klp 14 modul 4
TRANSCRIPT
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A. SCENARIO
A 68 years old woman was taken to the health center by her family.
According to her family, the patient suddenly crashed slipped close to her bed
this morning because of treading her own urine.The last few days, the patient intermittently to the toilet to urinate.
Patients experienced coughing and shortness of breath, and her appetite is
greatly reduced, but no fever since last week. Patients had been suffering from
diabetes and high blood pressure. Patients receive treatment from a doctor for
the disease. Patients experienced a stroke attack one year ago.
B. DIFFICULT WORDS CLARIFICATION
C. KEYWORDS
!. "oman, 68 years old
#. $uddenly falling down because slipped by her urine
%. Patient intermittent need to go toilet to urinate
&. 'oughing and shortness of breath
(. )ess of appetite
6. *o fever since last week
+. $uffering of - and high blood pressure
8. eceive treatment form doctor about her - and hypertension
/. $troke attack one year ago
D. PROBLEMS IDENTIFICATION
! "hat the etiology and risk factor of urin incontinence0
# "hat relation between other complain with urin incontinence0
% "hat relation between previous desease with urin incontinence0
& 1s there any relation between stroke attack with urine incontinence problem of
patient0
( "hat the impact of drug history0
6 2ow to assess the patient on scenario0
+ 2ow to manage the patient based in this scenario0
8 "hat the impact that we can suspect from urine incontinence0
/ 2ow to prevent the patient0
!3 4xplain 1slam point of view according to scenario5
E. PROBLEMS ANALYSIS
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1. What the etiology a! "i#$ %a&to" o% '"ie i&otie&e(
4tiologi
Acute rine 1ncontinence7
To make it easier to remember sorts of acute urinary incontinence and usually
reversible, between 1ain can utilie drip acronym, which stands for7 9:ane et al.;
7 elirium
7 restriction of mobility, retention
17 infection, inflammation, impaction tests
P7 Pharmacy 9drugs;, poliuri
The use of the word 1APP4$ can also help remember most of the causes of this
incontinence.
elirium7 awareness decreased urination effect on excitatory responses, as well
as knowing where to urinate. elirium is a ma not so with
asymptomatic bacteriuria.
Atrophic vaginitis and atrophic urethritis7 atropic generally will be accompanied
atrophic vaginitis and urethritis these circumstances cause incontinence in
women. sually there is a good response with oral estrogen preparations after a
few months of usage. Topical use less convenient and more expensive.
Pharmaceuticals7 medicines is one of the main causes of incontinence are
temporary, such as diuretics, antikotinergik, psychotropic, analgesic opioids,
alpha blockers in women, alpha agonists in men, and a calcium inhibitor.
Psychologic factors> severe depression with psychomotor retardation can reduce
the ability or incentive to reach a place to urinate.
4xcess urine output7 excessive urine output may exceed the ability of the elderly
to the restroom. 1n addition to diuretic medications, which often causes 1ain eg
treatment heart failure, metabolic disorders such as hyperglycemia, or too much
to drink.
estricted mobility7 mobility constraints to achieve a micturition. 1f mobility can
not be improved, providing urinals or dragons, can improve incontinence.
$tool impaction7 faecal impaction is also a fre=uent cause of incontinence in
those treated or immobilied. "hen obstipasi solved, will restore kontinens
again.
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?oth needed to urinate with a good level of awareness, motivation, mobility and
skills so that problems outside of bladder incontinence often results in geriatric. The
causes of this often causes incontinence temporary 9transient acute;, even if not
recognied and treated can be sustained incontinence 9persistent;.
Persistentent@'hronic rine 1ncontinence7
'auses of persistent incontinence should be sought, after the cause of incontinence that
while it has been treated and removed. 1n general cause persistent incontinence is due
to7
!. 4xcessive activity of detrusor 9ver Active ?ladder, urgency incontinence type;7
4xcessive activity of the detrusor muscle causing uncontrollable contraction of
the bladder and result in loss of urine. This situation is a ma
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cognitive disorders and the various barriers situation @ environment to another
before it is ready to urinate. Psichology factors such as anger, depression can
also cause functional incontinence types.9!;
isk Bactor
Bemale
ld age@elderly
2igh parity
-enopause
4ver had hysterectomy
sing a seat type of toilet
*eurological disorders
Trauma to the pelvic
adiation
eficit of nutrients
besity
$moker, alcoholism
4xcessive fluid intake or lack of activity.9#;
). What "elatio *et+ee othe" &o,-lai +ith '"ie i&otie&e(
At the time cough increased intra abdominal pressure, which involved
contracting the abdominal muscles that will suppress the organs contained in the
cavity vesica urinary andominal one of them, so there will be a reflex
contraction of the bladder wall, where the people who experience stress
inkontinencia impaired in function spinchter urethra which resulted in the
internal spinchter relaxation, followed by a relaxation of the external spinchter ,
and finally emptying the bladder occur spontaneously . as well as in the event of
shortness of breath, someone who is experiencing shortness of breath due to lack
of P# in the body, so it will be in excess of compensation with the inspiration
to improve the P# in the body , while the intra abdominal pressure increases
during inspiration 9 contraction of the diaphragm ; and decreased during
expiration 9 relaxation of the diaphragm ; .9%;
. What "elatio *et+ee -"e/io'# !i#ea#e +ith '"ie i&otie&e(
iabetes mellitus history7
a. :idneys7
1n patients with diabetes have a tendency to seventeen times more easily
impaired renal function caused by repeated infection factors that arise in the -
and the narrowing of blood vessels called capillaries diabetic microangiopathy
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b. ?ladder
1n patients with diabetes often experience urinary tract infection 9T1; is
repeated, except that the nerves that nourish bladder is often broken so that the
walls of the bladder become weak. The nature of the control nerve disrupted
causing sufferers often wet or urine out themselves unwittingly called urinary
incontinence.
ne cause of incontinence is polyuria. Polyuria in patients with - is
the result glucosuria resulting due to osmotic diuresis which increased spending
urine 9polyuria;, which will also lead to thirst 9polidipsi; and hunger
9polyphagia;. )ost with urinary glucose consumption resulting in a negative
calorie balance and reduced weight.
iabetes mellitus
2yperglycemia
?lood glucose exceed the renal threshold
Clucosuria
smotic diuresis
Polyuria
1nkontinence
1n such a scenario it is said that patients already taking drugs melitis
diabetes, so the chances of patients already have vascular complications of
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chronic 9longterm; both microangiopathy and makroangiopati. iabetic
microangiopathy is a specific lesion that attack capillaries and arterioles of the
retina 9diabetic retinopathy;, kidney glomerulus 9diabetic nephropathy;, muscles
and skin.
*europathic diabetic vascular complications of peripheral nerves in the
cord. *europathy arises due to interference polyol pathway 9glucosefructose
sosbitol; due to decreased insulin. There is accumulation of sorbitol in the lens,
causing cataracts, while the nerve tissue accumulation of sorbitol and fructose
and decreased levels of mioinositol that cause neuropathy. ?iochemical changes
in the neural network will interfere with the metabolic activity of $chwann cells
and lead to loss of axons. -otor conduction velocity will be reduced at an earlystage neuropathy trip. *europathy can affect peripheral nerves 9mononeuropathy
and polyneuropathy;, cranial nerves or the autonomic nervous system.
iabetic neuropathy can cause negative effects on the genitourinary tract,
intestinal tract, and cerebrovascular. 4specially urinary tract effects of diabetic
neuropathy is loss of sensation in the bladder that will lower the action @
contraction of the muscular dertrusor causing difficulty emptying the bladder
9neurogenic bladder; due to loss of tone due to disturbances in peripheral nerves,
which causes overflow incontinence.
2ypertension history
As for some of the aspects that can be analyed from a history of
hypertension in patients taking the drug in this scenario include7
Antihypertensive rugs have the effect of urinary incontinence according to the
workings of each.
!. iuretics can cause polyuria, fre=uency, and urgency.
#. 'a 'hannel ?locker decrease smooth muscle tone and decrease muscle
contraction detrussor that would cause retention of urine, causing overflow
incontinence
%. A'4 inhibitors may precipitate a cough which resulted in stress inkotinence
'hronic hypertension can lead to stroke. $troke in the blood vessels in the brain can
cause ischemic brain. This will give effect to the decline in the functions of
coordination, in this scenario affect the coordination function of the urethral sphincter.
Thus hypertension can cause urinary incontinence indirectly.9&;9(;
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0. I# the"e ay "elatio *et+ee #t"o$e atta&$ +ith '"ie i&otie&e -"o*le,
o% -atiet(
No",al Mi&"o't"itio
The process of normal micturition namely lower urinary tract 9bladder
and urethra; got the parasympathetic innervation of nerve fibers, sympathetic,
and somatic. 'orda parasympathetic fibers originating from the spinal segments
$# & 9brought by neruusrelvicus on urinarin and neruuspudendal bladder to the
urethra;.The parasympathetic system -.detrusor role in the contraction and
relaxation of the internal urethral sphincter.'orda sympathetic fibers derived
from the spinal segments T!3 )# 9brought on by nervous hypogastric;. The
sympathetic system plays a role in the relaxation and contraction of the urethral
sphincter -.detrusorinterna. "hile the somatic fibers derived from the anterior
horn of the spinal corda $# & 9taken by *.pudendus;. then taken to corteks
cerebral impulses that will lead to relaxation of the external urethral sphincter
9realied because it consists of skeletal muscle; at the time of micturition.
At the time of micturition, occur stimulation and inhibition of the
sympathetic and parasympathetic also intravesikal pressure exceeds intraurethral
pressure.
4ffective urination has several re=uirements, namely7
!. The function of lower urinary tract effective
'harging vesica urinary
ovesica urinary Accommodation in increasing urine volume with low pressure.
o The internal urethral sphincter that closes well.
o optimal sensation when vesica urinary full.
o The absence of muscle contraction disorders detrussor.
ischarging vesica urinary
o The ability of muscles to contract detrussor.
o The absence of anatomical obstruction.
o Cood coordination between muscle contraction detrussor with urethral
sphincter relaxation.#. Ability to walk to the toilet.
%. 'ognitive function is good to recognie the bodyDs need to urinate.
&. -otivation for effective micturition.
(. There is no interference from environmental factors and iatrogenic
Ne'"oaato,y
Brain
The brain is the master control of the entire urinary system.
The micturition control center is located in the frontal lobe of the brain.
The primary activity of this area is to send tonically inhibitory signals to the
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detrusor muscle to prevent the bladder from emptying 9contracting; until a
socially acceptable time and place to urinate is available.
'ertain lesions or diseases of the brain, including stroke, cancer, or
dementia, result in loss of voluntary control of the normal micturition reflex.
The signal transmitted by the brain is routed through # intermediate stops
9the brainstem and the sacral spinal cord; prior to reaching the bladder.
Brainstem
The brainstem is located at the base of the skull. "ithin the brainstem is
a specialied area known as the pons, a ma
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)esions of the brain above the pons destroy the master control center,
causing a complete loss of voiding control. The voiding reflexes of the lower
urinary tractEthe primitive voiding reflexEremain intact. Affected individuals
show signs of urge incontinence, or spastic bladder 9medically termed detrusor
hyperreflexia or overactivity;. The bladder empties too =uickly and too often,
with relatively low =uantities, and storing urine in the bladder is difficult.
sually, people with this problem rush to the bathroom and even leak urine
before reaching their destination. They may wake up fre=uently at night to void.
?esides that, stroke attack can lead difficulty walking or moving around
and the patient may not always be able to getthere in time9hemiparesis or
impaired mobility;. The same may be true if patient have communicationdifficulties and cannot make him@her understood in time.Any extra exertion
involved in moving mayitself make it more difficult to maintaincontrol. 1t cause
functional incontinence.
$tress incontinence is the complaint of involuntary leakage on effort,
sneeing, or coughing. $tress incontinence often precedes strokeonset but is
typically exacerbated after stroke by repeatedcoughing associated with
dysphagia and aspiration.
-oreover, some types of incontinence that can occur as a result of stroke
are reflex incontinence and overflow incontinence. eflex incontinence is
passing urine without realising it. This happens when a stroke has affected the
part of the brain that senses and controls bladder movement. Then overflow
incontinence is where the bladderleaks due to being too full. This can be due toa
loss of feeling in your bladder, or difficultyin emptying your bladder effectively
9urineretention;.96;9+;98;
. What the i,-a&t o% !"'g hi#to"y(
elationship hypertension therapy given with complaints of urinary
incontinence
a. Al-a *lo&$e"#would inhibit alpha ! receptors in the muscles of the internal
urethra spincther so sympathetic stimulation did not affect the result of the
internal fixed urethra muscle relaxation spincther so that incontinence type
overflow occurs
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b. Di'"etifor example furosamid hamper co transport of *a, :, 'l, so that
will draw water conse=uently the amount of fluid in the exhaust increase occur
incontinence.
c. ACE ihi*ito"#have sideeffects for example catopril cough so elevating
intraabdominal pressure pressing vesica urinary incontinence that can
precipitate. 9/;
3. 4o+ to a##e## the -atiet o #&ea"io(
2istory taking
2istory focuses on duration and patterns of voiding, bowel function, drug use,
and obstetric and pelvic surgical history. A voiding diary can provide clues to causes.
ver &8 to +# h, the patient or caregiver records volume and time of each void and each
incontinent episode in relation to associated activities 9especially eating, drinking, and
drug use; and during sleep. The amount of urine leakage can be estimated as drops,
small, medium, or soaking> or by pad tests 9measuring the weight of urine absorbed by
feminine pads or incontinence pads during a #&h period;. 1f the volume of most nightly
voids is much smaller than functional bladder capacity 9defined as the largest single
voided volume recorded in the diary;, the cause is a sleeprelated problem 9patients void
because they are awake anyway; or a bladder abnormality 9patients without bladder
dysfunction or a sleeprelated problem awaken to void only when the bladder is full;.
f men with obstructive symptoms 9hesitancy, weak urinary stream,
intermittency, feeling of incomplete bladder emptying;, about one third have detrusor
overactivity without obstruction. $torage symptoms include urinary fre=uency, urgency
9compelling need to void that cannot be deferred;, urgency incontinence, and voiding at
night 9nocturia;. Foiding symptoms include urinary hesitancy 9difficulty initiating the
stream;, straining to void, weak or intermittent stream 9starts and stops;, and incompletebladder emptying, also pain while urinating. These storage and voiding symptoms are
evaluated using the 1nternational Prostate $ymptom $core 91P$$; =uestionnaire. The
1nternational Prostate $ymptom $core 91P$$; is an 8 =uestion 9+ symptom =uestions G !
=uality of life =uestion; written screening tool used to screen for, rapidly diagnose, track
the symptoms of, and suggest management of the symptoms of the disease benign
prostatic hyperplasia 9?P2;. The + symptoms =uestions include feeling of incomplete
bladder emptying, fre=uency, intermittency, urgency, weak stream, straining and
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nocturia, each referring to during the last month, and each involving assignment of a
score from ! to ( for a total of maximum %( points. The 8th =uestion of =uality of life is
assigned a score of ! to 6.
3+ H -ildly symptomatic
8!/ H -oderately symptomatic
#3%( H $everely symptomatic
The 1P$$ was designed to be selfadministered by the patient, with speed and
ease in mind. 2ence, it can be used in both urology clinics as well as the clinics of
primary care physicians 9i.e. by general practitioners; for the diagnosis of ?P2.
Additionally, the 1P$$ can be performed multiple times to compare the progression of
symptoms and their severity over months and years. 1n addition to diagnosis and
charting disease progression, the 1P$$ is effective in helping to determine treatment for
patients.
The history may also include previous episodes of catheteriation. The physician
should in=uire about precipitating factors, including alcohol consumption, recent
surgery, T1, genitourinary instrumentation, constipation, large fluid intake, cold
exposure, and prolonged travel. A detailed medication history should be obtained for
prescribed and overthecounter medications, with special attention to those that are
known to cause urinary retention such as anticholinergics, antidepressants, 'I#
inhibitors, amphetamines, and opioids.
Assuming the patientJs walking problems do arise from the
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early morning stiffness that eases with activity, whilst noninflammatory conditions
are associated with pain more than stiffness, and the symptoms are usually exacerbated
by activity.
Pain
$tiffness
Koint swelling
Pattern of
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9problems with cholesterol levels;. 1n some cases, illnesses can cause confusion
or other signs of dementia.
b. "hether there is a history of AlheimerDs disease or dementia in the family.
c. The personDs family, social, cultural, and educational background, as well as any
recent unusual events in the personDs life. These things can influence how a
person performs on a mental status test. And some experts believe that they may
affect the risk of dementia.
d. "hat medicines the person is taking. $ome medicines can contribute to memory
loss or mental impairment. This side effect of certain drugs is an easy problem to
correct but is often overlooked as the cause of symptoms.
e. 2istory of alcohol or drug abuse.
f. -ood changes, hallucinations, or unusual behavior 9such as lack of inhibition;.
g. ecent problems with forgetfulness.
Again, the previous diseases should be examined and the progress should be
=uestioned, are they get better or worse. Also, the medication history should be paid
ateention to, too.
Physical 4xamination
The first thing to do for the patient is to check vital signs. The scenario has
shown that the patient has taken medications for hypertension and heart disease, also he
had history of stroke, therefore the examiner should check the blood pressure and pulse.
onJt forget to check respiratory rate and temperature because geriatric patients are at
risk of pulmonary oedem and respiratory infection such as pneumonia .
A brief screening examination, which takes !L# minutes, has been devised for
use in routine clinical assessment. This has been shown to be highly sensitive in
detecting significant abnormalities of the musculoskeletal system. 1t involves inspecting
carefully for
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o e=ual level of the iliac crests
o ability to fully extend the elbows and knees
o popliteal swelling
o abnormalities in the feet such as an excessively high or low arch profile,
clawing@retraction of the toes and@or presence of hallux valgus.
b. Arms
Ask the patient to put their hands behind their head. Assess shoulder abduction
and external rotation, and elbow flexion 9these are often the first movements to
be affected by shoulder problems;.
"ith the patientJs hands held out, palms down, fingers outstretched, observe the
backs of the hands for
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$=ueee across the metatarsophalangeal 9-TP;
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1nnervation of the external urethral sphincter, which shares the same sacral roots
as the anal sphincter, can be tested by assessing7
Perineal sensation
Folitional anal sphincter contraction 9$# to $&; The anal wink reflex 9$& to $(;, which is anal sphincter contraction triggered by
lightly stroking perianal skin
The bulbocavernosus reflex 9$# to $&;, which is anal sphincter contraction
triggered by pressure on the glans penis or clitoris
2owever, the absence of these reflexes is not necessarily pathologic. A rectal
examination should be performed to estimate prostate sie and to check for prostate
nodules and fecal impaction. ectal examination can identify fecal impaction, rectal
masses, and, in men, prostate nodules or masses. Prostate sie should be noted but
correlates poorly with outlet obstruction. $uprapubic palpation and percussion to detect
bladder distention are usually of little value except in extreme acute cases of urinary
retention. A bladder should be percussible if it contains at least !(3 m) of urine> it may
be palpable with more than #33 m).
The doctor should perform physical examination and look for signs of damage
to the nerves that affect the bladder and rectum. Tests are often needed. These may
include7
?ladder stress test. The doctor checks to see if the patient lose urine when
coughing.
tip test. The doctor inserts a cotton swab into the urethra while the patient
cough and strain. 4xcessive movement of the swab could mean weakening of
the tissues that support the bladder.
'atheteriation. The doctor inserts a catheter to see if more urine comes out. A
bladder that doesnDt empty completely could indicate overflow incontinence.An 4:C may be part of a routine physical exam or it may be used as a test for
heart disease. An 4:C can be used to further investigate symptoms related to heart
problems. 4:Cs are =uick, safe, painless, and inexpensive tests that are routinely
performed if a heart condition is suspected.4:C can be used for assessing heart rhythm,
diagnose poor blood flow to the heart muscle 9ischemia;, diagnose a heart attack,
evaluate certain abnormalities of the heart, such as an enlarged heart. An
echocardiogram is a test that uses ultrasound to evaluate heart muscle and heart valves.
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$upporting examination
)aboratory
rinalysis, urine culture, and measurement of ?* and serum creatinine are
re=uired. A urine culture 9an attempt to grow and identify bacteria in a laboratory dish;
is performed when a urinary tract infection is suspected. 1n the presence of severe or
chronic symptoms of ?P2, blood tests to detect abnormalities in creatinine, blood urea
nitrogen, and hemoglobin are used to rule out the presence of kidney damage or anemia.
ther tests may include serum glucose and 'a 9with albumin for estimation of protein
free 'a levels; if the voiding diary suggests polyuria, electrolytes if patients are
confused, and vitamin ? !# levels if clinical findings suggest a neuropathy. outine
tests such as complete blood counts, urinalysis, sedimentation rate 94$;,
biochemistries, and specialied tests such as rheumatoid factor and antinuclear antibody
9A*A; are useful simply to rule out other diseases that cause lab tests are used only to confirm the clinical picture. )aboratory
tests should never be used alone to diagnose arthritis.
Traditional diagnostic tools include fasting plasma glucose 9BPC; measurement
and oral glucose tolerance tests 9CTT; could be examined. Although these tests are
sensitive, they measure glucose levels only in the short term, re=uire fasting or glucose
loading, and give variable results during stress and illness.#,% $tandardied hemoglobin
A!c 92bA!c; assays reliably estimate average glucose levels over a longer term 9#%
months;, do not re=uire fasting or glucose loading, have less variability during stressand illness, and are more specific for identifying individuals at increased risk for
diabetes.% Therefore, the American iabetes Association 9AA; recommends 2bA!c as
an additional alternative for diagnosing diabetes and increased diabetes risk.
A prostatespecific antigen 9P$A; test is generally recommended. P$A values
alone are not helpful in determining whether symptoms are due to ?P2 or prostate
cancer because both conditions can cause elevated levels. 2owever, knowing a manDs
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P$A level may help predict how rapidly his prostate will increase in sie over time and
whether problems such as urinary retention are likely to occur.
Postvoid residual volume should be determined by catheteriation or
ultrasonography. Postvoid residual volume plus voided volume estimates total bladder
capacity and helps assess bladder proprioception. A volume Q (3 m) is normal> Q !33
m) is usually acceptable in patients R 6( but abnormal in younger patients> and R !33
m) may suggest detrusor underactivity or outlet obstruction.
rodynamic testing is indicated when clinical evaluation combined with the
appropriate tests is not diagnostic or when abnormalities must be precisely characteried
before surgery.
'ystometry may help diagnose urge incontinence, but sensitivity and specificity
are unknown. $terile water is introduced into the bladder in (3m) increments using a
(3m) syringe and a !# to !&B urethral catheter until the patient experiences urgency
or bladder contractions, detected by changes in fluid level in the syringe. 1f Q %33 m)
causes urgency or contractions, detrusor overactivity and urge incontinence are likely.
Peak urinary flow rate testing with a flow meter is used to confirm or exclude
outlet obstruction in men. esults depend on initial bladder volume, but a peak flow rate
of Q !# m)@sec with a urinary volume of S #33 m) and prolonged voiding suggest
outlet obstruction or detrusor underactivity. A rate of S !# m)@sec excludes obstruction
and may suggest detrusor overactivity. uring testing, patients are instructed to place
their hand on their abdomen to check for straining during urination, especially if stress
incontinence is suspected and surgery is contemplated. $training suggests detrusor
weakness that may predispose patients to postoperative retention.
Prostatespecific antigen 9P$A; blood test7 4levated levels of P$A in the blood
may sometimes be an indicator of prostate cancer.$ynovial fluid is the li=uid that is normally found within the higher counts should suggest inflammatory arthritis or infection.
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The fluid may also be examined for the presence of uric acid crystals 9seen in
gout; or calcium pyrophosphate crystals 9seen in pseudogout or chondrocalcinosis;. The
measurement of other biological markers is still experimental.
A lumbar puncture may also be used to check the protein levels in the brain. This
procedure involves taking a sample of spinal fluid from the lower back for testing signs
of AlheimerJs disease.
1maging and adiology
ltrasonography is the imaging study used most often in men with lower urinary
tract symptoms. The test involves pressing a microphonesied device
9transducer; onto the skin of the lower abdomen. As the device is passed over
the area, it emits sound waves that reflect off the internal organs. The pattern of
the reflected sound waves is used to create an image of each organ.
ltrasonography can be used to detect structural abnormalities in the kidneys or
bladder, determine the amount of residual urine in the bladder, detect the
presence of bladder stones, and estimate the sie of the prostate.
rodynamic testing. A doctor or nurse inserts a catheter into urethra and bladder
to fill the bladder with water. -eanwhile, a pressure monitor measures andrecords the pressure within bladder. This test helps measure bladder strength and
urinary sphincter health, and itDs an important tool for distinguishing the type of
incontinence the patient have.
'ystoscopy. A thin tube with a tiny lens is inserted into urethra. This procedure
allows the doctor to check, and possibly remove, abnormalities in the urinary
tract.
A chest Iray 9also called chest film; uses a very small amount of radiation to
produce an image of the heart, lungs, and chest bones on film. 'hest Iray can
be used for a glimpse of the structures of the chest 9bones, heart, lungs;, evaluate
placement of devices 9pacemakers, defibrillators; or tubes placed during
hospitaliation for treatment and monitoring 9catheters, chest tubes;, and to
diagnose lung and cardiac diseases.
'ystogram. The doctor inserts a catheter into urethra and bladder and in
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1FP, a procedure in which a special solution is in
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the heart;. 1t is also used to determine the presence of diseases such as coronary
artery disease, pericardial disease, cardiac tumors, heart valve disease, heart
muscle disease 9cardiomyopathy;, and congenital heart disease. 1n identifying
stroke, -1 is more time consuming and less available than 'T, but has
significantly higher sensitivity and specificity in the diagnosis of acute
ischaemic infarction in the first few hours after onset. An -1 scan can provide
detailed information about the blood vessel damage that occurs in vascular
dementia, plus any shrinking of the brain 9atrophy;. 1n AlheimerDs disease, the
whole brain is susceptible to shrinking, whereas in frontotemporal dementia the
frontal and temporal lobes are mainly affected by shrinking.
ther types of scan, such as a single photonemission computed tomography
9$P4'T; scan or a positron emission tomography 9P4T; scan, may be
recommended if the result of your 'T or -1 scan is uncertain. These scans
look at how the brain functions and can pick up abnormalities with the blood
flow in the brain.
1n some cases, an electroencephalogram 944C; may be taken to record the
brainDs electrical signals 9brain activity;.
Psychology
a. Bormal cognitive assessment
A more detailed assessment of memory is necessary and performed by using several
specific bedside cognitive tests. The role and method of using such tests has been
covered in a previous supplement. uring a thorough cognitive assessment it is useful
to examine the following7
rientationEin time and place
AttentionEfor example, serial sevens, months of the year or ")backwards
-emoryEfor example, address recall, name of prime minister, etc
)anguageEfor example, naming of items, reading, writing, comprehension,
repetition
4xecutive functionEfor example, letter and category fluency
PraxisEfor example, alternating hand movements, imitation of gestures
Fisuospatial functionEfor example, drawing a clock face, overlapping
pentagons.
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b. ating scales
The -ini -ental $tate 4xamination 9--$4; is the most commonly used test for
complaints of problems with memory or other mental abilities. 1t can be used by
clinicians to help diagnose dementia and to help assess its progression and severity. 1t
consists of a series of =uestions and tests, each of which scores points if answered
correctly. The --$4 tests a number of different mental abilities, including a personDs
memory, attention and language. --$4 is only one part of assessment for dementia.
'linicians will consider a personDs --$4 score alongside their history, symptoms, a
physical exam and the results of other tests, possibly including brain scans.
The --$4 can also be used to assess changes in a person who has already been
diagnosed with dementia. 1t can help to give an indication of how severe a personDs
symptoms are and how =uickly their dementia is progressing. Again, results should be
considered alongside other measures of how the person is coping together with clinical
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5. 4o+ to ,aage the -atiet *a#e! i thi# #&ea"io(
To manage the problem in this scenario, we shoul make priority scale from the
problem list.
A. 1ncontinentia9!(;
There are % incontinentia urine medication method 7
!; ?ehavioral training
)earn and practice steps to control the bladder and
spinchter muscle with bladder training and pelvic floor excercise.
#; -edication
rugs Type -ecanism1ncontinence
type
$ide 4ffectrugs name and
dossageAnticholinergic
and
antispasmodic
1ncrease bladder
capasity and
decrease of
bladder
involunter
rgency or
stress with
instabiliation
detrusor
ry mounth,
1ncreasing of
intraocular
pressure,
constipation,
delirium
ksibutinin 7
#,(( mg tid
Telterodine 7
#mg bid
Propantheline 7
!(% mg tid
yciclomine 7
!3#3 mg
1mipramine !3
(3 mg tid
Adrenergic
agonis
1ncrease smooth
muscle
contraction
$tress type and
sphincter
weakness
2eadache,
tacicardi,
increasing
blood
pressure
Pseudofedri
n 7 !(%3 mg
tid
Phenylpropa
nolamine 7
+( mg bid
1mipramine
!3(3 mg
tid
4strogen agonist 1ncreasi blood
flow in urethra
$tress type and
urgencythat hasrelation with
vaginitis atropi
4ndometrriu
m cancer,1ncrease
blood
pressure,
renal stone
ral 7 3,6#(
mg@hrTopical 7 3,(!
mg@application
'holinergic
agonist
?ladder
contraction
stimulation
Bor overflow
type with atonik
urinary
?radichardi ?ethanechol 7
!3%3 mg tid
%; $urgery
$phincterectomi
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&; 'hateteriation
1n this sscenario there are # typeof chateteriation in urin
incontinence
a. 1ntermitten chateter
#&x@day
b. 1ndwelling chateter
?. 1nfection 9suspect pneumonia;9!+;
$efalosporinsefadroxil (33!333 mg
'. Ball down9!(;
Treat the complication
Perform surgery if thereJs fracture
. Anoreksia*utritional treatment
4. 2ipertention9!8;
iuresis
?locker system adrenergik
Fasodilator
A system blocker
Antagonis 'adecrease urine secretoric
B. iabetes -ellitus9!+;9!8;
'ontrol the complication 2ipertention control
C. $troke9!8;
2ipertention control
$top smooking and not to drink alcohol
)ife style modification 9Physical activity management;
6. What the i,-a&t that +e &a #'#-e&t %"o, '"ie i&otie&e(
'omplications can accompany urinary incontinence
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Brom several references, it is not always possible to prevent urinary
incontinence, but a healthy lifestyle may reduce the chances of the condition
developing.
2ealthy weight
?eing obese can increase your risk of developing urinary incontinence.
besity with ?-1 %3 kg@m# or more will lead the constant retraction on bladder
and muscles around. 1t may therefore be able to lower your risk by maintaining a
healthy weight through regular exercise and healthy eating.
rinking habits
1t depending on particular bladder problem. 1f someone had urinary
incontinence, cut down on alcohol and drinks containing caffeine 9such as tea,
coffee and cola;, it will increase the risk of incontinence because the diuretic
effect of these drinks will fulfill the bladder faster and stimulate the sensation of
taking pee.
1f someone had to urinate fre=uently during the night 9nocturia;, try
drinking less in the hours before sleep. 2owever, make sure you still drink
enough fluids during the day.
Pelvic floor exercises?eing pregnant and giving birth can weaken the muscles that control the
flow of urine from the bladder. The pelvic floor muscles are located between the
legs, and run from the pubic bone at the front of the base and spine at the back.
As people get older, the pelvic floor muscles get weaker.
To strengthen the pelvic floor muscles, sit comfortably and s=ueee the muscle
!3 !( times in a row. o not hold the breath or tighten the stomach, buttock or
thigh muscle at the same time.
Avoid smoking
$moking will increase the risk of urinary incontinence, it will make the
bladder become more active because the effect of nicotine on wall bladder. 9#3;
18. E9-lai I#la, -oit o% /ie+ a&&o"!ig to #&ea"io:
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And your )ord has decreed that you not worship except 2im, and let the
mother and your father do well with the best. 1f one of the two or both until the
age further in the maintenance of you, then occasionally do not say to both the
word VahV and do not yell at them and say to them a noble word. V 9Al
1sra9 chapter !+;7 verse #%;9#!;
Atsar from 1bnu MAbbas radhiyallahu Manhuma7
VV 1t is not a -uslim who had both parents were -uslims who he is on
every day to do good to both of them, but Cod will open the door for him #
9heaven;. 1f the old man lived alone, then the first door that Cod opened. 1f he
makes angry @ furious one of them, then Cod is not going up to the pleasure of
his good pleasure. V$omeone said,V 1f both parents dalim0 V1bn DAbbas said,V
Although parents dalim5V9##;
F. )eaning b
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or drugs in subcortical or cortex of the brain will lead to inability to delay
micturition. 1f there is a willing of micturition, nerves impulse from cortex
continued through spinal core and pelvical nerves to the detrusor muscles by the
working of cholinergic substances. ?eside cholinergic, detrusor muscles also has
receptors for prostaglandin, thus every drugs that inhibit prostaglandin can also
inhibit detrussorJs work. ?ladder contraction is also depend on the work of
calcium ions. Activity of alfa adrenergic cause the contraction of urethral
sfingter. "hen micturition happening, stimulation of symphatic nerves decrease
and directly increasing of parasymphatic cause the bladder contract.
Cenerally, along the increasing of ages, bladderJs capacity will decrease.
rine residue in bladder, after micturition, tend to increase and involunterbladder muscles contraction is more often. This found in &3+(W of elderly who
got incontinence. 1n woman, being an elderly also cause reduction of urethral
and bladder orifice resistance. This associated with the reduction of estrogen
level and the weakness of pelvic muscles after labor, all the more with extra
action during labor.
eduction of estrogen influence on elderly, also can cause atrophy
vaginitis and urethritis that will lead to incontinence. 1n male, hyperplasia of
prostat gland on eldery seems to have risk do develop incontinence. 9#%;
Re%e"e&e#
!. -artono, 2. 2adi, Pranarka :ris. #3!!. ?uku A
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6. armo discussion !(6&. P-1
!#+/#!8
!#. http7@@www.arthritisresearchuk.org@healthprofessionalsand
students@[email protected]
!%. 2ealthwise $taff. -edical 2istory and Physical 4xam for ementia or
AlheimerDs isease Cuide. )ast pdated7 ctober #/, #3!#. 'ited
(@+@#3!(http7@@www.webmd.com@alheimers@tc@medicalhistoryand
physicalexamfordementiaoralheimersdiseasetopicoverview
!&. $ 'ooper, K " Creene. /he 'linical Assessment ! /he atient 0ith
Early ementia. 1 *eurl *eursur+ sychiatry 245+67v!(v#&
doi7!3.!!%6@
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!8. ilantono, )ily. ( ahasia Penyakit :ardiovaskular 9P:F;. Kakarta 7 B:
1. #3!%
!/. ?uku A