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gangguan nutrisi
Nurvita Risdiana
Nutritional Problems
 Nutrition
• Nutrition is the sum of processes by which
one takes in and utilizes nutrients (ASPEN
Board of Directors, 2005)
• Nutrition is the taking in and metabolism of
nutrient (food and other nourishing material)
by an organism so that the life is maintained
and growth can take a place (Dorland Pocket
Medical Dictionary)
 Normal Nutrition
• Nutrition is important for energy, growth,
maintenance and repair of body tissues.
• The daily caloric requirements of a person are
influenced by body build, age, gender and
physical activity
 Food Intake Pattern
• Basis for all of MyPyramid’s advice
• Identify what and how much to eat
• Adjustment in caloric intake are necessary depending
on changes in health statues and daily activity level
• Designed to meet DRI and DGA recommendations
– 12 patterns for varying population groups and energy
needs
– The estimate daily adult energy (calorie) requirements
based on resting metabolic rate for individuals
 Carbohydrates
• The body’s primary source of energy
• Carbohydrates are simple or complex
• Complex Carbohydrate or polysacharides
commonly appear in the diet such as cereal
grains, potatoes and legumes
• Simple carbohydrates come in two forms
– monosaccharides (eq: glucose and fructose) which are
found in fruits and honey, and
– disaccharides (sucrose, maltose, and lactose)which
found in sugar, malted cereal and milk
 Fats
• Mayor source of energy
• Fats are stored in adipose tissue and in the
abdominal cavity
• Fats also act as carriers fat-soluble vitamins
 Proteins
• Another essensial component of well balance diet
• Are obtained from both animal and plant source
• Ideally 10-35% daily caloric needs should come from
protein.
• They recommended daily protein intake is 0.8 to 1 g/kg
of body weight
• The body is capable of sinthesizing nonessential amino
acids if an adequate supply protein is available
• Protein are essential for tissue growth, repair, and
maintainance; body regulatory function; and energy
production
 Vitamins
• Organic compound required in small amounts
for normal metabolism
• Vitamins function primarily in enzyme
reactions that facilitate the metabolism of
amino acids, fats, and carbohydrate
• Vitamins are divided into two categories:
– Water soluble vitamins (Vit C and B complex)
– Fat soluble-vitamins (Vit A, D,E and K)
 Mineral salts
• E.g magnesium, iron, calcium make up
approximately 4% of total body weight
• Minerals are necessary for the body to build
tissues, regulate body fluid and assist in various
body functions.
• Some minerals are stored and can be toxic if
taken in excess amount
• A well balanced diet can usually meet the daily
requirement of needed minerals.
• However, deficiency states can occur
Major minerals and trace elements
• Calcium
• Magnesium
• Phosphorus
• Chloride
• Sulphur
• Trace element: Iron, Copper, Zinc, mangan,
fluoride, selenium, cobalt
 Special diets
• Vegetarian
• Cultural awareness
 Vegetarian Diet
• All vegetarians is the exclusion of the red meat from the
diet
• Many vegetarians are
– Vegans: who are pure or total vegetarians and eat only plants
– Lacto-ovo-vegetarians: who eat plants and sometimes dairy
product and eggs
• The primary deficiency of a strict vegan is lack of cobalamin
(can be obtained only from animal protein)
• Vegan not using cobalamin suplements are susceptible to
the development of megaloblastic anemia and the
neurologic signs of cobalamin deficiency
• Strict vegetarian and Lacto-ovo-vegetarians are also risk for
iron deficiency
 Cultural awareness
• People have unique cultural heritage that may
affect eating customs and nutritional status.
• Each culture has its own beliefs and behaviors
related to food and the role that food plays in the
etiology and treatment of disease
• Examples; Moslem have specific laws regarding
food (Halal food)
• You should include cultural and ethnic
considerations when assessing the patient’s diet
• It is important to know whether the patients
eats “traditional foods” associated with the
culture.
• If traditional foods are eaten, assess for their
impact on health, such as: high fat,
cholesterol, salt.
• Teaching related to dietary restrictions and
recommended dietary changes should involve
the patient’s family.
 Malnutrition
• Is a deficit, excess, or imbalance of the
essential components of balanced diet
• Malnutrition can refer to alterations in
macronutrients (carbohydrates, proteins, and
fat) or micronutrients (electrolytes, minerals,
and vitamins)
• Terms such as under nutrition and over
nutrition are also used to describe
malnutrition
 Under nutrition
• Under nutrition describes of states of poor
nourishment as a result of inadequate diet or
diseases that interfere with normal appetite
and assimilation of ingested food
• Is a problem in developing and developed
country
• Found in individually lower sosioeconomic
class or individual with chronic or acute illness
 Over nutrition
• Refers to the ingestion of more food than is
required for body needs as in obesity
 Types of Malnutrition
• Protein-Calorie Malnutrition
• Marasmus and Kwashiorkor
 Protein-Calorie Malnutrition
• Also called protein-energy malnutrition
• Common form of under nutrition
• Can result from either primary or secondary factors
• Primary PCM is present when nutritional needs are not
met
• Secondary PCM is the result of an alteration or defect
in ingestion, digestion, absorption, or metabolism
• Secondary malnutrition may occur as result of GI
obstruction, surgical procedure, cancer, malabsorbsi
syndrome, drugs or infectious diseases
• PCM may also deficient in protein
 Marasmus and Kwasiorkor
• Are the most severe forms of PCM
• Are most frequently seen in children in developing
countries
• Marasmus
– are characterized by generalized loss of body fat and muscle
– have normal serum protein
• Kwasiorkor
– Caused by a deficiency protein intake
– Characterized by edema and low serum protein levels
• Marasmic-Kwarsiorkor is the combined form of marasmus
and kwarshiorkor, It caracterized by severe tissue wasting,
loss of subcutaneous fat, and dehydration.
 Etiology of malnutrition
• Sosio economic factors
• Physical Illnessess
• Malabsorption syndrome
• Incomplete diets
• Food drugs interactions
 Sosio economic factors
• Individual with limited financial may have
food insecurity (inadequate access)
 Physical Illnessess
• Malnutrition is common consequence of
illness, surgery, injury, or hospitalization
• The hospitalized patients. Especially the older
adults, is at risk of becoming malnourished.
 Malabsorpsion syndrome
• Is the impaired absorption of nutrients from GI tract
• It may result from decreased digestive enzymes or a reduced bowel
surface area and can quickly lead to a deficiency state.
• Many drugs may have undesirable GI side effect , as well as alter
normal digestive and absorptive process. For example, antibiotics
changes the normal flora of the intestines, decreasing the body’s
ability to synthesize biotin.
• Fever accompanies many Illnesses, injuries and infections, with a
concomitant increase in the body’s basal metabolic rate (BMR).
• Each degree of temperature increase on the Fahrenheit scale raises
the BMR body about 7%.
• Without an increase in caloric intake, body protein stores will be
used to supply calories, and protein depletion can become problem.
 Incomplete Diet
• Vitamin imbalance
• Found among person with a pattern of alcohol
and drug abuse and person who chronically ill
• Person who have had surgery on GI tract may
be at a risk for vitamin deficiences
• Clinical manifestation of vitamin imbalance
are most commonly exhibited as neurologic
manifestation
 Food drug Interaction
• Food drug interaction can occur with use over-
the counter drugs and herb and dietary
supplements.
 Pathophysiology of starvation
1. Initially, the body selectively uses
carbohydrates (glycogen) rather than fat and
protein to meet metabolic needs.
2. Carbohydrate may be depleted in 18 hours
3. So, after carbohydrate depleted skeletal
protein begins to be converted to glucose for
energy termed glukoneogenesis (within 5-9
days, body fat fully mobilized to supply much
of the needed energy
4. In prolonged starvation up to 97% of calories are
provided by fat and protein is conserved.
5. Fat stores are generally used up to 4 to 6 weeks
6. As the protein depletion continues, liver function
becomes impaired, and synthesis of proteins
diminishes
7. Plasma oncotic pressure is lower because of
decreased protein synthesis, albumin leaks into the
interstitial space along with the fluid. Edema becomes
clinically observable
8. Often the edema present in the face and legs of the
patient masks the muscle wasting that occurs.
9. As the total blood volume is reduced, the
skin appears dry and wrinkled
10.Along with the shift of fluids to interstitial
space, ions also move. Sodium is found in
increased amount within the cell and
magnesium are shifted to the extracellular
space.
 Clinical Manifestation
• Dry and scaly skin, brittle nail, rashes and hair
loss
• Mouth (crusting and ulceration, change in
tongue)
• Muscles (decreased mass and weakness)
• CNS (mental changes such as confusion,
irritability)
• The speed at which the malnutrition develops
depends on the quantity and quality of the
protein intake, caloric value, illness and the age of
the person
• There is decreased protein available for repair,
and as a result, wound healing may be
delayed.
• The person is more susceptible to all types of
infections. Both humoral and cell-mediated
immunity are deficient in PCM
• Many malnourished individuals are anemic
 Nutritional Assessment
1. Nutritional status
2. Initial Nutritional Screening
3. Anthropometric Measurement
 1. Nutritional Status
1. Reflects the balance between nutrient
requirement and intake. Common factors that
affect these requirement are
a. Age
b. Gender
c. Infection
d. Psychological stress
2. Nutrient intake is influenced by Eating behavior,
Economic factors, Emotional stability, Disease,
Drug therapy, Cultural factors
3. Evaluation of nutritional status is an important
part of total patient assessment and includes:
1. Review of the nutritional history
2. Food and fluid intake record
3. Laboratory data
4. Food-drugs interaction
5. Health history and physical assessment
6. Anthropometric measurements
7. Psychosocial assessment
Monitor the nutritional status of
patient during hospitalization as
an important part of your initial
assessment. Collaboration with
the interdisciplinary health care
team to identify patients at risk
for nutritional problems
 2. Initial Nutritional Screening
• Inspection, measured height and weight,
weight history, usual eating habits, ability to
chew and swallow and any recent changes in
appetite or food intake (Form attached)
• The Mini Nutritional Assessment
• Ask about food intake, mobility and body
Mass index (BMI)
• Assess for weight loss, acute illness and
psychological health problems
3. Anthropometric Measurements
• Noninvasive methods of evaluating nutritional
status
• These measurement include height and
weight and assessment of body fat
• Change in body weight can be expressed by three
different formula:
• Weight as percentage of ideal body weight (IBW)
– %IBW = (Current weight/Ideal body weight) x 100
• Current weight as a percentage of usual body
weight (UBW)
– %UBW=(Current weight/Usual body weight) x 100
• Change in weight
– Weight change =((usual body weight – current
weight)/usual weight) x 100
The Body Mass Index (BMI)
 Physical Assessment
• Inspect the patient’s hair, eyes, oral cavity,
nails and musculoskeletal and neurologic
system
• Exam the skin patient’s
• Anthropometric measurement
 Psychosocial Assessment
• The psychososial history provides information
about the patient’s economic status,
occupation, educational level, living and
cooking arrangements, and mental status
• Determine whether financial resources are
adequate for providing the necessary foods
 Laboratory Assessment
• Low hemoglobin indicate:
– Anemia
– Recent hemorrhage or hemodilution caused by fluid retention
– Low hemoglobin because of secondary condition such as low
serum albumin, infection, catabolism or chronic disease
• Low hematocrit levels may reflects:
– Anemia
– Hemorrhage
– Excessive fluid
– Renal disease
– Ciroshis
– High hematocrit levels may indicate dehydration or
hemoconcentration
• Serum albumin but not sensitive
• E.g: patient who are dehydrated often have
high levels and those with fluid excess have a
lowered value.
• Normal serum albumin level for men and
women is 3,5 to 5 g/dl
 Nursing Diagnosis
• Risk for impaired skin integrity related to
alterations in nutritional state
• Risk for infection related to malnutrition
• Risk for Disturbed body Image related to
biophysical changes from weight loss
• Patient with prolonged malnutrition are at risk
for collaborative problems such as:
– Severe anemia
– Immunocompromised state
– Multiystem Failure
 Planing and Implementation
Imbalance nutrition: Less than body
requirement
• NOC Planning: Expected Outcomes
• The patient with malnutrition is expected to have
nutrients available to meet metabolic needs. Indicators
include that he or she will have normal:
– Nutrient intake
– Fluid intake
– Energy
– Weight-height ratio
– Hematocrit and hemoglobin
– Visceral protein levels
– Muscle tone
– Hydration
 NIC: Nutrition Management:
Assiting with or providing a balanced dietary intake of food and
fluids
• Ascertain patient’s food preferences
• Determine, in collaboration with nutritionist as
appropriate, number of calories and type of nutrients
needed to meet nutrition requirement
• Encourage increased intake of protein, iron and vitamin
C as appropriate
• Encourage calorie intake appropriate for body type and
lifestyle
• Offer snacks
• Provide patient with high-protein, high-calorie,
nutritious finger foods and drinks that can be easily
consumed
• Ensure the diet includes foods high infiber
content to prevent constipation
• Monitor and record intake for nutritional
content