7/23/2019 klp 14 modul 4

1/29

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

7/23/2019 klp 14 modul 4

2/29

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.

7/23/2019 klp 14 modul 4

3/29

?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

7/23/2019 klp 14 modul 4

4/29

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

7/23/2019 klp 14 modul 4

5/29

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

7/23/2019 klp 14 modul 4

6/29

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(;

7/23/2019 klp 14 modul 4

7/29

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

7/23/2019 klp 14 modul 4

8/29

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

7/23/2019 klp 14 modul 4

9/29

)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

7/23/2019 klp 14 modul 4

10/29

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

7/23/2019 klp 14 modul 4

11/29

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

7/23/2019 klp 14 modul 4

12/29

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

7/23/2019 klp 14 modul 4

13/29

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

7/23/2019 klp 14 modul 4

14/29

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

7/23/2019 klp 14 modul 4

15/29

$=ueee across the metatarsophalangeal 9-TP;

7/23/2019 klp 14 modul 4

16/29

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.

7/23/2019 klp 14 modul 4

17/29

$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

7/23/2019 klp 14 modul 4

18/29

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.

7/23/2019 klp 14 modul 4

19/29

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

7/23/2019 klp 14 modul 4

20/29

1FP, a procedure in which a special solution is in

7/23/2019 klp 14 modul 4

21/29

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.

7/23/2019 klp 14 modul 4

22/29

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

7/23/2019 klp 14 modul 4

23/29

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

7/23/2019 klp 14 modul 4

24/29

&; '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

7/23/2019 klp 14 modul 4

25/29

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:

7/23/2019 klp 14 modul 4

26/29

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

7/23/2019 klp 14 modul 4

27/29

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

7/23/2019 klp 14 modul 4

28/29

6. armo discussion !(6&. P-1

!#+/#!8

!#. http7@@www.arthritisresearchuk.org@healthprofessionalsand

students@studenthandbook@themskhistory.aspx

!%. 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@

7/23/2019 klp 14 modul 4

29/29

!8. ilantono, )ily. ( ahasia Penyakit :ardiovaskular 9P:F;. Kakarta 7 B:

1. #3!%

!/. ?uku A