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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