Minggu, 16 Agustus 2009

MANAGEMENT NUTRITION FOR UNCONCIOUS PATIENTS WITH BRAIN INJURY TO IMPROVE ANTIBODY

Introduction :

Everyday we needs nutrition to growth and develop, and also for our energy nutrition such as glucose, protein and electrolyte. The most common problem that emerge on a perioperative patient is malnutrition. With giving an adequate nutrition will help recovery process and increasing bodies immunity to handle infection. Patient with brain injury and consciousness disorder will easily have a nutrition problem as an effect from neurological deficit and long bed rest.

Nursing Problem for Unconscious Patient :

1. Orthostatic pneumonia cause by micro atelectasis and sputum retention

2. Fluid and electrolyte defisite

3. Neuro muscular paralyse ( disphagia )

4. Gastrointestinal disorder

5. Gastric ulcer

6. Decubitus

Malnutrition Can Caused By :

1. Secondary effect from a long fasting

2. Large operation

3. Surgery complication that affect oral absorption and septic catabolism

The Effect of Malnutrition in Unconscious Patient :

1. Decreasing of immuno system on patients

2. Easy to have infection

3. Operation wound will be difficult to heal

4. Cerebral edema will be expandable to happen

Immuno system extremely depends on somebody nutrition status. The giving of ordinary nutrition would not be enough to accomplish bodies need, because of that, it is important to give a specific nutrition that able to modulated immuno response and increase bodies immunity.

Early feeding of immuno Enhancing formula cotaining

L-Arginine, L Glutamine and Fish oil has demonstrated :

- Lower risk of infection

- Shorter length of hospital stay

- Fewer days on ventilator

- Accelerates wound healing

Results of Nutrition Support Are :

- To maintain body mass ( muscle and organ )

- To accomplish metabolic needs

- To promotes wound recovery and to increase immuno system

Surgery Patient That Need Nutrition Support Are :

- Patient that already have a malnutrition, surgery action, traumatic, sepsis

- Patient that will have malnutrition risk

Patient Which Have Malnutrition Risk Are :

- Patient that can ‘t eat for more than five days

- Patient with nutrition increasing in their body

- Patient with digestive disturbance function

- Patient that have critical disease

- Patient that need intestinal rest for along period

Nutrition has given, specially through enteral route to get better out come . According to Moore ( 1992 ) TEN ( Total Enteral Nutrition ) can

prevent gastrointestinal mucosa atrophy, easy stress respon, maintains immuno competence, protect intestinal normal flora and relatively cheaper in financing.

TPN ( Total Parenteral Nutrition ) needed for a condition that digestive system can not be used, increasing of gastrointestinal function, recovery of preoperation patient that have 10-15% weight loss, patient that can not accomplish energy needs only with oral intake, nitrogen balancing disturbance, non terminal coma.

Formula for Clinical Needs Are :

- Diabetic ( high fibre, low sugar, high fat )

- Hepatic ( low protein ) Aminoleban

- Pulmonary ( high calory,high fat ) Pan Enteral

- Kidney ( high calory, low electrolyte ) Kidmin

- Immuno – Enhancing ( L- Arginin, glutamine, omega 3 )

To determine TPN, the important things is to follow the metabolism change that happen. Remember to begin it with slowly and low dosage, started with titration. The last target is to use total enteral, and always synchronize it with patient situation and condition.

The Types of Immuno Nutrition at Present Day Are :

1. L-Glutamine

- Muscle metabolism and growth

- Energy source for cells of the intestinal mucosa

- Immuno system : macrophage and lymphocyte

- Oxidative fuel for rapidly replicating cells

2. L-Arginine

- Accelerates wound healing

- Reduces translocation of bacteria

- As metabolic intermediate

- Improves immune system competence

3. Omega 3 fatty acid

- Mayor component of the cell membrane

- An immune modulating

- Anti inflammatory agents

- Prevents essential fatty acids deficiency

Arginine Function :

  1. Immunomodulation

- Lymphocytes increased : - Thymic weight increased

- Mitotic stimulation

- Improve neutrophyl function

- Induction macrophage

  1. Increased gut function

- Promote mucosal growth + repair

- Healing of gastric ulcer,by supporting polyamine synthesis gastrin level

  1. Wound Healing

- Increased collagen deposition causing scars tissue, increased wound

strength

- Muscle metabolism

- Neo bone and tendon cells

Glutamine Function

- Muscle metabolism and growth

- Energy source for cells of the intestinal mucosa

- Immune systems : - Macrophage

- Lymphocyte

- Precursor of antioxidant : Glutathione

- Precursor ornithine

- Can readly passé Blood Brain Barrier : As brain fuel

GABA

Prevention : Uremia

- The body need N but free N produce ammonia that causing

toxic to brain tissue

- In the liver : N + Glutamic acid produce urea causing excreted in

the urine

Omega 3 Fatty Acids

- Fatty acids : Major component of the cell membrane

- Involved in process :

- Vessel : Dilatation and constriction

- Inhibition and clotting

- Cell devision and growth

- High level in fish oil and rape seed ( canola oil )

Nutrition Support Can Give Away On :

- Enteral : Given on patient that not have peristaltic function disorder

- Parenteral : Given through central peripheral

The Need of Calory and Protein on Enteral Nutrition :

Calory

- Adult : 25 - 35 k cal /kg weigh / 24 hours

- Old – adult : 23 - 30 k cal /kg weigh / 24 hours

Protein

- Depends on patient condition, generally 0,6 – 1,8 g/ kg weigh / 24 hours

The Selection and Number of Formulas :

1. Generally the formula contains 1 k cal / cc, if limited number was used,

it can also contains 1,5 – 2 k cal / cc

2. Fibrous or not fibrous, factory made formula containing fiber that can

loose on water

3. Contains protein, factory made formula, protein made casein soya and

eggs

4. Fat, normally fat composition contains 30 – 40 % from the daily need

5. Electrolyte,ideally before enteral nutrition was given, it has to be check

the containing of k, Na,Cl,Mg,Ca and phosphor

6. Vitamin and trace elements

Use Direction :

1. Bollus, contains 250 – 300 cc, given 5 – 8 times on more and 10 minutes

speed

2. Giving continue on 24 hours, which can give through the drip or using

pump nutrition

Complication :

1. Aspiration

2. Vomiting

3. Diarhoea

4. Obstipation

5. Dehidration

Nutrition Parenteral :

Use Indication :

1. Patient that can not allowed to use digestive system as a nutrition path

2. Patient with very high nutrition need

Types of Liquid Are :

1. Perypheral :

- Dextrose 5%

- Martos 10 %

- Pan amin G 2,8%

2 Central :

- Dextrose 20 %

- Triofusin 1000

- Amiparen

- Aminofel, aminofusin

SUMMARY

It is very important, to use nutrition enhancing on unconsciousness patient. Malnutrition can cause the increasing of clinical recovery cost, instead of worst condition because of the complication on a patient, so that it needs more day for clinical recovery, Which can increase clinical recovery cost . A good cooperation between doctor, nurse, family and hospital as a facilities supplier will result an optimal nursing for the patient.

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