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