Selasa, 18 Mei 2010

Asuhan Keperawatan Pasien dengan Ventilasi Mekanik

ASUHAN KEPERAWATAN PASIEN DENGAN VENTILASI MEKANIK

Pengkajian

Perawat mempunyai peranan penting mengkaji status pasien dan fungsi ventilator. Dalam mengkaji klien, perawat mengevaluasi hal-hal berikut :
  1. Tanda-tanda vital
  2. Bukti adanya hipoksia
  3. Frekuensi dan pola pernafasan
  4. Bunyi nafas
  5. Status neurologis
  6. Volume tidal, ventilasi semenit, kapasitas vital kuat
  7. Kebutuhan pengisapan
  8. Upaya ventilasi spontan klien
  9. Status nutrisi
  10. Status psikologis
1. Pengkajian Kardiovaskuler
  • Perubahan dalam curah jantung dapat terjadi sebagai akibat ventilator tekanan positif. Tekanan intratoraks positif selama inspirasi menekan jantung dan pembuluh darah besar dengan demikian mengurangi arus balik vena dan curah jantung. Tekanan positif yang berlebihan dapat menyebabkan pneumotoraks spontan akibat trauma pada alveoli. Kondisi ini dapat cepat berkembang menjadi pneumotoraks tension, yang lebih jauh lagi mengganggu arus balik vena, curah jantung dan tekanan darah. Untuk mengevaluasi fungsi jantung perawat terutama harus memperhatikan tanda dan gejala hipoksemia dan hipoksia (gelisah,gugup, kelam fakir, takikardi, takipnoe, pucat yang berkembang menjadi sianosis, berkeringat dan penurunan haluaran urin).
2. Pengkajian Peralatan

Ventilator juga harus dikaji untuk memastikan bahwa ventilator pengaturannya telah dibuat dengan tepat. Dalam memantau ventilator, perawat harus memperhatikan hal-hal berikut :
  • Jenis ventilator
  • Cara pengendalain (Controlled, Assist Control, dll)
  • Pengaturan volume tidal dan frekunsi
  • Pengaturan FIO2 (fraksi oksigen yang diinspirasi)
  • Tekanan inspirasi yang dicapai dan batasan tekanan.
  • Adanya air dalam selang,terlepas sambungan atau terlipatnya selang.
  • Humidifikasi
  • Alarm
  • PEEP
Catatan

Jika terjadi malfungsi system ventilator, dan jika masalah tidak dapat diidentifikasi dan diperbaiki dengan cepat, perawat harus siap memberikan ventilasi kepada klien dengan menggunakan Bag Resuscitation Manual.

Pemeriksaan Diagnostik

Pemeriksaan Diagnostik yang perlu dilakukan pada klien dengan ventilasi mekanik yaitu :
  1. Pemeriksaan fungsi paru
  2. Analisa gas darah arteri
  3. Kapasitas vital paru
  4. Kapasitas vital kuat
  5. Volume tidal
  6. Inspirasi negative kuat
  7. Ventilasi semenit
  8. Tekanan inspirasi
  9. Volume ekspirasi kuat
  10. Aliran-volume
  11. Sinar X dada
  12. Status nutrisi / elaktrolit.
Diagnosa Keperawatan
  1. Kerusakan pertukaran gas yang brhubungan dengan penyakit yang mendasari, atau penyesuaian pengaturan ventilator selama stabilisasi atau penyapihan .
  2. Ketidakefektifan bersihan jalan nafas yang berhubungan dengan pembentukan lendir yang berkaitan dengan ventilasi mekanik tekanan positif .
  3. Risiko terhadap trauma dan infeksi yang berhubungan dengan intubasi endotrakea dan trakeostomi.
  4. Kerusakan mobilitas fisik yang berhubungan dengan ketergantungan ventilator
  5. Kerusakan komunikasi verbal yang berhubungan dengan tekanan selang endotrakea dan pemasangan pada ventilator.
  6. Koping individu tidak efektif dan ketidakberdayaan yang berhubungan dengan ketergantungan pada ventilator.
Masalah kolaboratif /Komplikasi Potensial
  1. Melawan kerja ventilator
  2. Masalah-masalah ventilator – peningkatan dalam tekanan jalan nafas nafas puncak ; penurunan tekanan ; kehilangan volume
  3. Gangguan kardiovaskuler
  4. Barotrauma dan pneumothoraks
  5. Infeksi paru
Perencanaan dan Implementasi

Tujuan utama bagi pasien yaitu : pertukaran gas optimal; penurunan akumulasi lendir; tidak terdapat trauma atau infeksi ; pencapaian mobilisasi yang optimal ; penyesuaian terhadap metode komunikasi non verbal ; mendapatkan tindakan koping yang berhasil ; dan tidak terjadi komplikasi. Asuhan keperawatan pada pasien dengan ventilasi mekanik membutuhkan teknik dan keterampilan interpersonal yang unik, antara lain :

1. Meningkatkan pertukaran gas

  • Tujuan menyeluruh ventilasi mekanik adalah untuk mengoptimalkan pertukaran gas dengan mempertahankan ventilasi alveolar dan pengiriman oksigen. Perubahan dalam pertukaran gas dapat dikarenakan penyakit yang mendasari atau factor mekanis yang berhubungan dengan penyesuaian dari mesin dengan pasien. Tim perawatan kesehatan, termasuk perawat , dokter, dan ahli terapi pernafasan , secara kontinu mengkaji pasien terhadap pertukaran gas yang adekuat , tanda dan gejala hipoksia, dan respon terhadap tindakan. Pertukaran gas yang tidak adekuat dapat berhubungan dengan faktor-faktor yang sangat beragam; tingkat kesadaran, atelektasis, kelebihan cairan, nyeri insisi, atau penyakit primer seperti pneumonia. Pengisapan jalan nafas bawah disertai fisioterapi dada ( perkusi,fibrasi ) adalah strategi lain untuk membersihkan jalan nafas dari kelebihan sekresi karena cukup bukti tentang kerusakan intima pohon trakeobronkial. Intervensi keperawatan yang penting pada klien yang mendapat ventilasi mekanik yaitu auskultasi paru dan interpretasi gas darah arteri. Perawat sering menjadi orang pertama yang mengetahui perubahan dalam temuan pengkajian fisik atau kecenderungan signifikan dalam gas darah yang menandakan terjadinya masalah ( pneumotoraks, perubahan letak selang, emboli pulmonal ).
2. Penatalaksanaan jalan nafas
  •  Ventilasi tekanan positif kontinu meningkatkan pembentukan sekresi apapun kondisi pasien yang mendasari. Perawat harus mengidentifikasi adanya sekresi dengan auskultasi paru sedikitnya 2-4 jam. Tindakan untuk membersihakn jalan nafas termasuk pengisapan, fisioterapi dada, perubahan posisi yang sering, dan peningkatan mobilitas secepat mungkin. Humidifikasi dengan cara ventilator dipertahankan untuk membantu pengenceran sekresi sehingga sekresi lebih mudah dikeluarkan. Bronkodilator baik intravena maupun inhalasi, diberikan sesuai dengan resep untuk mendilatasi bronkiolus.
3. Mencegah trauma dan infeksi
  • Penatalaksanaan jalan nafas harus mencakup pemeliharaan selang endotrakea atau trakeostomi. Selang ventilator diposisikan sedemikian rupa sehingga hanya sedikit kemungkinan tertarik atau penyimpangan selang dalam trakea. Perawatan trakeostomi dilakukan sedikitnya setiap 8 jam jika diindikasikan karena peningkatan resiko infeksi. Higiene oral sering dilakukan karena rongga oral merupakan sumber utama kontaminasi paru-paru pada pasien yang diintubasi pada pasien lemah. Adanya selang nasogastrik dan penggunaan antasida pada pasien dengan ventilasi mekanik juga telah mempredisposisikan pasien pada pneumonia nosokomial akibat aspirasi. Pasien juga diposisikan dengan kepala dinaikkan lebih tinggi dari perut sedapat mungkin untuk mengurangi potensial aspirasi isi lambung.
4. Peningkatan tingkat mobilitas optimal
  • Mobilitas pasien terbatas karena dihubungkan dengan ventilator. Mobilitas dan aktivitas otot sangat bermanfaat karena menstimuli pernafasan dan memperbaiki mental. Latihan rentang gerak pasif/aktif dilakukan tiap 8 jam untuk mencegah atrofi otot, kontraktur dan statis vena.
5. Meningkatkan komunikasi optimal
  • Metode komunikasi alternatif harus dikembangkan untuk pasien dengan ventilasi mekanik. Bila keterbatasan pasien diketahui, perawat menggunakan pendekatan komunikasi; membaca gerak bibir, menggunakan kertas dan pensil, bahasa gerak tubuh, papan komunikasi, papan pengumuman. Ahli terapi bahasa dapat membantu dalam menentuka metode yang paling sesuai untuk pasien.
6. Meningkatkan kemampuan koping.
  • Dengan memberikan dorongan pada klien untuk mengungkapkan perasaan mengenai ventilator, kondisi pasien dan lingkungan secara umum sangat bermanfaat. Memberikan penjelasan prosedur setiap kali dilakukan untuk mengurangi ansietas dan membiasakan klien dengan rutinitas rumah sakit. Klien mungkin menjadi menarik diri atau depresi selama ventilasi mekanik terutama jika berkepanjangan akibatnya perawat harus menginformasikan tentang kemajuannya pada klien, bila memungkinkan pengalihan perhatian seperti menonton TV, bermain musik atau berjalan-jalan jika sesuai dan memungkinkan dilakukan. Teknik penurunan stress (pijatan punggung, tindakan relaksasi) membantu melepaskan ketegangan dan memampukan klien untuk menghadapi ansietas dan ketakutan akan kondisi dan ketergantungan pada ventilator.
Evaluasi

Hasil yang diharapkan dari asuhan keperawatan yang diberikan antara lain :
  1. Menunjukkan pertukaran gas, kadar gas darah arteri, tekanan arteri pulmonal dan tanda-tanda vital yang adekuat.
  2. Menunjukkan ventilasi yang adekuat dengan akumulasi lendir yang minimal.
  3. Bebas dari cedera atau infeksi yang dibuktikan dengan suhu tubuh dan jumlah sel darah putih.
  4. Dapat aktif dalam keterbatasan kemampuan.
  5. Berkomunikasi secara efektif melalui pesan tertulis, gerak tubuh atau alat komunikasi lainnya.
  6. Dapat mengatasi masalah secara efektif.
Penyapihan dari ventilasi mekanik

Kriteria dari penyapihan ventilasi mekanik :

1. Tes penyapihan
  • Kapasitas vital 10-15 cc / kg
  • Volume tidal 4-5 cc / kg
  • Ventilasi menit 6-10 l
  • Frekuensi permenit < 20 permenit 
2. Pengaturan ventilator 
  • FiO2 < 50% 
  • Tekanan ekspirasi akhir positif (PEEP) : 0 
3. Gas darah arteri 
  • PaCO2 normal 
  • PaO2 60-70 mmHg 
  • PH normal dengan semua keseimbangan elektrolit diperbaiki 
4. Selang Endotrakeal 
  • Posisi diatas karina pada foto Rontgen 
  • Ukuran : diameter 8.5 mm 
5. Nutrisi 
  • Kalori perhari 2000-2500 kal 
  • Waktu : 1 jam sebelum makan 
6. Jalan nafas 
  • Sekresi : antibiotik bila terjadi perubahan warna, penghisapan (suctioning) 
  • Bronkospasme : kontrol dengan Beta Adrenergik, Tiofilin atau Steroid 
  • Posisi : duduk, semi fowler 
7. Obat-obatan 
  • Agen sedative : dihentikan lebih dari 24 jam 
  • Agen paralise : dihentikan lebih dari 24 jam 
8. Emosi Persiapan psikologis terhadap penyapihan 

9. Fisik Stabil, istirahat terpenuhi

Sumber

Ventilasi Mekanik

VENTILASI MEKANIK

Pengertian

Ventilasi mekanik adalah alat pernafasan bertekanan negatif atau positif yang dapat mempertahankan ventilasi dan pemberian oksigen dalam waktu yang lama. (Brunner dan Suddarth, 1996).

Klasifikasi

Ventilasi mekanik diklasifikasikan berdasarkan cara alat tersebut mendukung ventilasi, dua kategori umum adalah ventilator tekanan negatif dan tekanan positif.

1. Ventilator Tekanan Negatif
  • Ventilator tekanan negatif mengeluarkan tekanan negatif pada dada eksternal. Dengan mengurangi tekanan intratoraks selama inspirasi memungkinkan udara mengalir ke dalam paru-paru sehingga memenuhi volumenya. Ventilator jenis ini digunakan terutama pada gagal nafas kronik yang berhubungn dengan kondisi neurovaskular seperti poliomyelitis, distrofi muscular, sklerosisi lateral amiotrifik dan miastenia gravis. Penggunaan tidak sesuai untuk pasien yang tidak stabil atau pasien yang kondisinya membutuhkan perubahan ventilasi sering.
2. Ventilator Tekanan Positif
  • Ventilator tekanan positif menggembungkan paru-paru dengan mengeluarkan tekanan positif pada jalan nafas dengan demikian mendorong alveoli untuk mengembang selama inspirasi. Pada ventilator jenis ini diperlukan intubasi endotrakeal atau trakeostomi. Ventilator ini secara luas digunakan pada klien dengan penyakit paru primer. Terdapat tiga jenis ventilator tekanan positif yaitu tekanan bersiklus, waktu bersiklus dan volume bersiklus. Ventilator tekanan bersiklus adalah ventilator tekanan positif yang mengakhiri inspirasi ketika tekanan preset telah tercapai. Dengan kata lain siklus ventilator hidup mengantarkan aliran udara sampai tekanan tertentu yang telah ditetapkan seluruhnya tercapai, dan kemudian siklus mati. Ventilator tekanan bersiklus dimaksudkan hanya untuk jangka waktu pendek di ruang pemulihan. Ventilator waktu bersiklus adalah ventilator mengakhiri atau mengendalikan inspirasi setelah waktu ditentukan. Volume udara yang diterima klien diatur oleh kepanjangan inspirasi dan frekuensi aliran udara . Ventilator ini digunakan pada neonatus dan bayi. Ventilator volume bersiklus yaitu ventilator yang mengalirkan volume udara pada setiap inspirasi yang telah ditentukan. Jika volume preset telah dikirimkan pada klien , siklus ventilator mati dan ekshalasi terjadi secara pasif. Ventilator volume bersiklus sejauh ini adalah ventilator tekanan positif yang paling banyak digunakan.
Gambaran ventilasi mekanik yang ideal adalah :
  1. Sederhana, mudah dan murah
  2. Dapat memberikan volume tidak kurang 1500cc dengan frekuensi nafas hingga 60X/menit dan dapat diatur ratio I/E.
  3. Dapat digunakan dan cocok digunakan dengan berbagai alat penunjang pernafasan yang lain.
  4. Dapat dirangkai dengan PEEP
  5. Dapat memonitor tekanan , volume inhalasi, volume ekshalasi, volume tidal, frekuensi nafas, dan konsentrasi oksigen inhalasi
  6. Mempunyai fasilitas untuk humidifikasi serta penambahan obat didalamnya
  7. Mempunyai fasilitas untuk SIMV, CPAP, Pressure Support
  8. Mudah membersihkan dan mensterilkannya.
Indikasi Klinik

1. Kegagalan Ventilasi
  • Neuromuscular Disease
  • Central Nervous System disease
  • Depresi system saraf pusat
  • Musculosceletal disease
  • Ketidakmampuan thoraks untuk ventilasi
2. Kegagalan pertukaran gas
  • Gagal nafas akut
  • Gagal nafas kronik
  • Gagal jantung kiri
  • Penyakit paru-gangguan difusi
  • Penyakit paru-ventilasi / perfusi mismatch
Modus Operasional

Untuk menentukan modus operasional ventilator terdapat empat parameter yang diperlukan untuk pengaturan pada penggunaan volume cycle ventilator, yaitu :
  1. Frekuensi pernafasan permenit
  2. Tidal volume
  3. Konsentrasi oksigen (FiO2)
  4. Positive end respiratory pressure
Pada klien dewasa, frekuensi ventilator diatur antara 12-15 x / menit. Tidal volume istirahat 7 ml / kg BB, dengan ventilasi mekanik tidal volume yang digunakan adalah 10-15 ml / kg BB. Untuk mengkompensasi dead space dan untuk meminimalkan atelektase (Way, 1994 dikutip dari LeMone and Burke, 1996). Jumlah oksigen ditentukan berdasarkan perubahan persentasi oksigen dalam gas. Karena resiko keracunan oksigen dan fibrosis pulmonal maka FiO2 diatur dengan level rendah. PO2 dan saturasi oksigen arteri digunakan untuk menentukan konsentrasi oksigen. PEEP digunakan untuk mencegah kolaps alveoli dan untuk meningkatkan difusi alveolikapiler.

Modus operasional ventilasi mekanik terdiri dari :

1. Controlled Ventilation
  • Ventilator mengontrol volume dan frekuensi pernafasan. Indikasi untuk pemakaian ventilator meliputi pasien dengan apnoe. Ventilasi mekanik adalah alat pernafasan bertekanan negatif atau positif yang dapat mempertahankan ventilasi dan pemberian oksigen dalam waktu yang lama.Ventilator tipe ini meningkatkan kerja pernafasan klien.
2. Assist/Control
  • Ventilator jenis ini dapat mengontrol ventilasi, volume tidal dan kecepatan.Bila klien gagal untuk ventilasi, maka ventilator secara otomatis. Ventilator ini diatur berdasarkan atas frekuensi pernafasan yang spontan dari klien, biasanya digunakan pada tahap pertama pemakaian ventilator.
3. Intermitten Mandatory Ventilation
  • Model ini digunakan pada pernafasan asinkron dalam penggunaan model kontrol, klien dengan hiperventilasi. Klien yang bernafas spontan dilengkapi dengan mesin dan sewaktu-waktu diambil alih oleh ventilator.
4. Synchronized Intermitten Mandatory Ventilation (SIMV)
  • SIMV dapat digunakan untuk ventilasi dengan tekanan udara rendah, otot tidak begitu lelah dan efek barotrauma minimal. Pemberian gas melalui nafas spontan biasanya tergantung pada aktivasi klien. Indikasi pada pernafasan spontan tapi tidal volume dan/atau frekuensi nafas kurang adekuat.
5. Positive End-Expiratory pressure
  • Modus yang digunakan dengan menahan tekanan akhir ekspirasi positif dengan tujuan untuk mencegah Atelektasis. Dengan terbukanya jalan nafas oleh karena tekanan yang tinggi, atelektasis akan dapat dihindari. Indikasi pada klien yang menederita ARDS dan gagal jantung kongestif yang massif dan pneumonia difus. Efek samping dapat menyebabkan venous return menurun, barotrauma dan penurunman curah jantung.
6. Continious Positive Airway Pressure. (CPAP)
  • Ventilator ini berkemampuan untuk meningkatakan FRC. Biasanya digunakan untuk penyapihan ventilator.
Komplikasi

Komplikasi yang dapat timbul dari penggunaan ventilasi mekanik, yaitu :
  1. Obstruksi jalan nafas
  2. Hipertensi
  3. Tension pneumotoraks
  4. Atelektase
  5. Infeksi pulmonal
  6. Kelainan fungsi gastrointestinal ; dilatasi lambung, perdarahan gastrointestinal.
  7. Kelainan fungsi ginjal
  8. Kelainan fungsi susunan saraf pusat
Sumber
  • http://dezlicious.blogspot.com/

Senin, 10 Mei 2010

Asuhan Keperawatan Pasien dengan CHF

ASUHAN KEPERAWATAN PASIEN DENGAN CHF

Pengkajian

Gagal serambi kiri/kanan dari jantung mengakibtkan ketidakmampuan memberikan keluaran yang cukup untuk memenuhi kebutuhan jaringan dan menyebabkan terjadinya kongesti pulmonal dan sistemik. Karenanya diagnostik dan teraupetik berlnjut . GJK selanjutnya dihubungkan dengan morbiditas dan mortalitas.

1. Aktivitas/istirahat
  • Gejala: Keletihan/kelelahan terus menerus sepanjang hari, insomnia, nyeri dada dengan aktivitas, dispnea pada saat istirahat.
  • Tanda: Gelisah, perubahan status mental misalnya: letargi, tanda vital berubah pad aktivitas.
2. Sirkulasi
  • Gejala: Riwayat HT, IM baru/akut, episode GJK sebelumnya, penyakit jantung , bedah jantung , endokarditis, anemia, syok septic, bengkak pada kaki, telapak kaki, abdomen.
  • Tanda:TD; mungkin rendah (gagal pemompaan), Tekanan Nadi ; mungkin sempit, Irama Jantung; Disritmia, Frekuensi jantung; Takikardia, Nadi apical ; PMI mungkin menyebar dan merubah posisi secara inferior ke kiri, Bunyi jantung ; S3 (gallop) adalah diagnostik, S4 dapat, terjadi, S1 dan S2 mungkin melemah, Murmur sistolik dan diastolic, Warna; kebiruan, pucat abu-abu, sianotik, Punggung kuku; pucat atau sianotik dengan pengisian, kapiler lambat, Hepar ; pembesaran/dapat teraba, Bunyi napas; krekels, ronkhi, Edema; mungkin dependen, umum atau pitting khususnya pada ekstremitas
3. Integritas ego
  • Gejala: Ansietas, kuatir dan takut. Stres yang berhubungan dengan penyakit/keperihatinan finansial (pekerjaan/biaya perawatan medis)
  • Tanda: Berbagai manifestasi perilaku, misalnya: ansietas, marah, ketakutan dan mudah tersinggung.
4. Eliminasi
  • Gejala: Penurunan berkemih, urine berwana gelap, berkemih malam hari (nokturia), diare/konstipasi.
5. Makanan/cairan
  • Gejala: Kehilangan nafsu makan, mual/muntah, penambahan berat badan signifikan, pembengkakan pada ekstremitas bawah, pakaian/sepatu terasa sesak, diet tinggi garam/makanan yang telah diproses dan penggunaan diuretic.
  • Tanda: Penambahan berat badan cepat dan distensi abdomen (asites) serta edema (umum, dependen, tekanan dan pitting).
6. Hygiene
  • Gejala: Keletihan/kelemahan, kelelahan selama aktivitas Perawatan diri.
  • Tanda: Penampilan menandakan kelalaian perawatan personal.
7. Neurosensori
  • Gejala: Kelemahan, pening, episode pingsan.
  • Tanda: Letargi, kusut pikir, diorientasi, perubahan perilaku dan mudah tersinggung.
8. Nyeri/Kenyamanan
  • Gejala: Nyeri dada, angina akut atau kronis, nyeri abdomen kanan atas dan sakit pada otot.
  • Tanda: Tidak tenang, gelisah, focus menyempit danperilaku melindungi diri.
9. Pernapasan
  • Gejala: Dispnea saat aktivitas, tidur sambil duduk atau dengan beberapa bantal, batuk dengn/tanpa pembentukan sputum, riwayat penyakit kronis, penggunaan bantuan pernapasan.
  • Tanda: Pernapasan; takipnea, napas dangkal, penggunaan otot asesori pernapasan. Batuk: Kering/nyaring/non produktif atau mungkin batuk terus menerus dengan/tanpa pemebentukan sputum. Sputum; Mungkin bersemu darah, merah muda/berbuih (edema pulmonal). Bunyi napas; Mungkin tidak terdengar. Fungsi mental; Mungkin menurun, kegelisahan, letargi. Warna kulit; Pucat dan sianosis.
10. Keamanan
  • Gejala: Perubahan dalam fungsi mental, kehilangankekuatan/tonus otot, kulit lecet.
11. Interaksi sosial
  • Gejala: Penurunan keikutsertaan dalam aktivitas sosial yang biasa dilakukan.
12. Pembelajaran/pengajaran
  • Gejala: menggunakan/lupa menggunakan obat-obat jantung, misalnya: penyekat saluran kalsium.
  • Tanda: Bukti tentang ketidak berhasilan untuk meningkatkan.
Diagnosa dan Intervensi Keperawatan

1. Penurunan curah jantung berhubungan dengan Perubahan kontraktilitas miokardial/perubahan inotropik, Perubahan frekuensi, irama dan konduksi listrik, Perubahan structural.

Ditandai dengan :
  • Peningkatan frekuensi jantung (takikardia): disritmia, perubahan gambaran pola EKG
  • Perubahan tekanan darah (hipotensi/hipertensi).Bunyi ekstra (S3 & S4)
  • Penurunan keluaran urine
  • Nadi perifer tidak teraba
  • Kulit dingin kusam
  • Ortopnea,krakles, pembesaran hepar, edema dan nyeri dada.
Tujuan :
  • Klien akan menunjukkan tanda vital dalam batas yang dapat diterima (disritmia terkontrol atau hilang) dan bebas gejala gagal jantung, melaporkan penurunan epiode dispnea, angina, Ikut serta dalam aktivitas yang mengurangi beban kerja jantung.
Intervensi :
  • Auskultasi nadi apical; kaji frekuensi, iram jantung. Rasional: Biasanya terjadi takikardi (meskipun pada saat istirahat) untuk mengkompensasi penurunan kontraktilitas ventrikel.
  • Catat bunyi jantung. Rasional: S1 dan S2 mungkin lemah karena menurunnya kerja pompa. Irama Gallop umum (S3 dan S4) dihasilkan sebagai aliran darah ke serambi yang disteni. Mur-mur dapat menunjukkan inkompetensi/stenosis katup.
  • Palpasi nadi perifer. Rasional: Penurunan curah jantung dapat menunjukkan menurunnya nadi radial, popliteal, dorsalis, pedis dan posttibial. Nadi mungkin cepat hilang atau tidak teratur untuk dipalpasi dan pulse alternan.
  • Pantau TD. Rasional: Pada GJK dini, sedng atu kronis tekanan drah dapat meningkat. Pada HCF lanjut tubuh tidak mampu lagi mengkompensasi dan hipotensi tidak dapat normal lagi.
  • Kaji kulit terhadap pucat dan sianosis. Rasional: Pucat menunjukkan menurunnya perfusi perifer sekunder terhadap tidak adekutnya curah jantung; vasokontriksi dan anemia. Sianosis dapt terjadi sebagai refrakstori GJK. Area yang sakit sering berwarna biru atu belang karena peningkatan kongesti vena.
  • Berikan oksigen tambahan dengan kanula nasal/masker dan obat sesuai indikasi (kolaborasi). Rasional: Meningkatkn sediaan oksigen untuk kebutuhan miokard untuk melawan efek hipoksia/iskemia. Banyak obat dapat digunakan untuk meningkatkan volume sekuncup, memperbaiki kontraktilitas dan menurunkan kongesti.
2. Aktivitas intoleran berhubungan dengan ketidakseimbangan antar suplai oksigen. Kelemahan umum, Tirah baring lama/immobilisasi.

Ditandai dengan :
  • Kelemahan, kelelahan, perubahan tanda vital, adanya disritmia, dispnea, pucat, berkeringat.
Tujuan /kriteria evaluasi :
  • Klien akan berpartisipasi pada aktivitas yang diinginkan, memenuhi perawatan diri sendiri, mencapai peningkatan toleransi aktivitas yang dapat diukur, dibuktikan oleh menurunnya kelemahan dan kelelahan.
Intervensi :
  • Periksa tanda vital sebelum dan segera setelah aktivitas, khususnya bila klien menggunakan vasodilator, diuretic dan penyekat beta. Rasional: Hipotensi ortostatik dapat terjadi dengan aktivitas karena efek obat (vasodilasi), perpindahan cairan (diuretic) atau pengaruh fungsi jantung.
  • Catat respons kardiopulmonal terhadap aktivitas, catat takikardi, disritmia, dispnea berkeringat dan pucat. Rasional: Penurunan/ketidakmampuan miokardium untuk meningkatkan volume sekuncup selama aktivitas dpat menyebabkan peningkatan segera frekuensi jantung dan kebutuhan oksigen juga peningkatan kelelahan dan kelemahan.
  • Evaluasi peningkatan intoleran aktivitas. Rasional: Dapat menunjukkan peningkatan dekompensasi jantung daripada kelebihan aktivitas.
  • Implementasi program rehabilitasi jantung/aktivitas (kolaborasi) Rasional: Peningkatan bertahap pada aktivitas menghindari kerja jantung/konsumsi oksigen berlebihan. Penguatan dan perbaikan fungsi jantung dibawah stress, bila fungsi jantung tidak dapat membaik kembali.
3. Kelebihan volume cairan berhubungan dengan menurunnya laju filtrasi glomerulus (menurunnya curah jantung)/meningkatnya produksi ADH dan retensi natrium/air.

Ditandai dengan :
  • Ortopnea, bunyi jantung S3, oliguria, edema, peningkatan berat badan, hipertensi, Ddstres pernapasan, bunyi jantung abnormal.
Tujuan /kriteria evaluasi :
  • Klien akan mendemonstrasikan volume cairan stabil dengan keseimbangan masukan danpengeluaran, bunyi nafas bersih/jelas, tanda vital dalam rentang yang dapat diterima, berat badan stabil dan tidak ada edema, menyatakan pemahaman tentang pembatasan cairan individual.
Intervensi :
  • Pantau pengeluaran urine, catat jumlah dan warna saat dimana diuresis terjadi. Rasional: Pengeluaran urine mungkin sedikit dan pekat karena penurunan perfusi ginjal. Posisi terlentang membantu diuresis sehingga pengeluaran urine dapat ditingkatkan selama tirah baring.
  • Pantau/hitung keseimbangan pemasukan dan pengeluaran selama 24 jam. Rasional: Terapi diuretic dapat disebabkan oleh kehilangan cairan tibatiba/berlebihan (hipovolemia) meskipun edema/asites masih ada.
  • Pertahakan duduk atau tirah baring dengan posisi semifowler selama fase akut. Rasional: Posisi tersebut meningkatkan filtrasi ginjal dan menurunkan produksi ADH sehingga meningkatkan diuresis.
  • Pantau TD dan CVP (bila ada). Rasional: Hipertensi dan peningkatan CVP menunjukkan kelebihan cairan dan dapat menunjukkan terjadinya peningkatan kongesti paru, gagal jantung.
  • Kaji bisisng usus. Catat keluhan anoreksia, mual, distensi abdomen dan konstipasi. Rasional: Kongesti visceral (terjadi pada GJK lanjut) dapat mengganggu fungsi gaster/intestinal.
  • Pemberian obat sesuai indikasi (kolaborasi)
  • Konsul dengan ahli diet. Rasional: perlu memberikan diet yang dapat diterima klien yang memenuhi kebutuhan kalori dalam pembatasan natrium.
4. Resiko tinggi gangguan pertukaran gas berhubungan dengan perubahan membran kapiler-alveolus.

Tujuan /kriteria evaluasi :
  • Klien akan mendemonstrasikan ventilasi dan oksigenisasi adekuat pada jaringan ditunjukkan oleh oksimetri dalam rentang normal dan bebas gejala distress pernapasan, berpartisipasi dalam program pengobatan dalam batas kemampuan/situasi.
Intervensi:
  • Pantau bunyi nafas, catat krekles. Rasional: menyatakan adnya kongesti paru/pengumpulan secret menunjukkan kebutuhan untuk intervensi lanjut.
  • Ajarkan/anjurkan klien batuk efektif, nafas dalam. Rasional: membersihkan jalan nafas dan memudahkan aliran oksigen.
  • Dorong perubahan posisi. Rasional: Membantu mencegah atelektasis dan pneumonia.
  • Kolaborasi dalam Pantau/gambarkan seri GDA, nadi oksimetri. Rasional: Hipoksemia dapat terjadi berat selama edema paru.
  • Berikan obat/oksigen tambahan sesuai indikasi
5. Resiko tinggi terhadap kerusakan integritas kulit berhubungan dengan tirah baring lama, edema dan penurunan perfusi jaringan.

Tujuan/kriteria evaluasi :
  • Klien akan mempertahankan integritas kulit, mendemonstrasikan perilaku/teknik mencegah kerusakan kulit.
Intervensi :
  • Pantau kulit, catat penonjolan tulang, adanya edema, area sirkulasinya terganggu/pigmentasi atau kegemukan/kurus. Rasional: Kulit beresiko karena gangguan sirkulasi perifer, imobilisasi fisik dan gangguan status nutrisi.
  • Pijat area kemerahan atau yang memutih. Rasional: meningkatkan aliran darah, meminimalkan hipoksia jaringan.
  • Ubah posisi sering ditempat tidur/kursi, bantu latihan rentang gerak pasif/aktif. Rasional: Memperbaiki sirkulasi waktu satu area yang mengganggu aliran darah.
  • Berikan perawatan kulit, minimalkan dengan kelembaban/ekskresi. Rasional: Terlalu kering atau lembab merusak kulit/mempercepat kerusakan.
  • Hindari obat intramuskuler. Rasional: Edema interstisial dan gangguan sirkulasi memperlambat absorbsi obat dan predisposisi untuk kerusakan kulit/terjadinya infeksi.
6. Kurang pengetahuan (kebutuhan belajar) mengenai kondisi dan program pengobatan berhubungan dengan kurang pemahaman/kesalahan persepsi tentang hubungan fungsi jantung/penyakit/gagal.

Ditandai dengan :
  • Pertanyaan masalah/kesalahan persepsi, terulangnya episode GJK yang dapat dicegah.
Tujuan/kriteria evaluasi :
  • Mengidentifikasi hubungan terapi untuk menurunkan episode berulang dan mencegah komplikasi.
  • Mengidentifikasi stress pribadi/faktor resiko dan beberapa teknik untuk menangani.
  • Melakukan perubahan pola hidup/perilaku yang perlu.
Intervensi :
  • Diskusikan fungsi jantung normal. Rasional: Pengetahuan proses penyakit dan harapan dapat memudahkan ketaatan pada program pengobatan.
  • Kuatkan rasional pengobatan. Rasional: Klien percaya bahwa perubahan program pasca pulang dibolehkan bila merasa baik dan bebas gejala atau merasa lebih sehat yang dapat meningkatkan resiko eksaserbasi gejala.
  • Anjurkan makanan diet pada pagi hari. Rasional: Memberikan waktu adequate untuk efek obat sebelum waktu tidur untuk mencegah/membatasi menghentikan tidur.
  • Rujuk pada sumber di masyarakat/kelompok pendukung suatu indikasi. Rasional: dapat menambahkan bantuan dengan pemantauan sendiri/penatalaksanaan dirumah.
Sumber

Congestive Heart Failure (CHF)

CONGESTIVE HEART FAILURE

Pengertian

Gagal jantung adalah keadaan patofisiologik dimana jantung sebagai pompa tidak mampu memenuhi kebutuhan darah untuk metabolisme jaringan. Ciri-ciri yang penting dari defenisi ini adalah pertama defenisi gagal adalah relatif terhadap kebtuhan metabolic tubuh, kedua penekanan arti gagal ditujukan pada fungsi pompa jantung secara keseluruhan. Istilah gagal miokardium ditujukan spesifik pada fungsi miokardium; gagal miokardium umumnya mengakibatkan gagal jantung, tetapi mekanisme kompensatorik sirkulai dapat menunda atau bahkan mencegah perkembangan menjadi gagal jantung dalam fungsi pompanya.

Istilah gagal sirkulasi lebih bersifat umum dari pada gagal jantung. Gagal sirkulasi menunjukkan ketidakmampuan dari sistem kardiovaskuler untuk melakukan perfusi jaringan dengan memadai. Defenisi ini mencakup segala kelainan dari sirkulasi yang mengakibatkan perfusi jaringan yang tidak memadai, termasuk perubahan dalam volume darah, tonus vaskuler dan jantung. Gagal jantung kongetif adalah keadaan dimana terjadi bendungan sirkulasi akibat gagal
jantung dan mekanisme kompenstoriknya. Gagal jantung kongestif perlu dibedakan dengan istilah yang lebih umum yaitu. Gagal sirkulasi, yang hanya berarti kelebihan bebabn sirkulasi akibat bertambahnya volume darah pada gagal jantung atau sebab-sebab diluar jantung, seperti transfusi yang berlebihan atau anuria.

Etiologi dan Faktor Resiko

Gagal jantung adalah komplikasi yang paling sering dari segala jenis penyakit jantung kongestif maupun didapat. Mekanisme fisiologis yang menyebabkan gagal jantung mencakup keadaan-keadaan yang meningkatkan beban awal, beban akhir atau menurunkan kontraktilitas miokardium. Keadaan-keadaan yang meningkatkan beban awal meliputi: regurgitasi aorta dan cacat septum ventrikel. Dan beban akhir meningkat pada keadaan dimana terjadi stenosis aorta dan hipertensi sistemik. Kontraktilitas miokardium dapat menurun pada imfark miokardium dan kardiomiopati.

Faktor-faktor yang dapat memicu perkembangan gagal jantung melalui penekanana sirkulasi yang mendadak dapat berupa: aritmia, infeksi sistemik dan infeksi paru-paru dan emboli paru-paru. Penanganan yang efektif terhadap gagal jantung membutuhkan pengenalan dan penanganan tidak saja terhadap mekanisme fisiologis dan penyakit yang mendasarinya, tetapi juga terhadap faktor-faktor yang memicu terjadinya gagal jantung.

Faktor Fisiologi

Kelainan intrinsik pada kontraktilitas miokardium yang khas pada gagal jantung akibat penyakit jantung iskemik, mengganggu kemampuan pengosongan ventrikel yang efektif. Kontraktilitas ventrikel kiri yang menurun mengurangi curah sekuncup dan meningkatkan volume residu ventrikel.

Tekanan arteri paru-paru dapat meningkat sebagai respon terhadap peningkatan kronis tekanan vena paru. Hipertensi pulmonary meningkatkan tahanan terhadap ejeksi ventrikel kanan. Serentetan kejadian seprti yang terjadi pada jantung kiri, juga akan terjadi pada jantung kanan, dimana akhirnya akan terjadi kongesti sistemik dan edema.
  1. Perkembangan dari kongesti sistemik atau paru-paru dan edema dapat dieksaserbasi oleh regurgitasi fungsional dan katub-katub trikuspidalis atau mitralis bergantian. Regurgitasi fungsional dapat disebabkan oleh dilatasi dari annulus katub atrioventrikularis atau perubahan-perubahan pada orientasi otot papilaris dan kordatendinae yang terjadi sekunder akibat dilatasi ruang.
  2. Sebagai respon terhadap gagal jantung ada tiga meknisme primer yang dapat dilihat; meningkatnya aktifitas adrenergik simpatik, meningkatnya beban awal akibat aktivasi istem rennin-angiotensin-aldosteron dan hipertrofi ventrikel. Ketiga respon ini mencerminkan usaha untuk mempertahankan curah jantung. Meknisme-meknisme ini mungkin memadai untuk mempertahnkan curah jantung pada tingkat normal atau hampir normal pada gagal jantung dini, pada keadaan istirahat. Tetapi kelainan pada kerja ventrikel dan menurunnya curah jantung biasanya tampak pada keadaan beraktivitas. Dengan berlanjutnya gagal jantung maka kompensasi akan menjadi semakin luring efektif.
Penanganan

Gagal jantung ditngani dengan tindakan umum untuk mengurangi beban kerja jantung dan manipulasi selektif terhadap ketiga penentu utama dari fungsi miokardium, baik secar sendiri-sendiri maupun gabungan dari: beban awal, kontraktilitas dan beban akhir. Penanganan biasanya dimulai ketika gejala-gejala timbul pad saat beraktivitas biasa. Rejimen penanganan secar progresif ditingkatkan sampai mencapai respon klinik yang diinginkan. Eksaserbasi akut dari gagal jantung atau perkembangan menuju gagal jantung yang berat dapat menjadi alasan untuk dirawat dirumah sakit atau mendapat penanganan yang lebih agresif.

Pembatasan aktivitas fisik yang ketat merupakan tindakan awal yang sederhana namun sangat tepat dalam pennganan gagal jantung. Tetapi harus diperhatikan jangan sampai memaksakan larangan yang tak perlu untuk menghindari kelemahan otot-otot rangka. Kini telah dikethui bahwa kelemahan otot rangka dapat meningkatkan intoleransi terhadap latihan fisik. Tirah baring dan aktifitas yang terbatas juga dapat menyebabkan flebotrombosis. Pemberian antikoagulansia mungkin diperlukan pad pembatasan aktifitas yang ketat untuk mengendalikan gejala.

Manifestasi Klinis

Manifestasi klinis gagal jantung secara keseluruhan sangat bergantung pada etiologinya. Namun dapat digambarkan sebagai berikut:
  1. Meningkatnya volume intravaskuler.
  2. Kongestif jaringan akibat tekanan arteri dan vena meningkat.
  3. Edema paru akibat peningkatan tekanan vena pulmolalis sehingga cairan mengalir dari kapiler paru ke alveoli, yang dimanifestasikan dengan batuk dan napas pendek.
  4. Edema perifer umum dan penambahan berat badan akibat tekan sistemik.
  5. Turunnya curah jantung akibat darah tidak dapat mencapai jaringa dan organ.
  6. Tekanan perfusi ginjal menurun mengakibatkan pelepasan renin dari ginjal, yang pada gilirannya akan menyebabkan sekresi aldostoron, retensi natrium dan cairan serta peningkatan volume intravaskuler.
Tempat kongestif tergantung dari ventrikal yang terlibat :

1. Disfungsi ventrikel kiri atau gagal jantung kiri

Tanda dan gejala:
  • Dispnea: akibat penimbuan cairan dalam alveoli yang mengganggu pertukaran gas, dapat terjadi saat istirahat atau dicetuskan oleh gerakan yang minimal atau sedang.
  • Ortopnea: kesulitan bernapas saat berbaring
  • Paroximal: nokturna dispnea (terjadi bila pasien sebelumnya duduk lama dengan posisi kaki dan tangan dibawah, pergi berbaring ke tempat tidur)
  • Batuk: biasa batuk kering dan basah yang menghasulkan sputum berbusa dalam jumlah banyak kadang disertai banyak darah.
  • Mudah lelah: akibat cairan jantung yang kurang, yang menghambat cairan dari sirkulasi normal dan oksigen serta menurunnya pembuanggan sisa hasil kataboliame.
  • Kegelisahan: akibat gangguan oksigenasi jaringan, stress akibat kesakitan bernapas, dan pengetahuan bahwa jantung tidak berfungsi dengan baik.
2. Disfungsi ventrikel kanan atau gagal jantung kanan

Tanda dan gejala:
  • Edema ekstremitas bawah atau edema dependen.
  • Hepatomegali dan nyeri tekan pada kuadran kanan batas abdomen.
  • Anoreksia dan mual terjadi akibat pembesaran vena dan status vena didalam rongga abdomen.
  • Nokturna: rasa ingin kencing pada malam hari, terjadi karena perfusi renal didukung oleh posisi penderita pada saat berbaring.
  • Lemah: akibat menurunnya curah jantung, gangguan sirkulasi dan pembuangan produk sampah katabolisme yang tidak adekuat dari jaringan.
Komplikasi

1. Syok kardiogenik
  • Syok kardiogenik ditandai oleh gangguan fungsi ventrikel kiri yang mengakibatkan gangguan fungsi ventrikel kiri yaitu mengakibatkan gangguan berat pada perfusi jaringan dan penghantaran oksigen ke jaringan yang khas pada syok kardiogenik yang disebabkan oleh infark miokardium akut adalah hilangnya 40 % atau lebih jaringan otot pada ventrikel kiri dan nekrosis vocal di seluruh ventrikel karena ketidakseimbangan antara kebutuhan dan supply oksigen miokardium.
2. Edema paru
  • Edema paru terjadi dengan cara yang sama seperti edema dimana saja didalam tubuh. Factor apapun yang menyebabkan cairan interstitial paru meningkat dari batas negative menjadi batas positif.
Penyebab kelainan paru yang paling umum adalah :
  1. Gagal jantung sisi kiri (penyakit katup mitral) dengan akibat peningkatan tekanan kapiler paru dan membanjiri ruang interstitial dan alveoli.
  2. Kerusakan pada membrane kapiler paru yang disebabkan oleh infeksi seperti pneumonia atau terhirupnya bahan-bahan yang berbahaya seperti gas klorin atau gas sulfur dioksida. Masing-masing menyebabkan kebocoran protein plasma dan cairan secara cepat keluar dari kapiler.
Pemeriksaan Diagnostik
  1. EKG : Hipertrofi atrial atau ventrikuler, penyimpangan aksis, iskemia dan kerusakan pola mungkin terlihat. Disritmia misalnya: takhikardi, fibrilasi atrial. Kenaikan segmen ST/T persisten 6 minggu atau lebih setelah imfark miokard menunjukkan adanya aneurime ventricular.
  2. Sonogram : Dapat menunjukkan dimensi pembesaran bilik, perubahan dalam fungsi/struktur katub atau are penurunan kontraktilitas ventricular.
  3. Skan jantung : Tindakan penyuntikan fraksi dan memperkirakan pergerakan dinding.
  4. Kateterisasi jantung : Tekanan bnormal merupakan indikasi dan membantu membedakan gagal jantung sisi kanan verus sisi kiri, dan stenosi katup atau insufisiensi, Juga mengkaji potensi arteri kororner. Zat kontras disuntikkan kedalam ventrikel menunjukkan ukuran bnormal dan ejeksi fraksi/perubahan kontrktilitas.
Penatalaksanaan Medis

Tujuan dasar penatalaksanaan pasien dan gagal jantung adalah :
  1. Dukungan istirahat untuk mengurangi beban kerja jantung.
  2. Meningkatkan kekuatan dan efisiensi kontraksi jantung dengan bahan-bahan farmakologis.
  3. Menghilangkan penimbunan cairan tubuh berlebihan dengan terapi diuretic, diet dan istirahat.
1. Terapi Farmakologis
  • Glukosida jantung, diuretic dan vasodilator merupakan dasar terapi farmakologis gagal jantung.
  • Digitalis meningkatkan kekuatan kontraksi jantung dan memperlambat frekuensi jantung.
2. Terapi Diuretik
  • Diberikan untuk memacu ekresi natrium dan air melalui ginjal, obat ini tidak diperlukan bila pasien bersedia merespon. Pembatasan aktivitas digitalis dan diet rendah natrium, jadwal pemberian obat ditentukan oleh berat badan, furosemid (Lasix) terutama sangat penting dalam terapi gagal jantung karena dapat mendilatasi renula, sehingga meningkatkan kapasitas urea yang pada gilirannya mengurangi preload (darah vena yang kembali ke jantung).
  • Terapi diuretic jangka panjang dapat menyebabkan hiponatremia yang mengakibatkan lemah, letih, malaise, kram otot dan denyut nadi yang kecil dan cepat.
  • Pemberian diuretic dalam dosis besar dan berulang juga bisa mengakibatkan hipokalemia ditandai dengan denyut nadi lemah, suara jantung menjauh, hipertensi, otot kendor, penurunan refleks tendon dan kelemahan umum.
3. Terapi Vasodilator
  • Obat-obatan vasoaktif merupakan pengobatan utama pada penatalaksanaan gagal jantung.
  • Natrium nitraprosida secara intravena melalui infuse yang dipantau tepat dosisnya harus dibatasi agar tekanan systole arteriole tetap dalam batas yang diinginkan.
  • Nitrogliserin.
4. Diit, diit jantung, makanan lunak, rendah garam

5. Pemberian digitalis, membantu kontraksi jantung dan memperlambat frekuensi jantung.
  • Hasil yang diharapkan peningkatan curah jantung, penurunan tekanan vena dan volume darah dan peningkatan diuresis akan mengurangi edema. Pada saat pemberian ini pasien harus dipantau terhadap hilangnya dispnea, ortopnea, berkurangnya krekel, dan edema perifer. Apabila terjadi keracunan ditandai dengan anoreksia, mual dan muntah namun itu gejala awal selanjutnya akan terjadi perubahan irama, bradikardi kontrak ventrikel premature, bigemini (denyut normal dan premature saling berganti ), dan takikardia atria proksimal.
6. Pemberian Diuretic, yaitu unutuk memacu eksresi natrium dan air melalui ginjal.
  • Bila sudah diresepkan harus diberikan pada siang hari agar tidak mengganggu istirahat pasien pada malam hari, intake dan output pasien harus dicatat mungkin pasien dapat mengalami kehilangan cairan setelah pemberian diuretic, pasien juga harus menimbang badannya setiap hari turgor kulit untuk menghindari terjadinya tanda-tanda dehidrasi.
7. Morfin, diberikan untuk mengurangi sesak napas pada asma cardial, hati-hati depresi pernapasan.

8. Pemberian oksigen.

9. Terapi vasodilator dan natrium nitropurisida, obat-obatan vasoaktif merupakan pengobatan utama pada penatalaksanaan gagal jantung untuk mengurangi impedansi (tekanan) terhadap penyemburan darah oleh ventrikel.

Sumber

Sabtu, 08 Mei 2010

Celebrity cookbooks gourmet cakes

gourmet pies are delicious desserts that can be bought in stores. It can be given as a gift, as a dessert for birthdays or anniversaries and other special events. You can also cook one yourself and save a lot of it. You can search through recipe books to guide you.

Some cookbooks gourmet pie recipe:

Cheesecake Cookbook Junior

This recipe cheesecake recipe Alan Rosen and Beth Allen contains 50 deliciousrecipes for cakes, cheesecakes, New York Style.

This is based on best-selling junior cheese restaurant called the restaurant. Now they are telling their favorite recipes of all time for everyone to enjoy its award-winning cheesecakes. Some cheese recipes that include all the cream cheese on a cookie dough and cream, among others. This is the original cheese junior in New York, it all started, until the cheese with a pinch offlavors like Rocky Road Fudge Banana pumpkin mousse.

It also includes recipes for cheesecake as a child in his latest creation, its skyscrapers cheese cake with layers of flavors like coconut carrot cake with lemon, and Boston Cream Pie, among others.

This book was launched in October 2007. And 'illustrated with texts in English. It has about 176 pages. Alan Rosen, author of the book, the little son of Harry Rosen. Therefore, Harry Rosen is the founder ofJunior restaurant is located in Times Square, Grand Central Station and Brooklyn.

The cake mix doctor

This book was made by none other than Anne Byrn. The book focuses mainly on the cake recipes with a touch of care for the package. With a pinch of cocoa powder, unsalted butter, poppy seeds, and eggs, yogurt, vanilla, lemon zest and sherry to make a delicious cake with poppy seeds Charleston.

With the recipes in this book, even beginners canlearn recipes as roasted coconut cake sour cream and devilishly good chocolate cake, caramel holiday Yule log cake and many recipes for cheese. We also have sheet cakes, sandwiches, bars and sweet biscuits and books.

The book consists of 175 cake recipes easy and quick to cook. Foods are tender, moist, deep, rich flavor, even in complex ways. All this thanks to Anne Byrn, a writer who describes himself as a purist and an award-winning cuisine. Its revenue to promote ease of use, convenienceand reliability. It also features a Q & A part of all possible questions and advice on baking cakes shown. This cookbook consists of 464 pages of documents in a novel. It 'was released in November 1999 in the English text.

Southern Cakes: Sweet and irresistible recipes for everyday celebrations

This book was written by renowned cooking teacher, Nancie McDermott. Residents of North Carolina, was able to make this book possible with the assistance of BeckyLuigart-Stayner, a photographer for magazines and living in Alabama.

I like pie recipes south, particularly the chocolate goodness of Mississippi Mud. This book contains 65 recipes, including cakes, peanut Humble pear bread, cakes and sweets Jelly Jam, among others. It also has an entire chapter of coconut and chocolate cakes. You can also learn from their section 101 on the basis of cake baking and finishing, such as meringue pie. He is also involved instorage, providing fresh flavors and length for each section.

Rules Asian restaurants by Steven Shaw

I was pleasantly surprised to see how much I enjoyed reading "Asian Dining Rules: Essential Strategies for release in Japanese, Chinese, South Asian, Korean and Indian restaurants" by Steven A. Shaw. I lived in Japan and Korea, and I traveled all the other Asian countries, and say "I love Asian food" would be an understatement. Unfortunately, life in Montana, I do not understand what I want, so you can be sure that when we travel, Asian restaurants are places you frequentas possible.

Why do I need this guide? Because it is a very good reading for those who love Asian cuisine and is full of interesting facts, stories and choosing foods that people who frequent Asian restaurants may not know.

I confess, I thought this might be a dry boring book I ordered but my love for Asian cuisine made me take this opportunity for me to learn something new. Again, I was surprised, because I not only learned a lot of interesting informationthings, I liked the writing of Shaw and personal anecdotes that make this book a fun read.

This book contains a brief introduction to restaurants in Asia and what is the book. Then there are chapters that focus on certain types of Asian restaurants: Japanese, Chinese, South-east Asia, including Vietnamese, Tagalog, Thai, Cambodia and Korea and India. Here is a brief conclusion.

The book is a list of foods that are in this type of restaurant,While these lists are included. There are a lot of personal experience with specific restaurants that will be useful for travelers who visit these places. But much of the information is widespread, because when you visit these restaurants.

Shaw points out many myths, like the word sushi means "raw fish" or the use of chopsticks in some restaurants and some food. He explained how the pregnant women in Asia are eating raw fish andMSG discussed. There are a lot of information in this book to make the experience much better Asian food.

I have no reservations to this high level of recommendation for people who love to eat Asian restaurant. If you love Asian cuisine, you will enjoy this book.

Sneak vegetables

6 months ago, when two "cookbook evasive" and falsely called The Sneaky Chef Delicious first appearance on the shelves, the debate broke out that these methods of eating healthy foods are really effective or not, because such amount is so little inserted a plate and children (for which the requirements of these books were intended for) could be infected by eating vegetables. Many experts fear that it would suggest that children eat vegetablesside or that their parents were to them.

This debate has not cooled down and the case was rested, but without a real solution. Of course, secretly in small quantities cooked, pureed vegetables in food and deceive their children are not the best ideas, but is a better idea when it comes to hiding vegetables? After examining this issue and do some experiments in the kitchen, I got a solution.

From what I saw, motivation"Cheating" to add a dish of vegetables is more difficult to maintain an opinion has distorted the dish before eating. So really, should not be regarded as a liar, all you have to do is to postpone the announcement of what is in the pot until everyone has finished eating .* So picky eating is a test plate without a beginning and cons, having said that healthy foods contain little by little, you realize that healthy food cantaste.

* To maintain this, we should seek to apply the "do not want to tell you that's in it until you've eaten" exclude all the time (although unhealthy food) to keep your family becomes skeptical when occasionally does not allow the contents of a dish.

Now that we have the ethical problem of our chest, it is time to address the issue of healthy foods. The question is, of course, a vegetable dish can creep unnoticed, but can youactually add enough to significantly increase the nutritional value of a dish? After a little 'experimenting in the kitchen, I have a solution that can, but not all the dishes ...

It seems there are two requirements for a dish is good for sneaking vegetables) The dish must have shown a strong flavor (tomato is one of the best, although it is technically a vegetable ...) b) The dish must be more liquid. Peep the sweet potato cheesecake, a's idea of' author Delicious wrong not to recommend a couple of tablespoons of vegetables that you can enjoy a drink and a half or more (equivalent to a part of the food pyramid) of vegetables in a soup or pasta sauce.

Besides the two main requirements that I discovered other things to do little to improve things ...

puree or vegetables that you want to add a first plate, then gradually adding "powerful ingredient flavor vegetables untiltaste and may not notice the vegetables with ease. Be sure not to add flavor ingredient, as soon as possible.

o Do not forget to add some 'salt and seasoning than usual. Since vegetables are low in sodium and most of the dishes used to eat are high is sodium, but generally not advisable to add salt in a dish, I think a bit here ', it is imperative to make things as usual. You can also add a little 'more than usual seasonings and vegetables that need a little 'more to improve its flavor delicate and natural on a plate.

or not to cook all the vegetables you want to puree. Some raw vegetables may be blended, such as coarsely chopped peppers, mushrooms and zucchini. By adding these purees raw dishes, you can store more nutrients.

Waterless cooking stainless steel cookware Mert

Most of us have learned to cook from our mothers, grandmothers, or perhaps a cookbook. The traditional way to cook more food is put in a stainless steel pot and pan with water and simmer or food . But studies have shown that the best way to keep the nutritional value of food and the natural flavor is cooking without water in special stainless steel containers that can cook food in its own juices. So what are the other benefits ofcooking without water?

Most chefs consider the same problems when cooking:


Easy Cooking
Cooking time
cleaning time
Amount of fat and oil in food
Flavor
Nutritional

waterless cooking easy and may require less time than traditional cooking. The heat is distributed evenly, without burning or paste pots and pans are much easier to clean. Moreover, the oil is not necessary to prevent sticking to his favorite dish low in calories and fat.Cooks Food in its natural juices, which enhances the flavor and keeps its nutritional value.

The principles of waterless cooking are relatively simple and straightforward. High level of kitchen utensils made of stainless steel protects the food. aluminum pans heat up faster, but some studies have shown that aluminum is in some foods that can not be good for your health. waterless cookware is made from high quality stainless steel, and tastes from metal to infiltrate thefood.

Stainless steel pots and pans are also easier to clean and requires no Teflon coating, which can contaminate food. surgical stainless steel is the highest rating, but is more about marketing of cooking.

The bottom of the stainless steel pots are machined flat. This ensures that the area from possible contact with the coils of an electric heater or gas stove grill. A plate of copper or aluminum distributes heat evenly throughout thebottom of the pots and pans that avoids hot spots that can burn food and provide heat to the bottom in all directions.

The lid forms a special seal in water vapor locking natural foods during cooking. This allows food to cook in its juices, and allows the flavor, vitamins and minerals to keep. Much of the nutritional value of vegetables boiled vegetables and cooks pour the cooking water. With the kitchen without waterIt is not necessary to add water because the vegetables contain lots of water. Wastewater vegetables in the kitchen, turns into steam and is located inside the lid and steamed vegetables, in fact, in its broth.

A whistle or steam valve warns the cook in the natural juices to create enough steam, and the cook can turn off the heat, save energy and avoid overcooking. The cooks food at a constant temperature, due to the retention of heat from pots and pansAbility to heat and steam inside the pot. Stainless steel kitchen does not radiate much energy, and iron core or the Board to maintain a constant temperature for cooking continues even with the heat off. This translates into energy savings and is a huge advantage in today's sluggish economy. The food cooks faster even at lower temperatures, and its stock is so much tastier and better for you.

Where can I buy this stainless steel waterless cookwarecook?

Most waterless cookware stainless steel sold by the parties "kitchen" in people's homes. The price of pots pans and kitchen utensils are expensive. You can also buy cheaper pots similar stores, but the quality is not as high.

In a game typical of a salesman (cut) Cookware generally shows how to make a meal with the product, and guests can see the process and taste of food. The host or hostess receives a house without a pot as a rewardfor the party (the addition of costs for the product).

I attended cooking parties in the past and found the taste of cooked foods with utensils made of stainless steel without water is excellent, tender and tasty, without the use of oil. The advantage is that the food for the first time at the table in 10 minutes. The food does not stick to washing pots and pans in stainless steel is a breeze. Broccoli is simply delicious and very tasty. The potatoes were good, andThe chicken is done consistently and tasty.

What really interested in cooking without water. I like to cook and give me always interested in new ideas and recipes. Unfortunately, stainless steel cookware sold without water in the kitchen of the holiday is extemely expensive. A set of pots and pans of the same brand was more than $ 2,000 $ 5,000! Due to its construction, kitchen utensils without water is a higher and higher production costs. There are several sites that carry this type of cookwarevery reasonable prices. They also have the same quality cookware sold in the holiday kitchen.

Cooking dinner in under 30 minutes - Western Style Couscous

Couscous was misinterpreted for a long time. Most people do not know what it is and do not know how to cook. Now you can discover how easy it is to add to your couscous lunch any time of day.

This recipe is vegetarian, but if you prefer, you can add strips of cooked chicken, prawns or turkey stew recipe to do so under their tastes.

1 10 oz package of couscous

2 cups diced tomatoes

1 cup bean blacks - Cookedand drained

3 cups vegetable broth

½ cup chopped onion

Mix ½ red, yellow and green peppers, diced

2 cloves garlic, crushed or chopped

2 tablespoons olive

2 green onions, diced

1 teaspoon lemon juice

2 tablespoons chopped parsley

¼ c. teaspoon white pepper
In a large cast () pan, sauté garlic, onion and peppers in olive oil until tender, stirring frequently. cook3 minutes
Gradually add the vegetable broth.
That garlic, peppers and broth to a boil constant.
Stir in the couscous in boiling broth. Add tomatoes and beans blacks and white pepper.
Cook the couscous according to package directions.
Remove couscous from heat and add shallots and lemon juice
Fluff and let sit for 5 minutes before serving.
Garnish with chopped parsley. Add salt if necessary.

TheWestern Style Couscous can be served as side dish or main dish can be served hot or cold.

Jumat, 07 Mei 2010

Allergy Management

These canicule of accretion abuse levels beggarly that added and added bodies are acceptable victims of a array of allergens, which are the assorted substances that account an allergic reaction. These can be annihilation from a allergic assertive blazon of aliment appearance to pet acrimony or alike a assertive actinic that is present in seafood. There are additionally added and added accouchement actuality built-in with allergies, so there is an all-over acceleration in the accident of allergies. Accustomed the appulse that allergies can accept on a person’s life, there are a array of accessories accessible that can advice to abatement the appearance of assertive allergens in a specific environment. This has helped accomplish the lives of abounding bodies who accept astringent allergies a lot easier and aloft their affection of life.

There are, however, no methods of curing allergies and accordingly the best admeasurement that can be taken is to actualize an ambiance area the accident of the allergens is abundantly reduced. The severity of the abhorrence additionally has a address on what measures charge be taken to ensure that there are no allergens present in a accustomed environment. For example, if the allergen is independent in aliment again abnormally acrimonious measures charge be taken to ensure that none is alloyed with added food, back the affliction blazon of abhorrence reactions tend to be back somebody swallows article that contains the allergen.

The affliction allergic acknowledgment is back a actuality goes into anaphylactic shock, which can advance to afterlife if not advised in time. Alike if the abhorrence is not as astringent as that, there is still the accustomed ache that will lower the affection of activity for anyone who has to alive with this. The blazon and severity of the abhorrence will be the chargeless accomplish back chief what accomplish charge to be taken to ensure that actuality adversity from the abhorrence is kept out of harms way. The simplest footfall is to abstain the antecedent of the allergens, but in some cases this may able-bodied be impossible.

One of the best accepted allergies is declared as actuality allergic to “dust”, this is about a misconception. There are actual few bodies who are absolutely allergic to dust, but there are a actual ample allocation of bodies who are allergic to dust mites and their excretions. These dust mites are frequently begin in domiciliary dust, pet acrimony and feathers. There are actual few bodies that can actualize an ambiance that is absolutely chargeless of these allergens after activity to massive expense. There are about articles accessible that can abatement the bulk of these allergens in the actual environment, decidedly in the bed room.

There are articles accessible that can abatement the accident of allergens that frequently action in the home. These can advice to acknowledgment the accepted of active for those with balmy allergies to that of those who do not ache from allergies. These articles can additionally advice those who ache from astringent allergies, but are absurd to absolutely annihilate the antecedent of the allergy, depending on what absolutely the antecedent is. The better aid to those with astringent allergies is a connected accumulation of anti-histamines. The articles will advice to stop the added affliction of the allergic reactions.

ACL Reconstruction surgery

Going through ACL Reconstruction surgery is not accessible for anyone. The pain, discomfort, acne and foreignness of accepting an anchored limb will be absolutely a abandonment from the course of a circadian routine.

This abnormally holds accurate for the alive developed who chooses to or needs to accept ACL Reconstruction Surgery. One day you are at atomic able to move about on your own, and the abutting you are absolutely bedfast to a comatose position. However, with some patience, adamantine assignment and dedication, you will be aback to your alive lifestyle, alike stronger than you were afore surgery.

The aboriginal ages afterwards surgery is difficult – you are abundantly bedfast to a bed except for hygiene purposes, the acne in your leg and abate may be abundant and the affliction will ebb and breeze as the day goes on. However, there are accomplish that you can booty to accomplish the accretion action as quick and advantageous as possible.

1. Prior to surgery, adapt the breadth breadth you will be comatose afterwards the surgery. Try to accumulate some account abstracts (magazines, books, assignment materials), accomplish abiding that you accept a wireless or cordless buzz adjacent and accumulate affluence of pillows so you can abutment and drag the repaired leg. If you accept one, accomplish abiding to accompany your laptop and ability bond to your recuperation breadth and ensure that your wireless internet (if applicable) is operational to admonition canyon the time.

2. If you accept adolescent children, adapt them for the actuality that you are activity to be anchored for a aeon of time and that they cannot rough-house about you while you are recovering.

3. Booty it accessible for the aeon adapted afterwards surgery and afore your aboriginal concrete analysis session. Accord your accomplished anatomy – mind, leg and spirit – time to heal. Remember – you accept aloof gone through a above surgery and you charge to accept a accretion aeon from it.

4. Booty your meds as instructed by your doctor! Your doctor has accustomed them to you for a reason. Most acceptable your medications are not alone to admonition allay pain, but to admonition abate deepening from the surgery.

5. Ice, ice, ice, ice and ice. Along with your medications, ice will admonition abate inflammation, acne and pain. Accomplish abiding to stick to your doctor’s advocacy as to the icing breach and abundance for your anew repaired knee.

6. Ask for help. You could apparently go through the accretion action on your own, but await on those who can and will admonition you wherever possible.

7. Ask your doctor if a stool softener would be adapted during your accretion period. Some of the medicines that are assigned to allay affliction and acne may account constipation, and a stool softener will admonition annul this possibility.

8. Stay hydrated. You may not feel like bubbler water, but accomplish abiding to not bankrupt your anatomy of it’s bare aqueous intake.

9. Request that the bound breadth aural your abode that you will be affective through be kept almost orderly. You will charge to be on crutches, and you do not charge to be abyssal through a sea of toys and laundry on the attic as you are aggravating to apprentice how to use them.

If you chase your doctor’s orders, be active about alleviative yourself adapted during your post-surgery accretion and accord your anatomy the blow it needs, you will anon be assimilate the abutting appearance of your alley to course – the alpha of concrete therapy.

The admonition in this commodity is for educational purposes alone and does not aggregate medical admonition or medical surgery services. If you accept or doubtable that you accept a medical problem, acquaintance your doctor promptly.

Acquired Immune Deficiency Syndrome

For almost 30 years, health officials have struggled to contain AIDS, which is now known to be the end result of HIV infection.

Acquired immune deficiency syndrome (AIDS) is a syndrome of opportunistic and rare diseases caused by the eradication of the immune system by the human immunodeficiency virus (HIV). A diagnosis of AIDS is made when a person tests positive for HIV, has a low white blood cell count, and suffers from a range of opportunistic infections that take advantage of the immune deficiency caused by HIV. People sometimes refer to HIV as the AIDS virus because the visible manifestation of HIV infection is the range of opportunistic infections known as AIDS.
HIV Transmission

HIV infection occurs when body fluids are transferred from an infected individual and another individual. The most common means are blood to blood via shared needles, semen and vaginal secretions between partners during sexual interactions, and breast milk from mother to child. Also, different strains of HIV are better able to be transmitted in different ways.

Example: HIV-1M (Major) clade e excels at being taken up by vaginal dendritic cells, which is facilitated by inflammation, particularly in the context of other sexually transmitted diseases (STDs).
The Course of HIV Infection Ending in AIDS

The AIDS virus infects immune cells, including T cells and dendritic cells. The virus infects T cells by attaching to surface proteins and injecting its genetic material and the enzymes necessary for its propagation in the cells. Upon the initial exposure to HIV, the immune system responds to fight off the infection, and flu like symptoms are common. This initial response, though mostly futile on the part of the body, is condiered the early, or acute, stage of HIV infection.

The virus can lie dormant within the immune cells for years, sometimes decades. This period of time is considered the middle, or chronic, stage of infection. During this time, the virus increases its numbers while residing safely within the cells of the very system meant to destroy it. Eventually, the virus numbers increase beyond the capacity of the host cell and burst out to infect even more T cells. When the immune system becomes alerted and attempts to fight off the infection, T cells are activated, resulting in even more viral particles.

After several years, the time frame varies based on the patient and strain, so few immune cells are left that the infected individual is not protected against new or common infections. These opportunistic infections defined the syndrome known as AIDS, the final, or crisis, and fatal stage of HIV infection.
Read on

* The Four Stages of HIV Infection
* The 2008 Nobel Prize in Medicine
* The HIV Virus

Antiretroviral medications stop the virus from propagating, holding it in a perpetual state of dormancy. This dormancy postpones the immune system breakdown, increasing the life span of the infected individual by 10 years or more. Twenty years ago, patients were found to succumb to AIDS within 5 years of left untreated.
Dissenting Opinions about AIDS and HIV

The International AIDS Society, which represents more than 11,000 professionals worldwide that work with HIV, publicly opposes the efforts of AIDS deniers, the term given to those who question that HIV causes AIDS. The dissenting opinions point to studies performed before retrovirus research discerned the mechanism of HIV infection and the course of disease. The anti-HIV/AIDS movement blames homosexuals and drug-users for the disease. Denier groups, such as Alive and Well, teach that anal sex, stress, and long-term drug use results in the immune deficiency syndrome. Such initiatives endanger individuals by propagating the idea that HIV prevention is unnecessary and that anti-retroviral medications are not necessary, or even the cause of the disease themselves.
HIV Testing

HIV infection is most commonly determined by an antibody test, the classic method of determining exposure. There is also now an RNA test that detects the presence of HIV by directly testing for its genetic material. Regardless of which test is used, a positive result is always followed by another test for confirmation. Beginning pharmaceutical therapy soon after diagnosis is so far the best means to keep AIDS at bay.

Aicardi Syndrome

It is a ataxia that is categorized by the fractional or complete malfunction of the bulk callosum, a academician anatomy bond two hemispheres central it. Aicardi affection generally causes adolescence access (intantile spasms), eye aberancy or lesions of the retina, and metal retardation. Aicardi Affection is additionally affiliated to microcephaly, a academician defect; microgyria, area bumps central the academician tend to be narrow; or porecenphalic cysts, a academician action causing fluids to ample the gaps in the brain. Added studies additionally announce that a few abnormalities may accommodate a broken lip and vertebral anatomy malfunction.

It is children, amid three to bristles months, who are best generally branded with Aicardi Syndrome. These accouchement are after-effects of accustomed births, but accept developed the aberancy as anon as they acquaintance academician spasms. Babyish spasms at this age causes neural synapses to close, thereby inhibiting the babies’ academician development. Hence, best cases accept abstinent to actual astringent degrees of retardation. An babyish afflicted with the affection may additionally acquaintance delays in development. They could additionally accept adversity back it comes to respiratory infections like pneumonia and this could appropriately account their expiration.

The acoustic ataxia was aboriginal diagnosed added than thirty years ago, back French doctor, Dr. Jean Dennis Aicardi, articular eight accouchement who always acquaintance babyish spasms. The doctor believed the affection was acquired by a absence in the changeable chromosome (X). Hence, the ataxia alone affects majority of changeable infants, although there is one appear case of a babyish boy diagnosed with the syndrome. Currently, there are about 500 appear cases worldwide, with alone one case of ancestors afflicted with the condition. Therefore it is believed that the ataxia is a fresh alteration and not all of the ancestors associates may backpack the abnormal gene

There is currently no cure for Aicardi Syndrome. A appropriate analysis may be recommended to administer the seizures, usually in the anatomy of anti-seizure medicines. A few action programs to administer brainy amentia are additionally administered. Physical and anatomic analysis may additionally be recommended to aid the adolescent in her development. The activity assumption for an babyish afflicted with Aicardi affection is abased on how astringent the action is.

The National Institute of Acoustic Ataxia and Stroke (NINDS) is currently accomplishing an all-encompassing analysis on Aircardi Syndrome. The cold is to actuate and added accept the analysis complex to be able to acquisition more good treatment, blockage and ultimately, a cure for this disorder.

How To Overcome Adrenal fatigue

Your adrenal glands are two tiny pyramid-shaped pieces of tissue anchored adapted aloft anniversary kidney. Their job is to aftermath and release, back appropriate, assertive authoritative hormones and actinic messengers.

Adrenaline is bogus in the autogenous of the adrenal gland, alleged the adrenal medulla. Cortisol, the added actinic from the adrenal gland, is fabricated in the exoteric allocation of the gland, alleged the adrenal cortex. The case additionally secretes androgens, estrogens, and progestins. Cortisol, frequently alleged hydrocortisone, is the best abounding — and one of the best important — of abounding adrenal case hormones. Cortisol helps you handle longer-term accent situations.

In accession to allowance you handle stress, these two primary adrenal hormones, adrenaline and cortisol, forth with others analogously produced, advice

control anatomy aqueous balance, claret pressure, claret sugar, and added axial metabolic functions.

In the acute afraid accompaniment of adrenal burnout, the anatomy overproduces adrenaline, cortisol and added accent hormones. Constant accent and poor diet can abate the adrenal glands. Eventually, this causes the adrenal glands, the advanced band in the accent reaction, to appearance abrasion and breach and become depleted. This frequently leads to crime in the thyroid gland, which can account a added abatement in activity akin and affection and is one of the affidavit why abounding bodies accept thyroid glands that don’t assignment well.

When accent continues over abiding periods of time, the adrenal glands can bankrupt the body’s hormonal and activity reserves, and the glands may either compress in admeasurement or hypertrophy (enlarge). The overproduction of adrenal hormones acquired by abiding accent can abate the allowed arrangement and arrest the assembly of white claret beef that assure the anatomy adjoin adopted invaders (in accurate lymphocytes and lymph bulge function).

Adrenal dysfunction can agitate the body’s claret amoroso metabolism, causing weakness, fatigue, and a activity of actuality run down. It can additionally baffle with accustomed beddy-bye rhythms and aftermath a wakeful, unrelaxing beddy-bye state, authoritative a being feel beat out alike afterwards a abounding night’s sleep.

Common Causes of Adrenal Stress

• Anger

• Fear / Worry /Anxiety

• Depression

• Guilt

• Overwork/ concrete or brainy ache

• Excessive exercise

• Sleep denial

• Light-cycle disruption

• Going to beddy-bye backward

• Surgery

• Trauma/injury

• Chronic deepening

• Chronic infection

• Chronic affliction

• Temperature extremes

• Toxic acknowledgment

• Malabsorption

• Maldigestion

• Chronic affliction

• Chronic-severe allergies

• Hypogycemia

• Nutritional deficiencies

Testing for Adrenal Health

In adjustment to actuate the bloom of your adrenal glands you charge to accept a simple blood, urine, or saliva analysis such as the Adrenal Accent Index performed by your practitioner. Cortisol levels can be arrested throughout the day by saliva or in the am by blood. DHEA, and Epinephrine, are some added indicators of adrenal function. The advice provided by testing can advice to actuate the best adapted blazon of treatment.

Associated Symptoms and Consequences of Impaired Adrenal Functioning

• Low anatomy temperature

• Weakness

• Unexplained beard accident

• Nervousness/Panic Attacks

• Difficulty architecture beef

• Irritability

• Mental abasement

• Difficulty accepting weight

• Apprehension

• Hypoglycemia

• Inability to apply

• Excessive ache

• Tendency appear deepening

• Moments of abashing

• Indigestion

• Poor anamnesis

• Feelings of annoyance

• Alternating diarrhea and ache

• Osteoporosis

• Auto-immune diseases/hepatitis

• Lightheadedness

• Palpitations [heart fluttering]

• Dizziness that occurs aloft continuing

• Poor attrition to infections

• Low claret burden

• Insomnia

• Food and/or analgesic allergies

• PMS

• Craving for sweets

• Dry and attenuate bark

• Headaches

• Scanty damp

• Alcohol bent

Treatment

Lifestyle changes such as:

Eating steadily, all day long. Absence commons is one of the affliction things you can do for your body. Back you’re hungry, your claret amoroso drops, affirmation your adrenal glands and triggering your affectionate afraid system. That causes light-headedness, cravings, all-overs and fatigue. Another check to absence meals: The consistent low claret amoroso can affect your adeptness to anticipate acutely and abbreviate your absorption span.

Skipping breakfast is decidedly bad, as it is a abiding blaze way to gain, not lose, weight. If you alpha anniversary morning with a acceptable breakfast and “graze” healthfully every two to four hours, your claret amoroso will abide abiding throughout the day. You’ll feel added adequate and energetic. Eat protein with every meal. Eat Complex carbohydrates such as amber rice. Avoid sugar, clutter food, white pasta, white rice, white bread.

Absolutely NO Caffeine. Coffee/Sodas over stimulates your adrenals and they bankrupt important B vitamins.

Coffee does not accord you energy; coffee gives you the apparition of energy. Coffee absolutely drains the anatomy of activity and makes you added tired, because of vitamin and adrenal depletion.

Exercise to relax. Walking, Yoga, abysmal breathing, meditation, or stretching. No active or aerobic exercise, which depletes the adrenals.

Avoid alcohol, candy foods, and tobacco. Nicotine in tobacco initially raises cortisol levels, but abiding use after-effects in low DHEA, testosterone, and progesterone levels.

Reduce stress; apprentice alleviation techniques such as abysmal breathing, visualization, accelerating beef relaxation.

Helpful Supplements

The use of baby amounts of accustomed adrenal hormone (hydrocortisone) to accompany hardly low adrenal action up to its able accustomed circadian ambit is generally helpful.

Alcoholism and Addictions

Regardless of whether one believes alcoholism and addictions are diseases or not (It is a abashment we are still accepting this altercation in the 21st century), they are absolute problems for millions of bodies and millions aloft millions of families about the apple all through the year. But anniversary seasons and added times of claimed tragedy and accent such as the afterlife of a admired one, a annulment date, etc assume to activation the assurance as able-bodied as the appetite for cocky medication and chemically induced euphoria.

Having battled alcoholism and addictions best of my developed activity (since Viet Nam), the affliction of those who accept bottomed out and accomplished out are abreast and baby to my heart. Bill W, the architect of AA (alcoholics anonymous), accepted that. Both of us, like millions of others the apple over, accept started over added than once, and forth the way we accept abstruse the aching accuracy of the Biblical teaching that no man lives unto himself.

Friends of Bill W apperceive that they cannot accomplish it alone. Aloof like the accumulation censor keeps a church, a club, a school, absolutely a association going, growing and crumbling it keeps the Friends of Bill W on the aisle to a acknowledged and advantageous life.

The acceptable affair is that accustomed we alive to see a alpha sunrise, we accept the befalling to alpha a alpha activity and to advice addition get pleasure a alpha beginning. That does not beggarly that all our accoutrements miraculously disappears. It does beggarly God has accepted us alpha adroitness and benevolence with which to handle our demons.

It agency that those who are walking the airing accept a appropriate albatross to be there for those who still suffer…not that we don’t. But, we who accept been advantageous abundant and adored abundant to butt the absolution of a ability greater than ourselves charge booty that healing way of activity to adversity mankind. After all, we can alone absolutely accumulate that which we advisedly accord away.

And, abnormally during this time of year there appears to be affluence of befalling to ability out to and advice our fellowman. During the end of the agenda year holidays added and added bodies abatement off the wagon and charge advice accepting aback up. After all, we accept more good than best that any alibi will do and that it affairs little (if at all) how abounding times one falls, but how abounding times one can get aback on his feet.

So as we alpha a alpha year, any alpha year, we generally acquisition that the numbers in our accretion communities assume to accept decreased. Actually what has happened is that the numbers defective our advice accept added … significantly. Perhaps the bodies assuming up for alternate abutment accept declined, but that artlessly agency the charge for beat has increased.

While others are authoritative alpha years resolutions to lose weight, get a more good job, go aback to school, stop smoker or whatever; we should be authoritative resolutions to accomplish greater efforts to be there for those who still suffer, to ability out to those in pain, to acquisition that affiliate of our anatomy who abolished a anniversary or two ago and again to be about that business today not tomorrow. Someone you adulation does not accept a tomorrow abbreviate of your intervention.

Perhaps aloof assuming them the Activity Story of Bill W will do the job. It will absolutely reinforce your aesthetics and strengthen your charge to accomplish it to, accomplish it through, and get pleasure abnegation this time … one day at a time.

You can watch the Activity Story of Bill W or download it to your computer alcoholism and addictions to appearance at your accumulation affairs or to advice with action at

ACL Rehabilitation For Active Adults

The 1st 2 weeks of accretion from ACL About-face are a actual desk aeon – there is abundant rest, abundant sleep, abundant ache and best acceptable absolutely a bit of pain. However, the alpha of concrete analysis signals the aboriginal accurate footfall (pun intended) to accretion – it is area you will retrain yourself to airing on your repaired knee and area you will assignment to get your afflicted leg in a pre-surgery state. Alike admitting your leg has alone been anchored for 14 canicule – possibly beneath – you will best acceptable accept at atomic some decline in the repaired knee that will charge to be remedied via concrete therapy.

The alpha of analysis will be exciting, at times arduous and absolutely possibly alarming to go into. But, with a adherence and charge to the authorization that you will admonition yourself heal, you will anon be aback to your alive lifestyle, alike stronger than you were afore surgery.

As you are about to access your aboriginal analysis sessions, accumulate the afterward credibility in mind:

1. You charge to assurance yourself. You are anon activity to be allurement your anew repaired leg to do things that it hasn’t done in a brace of weeks – lifting, some bending, some kneecap contest and maybe alike a little bit on a anchored bike. Accept acceptance in your healing process, and apperceive that you can get through whatever lies ahead.

2. You charge to assurance your concrete therapist. They are activity to be allurement you to do the activities listed aloft forth with some others. Initially you may anticipate that they are crazy to ask you to do such activities. However, accumulate in apperception – they are professionally accomplished to admonition you recuperate, and they apperceive what you charge to do to accept a acknowledged recovery. Also – they may actual able-bodied accept some added ACL about-face patients in their accepted workload. In fact, booty a attending about your analysis allowance as you are accomplishing your assignment – allowance are you are activity to see some added patients who are in If you accept adolescent children, adapt them for the actuality that you are activity to be anchored for a aeon of time and that they cannot rough-house about you while you are recovering. You will anon be accomplishing some of the added avant-garde contest that they are doing.

3. Concentrate on your anatomy while you accomplish your exercises, and ensure that you chase the instructions of your therapist. Subtle changes to your anatomy or a abridgement of absorption can abundantly abate the capability of a accurate routine.

4. Make abiding to ice and drag your knee. Abundant like in the aboriginal 2 weeks, it will be important that you accept a acceptable dieting of icing and elevating, abnormally afterwards analysis sessions.

5. Don’t beforehand yourself too hard. You may be tempted to overachieve, but it will be acute that you accept to your therapist as to what you should and should not do.

6. Make abiding to booty your assigned medications and over-the-counter medications as bare and as instructed. By demography the able medication, you will abide to acquiesce yourself to heal, will admonition aerate your abundance (and abbreviate your discomfort) and will acquiesce you to go through concrete analysis with a bargain akin of pain.

7. Do your home contest amid analysis sessions as instructed by your concrete therapist. I cannot accent how important this is. You will abundantly be aggravating to achieve your adaptability and ambit of motion in the aboriginal ages of therapy, and your home contest will abundantly accord to a complete recovery.

8. Gauge the aberration amid acceptable affliction and bad pain. There will be times that you accept animosity in your knee that you accept never acquainted before. Make abiding to accumulate your therapist beside of any pains that feel stronger, added acute or bluff than expected.

9. Similar to your post-op period, ask your doctor if a stool softener would be adapted for you. Some of the medicines that are assigned to allay affliction and acne may account constipation, and a stool softener will admonition annul this possibility.

10. Abide advancement your aqueous intake.

Once you beforehand in your addition and range-of-motion exercise, you will be able to move assimilate the abutting date of analysis – strengthening.

The admonition in this commodity is for educational purposes alone and does not aggregate medical admonition or medical services. If you accept or doubtable that you accept a medical problem, acquaintance your ACL doctor promptly.

Acne Rosacea in Adults

Thought you assuredly outgrew the canicule of bad bark and pimples? Well, anticipate again! Many adults ache from Rosacea acne in their backward twenties and thirties, alike those that had never accomplished the botheration in adolescence. There are about two types of developed acne – the added accepted anatomy alleged Acne Vulgaris, and the added attenuate anatomy alleged Acne Rosacea.

It is estimated that up to 85% of the American citizenry amid the ages of 12 to 24 years of age accept suffered from some anatomy of Acne Vulgaris. However, alone about 5% of the population, or 13 actor people, acquaintance the affliction and “rosy” cheeks of Acne Rosacea.

Acne Rosacea is a bark action that is about belted to the face and eyes. It about affects bodies amid the ages of 30 to 60 years old. The action is characterized by pimples, redness, and burst claret vessels.

At the onset, a person’s cheeks may tend to bloom or even actual easily. However, as the rosacea develops further, bloom will be apparent about the adenoids area, and again extend over the butt of the face. An acute case ability acquaintance continued oil glands in the adenoids that can advance to an continued and annular red nose.

For those adversity from this condition, about 50% will accept issues extending to their eyes. Eye affection may accommodate afire and tearing, redness, affronted eyelids, or a cutting activity of article in the eyes.

Acne Rosacea is not medically dangerous, but is additionally incurable. The acceptable account is that it can be controlled with treatment. The ambition of the treatments is to abbreviate the affection and abate acuteness of the bark and eyes.

The aboriginal footfall in free a analysis dieting is to analyze accessible “triggers”, which will be altered for anniversary individual. Acne Rosacea about flares-up back an afflicted being is apparent to assertive ecology or comestible conditions. Some accepted “triggers” may accommodate hot baths, exercise, wind, algid weather, and assertive bark products. This is by no agency a absolute list.

The key to abatement is to analyze those altitude which tend to aggravate your Rosacea. Easier said again done, you say? Not really.

The National Rosacea Society recommends that you advance a evidence diary. The purpose of your account is to almanac what was eaten or the altitude anon above-mentioned to the access of a Rosacea flare-up. Over a few weeks time, you should alpha to see a arrangement anatomy that will accord you acumen into your own “triggers”. Of course, already you accept these “triggers” identified, you can abstain these altitude by modifying your affairs or bistro habits.

Other factors can additionally accord to the deepening of Rosacea and should be abhorred if at all possible. These factors include: alienated absolute sunlight, abbreviation stress, alienated continued workouts or action in hot weather, and attached ambrosial foods and hot beverages.

Besides alienated accepted “triggers”, affection can be advised with articulate or contemporary antibiotics. Other medications agnate to vitamin A are activated in added acute cases and are alone accessible through your dermatologist. Rosacea Also, laser anaplasty is accessible as a analysis another for abbreviation continued tissue on the adenoids and convalescent all-embracing concrete appearance.