widening of the pulse pressure.

Once considered to be harmless, a high pulse pressure is now considered an important precursor or indicator of health problems and potential end-organ damage. Isolated systolic hypertension is associated with a two to four times increased future risk of an enlarged heart, a heart attack (myocardial infarction), a stroke (brain damage), and death from heart disease or a stroke. Clinical studies in patients with isolated systolic hypertension have indicated that a reduction in systolic blood pressure by at least 20 mm to a level below 160 mm Hg reduces these increased risks.

White coat high blood pressure

A single elevated blood pressure reading in the doctor's office can be misleading because the elevation may be only temporary. It may be caused by a patient's anxiety related to the stress of the examination and fear that something will be wrong with his or her health. The initial visit to the physician's office is often the cause of an artificially high blood pressure that may disappear with repeated testing after rest and with follow-up visits and blood pressure checks. One out of four people that are thought to have mild hypertension actually may have normal blood pressure when they are outside the physician's office. An increase in blood pressure noted only in the doctor's office is called 'white coat hypertension.' The name suggests that the physician's white coat induces the patient's anxiety and a brief increase in blood pressure. A diagnosis of white coat hypertension might imply that it is not a clinically important or dangerous finding.

However, caution is warranted in assessing white coat hypertension. An elevated blood pressure brought on by the stress and anxiety of a visit to the doctor may not necessarily always be a harmless finding since other stresses in a patient's life may also cause elevations in the blood pressure that are not ordinarily being measured. Monitoring blood pressure at home by blood pressure cuff or continuous monitoring equipment or at a pharmacy can help estimate the frequency and consistency of higher blood pressure readings. Additionally, conducting appropriate tests to search for any complications of hypertension can help evaluate the significance of variable blood pressure readings.

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


How is the blood pressure measured?

How is the blood pressure measured?

The blood pressure usually is measured with a small, portable instrument called a blood pressure cuff (sphygmomanometer). (Sphygmo is Greek for pulse, and a manometer measures pressure.) The blood pressure cuff consists of an air pump, a pressure gauge, and a rubber cuff. The instrument measures the blood pressure in units called millimeters of mercury (mm Hg).

The cuff is placed around the upper arm and inflated with an air pump to a pressure that blocks the flow of blood in the main artery (brachial artery) that travels through the arm. The arm is then extended at the side of the body at the level of the heart, and the pressure of the cuff on the arm and artery is gradually released. As the pressure in the cuff decreases, a health practitioner listens with a stethoscope over the artery at the front of the elbow. The pressure at which the practitioner first hears a pulsation from the artery is the systolic pressure (the top number). As the cuff pressure decreases further, the pressure at which the pulsation finally stops is the diastolic pressure (the bottom number).

How is high blood pressure defined?

Blood pressure can be affected by several factors, so it is important to standardize the environment when blood pressure is measured. For at least one hour before blood pressure is taken, avoid eating, strenuous exercise (which can lower blood pressure), smoking, and caffeine intake. Other stresses may alter the blood pressure and need to be considered when blood pressure is measured.

Even though most insurance companies consider high blood pressure to be 140/90 and higher for the general population, these levels may not be appropriate cut-offs for all individuals. Many experts in the field of hypertension view blood pressure levels as a range, from lower levels to higher levels. Such a range implies there are no clear or precise cut-off values to separate normal blood pressure from high blood pressure. Individuals with so-called pre-hypertension (defined as a blood pressure between 120/80 and 139/89) may benefit from lowering of blood pressure by life style modification and possibly medication especially if there are other risk factors for end-organ damage such as diabetes or kidney disease (life style changes are discussed below).

For some people, blood pressure readings lower than 140/90 may be a more appropriate normal cut-off level. For example, in certain situations, such as in patients with long duration (chronic) kidney diseases that spill (lose) protein into the urine (proteinuria), the blood pressure is ideally kept at 130/80, or even lower. The purpose of reducing the blood pressure to this level in these patients is to slow the progression of kidney damage. Patients with diabetes (diabetes mellitus) may also benefit from blood pressure that is maintained at a level lower than 130/80. In addition, African Americans, who have an increased risk for developing the complications of hypertension, may decrease this risk by reducing their systolic blood pressure to less than 135 and the diastolic blood pressure to 80 mm Hg or less.

In line with the thinking that the risk of end-organ damage from high blood pressure represents a continuum, statistical analysis reveals that beginning at a blood pressure of 115/75 the risk of cardiovascular disease doubles with each increase in blood pressure of 20/10. This type of analysis has led to an ongoing "rethinking" in regard to who should be treated for hypertension, and what the goals of treatment should be.

http://www.medicinenet.com/high_blood_pressure/page2.htm#toc2bp

What is high blood pressure/hypertension?

High blood pressure (HBP) or hypertension means high pressure (tension) in the arteries. Arteries are vessels that carry blood from the pumping heart to all the tissues and organs of the body. High blood pressure does not mean excessive emotional tension, although emotional tension and stress can temporarily increase blood pressure. Normal blood pressure is below 120/80; blood pressure between 120/80 and 139/89 is called "pre-hypertension", and a blood pressure of 140/90 or above is considered high.

The top number, the systolic blood pressure, corresponds to the pressure in the arteries as the heart contracts and pumps blood forward into the arteries. The bottom number, the diastolic pressure, represents the pressure in the arteries as the heart relaxes after the contraction. The diastolic pressure reflects the lowest pressure to which the arteries are exposed.

An elevation of the systolic and/or diastolic blood pressure increases the risk of developing heart (cardiac) disease, kidney (renal) disease, hardening of the arteries (atherosclerosis or arteriosclerosis), eye damage, and stroke (brain damage). These complications of hypertension are often referred to as end-organ damage because damage to these organs is the end result of chronic (long duration) high blood pressure. For that reason, the diagnosis of high blood pressure is important so efforts can be made to normalize blood pressure and prevent complications.

It was previously thought that rises in diastolic blood pressure were a more important risk factor than systolic elevations, but it is now known that in people 50 years or older systolic hypertension represents a greater risk.

The American Heart Association estimates high blood pressure affects approximately one in three adults in the United States - 73 million people. High blood pressure is also estimated to affect about two million American teens and children, and the Journal of the American Medical Association reports that many are under-diagnosed. Hypertension is clearly a major public health problem.

http://www.medicinenet.com/high_blood_pressure/page2.htm#toc2bp

Diet Golongan Darah AB

Golongan darah AB, adalah golongan darah terakhir, yang diketahui 1000 tahun SM. Dr. Peter J.D'Adamo mengatakan saat itu leluhur kita mulai mengubah gaya hidupnya ke arah modern. Jenis makanan yang disarankan adalah perpaduan antara makanan yang diperbolehkan dikonsumsi oleh para pemilik golongan darah A dan B.

Sebenarnya, jenis makanan golongan darah A dan B sangat bertolak belakang. Orang bergolongan darah B disarankan untuk mengonsumsi berbagai jenis makanan, sedangkan pemilik golongan darah A disarankan hanya mengonsumsi tumbuh-tumbuhan, alias berpola makan vegetarian. Untuk itu Dr. Peter J.D'Adamo menganjurkan agar pemilik golongan darah AB lebih banyak melakukan diet vegetarian tapi tetap mengkonsumsi produk susu pada saat tertentu. Terutama saat berolahraga.Golongan darah AB sendiri sebagai golongan darah yang masih cukup jarang dijumpai secara keseluruhan lebih stabil dari golongan darah A dan B karena dapat memiliki sebagian besar keuntungan dan intoleransi dari golongan darah A dan B. Golongan darah ini juga dinilai memiliki sistem daya tahan tubuh paling baik dibandingkan golongan darah lain, namun di sisi lain juga rentan terhadap penyakit-penyakit serius seperti penyakit jantung, saraf dan kanker.

Pada golongan darah AB juga dianjurkan olahraga yang berkaitan dengan relaksasi dan meditasi. Makanan-makanan yang dianjurkan untuk golongan darah ini antara lain adalah makanan laut, produk susu, beberapa jenis kacang-kacangan dan yang tidak dianjurkan adalah seperti daging merah, kacang merah dan jagung.

Berkaitan dengan nutrisi yang dibutuhkan ini, tubuh sebenarnya memerlukan makanan-makanan organik termasuk bahan nabati organik dengan kelengkapan gizi yang sesuai dengan golongan darah tertentu, dan ini menyangkut semua kebutuhan prebiotik dan probiotik serta enzim-enzim, vitamin, mineral serta asam amino esensial untuk mengoptimalkan fungsi tubuh.


http://dietsehatalami.com/

Diet Golongan Darah O

Di dalam bukunya Dr. Peter J.D'Adamo mengatakan bahwa berdasarkan sejarah evolusi sekitar 50.000 hingga 25.000 tahun SM, leluhur manusia memiliki golongan darah yang sama, yakni O. Mereka adalah para pemburu sejati yang selalu mengkonsumsi daging hasil buruan. Untuk itulah Dr. Peter J.D'Adamo menyarankan agar pemilik golongan darah O lebih banyak mengonsumsi makanan berprotein tinggi, mengikuti diet rendah karbohidrat dengan banyak makan daging atau ikan tapi menghindari produk susu dan gandum.

Pemilik golongan darah O bebas mengonsumsi daging dan ikan yang dicampur minyak zaitun. Selain itu, bebas mengonsumsi telur, kacang, tetapi sebaiknya membatasi buah. Sementara makanan yang harus benar-benar dihindari adalah sereal, berbagai jenis pasta dan nasi. Untuk mendapatkan stamina tubuh yang maksimal Dr. Peter J.D'Adamo menganjurkan untuk melakukan olahraga erobik yang gerakannya mirip gerakan para pemburu.

Ciri khas golongan darah O

• Memiliki sistem kekebalan tubuh yang lebih tinggi dibandingkan tipe darah lain.

• Mudah beradaptasi dengan berbagai makanan pada lingkungan yang ditempati.

• Untuk mengatasi stres disarankan melakukan erobik.

• Dianjurkan untuk mengonsumsi makanan tinggi protein dan rendah karbohidrat, seperti daging, buah, ikan, sayuran.

Bila makanan yang dikonsumsi tidak sesuai, maka Anda berisiko terkena penyakit yang disebabkan oleh radang dan kerusakan organ seperti arthritis

Menu diet yang dianjurkan:

Sarapan : 2 potong roti bakar lapis mentega + Satu buah Pisang

Snack siang : Teh herbal

Makan Siang: Sepotong daging panggang + Salad bayam + Apel

Snack Sore : Sepotong kue

Makan Malam : Sepotong daging domba dan asparagus yang direbus + Kentang rebus + Buah + Teh herbal

http://dietsehatalami.com/

Diet untuk Golongan Darah B

Ciri khas golongan darah B:
• Dianjurkan untuk melakukan diet dengan berbagai variasi makanan golongan darah, namun membatasi asupan daging.
• Disarankan mengonsumsi makanan dan minuman berbahan dasar susu untuk meningkatkan sistem kekebalan tubuh.
• Olahraga yang cocok dilakukan adalah renang, tenis, jalan kaki dan meditasi.
• Untuk mengatasi stres, sebaiknya mencari kegiatan rutin berupa hobi dan kreativitas.

Orang bergolongan darah B disarankan untuk mengonsumsi berbagai jenis makanan, sedangkan pemilik golongan darah A disarankan hanya mengonsumsi tumbuh-tumbuhan, alias berpola makan vegetarian. Untuk itu Dr. Peter J.D'Adamo menganjurkan agar pemilik golongan darah AB lebih banyak melakukan diet vegetarian tapi tetap mengkonsumsi produk susu pada saat tertentu. Terutama saat berolahraga.

Karakteristik pemilik golongan darah B adalah:
• Memiliki jalur pencernaan yang sensitif.
• Disarankan untuk mengkonsumsi makanan dalam jumlah sedikit, namun kekerapan makan lebih padat (lebih sering makan dengan porsi kecil)
Untuk lebih berenergi biasakan berolahraga di pagi hari.


Menu Diet yang dianjurkan
• Sarapan : Air putih dicampur jeruk nipis + Juice Anggur + Roti dua potong + Satu potong keju.
• Snack siang : Yogurt
• Makan Siang : Dada Ayam 4 irisan + Salad + 2 buah Plum + Teh Herbal
• Snack Sore : Cheesecake + Teh Herbal
Makan Malam : Omelet + Salad Buah + Kopi


http://dietsehatalami.com/

Diet Golongan Darah A

Dr. Peter J.D'Adamo dalam bukunya, Eat Right For Your Type menyebutkan pada 15.000 SM golongan darah A ditemukan. Pada masa itu, leluhur kita adalah pemburu yang mulai membentuk komunitas dan bertempat tinggal tetap.

Mereka mulai bercocok tanam dan mengonsumsi sayur-sayuran dan hanya makan daging dalam jumlah sangat sedikit. Untuk itulah Dr. Peter J.D'Adamo menyarankan agar pemilik golongan darah A menjalani diet vegetarian.

Ciri khas Golongan darah A

• Memiliki sistem pencernaan yang relatif sensitif.

• Harus menghindari makanan yang terbuat dari produk susu dan daging

• Dianjurkan menjadi vegetarian atau mengonsumsi makanan berkadar karbohidrat tinggi, namun rendah lemak.

• Meminimalisasi stres dengan meditasi, atau olahraga non kompetitif dan cukup istirahat

Menu diet yang dianjurkan

• Sarapan : Air putih dicampur jeruk nipis + Oatmel

• Snack Siang : Juice Anggur / Kopi

• Makan Siang : Salad + Roti Gandum satu potong + Teh Herbal

• Snack Sore : Kue Beras dua potong + Teh Hijau

( Bila perlu boleh makan Malam : Pasta tanpa daging + Brokoli + Yoghurt + Teh Herbal )


http://dietsehatalami.com/

Selasa, 11 November 2008

Berat Badan Bayi Lahir Rendah (BBLR)

1. Definisi

BBLR adalah bayi baru lahir dengan BB 2500 gram/ lebih rendah (WHO 1961)

Klasifikasi BBLR

v Prematuritas murni

Masa Gestasi kurang dari 37 minggu dan Bbnya sesuai dengan masa gestasi.

v Dismaturitas

BB bayi yang kurang dari BB seharusnya, tidak sesuai dengan masa gestasinya.

2. Etiologi

a. Faktor ibu

Faktor penyakit (toksemia gravidarum, trauma fisik dll)

Faktor usia

Keadaan sosial

b. Faktor janin

Ø Hydroamnion

Ø Kehamilan multiple/ganda

Ø Kelainan kromosom

c. Faktor Lingkungan

Ø Tempat tinggal didataran tinggi

Ø Radiasi

Ø Zat-zat beracun

3. Patofisiologi?

4. Gejala Klinis

v BB <>

Pb <>

Lingkar dada <>

Lingkar kepala <>

5. Pem. Penunjang

Analisa gas darah

6. Komplikasi

v RDS

v Aspiksia

7. Penatalaksanaan medis

v Pemberian vitamin K

v Pemberian O2

8. Askep Pengkajian

v Tanda-tanda anatomis

¨ Kulit keriput, tipis, penuh lanugo pada dahi, pelipis, telinga dan lengan, lemak jaringan sedikit (tipis).

¨ Kuku jari tangan dan kaki belum mencapai ujung jari

¨ Pada bayi laki-laki testis belum turun.

¨ Pada bayi perempuan labia mayora lebih menonjol.

v Tanda fisiologis

¨ Gerakan bayi pasif dan tangis hanya merintih, walaupun lapar bayi tidak menangis, bayi lebih banyak tidur dan lebih malas.

¨ Suhu tubuh mudah untuk menjadi hipotermi.

Penyebabnya adalah :

o Pusat pengatur panas belum berfungsi dengan sempurna.

o Kurangnya lemak pada jaringan subcutan akibatnya mempercepat terjadinya perubahan suhu.

o Kurangnya mobilisasi sehingga produksi panas berkurang.

9. Diagnosa Keperawatan

  1. Tidak efektifnya pola nafas b.d imaturitas fungsi paru dan neuromuskuler.
  2. Tidak efektifnya termoregulasi b.d imaturitas control dan pengatur suhu tubuh dan berkurangnya lemak sub cutan didalam tubuh.
  3. Resiko infeksi b.d defisiensi pertahanan tubuh (imunologi).
  4. Resiko gangguan nutrisi kurang dari kebutuhan b.d ketidakmampuan tubuh dalam mencerna nutrisi (imaturitas saluran cerna).
  5. Resiko gangguan integritas kulit b.d tipisnya jaringan kulit, imobilisasi.
  6. Kecemasan orang tua b.d situasi krisis, kurang pengetahuan.

RENCANA ASUHAN KEPERAWATAN

No.

Diagnosa Keperawatan

Tujuan

Perencanaan

1.

Tidak efektifnya pola nafas b.d imaturitas fungsi paru dn neuro muscular

Pola nafas efektif .

Kriteria Hasil :

¨ RR 30-60 x/mnt

¨ Sianosis (-)

¨ Sesak (-)

¨ Ronchi (-)

¨ Whezing (-)

1. Observasi pola Nafas.

2. Observasi frekuensi dan bunyi nafas

3. Observasi adanya sianosis.

4. Monitor dengan teliti hasil pemeriksaan gas darah.

5. Tempatkan kepala pada posisi hiperekstensi.

6. Beri O2 sesuai program dokter

7. Observasi respon bayi terhadap ventilator dan terapi O2.

8. Atur ventilasi ruangan tempat perawatan klien.

9. Kolaborasi dengan tenaga medis lainnya.

2

Tidak efektifnya termoregulasi b.d imaturitas control dan pengatur suhu dan berkurangnya lemak subcutan didalam tubuh.

Suhu tubuh kembali normal.

Kriteria Hasil :

¨ Suhu 36-37 C.

¨ Kulit hangat.

¨ Sianosis (-)

¨ Ekstremitas hangat.

§ Observasi tanda-tanda vital.

§ Tempatkan bayi pada incubator.

§ Awasi dan atur control temperature dalam incubator sesuai kebutuhan.

§ Monitor tanda-tanda Hipertermi.

§ Hindari bayi dari pengaruh yang dapat menurunkan suhu tubuh.

§ Ganti pakaian setiap basah.

§ Observasi adanya sianosis.

3.

Resiko infeksi b.d defisiensi pertahanan tubuh (imunologi)

Infeksi tidak terjadi.

Kriteria Hasil :

¨ Suhu 36-37 C

¨ Tidak ada tanda-tanda infeksi.

¨ Leukosit 5.000 – 10.000

§ Kaji tanda-tanda infeksi.

§ Isolasi bayi dengan bayi lain

§ Cuci tangan sebelum dan sesudah kontak dengan bayi.

§ Gunakan masker setiap kontak dengan bayi.

§ Cegah kontak dengan orang yang terinfeksi.

§ Pastikan semua perawatan yang kontak dengan bayi dalam keadaan bersih/steril.

§ Kolaborasi dengan dokter.

§ Berikan antibiotic sesuai program.

4.

Resiko gangguan nutrisi kurang dari kebutuhan b.d ketidakmampuan mencerna nutrisi (Imaturitas saluran cerna)

Nutrisi terpenuhi setelah

Kriteria hasil :

¨ Reflek hisap dan menelan baik

¨ Muntah (-)

¨ Kembung (-)

¨ BAB lancar

¨ Berat badan meningkat 15 gr/hr

¨ Turgor elastis.

§ Observasi intake dan output.

§ Observasi reflek hisap dan menelan.

§ Beri minum sesuai program

§ Pasang NGT bila reflek menghisap dan menelan tidak ada.

§ Monitor tanda-tanda intoleransi terhadap nutrisi parenteral.

§ Kaji kesiapan untuk pemberian nutrisi enteral

§ Kaji kesiapan ibu untuk menyusu.

§ Timbang BB setiap hari.

5

Resiko gangguan integritas kulit b.d tipisnya jaringan kulit, imobilisasi.

Gangguan integritas kulit tidak terjadi

Kriteria hasil :

¨ Suhu 36,5-37 C

¨ Tidak ada lecet atau kemerahan pada kulit.

¨ Tanda-tanda infeksi (-)

§ Observasi vital sign.

§ Observasi tekstur dan warna kulit.

§ Lakukan tindakan secara aseptic dan antiseptic.

§ Cuci tangan sebelum dan sesudah kontak dengan bayi.

§ Jaga kebersihan kulit bayi.

§ Ganti pakaian setiap basah.

§ Jaga kebersihan tempat tidur.

§ Lakukan mobilisasi tiap 2 jam.

§ Monitor suhu dalam incubator.

6.

Kecemasan orang tua b.d kurang pengetahuan orang tua dan kondisi krisis.

Cemas berkurang

Kriteria hasil :

Orang tua tampak tenang

Orang tua tidak bertanya-tanya lagi.

Orang tua berpartisipasi dalam proses perawatan.

§ Kaji tingkat pengetahuan orang tua

§ Beri penjelasan tentang keadaan bayinya.

§ Libatkan keluarga dalam perawatan bayinya.

§ Berikan support dan reinforcement atas apa yang dapat dicapai oleh orang tua.

§ Latih orang tua tentang cara-cara perawatan bayi dirumah sebelum bayi pulang.

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