koas 88

STRES berkaitan erat dengan seberapa banyak aktivitas seks yang bisa Anda lakukan. Saat Anda merasakan stres berat sepanjang hari, segera ajak pasangan untuk bercinta malam ini.

"Stres memberi dampak pada libido, maka penting untuk memahami bahwa bercinta adalah pemulihan terbaik terhadap stres," kata Tayo Irvine Hendrix, seksolog, seperti dilansir dari Femalefirst.

Sebuah studi di Amerika Serikat yang dilakukan terhadap wanita usia 50 tahun ke atas ditemukan hasil, seks ataupun sekadar bentuk kasih sayang fisik dari pasangan secara signifikan mengurangi mood negatif dan stres. Kondisi ini sekaligus menciptakan mood positif sepanjang hari.

Namun, keampuhan bercinta tersebut tak didapat pada wanita yang orgasme tanpa lawan "main".

Tayo menambahkan, " Apakah Anda tahu bahwa orgasme sebanyak dua kali atau lebih dalam seminggu bisa meningkatkan kualitas kesehatan?".

Ia membeberkan sebuah fakta berdasarkan hasil penelitian di Inggris bahwa terlihat hubungan antara frekuensi orgasme (dua atau lebih seminggu) dengan kesuburan pada pria. Pria yang frekuensi orgasmenya lebih sering cenderung berisiko lebih kecil terhadap kematian dibanding mereka yang jarang orgasme.

Bukan hanya meredakan stres atau menurunkan risiko kematian, orgasme berkualitas dengan kuantitas terjada juga bisa mengurangi tekanan darah, membantu mengatasi gangguan sulit tidur, mengurangi gangguan prostat, dan migren.


Source : Fitri Yulianti - Okezone.com

Tanpa terasa, koas jilid II akan segera di mulai,....walaupun blom ad pengumuman pasti....namun desas-desus<<>>nya,...maupun kabar dari angin yang berhembus...koas jilid II ini akan dimulai tanggal 30 Nopember 2009....
Akhirnya liburan panjang usai,..dan bersiap menghadapi rutinitas baru yang mungkin akan jauh lebih sibuk dibandingkan dengan koas jilid I dulu,..klo jilid I dulu, yang pasti jaga malam ga disemua stase,jaga malam hanya distase tertentu....klo jilid II ini smua stase ada jaga malamnya.....hufff
Tapi,...bagaimanapun ini harus tetap dijalani....Stase Obgyn, Penyakit Dalam, Anak dan Bedah...
Untuk stase yang pertama kena di obgyn, smoga banyak mendapat pengalaman yang berguna dalam bekal untuk praktik menjadi dokter nantinya.....

Produk SMART Telecom

Definisi
Suatu keadaan keluarnya jaringan/organ tubuh dari suatu ruangan melalui suatu lubang/celah keluar di bawah kulit atau menuju rongga lainnya ( secara kongenital / aquisital)
Kelainan kongenital misal : batang otak turun melalui foramen occipital magnum. Berdasarkan definisi di atas , bila ada suatu organ yang keluar sampai ke kulit disebut Hernia, misal : post laparatomi, timbul infeksi pada jahitan sehingga jahitan robek (dehisiensi) dan terjadi eviserasi ( jahitan robek organ keluar ke permukaan kulit ). Hernia terjadi akibat adanya tempat2 yang lemah disebut Locus Minoris Resistentiae (LMR), misal :
• : Fascia transversa abdominis
• : Processus vaginalis peritonii persistent

Bagian-bagian Hernia
1. Pintu Hernia  LMR yang dilalui kantong hernia
2. Kantong Hernia  peritoneum parietal
Tidak semua hernia mempunyai kantong, misal : H.Incisional,H.Adiposa
3. Leher Hernia  bagian tersempit
4. Isi Hernia  Gaster, usus, vu, ovarium, omentum

Etiologi
 Kongenital
• Sempurna  proses intra uterin
Terjadi sejak lahir, misal : H.Umbilikalis, H.Epigastrika, Omphalocele congenital

• Tidak Sempurna
Waktu lahir tak tampak, setelah ada faktor predisposisi baru nampak, misal : HIL akibat processus vaginalis abdominis persistens tak dapat masuk ke scrotum

 Acquisita
• Tekanan intra abdominal yang meninggi
Pada pasien2 yang sering mengejan, faktor pencetus : Batuk kronis, BPH, partus, ascites,vesicolithiasis
• Konstitusi tubuh
Orang gemuk lebih sering dari orang kurus (Asthenis), karena banyak jaringan lemaknya
• Banyak Preperitoneal fat  H.Adiposa, H.epigastrika
• Distensi dinding perut  ascites, partus
• Sikatrik  jahitan tak sempurna
• Penyakit yang melemahkan otot2 dinding perut  poliomyelitis anterior

Faktor2 yang mempengaruhi Insiden Hernia
 Herediter  Individu type asthenik (fascia transversa abdom lemah)
 Umur dan Pekerjaan  usia > 50 th krn dinding perut mulai melemah
 Jenis Kelamin
 HIL banyak pada laki2 krn terdapat processus vaginalis peritonii
 H.Femoralis banyak pada wanita karena :
• Sering partus  tekanan intraabdominal meningkat dan anulus femoralis melemah
• Bentuk pelvis lebih horisontal  tekanan lig inguinale lebih besar  anulus femoralis melemah
 Keadaan Tubuh
Obesitas  preperitoneal fat banyak  fasc transversa abdominis lemah  H.Adiposa

 Conjoint tendon dibentuk oleh MOAI & m.transversus abdominis
 Trigonum Hasselbachii terletak antara m.rektus abdominis dan Fovea inguinalis medialis
Pembagian Hernia
 Secara Klinis
• Reponabilis  dapat dimasukkan kembali tanpa operasi
• Irreponabilis  Tidak dapat dimasukkan, harus operasi (strangulasi)
• Inkarserata  H.Irreponabilis disertai gejala Illeus
• Akreta  mengalami perlengketan

 Hernia Abdominalis
• Externa
Isi hernia berasal dari cavum abdominalis melalui LMR keluar sampai subkutis, terdiri dari :
 HIL, HIM
 Umbilikalis
 Epigastrika
 Lumbalis
 Semilunaris
 Pelvica  femoralis, obturatoria, perinealis, ischiadica

• Interna
Isi hernia dari cavum abdominalis masuk ke rongga lain
Diagnosis ditentukan dengan rontgen foto
• Intra-peritonealis
 H.Epiploicum Winslowi
 H.Bursa omentalis
 H.Mesenterica
• Retro-peritonealis
 H.paraduodenalis
 H.recessus illeocecalis
 H.recessus sigmoideus
• Hernia Diafragmatica  Morgagni. Bochdalek, Hiatal

 Ada tidaknya kantong
• Berkantong  peritoneum
• Tidak berkantong  H.adiposa, H.Incisionalis, H.sikatriks

 Hernia bentuk khusus
• Hernia Richter
Sebagian dinding usus menonjol, sedang sebagian besar dari usus diluar kantog hernia.

• Hernia Littre
Kelainan embrionik, adanya divertikulum Meckeli yang keluar melalui LMR

• Hernia Sliding
Suatu keadaan dimana organ peritoneal (usus,colon sigmoid) seakan meluncur kebawah, dan akan membentuk dinding posterior kantong hernia.

• Hernia Interstitialis
Akibat kesalahan reposisi, sehingga organ tidak masuk ke cavum abdomen tetapi masuk ke celah antara jaringan (lamina musculoaponeurotic)
Akibat yang ditimbulkan : pembuluh darah pecah, ruptur isi hernia

• Hernia Pantalon
Terdapatnya H.Inguinalis dan medial secara bersama-sama pada satu sisi.

• Hernia Spiegel
Terjadi pada linea semilunaris dibawah linea semisirkularis, namun diatas vasa epigastriga inferior menyilang tepi lateral m.rektus abdominis
• Hernia Permagna  separo isi rongga perut masuk ke kantong hernia
Komplikasi Hernia
• Perlekatan / H.Akreta
• Hernia Irreponabilis
• Jepitan  vaskularisasi terganggu  iskhemi  ganggren  nekrose
• Infeksi
• Obstipasi  obstruksi / konstipasi
• Hernia Inkarserata  Illeus

Treat “lazy eye” in early childhood
What is amblyopia?
Amblyopia (“lazy eye”) happens when the vision in
one eye doesn’t develop properly in early childhood.
You may not be able to notice it easily in your child,
but if it isn’t treated it will become a permanent
visual problem.
What causes amblyopia?
Babies are able to see when they are born, but they
have to learn how to use their eyes. They have to
learn how to focus, and then how to use both eyes
together. Our vision continues to develop until we
are about 9 to 12 years old. After that, our eyesight
is complete and can’t be easily changed.
However, sometimes the vision in one eye doesn’t
develop properly. This may be caused by misaligned
eyes (called strabismus) or because one eye is
out of focus compared with the other. When this
happens, the brain “shuts off” the eye that is out of
focus, and the child depends only on the better eye
to see.
An eye disease such as a cataract or anything else
that stops a clear image from being focused inside
the eye can cause amblyopia in children. They may
also inherit conditions from their parents that lead
to amblyopia.
AmblyopiaHow is amblyopia diagnosed?
You may not be able to tell that your child has amblyopia. Many
children with the condition look completely normal and see well with
their good eye. If your child has an eye that turns in, out, or up, or if
he or she closes one eye (especially in bright sunlight), these are
warning signs.
Some family doctors and pediatricians screen eyesight. There might
also be vision screening as part of a preschool checkup in your
community. If there is any doubt about your child’s vision, they will
refer you to an eye doctor for more tests.
How is amblyopia treated?
A child’s vision is fully developed by age 9, so amblyopia must be
treated early in life, preferably before age 6. It is hard to reverse
amblyopia after that age. If it is treated early enough, amblyopia can
usually be reversed.
The doctor’s role
Amblyopia is best treated by an ophthalmologist, often with the help
of an orthoptist. Treatment may involve glasses to correct blurred
vision or help straighten the eyes, and patching or blurring the vision
of the good eye to force the lazy eye to work. Surgery can be
necessary as well, to mechanically realign the eyes. Exercises or other
types of visual training are not effective in treating amblyopia.
The parents’ role
If amblyopia isn’t treated, it will lead to a lifetime of poor vision in one
eye. This puts your child at higher risk of vision loss if the seeing eye
is injured. As well, an eye with poor vision can become misaligned
(strabismus), which can affect your child’s3-D vision, making certain
activities difficult and even limiting some job opportunities.
Parents play a vital role in making sure their child does not have this
disability. First, it is important to recognize any signs of a problem.
For example, it is not true that all babies are cross-eyed. If your child is 6 months old and is still cross-eyed, you should see a doctor as soon
as possible. Second, you should never wait for your child to “just grow
out of ” an eye problem. If you think something is wrong with your
child’s eyesight, have it checked.
You will need to work with the doctors and others (such as teachers) to
ensure your child wears the glasses or patch as prescribed. You play a
key role in making sure your child has a lifetime of good eyesight. The
earlier the treatment is started, the sooner it is likely to be successful.
Glossary
Cataract: A clouding of the lens of the eye. Seeing when you have
cataracts is like looking through a dirty window.
Ophthalmologist: A medically trained eye doctor and surgeon.
Orthoptist: An eye care professional who works with the ophthalmologist
in the treatment of amblyopia and strabismus.
Strabismus: The medical term for two eyes that are not straight. One
eye may be turned inward, turned outward, or not aligned vertically.
Canadian Ophthalmological Society
1525 Carling Avenue, Suite 610
Ottawa, Ontario Canada K1Z 8R9
© 2007

Demam berdarah dengue (DBD) merupakan salah satu penyakit infeksi yang sampai saat ini masih merupakan masalah kesehatan di negara kita, khususnya kota-kota besar. Di Jakarta sendiri DBD justru menunjukkan sifat yang endemis dengan jumlah yang meningkat dari tahun ke tahun, khususnya di awal dan akhir musim penghujan, serta adanya ledakan kasus setiap lima tahun yaitu pada tahun 1988, 1993, 1998, dan terakhir di penghujung tahun 2003 hingga awal 2004 ini, yang merupakan ledakan kasus yang lebih tinggi dari tahun sebelumnya.1 Sampai akhir Februari 2004 korban tewas di Indonesia telah mencapai 247 orang dengan jumlah penderita sebanyak 12.294 orang, dimana jumlah kasus terbanyak didapatkan di Jakarta yaitu sekitar 3500 jiwa.2
Beratnya penyakit dan angka kematian DBD dewasa lebih rendah dibandingkan dengan DBD pada anak, tetapi walaupun demikian penatalaksanaannya masih mengalami kendala/ketidakseragaman khususnya mengenai pemberian cairan infus, transfusi trombosit/komponen darah dan monitoring pemeriksaan Hb, Ht, dan trombosit, sehingga selain penatalaksanaan pasien kurang tepat dan tidak praktis, juga biayanya menjadi tinggi. Berkaitan dengan hal tersebut dibutuhkan protokol penatalaksanaan DBD dewasa yang dapat mengatasi kendala-kendala tersebut di atas.1
Penatalaksanaan DBD dengan transfusi trombosit/komponen darah masih terdapat ketidakseragaman yang justru terjadi di kalangan praktisi kesehatan sendiri. Adanya mis-komunikasi antar praktisi kesehatan menyebabkan pada tahun 1998, menyebabkan hampir semua pasien dengan DBD diberikan transfusi trombosit tanpa indikasi yang jelas.3

Pika adalah terus - menerus makan zat yang tidak bergizi (tanah, serpihan cat, dsb). Pika dapat timbul sebagai salah satu gejala dari sejumlah gangguan psikiatrik yang luas (seperti autisme), atau sebagai perilaku psikopatologis yang tunggal. Fenomena ini paling sering terdapat pada anak dengan retardasi mental, namun demikian pika dapat juga terjadi pada anak biasa yang mempunyai inteligensia normal (biasanya pada usia dini).
Diantara orang dewasa, bentuk pika tertentu termasuk geofagia (makan tanah) dan amilofagia (makan kanji), telah dilaporkan terjadi pada wanita hamil dan cukup tinggi di Aborigin Australia. Tetapi menurut DSM-IV, jika tindakan tersebut ditentukan secara kultural, itu tidak termasuk kriteria diagnostik untuk pika.
Kriteria Diagnostik untuk Pika (DSM-IV)
1. Terjadi selama periode sekurang-kurangnya 1 bulan
2. Makan zat tidak bergizi adalah tidak sesuai menurut usianya
3. Bukan bagian dari ritual atau kultural
4. Jika terjadi semata-mata pada perjalanan gangguan mental lain, itu memerlukan perhatian klinis tersendiri.
Epidemiologi
Pika diperkirakan terjadi pada 10 sampai 32 persen anak-anak antara usia 1 dan 6 tahun. Pada anak yang lebih dari 10 tahun, kurang lebih 10 persen. Pada anak yang lebih tua dan remaja dengan kecerdasan normal, frekuensi pika menurun. Pada anak retardasi mental, pika dilaporkan terjadi pada sampai seperempat anak-anak usia sekolah dan remaja. Pika tampaknya mengenai kedua jenis kelamin dengan sama banyaknya.
Etiologi
Defisiensi nutrisi telah didalilkan sebagai penyebab pika, karena keadaan kecanduan tertentu untuk zat yang tidak dapat dimakan yang telah ditimbulkan oleh defisiensi. Sebagai contoh, kecanduan akan tanah dan es kadang-kadang berhubuungan dengan defisiensi zat besi dan seng yang dihilangkan dengan pemberiannya. Tingginya insidensi penelantaran dan kehilangan orang tua telah dihubungkan dengan kasus pika, yang juga dihubungkan dengan pemuasan kebutuhan oral yang tidak terpenuhi. Dan tidak lupa adalah faktor ritual dan kultural.
Diagnosis dan Gambaran Klinis
Onset pika biasanya antara usia 12 dan 24 bulan, dan insidensi menurun seiring bertambahnya usia. Zat tertentu yang dimakan adalah bervariasi , biasanya anak kecil memakan cat, plester, tali, rambut dan kain dsb.; anak yang lebih besar dapat mengambil kotoran, feses binatang, batu, kertas dsb.
Implikasi terberat adalah keracunan timbal, biasanya dari cat yang mengandung timbal; parasit usus setelah memakan tanah atau feses; anemia dan defisiensi zat seng setelah ingesti tanah liat, defisiensi zat besi yang parah setelah ingesti sejumlah besar kanji; dan obstruksi usus akibat ingesti gumpalan rambut dan batu.
oleh Firman Ramdhani
Daftar pustaka:
• PPDGJ III
• Sinopsis Psikiatri (Kaplan dan Sadock)

1
THE BASIC PRINCIPLES OF WOUND HEALING
David Keast MSc, MD, CCFP
Heather Orsted RN, BN, ET
An understanding of the basic physiology of wound healing provides the clinician with the
framework necessary to implement the basic principles of chronic wound care.
Introduction:
Wound healing is a complex and dynamic process with the wound
environment changing with the changing health status of the individual. The
knowledge of the physiology of the normal wound healing trajectory through the
phases of hemostasis, inflammation, granulation and maturation provides a
framework for an understanding of the basic principles of wound healing. Through
this understanding the health care professional can develop the skills required to care
for a wound and the body can be assisted in the complex task of tissue repair.
A chronic wound should prompt the health care professional to begin a search
for unresolved underlying causes. Healing a chronic wound requires care that is
patient centered, holistic, interdisciplinary, cost effective and evidence based.
This is one of five articles made available by the Canadian Association of Wound
Care to assist the wound care clinician develop an increased understanding of wound
healing. This article explores:
· Why wounds happen.
· How wounds heal.
· When is a wound considered chronic?
· The nature of good chronic wound care
It is hoped that these basic principles will provide a framework for further
study and exploration into the complex area of wound care. For more articles in this
series see www.cawc.net
Why Do Wounds Happen?
In any natural disaster the damaging forces must be identified and stopped
before repair work can begin. So too in wound care the basic underlying causes and
factors that affect healing must be identified and controlled as best we can before
wound healing will begin. Following are some of the common underlying causes or
factors, which may interfere with wound healing:
· Trauma (initial or repetitive)
· Scalds and burns both physical and chemical
· Animal bites or insect stings
· Pressure
· Vascular compromise, arterial, venous or mixed
· Immunodeficiency
· Malignancy
· Connective tissue disorders
· Metabolic disease, including diabetes
· Nutritional deficiencies
· Psychosocial disorders
· Adverse effects of medications2
In many cases the underlying causes and factors interfering with wound
healing may be mutlifactorial.
Figure 1 illustrates an elderly patient who suffered trauma when she banged her leg
on a coffee table. She is on coumadin which contributed to the injury becoming a
large black hematoma of old blood. What is the safest way to heal this wound?
In figure 2 we see a young spinal cord injured patient with a chronic pressure ulcer
surrounded by erythema. Is the erythema caused by infection, irritation of wound
fluid, incontinence or continual pressure to the area?
In figure 3 we see chronic ulcers in a frail elderly woman that has lower leg edema
related to decreased mobility. The ulcer drains copious amounts of chronic wound
drainage causing irritation to the surrounding skin. The patient sits most of the day in
a dependent position which worsens the leg edema. How can the wound fluid be
controlled to enable healing?
The clinician working in wound care needs to be a good detective and needs to
consider all possible factors influencing healing.
How Do Wounds Heal?
Research work on acute wounds in an animal model shows that wounds heal
in four phases. It is believed that chronic wounds must also go through the same
basic phases1
. Some authors combine the first two phases.
The phases of wound healing are:
· Hemostasis
· Inflammation
· Proliferation or Granulation
· Remodeling or Maturation
Kane’s analogy to the repair of a damaged house provides a wonderful
framework to explore the basic physiology of wound repair
2
(See Table 1).
Hemostasis:
Once the source of damage to a house has been removed and before work
can start, utility workers must come in and cap damaged gas or water lines. So too
in wound healing damaged blood vessels must be sealed. In wound healing the
platelet is the cell which acts as the utility worker sealing off the damaged blood
vessels. The blood vessels themselves constrict in response to injury but this spasm
ultimately relaxes. The platelets secrete vasoconstrictive substances to aid in this
Figure 1 Figure 2 Figure 32
process but their prime role is to form a stable clot sealing the damaged vessel.
Under the influence of ADP (adenosine diphosphate) leaking from damaged tissues
the platelets aggregate and adhere to the exposed collagen3
. They also secrete
factors which interact with and stimulate the intrinsic clotting cascade through the
production of thrombin, which in turn initiates the formation of fibrin from fibrinogen.
The fibrin mesh strengthens the platelet aggregate into a stable hemostatic plug.
Finally platelets also secrete cytokines such as platelet-derived growth factor
(PDGF), which is recognized as one of the first factors secreted in initiating
subsequent steps. Hemostasis occurs within minutes of the initial injury unless there
are underlying clotting disorders.
Inflammation Phase:
Clinically inflammation, the second stage of wound healing presents as
erythema, swelling and warmth often associated with pain, the classic “rubor et tumor
cum calore et dolore”. This stage usually lasts up to 4 days post injury. In the wound
healing analogy the first job to be done once the utilities are capped is to clean up the
debris. This is a job for non-skilled laborers. These non-skilled laborers in a wound
are the neutrophils or PMN’s (polymorphonucleocytes). The inflammatory response
causes the blood vessels to become leaky releasing plasma and PMN’s into the
surrounding tissue4
. The neutrophils phagocytize debris and microorganisms and
provide the first line of defense against infection. They are aided by local mast cells.
As fibrin is broken down as part of this clean-up the degradation products attract the
next cell involved.
The task of rebuilding a house is complex and requires someone to direct this
activity or a contractor. The cell which acts as “contractor” in wound healing is the
macrophage. Macrophages are able to phagocytize bacteria and provide a second
line of defense. They also secrete a variety of chemotactic and growth factors such
as fibroblast growth factor (FGF), epidermal growth factor (EGF), transforming growth
factor beta (TGF-__ and interleukin-1 (IL-1) which appears to direct the next stage5
.
Proliferative Phase ( Proliferation, Granulation and Contraction):
The granulation stage starts approximately four days after wounding and
usually lasts until day 21 in acute wounds depending on the size of the wound. It is
characterized clinically by the presence of pebbled red tissue in the wound base and
involves replacement of dermal tissues and sometimes subdermal tissues in deeper
wounds as well as contraction of the wound. In the wound healing analogy once the
site has been cleared of debris, under the direction of the contractor, the framers
move in to build the framework of the new house. Sub-contractors can now install
new plumbing and wiring on the framework and siders and roofers can finish the
exterior of the house.
The “framer” cells are the fibroblasts which secrete the collagen framework on
which further dermal regeneration occurs. Specialized fibroblasts are responsible for
wound contraction. The “plumber” cells are the pericytes which regenerate the outer
layers of capillaries and the endothelial cells which produce the lining. This process
is called angiogenesis. The “roofer” and “sider” cells are the keratinocytes which
are responsible for epithelialization. In the final stage of epithelializtion, contracture2
occurs as the keratinocytes differentiate to form the protective outer layer or stratum
corneum.
Remodeling or Maturation Phase:
Once the basic structure of the house is completed interior finishing may
begin. So too in wound repair the healing process involves remodeling the dermal
tissues to produce greater tensile strength. The principle cell involved in this process
is the fibroblast. Remodeling can take up to 2 years after wounding and explains why
apparently healed wounds can break down so dramatically and quickly if attention is
not paid to the initial causative factors.
Table 1 Phases of Healing
Phase of
Healing
Days post
injury
Cells involved in
phase
Analogy to House Building
Hemostasis Immediate Platelets Capping off conduits
Inflammation Day 1 - 4 Neutrophils Unskilled laborers to clean up
the site
Proliferation
Granulation
Contracture
Day 4 - 21 Macrophages
Lymphocytes
Angiocytes
Neurocytes
Fibroblasts
Keratinocytes
Supervisor Cell
Specific laborers at the site:
Plumber
Electrician
Framers
Roofers and Siders
Remodeling Day 21 – 2 yrs Fibrocytes Remodelers
When Does a Wound Become Chronic?
In healthy individuals with no underlying factors an acute wound should heal
within three weeks with remodeling occurring over the next year or so. If a wound
does not follow the normal trajectory it may become stuck in one of the stages and
the wound becomes chronic. Chronic wounds are thus defined as wounds, which
have “failed to proceed through an orderly and timely process to produce anatomic
and functional integrity, or proceeded through the repair process without establishing
a sustained anatomic and functional result.”
6
Once a wound is considered chronic it
should trigger the wound care clinician to search for underlying causes, which may
not have been addressed. Better yet, an understanding of the causative factors
should lead us to be proactive in addressing these factors in at risk populations so
that chronic wounds are prevented.
Basic Principles of Wound Care
There are three basic principles which underlie wound healing.
1. Identify and control as best as possible the underlying causes.
2. Support patient centered concerns
3. Optimize local wound care.
The CAWC Best Practice Recommendations for wound care (wound bed prep,
venous ulcer management, pressure ulcer management and diabetic ulcer
management) extensively covers all three principles (www.cawc.net). Figure 4,2
excerpted from Wound Bed Preparation, outlines an algorithm that provides a
framework for chronic wound management.
Figure 4
OstomyWound Management; 2000 46(11):16
Optimize Local Wound Care
In 1962 George Winter described improved wound healing under moist
conditions7
. Despite that seminal work it is only in the last decade that the
advantages of moist interactive wound healing have become more widely recognized
and applied in clinical practice. Some of the advantages include the following:
· Decreased dehydration and cell death. As described earlier, the task of
wound repair requires the activity of a host of cells from neutrophils and
macrophages to fibroblasts and pericytes. These cells cannot function in a
dry environment.
· Increased angiogenesis. Not only do the cells required for angiogenesis
require a moist environment but also angiogenesis occurs towards regions
of low oxygen tension such that occlusive dressings may act as a stimulus
in the process8
.
· Enhanced autolytic debridement. By maintaining a moist environment
neutrophil cell life is enhanced and proteolytic enzymes are carried to the
wound bed allowing for painless debridement
9
. Further as discussed earlier
these fibrin degradation products are a factor in stimulating macrophages to
release growth factors into the wound bed.
· Increased re-epithelialization. In larger, deeper wounds epidermal cells
must spread over the wound surface from the edges. They must have a
supply of blood and nutrients. Dry crusted wounds reduced this supply and
provide a barrier to migration thus slowing rates of epithelialization10
.
· Bacterial barrier and decreased infection rates. Occlusive dressings
with good edge seals can provide a barrier to migration of microorganisms
into the wound. Bacteria have been shown to pass through 64 layers of
moist gauze11
. Wounds covered with occlusive dressings have been
Chronic
Wound
Diagnosis
Treat Cause Local Wound Care Patient-Centered
Concerns
Debridement Bacterial Balance
Moist
Interactive
Healing
Non-Healing Wounds
Biological Agents2
shown to have lower rates of infection than those with conventional gauze
dressings12
.
· Decreased pain. It is believed that the moist wound bed insulates and
protects the nerve endings thereby reducing pain. Furthermore occlusive
dressings often require fewer dressing changes, which may be
uncomfortable for patients.
· Decreased costs. While occlusive dressings have a higher per unit cost
than conventional gauze, the reduced frequency of dressing changes and
increased healing rates may proved to be cost effective in the long term.
While moist wound healing has clear advantages, debate continues on how
moist is moist. Dressings should retain enough moisture to stimulate good healing
and yet should not cause maceration or irritation to the surrounding tissues.
The Ideal Dressing
So how do we provide for good moist interactive wound healing? In 1979
Turner described the ideal dressing as having the following characteristics13
:
· Removes excess exudate and toxins
· High humidity at the dressing wound interface
· Allows for gaseous exchange
· Provides thermal insulation
· Protects against secondary infection
· Free from particulate and toxic components
· No trauma with removal
Over the past 15 years an ever-expanding list of dressing products has come
onto the market in an attempt to meet these conditions. Among these are the
transparent film dressings, hydrogels, hydrophilic foams, alginates, hydrocolloids and
the new antibacterials and biologic dressings or devices. There is however no magic
“one-size-fits-all” dressing. The clinician needs to become familiar with the
characteristics of the different classes of dressings and to tailor the dressing used to
the phase of healing, characteristics of the wound, the needs (and risk factors) of the
patient and the availability and skill of the caregiver.
Summary
In summary wound healing requires an approach that is:
· Patient centered: It is always wise to remember that we are dealing with a
person who happens to have a chronic wound. We can develop a
wonderful management plan but if we do not have patient buy-in the plan is
doomed to failure.
· Holistic: Best practice requires the assessment of the whole patient, not
just the “hole in the patient”. All possible contributing factors must be
explored.
· Interdisciplinary: Wound care is a complex business requiring the skills of
many disciplines. Skilled nurses, physiotherapists, occupational therapists,
dietitians and physicians both generalists and specialists (dermatologists,
plastic surgeons and vascular surgeons depending on need) are central2
members of the team. In addition in some settings social work involvement
may be important.
· Evidence based: In today’s healthcare environment treatment must be
based on best available evidence and be cost effective.
References:

1
Kerstein MD: The scientific basis of healing. Adv Wound Care 1997; 10(3):30-362

2
Kane D: Chronic wound healing and chronic wound management, in Krasner D, Rodeheaver
GT, Sibbald RG. (eds): Chronic Wound Care: A Clinical Source Book for Healthcare
Professionals, Third Edition. Wayne, PA, Health Management Publications, 2001,pp 7-17.
3
MacLeod J (ed): Davidson’s Principles and Practice of Medicine, Thirteenth Edition.
Edinburgh UK, 1981, pp 590-592
4
Wahl LM, Wahl SM: Inflammation, in Cohen IK, Diegelman RF, Lindblad WJ (eds): Wound
Healing: Biochemical and Clinical Aspects. Philadelphia, PA, W.B. Saunders, 1992, pp 40-
62
5
Kerstein MD: Introduction: moist wound healing. American Journal of Surgery 1994;
167(1A Suppl): 1S-6S
6
Lazarus G, Cooper D, Knighton D, Margolis D, Pecoraro R, Rodeheaver G, Robson.
Definitions and guidelines for assessment of wounds and evaluation of healing. Archives of
Dermatology 1994;130:489-493
7
Winter GD: Formation of scab and rate of epithelialization of superficial wounds in the skin
of the young domestic pig. Nature 1962;193:293-294
8
Knighton DR, Silver JA, Hunt TK. Regulation of wound-healing angiogenesis: effect of
oxygen gradients and inspired oxygen concentration. Surgery 1981;90:262-270
9
Baxter CR. Immunologic reactions in chronic wounds. American Journal of Surgery
1994;167(1A Suppl):12S-14S
10
Haimowitz JE, Margolis DJ: Moist wound healing, in Krasner D, Kane D (eds): Chronic
Wound Care: A Clinical Source Book for Healthcare Professionals. Wayne, PA, Health
Management Publications, 1997, 49-55
11
Mertz PM, Marshall DA, Eaglestein WH. Occlusive dressings to prevent bacterial invasion
and wound infection. J Am Acad Dermatol 1985;12:662-668
12
Hutchinson JJ, McGuckin M. Occlusive dressings: A microbiologic and clinical review. Am
J Infect Control 1990;18:257-268
13
Turner TD. Hospital usage of absorbent dressings. Pharma J 1979;222:421-426

Ulkus Kornea
Definition :
Ulkus Kornea adalah luka terbuka pada lapisan kornea yang paling luar.
Cause :
• Infeksi oleh bakteri (misalnya stafilokokus, pseudomonas atau pneumokokus), jamur, virus (misalnya herpes) atau protozoa akantamuba
• Kekurangan vitamin A atau protein
• Mata kering (karena kelopak mata tidak menutup secara sempurna dan melembabkan kornea).

Faktor resiko terbentuknya ulkus:
- Cedera mata
- Ada benda asing di mata
- Iritasi akibat lensa kontak.

Sign & Symptoms :
Ulkus kornea menyebabkan nyeri, peka terhadap cahaya (fotofobia) dan peningkatan pembentukan air mata, yang kesemuanya bisa bersifat ringan.
Pada kornea akan tampak bintik nanah yang berwarna kuning keputihan.

Kadang ulkus terbentuk di seluruh permukaan kornea dan menembus ke dalam.
Pus juga bisa terbentuk di belakang kornea.
Semakin dalam ulkus yang terbentuk, maka gejala dan komplikasinya semakin berat.

Gejala lainnya adalah:
- gangguan penglihatan
- mata merah
- mata terasa gatal
- kotoran mata.

Dengan pengobatan, ulkus kornea dapat sembuh tetapi mungkin akan meninggalkan serat-serat keruh yang menyebabkan pembentukan jaringan parut dan menganggu fungsi penglihatan.
Komplikasi lainnya adalah infeksi di bagian kornea yang lebih dalam, perforasi kornea (pembentukan lubang), kelainan letak iris dan kerusakan mata.
Diagnose :
Pemeriksaan diagnostik yang biasa dilakukan adalah:
- Ketajaman penglihatan
- Tes refraksi
- Tes air mata
- Pemeriksaan slit-lamp
- Keratometri (pengukuran kornea)
- Respon refleks pupil
- Goresan ulkus untuk analisa atau kultur
- Pewarnaan kornea dengan zat fluoresensi.
Treatment :
Ulkus kornea adalah keadaan darurat yang harus segera ditangani oleh spesialis mata agar tidak terjadi cedera yang lebih parah pada kornea.

Tergantung kepada penyebabnya, diberikan obat tetes mata yang mengandung antibiotik, anti-virus atau anti-jamur.

Untuk mengurangi peradangan bisa diberikan tetes mata corticosteroid.

Ulkus yang berat mungkin perlu diatasi dengan pembedahan (pencangkokan kornea).

Sakit saat berhubungan seksual (bersenggama) dalam istilah medis di sebut sebagai dyspareuni. Rasa nyeri ini dapat dibagi menjadi dua. Yaitu, primer, bila nyeri terjadi selama berlangsungnya aktifitas seksual. Sekunder, bila rasa nyeri timbul sesudah akfifitas seksual. Rasa nyeri memang bisa terjadi saat dimulainya rangsangan seksual maupun saat penetrasi.

Penyebab dispareunia ini bergantung dengan lokasi terjadinya rasa nyeri. Karena itu, sebaiknya harus diketahui lokasi nyerinya terlebih dulu. Nyeri yang terjadi di sekeliling mulut vagina atau nyeri permukaan disebut superficial dyspareunia. Nyeri ini sering kambuh dan berulang. Rasanya gatal, bahkan terkadang seperti terbakar.

Waktunya, bisa saat dimulainya stimulasi seksual, tapi juga dapat terjadi setiap saat. Nyeri jenis ini dapat dipicu oleh aktifitas non seksual seperti berjalan. "Umumnya, penyebab utama nyeri ini adalah keradangan. Tapi, bisa juga karena lubrikasi yang kurang memadai.
Sedangkan, deep dyspareunia atau dispareunia dalam, biasanya disebabkan radang panggul, tumor genital (fibroid) atau infeksi saluran kencing. Kadang-kadang karena posisi yang salah saat melakukan hubungan. Posisi salah itu menekan ovarium, sehingga menimbulkan rasa nyeri.
Kemungkinan lain, seperti faktor psikologis juga mempengaruhi. Perasaan tegang saat kali pertama melakukan sanggama dapat memicu timbulnya rasa nyeri. Karena hal itu merupakan pengalaman baru terhadap diri seseorang. Edukasi seks yang tidak benar juga berpengaruh.

Misalnya, cerita yang mengatakan bahwa berhubungan seksual kali pertama itu sakit. Informasi yang salah ini mungkin membekas tanpa disadari. Sehingga merasa tegang bahkan takut saat melakukan hubungan seks. Hal ini bisa memicu rasa sakit.

Efeknya, sangat merugikan. Terkadang, rasa sakit yang hebat mengakibatkan penolakan terhadap hubungan seksual. Sehingga terjadi kekejangan otot sekitar vagina yang biasa disebut vaginismus. Dispareunia bisa menyebabkan vaginismus bila dibiarkan berlangsung lama.

Selain itu, juga menimbulkan ketakutan atau penolakan untuk berhubungan seks. Sehingga menyebabkan hilangnya gairah berhubungan seks. Bahkan, tidak tercapainya orgasme mengakibatkan hilangnya keinginan untuk berhubungan seks

Untuk memastikan apa yang sebenarnya dialami, diperlukan evaluasi dan pemeriksaan lebih jauh, baru dilakukan pengobatan. Tanpa pemeriksaan, sulit melakukan pengobatan yang benar. "Yang jelas, apabila anda merasakan keluhan saat melakukan hubungan seks, jangan sungkan bertanya atau memeriksakan diri ke dokter.


Penyebab dasarnya harus diketahui terlebih dahulu. Contohnya, bila dispareunia terjadi karena infeksi pada vagina, infeksi ini yang harus diatasi lebih dulu. Namun, Bila ternyata penyebabnya karena faktor psikologis, seperti pengetahuan yang tidak benar tentang cara berhubungan seks, maka hanya dengan memberi informasi yang benar tentang seksualitas, penyakit itu bisa diatasi.
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