Asesmen Gizi
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NUTRITION CARE PROCESS(Proses asuhan gizi)
Dr. Risky ika Riani, Sp.GK
NUTRITION CARE PROCESS(Proses Asuhan Gizi)
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Proses Asuhan Gizi ( Nutrition Care Process )
• Adalah metode pemecahan problem secara sistematik dibuat oleh ADA yang digunakan oleh ahli gizi untuk berpikir kritis, membuat keptusan mengenai gizi yang berhubungan dg nutrisi, dan menyediakan asuhan gizi yang berkualitas tinggi, efektif dan aman
Sumber : (Lacey and Pritchett 2003).
• Tujuan utama Asuhan Gizi adalah memenuhi kebutuhan zat gizi pasien secara optimal baik berupa pemberian makanan pada pasien yang dirawat maupun konseling gizi pada pasien rawat jalan.
Sumber : (Pedoman Pelayanan Gizi RS, Depkes RI 2006 cetakan 3). memperbaiki kondisi gizi manjadi seimbang dengan mempengaruhi
berbagai faktor yang berkontribusi terhadap ketidakseimbangan atau mengubah kondisi status gizi seseorang menjadi lebih baik.
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Langkah:
Step 1. Nutrition Assessmet
• Nutrition Assessment adalah step pertama dalam “Nutrition Care Process”. Step ini dilakukan untuk mendapatkan informasi yang adekuat untuk mendapatkan masalah yang berhubungan dengan nutrisi.
• Sumber data dalam Nutrition Assessment adalah dari informasi referal dan atau catatan interdisiplin, interview dengan pasien, data survey komunitas atau kelompok, laporan statistik dan, studi epidemiologi
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Step 2. Nutrition Diagnosis
• Nutrition Diagnosis adalah step kedua dalam “Nutrition Care Process”dan ini adalah identifikasi dan labeling yang mendeskripsikan masalah nutrisi aktual, risiko atau potensial yang digunakan oleh dieticiant untuk memberikan therapi secara mandiri.
• Komponen Nutritition Diagnosis terdiri dari 3 :
1. Problem (Diagnostic Label) 2. Etiology (Causa/Contributing Risk Factor) 3. Sign/Symptom (defining Characteristic)
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Step 3. Nutrition Intervention• Nutrition Intervention adalah step ke tiga dalam
“Nutrition Care Process”. • Dalam step ini termasuk a). Seleksi b). Planning c).
Implementasi. Dietetics Profesionals bekerja berkolaborasi dengan pasien, keluarga, caregiver untuk memberikan perencanaan yang realistik.
Step 4. Nutrition Monitoring and Evaluation• Komponen dalam monitoring and evaluation adalah :• Monitor perkembangan• Penukaran outcome• Evaluasi outcome
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SKRINING & PENILAIAN STATUS GIZI
(Screening and Nutritional Assessment)
Dr.Risky Ika Riani, Sp.GK
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Skrining Gizi
•Identifikasi tanda dan gejala yang berhubungan dengan masalah gizi
•Identifikasi pasien yang berisiko malnutrisi
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Penilaian Status Gizi
•Mengumpulkan dan menilai kondisi klinis, asupan makan, komposisi tubuh, antropometri dan hasil laboratorium
•Mengelompokkan pasien berdasarkan status gizi: status gizi baik atau kurang
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Persamaan Skrining dan Penilaian Status Gizi: Kesamaan Tujuan
•Identifikasi pasien berisiko malnutrisi untuk menurunkan▫Komplikasi▫Kegagalan terapi▫Masalah fisiologis▫Biaya pengobatan
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Perbedaan Skrining dan Penilaian Status Gizi
•Jenis dan lingkup informasi•Pendidikan dan ketrampilan petugas
yang mengumpulkan data•Waktu yang dibutuhkan untuk proses
pengumpulan data•Biaya pengumpulan data
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Skrining Gizi
•Peningkatan/penurunan berat badan involunter >10% selama 6 bulan atau > 5% selama 1
•Asupan per oral tidak adekuat•Berisiko malnutrisi / tidak
Barrocas et al. J Am Diet Assoc 1995
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Instrumen Skrining: SGA & MNA
• SGA (Subjective Global AssessmentInstrumen sederhana, non invasif dan murah untuk skrining. Kategori SGA (C) berhubungan dengan peningkatan risiko komplikasi yang berhubungan dengan gizi dan risiko mortalitas
(Sacks et al, 2000)
• Skor MNA yang rendah (<17) berhubungan dengan peningkatan risiko mortalitas dan lama rawat yang lebih panjang
(Van Nes et al 2001)
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Tujuan Penilaian Status Gizi
•Mengidentifikasi pasien •Merencanakan terapi gizi yang adekuat•Mengevaluasi efektivitas terapi gizi
2/8/2012
15
Tujuan tersebut bisa dicapai jika PSG dilakukan secara menyeluruh – dikaji aspek medis, sosial dan riwayat diet, pengukuran antropometri, analisis biokimia dan pemeriksaan fisik.
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Metoda Penilaian Status Gizi•Tidak ada metoda tunggal atau standar•Penilaian status gizi sederhana tanda
awal malnutrisi•Penilaian status gizi yang lebih detail
diperlukan untuk menentukan dukungan gizi yang diperlukan
•Penilaian status gizi lebih dalam dan kompleks – pada penyakit kritis
•Spesifik pada penyakit tertentu
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Parameters
•Anamnesis: Riwayat medis, sosial, diet•Anthropometri•Klinis & pemeriksaan fisik•Laboratorium :biokimia & hematologi
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NUTRITION CARE PROCESS(Proses asuhan gizi)
ANAMNESIS
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•Include: medical, social and dietary history
•The main aspect of this is the dietary history, but often weight loss and poor nutrition are related to medical, psychological or financial factors
waktu Kehilngan bb (%)
Kehilangan bb masif (%)
1 minggu 1-2 >2
1 bulan 5 >5
3 bulan 7,5 >7,5
6 bulan 10 >10
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a. Medical historyAsk specifically about:- Loss of appetite- How much weight loss or gain? The time
course of the weight change- Dysphagia, nausea, vomiting- Periods of weight loss or gain in the past; use
of laxatives- Symptomps of hyperthyroidism: weight loss,
increase appetite, irritability etc- Psychiatric history, especially if there is the
possibility of depression or eating disorder (eg anorexia nervosa)
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b. Social history
In develop countries: Malnutrition may be related to the poor
socioeconomic status or family Inquire about housing , social support and
income support Nutritional deficiency may be related to
war, poor crops
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c. Dietary history
Dietary recall: ask specifically What do you eat in typical day? Like & dislike eating Access to food or presence of financial
problems Attention to what to eat; any particular
diet Alcohol intake
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NUTRITION CARE PROCESS(Proses asuhan gizi)
ANTROPOMETRI
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•Pemeriksaan sederhana, murah dan non invasif
•Menunjukkan status kesehatan dan gizi dan dapat
memprediksi performance, kesehatan dan
survival
•Salah satu parameter antropometri untuk
menentukan status gizi adalah
IMT= BB (kg)/TB(m) ²
•Kombinasi dengan Lingkar Perut untuk faktor
risiko sindrom metabolik
•Triceps or sub scapular thickness of skin fold
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Berat badanBerat badan biasanya (usual body weight)
parameter yang sangat berguna dibandinngkan berat badan ideal, apabila digunakan pada orang sakit. Kelemahannya adalah sangat tergantung pada memori pasien.
• Berat badan aktual : sangat tergantung dari hasil pengukuran yang akurat. Interpretasi hasil sangat dipengaruhi oleh status cairan (adanya udema, asites).
• Lingkar Lengan Atas: - Laki2= LILA / 25,7 x (TB-100)- Wanita= LILA / 26,3 x (TB-100)
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Pengukuran Tinggi Badan dan Berat Badan
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Pengukuran Tinggi Lutut
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Rumus prediksi tinggi badan berdasarkan tinggi lutut
•Laki-laki [TL (cm) X 2.03] - [0.04 x U (th)] + 64.19
•Perempuan [TL (cm) X 1.83] - [0.24 x U (th)] + 84.88
Chumlea, 1985
TL= tinggi lututU = umur
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WaistCircum-ference
Obesitas sentralWanita: ≥80 cm
Laki-laki: ≥90 cm
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Body fat by skin fold thickness
© 2002 Charles H. Halsted
Normal: 12.5 to 16.5 mm, depletion <~ 12,5 mm
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Mid-arm muscle circumference
Normal 25.5, 23 cm. Severe depletion < 15, 14 cm © 2002 Charles H.
Halsted
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Kriteria WHO IMT (kg/m2)
Severe underweight < 16,0
Moderate underweight 16,0-16,9
Mild underweight 17,0-18,49
Underweight <18,5
Normal 18,5-24,9
Overweight ≥ 25
Pra-obese 25-29,9
Obese ≥ 30,0
Obese I 30-34,9
Obese II 35-39,9
Obese III > 40
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NUTRITION CARE PROCESS(Proses asuhan gizi)
PEMERIKSAAN FISIK
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Physical examination is non-specific method; it only detects about 25% of moderate cases of malnutrition
Clinical sign:- Wasting or cachexia- Pallor, which indicates anemia,
possibly caused by an iron, vitamin B12 or folate deficiency
- Specific effects of vitamin deficiency: for example, deficiency of vitamin A causing Bitot’s spot on the eyes; or deficiency of vit D or calcium causing rickets
- Oedema
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Wasting, cachexia and obesity
Physical examination
Symptomps and signs
Possible diagnosis
Wasting: look for generalized muscle wasting
• when severe, patient has emaciated appearance, almost skeletal, and it is referred as cachexia•Skin is wrinkled and there may be hair loss
implies serious ds, in developin countries: due to malnutrition caused by marasmus in children also consider malabsorbtion
Obesity: observe, and:-Measure BMI- Compare with referrence
• When severe it is obvious on inspection• BMI > 30, is regarded as obese
usually energy input is greater than energy outputObesity is also a sign of Cushing’s syndrome, hypothyroidsm, using corticosteroid, DMT2
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Clinical sign and their signifficance to nutrient disorder
Physical examination Possible nurient disorder
Pallor : observe skin colour and conjunctiva
Iron deficiency anemia; B12/ folate def, secondary to pernicious anemia
Nails: clubbing: loss of the angle between nail and the nail-bed; underlying nail feels soft, fluctuant and ‘boggy’; increase curvature in all directions
haemochromatosis (↑ iron) Wilson ds (↑ copper)
koilonychia: spoon-shaped brittle nails , may be ridges
Iron deficiency anemia
Xanthelasma : yellow fatty lump in skin or eyelids
may or maynot indicate dyslipidemia
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Gum hypertrophy: scurvy
© 2002 Charles H. Halsted
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Pellagra in Egyptian farmer
© 2002 Charles H. Halsted
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Niacin deficiency (pellagra) before and after tx
© 2002 Charles H. Halsted
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Zinc deficiency before and after tx
© 2002 Charles H. Halsted
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NUTRITION CARE PROCESS(Proses asuhan gizi)
PEMERIKSAAN LABORATORIUM
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Pemeriksaan Biokimia
•Hb, Ht•Albumin/pre-albumin•Profil lipid•Gula darah puasa/2 jam pp•Ureum, creatinin•Fungsi hati
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Nutrient Tests
Protein Serum protein, albumin, prealbumin
Fat Total cholesterol, triglycerides
Carbohydrate
Blood glucose
Vitamin A Plasma vitamin A, retinol binding protein
Vitamin D ↓ calsium & phosphate; ↑ alkaline phosphatase; measure vitamin D levels and parathyroid hormone
Vitamin K ↑ prothrombine time
Vitamin C White cell vitamin C content
Thiamin Red blood cell (RBC) thiamin
B12 Serum B12, MCV
Folate Serum and RBC folate
Iron Feritin, MCV, transferin, …
Some biochemical tests related to nutritional status
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MARKERMARKER NormalNormal MildMild ModerateModerate Severe Severe t 1/2t 1/2
AlbuminAlbumin > 3.5> 3.5 3.1-3.53.1-3.5 2.1-3.02.1-3.0 < 2.1< 2.1 20 d20 d
TransferrinTransferrin >200>200 151-200151-200 100-150100-150 <100<100 8 d8 d
PrealbuminPrealbumin >15>15 10-1510-15 5-105-10 <5<5 2-3 d2-3 d
Total Total Lymphocyte Lymphocyte Count (TLC)Count (TLC)
> 2000> 2000 1200-1200-20002000
800-1199800-1199 < 800< 800
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Diagnosis gizi
SKRINING: BERISIKO MALNUTRISI/GIZI BAIK
STATUS GIZI: UNDERWEIGHT/NORMOWEIGHT/OVE
RWEIGHT/OBESESTATUS METABOLIK:
MENINGKAT/ NORMAL/TURUNSTATUS GIT:
FUNGSIONAL/DISFUNGSIONALSTATUS CAIRAN:
HIPOVOLEMIK/EUVOLEMIK/HIPERVOLEMI/OEDEMA
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MONITORING EVALUASI
A.ASUPANB.TOLERANSI DIIT
C.KLINIS/HEMODINAMIKD.LABORATORIUM
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TERIMA KASIH