Modul Dietetik Penyakit Infeksi

Dietetic Infectious Diseases
PART I
CONCEPT PGRS
A. SCOPE
The scope of hospital nutrition services include:

Outpatient nutritional services
Inpatient nutrition services
Implementation of food
Research and development of nutrition
B. DEFINITION OF OPERATIONS
Nutrition services an effort to improve, improve nutrition, food, dietetic
community, group, individual or client which is a series of activities that includes
gathering, processing, analysis, conclusions, advice, implementation and evaluation
of nutrition, food and dietetic in order to attain the status of optimal health condition
healthy or sick
Nutritional therapy is a nutritional services provided to klienberdasarkan
nutritional assessment, which includes diet therapy, nutrition counseling and special
meals or gifts in order to cure the patient. (Nutrition and Diet Therapy Dictionary,
2004)
upbringing Nutrition a series of activities organized / structured allowing for the
identification of nutritional needs and the provision of care to meet those needs.
Standardized Nutrition Care Process (PAGT) is Pendekatansistematik in
providing quality nutrition care services, through a series of organized activities
include the identification of nutritional needs through the provision of services to
meet nutritional needs.
dietetic is the integration, application and communication of principles
prinsipkeilmuan food, nutritional, social, business and scientific basis to achieve and
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maintain the status of optimal nutrition individually, through the development,
provision and management of nutrition services and food at various area /
environment / background service practices ,
Clinical Nutrition is a study of the relations between diet and health of the
human body including the study of nutrients and how digested, absorbed, used,
metabolized, stored and removed from the body.
Nutrition counseling is a series of events as a two-way proseskomunikasi
conducted by Nutritionist / Dietisien to instill and promote understanding, attitudes,
and behaviors of patients in recognizing and addressing nutritional problems, so
patients can decide what he would do.
nutrition counseling is a series of activities conveying messages of nutrition and
health who planned and executed to instill and promote understanding, positive
attitudes and behavior of patients / clients and the environment against the efforts to
improve the nutritional status and nutrient kesehatan.Penyuluhan intended for mass
community group or groups, and targets expected understanding health aspects of
behavior in everyday life.
referral nutrition is a system in hospital nutrition services yangmemberikan
reciprocal delegation of authority on patients with nutritional problems, either
vertically or horizontally.
Nutrition Professionals is a work in the field of nutrition implemented based on
a scientific (body of knowledge), has the competencies acquired through a tiered
education, has a code of ethics and is serving the community.
Power Nutrition Professional Standards is limit the ability minimalyang be
owned / controlled by the power of nutrition to be able to carry out the work and
practice of nutrition services are professionally arranged by professional
organizations.
power Nutrition is any person who has passed field of nutrition education in
accordance with laws and regulations.
Bachelor Nutrition is one who has followed finish minimal formal education and
nutrition scholars (S1) recognized government of the Republic of Indonesia.
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nutritionist: is someone who is given the task, the responsibility answer and fully
authorized by the competent authorities to conduct a functional technical activities in
the field of nutrition services, food and dietetic, both community and hospital and
other medical practitioners unit
Registered nutritionist is a nutritional power Bachelor of Applied Nutrition
Nutrition danSarjana who have passed a competency test and registered in
accordance with legislation
C. CONCEPT OF HOSPITAL NUTRITION SERVICES
Nutrition services at the hospital is a service provided and adjusted to the
patient based on the clinical situation, nutritional status, and the status of the body's
metabolism. The nutritional state of the patient is very influential in the healing
process, otherwise the course of the disease can affect the nutritional status of
patients. It often happens that the patient's condition is getting worse
Nutritional therapy or diet therapy is part of treatment of diseases or clinical
conditions which must be observed that the gift does not exceed the ability of organs
to carry out metabolic functions. Nutritional therapy should always be adapted to the
changes in organ function. Giving the patient's diet should be evaluated and repaired
in accordance with changes in the clinical situation and the results of laboratory tests,
both inpatients and outpatients. Efforts to improve the nutritional and health status
of society both inside and outside the hospital, is the duty and responsibility of health
personnel, particularly human nutrition.
D. MECHANISM OF HOSPITAL NUTRITION SERVICES

Hospital Nutrition Services activities, including:
1. Nutrition Outpatient Care
2. Nutrition Inpatient Care;
3. Implementation of Food;
4. Research and Development.
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
Mechanism of Nutrition Services at Hospital

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Inpatient Food
D. NUTRITION SERVICES OUTPATIENT

Outpatient nutritional services is a process of continuous nutritional care activities
starting from the assessment / assessment, provision of diagnosis, and monitoring and
evaluation of nutritional interventions to clients / patients on an outpatient basis.
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Outpatient nutritional upbringing commonly called nutritional and dietary counseling or
education / nutrition counseling
- Aim
Providing services to clients / outpatient or groups to help find solutions nutrition

problems through nutritional advice regarding the appropriate amount of food
intake, type of diet, proper eating schedule and how to eat, the type of diet to
health.
- Mechanisms Activity
Outpatient nutritional services include individual counseling activities such as;
nutritional and dietetic counseling services at the outpatient unit integrated
geriatric integrated services, integrated service unit with HIV-AIDS, a major
integrated outpatient unit / VIP and special units of individual nutritional counseling
children can also be focused on a spot. Counseling Services in groups such as; the
provision of education in groups of diabetic patients, hemodialysis patients,
pregnant and lactating women, patients with coronary heart disease, patients with
AIDS, cancer, etc.
Mechanisms to find these patients in an outpatient nutritional care in the form of
nutritional counseling for patients and families as well as nutrition counseling for
the group are as follows:
 Nutrition counseling
1. Patients come to room nutritional counseling with a letter of referral from the
clinic in a hospital or outside the hospital.
2. Dietisien recording patient data in the registration book.
3. Dietisien perform nutritional assessment begins with anthropometric
measurements in patients who do not have data TB, BB.
4. Dietisien continuing assessment / assessment of nutrition in the form of a
history of eating anamnesis, personal history, read the results of physical
examination and clinical laboratory (if any). Then analyzes all the nutritional
assessment data.
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5. Dietisien set nutritional diagnosis.
6. Dietisien provide nutrition interventions such as education and counseling by
step set up and fill the leaflet flyer / brochure diet as the disease and the
nutritional needs of patients and explain the purpose of diet, schedule, type,
number of grocery using props food models, explain the recommended food
and not recommended, way of cooking and others adapted to the diet and the
willingness and ability of the patient.
7. Dietisien encourage patients to repeated requests, to determine the success of
the intervention (M & E) do monitoring and evaluation of nutrition
8. Recording the results of nutrition counseling with ADIME format (Assessment,
Diagnosis, Intervention, Monitoring & Evaluation) is inserted into the patient
record or delivered to the patient's physician through the patient outside the
hospital and archived in the counseling room.
 Nutrition counseling
E. NUTRITION SERVICES HOSPITAL

Inpatient nutrition services is a nutrition service that starts from the assessment
process of nutrition, nutritional diagnosis, nutrition interventions include planning,
provision of food, counseling / education, and nutrition counseling, and monitoring
and evaluation of nutrition.
- Mechanisms Activity
Mechanism inpatient nutrition services are as follows:
a. nutritional screening
Stages inpatient nutrition services begins with screening / nutrition screening by
nurses room and the determination of the start order diet (diet prescriptions
early) by a doctor. Nutritional screening aims to identify patients / clients who
are at risk, not at risk of malnutrition or special conditions. Special conditions in
question are patients with metabolic disorders; hemodialysis; child; geriatric;
cancer with chemotherapy / radiation; Burns ; patients with decreased
immunity; critical illness and so on.
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Ideally, screening is performed on a new patient 1 x 24 hours after the patient's
admission. Screening method should be short, quick and adapted to the
conditions and agreements at each hospital. Examples of screening methods
among others Malnutrition Universal ScreeningTools (MUST), Malnutrition
Screening Tools (MST), Nutrition Risk Screening (NRS) 2002. Screening for
pediatric patients 1-18 years of dapatdigunakan Pediatric Malnutrition Yorkhill
Score (PYMS), ScreeningTool for Assessment of Malnutrition ( STAMP), Strong
Kids.
If the nutritional screening results indicate that patients at risk of malnutrition,
they do study / assessment of nutrition and proceed with measures of nutrition
care process standardized by Dietisien. Patients with good nutritional status or
risk of malnutrition, it is recommended to do re-screening after 1 week. If the
results of the risk for malnutrition screening is carried standardized nutrition
care process.
F. NUTRITION CARE PROCESS standardized (PAGT)
Standardized nutrition care process performed in patients at risk of malnutrition,
already malnourished and or special conditions with certain diseases, this process is a
series of recurring events (cycles)
a. Assessment / Assessment of nutrition
b. Nutrition diagnosis
c. Nutritional intervention
d. Monitoring and Evaluation of Nutrition
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CHAPTER II
NUTRITION SCREENING
The first step in the prevention of malnutrition in hospital with nutritional

screening (Hernandez et al, 2012). Nutritional screening is the process of identifying
and recording characteristic that is found in helping the process of identifying patients
at risk of malnutrition or malnutrition (Lim et al, 2009). Nutritional screening is an
important aspect for certain pathological conditions causing malnutrition
(Lomivorotov et al, 2013). Therefore, The Joint Commission on Accreditation of
HealthcareOrganization (JCAHO) recommends that a minimum nutritional screening
done dalamwaktu 24 hours of the time the patient began to enter the hospital (MoH
RI, 2014).
The identification of patients at risk of malnutrition or malnutrition is the first step

in order to establish an adequate nutritional support as soon as possible (Orfila et al,
2012). Patients who immediately conducted nutritional screening will result in
accuracy in nutritional interventions that can prevent malnutrition in hospitals and
accelerate the healing process (Susetyowati, 2013). If the nutritional screening results
indicate that patients at risk of malnutrition, they do study / assessment of nutrition
and proceed with measures of nutrition care process standardized by Dietisien.
Patients with good nutritional status or risk of malnutrition, it is recommended to do
re-screening after 1 week. If the results of the risk for malnutrition screening is carried
standardized nutrition care process
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(MoH RI, 2013). Algorithms screening and nutritional assessment in adult patients is
presented in Figure 2.
Nutrition Screening:
 Acute Disease: within 24 hours

 Chronic patients or new patients enter: within a maximum of 48 hours
 Home care: During the first health worker visits
Patients at risk:
Adult patients at risk of malnutrition is if you have any signs of the following:
Decrease / increase in weight is undesirable> 10% weight usually in the last 6

months, or> 5% of body weight usually within 1 month of the last, or
weight> 120% or <80% of ideal body weight, chronic suffering or
increase metabolism
Changes in diet (received TPN / enteral feeding, surgery, pain or trauma)
Nutrient intake is not adequate (because they do not get food / food
products, a decrease in the ability of digestion and absorption)> 7 days
not at Risk risky
Nutritional assessment carried

Re-screening at: out include:
Review the history of
1. Specific time intervals or  nutrition
There is a change in Evaluation of
2. conditions  anthropometric data,
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clinical / nutritional status and related biochemical
nutrition
 Review of clinical data
Stable Risky  Rating physical data
Create a nutrition care plan is based on:
Inter-disciplinary approach
The purpose of nutritional care both

short- and long-term, the need for
nutrition education, and patient
discharge planning or training at home
Planning prescription diet
Giving enteral / parenteral
Re-assessment based on:

Clinical data changes
Pattern enteral nutrition / parenteral
Protocol / provision available
Figure 2. Screening and Assessment Algorithm Nutrition in Adult Patients (ADA, 2009)
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ESPEN recommendations and ASPEN determined that nutritional screening needs
to be done at the beginning of the patients admitted to the hospital to identify
patients who are at risk of malnutrition and repeated periodically. Patients who have
nutritional problems evaluated by health personnel who work in teams of nutritional
support (Mueller, 2011; Lorenzo, 2005).
The purpose of screening is to identify a person's nutritional malnourished or at
risk of malnutrition to do further assessment and early nutritional intervention (MoH
RI, 2013; Hernandez et al, 2012; Lim et al, 2009). A similar opinion was expressed
Rasmussen et al (2010) and Gupta et al (2011) that the purpose of nutritional
screening is to predict the probability of improving or worsening of outcomes related
to nutritional factors and determine the effect of nutritional intervention. Outcome of
nutrition interventions can be assessed by several methods, that improvement or
prevention of decline in physical and mental functioning, reduction of disease
complications, accelerate the recovery from disease and decrease the duration of
treatment.
Nutritional screening generally has two roles. The first role can identify or predict
the risk of developing a condition such as complications including death and fees.
Screening can to prevent or treat conditions or complications occur, because it can be
used as the basis for follow-up in providing appropriate interventions. The second role
of screening is to identify individuals who may or may not benefit from such treatment
(Elia and Stratton, 2012).
Nutritional screening component according to ESPEN consists of four main
components (Rasmussen et al, 2010), namely:
1. Current conditions, illustrated through the measurement of height and weight
to determine body mass index (BMI). BMI is an index measuring the
nutritional status of a simple and objective as well as an important component
of nutrition screening but BMI can not be used as an accurate determinant
malnutrisisecara status. Patients who have a high BMI can be malnourished
due to lack of food intake or malignancy disease (Tsaousi et al, 2014). When
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the measurement of weight and height can not be done then we can use
measurements of upper arm circumference.
2. Stable condition, illustrated with weight loss obtained from the patient's
history. Weight loss (either intentionally or unintentionally) is one important
part of the nutritional assessment associated with mortality (Tsaousi et al,
2014). Losing weight unintentional by 5% or more for 3 months are usually
considered significant
3. Condition worsens, illustrated with questions related to decreased food intake
which includes the amount and duration of intake reduction.
The influence of the disease to a decrease in the nutritional status, illustrated by the
effect of a disease that causes a decrease in appetite and an increase in the
metabolic stress-related needs. The relationship between malnutrition and
gastrointestinal fistula complications (OR = 2.4; 95% CI: 1.1 to 5.1) and intestinal
failure (OR = 4.3; 95% CI: 1.8 to 10.4). Kidney disease are malnourished higher (OR
= 2.8; 95% CI: 1.9 to 4.0) for kidney failure is often associated with sepsis, trauma
and multi-organ failure (Orfila et al, 2012).
Characteristics of a screening method should meet the following requirements:
a. Simple, it means that the method can be easily used by hospital personnel
others.
b. Easily accepted, which means that the method can be accepted subject and
others.
c. Cost.
d. Accuracy, meaning the degree of ability to produce a measurement between
the measured variable is the same as reality.
e. Coincidentally, that means proximity measurement results with reality.
f. Sensitivity, meaning the proportion of subjects who are sick, and the test results
were also positive.
g. Specificity, meaning that the proportion of the healthy subjects and the test
results are also negative.
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Various studies have been conducted for the development of nutritional
screening tool is best and appropriate for use in a variety of conditions, place and
population. As for the kinds of tools / methods of screening nutrition among others
Malnutrition Screening Tool (MST), Malnutrition Universal Screening Tool (MUST), the
Nutritional Risk Screening-2002 (NRS-2002), Short Nutritional Assessment
Questionnaire (SNAQ), Subjective GlobalAssessment (SGA), Mini Nutritional
Assessment-Short Form (MNA-SF), Pediatric Malnutrition Yorkhill Score (PYMS) and
others (Ministry of Health, 2013).
MST is a nutritional screening method is simple, fast, valid and flexible to identify
patients who are at risk of malnutrition. MST was developed based on the selection of
nutritional screening questions at the level of the highest sensitivity and specificity
compared with SGA score (Susetyowati, 2013).
MST screening method consists of two questions that weight loss is not expected
and a decrease in appetite that has been validated used for general patients, surgery
and cancer (Barker et al, 2011). Losing weight the screening method MST: (1) if the
weight loss of 1 kg to 5 kg, it is given a score of 1, (2) if the loss of weight 6 kg to 10 kg,
it is given a score of 2, (3) if you lose weight 11 kg up to 15 kg, it is given a score of 3,
(4) if the weight loss of more than 15 kg then given a score of 4, and (5) if the
hesitation in identifying lose weight, then given a score of 2. A decrease in appetite is
given a score 1. Conclusion of screening that patients with malnutrition risk category, if
the total score greater than or equal to 2, then concluded the patient runs the risk of
malnutrition (Susetyowati, 2013).
Screening methods MST has been demonstrated by the level of accuracy in the
evaluation consisted of 1513 quote and 9 research of electronic journals written by
congress and abstract ASPEN and ESPEN 2000 to 2005, obtained MST is a method that
the level of accuracy higher than with other screening (Venrooij et al, 2007). Results
Consensus NutritionEducation Nutritionist of Materials Online (NEMO) of 2014 also
showed MST memilikisensitifitas and high specificity for each 93%; kappa between
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0.88 nutritionists and patients are detected are at risk of malnutrition was able to
predict a longer LOS. However, the MST can not be applied to patients with
communication difficulties (Herath et al, 2014)
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CHAPTER III
CARE NUTRITION ACCORDING TO PROCESS CARE NUTRITION
standardized
Basic Concepts of Nutrition Care Process Standardized (PAGT)
On this topic will explain the basic concepts Standardized Nutrition Care Process
(PAGT) is a standardized process as a systematic problem-solving methods in dealing with
nutritional problems so as to provide nutritional care that is safe, effective and of high
quality. Standardized question is provide care nutrition with the standardized use of the
structure and a consistent framework so that every patient who has malnutrition receive
care nutrition through four (4) step is the assessment of nutrition, diagnosis nutrition,
nutritional interventions, and monitoring and evaluation of nutrition , The three steps of
PAGT, namely nutrition assessment, nutrition intervention and monitoring
Nutritional evaluation is already known by dietisien, but the move to two, nutrition diagnosis
is still not well defined.
Diagnosis of nutrition is the missing link in nutrition care process has been done
before. Diagnosis of these nutrients is a bridge between the assessment of nutrition and
nutritional interventions. Nutrition Diagnosis is made through data collected in the study of
nutrition, assembled, analyzed and summarized the problem, this activity is like stringing
"puzzle", which eventually obtained a clear picture. If the problem is known, also known
symptoms, signs and causes the intervention will be more focused and measurable.
Although the nutrition care process is standardized, but the nutritional care is still
given individually for patients with the same medical diagnosis is not necessarily at risk or
the same nutrition problems. For example, in one room there were 3 patients with a medical
diagnosis of dengue, but the risk of nutritional disorders in such patients can vary, for
example the first patients with eating disorders through the oral, the second patient suffered
impaired absorption of certain nutrients, the third patient experienced a problem intake less
because they do not want eating hospital food. Under these conditions the three patients
require different nutritional therapy and dietary modifications should be made standard
according the needs of each patient.
Nutritional quality upbringing means to do it properly, at the right time, using the right
way for the right individuals to achieve the best results possible. Nutritional upbringing given
to patients in the form of diet design, education and counseling appropriate to the problems
and needs of the client and documented nutritional quality service is a form of nutritional
care. Quality is measured by the level of success or the end result of intervention and
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compliance with applicable implementing the care process. Thus the results of nutritional
care can be predicted and are not biased when dietisien using standardized nutrition care
process.
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NUTRITION CARE MODEL AND PROCESSES standardized
Model PAGT
NOW you learn about PAGT models. Before learning models PAGT
we understand first that started the nutritional care of patients entered in the clinic or
hospital. Further assessments will be conducted on the patient, then planned and
implemented the intervention measures. Third last thing is a cycle that continues until the
patient no longer need nutritional care, move or return.
In the picture below (inner circle) is beginning PAGT which starts from the
collaboration between dietisien and patients, and the process is then performed PAGT based
4-step continuous namely Assessment of Nutrition, Diagnosis Nutritional Intervention
Nutrition to Monitoring and Evaluation of Nutrition (box-2 from the inside).
Source: Adaptation of lacey, K and Prichett, E. Nutrition Care Process and Model: ADA
adpots road map to quality care and outcomes management, Journal of Ameriran
Dietetic Association, 2003.
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Figure 1.1
Nutrition Care Model and Standardized Nutrition Care Process
Furthermore, in the image above (box 3 from the) show that, to carry out PAGT, a
dietisien must have communication skills, collaboration, and a dietisien should have the
competence to think critically to solve problems of patients based on knowledge dietetic
actual (factual) and applying a professional code of ethics nutrition field.
Based on the picture above PAGT Model (outer loop), A ditisien in applying these
PAGT, can not be separated from environmental factors he worked as the prevailing health
care system, social system, cultural and economic conditions.
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PAGT area outside, there are 2 system that supports PAGT namely:
The first system is a screening and referral, which is access into the PAGT cycle. Patients who
received PAGT is identified patients who require nutritional care through screening and
referral process. This process is not included in PAGT, but it is the key to get in PAGT.
At this stage the identified needs of each individual patient to get the nutrients needed
care and may also need to be integrated with other health team. For example, patients
with diabetes mellitus for the treatment require nutritional care apart from dietisien
which regulates food, also require the involvement of other health professionals such
as doctors in charge of patients, specialists in internal medicine, nursing and health
analysts power.
The second system is the reporting and evaluation of the impact. The effectiveness and
efficiency of the process can be measured through this system. Related data are
collected, analyzed periodically and compared with certain agreed standards.
Monitoring and evaluation of nutrition in PAGT be the primary measure of the
relationship between the process and the impact of nutritional care. For example it can
be evaluated the impact of a diet administered to the patient whether to improve
nutritional status can be seen from the data the patient's weight gain during
hospitalization.
Standardized Nutrition Care Process
understanding
Nutrition care process is the standard method to solve problems of nutrition, improve
the quality and success of nutritional care, require critical thinking and using
international terminology. In essence in providing nutritional care with PAGT approach,
a dietisien analysis and assimilation of data with a critical frame of mind, then of the
data identified nutritional problems and then provide the nutritional quality care that
is right way, the right of patients timely and safe for the patient.
Interest PAGT
The purpose of nutrition care process that helps patients to solve nutrition problems
by addressing the various factors that have contributed to the imbalance or changes in
nutritional status. This objective is achieved through measures in PAGT begin collecting
data later identified nutritional problems and their causes. The accuracy in determining
the root causes will influence the selection of appropriate interventions. Based on the
symptoms and signs of nutritional problems can be monitored and measured
development to determine further action.
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Basically, nutrition care services is to restore patients in good nutritional status by
intervening in various factors. PAGT success is determined by the effectiveness of
nutrition interventions through education and effective nutritional counseling, feeding
the appropriate diet for patients in hospitals and collaboration with other professions
very
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PAGT affect success. Monitoring and evaluation using measurable indicators of nutritional
care is done to demonstrate the successful handling of nutritional care and necessary
documentation of all stages of the process of nutritional care.
BENEFITS FOR PROFESSIONALS PAGT DIETESIEN

When the nutrition care process is done correctly and consistently the benefits are
services based on the facts (evidence based); closer to the desired result; dietisien show as a
provider of quality nutrition services.
Through the nutrition care process will be seen the relationship between the quality of
service to the authority (PROFESSIONAL Autonomy) a ditisien. In this case dietisien
profession has specific authority to decide on actions within the limits of his professional
ability.
PAGT implemented in all health care settings, such as in hospitals (in inpatient and
outpatient), clinical nutrition and dietary counseling services, community health centers, and
in the community, including in the field of research. PAGT target individual or group health
status.
TERMINOLOGY / LANGUAGE IN BAKU PAGT
Every step of PAGT have respective terminology with the purpose of uniformity of
understanding and documentation. Uniformity of language in dietary practices necessary to
facilitate communication, perception, observe and measure the final results as well as the
continuity of service. Nutritional care terminology used to refer to the International Dietetics
and Nutrition Terminology (idnt) reference manual: a standardized language for the nutrition
care process, which was developed by the American Dietetic Association as an international
language in dietetic. Standardized language also play a role as a profession in this case the
identity and characteristics dietesien is then a / an opportunity for professional autonomy.
STEPS IN RELATION PAGT

Nutrition care process consists of four steps that are interrelated and influence that
nutrition assessment, nutrition diagnosis, intervention and monitoring of nutrition and
nutritional evaluation.
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Dietetic Infectious Diseases
Source: TOT Training Modules Standardized Nutrition Care Process (PAGT) for Power
Nutrition Care Facilities
Health, Dit. Nutrition MoH RI, WHO, PERSAGI, Asdi. 2014.
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Figure 1.2
Relationship Steps in PAGT
Can be seen in Figure 1.2 above, step 1 PAGT is Nutritional Assessment, a method for
collecting data, verifying the data needed to identify problems, their causes and symptoms
related to nutrition signs that will be associated with the second step is of diagnostic
nutrition.
Diagnosis of nutrition is an activity to identify and name the actual nutritional

problems, or conditions that risk causing nutritional problems that are the responsibility
dietisien to handle it independently. Nutrition Diagnosis expressed by the PES format
(problem-etiology-sign / symptom). Diagnosis of nutrition are temporary and change
according to patient's response to nutritional intervention is given. The diagnosis was
established by dietisien or is the result of discussions with the team. Problem, etiloogi and
sign symptom
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is the basis for determining the final outcome, select interventions and progress to achieve
the target of nutritional care.
The next step is Step 3 is a nutritional intervention that planned actions designed to
change behavior, nutritional or environmental conditions related to the health aspects of
individual aspects including families and carers, a specific target group or a particular
community in a positive direction. Selection of nutritional interventions is based on
nutritional diagnosis and etiology. However, if the etiology can not be solved by a dietisien,
the nutritional intervention aimed at minimizing signs / symptoms of the problem. This step
includes the process of designing the prescription diet including care objectives and the
implementation of an intervention plan.
The final step is the monitoring and evaluation of nutrition, which consists of activities
monitor, measure and evaluate. Monitoring is the process of reviewing and measuring the
status of the patient / client at the time of scheduled departure time in accordance with the
diagnosis of nutrition, objectives and plans of intervention and the results, while the
evaluation is to compare systematically the data client data current with the previous status,
the purpose of the intervention, or reference standards to the impact of interventions on
outcome. Monitoring and evaluation using outcome indicators selected according to the
needs of the patient, the diagnosis, the purpose and conditions of the disease. In this step it
was decided for the continuation of dietetic measures to be undertaken.
DIFFERENCES IN MEDICAL NUTRITION THERAPY (TGM) PROCESS CARE AND NUTRITION

standardized (PAGT)
Medical Nutrition Therapy (TGM) is a standard of care that is showing on "what should
be" and are a key component of care in certain diseases. Standardized Nutrition Care Process
is a standardized process, it shows "how care (TGM) is done". In essence PAGT accurately
represent the spectrum of nutritional care that emphasizes the consistent steps and specifics
of dietesien time of TGM as well as guidance in nutrition education and other nutrition care
services that are preventive.
The implementation of appropriate measures shows PAGT the harmonization of four
steps that are consistent and standardized regarding nutrition care services, although such
services performed in different places. Therefore, with the application of current PAGT, TGM
can no longer represent the entire picture of nutrition services provided by dietesien, but
became more components showing "how care (TGM) is done".
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Changes dietisien overview of the task to change the paradigm that has been adopted.
This new paradigm appears to be more complex, requiring greater responsibility, but can
explain your thoughts or observations better. Finally, dietesien can provide services in a way
that makes it possible to achieve the desired result or as expected. This paradigm will further
strengthen the presence of dietesien as perpetrators health services.
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CONCEPT OF NUTRITION MATTERS
understanding
Nutrition is very important in maintaining, preventing and treating pain conditions.
Status
health can be transformed from a state of the start of a healthy, resistant to disease, acute
illness or living with chronic and terminal illnesses. In healthy conditions of nutrition needed
for optimal growth and development, maintaining public health, support the activities of
daily life, and protect the body against disease. While in times of illness nutrition contribute
to the healing of disease, the incidence of complications, duration of the treatment and
determine mortality. Therefore it is very important to know the nutritional status of a
person.
Nutritional reserves such as energy, protein, water, vitamins and minerals in the body
is a picture of a person's nutritional status. If there is a balance between nutrient intake with
needs, it can be said that a good nutritional status, which means that the nutritional reserves
enough for optimal growth and development, maintaining the general health of their daily
activities and prevent disease. Conversely if the nutrient intake in both the number and the
type does not match their needs, there will be an imbalance of nutrient reserves that
became ultimately an issue of nutrition. Imbalance can occur due to nutritional reserves that
are less or excessive intake, there is growing demand, but there was enough intake of
impaired absorption and utilization disorders.
Assessing one's nutritional status not only compares the number and type of nutrients
a person consumes but also learns the factors that affect the nutrient intake and the needs
of the person because the process of consuming food or eating is a very complex process
influenced by a variety of external and internal factors a person the.
h. Factors that affect nutritional status
A person's nutritional status is influenced by several factors: human biological factors,
lifestyle factors, dietary factors and nutrients and system factors, and are described in
detail as follows:
Human Biological Factors
Human biological factors are identified as biological factors (age, genetics, genetics),
physiological phases (growth process, pregnancy, breastfeeding), pathological factors
(disease, trauma, changes in organ function or metabolism).
These factors can be exemplified for example breastfeeding mothers, physiologically
requires consumption of energy and protein, fat and carbohydrates more.
27
Lifestyle Factor
A person's lifestyle can be identified by attitude / belief (attitude / belief), knowledge
(knowledge), behavior (behavior)
8
These internal factors affect the selection of food and physical activity that someone does,
for example pregnant women believe that when drinking ice causes the weight of the baby
they contain to be large. This is because the mother does not know that the baby's weight
gain is caused by the amount and the nutrient content of the food consumed, not because of
ice as a single cause that affects the weight of the baby it contains.
Factors of food and nutrients
As is commonly known, food affects the nutritional status of a person. This factor can be
diisentisikasi from: Intake and composition of energy and nutrients from food. The amount
as needed for growth according to the life cycle of man. Quality or content of energy and
nutrients present in food to maintain health or to cure from illness
Environmental factor
Environmental factors that affect nutritional status are identified as: Social relationships
between humans form a culture of eating and trust, parenting and will affect the
surrounding community groups.
Economics in the household economic level, where economic ability affects the purchasing
power of the food both in quantity and quality of food consumed.
Food safety and sanitation guaranteeing uncontaminated food consumption or handling
unsafe food / food will affect the quality of food consumed.
Access and availability of food.
Currently there are technological advances such as online food shopping, food delivery
services to buyers, easy access to food, especially in big cities such as Jakarta. The presence
of minimarkets scattered in to the level of the villages also facilitate access food around the
community.
System factor
System factors that affect nutritional status are:
Health Service System.
Education system.
Food supply systems (industry, agriculture, institutions).
These factors are external factors that impact on the provision and service of food and
nutrients. Examples in a remote area of society in the area are not easily accessible to health
services so that the handling of diseases / other health problems is constrained, or in an
28
atmosphere of disaster where access to the site is disconnected so that food availability is
impaired and then affects nutritional status.
The concept of nutritional problems

Less intake, impaired absorption, or high nutritional loss
causing a decrease in body reserves or tissue depletion. If this happens for a long time then
there will be biological dysfunction and continue on the condition of physiological
dysfunction or physiological changes. If this condition is not treated properly then depletion
of nutrients can cause dysfunction at the cellular level, then the incidence of clinical signs
and symptoms. Furthermore, if the condition continues to cause sickness / morbidity and
can lead to death.
Identifying or identifying risks that cause nutritional problems as early as possible is very
important. This identification is done through nutritional assessment activities. To identify /
recognize nutritional problems that are deficient or excessive intake can be done through
the asphyxiation of history, recognize the sign of how much reserve decline at the tissue and
cellular levels can be assessed through biochemical assessments and symptoms and clinical
signs. Asemen vital signs are very necessary when the patient is sick, especially in severely ill
patients.
The nutritional problem is divided into three domains:
Domain intake (actual nutritional problems related to the intake of energy, nutrients, fluids,
substances
bioactive both through oral and enteral and parenteral).
b. The behavioral and environmental domains are nutritional problems that occur related to
knowledge, attitudes / beliefs, physical environment, food access and food safety that affect
the excess or lack of energy intake and nutrients.
Clinical domain is a nutritional problem related to the physical and medical condition of a
person that affects the ability of his food intake.
Exercise
Describe the purpose and benefits of PAGT!
Describe the PAGT standard terminology / language!
Briefly explain the PAGT steps and the relationship between the steps of the PAGT!
Explain the difference between TGM and PAGT!
Explain 3 domains of nutritional problems!
Instructions Exercise Answer
To assist you in doing the exercises please review the following materials:
29
Understanding PAGT.
PAGT steps.
Understanding and differences between TGM and PAGT.
The concept of nutritional problems.
Summary
From the topics that have been studied above, the summary is PAGT is a standardized
process for dietisien in providing nutritional care in patients with various diseases.
With standardized processes it does not mean that all patients with the same disease
will get the same nutritional care as described above, each of the same patients may
have different nutritional problems requiring different interventions. The process of
nutritional care consists of 4 interrelated and influential steps of nutrition assessment,
nutrition diagnosis, nutrition intervention and nutrition monitoring and evaluation.
Appropriate PAGT measures show a harmonization of 4 consistent and standardized steps
regarding nutritional care, even if the service is conducted in different places.
Therefore, with the current PAGT implementation, TGM can no longer represent the
picture of all the nutritional services provided by dietesia, but it is a component that
shows more "how care is done".
Nutritional problems are influenced by some internal and external factors. Internal factors
that affect nutritional status are biological, physiological, pathological such as the
presence of diseases that interfere with one's nutritional balance. External factors such
as culture, knowledge, socio-economic environment and geography affect access to
health services and food sufficiency.
Briefly nutritional problems in PAGT are classified in the domain, intake, behavior and
environment and clinical physical domain.
Test 1
Choose the best answer!
The purpose of developing standardized Nutrition Process is ....
Nutrition care provided by professionals
The patient's nutritional problems are clear and the results of care can be measured
Patients are more satisfied to get nutrition care services
Dietisien more confident in providing nutritional care
Dietisien more professionalism recognized by other health workers
30
Medical Nutrition Therapy (TGM) focuses more on what should be given to patients
according to the disease and condition of the patient, while the Nutrition Process
emphasizes on the ....
The language used is standardized
Nutrition care form in patients
A standardized care process
Results of nutritional care can be measured

Dietary professionalism
Observing and measuring the intake of feeding patients during hospitalization in PAGT
including steps ....
Nutrition study
Diet history
Monitoring
Evaluation
Screening
Internal factors that affect the patient's nutritional status is ....
Age
Psychology
Economics
Education
Food security
A patient is not used to consuming vegetables and fruits. The nutritional problems of these
patients are grouped into the ....
Intake
Behavior
Clinical physics
Environment
Knowledge
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Topic 2
Nutritional Assessment
Now we begin to study step 1 in Standardized Nutrition Process (PAGT). On this topic you
will learn about the definition of nutrition assessment, objectives, roles and functions, the
relationship of nutritional assessment with other stages in PAGT as well as the terminology /
standard language of nutritional assessment. At the end of this topic there are exercises so
you can assess what you already understand from this topic.
THE BASIC CONCEPT OF NUTRITION ASSESSMENT
Understanding
Nutritional assessment is a systematic approach in collecting, verifying
and interpret patient / family / caregiver data or relevant groups to identify nutritional
problems, causes, and signs / symptoms. Nutritional assessment activities are conducted as
soon as the patient / client is identified as being at risk of malnutrition (the result of the
nutritional screening process).
Aim
The nutritional assessment is to obtain sufficient information in identifying
and make decisions / determine the problem picture, the cause of nutritional related
problems as well as signs and symptoms.
Specifically the purpose of nutritional assessment for:
Prevent the ongoing incidence of malnutrition in patients / clients at risk of malnutrition by

identifying possible nutritional problems early in the intervention or referral.
Identify possible nutritional problems of patients / clients who are malnourished for
nutritional intervention.
32
Detect practices that may increase the risk of malnutrition and infection. For example, the
provision of certain drugs as an attempt to medical action can cause the patient to lose
appetite.
To detect possible nutritional problems of clients requiring education and counseling.
Determine the right nutrition care plan.
Role and function
Nutritional assessment acts as a basis in the process of nutritional care that is directing
determination of nutritional diagnosis and the purpose of nutritional intervention and

determine the success of patient outcome. Therefore one of the successes of a nutritional
care process lies in the early stages of this management is complete and accurate.
Nutrition Assessment Relationships with Other Stages
The process of standardized nutritional care is done systematically (sequentially) and not
linear
depending on the presence or absence of new nutritional problems so known as the initial
nutritional assessment and nutritional re-assessment / reassessment (as in the scheme)
below:
Source: Training Module TOT Standard Nutrition Care Process (PAGT) for Nutrition at Health
Service Facilities, Dit. Nutrition Kemenkes RI, WHO, PERSAGI, AsDI. 2014
33
Figure 1.3
Relationship of Assessment, Diagnosis, Intervention and Monitoring of Nutrition Evaluation
Detailed data on nutritional assessment results are related when:
Directing and defining nutritional problems in which the sign / symptom of the nutritional
diagnosis statement comes from nutritional assessment data.
Determine the purpose of nutritional intervention of nutritional problems results assessment

of nutritional assessment data.
Example: the results of assessment of nutritional assessment data and problem

determination is "Less Energy Intake" hence the purpose of nutrition intervention is to
increase energy intake.
14
34
Dietetik Penyakit Infeksi
Table 1.1
5 Nutrition Assessment Data Domains
DOMAIN/
KELOMPOK JENIS DATA
a. Feeding intake and

nutrients
b. Provision of food and
nutrients
c. Treatment & Use of
complement drugs
/alternative
d. Knowledge / belief /
attitude
e. Behavior
History related to f. Availability of food supply
nutrition and g. Activities and functions
Food h. Nutritional values
Height, weight, Body Performance Index (BMI),

Anthropometry indicator / ranking percentil growth pattern,
data history of weight.
Biochemical data, Laboratory data (eg electrolytes, glucose) and tests

medical tests and medical (eg, time of gastric emptying, resting
Procedure metabolic rate).
35
Physical
examination of Physical appearance, loss of muscle and fat,
nutritional focus function swallow, appetite.
Personal history, medical

history / health /
family, treatment,
therapy and
Client history social history.
All of the above data parameters are communicated and documented in a standardized
language called nutritional assessment terminology. In total there are 30 classes and 338
terminology as well as 1 group of comparable standards, with the following description
below:
Table 1.2
Domain, Number of Classes and Terminology of Nutritional Assessment
Domain Klas Terminologi
1. History related to nutrition and food 8 151

2. Anthropometry 1 7
Biochemical data, medical tests and
3. procedures 12 93
4. Physical examination of nutritional focus 1 9
5. Client history 4 35
Domain Klas Terminologi
Comparative Standards 4 43
Total 30 338
36
Sumber : Modul Pelatihan TOT Proses Asuhan Gizi Terstandar (PAGT) bagi Tenaga Gizi di
Fasilitas Pelayanan Kesehatan, Dit. Gizi Kemenkes RI, WHO, PERSAGI, AsDI. 2014
15
37
In the nutritional assessment reference sheets, each terminology of the
nutritional assessment is given information on definitions, indicators,
measurement methods or data sources, possible nutritional diagnoses,
evaluation criteria and examples of nutritional assessments of each terminology.
The description of each picture is as follows:
Definition: describes the specific parameters of each terminology. An example of
the terminology of energy intake is the energy intake of various food and
beverage sources compared with the nutritional recommendations
Indicator
Also referred to as nutritional indicators are nutritional assessment data with
clear boundaries and can be observed or measured. Example: the indicator of
energy intake is calories / day. In this case the calorie / day unit shows an
indicator of the energy intake that can be measured in 1 day. Indicators of
nutritional assessment data contain information on the magnitude or severity of
a sign and symptom of specific nutritional problems when compared to certain
criteria on the nutritional diagnostic sheet called defining characteristic. An
example indicator of a patient's nutritional problem is "Inadequate Energy Feed"
(see nutritional diagnosis page 236 sheet on the bookIDNT). The understanding
is that if a patient is diagnosed with a nutritional problem "Inadequate Energy
Feed" then the energy intake data needs to be collected, assessed and proven
that it shows a low number of needs and is a description of the magnitude of the
nutritional problem.
Measurement Method or Data Source

Shows data sources that can be selected and used to collect nutritional
assessment data according to the patient's condition. Examples of sources and
methods of energy intake data are from food intake records, 24-hour recall, 3 to
5 diary food, food frequency questioner, caretaker intake records, analysis
menu, intake and output records.
Diagnosis of Nutrition
On the reference sheet of the terminology of the nutritional assessment, it is
mentioned that each nutritional assessment indicator is related to several
nutritional diagnoses so as to describe the nutritional assessment data as a sign
38
of the nutritional problem of a nutritional diagnosis. Example: energy intake data
is commonly used to indicate nutritional problems in nutritional diagnosis
inadekuat energy intake, excess energy intake, protein-caloric malnutrition,
protein energy intake intake, underweight, unexpected weight loss, overweight /
obesity, weight gain not expected, difficulty swallowing, difficulty breastfeeding,
changes in gastrointestinal function, limitations following nutritional
recommendations.
Criteria
Criteria of nutritional care is a comparison of indicators of nutritional care so that

it can be assessed the magnitude of nutritional problems. Criteria usually
include:
Nutrition prescription
Nutrition prescription is a recommendation of energy intake, food or individual
nutrients in accordance with the guidelines used as a reference.
16
39
Standard reference
The standards used can be either international or national. For example the reference
standard calculation of energy demand estimates for diabetic patients is to use the
calculation of Diabetes Mellitus consensus.
Examples of nutritional assessment documentation

Explain examples of how documenting nutritional assessments. The examples provided
illustrate only one indicator or many indicators obtained at one time the patient is treated in
inpatient or outpatient care.
Reference
Reference is a reference in conducting the assessment, this reference does not limit a
dietitian in referencing references at the time of nutritional assessment.
For more details can be seen from 1 example description of the terminology below
according to IDNT:
Tabel 1.3
Dokumentasi Asesmen Gizi
Rincian Contoh : Terminologi “Asupan Energi”
The amount of energy from various sources, eg food,

beverages, breast milk / formulas, supplements as well as
via enteral and
a. Definition parenteral route.
b. Indicator asesmen Total energy = calories / day, calories / kg / day

c. Measurement Food intake records, 24-hour recall, 3-5 day food diary,
methods food frecuancy questionnaire, caretaker intake records,
or data source menu analysis, intake & output records.
• Insufficient energy intake
• Malnutrition of protein energy
40
•
• Excessive energy intake
• Underweight
• Overweight / obesity
•
d.
Difficulty swallowing
• Breastfeeding difficulties
Diagnosis of nutrition • Changes in gastrointestinal function
may be related •
Comparing with reference objectives or standards:

1. Purpose (individual needs according to conditions
patient / client) or
2. Reference standard (approximate energy requirement
e. / measurable)
Evaluation criteria
17
41
Rincian Contoh : Terminologi “Asupan Energi”
Based on patient / client food records, patient / client

Sample consumes 2600 calories / day, 144% of recommendations
documentation diet (1800 calories / day). Will be evaluated caloric intake
f. nutritional assessment on my next visit.
g. Reference Charney P, Malone A. ADA Pocket Guide to Nutrition

Assessment, 2nd ed. Chicago, IL: American Dietetic
Assosiation; 2009.
DOMAIN HISTORY CLIENT (CLIENT HISTORY-CH)

In the reference sheet of the Nutrition Assessment of IDNT, this domain is structured as the
last domain. But related to the ease in understanding the nutritional assessment steps then
this domain is explained in advance compared to other domains.
Understanding
Included in the client history are personal history, medical history
patient / family and social history. These reports may indicate nutritional issues early in the
assessment that may be the cause of nutritional problems such as nutritional patient
perceptions that indicate the level of understanding, acceptance or rejection of a
recommended dietary recommendation.
Client history also forms the basis for thinking in collecting data from other nutritional
assessment domains. Example: related to DM client then to know the nutritional problem
42
need to be explored some related data such as intake of amount and type of carbohydrate,
physical activity, medication used, current blood sugar level, client understanding level
related to DM diet and way client self monitor and other etc.
Data Types and Terminology / Standard Language
The table below describes what kind of data is included in the domain
client history along with the indicator and linkage of that data to the cause of nutritional
problems.
Table 1.4
Client / Clent History-CH Domain)
Cause Cause of Nutrition
Data type & Indicator Indicator Problem
Personal data
Tribes of the nation
(sunda, jawa etc.)
Language (Indonesia,
sunda,
jawa etc)
Ability to read (capable,
illiterate)
- Education (SD, SMP etc)
The role of the family
(mother,
children etc)
Client / patient information Smoking history (yes,
such as no)
age, gender, tribe Physical limitations (tuna
nation, occupation, smoking lethargy, speech, etc.) Ability to eat,
habits and limitations - Mobility (in bed, food access, behavior and
physical - at home) patient / client attitude / trust
-
-
43
Macam Penyebab Masalah
Jenis data & indikator Indikator Gizi
Riwayat medis/kesehatan klien :

a. Medical history:
Client / patient
statement
or family, conditions and
disease that affects Peningkata
on nutritional status Keluhan terkait penyakit n kebutuhan gizi,
khusus seperti penyakit: gangguan pencernaan dan
gizi
Cardiovaskular, Endokrin , utilisasi zat , gangguan
metabolism ekskres
Ekskretori , Gastrointestinal, e dan i zat
44
gizi, penurunan berat
Ginekologi, Hematologi, badan
Immune, Integumentary ,
Musculosketa , Neurologi,
Psikologis, Respirasi
b. Treatment / therapy: Disturbing absorption and
Treatment / surgical drug effectiveness or
therapy otherwise
or medical records interrupt enter,
in medical records and digestion and nutrient
impact on status nutrition - Terapi medis (kemoterapi, absorption
dialisis, radioterapi, dsb)
- Tindakan bedah (gastro
bypass, coronary arteri
bypass)
Pelayanan
- paliativ/terminal
Sosial history
Socio-economic
(constrained
- major / minor, accessfull,
limited, not at all)
Situation of the house
(stay
Client / patient information alone, together with the
such as enthusiast,
social economy, home lonely)
situation, Social and medical Able to carry out therapy
support medical services, support nutrition given to
work, engagement (family members, meet the nutritional needs
with social groups caregivers, groups patient / client
45
Macam Penyebab Masalah
Jenis data & indikator Indikator Gizi
community / church etc.)

Geographic location
(urban,
rural) - Employment (IRT,
students, pensions etc)
Religion (catholic, islam)
History of the crisis
(unemployment, death
family members, trauma,
surgery, etc.)
-
-
-
46
When choosing a client history data indicator it is necessary to take into account clinical
conditions including determining measurement techniques and defining reference standards.
An example of social history / cognitive function data is that the patient is confused, the
behavior of ignoring the food served needs to be investigated in depth because the
possibility of such behavior may be the cause of the patient / client's nutritional problems.
NUTRITION-RELATED HISTORY (FH) DOMAIN RELATED HISTORY (FH)
Understanding
Nutrition and food history / history-related databases have an important role in nutritional
assessments in which this group of data can be used to identify nutritional problems related
to intake and environmental behaviors as well as identify factors that affect food intake.
Identification of nutritional problems begins with how to determine the content of food
consumed and then assessed the accuracy of patient / client intake, which is specifically
related to:
Composition and amount of food intake and nutrients.
Example: patient / client intake 2600 calories / day followed by the fact that the food intake
composition comprises 37% of fat it can be determined that the energy intake is largely due
to excessive patient fat intake.
Source of food intake or feeding / diet.
Example: a patient intake of 2600 calories / day followed by the fact that the source of food
intake comes from fried foods, sweet cakes and patients have already run a low calorie diet
of 1500 calories before it can be determined that the current patient / client is not obedient
to his diet
Knowledge and belief in nutritional recommendations, awareness and compliance. Example:

patient intake 2600 calories / day followed by the fact that when the patient is tired then
47
foods such as fried and sweet cake can increase stamina. In this case it can be determined
that the patient's attitude towards the food is less precise.
Feeding behavior.
Example: patient intake of 2600 calories / day followed by the fact that the current patient
no longer do the weighing of food and body weight periodically as suggested then it can be
determined there is a problem of inability to monitor themselves related nutrition therapy.
Treatment and use of complement / alternative medicine.
Example: a patient intake of 2600 calories / day followed by the fact that is not currently in
the use of drugs associated with increased appetite, it can be determined that the intake of
feeding the patient is true only related to intake, behavior and inability to monitor yourself.
Physical activity and sports
Example: patient intake of 2600 calories / day accompanied by the fact that most of the
patient's activity is watching TV, reading books and playing games it can be determined that
the activity of the less patient is likely to be the cause of obese patients.
Availability of food supply
Example: a patient intake of 2600 calories / day followed by the fact that the environment
around the patient's job in the big city is widely available where to sell fast food. In this case
it can be determined that the possible causes of such intake are related to limited access to
healthy food.
"Quality Nutrition of Life (QOL)"
Example: patient / client intake of 2600 calories / day followed by the fact that the patient no
longer cares about his dietary suggestion it can be determined that the patient's intake is
related to the QOL of the low patient.
Data Types & Terminology / Standard Language
48
Various types of data included in the domain / group of nutrition and food history data have
been prepared in International Dietetics Nutrition Terminology (IDNT) as follows:
Food and Nutrient Intake: indicates the type and amount of food and nutrient intake.
Tabel 1.5
Domain Riwayat Terkait Gizi Dan Makanan (Food/Nutrition-Related History - FH)
energyintake (1.1) Total energy
- liquids in drinks / groceries

/ supplements as well as quantities
- Type, number, pattern, quality and variety
Food & beverage intake (1.2) Food
Type and route of delivery (eg flush)

Intake of Enteral & Parenteral enteral
Nutrition - Type and route of delivery (eg: Intra
(1.3) - Veins) parenterally
- volume, size and pattern of alcohol intake

- Type of bioactive substance intake
Intake of Bioactive Substance (1.4) - Total caffeine intake
Macronutrient intake (1.5) Total and type of fat and cholesterol

(saturated, trans etc.)
- Total and protein quality (HBV, casein
etc.)
Total and type of carbohydrates (sugar,
starch
etc.)
49
- Total and fiber types (soluble &
insoluble)
-
Amount of vitamin intake (A, C, etc)
The amount of mineral intake (Ca, Cl, Fe
Micronutrien intake (1.6) etc.)
Source: Training Module TOT Standard Nutritional Care Process (PAGT) for Nutritionists
at Health Services Facility, Dit. Nutrition Kemenkes RI, WHO, PERSAGI, AsDI. 2014
Provision of food and nutrients: shows an overview of food sources and nutrients.
Diet History (2.1) Ordering current diet (normal, modified, enteral,

parenteral)
Previous diet, dietary education / counseling, food allergies,
50
food intolerance, etc.
Neighborhood food: location, ambiance, self-feeding
Access and body position in enteral and parenteral

administration
Behavior
Shows an overview of patient activities and actions that affect achievement of nutrition-
related goals.
Compliance with self-monitoring, visits to diet, therapeutic goals.
Behavior avoid food and its causes.
Behavior of binge and purging eating.
Behavior related to eating: duration, percentage, refuse, throw away, rumination,

limitations, eating process.
Ability to build and use social networking.
Factors affecting food access and related food / nutrient supplies
Suitability and participation with government and community programs.
Availability of shopping facilities, safe food, food preparation and storage, clean water.
Access to food supplies and nutrients, meal aids and food preparation.
Physical activity and functions
51
A description of physical activity, cognitive and physical abilities to perform certain tasks such
as breastfeeding, self-feeding.
Breastfeeding: initiation, duration, exclusive breastfeeding, problems.
Physical abilities in completing self-preparation, self-feeding, placing yourself in the position

of plates, receiving food aid, using dinner aids, asking for food.
Patient / client values related to nutrition. Idem
Patient / client perception of intervention and its impact on life.
Data Collection Method
Qualitative methods include Dietary History and Food Frequencies Questionare (FFQ), both
of which are retrospective information related to diet over a long period of time (almost
unspecified period):
Dietary History.
Food Frequencies Questionare (FFQ).
Quantitative methods include Food Record, Food Recall 24 hours and Weighed Food
Records.
Food Record.
Food Recall 24 hours.
Weighed Food Record.
Success in data collection (quality and data accuracy) above you can learn on the Course
Module Food Consumption Survey.
Evaluation Criteria
52
The evaluation criteria for dietary history are selected according to the type and extent of
the required information, as follows:
The energy and macronutrient intake is estimated using the value of the general portion of
food or using an exchanger of the same type of food. Recommendations of energy intake
and nutrients according to patient condition and type of intake.
Recommended Nutritional Sufficiency (KGA), Common Balanced Nutrition Message (PUGS)

and Food Pyramid: comparison of energy intake and nutrient for patient / client / community
healthy group.
Needs of individual nutrients: comparison in patients with health conditions
special. Example: estimation of individual calorie and macronutrient calculations, DM and

kidney consensus, KGA (micronutrient needs) etc.
The goal of individual therapy: comparison of bioactive substance intake.
Infant and child feeding skills by comparing infant and child skills are generally age-
appropriate such as skill / skill and oral motor skills. For example: the ability to breastfeed
the baby and so on.
Diet compared with age-appropriate diet recommendations. Example: infant diet> 6 months
- 8 months begin to be introduced with other complementary foods such as milk porridge 2
times, biscuit 1 times, juice 2-3 times.
Data Interpretation Method
The accuracy of interpreting the data depends on the knowledge of the dietisien against
the criteria selected and the patient's health condition. Several standard criteria and
descriptions can be used as a consideration in interpreting patient history data related to
nutrition and food:
AKG and PUGS: although it is an important educational and food planning tool, it is not a tool
that can evaluate individual diets but only provides an overview of food in outline.
Food pyramid: the amount of food from each food group in the food pyramid provides an
illustration of the adequacy, variety, balance of food intake, in other words is able to give an
53
idea of the quantity and quality of food.
Diabetic Exchanges (Carbohydrate Counting) exchanger: provides a rough estimate of caloric

intake, protein, carbohydrates and fat in the diet to assess diabetic patients' dietary intake
and see the balance of intake with the use of insulin doses.
Dietary Reference Intakes (DRI) is a standard for assessing the intake of energy, protein,
vitamins and minerals in healthy individuals defined by the National Conditions of certain
diseases have unique nutritional needs assessment. Example: patients with burns require
assessment of vitamin C and zinc intake to ensure wound healing. Meanwhile, due to
medication and medical action performed on the patient, it requires an assessment of
whether the patient has met his nutritional needs that are increased due to changes in
absorption, utilization, excretion or storage of specific nutrients.
DOMAIN ANTROPOMETRY (ANTROPOMETRIC DATA - AD)

Understanding
Anthropometry is a measure of size, weight and proportion body. This data group is used to
determine the sign of an impact of imbalance between intake and nutritional needs
(nutritional problems). The results of this measurement can describe the patient's nutritional
condition when it has been assessed along with other measurement indicators or personal
data of patients such as age, sex and so on. Examples of measurements of body parts related
to nutrition:
Measurements on the body parts of children and infants can show the accuracy of their
growth. Example: BB / TB measurement <-3 SD indicates stunting condition or there is a
problem in child growth.
Healthy individual conditions show a stable body's nutritional reserves, as indicated by the
absence of weight loss.
The condition of sickness or stress indicates a change in the nutrient reserve as indicated by
significant weight loss.
54
Associated with standardized nutrition care processes, antopometric assessment results can
also be used to:
See the effects of a disease / health condition.
Identify the purpose of nutritional intervention. Example: The results of the current body
weight assessment show "unexpected weight changes" hence it can be determined that the
purpose of nutritional intervention is to increase the patient's weight.
Data Types & Terminology / Standard Language
According to IDNT, the anthropometry indicator consists of 1 class of body composition /

body growth / weight history. The class is divided into 7 subclasses as listed below:
Height.
Weight.
Frame Size (frame size).
Changes in weight.
Body mass index (BMI).
Indicator / level of growth pattern.
Estimated body compartment.
Data Collection Method
Selection of anthropometric data collection methods requires consideration of the patient's

condition, such as height measurements made in patients aged 2 years and adult patients.
For elderly measurements of height is often not appropriate when using microtoice because
the condition of the body frame has been bent so it needs another method of knee height
measurement.
55
The selection of methods for data collection and measurement methods to obtain the right
anthropometry data, can be learned in the Course Module on Nutrition Status Assessment.
Evaluation Criteria
Criteria for evaluation of anthropometric data is selected according to patient / client type
for example
age, such as:
Growth pattern: used to compare BB and TB patients / clients with
B & B TB by age in a healthy reference population. Baby growth patterns and
children / growth charts or Healthy Towards Card (KMS).
b. Body Mass Index (BMI): used to assess signs of malnutrition. Good to use
for groups of children, adolescents and adults. In children aged> 5 years of calculation of BMI
compared with BMI standards by age on growth charts.
Changes in weight.
Changes in weight compared to the cut of point of weight changes that indicate the risk of
malnutrition. In general, adult patients are considered nutritional risk if there is unexpected /
planned weight change> 5% within 1 month or> 10% in 6 months.
Usual Body Weight (UBW): used to assess BB adult patients with standard Ideal BB.
Waist circumference: used to predict obesity and risk of chronic disease but not sensitive to
malnutrition.
56
Growth patterns:
Results <5 percentile indicate acute malnutrition or> 95 percentile indicates obesity.
If the assessment results show <3 percentile or> 97 percentile then it is necessary to assess
the assessment of the patient's health condition. Especially in the case of endocrine and
genetic problems in children with diabetes, this growth pattern can not be used.
Body Mass Index (BMI) is associated with nutritional and mortality risks
In children can be interpreted overweight (assessment results 85 ≤ 95 percentil), obesity (≥

95 percentile), underweight (<5 percentil).
In adults, overweight interpretation (BMI ≥25) and underweight (BMI <18).
Usual Body Weight (UBW)
Used to interpret the risks of malnutrition and health complications in the absence of a
planned diet program. Interpretation of nutritional risks if there is an unexpected 5% BB>
change in 1 month and or> 10% in 6 months.
Waist size
The presence of obesity and the risk of chronic disease (DM) can be interpreted from the
data
waist circumference of ≥ 90 cm in men and ≥80 cm women.
Skinfold
This data can be used to simulate energy reserves. However, during the Interpretation, the
data assessment should be thoroughly related to hydration status, fluid changes in the body
and skin elasticity (in the elderly) as it may affect the interpretation of skinfold measurement
results.
57
DOMAIN BIOCHEMICAL DATA, MEDICAL TEST AND PROCEDURE (BIOCHEMICALDATA,
MEDICAL TESTS & PROCEDURES-BD)
Understanding
These are physical characteristics that show a picture of the impact of nutritional problems
and become signs or symptoms of malnutrition or certain nutritional deficiencies. This data is
generally obtained from the results of examination of doctors or nurses such as disturbances
of the digestive tract or respiratory, blood pressure, body temperature etc. are recorded in
the medical record.
Data Types & Terminology
There is only 1 class that is the result of physical examination focus of nutrition include:
Overall appearance (such as body position, amputation, communication ability).
Body language (cultural specific variations).
The heart-lung system (such as edema).
Extremities, muscles and bones (such as perifir edema, subcutaneous fat, weakness, cold
feeling etc).
Digestive system (mouth to rectum) (sependa, dry mucus membrane, stomach heat etc).
27
58
Head and eyes (like bitot spot, blind etc).
Nerves and cognitive / cognition (such as confusion, difficult cocentration, nerve changes,
etc.)
Skin (such as dermatitis, dry, janudice, etc.).
Vital signs (such as blood pressure, respiration rate, pulse, temperature).
Indicators of this data group are "exist" and "none" except vital signs with indicators:
a. Blood pressure: mmHg

b. Nadi: times / minutes
c. Respiration: times / minutes
d. Temperature: degree
Data on physical examination results may indicate signs of possible nutritional problems
such as excess or lack of sodium, vitamin / mineral intake, fluid, parenteral / enteral
nutrition, overweight / obesity, underweight, unexpected weight loss. Example: edema may
indicate an excess sodium intake in a patient / client condition with renal impairment.
Method of collecting data
Method of examination: direct observation, patient report, medical record.
Evaluation Criteria
How to assess the results of the examination compared to:
Purpose (according to patient / client needs)
Example: patient / client blood pressure drops according to goal (135/85 mmHg) with
decrease in BB.
59
Reference standard
Example: patient / client blood pressure 150/90 mmHg above expected limit (<120 /
80mmHg) and consistent with stage 1 hypertension.
At the time of examining this clinical physical examination data always consider the cause
other / non nutrition. Usually the signs and symptoms of a nutritional deficiency state occur
after a poor dietary intake or in other words can be seen after severe deficiency, therefore it
should be related to the assessment of the history of eating / diet and medical conditions.
One indicator of physical examination results usually indicates two or more of the nutrient
deficiencies.
Example:
Hair: easily revoked, thin showing protein or biotin deficiency.
Mouth: cracked tongue indicates niacin deficiency and decreased taste / smell (zinc
deficiency)
Overall possible nutritional problems in the physical examination data group of nutritional
focus are:
Excess or lack of sodium intake, vitamins / minerals, fluids, parenteral / enteral nutrition.
Overweight / obesity.
Underweight.
Unexpected BB decline.
60
COMPARATIVE STANDARDS
Understanding
It is a national or international benchmarking standard or by consensus used to assess the

parameters of the indicators used in the nutrition assessment step and to define the goals of
nutritional intervention.
Type and Terminology
According to INDT, the types and terminology of comparative standards are as follows:
Energy requirements
It is the estimated total amount of energy needed for nutritional adequacy. The goal is to
identify the reference standard of the patient's nutritional needs used as a basis in assessing
the adequacy or surplus of the patient's energy intake. Commonly used indicators:
Recommended Nutrition Adequacy Rate (AKG).
Methods of estimation of needs, eg estimation (method of calculation and activity factor,

stress, pregnancy, breastfeeding, and or the presence of heat) or special measurements.
Needs of macro nutrients
It is the estimated amount of macro nutrients needed for nutritional adequacy and avoid
toxicity (vitamins and minerals). The goal is to identify the reference standard of the
patient's nutritional needs used as a basis in assessing the adequacy or surplus of the
patient's energy intake.
Indicators according to macro nutrients:
Estimated fat requirement:
Estimated total fat requirement, eg DRI (g / day, g / kg / day, calorie%).
61
Type of fat required, eg n-6 polyunsaturated fatty acid (g / day, g / kg / day, calorie%).
The method of estimating the need, eg AKG, specific reference standard according to
disease condition.
Estimated protein requirement:
Estimated total protein requirement, eg DRI except special condition (g / day, g / kg / day,%
calories).
Type of protein needed (g / day, g / kg / day,% calories).
Vitamin A (μg / day), vitamin C (mg / day), vitamin D (μg / day), vitamin E (mg / day), vitamin
K (μg / day) were obtained. .
Method estimates the need: DRI and assessment as needed.
Estimated mineral requirements: Calcium, chloride, iron, magnesium, potassium,

phosphorus:
Estimated mineral requirement: used AKG except special conditions
(Ca: mg / day, Cl g / day, etc.).
Methods of estimating the need: used AKG and assessment as needed.
Recommended body weight / body mass index / growth
Ideal weight / reference:
Method: determination of ideal BB / expected (eg calculation of Hamwi, growth chart), BBI
assessment (amputation condition, cord injury), BBI%, overweight / obesity BB / BB
calculation).
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Body Mass Index
Method: BMI (kg / m2) using normal range according to Asia, WHO and so on.
Growth
The expected growth patterns correspond to individual health, growth patterns and genetic
potential. Eg age 0-36 months (BB / percentile age / rank, PB / age percentile / rank, BB / PB,
percentile / rank) and so forth.
NUTRITIONAL ASSESSMENT COMPONENTS
The steps in performing the nutritional assessment consist of 3 components namely the
review
data, data clusters and data identification. The description of each component is as follows:
Review Data (collect and select data / information)
The purpose of nutritional assessment is to identify and provide evidence of nutritional

problems or nutritional diagnosis, the data collected focus on nutritional status and factors
that affect nutritional status. The types of data collected should be selected and relevant to:
Diagnosis of nutrition, causes and signs / symptoms
Example: the type of data selected in the malnutrition "nutritional diagnosis associated with
a lack of long-term energy intake marked with less intake of need, BMI <18 kg / m2, loss of
muscle mass and subcutaneous fat is the daily energy intake, energy requirement, body
weight , height, muscle mass assessment and subcutaneous fat.
Situations and conditions in which data are collected
Example: hemoglobin may be selected as a nutritional indicator showing changes in energy

and protein intake in ordinary care setting settings but not intensive care (Hb may be altered
by severe illness).
Current health conditions of patients / clients and groups
63
Example: body weight may describe the actual weight condition at present, but may not be
because of the patient's edema condition. Therefore weight is not the right data collected in
patients with edema.
The accuracy of the resulting data is influenced by
Selection Method
Depending on the type of data and type of nutritional care provided (individual or group).
Examples of various methods of collecting data on individual services and the types of data
collected as follow
Tabel 1.6
Metode
Metode Contoh Jenis data
The client's perception of health condition, food intake,

lifestyle, use of drugs / supplements, sserta
family history of disease.
Example:
a. Mother reported food intake during the last 24 hours.
Interview or b. Patients reported current drug use.
direct observation c. Patient states that she avoids sugar and
to the patient / client sweet foods according to the DM diet.
Measurement Weight, height

Record notes
medical & referral
service provider
other health Laboratory results related to nutrition
64
Interview, observation and measurement skills
The success of an interview is strongly influenced by the environment, the relationship

between patient and dietisien, the type of questions asked and the way of asking. Results
a measurement of body composition is influenced by the ability to choose the right method.
Some information related to gastrointestinal function may also be evaluated from interview
results such as chewing ability, dental use, swallowing ability, nausea, vomiting, constipation,
diarrhea, bloating or other symptoms that interfere with the ability to maintain adequate
food intake. The presence of odema, ascites, is pale as an anemic sign also needs to be
properly supported in the patient's observation skill.
Cluster Data (Grouping data by nutritional assessment category)
Each nutritional problem has a number of characteristics of signs and symptoms called
"defining characteristics". Therefore, once data has been collected, the data needs to be
grouped and compared with the defining characteristics of possible nutritional diagnoses
that are unthinkable. One data element can point to the facts of some nutritional problems
but at the same time grouping data can help identify nutritional problems appropriately.
Some dieters often unconsciously / automatically have determined the grouping. For
example, in evaluating laboratory data and feeding intake will vary according to age and
medical condition of the patient. That is the intake of 1-2 pieces of fruit (eg bananas or
oranges) in children aged 9 years with dialysis conditions will be interpreted differently from
the same intake in healthy 22-year-old students. The patient's first data will be clustered on
terminology of a nutritional assessment different from the second patient data terminology.
Example "Intake of 1-2 pieces of fruit / day in a patient patient aged 9 years with" dialysis
"condition, placed on:
Terminology of feeding intake: which describes how the intake in quantity, type, pattern
and / or quality / quality.
65
Terminology of beliefs and attitudes: which illustrates why patients have beliefs and
attitudes toward food and nutrients.
Food favorite terminology that explains why patients eat bananas and oranges.
It is strongly recommended to maintain consistency in data groupings, in which a dietitian

should place a piece of information / data in accordance with the nutritional assessment
terminology.
Identification
Where possible, the identification of nutritional problems is done by comparing data

obtained with national / institutional standards / regulations. An important consideration in
selecting and interpreting data to avoid errors in the determination of nutritional problems is
to identify reference standards or objectives, which are at least based on:
Type of nutrition and health services: eg inpatients or outpatient, or long term care.
Patient age: eg pediatrics, geriatrics.
Conditions of disease / injury and the level of gravity: eg kidney disease, diabetes, critical
illness.
Example: HbA1c is a valid measurement of glucose status within a period of 60-90 days.
Therefore, this nutritional indicator is appropriate to assess the nutritional status of patients
when admitted to hospital, but not the relevant data if the patient is treated with acute
conditions an increase in blood sugar levels.
Specific data on nutrient-specific intake, comparative standards in appendix terminology of

nutritional assessment can be used as guidelines for accurate documentation of nutritional
recommendations in patients and as a comparison of estimating the intake of one or more
nutrients.
Each situation will differ depending on the background of the type of health service, the type
and degree of disease other than the service policy, service standard, and quality
66
management objectives. Identification of incorrect nutritional assessment data or
misinterpretation will result in an incorrect malnutrition diagnosis.
How to Document the Nutritional Assessment
How to document nutrition care activities is given in the example below
this.
Proses Asuhan
Tanggal Catatan
Gizi Terstandar
15/7/2013
Based on 3 days of food records, consumption
fat 120 gr / day. Food from its restaurant
Nutritional often consumed is a high type of food
Early visit assessment fat. IMT patient / client = 29
Exercise
To deepen your understanding of the above practicum material, do the following exercise!
Understanding nutritional assessment.
The purpose of nutritional assessment in Standardized Nutrition Process.
Nutrition assessment relationship with next steps (nutrition diagnosis, nutritional

intervention and monitoring and evaluation) in Standardized Nutrition Process.
What are the nutritional assessment domains.
What are the steps in doing nutrition assessment.
Instructions for exercises
67
Understanding nutritional assessment.
The purpose of nutrition assessment.
Standardized Nutrition Process Care Picture and explanation.
Nutritional assessment domain.
Nutritional assessment component.
Summary
The nutritional assessment is the first step in the process of standardized nutritional care
(PAGT) and greatly determines the precision in the next nutritional step of nutrition
diagnosis, nutrition intervention and monitoring the evaluation of the results of nutritional
care in patients. In carrying out nutritional assessments, standard language / terminology of
nutritional assessment is used to facilitate the dietisien in collecting data that may lead to
the patient's nutritional problems.
Assessment domains consist of: nutrition and food related history, anthropometry,
biochemical data, medical tests and procedures, physical examination of nutritional focus,
client history and benchmark standards. Domains / groups of historical data related to
nutrition and food have an important role in nutritional assessment where this group of data
can be used for identify nutritional issues related to intake and environmental behaviors and
identify factors that affect food intake.
Anthropometric domains have an important role to identify nutritional problems related to

intake and this data is used to determine the sign of an imbalance between nutritional intake
and nutritional needs. The results of this measurement can describe the patient's nutritional
condition when it has been assessed along with other measurement indicators such as age,
sex.
68
Biochemical domains, medical tests and procedures, show a picture of the impact of
nutritional problems, and become signs or symptoms of malnutrition or certain nutritional
deficiencies. This data is generally obtained from the results of examination of doctors or
nurses such as disturbances of the digestive tract or respiratory, blood pressure, body
temperature etc. are recorded in the medical record. Components in performing nutritional
assessments are data reviews, data clusters and data identification.
Test 2
Personal data that can be used to identify behavior problems is ....
Demographic data
Prohibition of eating
Smoking habit
Socioeconomic level
Family environment
Clinical physical data on nutritional assessment is very important to determine the

nutritional intervention is ....
Color of urine
Patient complaints
Swallowing disorders
Signs of disease symptoms
Changes in weight
Eat food data can be identified any nutritional problems if ....
69
Describing habits
The diet is not balanced
As needed
There are food taboos
Supported by biochemical data
Biochemical data related to nutrition that describes the condition of patient malnutrition
is ....
Blood pressure
Haemoglobin
Urinary creatinine
Blood sugar
Albumin
Food intake data that describes environmental nutritional problems and the patient's
behavior is ....
Never consume fish
More often fried dishes
Consumption of vegetables 3-4 times a day
Drink 8-10 glasses of water per day
70
The staple food of noodles and rice
36
71
Topic 3
On the Nutrition Diagnostics topic, you'll learn the 2nd step of the Standard Nutrition Care
Process as a follow up step from the Nutrition Assessment you've learned on the previous
topic. Once you have finished studying this topic, you are expected to be able to explain
again about the definition of nutrition diagnosis, objectives, linkages to nutritional
assessment / assessment, nutrition diagnosis and thermonical statements of nutritional
diagnosis.
THE CONCEPT OF NUTRITION DIAGNOSIS
Understanding of nutrition diagnosis
Nutritional diagnosis is defined as "identifying and naming specific nutritional problems in

which the dietitian profession is responsible for dealing independently". Identification is to
find nutritional problems in individuals or groups, where each nutritional problem will be
given the name according to the label or code. Poblem nutrition is an actual nutritional
problem that occurs in individuals and / or circumstances that are at risk of causing
nutritional problems. The purpose of dealing independently is that a dietitian has the
authority to establish nutritional problems, determine the cause and prove his symptoms
and signs.
Diagnosis of nutrition differs from the medical diagnosis, both of its nature and its way of
writing. Diagnosis of nutrition is a description of the state of nutritional problems or risks /
potential nutritional problems that occur at this time, and may change according to the
patient's response, especially to nutritional interventions obtained. While medical diagnoses
more describe the condition of the disease or pathology of a particular organ or system of
the body and does not change along the pathological or disease conditions are still present.
Example: nutritional diagnosis problem: NI 5.8.4 Inconsistent carbohydrate intake medical
diagnosis: diabetes mellitus type 2.
The purpose of nutritional diagnosis
72
Diagnosis of nutrition is intended to explain and describe specific nutritional problems found
in individuals, causal factors or etiology, as well as evidenced by the presence of symptoms /
signs that occur in individuals.
The linkage of nutritional diagnosis with nutritional assessment
Diagnosis of nutrition is a summary of nutritional problems, where all data is
collected on nutritional assessment processed and identified into information. This

information will be the input on the process of establishing nutritional dignosis. Based on
this, the role of nutrition assessment is very important in determining nutrition diagnosis.
The completeness of the data and the accuracy of identification look very much related to
the precise determination of nutritional diagnosis.

For a precisely defined nutritional diagnosis, then:
First: nutritional assessment data should be fully available to support the establishment of a
nutritional diagnosis.
Second: nutritional assessment should be specific in order to show improvement.
The three nutritional assessments can be sign and symptom to indicate a defined problem
and aetiology.
To facilitate the understanding of the linkage of nutritional diagnosis can be seen in the
picture below.
Pengkajian Diagnosis Intervensi Monitoring

Gizi
Gizi Gizi Evaluasi Gizi
73
1. FH
PROBLEM
2. BD
(What?)
3. AD
4. PD
Etiologi
5. CH
(Why)
6. CS
SINGS/
SYMPTOMS
(How do I know?)
P berkaitan dengan E ditandai dengan S
Source: Training Module TOT Standard Nutritional Care Process (PAGT) for
Nutritionists
Figure 1.4.
74
the linkage of Nutrition Assessment to Diagnosis of Nutrition
Statement of nutritional diagnosis
The statement of nutrition diagnosis is a series of related sentences between the

Problem component with Etiology and Etiology with Sign / Symptom. The Problem
Statement with Etiology is related to the word "pertaining", while the etiology component
with sign / symptom is associated with the word "marked with". The full statement of the
nutritional diagnosis is written with the following sentence pattern arrangement:
Komponen diagnosis gizi terdiri dari Problem (P), Etiology (E) dan Signs & Sypmtoms (S)
dan disingkat menjadi P-E-S
Problem (P)
Describe whether the patient / client nutritional problems where dietisienen are responsible
for solving independently. Based on the problem can be made:
The goals and targets of nutritional interventions are more realistic, and measurable
Setting priorities for nutritional intervention
Monitor and evaluate changes that occur after nutrition intervention.
Etiology (E)
Indicates the cause or factors contributing to the problem (P). Can also be ascertained why
there are nutritional problems. Causes can be related to pathophysiology, psychosocial,
environmental, behavioral, eating habits and so on. Given the many factors associated with
nutritional problems, the etiological determination must be done carefully, and if the
problem complex can be done in a team. Thus the identified causal factor is really a major
contributing factor. This etiology is the basis of determining what interventions will be done.
Signs and Symptoms (S)
75
It is a statement that describes the magnitude or gravity of the patient / client condition.
Signs are generally objective data, while symptoms or symptoms are subjective data. Data
signs and symptoms are taken from previous nutritional assessment, and to find out how the
problem occurred. The specified signs and simptoms are the basis for monitoring and
evaluation.
A good nutrition diagnosis statement if it meets the following requirements:
Simple, clear and concise.
Specific to patient / client or specific group.
Relates to one patient / client or group problem related to nutrition.
Accurate with regard to the cause (etiology).
Based on accurate and reliable nutritional assessment data.
Example of nutritional diagnosis:
Excess intake of energy (P) associated with high-fat dietary consumption of large portions (E)
is characterized by an energy intake of more than 1000 kcal from the recommended and 6 kg
weight gain in the last 18 months (S).
The critical thing in nutritional diagnosis is choosing and establishing a specific diagnosis, and
establishing the appropriate nutrition diagnostic statement. Therefore, once the statement is
determined, a dietitian can know the accuracy of the nutritional diagnosis statement by
evaluating with the following questions:
Q - Can dietisans improve or solve? (either in individuals or groups).
E- Is the established etiology really the root of the problem? (can be overcome by dietisien
or based on sign & symptom).
39
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S- Can sign and symptom measure that specific problem can be fixed?
CATEGORY TERMINOLOGY DIAGNOSIS NUTRITION
Academy of nutrition and dietetetics categorizes nutritional problems into 4 categories
called domains, namely the intake domain (NI), clinical domain (NC) and behavioral -
environment (NB) domains. Then developed the fourth domaniant that there is no diagnosis
of nutrition (NO). Each domain describes a unique character of the problems that contribute
to health with a specific terminology and is divided according to its class.
Domain Intake (Intake)
This domain is a major nutritional problem (P) that is associated with an inability
energy intake, peroral food, nutrients (protein, fat, carbohydrates, vitamins and minerals)
and fluid intake both enteral and parenteral. In addition, the intake of bioactive substances
such as supplements, functional foods and alcohol. Domain intake consists of 10 classes and
several sub classes with the following understanding.
Tabel 1.7
Kelas domain asupan (intake)
No. Kelas Kode
1 Energy intake NI-1. (5 sub class)

2 Oral intake / nutrition suport NI- 2. (5 sub class)
3 Liquid intake NI- 3. (2 sub class )
4 Intake of bioactive substance NI- 4. (3 sub class)
5 Intake of nutrients NI- 5. (5 sub class)
6 Fat intake and cholesterol NI- 5. 6. (3 sub class)
7 Fat intake and cholesterol NI- 5.7. (3 sub class)
8 Intake of KH and fiber NI- 5.7. (3 sub class)
9 Vitamin intake NI- 5. 9. (2 sub class)
10 Mineral intake NI- 5. 9. (2 sub class)
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11 Multi nutrient intake NI- 5.11 (2 sub class)
Example Diagnosis Nutrition Domain Intake / Intake (NI)
Energy balance
NI-1.4. Inadequate energy intake (P) is associated with nausea and vomiting (uremia
syndrome) characterized by an energy intake of 40% requirement (S).

Food intake through oral
NI-2.1 Inadekuat oral intake (P) associated with a lack of knowledge (E) marked only want to
spend ½ meal of food served
(S).
Fluid intake
NI-3.2 Excess fluid intake (P) is associated with reduced urinary excretion through the kidney
(E), characterized by udeme and 2 kg weight gain in 3 days (S).
Substance bioactive
NI-4.3 Excess alcohol (P) associated with alcohol addiction (E) is characterized by an intake of
12 oz per day (S).
Nutrition
NI-5.3 Lack of protein energy (P) associated with limited access to food (E) is characterized by
60% protein intake and 45% protein, IMT 16.5 kg / m2 and albumin 4.5 g / dl (S).
78
Clinical Domains
This domain is the main nutritional problem (P) associated with the incompatibility of energy
intake, food peroral, nutrients (protein, fat, carbohydrates, vitamins and minerals) as well as
fluid intake both enteral and parenteral. In addition, the intake of bioactive substances such
as supplements, functional foods and alcohol. Domain intake consists of 10 classes and
several sub classes with the following understanding.
Tabel 1.8
Kelas Domain Klinis
Kelas Sub kelas
Difficulty swallowing NC-1.1

Difficulty chewing / biting NC-1.2
Difficulty feeding NC-1.3
Fungsional (NC -1.) Gastro Intestinal dysfunction NC-1.4
The nutrient utilization is disturbed by NC-2.1

Changes in laboratory values related to nutrition
NC-2.2
Biokimia (NC 2) The interaction of food and medicine NC-2.3
planned / expected NC-3.

•


• 
Weight (NC- 3) planned / expected NC-3.4
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Sumber: Modul Pelatihan TOT Proses Asuhan Gizi Terstandar (PAGT) bagi Tenaga Gizi
di Fasilitas Pelayanan Kesehatan, Dit. Gizi Kemenkes RI, WHO, PERSAGI, AsDI.
2014
Example of Clinical Nutrition Diagnosis (NC)
Functional
NC-1.1 Swallowing disorders (P) associated with residual stroke symptoms (E) are
characterized by frequent chokes during meals (S).
Biochemistry
NC-2.2 Changes in the nutritional value of lab (P) related to changes in endocrine function (E)
are characterized by blood sugar levels at 250 g / dl (S).
Weight
NC-3.3 Overweight (P) associated with excessive energy intake (E) is characterized by a BMI
of 28 kg / m2.
Domain Behavior - Environment (NB)
Environmental conditions such as knowledge, behavior, culture, food availability at
household and others can affect nutrient intake. Includes issues related to knowledge and
trust; physical activity; food security and food access. Domain behavior - environment has 3
classes, as follows.
Tabel 1.9
Kelas Domain Perilaku – Lingkungan
Kelas Sub kelas
Knowledge and trust (NB.1) 7 (sub kelas)

Physical activity and function (NB 2) 6 (sub kelas)
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Food safety and access (NB 3) 2 (sub kelas)
Sumber: Modul Pelatihan TOT Proses Asuhan Gizi Terstandar (PAGT) bagi
Tenaga Gizi di Fasilitas Pelayanan Kesehatan, Dit. Gizi Kemenkes RI, WHO,
PERSAGI, AsDI. 2014
Examples of Diagnosis of Nutrition Domain Behavior - Environment (NB)
Knowledge and trust
a. NB-1.5 Dietary disorders (P) are associated with poor maternal knowledge
marked infants get solid food starting at age 2 months (S).
NB-1.3 Inactivity of diet or dietary changes (P) associated with lack of motivation (E) is
characterized by an attitude of rejection of nutritional information
Domain Lain : (NO)
International Dietetics & Nutrition Terminology (IDNT) Reference Manual
mengembangkan domain saat ini tidak ada diagnosis gizi. Domain ini didefinisikan sebagai
tidak munculnya masalah gizi terkini karena adanya intervensi gizi, hasil dari pengkajian gizi
(NO-1.1)
Terminology of Diagnosis of Nutrition

Each nutritional diagnosis has been identified by observers with a unique terminology using
a 5 digit number, as well as code. Encoding is intended to facilitate electronic documentation
and recording. The Academy of Nutrition and Dietetic has compiled the manual as a
reference for terminology, to be used as a standard language in nutritional care in the
territory of the country. In Indonesia, the current terminology of nutritional diagnosis using
the 4th edition of IDNT. Each domain other than codes and numbers is also given a standard
limit. The use of these standards can help nutritionists use language consistent in their
profession. Example:
NI-1.4. Inadequate energy intake is defined as "less energy intake than the expenditure
energy or reference standard or recommendation determined by physiological needs".
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In IDNT 4th Edition has identified the possible etiology for each problem, as well as the sign /
symptom relating to the nutritional problem. In NI-1.4 there are 5 (five) possible causes
(aetiology), as well as potential indicator of potential sign / symptom.
STEP DETERMINATION OF NUTRITION DIAGNOSIS
In formulating a nutritional diagnosis, dieters use their critical thinking skills to find patterns
and relationships between data and possible causes of nutritional problems, through the
following steps.
Group and analyze assessment data to establish nutritional diagnosis.
Choosing a nutritional diagnosis.
Identify incomplete data to establish a more definitive diagnosis.
Use the signs and symptoms of the problem.
Identify priority nutrition diagnoses.
Identify the root of the problem as the basis of nutritional intervention.
Identify signs - symptoms can be corrected, minimized, or monitored / measured.
Integration of nutritional assessment data
Perform integration and analysis of assessment data and determine nutrition care indicators.
Food intake and nutrients that do not fit the needs will result in changes in the body. This is
demonstrated by laboratory changes, anthropometry and the clinical condition of the body.
Therefore, in analyzing important nutritional assessment data combining all information
from the history of nutrition, laboratory, anthropometry, clinical status and patient history
together. It should be understood that nutritional diagnosis can not be inferred from just
one paramete
82
Figure 1.5
Integrate data on nutritional assessment outcomes
Using the example case described in the nutritional assessment, we can integrate the
assessment data as listed in the chart below:
Search Possible Problem (P)
Determine the domains and problems / nutritional problems based on indicators of

nutritional care (signs
and symptoms). Nutritional problems are expressed with standardized nutritional

diagnosis terminology. It should be remembered that what is identified as a nutritional
diagnosis is a problem that handles nutritional therapy / intervention. Diagnosis of
nutrition is a specific nutritional problem which is the responsibility of dietisien to handle
it. Naming problems can refer to the terminology of nutritional diagnosis in the attachment
of nutritional diagnosis and terminology of nutritional diagnosis.
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Nutrition Problems (Problems) should be well traced to each category or 3 domains of
nutritional problems. The imagee s
Figure 1.6
84
Nutrition Based Diagnostic Search
Searching for nutritional problems for the intake domain, means extracting data on how
much energy, macro-micro nutrients, liquids consumed either orally, enteral or
parenterally, as well as the bioactive substances consumed, even those that cause
increased or decreased needs nutrients. In the clinical domain it is important to know
whether organs are affected by the disease, which affects the metabolic processes of
nutrients and causes certain nutritional problems. Tracking the nutrition issue of an
environment-behavioral domain is done through data mining that contributes to the
problem of unbalanced nutrition / food intake, such as knowledge of nutrition and food,
insecurity, food / food availability or physical activity.45
85
Tabel 1.10
Search for Possible Diagnosis of Nutrition
Sign and Simptoms Possibility

Diagnosis
Biokimia data Hb, Ht low
Less Nutrition Status (underweight)
IMT <18.5
Antropometri data BB decrease> 5% in 1 month
- Anorexia, nausea, vomiting

- Appetite decreased
Physic data - Loss of muscle mass
Since 1 month ago:

- E intake = 62% Inadekuat oral
- P intake = 40% intake
- Intake L = 66% Malnutrition
- KH intake = 65% Lack of
Food receive data is limited only knowledge
½p related
Dietery History Drugs cause nausea - nutrition
-
-
Conditions related to TB
Clien History (Catabolic disease)
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Source: Training Module TOT Standard Nutrition Care Process (PAGT) for
Nutrition at Health Service Facilities, Dit. Nutrition Kemenkes RI, WHO, PERSAGI,
AsDI. 2014
Category Etiology
On defining nutritional problems (P) is essential to understand, how to identify the

etiology or causes, as well as contributing risk factors. To establish a etiology or cause,
a nutritionist needs to think critically by asking why the nutritional problem (Problem)
occurs. The NCP committee imposes limits on two categories of etiology, so the diets
need to understand more deeply the concept of etiology. Identifying aetiology, has an
important role in determining nutritional intervention, because to address the root of
the problem. If the intervention can not address the root of the problem, then
intervention is aimed at minimizing the sign / symptom. Etiology is categorized by the
types of causes and contributing risk factors. IDNT 4th edition explains the definition of
the category in question. The following list is the etiology category:
Attitude - Trust
Culture
Knowledge
Physical function
Physiologically metabolic
Psychological
Social - personal
Care
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Access
Behavior
DETERMINATION OF NUTRITION DIAGNOSIS
Integrate the results of nutritional assessment into the possibility to look for the sign /
symptom (details that describe the fact or definining caracteristic that prove the problem
occurs).
Identify Problem (P) and determine why (why-why-why) to get the root of the problem
(etiology), then identify how to know or Sign / Symptom that proves the problem.
The results of determining the possibility of nutritional diagnosis as well as priority nutrition
diagnosis are as follows:
Problem Etiology Sign/symptom
- IMT 17.18
- BB decrease 8.3%
in 1 bln
- Losing sub fat
cutaneous
- E intake 62% keb, P
40% keb
Less eating intake Not everyday
in relatively time consumption of animal
long and there side dishes
increased nutritional needs and less like fruit
NI-5.2 Malnutrition** due to his illness and vegetables.
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Lack of
NB-1.1 Lack of *** education / information
nutrition-related knowledge related to nutrition
Exercise
Please answer with a clear and clear question the following questions:
What is the difference between a medical diagnosis and a nutritional diagnosis?
How can a nutrition diagnosis be properly determined?
Give an example of nutritional diagnosis and explain!
Explain how many domains diagnosis nutrition!
How to establish nutritional dignosis steps?
The purpose and relevance of nutritional diagnosis with nutritional assessment.
Writing nutrition diagnosis.
Requirements to establish a proper nutrition diagnosis.
Domain Diagnosis Nutrition.
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Steps to establish a nutritional diagnosis.
Summary
A nutritional diagnosis is defined as giving the name of a specific nutritional problem in

which the dietitian profession is responsible for self-handling, a dietitian has the authority to
establish nutritional problems, determine the cause and prove the symptoms and signs. Any
nutritional / nutritional problems will be given the name according to the label or code.
Poblem nutrition is an actual nutritional problem that occurs in individuals and / or
circumstances that are at risk of causing nutritional problems.
Determination of the diagnosis by statement with a series of P-E-S sentences where P =

Problem, describes the nutritional problems of patients where dietisienen are responsible
for solving independently. Based on the problem can be made: realistic and measurable
goals and targets of nutritional interventions and priorities of nutritional interventions to be
administered to the patient and can be monitored or evaluated for changes that occur after
intervention.
E = etiology Etiology, indicates the cause or factors that contribute to the occurrence of the
problem (P). Can also be ascertained why there are nutritional problems. Causes can be
related to pathophysiology, psychosocial, environmental, behavioral, eating habits and so
on. Many factors are related to nutritional problems, then this etiological determination
must be done carefully, and if the problem complex can be done by team. Thus the identified
causal factor is really a major contributing factor. This etiology is the basis of determining
what interventions will be done.
S = sygns / symptoms is a statement that describes the magnitude or gravity of the patient's
condition. Signs are generally objective data, while symptoms or symptoms are subjective
data. Data signs and symptoms are taken from previous nutritional assessment, and to find
out how the problem occurred. The specified signs and simptoms are the basis for
monitoring and evaluation.
The domain of nutritional diagnosis consists of an intake domain consisting of 11 classes,

clinical domain (3 classes), behavioral domain (3 classes) and other domains (NO). To
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establish a proper nutritional diagnosis the steps are to integrate the data of the nutritional
assessment outcomes, investigate the likelihood of the diagnosis domain, the next step is
how identify the etiology or causes, as well as the risk factors that contribute to the
nutritional problem.
Test 3
Writing nutritional problems in the correct nutrition diagnosis sentence should consider ....
Its dynamic
The magnitude of the problem
Can be overcome dietisien
Not a medical diagnosis
There is a terminology domain
The writing of etiology on the sentence of nutrition diagnosis must be correct because it
describes the ....
Interventions to be given
Indicators to monitor
Accuracy of nutrition assessment
The magnitude of nutritional problems
The cause of the problem
Sygns and symptoms in nutritional diagnosis sentences describe ....
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Big problem
Accuracy of nutrition assessment
Qualitative results of the study
Results of measurement data assessment
Domain monitoring and evaluation
4) One possible etiology problem of lack of knowledge related to nutrition

is a ....
Obesity
Malnutrition
Less vegetables and fruit
High blood glucose value
Weight gain
The existence of nutritional problems due to impaired Gastro Intestinal function can be
proven with data ....
Laboratory value
Feeding intake
Clinical data
Physical data
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Behavior
49
50
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Topic 4
Nutritional Interventions and Evaluation Monitoring
On this topic, you will learn Nutritional Interventions and Evaluation Monitoring is the next
step after you have established the exact nutritional diagnosis discussed on the 3rd topic. This
topic will learn about nutrition intervention and evaluation monitoring. After studying this
topic you will be able to explain the nutritional interventions that include, understanding and
objectives, the relationship of intervention with nutrition diagnosis, nutrition intervention
component, domain grouping and terminology of nutrition intervention and evaluation
monitoring including monitoring concept, outcome monitoring and evaluation category,
monitoring compo and evaluation and means of monitoring and evaluation documentation.
NUTRITION INTERVENTION
Understanding, Purpose and Function
Nutritional intervention is the third step of standardized nutritional care. Nutritional

intervention
is a planned action aimed at improving nutrition and health status, changing nutritional
behavior and environmental conditions that affect the patient's nutritional problems.
The purpose of nutritional intervention is to address the nutritional problems identified in the
nutritional diagnosis in the form of planning and implementation relating to individual /
patient / client health status, environmental behavior and conditions to meet
his nutritional needs. While the function of nutritional intervention is to standardize services
nutritional care in accordance with specific patient nutrition problems with individual
approach.
Intervention relationship with nutritional diagnosis
The relationship between nutritional diagnosis and diagnosis is illustrated in the scheme
below:
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The picture above shows that nutritional intervention in principle is to overcome / eliminate
etiology as exemplified below: Example:
DIAGNOSIS GIZI INTERVENSI
Reduce carbohydrate intake 10%

P Excess carbohydrate intake from the results of the study of intake
Nutrition education about the number,

Lack of knowledge about type and
the appropriate carbohydrate time to eat food sources
E intake carbohydrate
Hyperglycemia (gdp 200 mg / dl)

S and HBA1C (8.2%)
The figure below is also a link between nutritional diagnosis and nutritional
intervention illustrating that the etiology can not be corrected by nutritional intervention so
nutritional intervention is done to overcome etiology so that signs and symptoms can be
improved.
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The conditions described above can be seen in the following example:
DIAGNOSIS GIZI INTERVENSI
Post stroke complications
Modified form, frequency,

Swallow test result, complaint / report meal schedule and moment help
S choking at meals eat
The above examples with post complication etiology (after) stroke can not be corrected /
corrected with nutritional intervention. Under these conditions nutritional interventions help
to improve sign and symptom by providing a form of food that fits the patient's condition
(modified), helps to adjust the schedule and frequency of eating, so that patients can
consume their food and not choke while eating and can meet nutritional needs.
Component of nutritional intervention
Intervention consists of two interrelated components of planning and implementation,

namely:
Planning
In this component contains information on diet / nutritional recommendations based on

assessments / assessments made in the diet. The steps of planning are as follows:
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Set priorities for nutritional diagnosis based on the degree of gravity, safety and patient /
client needs. Interventions are directed to eliminate the cause (the etiology of the problem), if
the etiology can not be handled by nutritionists then interventions are planned to reduce
signs and symptoms (sign / simptoms).
Consider the dietary guidelines, consensus and applicable regulations.
Discuss the plan of care with the patient, family or caregiver of the patient.
Set goals that focus on the patient's needs. Objectives must be clear, the results measurable
within the set time.
Designing diet prescription. Nutrition prescription is a recommendation of individual

nutritional needs of the patient starting from determining the energy needs, the composition
of macro and micro nutrients, the type of diet in detail including giving strategies such as food
form, feeding frequency and feeding routes whether it is peroral, enteral and parenteral.
Nutrition education and counseling.

Implementation
Impedation is a nutrition intervention activity where nutrition personnel communicate a
defined nutritional intervention plan to the patient / client and to other related parties eg to
the food production department, the nurse including the patient / client family. In this activity
it is necessary to monitor, record and report the implementation of intervention. If there is a
change in the patient / client condition it is necessary to adjust the intervention strategy.

Grouping of domains and terminology of nutritional intervention
Grouping of domains and terminology of nutritional interventions aims to be used
as a standard for Dietissien / Nutrisionis in all health care facilities. Nutritional interventions
are grouped into four specific categories (domains) as follows:
Food / diet (International Code - ND- Nutrition Delivery
The provision of food or nutrients as needed through an individual approach includes:
Primary feeding and snack / distraction (ND.1);
Enteral and parenteral (ND.2);
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Supplements (ND.3);
Substance of bioactive (ND.4);
Food aids (ND.5);
Dining atmosphere (ND.4) and
Nutrition-related treatments (ND.5).
Education (International Code - E-Education)
It is a formal process of training skills or providing knowledge to help patients / clients

manage or motivate diet and behavior vs. willingly to maintain or improve their health.
Nutritional education includes:
Nutrition education about content / materials aimed at improving knowledge (E.1).
Apply nutrition education aimed at improving attitudes and skills (E.2).
Counseling (C)
Nutrition counseling is a process of providing support to patients / clients is manifested by the

relationship between dietisienen with patients / clients to address the nutritional health
problems perceived by the client by applying some behavioral changes (ketrpapun apply
dietary suggestions / activities). Changes in patient / client behavior are expected to be
changes that impact on better health / nutrition status. Through the process, dietisien helps
clients to prioritize problems, the goals of change to be achieved, and how to overcome
obstacles in its application.
Coordination of nutritional care
This intervention is a dietetic activity of consulting, referral or collaboration and coordination

with other health workers in the caring team of nutrition care who can assist or manage the
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patient's nutritional problems.
At the step of nutrition nutrition intervention should be critical in terms of:
Set priorities and targets / goals / goals.
Determining nutritional prescriptions or planning nutrition interventions.
Raising interdisciplinary relationships.

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Nutrition-related behavioral interventions.
Integrate nutritional intervention strategies with patient / client needs, nutritional
diagnoses, and values of the patient / client.
Determining the time and frequency of care.
Domain feeding (ND)
Eating is defined as the event of entering something into the mouth and chewing and
swallowing which includes various forms consisting of staple foods, meat /
chicken / fish, fruit and vegetable side dishes, and milk or
products. Snack food / snack is defined as the food served at
mealtimes
In the provision of interventions in the form of main food and food distractions should
be clear and specific in the form / type of food, the amount of nutritional value, the
amount of food and meal schedule. Provision of interventions tailored to the
patient's condition and the form of giving in the form:
Ordinary Food (healthy food diet).
The main food composition / food interlude.
Food Texture: Modified form of food in the form of liquid, strainer, soft, ordinary.
Energy diet modification (Low energy / calorie diet, high energy / calorie diet).
Modified diet Protein (Diet low protein, Diet high protein).
Modified Carbohydrate Diet (Low Carbohydrate Diet, High Carbohydrate Diet

Complex).
Modified fat diet (Low diet, low cholesterol diet).
Modified dietary fiber (High-fiber diet, Low residual diet).
Modified dietary liquid (full Diet liquid, Diet Liquid clear, Diet liquid without milk).
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Modified specific diet / Special diet (Diet with special calculations).
Modified vitamin-related diet.
Modified mineral-related diet.
Meal / fluid schedule (for example main meal & drinking hour 7:00, 12:00 pk, Pk 18:00
intermittent meal schedule 10:00, 16:00 pk.
Certain foods / drinks or other.
Major dietary interventions and snack foods are provided in accordance with the
diagnosis of nutrition, etiology, sygns and symptoms, and other considerations: the
conditions in which negotiations are required with the patient, require special
needs, the patient's readiness to change based on:
Compliance and patient skills.
Ability in membelimakanan (social economy).
Ability to change behavior and adhere to diet.
Availability / access to follow-up of nutritional intervention (monev) to nutrition.
54
101
Contoh : Pemberian Makanan utama dan makanan selingan
overweight is associated with excess energy intake

characterized by BMI 29 and estimated excess intake
Nutrition Diagnosis Energy
Tujuan intervensi Lose weight 2 kg in 1 month
Common Food Shape / Low calorie diet 1500

calories Main meal schedule 3 times interlude 2 times pk.7
morning,
pk.12.00 noon, pk.18.00 night, interlude pk 10.00 and
Planning pk.16.00. Insufficient water intake Oral line
Enteral (ND 2.1)
One form of handling nutritional problems is to use a supporting nutrient. Special Nutrition
Support (SNS) is defined as a provision for oral, enteral, or parenteral oral administration of
nutrients for the purpose of therapy including the provision of total enteral or parenteral
administration and provision of nutritional therapy in order to maintain and / or improve
status nutrition and health.
Enteral Foods (ME) is a method of ensuring the adequacy of nutrients in poor, unwilling, and
unlikely individuals to meet their nutritional needs through normal eating (Patricia W, 2003).
While according to ASPEN (2002) ME is a method of delivering food to individuals who are
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without their own will via tube feeding into the gastrointestinal tract. Enteral feeding can be
done as total therapy or nutritional supplementation.
In enteral feeding should pay attention to the following:
Name / description of enteral food, calories / ml, additives, macro nutritional value.
Enteral feeding path.
Frequency and volume / awarding.
Provision of enteral feeding interventions is administered under conditions appropriate to

the diagnosis of nutrition, etiology, signs and symptoms and other considerations: conditions
where negotiations need to be made with patients due to special patient needs and
preferences, and preparedness for change based on:
Condition of end of life / in palliative care.
Other nutritional intake (oral, enteral and parenteral).
Food availability
Example : Parenteral
Changes The gastrointestinal function is associated with a
decrease
Nutrition Diagnosis exocrine function characterized by pancreatic disorder
The purpose of the

intervention Gives parenteral food
Planning Parenteral food form (coordinate with DPJP) Diet:
Energy 1500 calories Protein 54 g, fat 76 g, KH 145 g Type
Parenteral food: Kabiven
Schedule of continuous administration, droplets tailored to
coordination with DPJP.
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Central venous access / pathway
Medical Food Suplement (ND 3.1)
Provision of supplements or commercial food to increase energy intake, protein, fat and
fiber and additional vitamins and minerals. In the provision of this intervention should take
the following points into account:
Individual recommendations, composition, type, frequency, time of giving and dismissal of

oral supplementation.
Description of the purpose of the supplement, for example to add energy source, protein,
fat, carbohydrate, fiber).
The provision of this intervention is provided under conditions appropriate to the diagnosis
of nutrition, etiology, signs and symptoms and other considerations requiring negotiation
with the patient's specific patient needs and preferences, as well as the readiness of changes
such as appetite and assistance. Example: Medical food supplement:
Inadequate protein and energy intake are associated with

decreased ability to consume is characterized by
Nutrition Diagnosis estimation of intake is less than requirement
Increase protein and energy intake reach more or

Tujuan intervensi equal to 80%
Rencana
The form of enteral food is in accordance with certain medical
conditions
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Diet: Diabetes food, Liquid DM
Chronic Kidney Disease, Low-protein Liquid
Constipation, High fiber liquid
Schedule: 2 times a day pk 10.00 and 16.00 or as needed
Oral food route
Vitamin and Mineral Supplements (ND 3.2)
Provision of vitamins and minerals that aims to meet the needs. In the provision of this
intervention should take into consideration the Recommendation individual, composition,
schedule, dose and discharge. Provision of supplements can not be given by dietisien
independently, but based on the consideration of nutrition care team chaired by the doctor
in charge of the patient.
The provision of this intervention is given to the conditions in accordance with the objectives
in the diagnosis of nutrition, among others based on the diagnosis of nutrition, etiology,
signs and symptoms and other considerations that need to negotiate with the patient
because of the needs and special desires of the patient, and the readiness to change such as:
In certain populations that require vitamin and mineral supplements based on the results of
the study.
Material availability.
Example: Vitamin supplement
Management of Bioactive Substance (ND 3.3)
The addition and alteration of bioactive substances in foods such as stanols and plant sterols
ester, pisillium, food additives and other bioactive substances. In the provision of this
intervention should take into account the dosage, shape, pathway, discontinuation of the
provision of bioactive substances.
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of nutrition, etiology, signs and symptoms and other considerations requiring negotiations
with the patient due to the patient's special needs and preferences, as well as the readiness
for change, among others, based on: specific populations requiring bioactive substance
supplements based on research results and availability of materials.
Example: Management of bioactive substances
Diagnosis gizi Asupan bioaktif (serat) sub optimal berkaitan dengan
kurang mengkonsumsi makanan sumber serat ditandai
dengan meningkatnya kholesterol
Tujuan intervensi Meningkatkan asupan serat mencapai 25 gram/hari
Rencana Bentuk makanan biasa/lunak
Diet tinggi serat
Jadwal makanan 3 kali makanan utama 2 kali makanan
selingan buah,
Pemberian sumber protein nabati/kedele, tumbuhan
sumber stanol dan sterol (buah, sayur kubis, minyak
sayur, kacang2an)
Food aid (ND 4)
Assistance or accommodation designed to support the patient's feeding ability to meet

adequate nutritional needs and reduce unplanned and dehydrated weight loss events. In the
provision of this intervention should take into account the specific conditions such as
equipment adjustments, eating positions, food cues, eating and exercise programs, oral care,
support facilities and menu selection.
of nutrition, etiology, signs and symptoms and other considerations that require negotiation
with the patient due to special needs and desires and readiness to change, among others:
Food support support is available.
An environment that does not support adequate intake.
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Lack of resources to help food such as helpful people, methods and therapists.
The ability to understand the reasons behind recommendations for change.
Example: Feeding Assistance

Diagnosis of Inadequate energy intake is associated with decline
nutritio memory is marked weight loss
The purpose of the

intervention Increase energy intake up to 80-100%
Form of regular food / soft
Diet energy 1700 calories, protein 60 g
Oral food route
Eat 3 times main meal 2 times food interlude
Coordinate with nurse / care giver to deliver
Planning eat and alert / alert time to eat
Feeding Environment (ND 5)
Physical conditions such as environment, temperature, comfort and interaction in the

location where food is given can affect food consumption. In the provision of this
intervention should pay attention to the selection of food tables, colors, arrangement and
height. Other factors include room temperature, lighting, food schedules, menu choices,
appetite boosting, positioning and minimizing intruders / room fragrances and should pay
attention to social interaction.
with the patient due to special needs and desires and readiness to change ie the availability
of resources to improve and modify the eating environment.
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58
108
Example: Feeding Environment
Inadequate oral intake is associated with disability
eating in a certain way marked incompetence
Nutrition Diagnosis food independently
The purpose of the Increase oral feed intake up to 80%

intervention Form of regular food / soft
The energy diet is 1900 calories, protein 60 g oral line
Coordinate with nurse / care giver to deliver
eating with the right food stuff and situation
Planning Comfortable
Nutrition Regulations Relating to Medical Measures (ND 6)
Modification of medications and herbs to optimize the nutritional status or patient's health
status.
In the provision of this intervention can be:.
Specific types of treatment are given such as insulin, appetite enhancing drugs and enzymes
with clear doses, schedules and routes
Provision of herbs such as peppermint oil, probiotics and others that must be clearly stated
dosisi, form, schedule and route.
Specific types of treatment are given for example: insulin, appetite enhancing drugs and
enzymes with clear doses, schedules and routes.
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with the patient due to special needs and desires and readiness to change that is based on:
Availability of access to clinical pharmacist.
The availability of certified practitioners has attended the training and
pharmacology education.
Example: Nutrition Arrangement Relating to Medical Measures (ND 6)
Nutritional changes related to the value of laboratory labels

Nutrition Diagnosis with hyperglycemia characterized by diabetes
The purpose of the Helps control blood sugar levels

intervention Form of regular food / soft / liquid
Oral food route
Planning Coordination with physicians related to insulin administration
Education Domain (E)
Nutrition education is provided to improve client / patient knowledge. Nutrition education
is a formal process to advise or train patients / clients for a skill or inculcate knowledge to
help patients / clients voluntarily organize or modify the food, nutrition, physical activity and
behavior chosen to maintain and improve health.
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Nutrition Education Component
Nutrition education in intervention consists of two classes, namely:
Educational content / material (international code: E-1).
Provide advice or train expected to improve nutrition-related knowledge.
Implementation of nutrition education (International Code: E-2).
Provide advice and train patients to improve nutrition-related understanding and skills.
The targets of patient / client nutrition issues that nutrition education should provide are:
Lack of knowledge, for example, has never obtained nutritional information both individual
education and nutritional counseling.
There is interest or interest in nutrition knowledge, for example in the lien / patients who
come to the nutrient to find out certain nutritional information.
Never get the wrong information, for example in pregnant women who never get certain
information related to myth.
Examples in providing nutritional education interventions:
Describes the nutritional relationship with the disease.
Explain the benefits of eating to help cure the disease (eg, aimed at patients with low
intake / no appetite).
Describe nutritional relationships, physical activity with health / illness.
Interaction of nutrients and drugs used by patients / clients.
Things that need to be overlooked in nutrition education are:
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Basic knowledge already possessed by patient / client.
How to study patients / clients differ from one another.
Presence of patient / client companion when given education.
60
Example :
Lack of energy intake is associated with lack of
Nutrition diagnosis nutritional knowledge marked intake of 70% requirement
The purpose of the

intervention Increase energy intake reaches 100%
Given nutritional education with the material:
- Individual nutritional needs
- How to increase energy intake
- Choosing foods with energy density and protein
Planning High
61 DOMAIN nutritional counseling (c)
Nutrition counseling is a process of providing support to patients / clients characterized by

a cooperative relationship between the counselor with the patient / client in determining
the priority of food, nutrition and physical activity, goals / targets, acceptable design
activities and can support the sense of responsibility to care for itself itself to solve existing
problems and to improve health.
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Nutrition Counseling in standardized nutrition care process includes:
Theory / Theory Approach (C-1)
Theory / Theory Approach (C-1) are the theories or models used for the planning and
application of interventions. Theories and models of theoretical models contain principles,
concepts and variables that provide a systematic explanation of the process of changing
human behavior:
Cognitive-Behavioral Theory (CBT)
Cognitive-Behavioral Theory (CBT) is a behavioral approach that is based on and directly

related to internal factors in the form of thinking patterns and external factors in the form
of stimuli from the environment related to behavioral problems which can be used to
influence my change of behavior. The goal of the CBT approach is to help patients / clients
to identify behavior that can be changed for the better.
Health Belief Model (HBM)
The Health Belief Model (HBM) is a psychological approach model focused on individual
attitudes and beliefs in the effort to explain and predict health behaviors.
HBM is based on the assumption that a person will be motivated to take action relating to
his health if he:
Feel that the negative effects of the condition of the illness (eg diabetics) can be avoided or
controlled.
Havi
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Have confidence that he will succeed in applying nutrition and health advice.
The application of HBM generally greatly helps nutritionists in planning interventions in

individuals with nutritional disorders such as diabetes, high cholesterol and / or
hypertension.
Social Learning Theory
It is a theory that uses a social cognitive skills approach that can help to change patient /
client behavior. In the approach we must identify the relationship between environment,
individual and behavior.
Transtheoretical Model / Stages of Change
This model shows the stages of change that involves attitudes and interests and behaviors in
achieving good behavioral changes that consist of precontemplation, contemplation,
preparation, action and maintanance.
Strategy (C-2)
Behavioral change methods undertaken to change a person's behavior requires a specific

strategy so as to apply the nutritional knowledge practice that has been provided. The
strategy should use the theoretical approach already listed in the theory approach (c1).
Interventions can include problem solving, joint goal setting, rewarding, group support,
stress management and self-monitoring.
Examples of nutrition counseling interventions:
Not ready to run nutritional recommendations related to

lack of opportunity to prepare food because
busy work is characterized by never breakfast and breakfast
Nutrition Diagnosis not infrequently consume fruit / vegetables
The purpose of the Prepare the client to run nutritional advice on

intervention next visit
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Given nutritional counseling with the material:
- Planning a practical breakfast menu
- Bring fruit / vegetables from home
- Involve families in preparing food
- Explain how to choose food when buying
Preskripsi food outdoors
62
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Sample case :
A 60-year-old female patient, a retired pns lives with a husband and there are maids who
come daily to clean the house and yard and wash and iron. Activities everyday watching tv
and a week 2 times participate pengajian in the mosque near his home, once a month family
gatherings with her husband with the most distant car takes 1 hour. Tb 155 cm, bb 65 kg
hospitalized with complaints limp and dizziness. Blood pressure examination 180/100 mmhg.
Total blood cholesterol 280 g / dl. Patients had a history of hypertension 2 years earlier but
did not adhere to taking medication given by doctors and found it difficult to avoid foods
containing lots of salt. Every dish cooked by always using seasoning flavor, love the savory
food-savory, snacking nuts / ceriping / rempeyek / fried crackers. Always available soy sauce
to add to the taste of cuisine. Vegetables prefer to be cooked with coconut milk and only 1
time / week to eat fruit such as: banana, papaya, orange or mango. Examples of nutritional
counseling education interventions provided
TERMINOLOGY
INTERVENTION
NUTRITION DIAGNOSA STRATEGY
(PES) EDUCATION AND
COUNSELING
RESULT OF CASE STUDY
Problem  Not adhering to dietary 

recommendations Describe the impact
More nutrition and
the link between the
disease
hypertension, obesity,
no diet
balance and activity
less physical (E)
Describe the food
a lot
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containing sodium
that should be
restricted (use
liflet) (E)
Explain / demonstrate
processing /
modification
eat low
sodium (use
liflet / example
recipe / modification
food is low
salt (E)
Describe the benefits /
profit to be recipe /
modification
food is low
salt (E)
Describe the benefits /
profit to be

Lack of knowledge
Less motivation
Less in skill
diet and modification
Etiologi  self-control



Sign/symptom  Blood pressure above
Normal
IMT: 27 (more nutrition)
Feed intake is high
Sodium
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Lack of vegetable
consumption and
Fruit
Lack of physical activity


 
63
118
INTERVENTION
STRATEGY
TERMINOLOGY EDUCATION AND
NUTRITION DIAGNOSIS COUNSELING

(PES)
RESULT OF CASE STUDY
felt in the future

will come with
following the advice
given (E)
•


there to do
change (C)
Dig up that obstacle
felt for
make a change
and give some
alternate options
behavior change (C)
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Domain Nutrition Coordination (RC)
Is a consultation activity, do a referral or coordinate with
health workers / institutions / other service facilities that can help address or manage
nutritional / patient-related problems. Coordination of these nutrients include:
Collaboration or referral services as long as the patient receives nutrition service (RC-1) is to
facilitate the service or provide interventions with other health care teams (doctors and / or
nurses), institutions or anyone who can represent patients as long as the patient gets
nutritional services.
Stopping or transferring nutritional care to other health-care facilities or other service

providers, such as to nursing home (RC, 2), ie planning the discharge of nutritional services or
referring nutritional services from a level of health service to another level of health service or
other service delivery .
Example:
Lack of energy intake related to post condition
stroke so it is not self-contained in the meal marked by
Nutrition Diagnosis intake 60% of the requirement
The purpose of Increase energy intake up to 100% in 3

intervensi day care
- Diet 1800 kcal protein protein 115 grams

- Form of soft rice food - oral line of food
- Consists of 3 main meals and 2 meals
Intermezzo
- Coordinate with nurses to provide assistance
Planning Eat
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MONITORING AND NUTRITIONAL EVALUATION
Understanding Monitoring and Evaluation of Nutrition
Nutrition monitoring and evaluation is the 4th step of the PAGT, consisting of words
monitoring and evaluation. Monitoring means that activities follow a program and its
implementation in a steady, orderly and continuous manner by listening, seeing and observing
and recording the circumstances and progress of the program. While evaluation means the
process of determining the value or price of a program toward the ultimate goal of generating
decisions about acceptance, rejection or innovation improvement.
Nutrition monitoring is the review and timely assessment of nutritional indicators of the
patient's status according to the prescribed needs, nutritional diagnosis, intervention and
outcome / output of nutritional care. Nutrition evaluation is systematically comparing the
current data with previous status, the purpose of nutritional intervention, the effectiveness of
general nutritional care and / or standard referral. Outcome of nutritional care is the result of
nutritional care that is directly related to nutritional diagnosis and the purpose of planned
intervention. Indicators of nutritional care are markers that can be measured and evaluated to
determine the effectiveness of nutritional care.
Objectives of Nutrition Monitoring and Evaluation
Basically, nutrition monitoring and evaluation aims to determine where the existing
developments and the achievement of objectives and expected outcomes.
The Role of Nutrition Monitoring & Evaluation
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Nutrition monitoring and evaluation is a critical component in the process of nutritional care
because of this stage:
Identify important patient changes and patient / client outcomes that are relevant to
nutritional diagnosis and nutritional interventions.
Describe how to measure and evaluate the outcome of the outcome as well as possible.
Relationship Monitoring and Evaluation of Nutrition with Other Stages
The relationship of nutrition monitoring and evaluation as an activity undertaken after

nutritional intervention is to answer the question: "Will the nutritional intervention strategy
be able to resolve the diagnosis of nutrition, its aetiology and or its signs and symptoms?".
The description can be seen in the chart below:
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Dietetik Penyakit Infeksi
Figure 1.7
Nutrition Monitoring Link
Data used in nutritional assessment with monitoring and evaluation tend to be the same, but
the purpose and use of the data is different. In nutrition monitoring and evaluation, data are
used to evaluate the impact of nutritional interventions in accordance with outcomes and
indicators of nutritional care. This step clearly defined the outcome of specific nutritional
care. For example, a patient newly diagnosed with hyperlipidemia may have goals related to
nutritional knowledge as well as fat, fiber and energy intake, as well as associated
biochemical measurements of total cholesterol and LDL cholesterol. Dietisien may develop
an "action plan" to periodically monitor, evaluate and document nutrition knowledge, fat
intake and / or saturated fat as well as laboratory values related to lipid profiles.
Source of data and instrument of monitoring & evaluation of nutrition
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Data used in nutrition monitoring and evaluation can be sourced from data already listed in
the medical record or data that needs to be added after nutritional care is done. To monitor
and evaluate patient / client / client development, the following instruments may be used:
Patient / client / client questionnaire.
Surveys.
Pre-test and post-test.
Interview patient / client / client or with family members.
Anthropometric measurements.
Biochemical test results or medical tests.
Food and nutrition intake instrument.
Physical examination related to nutrition.

The instruments used in points 5 - 8 can be seen in the Core Materials 1 of the Assessment of
Nutrition, while for the 1-4 instrument must be prepared by the dietisien in the monitoring
plan and its implementation in accordance with outcomes and indicators of nutritional care
of patients / clients.
Categories of outcome nutrition care
Outcome Concept
Nutritional care should result in important changes to improve the quality of behavior and or
nutritional status. In patients / outpatient and community outcomes, outcomes may include
increasing patient / client understanding of food and nutritional needs and the ability and
motivation to meet those needs. Whereas in hospital outcomes may include an increase in
biochemical parameters or on a basic understanding of nutritional prescriptions. In long-
term health care facilities, outcomes may include improving the ability of a patient / client /
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client to be able to eat independently and reducing the need for elemental enteral nutrition
support.
Characteristics of Outcome Nutrition Care
Characteristic outcome of nutritional care is as follows:
Describe the results of dietitian performance and nutritional care independently.
Can be linked to the goal of nutritional intervention.
Can be measured with instruments and resources available.
Occurred at the appropriate time period.
Logical and biologically or psychologically can be a stepping stone to other health outcomes
(such as health and disease, costs, and patient / client outcomes).
Domain Outcome Nutrition Care
There are 4 domains of nutritional care used to measure out come nutrition care that is:
History related to nutrition and food
Detailed explanations for the measurement and recording of food and nutrition related
history data can be seen in the Subject Material 1 Nutritional Assessment / Assessment.
Biochemical data, medical tests and procedures include laboratory data (electrolyte, gucose,
protein and lipid profiles) and tests (such as gastric emptying time, resting metabolic rate,
etc.). Detailed explanations for the measurement and recording of biochemical data, medical
tests and procedures can be seen in the Core Material I Nutrition Assessment.
Anthropometric measurements include height, body weight, body mass index (BMI), index
rank / percentile growth patterns and weight history. Detailed explanations for the
measurement and recording of anthropometric data can be seen in the Core Materials I
Nutrition Assessment.
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Physical examination of nutritional focus includes evaluation findings of body systems,
muscles and subcutaneous fat, oral health, the ability to suck / swallow / swallow and
appetite and its effects. Detailed explanations for the measurement and recording of
physical examination data of nutritional focus can be seen in the Core Materials I Nutrition
Assessment.
Client History Domain
Unnecessary Client History Domain in nutrition monitoring and evaluation activities.

Therefore the terminology or standard language on Nutrition Monitoring and Evaluation is
the same as the terminology or standard language in the Nutrition Assessment.
How to monitor and evaluate
Monitoring progress
Check the patient's understanding and acceptance of nutritional interventions.
Determine if the intervention has been implemented in prescriptions.
Provide evidence that nutritional interventions may or may not alter behavior or patients.
Identify positive or negative outcomes.
Dig information about explanations and reasons that identify absence or lack of
achievement.
The conclusions supported by the evidence.
Measure results
Select nutrition care indicator to measure the desired result.
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Use standardized care indicators to increase the validity and reliability of change
measurements.
Evaluate results
Compare the data being monitored for the purpose of nutritional intervention or referral
standard to assess progress and to determine further action.
Evaluate the impact of overall interventions on overall patient health outcomes.

Conclusions of monitoring and evaluation results Examples of monitoring results are as
follows:
Nutritional Aspects.
Aspects of clinical and health status.
Aspect of patient.
Aspects of health services.
The flow of monitoring and evaluation
Things to consider in implementing the Monitoring and Evaluation of Nutrition as follows:
DIAGRAM ALUR
FASE 1
FASE 2
FASE 3
Monitor Perkembangan : Pengukuran Outcome :

Evaluasi Outcome :
1. Check pemahaman 1. Pilih indikator
1. Bandingkan data
pasien dan kesesuaian Asuhan Gizi untuk
Monitoring
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dengan intervensi gizi mengukur outcome
dengan tujuan
2. Tentukan apakah yang diharapkan
atau preskripsi
intervensi dapat 2. Gunakan standar
gizi atau standar
diimplementasi sesuai indikator asuhan gizi
rujukan untuk
preskripsi gizi untuk meningkatkan
Asesmen
3. Sediakan Instrumen validitas dan
Perkembangan
(bukti) bahwa reliabilitas
dan menentukan
intervensi gizi tidak pengukuran
tindak lanjutnya
dapat atau dapat perubahan yg terjadi
2. Evaluasi dampak
merubah perilaku atau
dari kesimpulan
kondisi pasien
seluruh intervensi
4. Identifikasi pencapaian
pada outcome
outcome (baik negaitif
kesehatan pasien
HOW TO RECOMMEND THE NUTRITION OF NUTRITION
Understanding Documentation
Documentation is a record of the ongoing process whereby it supports all steps in the
Standard Nutrition Care Process.
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Aim
Provide information describing patient progress, achievement of intervention objectives and

problem solving on nutritional diagnosis.
Principles
The quality documentation should include some things like:
Time and date.
Measurable indicators, results and methods for the required measurements.
Criteria as comparison of indicators (eg nutritional prescriptions / intervention objectives or

reference standards).
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129
Factors that support or inhibit the development.
Some other positive or negative outcomes.
Future nutrition care plans, nutrition monitoring and follow-up or stop nutritional care.
How to Documentation Example:
Proses Asuhan
Tanggal Catatan
Gizi Terstandar
Based on 3 days of food records, consumption
fat 120 gr / day. Food from its restaurant
often consumed is the type of food that is
15/7/ 2013 Asesment high fat. Patient IMT = 29
Visit
early
Assessment
Excess fat intake is associated with

limited access to food
healthy during meals in the restaurant
with high fat proven by
Nutrition Diagnosis estimated average fat intake of 120 grams per day
Prescription diet: 60 grams of fat per day and

Intervention nutrition counseling is required
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Estimated fat intake (indicator) is currently 200%
from diet prescription (criteria). Will monitor
Monev changes in fat intake at the following visit
Patients reported difficulty ordering food

low fat in the restaurant. Provide education
comprehensive to identify
low fat food from the restaurant menu.
10/8/2013 Intervensi Patients carry out their own records
Follow up
Based on the 3 day diet record, several

development of dietary prescription such as
estimation
Fat intake has decreased from 120 grams
to 90 grams per day. Will monitor
changes in restaurant selection
(using patient's own records) and intake
Monev fat at the following visit
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7
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
Exercise
What are the domains and terminology of nutritional intervention?
What is the relationship of nutritional intervention with nutritional diagnosis?
What is the purpose of nutritional intervention?
What are the domains and terminology of monitoring and evaluation?
What is the relationship between nutrition monitoring and evaluation with nutritional
assessment and nutritional diagnosis?
The domain and terminology of nutritional intervention.
The relationship of nutritional intervention with nutritional diagnosis.
The purpose of nutritional intervention.
Domain and terminilogi monitoring and evaluation.
The relationship of monitoring and evaluation with nutritional assessment and

nutritional diagnosis.
Summary
The nutritional intervention is the 3rd step of the PAGT where the nutritional
intervention is to address the nutritional problems identified at the stage of nutritional
diagnosis. Nutritional intervention is given to the patient to correct the etiology that causes
nutritional problems. One example of excess weight is due to a dietary intake exceeding the
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requirement marked by BMI> 29 and an energy intake of 120% of the need, then the
nutritional intervention given is to modify the food and modify the diet. Whereas if
nutritional problems are defined as nutritional value-related laboratory problems, nutritional
interventions can not correct the etiology but minimize the signs and symptoms. Examples of
patient problems The value of blood sugar increased due to carbohydrate metabolism
disorders characterized by blood sugar 250 gr / dl and carbohydrate intake 130% of the
need, then the intervention is given to reduce the patient's blood sugar.
The domains and terminology of nutritional intervention are Feeding (ND), Education
(E), Counseling (C) and Nutrition Co-ordination (RC). While the nutritional intervention
component is planning and implementation.
The final step of the PAGT is Monitoring and Evaluation, aimed at seeing the results of
the nutritional interventions given to the patient. Monitoring is an observational activity on
the outcome of the intervention, whereas evaluation assesses the success of the
intervention. Monitoring and Evaluation of nutritional indicators is adjusted to the outcome
achievement objectives interensi. A
example misses reduce energy intake reaches 80% of its needs, then the monitored and
evaluated indicator is the energy intake.
The domain and terminology of nutrition monitoring and evaluation are similar to the
nutritional assessment domain, ie nutrition and food related history, anthropometry,
physical and nutritional focus clinics except the personal data domain (client history data).
Documentation of records of nutritional care used for nutrition care information provided to
patients, their goals and success as well as solving nutritional problems of the patient.
Test 4
A patient eating very low intake caused by swallowing disorders, then the nutritional
intervention provided is ....
Modify the method of feeding
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Modification of the eating environment
Modified form of food
Modify the frequency of eating
Modification of eating behavior
The patient's nutritional problem is obesity, then the right intervention is given.
Modification of diet and physical activity
Educate health-related values
Low carbohydrate feeding
Provision of high fiber supplements
Modify the frequency of eating
To assess the indicator of success of the nutritional intervention given to the patient, what
needs to be considered is ....
The measurement is correct
Standard used
Consistent with the assessment
Does not measure personal data
Performed by the same person
135
One of the important indicators to be monitored in patients with malnourished children as
an illustration of the development of nutritional care provided to the child is ....
Weight
Height
Body temperature
Blood pressure
Clinical conditions
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136
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Documentation of nutritional care information is intended for ....
Assess the success of nutritional care
Assess dietary professionalism
Assess the quality of health services
Documentation of patient development
Communication between health personnel
Key Test Answers

Tes 1
Tes 2
138
E
Tes 3
Tes 4
139
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Glossary
AND: Academy of Nutrition and Dietetic
Dietisien: Nutrition force according to Healthcare Act 2014
NCP: Nutrition Care Process
PAGT: Standardized Nutritional Care Process
MNT: Medical Nutrition Theraphy
TGM: Medical Nutrition Therapy
PES: Problem-Etiology-Sign / Symptom
ADIME: Assessment-Diagnosis-Intervention-Monitoring and Evaluation
140
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141
Bibliography
American Dietetic Association. 2017. Nutrition Diagnosis and Intervention : Standardized

language for the nutrition care process
American Dietetic Association. 2013. International Dietetics & Nutrition Terminology (IDNT)
Reference Manual, Fourth Edition.
Kemmenkes RI. 2014. Proses Asuhan Gizi Terstandar (PAGT)
Kemenkes RI. 2013. Pedoman Pelayanan Gizi Rumah Sakit. Kemenkes, Jakarta Miranti
Gutawa dkk. 2011. Proses Asuhan Gizi Terstandar, AsDI –PERSAGI, Abadi Publishing &
Printing, 2011
Kemenkes RI, WHO, AsDI, PERSAGI. 2014. Buku Pedoman Training of the Traininr
(TOT)Proses Asuhan Gizi Terstandar pada Tenaga Gizi di Pelayanan Kesehatan
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CHAPTER IV
MODIFICATION OF DIET
143
Dr. Iskari Ngadiarti, S.K.M., M.Sc
PRELIMINARY
Provision of diet therapy in sick people not merely provide adequate food alone, but
consider other factors such as how the ability to digest and absorb food, disease conditions,
and psychological factors. In general, the provision of diet therapy should be varied and less
likely to approach eating habits when the patient is healthy. Because the factors of favorite
food and daily diet should be taken into account other than socioeconomic, religious,
cultural, and environmental conditions. Individual dietary determinations of the patient may
refer to balanced nutrition guidelines and generally recommended nutritional adequacy
rates, but specifically remain physiologically concerned for basal metabolic needs,
pathological factors such as the presence of certain diseases that interfere with digestion or
increase nutritional needs, socio-economic factors such as presence the ability of individuals
to meet their nutritional needs. In other words the provision of diet therapy to provide
adequate diet but must make various modifications so that the diet has been provided can
be received in accordance with the patient's condition. Sometimes in the modification of the
diet needs to be aggressive, especially in reducing the occurrence of malnutrition in order to
avoid a great process of catabolism that can worsen the condition of patients known as
nutrition support provision. In this module, you are invited to learn the basic concept of
dietary modification conceptually, and when and how the principle of providing nutritional
support. With hope after reviewing the material you will understand well about dietary
modifications including the principle of providing nutritional support. This module consists of
3 learning activities, namely: 1. The basic principle of dietary modification. 2. Diet or Hospital
food. 3.The basic principle of nutritional support.
Furthermore, after studying this module, you are expected to be able to explain the basic
concepts of diet modification and nutritional support While specifically, the competencies
you are expected to be able to explain:
The significance of diet therapy and diet modification.
Principles and basic dietary modifications.
144
How to Make a Diet Modification
Hospital Diet and Requirements.
Three dietary standards at RS.
The importance of understanding the importance of nutritional support.
Steps in the provision of nutritional support.
Principles and scope of enteral feeding.
Principles and scope of parenteral food.
Dietetik Infection Disease
78

Dietetik Infection Disease
Topic 1
Basic Principles of Diet Modification
In this topic 1 we will discuss the significance of diet therapy and diet modification. What is
diet therapy? Provide food for the purpose of treatment of the disease. There are 3 types of
therapy given to the patient: treatment therapy, medical therapy and nutritional therapy or
diet therapy.
145
The goal of providing diit therapy include: maintaining or achieving optimal nutrition,
correcting possible nutritional deficiencies, resting the body organs due to illness, adjusting
to the patient's digestive system ability, adjusting the food with the body's ability to
metabolize the nutrients, correcting the addition of the BB if necessary , overcoming or
preventing edema and avoiding suspected foodstuffs.
FACTORS WHICH NEED TO BE CONSIDERED IN LEARNING DIET THERAPY
Many factors to consider in studying diet therapy include the underlying disease condition,
the length of illness, the food factors that need to be reduced to overcome the patient's
condition and how the patient's tolerance for food. Attention to the underlying disease is the
main thing that is pathophysiology so that the food is prepared accordingly. For example,
food for infectious diseases is Food High Energy and Protein (TETP). This is because food
other than to meet the needs of the body itself is also needed to bully the cause of body
infection out of the body, it requires energy for the health and protein as a weapon of
immunity. In addition to micronutrients such as vitamins and minerals as a supporter. The
duration of illness also affects the provision of diet therapy, for example, someone who is
chronically ill like tuberculosis then the provision of high energy foods should continue until
normal weight is achieved, because usually the indicator of success of TB therapy is the
occurrence of normal weight gain.
Selection of foodstuffs needs to be adjusted to the condition of the disease, for example,
there are gastrointestinal disturbances at the bottom such as constipation often occurs.
Based on the initial assessment it turns out the patient likes to drink sweet more than 3
times a day, but never consume fruit, and consume vegetables only carrots and white
pumpkin. Therefore, suggestions to reduce sweet drinking habits need to be done or
increase the intake of vegetables such as beans,
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Dietetik Penyakit Infeksi
146
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147
PRINCIPLE OF DIODE MODIFICATION
Basically setting the diet in patients are the 3 principles of freedom exist, individual and
simple (simple). Thus it can be interpreted that in making diet modifications there is freedom
or tolerance to change. But the change remains focused on the body's need for essential
nutrients needed according to the disease. The second principle is individualized means that
the planned food should be adjusted to eating habits, especially food intake, preferences,
economic status, religion, and environmental factors including food processing facilities and
infrastructure. For example if he is at home there is no facility to burn food, lest the
recommended regimen should be burned. The third principle is simple, it means that the
recommended regiman should not burden the provision so easy to implement. For example,
the daily family menu is vegetable asem, pepes fish, tempe bacem. Suggested suggestions
for high-energy and protein diets are fixed menus only a portion of side dishes increased in
number or coupled with 1 more side dish menu. Thus the suggested regimen is likely to be
performed and for the patient does not feel different from the family members.
BASIC AND HOW TO DIODE MODIFICATION
There are 2 main things to note in diet modification in addition to the modification principle
as above is the basic modification and various types of modifications.
Basic dietary modifications
The main basis of dietary modification is the individual nutritional needs of the patients
served. In quantity is the amount of energy and nutrients tailored to the needs of patients
with regard to age, sex, activities and other conditions. Other conditions to note are
nutritional status before illness, current nutritional status, and how should the next
nutritional status, whether need to be removed or lowered, or maintained. Various studies
suggest that good nutritional status is positively correlated with length of stay and healing
process (Budiningsari and Hamam Hadi 2004, and Chima CS, Barco K, Dewitt ML, et al.1997).
Other consideration factors to consider are the pathophysiology of the disease, the
prediction of the length of illness, the number and types of nutrients that may be lost during
148
illness, tolerance of the patient to food, socioeconomic conditions, culture, religion, likes and
others.
But qualitatively dietary modification can refer to balanced nutrition guidelines proclaimed
by the government is a tumpeng / pyramid of balanced nutrition or can be used guide my
dinner meets balanced nutrition that is:
½ of the dinner plate consists of vegetables and fruits. Maximize with consumption of
various types and colors.
¼ of the plate is filled with protein. Can choose fish, chicken or beans. The use of red meat or
processed meats such as sausage is reduced.

80

¼ of the dinner plate is filled with whole grains of rice, wheat or pasta. Sugar content from
white bread or rice is high, should be careful for those who have problems with blood sugar.
Complete a little oil, such as olive oil, soybean oil, corn oil and others. Avoid hydrogenation
oils that contain saturated fat.
Consumption of water, tea, or coffee. Limit milk and its derivative products, only about 1-2
times per day, juice about one glass per day and avoid drinks with high sugar content.
Type of diet modification
Dietary modifications can be done with various types of modifications
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consistency, modification of nutritional value, modification of administration. The
modification of consistency is to change the shape and consistency of the regimen or food
given to the patient. Basic modification of form or consistency remains on the nutritional
needs of the patient, if the nutritional needs are not achieved with consistency, then there
should be some consideration. For example, the food is given only 1-2 days or given with
other modifications, for example modification of oral and enteral giving. Including
modifications to consistency are soft foods, filter foods, minced foods and liquid foods. The
liquid food itself has clear liquid food, full liquid food and semi solid / liquid food.
The second type is the modification of nutritional value. Nutritional values are high-energy
high-protein diets (TETP diet), low-calorie diets (diet RK), low-salt diets (low-fat diets, GE
diet).
The third type is the modification of oral, enteral and parenteral administration. Examples of
enteral foods are self-developed or commercial liquid foods such as entrasol, ensure,
diabetasol, peptamen and others. While commercial parenteral food samples are cernevit,
minofusin paed, da
The purpose of providing diet therapy among others; a. Maintain and achieve optimal
nutritional status; b. Fixed if there is a lack of nutrients that occur due to illness
suffered; c. Resting a sick body part or organ; d. Adjust the ability of the
gastrointestinal work to digest food and the body's ability to metabolize
nutrients. d. Avoid the occurrence of new complications and avoid foods that are
suspected as the cause of nutritional problems or illness.
Factors to consider in studying dietary therapy are the underlying disease conditions
that require dietary changes, the likelihood of prolonged illness, the dietary
factors that must be changed to address nutritional and health problems and
how tolerance of natural patients receive food.
There are 3 Principles governing the patient's diet is kebebabasan, individual and
simple.
150
Basic dietary modification is a normal nutritional requirement; previous nutritional
status, pathophysiology of the disease; anticipate long sickness; factors of food or
food that need to be changed; the number and types of nutrients that may be
lost or increased in the body; tolerance, social economy, and other factors such
as religion, culture, etc.
There are 3 types of diet modifications are: a.Modification based on consistency like
common food, soft, strain, liquid; b. modification based on nutritional value such
as high energy diet and high protein, low-salt diet; c. Modified diet based on
administration of oral, enteral and parenteral foods. Example: The MB Diet
(Ordinary Food) is an oral type, commercial dairy liquid milk delivered through
pipes, such as ensure (commercial), and cernevit for parenteral food.
Summary
The main basis of dietary modification is to meet the nutritional needs of patients to
maintain or achieve optimal nutrition, which is lean to the guidelines of balanced
nutrition. Factors to consider are disease conditions, tolerance of patients in
receiving the diet, and the environment including socioeconomic, cultural, and
religious.
Test 1
The main purpose of diet therapy is ....
Provide food according to the patient's preferences
Provide food according to the patient's tolerance
Increase the energy and nutrient content of the patient
Maintain and achieve optimal nutritional status
151
Modify the patient's diet
82
Factors to consider in studying dietary therapies.
Probable duration of illness / duration of illness
Foodstuffs are available in the market
Modify the feeding distance
Type of diet based on administration
Nutritional needs of the patient
The principle of regulating the patient's diet is ....
Preferable-safe-attractive
Freedom-individual-simple
Permanent-individual-simple
Individually-as needed-interesting
Tolerant to change-individual-simple
Basic modification Dietary ....
Provide food according to the patient's preferences
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Provide food according to the patient's tolerance
Increase the energy and nutrient content of the patient
Maintain and achieve optimal nutritional status
Modify the patient's diet
Mistress is patient with swallowing disorder. The results of the food intake evaluation only
reached 15% of the needs, then to increase food intake at least 60% of the needs should be
modified diet in terms of ....
Consistency
Nutritional value
Giving
Consistency and nutritional value
Consistency and mode of giving
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154
Topic 2
Diet or Hospital Food
Students I'm proud of, after we know the importance of learning the basic modification of
diet, now we learn about dietary guidelines commonly used in hospitals. In general, hospital
dietary guidelines are specific and individualized. These guidelines are usually authorized by
the hospitals used to facilitate healing and improve the patient's nutritional status is also
used to calculate the cost of eating in the organization of eating in the hospital. Each hospital
has its own guidelines but the basic principle is the same, which follows the basic principles
of balanced nutrition.
DEFINITIONS AND TERMS
Diet is setting the amount and type of food eaten every day to keep someone healthy. While
the Hospital diet is a feeding with the aim of achieving or maintaining normal nutritional
status and help cure, as well as prevent new complications / new problems such as diarrhea
or intolerance to certain types of food.
Diet / food provided at the hospital should refer to balanced and diverse foods to ensure
adequate energy, carbohydrates, proteins, fats, vitamins, minerals and liquids. For example
there is a difference in the provision of diet in patients who are fat and thin. Dieting for
overweight or overweight patients is avoiding new risk factors such as metabolic syndrome,
high blood pressure, heart disease, stroke, diabetes, etc., while dieting in lean patients is
providing an adequate diet to increase nutritional status and increased endurance in the face
of disease, especially infections, and help the recovery of patients from disease by repairing
damaged tissue and restore balance in the body (homeostatis).
General hospital food requirements
There are several requirements in providing hospital food such as:
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Foods presented have a balanced nutrient content in accordance with the state of disease
and nutritional status. Nutritional value is the main requirement, besides attractive,
attractive, tolerant and safe. Fulfillment of nutritional value can be obtained by calculating
the nutritional needs of individual patients according to age, sex, weight, height, activity and
stress factors according to the type of illness.
The food served has the appropriate texture and consistency according to the
gastroinetstinal conditions and diseases suffered by each patient / patient. For example,
acute gastritis patients may receive food with a soft texture and semi-solid consistency for
several days, until inflammatory inflammatory conditions decline.
Food served is easy to digest and does not stimulate, and does not contain gas, so the
possibility of food intolerance can be reduced. Neutralized food is not too spicy, sweet,
salty or sour. As an example of individual food shrimp, crabs should not be used as a
basic menu, but the menu of choice because not everyone can eat these foods. The
selection of vegetables should be selected vegetables that have low and medium fiber
content not high, so the selection of fruit should also be selected neutral fruit such as
papaya, oranges, mangoes, apples, and avoid the stimulating fruits such as durian,
brown, jackfruit and others a kind.
Foods are cultivated free of harmful additives (preservatives, dyes, etc.). Fresh natural
foods are more preferable than canned ones. If you are forced to use canned food, you
should read the label, the expiry date, the physical condition of the can (avoid the
defective condition of the can). Thus the possibility of undesirable events can be
avoided.
Food strived to have good taste and attractive appearance to arouse appetite which
generally disturbed by disease. Appetite can be influenced from the sense of sight and
the sense of taste / smell.
GENERAL STANDARDS OF FOOD IN HOSPITAL
There are 3 standard of food in hospital that is 1. General hospital food standard (only
based on consistency); 2. Special hospital food standards (by type of disease) and 3.
Food standards for tests related to diagnostic reinforcement.
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General standard of hospital food
General Standard of Food RS that is Common food, Food soft, Food filter
and liquid food (clear, full, thick / semi solid).
Ordinary Food
This food is the same as everyday foods that are diverse, varied
with normal shapes, textures and aromas. The composition of the dish refers to the
balanced menu pattern and nutritional needs of individuals or patients whose illness
does not require special food. Food should be easy to digest and not stimulate the
gastrointestinal tract. This food is given to meet the nutritional needs of patients and
prevent and reduce tissue damage.
The usual dietary requirement is energy according to the normal needs of healthy
adults in rest or mild activity; protein 10-15% of total requirement, fat 20-30% of total
requirement and carbohydrate 55-70% total energy requirement, enough vitamins,
minerals, water and rich in fiber. Daily food is diverse and varied and does not
stimulate the gastrointestinal tract.
Foods that are not recommended are stimulating foods such as foods that have high
fat, too sweet, too spicy, too savory, too spiced and drinks containing alcohol.
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Soft Food
Soft foods are foods that have the texture that is easy to chew, swallow, and
digest compared to ordinary foods. These foods contain enough nutrients. Their
bio-foods are administered to patients who are infected with a temperature rise
but not too high, in patients with certain operations, patients with difficulty
chewing and swallowing. Soft foods can be given directly to the patient or are
transferred from filter food before being given regular food.
The requirement of soft foods is to have the content of energy, protein, and
other nutrients enough.Food soft or minced in accordance with the state of the
disease and the ability to eat patients. Food is given in moderation, 3 meals and
2 times the food interlude. Food easily digested, not stimulating, and low in
fiber. Examples of soft food menu is rice, pepes Ikan (without chilli), tempeh
bacem, vegetables clear spinach, papaya fruit
Food Filter
Filter foods are semi-solid foods that have a finer texture than soft foods, making
them easy to swallow and digest. These foods are usually administered to
patients with indications after undergoing certain surgeries, acute infections
including gastrointestinal infections; in patients with difficulty swallowing,
chewing or as a heavy liquid food shift to soft foods. The nature of food is semi-
solid with slightly less adequate nutritional value, less balanced because less
fiber and Vitamin C.
The condition of filter food is low in fiber, and only given in a short time that is 1
to 3 days, because it does not meet the nutritional needs, especially energy and
nutrients (vitamins and minerals). Food in the form of smooth or blended and
given in small portions with the provision of 6-8 meals. Examples of filtered
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foods are rice flour porridge, meat gadon, fried tofu, carrot cream soup, and
caramel podeng as dessert.
Liquid Food
Liquid foods are foods that have a liquid consistency until thick. These foods are
administered to patients with an indication of patients having chewing,
swallowing and digesting disorders caused by decreased awareness, high
temperature, nausea, vomiting, or on a post that has recently undergone
gastrointestinal bleeding as well as in a pre or postoperative patient. Liquid food
is an early stage food after gastrointestinal bleeding. This food can be
administered orally, enteral or parenteral.Based on the consisitensi liquid food
grouped in 3 types namely 1) clear liquid food; 2) full liquid food and 3) viscous
liquid food.
Clear liquid food
Liquid liquid foods are foods that are liquid at room temperature, with little / no
residual can be translucent if placed in a clear container. The purpose of giving is
to meet the needs of the liquid
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the body is easily absorbed and leaves little residue; prevents dehydration and relieves thirst.
This food is usually given to certain pre or post-surgical patients, patients with nausea and
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vomiting and early-stage post-gastrointestinal food diseases. The nutritional value of liquid
feeding is relatively low and contains only 1 carbohydrate . Terms of diet liquid foods include
food in the form of clear liquid that transparent; groceries only source from carbohydrates;
does not stimulate the gastrointestinal tract and is easily absorbed; has a residual sedkit,
given only 1-2 days only, every day can be given in 5-6 times gift between 150-200 cc (small
portions but often).
Foods that can be given include tea, fruit juice, syrup, clear broth and easily digestible fluids
such as fluids containing maltodektrin. Food can be supplemented with supplements that
have high energy but low residual.
The liquid food is full
Full liquid food is liquid food that is semi-solid at room temperature, and is not transparent
when placed in a clear place. This liquid food is given to patients who have the disorder to
chew, swallow or digest solid foods. Patients who receive these foods are usually patients
who experience mouth or throat surgery, and or on consciousness decreases. These foods
can be administered orally, enterally or parenterally.
Full liquid food requirements do not stimulate the gastrointestinal tract; if given more than 3
days, the food must meet the energy and nutrient needs of the patient; Energy content of at
least 1 kcal / 1ml. Liquid concentrations can be given gradually from ½, ¾, to full. Its
osmolarity is less than 400 mosml.
There are 2 types of full liquid food in hospital that is hospital formula (FRS) and commercial
formula (FK). Hospital formula is a formula developed in hospitals and is produced in
hospitals. The main ingredients are full cream milk, skim milk, sugar, chicken egg, oil,
cornstarch as thickener. This formula can be modified and adapted to the patient's
condition. Patients who are not resistant to lactose can be given a low-lactose formula, by
replacing fullcream milk with low-lactose milk. Patients with constipation then the basic
formula can be added fruit. There are 4 types of hospital formula food that is liquid food
filled with milk, without milk, low lactose and blender formula.
The second type of liquid food is a commercial formula. This commercial formula is adjusted
to its designation or indication of the disease. Diabetes mellitus, its commercial formula has
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a low glycemic index; Patients who are allergic to proteins, then the commercial formula is
given that contains hydrolyzed protein.
Patients who can not stand milk, can be fed liquid foods without milk, and the source of
protein can be obtained from green beans, tofu, tempeh, eggs, and cereal flour.
The liquid food is thick
Heavy liquid food is a liquid food that has a thick or semi-solid consistency at room
temperature and is easy to leave the throat, so it does not require mastication and prevent
aspiration, but can meet nutritional needs. This type of food is often given to patients with
inflammation of the esophagus, peptic ulcer, or structural or motor disorders of the oral
cavity. These foods should be enough fluids to maintain the balance of body fluids.
Conditions of thick liquid food is to be easily swallowed or immediately leave the esophagus
and not stimulate the gastrointestinal tract; enough energy and protein, given gradually
toward soft food and giving it a small portion but often that is given every 2-3 hours once in
12 hours.
This food can be made from full liquid food thickened with gelatin, or supplemented with
cornstarch, or margarine so that the consistency is liquid but thick, and slippery.
Special hospital food standard
Special hospital food standards are standards based on circumstances
his illness. Discussing hospital-specific foods there are two things: standards that are directly
related to the modification of nutrients to alleviate the disease and the standards directly for
the disease, then the dietary requirements that use modification.
Special dietary standards are directly related to the modification of nutrients
Specific food standards that are directly related to nutrient modification are typically
targeted for specific diseases. For example the High Protein High Energy Diet (Diet ETPT) Diet
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that is not only for infectious diseases only, but can be used for growing conditions such as
pregnant, lactating or growing. In the following discussion will be discussed some examples
of standard dietary special foods such as High Protein High Energy Diet (Diet ETPT), Low Fat
Diet (Diet LR), Low Protein Diet (Diet PR), Low Salt Diet (Diet GR) and Diet High Fiber ( Diet
TS).
High Protein High Energy Diet (ETPT Diet)
Characteristics of the High Energy and High Protein diet is to contain higher energy and
protein (approximately 30-50%) than normal needs. Protein sources should come from
proteins that have high biological value, carbohydrates and fats should be given enough so
as not to use protein as an energy source. This diet is usually given to patients who are
underweight, lack protein energy (FE), fever, infections, hypothyroid, burning, pregnancy,
breastfeeding, growth.
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Suggested food ingredients are all foods given to normal patients such as rice, bread, butter,
cream, sugar and oil but increased in number. Increased protein sources include milk, eggs,
cheese, meat, chicken and fish.
Low Fat Diet (Diet LR)
Understanding low-fat diet is a diet with the amount of fat is only about 10-15% of total
energy or about 20-30 g / per day. High fatty foods are avoided. Foodstuffs strived to be
cooked not using fat, but selected a high vitamin A content. Recommended foods are skim
milk, eggs, lean meats, low-fat cheese, fruit vegetables, rice and sugar. This diet is usually
given patients with malabsorption, acute pancreatitis, and cholecystitis and celiac disease.
Low Protein Diet (Diet PR)
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A low-protein diet means that the diverted diet has the same energy as normal, only low
total protein is less than 50% of the usual need. Under certain conditions such as acute
anuria, or even hepatic coma the protein is not given at all, meaning food or diet is only
sourced from CHO and fat. Generally low-protein diets, the amount of permitted protein
ranges between 20-30 g per day and 2/3 of these proteins should come from animal protein
or protein that has high biological values. Carbohydrates and fats should be enough so as not
to interfere with the fulfillment of protein needs. Potassium and sodium should be
monitored whether it should be restricted or not. Monitoring can be observed from
laboratory values such as potassium levels in blood, sodium levels in the blood and clinical
such as whether there is dizziness, weakness, rapid pulse and others. This diet is
administered to patients with acute gomerulonephritis, uremia, comahepatikum, chronic
glomerulo nephritis with nitrogen containment.
Foodstuffs that need to be observed are food sources of protein should not be the amount
of excess of the set, while the limited food items are legumes, nuts, rice, cereals, vegetables
and fruit.
Low Salt Diet (Diet GR)
Low salt diet is a diet that has a low sodium content of between 200-1300 mg per day. Keep
in mind that salt is not just the salt eye of the kitchen (NaCL), but also baking soda (NaHCO3),
baking powder, sodium benzoate, and vetsin (monosodium glutamate). Food or dietyang
given to patients should not not contain sodium, because sodium is necessary for the
balance of fluids and acid-base body is sebgai main cation in extracellular fluid, and play a
role in the transmission of nerves and muscle constituents. In general in our daily diet is our
sodium content higher than needed, but the body has the ability to neutralize / balance, that
is with
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Diet High Fiber (Diet TS)
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In principle, high-fiber diet is to provide food in accordance with the needs of the patient's
day but the fiber content is given more in order to stimulate intestinal peristaltic movement
so that defections run normally. The fiber in question is carbohydrates and the type of
polysaccharide contained in plant foods. Fiber in general can not be digested by digestive
enzymes but good for health effects.
The fiber is composed of 2 groups ie water soluble fiber and insoluble fiber. Water-soluble
fiber can reduce the risk, prevent and alleviate coronary heart disease and dyslipidemia
because this fiber can bind bile acids that can reduce the absorption of fat and blood
cholesterol. Which include this fiber is pectin, gum, mukilase which is found in havermouth,
nuts, vegetables, and fruits. Insoluble fiber water has a function of defecation to prevent
constipation, haemoroid, diverticulosis and prevent colon cancer by binding and removing
carcinogens from the intestine. Which include these fibers are cellulose, hemicellulose and
lignin which is widely found in rice bran, wheat, vegetables and fruits.
The management of a high-fiber diet is tailored to the patient's condition. If the patient is
obese then dieting is a low-calorie diet with a high emphasis on fiber. The definition of a diet
high in fiber is food has fiber content of more than 25 g is about 30-50 g / day. Other
requirements that need to be followed include Energy adjusted to the condition of the
patient's nutritional status, protein 10-15
of total energy, fat 20-25% total energy and liquid more than 2 liter per day.
Special dietary standards are directly related to the disease.
Special dietary standards that are directly related to the disease are dietary standards aimed
at illness or diseased organs, including diet of gastrointestinal diseases, diet of liver and gall
disease, diabetes mellitus diet, cardiac and blood vessel diet and the like. In this standard
only general requirements are described, for example the principle of feeding the sick is
gradual, then the standard is adjusted in terms of its type, amount of energy, type of
nutrient, and its gift. Well for the description of dietary standard khusu discussed only 2 diet
gastrointestinal diseases and diabetes mellitus diet.
GI disease
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In the standard gastrointestinal diet is made general and flexible fixed in its use is adjusted to
the condition of disease and nutritional status of each patient. Talking the gastrointestinal
tract is long starting from the mouth, esophagus, stomach, small intestine, large intestine
and anus. To facilitate the manufacture of standards divided into two, the standard upper
gastrointestinal disturbances (mouth to the stomach and intestines twelve fingers) and
bottom (small intestine up to the colon). In general, gastrointestinal disorders
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followed by symptoms that are nausea, vomiting, epigastrum pain, bloating, decreased
appetite and there are feelings quickly full. Because the standard basis is a modification that
can be attributed to modification of consistency / shape, and modification of nutrients
including certain proteins, fats, and vitamins in addition to fiber.
In acute conditions may be a modification of consistency used for example given liquid food,
just after the acute period is overcome coupled with the modification of nutritional value. In
the standard diet of gastrointestinal diseases are also various adjusted to the location of the
disorder, if ganggguannya in the stomach to eat diet diet stomach. The gastric diet itself
consists of a gastric diet of I to III. Usually this naming is based on the form and fulfillment of
nutrition. Gastric diet I is usually a liquid food form and nutritional fulfillment can not be
optimal, gradually for example only 70% of the needs of patients. The principle of hospital
feeding is gradually according to the condition of the organ and the body's ability to receive
food. This standard only makes it easy to plan for large quantities of food.
Diabetes mellitus disease Diet
It is known that there are two types of diabetes mellitus is the largest insulin dependent
(NIDDM) and insulin dependent (IDDM) and most patients DM is a type of NIIDM. One of the
risk factors for NIIDM DM disease is obesity and risk factors DM IDDM is thin, for example,
the standard DM is made up to 8 standards of 1 to 4 standard of obese patients, standard 5
and 6 for patients with normal nutritional status , and standards 7 and 8 for DM thin
patients. The standard also includes a day-to-day food distribution based on a balanced
nutrition guideline of rice / exchange, vegetable A / B / C, fruit, animal side dish or
exchanger, vegetable side dish or exchanger, milk or exchanger, oil or exchanger. For more
details can be seen in Table 2.1 and Table 2.2.
Table 2.1
Type of Diabetes Mellitus Diet according to Energy Content, Protein, Fat and Carbohydrate
Jenis diet Energi (Kkal) Protein (g) Lemak (g) Karbohidrat (g)
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I 1100 43 30 172
II 1300 45 35 192
III 1500 51.5 36.5 235
IV 1700 55.5 36.5 275
V 1900 60 48 299
VI 2100 62 53 319
VII 2300 73 59 369
VIII 2500 80 62 396
Source : Penuntun Diet, 2006
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Table 2.2
The amount of food per day according to standard diet of diabetes mellitus
(in units of exchange)
Group of Standard diet

materials
food
1100 1300 1500 1700 1900 2100 2300 2500
Rice /exchanger 2½ 3 4 5 5½ 6 7 7½
Fish /exchanger 2 2 2 2 2 2 2 2
Meat/penukar 1 1 1 1 1 1 1 1
Tempe/penukar 2 2 2½ 2½ 3 3 3 5
vegetable
/exchanger A S S S S S S S S
vegetable /penukar
B/exchanger B 2 2 2 2 2 2 2 2
Fruit/exchanger 4 4 4 4 4 4 4 4
Milk/exchanger - - - - - - 1 1
Oil/exchanger 3 4 4 4 6 7 7 7
Table 2.1 shows the type of diet and nutritional content, while Table 2.2. shows the
description of the menu pattern, from the menu pattern can be described menus tailored to
the patient's condition. For example there is a patient fat DM, age 56 years, then after
dilakuan assessment is determined DM diet is 1500 Kcal, ptn 50 g. The translation into the
menu can be seen in Table 2.3. As an example.
Table 2.3
Menu Pattern 1500 kcal based on meal time
Makan Pagi Makan Siang Makan Malam

Rice 1p Rice 1p Rice 1p
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Fish 1p Meat 1p Fish 1p
Tempe 1p Tempe 1p Tempe 1p
vEgetable A (s) vEgetable A (s) vegetable A (s)
Oil 1p vEgetable B 1p vegetable B 1p
Fruit 1p Fruit 1p
Oil 2p Oil 1p
Snack 10.00 Snack 16.00
Fruit 1 p Fruit 1p
From the menu pattern can be translated to the menu as an example menumakan
morning. Breakfast: White rice, Balado fish + tempe, boiled vegetable squash or white rice ¾
cup, omelet, stir-fry kobis and tempe. To make it easier to make a menu variation then there
should be a list of ingredients of the exchanger.
Diet for examination tests
Dietary standards for examination are used to check for abnormalities of organ abnormalities
such as gastrointestinal tract, kidney, gallbladder, colon and others. The function of the diet
is to clarify the results so that diagnosis can be done well. For example, to determine
whether there is bleeding in the gastrointestinal tract, can be done with a benzidine test. This
diet is usually given for 2-3 days only, food is given in soft form or strain, by giving the food
that there is no content of haemoglobin and chloropil.
Exercise
To deepen your understanding of the above material, do the following exercise.
Explain 3 dietary standards in the hospital!
explain the differences in general standards and special dietary standards Hospital!
Explain the difference and equation of liquid food clear, full and thick!
169
explain why diabetes mellitus diet made 8 standard!
Explain the difference between high energy diets and low energy diets!
3 dietary standards in hospitals are general dietary standards, special dietary standards and
special dietary standards for testing.
Common standards are commonly used in hospitals and hospital feeding guidelines are used.
Which includes common standards of ordinary foods, soft foods, filter foods and liquid foods.
While the hospital's specific food standard is a standard food made related to the underlying
disease and emphasizes the modification of its nutrients according to its illness or diseased
organ organs.
The fluid food can be given by oral, enteral and parenteral, whereas the difference in liquid
food is very low in nutrient content and limited in its nutrients so it is recommended to be
given in 1-2 days only. While full and thick liquid foods have relatively higher nutritional
value, and basic food ingredients can be selected from foods that have high biological and
density values.
The division of dietary diet is 8, is easier in its use, considering that there are diabetic
patients who depend on insulin and insulin dependent and usually sufferers have different
characteristics, so the provision of diet is adjusted to the condition of the patient.
High energy diets are defined as having energy content above 25% -50% of the bias, low
energy diits are diits arranged with lower energy 25-50% than normal requirement.
Summary
There are 3 standard hospital meals that are common standards, special standards, and
standards for tests related to diagnostic sharpening. In practice the provision of diet in the
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patient's basic therapy using a standard standard but in the form of food reference to the
general standard.
Test 2
In the following table there is an ordinary food lunch menu, try modifying it according to the
food form of soft foods, filter foods, and liquid foods.
Makanan biasa Makanan lunak Makanan saring Makan cair
Rice
Balado meat
Fried tempe
Vegetable lodeh
Lalapan and sambal - -
Papaya cut
Mr. A, age 50, has just been diagnosed with hypertension. The results of discussions with
nutritionist Mr. A set with a low salt diet II, then the amount of salt that may be added in
food is ....
No additions at all
One and a half teaspoon
One tea spoon
Half tea spoon
Two teaspoons
Mr. B, fat, age 60, complains of constipation. The recommended diet is high in fiber.
Examples of morning food is jam sandwich, orange juice and milk. If you want to be improved
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then the breakfast menu is the highest content of it is ....
White bread, scrambled eggs + carrots, tomato juice and milk
Wheat bread, scrambled contents of vegetables + eggs, fruit pieces
Havermouth + currant + milk, pineapple fruit cut, boiled soybeans

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Havermouth + banana + milk, guava juice, chocolate bar
White bread + banana + chocolate bar, the sweet, citrus fruits
Mr. A, age 40, diabetic patients, BMI: 17.8 (thin), then the standard diet is given.
Diet DM II 1300 kcal
Diet DM III 1500 kcal
Diet DM IV 1700 kcal
Dietary DM VI 2100 kcal
Diet DM VII 2300 kcal
The food ingredients that can be administered to patients undergoing benzidine

examination are ....
Beef
Spinach
Chayote
Avocado
Tempe
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6
Topic 3
Nutritional Support
Students I love, we are now on the topic of nutritional support. Adequate food fulfillment is
one of the keys to preventing risk factors for morbidity and mortality, especially in patients
with malnutrition risks. Feeding efforts not only to meet the nutritional needs but to prevent
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the occurrence of hypermetabolism process. With hypermetabolic conditions will occur
protein catabolism, degradation of smooth muscle tissue, and cause the patient's condition
worsened. An additional 20-25% is needed for both energy and protein to overcome it.
Ironically the patient's food intake in the hospital usually declines.
In this nutritional support topic will be presented in 3 parts namely the scope of support
Nutrition, the steps of giving, and type of nutritional support. The scope of nutritional
support will explain the purpose and how it is given; Measures will be initiated from
assessment or assessment of nutritional status, planning, implementation, monitoring and
evaluation of nutritional support; and last will explain about the type of nutritional support
that is enteral food and parenteral food.
NUTRITION SUPPORT SCOPE
The purpose of providing nutritional support
Nutritional support is provided to achieve and maintain optimal nutritional status to achieve
anabolic or positive protein balance conditions. There are four indications that the patient
needs to be given nutritional support:
If the patient shows any lack of certain nutrients;
Patients are at risk of malnutrition;
Patients under hypermetabolic status;
Patients have a daily nutritional intake not in accordance with nutritional needs. Nutritional
support is needed foods that have adequate nutritional value of energy, protein, fat,
carbohydrates, vitamins and minerals and antioxidants.
Way of giving
The provision / provision of nutritional support can be either enteral feeding or
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parenteral food or a combination of both. Enteral feeding is food that is usually given in
liquid form so that it can be administered orally (mouth) or through a pipe that can enter in
the gastrointestinal tract. While parenteral food is a liquid nutritional formula that is directly
administered through the circulatory system.
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NATURE SUPPORTING STEPS
In the provision of nutritional support both oral, enteral and parenteral there are steps that
are undertaking nutritional assessment; planning nutrition support; implementing nutrition
support and monitoring and evaluation.
Assessment of Nutrition Status
It has been explained earlier that the purpose of providing nutritional support is to achieve
the optimal nutritional status that is the basis of curing the disease. Therefore, the
assessment of nutritional status should be detailed which begins by conducting interviews to
obtain data related to nutrition. After that, an assessment related to physical test is the
measurement of anthropometry to see the clinical symptoms of malnutrition. A biochemical
assessment of the body to measure whether there is a depletion of visceral protein deposits;
followed by evaluating somatic protein stores; assessed physiological changes with
implications on nutritional assessment and reviewed psychological assessments of patients
to determine factors that influence dietary intake. From the results of assessment of
nutritional status above can be made conclusion that is: Normal nutritional status; at risk of
mild malnutrition; at risk of moderate malnutrition and at risk of severe malnutrition.
Planning Nutrition Support
Nutritional support should be provided immediately if the patient has shown any signs
weight loss, decreased appetite and gastrointestinal disturbances and under nutritional
status conditions at risk of undernourishment. Below are some examples of nutritional
stausal conditions and how the management of the diet so as not to happen less nutrition.
Table 2.4
Categories of Status and Management of Nutrition
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Status Gizi Contoh Tujuan Manajemen Gizi
Tidak terdapat kekurangan Stroke Keseimbangan Bergantung pada fungsi nafsu

gizi namun kondisi klinis N netral makan dan saluran cerna:
menempatkan orang suplemen diet, makanan
tersebut berisiko kurang gizi enteral atau parenteral atau
kombinasi kebutuhan gizi.
Somatik dan/atau KEP, Kesimbangan Enteral atau hiperalimentasi
berkurangnya protein cachexia. nitrogen parenteral: 40-45 Kkal/ kg
visceral Positif BBA; 1,5-2 mg pro/kg BBA
Hypermetabolik dengan Trauma, Keseimbangan Enteral atau hiperalimentasi
atau tanpa defisit zat gizi luka nitrogen netral parenteral: sampai 55 Kkal /
bakar, dan positif, kg BBA; Lebih dari 2 mg pro/kg
operasi, tergantung BBA
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Status Gizi Contoh Tujuan Manajemen Gizi
infeksi kebutuhan
perbaikan
jaringan
Source: The nutritionist-Dietetians'Association of the Philippines Foundation (1997).
Implementation of Nutritional Support Adjusted to Patient Condition

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Below is a scheme of how to implement nutritional support. If the condition of the
gastrointestinal tract is good and the oral input is good then nutritional support can be given
orally. However, if limited oral intake for example there are swallowing disorders, but good
gastrointestinal function can be given enteral feeding, but if the gastrointestinal tract does
not work then the food is given parenterally. For more details can be seen in the scheme of
nutritional therapy algorithm below.
Monitoring and evaluation
Monitoring and evaluation is done by using appropriate indicators
carried out at the time of doing nutrition services. The main evaluation is how the patient
receives the food or regimen that is given. The food received food is depleted or not
exhausted and the body's power is whether there is vomiting, nausea, diarrhea and
constipation. related to the outcome of whether regimens may improve body weight,
biochemical status, clinical and length of stay.
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179
ALGORITMA TERAPI GIZI
Kajian gizi
Fungsi saluran
cerna
Ya
Tidak
Nutrisi
Nutrisi Oral Nutrisi enternal parenteral
Jangka Jangka
Jangka
Panjang Pendek
Gastroto Pendek
my Nasogastric
Jejunusto Nasoduoden
my al
Nasojejunal
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Fungsi
saluran PN
PN perifer sentral
cerna
Normal Terganggu
Zat Fungsi saluran
Gizi/Formula cerna
Formula Khusus
standar membaik
Ya Tidak
Asupan Asupan Asupan
cukup, kurang, cukup,
ditingkatk Suplemen Ditingkatka
an PN n
menjadi
diet yang
Pemberian lebih
Makanan kompleks Pemberian
Melalui makanan
oral melalui
oral sesuai toleransi

Ditingkatkan
Menjadi nutrisi
Enteral total
Sumber: Lutz, C dan Przytulski K (2010).
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Gambar 2.2
Algoritma Terapi Gizi
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TYPES OF NUTRITION SUPPORT
It has been explained in the previous discussion that the provision of nutritional support can
be done orally, enteral and parenteral. But in the following discussion only focuses on
enteral and parenteral foods alone.
Enteral food
Enteral foods are foods that can be administered through a pipe or oral. The delivery time
can be given between main meals or along with the main meal. The amount of energy given
approximately 1 cc / 1 kcal to 1 cc / 1.5 kk al with the amount of liquid between 200-300 cc
drinking times. The type of oral enteral food can be prepared with adequate lactose, or low
lactose, high fiber or low fiber depending on the patient's condition. The effectiveness of this
gift depends on the patient's acceptance. Problems that often arise this gift is diarrhea,
bloating, constipation. Therefore, initial administration should be given in the form of low
density first, then slowly improved. Enteral feeding through the pipe is given if the patient is
unable to receive orally, and the oral intake is less than 30%, but the gastrointestinal tract is
still functioning well.
Contraindications that can arise with enteral feeding include: - stomach ulcers; peritonitis,
vomiting, intestinal paralysis, diarrhea, acute pancreatitis, shock, refusal or refusal patients.
The main things to consider in making enteral foods include osmolarity, digestibility, energy
density, lactose content, fat content, viscosity value.
Type of Formula
Standard / intact / polymeric formulas; aimed at patients who can digest and absorb
nutrients without difficulty. Most of the formulas consist of one or a combination of protein
isolates.
Hydrolysis Formula; makes it easy to digest - some proteins are given amino acid-derived
proteins (substances made from free amino acids and usually low fat and from MCTs ---
patients with gastrointestinal disorders.
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The modular formula: incomplete consists of only one nutrient (protein, CHO or fat) formula
supplemented with vitamins / minerals.
Example: Polymeric / Intact / Standard Formula: full liquid food; Nutrien, diabetasol, ensure,
entresol. While hydrolysis formulas such as peptamen, criticare HN; vivonex T.E.N. and
modular formulas such as Protein module: casec; pro-mod; CHO module: moducal; polycose
liquid; Module fats: mCT oil; microlipid
Characteristics that differentiate enteral foods:
The nutrient density of the standard formula is 1.0 kcal / ml to 1.2 - 2.0 kcal / ml.
Residues and fibers: high-fiber formulas are usually given in constipation patients, short
bowel syndrome.
Osmolality (measure of concentration of molecules and ion particles in liquids): Formula
usually has osmolality of 300mlos / kg of isotonic formula.
Hypertonic if osmolality> serum osmolitas.
Selection of formulas
If the condition of the gastrointestinal tract normal, normal BMR is recommended given the
type of polymeric.
If not able to eat, there is anorexia, eshopagus reflux should be given polymeric, isotonic and
low lactose.
If the metabolism is high: then given high density enteral feedings or large amounts.
Gastrointestinal disturbances such as pancreatic disorders, lower gastrointestinal infections,

etc.
The characteristics of the ideal formula of enteral feeding
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Affordable prices
Safe from the aspect of bacteria
Its osmolinity is low
Energy Density 1 cc / 1 kcal
Contains relatively good protein, ie every 120 cc contains 6.25 g protein
Adequate nutrients with the addition of vitamins and minerals and electrolytes if there is
indiikasi
Homogeneity and viscosity are appropriate
Delicious and easy to give
Examples of enteral foods are not commercial
Enteral feeds can be made by using food ingredients that have complete nutrients. Among
them are often developed in hospitals known as liquid food without milk and with milk.
Below is a table of food and nutritional value of liquid food without milk.
Table 2.5
Food ingredients given daily in liquid foods without milk
Energi (kkal)
Bahan Makanan 1000
Urt gram
Tepung beras 1 ½ sdm 10
Telur 2 butir 100
Kacang hijau 10 sdm 75
Wortel ½ gls 50
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102
Dietetik Penyakit Infeksi 
Energi (kkal)
Bahan Makanan 1000
Urt gram
Air jeruk ¼ gls 50
Gula pasir 10 sdm 100/75-80
Minyak kacang 1 sdm 10/20
Volume akhir setelah ditambah air 5 gls 1000 ml
Nilai Gizi
Energi (kkal) 968

Protein (g) 30.9
Lemak (g) 18
Karbohidrat (g) 175
Kalsium (mg) 189
Besi (mg) 8.86
Vitamin A (SI) 6747
Tiamin (mg) 0.78
Vitamin C (mg) 33.5
Natrium (mg) 86.9
Kalium (mg) 1441
Sumber : Penuntun Diet Anak,
2014
Parenteral Food
Understanding
Parenteral food is food in the form of liquid given through intravenous, because the body
can not accept orally or enteral.Indikasi main is the gastrointestinal tract does not work. In
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addition, these foods are usually administered to postoperative patients who can not receive
food orally and enterally. This food is also given to patients who have severe gastrointestinal
function impairment for 7 days or in ICU patients, or regular care who should have enteral
feed but 24 hours can not receive. In other words that parenteral food is given to patients
who are unable to absorb food; not eating anything more than 3 days or in addition if intake
of enteral is inadequate.
Giving involves nutrition care team that is nutritionist, doctor, nurse and pharmasis.
Nutrients present in parenteral foods are nutrients in simple form such as amino acids,
dectrosa (CHO), fatty acids, micronutrients and additional nutrients. It should be noted that
parenteral foods should not be administered to patients experiencing hemodynamic crises
such as shock or untreated dehydration.
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What conditions require parenteral food?
The condition indicates rather severe as Ileus obstruction. Peritonitis, Enterokutan Fistula,
Severe Malabsorption Syndrome, Vomitus, Severe Diarrhea, Malnutrition of protein or
protein-caloric and cancer. Determination of parenteral feeding, first is assessed whether the
patient's gastrointestinal tract can be used safely or not. If no answer then parenteral food
should be given. Parenteral use <one week can be used Parenteral Nutrition Peripher (PPN),
if more than one week is recommended using Total Parenteral Nutrition (TPN).
Table 2.6
The primary indication of the patient requires parenteral food
Sebelum Pembedahan Pasien kurang gizi yg kehilangan BB > 10%

pembedahan dihitung dari BB terakhir
Komplikasi sesudah
Sepsis, obstruksi usus ( ileus ), atau gastrointestinal stasis
pembedahan
Short bowel
Post infarction of bowel , trauma
syndrome
Penyakit saluran
Penyakit Crohn, ulcerative colitis , pankreatitis, enteritis radias
cerna
Luka bakar, kecelakaan, pasien yg dirawat intensif, gagal ginjal
Trauma besar
Akut
Source ; Lutz, C dan Przytulski K (2010).
Can parenteral feeding cause complications?
It is well known that parenteral food is expensive, complex and can cause complications.
There are 3 types of complications namely technical complications, infection and metabolic.
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Technical complications are associated with the installation of catheters such as
pneumothorax, air embolism. The impact of a technical infection can lead to infection
complications characterized by fever and phlebitis occurring at the site of installation.
Metabolic complications occur after food enters the body which can cause glucose balance
disorders (hyper / hipo), electrolytes (hypokalemia, hyperkalemia).
What is the parenteral food composition?
Basically, parenteral foods should meet the nutritional needs of patients. References
commonly used are energy: 25-30 kcal / kg BW / day; Protein: 1 - 2.5 g / kg BW / day, Fats: in
the form of fatty emulsions; Vitamins & minerals: As needed.
Nutrients needed for parenteral food may also be used the provision should contain CHO
which is used to maintain the intactness of blood sugar is 5-7 g / kg / day, protein / amino
acid element is 1-2 g / kg / day, the fat is the source essential fatty membrane cell
components or prostaglandin precursors required 0.3-1 g / kg / day, the need for adjusted
vitamins and minerals
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with enzyme activity, and nutrient metabolism. Amino acids are often recommended is a
branch chain amino acid or Branched-Chain Amino Acid (BCAA) is a combination of Isoleusin-
Leusin-Valin. Most of the Amino Acids are metabolized in the liver, but BCAA is activated by
skeletal muscle. The result is nitrogen, then combine with the breakdown of glucose  which
produces carbon to form glutamine which is essential for cell work in the wound healing
process, as fuel for intestinal cells and the formation of ammonia in the kidneys.
How to give parenteral food
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When viewed from the way infusion into the body there are 2 types of giving way that is
Peripheral Parenteral Nutrition (PPN) and Total Parenteral Nutrition (TPN).
VAT is administered via a catheter to a peripheral vein, and TPN through a catheter to a
central vein: jugular veins and subclavian veins. VAT is known as IV intarvena food that is
often used in hospitals. IV intravenous fluids usually consist of water, droplets, electrolytes,
and sometimes nutrients used to maintain fluid, electrolyte and acid-base balance. Amino
acids and fats may be administered by peripher. To prevent ketosis, emulsion is no more
than 60% of the total energy. The concentration of dectrose is not more than 10%, because
the peripheral vein can not be passed if the concentration exceeds 900 mOsmol / kg. The
weakness of VAT is that it can not provide adequate energy. The amount of energy that can
be met from the maximum VAT 1800 kcal. Hence the use of VAT is only short-term less than
10 days and often just as a supplement or complement of enteral feeding. How to calculate
energy in parenteral food: in the often written label D5W, D10 W, D50W. This code shows
the concentration of dectrose in water. D5W means 5% dextrose in 100 ml water, D10 W =
10% dextrose in 100 ml water.
Exercise Example: Mr. A gets a 1 liter D10W infusion. How much kcal energy
obtained from the infusion?

Answer: How to calculate how big the energy of D10W? The first translation of the D10 W
means 10% dextrose in every 100 ml of fluid, how many g dextrose if Master A consumes
1000 ml, the second makes the equation formula
10/100 ml = x / 1000 ml  100 x = 10,000- x = 100 g
It is known that 1 g dextrose = 3.4 kg - 100 g dectrose = 100x3.4 kcal-340 kcal.
What about TPN? It has been explained that TPN is a parenteral food that enters the body
through the superior vena cava which is one of the largest veins in the human body.
Parenteral food can provide foods with high nutritional value compared to VAT. The
advantages of TPN can be given to patients requiring nutritional support for more than 10
days, patients suffering from malnutrition requiring rapid repair, eg, preparation of surgery.
In addition TPN is usually given also postoperative patients who experience complications,
patients with very low intake and malabsorption.
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TPN Kelebiahan is a large infusion volume, fast flow, hypertonic. Patient is more comfortable
because there is no need to go back and forth intravenously. The energy of parenteral food
is adjusted to the needs of the patient. The first step is to calculate the need for fluids,
followed by calculating energy requirements, protein, new CHO and fat, and electrolytes and
vitamins.
In general, parenteral liquid food is packed in 500 ml. Pharmasis likes to mix dextrose with
proteins in one bag, while the fat itself. The frequently used protein concentrations are 5%,
8.5%, and 10%, fat is 10% and 20% lipid, dextrose D5W and D50W.
The benchmark used in calculating energy content in parenteral food is
Dextrose = 3.4 kcal / g
20% lipid = 2.0 kcal / ml
10% lipid = 1.1 kcal / ml
Protein = 4 kcal / g
1 g of nitrogen = 6.25 g protein
Example of exercise: Mr. A receives 500 ml of D50W, 500 ml of 10% amino acid and 250 ml
10% lipid. Calculate how much Mr. A's kcal is filled from the food and count
fulfillment of gizimakronya.
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Answer:
Dextrose (CHO) % concentration X avolume = ..... g dextrose
50/100 x 500 = 250 g dextrose (1 g dextrose = 3.4 kcal)
So the energy content of the source of CHO = 250 x 3.4 kcal = 850 kcal
Amino acid (ptn) % concentration x volume = .... g protein
10/100 x 500 ml = 50 g protein (1 g ptn = 4 kcal)
So the energy content of the amino acid (ptn) = 50 x4 kcal = 200 kcal
Fat (L)  kcal / ml x volume in ml = ... ..food fat
1.1 kcal / ml x 250 ml = 275 kcal fat
So the total energy of the food is = 850 kcal + 200 kcal + 275 kkal = 1325 kcal
The conclusion of these foods provides 1325 kcal, 21% comes from fat, 15% of protein, and
64% of CHO.
Monitoring
Monitoring, especially in the feeding of parenteral TPN needs to be done. Given the
metabolic complications most often occur in psien with TPN. Initial monitoring is a vital sign
such as respiration, pulse and temperature; weight, serum electrolytes; blood glucose,
creatinine levels, BUN content, magnesium, phosphorus, calcium in the blood; lipid profiles,
liver function tests, albumin / prealbumin, total blood, energy intake and nutrients.
Monitoring every 4-8 hours each day is a vital sign; every 24 hours is weight, fluid input and
output; electrolytes, glucose, creatinine, BUN in the blood for several days if it is stable can
be done 2 times per week. Weekly monitoring can be done is the function of liver, albumin,
calcium, magnesium and phosphor in the blood, and energy intake and actual nutrients and
others depending on the condition of the patient.
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Exercise
192
Mrs. A, 80 years old, has a swallowing disorder, but the intestine is still functioning well.
Currently Ny. A given enteral feed 6 x 200 cc commercial enteral food of polymeric type.
Please give an example of a commercial product that belongs to a polymeric type.
Explain the advantages of enteral feeds from the parenteral food for Ny.A?
Explain the 5 factors that may influence the selection of enteral formulas and
. Explain 3 ways of enteral feeding in tuh and 2 ways parenteral food is distributed in the
body?
Explain 4 possible complications if the patient is administered enterally and explain and give
reasons for the 3 factors that need to be monitored in enteral / parenteral feeding?
Calculate the energy and protein content of 1 liter of parenteral food consisting of 25%
dextrose and 4.25% amino acid, then added another 250 ml of the 20% fatty emulsion.
Explanation of Exercise Answers
Which includes polymeric formula is diabetasol, ensure, nutren
.Excess of enteral feed compared to parenteral food is less costeffectiveness; lower

likelihood of infection; repair damaged organs; surgical intervention is lowered; maintain
gastrointestinal function.
Factors in influencing the selection of enteral foods are density is a major factor. Not all
patients tolerance with foods with high density (minimum density of 1cc / 1 calorie and the
highest 1.5 cc / 1 kcal most tolerant). Then the new osmolality (+300 mOsm / kg), the three
vitamins and minerals, the four protein content (10-15% kcal), and the fifth is the price.
Enteral entering food in the body can be through 3 ways of naso gastric, nasointestinal and
gastrostomy while parenteral feed through the path of TPN and VAT.
the complications that occur in feeding through pipes are dehydration (food pipe syndrome);
electrolyte imbalances, hyperglycemia, and excess / lack of intake. The first monitored is the
amount of intake and output that comes out, weight; the second thing monitored is the
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blood sugar level whether there is hyperglycemia or not, due to hyperglycemia shows the
development of new complications. Third is the skin turgor whether there is edema or
dehydration.
1000 ml consists of 25% dextrose and 4.25% amino acid = 850 kcal + 170 kcal = 1020 kcal and
250 ml 20% fat emulsion = 250 x 2 kcal / ml = 500 kcal. So the energy obtained from the food
is 1020 + 500 kcal = 1520 kcal.
Summary
Nutrition support is provided immediately if the patient's condition is already at risk of

malnutrition, and in hypermetabolic conditions. Forms of nutritional support are foods that
have high density, usually liquid form full / thick so it can be given in the form of oral,
enteral, and parenteral. Provision of nutritional support in enteral form if gastrointestinal
condition still function well, whereas parenteral food if gastrointestinal function is not
working.
Test 3
Choose the best answer
Parameters that are one of the most sensitive indicators to the success of nutritional services
and are very helpful to make the goal of nutrition services, which are ....
Weight
Height
Arm circumference
Waist size
Hip circumference
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Which is not the reason given nutritional support is ....
Patients are at increased risk of nutrition
The patient had hypercatabolism
Patients are at risk of poor / nutritional status
Patient intake is less than 50% requirement
Pasein indicates a lack of certain nutrients
Inspection data to support the patient's nutritional diagnosis and determine nutritional
intervention and monitoring materials as well as evaluation of nutritional therapy, is ....
Anthropometric data
Physical examination data
Clinical examination data
Personal history data
Laboratory check data

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Osmolaritas, daya cerna, densitas energi, kandungan laktosa, kandungan lemak, nilai
viskositasnya, hal-hal tersebut diperhatikan dalam membuat makanan ....
Enteral
Parenteral
Oral dan enteral
Oral dan parenteral
Enteral dan parenteral
Berapa sumbangan energi dari 200 ml 50% dextrose, 800 ml 10% asam amino, dan 300 ml 10
% lipid ....
400 kkal + 272 kkal + 330 kkal = 982 kkal
340 kkal + 320 kkal + 330 kkal= 990 kkal
400 kkal + 320 kkal + 330 kkal =1050 kkal.
340 kkal + 320 kkal + 600 kkal =1260 kkal
400 kkal + 272 kkal +600 kkal = 1272 kkal
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197
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Key Test Answers
Test 1
Maintain and achieve optimal nutritional status.
Probable duration of illness / duration of illness.
Tolerant to change-individual-simple.
Provide food according to the patient's tolerance.
Consistency and mode of giving.
Test 2
1)
Makanan biasa Makanan lunak Makanan saring Makan cair

Nasi Nasi tim Bubur saring Campuran dari:
Balado daging Daging bumbu semur Gadon daging tepung beras,
Tempe goreng Tempe bacem Perkedel tempe bakar susu, telur, gula
Sayur lodeh Sayur bobor Soup cream bayam pasir, dan jeruk
Lalapan dan sambal - - manis,
minyak/margarin
Dijadikan sati
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dibuat minuman
Papaya potong Papaya potong Jus papaya
dengan
perhitungan 1 cc=
1 -1 1/2kkal
D. Half a teaspoon
C. Havermouth + raisins + milk, pineapple fruit cut, boiled soybeans
E. Diet DM VII 2300 kcal
C. Siamese Pumpkin
Test 3
A. Weight loss
A. Patients are at increased risk of nutrition
E. Laboratory examination data
E. Enteral and parenteral
B. 990 kcal

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110

Glossary
Dietary regimen: Racikan menu / menu patterns that have been customized with
patient condition.
BMR / Basal: The amount of energy (kcal) required by the body to
metabolism rate of organs work.
BBA / Actual weight: Current weight
Cachexia: The condition is very thin due to the accompanying malnutrition
metabolism disorders CHO and fat and usually occurs
in AIDS patients
200
111
201
Daftar Pustaka
Chima CS, Barco K, Dewitt ML, et al. 1997. Relationship of nutritional status to length of
stay,hospital costs and discharge status of patient hospitalized in the medicine service.
J AmDiet Assoc ;97(9):975-8.
Depkes RI. 2009. Pedoman Penyelenggaraan Tim Terapi Gizi di Rumah Sakit.
Dong KR dan Imai CR dalam dalam Mahan, LK; Stump, SE; dan Raymond, JL. 2012. Krause,s
Food and the nutrition Care Process; Medical nutrition therapy for HIV and AIDS, p864
-880.
Instalasi Gizi dan Asosiasi Dietisesn Indonesia. 2006. Penuntun diet edisi baru. Gramedia, hal
30 -119.
Mueller DH dalam Mahan, LK; Stump, SE; dan Raymond, JL Krause,s. 2012. Food and the
nutrition Care Process; Medical nutrition therapy for Pulmonary Disease; p788-
795Lutz, C dan Przytulski K (2010). Nutrition and Diet therapy; Nutrient delivery ;
edisike 5: pp 279-299.
R. Dwi Budiningsari1 & Hamam Hadi. 2004. Pengaruh Perubahan Status Gizi Pasien
DewasaTerhadap Lama Rawat Inap Dan Biaya Rumah Sakit; Jurnal Gizi Klinik Indonesia,
Volume 1 No.1 Mei 200436.
The nutritionist-Dietetians’Association of the Philippines Foundation. 1997. Fundamental

intherapeutic Nutrition; Dietary modifications; Cahpter 3.p 19-40.
AsDI, IDAI, Persagi. 2014. Penuntun Diet Anak (ed.3). Jakarta: Badan Penerbit Fakultas
Kedokteran Universitas Indonesia.
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CHAPTER V
NUTRITION OF NUTRITION IN BAD NUTRITION CHILDREN
PRELIMINARY
Disease deficiency in Indonesia is still high enough, due to the still high infectious diseases
that cause the body needs increased but the patient experienced a decrease in the ability to
receive food and if this condition occurs in patients with limited socioeconomic it will get
food that is not qualified so it will worsen the condition so that causing long healing
processes and resulting in decreased nutritional status such as suffering from less energy and
protein or iron nutrient anemia.
This chapter focuses on nutrition care in less energy and protein deficiencies in children and
deficiencies that are common in Indonesia: anemia, vitamin A deficiency (KVA) and Iodine
Deficiency Disorders (GAKI). This chapter discusses the basic theories of nutritional care in
less protein energy diseases and their implementation will be discussed in Chapter 8. For the
completeness of this chapter 4, it is necessary to refer to the Technical Guidelines for
Malignant Malnutrition Management Book I and Book II published by the Ministry of Health
of the Republic of Indonesia, Directorate General of Bina Nutrition and Health of Mother and
Child Directorate of Bina Nutrition 2011 and materials can be uploaded on Gizinet's website.
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148
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Topic 1
Nutritional Nutrition in Less Protein Energy Disease
This topic will discuss Nutrition Care in Disease of Less Energy and Protein especially for
children which include cause, signs and symptoms and Nutritional Nutrition in Child Less
Energy and Protein.
CAUSES OF LACK OF ENERGY AND PROTEIN
Factors causing the occurrence of Disease Less Energy and Protein on the one hand caused
by infectious diseases suffered by a person such as gastrointestinal infections such as
diarrhea due to cholera bacteria, typhoid abdominalis or respiratory tract infections (eg lung
tuberculosis) is getting worse if it lasts longer. A person suffering from infectious diseases, his
body requires energy and high nutrients to overcome the disease as a result of catabolism
(high body temperature) and for the healing process of the disease. However, in patients
with infection will experience a decrease in food intake caused by patients complaining of no
appetite, so this condition causes the patient to lose weight either mild or severe levels
known as Protein Energy Less.
On the other hand if a person does not get food intake that contains energy and adequate
nutrients according to their needs, the body's resistance decreases so susceptible to disease
Less Protein Energy. This condition is generally common in societies with low socioeconomic
status, so that limited access to quality food. This condition is more severe when it occurs in
children who are experiencing growth and development process that will affect the quality
of life in the future. In the picture below can be seen the relationship factors described
above and even the possibility of these factors will cause fatal or death in a person suffering
from Less Energy and Protein Disease.
205
Sumber : TOT Pelatihan Tata Laksana Anak Gizi Buruk
Gambar 4.1
Penyebab Kurang Energi dan Protein
149
206
GROWTH AND DEVELOPMENT
Understanding
Growth is the increase in physical size over time. Example: child
will gain weight and height until adulthood. The development is the increase of body
functions psychomotor, mental and social. Example: the child will develop begin to lean
body, stomach, crawl, walk, stand and talk. In children who suffer from disease Protein
Energy Energy will be obstacles in the process of growth and development.
Growth Monitoring
To monitor growth from birth to toddler can be monitored based on their weight every
month recorded on Healthy Card (KMS). By noting the child's weight gain will be seen
whether the child grows in line with the growth of healthy children. Children are said to be
healthy if their weight follows the growth bands listed on the KMS while the child is said to
be experiencing growth restriction (indicator of disturbance) if the weight is fixed or on the
KMS chart depicted horizontally or decreases the growth chart below.
Growth of children is said to be normal when the weight gain according to the minimum age
increases as shown in the following table:
Table 4.1
Minimal Weight Increase Underfive
Usia Penambahan Berat Badan

(bulan) Minimal (gram)
Laki-laki Perempuan
1 800
2 900
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3 800
4 600
5 500
6 400
7 400
7 – 10 300
8 – 11 300
11 – 60 200
12 - 60 200
Sumber : Direktorat Gizi. Kemenkes. (2014) Pelatihan bagi Pelatih Tata Laksana Gizi
Buruk bagi Tenaga
Kesehatan.
150
By comparing the child's weight with the increment to be achieved by age, it can be used as
a standard whether the child is healthy or has nutritional problems. To know clearly how the
child's weight growth is said to be normal or not normal based on the graph in KMS can be
seen in the picture below.
208
Source: Directorate of Nutrition. Ministry of Health. (2014) Training for Trainers of
Malnutrition for Power Management
Health.
Figure 4.2
Determine the Growth Status of the child based on Healthy Goal Card (KMS) of Toddler
In children who suffer from less energy and protein diseases then the results of weight
weighing can be used as a limitation whether the child has been experiencing disease energy
and protein. As the table below, the child is said to have malnutrition status or as a sign of
Disease Energy Deficiency and Protein if clinically can be seen thin, the presence of minimal
edema on both back and anthropometry results showed the value of BB / TB or PB <70% of
the median or Z score
3 SD. It should be noted when determining the weighing result, in a child with odema the
possibility of more weight so that the results of anthropometric measurements may not
show weight restrictions less or nutritional status of less / bad.
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151
Tabel 4.2
Penentuan Status Gizi secara klinis dan antropometri
Status Gizi Tanda Klinis Antropometri (BB/TB-PB)

Gizi Buruk Sangat Kurus dan atau edema <-3 SD *)
minimal pada kedua punggung kaki
Gizi Kurang Kurus ≥-3 SD - < -2SD
Gizi Baik Tampak Sehat -2 SD – 2SD
Gizi Lebih Gemuk >2 SD
*) If there is BB edema can be more
Source: MoH RI, Malnutrition Malnutrition Chart (Book I), 2011
SIGNS AND SYMPTOMS LESS ENERGY AND PROTEIN
In children with less Protein Energy Deficiency than can be known from the results of
anthropometric measurements, it can be seen from the accompanying clinical data and can
be classified into:
Malnutrition with Edema (Kwashiorkhor)
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In children with this qualification show the following signs:
Changes in mental status such as: apathetic, fussy
Thin hair, like corn hair, is easily removed without pain or loss
The face is round and swollen
A look of wistful eyes
There is an enlarged heart
At least there is edema on both backs, is pitting edema that when pushed back surface of the
foot does not return / not elastic
Muscle shrink (hypotrophy)
Skin disorders in the form of pink spots that extend and change color to dark brown and peel
(crazy pavement dermatosis)
Frequent infections (commonly acute) such as diarrhea, pneumonia Note: The degree of
edema *)
Odema in both backs
++ Odema in the legs and forearms
+++ Odema throughout the body (face and stomach)
*) is used to determine the amount of fluid administered
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152
212
Health.
Figure 4.3
213
Malnutrition with Edema (Kwashiorkor)
Malnutrition without Edema (Marasmus)
In malnourished children with no edema, the visible signs are:
Looks so skinny, like a bone wrapped in skin
Face like a parent
Fussy and crybaby
Skin wrinkles, tissue subcutis very little to none (like wearing baggy pants 'Baggy pants'
The stomach is generally concave, prominent ribs (ribs like icing or 'pianosign')
Often accompanied by infectious diseases, it is generally chronic and recurrent (eg persistent
diarrhea).
153
214
215
Health.
Figure 4.5
Malnutrition Children Marasmik-Kwashiorkhor
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155
NUTRITION OF NUTRITION IN LACK OF ENERGY AND PROTEIN
Assessment
To establish a medical diagnosis and nutritional diagnosis, an important assessment
performed on children with diseases Less Energy and Protein are:
Physical and clinical examinations such as:
Anthropometric measurements
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Signs of important dangers such as presence / absence of shock, letargis, vomiting and / or
diarrhea (dehydration), hypothermia, hypoglycemia
Feed intake with 24-hour recall method
The pattern of eating habits (food frequency method / diet history)
Assessment of other data such as to examine possible causes such as:
History of pregnancy & birth
Feeding history
History of immunization & administration of vit. A
History of comorbidities / complications
History of growth
The cause of death in siblings
Social, economic and family cultural status such as income, education and parent /
caregiver's work
To establish a proper nutrition diagnosis, it is necessary to support the data of the

assessment / assessment
precise and comprehensive of all aspects of the cause and signs of nutritional problems in
children with Less Energy and Protein Disease. The writing of nutritional diagnosis by listing
Problem (P), etiology or causes of nutritional problems (E) and signs and symptoms (S).
Example of nutritional diagnosis in case of Disease Energy and Protein: Malnutrition (NI-5.2)
is caused by poor food intake and diarrhea condition, characterized by Weight / Long Body
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indicating Z score ≤3 SD.
Nutritional Interventions
Nutritional interventions in pediatric patients with diseases of Lack of Energy and Protein are
given based on a nutritional diagnosis established and administered in 3 (three) stages: a)
Stabilization, b) Transition Phase and c) Rehabilitation Phase and in detail described as
follows:
Phase Stabilization Understanding:
In this phase the condition of patients with Less Energy and Protein Disease shows
clinical and metabolic conditions are not yet stable. To stabilize it takes 1-2 days may
be more if the child's condition is too bad or there are severe complications. In this
phase perlu dimonitor kemungkinan terjadi reffeeding syndrome karena intervensi gizi
dalam bentuk cairan yang agresif dan akan berediko menyebabkan gagal jantung.
Tujuan intervensi gizi :
Pada fase ini diet yang diberikan ditujukan untuk menstabilkan status metabolik tubuh
dan kondisi klinis anak.
Syarat pemberian diet :
Energi 80-100 kkal/kg Berat Badan (BB) per hari. BB yang digunakan untuk perhitungan
kebutuhan energi adalah BB aktual hari itu.
Protein 1-1,5 gram/kg BB/hari atau 4-7.5 % total kebutuhan energi per hari.
Diutamakan protein hewani, misalnya susu, daging ayam atau telur.
Cairan 130 ml/kg BB, 100 ml/kg BB perhari bila da edema berat.
Rendah laktosa.
Mineral mix 20 ml (8 gram)/ 1000 ml formula.
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Cara pemberian diet :
Untuk menghindari hipoglikemia dan beban saluran cerna, hati serta ginjal pasien,
maka pemberian makanan dilakukan dengan lebih sering dan jumlah sedikit.
Pada fase ini makanan formula (F75) diberikan setiap 2 jam (12 kali) atau setiap 3
jam (8 kali) dalam 24 jam. Bila anak mampu menghabiskan porsi yang diberikan
maka makanan dapat diberikan setiap 4 jam (6 kali)
Bila masih mendapat ASI, dapat diberikan setelah pemberian formula khusus.
Transition Phase Understanding:
In this phase is the phase of feeding movement when feeding in the stabilization phase does
not make the child's condition problematic. Usually in this phase takes between 3-7 days.
Objectives of nutritional intervention:
In this phase nutritional intervention is given to give the body an opportunity to adapt to
increasing energy and protein to prepare the child into the stabilization phase.
Terms of diet:
The energy 100-150 kcal / kg BW used for calculation is actual BB that day.
Protein 2-3 grams / kg per day
Fluid is given up to 150 ml / kg per day
Mineral mix 20 ml (8 gram) / 1000 ml formula
How to administer a diet:
Feeding F100 with frequent frequency and small portions, given every 4 hours.
219
In the first 48 hours (2 days) the volume given is still the same as
156
3) Next on the day s the transition phase of volume F 100 is added plus
every day until reaching 150 ml / kg per day (150 kcal / kg BW per day =
volume of beverages in table F 100)
When this volume has been reached and the child is able to spend the portion means the
transition phase is over and the child goes into the rehabilitation phase.
When the child is still breastfed, still given after the child spends the food.
Rehabilitation Phase Understanding:
Generally in this phase the child's appetite has returned and the food intake is completely
orally. If the child has not been able to consume food completely orally, then NGT can be
used. In this phase usually lasts for 2-4 weeks samapai BB / TB reach z score - 2 SD
Nutrition intervention goals:
The goals of nutritional interventions given in this phase are:
Provide adequate food to grow
Motivate children to spend their portions
Motivate mothers to keep breastfeeding
Preparing mom or caregiver to do home treatment
Terms of diet:
220
Energy 150-220 kcal / kg BB per day. BB used for the calculation of energy needs is actual BB
that day.
Protein 4-6 grams / kg body weight per day
Liquid 150- 200 ml / BB per day or more as needed energy
Mineral mix 20 ml (8 gram) / 1000 ml formula
How to administer a diet:
Give F 100 by adding volume daily until the child is not able to spend the portion but not
exceeding the maximum volume of F 100 (see Table F 100 / Book II). The total volume of F
100 / day is the total energy that the child needs to grow chase used for subsequent feeding.
Based on the total energy, the child can gradually be fed according to his BB (F 100 is
reduced and solid food is added).
Consistency of food given based on the BB condition of the child then that is
BB <7 kg: food given F 100 plus baby food.
BB ≥ 7 kg: food given F 100 plus children's food.
When the child is still breastfed, still given after the child spends the food.
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221
Nutritional needs
Nutritional needs for children with diseases of energy and protein deficiency can be seen in
the following table:
Table 4.3
Nutritional Needs of Malnutrition Children According to the Feeding Phase
STABILISASI TRANSISI REHABILITASI (minggu

ZAT GIZI
(hari ke 1-2) (hari ke 3-7) ke 2-6)
Energi 80-100 kkal/ kgBB 100-150 kkal/kg BB 150-220 kkal/kg BB/
/hari / hari Hari
Protein 1-1,5 gr/kg BB/hari 2-3 gr /kg BB/ hari 4-6 gr /kg BB/hari
Cairan 130 ml/kg BB/ hari 150 ml/kg BB/hari 150-200 ml/kg BB/ hari
Atau
100 ml/kg BB/hari bila
ada edema berat
Fe
 Tablet besi/ *) Beri setiap hari
Folat selama 4 minggu
(Fe SO4 200 untuk anak umur
mg+ 0,25 mg 6 bulan sampai 5
asam folat) tahun
 Sirup besi (Fe
SO4 150 ml) Dosis lihat Buku I Hal
1-3 mg 16
elemental
Vitamin A Umur Dosis
< 6 bulan 50.000 SI (1/2 kapsul Penderita
Biru) Xeropthalimia
6-11 bulan 100.000 SI (1 kapsul Biru)
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1-5 tahun 200.000 S! (1 kapsul
Merah)
Vitamin lain
Vit C BB < 5 kg : 50 mg/hari (1 tablet)
BB ≥ 5 kg : 100 mg/hari (2 tablet)
Asam folat 5 mg/hari pada hari pertama, selanjutnya 1

 Vit. B Komplek mg/hari
Mineral mix*)
 Zink *) Diberikan dalam bentuk larutan elektrolit/mineral, pemberiannya
158
223
STABILISASI TRANSISI REHABILITASI (minggu

ZAT GIZI
(hari ke 1-2) (hari ke 3-7) ke 2-6)
 Kalium dicampurkan kedalam Resomal, F-75 dan F-100 (dosis
 Natrium pemberiannya lihat cara membuat Cairan ReSoMal dan Cara
 Magnesium membuat larutan mineral mix, (Buku II hal. 19).
 Cuprum
Sumber : Kemenkes RI. (2011) Petunjuk Teknis Tata Laksana Anak Gizi Buruk
Tabel 4.4
Jadwal pemberian makanan menurut fase
JUMLAH CAIRAN (ml)

WAKTU JENIS
FASE FREKUENSI SETIAP MINUM
PEMBERIAN MAKANAN
MENURUT BB ANAK
 12 kali
modifikasi
Bebas

 F-75/ 8 kali
LIHAT TABEL PEDOMAN F-
modifikasi
STABILISASI Hari 1-2 75
Bebas
 ASI
 F-75/ 6 kali
modifikasi
224
Bebas
 ASI
Hari 3-7  F-100/ 6 kali LIHAT TABEL PEDOMAN F-
modifikasi 100
TRANSISI
Bebas
 ASI
JUMLAH CAIRAN (ml)
SETIAP MINUM
REHABILITASI
MENURUT BB ANAK
4 kg 6 kg 8 kg 10 kg
 F -100/
3 kali 90 100 - -
Modifikasi
 ASI Bebas - - - -
Minggu
BB < 7 kg Ditambah
2-6
 Makanan 3 x 1 porsi - - - -
bayi/
makanan
159
lumat
 Sari buah 1 kali 100 100 - -
 F -100/ - - 150 75
3 kali
Modifikasi
 ASI Bebas - - - -
225
Ditambah
BB ≥ 7 kg  Makanan 3 x 1 porsi - - - -
bayi/
makanan
lumat
 Sari buah 1 kali - - - -
Source: Ministry of Health RI. (2011) Technical Guidelines for the Management of
Malnutrition Children
Example Calculating Energy Requirement and Food Feeding Arrangement:
The energy needs of a child weighing 6 kg in the rehabilitation phase are: 6 kg x 200 kcal /
kgbb / hr = 1200 kcal / hr
The energy requirements can be met by:


3) F-100 : 4 x 100 cc 4 x 100 kkal = 400 kkal
4) Makanan bayi/ lumat 3 x 3 x 250 kkal = 750 kkal

5) Sari buah 1 x 100 cc 1 x 45 kkal = 45 kkal
Jumlah 1195 kkal
Nutrition Counseling
One of the factors causing KEP disease is poor knowledge and foster care in children, so
nutritional intervention in the form of counseling is very important to be given to parents or
nannies. In providing counseling to note are:
Use a leaflet lieflet that contains: number, type and frequency / feeding schedule
Provide sample menus
226
Promote breastfeeding for children under 2 years of age
Note the child's nutritional history
Consider the socio-economic conditions of the family
Demonstrate the practice of cooking food to the mother / nanny
FORM AND HOW TO MAKE FOOD
The form and content of energy and nutrients fluid or food given to children with Disease
Energy and Protein deficiencies tailored to the stages of nutritional intervention are:
160
Rhidration Solution For Malnutrition (ReSoMal) Consists of:
a. WHO-ORS powder *) for 1 liter = 1 pack

b. Sugar = 50 grams
c. Electrolyte / mineral solution **) = 20 ml
Plus boiled water until = 2000 ml (2 Liter) Description:
Each 1 liter of ReSoMal solution contains 37.5 mEq Na, 40 KM mEq and 1.5 mEq Mg.
*) WHO-ORS powder for 1 liter contains 2.6 gr Na CL, 2.9 gram trisodium
citrates according to a new formula of 1.5 grams of KCl and 13.5 gran glucose
**) How to make mineral mix: 1 sachet of mineral mix @ 8 gram dissolved in 20
227
ml of boiled water for material of 1 liter F75 / F100 / ReSoMal
ReSoMal replacement solution
a. If no electrolyte / mineral solution is available, alternatively
ReSoMal, solution can be made as follows:

- WHO-ORS powder = 1 pack
- Sugar = 50 grams
- Powder KCl = 4 grams
Plus boiled water until the solution becomes 2000 ml (2 Liter)
Or if a ready-made WHO-ORS solution is available (soluble), a substitute solution may be

prepared as follows:
1) WHO-ORS solution: 1 liter

2) Sugar: 50 grams
3) KCl powder: 4 grams
Plus boiled water until the solution becomes: 2000 ml (2 liters)
The substitute solution does not contain MG, ZN and CU, it is necessary to provide food
containing the substance to meet the mineral needs. Can also be given MgSO4 50% through
intramusskuler 1 time with dose 0,3 ml / kg BB maximum 2 ml
WHO Formula and Modifications
Food Formula WHO (F75 and F00).
Composition of WHO Formula.
228
161
229
Tabel 4.5
Komposisi Formula WHO
FORMULA WHO
Per
F 75 DENGAN
Bahan Makanan 1000 ml F 75 F100
TEPUNG
Formula WHO
Susu skim bubuk G 25 25 85
Gula Pasir G 100 70 50
Minyak Sayur g 30 27 60
Larutan Elektrolit ml 20 20 20
Tepung Beras g - 35
Tambahan air s/d ml 1000 1000 1000
NILAI GIZI
Energi Kkal 750 1000
Protein g 9 29
Laktosa g 13 42
Kalium mmol 36 59
Natrium mmol 6 19
Magnesium mmol 4,3 7,3
Seng mg 20 23
Tembaga (Cu) mg 2,5 2,5
% Energi Protein 5 12
% Energi Lemak 36 53
Osmolaritas mosm/L 413 419
230
Note: Formula 75 with flour has a lower osmolarity that is more appropriate for children
with diarrhea
How to Make Formula WHO 75 (F75)
Combine sugar and vegetable oil, stir until blended and add mineral mix solution, then enter
skim milk bit by bit, stir until smooth and gel-shaped. Dilute with warm water little by little
while stirring until homogeneous and the volume becomes 1000 ml. This solution can be
directly drunk. Cook for 4 minutes, for children who have dysentery or persistent diarrhea.
How to Make Formula WHO 100 (F100)
Combine sugar and vegetable oil, stir until blended and add mineral mix solution, then enter
skim milk bit by bit, stirring until dull and gel-shaped. Dilute with warm water little by little
while stirring until homogeneous volume to 1000 ml. This solution can be directly drunk or
cooked for 4 minutes.
How to Make F75 With Flour |
Combine sugar and vegetable oil, stir until blended and add mineral mix solution, then insert
skim milk and flour little by little, stir until smooth and gel-shaped. Add the water little by
little while stirring until homogeneous so that it reaches 1000 ml and boil while stirred until
dissolved for 5-7 minutes.
Modify the WHO Formula
WHO Formula Modification Composition

162
231
Table 4.6
WHO Formula
Composition
MODIFIKASI FORMULA WHO

TRANSISI dan
STABILISASI
FASE REHABILITASI
F75 I F75 II F 100
Susu Skim bubuk (g)
Susu full cream (g) 35 110
Susu sapi segar (ml) - 300 -
Gula pasir (g) 70 70 50
Tepung beras (g) 35 35 -
Tempe (g) - - -
Minyak sayur (g) 17 17 30
Margarin (g) - - -
Larutan Elektrolit (ml) 20 20 20
Tambahan air s/d (ml 1000 1000 1000
Source: Ministry of Health RI. (2011) Technical Guidelines for the

Management of Malnutrition Children
How to Make F75 Mods I and II
Combine sugar and vegetable oil, stir until blended and add mineral mix
solution. Then enter full cream / fresh milk and flour little by little, stir until
smooth and gel-shaped. Add the water little by little while stirring until
homogeneous so that it reaches 1000 ml and boil while stirred until
dissolved for 5 - 7 minutes.
232
How to Make F 100 Mods
Combine sugar and vegetable oil, stir until blended and add mineral mix
solution. Then put full cream / fresh milk and a little flour

163

for a little, stir until smooth and gel-shaped. Add the water little by little
while stirring until homogeneous so that it reaches 1000 ml and boil while
stirred until dissolved for 5 - 7 minutes.
Note:
To be more homogeneous WHO formula can be used blender.
On administration through NGT, it is not advisable to blend, as it may

cause air bubbles.
Food Formula
Formula Feeding Guidelines
Table 4.7
Formula Feeding Guidelines
Jumlah makanan formula yang harus diberikan

Karakteristik sesuai BB anak dalam sehari
BB < 7 kg BB 7-8 kg BB 9-10 kg BB 11-13 kg
A. Jenis makanan :
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1. Formula tempe 1,5 resep 2 resep 2,5 resep 3 resep
2. Formula ikan 1 resep 1,5 resep 1,5 resep 2 resep
3. Formula kacang hijau 1,5 resep 2 resep 2,5 resep 3 resep
4. Formula kacang hijau dan 1,5 resep 2 resep 2 resep 2,5 resep
kuning telur
5. Formula kacang hijau dan 1,5 resep 2 resep 2,5 resep 3 resep
Susu
6. Formula tahu ayam 1,5 resep 1,5 resep 2 resep 2,5 resep
7. Formula kentang 1,5 resep 2 resep 2,5 resep 3 resep
8. Formula tempe wortel 1,5 resep 2 resep 2,5 resep 2,5 resep
9. Formula Tim Hati ayam 3 resep 3,5 resep 4 resep 5 resep
10. Formula jagung pipil dan 3 resep 4 resep 4,5 resep
ikan *)
11. Formula jagung segar dan 4 Resep 5 resep 6 resep
Ikan
B. Bentuk makan Cair Saring Lunak/ Padat
Lembik
C. Frekuensi pemberian
8 kali 6 kali 5 kali 5 kali
makanan dalam sehari
Note:
Selected formula foods can be made 1 time for a day with 1 warm

164

234
Store in clean and closed containers
Use a clean spoon every time you take food
If the child still wants to eat, the mother can make again
Can be made formulas of solid form or other common foods according to local conditions
*) Piped corn and fish formula and fresh corn and fish formula should not be given to
children <7 kg, because using mustard leaves.
Examples of tempe-style foods
Tempe food ingredients formula used by the trainers is easy to get and the price is
affordable by the community, so this formula is quite well trained in the parents of children
suffering from malnutrition after completion of hospital treatment.
Table 4.8
Feeding Guidelines of Formula Tempe
Anjuran pemberian sehari sesuai dengan Berat Badan

Bahan (BB) anak
BB < 7 kg BB 7-8 kg BB 9-10 kg BB 11-13 kg
A. Jenis bahan :
1. Tempe 6 potong 8 potong 10 12
sedang sedang potong sedang potong
sedang
2. Terigu/tepung beras 6 sdm 8 sdm 10 sdm penuh 12 sdm
penuh penuh penuh
3. Gula 4,5 sdm 6 sdm rata 7,5 sdm rata 9 sdm rata
rata
4. Minyak goreng ¼ sdm 1 sdm 1 ¼ sdm 1 ½ sdm
B. Bentuk makanan cair cair Lunak/lembik Padat
C. Frekuensi pemberian 8 kali 6 kali 5 kali 5 kali
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makanan dalam sehari
RESEP FORMULA TEMPE (ONE RECIPE)

material
- Tempe 100 gr tempe (4 medium cut).
- wheat / rice flour 40 gr (4 tablespoons full).
- Sugar 25 gr (3 tablespoons average)
- cooking oil 5 gr (1/2 tablespoon)
iodized salt and water to taste. ways of making

165
236
prepare each ingredient according to the amount
tempeh cut into pieces and then boiled 10 minutes and then mashed
all ingredients are mixed, add one glass of starfruit, stir into one
then cooked over low heat while stirring for about 5-10 minutes.
MONITORING DAN EVALUASI ASUHAN GIZI
Untuk memonitor dan mengevaluasi keberhasilan intervensi gizi pada anak yang
mengalami kekuarangan energi dan protein (KEP), secara ringkas dapat diketahui dari
gambar dibawah:
Timbang berat badan setiap pagi sebelum makan
Hitung kenaikan berat badan dalam gram/kgBB/minggu
Bila kenaikan BB < 50g/Kg BB/Minggu Bila kenaikan BB ≥ g/kg BB/minggu
KURANG BERHASIL BAIK
Teruskan pemberian makan

Sesuai jadwal
Infeksi Pemenuhan zat gizi Masalah
237
Kurang dan defisiensi Psikologi
Zat gizi mikro
Asupan zat gizi kurang Ada gangguan saluran pencernaan
Tindakan Tindakan
Gunakan formula rendah atau bebas laktosa

Modifikasi Diet sesuai selera dan hipoosmolar
atau NGT Contoh : susu rendah laktosa, formula tempe
Dengan tepung-tepungan
Sumber : Kemenkes RI. (2011) Bagan Tata Laksana Anak Gizi Buruk
Gambar 4.5
Tata Laksana Gizi Buruk
166
Exercise
What are the signs and symptoms of a child suffering from Energy Deficiency Disease and
Protein both physically and clinically?
238
Explain how many phases of nutritional care are given to KEP children? and how does it
feed?
How is monitoring and valuation of successful nutritional care in children with KEP?
To help you in doing the exercises please review the material about
Signs and symptoms of less energy and protein diseases.
Nutritional care in patients with KEP disease.
Monitoring and evaluation of nutritional care.
Summary
Disease less Energy and Protein (KEP), especially in children caused by inadequate intake of
food and disease factors, especially infectious diseases. Both of these factors are influenced
by external factors such as socio-economic conditions, culture, natural environment, and
access to health services.
There are three phases of nutritional care: phase of stabilization, transition phase and
rehabilitation phase. Each stage of KEP patient is given caiaran and food according to the
patient's initial condition treated such as: whether there is odema or not, there is
dehydration, hypothermia or other comorbidities, and how patient response to food given.
Nutritional intervention in the form of food given to PEM children in the form of a formula
that is adjusted to the patient's ability. The formula given in each phase is expected to have
an impact on improving the health and nutrition status of the patient and after entering the
rehabilitation phase, body weight is used as an indicator of the success of nutritional
intervention provided.

239
167

Test 1
If the patient's malnutrition at the beginning of hospital treatment is dehydrated, what

should be given?
Sugar solution
ReSoMal
Oralit
240
Honey
F75
What are the signs of severe odema in malnourished children?
Odema on both backs
Odema on the back of the hand
Odema / asistes in the abdomen
Odema in the face
Odema throughout the body
In the stabilization phase, what formula should be administered to patients with diarrhea?
F 100
F75 with flour
F75 Modifications I
F75 modification II
F 100 Modifications
The change of F75 to F100 in the transition phase is done when ....
F 75 can be spent as needed
Patients show weight gain
Clinical signs of the patient are gone
241
There is no odema in the patient
Patients can not receive F75
Patient of malnutrition children in rehabilitation phase should be given infertile food if their
weight is ....
BB increments> 50 grams
BB initial treatment ≤ 3 SD
There are still comorbidities
There is still odema
Weight <7 kg
242
188
CHAPTER VI
NUTRITION OF NUTRITION IN HIV / AIDS
Dr. Iskari Ngadiarti. SKM., M.Sc
PRELIMINARY
Students that I am proud of, now we are in the five modules that learn about HIV / AIDS and
airway infections. Both of these infectious diseases are now a priority and their success is
one indicator of health development. For example, HIV / AIDS disease is one of the most
difficult infectious diseases, the only way is to prevent new complications and not to enter
into more severe stages where their morbidity and mortality are higher.
Topic 1
243
Nutrition Care in HIV / AIDS
In this discussion you are expected to explain the nutritional care in HIV / AIDS. The
explanation will be more easily understood by the patient, if you understand the etiology,
the pathophysiology of the disease. What exactly is HIV / AIDS disease. AcquiredImmune
Deficiency Syndrome (AIDS) disease is a disease caused by the body infected with the HIV
virus that threatens human life. This virus attacks the immune system and weakens the
body's ability to fight infections and diseases. The effects of HIV Virus are still a tough
challenge because this virus can only be attenuated with anti-viral drugs and optimal
nutritional intake. If the HIV virus can not be inhibited it will become AIDS. AIDS is the final
stage of viral infection characterized by severe immunosuppression that leads to
infectionoportunistik, secondary neoplasm and neurologic manifestations. At this stage, the
body's ability to fight infection is completely gone.
This topic will be divided into three parts. First about the scope of HIV that will discuss the
etiology and pathology of HIV disease as well as the side effects of HIV / AIDS. Second about
the management of drug therapy and nutritional care and conditions that need
consideration.
SCOPE OF HIV / AIDS DISEASES
Etiology
HIV / AIDS is a disease caused by a classified virus
Retrovirus called Human Immunodeficiency Virus (HIV). This virus is an inert particles, and
after entering the target cell, this new virus can develop especially in Lymfosit T cells,
because it has a receptor for the HIV virus called CD4 This virus is classified as sensitive to
environmental influences such as boiling water, sunlight and easy switched off with various
disinfectants such as ether, acetone, alcohol, iodine hypochlorite and so on, but relatively
resistant to radiation and utraviolet light.
The spread of the virus only occurs when having unsafe sex and alternating syringes when
using drugs / narcotics. Other spreads include through oral sex, using sex aids together or
244
alternately; blood transfusion from an infected person; using needles, injections, other
contaminated injecting equipment, such as sponges and cleaning cloths and mother-to-child
transmission during pregnancy, during childbirth or breastfeeding.
HIV virus is also known as a fragile virus, because it can not last long outside the human
body. This virus can only stand in body fluids (sperm fluid, vaginal fluid, anal fluid, blood, and
breast milk) from an infected person and can not spread through sweat or urine. In other
words if we as a health worker provide

189

health services and nutritional care such as feeding, medicating or educating, we need not
worry, do as we are with other patients.
The pathophysiology of AIDS
The HIV virus attacks the immune system and the nervous system. What is an Immunity?
Immunity is the body's ability to protect itself from various viruses, bacteria, pollutants and
other attacks from outside the body and that much, and if the body immunity is low then it is
easy to get sick especially infectious diseases. How to attack him? HIV virus enters the
human body directly into the blood and directly attack a specific protein cell that is CD4 in
lymphocytes. Lymphocytes are the main source of immune ability, which involves the
humoral immunity produced by Beta cells and immune mediated cells produced by T cells.
Therefore, the main characteristic of HIV sufferers is a decrease in CD4 cell count. In healthy
people, non-infected CD4 levels range from 500 to 1500 in each blood microliter. Decreased
245
levels of CD4 support patients are susceptible to certain infections and cancers and can
attack the nerves that eventually occurred brain damage.
AIDS will occur if the CD4 level is less than <200 mm3. In this condition the body does not
have the ability to fight infections so that almost all parts of the body are infected. This is
what is feared, so the provision of nutritional care can slow the virus is growing so as not to
become AIDS. The time it takes HIV to become AIDS if without any median therapy is 10
years.
Early person infected with HIV, within a period of 3 months more clinically the person has
not looked sick and has not experienced organ disorders or body functions. However,
serological tests have shown a decline in CD4 values and HIV infection can already be known.
The chart below illustrates the natural process of HIV becoming AIDS. There are 4 clinical
stages in HIV / AIDS disease, namely stage I, II, III, and IV. Stage I or acute according to WHO
is the body already infected with HIV in the blood causes, the CD4 count decreased but still
within the normal value limit so that the body can still overcome the infections that attack
the body so that the patient does not look sick, and nutritional status is still the same as
before infected.
At Stage II & III there has been cell destruction of CD4 + lymphocytes and a decrease in CD4
cell count which causes increased viral load resulting in metabolic disorders, opportunistic
infections (IO), and decreased nutritional status. Stage IV where the load of the virus
increased dramatically then the CD4 value decreased sharply happened CD4 vaccination by
the HIV virus and later opportunistic infections (IO) added, and nutritional status worsened,
cacheksia occurred and entered the AIDS Stadium.
190
246
Sumber : WHO,2015
Gambar 5.1
Perjalanan HIV menjadi AIDS
How are the symptoms of people affected by HIV?
247
HIV virus attacks all ages both children and adults. Symptoms that can be observed
in adult patients are major and minor symptoms. Major symptoms are weight loss of
10 percent or more in about a month without cause, diarrhea and prolonged fever for more
than one month. While the minor sign is a dry cough that is difficult to heal; itchy skin all
over the body; the presence of fungal infections in the mouth, tongue, or throat; gland
enlargement occurs in the armpit area, groin, and neck; stricken herpes zoster, recurrent
intellectual abilities, and peripheral nerve damage.
Symptoms that occur in children who are infected by the HIV virus in early conditions
may be almost invisible, after observed new major symptoms appear that there is growth
delay, chronic or recurrent diarrhea, interstitial pneumonia, or canker sores. While minor
symptoms are: itchy skin in all parts of the body; swelling in the neck, underarms, or groin;
Mushroom attacks in the throat, tongue, or mouth; ear, throat, or other organ infections; a
cough that does not subside. But the signs and symptoms that are apparent in AIDS are
weakness, anorexia, diarrhea, weight loss, fever and decreased white blood cells or
leukopenia. For that person for someone who is infected with HIV should immediately check
her health condition in order not to get health condition worse or decrease.
191
MANAGEMENT OF THERAPY IN HIV / AIDS PATIENTS
The goal of treatment management in HIV patients is to slow the progress of the infection
and to optimize its immune system and prevent new infectious diseases and as early as
possible to know the existence of new infectious diseases so that rapid therapy can be done
248
as well as severe complications such as cancer can be avoided. Therefore therapies
performed are drug therapy and therapy / nutritional care needed to maintain or achieve
optimal nutritional status so that HIV patients do not quickly go to AIDS.
Drug therapy / medical
Provision of drug therapy in HIV / AIDS patients is not solely aimed at HIV virus alone but is
also intended for complications. The most common complications are hyperglycemia,
hypertension, changes in body composition, pancreatitis, kidney and liver disease,
hypothyroid, hypogonadism, osteopenia, decreased CD4 cell count, increased viral load and
mental dysfunction. Common drug therapy is given to HIV / AIDS patients in general ie
antiretroviral drugs (antiretroviral therapy) that serves to inhibit the virus in damaging the
immune system. The drugs are administered in the form of tablets consumed daily. Examples
of drugs are tenofoir, retrovir, videx and others. These medications carry side effects
including diarrhea, nausea, vomiting, lipodystrophy, dyslipidemia, and insulin disorders. (2)
drugs to enhance immunity such as interleukin 2 and interferon, and some vitamin and
mineral supplements such as vitamins C, A, E and selenium. (3) antibiotic therapy drugs are
given if there is an oppurtinistic infection, and other infections such as tuberculosis, hepatitis
and prophylaxis; (4) drugs for dealing with complications: fat loss agents, anti-diabetic
agents; anti-hypertensive agents, appetite stimulants; and hormone replacement therapy;
(5) vaccines associated with opportunistic diseases. Examples of vaccinations that should be
done is a flu vaccine every year, pneumococcal vaccine five years.
Another thing to consider is drug interactions with food. Therefore asking the HIV patient
about any medications consumed including vitamins and supplements is necessary. The
interaction of nutrients with drugs can harm the effectiveness of the work of drugs and
nutrients. For example, patients drinking fruit juice along with protease inhibitor drugs that
both compete require the same enzyme, then the effect of the effectiveness of the drug
becomes low or nutrient compliance is disrupted.
Nutrition Care
It has been described above that nutrition care is equally important in suppressing patients
to not quickly become AIDS. Therefore the purpose of providing nutritional care, among
249
others, optimize the nutritional status and health and immunity; maintain / achieve normal
BB and maintain smooth muscle mass; prevent nutritional deficiencies and reduce the risk of
new complications (diarrhea, lactose intolerance, nausea, vomiting) and maximize
effectiveness of drug interventions.
192
Nutritional care in HIV / AIDS patients should be individualized and counseling is necessary to
determine the nutritional needs required. The best strategy in performing nutritional care in
HIV / AIDS patients with ADIME approach (Assessment, Diagonous nutrition, Nutritional
intervention, Monitoring and Evaluation). However, before undertaking nutritional therapy,
nutritional screening should be done to determine if the patient is at a risk for malnutrition
or requires only regular interventions. HIV patients are very close to malnutrition.
Assessment
The main nutritional assessment is to know the complete medical diagnosis with its stages.
Therefore identification of patient laboratory results is more important than patient
complaints. Other things that need to be identified are comorbidities and previous disease
history such as heart disease, diabetes, cancer, and other opportunistic infections such as
tuberculosis, canker sores and others. Laboratory results or biochemical examinations that
need to be examined are CD4 values; viral load, albumin, haemoglobin, iron status, lipid
profile, liver function, kidney function, glucose, insulin, vitamin levels in the blood.
The physical condition / anthropometry to note is the change in body weight. Therefore it is
necessary to ask how the weight 3-6 months ago. Anthropometric measurements that need
to be done are arm circumference, and waist circumference. Clinical symptoms that need to
be asked are whether there is tingling, numbness, and stiffness.
A history of diet or eating history that needs to be explored is the current eating habits, how
to feed the days, whether there is a history of allergies, how to use supplements, and the
type of drug taken. Thus can be identified the possibility of nutrient deficiency and the
factors causing it. Other factors that need to be explored are personal conditions such as
socioeconomic conditions, because this condition is also very determine the type of food and
the way of processing and the ability of drug purchasing (drugs are relatively expensive). The
250
thing that is often encountered is the patient is less attention to food, because funds are
concentrated on drugs or vice versa. Historical dietary information if difficult to obtain from
a patient can be obtained from the caregiver or a close friend / relative.
Diagnosis of nutrition
In general, HIV patients often have less nutritional problems, then the diagnosis of nutrition
in HIV patients usually is
Intake of eating and drinking less orally
Increasing energy and nutrient needs
Changed gastrointestinal function
Overweight / obesity
Low knowledge related to food and nutrition
The intake kelebiahan of supplements
Ability to prepare low meals
193
194
Difficulty access to food
251
Unclean / safe food intake c. Nutritional Interventions
Implementation of nutritional interventions in accordance with standardized nutrition care

process is first set objectives that are followed up with the prescription of a complete diet
with dietary requirements and education / counseling. Therefore, in nutritional intervention
is described based on stages / stages in HIV that are stage I, II and III and stage IV.
Stage I: the goal is to maintain optimal nutritional status and correct if any nutritional
deficiency occurs. So the dietary requirement is energy and high protein. High energy in
question is giving energy and protein approximately 110% above normal needs. For example
If the normal requirement is 1700 Kcal and 45 g protein, then it becomes 1900 Kcal, with
protein 50 g (rounded). In this condition the patient should be given vitamin
supplementation such as vitamin C, B12, B6 and folic acid as well as minerals of iron, zinc,
copper to help build the immune system. This supplementation does not need to be given
mega doses, quite the same as the recommended Nutritional Numbers (AKG).
Another thing that needs to be done is to maintain food safety ie food including free water
from bacteria or microbial contamination so that the body is protected from the cause of
opportunistic infections. Food handling hygiene, storage, preparation, and presentation need
to be well observed. What is often reminded is to avoid consuming vegetables and fruits in
raw or un-cooked form, raw or undercooked eggs, canned or preserved foodstuffs. Some
instructions for preparing and storing groceries are safe
Avoid ingredients protein sources consumed not cooked like raw eggs, half-cooked eggs,
sushi, low-cooked meat etc.
Do not use broken eggs, canned food that can be peyok
Frozen the frozen meat in the refrigerator (refrigerator) instead of room temperature
Use pre-pasteurized milk
Store hot food in hot temperature (60-83 derjat Celsius).
252
Deposits of cold food at cold temperatures (-1 s / d 4 degrees C)
Do not consume food that is placed in a temperature of 6 degrees celsius to 60 degrees

celsius more than 2 hours.
Place perishable ingredients immediately from store to refrigerator.
Keep food / ingredients that have been opened in an airtight place.
Stage II / III: The goal of nutritional intervention at this stage is to reduce symptoms and
complications such as anorexia, esophageal pain and thrush, malabsorption, neurological
complications and others. In these patients there is already a sign of infection oppurtunistik
then in the calculation of energy especially increased BMR 20 s / d
50% both adults and children. To ascertain whether the food is acceptable it is necessary to
monitor periodically and make adjustments immediately. Protein needs 10% of normal
needs. However morning patients with comorbidities such as cirrhosis, kidney and
pancreatitis, protein needs adjust.
Associated with micronutrients (vitamins and minerals) is indispensable for immunity.

Deficiency of micronutrients can affect immune function and accelerate disease progression.
It is known that low vitamin A, B12, and zinc levels are associated with accelerated
progression of disease, whereas vitamin C and B intake is associated with increased CD4 cell
count and decreased HIV progression to AIDS.
At this stage often appear sprue, it is necessary to be informed important things such as
always maintaining oral hygiene, avoid hot food, give soft food (mushed potato, scrambled
egg, minced meat), if drinking use a straw, avoid food which causes discomfort (too spicy,
too sweet, too hard etc.). To clarify can reopen module 2 topic 2 on terms of soft food form.
Stage IV: At this stage the patient is already in terminal condition, usually his oral intake is
low (<30%), or has rejected oral food, and possibly food given in enteral, or enteral and
parenteral combinations. The main problems that are often complained of is diarrhea and
malabsorption. Terms of diet that need to be considered in this condition is
253
The fluid intake needs to be increased to maintain hydration status
Yogurt and other foods containing Lactobacillusacidophilus cultures should be given, to

anticipate the effects of long-term anti-infective drug use
Small portions but often to relieve gastrointestinal work
Multivitamin supplements to help the provision of vitamins to be absorbed by the body
Oral high density drink supplements may be useful or supplements that have energy content
may also be useful.
Nutritional support may need to be given in enteral or parenteral forms
Provision of pancreatic enzymes may need to be given, but beforehand need to be asked to
the team of nutrition care / doctors in charge of patients
Avoid coffee and foods containing sorbitol, to avoid unwanted peristalsis and diarrhea.
195
Monitoring and Evaluation

After the intervention, it is necessary to monitor and evaluate to see output and outcome.
Evaluations should be done routinely according to the nutritional service plan. Interventions
should yield results that can be monitored whether they are achieved or not. For example,
the goal of nutritional intervention is to maintain normal weight by giving the ML TETP 1900
diet, 50 g protein, medium fiber. The first monitoring should be the patient's acceptance of
the food. The accepted feeding power is whether the food can be spent, or the patient still
feels hungry. In addition whether the food is acceptable by the body is characterized by no
nausea, vomiting, diarrhea, or constipation. After that new evaluated outcome by doing
anthropometry measurement, for example, weight. Whether there is weight gain or weight
loss or fixed weight according to the purpose of intervention and others. If the goal is not
254
achieved it needs to be re-planning in accordance with the problems and goals to be
achieved Another thing that needs to be monitored and evaluated is the result of laboratory
examination related to nutrition ie fasting blood fat; insulin levels / blood glucose; protein
status; blood pressure; testosterone levels; CD4 cell count, and viral load
Currently the government has socialized balanced nutrition guidelines (PGS) and healthy
community movement (GERMAS). This can be used as an educational tool in the prevention
and prevention of HIV disease. The guidelines call for a balanced and varied diet by
increasing the intake of fruits and vegetables; get used to clean living (eg washing hands
before meals) doing physical activity and regular weight monitoring and regularly and
regularly checking regularly. For more details, you are encouraged to find out more about
PGS and GERMAS.
SPECIAL CONDITIONS WHICH NEED TO BE CONSIDERED

There are several conditions caused by the presence of HIV infection such as wasting
syndrome, obesity and lipodystrophy syndrome. This syndrome is very close to nutritional
care.
Wasting syndrome
Wasting syndrome is a weight loss syndrome of less than 10% of the original weight
accompanied by one of chronic diarrhea without a clear cause. Sometimes it is followed by
the body feeling weak and accompanied by prolonged fever without any obvious cause. It
has been described previously that people with HIV often have anorexia, depression, fatigue,
nausea, vomiting, shortness of breath, diarrhea and infection. This results in inadequate
nutrition intake, unable to meet high nutritional needs and accompanied by acute infection.
The result is malnourished condition, and decrease functional capacity, and immune function
so that morbidity and mortality increase. Thus it is easy for people with HIV to fall into the
condition

malnutrition status that is multifaktor, not because of food intake alone but there is
interference absorpsi and nutrient metabolism, drug interaction and decreasing of physical
activity.
255
Obesity
Overweight in HIV patients is sometimes considered a good factor because
can protect the body from the malignancy of disease travel. But this is now refuted, because
obesity is the effect of antiviral drugs consumed by patients. It also accelerates the
occurrence of new complications such as heart disease, diabetes, dyslipidemia and others.
Therefore maintaining a normal BB is highly recommended by continuous monitoring.
Lipodystropy
Lipodystrophy appears to be associated with abnormal metabolism and surface
body changes, including the laying of fatty deposits, especially visceral adipo tissue in the
abdomen or fatty atrophy as indicated by subcutaneous fat loss in the face, buttocks and
extremities. Abnormal metabolics include dyslipidemia including LDL and high triglycerides,
low HDL, insulin resistance. This syndrome occurs independently and simultaneously. The
cause of lipodystrophy is multifactorial, but is related to duration of HIV infection, duration
of drug, age, sex, increased BMI (body mass index), virus load. Prompts to perform physical
activities, adequate fiber intake, can reduce the risk of laying fat. Omega 3 is very beneficial
to lower blood triglycerides, decrease inflammation and improve depression.
Exercise
Explain stage 4 clinical stages in a person infected with HIV / AIDS
Explain how the HIV virus enters the human body
Describe the impact of the HIV-infected body according to its pathological stages.
Explain the frequent complications of HIV-infected patients and what biochemical body
biopsy needs to be monitored periodically.
How is the usual drug therapy given to HIV patients
256
How Medic Nutrition Treatment Is Needed To Make The Patient Maintain Good Nutrition
Status.
To help you in doing the exercises please review the material about
HIV travel becomes AIDS.
Etiology and pathophysiology of HIV.
A frequent complication of HIV.
Drug therapy and nutritional care in HIV disease.
197
198
257
Summary
Nutritional care in HIV / AIDS disease should be able to build and pay attention to the needs
of individual patients. The emphasis that ongoing epeidemilogic research results suggests
that drug therapy and nutritional care should be undertaken to slow the progress of the
disease. In general, this disease will experience four stages of stage I is HIV infection, Stage II
and III There is HIV disease with symptoms and disease and infection and stage IV
oppurtunistik is AIDs with symptoms and various complications that lead to death. Primary
nutritional care provides adequate nutritional and nutritional support so that it can
overcome the wasting and malnutrition syndrome that is almost always present in the
disease. The process of nutritional care is done by involving the assessment of nutritional
status and the evaluation of a comprehensive individual nutritional needs. Planning
nutritional needs should be discussed and developed with the patient and and
family / caregiver.
Test 1
Choose the best answer !
Food suppliers in HIV / AIDS patients should use masks and gloves when sharing food.
Avoid transmission with HIV patients
Improve the safety of distributed food
Improve the health of food providers
Increase personal hygine of food provider
258
Improve the image of the hospital and the appearance of officers
In HIV patients with HAART therapy (highly active antiretroviral theraphy) in order to avoid
the syndrome of fat redistribution preferably in daily life is balanced with ....
Drink all prescription drugs
Drink vitamin and mineral supplements
Perform physical activity regularly
Consume high-protein high-protein low-fat diet
Increase intake of primarily sources of unsaturated fat
When compared with wasting syndrome, the incidence of cachexia is ....
The process is slower
The result of the body lacks energy and protein
Always associated with a low intake
Can be prevented by giving 400 cc of fluid per day
The process is faster along with the decrease in BB
Education of HIV / AIDS patients about food safety is needed to ....
Prevent the occurrence of opportunistic infections
Reduce the incidence of cancer complications
Prevent the occurrence of lipodistrophy
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Improve the work of kidney function
Prevent the occurrence of canker sores
Mr. S, age 30, was hospitalized with severe diarrhea, diagnosed HIV for 8 years. Weight 70
kg, height 175 cm. Os was tested for faeces, and allegedly unrelated to HAART
administration. Result of faeses culture not yet finished. While waiting for the diagnosis of
the disease from the doctor. Suggested diet for Mr S patients is given a diet ....
ML 1500 kcal plus extra fluid 400 cc per day
Clear MC 8x 200 cc plus mineral mix
MB 1500 kcal with high fat and high fiber
MC thick 6x250 kcal with high fiber
ML 1500 kcal with medium fiber
260
CHAPTER VII
NUTRITION OF NUTRITION ON HEART DISEASE
AND KITCHEN EMPEDU
Yenny Moviana, MND
PRELIMINARY
Liver disease due to the virus suffered by many people in the world. Hepatitis virus has long
infected humans and became a health problem in the world. Acute cases of hepatitis A in the
world as much as 1.5 million per year. WHO estimates there are tens of millions of people in
the world infected with this virus per year. Approximately one million patients with hepatitis B
die every year, and hepatitis B accounts for 80% of the cause of primary hepatocellular
carcinoma and ranks second as a cause of cancer after smoking. Unlike liver disease, incidence
of gallbladder disease in Indonesia is relatively lower than in western countries (Sanityoso and
Christine, 2014).
Liver and gallbladder are gastrointestinal organs. Both play an important role in the process of
digestion and metabolism of nutrients. Disorders that occur in these two organs will affect the
nutritional status of a person. The liver is an important organ in the metabolism, storage and
distribution of nutrients. Nutrition and liver disease are two interrelated conditions. In both
acute and chronic liver disease, care should be taken to provide optimal nutrition. Optimal
nutrition management will reduce complications and improve morbidity and mortality in liver
and bladder disease. To understand the nutritional care of liver and gallbladder diseases, this
chapter will describe clearly.
After studying this chapter, students are expected to:

a.
1. Explain the anatomy and physiology of the liver and gallbladder.
261
2. Describe the role of the liver and gallbladder in the process of metabolism of nutrients in the
body.
3. Identify clinical problems of liver and gall bladder disease.
4. Describe the impact of liver and gallbladder disease on nutritional aspects.
5. Identify the key indicators of nutritional problems in liver and gallbladder diseases.
6. Identify possible nutritional problems in liver and gallbladder diseases.
7. Designing nutritional therapy in patients with liver and gall bladder disease.
8. Develop a nutrition monitoring and evaluation plan for liver and gallbladder diseases.
Topic 1
Nutrition Care in Liver Disease
The liver is an important organ in the metabolism, storage and distribution of nutrients.
Nutrition and liver disease are two interrelated conditions. In both acute and chronic liver
disease, it is necessary to consider optimal nutrition. Optimal nutrition management will
reduce complications and improve morbidity and mortality in liver disease (Sucher and
Mattfeldt-Beman, 2011).
To understand the role of nutrition in the management of liver disease, you need to
understand the anatomy and physiology of the liver. The following figure shows the anatomy
of the heart.
262
Hati
Menerima zat-zat gizi dari Vena Hepatik
saluran cerna dan memproses Mengembalikan darah

zat-zat gizi tersebut untuk dari heti ke jantung
didistribusikanke seluruh
Arteri Hepatik
tubuh
Mensuplai darah yang
kaya oksigen dari jantung
ke hati
Sistem Bilier
Termasuk kantung empedu, Vena Portal
yang menyimpan dan men- Membawa darah yang

kaya zat gizi dari saluran
sekresi empedu, dan saluran cerna ke hati
empedu menyalurkan dari hati
ke kantung empedu, dari Vena Saluran Cerna

kantung empedu ke intestin Mentransport zat gizi
terserap ke vena portal
Sumber : S. Rolfes, K. Pinna, and E. Whitney. Understanding Normal and Clinical Nutrition, 7e,
p.
263
2006. dalam Sucher and Mattfeldt-Beman. Diseases of the Liver, Gallbladder, and
Exocrine Pancreas : Nutrition Therapy and Pathophysiology. 2e. 2011. Hal. 439
Gambar 6.1
Anatomi Hati dan Sistem Bilier
The liver is the largest gland in the human body. Textured soft, supple. Located in the upper
right abdominal cavity below the upper rib cage of the abdominal cavity just below the
diaphragm, weighs 1.2 - 1.8 kg (2-3% body weight). The liver has an important role because it
is a regulator of all the metabolism of carbohydrates, proteins & fats. Place synthesis of protein
components, blood clotting, cholesterol, urea & other substances

221
which is vital. Has a site for the formation and distribution of bile acids, detoxification centers
of toxins and destruction (degradation) thyroid hormones (eg estrogen)
PHYSIOLOGY OF HEART
The liver has a very diverse function, namely the function in the metabolism, storage and
distribution of nutrients. Portal vein circulation plays an important role in liver physiology,
especially in terms of metabolism of carbohydrates, proteins and fatty acids. The main function
of the liver is to play a role in the formation and excretion of bile. The liver excretes about one
liter of bile into the small intestine per day. The main ingredients of bile are water (as much as
97%), electrolytes and bile salts. Although bilirubin which is bile pigment is the end result of
metabolism and physiologically has no active role, but bile pigment is important as an indicator
of liver disease and bile ducts. This is because bilirubin gives color to the tissues and fluids
associated with it.
264
The following explanation of liver function in more detail.
Metabolism of nutrients
Liver plays an important role in the metabolism of carbohydrates, amino acids, proteins,
cholesterol and bile acids. Padametabolism Carbohydrates, the liver functioning of storing
large amounts of glycogen, convert galactose and fructose into glucose, Gluconeogenesis
process and form many important chemical compounds from the intermediate results of
carbohydrate metabolism.
In fat metabolism, the liver function oxidizes fatty acids to supply energy for other body
functions, forming most cholesterol, phospholipids and lipoproteins, and forming fats from
proteins and carbohydrates. In bile acid metabolism, the liver functions to transform
cholesterol into 7-hydroxycholesterol cholic acid and kenodeoksikolat acid. In heme
metabolism, heme is oxidized to biliverdin, which is then reduced for bilirubin; bilirubin is
transported to the liver where it is converted to diglucuronide bilirubin to be removed with
bile pigment
In vitamin metabolism, the liver plays a role in the formation of acetyl CoA from pantothenic
acid, the hydroxylation of vitamin D for 25-OH D3, the formation of 5-methyl tetrahydrofolic
acid (THFA), niacinamide methylation, phosphorylation of pyridoxine, thiamin
defosphorylation and coenzyme formation B12.
Regulation of blood sugar level
The liver produces and uses glucose
Detoxification and elimination of metabolic waste products, such as toxic ammonia, are
converted to urea to be secreted through urine; and foreign materials such as drugs or toxins
are also detoxified by the liver.
Fat digestion
The liver helps the digestion of fat by producing and excreting the bile salts that will emulsify
the fat, so it can be digested well.
265
Activation of vitamins and minerals
Liver converts carotene into vitamin A; turning folate into 5-methyl-tetrahydrofolic acid, and
converting vitamin D into an easy-to-digestone 25-hydroxycholecalciferol form.
Storage of nutrients
The liver stores carbohydrate reserves in the form of glycogen, and minerals (Fe, Zn, Co, Mg),
and vitamin B12
Enzyme Metabolism
The liver synthesizes enzymes alkaline phosphatase, mono-amine oxidases (MAOs),

acetylcholine, oxidases, cholesterol esterase, dehydrogenases, beta glucuronidase, glutamic
oxalacetic transaminase (SGOT / AST), and glutamic pyruvic transaminase (SPGT / ALT)
Heme metabolism
Heme is oxidized to biliverdin then converted to bilirubin; bilirubin is transported to the liver
and converted into bilirubin diglucuronide to be excreted along with bile pigment.
Unlike other solid organs, adult hearts have the ability to regenerate. When the ability of liver
cells to regenerate is limited, then a group of oval pluropotential cells derived from bile ducts
will proliferate to re-establish liver cells (hepatocytes) and biliary cells that have the ability to
regenerate. From animal studies it was found that single hepatocytes of rats could have
cleavage up to about 34 cal, or produce enough cell numbers to form 50 rat livers. Thus it can
be said that it is possible to do hepatectomy or to cut the liver so that 2/3 of the whole liver
(Amiruddni, 2011).
The liver also has an immunological function, because the liver is a central component of the
immune system. The Kupffer cell, which accounts for 15% of the liver mass as well as 80% of
266
the total phagocyte population of the body, is a very important cell in dealing with antigens
from outside our bodies (Amiruddni, 2011).
To see whether liver function is normal or has been impaired can be done with liver
biochemical function tests. A blood chemistry examination is used to detect liver disorders,
determine the diagnosis, find out the weight of the disease and follow the course of the
disease and assessment of treatment outcomes, including diet therapy. The following table will
show a liver function test.
222
267
Tabel 6.1
Tes Fungsi Hati
Petanda Nilai Normal Interpretasi
Bilirubin 5-18 umol/L Tidak spesifik untuk penyakit hati, meningkat juga
pada hemolisis dan obstruksi bilier. Jika berdiri
sendiri pertimbangkan hiperbilirubinemia herediter
SGOT/AST 5-40 IU/L Meningkat sesuai inflamasi atau nekrosis hepatosit.
SGPT/ALT 5-35 IU/L Biassanya tidak diperlukan mengukur keduanya,
namun rasio AST : ALT >2 sencerung ke penyakit
hepatitis alkoholik
Fosfatase Alkali 30-130 IU/L Biasanya meningkat bersamaan pada kolestatis,
Ŷ-GT 5-50 IU/L obstruksi bilier atau infiltrasi hepatik. Fosfatase
alkali juga diproduksi oleh tulang, usus dan
plasenta
Albumin 3.5-4.5 gr/L Menunjukkan fungsi sintesis hati. Konsentrasi
dapat menurun pada malabsorpsi, protein losing
enteropathy, penyakit kritis (kebalikan dari fase
akut protein), luka bakar dan sindrom nefrotik
LDH (Lactate 240-524 IU/L Sensitivitasnya dan spesifisitasnya rendah pada
Dehydrogenase) penyakit hati. Munkin meningkat pada hepatitis
iskemik. Kadarnya juga meningkat setelah
kerusakan tulang atau hemolisis
Sumber : Amirudin. 2014. Fisiologi dan Biokimia Hati : Ilmu Penyakit Dalam. Jakarta : Internal
Publishing. Hal. 1931.
Setelah mengetahui fungsi hati, perlu juga diketahui sirkulasi darah dari dan ke hati.
Gambar berikut menunjukkan bagaimana sirkulasi darah yang melibatkan hati di dalamnya.
268
223
269
Liver menerima aliran darah melalui 2

sumber :
1a. Darah arteri – memberikan suplai

O2 dan membawa blood-borne
metabolites untuk proses

2.
hepatik yang didistribusikan oleh
arteri hepatik.
1b. Darah vena mengaliri saluran
pencernaan yang dibawa oleh
vena portal hepatik ke liver untuk
proses dan penyimpanan zat-zat

1a.
gizi yang baru diabsorpsi.

2. Darah meninggalkan liver melalui
1b. vena hepatik
Sumber : Sherwood L. Human Physiology From Cell to System. 7e. 2010. dalam Sucher and
Mattfeldt-Beman. 2011. Diseases of the Liver, Gallbladder, and Exocrine Pancreas :
Nutrition Therapy and Pathophysiology. 2e. Hal. 440
270
Gambar 6.2
Sirkulasi Darah dari dan ke Hati
TYPES OF HEART DISEASES
Many types of liver disease, among which are acute viral hepatitis, fulminant hepatitis,
chronic hepatitis, alcoholic hepatitis and cirrhosis. In this chapter will limit the discussion on
acute viral hepatitis alone.
HEPATITIS ACUTE VIRUSES
Viral hepatitis is a liver disease caused by inflammation or inflammation of the liver. The
causes of such inflammation are viruses, bacteria, toxins, obstruction, parasites, and
chemicals. Virus types are viruses A, B, C, D, and E.
Clinical manifestations of liver disease are almost the same for all types of hepatitis. Here are
general clinical manifestations of liver disease:
Patients may experience jaundice (yellow on the skin, nails or eye sclera), dark urine such as
tea, anorexia, fatigue, headache, nausea, vomiting and fever / heat.
224
271
The liver of the patient is enlarged (hepatomegaly) and in some cases the spleen of the
patient is also enlarged (splenomegaly).
Biochemical examination showed an increase in blood bilirubin levels, alkaline phosphatase

(ALT) enzymes, and alanine transferase (AST) enzymes.
There are four phases of clinical manifestations of liver disease, namely:
Incubation phase, phase where malaise symptoms occur, loss of appetite, nausea and
nyeriperutut right above.
Pre-Ikterik Phase (no specific symptoms), in this phase the patient may experience body
fluidity, athralgia (joint pain), arthritis (bone pain), rash (rash), and angioedema (udem on the
lips).
Phase Ikterik, in this phase the sufferer experiencing jaundice (skin, mucous membrane and
eyes look yellow).
The phase of convaslescent / recorvery, the phase in which jaundice and the above
symptoms are taken away.
Clinical manifestations for each type of hepatitis and viral incubation period can be seen in
Table 6.2 below.
Table 6.2
Type of Hepatitis, Virus Incubation Period and Symptoms
JENIS MASA INKUBASI GEJALA
Hepatitis A 14-28 hari, bahkan Flu-like illness, jaundice, mual, fatigue, nyeri
sampai 50 hari abdomen, anoreksia, diare, demam
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Hepatitis B Bertahan 7 hari di Flu-like illness, jaundice, mual, fatigue, muntah,
luar tubuh demam, sering tanpa gejala
Hepatitis C Rata-rata 7–9 Sering tanpa gejala sampai sel hati rusak - flu-like
minggu; illness, fatigue, mual, sakit kepala, nyeri
Bertahan 28 minggu Abdomen
Hepatitis D Terjadi dengan Flu-like illness, jaundice, mual, fatigue, muntah,

adanya inveksi HBV demam, sering tanpa gejala
Hepatitis E 2–9 minggu Malaise, hilang nafsu makan, nyeri abdomen,

nyeri sendi, demam
Sumber : Sanityoso dan Christine. 2014. Hepatitis Viral Akut : Ilmu Penyakit Dalam. Jakarta :
Internal Publishing.
225
273
NUTRITION OF NUTRITION IN HEPATITICAL DISEASES
Patients with liver disease experience various nutritional problems that can affect nutritional
status. Nutritional care for people with liver disease will work well, if done with the steps on
the process of standardized nutrition care. The first step is a nutritional assessment to assess
the nutritional problems that may occur in people with hepatitis disease. Patients with
hepatitis disease with existing manifestations can provide nutritional implications. The
nutritional implications of Hepatitis are as follows:
Inadekuat oral intake, this can occur because of the symptoms of nausea, vomiting, loss of
appetite, abdominal pain, anorexia, fever, etc.
Unexpected weight loss, can occur due to inadequate oral intake.
Nutritional deficiency can occur due to inadequate oral intake.
Drug and food interactions (HCV treatment).
To obtain food intake data to determine the consumption of food / fluids and which can be
accepted by patients, conducted by the method of survey of consumption of 24-hour recall,
diet history, or food diary. In addition to the intake data, the nutritional assessment step is
also required biochemical data and clinical physical data to support the establishment of
nutritional diganosa (second step of standardized nutrition care process).
Here is an example of the components collected for review in the nutritional assessment
step in patients with hepatitis, and its interpretation.
Table 6.3
Component of Nutrition Assessment on Hepatitis and its Interpretation
PENILAIAN HASIL INTERPRETASI
274
SGPT-SGOT SGOT > 40 U/L Terjadi kerusakan sel hati
SGPT > 35 U/L
Fosfatase normal
Alkali
Total serum > 18 umol/L Meningkat – liver tidak dapat membuang

bilirubin bilirubin atau kelebihan destruksi sel darah
Berat Badan Turun ≥ 5% dalam 1 bulan Penurunan berat badan yang tidak
atau ≥ 10% dalam 6 bulan diharapkan.
Dampak Asupan tidak sesuai dengan

kebutuhan
226
PENILAIAN HASIL INTERPRETASI
Penampilan Tampak kurus Penurunan berat badan yang tidak

Fisik diharapkan.
275
Dampak Asupan tidak sesuai dengan
kebutuhan
Penampilan Kulit dan sklera mata Bilirubin meningkat – gangguan fungsi hati
Fisik berwarna kuning
Mulut Luka di bagian ujung - Defisiensi vtamin dan atau mineral

Cheilosis
Lidah Luka - Glossitis, cheilosis, Defisiensi vitamin dan atau mineral
After a nutritional assessment, there will be possible nutritional problems in patients

with hepatitis disease, which will be referred to as a diagnosis of nutrition. Some possible
nutritional problems in patients with hepatitis are:
inadequate oral intake; inadekuat protein and energy intake; drug and food
interactions; uterine nutritional disorders (changes in metabolism ability of nutrients and
bioactive substances); and unexpected weight loss.
Some examples of nutritional diagnoses in patients with hepatitis:
1. Impaired utilization of nutrients (P or Problem) associated with hepatitis (E or

Etiology) is characterized by BDT and SGPT abnormal, high bilirubin, yellow looking (SS or
Signs and Symtomps).
2. Inadequate oral intake (P or Problem) associated with nausea, vomiting (E or
Etiology) is characterized by less energy intake than necessity, weight loss, and skinny
appearance (SS or Signs and Symtomps).
Note: Remember the writing of Diagnosis of Nutrition with PES.
NUTRITION INTERVENTION
276
After the nutrition diagnosis is established, the next step is the nutritional intervention.
The planned nutritional intervention should have a common thread with a defined
nutritional diagnosis. Where P (Problem) on nutritional diagnosis directs the purpose of
intervention; and E (Etiology) on nutrition diagnoses determine nutrition intervention
strategies consisting of 4 domains.
In general the goal of nutritional intervention in liver disease is to achieve optimal

nutritional status or maintain optimal nutritional status without burdensome liver function.
The goals of the intervention are tailored to the existing nutritional problems and to support
cell regeneration; providing the best food and fluids; modify the frequency frequent meals
with small portions to overcome anorexia; and there are no restrictions on foods other than
alcohol.

277
Tabel 6.4
Contoh rencana intervensi gizi diambil dari contoh diagnosa gizi nomor 1 di atas.
Diagnosa Gizi Intervensi Gizi
PROBLEM Gangguan utilisasi zat Tujuan :

gizi Memberikan makanan sesuai kemampuan
tubuh dengan gangguan metabolisme zat gizi
ETIOLOGI Penyakit hepatitis Strategi :

Pemberian terapi diet hepatitis
SIGN / SGOT dan SGPT -

SYMPTOM abnormal, bilirubin
tinggi, tampak kuning
Nutrition Intervention consists of 4 domains, namely the provision of diet, nutrition

education, nutrition counseling and coordination.
Dietary or diet prescription in hepatitis disease (Diet Guides, 2004):
High energy to prevent protein breakdown, ie 40-45 Calories / kg body weight
Protein is rather high as an anabolism of proteins, 1.2-1.5 grams / kg body weight
Needs enough fat, ie 20-25% of total energy with digestible form or emulsion. If there is a fat
utilization disorder (jaundice or steatorrhea), then it is given:
fat restriction <30%

278
reduce the fat of Long Chain Triglycerides (LCT) sources or fat with long carbon chains and
use medium-sized Medium Chain Triglycerides (MCT) fats or medium-chain fatty acids
because they do not require the activation of lipase and bile enzymes in their metabolism.
However use should be cautious if there is a risk of diarrhea
Carbohydrate needs, which is the total residual energy, and is distributed in one day with
small portions but often to avoid hypoglycemia and hyperglycemia conditions.
Vitamin requirement fits the level of deficiency. When necessary with vitamin B complex
supplements, vitamin C, and vitamin K.
Mineral needs as needed, if necessary supplemented with iron (Fe), zinc (Zn), Magnesium
(Mg), calcium (Ca), and Phosfor (P). For sodium (Na) is limited when there is udema or
ascites, ie 2 grams / day.
The fluid requirement is given more than usual, unless there is contraindication, such as
udema or ascites.
The form of soft foods (when there is nausea and vomiting) or regular food form.
The food route is tailored to the patient's condition.
228
279
Selection of foodstuffs, there is limited food and not recommended. Restricted foodstuffs are
dietary sources of fat (fatty meats), and gaseous foods, such as sweet potatoes, red beans,
cabbage, mustard greens, turnips, cucumber, durian, jackfruit. While the food is not
recommended is food and beverages contain alcohol, tea and coffee.
Examples of nutritional prescriptions with the aim of providing food according to the ability
of the body with metabolic disorders of nutrients.
1500 Calories Diet, 30 grams of protein, 184 grams of carbohydrates, 60 grams of fat, 750 ml
of liquid. Limit the ingredients of sources of fat and gas and caffeine-containing foods,
feeding at 6 times the frequency of small portions, oral route.
For nutrition education domain intervention, nutrition counseling and coordination, can be
planned as follows:
Nutrition education by providing motivation and information and cooperate in achieving the
goal of diet therapy.
Nutritional counseling is planned by designing together to modify the diet (amount, type,
and way of fulfilling nutritional needs to achieve optimal nutritional status)
Nutrition coordination is consultation, referring or coordinating with other health workers in

the provision of nutritional care for hepatitis patients to be achieved.
MONITORING AND NUTRITIONAL EVALUATION
The final step of nutritional care with the Nutrition Care Process is the Nutrition Monitoring
and Evaluation. The purpose of this step is to look at the effectiveness of nutritional
interventions and the progress of the planned goals. Components monitored and evaluated
in accordance with signs and symptoms (Sign and Symptom or SS) of established nutritional
280
problems, namely: patient tolerance to the food given, changes in body weight, changes in
laboratory values, and patient comfort, especially in terms of eating.
Table 6.5
Example of monitoring and evaluation of advanced nutritional examples of nutrition
diagnosis number 1 above.
ND
PROBLEM Gangguan utilisasi Tujuan intervensi gizi :

zat gizi Memberikan makanan sesuai kemampuan tubuh
dengan gangguan metabolisme zat gizi
ETIOLOGI Penyakit hepatitis Strategi intervensi gizi :
229
Pemberian terapi diet hepatitis
SIGN / SGOT dan SGPT Rencana monev gizi :
281
SYMPTOM abnormal, Perbaikan nilai SGOT dan SGPT, bilirubin, hilang
bilirubin tinggi, penampilan tampak kuning
tampak kuning
Exercise
Cases of hepatitis
A 24-year-old female patient recently admitted to hospital with dizziness, nausea and
vomiting. Patients also complain of high fever in the late afternoon and a bit early in the
morning, which has lasted for 1 week. Doctors diagnose patients with Hepatitis A and
patients are recommended for hospitalization.
Patients come from Central Java and boarding in Bandung because they work in a
government hospital together with their friends. Everyday Nn T always snack for breakfast,
lunch and afternoon on the roadside around boarding and RS. During this time patients do
not know the risk factors for safe food against hepatitis A.
Laboratory results: SGOT 500 U / l and SGPT 650 U / l, Hb 13 g / dl, bilirubin 2 mg / dl.
The patient appears weak, pale and yellow. The patient weighs 45 kg and height 165 cm.
Weight is usually before the pain (1 week ago) 50 kg.
Feeding intake is only 50% of the usual (approximately 1350 Calories energy), the form of
porridge. Patients complain of no appetite, nausea and upper right abdominal pain. It has
been 3 days patient is not defecate. Patients have no food allergies but do not like milk.
Take a nutritional assessment step and determine the nutritional diagnosis of the above
case.
282
Assessment of nutrition in hepatitis disease.
Diagnosis of nutrition in hepatitis disease.
Summary
Liver disease and the biliary system have a significant effect on the nutritional status of the
patient. Clinical manifestations of the disease include jaundice or jaundice, anorexia,
abdominal pain, steatorrhoea, and malabsorption all affecting nutritional status.
Furthermore, the process of liver disease progression and potentially disruptive biliary
systems
230
normal metabolism and can put patients at significant nutritional risks. Therefore, nutritional
therapy is a vital component in treatment therapy.
Test 1
Choose one of the most appropriate answers
Indicators of nutritional care of anthropometric data that need to be collected and assessed
in patients with hepatitis disease are ....
a. Weight
b. Height
c. Upper arm circumference
283
d. Body Mass Index`
e. Changes in weight
The total serum of bilirubin that increases beyond normal value in hepatitis conditions
indicates ....
a. Damage to liver cells
b. Vitamin and mineral deficiency
c. The presence of hyperbilirubinemia jaundice
d. The impact of E & P intake does not match the needs
e. The liver can not dispose of red blood cell destruction
Often seen a physical appearance that looks thin in patients with hepatitis conditions. It
shows symptoms of ....
a. Vitamin and mineral deficiency
b. Inadequate energy intake
c. Unexpected weight loss
d. Liver cell damage and vitamin and mineral deficiency
e. Unsuitable energy intake and unexpected BB changes
The aspect of safe food access needs to be collected and assessed, especially in patients with
diseased conditions.
284
a. Hepatitis A
b. Hepatitis B
c. Hepatitis C
d. Hepatitis D
e. Hepatitis E
Comparative standard to assess whether energy intake in accordance with the needs of
hepatitis conditions is ....
a. 20 - 25 kcal / kg body weight
b. 25 - 30 kcal / kg body weight
c. 30 - 35 kcal / kg body weight
d. 30 - 40 kcal / kg body weight
e. 40 - 45 kcal / kg body weight
How to document anthropometric data on the correct condition of hepatitis below is ....
a. Weight is 35 kg
b. Changes in body weight 10 kg
c. Weight before 50kg
d. Current weight 35 kg, weight usually 45 kg, change body weight 10 kg
285
e. Current weight 35 kg, weight usually 45 kg, unexpected weight change 22% in 1 month
Nausea, vomiting, no appetite, E intake is less than the need and constipation in hepatitis
condition, showing signs and symptoms of nutritional problems which are below.
a. Inadequate oral intake
b. Impaired utilization of adequate nutrients
c. Drug and food interactions
d. Gastro intestinal changes
e. No fiber intake
In the condition of hepatitis always accompanied by the sign SGOT and SGPT increased,
bilirubin increased, the patient looked yellow, then the diagnosis of nutrients that can be
established is ....
a. Excessive fat intake associated with hepatitis was characterized by SGOT, SGPT and
bilirubin exceeded normal and patients looked yellow
b. Gastrointestinal changes associated with hepatitis are characterized by SGOT, SGPT and
bilirubin exceeding normal and patients appear yellow
c. Drug and food interactions associated with hepatitis were characterized by SGOT, SGPT
and bilirubin exceeded normal and patients looked yellow
d. Impaired utilization of fatty nutrients associated with hepatitis characterized by SGOT,

SGPT and bilirubin exceeded normal and patients looked yellow
e. Changes in fat-related laboratory values associated with hepatitis were characterized by

SGOT, SGPT and bilirubin exceeded normal and patients looked yellow
286
231
232
287
The purpose of nutritional intervention of hepatitis patients with nutritional problems

disorders utilization of fatty nutrients is ....
a. Increase 100% oral intake within 3 days
b. Achieve optimal nutritional status within 1 month
c. Provide food without heart for 3 days
d. Increase intake of food 80% of requirement for 3 days
e. Provide food in accordance with the conditions of disruption utilization of fatty

nutrients within 3 days
The data that needs to be monitored and evaluated on the nutritional problems of
gastrointestinal changes in hepatitis patients is ....
a. Changes in weight
b. Changes to meal schedules and medications
c. Changes to safe food selection
d. Changes in energy intake, changes in nausea, vomiting and constipation
e. Changes in laboratory values are nearly normal on SGOT, SGPT, bilirubin
288
289
233
290
Topic 2
Nutritional care in gallbladder disease
To understand the disorders that occur in the gall bladder, it is necessary to learn about the
anatomy and physiology of the gallbladder itself. The gallbladder is located on the underside
of the liver and the right side of the abdomen. The bile duct stores the bile from secretions
of the liver before entering the duodenum. Bile leaves the liver via the hepatic gland, which
joins the cystic gland of the gallbladder to form the bile glands. The gall glands join the
pancreatic gland forming the Vater ampulla, which enters the duodenum. Bile is secreted
into the small intestine because it responds to the presence of food (especially fat). The
following figure shows the location of the gall bladder and other digestive organs.
A, hati
B, kandung empedu
C, esofagus yang mengarah ke
lambung
D, lambung (garis titik-titik)
E, saluran empedu
F, duodenum;
G, pankreas dan saluran pankreatik;
291
H, limfa
I, ginjal
Source: Hasse and Matarese. 2017.Medical Nutrition Therapy for Hepatobiliary and
Pancreatic Disorders: Krause's. Food and the Nutrition Care Process. 14th ed. Canada:
Elsevier. P. 576
Figure 6.3
The location of Gall Bladder and its Relation to Other Digestive Organs
Liver, pancreas, and gallbladder are part of the digestive tract that is important in the
process of digestion, absorption and metabolism of nutrients.
Gallbladder plays a role in changing water and inorganic electrolytes from bile, then
increasing the concentration of organic solutions (become larger), storage of bile salts and
controlling the delivery of bile salts to the duodenum. Bile is a principal element of
cholesterol, bilirubin (from hemoglobin) and bile salts.
234
Bile salts themselves are essentially substances for digestion and absorption of fat, fat
soluble vitamins and some minerals. Bile salts are also an emulsifier agent so the gut can
break down the fat globules, and help the absorption of fatty acids, monoglycerides,
cholesterol, and other fats that form micelles that can dissolve in chime. Without bile salts,
most of the fat will be lost in the feces.
292
Bile secretion
Bile secretion and circulation involves other digestive organs. For more details
the following figure shows bile secretion and circulation.
2
3
Sekresi oleh liver

1
1. Pembuluh hepatik : menyatukan
lobus kanan dan kiri
2. Pembuluh cystic
4 3. Pembuluh empedu
* Ada sphincter Boyden kuat sebelum
5 bergabung dengan pembuluh
pankreas
4. Vater ampulla, membuka ke
usus halus
5. Sphincter Oddi.
293
Sumber : Sherwood L. Human Physiology From Cell to System. 7e. 2010. dalam Sucher
and Mattfeldt-Beman. 2011. Diseases of the Liver, Gallbladder, and Exocrine Pancreas :
294
Sirkulasi Empedu
295
Sumber : Sherwood L. Human Physiology From Cell to System. 7e. 2010. dalam Sucher and
Mattfeldt-Beman. 2011. Diseases of the Liver, Gallbladder, and Exocrine Pancreas : Nutrition
Therapy and Pathophysiology. 2e. Hal. 441
Figure 6.5
Bile Circulation
Bile is a complex dilute solution that is disekeresi by the liver. Ultimately all the bile flows
into 1 large vessel / channel from each lobe of the liver. 2 main branches, 1 from the right
lobe and 1 from the left, unite to form the hepatic vessels. The hepatic vessels are lowered
to the right a few inches and then unite with the cystic vessels of the gall bladder forming
the bile ducts. The bile vessels join the pancreatic vessels, forming a single vessel called the
ampulla of Vater. There is a strong sphincter of Boyden in the gallbladder before the
pancreas. Ampulla opens into the duodenum in duodenal papilla. Muscle tissue associated
with ampulla forms a weak sphincter called the Oddi sphincter.
The bile is secreted continuously by the liver cells and into the canaliculi to flow into the
gallbladder and end in the gall bladder. The gall component must remain at its high
concentration in the organic solution. The normal ratio for cholesterol Figure 6.5
Bile Circulation
296
concentration in the organic solution. The normal ratio for cholesterol236
Figure 6.5
Bile Circulation
concentration in the organic solution. The normal ratio for cholesterol
tidak mengendap dan membentuk batu empedu. Sel hatir mensintesa dan mensekresikan
600–1000 mL empedu per hari, walaupun volume maksimal kandung empedu hanya 30–60
mL. Namun demikian selama 12 jam, sekresi empedu (biasanya sekitar 450 mL) dapat
disimpan dalam kandung empedu karena air, natrium dan sebagian besar elektrolit lain
secara terus menerus diabsorbsi oleh mukosa kandung empedu, mengonsentrasi sisa
297
empedu (termasuk garam empedu, kolesterol, lecithin, and bilirubin. Empedu normal
terkonstrasi 5-kali tetapi dapat mencapai maksimal 20-kali.
Liver disease, pancreas and gallbladder are interrelated, so if one of these organs is
impaired, it will affect other organs. There are several diseases caused by bile or gallbladder
disorders, namely kolelitiasis (gallstones), koledokolitiasis (obstruction of bile ducts),
cholecystitis (inflammation of the biliary), and kolangitis (inflammation of the bile ducts).
Kolelitiasis (gallstones)
Cholestasis or gallstones are stone formations (calculi) in the gallbladder or biliary system
tract. There are 3 types of stone materials, namely cholesterol (more than 70%), pigment,
and stone mixture (usually calcium salt). Most patients with gallstones have no complaints.
The risk of people with gallstones is experiencing symptoms and complications are relatively
small, but once the gallstones begin to cause specific colic pain attacks, the risk of having
problems and complications will continue to increase. About 80% of patients with
asymptomatic gallstones. Surgical travel studies reported for 20 years as 50% of gallbladder
patients remained asymptomatic, 30% had biliary colic and 20% had complications. A
reliable symptom of gallstones is biliary colic, defined as upper abdominal pain lasting more
than 30 minutes and less than 12 hours. Usually the location of pain in the upper abdomen
or epigastrum, but can also on the left and precordial (Lesmana, 2014).
Risk factors of gallstones are obesity, inflammatory bowel disease, cystic fibrosis, prolonged
use of parenteral nutrition, short bowel syndrome, multiple pregnancy estrogen and
genetics.
Factors that play an important role in the formation of gallstones are:

Too much absorption of water and bile acids in the gall bladder.
Too much cholesterol absorption in bile disorders of gallbladder and gut motility, such as
epithelium inflammation - due to chronic infection that can change the function of mucosa
to become abnormal.
Clinical manifestations of gallstones are as follows:
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Pain, usually most of the typical pain and symptoms lasting several minutes to hours, occurs
after heavy food consumption and contains high fat.
Pain radiates to the right shoulder as the arm is raised.
Fever, nausea and vomiting.
Jaundice (obstruction of the gallbladder).
Acute pancreatitis (gallstones enter the duct into the pancreas and block it).
Clinical management of gallstones with:
Cholecystectomy or remove gallstones
Drugs, such as ursodeoxycholic acid / ursodeoxycholic acid) dissolve stones, antibiotics to

treat infections, analgesics as anti-pain and antiemetics to reduce the symptoms of nausea
and vomiting.
Koledokolitiasis (obstruction of bile ducts)
Koledokolitiasis (obstruction of bile ducts) is an obstruction in the gall bladder,
head of the pancreas, or bile ducts. This condition will result in:
299
Colic bile ducts (upper right pain).
Bile is not brought to the gut.
Maldigesti and fat malabsorption.
Excretion of bile pigment.
into the urine that causes dark urine color.
to the stool, thus causing the feces no pigment, the color is gray (claycoloured).
If uncorrected Koledokolitiasis can cause liver obstruction so that the liver becomes
damaged (biliary chirosis) and jaundice. This condition can also cause an ampulla obstruction
of Vater resulting in acute pakreatitis.
Clinical management of Koledokolitiasis with:
Endoscopic retrograde sphincterotomy.
Antibiotics, analgesics and antiemetics.
Cholecystitis (gallbladder inflammation)
Inflammatory causes of the gallbladder are obstruction, infection and ischemia
in a gallbladder that may occur acutely or chronically. This condition leads to infection and
necrosis (tissue damage). Clinical manifestations of gall bladder inflammation may lead to
liver infection and sepsis. This condition can provide complications "lifethreatening"
especially in the elderly.
Clinical management Cholecystitis is an initial therapy: antibiotics, fluid resuscitation and

correction of blood clots. Impact of gallbladder disorders on nutrition:
300
The cause of stone deposits: cholesterol, occurs due to high fat intake.
Acute attacks of patients with cholangitis, nil orally for 12 hours before surgery.
Maldigesti and malabsorption of fat, indicating a disruption of nutrient utilization.
Bloating, can cause low feed intake.
Diarrhea after surgery, can also cause a low intake of eating.

Changes in nutritional status, can cause patients to fall into the condition of malnutrition.
Table 6.6
Indicator of Nutritional Problems in Gallbladder Disease
Indikator Nilai Implikasi
Asupan serat Rendah dari kebutuhan Batu empedu
Asupan lemak Tinggi dari kebutuhan Batu empedu, chronic cholecystitis

Terutama jenis lemak jenuh
Vitamin C pada Tinggi dibanding kebutuhan Pembentukan batu empedu

vegetarian (katabolisme kolesterol menjadi
asam empedu)
Riwayat (naik/turun) yang berulang pada kolelitiasis treatment perlu

perubahan BB dengan riwayat puasa dan dibantu dengan peningkatan
rendah kalori aktifitas
Keluhan abdomen Kembung, flatus Gangguan kandung empedu
Gastrointestinal Mual, muntah Asupan oral rendah
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Possible nutritional problems in gallbladder disorders are:
1. Excess fat intake.

2. Low fiber intake.
3. Inadequate intake of food and drink.
4. Changes in gastrointestinal function.
5. Impaired utilization of nutrients.
6. Drug-food interactions.
7. Increased nutritional needs.
In general, the goal of nutritional intervention in gallbladder disorders is to achieve and

maintain optimal nutritional status, as well as rest the gallbladder.
The strategy of nutritional intervention in patients with gallbladder disorders is:
1. Lose weight
2. Restrict foods that cause bloating / abdominal pain.
3. Overcoming fat absorption.
239
240
302
Nutritional interventions:
Energy is provided as needed. If the patient is overweight, avoid weight loss that is too fast.
Protein is given in moderate to high amount, ie 1 to 1.25 grams / kg body weight.
Fat is given according to the patient's condition
Acute condition given free of fat.
Chronic state is given 20-25% of total energy.
Steatorea state (leak faeces> 25 grams / 24 hours) given the type of MCT.
Supplements of vitamins A, D, E and K if needed.
The fiber is given high in pectin form to bind the excess bile acids.
Avoid foods that cause bloating and discomfort.
Special post-gallbladder surgery is given a regular diet according to tolerance. The acute
condition of cholecystitis, food is administered by parenteral or intravenous. However, it is
not recommended for a long time. If it is reduced or resolved, then given a low-fat diet.
Nutrition Monitoring and Evaluation
In monitoring and evaluation steps need to be seen:
Acceptance of food.
If the patient is NPO (nil orally) and or there is an infection.
303
Nutritional status of patients, judging by changes in body weight and associated
laboratoirum value.
Exercise
Cases of Cholestasis
A 35-year-old housewife is diagnosed with cholinasis because complaints often feel nausea
that disappears and upper right abdominal pain that radiates up to the right shoulder.
Patients feel the complaint is more than 1 month ago. But just need help to the doctor
because the pain felt more and more great for more than 15 minutes. The current condition
of the patient is also in a yellow state throughout the body.
Current patient intake begins to decrease than usual. Diet 3 times a day, but can not eat
much. Every meal, patients can only eat 10 tablespoons of rice, ½ piece of animal (most
choose fried chicken) and vegetable (most of the choice is fried tempe). Patients do not like
vegetables and fruits. Eating habits before the sick, patients often consume fried (fried and
fried) every day as much as @ 3 medium fruit, chips and hotcakes 3 times a week
approximately 1 hand held adult. Patients claimed not to know what causes the incidence of
current disease with eating habits.
The results of laboratory tests showed the urine of patients brown, high cholesterol levels,
there is fat in the feces. The patient's weight changes from 63 kg to 60 kg in one week, while
the patient's height is 168 cm.
Assessment of nutrition in the disease kolelitiasis.
Diagnosis of giz on disease kolelitiasis.
304
Summary
Liver disease and the biliary system have a significant effect on the nutritional status of the
patient. Clinical manifestations of the disease include jaundice or jaundice, anorexia,
abdominal pain, steatorrhoea, and malabsorption all affecting nutritional status.
Furthermore, the process of liver disease progression and potential biliary systems disrupts
normal metabolism and can place patients at significant nutritional risks. Therefore,
nutritional therapy is a vital component in treatment therapy. Especially for nutritional care
in gallbladder disease nutritional intervention focuses more on the provision of fat, both the
amount and type according to the condition of the patient.
Test 2
Choose one correct answer.
Types of anthropometric data suggesting nutritional problems in patients with cholelithiasis

and obesity are:
a. Body Mass Index> 25 kg / m2

b. Body Mass Index> 30 kg / m2
c. Unexpected weight loss
d. Unexpected weight gain
e. Changes in weight loss and recurrence
f. Indicators of nutritional care from biochemical data indicating biliary obstruction are:
g. High total bilirubin serum and high direct bilirubin
h. High total bilirubin serum and high indirect bilirubin
i. Normal total bilirubin serum and high direct bilirubin
241
d. Normal total bilirubin serum and high indirect bilirubin
305
e. High total bilirubin serum and normal direct bilirubin
Disorders of the gallbladder can cause nutritional problems of low oral intake. The
cause or etiology is:
a. Nausea and vomiting
b. Appetite down
c. Flatulent and flatus
d. Pain and shortness of breath
e. Shortness of breath and difficulty swallowing
Symptoms of digestive disorders of fat due to obstruction of gall stones are:
a. Vomiting while eating after eating fat source
b. Nausea and vomiting ½ hour after eating fat source
c. Nausea and vomiting <3 hours after eating fat source
d. Nausea and vomiting> 3 hours after eating fat source
e. Nausea and vomiting every meal
Feeding and drink intake is low from need, low E intake of need, nausea and vomiting
are some of the symptoms in conditions with biliary disorders that indicate
nutritional problems below:
306
b. Inadekuat oral intake
c. Impaired utilization of nutrients
d. Drug and food interactions
e. Unexpected weight loss
Fat intake is more than a requirement, normal cholesterol ester and clay color stools in
biliary disorder condition indicate a nutritional problem:
a. Increased fiber requirement
b. Changes in gastrointestinal function
c. Fat intake of excess cholesterol
d. Impaired utilization of nutrients (fat)
e. Drug interactions and food sources of fat
Provision of appropriate fats according to the patient's condition are:
a. Fat free in chronic conditions
b. The amount of fat is sufficient in acute conditions
c. The amount of fat 20-25% in chronic conditions
d. Type of MCT food ingredients in acute condition
e. Types of MCT food ingredients in chronic conditions
242
307
Provision of diet therapy on nutritional diagnosis "Changes in gastroinetstinal function

associated with acute cholytitis characterized by E intake of 24 hours 0 calories, heartburn,
nausea and vomiting of stomach fluid" are:
a. Fat free
b. Low-fat diet
c. Regular diet according to tolerance
d. Food is orally discontinued and provide parenteral nutrition
e. Avoid foods that cause bloating and discomfort
The types of foods that can be administered to patients with biliary disorder are:
a. Avocado
b. Cake, pie, ice cream
c. Whole milk and chocolate milk
d. Skim milk, buttermilk and yogurt from skim milk
e. Cheese bread, muffins and popcorn cooked with butter
The data monitored and evaluated in biliary disorder conditions with nutritional problems of
gastrointestinal changes are:
a. Changes in energy intake for 3 days
308
b. Yellow stool color change for 3 days
c. Changes in body weight for 7 days rose 0.5 kg
d. Changes in total, direct and indirect bilirubin laboratory values
e. Changes of complaints of nausea, vomiting, bloating and energy intake for 3 days
243
309
Key of answer
Tes 1
Tes 2
310
A
311
244
Glossary
ALT Alanine amino transferase or SGPT is a large enzyme
found in liver cells as well as effective for diagnosing hepatocellular destruction

Anorexia Loss of appetite
AST Aspartate Amino transferase or SGOT is an enzyme
found in the heart muscle and liver, while in concentrations are being found in skeletal
muscle, kidney and pancreas
Biliverdin The bile pigment compound of the porphyrylicated trajectory family
catabolic heme groups of hemogloblins present in the erythrocytes, by hemeoxygenase

Cheilosis The type of inflammatory lesions that appear on the lip joint (at the corner of the
mouth),
312
caused by the accumulation of saliva and sometimes with yeast involvement as a result of
fungal infections of the oral cavity
Phagocytes White blood cells play a role in the immune system in a way
phagocytosis / swallowing pathogens
Fatigue fatigue
Alkaline phosphatse Enzymes produced mainly by the liver epithelium and osteoblasts (cell-
new bone-forming cells); This enzyme is also derived from the intestinal tubules
proximal to the kidneys, placenta and mammary glands that make
milk
Fulminant hepatitis Inflammation and damage to the liver tissue that causes it
severe, rapid, and prolonged liver function due to viral infection or other causes
Glossitis Inflammation of tongue infection
Ischemic Insufficiency of blood supply to the tissues or organs of the body
LDH Lactate Dehydrogenase is an intracellular enzyme present

in almost all cells that metabolize, with concentration
highest in the heart, skeletal muscle, liver, gibal, brain, and cell
Red blood.
Malaise General conditions that are weak, uncomfortable, less fit or feeling
sick
MCT Medium Chain Triglyseride or triglyceride (fat) chains
medium / medium with carbon chain C6 - C12 which is saturated,
his metabolism does not require carnitine so much faster
produce energy
Obstruction of obstruction
Cell Kupffer A kind of macrophages that only live in the heart
245
313
Bibliography
Amirudin. 2014. Physiology and Biochemistry of the Heart: Science of Internal Medicine.
Jakarta: Internal Publishing. P. 1931.
Hasse and Matarese. 2017. Medical Nutrition Therapy for Hepatobiliary and Pancreatic
Disorders: Krause's. Food and the Nutrition Care Process. 14th ed. Canada: Elsevier.
Nutrition Installation Perjan RSCM and AsDI. 2004. Diet Guides. Jakarta: PT Gramedia
Pustaka Utama,
Lesmana LA. 2014. Gallstone Disease: Internal Medicine. Jakarta: InternalPublishing.
Sanityoso and Christine. 2014. Acute Viral Hepatitis: Internal Medicine. Jakarta: Internal
Publishing.
Sucher and Mattfeldt-Beman. 2011. Diseases of the Liver, Gallbladder, and Exocrine
Pancreas: Nutrition Therapy and Pathophysiology. 2nd ed.
314
CHAPTER VIII
NUTRITION OF NUTRITION IN CASES OF TBC AND COPD
Dr. Iskari Ngadiarti, M.Sc, SKM
PRELIMINARY
We study the theory or management of nutritional care in respiratory tract infections

especially tuberculosis and COPD. In Module 7 this is how to carry out the process of
nutritional care in these patients. It has been described in the first module that the current in
the process of care refers to the process of standardized nutritional care (PAGT) with the
approach of ADIME (Assessment, Diagnosis of nutrition, Intervention, Monitoring and
Evaluation) on HIV / AIDS and respiratory infections.
In this module you will be given some case exercises with respiratory tract infections
(tuberculosis and COPD). But before you settle the case, you will be given study guides, and
an example of the settlement of the case. In general, this module consists of two topics,
namely the process of nutritional care in the case of respiratory tract infections of
tuberculosis, and non-respiratory infections respiratory COPD (Chronic lung diseases lung).
It is hoped that after studying this module, you are able to practice standardized nutrition
services and be able to arrange the menus according to the specified regimen. Thus the
output and outcome of nutrition services can be measured, and the results according to
patient expectations.
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Topic 1
Nutrition Care On Disease Tbc
A special program student I'm proud of, after you've learned Module 5 on medical nutrition
therapy in tuberculosis now is the practice of how to provide nutritional care. It is known
that there is an interdependent relationship between nutritional status and TB disease. In
other words, TB patients are very susceptible to suffering from malnutrition, and if the
patient improves nutritional status it is said that the patient has improved prognosis.
Nutrition improvements depend on the amount of food intake of the patient. The intake of
feeding the patient is very close to an attractive diet so that it can increase appetite.
Good food is not merely attractive is attractive from the aspect of appearance, color, odor
only, but must meet the nutritional needs of patients and safe / hygine / clean. Therefore, to
prepare the menu of tuberculosis patients need to do a detailed assessment for nutritional
needs, and others in accordance with the patient's condition. Ironically TB patients are often
associated with socioeconomic conditions. Assistance to food selection with caregivers and
patients needs to be done well so that nutritional care can help overcome the disease.
PROCESS STEPS OF NUTRITION OF NUTRITIONS ON TBC DISEASES
The goal of providing nutritional care in TB patients is to maintain or achieve normal

nutritional status. TB disease is a dangerous respiratory disease, because it can be a long
chronic disease even deadly if not doing well. The key discipline in doing drug therapy and
adequate nutritional care. Ironically, many TB patients are less concerned about nutrition
because they feel that nutrition is expensive. Therefore, in providing nutritional care the
nutrition review process should be done comprehensively, so that in the intervention
tailored to the real condition of the patient, and if there is need for health personnel
including nutritionists help problem solving so that adequate food can be prepared, but with
limited conditions. The steps in providing nutritional care are described below:
Assesement:
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Medical: diagnosis of previous health condition.
Medication: the type of drug given whether there is an antagonist with nutrients.
Social history: economic status, purchasing power of food, family / friends support,
education level, home location.
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307
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Anthropometry: TB; BB at this time, BB history (highest BB ever reached, BB usually). BMI for
adults, and child is BB / TB with child growth standard, WHO 2005.
Biochemistry: Visceral protein (albumin, prealbumin), hematology (haemoglobin,

hematocrit), immunological ability of lab results, electrolyte, pH, glucose, arterial blood gas,
serum alkaline phosphate (vitamin D), protombrin time (vitamin K); serum carotene, retinol
binding protein (vitamin A), serum tocopherol (vitamin E), erytrositic hemolysis (vitamin E),
serum zinc (zinc).
Clinical: limp,
Nutrition history: eating habits, food recall 1 x 24 hours, whether there is a malfunction of
swallowing / chewing, whether there is the ability to cook or provide food, food allergies,
previously restricted foods, religion, culture, ethnicity associated with diet, education
nutrition ever obtained.
Diagnosis of nutrition that is often encountered in patients with TB disease are:
Inadekuat food / beverage intake.
Hypermetabolime.
Inadekuat energy intake.
Adequate protein intake.
Food and drug interactions.
Malnutrition.
Weight loss is not intentional.
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Difficulty swallowing / difficulty chewing.
Example: NC. 3.2. Patients experience unintentional weight loss as evidenced by an

unplanned BB incidence of 10% in the last 3 months followed by weakness.
Intervention
Patients will consume a minimum of 2200 kcal per day.
Increase the nutrient density of food consumed by providing education with to select and
prepare food.
Give dietary regimens with enough fat, high in monounsaturated fatty acids, high in vitamin
C, iron, high in vitamins A, B6, B1 and D.
The form of soft food, enough liquid and fiber.
Monitoring and evaluation:
Monitor weight at least one week seklai.
Patients will be monitored daily food intake.
Indicators of successful treatment of TB one of which is the increase in BB and blood protein
(albumin and haemoglobin).
EXAMPLES OF TB CASES DISEASES
Case with ADIME and nutrition therapy plan complete with the menu plan: Boy, age 5 years.
BB 6 months ago 14 kg, BB now 11 kg, TB 90 cm. LILA = 9 cm. Signed in hospital for TB and
Nutrition. The perceived complaints are diarrhea, fever, cough, weakness, weak legs,
swelling of the feet and hands. The doctor's diagnosis is TB Miller and Malnutrition
Marasmik-Kwashiorkor. Clinical conditions are pale eyes, round isokor pupils, face like old
prang. Laboratory results showed Hb levels of 7.9 g / dl, 24.7% hematocrit, 1130 rb / ml
leukocyte, and platelets 573,000 rb / ml. Feeding habits are main meals 3x daily: 5
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tablespoons porridge + boiled fish ½ piece + vegetable carrots 2 tablespoons, Snack 2x a day:
Biscuits 3 pieces, 1 cup milk (2 tablespoons milk powder + 1 tablespoon sugar).
Assessment
Diagnosis of Disease and Personal History Male patients, 5 years of age
Diagnosis of Doctors: Miller TB and Malnutrition Marasmik-Kwashiorkor.
SMRS: Diarrhea, cough, weakness, weak legs, swelling of the feet and hands.
MRS: fever.
Anthropometric data
1) TB: 90 cm AD-1.1.1
2) BB now: 11 kg AD-1.1.2
3) BB SMRS: 14 kg
4) LILA: 9 cm
5) BB change: down 3 kg in 3 months AD-1.1.4
6) IMT / U SMRS: 17.28 kg / m2
IMT / U current: 13.58 kg / m2
Biochemical Data
Table 9.5
Laboratory examination
Pemeriksaan Hasil Satuan Nilai Normal
Hb 7,9 gr/dl 12-16 Rendah

Ht 24,7 % 36-46 Rendah
Leukosit 1130 rb/ml 5000-10.000 Rendah
Trombosit 573000 rb/ml 150.000-400.000 Tinggi
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Klinis/Fisik Fisik
Mata pucat, pupil bulat isokor.
Gigi dan mulut mukosa lembab, wajah seperti orang tua Iga gambang dan odema di
perut ,tangan, dan kaki.
Tabel 9.6
Pemeriksaan Klinis
Pemeriksaan Hasil Kadar Normal Satuan
Tekanan Darah 90/50 (rendah) 130-150/80/90 mmHg

Nadi 140 (tinggi) 70-80 x / menit
Suhu Tubuh 39 (tinggi) 36,6-37,2 x / menit
Dietary History Eating Habits
Main meals 3x a day: 5 tablespoons porridge (¼ p) + boiled fish ½ piece (½ p) + vegetable

carrots 2 tbsp (1/4 p).
Snack 2x a day:
Biscuits 3 pieces (¾ p), 1 cup milk (milk powder ½ p + 1p sugar).
During the 3rd day in the hospital got formula food for malnourished children and can spend
80%.
Quantitative Analysis
Table 9.7
Quantitative Analysis
Jenis
Porsi Energi(kkal) Protein(gr) Lemak(gr) KH(gr)
Makanan
Karbohidrat 2¼P 393,75 9 - 90
Protein 1½P 75 10,5 3 -
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Hewani
Protein - - - - -
nabati
Sayur ¾p 18,75 0,75 - 3,75
Buah - - - - -
Minyak - 45 - 5 -
Gula 2P 102,44 - - 24,4
Susu 1p 75 7 - 10
JUMLAH 710,27 27,25 8 128,15
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Qualitative Analysis
Less energy.
Less protein intake.
Less intake of carbohydrates and vegetables.
Requirement Calculation:
Energy Requirement: (BB CDC + BB / week - edema) x Transitional Phase Energy

Requirement
BB CDC = 14 kg
Addition of BB (50 gr / kgBB) = 50 gr / kgBB x 11 kg = 550 gr = 0.55 kg
Odem Correction The Weight of Oedema Rate = 30% x BB Now = 30% x 11 kg = 3.3 kg
Transition Phase Energy Requirement (100-150 kcal / kgBW / hr)
Energy requirements: 14 + 0.55 - 3.3 = 11.25 kg x 120 kcal / kgBW / hr = 1350 kcal
Protein requirement (34gr): 11.25 kg x 4 gr = 45 gr (13.3%)
Fat requirement: 40% x 1350/9 = 60 gr
Carbohydrate requirement: 46.7% x 1350 kcal / 4 = 157.6 gr
Energy requirements Rehabilitation Phase (150-200 kcal / kg / day)
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Assumed the child's BB has gone up to 12 kg, no oedema and no diarrhea, then the
nutritional requirement: 12 kg x 150 kcal / kg / BB = 1800kcal
Needs protein = 12 kg x 5 g = 60 g
Fat requirement = 30% x 1800 kcal = 540 kcal / 9 = 60 gr
Needs CHO = 1800- {(60x4) - 540 kcal} = 205 kcal
Comparison of Food Intake with Needs
Energy = 710/1350 x100% = 52.59% (less)

Protein = 27.25 / 45 x100% = 69.55% (normal)
Fat = 8/60 x 100% = 13.3% (less)
Carbohydrates = 128.15 / 151.9 x100% = 84.4% (normal)
Table 9.8
Possible Matrix of Diagnosis of Nutrition
Kategoriri Parameter Kemungkinan diagnosis gizi
 Kurang konsumsi makanan Kurangnya kemampuan untuk

FH
energi sumber protein, lemak menerima makanan


BD leukosit tinggi, trombosit Infeksi (TBC)
Tinggi
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Kategoriri Parameter Kemungkinan diagnosis gizi
 Z score - 3SD
AD  Perubahan berat badan turun KEP
3 kg dalam 3 bulan



Marasmik-Kwashiorkor
lembab, wajah seperti orang
PD
Tua

perut ,tangan, dan kaki
Determination of Diagnosis of Nutrition:
PES: Inadekuat energy intake (NI.4.3) associated with infectious diseases characterized by
energy intake 49.2%.
PES: Inadekuat fat intake (NI 51.1.) Associated with infectious diseases
which is characterized by less than 4.3% fat intake.
PES: Changes in laboratory values related to nutrition (NC.2.2) caused by
TB infection infections characterized by Haemoglobin values, hematocrit, leukocytes
low and high platelet values.
PES: poor nutritional status (NC.3.1) associated with low food intake marked by Z-score -3.
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PES: inappropriate selection and use of foodstuffs caused by lack of knowledge characterized
by poorly selected food so low soup.
Nutritional InterventThe goal setting:
Improve energy intake, and nutrients gradually to achieve normal nutritional status.
Giving food with 1350 kcal at the transition stage until the disarray of diara and fever can be
overcome.
Increase lab values to normal.
Provide education to family / caregivers about how to create
food at the transition stage and when the patient is given may be given again.
Terms of diet:
Energy is given 1350 kcal with 6 times ie 3 x 250 cc and 3 x 200 cc transition phase, if safe will
be passed to 1500 kcal to restore the original weight.
Strive for all equipment and foodstuffs clean.
Quite fluids, vitamins and minerals are primarily vitamin A, C, D, B6, zinc and Fe).
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Implementation
Giving praise to caregivers that there has been a BB increase even if only a little.
Tell the caregiver and Patients are currently given a 1350 diet, with 3 x 250 cc and 3x 200 cc
and will be evaluated if this can be spent and improved. The patient will be given soft and
extra milk foods (as nutritional support) between main meals.
Helping the patient to make an alternative selection of food / food that has high density but
the volume is small and easily digested and does not cause diarrhea.
Helps patients choose a good source of fat and milk for the gastrointestinal tract.
Supports patient and caregiver to the spirit and holds food that is stimulating and high in
saturated fat like chocolate for a while.
Provide complete education with good food samples for patients on family / caregiver of
patients.
Appeal to patients, if after normal conditions, should often eat with small portions and often,
and try every drink to try drinks that have energy. In addition, patients are encouraged to
participate in breathing exercises in the children's respiratory exercise group to be happy for
many friends.
Monitoring and Evaluation
Monitoring
Check back food intake every day.
Weighing 3x a day.
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Patients adhere to the given diet.
Ask about the complaints experienced by the patient.
Check back Hb, Ht, Leucocyte and platelet counts every four days.
Evaluation
Nutritional status according to growth line based on BB / TB.
Consumption of feeding the patient into a balanced diet.
BB rose equal to 0.5 kg / Sunday.
The value of laboratory examination becomes normal.
There is no odema in the stomach, hands, and feet.
SETTING MENU
After completing the nutritional care plan, you are required to make a diet regimen that has
been determined above. Currently patients will be given a 1350 kcal MC diet with 3x 200 cc,
and 3 x 150 cc. In addition you are asked to plan the menu during the rehabilitation phase,
which is ML 1800 kcal. To make it easy to make the menu pattern first.
Tabel 9.9
Pola menu Makanan Cair 1350 kkal
Jumlah Energi Protein

Lemak (g) KH (g)
Porsi (kkal) (g)
Susu skim 2 150 14 - 20
Susu fullcream 4 450 21 40 30
Minyak 3 135 15 -
Gula 8 400 - - 96
Telur ayam 2 150 14 10 -
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Tabel 9.10
Pola menu ML 1800 kkal, 60 g protein, 60 g lemak, 205 g CHO

Lemak (g) KH (g)
porsi (kkal) (g)
Nasi /penukar 2 350 8 - 80
Lauk hewani/penukar 3 225 14 10
Lauk nabati/penukar 2 150 10 6 14
Sayur A S S S s S
Sayur B 1 25 1 - 5
BUah 2 80 - - 20
Susu skim 4 225 21 - 30
Minyak 8 400 - 40 -
Gula 6 300 - - 72
1755 56 56 221
Tabel 9.11
Contoh menu sehari DPPOK MS/MC 1900 kkal
Ukuran rumah
Waktu Bahan makanan Penukar Menu
Tangga
Pagi Nasi ½p 1/3 gls Nasi lembek
Telur ayam 1p 1 butir Telur dadar
Minyak/santan 1p ½ sdm
Sayuran A S ½ gelas Ca sawi putih
Buah /apel ½½p ¼ butir Mus apel
Pukul 10.00 Susu skim 1 1/3p 5 sdm Formula cair
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Ukuran rumah
tangga
Miyak 2p 1 sdm
Gula 2p 2 sdm
Jeruk ½ ½ butir
Makan siang Nasi 1p 11/2 gls Nasi tim /bubur
Lauk hewani 1p 11/2 ptg sedang Gadon daging
Lauk 1p 1 ptg sedang Tempe bacem
nabati/tempe
Sayur B 1/2 p ½ Mangkuk Sup sayur
Buah ½p ½ ptg sedang Mus papaya
Minyak 1p 1/2 sdm
Snack pukul Susu skim 11/3 p 5sdm Formula cair
16.00
Minyak 3p 11/2 sdm
Gula 2p 2sdm
Makan malam Nasi 1/2 p 1/3 gls Nasi /bubur

Ayam tanpa 1 p 1 potong Tim ayam
Kulit
Tahu 1p 1 potong sdg Perkedel tahu
panggang
Wortel ½p 1/2 gelas Ca wortel
Alpukat 1/2 p 1 potong sedang Mus alpukat
Minyak 1/2 p ½ sdm
Snack malam Susu 11/3 p 5 sdm Formula cair
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Gula 2p 2 sdm
Minyak 3 11/2 sdm
Exercise
In this exercise, you are given examples of cases with TB disease. You do as in the example
above.
A father of middle-class socio-economic entrepreneurs, aged 28, admitted to hospital with

complaints
cough up blood 2 days, cold sweat and chills, cough with phlegm <2 weeks.
Check up result:
BB 50 kg, BB is usually 55 kg, TB 170 cm
HB 12.3 g / dl, leukocyte 8.47 thousand / ul, hematocrit 38% SGOT 13 u / L, SGPT 9 u / L

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Microbiology of acid-resistant smear 1+
Clinical examination:
Blood pressure 110/90, temperature 36 degrees Celsius, pulse 81x / minute
Os complained of dry cough and tightness, cold sweat, upper left abdominal pain
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Drug therapy: DOTs (the list of standardized drugs for tuberculosis consists of rimfaficin,
enthabutol and
INH): 1 x 3 for 6 months should not stop taking medication at all.
Mixed salbutine cap 3 x 1; Vytazym and CTM
Eating habit:
Os is often sugary foods and drinks, but has not eaten fried food since the last 2 weeks
because it is overcrowded. Morning at 06.00: 1 cup sweet tea, 1 fruit banana ambon
At 07.00: rice uduk contents of tempe orek 2 tbsp, 2 tbsp vermicelli, egg stew 1 fruit
Afternoon: 1 p rice, 1 p clear vegetable, 2 fried pheasant f, fried chicken 1 p and 1 gleas
sweet tea
Night: 1 p rice and chicken soup 1 p
Question: Review cases with NCP and ADIME and plan interventions including nutrition
counseling.
Instructions for exercises
To facilitate you to solve the above problem besides, referring to the example above should
you learn as well
Read Module 2 on diet modification.
Read Module 5 on the topic of nutritional care in TB disease.
Read Module 4 on nutritional care in diseases of protein energy and other nutritional
deficiencies.
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Summary
In providing nutritional care to TB patients, it is important that early nutritional assessment is

so important that it is known whether the patient is at risk of malnutrition or not. If there is a
risk of malnutrition then the provision of nutritional care should be aggressive optimize
intake, so that optimal nutrition fulfillment can be achieved. One of its increasing intake
strategies is to increase intake between meals with high density foods such as milk,
margarine, honey, and eggs. Nutrition counseling that emphasizes the importance of
adequate food intake, medication adherence, clean living behavior including healthy homes
(adequate ventilation) and regular weight monitoring. If patient compliance is low at all times
need to be informed of the effect if not cured completely, so optimal health free of TB can be
realized.
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Test 2
Among these foods that are most appropriate given in TB patients is ....
a. Cream soup fill the meat balls
b. Rujak Gobet sugar sauce
c. Wedang sekoteng
d. Sugar sauce marrow porridge
e. A pod of orange sauce
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One of the easiest indicators to see adequate food intake is
a. Album values
b. Weight
c. Body temperature
d. Blood pressure
e. Body mass index
How to quickly calculate the nutritional needs in patients 5 years old children weighing 25 kg
is ....
a. 2500 kcal
b. 2000 kcal
c. 1 800 kcal
d. 1600 kcal
e. 1350 kcal
Among these are the requirements of soft foods.
a. High in fiber
b. low leftovers
c. not stimulating
d. high sugar
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e. low fiber
Mr. A, is a TB patient, BB = 60 kg, TB = 172 cm. How do you interpret the value of Mr. A's
nutritional status ....
a. Weight loss weight level
b. Lack of light weight level
c. Being overweight
d. Being overweight
e. Normal
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Topic 3
Nutritional Care In Cigarette Disease
Nutrition student I'm proud of, we are now entering the practice of nutrition care COPD. As
in Module 5, it has been discussed that COPD disease is a non-infectious disease but the lung
organ has decreased the function of persistent. Therefore the main purpose of providing
nutritional care including the provision of food is that alleviate the function of organs so that
the quality of life of patients can be maintained.
Another thing that needs to be underlined is how to maintain weight because weight loss in
COPD patients is a symptom that often arises. Drug-drug interactions are common.
Therefore, knowing the drugs consumed also need to be perfected.
Before preparing the menu, we will start with the steps of nutritional care in COPD disease
as a review, followed by complete nutrition training.
PROCESS STEPS OF NUTRITION NUTRITION ON COCONUT DISEASE
The purpose of providing nutritional care in COPD patients is to maintain or achieve normal
nutritional status. It has been described in Module 5 that adequate feeding by providing
optimal nutritional support is one of the key. However, it will be easy to implement, as long
as the assessment of the factors that may be the cause of the nutritional problems is well
identified. Therefore an understanding of what needs to be emphasized in the nutritional
care process is described below which begins from the assessment, diagnosis, intervention
and monitoring of the evaluation.
Assessment / Assessment of Nutrition
Medical: diagnosis of previous hearing conditions or whether there is surgery.
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Drugs: be careful with the use of corticosteroids.
Social history: economic status, purchasing power to food, family / friends support,
education level.
Assessment of diet: the ability to chew, whether there are swallowing problems, nausea,
vomiting, constipation, diarrhea, self-eating ability, heart burn, signs of having trouble
receiving food, the ability to cook or provide food, food allergies, pre-limited foods, , tribes
associated with diet, nutritional education ever obtained.
Diet: food recall 24 hours, food history, and food frequency.
Anthropometry: TB; BB at this time, BB history (highest BB ever reached, BB usually),

IMT standard, physical examination (temporary wasting, edema).
Biochemistry: Visceral protein (albumin, prealbumin), hematology (haemoglobin,

hematocrit), immunological ability of lab results, electrolyte, pH, glucose, arterial
blood gas, serum alkaline phosphate (vitamin D), protombrin time (vitamin K);
serum carotene, retinol binding protein (vitamin A), serum tocopherol (vitamin
E), erytrositic hemolysis (vitamin E), serum zinc (zinc).
Diagnosis of nutrition that is often encountered in patients with COPD disease are:
Hypermetabolime.
Increased energy expenditure.
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Malnutrition.
Physical activity is low.
Example: NC. 3.2. Patients experience unintentional weight loss as evidenced by an

unplanned BB incidence of 18% in the last 8 months followed by a state of
weakness, shortness of breath.
Intervention
Patients will consume a minimum of 2200 kcal per day
Increase the nutrient density of food consumed by providing education with untu k
choose and prepare food
Provide education of physical activity regimen suitable for rehabilitation of respiratory

system
It is advisable to use oxygen supplements during meals and snacks
Monitoring and evaluation:
Monitor weight and other nutritional indicator.
Patients will be monitored daily intake.
Will be visited every week at the time the patient visits the respiratory tract
rehabilitation center.
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Hypermetabolime.
Increased energy expenditure.
Malnutrition
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Physical activity is low.
B. EXERCISE OF COPD DISEASE CASE
Examples of cases studied with ADIME and their nutritional therapeutic plans are complete
with the menu plan:
Mrs. N. Age 61 years old, socially preventive, merchants, children and daughter-in-law
smoke, live in densely populated areas. The perceived complaints are shortness of breath,
night cough and cold sweat, unable to get up, and hard to eat. Medical diagnosis of chronic
tuberculosis. Drugs given there are 4 types of Ceftriaxone; Gastrofer omeprazole, RL and
Amino fluid. Anthropometric data: current BB 40 kg, BB 6 months ago 44 kg, BMI: 16.8
(skinny), LILA; 22 cm. Biochemical data: haemoglobin 11.3 g / dl, hematocrit 33%, leukocyte
13000 mm3, albumin 2.25 g / dl, globulin 1.25 g / dl. Clinical conditions: normal blood
pressure, only pulse and rapid breathing, body temperature slightly above normal. The
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results of the history of feeding is 1020 kcal, 30 g protein, fat 18 g, and CHO 144 g. The case
resolution described below begins with a nutritional assessment
Nutritional assessment
a. Medical and physical condition: medical diagnosis is chronic tuberculosis to COPD,

awareness of cospoosmentis, followed by complaints Shortness of breath, night cough and
cold sweat, can not wake up, followed by clinical results as in the table below.
Table. 9.12
Clinical data Ny. S
Pemeriksaan Hasil Kadar normal Satuan
Nadi 90 (Cepat) 70-80 x / menit
Pernapasan 30 (Cepat) 16-20 x / menit
Suhu Tubuh 38 (Tinggi) 36,6-37,2 oC
Tekanan Darah 120/70 (Normal) 130-150/80-90 mmHg
Drugs: 1) Ceftriaxone; class of antibiotics cephalosporin which can be used to treat some
conditions due to bacterial infections, such as pneumonia etc.), 2) .Gastrofer omeprazolo
(class of proton pump inhibitors (PPIs) Gastroferomeprazolo (class of proton pump inhibitors
(PPIs)

abdomen relieve symptoms of abdominal heat, difficulty swallowing, and a persistent

cough), 3). RL (source of electrolyte and water), 4. Amino fluid.
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Social history: merchant, middle to low economic status, living in a densely populated
environment with a family of smokers.
Anthropometry: current BB 40 kg (10% reduction); BB 6 months ago was 44kg, IMT 16.8
(skinny), LILA 22 cm (KEK)
Biochemistry: presented in the following table.
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Table. 9.13
Laboratory examination results
Pemeriksaan Hasil Kadar normal Satuan
HB 11,3 (Rendah) 12-16 Gr/dl

Ht 33 (Rendah) 36-46 %
Leukosit 13000 (Tinggi) 5000-10000 mm3
Trombosit 17000 (Normal) 150000-400000 mm3
Albumin 2,25 (Rendah) 3,5-5,0 gr/dl
Globulin 1,25 (Rendah) 1,5-3,5 gr/dl
Sumber; buku rekam medis ny. S dari RS X, tertanggal x
Eating History
Patients were given an ML 1100 kcal and enteral diet of 2 x 200 cc and increased intake from
previous days. Analysis of the last intake was 1020 kcal, 30 g protein, 18 g fat, and CHO 144 g
Calculation of Needs
Energy Requirement:
1) BMR = 655 + (9.6 x BBA) + (1.8 x TB) - (6.8 x U)
655 + (9.6 x 40) + (1.8 x 154.3) - (6.8 x 61)
901.94 kcal
Fever correction (initial BMR + (13% x BMR) = 1223.03 kcal
2) Energy = BMR x FA x FS (normal condition)
= 1223.03 kcal x 1.2 x 1.4
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= 2054.69 kcal
Protein requirement
15% x 2054,69 = 308,2 / 4 = 77,05 gr Correction of demam 77 g + 10 g = 87 g
Fat requirement 40% x 2055 kcal = 822/9 kcal = 91 gr
Carbohydrate requirement 2055 - {(87x4) + (91x9)} = 888/4 = 222 g
Fluid = 8 - 10 gls per day
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Nutrition needs at the time of recovery will be coupled with a decrease correction
weight
That is 2300 kcal.
Comparison of Food Intake with Needs
1) Energy = 1020 / 2054,69 x100% = 50% (less)

2) Protein = 30/87 x100% = 35% (less)
3) Fat = 18/91 x100% = 20% (less)
4) Carbohydrate = 144/222 x100% = 64% (more)
Diagnosis: Diagnosis of intake:
PES: Inadekuat energy and protein intake (NI.5.3) associated with chronic infectious diseases
characterized by energy intake of only 50% and protein intake only 35%
PES: Inadekuat fat intake (NI.51.1) associated with chronic infectious disease as evidenced by
fat intake only 20%.
Clinical diagnosis:
PES: Changes in laboratory values (NC.2.2) associated with giziditis due to infection marked
by visceral, hematologic, low immune PES status: poor nutritional status (NC.3.1) associated
with low food intake marked by BMI 16.8
Diagnose behaviour
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PES: Inability to prepare food well (NB.2.4) is associated with a lack of knowledge
characterized by the main food intake originating from carbohydrates.
Goal setting (planning)
Increase intake of energy, protein, and fat gradually
Increase lab values to normal
Increase nutritional status to normal
Provide education to families and patients about diet for COPD disease and things that need
to be done to reduce such patient complaints
out of breath
The initial stage of the regimen is given 80% of the new needs are evaluated
Dietary Prescription: ML. 1100 kcal, with MC 3x 200 cc
Terms of diet:
Energy is given a minimum of 1900 kcal starting stage, continued to 2300 kcal to restore the
original weight.
Strive every snack to be given a drink with high energy density.
Easy to digest and not gaseous.

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Small portions but often.
Simply vitamins and minerals are primarily vitamin A, C, D, B6, zinc and Fe).
Implementation
Giving praise to the patient that he can finish the drink between meals, and ask what food he
likes because the food intake is still not exhausted.
Helping the patient to make an alternative selection of foods / foods that have high density
but the volume is small and easily digested and chewed.
Provide complete education with good food samples for patients in the patient's family.
Appealing to the patient, if after normal conditions, can walk again, it is recommended to
participate in breathing exercises in the respiratory exercise groups that alamtanya close to
the patient's home.
Monitoring
Check back food intake every day.
Adhere to the given diet.
Ask about the complaints experienced by the patient.
Check back Hb, Albumin, Total Protein, Leukocytes, and Platelets.
Evaluation
Intake of nutrients reaches 80%.
Absence of shortness of breath, Cough, fever, weakness.
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The family can know the nutritional needs of the patient and can explain the importance of a
balanced diet associated with the patient's illness.
Nutritional status reaches normal BMI.
C. SETTING MENU
After completing the nutritional care plan, you are required to make a diet regimen that has
been determined above. Currently Ny. S. will be given a 1900 kcal diet with ML. 1100 kcal,
and MC 3 x 200 cc. To make it easier to create menu patterns first.
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349
Pola menu:
Tabel 9.14
Pola makan sehari diet 1900 kkal

Lemak (g) KH (g)
porsi (kkal) (g)
Nasi/penukar 2 350 8 - 80
Daging/ikan/ayam/telur 4 300 28 20 -
Tempe/tahu/kacang2an 1 75 5 3 7
Sayuran A S - - - -
Sayuran B 2 50 - 10
Buah 4 160 - - 40
Susu skim 3 21
225 - 30
Minyak/lemak 12 600 - 60 -
Gula 3 150 - 38
62 (13 % 93 (44 % 205 43
E) E) ( % E)
1910
Ket : *) DBMP II yang
digunakan
Tabel 9.15
Pembagian makanan sehari DPPOK 1900 kkL
Makan pagi Snack Makan siang Snack Makan Snack total
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pagi sore malam malam
Nasi/penukar ½ - 1 - ½ - 2
Lauk hewani 1 ¼ 11/2 ¼ 1 4
Lauk nabati - ½ ½ 1
Sayur A S S
Sayur B 1 1 2
Buah 1 1 1 1 4
Susu 1 1 1 3
Minyak 1 3 1 3 1 3 12
Gula 1 1 1 3
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351
Tabel. 9.16
Contoh menu sehari DPPOK MS/MC 1900 kkal
Ukuran rumah
tangga
Pagi Nasi ½p 1/3 gls Bubur
Telur ayam 1p 1 butir Telur rebus
Minyak/santan 1p ½ sdm
Sayuran A S 1 gelas Jus tomat
(tomat direbus
sebentar)
Pukul 10.00 Susu skim 1p 4 sdm Formula cair
Miyak 3p 11/2 sdm
gula 1p 1 sdm
Telur kuning ¼p 1 sdm
Makan siang Nasi 1p 11/2 gls Nasi tim /bubur
Lauk hewani 11/2 p 11/2 ptg sedang Gadon daging
bali
Lauk ½p 1 ptg sedang Tempe bacem
nabati/tempe
Sayur B 1/2p ½ mangkuk
Buah 1p 1 ptg sedang Mus papaya
Minyak ¾ sdm
Snack pukul Susu skim 1p 4 sdm Formula cair
16.00
Minyak 3p 1/ 2sdm
Gula 1p 1 sdm
Telur kuning ¼p ½ sdm
Makan malam Nasi 1/2 p 1/3 gls Nasi /bubur
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ikan 1p 1 potong Tim ikan
Tahu ½p 1 potong sdg Perkedel tahu
panggang
Wortel ½p 1/2 gelas Ca wortel
Alpukat 1p 1 potong sedang Mus alpukat
Minyak 1p ½ sdm
Snack malam Susu 1p 4 sdm Formula cair
Gula 1p 1 sdm
Minyak 3p 11/2 sdm
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Exercise
Below is a case of COPD
Mr. B is 56 years old, BB 44 kg, TB 165 cm. Living in densely populated areas. Frequent
shortness of breath, fever, cough and sputum is difficult to get out. Os feels there is an
oedema in the leg. Os was hospitalized for a severe shortness of breath. After admission in
the hospital, fluid suctioning in the pleura, and the appetite began to improve. But the body
is still weak. Os also got a blood transfusion and now the HB level has become 11 g / dl. Os
diagnosed: Chronic lung disease obstruction.
Laboratory results
Total protein: 6.3 g / dl
Albumin 2.3 mg / dl;
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gobulin 4.7 mg / dl.
ureum 33 mg / dl
Creatinine 0.7 mg / dl
Glucose during 190 g / dl.
Eating habit before entering hospital
Breakfast: 1 cup porridge and 1 boiled egg
10:00 am: instant noodles ½ portion
Lunch: ½ p rice, 1 ft peping tempe, 1 cup bowl soup
Dinner: 1 p rice, 1 pt of tempe, fish ½ p, vegetable stir-fry ½ p
Question:
Review the above case with ADIME and create a nutritional therapy plan.

To help you in doing the exercises please study the case examples that have been completed
above. In addition, as an additional material can be used:
Module of dietary modification and nutritional support.
Medical nutrition therapy module on COPD disease.
Step process of nutritional care in COPD patients.
Diet Guides.
354
List of Food Exchangers.
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355
Summary
Knowing the condition of nutritional status in COPD patients at the beginning or before
the nutritional care is very important so as to facilitate the modification of the
diet. If the intake of pasein orally is low then immediately modified form and
mode of administration. Efforts to increase intake / nutritional support can be
given between meals / time sanck. Drug and food interactions in patients often
occur then compliance between meals and taking medication should be
maintained and observed intake of food ingredients have antioxidant functions
need to be considered. Because of education / counseling it is necessary to do
both in patients and their immediate family. Remember this disease is
irreversible and progressive chronic disease.
Test 3
A is a patient with COPD, oral intake is less than 50%, no gastrointestinal disturbance
hence the fulfillment of its energy can be fulfilled by giving ....
a. Oral intake with modification
b. Enteral food
c. Parenteral food
d. Favorite food
e. Vitamin supplements appetite supplements
Foodstuffs that are thought to have antioxidant function are ....
356
a. Meat smoke, corned meat
b. Salted fish, shrimp ebi
c. Vegetable and fruit
d. Fish from the deep sea
e. Freshwater fish
Foods that are the best source of calcium are ....
a. Spinach, kale, beans
b. Anchovy, cork fish, catfish
c. Milk, cheese, joghurt
d. Sugar, honey, fruit jam
e. Peanut oil, corn oil
Foodstuffs that are good sources of zinc are ....
a. Spinach, kale, beans
b. Anchovy, cork fish, catfish
c. Milk, cheese, joghurt

d. Meat, liver, and corned beef
e. Peanut oil, corn oil
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Recommended food ingredients to be administered to patients with low haemoglobin
(Hb) are ....
a. Meat, liver, and beet
b. Chicken liver, spinach, cassava leaves
c. Young jackfruit, meat and oranges
d. Eggs, pineapple, and durian
e. Sardines, radishes and eggs
358
327
359
Key Test Answers
Tes 1
Tes 2
Tes 3
360
C
361
328
362
Bibliography
Nutrition Installation Perjan RSCM and AsDI. 2004. Diet Guides. Jakarta: PT. Gramedia
Pustaka Utama.
AsDI, IDAI, Persagi. 2014. Child Diet Guidance (ed.3) Jakarta. Agency Publisher Faculty of
Medicine University of Indonesia.
American Dietetics Association International Dietetics and Nutrition Terminology (IDNT)

Refference Manual. 2008. Standardized Language for the Nutrition Care Process First Edition.
WHO. 2015. Pocket Book "Nutrition Care at Puskesmas' Guidelines for Nutrition Service for
healthcare p. 132.
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CHAPTER IX
NUTRITION OF NUTRITION IN PATIENT DISEASES CERNA
Yenny Moviana, MND
PRELIMINARY
Gastrointestinal disturbances are the most common health problems in the community.
Food habits and some specific foods play an important role as the cause, therapy and
prevention of most gastrointestinal problems. Nutrition therapy is an integral part of
prevention, therapy for malnutrition and deficiency that can develop from gastrointestinal
tract. Diet and lifestyle modification can improve the quality of life of patients by reducing or
eliminating symptoms of gastrointestinal disturbances, lowering visits to health facilities and
health costs associated with gastrointestinal diseases.
The gastrointestinal tract is the longest organ, starting from the mouth and ending in the
anus. Thus gastrointestinal disturbances can occur in many places between the mouth to the
human anus. What are gastrointestinal disorders? How does the disorder cause nutritional
problems? Which diet or nutrition management arrangements can help prevent and or treat
gastrointestinal diseases?
To understand these questions, please study the explanation and do the following exercise!
After studying this module, students are expected to:
1. Explain the normal anatomy and physiology of the gastrointestinal tract.
2. Explain the pathophysiology of gastrointestinal diseases.
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3. Identify components of nutritional assessment in patients with gastrointestinal diseases.
4. Identify nutritional problems or nutritional diagnoses in patients with gastrointestinal

disease.
5. Explain nutritional intervention in patients with gastrointestinal disease.
6. Explain the component of nutrition monitoring and evaluation in patients with

gastrointestinal disease.
This chapter will describe gastrointestinal anatomy and physiology, pathophysiology of

gastrointestinal diseases and nutritional care in gastrointestinal diseases using standardized
nutritional care process steps. Further learning materials will be divided into two topics. The
first topic of physiology anatomy, pathophysiology and nutritional care in upper
gastrointestinal diseases; and a second topic on physiological anatomy, pathophysiology and
nutritional care in lower gastrointestinal diseases.
Topic 1
Nutrition Care in Upper Gastrointestinal Disease
This topic will discuss nutritional care in upper gastrointestinal diseases. Before discussing
the nutritional upbringing of this disease, it is necessary to first study the anatomy and
normal physiology of organs belonging to the upper gastrointestinal tract and discuss its
normal function in the four basic functions of the gastrointestinal tract, namely molecity,
secretion, digestion and absorption. Disorders or gastrointestinal diseases may affect any or
all of these gastrointestinal functions.
ANATOMY AND PHYSIOLOGY OF THE CHANNEL CERNA
To understand the disorders or diseases of the gastrointestinal tract, you must understand
the anatomy and physiology of the gastrointestinal tract first. The gastrointestinal tract is the
organ with the longest size of human body. Gastrointestinal tract begins from the mouth,
oral cavity, esophagus, stomach, small intestine, colon and ends in the rectum and anus. To
better understand the anatomy of the gastrointestinal tract, you can study the following
images.
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366
Gambar 3.1
Anatomi Saluran Cerna
114
The gastrointestinal tract is often described as a pipe length of about 15 feet or 450 cm, and
can be divided into upper gastrointestinal tract, lower gastrointestinal tract and additional
organs. The upper gastrointestinal tract consists of: mouth, pharynx, esophagus and
stomach.
The lower gastrointestinal tract consists of: the small intestine (consisting of duodenum,
jejunum, ileum)
and colon / colon.
The additional organs consist of: liver, biliary system, and pancreas.
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The upper gastrointestinal tract has motility, secretion, digestion and absorption functions.
The following describes the four functions.
Motility, Secretion, Digestion and Absorption.
Motility is the movement of food consumed along the gastrointestinal tract.
The drive of contraction and mixing motion serves not only to move food toward the
location of digestion and absorption, but to mix food and digestive secretions and maximize
potential absorption. The secretions of the gastrointestinal tract include water, electrolytes,
enzymes, bile salts and mucus.
Roughly on the digestion process, the complex molecule is converted to its simplest form.
Carbohydrates are digested from the complex forms of polysaccharides into monosaccharide
forms such as glucose, fructose, galactose. Proteins are converted from polypetides to amino
acids, dipeptides and tripeptides. Lipids are digested into simple forms such as free fatty
acids, mogoglycerides, glycerol, phospholipids and cholesterol. Once ingested, the three
basic molecules are absorbed with water, electrolytes, vitamins and minerals to provide
essential nutrients for each cell. Locations where digestion, secretion and absorption occur
can be seen in the figure below.
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115
369
370
Sumber : Tappenden. 2017. Intake : Digestion, Absorption, and Excretion of Nutrients :
Krause’s Food and the
Nutrition Care Process. Canada : Elsevier. Hal. 4
Gambar 3.2
Tempat sekresi, digesti dan absorpsi pada saluran cerna
371
116
372
Anatomy and Physiology Normal Ephophagus
The esophagus is a straight pipe with a length of about 25 cm and a diameter of 2 cm.
The esophagus has sphincter muscles at the edges. The esophageal wall consists of four
layers of tissue, mucosa, submucosa, muscle and connective tissue. An individual
unconsciously consumes as much as 600 times each day. Each ingestion process consists of
four phases.
The first phase is the oral preparatory phase, where food is chewed and mixed with saliva.
The second phase is the oral transit phase, where there is a voluntary movement of the food
bolus from the front of the oral cavity to the back. The third phase is called the pharyngeal
phase. The most important part of this phase is to make sure the food bolus is directed
towards the esophagus and prevent entry to the trachea. The fourth phase of ingestion is the
esophageal phase. Upper esophageal sphincter (UES) or pharyngoesophageal sphincter is
located at the top of the esophagus. This sphincter, open-minded, lets the food bolus into
the esophagus. When the spinchter is closed, it prevents air during breathing into the
gastrointestinal tract. After the food bolus moves through the UES into the esophagus, the
sphincter closes and the normal breathing can recur. The following figure shows the process
of swallowing.
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Sumber : Zupec-Kania and O’Flaherty. 2017. Medical Nutrition Therapy for Neurologic
Disorders dalam
Krause’s :Food and the Nutrition Care Process. 14th. Ed. Canada : Elsevier. Hal. 821
Gambar 3.2
Proses Menelan
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374
When the esophageal phase begins, autonomic control initiates a peristaltic movement that
moves the food bolus down from the esophagus to the stomach. Mucus secreted by the
esophagus lubricates the food bolus. At the lower end of the esophagus, the lower
esophageal sphincter (LES) controls the release of the food bolus from the esophagus to the
stomach. LES functions as a barrier that protects the esophageal mucosa of the contents of
the stomach, so as not to rise back into the esophagus. The process of swallowing is
complete when the food bolus passes through LES. Under normal conditions Phrayngeal and
esophageal phases in the process of swallowing range from 6 to 10 seconds only. The
following figure shows peristaltic movement in the esophagus.
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Sumber : Sherwood L. Human Physiology : From Cell to System. 7e. 2010. dalam Sucher and
Nutrition Therapy and Pathophysiology. 2e. Hal344
Figure 3.3
Etiophagus Peristalsis Movement
The final portion of the lower gastrointestinal tract is the stomach. The stomach consists of
fundus, corpus, antrum, pylorus. The portion of the stomach that connects the esophagus
and the duodenum is called the sphincter. Sphincter at both ends of the stomach regulates
the flow of food from the esophagus and to the intestine (intestin). The main function of the
stomach includes 4 processes, namely motility, secretion, digestion and absorption. The
following figure shows the normal anatomy of the stomach.
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376
Sumber : Sherwood L. Human Physiology : From Cell to System. 7e. 2010. dalam Sucher and
Figure 3.4
Gastric Anatomy
Motility of the Stomach
The process of gastric motility includes stomach fill, food storage, gastric mixing, and finally
gastric emptying into the small intestine. When empty, the stomach volume is only about 50
mL, but the stomach can expand until the capacity is more than 1000 mL. Storage occurs
mainly in the body of the stomach or the corpus. Mixing occurs in the antrum part.
Gastric secretions
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Gastric secretes about 1 to 3 liters of stomach fluids each day. Gastric fluids consist of water,
mucus, HCl, enzymes, and electrolytes. The mucosa, which coats the fundus and the body of
the stomach, contains glands. Several different cell types are located in the gland. The
mucus-secreting mucus cells, which protect the lining of the stomach from mechanical and
acidic damage. Chief cells secrete pepsinogen zymogens and gastric lipase enzymes. The
parietal cells secrete hydrochloric acid (HCl) and intrinsic factor. HCl activates pepsinogen,
kills microorganisms, and denatures proteins. Intrinsic factor is an important protein for
vitamin B12 absorption.
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120
Digestion and Absorption of the Stomach
Digestion or digestion in the stomach is mechanically and chemically. Of the three nutrients
macro, protein is a nutrient that is digested in the stomach, carbohydrates and fats are very
limited. Absorption in the stomach is limited, no food is absorbed only a small part of the
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water is absorbed. Exceptions to alcohol and bebearpa drugs. Most drugs are absorbed in
the small intestine, unless acetylsalicylic acid (aspirin) can enter the epithelial cells of the
gastric mucosa.
DISEASES ON THE CHANNEL CERNA
Many disorders or diseases can occur in the upper gastrointestinal tract. Some disorders or
diseases that are often found in the esophagus are Gastroesophageal Reflux Disease (GERD)
and dysphagia. Some of the problems in the stomach that are often experienced by many
people are indigestion or dyspepsia, nausea / nausea and vomiting, gastritis and peptic ulcer.
The following description of the disorder or disease of the upper gastrointestinal tract.
Gastroesophageal Reflux Disease (GERD)
GERD occurs as a result of reflux or the return of gastric or gastric contents to
esophagus. Lower esophageal sphincter (LES) normally serves as a barrier between the
esophagus and the stomach. The signs and symptoms relate to acid reflux of the stomach
and pepsin, and occur during LES relaxation. This period occurs outside the period of
swallowing and can be stimulated by the presence of food in the stomach after meals. The
etiology or cause of reflux is multifactorial and may include physical factors and lifestyle.
Factors that may decrease LES stress and contribute to LES inability are: 1) increased
secretion of gastrin, estrogen and progesterone hormones; 2) the existence of medical
conditions such as hiatal hernoa, scleroderma or obesity; 3) smoking; 4) the use of drugs
including dopamine, morphine, and theophylline; 5) certain foods. Foods high in fat,
chocolate, peppermint, alcohol, caffeine, all can lower LES pressure.
GERD symptoms include dysphagia (difficulty swallowing), heartburn (burning sensation in

the esophagus) increased salivary production, and belching. In some cases, severe pain may
spread to the back, neck, or jaw. Symptoms similar to heart disease. For some patients the
pain gets worse during the night when lying down. Complications of uncontrolled GERD may
be swallowing, aspiration of the stomach contents to the lungs, ulcer, and perforation or
stricture in the esophagus. Therapy for GERD has three objectives: 1) improving LES
capability; 2) decrease the acidity of the stomach, thus decreasing the symptoms; 3) increase
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the emptying of food in the esophagus. Surgery will be necessary if complications are severe
and drugs can not be responded well by the patient.
Dysphagia
Dysphagia or difficulty swallowing is a symptom caused by a variety
interference. Symptoms depend on the swallowing disorders that occur. If the problem
occurs in the oral preparation phase, food can be stored in the buccal mucosa (the cheek
area) because the patient can not move the bolus food effectively from the front of the oral
cavity to the pharyngeal area. Other common symptoms include salivating, coughing, and
choking. Many sufferers lose weight and malnutrition because of the inadequate nutritional
intake. Aspiration or inhalation of oropharyngeal contents is a major complication of
dysphagia. This can lead to aspiration of pneumonia that accompanies the infection and this
is the reason for recommending nutritional support in the form of enteral feeding. Diagnosis
and therapy of dysphagia involve many members of the health team, such as doctors,
nurses, speech therapists, dietitians, physical therapists, and occupational therapists.
Indigesti
Indigesti or dyspepsia, not a special condition. Most people use the term "indigestion" to
show a set of symptoms that include abdominal pain, fullness of stomach, gassing, bloating,
belching, nausea, or sometimes including gastroesophageal reflux.
Nausea / Nausea and Vomiting
Nausea is an uncomfortable sensation that indicates a desire for
gag. Vomiting is the discharge of the contents of the stomach.
Gastritis
Gastritis is an inflammation or inflammation of the gastric mucosa. This condition is not
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a single disorder and can be as a result of a number of conditions. Under normal conditions,
the gastric mucosa is protected from disturbances. Production of mucus as a barrier that
prevents cell damage. Acute gastrititis is caused by local irritation of the gastric mucosa.
These irritations can be caused by infections, such as Helicobacter pylori (H. pylori), alcohol
consumption food poisoning, or drugs such as nonsteroidal anti-inflammatory drugs
(NSAIDs).
Symptoms of gastritis include burping, anorexia, abdominal pain, vomiting, and in severe
cases, bleeding and hematemesis. Chronic gastritis is usually classified based on its etiology
or part of the affected stomach.
Chronic type A gastritis involves the fundus and is associated with an autoimmune process,
which results in the formation of antibodies against parietal cells. Type A chronic gastritis
also occurs with pernicious anemia.
Chronic type B gastritis is due to gastric atrophy of mucosa and most commonly associated
with infection of H. pylori.
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The incidence of chronic gastritis increases with age and is often seen with achlorhydria.
Achlorhydria are associated with nutritional implications including B12 malabsorption, iron
and calcium.
Peptic ulcer disease (UP)
Peptic ulcer is a wound or ulcer of the gastric or duodenal mucosa that can penetrate the
submucosa. Peptic ulcer usually occurs in the antrum part of the stomach or a few
centimeters of the early part of the duodenum. Approximately 92% of duodenal ulcers and
70% of gastric ulcers are caused by H. pylori.
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Aetiology also includes factors that may decrease the integrity of the mucosa, such as
decreased protection from prostaglandins due to the use of NSAIDs (eg, ibuprofen) or
alcohol, excess secretion of glucocorticoid or steroid drugs and factors that decrease blood
supply, such as smoking, stress or shock. Factors that increase acid secretion, including
certain foods, rapid gastric emptying, or increased gastric secretions, also contribute to the
development of peptic ulcer disease.
The image below shows the ulcer in the stomach or duodenum and has penetrated
submucosa. It is conceivable that eating problems may be experienced by peptic ulcer
patients.
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Sumber : Atlas of Gastrointestinal Endoscopy www.EndoAtlas.com
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NUTRITION OF NUTRITION DISEASES ON THE CHANNEL CERNA
Once you understand the anatomy of physiology and upper gastrointestinal

pathophysiology, we will continue the discussion of nutritional upkeep on upper
gastrointestinal disorders or diseases.
Nutrition Care on GERD
Nutritional implications
Most patients can identify the foods that they feel aggravate gelaja and then lower the
intake of these foods. In these conditions, the hatching of such food groups may lead to
weight loss or nutritional deficiency. Nutrition therapy not only focuses on these nutritional
problems, but also reduces the symptoms experienced by patients. The long-term use of
GERD drugs may interfere with calcium absorption and iron status and vitamin B12.
For GERD, a consumption survey conducted (24-hour recall, diet history, or food diary)
should focus on foods that cause LES pressure drop, boost stomach acid, or foods that can
not be tolerated by patients. Lifestyle factors such as smoking and physical activity patterns
also need to be asked.
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Common nutritional diagnoses associated with GERD include adequate oral intake of food /
drink; excess fat intake; difficulty swallowing; drug-food interactions, overweight / obesity;
intake of iron and calcium inadekuat; lack of knowledge related to nutrition and food; and
the choice of food is not favored.
The goal of nutritional therapy in GERD disease is consistent with the purpose of medical
care. The goals of nutritional therapy include lowering stomach acid and dietary restriction
that lowers LES stress. To reduce stomach acid avoid pepper, coffee (both caffeinated and
decaffeinated), and alcohol, because these foods can stimulate the production of stomach
acid. Foods with large portions tend to increase the production of stomach acid, slow the
emptying of the stomach, and increase the risk of reflux. because it should be given small
portions of food with frequent delivery. Foods indicated to potentially reduce LES pressure
are also avoided. Start by avoiding cokalt. Mint, and foods that are high in fat. Also avoid
foods indicated by irritating patients. If the patient is obese, weight loss is a critical
component of a nutritional therapy plan. Possible supplements of calcium, iron and other
micronutrients are needed.
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Nutritional interventions for GERD patients can be seen in the following table:
Table. 3.1
Foods Avoided for Patients GERD
Makanan yang dapat menurunkan LES

Peppermint
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Coklat
Makanan digoreng atau makanan yang ditambahkan banyak

lemak Alkohol
Kopi (caffeinated atau decaffenaited)
. Makanan yang dapat meningkatkan sekresi asam lambung

Kopi (caffeinated atau decaffenaited)
Alkohol
Merica
Kelompok Makanan Makanan yang dihindari (jika ada gejala)

Minuman Minuman berkarbonat, kopi caffeinated dan decaffeinated,
teh, coklat, alkohol
Susu dan produknya Susu 2%, krim, yogurt tinggi lemak, susu coklat
Telur Digoreng atau didadar dengan cara memasak menggunakan
lemak banyak
Serealia Yang tinggi lemak seperti pastries
Daging dan sumber Daging goreng, bacon, sosis, pepperoni, salami, bologna,
protein Hotdog
Sayuran Hanya yang menimbulkan gejala pada pasien, biasanya yang
bergas, seperti kol, nangka muda, dll
Buah Hanya yang menimbulkan gejala pada pasien, biasanya yang
bergas seperti nangka matang, durian, atau yang rasanya asam
seperti mangga muda, jeruk, nanas, dll
Lemak Dalam jumlah yang dapat ditoleransi oleh pasien
Dessert Semua yang tinggi lemak atau digoreng, terlebih digoreng
dengan balut tepung
Lain-lain Merica, jahe
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Sumber : N. Nelms. 2011. Disease of the Upper Gastrointestinal Tract : Nutrition Therapy and
Patophysiology. 2e. hal 355
Interventions are evaluated by measuring specific outcomes, which include food tolerance,
the amount of formula consumed and weight gain.

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Nutritional Care for Dysphagia

Implications and Nutritional Assessment
The main nutritional implications are weight loss and nutritional deficiency that can occur
due to inadequate dietary intake. It is therefore very important to measure anthropometry
accurately and to get as much information as possible about the nutritional intake and diet
of the patient. After reviewing the swallowing test results, the health team can determine
how the patient can cope with various food and fluid textures.
A common nutritional diagnosis of dysphagia includes inadequate oral intake of food / drink,
inadequate fluid intake, malnutrition, inadequate protein intake, and difficulty in swallowing.
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The goals of nutritional intervention in patients with dysphagia are: 1) lowers aspiration risk
due to ingestion of food into the respiratory tract and 2) prevents and corrects nutritional
and fluid deficiencies. To achieve this goal can be done by providing foods that:
Enough energy, protein and other nutrients.
Easy to digest with portions of snacks and given with frequent frequency.
Quite fluid.
The form of food depends on the ability to swallow and is given gradually, starting from full
liquid food or thick liquid, filter food,
then soft food.
Note: Clear Liquid Food is not given because it often causes choking or aspiration with food
either orally or through pipes.
The health team will reevaluate the patient's ability to swallow the food given according to
his dietary prescription. If swallowing difficulties increase then further dietary restrictions are
made or the texture or consistency of the food is altered. Patient's weight, nutritional
parameters, and hydration status need to be more closely monitored to ensure the patient's
nutritional adequacy.
Nutrition Care on Nausea and Vomiting
Nutritional Implications
The nutritional implications of nausea and vomiting can lead to inadequate nutritional
intake, dehydration, and acid-base imbalances, in the long run can lead to food rejection.
This is what can cause a person to choose to avoid certain foods.
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125
Some nutritional diagnoses in nausea and vomiting include alterations in gastrointestinal

function, unexpected weight loss, inadequate fluid intake, and inadequate oral intake.
Nutritional therapy does not deal with nausea and vomiting but minimizes symptoms and
discomfort due to nausea and vomiting. Nutritional therapy can help in maintaining
nutritional status during nausea and vomiting occurs. If the patient can regulate oral intake,
cold and hard-flavored foods are usually well tolerated. Some drinks and foods can reduce
nausea and vomiting. Drinks that can be given after vomiting stop are: water, apple juice,
sports drinks, warm or cold tea, and lemonade. Giving a drink should start by sucking ice
cubes (if age above 3 years). If it can be tolerated start by giving 1 tsp every 10 min. Then
increase to 1 tbsp every 20 minutes. If it is tolerable increase the feeding volume to 2-fold
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every 1 hour. Can be given other types of beverages if water can be tolerated. If there is
diarrhea, give a rehydration drink, such as ORS.
For solid foods, after vomiting does not appear again in 8 hours, give staged with small
portions. Avoid foods high in fat or fiber, including foods that smell sharp and that produce
gas. Ginger can be used to treat nausea and vomiting. If the patient is taking the drug, it
should be taken after meals. The foods that can be given as soon as the vomit is gone are the
dried up ones like krekers, toast.
The hydration status and duration of patients without adequate oral intake are important for
monitoring. By knowing these things, it will be predictable nutritional problems that may
occur in these patients. Nutritional support will be needed for patients who can not fulfill
their nutritional needs orally.
Nutritional Care in Gastritis and Peptic ulcer

In gastritis and Peptic ulcer patients, symptoms of abdominal pain may interfere with oral
intake and lead to weight loss and / or nutritional imbalance. It is therefore important to get
as much information as possible about weight loss and changes in dietary intake and to
evaluate the relationship of the data with medical history of abdominal pain and other
symptoms.
Nutritional diagnoses associated with gastritis and peptic ulcers include inadequate oral
intake, inadequate food / drink intake, altered gastrointestinal function, unexpected weight
loss, and lack of knowledge related to food and nutrition.
389
126
The goal of nutritional therapy for gastritis and peptic ulcer is to support medical therapy,
maintain or improve nutritional status, and provide adequate food and fluids that do not
burden the stomach and prevent and neutralize excessive gastric acid secretion. The
following table lists the recommended foods and is not recommended for peptic ulcer
patients.
Table. 3.2
Recommended and Not Recommended Foods for Peptic ulcer
Kelompok
Makanan yang Dianjurkan Makanan yang Tidak Dianjurkan
Makanan
Minuman berkarbonasi non cola,

Minuman Cola, kopi, teh, cocoa, alkohol
teh herbal
Susu dan Skim, 1% mentega susu, yogurt 2% atau susu penuh, krim, yogurt
produk susu rendah lemak tinggi lemak, susu coklat
Telur Ceplok air, rebus, orak arik Digoreng atau orak arik dengan
390
dimasak dengan minyak sedikit minyak banyak
Serealia Siap santap atau dimasak Tidak ada
Dipanggang, dibakar, direbus,

Daging dan Daging goreng, sosis, bacon, salami,
lemak (visible) dihilangkan, keju
sumber protein hot dog
rendah lemak
Kentang/nasi/
Semua kecuali digoreng Tidak ada kecuali digoreng
pasta
Sayuran Semua, kecuali yang bergas Sesuai toleransi
Buah Semua, kecuali yang bergas Sesuai toleransi
Lemak Sesuai toleransi pasien
Digoreng atau tinggi lemak seperti
Dessert Semua yang rendah lemak
pastries dan donat
Semua kecuali merica, jahe dalam

Lain-lain Merica dan jahe
jumlah banyak
391
Source: Nelms, MN. 2011. Diseases of the Upper Gastrointestinal Tract: Nutrition Therapy
and
Pathophysiology. 2nd ed. International edition. Wadsworth: Cengage Learning. p. 363
Other components of nutritional therapy in gastritis and peptic ulcer are to regulate meal
schedules and serving sizes. Give foods that are easy to digest, small portions, with frequent
delivery frequency. Amount of energy and protein enough and adjusted ability of patient to
accept it. Fat is given low, ie 10-15% of the total energy needs are increased gradually to fit
the daily needs of patients. For fiber is given a low, especially water soluble fiber that is
increased gradually if the symptoms are reduced. The need for fluids is sufficient, especially
when there is vomiting. Give food that does not contain food or sharp seasoning, either

thermally, mechanically, and chemically adapted to individual patient's receiving power. If
there are symptoms of lactose intolerance, give low-lactose milk, but it is generally not
advisable to drink too much milk. Instruct the patient to eat slowly with a quiet environment.
Some things to note further in patients with stomach disease are as follows:
In the acute phase parenteral food may be given for 24-48 hours to give rest to the stomach
The patient's tolerance to food is highly individual, so adjustments are needed
Frequent feeding frequency, in certain patients can stimulate excessive stomach acid
expenditure
Certain eating behaviors can lead to dyspepsia, such as overeating, overeating, or lying down
/ sleeping immediately after meals
Adequacy of nutritional intake and tolerance to food is the focus on monitoring and
evaluating the nutrition of patients with gastritis and peptic ulcer. And to maintain the
nutritional status of the patient on good nutritional status, anthropometry and clinical
physical patient data should be monitored.
392
Thus the nutritional care in upper gastrointestinal diseases, then please do the exercises
below.
Exercise
A 20-year-old male patient had an accident that suffered a fracture in his jaw. Doctors
perform surgery to improve the position of the jaw that shifted 2 days ago. Currently
patients can not eat normally because it is still difficult to chew. Make a nutritional planning
plan for this patient by using standardized nutrition care steps.
The steps of standardized nutrition care process

Asuhan gizi pada disfagia
128
393
129
Summary
Upper gastrointestinal disorders or diseases may include Gastroesophageal Reflux (GERD),

dysphagia, indigestion / dyspepsia, nausea / nausea and vomiting, gastritis and peptic ulcer.
Nutrition problems in patients with the disorder or disease often cause inadequate feeding
intake and may affect the nutritional status of the patient. Nutrition assessments in patients
with this disease require information about foods that cause discomfort after eating and
eating habits, as well as anthropometric data. Some of the common nutritional diagnoses in
patients with this disease include inadequate oral intake, gastrointestinal function disorders,
difficulty chewing / swallowing, and lack of nutritional and food related knowledge.
Nutritional interventions include certain dietary restrictions that aggravate symptoms and
reduce gastrointestinal workload, as well as lifestyle modification. Nutrition monitoring and
evaluation needs to be done is about the patient's tolerance of food restrictions and
nutritional status.
Test 1
Choose the Most Accurate Answer.
Heartburn after eating large servings or fatty foods is a symptom of ....
a. Esophageal stricture
b. GERD
c. Gastric ulcer
d. Duodenal ulcer
e. Akalasia
394
A dietary goal for patients with dysphagia:
a. Fixed swallowing nerve damage
b. Decreases the risk of aspiration
c. Resting the gastrointestinal tract
d. Neutralize stomach acid
e. Improve the patient's nutritional status
Terms of diet stomach:
a. Enough energy and protein, enough fat, low fiber, enough fluids
b. Enough energy and protein, enough fat, enough fiber, enough fluids
c. Enough energy and protein, low fat, enough fiber, enough fluids
d. Enough energy and protein, low fat, low fiber, enough fluids
e. Enough energy and protein, low fat, high fiber, high liquid
Foods that can increase gastric acid secretion are:
a. Coffee is caffeinated
b. Coffee decaffenaited
c. Alcohol
d. Pepper
e. Chocolate
395
Drinks to avoid in peptic ulcer:
a. Melon juice
b. Decaffeinated coffee
c. Skim milk
d. Mineral water
e. green bean juice
Topic 2
Nutrition Care in Lower GI Disease
Nutrition and gastrointestinal status are interrelated and inseparable from one
another. Nutrition interventions for many lower gastrointestinal diseases are primarily
intended to reduce symptoms and correct nutritional deficiencies. This is related to the main
function of the lower gastrointestinal tract is absorption. A comprehensive nutritional
assessment needs to be done to determine the nature and severity of gastrointestinal
problems. Important information is collected including a history of weight change, drug use
(including supplements), symptoms that affect oral intake and fluid loss, and signs of
potential symptoms of micronutrient deficiency. Before discussing nutritional care in lower
gastrointestinal diseases, let us first learn about the anatomy and normal physiology of the
lower gastrointestinal tract.
ANATOMY AND PHYSIOLOGY LINE CERNA BELOW
The lower gastrointestinal tract can be divided into the small intestine and colon. The
small intestine consists of three parts, namely duodenum, jejunum and ileum. Though
composed of three parts, they are not separate parts of one another but have different
anatomy, motility, digestion and absorption.
396
The anatomy of the small intestine is unique and highly functional. Anatomy is
designed to provide the maximum surface for digestion and absorption of almost all foods.
The motility of the small intestine is controlled by the neuro enteric system and is affected
by various hormones, peptides, and neurotransmitters. Smooth and large bowel motility is
important to learn because of its role in some diseases that require enteral nutrition
support. Understanding the motility and identification of target receptors for motility control
can be helpful in treating diseases, such as irritable bowel syndrome, chronic constipation
and diarrhea.
The small intestine produces secretions and receives secretions from other
gastrointestinal organs of the pancreas and gallbladder. These secretions include hormones,
digestive enzymes, bicarbonates and bile. Pancreatic fluid provides the main digestive
enzymes in the small intestine, ie trypsinogen, kimotripsinogen, procarboxylase and elastase.
Pancreatic amylase is the major enzyme for starch or carbohydrate digestion. Pancreatic
lipase and collage for fat digestion.
Each nutrient has a place of absorption in the small intestine and colon. For the
absorption or absorption of nutrients in the small intestine and colon can be seen in the
following figure.
131
397
398
Sumber : Smith. Groff dan Gropper. 2005. Advanced Nutrition and Human Metabolism. 4e.
hal. 47.
Figure 3.6
Absorption of Nutrition in the Intestines and Colon
Colon (colon) includes areas of caecum (appendix attachment), ascending colon, transverse
colon, descending colon, sigmoid, rectum, and anus. Anatomy of the large intestine with the
small intestine. The mucosa of the large intestine is three straight curves, unlike small
intestine-shaped or circular creases. The curvature of the colon consists of ascending,
transverve and descending. The end of the colon is called the sigmoid because it is an S.
shape. The sigmoid end of the colon is the rectum as an anal sphincter that controls the
release of intentin content voluntarily. The colon also has no villi or

mikoivil like the small intestine which is the absorption surface of nutrients. For more details
the anatomy of the colon can be seen in the following figure.
399
Source: Sherwood L. Human Physiology From Cell to System. 7e. 2010. in Sucher and
Mattfeldt-Beman. 2011. Diseases of the Liver, Gallbladder, and Exocrine Pancreas: Nutrition
Therapy and Pathophysiology. 2e. P. 385
Picture. 3.7
Anatomy of the Colon
Compared with the small intestine, the small intestine produces little secretion. Goblet cells
produce mucus that protects the epithelium and helps in the formation of feces. Potassium
400
and bicarbonate dilepaskasn by the large intestine in the absorption of electrolytes and fluid
yanh occur in the colon.
There is no enzymatic digestion in the colon. The primary function of the colon is to provide
a place for reabsorption of water, electrolytes, and some vitamins (see Figure 3.2.1). The role
of the colon or colon increases when interference or disease occurs in the small intestine.
The colon can increase absorption significantly by three to five times compared to normal
conditions. In conditions where absorption does not occur in the small intestine, nutrients
from the small intestine will be wasted into the feces unless the substrate can be
fermented into short chain fatty acids such as fiber and resistant starch substances. The
second function of the colon is as a place of formation and storage of feces.
DISEASES ON THE CHANNEL CERNA BELOW
Common underlying gastrointestinal problems include gas intestinal, flatulence,

constipation, and diarrhea. While the disease in the lower gastrointestinal tract is a disease,
inflammatory bowel disease, and diverticular disease.
Intestinal and Flatulent Gases
The daily human intestinal gas volume is about 200 ml, and comes from complex
physiological processes, including air swallowing (aerophagia) and bacterial fermentation by
the gastrointestinal tract.
These gases are emitted through burp (eructation) or through the rectal (flatus). Gases
including gas intestinal are carbon dioxide (CO2), oxygen (O2), nitrogen (N2), hydrogen (H2),
and sometimes methane (CH4).
When the patient complains of flatulence, this can be translated as an increase in the volume
or frequency of burp or gas in the rectal. Patients may also complain of abdominal
distension, cramps associated with accumulation of gases in the upper and lower
gastrointestinal tract. The amount of air swallowed increases by eating or drinking too fast,
smoking, eating chewing gum, sucking hard candies, using straws, drinking carbonated
beverages, or using loose false teeth. Foods that produce gas may differ in different
401
individuals, depending on the individual colonic microorganisms. Inactivity, decreased
motility, aerophagia, food components, and certain gastrointestinal disorders may alter the
amount of intestinal gas and its symptoms.
Constipation
Constipation is defined as the difficulty of defecation in which there is a decrease in the

movement of the colon or with dyschezia (pain, hard, or incomplete). The normal frequency
of defecation is between 3 times per day up to 3 times per week (Cresci and Escuro, 2017).
Constipation is caused by several factors, namely systemic factors and gastrointestinal

disorders. Here are the causes of systemic constipation: constipation of drug side effects
(such as narcotics), endocrine metabolic abnormalities (such as hypothyroidism, uremia and
hypercalcemia), lack of exercise / activity, ignoring defecation, vascular disease of the colon,
systemic neuromuscular disease leading to voluntary deficiency muscles, low-fiber diet, and
pregnancy. Constipation may also occur due to a gastrointestinal disorder. These
gastrointestinal disorders include celiac disease, peptic ulcer, gastric cancer, bowel disease,
irritable bowel syndrome, hemorrhoid, and incorrect laxative use.
134
Diarrhea
According to Simadibrata and Daldiyono (2014) diarrhea is a bowel movement with feces
liquid or semi-solid, with a stool content of more than 200 grams or 200 ml / 24 hr. Or it can
be defined with a watery defecation of more than 3 times per day with / without mucus and
blood. Acute diarrhea is diarrhea lasting less than 25 days. While chronic diarrhea is diarrhea
lasting more than 15 days.
Diarrhea occurs when intestinal contents accelerate through the small intestine, decreased
digestion of food by enzymes and decreased absorption of fluids and nutrients. Diarrhea is
associated with inflammatory diseases, fungal infections, bacteria, or viruses, drugs, sugar
consumption or other osmotic substances excessive, food allergic responses, or damage to
the absorption area of the mucosa.
402
Seliak disease
The disease called gluten-sensitive enteropathy. The disease is caused by an autoimmune

reaction to gliadin (found in gluten) that causes damage to the intestinal mucosal villi to
atrophy and flattening (as Figure 3.8). Selective celiac disease or causes malabsorption of all
nutrients. This condition can be accompanied by dermatitis herpetiformis, anemia, bone
loss, muscle weakness, polyneuropathy, and follicular hyperkeratosis.
Source: Nelms. 2011. Disease of the Lower Gastrointestinal Tract. Krause's: Food and the
Nutrition Care Process. 2nd.ed. Australia: Wadsworth. P. 403.
Figure 3.8
Normal microvilli and atrophic and flattening microvilli (celiac disease)
Symptoms of celiac disease
Classical clinical symptoms of a disease of the disease include diarrhea, abdominal pain and
cramps, bloating, and gas production. Other symptoms may occur outside the digestive tract,
including joint and joint pain, muscle cramps, fatigue, peripheral neuropathy, seizures, red
spots on the skin, and mouth sores. But some patients do not experience signs and

403
135

classic gastrointestinal symptoms. Some patients also have iron nutritional anemia, chronic
fatigue, constipation, and irritable bowel syndrome (Nelms, 2011).
Inflammatory Bowel Diseases
Inflammation especially in the ileum and colon, with symptoms of diarrhea, accompanied by
blood,
mucus, abdominal pain, decreased body weight, decreased appetite, fever, and possible
steatorea (the presence of fat in the feces). The disease may be ulcerative colitis and Crohn's
disease.
Etiology of Ulcerative Colitis
Infection Factors: Virus, bacterial or parasitic infections from dirty foods, drinks or hands,
generally: Shigella, E. Coli, Salmonella and Campylobacter. Amoeba can also cause colitis
(causing bloody diarrhea, fever and dehydration) and Parasites: Giardia. Immunologic factors
provide extraintestinal manifestations, such as: arthritis. Psychological factors, major
psychological stress (eg, loss of family members), are vulnerable to emotional stress that can
stimulate the disease of colitis.
Ulcerative colonic illness only involves the colon and extends to the rectum. If the disease
continues it can cause no areas unaffected. The colonic mucosa is inflamed and may be a
mild ulcer or stricture. In this disease often occurs rectal bleeding and bloody diarrhea. If all
the are exposed, often the colon will be removed / cut.
The disease provides signs and symptoms that include bloody diarrhea, abdominal pain
(increased pain during diarrhea, then decreases), often shivering fever and other signs of
404
infection (as is the cause of colitis). In this disease also gives symptoms where the feces
contain a little blood (mild cases), bloating and increased intestinal air. In severe cases
weight loss.
Crohn's disease
If the inflammation that occurs in the above kolotis ulcerative disease, in Crohn's disease
involves more parts of the gastrointestinal tract, from the mouth to the anus. Typically
involving the small intestine and large intestine segmentally and about the entire mucosal
lining. The mucosa may develop inflammation, ulcers, abscesses, fistulas, fibrosis,
submucous thickening and scarring which can cause partial or even partial narrowing or
obstruction. Under such conditions, multiple surgeries are common with intestinal resection.
This disease causes malabsorption of fluids and nutrients, so it may require parenteral
nutritional support to maintain adequate nutritional intake and for hydration.
Diet of Diverticular Disease

The diverticular disease consists of diverticulosis and diverticulitis. Disease Dichertikulosis is
the presence of small pockets formed on the walls of the colon that occur due to high
intracolon pressure on chronic constipation. This happens with age advanced that eat low
fiber. Diverticulitis disease occurs when the accumulation of food waste in the diverticular
causes inflammation. Symptoms of this disease include cramps in the lower left abdomen,
nausea, bloating, vomiting, constipation or diarrhea, chills, and fever. Figure 3.9. shows
normal colon and colon with diverticulosis sacs.
136
Figure 3.9
Normal colon and colon with diverticulosis sacs
NUTRITION OF NUTRITION DISEASES ON CERNA CHANNELS
This section will describe about the nutritional care of lower salurancerna disease which has
been described the definition, causes and symptoms above.
Nutritional Care on Constipation
405
In constipation cases nutritional assessments focus on nutritional history data on fluid and
beverage intake, dietary fiber intake, bioactive substance intake, food confidence and
attitudes, and drug abuse (eg Laxatives).
137
406
Diagnosis of Nutrition in Constipation
Common nutritional problems in constipation and can be defined as a nutritional diagnosis

are:
Inadequate fluid intake.
Inadequate fiber intake.
Changes in GI function.
Not ready for diet / behavior change.
Selection of wrong foods. c. Nutritional Interventions
The goal of nutritional intervention in constipation is to help smooth the defective process
impaired by constipation.
Strategies that can be done on nutritional interventions are:
Suggest to patient to increase physical activity if possible.
Suggest patient to respond to defecation desire, do not be delayed or ignored Give a high
fiber diet or high residual diet. The recommended amount of fiber is 25 grams per day. The
addition of fiber should not be more than 50 grams per day, and gradually increased
gradually, for example in the span of one month. If excessive fiber and less fluid intake, can
cause other problems, such as gastric and stool obstruction. This condition can cause
gastrointestinal constriction.
Give enough fluids, about 2 liters per day.
If the cause of constipation is a drug, it may not be curable with diet.
407
Proper use of laxatives and fecal softeners can help to overcome constipation.
Constipation patients need to be monitored for fiber and fluid intake, as increased fiber
intake should be offset by an increase in fluid intake. It needs to be monitored whether
patients can tolerate increased fiber and fluid administration that is implemented in
nutritional intervention. Another thing that needs to be monitored is whether the defective
disorder has diminished.
Diarrhea
The nutritional consequences of diarrhea depend on loss of gastrointestinal volume and

duration of diarrhea. Large rapid volume loss causes dehydration and electrolyte and acid-
base imbalances. Hyponatremia and hypokalemi often occur in diarrhea. Metabolic acidosis
may occur because of the great loss of bicarbonate ions. Infants and the elderly are the most
at-risk group because they are more sensitive to fluid imbalances and fluid imbalances
Nutritional Assessment of Diarrhea
In nutritional assessment for diarrhea patients need to focus the collection of nutritional
history data on fluid and beverage intake, energy and mineral intake, drug use and herbal
supplements and weight changes. For biochemical data it is necessary to assess hydration
status. Data Nutrition-focused findings collected data relating to the digestive system and
skin. Personal history data asked about previous surgery history.
Diarrhea Diarrhea
Common nutritional problems that can be established as a nutritional diagnosis are

inadequate energy intake, inadequate oral intake, inadequate fluid intake, altered
gastrointestinal function and unexpected weight loss.
Nutrition Interventions in Diarrhea
408
The goal of nutritional intervention in diarrhea is to prevent dehydration and fluid and
electrolyte imbalances.
Strategies that can be done on nutritional interventions are:
Replace fluid and electrolyte losses using oral glucose electrolyte solution or saline or oralite
sugar solution.
Low residual diet initiation, ie food is completely digested, absorbed well and foods that do
not increase gastrointestinal secretions. Foods restricted to low-residual diet are those
containing lactose, such as milk (low milk or non-lactated), caffeine and alcohol.
Avoid sugar and excess alcohol.
Prebiotics can be given in moderate amounts, including pectin, oligosaccharides, inulin, oats.
Probiotics, food cultures and supplements are the source of beneficial gut flora.
Diarrhea patients should be monitored for fluid status by looking at clinical physical data
leading to dehydration. Has the fluid and electrolyte imbalance been resolved.
Nutritional Care in Seliak Disease
Severe malabsorption of the disease of the breeds can lead to significant weight loss, vitamin
and mineral deficiencies, and less protein energy. Some patients only have micronutrient
deficiencies. The nutritional assessment not only measures anthropometric changes and
nutritional imbalances, but also the patient's personal history of social, knowledge and
beliefs and poor behavior on the disease.
139
409
140
Nutritional problems in patients with celiac disease include impaired nutritional utitization
and alteration of gastrointestinal function.
The goal of nutritional intervention in patients with the disease is to prevent the decline or
maintain nutritional status. Nutrition intervention in patients with celiac disease is lifelong
and requires adherence to a given diet. Diet is a therapy in celiac disease.
The strategy of nutritional intervention in this disease are:

1. In the acute phase, therapy loses electrolytes and fluids.
2. Supplementation of vitamins and minerals (calcium, vitamin D, vitamin K, iron, folate, B12,
A and E).
3. Avoiding sources of gluten from food (wheat, rye, barley, oats).
4. Replace with corn, potatoes, rice, soybeans, tapioca.
5. Read the labels carefully to see the composition of food products.
6. A very small amount of gliadin can be a problem.
7. Be careful with: thickener, flavor enhancer, sauce, gravies, coatings / coatings, vegetable
protein.
410
The important thing to monitor in patients with celiac disease is its nutritional status,
including anthropometric measurements and weight changes. In addition it is important to
monitor nutritional deficiencies both macro and micro.
Inflammatory Bowel Disease (IBD)
Due to the important complications and nutritional problems associated with IBD,
comprehensive nutritional assessment is required.
Common nutrition problems in IBD patients are:
Malnutrition
Inadequate energy intake
Inadequate oral intake
Increased nutritional needs
Vitamin / mineral intake is inadequate
The utilization of nutrients is disrupted
Changes in nutritional value of the lab
The goals of nutritional intervention in patients with diseases of the disease are:
Fixed fluid and electrolyte imbalances
411
Replace lost nutrients and improve nutritional status is lacking
Prevents further irritation and inflammation
Resting the gut in the acute period
Nutrition intervention strategy is done by:
In the acute phase it is empowered and fed only parenterally
When the acute phase is resolved, the patient is fed gradually, starting from the liquid form
(by mouth or enteral), then increasing to a Low and Low Fiber Diet
When the symptoms disappear can be given Ordinary Food
Nutritional Needs:
High energy and high protein.
Vitamin and mineral supplements of vitamin A, C, D, folic acid, vitamin B12, calcium, iron,
magnesium, and zinc.
Low Enteral Foods or Free Lactose and medium chain triglycerides (MCTs) can be given
because of frequent lactose intolerance and fat malabsorption
Quite fluid and electrolyte
Avoid foods that cause gas
Low Time and gradually return to Ordinary Food
Diverticular disease
412
To identify nutritional problems in patients with diverticulosis / Diverticulitis it is important

to do a consumption survey to evaluate dietary fiber intake. It is also important to collect on
nutritional assessments is to examine the patient's knowledge of the disease (the patient
should have been educated to reduce fiber intake).
Common nutritional diagnoses or commonly found in patients with diverticular disease are
changes in gastrointestinal function and inadequate fiber intake.
Aim at nutritional intervention in Diverticulosis disease
Increase the volume and consistency of feces
Lower intra luminal pressure
Prevent infection
141
142
Strategies on nutritional intervention:
Needs energy and normal nutrients
High liquid, 2-2.5 liters a day
413
High fiber
The goal of Diverticulitis disease intervention
Resting the gut to prevent perforation
Prevent the laxative effects of high fiber foods
His nutritional intervention strategy:
Ensuring the intake of energy and nutrients adequately conform to the defined dietary
constraints
In case of bleeding, begin with Liquid Foods Clear
Food is given gradually, starting from the Lowest Time I Diet to the Lowest Time II Diet with a
consistent adjusted
Avoid foods that contain lots of small seeds, such as tomatoes, guava, and strawberries,
which can accumulate in diverticic
If necessary, Low Enteral Food or Lactose-Free
To prevent constipation, drink at least 8 glasses a day
Exercise
Tn. AM an IT company manager, 28 year old single, came to poly nutrition with complaints
already three days can not be defecate, stomach feels full, bloated and feel uncomfortable in
the area around the stomach. This condition has been experienced several times Tn AM in
the last month. Tn AM has checked to the doctor and given laxatives, but because it has
several times experienced the same condition, the doctor refers Tn AM to the Nutritionist.
Mr. AM has irregular eating habits because of his busy life. Dishes that are often consumed is
'fast food' because of limited time to eat, especially lunch. Around the workplace Tn. AM
414
there are many restaurants; such as KFC, Mc Donald, Pizza Hut, Solaria, Padang Restaurant
and Sundanese Restaurant. However, Mr. AM more often orders food from KFC and Pizza
Hut because it is fast and can 'delivery order' and only occasionally order Padang and Sunda
cuisine. Tn AM only consumes fruit if dinner at home, and this is very rare because Tn AM
more often dinner outside. As a manager, Tn AM works more often with computers and
often drinks coffee (2-3 cups a day). In addition, Tn AM also rarely exercise. Weight is
currently 72 kg with a height of 171 cm.
Make nutritional care for Ny A using standardized nutrition care process steps.
The steps of standardized nutrition care process.
Anatomy and lower gastrointestinal physiology.
Nutritional care in constipation patients.
Summary
Disorders or diseases of the lower gastrointestinal tract may include constipation, diarrhea,
celiac disease, and diverticular disease (diverticulosis and diverticitis). Nutritional problems
in patients with the disorder or disease will cause impaired absorption of nutrients and can
decrease the nutritional status of patients. Nutrition assessments in patients with this
disease require information about foods that cause discomfort after consumption,
malabsorption of nutrients, impaired gastrointestinal function, and anthropometric data.
Some of the common nutritional diagnoses in patients with this disease include inadequate
oral intake, gastrointestinal function disorders, unexpected weight loss, malnutrition and
lack of nutritional and food related knowledge. Nutritional interventions include certain
dietary restrictions that aggravate symptoms and reduce gastrointestinal workload, as well
as lifestyle modification. Nutrition monitoring and evaluation needs to be done is about the
patient's tolerance of food restrictions and nutritional status.
415
Test 2
Choose the most appropriate answer.
The presence of fat in the feces is called:
Steatorea
Fistula
Abscess
Ulcers
Stricturing
The presence of small pockets formed on the walls of the colon that occur due to the high
intracolon pressure on chronic constipation, called disease:
Diverticulosis
Diverticular
Diverticulitis
Irritable Bowel Syndrome
Chron's diseases
143
416
144
417
The goal of diet in the disease at No. 2:
Increases intra-luminal pressure
Increase the volume and consistency of feces
Prevents gastrointestinal irritation
Improve nutritional status
Improves fluid and electrolyte balance
High fiber diet contains fiber:
> 25 grams / day
> 35 grams / day
10-25 grams / day
25-50 grams / day
> 50 grams / day
Water absorption occurs in the gastrointestinal tract below:
Duodenum
Jejunum
Colon
ileum
418
stomach
key test answer
Tes 1
Tes 2
419
420

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Dietetic Infectious Diseases

The scope of hospital nutrition services include:

D. MECHANISM OF HOSPITAL NUTRITION SERVICES

patient Login Necessary

Nutrition assessment Nutrition

Patient Food material

D. NUTRITION SERVICES OUTPATIENT

Providing services to clients / outpatient or groups to help find solutions nutrition

E. NUTRITION SERVICES HOSPITAL

The first step in the prevention of malnutrition in hospital with nutritional

The identification of patients at risk of malnutrition or malnutrition is the first step

 Acute Disease: within 24 hours

Decrease / increase in weight is undesirable> 10% weight usually in the last 6

Nutritional assessment carried

 Review of clinical data

Stable Risky  Rating physical data

Create a nutrition care plan is based on:

The purpose of nutritional care both

Re-assessment based on:

BENEFITS FOR PROFESSIONALS PAGT DIETESIEN

STEPS IN RELATION PAGT

Health, Dit. Nutrition MoH RI, WHO, PERSAGI, Asdi. 2014.

Diagnosis of nutrition is an activity to identify and name the actual nutritional

DIFFERENCES IN MEDICAL NUTRITION THERAPY (TGM) PROCESS CARE AND NUTRITION

The concept of nutritional problems

Results of nutritional care can be measured

THE BASIC CONCEPT OF NUTRITION ASSESSMENT

Nutritional assessment is a systematic approach in collecting, verifying

The nutritional assessment is to obtain sufficient information in identifying

Specifically the purpose of nutritional assessment for:

Prevent the ongoing incidence of malnutrition in patients / clients at risk of malnutrition by

Determine the right nutrition care plan.

Role and function

determination of nutritional diagnosis and the purpose of nutritional intervention and

Relationship of Assessment, Diagnosis, Intervention and Monitoring of Nutrition Evaluation

Detailed data on nutritional assessment results are related when:

Determine the purpose of nutritional intervention of nutritional problems results assessment

Example: the results of assessment of nutritional assessment data and problem

a. Feeding intake and

Height, weight, Body Performance Index (BMI),

Biochemical data, Laboratory data (eg electrolytes, glucose) and tests

Personal history, medical

1. History related to nutrition and food 8 151

Measurement Method or Data Source

Criteria of nutritional care is a comparison of indicators of nutritional care so that

Examples of nutritional assessment documentation

Rincian Contoh : Terminologi “Asupan Energi”

The amount of energy from various sources, eg food,

b. Indicator asesmen Total energy = calories / day, calories / kg / day

Comparing with reference objectives or standards:

Rincian Contoh : Terminologi “Asupan Energi”

Based on patient / client food records, patient / client

g. Reference Charney P, Malone A. ADA Pocket Guide to Nutrition

DOMAIN HISTORY CLIENT (CLIENT HISTORY-CH)

Included in the client history are personal history, medical history

Riwayat medis/kesehatan klien :

community / church etc.)

NUTRITION-RELATED HISTORY (FH) DOMAIN RELATED HISTORY (FH)

Composition and amount of food intake and nutrients.