Post on 24-Oct-2014
ENTERAL & PARENTERAL NUTRITIONAL SUPPORT
Ns. Shanti Farida Rachmi, S.Kep
DEFINISI NUTRITIONAL SUPPORT
"Pemberian nutrisi secara oral, enteral atau parenteral dengan tujuan terapeutik.Hal ini mencakup, namun tidak terbatas pada, pemberian dukungan nutrisi enteral atau parenteral keseluruhan, dan penyediaan terapi nutrisi untuk mempertahankan dan / atau mengembalikan status gizi dan kesehatan yang optimal. "
When normal diets fail to meet the daily requirements.
Definition of nutritional support
When assessment documents deficiencies
or
Nutrition planning becomesa part of medical therapeutics
Nutrisi Enteral
Nutrisi yang diberikan melalui saluran cerna.
Makanan cair yang diberikan melalui oral/pipa ke dalam saluran cerna dengan syarat saluran cerna masih berfungsi baik untuk menyerap atau mencerna
Makanan formula sebagian besar tersedia siap pakai yaitu dalam bentuk powder/bubuk.
Total Parenteral Nutrition
Definition:
A method of providing nutrient to the body by an IV route.
Provision of all nutrition's through other than the alimentary tract.
The Goal of TPN
Goal: • To improve nutritional status• Establish a positive nitrogen balance
• Maintain muscle mass• Promote weight maintenance
• Enhance the healing process
Clinical Indication
The indication for PN include a 10% deficit in body weight (compared with pre-illness weight).
An inability to take oral food or fluids within 7 days after surgery
Hyper catabolic situations
The following situation indicated for PN1. The patients intake is insufficient to
maintain an anabolic state.2. The patient ‘s ability to ingest food
orally or by tube is impaired 3. The patient unwilling or unable to
ingest adequate nutrients.4. The underlying medical condition
precludes being fed orally or by tube5. Preoperative and post operative
nutritional needs are prolonged
Administration Methods
1. Peripheral method2. Central method
With consideration of patient condition and length of therapy!
Peripheral Parenteral Nutrition (PPN)
Administered through a peripheral vein
PPN formula biasanya bukan merupakan nutrisi yang komplit. Kadar dekstrose dalam formula PN lebih rendah.
Lipids diberikan secara simultan sebagai buffer.
Length of therapy using PPN is 5 to 7 days.
Peripheral IV: short-linePROSLeast
expensiveEasily placed
and removed
Beneficial for short-term support (< 1 week)
CONSNeed to change
often ◦Every 48-72h
Phlebitis and vein injury
Only one lumenLimits energy
delivery◦Volume◦Osmolality (600-
900 mOsm/l) ◦pH restriction
(pH 5-9)
Peripheral IV: mid-linePROSMay be used
for a longer duration than peripheral
Ease of placement compared to central lines
Allows access to larger vessel
CONSNot a central
line Must follow
guidelines for peripheral lines for concentration, pH and infusion rates
Central MethodThe catheter inserted into a high
flow, large blood vessel (the subclavian vein).
Can prevent phlebitis and other venous complications
Concentrated solutions are then very rapidly diluted to isotonic levels by the blood in this vessel
There four types central venous access devices (CVADs).
Non Tunneled Central CathetersUsed for short term (< 6
minggu), diberikan sebagai terapi akut, long term care, and home care settings.
Insersi dilakukan pada vena subclavia
Tipe single-, double-, and triple-lumen central catheter dapat diberikan pada NTCC.
Non tunneled central cath
Penggunaan single lumen:
1. Tidak boleh memberikan transfusi darah pada main line
2. Pengobatan tidak boleh diberikan pada main line.
Persiapan Insersi Nontunneled Central cath 1. Prosedur dijelaskan kepada pasien2. Posisi pasien terlentang dengan posisi
trendelenburg3. Area insersi dibersihkan (dicukur apabila
ada rambut atau bulu)4. Area insisi dibersihkan dengan
menggunakan iodine atau chlorhexidine5. Instruksikan pasien untuk menolehkan
kepala menjauh dari tempat insersi dan mengingatkan pasien untuk mengurangi gerakan yang akan mempengaruhi proses insersi.
Tunneled Central CatheterLong term use (1-3
thn)Memiliki cuffed dan
bisa single atau double lumen
Inserted surgicallyThreaded under the
skin to the subclavian vein.
End of cath advanced into the superior vena cava
Central IV: Hickman / BrovacPROSCan infuse
solutions> 900 mOsmol/l
Allow full IV nutritional support
Can be multi-lumen
Longevity: 1 -3 years
Easier self-care (than PICC &, possibly, port)
CONSSurgical /
Radiological procedure◦More complex◦More difficult to
removeTube protruding
from chest may affect body image
More restrictive than a port
Peripherally Inserted Central Catheter (P.I.C.C.) Line
Tip in SVC
O
• More expensive than peripheral lines• More difficult to place• Last up to 6–12months• Restrict arm movement• Allow higher osmolarity “Central” TPN solutions
Central IV: PICC
PROSCan infuse
solutions> 900 mOsmol/l
May be placed by RN
Decreased CRI vs other central lines: HPN
Can be multi-lumen
Usable for CT contrast
CONSShorter life
than other central lines (< 12 m)
More difficult self care
Blood sampling not always possible
More frequent flushing and maintenance
More painful
Implanted Venous Access Device
Implanted PortsUse for long term home IV therapyThe end of cath is attached to a
small chamber that is placed in subcutaneous pocket
Easy and minimal care Allow the patient complete
freedom of activity.More expensive than the external
catheter
Gambar implanted port
Formula for TPNCentral PN (TPN) is a concentrated formula
which is hyperosmolar and must be delivered into a central vein. TPN provides:1. Carbohydrates in the form of glucose. 2. Protein in the form of amino acids. 3. Lipids in the form of triglycerides.4. Electrolytes.5. Vitamins and trace minerals.
PN can be administered by:Simple intravenous NutritionComplete intravenous Nutrition
Who Needs PN?Assessing Nutritional Status
Focused nutrition historyAssess current weight and weight-
loss historyPhysical examinationAssess malabsorption, example
− Fecal fat test• SGA – Subjective Global
Assessment
Bashir S, et al. Prim Care 2001;28:629-645.
Assessing Nutritional Status:The SGA
A. History Weight change
<5% = “small”5–10% = “potentially significant”
>10% = “definitely significant” Change in dietary intake Gastrointestinal symptoms
(nausea, vomiting, diarrhea, anorexia)
Functional capacity Disease and its relation to
nutritional requirements
B. Physical Loss of subcutaneous fat Muscle wasting Ankle edema Sacral edema Ascites
C. SGA Rating A = Well nourished B = Moderately malnourished C = Severely malnourished
Detsky AS et al. JPEN 1987;11:8-13.
Nursing DiagnosisNutrisi kurang dari kebutuhan tubuh b,d
intake oral yg tidak adekuatResiko tinggi infeksi b.d kontaminasi pada
central catheter site atau selang infusResiko kekurangan atau kelebihan cairan b.d
pemberian infus yg tidak tepatResiko gangguan mobilitas fisik b.d
kecemasan akan dislokasi cateter atau oklusi
Resiko in efektif regimen terapi b.d kurangnya pengetahuan mengenai PN saat dilakukan di rumah
GoalMencapai level status nutrisi
yang optimalTidak terjadi infeksiVolume cairan adekuatPasien mencapai kondisi aktivitas
dan mobilitas yang optimal Pengetahuan dan skill self care
pasien meningkatTidak terjadi komplikasi
Intervensi Keperawatan
Menjaga status nutrisi pasien tetap optimal◦Pemberian PN berkesinambungan,
periode 24 jam◦Mengukur pertambahan BB pasien
setiap 3-4 x dalam seminggu.◦Pengukuran dan dokumentasi intake-
output cairan.Dokter setiap hari meresepkan
formula PN sesuai kebutuhan pasien
Cont’
Mencegah terjadinya infeksi:◦Kassa oklusif yg menutup catheter
site diganti setiap hari.◦Dressing CVAD diganti apabila
ditemukan adanya darah, lembab, hilang atau kotor. Tehnik aseptik dan pengkajian integumen serta kepatenan selang PN.
◦Mainline IV tubing dan filter diganti setiap 72-96 jam.
◦Dokumentasi
Cont’
Mempertahankan balance cairan◦Laju pemberian larutan di set dalam
milliliter per jam dan laju di cek setiap 3-4 jam sekali
◦Intake dan output cairan diukur dan didokumentasikan setiap 8 jam
◦Kaji tanda-tanda dehidrasi◦Monitor GD pasien
Mendorong Aktivitas pasien
Komplikasi
1. Pneumothorax2. Emboli udara3. Bekuan darah di cateter line4. Cateter displacement atau
contamination5. Sepsis6. Hiperglikemi7. Overload cairan8. Rebound hipoglikemia
Sekian dan Terima Kasih