neuropsikiatri - unhalu 2010

7/28/2019 neuropsikiatri - unhalu 2010

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DUKUNGAN NUTRISIENTERAL PADA PENDERITAKRITIS STROKE

Nurpudji A Taslim

Nutrition DepartmentSchool of Medicine Hasanuddin University

@2008


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STROKE KEMAMPUAN MAKAN MASALAH :- PENDERITA- KELUARGA

?

N

U

TR

I

S

I

FI

SIOTER

API

MED

IKAAMEN

TOSA

T

I

N

D

A

K

AN

PENDAHULUAN


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TUJUAN PENGELOLAAN NUTRISI

Mempertahankan fungsi neurologi Fasilitasi pengembalian fungsi-fungsi

tubuh secara optimal


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ADA 3 HAL PENTING PADA KASUSCRITICAL ILL

Hipermetabolisme

Hiperkatabolisme

Immunosupressan


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KAPAN NUTRISI ENTERAL DIBERIKAN Pemberian nutrisi enteral direkomendasikan

setelah kondisi hemodinamik stabil Memasuki fase flow


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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)


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PENILAIAN STATUS NUTRISI Penilaian perubahan body composition akibat

berkurangnya pergerakan badan

Pemeriksaan biokimia laboratorium

Pasca perawatan malnutrisi dukungan nutrisi

yang adekuat


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PENGELOLAAN NUTRISIStroke akut hipermetabolik

Pasca stroke

Penilaian status nutrisi

Pemeriksaan dan penghitungan kebutuhan nutrien

Penentuan jenis, bentuk, cara dan jalur pemberian

nutrienPemantauan dan evaluasi penyesuaian


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EBB PHASE

RESPONSE

FLOW PHASE

Acute response Adaptive response

Hypovolemic

Shock

Tissue perfussion

metabolic rate

Oxygen Consump.

Blood pressure

Body temperature

Catabolism

predominates

Glucocorticoid

GlucagonCathecolamine,

Release of cytokines,

lipid mediators,

Production of acute

phase protein

Excretion of nitrogen

Metabolic rate

Oxygen consumption

Impaired utilization of fuel

Anabol ism

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


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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

RestingMetabolism(%

normal)

Major burn

Peritonitis

Fracture

Partial

Starvation

TotalStarvation

SOURCE:HANDBOOK OF CLINICAL NUTRITION, 1997

NORMAL RANGE


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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

itrogenexcretion(g/day)

Major burn

Skeletal

trauma

Severe sepsis

Infection

Elective op

Partial

Starvation

TotalStarvation

SOURCE:HANDBOOK OF CLINICAL NUTRITION, 1997

NORMAL RANGE


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STRESS METABOLIKHipoksia,

Inflamasi,Nekrosis,

Trauma

Infeksi

Respons:Lokal

Sistemik


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PENILAIAN KEBUTUHANKALORI

Sangat sulit

Basal Expenditure Energy (BEE) bisa

meningkat

Estimasi BEE:

A. Indirect Calorimetri

B. Harris Benedict Equation

C. Resting Expenditure Energy (REE)


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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


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ACTIVITY FACTORS1,2 for pt confined in bed

1,3 for ambulatory pt1.2 1,75 most normally active person

2,0 extremely active person

INJURY FACTORS1,2 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


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PENILAIAN KEBUTUHAN LEMAK Menurunkan lemak total

Menurunkan lemak jenuh dan kolesterol

Menurunkan kalori apabila penderita overweight

/obese


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MODEL DIET

Diet langkah I

Total lemak 30% Lemak jenuh < 10%

PUFA : sampai 10% MUFA : sampai 15%

KH : 55% Protein : 15%

Kolesterol : < 300 mg/hari

Diet langkah II

Total lemak 30% Lemak jenuh < 7%

PUFA : sampai 10% MUFA : sampai 15%

KH : 55% Protein : 15%

Kolesterol : < 200 mg/hari


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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 hepaticencephalophaty)

Serum albumin dipertahankan diatas 2.2 g/dL.


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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

].][[ UrineVolUUNtotalUUN

]4[25.6

Prsup]/[ UUN

oteinanAharigN


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Contoh:

Seorang penderita yang mempunyai asupan protein62.5 g/hari sekresi urin 500 mg/dl UUN dalam 2000ml 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)


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2. Berdasarkan kebutuhan energi penderita:

tentukan kebutuhan energi penderita dalam sehari

Perkirakan ratio energi dan nitrogen, hal ini bervariasi

tergantung kondisi penderita. Dapat digunakan 1:150untuk proses anabolisme dan atau 1:200 untukmaintenance

Hitung kebutuhan nitrogen dengan menggunakan rumus:

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

Dengan menggunakan hasil tersebut di atas dapatditentukan kebutuhan protein:

Pro[g] = Nitrogen [g] x 6.25

= 15 x 6.25

= 95.75 protein

NratioKcal

KcalgKebutuhanN

:

][

gNitrogengN 15

150

2250][


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PENILAIAN KEBUTUHAN ELEKTROLIT

Monitor kadar elektrolit dalam darah : Na, K, Cl ,

HCO3, Ca

Monitor Blood Gas


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JALUR PEMBERIAN NUTRISI Nutrisi enteral

Nutrisi parenteral (perifer atau sentral)

Kombinasi enteral + parenteral


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Penilaian Nutrisi

Fungsi Saluran Pencernaan

Ya Tidak

Nutrisi Enteral Nutrisi Parenteral

Fungsi Sal Cerna

Jangka pendekJangka panjang atau

Pembatasan cairan

Fungsi saluran

cerna membaik

Jangka panjang

Gastrostomi

Jejunostomi

Jangka pendek

Nasogastrik

Nasoduodenall

Nasojejunal

Nutrisi

Parenteral PeriferNutrisi

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

penerimaanDilanjutkan ke nutrisi

Enteral total

Ya Tidak

NutrientsTolerance

Sumber: ASPEN Board of Directors

Guidelines for the use of Parenteral and

Enteral Nutrition in adult and pediatric

Patients. JPEN 1993: 17.


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KEUNTUNGAN NUTRISIENTERAL 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.


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INDIKASI NUTRISI ENTERALDiberikan secara oral

perhatikan cita rasa

Bisa juga menggunakan cara :

Nasogastric feeding

Gastro tube feeding

Jejunos


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INDIKASI NUTRISI PARENTERAL1. 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


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PENGELOLAAN NUTRISI PADA PASCA STROKE

Pantau sesering mungkin

Modifikasi diet

Modifikasi diet bila ada kesulitan mineral


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KEBUTUHAN KALORI PASCA STROKE

23 28 kcal/kgBB/hari (parese)

Pantau BB : hindari BB yang berlebihan

Dekubitus tingkatkan kebutuhan protein


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EATING DISORDER Anorexia Nervosa

Bulimia Nervosa

Other Conditions


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CHAPTER OBJECTIVES1. Contrast healthy attitudes toward uses of food withbehavior 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 personsaffected by and treatment for anorexia bulimia

4. Describe still other forms of eating disorder; binge-

eating disorder, night eating syndrome and the athlete

triad5. Relate the presence of eating disorders to current

social trends

6. Describe methods to reduce the development of eatingdisorders, including the use of warning signs to identify

early cases


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OBJECTIVES To understand the differences between various

eating disorders e.g. anorexia and bulimia

nervosa

To consider causative factor presentingfeatures, at risk groups, medical complications,

prevention and treatment


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CHAPTER OUTLINE1. Refresh your memory

2. From ordered to disordered eating habits

3. Anorexia Nervosa4. Anorexia Bulimia

5. Prevention of eating disorders


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REFRESH YOUR MIND YOU MAY REVIEW:

The effects of neurotransmitters on foodintake

The role of genetic risk in diseasesusceptibility

Calculation of BMI

The effects and treatment of osteoporosis The effects and treatment of iron deficiency

anemia


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EATING BEHAVIORS Why do we eat?

Internal hunger

Energy external pleasure, social, personality, environment

What is abnormal eating behavior?

Abnormal eating behavior = eating disorder?


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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


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MANY OF US, OCCASIONALLY EAT UNTILWERE 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 physicalactivity

Obesity chronic diseases most common eatingdisorder in our society

Some people are more susceptible to these eatingdisorders than other people are for genetic,physiological and physical reasons

Successful treatment must go beyond nutritionaltherapy

Eating disorders any age in both female and male, notrestricted to any socio-economic class or ethnicity


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FROM ORDERED TO DISORDERED EATINGHABITS Eating : completely instinctive behavior for animal

extra ordinary number of physiological, social andculture purposes for humans

Take a religion meanings

Signify bonds within family and ethnic groups

Provide a means to express hostility, affection, prestigeor class values

Within the family, supplying, preparing and distributing

food may be a means of expressing love, hatred oreven power


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IN FACTMEDIA, AUDIOVISUAL INFLUENCES Ultraslim body will bring :

happiness

Love

ultimately success

Contradictory

Much society becoming fatter/obese


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FOOD :MORE THAN JUST A SOURCE OFNUTRIENTS From birth adult; food link with personal and

emotional experiences

Food can be symbol of comfort

Eating stimulate neurotransmitter (serotonin) andnatural 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


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USING FOOD AS A BARGAINING Contributing to abnormal eating behavior

Extreme lead to disordered eating

Mild or short term change effect of stressful orillness or desire to modify the diet for variety ofhealth and personal appearance reason

Problems

bad habit, a style eating adapted fromfriends 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


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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


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BULIMIA NERVOSA An eating disorder in which large quantities of

food are eaten at one time (binge eating) andthen purged from the body by vomiting or

misuse of laxative, diuretics or enemas

Alternate means to counteract the bingebehavior are fasting and excessive exercise


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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


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PROGRESSION FROM ORDERED TODISORDERED 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 isattempted very restricted eating

Clinically evident eating disorder recognized


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MEDICAL COMPLICATIONS OF ANOREXIANERVOSA AND BULIMIA NERVOSA Cardiovascular : arrhythmia, bradycardia, oedema

cardiomyopathy, hypotension, peripheral cyanosis

Dermatologic : callus formation on hands, carotenepigmentation, 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, dentalcaries, diarrhoea, oesophageal rupture

Hematologic : mild anaemia, low white blood cell count

Metabolic : hypokalemia, hyponatremia, hypokalemia

Musculoskeletal : delayed bone maturation, reduced stature,osteoporosis, seizures


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TYPICAL CHARACTERISTIC OF ANOREXIANERVOSA Loss weight >85% : BMI


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TYPICAL CHARACTERISTICS OF BULIMIANERVOSA Secretive binge eating (not in front of others)

Eating when depressed or under stress

Bingeing on a large of food followed by fasting, laxativeor diuretic abuse, itself induce vomiting or excessive

exercise Fluctuating weight

Shame, embarrassment, deceit and depression, lowself esteem and guilt

Loss of control, fear of not being able to stop eating

Perfectionism ; peoplepleaser

Erosion of teeth, swollen glands

Purchase of syrup of ipecac to induces vomiting


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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


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TREATMENT OF ANOREXIANERVOSA 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


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HEALTH PROBLEMS STEMMINGFROM 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 theheart, liver and kidneys


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TREATMENT OF BULIMIANERVOSA Decreased the amount of food consumed in binge

session

Psychotherapy improved self acceptance lessconcern about body weight

Cognitive behavior

Pharmacological therapy may be beneficial inconjunction with other therapy

Nutrition counseling

Correcting misconceptions about food Re-establishing regular eating habits

DEVELOPING REGULAR EATING HABITS


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neuropsikiatri - unhalu 2010

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