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Gizi Buruk
Bag.I.kesehatan AnakFakultas Kedokteran Universitas YARSI
Dr.Wan Nedra K. Sp.A
PENANGANAN PASIEN GIZI ANAK:
1. mengerjakan ANAMNESIS2. mengerjakan PEM.FISIK3. menentukan PEM.PENUNJANG4. menegakkan DIAGNOSIS5. memberikan TERAPI6. mempertimbangkan PROGNOSIS7. mengusahakan PREVENSI
1. Anamnesis :Riwayat makanan : - jangka pendek : sblm
sakit - jangka panjang: sejak bayi
Nafsu makan : baik / kurang / buruk ?
Masukan makanan : jumlah dan jenis mak. yang
dikonsumsi --> dapat utk menilai / kesan ttg :
kwalitas : baik / kurang, berdasarkan :
- jenis mak.- komposisi nutrien- distribusi kalori
kwantitas : cukup / kurang / lebih --.> thd. RDA - energi / protein / vitamin / mineral dll.
2. Pemeriksaan fisik 2.1. Tanda / gejala penyakit gizi :
- MEP : wajah, rambut, otot, jar.lemak subkutis, edema, dsb.
- KVA ( Xerophthalmia ) : bercak Bitot, xerosis konyungtiva, ulkus kornea, dst.
- Anemia defisiensi : pucat ( organomegali - )- GAKI : kel.tiroid >, kretin, dll.- def.vit B1 : beri-beri / edema, polineuritis,
refleks fisiol. <- def.vit B2 : stomatitis angularis
- def.vit C : skorbut- dll.
2. Pemeriksaan fisik 2.2. Membuat KESAN KLINIS tentang status gizi :
- gizi lebih ( overweight --> obesitas )- gizi baik ( wellnourished )- gizi kurang ( undernourished )- gizi buruk ( severe malnutrition)
Kesan klinis dibuat berdasarkan tanda / gejala klinis.
2.3. Menentukan status gizi secara ANTROPOMETRIS :
- BB/U - BB/TB- TB/U - LILA, dsb.
Status Gizi anak laki2, 2 thn
• BB: 7 kg
• TB: 60 cm
• Status Gizi:
• BB/U: 7/ 12,8: x 100%: 54 % (G.Buruk)
• BB/TB: 7/ 6 x 100%: 116%
• TB/U: 60/ 87 x 100: 69%
Defisiensi vit A (Xerophthalmia)
Bitot’spot Ulcuscornea
Xerosis conyunctiva & cornea Keratomalacea
2. Pemeriksaan fisik 2.2. Membuat KESAN KLINIS tentang status gizi :
- gizi lebih ( overweight --> obesitas )- gizi baik ( wellnourished )- gizi kurang ( undernourished )- gizi buruk ( severe malnutrition)
Kesan klinis dibuat berdasarkan tanda / gejala klinis.
2.3. Menentukan status gizi secara ANTROPOMETRIS :
- BB/U - BB/TB- TB/U - LILA, dsb.
Kwashiorkor & Marasmus
Iga gambang
Rambut
Hepar >>
Edema
Atrofi otot
Lemak SC <<
Marasmic-Kwashiorkor
Baggy pants
Edema
Iga gambang
Atrofi ototJar.lemak SC <<
3. Pem. Penunjang :
3.1. Pem. Laboratoris :- Hb
- protein serum, albumin, globulin- profil lipid ( lipid total, triglserida,
kolesterol, LDL, HDL)
- BUN, dll
3.2. Pem.radiologis : - usia tulang
- osteoporosis/osteomalasia
3.3. Pem.antropometris: - BB, TB/PB, LILA, LK, TLK.
4. Diagnosis :
4.1. Sehat : - status gizi baik
- T-K normal / optimal - + kriteria sehat lain
4.2. Penyakit gizi :- defisiensi : MEP, Vit - Min.
- kelebihan : Obesitas, intoksikasi vit-min.
5. Terapi :
5.1. Terapi nutrisi : - oral / enteral / parenteral
- dukungan thd. penyakit utama : ginjal, sal.cerna, DM, IEM, dsb.
5.2. Menentukan dosis obat
5.3. Pemantauan respons th/ keseluruhan
6. Prognosis :6.1. Perbaikan / kemunduran :
- perbaikan --> penyembuhan :- nafsu makan >- BB >
- kemunduran --> perburukan :- nafsu makan <
- BB <
6.2. Memperkirakan ( berdasarkan status gizi ) :
- daya tahan tubuh
- kemungkinan komplikasi / penyembuhan
7. Prevensi :
7.1. Keadaan defisiensi
7.2. Penyakit gizi iatrogenik
Anaemia
Severe PEM : Kwashiorkor hair face
Oedema
‘Puffy’
Severe PEM : Kwashiorkor
Crazy pavementdermatosis
oedema
Hepatomegaly
Severe PEM : Marasmus
face
hair
Ribs
Muscles atrophySC fat <<
Severe PEM : Marasmus + KP
lymphadenopathy
Severe PEM : Marasmus + KP
‘Caverne’
6 weeks after th/‘Destroyed lung’
PEM.
Laboratory tests:• Tests that may be useful :
Blood glucose : < 54 mg/dl = hypoglycaemia Blood smear : parasit malaria Hb or Ht : < 4 g/dl or < 12% = severe anaemia Urine exam/culture: bacteria + or > 10 lekosit/HPF
infection Faeces : blood + disentri Giardia + / parasit lain
infeksi X-ray : - thorax : Pneumonia
Heart failure - bone : rickets, fracture
Tes tuberkulin : often negative
• Tests that are little ot no value : serum protein, HIV, electrolytes
PEM.
Therapy:
Mild-moderate PEM (Gizi kurang) : - no specific clinical signs : thin,
hypotrophic- not necessary to hospitalize- looking for the probable causes- nutr. education & supplementation
Severe PEM : should be hospitalized
PEM.
Other criteria :
Very low BW : - W/H < 70%- W/A < 60%(- W/A > 60% + oedema)
+ clinical signs & symptoms : - oedema (M-K)- severe dehydration- persistent diarrhoea and / or
vomiting- severe pallor, hypothermia, shock- signs of systemic/local infection, URI- severe anaemia ( Hb < 5 g/dl)- jaundice- anorexia- < 1 yr of age
PEM.
Signs & symptoms of dehydration :
- history of diarrhoea or no/diminished intake
- weak, apathetic unconscious
- weak to absent radial pulse
- thirst, dry mouth and absent of tears
- sunken eyes and fontanel
- hypothermia
- cold hands and feet
- Urine flow << / -
Dehydration
Sunken eyes
Dehydration
Turgor :
PEM.
Therapy:
Mild-moderate PEM (Gizi kurang) : - no specific clinical signs : thin,
hypotrophic- not necessary to hospitalize- looking for the probable causes- nutr. education & supplementation
Severe PEM : should be hospitalized
PEM.
5 ASPECTS in the MANAGEMENT of Severe PEM :
A. 10 main steps
B. Treatment of underlying diseases
C. Failure to respond to treatment
D. Discharge before recover
E. Emergency
PEM.
A : “10 main steps” No Interven- Stabilization Transition Rehabilitation
Follow-up tion d.1-2 d.3-7 wk-2 wk 3-6 wk 7-26
1. Treat/prevent hypoglycaemia
2. Treat/prevent hypothermia
3. Treat/prevent dehydration
4. Correct electr. imbalance
5. Treat infection 6. Correct micro- without Fe + Fe
nutrients defic. 7. Begin feeding 8. Increase feeding 9. Stimulation10. Prepare for discharge
PEM.
B. Treatment of underlying diseases / infection :
Bacterial infection : - no apparent signs of infection/no
complication: cotrimoxazole ( 5 mg TMP/kg, 2x/d, 5 days )
- signs of infection / complications / sepsis :- ampicilline 50 mg/kg/6 hrs, IM/IV, for 2 days oral (ampi / amoxy)- gentamycin 7.5 mg/kg, IM/IV, 7 days- KP + anti-TB drugs
Viral infection : no specific th/- all PEM should receive measles vaccine
PEM.
C. Failure to respond to treatment :
Frequent causes of failure to respond :
a. Problems with the treatment facility :
- poor environment for malnourished
children
- insufficient or inadequately trained staff
- inaccurate weighing machine
- food prepared or given incorrectly
PEM.
C. Failure to respond to treatment :
Frequent causes of failure to respond :
b. Problems of individual children :- insufficient food given- vitamin-mineral deficiency- malabsorption of nutrients- rumination- infections- serious underlying disease
PEM.
C. Failure to respond to treatment :
Criteria Time of admissionPrimary failure to respond:- failure to regain appetite Day 4- Failure to start to lose oedema Day 4- Oedema still present Day 10- Failure to gain at least 5 g/kg/d Day 10
Secondary failure to respond :- failure to gain at least 5 g/kg/d During
rehabilitation for 3 consecutive days
PEM.
C. Failure to respond to treatment :
1. Death = within first 24 hrs :
- hypoglycemia- hypothermia- dehydration- sepsis
= within 24 – 72 hrs :- volume of formula >>- caloric density >>
PEM.
C. Failure to respond to treatment :
2. Inadequate gaining weight :- infection- diet- psychologic
Weight gain := satisfactory: > 10 g/kg/d good == sufficient : 5-10 g/kg/d > 50 g/kg/wk= poor : < 5 g/kg/d or < 50 g/kg/wk
PEM.
D. Discharge before fully recover:
= Dietary advice :- high protein and calorie- frequent feeding ( 5x/d )- finish all meals given- vit-min supplementation &
electrolytes- continue BF
= frequent controle ( 1x/wk )
= Immunization
Emergency :
Shock :
N2 or RLG5%15 ml/kg, 1 hr
Repeat 1 hr more
Resomal 10 ml/kg, 10 hrs
Special formula
sepsis
Maintenance, 4 ml/kg/hrFresh blood, 10 ml/kg
Improvement+
_
Emergency :
Severe anaemia.
Hb ?
Hb < 4 g/dl Hb 4-6 g/dl
Resp.distress/heart failure?
Fresh blood 10 ml/kg*
PRC 10 ml/kg* Observation
* : give furosemid 1 mg/kg, iv, before transfusion
+ _
PEM.
Prepare for discharge :
- W/H : - 1 SD or severe PEM moderate/mild
- Education for mother :- hygiene & sanitation- healthy foods- immunization- stimulation- regular controle
- to continue the th/ of chronic diseases
- to completing immunization
On admission :Sh, girl, 2 yrs,W : 3.875 gH : 67 cmW/H : < -4SD
2 weeks later : W : 4.750 g H : 67.4 cm W/H : < -3 SD
4 weeks later : W : 5.310 g H : 67.7 cm W/H : + -3 SD
5 weeks later :W : 6.280 g H : 67.8 cmW/H : - 2 SD
7 yrs,10 kg
Recovery : 16 kg