42
Malnutrisi

Mal Nutri Si

Embed Size (px)

Citation preview

Page 1: Mal Nutri Si

Malnutrisi

Page 2: Mal Nutri Si

Konsep Dasar

• inadequacy of any nutrient in the diet. Whilst recognised in people with a limited or restricted food intake, it is also associated with excessive food intake.

• Patients with malnutrition may have evidence not only of protein-energy malnutrition but also of vitamin and mineral deficiencies, especially after major surgery or chronic illness.

Page 3: Mal Nutri Si

Definisi

• Malnutrition is caused by an inadequate availability of nutrients,

• because of either poor intake or deficiency as a result of disease.

• In developed countries, malnutrition is usually a consequence of disease

Page 4: Mal Nutri Si

Dampak

• decreased dietary intake• increased nutritional requirements• impaired ability to absorb or utilise nutrients

Poor nutrition compromises immune function. Suppression of theimmune system by malnutrition has been implicated as one of themajor causes of complications in hospitalised patients (Ferguson et al.,1999).

Page 5: Mal Nutri Si

Klasifikasi

• Primary malnutrition is seen in those who are dependent upon others for nourishment: infants, children, the elderly, the disabled, prisoners and the mentally ill are the most vulnerable groups.

• Secondary malnutrition is seen with any disease that disturbs appetite, digestion or the absorption of nutrients. Socioeconomic factors can profoundly influence nutritional status

Page 6: Mal Nutri Si

Konsekuensi • impaired immune function, which increases risk of infection• delayed wound healing• increased risk of tissue breakdown and pressure ulcers• muscle wasting and weakness, which can affect:

– respiratory function– cardiac function– mobility

• altered structure of the small intestine (e.g. following surgery), which can result in malabsorption

• increased risk of post-operative complications• apathy and depression• general sense of weakness and illness

Page 7: Mal Nutri Si

Specifi c deficiencies

Malnutrition may be due to :• inadequate energy intake• inadequate protein intake• inadequate vitamins or minerals

Page 8: Mal Nutri Si

Protein-energy malnutrition

• is the inadequate intake of protein, mainly seen in developing countries.

• Kwashiorkor is the name given to malnutrition resulting from protein deficiency,

• marasmus is a deficiency of both protein and energy.

Kwashiorkor results in:• muscle wasting• a low serum albumin resulting in peripheral oedema (which

may make the muscle wasting less obvious)• fatty liver with hepatomegaly.

Page 9: Mal Nutri Si

• Marasmus is due to both protein and energy defi ciencies, which are

• characterised by the classic features of starvation, including:– growth reduction– absence of body fat– muscle wasting

Page 10: Mal Nutri Si

Specific vitamin and mineral deficiencies

• Vitamin A– The absorption of vitamin A is related to fat absorption in the

gut, and requires protein for synthesis. Therefore, a deficiency of fat, protein or a gut-related illness can result in vitamin A deficiency.

– Deficiency results in growth reduction and visual problems Xerophthalmia may occur in vitamin A deficiency and is characterised by conjunctivitis, abnormal and severe dryness of the surface of the cornea and conjunctiva.

– Bitot’s spots (white, soft deposits on the conjunctiva) and– night blindness may also occur. Where a deficiency exists,

there maybe a reduction in immunity

Page 11: Mal Nutri Si

Good dietary sources of vitamin A (and beta-carotene, a precursorto vitamin A) include

• carrots• oily fish• liver and liver products• fortified margarine and fat spreads• fish liver oils• dairy products (milk, cheese, cream and butter)• egg yolks• peaches, apricots and mangoes• tomatoes and red peppers• dark-green leafy vegetables (such as spinach).

Page 12: Mal Nutri Si

Vitamin B1 (thiamine) deficiency• Vitamin B1 deficiency may be seen in individuals who abuse alcohol

as, although it is present in many foodstuffs, vitamin B1 is not present in alcohol. In addition, the body does not store vitamin B1, as it is awater-soluble vitamin.

• Thiamine is mainly required during the metabolism of carbohydrates, fat and alcohol. Diets high in carbohydrate require more thiamine than diets high in fat.

• The deficiency is commonly known as beriberi. – ‘Dry beriberi’ refers to the development of neurological problems, such as

Wernicke’s encephalopathy (ataxia, confusion, nystagmus and sixth cranial nerve palsy), peripheral and motor neuropathy.

– ‘Wet beriberi’ refers to the development of neurological problems with additional heart failure.

– The problems are• reversible if suffi cient thiamine is given, intravenously if necessary

Page 13: Mal Nutri Si

Sources

• yeast and yeast extract• wholegrain cereal foods• pork• nuts• Pulses• Cereal

Page 14: Mal Nutri Si

Deficiency Vitamin B2

• Vitamin B2 is water-soluble and is found in small amounts in many foods. levels rapidly decrease under serious illness or with the intake of some drugs, for example amitriptyline, imipramine, chlorpromazine or oral contraceptives.

• A deficiency of riboflavin results in lesions on the mucocutaneous surfaces of the mouth (angular stomatitis, atrophic lingual papillae and magenta tongue), cracked, bleeding lips and glossitis. Itchy perineum and hair loss may be seen. There may also be neurological sequelae with photophobia and ataxia.

• Ribofl avin deficiency is often accompanied by iron deficiency – possibly as a result of impaired absorption

Page 15: Mal Nutri Si

Sources

• yeast and yeast extract• liver and offal meats• green, leafy vegetables• eggs• milk and dairy products and cereals and cereal

products.

Page 16: Mal Nutri Si

Folic acid

• Folic acid is the parent molecule of a large number of derivatives collectively known as ‘folates’.

• In deficiency states, it causes megaloblastic anaemia, atrophic tongue and growth retardation.

• Deficiency is most likely to occur as a result of:– Malabsorption (e.g. in Coeliac disease): The use of certain

drugs nterferes with folic acid metabolism (notably methotrexate to treat rheumatoid arthritis and anticonvulsants used in the treatment of epilepsy).

– Cell proliferation: Some disease states can cause an increase in cell proliferation (e.g. leukaemia).

Page 17: Mal Nutri Si

Sources

• liver• green vegetables• yeast extract• pulses• some fruits (oranges and orange juice).

Page 18: Mal Nutri Si

Vitamin C (ascorbic acid)

• Vitamin C is water-soluble and easily destroyed in cooking. It is biochemically active in collagen synthesis, iron absorption and in immunologic function.

• a deficiency in vitamin C, better known as ‘scurvy’, is characterised by swollen, bleeding gums, wiry hair, anaemia and a predisposition to infections, and easy bruising.

• people with poor diets devoid of fresh food, and those with increased vitamin C requirements, such as cigarette smokers or post-operativepatients, are likely to have suboptimal levels.

• Owing to its role in collagen synthesis, adequate vitamin C is essentialfor wound healing.

Page 19: Mal Nutri Si

Sources

• fruits and fruit juices (particularly citrus fruits, strawberries, kiwi

• fruit, berries, currants and guava)• some green vegetables (such as green

peppers, broccoli, cabbage and spring greens); • significant losses can occur during storage and

cooking.

Page 20: Mal Nutri Si

Zinc• A deficiency in zinc may occur in patients who require long-term

administration of parenteral or enteral feeding, if they have high requirements, with only standard amounts being provided.

• There are very small body stores of zinc; so problems can arise if it is not present within the diet on a regular basis.

• Conditions which predispose people to zinc deficiency are relatedto:– reduced intake (perhaps associated with an eating disorder)– reduced absorption/bioavailability (owing to an inhibitor, such as a high-

phytate diet)– increased losses (such as in diarrhoea or excessive vomiting)– increased requirement associated with growth (also in pregnancy/lactation)– and are secondary to conditions such as alcoholism.

Page 21: Mal Nutri Si

Sources

• red meat• fish and shellfish• milk and milk products• poultry• eggs• other sources of zinc include bread and cereal

products, green,• leafy vegetables and pulses, although these all

have a lower bioavailability.

Page 22: Mal Nutri Si

Iron• Iron is an essential component of

haemoglobin and myoglobin, with its major function being that of carrying oxygen. Many enzymescontain or require iron, and it is required for many metabolic processes.

• In contrast to other minerals, no mechanism exists in the body to excrete iron, therefore body levels of iron are regulated by absorption.

Page 23: Mal Nutri Si

• Iron deficiency results in a reduced ability to transport oxygen around the body. This can have many harmful effects on cardiovascular and respiratory systems, brain and muscle function, and wound healing.

• Both a deficiency and excess of iron are associated with an increased susceptibility to infection. Iron deficiency, with or without anaemia, results in a wide range of defects in immune function

Page 24: Mal Nutri Si

Sources

• red meat, liver and offal• poultry and fish (contain smaller amounts)• cereal products and fortified breakfast cereals;

these can contribute significant amounts of non-haem iron, but this is less well absorbed than iron from meat products (haem iron).

Page 25: Mal Nutri Si

Manajemen Malnutrisi

• a body mass index (BMI) of less than 18.5 kg/m2, or• have recently lost more than 10% of their body

weight unintentionally,or• have a BMI of less than 20 kg/m2, and 5% recent

weight loss• if the patient has not eaten for fi ve days and is

unlikely to eat for at least the next five days• has large nutritional losses, is highly catabolic or has

a poor absorptive capacity

Page 26: Mal Nutri Si

Nutritional Support• Despite help with and support to eat food

whilst in hospital, there will always be a number of patients who, owing to their underlying illness or condition, will require further nutrition support.

• This maybe either enterally (using supplemented diet, sip feeds or liquid nutrition) or intravenously (using parenteral nutrition).

Page 27: Mal Nutri Si

• Therapeutic feeding will require appropriate line access, whether by a fine-bore nasogastric/nasojejunal feeding tube, percutaneous endoscopic gastrostomy (PEG), or jejunostomy, or by a central catheter for parenteral nutrition (PN).

Page 28: Mal Nutri Si

Nurse’s role

• assessing and monitoring a patient’s nutritional status.

• Nutrition screening (Malnutrition Universal Screening Tool, or MUST)

• Nurses weigh and measure patients, which enables them to calculate a patient’s BMI. They are also in a key position to ask questions regarding recent weight loss, and appetite and dietary changes.

Page 29: Mal Nutri Si

• During a patient’s stay in hospital, repeated weights need to be taken, and clearly documented, at regular intervals as weight loss within hospital is common

• weight measurements will depend upon the patient’s illness and the acuity of that illness.

Page 30: Mal Nutri Si

• Food- and fluid-intake charts and nutritional care plans frequently need to be implemented by nursing or care staff, as they are the healthcare professionals in most frequent contact with the patient, and are therefore best placed to notice when someone is failing to eat anadequate amount.

• The nurse is also responsible for facilitating adequate food suitable to the patient, and in a manner that they can take it. It may be necessary to refer to a dietitian or speech and language therapist to achievethis

Page 31: Mal Nutri Si

Catering staff ?

• Food needs to be accessible, palatable and nutritious.

• To achieve this, there needs to be an effective communication channel between Trust management, hospital chefs, dietetic departments, clinical areas and patients so that appropriate meals can be provided 24 hours a day to those that require them.

Page 32: Mal Nutri Si

• Hospital catering is often seen as a Cinderella service, given little respect, only contacted when there is a problem with a meal and often not considered to be involved in patient care, but it has a vital role to play in providing adequate and appealing nutrition for patients –

• often on a budget of less than £2–£2.50 per day per patient.

Page 33: Mal Nutri Si

Dietitians• Dietitians frequently work with catering staff

at a strategic level to ensure that the meals provided are healthy and well balanced.

• Largely, this may be achieved in the planning, monitoring and quality control of menus.

Page 34: Mal Nutri Si

• In selected cases, following referral by a nurse, doctor or speech and language therapist, special diets or support may be required.

• Referral to a dietitian for those at risk, i.e. with a BMI <18.5 kg/m2, is essential and should be made as soon as possible once all criteria for referral have been met, i.e. the patient has been nutritionallyscreened and action plans within the screening tool have been implemented by nursing staff

Page 35: Mal Nutri Si

• Referral to the dietitian is also recommended for those patients who present with specifi c conditions, such as renal or liver failure, or a non-functioning gut.

• Dietitians can provide a more formal assessment of nutrition assessment and may use anthropometric measurements to determine, for example, the triceps’ skin-fold thickness, indicating fat storage, while the mid-arm muscle circumference indicates muscle mass.

Page 36: Mal Nutri Si

Medical staff

• The role of the medical practitioner is to recognise the signs of malnutrition through clinical assessment and thorough history-taking and to liaise with other healthcare professionals to organise referrals

• for further assessment, for example to speech and language therapists, dietitians, clinical psychologists, occupational therapists and the Nutrition Support Team

Page 37: Mal Nutri Si

Managing obese

• Obesity does not preclude patients from developing malnutrition, though it may be a natural reaction to think it should.

• Obese individuals do not usually appear malnourished.

• The increasing prevalence of obesity in the community suggests that an increasing number of patients admitted to hospital will be obese

Page 38: Mal Nutri Si

• Increased morbidity has been reported in the injured obese patient;

• this may be related to poor nutrition support. • If an obese individual has been trying to lose

weight prior to their admission to hospital, this should be an indication that they may be at risk of malnutrition.

• It can be diffi cult to consume all the essential nutrients (vitamins and minerals) together with adequate protein in an energy-restricted diet

Page 39: Mal Nutri Si

• It can also be difficult to consume all the essential nutrients if the diet mainly consists of high-energy, low-nutrient foods – such as fizzy drinks, sweets and cakes – rich in fats, oils and sugar. An excess of energy is consumed;

• the diet may still be deficient in essential nutrients such as minerals, vitamins and essential fatty acids

Page 40: Mal Nutri Si

• In such cases, individuals are consuming adequate energy, although the quality of their diet is poor. This phenomenon has been termed ‘modern malnutrition’

• Although obesity may give an increased chance of survival in situations of starvation, it does not seem to confer the same advantage following injury, when metabolic response is exaggerated in these individuals (Elia, 2003).

Page 41: Mal Nutri Si

Conclusion

• It is important to remember that screening will only indicate nutritional risk, not actual nutritional status.

• The screening process is not a means to an end; it is a way of informing the healthcare practitioner whether a more objective nutrition assessment is required.

• In hospitals where a thorough nutrition screening process is undertaken on admission and the use of a multidisciplinary approach to nutrition is used, the effects of malnutrition can be minimised.

• It is important to remember that malnutrition is both a cause and a consequence of ill health.

Page 42: Mal Nutri Si

Referensi

• Nutrition: A Handbook for Nurses. 2008. Edited by Carolyn Best. John Wiley & Sons