Mastitis or Breast Infection Care

Mastitis is usually during lactation

Post-partum period is a period between the delivery until the reproduction system back to normal condition. We need to underline that this period is in non-pregnant condition, but in pregnancy. This period is also called puerperal period. The recovery period will back in 6 weeks postpartum.

Pregnancy, childbirth and breastfeeding is a physiological process that needs to be prepared by the women or couples so that this period will be safe. During pregnancy, the mother and the fetus is an integral function units that can not separate between them.

Breast Anatomy

The breast anatomy consist of alveoli, lactiferous duct, lactiferous sinus, ampulla, pore papilla and alveolar edge. Lymphatic drainage of the breast approximately 75% to the axilla or armpit area. Another lymphatic drainage is to parasternal nodes, in detail to central and medial area and some interpectoral gland.

Breast Function

Breast has three changes that affected the hormone. The first change starts from child to puberty, fertility period, climacteric, and menopause. Since puberty period, the influence  of estrogen and progesterone produced by the ovaries and pituitary hormones, it will cause growing and development of ductal acini.

The second change is the changes in the menstrual cycle. After the eighth day of menstruation, breasts become larger and in a few days before the next menstruation the breast will be maximum size. Sometimes the breast is felt painful and swollen. For several days before menstruation breast becomes tense and painful toward physical examination, especially palpation assessment. In the mammogram assessment is not assessable because the contrast of the breast is too large. When enter the menstruation time, the pain and swelling is reduced.

The third change occurs during pregnancy and lactation. In pregnancy, the breasts become larger because lobule ductal epithelium and alveolar ducts proliferate, develop and grow new duct.

The secretion of the hormone prolactin from the anterior pituitary gland inside the brain will trigger lactation. The milk produced by the cells of the alveoli, acini fill, then it will excrete through the ducts to the nipple.

Definition Mastitis

Mastitis is an inflammation in the breast because of infection or non-infection. The infection usually caused by staphylococcus aureus through the wound in nipple or blood flow. This disease usually occurs in lactation period , so it is usually called lactation mastitis or mastitis puerperal. This disease can be fatal if there is no adequate treatment.

Breast abscess or local pus is a severe complication in mastitis. Mastitis can be divided in many type based on its causes and condition.

1. Mastitis based on its location:
2. Mastitis that cause abscess under areola
3. Mastitis in the middle of breast
4. Mastitis under dorsal glands and its abscess in the muscle.

Mastitis based on its causes:

Periductal Mastitis

Periductal mastitis occurs in woman before menopause, the cause of this mastitis is unknown. This condition usually called ectasia duct, it means blockage in breast duct.

Lactational or Puerperal Mastitis

This mastitis usually occurs in pregnancy and lactation. The main cause of this mastitis are germs in mother breast that transmitted to nipple by direct contact.

Mastitis Supurative

Mastitis supurative is common mastitis, this cause of mastitis is staphylococcus, fungi, TBC, and syphilis. TBC infection needs extra intensive treatment. If the treatment is not complete, the breast removal can be done for it.

Etiology

The main cause of mastitis is breast milk stasis and infection. Breast milk stasis is usually the primary cause which may be make infection in it.

Breast Milk Statis

Breast Milk statis will occur if breast milk is not flow efficiently. This condition occurs when breast produce immediately after birth and the baby does not suck milk, baby's power is bad in sucking breast milk, ineffective in sucking, restrictions on the frequency / duration in breastfeeding, blockage of the ducts, high milk supply and breastfeeding for twin.

Infection

The most common organisms found in mastitis and breast abscess are Staphylococcus aureus and Staphylococcus albas. Escherichia coli and Streptococcus sometimes can be found. Mastitis may be found as a complication of typhoid fever.

Staphylococcus Aureus

Predisposition factors

Some factors that may increase the risk of mastitis:

Age

21-35 years old women are more often suffer from mastitis than women under 21 years old or above 35 years old.

Parity

Mastitis is usually in first pregnancy.

Mastitis History

The first mastitis attacks tend to be recurrent, this is because of poor breastfeeding techniques.

Childbirth

Complications of delivery may increase the risk of mastitis disease, but the use of oxytocin hormone does not increase the risk of mastitis disease.

Nutrition

Salt and high fat intake and anemia lead to mastitis. Antioxidants such as like vitamin E, vitamin A and selenium may reduce the risk of mastitis.

Immune Factors

Immune system play role in protecting the infection. Immune factors in breast milk may provide a defense mechanism in the breast.

Stress and Fatigue

Women who is sick and fever often feel tired and want to rest, but it is unclear whether fatigue can cause this condition or not.

Work

This mastitis can be caused by breast milk static, it is because of the long interval between breastfeeding and lack of time in spending adequate breast milk.

Trauma

Trauma in breast can damage breast gland tissue and ducts and this can cause mastitis.

Mastitis Sign and Symptoms

1. Breast pain, tension, or swelling
2. Redness with clear boundaries
3. Usually only affect one breast
4. Occurred between 3-4 weeks postpartum

Prevention

Breast care during lactation is an important effort to prevent mastitis. The breast care consists of cleaning the breast with soap before and after feeding to remove scale and dried milk. Besides that breast care also can prevent the baby from infection. If there is an injury to the nipples, the baby should not breastfeed in mother's milk until the wound healed. Breast milk can be excreted by a massage.

Breastfeeding Position

The position of the baby during breastfeeding is very important in effectiveness breastfeeding and prevent breast milk stasis, then make sure the mother hug her baby properly. The young mother will need help in breastfeeding.

Correct breastfeeding position:

1. Mother's arm sustains his baby's head, neck, and the baby's body (baby's head and body are in a straight line) baby's face is facing the mother's breast. Put the baby's nose in front of mother's breast, the baby's position should be in front of the mother's stomach.
2. Mothers makes the baby close to the body and the mothers must observe the baby during breastfeeding.
3. Mother put the nipple to baby's mouth, wait until the baby's mouth is wide open and then put the baby's mouth to the mother's nipple so that the baby's lips can catch the nipple.

Correct breast feeding position

Good breastfeeding in baby must:

1. Chin touches the breast.
2. Mouth wide open.
3. The baby's nose touching the breast.
4. The baby's mouth covers the areola.
5. The infant's tongue sustain the nipple and lower areola.
6. Babies suck deep, strong, and slowly.

Treatment

Soon after mastitis was diagnosed, breast that has mastitis is stopped and antibiotics is prescription. By this treatment, the abscess is often preventable because it is usually caused by Stapilococus aureus infection. Penicillin in high enough doses can be prescribed too. Before penicillin prescription, it can test the infection in breast milk, so that the cause of mastitis is completely known and the best antibiotic can be prescribed. If there is an abscess and pus removed, next is installed pipes to the middle of the abscess so that the pus can come out constantly.

In summary, mastitis is an infection that occurs in 1-2% of women who are in lactation period. Mastitis is common disease in 1-5 weeks after childbirth, especially in first pregnancy. Infection occurs through wounds on the nipple, but possibly also through blood circulation. Mastitis is characterized by pain in the breast, redness, swollen breast area, fever, and the patient feels weak and no appetite. Mastitis occurred a few weeks after childbirth. The common causes are Stapilococus aureus infection.

Mastitis is treated with antibiotics prescription. Breast infection or mastitis should be concerned by mothers who had just had childbirth. These infections usually occur approximately two weeks after childbirth, mastitis is caused by bacteria that live on the surface of the breast. Fatigue, stress, and tight clothing can cause blockage of the breast ducts, if it is not treated properly it leads to abscess and worse is breast removal.

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Know Schizophrenia in Easy Way

Definition of Schizophrenia

Schizophrenia is a major mental disorder with many symptoms such as like delusions (the belief in something that is not real) and hallucinations (the belief in seeing or hearing something that does not exist or is not real). There are 3 negative symptoms that recognized in DSM-IV :

Illustration of Schizophrenia

Affective flattening

Loss of emotional responses toward the environment around. (facial expression does not change for long time, speaking with a monotonous intonation, and the patients have no eye contact when talking to other people).

Alogia

Reduced or loss of speaking ability. (the patients do not have initiative or start to communicate with others, if they are asked, they will answered with a brief answers or it may be not the right answer).

Avolition

Inability to focus in an activity that leads to the goal of that activity,  it may be in work, school, etc. (the patient may only sit all day without doing something, withdrew from the social, social isolation).

Schizophrenia Types

There are 3 types of schizophrenia:

1. Paranoid Type (Absurd thoughts, illogical, delusional changing, unpredictable, over thinking about important things, power, knowledge, or identity).
2. Catatonic type (Extreme withdrawal from social life, the most common behavior in this type of schizophrenia is silent for the long term).
3. Disorganization Type (Over thinking in doing something, focus on the religious and philosophical problem. This type does not have clear delusions or hallucinations, the patients mind and behavior are very disorganized. For instance: the way they talk is difficult to understand, not systematic, emotional blowing such as laughing or crying so hard).

Based on DSM-IV-TR, schizophrenia criteria are:

1. There are two or more symptoms with a significant symptoms at least one month: delusions, hallucinations, disorganized speech, disorganized behavior or catatonic behavior, negative symptoms.
2. Social and working function is decrease since the onset of these disorders.
3. The symptoms of disorders occur for at least six months; at least one month of mild symptoms on the first point above, mild negative symptoms or other symptoms on the first point.

Etiology

Heredity

There are abnormal genes that increase the schizophrenia development and increase the severity of the disorder.

Abnormal Brain Structure

Scientists believe that there is a different in the people brain with schizophrenia with normal one. The main structure of the brain is abnormal ventricular part of the brain, it tends to be ventricle enlargement (enlarged ventricle). Ventricle is a fluid-filled cavities in the brain. This enlargement triggered atrophy and deterioration in other brain tissues. People with schizophrenia tend to show an abnormality in social function, emotion and behavior before they develop primary symptoms of schizophrenia (core symptoms).

Schizophrenia Brain Abnormality

Birth Complications

Serious complications during the prenatal period and pregnancy problems is like a common history of people with schizophrenia.

Cross-Cultural Perspective

Culture is very diverse in explaining schizophrenia. There is a belief that this problem is caused by a biological disorder and stress, lack of knowledge of spiritual and family dynamics.

Neurotransmitters

dopamine neurotransmitters plays a role in schizophrenia. The symptoms of schizophrenia is caused by dopamine level in the brain, especially in the frontal lobes and the limbic system.

Schizophrenia Theories

Psychodynamic

Earlier psychodynamic theorists assume that schizophrenia is the result of various negative experiences that occurred in the early days of life (childhood) between a child and her or his primary caregiver (mother). Nowadays, there are many researches that examine the family interaction and schizophrenia which focuses on a family stress whether it can increase or reduce the disorder schizophrenia.

Cognitive and Behavioral Perspectives

Behaviorism belief that this mental disorder is caused by a wrong caring that makes the patient does not know how to respond toward a stimulus that is socially acceptable. Some experts consider that the cognitive deficit is a fundamental in the perception and attention  as a basic biology.

Learning Perspectives

Ullman and Krasner believe in patients with schizophrenia is probably grow in a nonreinforcing environment because of the influence of bad parenting patterns or environmental influences. According to Sullivan, schizophrenia is caused by the social rejection because the "weird" label. This weird behavior pattern can be strengthened by a reinforcement that is accidentally received from the environment as an attention and sympathetic expression.

Psychosocial Factors

Psychosocial factors shows a hereditary factors that are getting powerful along of the day, psychological trauma, the parent and child relationship are pathogenic, and pathogenic interactions within the family.

Prevention

Primary Prevention

This primary prevention is to prevent the patients with schizophrenia by encouraging the development of effective treatment in health and behavior, biological, psychosocial and sociocultural. These program should be considered well such as like health care, prenatal and postnatal care, and public education about mental health.

Secondary Prevention

Prevention of this stage is to emphasis on early detection and handling maladaptive behaviors in families and communities.

Tertiary Prevention

Tertiary Prevention is after the mental health disorder, this prevention is better to engage support and appropriate treatment to patients, the purpose is to prevent mental disorder become chronic and allow individuals to have a healthy mental as soon as possible.

Treatment for Schizophrenia

Schizophrenia treatment usually takes long term of treatment, even if the symptoms have already gone . It is because the symptoms of schizophrenia can back again at any time.

Schizophrenia is treated with a combination between medication and therapy (psychological treatment). In acute symptoms of schizophrenia, hospitalization in a psychiatric hospital may be necessary to ensure the nutrition, hygiene, rest, and provide the personal safety of patients and the people around them.

Drugs Treatment

Drugs are the first treatment of schizophrenia. The drugs are prescribed by doctors, and its drugs are antipsychotics. Antipsychotics involve the performance of dopamine and serotonin in the patients brain. This medication can prevent, reduce, and even eliminate the hallucinations, delusions, agitation, and anxiety in patients with schizophrenia.

Patients who use antipsychotic, their behavior is not as aggressive as other patients who did not use these drugs. Moreover, according to a research, those antipsychotics prescription can not be recurrence after his condition improved.

Anti-psychotic can be used in two ways, namely by mouth or injected. For patients with schizophrenia who have been through a period of acute administration of antipsychotics should be administered as a preventive measure.

There are two categories of antipsychotic drugs, those are antipsychotics old generation (fluphenazine, perphenazine, chlorpromazine and haloperidol) and the new generation (clozapine, ziprasidone, quetiapine, olanzapine, risperidone, aripiprazole, and paliperidone)

Side effects those drugs are only in the old antipsychotics generation, the common side effects are muscle twitching, trembling body, and muscle spasms. There are side effects on both types of antipsychotics are weight gain, constipation, drowsiness, blurred vision, dry mouth, and decreased sex desire.

Currently a new antipsychotics generation are the most common and recommended by doctors because it has fewer side effects than the old one.

Psychological Treatment

After schizophrenia symptoms is gone or during the drugs treatment, patients need psychological treatment. There are some things that are included in this psychological treatment.

Individual Therapy

The first is individual therapy. At this therapy the patient is taught how to cope to stress physical or psychological and  they need to control schizophrenia by identifying signs of early recurrence. This therapy is also useful to restore their confidence. Individual therapy is also useful to re-develop their ability to work in next the routine life.

Moreover, in individual therapy, patients with schizophrenia will also be taught about the ways to control emotion and thought patterns. The goal is to replace negative thinking with positive thinking.

Social Skill Therapy

The second is social skills therapy. In this therapy the patient is taught how to improve communication and interaction with other people.

Family Counseling

And the third is dedicated to family counseling. This therapy is to provide education and same perception on families of schizophrenics, it is about how to resolve problems due to the symptoms that appear sometime, and how to provide support for people with schizophrenia.

Summary

In summary, Schizophrenia is a severe mental disorder and chronic classification of mental disorder(psychotic). Generally this mental disorder characterized by distorted thinking, and affective disorders. Schizophrenia  is caused by many things, such as like an imbalance of neurotransmitters in the brain, education and mental development since childhood, psychosocial stress, chronic mental disorder, and it is easy to be recurrent. It is like the patients can not be normal again along of their life. The symptoms of chronic schizophrenia has made schizophrenia treatment become monotonous and boring for the patients. The psychiatry and health care workers love to give drugs  treatment than electric convulsive therapy (ECT). In the development of drugs treatment, this medicine is capable to provide a better quality of healing, especially for those who are resistant to certain drugs. However, these drugs coast is so high. It becomes a big problem and a huge obstacle for the patients with schizophrenia who generally come from lower socioeconomic society.

Some surprising thing is in a psychiatric congress and seminar on an international scale have demonstrated the superiority of the usefulness of psychotherapy for psychiatric cases. Apparently there is a new hope and optimism to cure schizophrenia in the whole world with comprehensive treatment.

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Kidney Stone's Complete Information

Kidney stone is urinary stones (urolithiasis), it had been known since Babylon era and ancient Egypt with the discovery of stones in the mummy bladder. Urinary tract stones can be found in the urinary tract; the kidney Calix system, pielum, ureters, bladder and urethra. These stones may form in the kidneys and then travel to the lower urinary tract or it can be formed in the lower urinary tract due to stasis of urine movement such as bladder stones due to prostatic hyperplasia or urethra stones in the urethra diverticula condition.

Kidney Stone

Urinary tract stone disease spreads throughout the world with distinction in many developing countries found a stone in inner urinary tracts, while in developed countries is more common in upper urinary tract stones, this difference is influenced by the nutritional status and activities daily living. The average prevalence rate in worldwide is about 1-12% of the population suffer from urinary tract stones.

Definition of Kidney Stone

Kidney stone is a condition where the hard material block the urinary tract or kidney itself. The material comes from residual substances in the blood, its residual substances become hard and crystal in time. Sedimentary stone in the kidneys can be caused by many things such as food or other health problems. Based on the types of kidney stones, these conditions can be divided into four main types, the differences are only in stone substance; calcium stones, uric acid stones, struvite stones and cystine stones.

Kidney stone is a condition where there is accumulation of minerals in the kidneys. The minerals that accumulate become solid and its components are from urine concentrate or waste product. Kidney stone is usually called nephrolithiasis.

A human has two kidney in the body, its position lies behind the stomach and in front of the spine. Human kidney is like a bean-shaped and it has 4 inches size. To know more about kidney function, you may click here.

Kidney's function is like an organ that responsible for the disposal of residual substances from the blood or body fluid, in general the kidney will make the blood becomes clean and then flows out from the body. The last product of the substances form urine and it will excrete out the body.

So, when kidney stones are formed, inside the kidney there will be a small or large lump that formed stone. The condition occurs due to the deposition of substances such as uric acid and calcium, which should not remain in the body. This condition will make renal colic occurs when the kidney stone that is in the body, it will be so painful for the patients.

Kidney stone is usually found around 30 to 60 years old. The problem will appear if the stone blocked the urinary tracts. If the condition is not serious, kidney stones can be excreted without pain and not even felt at all when urinating. Not only that, the serious condition of kidney stones will block the urinary system, especially the ureter, renal channel, and the bladder. Urethra or urine tubes which are like a pathways will be blocked. On any part of blockage, the patient will always feel serious pain in the abdomen, it leads to urinary tract infections.

In addition, residual substances that form kidney stones will be hard accumulate little by little and become kidney stones. This condition can occur because of the habit, such as like lack of drinking water. However, if you are taking certain types of drugs, the drugs have also the potential to increase the levels of chemicals accumulation in the urine and it will contribute kidney stones formation.

Basically human immune system will naturally recognize kidney stones as foreign bodies that live inside the body. Consequently, when a kidney stone is forced to come out of the urinary tract. When the size of kidney stones are too large, the patients need X-ray or ultrasound to break the stone into smaller size pieces, and the result is small kidney stone formed and it is easy to excrete. Treatment of kidney stones is often still have a percentage of failure that still had to do kidney stone surgery.

Unfortunately, once the patients are suffering from kidney stones, then it has a high recurrence after recovered from kidney stone.

Etiology

The cause or etiology of kidney stones is definitely unknown. In many cases it probably due to hyperparatirodisme which can cause the occurrence of hypercalciuria. Sometimes it can be caused by a bacterial infection such as Proteus, pseudomonas, staphylococcus alba and several types coli.

Causes the formation of urinary tract stones associated with urinary tract disorders, metabolic disorders, urinary tract infections, dehydration and other circumstances that remain unclear (idiopathic).

Epidemiologically, there are several factors that facilitate the occurrence of urinary tract stones, those are distinguished into two factors; intrinsic and extrinsic factors.

Intrinsic Factors are:

1. Hereditary; it maybe from closest relatives from generation to generation.
2. Age; it is most often obtained at the age about 30-50 years.
3. Sex; the number men suffering with this disease is 3 times more than women patients.

Extrinsic Factors include:

1. Geography; in certain areas have a higher incidence than other areas.
2. Climate and temperature.
3. Fluid intake; lack of water intake and high levels of mineral calcium may increase the incidence of urinary tract stones.
4. Diet; a diet that is high ingredient of purine, oxalate and calcium will facilitate the occurrence of urinary tract stones.
5. Occupation; This disease is often found in people who work a lot of sitting or lack of physical activity (sedentary lifestyle).

Kidney Stone Formation

1. The formation of urinary stone have three theories, those are:
2. Nucleation theory: stones formed in the urine tract because of stone belt (nucleus). Particles that are too thick solution will settle in the nucleus, then it will form stones immediately. This stone belt can be crystal or foreign objects in urinary tract.
3. Matrix theory: organic matrix such as like urinary proteins (albumin, globulin and mucoprotein) are as a framework for formation of stone.
4. Crystallization inhibitor theory: Urine normally contains the crystal-forming inhibitors, those are magnesium, citrate, pyrophosphate, mucoprotein and peptides. If the levels of one or more of these substances is decrease in the body, it will help the formation of stones in the urinary tract.

Type of Kidney Stones

In general, the kidney stones contain elements such as calcium oxalate, calcium phosphate, uric acid, magnesium-ammonium-phosphate (MAP), xanthine and cysteine. Good information about this composition is important in the prevention of the possibility of recurrent kidney stones.

Calcium stones

Calcium stones (calcium oxalate or calcium phosphate) are most commonly found in kidney stone around 75-80%. Factors that lead to calcium stone formation are:

1. Hypercalsiuria: urine calcium level is over 250-300 mg / 24 hours, it may occur because of increased calcium absorption in the intestine (absorptive hypercalciuria), in a condition such as like inability calcium reabsorption in the renal tubules (renal hypercalciuria) and an increase in bone resorption (hypercalciuria resoptif) as the primary hiperparatiridisme or parathyroid tumors.
2. Hyperoxaluria: Urine oxalate excretion is over 45 g / 24 hours, this circumstance is found in patients with post-surgical gastro intestinal and consumption of oxalate-rich foods such as tea, instant coffee, soft drinks, cocoa, strawberry, lemon and green vegetables, especially spinach.
3. Hyperuricosuria: urine uric acid levels is over 850 mg / 24 hours. Uric acid in the urine can be an indicator for formation of calcium oxalate stones. Uric acid in the urine can come from the  rich purine foods or derived from endogenous metabolism.
4. Hypocytraturia: In urine, citrate reacts with calcium to form calcium citrate, thus blocking the binding of calcium with oxalate or phosphate. Hypocitraturia circumstances can occur in renal tubule acidosis disease, malabsorption syndrome or the use of thiazide diuretics in the long term consumption.
5. Hypomagnesiuria: just like citrate, magnesium reaction is as an inhibitor of calcium stones because urine magnesium will react with oxalate into magnesium oxalate, then it will prevent calcium oxalate bond.

Struvite Stones

Struvite stones is also known as infection stones, the stone formation is triggered by a urinary tract infection. Germs that cause these infections are breaking urea group bacterial (urea splitter such as Proteus spp., Klebsiella, Serratia, Enterobacteria, Pseudomonas and staphylococci). These bacteria produce the enzyme urease and transform urine into alkaline by hydrolysis of urea into ammonia. It facilitates alkaline salts of magnesium, ammonium, phosphate and magnesium ammonium carbonate to form  magnesium-ammonium-phosphate (MAP) and carbonate.

Uric Acid Stones

Uric acid stone is about 5-10% of all urinary tract stones, this uric acid substance may be got by patients with gout, myeloproliferative diseases, patient with drug cytostatic and uricosuria (sulfinpyrazone, thiazide and salicylate), obesity, alcoholism and high-protein diets have a high risk for having this disease. Factors that contribute the formation of uric acid stones are: urine is too acidic (pH <6, urine volume <2 liters / day or dehydration and hyperuricosuria.

Kidney Stone Sign and Symptoms

The most common sing and symptoms that is felt by the patient are low back pain, decrease urine output, urine retention, fever if there is an infection in the urinary tracts, nausea, vomit, hematuria or blood in urine, abdomen distention, and anuria bilateral obstruction.

According to Smeltzer in his book (perioperative nursing care) describes the patients complaints are depends on the location and the size of the stones. On physical examination there may be a pain in the urinary system area, kidney can be touched as the result of hydronephrosis, renal failure signs, urinary retention and infection can be obtained if the kidney stone is accompanied by fever.

Here is some of the clinical picture of nephrolithiasis:

1. Stone, especially the small ones in ureter, it may not cause symptoms.
2. Stone in the bladder can cause pain in the lower abdomen. Stones that obstruct the ureter, renal pelvis or renal tubules can cause back pain or renal colic (severe colicky pain). Renal colic is like intermittent pain and it is usually in the area between the ribs and hips, abdomen, pubic area, and inner thighs.
3. Symptoms are nausea and vomiting, abdominal distention, fever, and blood in the urine. Patients always want to urinate, especially when stones pass through the ureter.
4. Stones in the urinary tract can cause urinary tract infections. If the stones blocked the urine flow, microorganism will trapped in urinary tract, so the infection will occur. If the blockage is remain there in long time, the urine will flow back into the channel in the kidney, it will lead to hydronephrosis and it could damage the kidneys or kidney failure.

Diagnosis Test of Kidney Stone

1. Renal physiology test
2. Urine sediment test
3. X-ray to show the majority of kidney stones
4. Urography to confirm the diagnosis and determine the size and location of the kidney stone.
   Renal ultrasound to detect the changes of obstruction such as unilateral or bilateral hydronephrosis.
5. Laboratory examination
6. Routine laboratory tests that need to examine are:
   • Urine Sediment to determine erythrocytes, leukocytes, bacteria (nitrite), and the pH of urine.
   • Serum creatinine to determine kidney function.
   • C-reactive protein, leukocyte count of B cells, and urine culture is usually tested in fever.
   • Sodium and potassium are examined during vomiting.
   • Calcium and uric acid level to look for metabolic risk factors.

Treatment

Stones that make problems in the urinary tract should be removed as fast as it can, so the severe complication can be prevented. Indications to perform a treatment usually when the urinary tract stones have already blocked, infection, or social indications. Kidney stone can be removed with medical procedures, solved with ESWL, endourology treatment, laparoscopic surgery, or open surgery.

ESWL / Lithotripsy

ESWL is a non-invasive procedure that is used to destroy kidney stones. Once the stone is destructed into small pieces and it will getting smaller and smaller.

Endourology

Endourology method is a combination of radiology and urology to remove renal stones without major surgery.

Percutaneous Nephrostomy

Percutaneous nephrostomy is a tube installation through the skin into the renal pelvis. This procedure is performed for urine external drainage with a catheter, destroying kidney stones, dilate strictures. Ureterscopy includes visualization and ureter access by inserting an instrument through cystoscopy. Kidney stone can be destroyed using a laser, electrohydraulic lithotripsy, or ultrasound and then removed.

Kidney Stone Fluid .

After percutaneous nephrostomy is done, irrigate the warm fluid flowed continuously into the kidney stone. Irrigation fluid flows through the kidney ducts, ureter or nephrostomy tube.

Surgery

Nephrolithotomy.

Incision in the kidney to remove the stone. It can be done if the kidney stone located in the kidney.

Pielolitotomy.

It can be only done if the kidney stone located in the kidney, not in the ureter or bladder.

Drugs Treatment

1. Drugs treatment depend on types of kidney stone.
   Calcium stone: Paratirodectomy for hyperparathyroidism, limit milk and cheese consumption, potassium phosphate acid (3-6 grams per day) can reduce calcium level in urine, a diuretic (hydrochlorothiazide 50 mg for 2 times a day), or cranberry juice (200ml for 4 times a day) to acidify the urine and makes calcium level more soluble in urine.
2. Oxalate stone: limit the oxalate diet and calcium phosphate (3-5 grams of potassium phosphate acid every day), pyridoxine (100 mg, 3 times a day).
3. Metabolic stone: cysteine and uric acid precipitate in acidic urine (urine pH should be over than 7.5 by giving 4-8 ml of 50% nitric acid, 4 times a day) and tell the patient about right diet such as mineral alkaline diet, limit purine diet in patients with uric acid stones (prescribe 300mg allopurinol (zyloprin) once or twice a day). In patients sistienura, a low diet in methionine and penicillamine (4 grams per day).

Management of kidney stone treatment should be placed the patient in a room with adequate ventilation, pay attention to urine output, prevent the distension and bleeding and pay attention to the installation  location of drainage.

Kidney Stone Prevention
After the stone is removed, the most important things are to prevent a recurrence. Urinary tract stone recurrence is about 7% per year or 50% in 10 years. The prevention is based on the content of stone elements has been removed. In general, the prevention that need to be done are:

1. Avoid dehydration by drinking enough water, so the urine output will be enough about 2-3 liters per day
2. Limit the diet that lead to stone formation.
3. Exercise
4. Drugs prevention
5. Some diets are recommended for reducing recurrence are:
• Low protein, because protein will stimulate urinary calcium excretion and cause the urine to become more acid.
• Low oxalate diet.
• Low salt because natiuresis will lead to hypercalciuria.
• Low purine diet. This diet is recommended for the patients suffering from kidney disease and gout arthritis.
• Low calcium diet are not recommended except in type II absorptive hypercalciuria condition.

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Sinusitis Nursing Theoritical Background

Definition of Sinusitis

Sinusitis is like a common disease in our life, it is usually like influenza. Influenza is one of the most easy recognized symptom of sinusitis. Other symptoms that may appear are fever, pain in the face-especially around the cheeks and nose, headache, and fatigue.

Sinus is a cavity in face area, so sinusitis is an inflammation of the sinus cavities. These cavities are as a place to process the incoming air through the nose before it is processed and distributed by the lungs throughout the body. Overall, there are four pairs of sinus cavities that is connected with the nose:

1. On the forehead there are two pairs of cavities, the frontal sinuses.
2. Two pairs of cavities ethmoidal located between the eyes and just behind the nose.
3. Two pairs of sinuses sfenoidalis located behind the ethmoid sinuses.
4. Two pairs of maxillary sinuses located between the cheekbone, right beside the nose.

Sinus Cavities Location

Inside the sinus cavities there are hairs called cilia. Its function is to produce the mucus in the nose. This mucus will clean respiratory tract from foreign things and microorganisms that inhaled with the air. When the sinus is swelling and inflammation, mucus can not flow normally and it will be trapped in the sinus cavities. That's why you feel like a stuffy nose.

Overall, there are two major types of sinusitis, which is based on period of disease process and based on the type of inflammation. First is based on period of disease process, sinusitis is divided into three period of disease processes:

1. acute sinusitis (less than 30 days or 1 month).
2. Sub-acute sinusitis (about 1-3 months).
3. Chronic sinusitis (more than 3 months).

And the second type of sinusitis is based on the type of infection or inflammation, it can be divided into two types, it called infectious and non-infectious sinusitis.

Etiology

Actually, sinusitis is not a primary disease, it is not stand alone. So, sinusitis will occur because of other diseases. One of the most common diseases that trigger sinusitis is common cold or influenza. While we got influenza or flu, flu virus can also attack the lining of the sinus cavities. When this happens, the body will react by producing more mucus. Mucus trapped in the sinus cavity is like an optimum situation for bacteria and germs breeding. As a result, the body will react for those infection and there is an infection and inflammation in sinus cavities.

Sinusitis can be triggered by teeth problem such as like caries. Normally, the teeth are most often the culprit sinusitis are upper molars. In some cases, the roots of molars are connected to the sinus cavity. When there is an infection in the tooth, bacteria can easily move into the sinus cavity through the root of the tooth. As a result, there is an infection and inflammation of the sinuses. Another thing that also can trigger an allergic reaction sinusitis, polyps, trauma to the face, asthma, GERD (gastro esophageal reflux disease).

In detail the sinusitis etiology are:

Acute Sinusitis

The causes of acute sinusitis can caused by viruses, bacteria, or fungi. According to Gluckman, the most common germs that cause acute sinusitis are Streptococcus pneumonia and Hemophilic influenza, the cause of microorganism were found in 70% of sinusitis cases and it is like a large number of microorganism that attack sinus cavity.

Other causes are caused by other diseases such as like acute rhinitis; pharyngeal infections, adenoiditis, acute tonsillitis. Then the teeth problem such as infection in molar tooth, especially M1, M2, M3, and premolars P1, P2. Swimming and diving can be a cause of sinusitis because the contaminated water can be inhaled unconsciously. Trauma that may leave a wound in sinus cavity.

Then the mechanical obstruction lead to sinus infection such as septal deviation, foreign things that come into the nose, tumors, or polyps. Also allergic reaction such as rhinitis, chronic rhinitis, environmental pollution.

Chronic Sinusitis

The etiology of chronic sinusitis are chemical pollution, allergy and immunologic deficiency that make defective cilia, and the result is changes in the nasal mucosa. These changes in nasal mucosa can lead to infections in many microorganism. If there is Konka edema, it will disturb drainage of secretions and make ineffective cilia or tiny hair inside the nasal cavity to bring out the microorganism. If the treatment of acute sinusitis is not show the best recovery, there will be a chronic infection of sinusitis.

Sign and Symptoms of Sinusitis

Early symptoms that may be caused by infection are runny nose with yellow or green nasal mucosa accompanied by orofacial pain in cheeks area, forehead, eye and the pain may spread to jaw and teeth. Sinusitis usually occurs after part of upper respiratory tract infection such as a common cold or influenza. Then sinus inflammation or sinusitis can be classified into 2 groups:

Acute Sinusitis

This type of sinusitis is the most common type in children. The sign and symptoms are like symptoms in flu such as like cough, nasal congestion, discharge of mucus that is not accompanied by fever and mucus color is green to yellow. If the sinusitis occurs in children, most of these symptoms will be appear about ten days and the children's conditions will be worse in day seven.

Chronic Sinusitis

Symptoms of chronic sinusitis will be similar to acute sinusitis, the different between them is just period of the disease, the chronic sinusitis sign and symptoms are longer then acute sinusitis. Chronic sinusitis sign and symptoms is still be there almost three months, and it is compounded by the pain on around the head. In addition to this type of sinusitis will be thick layer in long period of disease and it will make the tissue development and it will block the nose ways called polyps.

If we are talking about the main complaint of patients, it will be vary. But all patient will feel pain in the sinus accompanied by headache. In acute sinusitis, the patient will have an extreme pain and the pain is permanent. It is different with chronic sinusitis, the patient will not have a pain or it can be intermittent pain. Pain that is felt will be worse in 3-4 hours after wake up in the morning, because of the accumulation of exudation in the sinuses cavities. Other symptoms are like fever, sore throat, postnasal drips, and the runny nose.

Diagnosis Test

Diagnosis test for sinusitis is transillumination test. it uses a flashlight that lights affixed above the maxillary sinus with the closed mouth, then observe a bright light in sinus cavities. The normal sinus will appear as a bright light in sinus cavities because normal sinus only filled with air. If dark are found in sinus cavities during translumination, it indicates the presence of purulent secretions and sinus congestion. Examination with X-rays of the sinuses and nasal endoscopy can also be done, but this is rarely done unless the patient has a chronic and recurrent disease.

Treatment

Acute sinusitis

Acute sinusitis treatment goal is to control the infection, restore the condition of the nasal mucosa, and relieve pain. The antibiotic usually prescribed for acute sinusitis because the main problem in sinusitis is bacteria infection, the antibiotics are amoxicillin and ampicillin. An alternative treatment for patients who have allergic reaction to penicillin are trimethoprim / sulfamethoxazole (double strength) (Bactrim DS, DS Spetra). Oral or topical decongestants may be given to help the nose congestion. Warmed or irrigated saline can be effective treatment to open the obstruction, the warm saline can allow drainage of purulent mucosa. Common oral decongestant that is usually prescribed are Drixoral and Dimetapp. Topical decongestants commonly prescribed is Afrin and Otrivin. Topical decongestants should be administrated with the position of the patient's head like looking up, it is useful to increase the maximum drainage. If the patients still have symptoms after 7-10 days, then the sinus needs to be irrigated.

Chronic Sinusitis

Medical management for chronic sinusitis is as same as acute sinusitis treatment. Surgery is indicated in chronic sinusitis to repair the sinus structural deformity. Surgical excision may include polyps, septal deviation repairment, and incision and drainage of the sinus Some patients with chronic sinusitis can be cured by moving to the area with a dry climate.

Computer tomography test is indicated for the evaluation of chronic sinusitis that does not improve during the treatment, sinusitis complications, preoperative evaluation, and if there is suspicion of malignancy or tumor. Magnetic Resonance Imaging (MRI) is better than computed tomography in resolution and easy to differentiate sinusitis due to mold, neoplasms, and intra cranial expansion, but the resolution of MRI is not reflected good bone and the MRI test is so expensive.

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Complete Kidney Failure Theoritical Background

Definition of Kidney Failure

Acute Renal Failure (ARF)

Acute Renal Failure (ARF) is a condition where the glomerular filtration rate (GFR) is decrease spontaneously and kidney function ability in maintaining balance water excretion. It called clinical syndrome that is caused by metabolic damage or kidney pathology, this condition is signed by kidney function decrease and it occurs fast and azotemia.

Chronic Renal Failure (CRF)

Chronic renal failure is a condition where kidney function can not work well in maintaining fluid and electrolyte balance, glomerular filtration rate is decrease progressively and irreversible, the kidney is fail to maintain body fluid and electrolyte balance, and this condition will appear as uremia.

Dialysis

Etiology of Kidney Failure

Acute Renal Failure (ARF)

Three categories of Acute Renal Failure (ARF) are pre-renal, intra-renal, and the last is post-renal. These etiologies will explain in detail.

Pre-renal

Pre-renal is an etiology of Acute Renal Failure (ARF) that is caused by kidney hypoperfussion and glomerulus filtration rate (GFR) decrease. General clinical condition about this hypoperfussion may caused by blood or plasm loss; bleeding and massive burn wound, extracellular fluid loss; vomit and diarrhea, capillary capacity increase; sepsis, ganglion blockage and anaphylaxis reaction, cardiac output failure; congestive heart failure, dysrhythmia, lung emboli, and heart infarct.

Intra-renal

Intra-renal etiology is glomerulus structure or distal tubules damage. The condition such as burn and edema which caused by trauma, infection, or necrotic agent can make acute tubules necrosis (ATN) and kidney stop working. Bad transfusion reaction can cause intra-renal failure, hemoglobin will be released by hemolysis mechanism through glomerulus membrane and it will be concentrated in distal tubules, and it will be hemoglobin factor production. The main factor is non steroid anti inflammation consumption, especially in elderly.

Post-renal

This etiology is an etiology of Acute Renal Failure (ARF) caused by obstruction in distal tubules, distal tubules pressure will decrease, and glomerulus filtration rate (GFR) is increase.

Chronic Renal Failure (CRF)

The causes of chronic renal failure (CRF) is so many, but in general it can divided into two groups:
Systemic Disease; diabetes mellitus, glomerulonephritis, pyelonephritis, uncontrolled hypertension, urinary tract obstruction, vascular disturbances, infection, medication or toxic agent, and hereditary lesion such as kidney polycystic. Environment and Toxic Agent are the second one.

Pathophysiology

Acute Renal Failure (ARF)

To know more about pathophysiology of kidney makes you understand well, click here. Some conditions such as like hypovolemia, hypotension, cardiac output decrease or congestive heart failure, kidney obstruction or bladder obstruction that is caused by tumor, blood coagulation, artery and vein obstruction. If those condition is treated before permanent damage, BUN level, oliguria, and other sign and symptoms of acute renal failure (ACF) can be handled. There is four clinical steps of acute renal failure:

First Stadium

First stadium is first respond of kidney toward many condition, and the result of this respond is signed by oliguria.

Second Stadium

Second stadium or oliguria stadium is signed by 75% tissue damage, this tissue is a tissue that produce urine. BUN level will increase. BUN level increase is different in diet. In this stadium, creatinine serum level starts increase above normal level. Azotemia is usually mild except the patient is infected, heart failure, or dehydration. In this stadium also has nocturia symptoms, nucturia is caused by thickening failure. The symptoms appear as a respond toward stress and diet changes spontaneously. The patient usually does not pay attention on this symptoms. Persistent peeing at night time until 700 ml urine production, or the patient woke up to pee frequently at night. In normal condition, the ration between peeing at night and day is 3 : 1 or 4 : 1. Nocturia sometimes is as a respond of anxiety or water consumption. Polyuria in kidney failure is more sever in tubules damage, polyuria might be mild and  rarely more than 3 liters a day. Anemia may appear in kidney failure with kidney function between 5 to 25%. Kidney function is clearly decrease and it may have anemia symptoms and the blood pressure will increase and the result is the patient activities disturbed.

Third Stadium

Third stadium where the symptoms is clear and the patient can not do some activities daily living as usual. The symptoms are nausea, vomit, loss of appetite, seizure, and even coma. The last stadium will appear about 90% from nephron destruction. The GFR level is about 10% higher than normal condition, it may be 5 to 10 ml per minutes. In this condition, creatinine serum and BUN level will increase. In last kidney stadium, the patient will have sever symptoms because the kidney can not maintain homeostatic balance between fluid and electrolyte in the body. The patient usually have oliguria less than 500 ml per day because of  glomerulus failure although disease process is started by kidney tubules attack. Biochemical changes and symptoms called uremia syndrome influenced every systems in the body. In last stadium, the patient will die except the patient has kidney transplantation treatment or dialysis.

Clinical Manifestation

Acute Renal Failure (ARF)

Urine output is low with or without blood, BUN and creatinine level are increase, anemia, hyperkalemia, acidosis metabolic, edema, anorexia, nausea, vomit, skin turgor is bad and irritation on the skin.

Chronic Renal Failure (CRF)

Respiration disturbance, edema, hypertension, anorexia, nausea, vomit, gastric ulcer, stomatitis, proteinuria, hematuria, lethargy, apathies, anemia, bleeding, bad skin turgor, skin irritation, renal dystrophy, hyperkalemia, and metabolic acidosis.

Diagnosis Tests

1. Urine: volume, color, sediment, urine mass, protein and creatinine
2. Blood: BUN or creatinine, red blood cells, natrium serum, kalium, magnesium phosphate, protein, and osmolality serum.
3. Radiology: kidney size, the location ureter or bladder, check the obstruction.
4. Pyelography retrograde: to show kidney pelvic and ureter abnormality
5. Arteriogram: to check the kidney blood supply and a mass around the kidney.
6. Sistouretrogram: to show the bladder size, ureter reflux, and retention.
7. Ultrasonography: to check the kidney and bladder size, mass, cyst, and upper urinary tract obstruction.
8. Biopsy: perhaps it need to do with endoscopy to make sure tissue cells for histology diagnosis.
9. Endoscopy: it need to do to find kidney pelvic; kidney stone, hematuria, or tumor.
10. ECG: the heart may show abnormality in electrolyte, acid-base balance, arrhythmia, ventricle hypertrophy, or pericarditis signs.

Treatment

Acute Renal Failure (ARF)

Hyperkalemia

The fluid and electrolyte balance is a main problem in Acute Renal Failure (ARF); hyperkalemia is really threaten life, so it need to minimize kalium level in the blood. The patients need to monitor their kalium level through electrolyte test (kalium > 5.5 mEq/L; International Standard (IS) : 5.5 mmol/L), ECG change (Tall T sign in the ECG is a sign for hyperkalemia), and clinical status of the patients. Kalium level can be minimized by resin ion replace (natrium pohstruren sulfonate / kayexalatel) with oral or enema ways. Sorbitol is always prescribed together with kayexalate to induce diarrhea type (fluid loss in gastrointestinal). If enema retention is prescribed (colon is the main place in kalium substitution), rectal catheter can be prescribed to minimize the retention. Patients with high kalium level need dialysis, peritoneal dialysis or hemofiltration immediately. Glucose, insulin, or calcium gluconate intra vein can be done as an emergency procedure for hyperkalemia. Natrium bicarbonate can be prescribed for pH plasm so that kalium will move into cells and the result is kalium level decrease. All of extra renal kalium production need to minimize.

Fluid Balance

Fluid balance needs to be in normal balance, it based on body weight, central vein measurement, urine concentration and serum, fluid loss, blood pressure, and clinical status of the patients. Oral input and output from urine, gastric drainage, wound drainage, and perspiration must be counted and used as a basic fluid therapy. Fluid loss from skin (sweat) and respiration that are from normal metabolism process need to think about, and it can contribute fluid therapy. The patients need to measure their body weight and they can be predicted decrease their body weight about 0.2 to 0.5 kilogram everyday if the nitrogen balance is negative (colon input that is received less than needed). If the patients losses their body weight or have hypertension, it is like a sign for fluid retention. Excessive body fluid can be detected through clinical manifestation such as like dyspnea, tachycardia, and neck vein distention. Lung auscultation will have a wet crackles signs. It is because of pulmonary edema. The excessive fluid can make this condition, so the aware of parenteral input (infusion or water consumption) need to do to prevent excessive body fluid. Edema in whole body need to assess presacreal and pretibial area everyday.

Nutrition

Protein diet is minimized until 1 g/kg while oliguria phase to decrease protein metabolism and prevent toxic accumulation. Calorie need is influenced by high carbohydrate diet because carbohydrate has an effect toward protein (high carbohydrate diet, protein will not use for energy but protein can be used for growth and tissue repair). Food and drinks that consist of kalium and phosphate (banana, orange, and coffee) is minimized. Kalium input must be limited about 2 gram per day.

Intra Vein Fluid and Diuretic

Adequate blood supply to kidney can be maintained through intra vein fluid and medication. Mannitol furosemide or extracrinic acid can be prescribed to start diuresis and prevent kidney failure. If Acute Renal Failure (ARF) is caused by hypovolemia hypoproteinemia, albumin infusion can be helpful. Shock and infection can be handled, if they are there.

Acidosis Correction and Phosphate Level

If the acidosis is severe occurred, artery gas must be monitored, ventilation procedure must be done if there is respiration problem. Patients need bicarbonate therapy or dialysis. Serum phosphate in patients can be controlled with phosphate binder agent (aluminium hydroxide), this agent prevents high level of phosphate serum by decrease the phosphate absorption in gastrointestinal system.

Continuous Monitor

During oliguria phase of Acute Renal Failure (ARF) from 10 to 20 days and followed diuretic phase where urine output is increase as a sign of kidney recovery. Evaluate the blood chemical and it can monitor the natrium level in the blood. Kalium and fluid that is needed during assessment toward high hydration or low hydration. During the diuretic phase, patients is given high protein diet, high calorie and do some activity step by step.

Dialysis

Dialysis can be done for complication prevention, such as like hyperkalemia, pericarditis, and seizure.

Chronic Renal Failure (CRF)

The purpose of chronic renal failure treatment is to maintain the homeostatic and prevent the complication by collaborative approach; hyperkalemia caused by excretion decrease, acidosis metabolic, catabolism and excessive diet. Pericarditis, pericardium effusion, heart temponade caused by waste product retention, and inadequate dialysis. Hypertension caused by fluid and natrium retention and angiotensin-aldosterone system malfunction. Anemia caused by erythropoietin decrease, red blood cells damage, gastrointestinal bleeding caused by toxin agent irritation and blood loss during hemodialysis. Bone disease and metastatic calfication caused by phosphate retention, low level of calcium, abnormal vitamin D metabolism. Complication can be prevented or handled by antihypertension, erythropoietin, Fe supplement, calcium supplement and phosphate binder agent. It need to do dialysis.

Diet Intervention

In kidney failure, the diet must be monitored include protein diet regulation, fluid input and output, natrium consumption, and kalium limitation. The basic data is about rest and activity of the patients, the patient may be fatigue or too weak to do some activity.

Circulation

Are there hypotension, pale, tissue edema, urinary pattern change, dysuria, abdomen retention. Fluid and food; body weight increase caused by edema, loss of body weight, nausea, vomit, and anorexia, epigastric pain. Neurosensory; headache, muscle cram, and seizure. Respiration; dyspnea, tachypnea, frequency and deep breath changes, ammonia smell, productive cough. Skin; ptikie, pruritus, and dry irritation skin.

The intervention for this condition are assessing the edema because the edema is identified as excessive fluid intake and it need to minimized so that the body weight can be maintained in ideal body weight. Controlling the fluid intake in 24 hours a day because it can be a sign for kidney function, fluid need, and fluid balance in the patients body. Measure the patient's body weight every day to help in maintaining the patients body fluid balance everyday. If the body weight is more than 0,5 kg per day, it show fluid balance change. An information about patients' condition can be helpful and the family can limit the fluid intake. Uncooperative patients with excessive body weight with fluid intake need dialysis. Then the drugs medication has important role in kidney failure, for instance antidiuretic, antidiuretic can expand the tubular from any debris, decrease hyperkalemia and increase adequate urine volume. The drugs that usually used is Furosemide. We have to know the treatment progress toward lab test, the result of kidney function lab can be a guidance for next medication.

Nutrition Intervention

The observation of patients' diet can be helpful in identifying patients' status and diet effectivity. Patients' general condition, uremic status, and diet can influence the nutrition. The patients need to do oral hygiene before and after meal, because oral hygiene can decrease the mouth smell and uncomfortable feeling in the mouth because of microorganism. Not only those benefits, but the oral hygiene prevent stomatitis or mouth ulcer. The patients are only given less protein and fat diet, and high carbohydrate so that there is no protein accumulation lead to acid circumstances. The patients must limit the salt consumption because the salt or natrium can accumulate the fluid inside the body. Small portion can be helpful for patient because of nausea and vomit, and they can be prevented well. Drugs medication for patient with kidney failure related to nausea and vomit (usually caused by fetouremic or the patients' breath smell is like feton) is antiemetic. If the patients do not have a nausea feeling, the oral nutrition can be given well.

Activity

The patients' need in some activities must be assessed because it will give a guidance for next treatment intervention. Assessing the fatigue is to know about activity intolerance. Not only about those, but also about the patients' psychology or stress factors because the psychology factors about activities can contribute as well. Relax environment and activity schedule must be regulated. The patients will need help in self-care, so the nurses must help them.

Collaboration in blood laboratory examination, Imbalance calcium, magnesium, kalium, and natrium may interfere with neuromuscular function which is requiring energy use to increase hematocrit and hemoglobin which is showing one indication in erythropoietin disorders.

The patients maybe have an anxiety feeling so we need to assess client's level of anxiety for the degree anxiety. The patients usually don not know about their condition and give them accurate information of the disease so that patients can learn about the disease and treatment, in order to understand and accept the diagnosis and medical consequences. Help the patients to identify how understand various changes due to illness so that the patients can understand that life does not have to undergo significant changes as a result of the illness. Let patients and families express their feelings so that it will reducing the burden of thinking and it can reduce anxiety and can be cooperative with procedures and the nurses will be easier to carry out the next intervention. Manage visiting time which allows the presence of ancestry because it can reduce the level of anxiety by presenting family support.

Patient with chronic kidney failure  have problem in breathing pattern, so the patients' breathing pattern is needed to assess because dyspnea, tachycardia, and irregular breathing and the sound of Rhonchi is an indication of respiratory disorders. Skin color, nails and mucous membranes are like an indicator, paleness and cyanosis is an indication of anemia associated with congestion and heart failure resulting in inadequate tissue perfusion. The best position of patient with breathing problem is semi-Fowler position, that position allows abdominal organs away from the diaphragm, so lung expansion will be maximal. Observing the vital signs (pulse, blood pressure, breathing frequency, and body temperature) because the impaired exchange of O2 is a result in changes of vital signs, especially blood pressure, breathing frequency, and pulse. The last thing that we can do is collaboration for supplemental oxygen administration, maximum oxygen is needed for the heart muscle or myocardium. Blood gas is needed to monitor because blood gas analysis is very important to know the disruption of gas exchange in the lungs.

Skin integrity damage

Skin integrity damage with edema and hoarding orokrom can be a big problem in all patient. The skin color, turgor, and vascular are needed to observe. It indicates poor circulation area / damage that can cause pressure ulcer or decubitus. The patients need to change the position as often as possible. This procedure is to reduce the pressure ulcer. Give skin care (hygiene) and providing lotion to minimizing dermal irritation and the risk of skin damage. Maintain dry linen and free of wrinkles because it will make dermal irritation and decrease the risk of skin damage. The patients use a moist compress and keep nails stay short, this procedure can eliminate the discomfort feeling and reduce the risk of injury (skin). The patient is not allowed wear tight clothing, it can make the skin irritation.

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Children's HIV/AIDS Theoritical Background

Definition of HIV/AIDS

AIDS is severing disease signed by cellular immunity damage that is caused by retrovirus (HIV) or fatal disease where the patient needs intensive care during the disease process. According to Mansjoer, AIDS (Acquired Immunodeficiency Syndrome) is a group of symptoms that is caused by immune deficiency progressively and the main cause of this disease is HIV (Human Immunodeficiency Virus).

HIV infection progressively destroy white blood cells, it will make immune system is collapse. This circumstance will lead to opportunistic infection and certain cancer (especially in adults). HIV in children usually are usually caused by mother transmission through placenta. It may from breast milk infect the baby.

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