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. "

Definition of nutritional support

When normal diets fail to meet the daily requirements.

or

When assessment documents deficiencies

Nutrition planning becomes a 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 PN

1. 2.

3.
4. 5.

The patients intake is insufficient to maintain an anabolic state. The patient s ability to ingest food orally or by tube is impaired The patient unwilling or unable to ingest adequate nutrients. The underlying medical condition precludes being fed orally or by tube Preoperative and post operative nutritional needs are prolonged

Administration Methods
Peripheral method 2. Central method
1.

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-line

PROS Least expensive Easily placed and removed

CONS Need to change often

Every 48-72h

Beneficial for shortterm support (< 1 week)

Phlebitis and vein injury Only one lumen Limits energy delivery

Volume Osmolality (600-900 mOsm/l) pH restriction (pH 5-9)

Peripheral IV: mid-line

PROS May be used for a longer duration than peripheral Ease of placement compared to central lines Allows access to larger vessel CONS Not a central line Must follow guidelines for peripheral lines for concentration, pH and infusion rates

Central Method
The 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 Catheters

Used 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

Prosedur dijelaskan kepada pasien Posisi pasien terlentang dengan posisi trendelenburg 3. Area insersi dibersihkan (dicukur apabila ada rambut atau bulu) 4. Area insisi dibersihkan dengan menggunakan iodine atau chlorhexidine 5. Instruksikan pasien untuk menolehkan kepala menjauh dari tempat insersi dan mengingatkan pasien untuk mengurangi gerakan yang akan mempengaruhi proses insersi.
1. 2.

Tunneled Central Catheter

Long term use (1-3 thn) Memiliki cuffed dan bisa single atau double lumen Inserted surgically Threaded under the skin to the subclavian vein. End of cath advanced into the superior vena cava

Central IV: Hickman / Brovac

PROS Can 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) CONS Surgical / Radiological procedure
More complex More difficult to remove

Tube protruding from chest may affect body image More restrictive than a port

Peripherally Inserted Central Catheter (P.I.C.C.) Line

More expensive than peripheral lines

More difficult to place

Last up to 6 12months

Restrict arm movement

Tip in SVC

Allow higher osmolarity Central TPN

Central IV: PICC

PROS Can 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 CONS Shorter 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 Ports
Use for long term home IV therapy The 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 TPN

Central PN (TPN) is a concentrated formula which is hyperosmolar and must be delivered into a central vein. TPN provides:
1. 2. 3. 4. 5. Carbohydrates in the form of glucose. Protein in the form of amino acids. Lipids in the form of triglycerides. Electrolytes. Vitamins and trace minerals.

PN can be administered by: Simple intravenous Nutrition Complete intravenous Nutrition

Who Needs PN? Assessing Nutritional Status

Focused nutrition history Assess current weight and weight-loss history Physical examination Assess 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

B. Physical

Weight change Loss of subcutaneous fat <5% = small Muscle wasting 510% = potentially significant Ankle edema >10% = definitely significant Change in dietary intake Sacral edema Gastrointestinal symptoms Ascites (nausea, vomiting, diarrhea, anorexia) C. SGA Rating Functional capacity Disease and its relation to nutritional A = Well nourished requirements B = Moderately malnourished

C = Severely malnourished

Detsky AS et al. JPEN 1987;11:8-13.

Nursing Diagnosis
Nutrisi kurang dari kebutuhan tubuh b,d intake oral yg tidak adekuat Resiko tinggi infeksi b.d kontaminasi pada central catheter site atau selang infus Resiko kekurangan atau kelebihan cairan b.d pemberian infus yg tidak tepat Resiko 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

Goal
Mencapai level status nutrisi yang optimal Tidak terjadi infeksi Volume cairan adekuat Pasien mencapai kondisi aktivitas dan mobilitas yang optimal Pengetahuan dan skill self care pasien meningkat Tidak 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 intakeoutput 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.

2.
3. 4. 5. 6.

7.
8.

Pneumothorax Emboli udara Bekuan darah di cateter line Cateter displacement atau contamination Sepsis Hiperglikemi Overload cairan Rebound hipoglikemia

Sekian dan Terima Kasih