NUTRITION CARE OF

DEHYDRATED ADULT
PATIENT
(A special concern)
Winarko Luminturahardjo
RS Panti Nirmala Malang
3 Oktober 2015
 Link CRITICAL ILL-DEHYDRATION-
DEHYDRATION-MALNURITION
NUTRITION

SEPSIS BURN

CRITICAL MALNU
SURGERY
ILL TRITION

DEHY
TRAUMA
DRATION

Bone RC et al, Chest 1992;101:1644-

56
 Hospital Malnutrition prevalence
A Problem of Physician Awareness
Up to 50% of hospitalized patients may be
malnourished on admission
2011 Australian studies:
Only 23% patients were assessed for nutritional
status
Prevalence malnutrition on private hospital: 42%
Preferred method: SGA (Subjective Global
Assessment)

Int J Environ Res Public Health. 2011;8:514-27

 High Cost of Malnutrition
Reilly et al conducted 771 patients to determine
Likelihood of Malnutrition (LOM) to evaluate the
economic impact patients with LOM
3,4 times have major complications & 3,8 times have
likely to die than without LOM
Costs increased $1,738 per LOM patients
Hospital charges:
- $16000: malnourished group
- $14118: borderline malnourished group
- $7692 : well-nourished group
Roediger 1994; Green 1999; Zarowitz 1990

Int J Environ Res Public Health. 2011;8:514-27

 Malnutrition and its Consequences
Decreased wound healing ability
Diminish functional ability
Compromised immune function
Changes multiple organ systems
Increased morbidity and mortality
Length of stay
Many studies have shown that
complications are 2 to 20 times more
frequent in malnourished patients than in
well-nourished patients.
Int J Environ Res Public Health. 2011;8:514-27
PENGERTIAN
Nutrisi
Segala sesuatu yg dimakan sso
dan bgm tub menggunakannya.
Nutrient
Zat kimia organik / anorganik
yang ditemukan dlm makanan
dan diperlukan u/berfungsinya
tubuh.
Bila intake/ masukan adekuat
(cukup) = Nutrient essensial
 NUTRIENT ESSENSIAL
Karbohidrat

Protein
Lemak
Vitamin
Mineral
 1. KARBOHIDRAT
1 gr = 4 kkal, sumber energi utama
Monosakarida : glukosa(dekstrosa),
fruktosa
Disakarida : Sukrosa, laktosa,
maltosa
Polisakarida : glikogen serat
(pektin, gum, hemiselulosa, getah)
Glikogen : sumber energi utama
saat puasa
 2. Protein
Fungsi : u/pertumbuhan, pemeliharaan
dan perbaikan jar.tubuh
1 gr = 4 kkal
Bentuk sederhana : as.amino yg
disimpan dlm jaringan berbentuk
hormon dan enzim
As amino esensial tdk dpt disintesis dlm
tubuh tapi harus di dapat dr makanan
Sumber : daging, hewan ternak, susu,
dan telur
Asupan : 10-15%
 3. Lemak
Sumber energi paling besar
1 gr = 9 kkal
Lipid : lemak yg dpt membeku pd suhu
ruangan tertentu
Lipid : trigliserid + as lemak
Lipogenesis : proses sintesis as lemak
As lemak esensial : as lemak linoleat
As lemak non esensial : as lemak
linolenat, arakidonat
Asupan : 35-40%
 4. AIR
Komponen kritis dlm tubuh
Air menyusun 60-70% dr seluruh BB

Sumber : konsumsi cairan, buah2an

segar, sayuran, dan air yg diproduksi
selama oksidasi makanan
Pd org sehat : intake cairan = output
melalui eliminasi, respirasi, dan
berkeringat
 5. Vitamin
Vitamin larut air : Vit C dan B
Vitamin larut lemak : Vit A, D, E, dan K

6. Mineral
Elemen esensial nonorganik sebagai
katalis dlm reaksi biokimia
Kalsium, Magnesium, Fosfor, dll
 KEBUTUHAN NUTRISI
Kebutuhan Kalori
Kebutuhan Protein
Kebutuhan Lemak
Kebutuhan Vitamin & mineral
Kebutuhan Cairan

Komposisi Diet :
KH : 45-50%
Lemak : 35-40%
Protein : 10-15%
 Nutrition Guidelines

Energy (Calorie)
Obesity Ideal Underweight
Fluid:
30-40 mL/kgBW/day
20-25 25-30 35-40
Kkal/KgBW Kkal/KgBW Kkal/KgBW

CHO PROTEIN LIPID

50-60 % 10-20 % 20-40%
1-1,5 g/kgBB/hari 1-3 g/kgBB/hari
3-4 g/kgBB/hari

1. August D, et al. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric
patients. JPEN. 2002;26(1):1SA- 138SA.
2. Galen. Basic in Clinical Nutrition 2004.
3. Singer P, et al. ESPEN guidelines on parenteral nutrition: Intensive care. Clin Nutr. 2009;28(4):387-
400.
 MENGHITUNG
KEBUTUHAN NUTRISI
 Calorie Calculation
1. Kebutuhan Kalori Org Dewasa
(kkal/kgBB/hari)
Rule of Thumb
Calorie requirement = 25 to 30 kcal/kg/day
50% of total calories could be given in the
first day and increase slowly each day.
100% of total calories should be given in the
third day.

J Parenter Enteral Nutr. 2002;26(1):1SA-138SA.

 Rumus Harris Benedict (kcal/hari)
BEE Pria = 66.5 + 13.8 X BB (kg) + 5 X T (cm) 6.8 X U (tahun)
BEE Wanita = 655 + 9.5 X BB (kg) + 1.8 X T (cm) 4.7 X U
(Kcal/hari)
BB = Berat Badan T = Tinggi Badan U = Usia

Tabel 6 : AEE = Actual Energy Expenditure

Malnutrisi = 1.2 X BEE
Malnutrisi + Trauma/pembedahan = 1.5 X BEE
Malnutrisi + Sepsis/luka bakar = 2 X BEE

Tabel 7: Tabel perhitungan koreksi Stress Factors

AEE = BEE X STRESS FACTOR X 1.25
STRESS FACTORS
Koreksi
Kelaparan 0.85
1.00
Pasca bedah 1.00 1.05
Patah tulang 1.15
1.30
Peritonitis 1.05
1.25
Multitrauma / sepsis 1.30
 AF (Activity Factor)
1. Sangat Ringan : banyak
duduk,bedrest
L : 1,3 P : 1,3
2. Ringan : pekerja kantoran, IRT
L : 1,6 P : 1,5
3. Sedang : petani, mahasiswa aktif
L : 1,7 P : 1,6
4. Berat : atlet di TC, tentara yg berlatih
L : 2,1 P : 1,9
5. Sangat Berat : pandai besi, pekerja
konstruksi wanita
L : 2,4 P : 2,3
 Obesity
Ideal Weight
Actual Weight

In obesity, energy expenditure must be calculated on ideal

weight.
 Malnutrition
Ideal Weight
Actual Weight

In malnutrition, energy expenditure must be calculated

based on actual body weight.
 2. Kebutuhan Protein
Dewasa : 1 gr/kgBB/hari
Neonatus prematur : 3 gr/kgBB/hari
0-1 tahun : 2,5 gr/kgBB/hari
2-13 tahun : 1,5-2 gr/kgBB/hari
Remaja : 1-1,5 gr/kgBB/hari
3. Kebutuhan Lemak
Rata- rata 35% dari total kalori
Untuk yg obesitas : 10% dr total
kalori (pelarut vitamin)

4. Kebutuhan Vitamin
RDA lihat referensi
 5. Kebutuhan Cairan

Dewasa : 30-35 ml/kgBB/hari

Mineral2 penting :
Makro : Ca, P, Mg, S, Na, K, Cl
Mikro : Cr, Co, Cu, I, Fe, Mn, Zn, F,
Se, Mo
 Stress Response
Surgery
Hypoxemia
Pneumonia
Severe infection sepsis
Trauma
Burn
Pain
DEHYDRATION !!!
 Stress RESPONSE
Burns, trauma, Sepsis, Pancreatitis, Peritonotis
Surgery, Radiation, Dehydration Th/
Ebb phase
Stress
response
Shock, hypoxia, etc
ResuscitationFluid
Hypercatabolic Acute responses
phase

Flow phase
Recovery Adaptive response
(anabolic phase) Require
nutrition
 Metabolic Response to Stress

Ebb
Ebb Phase
Phase Flow
Flow Phase
Phase
Energy Expenditure

Time

Adv Clin Chem. 1969;12:1-55

 Feeding Routes
Tube feeding less than 4 Tube feeding more than 4
weeks. weeks
Nasogastric Enterostomy
Gastrostomy
Postplorically.
Jejunostomy
Nasoduodenal

Gastric feedings are the
Nasojejunal
These tubes are weighted or non-weighted preferred route
with stylets to guide placement
Easily tolerated & less
Orogastric complicated
Mouth to stomach Not good for patients at risk for
Good for vent patients aspiration

August D, et al. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN. 2002;26(1
Suppl):1SA-138SA.
2007 Thomson - Wadsworth
 2007 Thomson - Wadsworth
 Enteral Feedings
Formula Selection
Bolus feeding
Standard formula Continuous
Disease-specific infusion
High calorie Intermittent
High protein infusion
Modular formulae

Lochs H, Allison SP, Meier R, et al. Introductory to the ESPEN guidelines on enteral nutrition: Terminology, definitions, and general
topics. Clin Nutr. 2006;25:180-6.
 Parenteral Nutrition
Definition: The administration of nutrients
intravenously, for those individuals who
cannot, should not, or will not eat
adequately via an enteral/oral route.

J Parenter Enteral Nutr. 2002;26(1):1SA-138SA.

 Parenteral Nutrition Support
Indicated for patients Indications
who do not have
Short-bowel syndrome
functioning GI tract & Severe pancreatitis
who are malnourished Malabsorption disorders
(or likely to become so). Intestinal obstruction or
Used when enteral fistula
formulas cannot be used Severe burns or trauma
or intestinal function is Critical illnesses or wasting
inadequate. disorders
Bone marrow transplant
Life-saving option for Malnourished with
critically-ill persons. high risk for aspiration
Two main access sites:
central or peripheral
vein.
DeBruyne LK, et al. Nutrition & Diet Therapy. 7 th ed. 2008.
 Parenteral Nutrition Support
If enteral feeding is completely stopped or ineffective,
Total Parenteral Nutrition is used (TPN).

If enteral feeding is just not enough , supplementation

with Partial Parenteral Nutrition (PPN) is indicated.

J Parenter Enteral Nutr. 2002;26(1):1SA-138SA.

 Contraindications of PN
Condition Suggested criteria
Hyperglycemia Glucose >300 mg/dl
Azotermia BUN >100 mg/dl
Hyperosmolarity Osmolarity >350 mOsm/kg
Hypernatremia Na > 150 mEq/L
Hypokalemia K< 3 mEq/L
Hyperchloremic metabolic Cl > 115 mEq/L
acidosis
Hypophosphatemia Phosphor < 2 mg/dl
Hyperchloremic metabolic Cl < 85 mEq/L
alkalosis
 SUMMARY
Malnutrition will give consequences like: decreased
wound healing ability, diminish functional ability,
compromised immune function, changes multiple organ
systems, increased morbidity and mortality, and length of
stay
Its important to consider make evaluation of fluid and
nutrition when nursing patients
Nutrition therapy is more relevant during the flow phase,
in the ebb phase the priority is resuscitation
Nutrition therapy can be given via enteral or par enteral
route,but more beneficial by enteral route
Matur Suwun