DUKUNGAN NUTRISI

ENTERAL PADA PENDERITA

KRITIS STROKE
Nurpudji A Taslim
Nutrition Department
School of Medicine Hasanuddin University
@2008
STROKE KEMAMPUAN MAKAN + MASALAH :
- PENDERITA
- KELUARGA
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PENDAHULUAN
TUJUAN PENGELOLAAN NUTRISI

Mempertahankan fungsi neurologi
Fasilitasi pengembalian fungsi-fungsi
tubuh secara optimal

ADA 3 HAL PENTING PADA KASUS
CRITICAL ILL
Hipermetabolisme
Hiperkatabolisme
Immunosupressan
KAPAN NUTRISI ENTERAL DIBERIKAN
Pemberian nutrisi enteral direkomendasikan
setelah kondisi hemodinamik stabil
Memasuki fase flow
PEMBERIAN KALORI BERDASARKAN
Antropometri
Timbang berat badan (BB)
Kasus BB normal dan cenderung malnutrisi
BB actual ( Brocca)
Orang dewasa dengan obesitas
menggunakan perhitungan BB Ideal (BBI)

PENILAIAN STATUS NUTRISI
Penilaian perubahan body composition akibat
berkurangnya pergerakan badan
Pemeriksaan biokimia laboratorium
Pasca perawatan malnutrisi dukungan nutrisi
yang adekuat
PENGELOLAAN NUTRISI
Stroke akut hipermetabolik
Pasca stroke
Penilaian status nutrisi
Pemeriksaan dan penghitungan kebutuhan nutrien
Penentuan jenis, bentuk, cara dan jalur pemberian
nutrien
Pemantauan dan evaluasi penyesuaian
EBB PHASE
RESPONSE
FLOW PHASE
Acute response Adaptive response
Hypovolemic
Shock
+Tissue perfussion
+ metabolic rate
+Oxygen Consump.
+Blood pressure
+Body temperature
Catabolism
predominates
Glucocorticoid
Glucagon
Cathecolamine,
Release of cytokines,
lipid mediators,
Production of acute
phase protein
Excretion of nitrogen
Metabolic rate
Oxygen consumption
Impaired utilization of fuel


Anabolism
predominates

Hormone response
gradually diminish
+Hypermetabolic rate
Associated with recovery
Potential for restoration
of body protein
Wound healing depends
in part on nutrient intake
CHARACTERISTIC OF METABOLIC PHASE OCCURRING
AFTER SEVERE INJURY
Source: Krauses FOOD,NUTRITION & DIET THERAPY, 2004
Changes in metabolic rate with various type of
physiiologic stress. Normal ranges are indicaed by
shaded areas.
0
30
60
90
120
150
180
0 10 20 30 40 50 60 70
Days
R
e
s
t
i
n
g

M
e
t
a
b
o
l
i
s
m

(
%

n
o
r
m
a
l
)
Major burn
Peritonitis
Fracture
Partial
Starvation
Total
Starvation
SOURCE:HANDBOOK OF CLINICAL NUTRITION, 1997
NORMAL RANGE
Changes in nitrogen excretion with various
types of physiologic stress
0
4
8
12
16
20
24
28
0 10 20 30 40
Days
N
i
t
r
o
g
e
n

e
x
c
r
e
t
i
o
n

(
g
/
d
a
y
)
Major burn
Skeletal
trauma
Severe sepsis
Infection
Elective op
Partial
Starvation
Total
Starvation
SOURCE:HANDBOOK OF CLINICAL NUTRITION, 1997
NORMAL RANGE
Hipoksia,
Inflamasi,
Nekrosis,
Trauma
Infeksi
Respons:
Lokal
Sistemik
PENILAIAN KEBUTUHAN
KALORI
Sangat sulit
Basal Expenditure Energy (BEE) bisa
meningkat
Estimasi BEE:
A. Indirect Calorimetri
B. Harris Benedict Equation
C. Resting Expenditure Energy (REE)


HARRIS BENEDICT EQUATION
LAKI-LAKI

BEE = 66 + 13,7 W + 5 H 6.8 A

PEREMPUAN

BEE = 655 + 9.6 W + 1.7 H 4.7 A





ACTIVITY FACTORS
1,2 for pt confined in bed
1,3 for ambulatory pt
1.2 1,75 most normally active person
2,0 extremely active person


INJURY FACTORS
1,2 minor surgery
1,35 skeletal trauma
1,44 elective surgery
1,6 1,9 mayor sepsis
1,88 trauma plus steroid
2,1 2,5 severe thermal burn





PENILAIAN KEBUTUHAN LEMAK
Menurunkan lemak total
Menurunkan lemak jenuh dan kolesterol
Menurunkan kalori apabila penderita overweight
/obese
MODEL DIET
Diet langkah I
Total lemak s 30%
Lemak jenuh < 10%
PUFA : sampai 10%
MUFA : sampai 15%
KH : > 55%
Protein : 15%
Kolesterol : < 300 mg/hari

Diet langkah II
Total lemak s 30%
Lemak jenuh < 7%
PUFA : sampai 10%
MUFA : sampai 15%
KH : > 55%
Protein : 15%
Kolesterol : < 200 mg/hari

PENILAIAN KEBUTUHAN PROTEIN
Ekskresi nitrogen
Anjuran : 1.5 2.2 g/kgBB/hari secara bertahap
Pemantauan : UUN dan kreatinin urin
Monitor : fungsi ginjal (ureum & kreatinin) dan
fungsi hepar
Brain Chaned Amino Acid (BCAA) dapat
dipertimbangan (pada pasien dengan hepatic
encephalophaty)
Serum albumin dipertahankan diatas 2.2 g/dL.
CARA MENGHITUNG KEBUTUHAN NITROGEN
1. Berdasarkan sekresi urea pada urine [urinary urea nitrogen =
UUN]. Untuk ini dibutuhkan urine tampung 24 jam. Langkah-
langkah yang harus dilakukan:
Ukur UUN 24 jam
Hitung total UUN dengan menggunakan rumus:


Hitung asupan protein penderita/hari
Hitung nitrogen balans dengan menggunakan rumus:



Keterangan : asupan protein yang dikonversi ke nitrogen = 6.25
UUN = 4 gr [rata-rata nitrogen yang dikeluarkan melalui urine]

100
] . ][ [ Urine Vol UUN
totalUUN =
] 4 [
25 . 6
Pr sup
] / [ + = A UUN
otein an A
hari g N
Contoh:
Seorang penderita yang mempunyai asupan protein
62.5 g/hari sekresi urin 500 mg/dl UUN dalam 2000
ml urine

Maka:
UUN = 500 x 2000/100
= 10.000 mg atau 10 gr

N [g/hari] = [62.5/6.25] [10 + 4]
= 10 14
= - 4 (negatif nitrogen balance)
2. Berdasarkan kebutuhan energi penderita:
tentukan kebutuhan energi penderita dalam sehari
Perkirakan ratio energi dan nitrogen, hal ini bervariasi
tergantung kondisi penderita. Dapat digunakan 1:150
untuk proses anabolisme dan atau 1:200 untuk
maintenance
Hitung kebutuhan nitrogen dengan menggunakan rumus:

Contoh:
Diasumsikan kebutuhan energi penderita sehari=2250
kcal, dan ratio kcal nitrogen 1:150, maka kebutuhan
nitrogen penderita tersebut adalah:


Dengan menggunakan hasil tersebut di atas dapat
ditentukan kebutuhan protein:
Pro[g] = Nitrogen [g] x 6.25
= 15 x 6.25
= 95.75 protein
Nratio Kcal
Kcal
g KebutuhanN
:
] [ =
gNitrogen g N 15
150
2250
] [ = =
PENILAIAN KEBUTUHAN ELEKTROLIT

Monitor kadar elektrolit dalam darah : Na, K, Cl ,
HCO3, Ca
Monitor Blood Gas



JALUR PEMBERIAN NUTRISI
Nutrisi enteral
Nutrisi parenteral (perifer atau sentral)
Kombinasi enteral + parenteral
Penilaian Nutrisi

Fungsi Saluran Pencernaan
Ya Tidak
Nutrisi Enteral
Nutrisi Parenteral
Fungsi Sal Cerna
Jangka pendek
Jangka panjang atau
Pembatasan cairan

Fungsi saluran
cerna membaik
Jangka panjang
Gastrostomi
Jejunostomi
Jangka pendek
Nasogastrik
Nasoduodenall
Nasojejunal

Nutrisi
Parenteral Perifer

Nutrisi
Parenteral Total

INDIKASI NUTRISI
ENTERAL DAN
PARENTERAL
Keputusan untuk memulai Dukungan Nutrisi Khusus
Normal

Nutrisi Lengkap

Compromised

Formula Khusus

Mencukupi
Berlanjut ke
Makanan
Oral
Tidak mencukupi
Nutrisi parenteral
Sebagai suplemen
Mencukupi
Diet yg lebih
Kompleks dan
Makanan oral
Sesuai dengan
penerimaan
Dilanjutkan ke nutrisi
Enteral total
Ya
Tidak
Nutrients
Tolerance

Sumber: ASPEN Board of Directors
Guidelines for the use of Parenteral and
Enteral Nutrition in adult and pediatric
Patients. JPEN 1993: 17.



KEUNTUNGAN NUTRISI
ENTERAL
Ekonomis
Memacu sekresi hormon pencernaan
Mencegah atrofi villi
Menghambat pertumbuhan bakteri dan
translokasi bakteri
Tanpa resiko sepsis kateter dan flebitis.
Heimburger, Douglas C. Handbook of Clinical Nutrition. Mosby, 1997. P 209 211.
INDIKASI NUTRISI ENTERAL
Diberikan secara oral
perhatikan cita rasa

Bisa juga menggunakan cara :
Nasogastric feeding
Gastro tube feeding
Jejunos
INDIKASI NUTRISI PARENTERAL
1. post op 3-4 hari
2. peradangan usus
3. fistula enterokutaneus
4. short bowel sindrom
5. pankreatitis akuta, tambahan oral kebutuhan meningkat
6. hiperkatabolik akut renal failure
7. terapi tambahan kanker
8. luka bakar hebat, malformasi traktus gastrointestinal (TGI)
pada neonatus
9. koma hepatik

PENGELOLAAN NUTRISI PADA PASCA STROKE
Pantau sesering mungkin
Modifikasi diet
Modifikasi diet bila ada kesulitan mineral

KEBUTUHAN KALORI PASCA STROKE
23 28 kcal/kgBB/hari (parese)
Pantau BB : hindari BB yang berlebihan
Dekubitus tingkatkan kebutuhan protein
EATING DISORDER
Anorexia Nervosa
Bulimia Nervosa
Other Conditions
CHAPTER OBJECTIVES
1. Contrast healthy attitudes toward uses of food with
behavior pattern that could lead to unhealthy uses of
food
2. Outline the causes of, effects of, typical persons
affected by and treatment for anorexia nervosa.
3. Outline the causes of, effects of, typical persons
affected by and treatment for anorexia bulimia
4. Describe still other forms of eating disorder; binge-
eating disorder, night eating syndrome and the athlete
triad
5. Relate the presence of eating disorders to current
social trends
6. Describe methods to reduce the development of eating
disorders, including the use of warning signs to identify
early cases
To understand the differences between various
eating disorders e.g. anorexia and bulimia
nervosa
To consider causative factor presenting
features, at risk groups, medical complications,
prevention and treatment
1. Refresh your memory
2. From ordered to disordered eating habits
3. Anorexia Nervosa
4. Anorexia Bulimia
5. Prevention of eating disorders
REFRESH YOUR MIND

YOU MAY REVIEW:

The effects of neurotransmitters on food
intake
The role of genetic risk in disease
susceptibility
Calculation of BMI
The effects and treatment of osteoporosis
The effects and treatment of iron deficiency
anemia
EATING BEHAVIORS

Why do we eat?
Internal hunger
Energy external pleasure, social, personality, environment
What is abnormal eating behavior?
Abnormal eating behavior = eating disorder?
EATING BEHAVIORS
Why do we stop eating ?
We stop eating when we are satisfied?

Eating is a behavior, not necessarily related to
hunger or fullness

MANY OF US, OCCASIONALLY EAT UNTIL
WERE STUFFED AND UNCOMFORTABLE
Problems controlling our food intake and body weight
Progressive weight gain lead to medical problems
Associated with simple overeating and too little physical
activity
Obesity chronic diseases most common eating
disorder in our society
Some people are more susceptible to these eating
disorders than other people are for genetic,
physiological and physical reasons
Successful treatment must go beyond nutritional
therapy
Eating disorders any age in both female and male, not
restricted to any socio-economic class or ethnicity

FROM ORDERED TO DISORDERED EATING
HABITS
Eating : completely instinctive behavior for animal
extra ordinary number of physiological, social and
culture purposes for humans
Take a religion meanings
Signify bonds within family and ethnic groups
Provide a means to express hostility, affection, prestige
or class values
Within the family, supplying, preparing and distributing
food may be a means of expressing love, hatred or
even power
IN FACT
MEDIA, AUDIOVISUAL INFLUENCES
Ultraslim body will bring :
happiness
Love
ultimately success

Contradictory
Much society becoming fatter/obese
FOOD :
MORE THAN JUST A SOURCE OF
NUTRIENTS
From birth adult; food link with personal and
emotional experiences
Food can be symbol of comfort
Eating stimulate neurotransmitter (serotonin) and
natural opiods (endorphins)---produce a sense of calm
and euphoria in the human body
Stress some people turn to food for a drug like,
calming effect
USING FOOD AS A BARGAINING
Contributing to abnormal eating behavior
Extreme lead to disordered eating
Mild or short term change effect of stressful or
illness or desire to modify the diet for variety of
health and personal appearance reason
Problems bad habit, a style eating adapted from
friends or family members or an aspect of preparing for
athlete competition
Disordered eating:
lead to weight loss or weight gain
certain nutritional problems
requires in depth professional attention.
sustained, distressing professional intervention

ANOREXIA NERVOSA
An eating disorder involving a physiological
loss or denial of appetite
Followed by self starvation
Related in part to distorted body image and to
various social pressure commonly associated
with puberty
BULIMIA NERVOSA
An eating disorder in which large quantities of
food are eaten at one time (binge eating) and
then purged from the body by vomiting or
misuse of laxative, diuretics or enemas

Alternate means to counteract the binge
behavior are fasting and excessive exercise
BINGE EATING DISORDER
An eating disorder characterized by recurrent
binge eating and feelings of loss of control over
eating that have at least 6 months

Can be triggered by frustation, anger,
depression, anxiety, permission to eat
forbidden food and excessive hunger
PROGRESSION FROM ORDERED TO
DISORDERED EATING
Anxiety to hunger and satiety signal; limitations of
calorie intake to restore weight to healthful level

Some disordered eating habits begins as weight loss is
attempted very restricted eating

Clinically evident eating disorder recognized
MEDICAL COMPLICATIONS OF ANOREXIA
NERVOSA AND BULIMIA NERVOSA
Cardiovascular : arrhythmia, bradycardia, oedema
cardiomyopathy, hypotension, peripheral cyanosis
Dermatologic : callus formation on hands, carotene
pigmentation, dry skin/nails, lanugo hair, thinning scalp hair,
irritation at corners of mouth
Endocrine : amenorrhoea, decreased triiodothyronine and
thyroxine levels, increased cortisol and growth hormone levels
Gastrointestinal : bloating, early satiety, constipation, dental
caries, diarrhoea, oesophageal rupture
Hematologic : mild anaemia, low white blood cell count
Metabolic : hypokalemia, hyponatremia, hypokalemia
Musculoskeletal : delayed bone maturation, reduced stature,
osteoporosis, seizures
TYPICAL CHARACTERISTIC OF ANOREXIA
NERVOSA
Loss weight >85% : BMI <17,5
False body perception
Ritual involving food
Maintain of rigid control in lifestyle
Felling of panic after small weight gain
Felling of purity, power and superiority
Preoccupation of food
Helplessness in the presence of food
Lack of menstrual periods for at least 3 months
Possible presence of bingeing and purging practices

TYPICAL CHARACTERISTICS OF BULIMIA
NERVOSA
Secretive binge eating (not in front of others)
Eating when depressed or under stress
Bingeing on a large of food followed by fasting, laxative
or diuretic abuse, itself induce vomiting or excessive
exercise
Fluctuating weight
Shame, embarrassment, deceit and depression, low
self esteem and guilt
Loss of control, fear of not being able to stop eating
Perfectionism ; people pleaser
Erosion of teeth, swollen glands
Purchase of syrup of ipecac to induces vomiting
PHYSICAL EFFECTS OF ANOREXIA NERVOSA
Lower body temp
Slowed metabolic rate from decreased synthesis of
thyroid gland
Decreased heart rate
Iron deficiency anemia
Rough, dry, scaly, and cold skin
Low WBC
Abnormal feeling of fullness or bloating
Loss of hair
Appearance of lanugo
Constipation
Low blood potassiumheart rhythm disturbancedeath
Loss of menstrual periods
Loss of teethacid erosion
Muscle tears and stress fractures in athlete--- decreased
bone and muscle mass




TREATMENT OF ANOREXIA
NERVOSA
Nutrition therapy
Gain the persons cooperation and trust
Gain weight 2-3 pounds/weeks
Monitoring blood levels of mineral (K, PO4, Mg)
Maintain adequate food intake
Psychological and related therapy
Emotional problems
Use cognitive behavior therapy
Family therapy
Food is a drug of choice for anorexic patient

HEALTH PROBLEMS STEMMING
FROM BULIMIA NERVOSA
Demineralization of teeth as an impact of the
acid in vomit
Blood potassium drops significantly
Salivary gland swollen
Stomach ulcer and bleeding
Constipation
Ipecac syrup induced vomitingis toxic to the
heart, liver and kidneys
TREATMENT OF BULIMIA
NERVOSA
Decreased the amount of food consumed in binge
session
Psychotherapy improved self acceptance less
concern about body weight
Cognitive behavior
Pharmacological therapy may be beneficial in
conjunction with other therapy
Nutrition counseling
Correcting misconceptions about food
Re-establishing regular eating habits

DEVELOPING REGULAR EATING HABITS