NURSING CARE IN HIV-AIDS

 HIV AIDS

DEFENITION

A (Acquired)  is spread from person to person.

I (Immune)  Deplete the human immune system. Immunity is part of the body to defend itself against infection with such bacteria or viruses.

D (Deficiency) Creating a loss or reduced immune system.

S (Syndrome)  People with AIDS have bbg opportunistic infections & other diseases.

Etiology

• H: Human 
• I: Immunodeficiency 
• V: Virus 
HIV is the virus that causes AIDS & who belong to a group of retroviruses (the enzyme reverse transcriptase)

Modes of transmission

• Through sexual contact 
• Blood transfusion 
• Syringes
• Of the HIV + mothers to their babies during pregnancy, childbirth, through ation.

Signs and symptoms of major 

• Weight loss in 1 month more than 10% 
• Chronic diarrhea is more than a month. 
• prolonged fever for more than 1 month. 
• Decrease in consciousness and neurologic disorders. 
• dementia

Signs and symptoms of minor    
  
• persistent cough for more than 1 month 
• Dermatitis 
• Presence of recurrent herpes zoster 
• Oropharyngeal candidiasis 
• Herpes simplex chronic progressive 
• Generalized lymphadenopathy 
• recurrent yeast infections in the genitals

Clinical Manifestations 
Course of HIV disease is divided into stages based on clinical circumstances and the number of CD4

a. Acute retroviral infection 
• Fever• Enlarged lymph 
• Hepatoslenomegali 
• throat pain 
• myalgia 
• Rast like morbili

b. Asymptomatic period 
• At this time the patient showed no symptoms, but interchangeable occur lymphadenopathy. 
• Decrease in CD4 cell counts occur in stages called the window period.

c. The period of early symptomsDuring this fourth CD ranged from 100-300, this phenomenon arises due to pneumonia infection, vaginal candidiasis, canker sores herpes zoster, pulmonary tuberculosis.

d. The period of continued symptomsCD4 counts below 200, lower resistance to further this cause a high risk of opportunistic infections

The correlation of complications with CD4> 500 
• Acute retroviral syndrome 
• Vaginitis candid 
• Lymphadenopathy 
• Syndrome gullain barree 
• Myopathy• Meningitis

200-500 
• Pneumonia 
• TBC 
• Herpes zoster 
• Candidiasis oroparing 
• cervical neoplasms 
• ITP

<200 
• Pneumonia 
• dementia 
• peripheral neuropathy 
• miliary TB and extra pulmonary 
• Cardiomiopati 
• Poliradikulopati

<100 
• Herpes simplex 
• Toxoplasma gondii 
• Candida oesophagitis

<50 
• Cytomegali virus 
• Lymphoma of the ssp

The principle of treatment 
1. Supportive treatment 
• Treatment aims to improve the patient's general condition, by providing appropriate nutrition, systemic medications, vitamins, psychosocial support.

Nutritional needs in patients with HIV-AIDS 
• High energy is 45-50 kcal / kg• Protein from 1.1 to 1.5 g / kg / mm at a normal weight at the BB-2 ,1,5 actual kaheksia. 
• 17-20% fat of total calories.

2. Treatment of opportunistic infections 

3. Antiretroviral treatmentPrinciples of ARV: 

• Indications according to the guidelines WH 
• Overcome first opportunistic infection. 
• Be careful disruption fungsihati 

Nursing assessment 

1. History of present illness 
• Losing weight 
• Fever 
• Diarrhea 

2. Accompanying diseases 
• Candidiasis 
• Herpes simplex 
• lymphoma 

3. Past history of disease 
• History of receiving blood transfusion 
• History of sexual diseases 

4. Social History 
• Use of illicit drugs drugs 
• Jobs 
• Travel 
• Support system

Physical examination 
• General appearance looks sick moderate, severe 
• Vital signs 
• The skin there is a rush, Stevens-Johnson
• Red eyes, icterik, impaired vision 
• Neck: enlargement of the KGB 
• Ears and noses; sinusitis buzzing 
• Oral cavity: candidiasis 
• Lungs: shortness, pleural effusion, muscle aids 
• Cardiac: cardiac enlargement 
• Abdomen: ascites, abdominal distension, enlarged liver 
• genetalia and rectum: herpes 
• Neurology: seizures, memory impairment, neuropathy.

Investigations 

• Calculate lymphocytes
 CD4 
• Mantouk test 
• Test elisa

NURSING DIAGNOSIS 

High risk of infection b.d. immunodeficiency 
• Reduce and limit the number of patient visits 
• Describe personal hygiene techniques 
• Keep an eye on further signs of infection

Ineffective airway b.d. accumulation of mucus 
• Teach effective cough 
• Give bed semi-Fowler position 
• Maintain cleanliness of the airway 
• Assess the pattern of breathing, rhythm

Resti / actual lack of fluid volume b.d. Excessive fluid loss 
• Give fluid intake adequat reply 
• Avoid foods that stimulate diarrhea 
• Monitor vital signs 
• Assess the elasticity turgor and mucous membranes humidity 
• Monitor intake and output• Weigh the BB every day

DK who else ... 
• Impaired skin integrity b.d. immobilization 
• Social isolation b.d. stigma, fear 
• Disturbance in sleep patterns b.d. worry 
• Intolerance activities b.d. physical weakness 
• Disturbance role b.d. Chronic diseases

NURSING CARE IN Scabies

 SCABIES

Definition of Scabies
According to Handoko (2007), scabies is a contagious skin disease caused by infestation and sensitization to mite (mite) Sarcoptes scabei. The disease is also known as the itch, scabies, or itch Agogo.
Disease scabies is a contagious disease by lice infestation is itching Sarcoptes scabei, the tick enters the skin stratum corneum, forming canaliculi or straight or curved tunnel along the 0.6 to 1.2 centimeters.Classification of Scabies
There are several forms of atypical scabies are rare and hard to recognize, so that it can lead to misdiagnosis. Some forms include (Sungkar, S, 1995):
a. Scabies on the net (scabies of cultivated).
This form is characterized by lesions in the form of papules and tunnels are few in number so it is very difficult to find.
b. Scabies incognito.
This form occurs in scabies treated with corticosteroids that symptoms and clinical signs improved, but the mites remain and transmission can still occur. Scabies incognito often also show clinical symptoms of unusual, atypical distribution, lesion area and similar other diseases.
c. Nodular scabies
In this form of lymph node lesions are itchy reddish brown. Node there is usually a closed area, especially on the male genitalia, inguinal and axillary. These nodes arise as a reaction to the mites scabies hipersensetivitas.
On the node that was more than a month mites are rarely found. Nodes may persist for several months to a year although it had been given anti-scabies treatment and corticosteroids.
d. Scabies is transmitted through animals.
In America, the main source of scabies is a dog. The disorder is different from human scabies that there are no tunnels, no attack between the fingers and external genitalia. Lesions are usually found in areas where people often contact / hug pet the thigh, abdomen, chest and arms. The incubation period is shorter and easier transmission. This disorder is temporary (4-8 weeks) and can heal itself because S. scabiei var. animals can not continue its life cycle in humans.
e. Norwegian scabies.
Norwegian scabies or scabies krustosa characterized by extensive lesions with crusting, and hyperkeratosis skuama generalized thick. Place predilection usually scalp hair, ears buttocks, elbows, knees, palms and feet that can be accompanied by nail dystrophy. In contrast with ordinary scabies, itching in patients with Norwegian scabies is not prominent but form is highly contagious because the number of mites that infest so many (thousands). Norwegian scabies caused by immunologic deficiency so the body's immune system fails to limit the proliferation of mites can multiply with ease.
f. Scabies in infants and children.
Scabies lesions in children can affect the entire body, including the entire head, neck, palms, soles of the feet, frequent infections and secondary impetigo, ektima so the tunnels are rarely found. In infants, lesions on the face. (Harahap. M, 2000).
g. Scabies lying in bed (bed ridden).
Patients with chronic illnesses and the elderly who are forced to stay in bed suffering from scabies which lesions can be limited. (Harahap. M, 2000).Etiology Scabies
Scabies can be caused by fleas or germs sercoptes scabei hominis variants. Sarcoptes Arthopoda scabieiini including phylum, class of arachnids, the order Ackarina, Sarcoptes superfamily. In humans is called Sarcoptes scabiei var. hominis. Unless there is S. scabiei others in goats and pigs. In morphologic a mite small, oval, convex back and abdomen flat. Mite is transient, dirty white, and not-eyed.Scabies Clinical Manifestations
Diagnosis is made by finding two of the four cardinal signs of the following:
- Noktuma Pruritus (itch at night) because the activity of mites was higher in the humid and hot temperatures.
- Commonly found in a group of humans, for example about seliruhanggota eluarga.
- The tunnel (kunikulus) in predilection sites are white or grayish, forming straight or curved lines, the average length of 1cm, the uung be pimorfi (pustu, ekskoriosi). Place of predilection are usually areas with komeum tpis stratum, ie between the fingers, the volar wrist, elbow the outside, fold the front of the armpits, breast and fold aerola glutea, umbilicus, buttocks, external genitalia, and lower abdomen. In infants can affect the palms and soles of the feet and even the entire surface ulit. In adolescents and adults may occur on the scalp and face.
- Finding mites are the most diagnostic. Can ditemikan one or more life stages of this mite.
In patients who always maintain hygiene, lesions that arise only slightly so that the diagnosis is sometimes difficult to enforce. If the illness lasts a long time, can arise likenifikasi, impetigo, and furunkulsis.Scabies pathophysiology
Skin disorders may be caused not only from scabies mites, but also by patients themselves due to scratching. And because shaking hands or arm so that it contacts the skin is strong, causing lesions arise on the wrist. Itching that occurs due to leh sensitization to mites ekskret secret and that takes about a month after infestation. At the moment it resembles a skin disorder ditemuannya dermatitis with papules, vesicles, and Urtica. By scratching may arise erosion, ekskoriasi, crusting, and secondary infections. And itchy skin disorder that occurs can be wider than the location of mites.Management of Scabies
Terms ideal drug is effective against all stages of mites, not to cause irritation and toxic, no smell or dirty, no damage or color of clothing, easily available and cheap.
Types of topical drugs:
- Sulfur creep (sulfur presipitatum) 40-20% in the form of ointment or cream. In infants and adults presipitatum 5% sulfur in oil is very safe and effective. The drawback is the use must not be less than 3 days because it is not effective against the egg stage, smelly, dirty clothes and can cause irritation.
- Benzyl-benzoate emulsion 20-25% effective against all stages, is given every night for 3 times. These drugs are difficult to obtain, often giving irritation, and sometimes more itchy after use.
- Gama benzene hexa chloride (gameksan) 1% cream or lotion form daam, including choice of drugs effective against all stages of the arena, easy to use, and rarely gives irritation. The drug is not dianurkan in children under 6 years old and pregnant because toksi Wanta central nervous system. Gift cup once in 8 hours. If masihada symptoms, repeated a week later.
- Krokamiton 10% dalamkrim or lotion as antiscabies mempunyaidua effects and itching. Should be kept away from eyes, mouth, and urethra. Cream (eurax) efetif only in 50-60% of patients. Used for 2 consecutive nights and after 24 hours of usage dbersihkan Evaluasiir teraKriteria.
- 5% permethrin cream was the drug most effective and safe arena for deadly parasites S.scabei and have low toxicity in humans.
- Antibiotics can be used if there is secondary infection, such as pus in the affected area (between your fingers, genitalia) caused by scratching.Basic Concepts Askep Scabies
Nursing Assessment
Biodata
a. The identity of the patient
b. The identity of responsible
Riwyat health
a. The main complaint
In patients with skin lesions of scabies are the back and feel the itch mainly at night.
b. Health history now
Patients began to feel the itch that heats up and then be due to edema due to scratching an itch that was great.
c. Past medical history
Patients had admission due to allergies
d. Family health history
In families of patients are suffering from illnesses such as a natural client is ringworm, scabies.
Patterns of health functions
a. The pattern of perceptions of health
When sick, regular clients in TKO membeliobat atauapabila terdeat drug does not change the patient push yourself to the nearest clinic or hospital.
b. The pattern of exercise activity
Exercise activity during the illness:
Eat
Bath
Dress
Elimination
Mobilization in bed
c. The pattern of bed rest
In patients with sleep pattern disturbance scabies occur due to intense itching at night.
d. Nutritional patterns of metabolic
No disturbances in metabolic nutrition.
e. The pattern of elimination
Clients CHAPTER 1x a day, with mushy consistency, characteristic odor and yellow color BAK 4-5x a day, with clear yellow color characteristic odor.
f. The pattern of cognitive perceptual
Currently Kien sober assessment, clear speech, hearing and normal vision.
g. The pattern of role relationships
j. Patterns of sexual reproduction
On the client scabies impaired in sexual reproduction.
k. Coping patterns
The main problem that occurred during the client's illness, the client always feels itchy, and the patient became lazy to work.
Loss or changes in clients lazy to perform daily activities.
Fearful of violence: no
Outlook towards the future
Clients optimistic for recoveryNursing Diagnosis In Askep Scabies
1. Acute pain associated with injury to biological agents
2. Disturbances in sleep patterns associated with pain
3. Body image disturbance associated with changes in secondary penampian
4. Anxiety associated with changes in health status
5. risk of infection associated with tissue damage biscuits and invasive procedures
6. Damage to skin integrity related to edemaNursing Intervention On Scabies Askep
Diagnosis 1
Acute pain associated with injury to biological agents
After the action of nursing care for 3 × 24 hours, is expected to be resolved with the client's pain Evaluation Criteria:
- Pain control
- Itching started to disappear
- Puss missing
- The skin is reddened
Intervention:
- Assess pain intensity, characteristics and note the location of
- Provide frequent skin care, get rid of the unpleasant stimuli lingungan
- Collaboration with physicians in the delivery of analgesics
- Collaboration of antibiotics
Diagnosis 2
Disturbances in sleep patterns associated with pain
After the action of nursing care for 3 × 24 hours of sleep the client is not expected to interfere with Evaluation Criteria:
- The client's eyes are not swollen anymore
- Clients do not often awake at night
Intervention:
- Give comfort to the client (the client hygiene bed)
- Collaboration with physicians in the delivery of analgesic
- Record the number of clients awake at night
- Provide a comfortable environment and reduce noise
- Give a warm drink (milk) if necessary
- Give classical music as a bedtime
Diagnosis 3
Body image disturbance associated with changes in secondary penampian
After the action of nursing care for 3 × 24 hour client expected a disruption in how the application of self-image with the Evaluation Criteria:
- Reveal the acceptance of the disease in its natural
- Recognizing and re-establish the existing support systems
- Encourage individuals to express feelings, especially about the thoughts, views himself
- Encourage individuals to ask about handling problems, development of health
Diagnosis 4
Anxiety associated with changes in health status
After the action of nursing care for 3 × 24 hours is expected the client is not concerned anymore with the Evaluation Criteria:
- Clients do not fret
- The client was calm and able to accept bank on the fact
- Clients are able to identify and express symptoms of anxiety
- Posture facial expressions, body language and showed reduced activity levels of anxiety
- Identification of anxiety
- Use a calm approach
- Accompany the patient to memberian security and reduce fear
- Help patients recognize situations that cause anxiety
- Provide factual information about diagnosis, prognosis action
Diagnosis 5
Risk of infection associated with tissue damage biscuits and invasive procedures
After the action of nursing care for 3 × 24 hours the client is expected to occur no risk of infection with the Evaluation Criteria:
- Clients are free from signs and symptoms of infection
- Indicates the ability to prevent infection
- Demonstrate healthy behavior
- Describe the process of transmission of the disease, factors that influence the transmission and management
- Monitor for signs and symptoms of infection
- Monitor susceptibility to infection
- Limit visitors when necessary
- Instruct visitors to wash their hands when visiting remedy and after leaving the patient
- Maintain aseptic lingkngan during the installation of equipment
- Provide skin care in the area epidema
- Inspection of skin and mucous membranes of the redness, heat
- Inspection of the wound condition
- Provide antibiotic therapy if necessary
- Teach how to avoid infection
Diagnosis 6
Damage to skin integrity related to edema
After the action of nursing care During a 3 × 24 hour skin layer clients are expected to look normal, with the Evaluation Criteria:
- The integrity of the skin which can sink dipetahankan (sensation, elasticity, temperature)
- No cuts or lesions on the skin
- Able to protect the skin and keep skin moist and natural treatments
- Well tissue perfusion
- Keep the skin clean to keep them clean and dry
- Monitor the existence of skin redness
- Bathe the patient with warm water and soapImplementation of Nursing
1. Assessing pain intensity, characteristics and note the location
2. Provide frequent skin care, get rid of unpleasant environmental stimuli
3. Collaborate with physicians in the delivery of analgesics and antibioticsNursing Evaluation
Interference problem is said to comfort the pain is resolved if:
- Pain control
- Itching began to disappear
- Puss missing
- Skin does not redden

NURSING CARE IN CHILDREN with cerebral palsy

cerebral palsy

A. BACKGROUND

Every parent would want his son was born with perfect, get an education and decent work. When it is not met, often among those who are disappointed not even want to send their children with special needs.
Actually there is no disabled children but children with special needs, because children are considered disabled it is the same with children in general, have advantages and disadvantages. But because some people who lack understanding, then the society that label disabilities that.
For that we need to understand an approach to society that those who have limitations in their environment, both have the same rights as normal children in general.
If we see children who have mental disabilities, we may assume that they are experiencing the same kind of mental disability. But we must know the mental disability experienced by children differently in this case the cause is cerebral palsy.
Although the developments and progress in the field of obstetrics and perinatologi will lead to lower infant mortality rate is rapid, but can not prevent an increase in the number of children with disabilities. This is due, even though the baby was rescued from the state of emergency, but usually leave residual symptoms due to brain tissue damage whose symptoms may appear immediately or later in life.
Cerebral Palsy is one of its sequelae are quite often found. The term Cerebral Palsy (CP) was first suggested by Phelps. Cerebral: related to the brain; Palsy: imperfection muscle function. In literature, the CP is often also called spastic diplegia, but this name is not quite right, because not only manifest spastic CP and the two limbs, but can also be found in other forms and can be about the 4 limbs. Other names are: Little's disease, because the physician John Little was the first in the mid-19th century, describes the clinical picture of CP.
This paper outlines: definition, incidence, etiologik, neurofisiologik and pathological, clinical picture and classification, diagnosis, differential diagnosis, special examinations, treatment, prevention and prognosis of CP.

B. THEOLOGICAL PROBLEMS

From the description above background papers, we want to outline some of the problem formulation as follows:

    What is the definition of Cerebral Palsy?
    How does the incidence of cases of Cerebral Palsy?
    What is the aetiology of Cerebral Palsy?
    What are the clinical symptoms in clients who have Cerebral Palsy?
    How is its management?
    How Nursing in clients with Cerebral Palsy?

C. PURPOSE

The purpose of writing papers in the literature study are:
1. In order for students to understand and know about the problems that arise in the case of Cerebral Palsy.
2. Gain an understanding of the true concept of Cerebral Palsy that can later be applied in providing nursing care to clients.
3. Nursing care that we provide will be of higher quality when there is a balance between theory and skills pengetaahuan praktice.
4. Courses to fulfill the task of Pediatric Nursing.


A. DEFINITION

Various definitions have been put forward by scholars. Clark (1964) argues, is the CP is a condition of brain tissue damage in the central
motor or the connecting network, which is eternal and not progressive, which occurs during the prenatal, during delivery or before the central nervous system becomes sufficiently mature, characterized by paralysis, paresis, coordination disturbances or abnormalities of motor function. In 1964 the World Commission on Cerebral Palsy suggested the following definition of CP: CP is a disorder of function of movement and posture caused by abnormalities or defects in the brain tissue that has not finished growing. While Gilroy et al (1975), defines CP as a syndrome, abnormalities in the cerebral control of motor function as a result of developmental disruption or damage to motor centers or network connecting the central nervous system.
Another definition: CP is a condition lasting damage to brain tissue and non-progressive, occurs at a young (since birth), and impede normal brain development with a clinical picture that can change during life, and showed abnormalities in the attitude and movement, accompanied by abnormalities neurologic form of spastic paralysis, disorders of the basal ganglia and cerebellum.

B. Incidence

Researchers from different countries report varying incidence are: 1.3 per 1000 births in Denmark (Erik Hansen); 5 per 1,000 children in the United States (Gilroy), and 7 per 100,000 births in the U.S. (Phelps); 6 per 1,000 live births in the U.S. (Ingram, 1955 and Kurland, 1957). In Indonesia, there are no data regarding the incidence of CP. In KONIKA V Field (1981), R. Suhasim and Titi Sularyo reported 2.46% of the total population of Indonesia holds a disability, and in between ± 2 million are children. CP is a type of defect in children who ever encountered. In Jaipur, Meenakshi Sharma et al (1981) investigated the CP 219, 150 of whom were male and 69 female. Consisted of 42 children aged less than 1 year, 113 were between 1-5 years, 52 between 50-10 years and 12 over 10 years.
The number of events around 1-5 per 1000 children. Men more than women. Often found on the first child, first child may more frequently have difficulty pad at birth. The number of events was higher in LBW infants and the twins. Mother's age is often more than 40 years, more so in multiparas.
Frankie (1994) research in Sanglah Hospital in Denpasar, found that 58.3% of cerebral palsy patients studied were male, 62.5% first child, the mother of all under the age of 30 years, 87.5% came from the location of spontaneous labor heads and 75% of pregnancies.

C. Etiology

CP is not a single disease with one cause. CP is a group of diseases with the problem of governing the motion, but can have different causes. To determine the cause of CP, should be dug about it: the form of CP, a history of maternal and child health, and disease onset.
In the USA, approximately 10-20% due to illness after birth (percentage will be higher in countries with underdeveloped). CP can also be the result of brain damage in the first months or first years of life which is the remainder of the brain infection, such as bacterial meningitis or viral encephalitis, or is the result of head trauma often caused by traffic accidents, falls, or child abuse .
The causes which can cause CP in umulnnya chronologically can be grouped as follows:
{Prenatal:
· Impaired brain growth
· Metabolic diseases
· Placental disease
· Maternal disease: toxemia gravidarum, toksopiasmosis, rubella, syphilis and the radiation
{Christmas:
· Long parturition
· Birth trauma with subdural hemorrhage
· Prematurity
· Penumbungan or winding talipusat
· Persistent atelectasis
· Aspiration of gastric and intestinal contents
· Heavy sedation in the mother
{Post natal:
· Infectious diseases: encephalitis
· Lesions by trauma, such as skull fracture
· Hyperbilirubinemia / kernicterus
· Blood circulation disorders such as pulmonary embolism / cerebral thrombosis
RISK FACTORS
Risk factors that cause the greater the likelihood of CP are:
1. Location of breech.
2. The delivery process is difficult.
Vascular or respiratory problems selamaa child labor is an early sign that indicates a problem of brain damage or a baby's brain does not develop normally. These complications can cause brain damage permaanen.
3. Low Apgar scores.
Low Apgar score up to 10-20 minutes after birth.
4. LBW and prematurity.
Higher risk of CP among infants with birthweight <>
5. Multiple pregnancy.
6. CNS malformations.
Most babies born with CP showed significant CNS malformations, such as abnormal head circumference (microcephaly). This shows that the problem has occurred during the CNS development in the womb.
7. Perdarahaan maternal or heavy proteinuria at the end of pregnancy.
Vaginal bleeding during months 9 through 10 pregnancies and increase the amount of protein in the urine associated with an increased risk of CP in infants.
8. Hipertiroidism maternal, mental retardation and seizures.
9. Seizures in newborns.

D. NEUROFISIOLOGIK AND PATHOLOGIC
 
Neuropatologik changes in the CP depends on the pathogenesis, the degree and localization of damage in the central nervous system (CNS). All CNS tissues sensitive to oxygen deprivation. The most severe damage occurred in neurons, neuroglia and less on supporting networks (supporting tissue) and at least in brain blood vessels. The degree of damage to acute neuronal necrosis has to do without damage to the neuroglia. Healing occurs by phagocytosis of necrotic part, the proliferation of neuroglia and the formation of scar tissue followed by a secondary retraction. In more severe hypoxia, there is damage in both neurons and neuroglia, resulting in areas with perlunakan, slow healing, atrophy and extensive scar tissue formation. Damage that occurs in the most severe CNS is highly sensitive to hypoxic cerebral cortex, somewhat less in the basal ganglia and cerebellum, whereas the brainstem and spinal cord damage is lighter. Mild bleeding by birth trauma are usually absorbed without permanent damage. Subdural hematoma is usually unilateral common found in the sinus longitudinalis verteksi close, causing damage to brain tissue beneath it because of pressure necrosis, resulting in malaria ensefalo eventually happened atrophy and scar tissue formation. Intracerebral hemorrhage rarely produce porencephalic cavity.
.
According to Perlstein and Barnett, a head trauma and intracranial bleeding in general will involve the pyramidal system, whereas anoxia especially regarding extrapyramidal system. Clinical manifestations of this disorder depend on the great and
localization of lesions that occur, whether he is in the cerebral cortex, basal ganglia or the cerebellum. Kernicterus causing damage to the nucleus are in, marked in yellow, the damage in the form of necrosis and lysis of neurons followed by proliferation of neuroglia and great shrinkage. In congenital brain abnormalities, such as agenesis / hipogenesis parts of the brain and hydrocephalus, developmental delay will occur.

E. CLINICAL FEATURES AND CLASSIFICATION

Clinical manifestations of CP depends on the localization and extent of brain tissue damage, whether in the cerebral cortex, basal ganglia or cerebellum. Thus, clinically indistinguishable three basic forms of motor disorders in CP are: spasticity, and ataxia atetosis.
a) Spasticity.
Spasticity occurs especially when the damaged pyramidal system, covering 50-65% of cases of CP. Spasticity is characterized by hipertoni, hiperrefleksi, klonus, positive pathological reflexes. Paralysis that occurs may monoplegi, diplegi / hemiplegi, triplegi or tetraplegi. Paralysis is not just about the arms and legs, but also the neck muscles that function to uphold the head.
b) Atetosis.
Atetosis covers 25% of cases of CP, an abnormal movements that arise spontaneously from the arm, leg or neck is marked with a circular motion around the axis "kranio-caudal", the movement grew when in a state of emotion. The damage lies in the basal ganglia and is caused by heavy asfiksi or jaundice.
c) Ataxia.
Infant / child with ataxia showed impaired coordination, impaired balance and presence of nystagmus. Children walk with wide steps, there
intention tremor include ± 5%. Localization of the lesions in the cerebellum.
d) Rigidity.
Is a mixed form of brain damage due to the diffuse. In addition to motor symptoms, may also be accompanied by symptoms rather than motor, such as impaired mental development, growth retardation, seizures, impaired sensibility, hearing, speech and eye disorders.
Hearing Loss
There pda 50-10% of children with Cerebral Palsy. Disorders of perception abnormalities neurogen especially high tones, making it difficult to capture in words.
Speech Disorders
Caused by hearing loss or mental retardation. Movement that occurs by itself on the lips and tongue makes it difficult to control these muscles so that the child is difficult to form words and frequently looked child salivating.
Eye disorders
Eye disorders is usually in the form of convergent strabismus and refractive abnormalities. In the state of severe asphyxia can occur cataracts. Nearly 25% of patients suffering from eye disorders Cerebral Palsy.
Based on the clinical manifestations of CP, the American Acedemy for Cerebral Palsy suggested classification as follows.
Classification neuromotorik
1. Spastic, is the addition of the stretch reflex and deep tendon reflex
elevated in the affected parts.

    Atetosis, is characteristic of gentle movements resemble worms, involuntary, uncontrolled and aims.
    Rigidity. If the affected part is moved there will be continuous custody, in both agonist and antagonist muscles. Describing the sensation membongkokkan "lead pipe" (lead pipe rigidity).
    Ataxia. Showed a disturbance of balance in ambulation.
    Tremor. Movements are involuntary, uncontrollable, reciprocal with a regular rhythm.
    Mixed.
Topographic distribution of involvement neuromotorik
1. Paraplegi. Affected is the inferior extremity, always spastic type.
2. Hemiplegi. Exposed to only one inferior and one superior extremity on the same side. Almost always spastic, sometimes there are atetosis.
3. Triplegi. 3 exposed extremities, usually spastic.
4. Quadriplegia or tetraplegi. Exposed to all extremities.
Classification based on severity. gluttonous based on the severity of involvement neuromotorik that limit the ability of patients to perform activities for the purpose of life (activities of daily living).
1. Lightweight. Patients do not require treatment because he had no problem talking and able to do everyday purposes and can be moved without using helper tools.
2. Moderate. Patients require treatment because he is incompetent to maintain themselves, ambulation and speech. It requires a brace and self-help tools.
3. Weight. Patients require treatment. The degree of involvement so intense, so the prognosis for maintaining themselves, ambulation and speech are ugly.

F. DIAGNOSTIC EXAMINATION

Early diagnosis and proper presence of lesions in the brain are essential for the selection of therapeutic procedures to be taken.
In the history to know about the history of prenatal, childbirth and post natal which can be associated with the presence of brain lesions. Stages of physical development of children should be asked, for example when starting up, turn around, sitting, crawling, standing and walking.
On physical examination noted the existence of spasticity arm / leg, involuntary movements, ataxia and others. The existence of physiological reflexes such as the Moro reflex and
tonic neck reflex in children aged 4 months to be suspected of CP, as well as impaired vision, hearing, speech and swallowing, the asymmetry of a group of muscles, contractures and legs crossed like scissors.
DIAGNOSIS
CP needs to be distinguished by: the process of CNS degeneration, myopathy, neuropathy, spinal cord tumors, brain tumors, hydrocephalus, atypical poliomielitik, idiocy, brain or peripheral nerve trauma, Sydenham's Korea, higroma subdural and intracranial tumors.

G. SPECIAL EXAMINATION

To get rid of diagnosis and for treatment of patients, it takes some special examination. Frequent checkpoints, are:

    Eye and hearing examinations conducted soon after the diagnosis of CP is established.
    Lumbar puncture should be done to get rid of a degenerative process. On CP normal cerebrospinal liquor.
    Electrical Inspection Ensefalografi performed in patients with seizures or hemiparesis in both convulsive groups or not.
    Photos of the head (X-ray) and CT Scan.
    Psychological assessment needs to be done to determine the level of education necessary.
    Metabolic examination to rule out other causes of mental retardation.
In addition to the above, it is sometimes necessary examination and arteriography pneumoensefalografi individuals.
To obtain maximum results, people with CP need to be addressed by a
Team consisting of: pediatricians, neurologists, psychiatrists, orthopedic surgeons, physiotherapists, occupational therapists, outstanding teachers, parents, patients and if necessary, coupled with eye specialists, ENT specialists, nurses and other children.

H. MANAGEMENT

In general, the handling of patients with CP include:
1) re-education and rehabilitation.
Given the multifaceted nature of disability, someone with CP needs to get treatment in accordance with the disability. Evaluation of the objectives need to be made by each therapist. Objectives to be achieved should also be communicated to parents / families of sufferers, because then he can give up her child gets the appropriate treatment and care were also done earlier in his own neighborhood. Physio therapy aims to develop a range of motion necessary to independently acquire the skills to everyday activities. Physio therapy should be started immediately intensively. To prevent contractures to note the position of patients during rest or sleep. For patients who weight is recommended for temporary residence at a training center. Physio therapy is carried out throughout the person's life. In addition to physio therapy, patients with CP should be educated in accordance with the level of intelligence, in the School Extraordinary and where possible in regular schools together with children who are normal. At the Special School to do speech therapy and occupational therapy that are tailored to the circumstances of the patient. They should be treated as an ordinary boy who came home with a vehicle-bersanrm same so do not feel alienated, living in a normal atmosphere. Parents should not over-protect children and to the social worker can help at home with the view as necessary.
2) psycho therapy to children and their families.
Therefore, behavioral disturbances and social adaptation often accompany CP, then the psycho therapy should be given to both the patient and his family.
3) Correction surgery.
Aiming to reduce muscle spasm, equating the antagonist muscle strength, stabilize the joints and correcting deformity. Surgery more often done on the type of spastic than other types. Also more frequent in the lower limbs compared with the upper limbs. The surgical procedure performed tailored to the type of operation, whether the operation was performed on
motor nerve, tendon, muscle or bone.
4) Drugs.
Provision of drugs on the CP aims to improve behavioral disturbances, neuro-motor and to control seizures.
In patients with spastic CP. anti-seizure medication memeerkan good results in controlling seizures, but the type of spastic CP and atetosis drug is less successful. Similarly, drug muskulorelaksan less successful in reducing muscle tone in spastic CP type and atetosis. In patients with anti-convulsive seizures are given maintenance tailored to the characteristics of the seizures, such as luminal, dilantin and so on. In a state of excessive muscle tone, benzodiazepine class of drugs, for example: Valium, Librium or mogadon can be tried. In the circumstances given artane choreoathetosis. Tofranil (imipramine) is given in a state of depression. In patients who are hyperactive can be given dextroamphetamine 50-10 mg in the morning and from 2.5 to 5 mg at noon.

I. PREVENTION

Prevention is the best effort. CP can be prevented by eliminating the factors etiologik brain tissue damage during the prenatal, natal and post natal. Some of it can already be removed, but still many are also difficult to avoid. "Prenatal and perinatal care" which may either reduce the incidence of CP. Kernicterus caused 'haemolytic disease of the new born "can be prevented by an early exchange transfusions," Rh incompatibility "can be prevented by giving" anti-D immunoglobulin hyperimmun "on mothers who have a rhesus negative. Other preventive measures that can be done is that immediately on the state of hypoglycemia, meningitis, status epilepsy and others.

J. PROGNOSIS

The prognosis depends on many factors, among other things: the severity of CP, given the rapid treatment, the symptoms that accompany CP, attitude and cooperation of patient, family and community. According to Nelson WE et al (1968), only a small number of patients with CP who can live free and enjoyable, but Nelson KB et al (1981) in his study of 229 patients with CP yang.didiagnosis at 1 year of age, after age 7 years was 52% of them has been free from motor disturbances. It was reported that a mild form of CP, monoparetik, ataksik, diskinetik and diplegik more experienced improvement. Healing is also more common in group of black children compared with whites. In developed countries, for example diInggris and Scandinavia, there are 20-25% of patients with CP as a day laborer work full of 30-50% live in the "Institute of Cerebral Palsy". The more accompanying symptoms and more severe motor impairment, the worse the prognosis. Generally the intelligence of children is an indication prognosis, the more intelligent the better the prognosis. Patients are often seizures and can not be overcome by anti-seizure has a poor prognosis. In patients who did not receive treatment, a spontaneous clinical improvement can occur despite slow. With frequent child to move where, movement members receive training in moving and healing can occur in childhood. The sooner and the more intensive treatment of the results achieved increasingly better. In addition to the factors mentioned above, the role of parents / families and communities in determining prognosis. The higher the acceptance of cooperation and the better the prognosis.


NURSING CARE

A. ASSESSMENT
1. Biodata

    Men more than women.
    Common in children è difficulty at first childbirth.
    Kejadin higher in low birthweight and infant twins.
    Maternal age over 40 years, more so in multiparas.

2. Medical history.
Kesehaataan history associated with prenatal factors, natal and post natal as well as the circumstances surrounding the mempredisposisikan kelaahiran fetal anoxia.
3. Complaints and clinical manifestations
Observation of manivestasi cerebral palsy, especially those related to the achievement of development:

    Slowing the development of gross motor
Common manifestations, motor slowing on all achievement, increases with growth.

    Display abnormal motor
The use of unilateral terlaalu hand early, asymmetric merangkaak abnormal, or standing on tiptoes, involuntary movements or uncoordinated, poor sucking, difficulty makaan, tongue canker sores persist.

    Changes in muscle tone
Increased resistance ataau decrease in passive movement, posture opistotonik (arch your back too much), feeling stiff in the holding or dressing, difficulty in using diapers, stiff or does not bend at the hip and knee joint when pulled to sitting position (early sign).

    Posture abnormal
Keeping your hips higher than the body on the tummy, legs crossed ataau extends to the foot plantar flexion in the supine position, posture, persistent infantile sleep and rest, arm abduction at the shoulder, elbow flexion, the hand clenched.

    Reflex abnormalities
Primitive reflex infantile persistent (tonic neck reflex exist at any age, do not settle over the age of 6 months), Moro reflex, plantar, and holding menetaap or hyperactive, Hiperefleksia, klonus ankle and stretch reflexes appeared on many muscle groups at a fast passive movements .

    Comorbid disorders (bias exists, or may not).
Subnormal learning and reasoning (mental retardation in approximately two-thirds of individuals).
Damage behavior and interpersonal relationships
Other symptoms can also be found in the CP:- Below normal intelligence- Mental retardation- Seizures / epilepsy (mainly on the type of spastic)- Sucking or eating disorders- Breathing irregular- Impaired development of motor skills (eg reaching for something, sit, roll over, crawl, walk)- Impaired speech (dysarthria)- Impaired vision- Hearing loss- Joint contracture- Movement is limited.
4. Investigations
(Can be seen on the basic concept).

B. NURSING DIAGNOSIS

    The risk of changes in nutrition: less than body requirements related to dysphagia secondary to oral motor disorders.
    High risk of damage to skin integrity related to immobility.
    The risk of injury associated with the inability to control the movements secondary to spasticity.
    Verbal communication-related damage dengaan damage the ability to say words that relate to the involvement of secondary muscles of facial rigidity.

C. INTERVENTION, RATIONAL AND EVALUATION

1. The risk of changes in nutrition: less than body requirements related to dysphagia secondary to oral motor disorders.
Objectives:
Children participate in activities according to their ability to eat
Children consume an adequate amount
Intervention:
Provide nutrients in a manner consistent with the child's condition
Record the input and output
Monitor intravenous feeding (when instructed)
Give the formula foods determined by a nasogastric tube (as indicated)
Give him the child some autonomy in a passive way to eat
Lay the patient with head of bed 30-45 degrees, sitting position and neck straightened
R / ideal position while eating and thus reducing the risk of choking
Get involved in the selection and sequence of eating food that was served (in terms of diet and nutrition)
Give semisolid foods and liquids through a straw for a child who was lying on the tummy
R / prevent aspiration and make eating / drinking becomes easier
Provide high-calorie foods kudapaan differences and high protein
R / meet the needs of the body for metabolism and growth
Give foods that are preferred by children
R / encourage children to eat
Enrich your diet with nutritional supplements mis.susu powder or other supplements
R / maximize the quality of food intake
Monitor body weight and growth
R / intervention providing extra nutrients may diimpementasikan when growth starts to slow down and weight loss
Perform oral hygiene every 4 hours and after meals
Evaluation:
The client gets the input of nutrients to meet metabolic needs.
2. High risk of damage to skin integrity related to immobility.
Objectives:
Clients maintain the integrity of the skin.
Intervention:
Assess the skin every 2 hours and prn to depressed areas, reddish and pale.
R / appropriate assessment and early treatment will sooner best on problems that occur on the client
Place the child on the surface which reduces pressure
R / mencegaah tissue damage and necrosis due to pressure
Change position often, unless contraindicated
R / prevent dependent edema and stimulates circulation
Protect pressure points (eg: trikanter, sacrum, pergelangaan legs, shoulders and occiput)
Keep skin clean and dry skin in a state
Provide adequate fluids for hydration
Give the input of a dietary protein and carbohydrate are adequate.
Evaluation:
Client's skin remains intact, clean and dry
3. The risk of injury associated with the inability to control the movements secondary to spasticity.
Objectives:
Clients do not experience physical injury
Intervention:
Provide a safe physical environment:
Give pads on furniture. R / for protection.
Attach fence bed. R / to prevent falls.
Strengthen the furniture that is not slippery. R / to prevent falls.
Avoid polished floors and carpets are a mess. R / to prevent falls.
Select toys to suit the age and physical limitations. R / to prevent injuries.
Encourage adequate rest. R / because fatigue can increase the risk of injury.
Use restrein when children are in a chair or vehicle.
Do the right technique to drive, move the temptation to manipulate parts of the body paralysis.
Implement appropriate security measures to prevent thermal injury. R / there is a loss of sensation in an area hospital.
Provide protective helmets to children who tend to fall and push to use it. R / preventing head injuries.
Give anti-epilepsy drugs appropriate provisions. R / prevent seizures.
Evaluation:
Families provide a safe environment for children.
Children are free from injury.
4. Verbal communication-related damage dengaan damage the ability to say words that relate to the involvement of secondary muscles of facial rigidity.
Objectives:
Melakukaan client communication process within the limits of damage.
Intervention:
Tell a speech therapist with early
R / before the children learn the habit of poor communication.
Talk to the child slowly
R / allow time for children to understand speech padaa
Use the articles and pictures
R / circumstances push to talk reinforces the understanding
Use eating techniques
R / help make it easier to talk like using the lips, teeth and tongue movements.
Teach and use non-verbal communication methods (eg, sign language) for children with severe dysarthria.
Help families obtain electronic tools to facilitate non-verbal communication (eg, typewriter, microkomputer with sound processing).
Evaluation:
Children are able to communicate the needs of the caregiver.

CHAPTER V
CLOSING

A. CONCLUSION

Cerebral Palsy is a brain tissue damage that is permanent and not progressive. However, clinical picture can still change their way of life of patients. Incidence of the disease abroad varies between 0.07 - 6per 1,000 live births. In Indonesia is still unknown. Causative factor may lie in the prenatal, natal and post natal. Neuropatologik changes in CP are located in the motor cortex, basal ganglia and cerebellum. Clinical manifestations depend on the localization and extent of damage to brain tissue. Distinguished three basic forms of motor disorders in CP, ie spasticity, and ataxia atetosis. Diagnosis is made on a history relating to the possibility of brain tissue damage and physical disorder / neurological accordingly. Sometimes necessary investigation.
Handling includes: re-education / rehabilitation, psycho therapy, surgery and medication, which involves a team consisting of disciplines to share expertise. Prognosis depends on: the severity of CP, accompanying symptoms, rapid starts and intensipnya handling, attitude and cooperation of the patient / family and the community.

B. ADVICE

The treatment of these children requires skill and, if they are treated at home, then there must be effective support services. Specific maintenance actions aimed at:
© Prevention of decubitus
© Memperthankan airways are clean
© Finding the best way to provide food to children and ensure adequate food intake
© Determining a communication system so that children can express, needs, desires and longings, and
© Encourage children to use their skills and help children fully develop his abilities.
CP can not be cured, treatment is done to improve the capabilities of children. During its development, to this goal is to try the therapy in CP patients can live near normal life by managing the existing neurological problems as optimally as possible. Here there is no standard therapy that apply to all people with CP. Clinicians are expected to work together in teams, to identify the specific needs of each child and the abnormalities that exist and then determine a suitable individual therapy for each patient.
CP did not always disturb the patient's intelligence. There are patients that can precisely and school achievement. For instance, there are patients who are now six classes, even classes in the UI. Patients from Bandung for example, grade 5 class champion. Actually, about the intelligence on the CP, there are indeed taxable, some not, depending on the severity of his CP. 

nursing care in child abuse

 child abuse

Definition

 Child abuse or wrong treatment of children is defined as any child abuse or adolens by parents, guardians, or others who sought to preserve, maintain, and care for them.Child abuse is an act or acts of negligence parents or carers of children who lead children to become mentally or physically impaired, emotional development, and child development in general.While according to the U.S. Department of Health, Education and Child abuse Wolfare definition as a physical or mental violence, sexual violence and neglect against children under the age of 18 made by people who should be responsible for the welfare of children, so safety and welfare of children is threatened.
ClassificationThere are two major categories, namely:In familiesPhysical abuse, non Accidental "injury" ranging from mild "Bruiser laceration" to the severe neurological trauma and death. Physical injury as a result of corporal punishment out of bounds, giving cruelty or toxins.Penelantantaran child / neglect, namely: direct an activity or behavior that may cause deleterious effects on children's physical condition and psychological development. Negligence can be:v Maintenance inadequate. Cause failure to thrive, children feel the loss of affection, psychiatric disorders, developmental delayv Inadequate Supervision. Cause the child fail at risk for the occurrence of physical and mental trauma.v Failure to get treatmentv Failure in treating children wellv Negligence in education, including a failure to educate children to be able to interact with its environment, or have failed to send their children to earn a living for the family that the child was forced to drop out of school.
Emotional maltreatmentMarked by fire / words that are degrading the child, does not recognize as a child. Persecution like this are almost always followed by other forms of persecution.Sexual abuse to use a persuasive approach. Coercion on the person taking the child to behave / conduct a real sexual activity, so that depict activities such as: sexual activity (oral-genital, genital, anal, or sodomy), including incest.OutdoorsIn institutions / agencies, in workplaces, on the road, on the battlefield.

Etiology 

There are several factors that cause children experiencing violence. Both physical violence and psychological violence, including:Stress stemming from the child.
a. Physically different, is physically different is the physical condition of children is different from other children. Examples can be seen is the child has a physical disability. Children have physical abnormalities and different from other children who have perfect physical.
b. Mentally different, that is mentally retarded child so the child has developmental problems and difficulty interacting with the surrounding environment. 
c. Different temperament, a child with a weak temperament tend to experience a lot of violence when compared with children who have a strong temperament. This is because the child who has a hard temperament tend to fight when compared to the weak-tempered child. 
d. Behave differently, ie the child has a behavior that is not reasonable and different from other children. For example a child behaving and acting strangely in the family and the neighborhood. 
e. Adopted children, adopted children tend to get rough treatment because parents assume that the adopted child is not the baby of the marriage itself, so instinctively there is no strong emotional ties between foster children and parents.

Family stress.
a. Poverty and unemployment, both of these factors are the strongest factors that cause violence in children, because these two factors strongly associated with survival. So anything will be done by parents, especially for the sake of earning his living, including having to sacrifice family.
b. Mobility, isolation, and inadequate housing, these three factors also greatly affect the occurrence of child abuse, because the environment sekitarlah the biggest factor in shaping personality and behavior of children. 
c. Divorce, divorce cause stress in children, because children will lose the affection of both parents.d. Children are not expected, this will also result in the emergence of violent behavior in children, because children do not correspond with what is desired by parents, for example lack of physical, mental weakness, and so on.
3. Stress comes from the parents, namely: 
a. Low self-esteem, children with low self-esteem will often get violent, because the child always feels useless and always disappointing others. 
b. As a child gets abuse, parents who experienced abuse in childhood will melakuakan the same thing to other people or their children as a form of impingement of the incident had ever experienced. 
c. Expectations on children that are not realistic, unrealistic expectations will make weight so that parents experience stress when unable to meet the needs of children, parents tend to make the child as an outlet for his frustration with violence.

Clinical Manifestations 

Due to the child's physicala. Abrasions, hematoma, bite wounds, burns, fractures, bleeding from 
a. subdural hematoma retinaakibat and the presence of damage in other organs. 
b. Sequel / disabled as a result of trauma, such as scarring, nerve damage, hearing loss, eye damage and other disabilities. 
c. Death.Due to the development of the child.

Growth and development of children who suffered abuse, are generally slower than normal children, namely: 
a. Physical growth of children in general less than peers who did not mendaapat anak2 mistreatment. 
b. Psychological development is also impaired, namely: 

§. Intelligence- Various studies have reported delays in cognitive development, language, reading, and motor.- Mental Retardation may result from direct trauma to the head, as well as malnutrition.- In some cases this delay is reinforced by the absence of adequate stimulation or because of emotional disorders. 
§. Emotions- There is emotional disturbance on: the development of positive self kosnep, or hostile in dealing with aggression, the development of social relationships with others, including the ability to confidently.- There was pseudomaturitas emotion. Some children become aggressive or hostile with adults, while others become withdrawn / away from the association. Children like bedwetting, hyperactivity, bizarre behavior, learning difficulties, school failure, difficulty sleeping, tempretantrum, etc..  
§ Self-conceptChildren who treated one felt ugly, unloved, unwanted, sad, and unhappy, incapable of enjoying the activity and some even attempted suicide. 
§. AggressiveChildren who receive physical mistreatment, more agresifterhadap peers. Often these actions egresif imitate their parents' actions or divert aggressive feelings to his peers as a result of poor self-concept. 
§. Social relationsIn this anak2 often less able to get along with peers or with adults. They have few friends and like to interfere with adults, for example by throwing stones or other criminal perbuatan2.As a result of sexual abuseSexual Tanda2 penganiayaan among others:Sign of trauma or local infection, such as perianal pain, vaginal secretions, and rectal bleeding.Signs of emotional disturbance, such as reduced concentration, enuresis, enkopresis, anorexia, or changes in behavior.Sexual behavior or knowledge of children who are not in accordance with age. Examination of genitalia dilakuak with respect to the vulva, hymen, and the child's anus.Munchausen SyndromePicture of this syndrome consists of symptoms:Symptoms are unusual / non-specificSymptoms appear only if there are parentsGetting treatment by her parents remarkableExcessive parental behavior.

Diagnostic Evaluation 

Diagnostic mistreatment can be enforced based on disease history, a thorough physical examination, documentation of a complete psychological history, and laboratory.Medical history and physical examinationPhysical abuseSigns patogomonik result of child abuse can be:Bruises, especially in the face, lips, mouth, ears, head, or back.Patogomonik burns and common: smoking, dipping an accomplice in hot water, or circular burns on the buttocks. Burns caused by electricity such as ovens or irons.Head trauma, such as skull fracture, intracranial trauma, retinal hemorrhages, and multiple long bone fractures with different levels of healing.Abdominal and thoracic trauma less frequently than the head trauma and bone on child abuse. Physical abuse is more dominant in children over age 2 years.NeglectNeglect of non-organic failure to Thrive, a condition that resulted in failure to follow the pattern of growth and development of children who should be, but responds well to the fulfillment of food and emotional needs of children.Medical neglect, which did not receive adequate treatment in children with chronic illness because the parent denies the child suffering from chronic diseases. Not able to immunization and other health care. Deliberate failure by the parents also include the failure to oral health care for children so that the damaged tooth.Sexual abuseTnda and symptoms of sexual abuse consists of:Painful vagina, anus, and penis as well as the presence of bleeding or secretions in the vagina.Chronic dysuria, enuresis, constipation or encopresis.Premature puberty in femalesSpecific behaviors: sexual activity with peers, animals, or a particular object. Not according to the age of the child's sexual knowledge and behavior that excites.Non-specific behavior: suicide attempts, feelings of fear in adults, nightmares, sleep disturbances, withdrawal, low self-esteem, depression, post-traumatic stress disorder, prostitution, eating disorders, etc..LaboratoryIf found bruises, bleeding need dilakuak screening. On sexual abuse, examination:Swab for analysis of acid phosphatase, spermatozoa within 72 hours after sexual abuse.Culture specimens from the oral, anal, and vaginal for genokokusTests for syphilis, HIV, and hepatitis BAnalysis of pubic hairRadiologyThere are two role of radiology in the diagnosis of abuse in children, namely to:a. Identifiaksi focus of the lesionb. Documentation
Radiological examinations in children under age 2 should be conducted to examine the bones, whereas in children over 4-5 years old need only be done if there is bone pain, limitation of movement during physical examination. The existence of multiple fractures with a cure rate of physical persecution.CT-scan is more sensitive and specific for acute and chronic cerebral lesions, only indicated in pengniayaan child or an infant who suffered severe head trauma.MRI (Magnetic Resonance Imaging) is more sensitive at the subacute and chronic lesions such as subdural and sub-arachnoid haemorrhage.Ultrasound is used to diagnose the presence of visceral lesionsColposcopy examination to evaluate children who suffered sexual abuse.

Management

Prevention and control of abuse and violence in children is through:Health servicesHealth services can perform a variety of activities and programs aimed at individuals, families, and communities.Primary prevention-goals: the promotion of parental and family welfare.Individual- Family life education in schools, places of worship, and community- Education for children about conflict resolution- Sexual education in adolescents at risk- Baby care education for adolescents who care for infants- A reference service life care- Training of professionals for early detection of violent behavior.Family- Class preparation parenting in hospitals, schools, institutions in society- Facilitate the fabric of affection on the new parent- Refer new parents at the health center nurse for follow-up (follow up)- Social services for familiesCommunity- Health education on family violence- Reduce the media containing the violence- Develop community support services, such as crisis services, shelters children / families / elderly / women who are abused- Control of holders of firearms and sharp 
§. Prevention of secondary objectives: diagnosis and action for families who stress- Individuals- Complete assessment of each incident of violence in the family in each health service- Plan of escape for victims adequately- Knowledge of sentence to ask for help and protection- Place of care or "Foster home" for the victims
§. Family- Community service for individuals and families- Refer to support groups in the community (self-help-group). For example: a group of prosperous families observer- Refer to the agency / institution in the community that provide services to victims 
§. Community- All healthcare professionals skilled at providing services to victims with a standard procedure in helping victims- Units and unit emergency services 24 hours to respond, report, service cases, coordination with law enforcement / social services for immediate service.- Tim coroner due to accidents / injuries, especially infants and children.- The role of government: police, courts, and local government- Epidemiological approach to the evaluation- Control of holders of firearms and sharpTertiary prevention-goals: redukasi and rehabilitation of families with violence 
§. Individuals- Recovery strategy strength and confidence to the victims- Professional counseling to individuals- Family- Re-education parents in the upbringing of children- Professional counseling for families- Self-help-group (group care) 
§. Community- "Foster home", a refuge- The role of the government- "Follow up" in cases of abuse and violence- Control of holders of firearms and sharpEducationThe school has the privilege of teaching a very private body part, namely the penis, vagina, anus, mammary in biology class. It should be emphasized that the part is very personal and harud maintained so as not to be disturbed others. Schools also need to improve the safety of children in school. Attitude or way of educating children also need attention in order to avoid emotional mayhem. Teachers also can help detect tanda2 physical persecution and neglect in child care.Law enforcement and securityLaw no.4 should yrs, 1979, regarding the welfare of children quickly enforced consistently. This will protect the child from all forms of abuse and violence. Chapter II, Article 2 states that "children are entitled to protection of the environment that may harm or hinder the growth and development of natural causes.Mass mediaCoverage of persecution and violence in children should be followed by artikel2 prevention and mitigation. The impact on children both short and long term prevention programs reported to be more emphasized.

Assessment

The focus of the overall assessment to establish the nursing diagnoses related to child abuse, among others:Psychosocial1) self neglect (neglect), clothes and hair dirty, smelly2) Failure to thrive3) Delays in the development of the cognitive, psychomotor, and psychosocial4) With drawl (secede) from adult orang2Musculoskeletal1) Fracture2) Dislocation3) Sprain (sprains)Genito urinary1) Urinary tract infections2) bleeding per vagina3) Injury to the vagina / penis4) Painful micturition time5) laceration to the external genetalia organs, vagina, and anus.Integumentary1) circulation lesions (usually in cases of burns due to smoking)2) burns the skin, bruising and abrasion3) The existence of a human bite tanda2 unexplained4) Swelling.

Nursing Dx 

a. Damage parenting b.d. young age, especially adolescents, lack of knowledge regarding the fulfillment of children's health and child care arrangements ketidakadekuatan. 
b. Adaptive capacity: a decrease in intracranial brain injury bd 
c. Imbalance nutrition less than body requirements include the inability bd, digest and absorb food due to psychological factors. 
d. The risk of developmental delay was caused by damage bd violence.

Intervention 

Dx I: Damage parenting b.d. young age, especially adolescents, lack of knowledge regarding the fulfillment of children's health and child care arrangements ketidakadekuatan.NOC: After nursing care then parents will be addressed in a constructive discipline, to identify effective ways to express anger or frustration that does not harm the child, and actively participate in counseling or parenting classes.
Intervention:- Support the disclosure of feelings- Help parents identify deficits or changes in parenting- Provide opportunities for interaction that is often a parent or child- Role models of parenting skills.
 
Dx II: adaptive capacity: a decrease in intracranial brain injury bdNOC: After nursing care then the client will show an increase in intracranial adaptive capacity is shown with fluid balance, electrolyte balance and acid-base. Neurological status, and neurological status: consciousness. 
Intervention:- Monitor the intracranial pressure and cerebral perfusion pressure- Monitor neurological status at regular intervals- Consider the events that stimulate a change in the wave of ICT- Determine the baseline vital signs and cardiac rhythm and monitor changes during and after activity- Teach caregivers about tanda2 indicating increased ICP (eg: increased seizure activity)- Teach caregivers about specific situations that stimulate the ICT on the client (eg, pain and anxiety); discuss appropriate interventions. 

Dx III: The imbalance nutrition less than body requirements bd inability to incorporate, digest, and absorb food due to psychological factors.NOC: After nursing care then the client will show the status gizia; intake of food, fluids, and nutrition, characterized by the following indicators (the range of values ​​1-5: inadequate, mild, moderate, strong, or adequate total).Oral diet, feeding through the tube, or total parenteral nutrition.Intake of fluids orally or IV
Intervention:- Identify faktor2 that can affect the patient's loss of appetite- Monitor laboratory values, particularly transferrin, albumin and electrolytes- Management of nutrition: to know the client's favorite food, monitor the nutritional and caloric intake on a mold, weigh the client at appropriate intervals- Teach a method for planning meals- Teach client / family about nutritious food and not expensive- Management of nutrition: give precise information about the nutritional needs and how to fulfill it.

Dx IV: The risk of developmental delay bd damage was caused by violence.