mmlnu s eneg oenalnutrisi energi...
TRANSCRIPT
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MALNUTRISI ENERGI PROTEINM LNU S ENE G O E N
Subbag.Nutrisi dan MetabolikBag I Kesehatan AnakBag.I.Kesehatan Anak
FKUSU-RSHAMMedan
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MEP
Masalah Gizi di Indonesia
Malnutrisi Energi Protein (MEP)
Anemia defisiensi besi
Gangguan akibat kurang iodium (GAKI)Gangguan akibat kurang iodium (GAKI)
Defisiensi Zn
Defisiensi vitamin A
ObesitasObesitas
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Theoretical framework of Nutrition Problems.
Nutrition problems Nutrition problems
F d intake Infect DiseaseFood intake Infect Disease directcauses
F d l b l M h & h ld H l hFood availability Mother & child Health indirectin household caring service causes
POOR FAMILY & EDUCATION, mainFOOD STUFF & JOB OPPORTUNITY problemFOOD STUFF & JOB OPPORTUNITY problem
ECONOMIC & POLITIC CRISIS coreECONOMIC & POLITIC CRISIS coreproblem
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Three level of determinants lead to nutrition status
Immediate :Intervention programs
S ppl side
Immediate :Inadequacy of dietary intake manifested :
- PEMMi t d fi i Supply side :
- access : health care facilities- supplementation of food &
micronutr.i i ti
- Micronutr.deficiency - Diarrhea & worm disease- ARI
Supply & coverage immuniz
Underlying :- Household food security- Access to PHC
- immunization- quality: providers’skill- information system: coverage
of suplpement., fortification,ill tAccess to PHC
- Community of awareness & care for children & women
Basic :
surveillance, etc. Health &NutritionStatus of
Basic :- Socio-economic conditions
(poverty & crisis)- Political factors
T diti l ti (i f t
Demand side:- empowerment- family awareness of nutrition
Children
- Traditional practices (infant feeding)
- Environment & sanitation
- subsidies / health insurance
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MEP
PERMASALAHAN MEP :
merupakan masalah kesehatan utama
primadona peny. gizi
berperan pd morbiditas & mortalitas balitaberperan pd. morbiditas & mortalitas balita
deteksi dini dan tatalaksananya penting sebagai upaya pencegahan melanjutnya MEPupaya pencegahan melanjutnya MEP
MEP berat perlu perawatan di RS
dampak thd. kualitas SDM
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Malnutrisi Energi Proteing
Penyakit akibat kekurangan energi dan protein, umumnya disertai defisiensi nutrien lainumumnya disertai defisiensi nutrien lain.
P i k k Primer : - masukan makanan <<- kualitas / kwantitas <<
Sekunder : - kebutuhan / keluaran (output) >>
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Malnutrisi Energi Protein
Status gizi merupakan spektrum : g m p p m
BB/TB
buruk kurang baik lebihg70 80 90 110 120 %-3SD -2SD +2SD +3SD
EP b d h bMEP berat sedang ringan overweight obese-Kwashiorkor ringan-Marasmus sedangMarasmus sedang-M-K berat
super
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MEP.
Klasifikasi Gizi Buruk :Klasifikasi Gizi Buruk :
1. GOMEZ (195..) : BB/U
2. MacLarren (196..) : Klinis + laboratoris
3 The Wellcome : Klinis + antropometris3. The Wellcome : Klinis + antropometrisTrust Party (1970)
4 Waterlow (1973) : BB/TB4. Waterlow (1973) : BB/TB
5. WHO (1999) : Klinis + antropometris
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MEP.
Klasifikasi Gizi Buruk (WHO 1999) :Klasifikasi Gizi Buruk (WHO,1999) :Gizi kurang Gizi buruk
Edema simetris -- + (oedematousl t iti )malnutrition)
BB/TB -3< Z-score <-2 < -3 Z-score (70-79%) (<70%)
(severe wasting)
TB/U -3< Z-score <-2 < -3 Z-score(85-89%) (<85%)
(severe stunting)(severe stunting)
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TANDATANDA DAN GEJALADAN GEJALA KLINISKLINISANAK GIZI BURUKANAK GIZI BURUK
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1. KWASHIORKOR1. KWASHIORKOR
EEdd-- EEdema dema -- Wajah membulat dan sembabWajah membulat dan sembab-- Pandangan mata sayuPandangan mata sayu-- Rambut tipis, kemerahan spt warna rambutRambut tipis, kemerahan spt warna rambut
jagung, mudah dicabut tanpa jagung, mudah dicabut tanpa sasakit,rontokkit,rontok-- Perubahan status mental: apatis & rewelPerubahan status mental: apatis & rewel
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TANDATANDA--TANDA KLINIS TANDA KLINIS ANAK GIZI BURUKANAK GIZI BURUKANAK GIZI BURUKANAK GIZI BURUK
EdemaEdema
Mi i l d k d k ki b if tMi i l d k d k ki b if t-- Minimal pada kedua punggung kaki, bersifat Minimal pada kedua punggung kaki, bersifat pitting edemapitting edema
-- Derajat edema:Derajat edema:Derajat edema:Derajat edema:++ Pada tangan & kakiPada tangan & kaki++++ Tungkai & lenganTungkai & lengang gg g++++++ Seluruh tubuh (wajah & perut)Seluruh tubuh (wajah & perut)
Derajat edema utk menentukan jumlah cairan Derajat edema utk menentukan jumlah cairan dib ikdib ikyang diberikanyang diberikan
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KWASHIORKOR (lanjutan)KWASHIORKOR (lanjutan)
-- Pembesaran hatiPembesaran hati-- Otot mengecil (hipotrofi)Otot mengecil (hipotrofi)g ( p )g ( p )-- Kelainan kulit berupa bercak merah mudaKelainan kulit berupa bercak merah muda
ygyg meluas & berubah warna menjadi coklat meluas & berubah warna menjadi coklat k hit d t k l (k hit d t k l ( ttkehitaman dan terkelupas (kehitaman dan terkelupas (crazy pavement crazy pavement dermatosisdermatosis))
-- Sering disertaiSering disertai:: peny infeksi (umumnyapeny infeksi (umumnya-- Sering disertaiSering disertai: : peny. infeksi (umumnyapeny. infeksi (umumnyaaakut),kut), anemia, dan diareanemia, dan diare
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Gizi buruk : Kwashiorkor
edemarambut k hkemerahan,mudah dicabutkurang aktifkurang aktif, rewel/cengengpengurusan otot crazy pavement dermatosis
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Gizi buruk : Kwashiorkor
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Gizi buruk : KwashiorkorGizi buruk : Kwashiorkor
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KwashiorkorKwashiorkorKwashiorkorKwashiorkor
HepatomegaliHepatomegali
Pitting Edema
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KWASHIORKORKWASHIORKOR (lanjutan)(lanjutan)KWASHIORKORKWASHIORKOR (lanjutan)(lanjutan)
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TANDATANDA--TANDA KLINISTANDA KLINISANAK GIZI BURUK (lanjutan)ANAK GIZI BURUK (lanjutan)ANAK GIZI BURUK (lanjutan)ANAK GIZI BURUK (lanjutan)
2. MARASMUS2. MARASMUS
-- Tampak sangat kurus, hingga seperti Tampak sangat kurus, hingga seperti tulang terbungkus kulittulang terbungkus kulitWajah seperti orang tuaWajah seperti orang tua-- Wajah seperti orang tuaWajah seperti orang tua
-- Cengeng, rewelCengeng, rewel-- Kulit keriput, jaringan lemak subkutisKulit keriput, jaringan lemak subkutisKulit keriput, jaringan lemak subkutis Kulit keriput, jaringan lemak subkutis
sangat sedikit sampai tidak ada sangat sedikit sampai tidak ada (~pakai celana longgar(~pakai celana longgar--baggy pantsbaggy pants))
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MARASMUS (lanjutan)MARASMUS (lanjutan)MARASMUS (lanjutan)MARASMUS (lanjutan)
-- Perut Perut umumnya cekungumumnya cekung-- Iga gambangIga gambangg g gg g g-- Sering disertai: Sering disertai:
penyakit infeksi (umumnya kronispenyakit infeksi (umumnya kronisb l ) d dib l ) d diberulang) dan diareberulang) dan diare
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MarasmusMarasmusMarasmusMarasmus
wajah seperti orang tua kulit terlihat longgarkulit terlihat longgar tulang rusuk tampak terlihat jelaskulit paha berkeriputterlihat tulang belakang lebih gmenonjol dan kulit di pantat berkeriput ( baggy pant )( baggy pant )
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MarasmusMarasmusMarasmusMarasmus
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MarasmusMarasmusMarasmusMarasmus
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MARASMUS (lanjutan)MARASMUS (lanjutan)MARASMUS (lanjutan)MARASMUS (lanjutan)
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MARASMUS (lanjutan)MARASMUS (lanjutan)MARASMUS (lanjutan)MARASMUS (lanjutan)
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TANDATANDA--TANDA KLINIS TANDA KLINIS ANAK GIZI BURUK (lanjutan)ANAK GIZI BURUK (lanjutan)ANAK GIZI BURUK (lanjutan)ANAK GIZI BURUK (lanjutan)
3. MARASMIK 3. MARASMIK -- KWASHIORKOR KWASHIORKOR
Gambaran klinik merupakan campuran dariGambaran klinik merupakan campuran daribeberapa gejala klinik Kwashiorkor dan beberapa gejala klinik Kwashiorkor dan Marasmus dengan BB/Marasmus dengan BB/TBTB << 3 SD3 SD disertaidisertaiMarasmus dengan BB/Marasmus dengan BB/TB TB <<--3 SD3 SD disertai disertai edema yang tidak mencolokedema yang tidak mencolok
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MARASMIK - KWASHIORKOR
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KEKURANGAN MIKRO NUTRIENKEKURANGAN MIKRO NUTRIEN(Menyertai Gizi Buruk)(Menyertai Gizi Buruk)
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KEKURANGAN MIKRO NUTRIENKEKURANGAN MIKRO NUTRIEN(Menyertai Gizi Buruk) (Menyertai Gizi Buruk)
1. Kekurangan Vitamin A1. Kekurangan Vitamin A2.2. Anemia (Kekurangan Fe, Cu, Vit. B12, Anemia (Kekurangan Fe, Cu, Vit. B12, ( g , , ,( g , , ,
Asam Folat) Asam Folat) 3. Stomatitis (kekurangan vit. B, vit. C)3. Stomatitis (kekurangan vit. B, vit. C)44 K l i d k lit t b hK l i d k lit t b h4.4. Kelainan pada kulit, gangguan pertumbuhan Kelainan pada kulit, gangguan pertumbuhan
((kekurangan kekurangan Zn)Zn)5 Beri5 Beri--beri (beri (kekurangan vitaminkekurangan vitamin B1)B1)5. Beri5. Beri--beri (beri (kekurangan vitamin kekurangan vitamin B1)B1)
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KEKURANGAN MIKRO NUTRIENKEKURANGAN MIKRO NUTRIEN(lanjutan) (lanjutan) ( j )( j )
1. Kekurangan Vitamin A (KVA)1. Kekurangan Vitamin A (KVA)
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KLASIFIKASI XEROFTALMIA
Xn Rabun Senjaj
X1 (Dryness of conjunctiva/ kekeringan Dryness of conjunctiva/ kekeringan k j i )k j i ) di i d ikonjungtiva)konjungtiva), , terdiri dari:
X1a Kekeringan pada konjungtiva (Dryness Dryness ofof conjunctiva)conjunctiva)ofof conjunctiva)conjunctiva)
X1b BBercak putih seperti busa sabun/keju pada sisi mata luar (bitot spot)bitot spot)pada sisi mata luar (bitot spot)bitot spot)
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KLASIFIKASI XEROFTALMIA (Lanjutan)
X3 (Corneal ulcer/ ulkus pada korneaCorneal ulcer/ ulkus pada kornea) )
T di i d i X3T di i d i X3 d X3d X3bbTerdiri dari X3Terdiri dari X3aa dan X3dan X3bbTanda-tanda:
kornea melunak seperti bubur & dapat menjadi ulkus X3a < 1/3 kornea , X3b ≥ 1/3 kornea / , /Keadaan umum anak sangat buruk, dapat terjadi perforasi kornea/ pecah
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X1X1aa (Dryness of conjunctiva/ kekeringan Dryness of conjunctiva/ kekeringan konjungtiva)konjungtiva)j g )j g )
Tanda-tanda:
• Penumpukan keratin & sel epitel yang khas• Konjungtiva kering, tampak menebal danKonjungtiva kering, tampak menebal dan
berlipat-lipat• Keluhan orang tua mata anaknya bersisik
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X1X1aa
Kerutan dan hiperpigmentasi
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Bitot’ spotBitot’ spot
‘Foam‘Foam--like’ substancelike’ substance
H i i & i klHyperpigmentation & wrinkle (X-1b)
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KLASIFIKASI XEROFTALMIA (Lanjutan)
X2 (Dryness of cornea/ kekeringan pada kornea)X2 (Dryness of cornea/ kekeringan pada kornea)Tanda-tanda :•Kekeringan meluas sampai kornea•Kornea tampak suram & kering dan permukaan kasarKornea tampak suram & kering dan permukaan kasar•K.U. anak biasanya buruk (gizi buruk & penyakit penyerta lain)
Kerutan dan hiperpigmentasi
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X3X3aa
C l l 1/3C l l 1/3Corneal ulcer < 1/3Corneal ulcer < 1/3
Conjunctival & ciliary injection
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X3X3bb
Ulkus kornea > 1/3Ulkus kornea > 1/3
KeratomalaceaKeratomalacea
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KLASIFIKASI XEROFTALMIA (Lanjutan)(Lanjutan)
XS (Corneal scar/ jaringan parut pada kornea)Corneal scar/ jaringan parut pada kornea)( / j g p p )/ j g p p )Tanda-tanda:
Kornea mata tampak putih/ bola mata mengecilKornea mata tampak putih/ bola mata mengecilMeninggalkan bekas luka parut/ sikatrikMenjadi buta & tidak dpt sembuh, walau dioperasi
k k kcangkok kornea
Corneal scarCorneal scar
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KEKURANGAN MIKRO NUTRIENKEKURANGAN MIKRO NUTRIEN(lanjutan) (lanjutan) ( j )( j )
2. Anemia (kekurangan Fe, Cu, Vit. B12,2. Anemia (kekurangan Fe, Cu, Vit. B12,( g , , ,( g , , ,Asam folat) Asam folat)
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ANEMIAANEMIA
Kadar Hb dibawah normalKadar Hb dibawah normal
Kadar Hb normal:Kadar Hb normal:6 bulan6 bulan 5 tahun5 tahun : 11: 11 g/ dlg/ dl6 bulan 6 bulan –– 5 tahun5 tahun : 11: 11 g/ dlg/ dl6 tahun 6 tahun –– 11 tahun11 tahun : 11, 5 g/ dl: 11, 5 g/ dl12 tahun 12 tahun –– 13 tahun13 tahun : 12 g/ dl: 12 g/ dl
TandaTanda--tanda klinis:tanda klinis:-- daya tahan terhadap penyakit menurundaya tahan terhadap penyakit menuruny p p yy p p y-- mudah lelahmudah lelah-- pucat (mata, telapak tangan)pucat (mata, telapak tangan)
(Sumber: indicators for assessing iron deficiency and strategies for its (Sumber: indicators for assessing iron deficiency and strategies for its prevention, WHO, UNICEF, UNU, 1998)prevention, WHO, UNICEF, UNU, 1998)
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ANEMIA (lanjutan)ANEMIA (lanjutan)ANEMIA (lanjutan)ANEMIA (lanjutan)
•• Anemia kekurangan Fe (zat besi)Anemia kekurangan Fe (zat besi)
F ( t b i)F ( t b i)Fe (zat besi):Fe (zat besi):
-- Kofaktor enzim pada metabolisme KarbohidratKofaktor enzim pada metabolisme KarbohidratKofaktor enzim pada metabolisme Karbohidrat,Kofaktor enzim pada metabolisme Karbohidrat,lemak dan protein.lemak dan protein.
-- Pertumbuhan, transpor oksigen dan kekebalan.Pertumbuhan, transpor oksigen dan kekebalan., p g, p g
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ANEMIA (lanjutan)ANEMIA (lanjutan)ANEMIA (lanjutan)ANEMIA (lanjutan)
•• Anemia kekurangan Fe (zat besi)Anemia kekurangan Fe (zat besi)
F ( t b i)F ( t b i)Fe (zat besi):Fe (zat besi):
-- Kofaktor enzim pada metabolisme KarbohidratKofaktor enzim pada metabolisme KarbohidratKofaktor enzim pada metabolisme Karbohidrat,Kofaktor enzim pada metabolisme Karbohidrat,lemak dan protein.lemak dan protein.
-- Pertumbuhan, transpor oksigen dan kekebalan.Pertumbuhan, transpor oksigen dan kekebalan., p g, p g
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ANEMIA (lanjutan)ANEMIA (lanjutan)ANEMIA (lanjutan)ANEMIA (lanjutan)
•• Anemia kekurangan Cu (Copper)Anemia kekurangan Cu (Copper)•• Anemia kekurangan Cu (Copper)Anemia kekurangan Cu (Copper)
Cu: pertumbuhan, kekebalan, homeopoesis, Cu: pertumbuhan, kekebalan, homeopoesis, p , , p ,p , , p ,metabolisme glukosa dan lemakmetabolisme glukosa dan lemak, kofaktor, kofaktor enzimenzim
Defisiensi Cu:Defisiensi Cu:-- Absorpsi zat besi turunAbsorpsi zat besi turun
Zat besi tidak dapat dimanfaatkan dengan baikZat besi tidak dapat dimanfaatkan dengan baik-- Zat besi tidak dapat dimanfaatkan dengan baik Zat besi tidak dapat dimanfaatkan dengan baik oleh sel darah merah.oleh sel darah merah.
-- Pengeluaran cadangan zat besi meningkatPengeluaran cadangan zat besi meningkatPengeluaran cadangan zat besi meningkatPengeluaran cadangan zat besi meningkat-- Anemia hipokromik dan netropeniaAnemia hipokromik dan netropenia
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ANEMIA (lanjutan)ANEMIA (lanjutan)
•• Anemia kekurangan vitamin B12 (Kobalamin)Anemia kekurangan vitamin B12 (Kobalamin)Anemia kekurangan vitamin B12 (Kobalamin)Anemia kekurangan vitamin B12 (Kobalamin)
Defisiensi B12:Defisiensi B12:
-- glositis atrofik (lidah yang halus & mengkilap)glositis atrofik (lidah yang halus & mengkilap)t titi ( d t l t t kt titi ( d t l t t k t k)t k)-- stomatitis (sudut mulut retakstomatitis (sudut mulut retak--retak)retak)
-- mual, muntah, diare bergantian dgn konstipasimual, muntah, diare bergantian dgn konstipasi-- getah lambung tidak ada (achlorhydria &getah lambung tidak ada (achlorhydria &getah lambung tidak ada (achlorhydria & getah lambung tidak ada (achlorhydria & achylia gastrica)achylia gastrica)
-- anemia makrositik hiperkromisanemia makrositik hiperkromispp
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ANEMIA (lanjutan)ANEMIA (lanjutan)ANEMIA (lanjutan)ANEMIA (lanjutan)
•• Anemia kekurangan asam folatAnemia kekurangan asam folat•• Anemia kekurangan asam folatAnemia kekurangan asam folat
Defisiensi asam folat:Defisiensi asam folat:-- perubahan pada eritrositperubahan pada eritrosit-- anemia makrositik megaloblastikanemia makrositik megaloblastik-- perubahan mukosa gastroperubahan mukosa gastro--intestinumintestinum-- diarediare
(Ilmu Gizi Klinis pada Anak, FKUI, 1990, Prof. DR.dr.Solihin Pudjiadi, DSAK)(Ilmu Gizi Klinis pada Anak, FKUI, 1990, Prof. DR.dr.Solihin Pudjiadi, DSAK)
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ANEMIAANEMIAANEMIA ANEMIA
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KEKURANGAN MIKRO NUTRIENKEKURANGAN MIKRO NUTRIEN(lanjutan) (lanjutan) ( j )( j )
3. Stomatitis (kekurangan vit. B, vit. C)3. Stomatitis (kekurangan vit. B, vit. C)
•• Kekurangan vitamin B2 (riboflavin), B6Kekurangan vitamin B2 (riboflavin), B6(adermin), B12 (kobalamin)(adermin), B12 (kobalamin)
•• Kekurangan vitamin C (asam askorbik)Kekurangan vitamin C (asam askorbik)
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KEKURANGAN MIKRO NUTRIENKEKURANGAN MIKRO NUTRIEN(lanjutan) (lanjutan)
4. Kelainan pada kulit, gangguan pertumbuhan 4. Kelainan pada kulit, gangguan pertumbuhan (kekurangan Zn)(kekurangan Zn)
Seng (Zn) berfungsi sebagai koenzim pada Seng (Zn) berfungsi sebagai koenzim pada berbagai sistem enzim. berbagai sistem enzim.
TandaTanda--tanda kelainan pada kulit:tanda kelainan pada kulit:- Hipo/ hiperpigmentasi - Deskuamasi (mengelupas)- Lesi ulserasi eksudatif (menyerupai luka
bakar) sering disertai infeksi sekunderbakar) sering disertai infeksi sekunder (candida)
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Kelainan kulit (defisiensi Zn)
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KEKURANGAN MIKRO NUTRIENKEKURANGAN MIKRO NUTRIEN(lanjutan) (lanjutan) ( j )( j )
5. Beri5. Beri--beri beri (kekurangan vitamin B1/ Thiamin)(kekurangan vitamin B1/ Thiamin)(kekurangan vitamin B1/ Thiamin)(kekurangan vitamin B1/ Thiamin)
Vit.B1 sebagai koVit.B1 sebagai ko--enzim metabolisme karbohidratenzim metabolisme karbohidrat
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PENYAKIT BERIPENYAKIT BERI--BERIBERI
TandaTanda--tanda klinis:tanda klinis:
-- BeriBeri--beri infantil (keadaan akut)beri infantil (keadaan akut)d k d k k b b d l k dd k d k k b b d l k dTidak ada kenaikan berat badan, pilek, diare,Tidak ada kenaikan berat badan, pilek, diare,
kelainan jantung, kongesti parukelainan jantung, kongesti paru--paru, edemaparu, edema
-- BeriBeri--beri late infancy & childhood (keadaan beri late infancy & childhood (keadaan menahun). Postur lebih kecil dari anak yangmenahun). Postur lebih kecil dari anak yangmenahun). Postur lebih kecil dari anak yang menahun). Postur lebih kecil dari anak yang sehat, gizi kurang, edema, perut membuncit sehat, gizi kurang, edema, perut membuncit oleh meteorismus)oleh meteorismus)
(Ilmu Gizi Klinis pada Anak, FKUI, 1990, Prof. DR.dr.Solihin Pudjiadi, DSAK)(Ilmu Gizi Klinis pada Anak, FKUI, 1990, Prof. DR.dr.Solihin Pudjiadi, DSAK)
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POKOK BAHASAN 4POKOK BAHASAN 4
TANDATANDA--TANDATANDAPENYAKIT PENYERTAPENYAKIT PENYERTA
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TANDATANDA--TANDAPENYAKIT PENYERTATANDAPENYAKIT PENYERTA
1. Diare Persisten1. Diare Persisten1. Diare Persisten1. Diare Persisten2. Parasit cacing2. Parasit cacing3. Tuberkulosis Paru3. Tuberkulosis Paru3. Tuberkulosis Paru3. Tuberkulosis Paru4. Malaria 4. Malaria 5. Pneumonia5. Pneumonia5. Pneumonia5. Pneumonia
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TANDATANDA--TANDA PENYAKIT PENYERTA TANDA PENYAKIT PENYERTA (lanjutan)(lanjutan)(lanjutan)(lanjutan)
i ii i1. Diare Persisten1. Diare PersistenDiare Diare >> 14 hari dengan atau tanpa dehidrasi14 hari dengan atau tanpa dehidrasi
Tanda dehidrasi: Tanda dehidrasi: -- letargis, gelisah dan rewelletargis, gelisah dan rewelletargis, gelisah dan rewelletargis, gelisah dan rewel-- sunken eyes (+/sunken eyes (+/--))-- haus (minum sedikit/ banyak)haus (minum sedikit/ banyak)-- turgor kulit lambatturgor kulit lambat
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DehydrationDehydration
Turgor :
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DehydrationDehydration
Sunken eyes
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TANDATANDA--TANDA PENYAKIT TANDA PENYAKIT PENYERTA (l j t )PENYERTA (l j t )PENYERTA (lanjutan)PENYERTA (lanjutan)
2. Parasit cacing2. Parasit cacingDi k i / l i d lDi k i / l i d lDitemukan cacing/ telur cacing dalam Ditemukan cacing/ telur cacing dalam tinja penderitatinja penderita
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TANDATANDA--TANDA PENYAKIT TANDA PENYAKIT PENYERTA (lanjutan)PENYERTA (lanjutan)PENYERTA (lanjutan)PENYERTA (lanjutan)
b k l ib k l i3. Tuberkulosis Paru3. Tuberkulosis Paru
kontak dgn penderita TB/ BTA positif- kontak dgn penderita TB/ BTA positif- uji tuberkulin positif (>10 mm)
gambaran foto rontgen mendukung TB- gambaran foto rontgen mendukung TB- reaksi kemerahan yang cepat (3-7 hari)
setelah imunisasi BCGsetelah imunisasi BCG - batuk-batuk > 3 minggu
hambatan pertumbuhan- hambatan pertumbuhan
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Tuberkulosis ParuTuberkulosis Paru(lanjutan)(lanjutan)(lanjutan)(lanjutan)
sakit/ demam lama/ berulang tanpa- sakit/ demam lama/ berulang tanpasebab jelaspembesaran kelenjar limfe- pembesaran kelenjar limfe
Bila ditemukanBila ditemukan >> 3 positif dari tanda3 positif dari tanda--tandatandaBila ditemukan Bila ditemukan >> 3 positif dari tanda3 positif dari tanda tanda tanda diatas, diatas, dianggap TB Paru dianggap TB Paru
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Gizi Buruk dengan TB ParuGizi Buruk dengan TB Paru
Sumber: Pedoman Nasional TB anak, UKK
Pulmonologi PP IDAI, 2005
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TANDATANDA--TANDA PENYAKIT TANDA PENYAKIT PENYERTA (l j t )PENYERTA (l j t )PENYERTA (lanjutan)PENYERTA (lanjutan)
4 Malaria4 Malaria4. Malaria4. Malaria(Daerah malaria/ riwayat kunjungan ke daerah risiko tinggi)daerah risiko tinggi)
- Demam (teraba panas, suhu >37,5 ºC)( p , , )- Renjatan (shock)- Kaku kuduk atau kejang
K lit b f- Kesulitan bernafas- Kuning (ikterik)- Perdarahan- Perdarahan- Sediaan darah tebal (+) malaria
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MALARIA (lanjutan)MALARIA (lanjutan)( j )( j )
TandaTanda--tanda bahaya:tanda bahaya:TandaTanda tanda bahaya:tanda bahaya:
-- tidak dapat makan/ minumtidak dapat makan/ minum-- tidak sadartidak sadar-- kejangkejang
t h b lt h b l-- muntah berulangmuntah berulang-- sangat lemah (tidak dapat duduk/ berdiri)sangat lemah (tidak dapat duduk/ berdiri)
(Pedoman Tatalaksana Kasus Malaria di Indonesia, Ditjen (Pedoman Tatalaksana Kasus Malaria di Indonesia, Ditjen Pemberantasan Peny Menular & Penyehatan LingkunganPemberantasan Peny Menular & Penyehatan LingkunganPemberantasan Peny. Menular & Penyehatan Lingkungan, Pemberantasan Peny. Menular & Penyehatan Lingkungan, Depkes RI, 2005)Depkes RI, 2005)
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TANDATANDA--TANDA PENYAKIT PENYERTA TANDA PENYAKIT PENYERTA (lanjutan)(lanjutan)(lanjutan)(lanjutan)
5. Pneumonia5. Pneumonia5. Pneumonia5. Pneumonia
a. Pernafasan cepat dan tarikan dinding dada:a. Pernafasan cepat dan tarikan dinding dada:-- < 2 bulan< 2 bulan : : >> 60 x/menit60 x/menit-- 2 bulan 2 bulan –– 12 bulan12 bulan : : ≥≥ 50 x/menit 50 x/menit > 12 b l> 12 b l 5 t h5 t h ≥≥ 40 / it40 / it-- > 12 bulan > 12 bulan –– 5 tahun5 tahun : : ≥≥ 40 x/menit40 x/menit
b Batuk atau kesulitan bernafasb Batuk atau kesulitan bernafasb. Batuk atau kesulitan bernafasb. Batuk atau kesulitan bernafas
((Sumber: MTBS, WHO)Sumber: MTBS, WHO)
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MEP.
DIAGNOSIS :
1. Anamnesis
2. Pem.fisis
3. Pem. Penunjang : - laboratorium- antropometrip- analisis diet
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MEP.
Checklist : anamnesisChecklist : anamnesis• Makanan sehari-hari sebelum sakit
P b i ASI• Pemberian ASI• Makanan/minuman beberapa hari terakhir• Mata cekung• Mata cekung• Lama & frekuensi muntah-diare, penampilan
muntahan / feses• Kapan kencing terakhir?• Kematian pada saudara kandung
B t l hi ?• Berat lahir?• Perkembangan psikomotor• Kontak dgn penderita KP atau CampakKontak dgn. penderita KP atau Campak• Imunisasi
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MEP.
Checklist: pemeriksaan fisikChecklist: pemeriksaan fisikBB TB atau PB• BB, TB atau PB
• Tanda gangguan sirkulasi: tangan/kaki di i di l h k d dingin, nadi lemah, kesadaran menurun
• Suhu : hipotermia atau demam• Frekuensi dan tipe pernafasan : tanda
pneumonia atau gagal jantung• Sangat pucat --> anemia berat• Mata: - lesi tanda defisiensi vit.A
- cekung dehidrasi
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MEP.
Checklist: pemeriksaan fisikChecklist: pemeriksaan fisik• Rasa haus mukosa mulut keringRasa haus, mukosa mulut kering,• THT : tanda infeksi• Abdomen : kembung, bising usus ?• Pembesaran atau nyeri pd hati; ikterusy p• Kulit : tanda infeksi, purpura, lemak SC • Edema atrofi otot• Edema, atrofi otot• Penampilan feses
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MEP berat : KwashiorkorR b tRambut Wajah
‘Puffy’
Edema
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MEP berat : Kwashiorkor
Crazy pavement EdemaHepatomegali
Crazy pavementdermatosis
Edema
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MEP berat : MarasmusWajah
Rambut
Atrofi otot
Iga gambang
Atrofi ototLemak SC <<
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MEP berat : Marasmus
limfadenopati
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MEP berat : Marasmus + KPMEP berat Marasmus KP‘Caverne’
6 l h i‘D d l ’ 6 mgg setelah terapi‘Destroyed lung’
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MEP.
Pemeriksaan laboratorium :Pemeriksaan laboratorium • Ada manfaatnya :
Gula darah : < 54 mg/dl = hipoglikemiag p gprep.apus darah : parasit malariaHb atau Ht : < 4 g/dl atau < 12% = anemia beratUrin rutin/kultur: bakteri + atau > 10 lekosit/LPB = infeksi Feses : darah + = disentri
Giardia + / parasit lain = infeksiGiardia + / parasit lain = infeksiFoto Rontgen : - toraks : Pneumonia
Gagal jantung- tulang : rikets, fraktur
Tes tuberkulin : seringkali negatif
• Kurang manfaatnya : protein serum, HIV, elektrolit
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MEP/tatalaksana.
TATALAKSANATATALAKSANA:
- MEP ringan-sedang :- gejala klinik - , tampak kurus / hipotrofig j , p p f- tidak perlu dirawat- identifikasi penyebabidentifikasi penyebab- penyuluhan & suplementasi
- MEP berat : rawat di RS
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MEP/tatalaksana.
Kriteria lain utk perawatan di RS :Kriteria lain utk perawatan di RS :
BB sangat rendah : - BB/TB < 70%- BB/U < 60%(- BB/U > 60% + edema)
d j l l i :dengan gejala lain :- edema (M-K)- dehidrasi beratdehidrasi berat- diare persisten dan/atau muntah- sangat pucat, hipotermia, syok
tanda infeksi sistemik/lokal sal nafas- tanda infeksi sistemik/lokal, sal nafas- anemia berat ( Hb < 5 g/dl)- ikterus- tidak nafsu makan- usia < 1 thn
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MEP/tatalaksana.
T nd / j l d hid si pd MEP b t :Tanda / gejala dehidrasi pd. MEP-berat :
- Anak lemas, apatis sp.tidak sadar- Nadi cepat dan lemah- Tidak ada air mata bila menangis- Mata & UUB cekungMata & UUB cekung- Mukosa mulut kering
kulit pucat dingin turgor <- kulit pucat, dingin, turgor <- Diuresis << / -
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MEP/tatalaksana.
5 ASPEK TATALAKSANA MEP BERAT 5 ASPEK TATALAKSANA MEP-BERAT :
A. 10 langkah utama
B P n b t n p n kit p n tB. Pengobatan penyakit penyerta
C Kegagalan pengobatanC. Kegagalan pengobatan
D. Pulang sebelum pemulihan tuntasg p
E. Tindakan pada kegawatan
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MEP/tatalaksana.A : “10 langkah utama”
No Tindakan Stabilisasi Transisi Rehabilitasi Tindak lanjuth 1-2 h 3-7 mg-2 mg 3-6 mg 7-26
1 Atasi/cegah 1. Atasi/cegah hipoglikemia
2. Atasi/cegahhipotermiahipotermia
3. Atasi/cegahdehidrasi
4. Perbaiki gang-g gguan elektrolit
5. Obati infeksi6. Perbaiki def. tanpa Fe + Fe
N i ikNutrien mikro7. Beri diit awal8. Beri diit T.kejar9 Beri stimulasi9. Beri stimulasi10. Siapkan tindak
lanjut
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MEP/tatalaksana
B PENGOBATAN PENYAKIT PENYERTA :B. PENGOBATAN PENYAKIT PENYERTA :
Infeksi bakteri :Infeksi bakteri :- bila tanda infeksi tdk nyata : kotrimoksasol
( 5 mg TMP/kgbb, 2x/hari )( g g )
- bila tanda infeksi nyata / sepsis :i ili 50 /k bb/6 j IM/IV - ampisilin 50 mg/kgbb/6 jam IM/IV
selama 2 hari oral- gentamisin 7.5 mg/kgbb IM/IV, 7 harigentamisin 7.5 mg/kgbb IM/IV, 7 hari
- bila KP + OAT
Infeksi virus : tidak diobati / simptomatik- pasien MEP perlu mendapat vaksin Campak
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MEP/tatalaksana
C KEGAGALAN PENGOBATAN : C. KEGAGALAN PENGOBATAN :
1 Pasien meninggal :1. Pasien meninggal := dlm 24 jam pertama :
hipoglikemia- hipoglikemia- hipotermia- dehidrasidehidrasi- sepsis
dl 24 72 j = dlm 24 – 72 jam :- volume formula >>
densitas kalori >>- densitas kalori >>
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MEP/tatalaksana
C KEGAGALAN PENGOBATAN : C. KEGAGALAN PENGOBATAN :
2 Kenaikan BB tidak adekwat :2. Kenaikan BB tidak adekwat :- infeksi- diet- diet- psikologik
Kenaikan BB := baik : > 10 g/kgbb/h baik == baik : > 10 g/kgbb/h baik == sedang : 5-10 g/kgbb/h > 50 g/kgbb/mg= kurang : < 5 g/kgbb/h atau < 50 g/kgbb/mg= kurang : < 5 g/kgbb/h atau < 50 g/kgbb/mg
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MEP/tatalaksana
D PULANG SEBELUM PEMULIHAN TUNTAS:D. PULANG SEBELUM PEMULIHAN TUNTAS:
b i h k = beri nasehat makan :- TKTP
frekwensi makan sering ( 5x/hr )- frekwensi makan sering ( 5x/hr )- harus habis- suplementasi vit-min elektrolitsuplementasi vit min, elektrolit- teruskan ASI
= kontrol sering ( 1x/mg )= kontrol sering ( 1x/mg )
= Imunisasi mun sas
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E. Tindakan pd kegawatan :
5.1. Syok (renjatan) :
N2 atau RLG5%15 ml/kgbb, 1 jam
Perbaikan+
_
Ulangi 1 jam lagi sepsis
Resomal 10 ml/kgbb, 10 jam Cairan rumat, 4 ml/kgbbDarah segar, 10 ml/kgbb
Formula khusus
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5. Tindakan pd kegawatan :
5.2. Anemia berat.
Hb ?
Hb < 4 g/dl Hb 4-6 g/dl
Distres resp./gagal jantung?
Darah segar 10 ml/kgbb* + _g g
PRC 10 ml/kgbb* Observasi
* : beri furosemid 1 mg/kgbb, iv, sblm transfusi
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MEP/tatalaksana
PERSIAPAN PULANG PERSIAPAN PULANG :
BB/TB sesuai t u- BB/TB sesuai, atauMEP berat sedang/ringan
- penyuluhan untuk ortu tentang :- higiene dan sanitasihigiene dan sanitasi- makanan sehat- pentingnya imunisasip g y m- kontrol teratur
b t kh ik / B t k- pengobatan peny.khronik / TBC teruskan
- imunisasi dilengkapi
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MEP/prognosis
PROGNOSIS :PROGNOSIS :
- Jangka pendek : mortalitas masih tinggi( 20-30 % )
- Jangka panjang : kualitas SDM <Jangka panjang kualitas SDM
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