Odem

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Scenario
A man aged 50 years, was taken to hospital by his family complained of fatigue, there was a visible Odem in periorbital area and both of legs.His family said that the patient had no history of previous illness.

General Learning Objectives: Upon the completion of this tutorial activities, the students are able to understand the blood circulation




Step 1 : Clarifying unfamiliar terms
  1. Periorbital
  2. Odem
  3. Fatigue
The answers :
  1. Periorbital : Peri Surrounding
                          Orbital the eye
So, periorbital is an area in the surrounding of eye.
  1. Odem : the acculumation of fluid that abnormal in intercellular and extravasculer part.
  2. Fatigue : high quality of tired


Step 2 : Problem Definition
  1. What’s the cause of odem?
  2. What’s the impact if the odem can’t be handled?
  3. Is the age impact the odem?
  4. Why the odem is happened in the periorbital area and both of legs?
  5. Why the the man can suffer the disease although he haven’t the history of illness?
  6. Why the odem can be suffered by the man?
  7. Why the man complained the odem?
  8. What are the symptomps of odem?
  9. Is the odem include to the heredity disease?
  10. Can the odem be healed?
  11. Why inbalance of liquid in our body can cause the odem?


Step 3 : Brainstorming
  • There is the fluid left in the interstitial
    • It because hepatitis and hipoprotein
    • The plasma of protein goes out from the vessel
    • The limp’s vessel is get the obstruction
    • Cardiac failer
    • Increasing the fluid in intraceluler, extracellular, and extravascular
    • The fluids is failed to return to artery or vein
    • Retention fluid in the kidney
    • Distrubing the balance of ADH
  1. It can cause the die.
Proteinemia
  1. Yes, it is
No, itsn’t
  1. Because it is the location of odem
  1. Because he is 50 years old

  1. The man suffer cardiac failer
  1. -   The man suffer proteinemia
  • schemia of muscle
  1. There is a pitting scar
  1. No, itsn’t

  1. Yes,it can
  1. ADH can’t controlling the fluid


Step 4 : Analyzing the Problem
  1. ^^ The retention of fluid, so it can be :
  1. Increase the blood circulation to our heart
  2. Increase the pressure
  3. Increase the circulation in right atrium
  4. The heart’s muscle be bigger so the contraction be faster and the blood and fluids is accumulated in our legs if we standing.
^^ The cardiac failed to pump the blood so the vein and capiler’s pressure is so high, capiler filtration is so high, artery’s pressure is so low , the excretion of water and Natrim is so low, the hydrostatic pressure is so high and all of it cause the odem.
^^ The accumulation of the blood in the intravascular
^^ Increasing the fluid/blood in :
  1. Intraseluler =it can cause by the depression of metabolism and no nutrition,the system can’t work to distribute the fluid and can be odem
  2. Extraseluler=blood is overload because there is abnormal fluid in the interstitial
^^ it can be the accumulation in the limp’s vessel so limp’s vessel can’t deliver the blood return to heart and it can be the odem.
^^ If ADH can’t controlling fluid, it can disturb the distribution of fluid too so there is an accumulation in specific part or called odem
added question : How if the odem suffer the kidney ?
Answer : we never heard about the odem in the kidney
  1. It will make he odem in other part, the tissue can suffer necrosis and it can cause the die.
  1. ^^Odem isn’t a directly disease.Odem is caused by cardiac failer, cardiac failer is work step by step to “make” the odem.So, in that old(50 years old) is the final step of the cardiac failer “make” the odem.
^^Odem not accordingly to the old, it just caused by the cardiac failer
  1. ^^In the legs the vena vessel in the legs can’t pump the blood to the heart so it can be accumulation of the fluid in the legs.
^^According to the gravitation, the fluid moved slowly, so the fluid accumulated in legs and periorbital.
  1. ^^He was old, he can suffered the cardiac failer and make the odem
^^ not just because the old, but because the cardiac failer
  1. (it is clear on step 3)
  1. ^^if someone get the odem, the blood vessel gagged, the protein can’t reach the organs, the oxygen can’t reach the brain too so it is disturb the process of ATP’s making, the muscle also can’t do the regeneration  and it can cause fatigue

  1. If they push the odem, there is a “pitting”
  1. It is not caused by DNA, it is just cause by the bad condition of the body.

  1. ^^it can be healed if he get the ADH’s supply so the ADH can’t controlling the fluid’s/blood’s circulation
^^it can be healed by get surgery/operation
^^it can’t be healed full, he stiil need the medicine to controlling the blood circulation
  1. If ADH can’t controlling, the fluid is over load, so it can disturb the heart activity to pump the blood, the distribution is abnormal, and can make the accumulation of the blood/liquid in some part or called odem.





Step 5 : Formulating Learning issues
  1. Anatomy and Physiology of blood’s circulation
  2. Mechanism of odem
  3. Symptomps of odem
  4. How to cure the odem
  5. The cause of odem
  6. Kinds of odem
  7. How to examine, somebody is get odem or not?(physical assessment

Step 7 : Reporting
  1. Anatomy and Physiology Sirculation System

Sirculation system consist by blood vessel. There are artery and veins.
  • Artery
Arteri is blood vessel that go out from the heart. It’s bring the blood to all of the body. The bigest artery blood vessel called aorta. Artery has strong and thin wall. Big artery that go out from heart there are :
  • Aorta , have three part :
  • Pars ascendens aortae
  • Arcus aortae, have branches :
  • Truncus brachiocephalicus
  1. Arteria carotis comunis dextra
  2. Arteria subclavia dextra
  • Arteria carotis comunis sinistra
  • Arteria subclavia sinistra
  • Pars decendens aortae, have branch : arteria intercostales posteriores
  • Truncus Pulmonalis
  • Arteria pulmonalis dextra
  • Arteria pulmonalis sinistra



  • Vein
Vein ( return blood vessel ) is the blood vessel that bring the blood from all of body to enter to the heart.
There are vein that enter to the heart :
  • Venae cordis = bring the blood from myocardium
  • Venae cava superior = bring the blood from the upper part of body, head and neck
  • Venae cava inferior = bring the blood from the lower part of body and membrum inferior
  • Venae pulmonalis = bring the blood from pulmonari
Vena cava superior get the blood from :
  • Vena brachiochepalicus ( dextra / sinistra )
  • Vena jugularis interna
  • Vena cerebri
  • Vena azygos
  • Vena membri superior
  • Capiler
Capiler ( hair blood vessel ) is the smooten blood vessel. Its diameter around 0,008mm. Its wall is endotel layer. Some part of the body that non have capiler are : hair, nail, and cartilago. Capiler blood vessel usually consist the tissue’s cells. Because the wall is very thick, so plasma and nutrition will permeate to the intercell tissue fluid easily.

The function of capiler blood vessel are :
  1. Connecting tools between artery and vein blood vessel
  2. The place that use to changes the subtances between blood and tissue’s fluid
  3. To take the results from the glands
  4. To absorb nutrition that stay in intestine
  5. To filter the blood that stay in kidney


  • Limphatica System
Limphe vessel’s structure is almost same with the blood vessel. But its has many valves so limphe vessel seems like “ merjan series”. Ductus lymphaticus has function to collect, to filter, and to canalize again the lymphe fluid to the blood. Lymphe vessel as smooth tissue is stay in various organ, espesially in villi’s intestinum.
System Lymphatica consist by :
  • Vasa lymphatica
  • Trunchi lymphatica
  • Ductus lymphatica
  • Ductuc thoracicus

  1. Edema Causes and It’s Mechanism
  • Decreasing kidney blood vessel.
    Efective Blood Artery Volume ( EBAV ) is a important case to know about why the kidney holding natrium and water. EBAV is adecuat blood artery volume to fiil in all of artery capacity.  Decreasing the EBAV will be activate volume reseptor at the big blood vessel, included     low-pressure baroreseptor, internal reseptor so it will be increasing the simpatic tonus. It can make decreasing theblood stream in kidney. If the blood stream to kidney is defisit, so it will compensated by kidney with holding the natrium and water. And its mechanisms are :
  • Increasing natirum and water absorbtion in proximal tube
Decreasing of blood stream to the kidney is perceptioned by the kidney as decreasing  the blood pressure so  secresion the renin by apparatus juxtaglomerulus is occur. Renin will increasing formation of angiotensin II. Angiotensin II will cause arteriol efferen contraction, so it’s can occur the filtration and osmotic pressure in capiler will be increase. It’s can cause increasing water reabsorbsion in proximal tube.
  • Increasing natirum and water absorbtion in distalic tube
Angiotensin II will stimulate adrenalin glands to take down the aldosteron. Aldosteron will cause natrium retention in distalic tube.

  • NefroticSyndrome
    Nefrotic Syndrome is glomerulus disease that have characteristic proteinuria ( loss the protein pass through urine more than 3,5 gram/day). At certain condition, loss the protein and albumin can very hard, so plasma volume be decrese. Its cause decreasing kidney perfusion that also stimulate to natrium and water retention.
There are 2 mechanism that cause the edema at nefrotic syndrome, that are :
  • Underfilling mechanism
At this mechanism, edema caused by albumin degree was low, so it’s cause osmotic plasma pressure decrease too. Next, its followed by incease the transudation fluid from capiler to interstitial room.
Proteinuria

Hipoalbuminea

Plasma Osmotic Pressure

Plasma Volume

     ADH Renin-Angiotensin System    ANP

Water Retention Natrium Retension                Retention

 EDEMA

















  • Overfilling mechanism
At some of patient with nefrotic syndrome there is primer abnormaly that can disturb natrium ekscretion at distalic tube, so as a result is increasing the blood volume, press the renin-angiotensin system and vasopressin. It’s condition that followed by low osmotic pressure too has impact to transudating fluid from capiler to interstitial room.


      Primary tube’s defect

             Na Retention

            Plasma Volume

ADH                 Aldosteron ANP

  Water Retention                  Resistention tube about ANP

EDEMA

















  • Congestive Cardiac Failure
Congestive cardiac failure is marked by failure of cardiac pumping. When the heart is fail to pump the blood, the blood will accumulate at veins system and at this time artery blood volume will decrease.  Reduction of falling in the blood to artery will be responsed by simpatic nerve system with the compensation is vasocontriction the blood vessel. The effect from this vasocontriction is decreasing the blood supplay to the brain, heart and lung. At the other organ, like kidney will decresing the blood stream.  And the impact is natrium and water retenstion by kidney



Heart Failure Heart Failurehigh-output low-output

Pheriperal Vasculer Resistention Cardiac Output

      EBAV

Vasopresin extrication  Simpatic Nerve System Renin-Angiotensin-Aldosteron

    Water and Natrium Retention by Kidney

              EDEMA














  • Medicine
Edema maybe causes by a variety of medication, for example steroids, calcium channel blockers ( CCBs ), thiazolidinedionez, nonsteroidal antiinflamatory drugs ( NSAIDs), estrogen, etc.
  • Sirocis Hepatica
The symptoms is heart’s tissue has a fibrosis whict the shape of nodul. Large of  heart fibrosis has followed by distortion of parenkim stucture. When the canges the parencim structure is continue, it will cause the shape of phortosistemic will continue too. And vasodilatation in peripheral. Decreasing the albumin volume will be happen too, so it can cause filtration speed is decrease too.
  • Idiophatic Oedema
Accumulation of fluid in surrounding tissues with no identifiable caause is reffered to as idiophatic edema.
  • Limphe Obstruction
If the limphe has limphe stream disturbance in some region, so body fluid that come from blood plasma and metabolism that fill in limphe tube will be accumulationed ( limphadema ). Limphadema happen as a result from radical masectomi to remove the malignant at mamae or at limphe glands.
  • Hipoproteinemia
Decreasing blood protein volume ( hipoproteinemia ) cause decreasing the water power-string of plasma protein. So plasma fluid will permeate goes out from vascular as a edema fluid.
  • Pregnancy
Edema during pregnancy may accur because pregnant women have a greater volume of fluid circulating in teh body, and because they also retain more fluid. A woman may also experience postpartum edema.
  • Venous Insufficiency
This is a common condition in which blood does not return to the heart efficiently from the peripheral areas of the body ( for example the ankles, legs, feet, hands) which result in edema. This typically result in edema in both legs.

  1. Edema Symptoms

Symptoms will depend on the cause of edema.
  • Peripheral edema
Symptoms of peripheral edema include swelling of the affected areas, which causes the surrounding skin to “tighten”. The swelling from peripheral edema is gravity-dependent ( it will into increase or decrease with change in the body position ). For example, if a person is lying on their back ( supine ), the swelling will not appear in the legs, but will appaer in the area around the sacrum. The skin over the swollen area appear tight and shiny, and often when pressure is applied to the area with a finger, an identation appears. This is called pitting edema.
  • Pulmonary edema
In the case of pulmonary edema, there is often no evidence of fluid retention or noticeable swelling on examination of the patients extremities. This is because the fluids is backing up into the lungs. Signs and symptoms of pulmonary edema include :
  • Shortness of breath
  • Difficulty breathing when lying flat
  • Waking up breathless
  • Requiring multiple pillows raisethe head at night for a comfortable sleep.

  1. A lot of Kinds the Edema
  • Intracell Edema
There are 2 condition that make light of intracell swelling :
  1. Depression of metabolism system
  2. Unavailable nutrition for cells
For example : if blood stream to tissues decrease, it can cause accumulation ion Na. Its caused the water enter to the cells, so intracell volume be increase. Intracell edema also occur on inflamatory tissue. Inflamatory usually have effect to cell’s membran directly, that is increasing membran’s permeability and enable to difusion on natrium and other ion in the cell.
  • Ekstracell Edema
Caused by :
  1. Fluid leakage from plasma to the interstitial abnormally.
  2. Lymphatic system’s faillure to return the fluid from intestinum to the blood.
  • Pitting Edema
Pitting edema can be demonstrated by applying pressure to the swollen area by depressing the skin with a finger. If the pressing causes an identation that persists for some time after the release of the pressure, the edema is reffered to as pitting edema. Any form of pressure, such as from the elastic in socks, can induce pitting with this type of edema.
  • Non-pitting Edema
It’s usually affect the legs or arms, pressure that is applied to the skin does not result in a persistent indentation. It’s can occur in certain disorder of the lymphatic system such as lymphedema, which is a disturbance of the lymphatic circulation that may occur after a mastectomy, lymph node surgery, or congenitally. Another cause of non-pitting edema of the legs is called pretibial myxedema, which is a swelling over the shin that occurs in some patients with hyperthyroidism. Non-pitting edema of the legs is difficult to treat. Diuretic medications are generally not effective, although elevation of the legs periodically during the day and compressive devices may reduce the swelling.
  • Anasarca edema
General edema at all of sub-cutan tissue
  • Hydrothorax
Edema at thorax cavities
  • Hydropericardium
Edema at pericardium cavities
  • Hydroperitoneum
Edema at peritoneum cavities
  • Local Edema
Edema that occur in certain region only.



  1. How to Examine Some Body who Suffer Oedema by the Physical Assesment
  • Inspection = look at the object.  There is inflamation or not,,swelling or not.
  • Palpasion = press the object. There are four degree to determine the edema :
  • 1st degree : deep = 1-3 mm, and time to return = 3 second or less
  • 2nd degree : deep = 3-5 mm, and time to return = 5 second
  • 3rd degree : deep = 5-7 mm, and time to return = 7 second
  • 4th degree : deep = more than 7 mm, and time to return more than 7 second
  • Percusion = we can do it and we will get dullness sound if there is edema.
  • Auscultation = we will hear the “ krakels suond” in the lung
Depending on the details of the patient's history, the health care practitioner will perform a thorough examination. The health care practitioner may order tests, for example:
It is important to understand that while the edema itself can be physically limiting, ascertaining the underlying cause is important so that treatment can be targeted specifically to the condition causing edema. Sudden swelling of one or both legs may be a sign of a serious medical problem. If this occurs, see a health care practitioner immediately.

  1. How to Cure the Oedema
Once again, the treatment depends on the condition causing edema. In general, the treating principle is to reverse the forces that are not working properly:
  1. Increase the forces that keep fluid inside the blood vessels
  2. Reduce the forces that cause fluid to leak out of the blood vessels
  3. Identify the cause of the leaking blood vessel walls
For example, increasing the blood protein (albumin) level in a patient with a nutritional deficiency can help retain fluid in the blood vessels. Healing tissues exposed to trauma, (for example, swelling from a sprained ankle) assists in preventing fluid leaking from blood vessels.
The ultimate goal with edema treatment is to rid the excess fluid that has accumulated in the surrounding tissues in the body. The most common treatment is a diuretic. Diuretics make the kidneys excrete excess fluid from the body; which reduces the general fluid volume in the body. Diuretics should be used with caution as dehydration can be a side effect. There are many different types of diuretics that have different mechanisms of action and different potencies.

Edema Treatment

Self Care at Home

Compression stockings can be helpful by increasing the resistance to fluid leaking out of the vessels. These can be purchased in any medical supply store, and are particularly useful for peripheral edema. Body positioning can also be helpful for both peripheral and pulmonary edema to ease symptoms. For example, elevating the head with pillows in bed may benefit someone with pulmonary edema, while elevating the legs may minimize ankle and/or leg edema.

  1. Islamic Relevant Knowledge
  • Al Haqqah ayat 45-46
The meaning : “ Certainly really We are holding him/her at right of his/her hand. Next really We are cutting his/her heart node.”
  • Hadist Rasulullah
“Use Habbatussauda because in it there are medicine for all of disease,, except died.” ( HR. Bukhori Muslim )




















REFERENCE

Arthur.C.Guyton and Jhon.E.Hall, 2006, Buku Ajar Fisiologi Kedokteran, Jakarta : EGC

Setiadi, 2007, Anatomi & Fisiologi Manusia, Yogyakarta : Graha Ilmu

Syaifuddin, 2006 , ANATOMI FISOLOGI untuk Mahasiswa Keperawatan, Jakarta : EGC

Effendi Ian,Passaribu Restu, 2006, EDEMA PATOFISIOLOGI DAN PENANGANAN,Jakarta :  
          EGC

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