Prinsip Dasar Gizi Klinik :

Pendahuluan

Malnutrition and its consequences

Nutritional support
 (1)
Malnutrition and its
Consequences
 Introduction
Adequate nutrition plays an important role in
maintaining optimal health.

The consequences of malnutrition have been

well documented and contribute significantly
to morbidity and mortality.

Malnutrition increases health care costs by

prolonging hospital length of stay due to the
increased probability of medical complications
which result from compromised immune
function and impaired wound healing.
 Malnutrition may be
envisioned as a continuum
with four basic stages.
decreases in nutrient intake (e.g. poor diet,
eating difficulty) or excessive losses (e.g.
chronic diarrhea, abnormal bleeding, large
draining wounds).
nutrient stores are depleted as nutrients are
required to meet metabolic demands.
metabolic or biochemical changes occur,
leading to marginal malnutrition.
These are followed by deficiency symptoms
 Deficiency symptoms
Referred to as clinical or
symptomatic malnutrition,
Cell or tissue damage is present and
nutrient deficiencies are manifest by
specific, observable symptoms.
Frequently accompanies acute and
chronic diseases, as well as trauma.
 Illness
Example :
Cancer

Altered Altered
Altered Digestion and Altered Nutrient
Food Intake Absorption Metabolism Excretion

Examples: Loss Examples: Example: Examples: fecal

of appetite, radiation increased energy loss of fat-soluble
altered food enteritis, surgical needs due to vitamins and
likes/dislikes, resection of GI altered energy use calcium in clients
difficulty chewing tract, diarrhea in cancer with cancers that
and swallowing, affect enzyme
reduced saliva secretion or bile
secretion salt production

Malnutriti
on
 Types of Malnutrition

Marasmus (Chronic)
Kwashiorkor (Acute)
Mixed

Because this is a disease with multiple etiologies, the

best terminology would probably be polydeficient
malnutrition.

Green CJ. Clin Nutr 1999;18(s):3-28

 Hospital Malnutrition:
Critical Evidence

The Skeleton in the Hospital Closet

Height not recorded in 56% of cases
Body weight not recorded in 23% of cases
61% of those whose weight was recorded lost > 6 kg
37% had albumin < 3.0 g/dL

I am convinced that iatrogenic malnutrition

has become a significant factor in
determining disease outcomes in many
patients.
Butterworth CE. Nutr
Today 1974
 Hospital Malnutrition:
Prevalence
Numerous studies on hospital malnutrition
have been published.
Prevalence of malnutrition in U.S. hospitals
today ranges from 30% to 50%.
Patients nutritional status declines with
extended hospital stay.
 Malnutrition Among Hospitalized Patients:
A Problem of Physician Awareness

Up to 50% of hospitalized patients may be malnourished

on admission
Before nutritional assessment training:
Only 12.5% of malnourished patients are
identified
After 4 hours of training:
100% of patients are identified
 Prevalence of
Malnutrition in
Hospitalized Patients
10%
Severely Malnourished

21%
Moderately
Malnourished
69%
Adequate
Nutritional
State

Detsky et al. JPEN 1987

 Prevalence of Malnutrition in
Hospitalized Patients

In a published British study:

46% of general medicine patients
45% of patients with respiratory problems
27% of surgical patients
43% of elderly patients

Percentage of malnourished patients at time of

admission
 Hospital Malnutrition in
Brazil
Study of 4,000 patients in 25 hospitals to evaluate the
prevalence of hospital malnutrition and awareness by
health care providers.
Findings:
12.6% severe malnutrition
35.5% moderate malnutrition
Prolonged length of stay directly linked to malnutrition
Little awareness about the importance of nutritional status of hospitalized
patients
Malnutrition and its Consequences

Changes in intestinal barrier

Reduction in glomerular filtration
Alterations in cardiac function
Altered drug pharmacokinetics
Malnutrition and its Consequences

Loss of weight
Slow wound healing
Impaired immunity
Increase in length of hospital stays
Increased treatment costs
Increase in mortality
 Malnutrition and Increased
Complications

Many studies have shown that

complications are 2 to 20 times more
frequent in malnourished patients than
in well-nourished patients.
 Malnutrition and
Slow Wound Healing

Foot Amputation
86% of well-nourished patients healed
without problems
Only 20% of malnourished patients healed
successfully
 Malnutrition and Increased
Complications

42% of severely malnourished patients suffer

major complications
9% of moderately malnourished patients suffer
major complications
Severely malnourished patients are four times
more likely to suffer postoperative complications
than well-nourished patients
 Cumulative Mortality
% Mortality

Months After Hospitalization

 Hospital Stay
Malnutrition increases time and costs
Severe
Nutritional Status

Mild

Normal

Days
Robinson et al. JPEN 1987
 Nutrition Therapy Affects Outcomes:
Fewer Complications

1st hospitalization
2nd hospitalization
At 6 months
15
Number of Complications

With Nutrition Therapy

10 Without Nutrition Therapy

0 n = 28
n = 32n = 9n = 15n = 25
n = 27
n = Number of hip fracture patients
Delmi M et al. Lancet 1990
 Nutrition Therapy Affects
Outcomes: Quality of Life Index
2 Without
PEG
With
1 *p = 0.038
PEG
Quality of Life Index
(arbitrary units)

- *
1 Radiation Therapy
-
2 0 2 4 6 12 18 24
Weeks
 Nutrition Therapy Affects Outcomes:
Early Nutrition

80
76 Days
Length of Stay (days)

40
30 Days

0
Fed at 3 days At 7 days
Garrel et al. J Burn Rehabil 1991
 Summary
Malnutrition
Extensive prevalence
Linked to:
Increased complications

Increased length of hospital stay

Higher costs

Increased mortality

Nutritional therapy must become an integral part of

patient care.
 (2)
Nutritional support

Nutrition Care
Nutrition Therapy
The Nutrition Care Process

Nutritional Assessment
Estimating Nutritional

Requirements
Nutrition Modalities

Monitoring Nutritional Therapy

 Nutritional Assessment
Risk Factors
Diet History
Medical History
Physical Examination
Subjective Global Assessment
Laboratory Tests
Estimating Nutritional Requirements

Determine Ideal or Adjusted Body Weight

Energy Requirements
Protein Requirements
Fluid Requirements
Electrolyte Requirements
Fat Requirements
Micronutrient Requirements
 Nutrition Modalities
Oral Diet
Enteral Nutrition
Parenteral Nutrition
 Oral route
the preferred route for providing nutritional
intake.
Many different types of oral diets are available
In addition, commercially prepared liquid oral
supplements can be used in conjunction with an
oral diet to promote adequate nutrient intake.
Dietitians can perform a nutrient intake
analysis (calorie/protein count) to evaluate
the adequacy of daily oral nutrient intake if
needed.
 Enteral Nutrition
Tube feedings are indicated for patients who are
unable to ingest adequate nutrients normally and
safely by mouth but who have at least a partially
functional GI tract.
Enteral nutrition support is preferred to
parenteral nutrition because it facilitates
maintenance of intestinal structure and function,
improves immunity, and avoids catheter-related
complications associated with the use of PN.
Enteral nutrition support is significantly less
expensive than parenteral nutrition.
 Parenteral Nutrition
Parenteral nutrition support is indicated in
the presence of compromised nutritional
status when adequate protein and
calories cannot be provided by oral or
other enteral routes.
Parenteral nutrition includes both
peripheral parenteral nutrition (PPN) and
central or total parenteral nutrition (TPN).
 Monitoring Nutritional
Therapy
Physical Examination
Functional Assessment
Laboratory Tests
Basic Test Schedule
Nitrogen Balance
Protein-energy Balance Markers
Evaluating Acid/Base Balance
Vitamins and Minerals
Liver Dysfunction
Team Approach (Interdisciplinary)

Physician
Registered Dietitian
Registered Nurse, Licensed Vocational Nurse,
Certified Nursing Assistant
Pharmacist
etc
 THE PATIENT
SHOULD BE AN ACTIVE
PARTICIPANT IN THE CARE
PROCESS!