BAB I PENDAHULUAN
A. Latar Belakang
Rumah
sakit
merupakan
suatu
institusi
yang
memberikan
pelayanan kesehatan secara menyeluruh kepada masyarakat. Salah satu bentuk pelayanan yang di berikan oleh rumah sakit adalah memberikan pelayanan makanan kepada semua pasien yang dilayani. Pelayanan Gizi Rumah Rumah Sakit ( PGRS) adalah pelayanan yang di sesuaikan dengan keadaan pasien berdasarkan keadaan klinis, status gizi, dan status metabolisme tubuhnya. Keadaan gizi pasien sangat berpengaruh pada proses penyembuhan penyakit, sebaliknya perjalanan penyakit dapat berpengaruh terhadap keadaan pasien. Pelayanan Gizi Rumah Sakit ( PGRS ) merupakan bagian integral dari pelayanan kesehatan paripurna rumah sakit dengan beberapa kegiatan antara lain : perawatan gizi rawat inap dan perawatan gizi rawat jalan ( PGRS.2003). Untuk mencapai serta memelihara kesehatan dan status gizi optimal, tubuh perlu mengkonsumsi makanan sehari -hari yang mengandung zat-zat gizi yang seimbang. Bila tubuh dapat mencerna, mengabsorbi dan memetabolisme zat-zat gizi tersebut secara baik, maka akan tercapai keadaan gizi seimbang. Tetapi dalam keadaan sakit melalui modifikasi diet diupayakan agar gizi seimbang tetap bisa tercapai. ( Almatsier, 2007 ) Dalam upaya pemenuhan zat gizi yang optimal pada pelaksanaan asuhan gizi diperlukan keterlibatan dan kerja sama yang erat antar berbagai profesi terkait yang tergabung dalam tim asuhan gizi terutama ahli gizi karena pengaturan makanan yang baik merupakan kegiatan yang harus diperhatikan. Oleh karena itu peran seorang ahli gizi sangat diperlukan yaitu dalam menetapkan preskripsi diet, rencana diet, evaluasi status gizi, serta memberikan konseling gizi kepada pasien sesuai dengan informasi ya ng dibutuhkan ( Almatsier, 2007 )
1
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Sehubungan dengan uraian di atas maka mahasiswa diwajibkan diwajibkan untuk turut serta dalam kegiatan Manajemen Asuhan Gizi Klinik terhadap pasien ´Hepatitis B Akut ´ yang berada di Ruang Pandan Wangi kelas III RSUD Dr. Soetomo Surabaya selama empat hari dimulai tanggal 7 Juni 2010 sampai dengan 10 Juni 2010.
B. TUJUAN
b.1 Tujuan Umum Mahasiswa mampu melaksanakan manajemen asuhan gizi klinik pada Penderita Hepatitis B Akut di Ruang Pandan Wangi RSUD. Dr. Soetomo Surabaya. b.2 Tujuan Khusus a. Mahasiswa mampu mampu membaca dan mencatat mencatat data penderita. b. Mahasiswa mampu mampu melakukan anamnesa anamnesa riwayat gizi pasien c. Mahasiswa mampu melakukan melakukan recall 24 jam d. Mahasiswa mampu menghitung asupan zat gizi pasien berdasarkan recall 24 jam e. Mahasiswa mampu menganalisa menganalisa data subyektif dan obyekif untuk menentukan diagnosa gizi gizi pasien f.
Mahasiswa mampu menyusun asuhan gizi dengan metode NCP (Nutrition Care Process)
g. Mahasiswa
mampu
melakukan
pengukuran
antropometri ,
menganalisis data laboratorium, data klinis dan data fisik pasien. h. Mahasiswa mampu menentukan status gizi pasien i.
Mahasiswa mampu mampu merencanakan terapi diet yang sesuai dengan penyakit dan kebutuhan zat ± zat gizi pasien
j.
Mahasiswa mampu merencanakan merencanakan dan melakukan penyuluhan serta konsultasi gizi
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l.
Mahasiswa
mampu
menyusun
laporan
kegiatan
yang
telah
dilakukan
C.
MANFAAT
c.1 Bagi Mahasiswa Dapat mempelajari dan memahami penatalaksanaan diet serta intervensi pada pasien dengan diagnosa medik Hepatitis B Akut. c.2 Bagi Rumah Sakit Dapat memberi masukan untuk pelayanan gizi di Rumah Sakit. c.3 Bagi Instalasi Gizi Dapat memberikan pelayanan dan meningkatkan kualitas dan kuantitas pelayanan gizi di Rumah Sakit. c.4 Bagi pasien dan Keluarga Pasien Dapat meningkatkan pengetahua n keluarga tentang pemberian diet yang sesuai dengan kondisi penyakit pasien.
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BAB II TINJAUAN PUSTAKA
A. Hepatitis B a.1. Pengertian
Hepatitis B adalah suatu penyakit hati yang disebabkan oleh "Virus Hepatitis B" (VHB), suatu anggota famili Hepadnavirus yang dapat menyebabkan peradangan hati akut atau menahun yang pada sebagian kecil kasus dapat berlanjut berlanjut menjadi menjadi sirosi hati atau kanker hati. Mula-mula dikenal sebagai "serum hepatitis" dan telah menjadi epidemi pada sebagian Asia dan Afrika. Hepatitis B telah menjadi endemik di Tiongkok dan berbagai negara Asia (Hermansyah, 2009) Penyebab Hepatitis ternyata tak semata-mata virus. Keracunan obat, dan paparan berbagai macam macam
zat kimia seperti karbon
tetraklorida, chlorpromazine, chloroform, arsen, fosfor, dan zat -zat lain yang digunakan sebagai obat dalam industri modern, bisa juga menyebabkan Hepatitis. Zat-zat kimia ini mungkin saja tertelan, terhirup atau diserap melalui kulit penderita. Menetralkan suatu racun yang beredar di dalam darah adalah pekerjaan hati. Jika banyak sekali zat kimia beracun yang masuk ke dalam tubuh, hati bisa saja rusak sehingga
tidak
dapat
lagi
menetralkan
racun -racun
lain.
( Hermansyah, 2009 ) a.2. Etiologi
1. Hepatitis virus B Virus yang lengkap berupa partikel dua lapis berukuran 42 nm yang di sebut partikel Dane. 2. Keracunan obat, dan paparan berbagai macam zat kimia seperti karbon tetraklorida, chlorpromazine, chloroform, arsen, fosfor, dan
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a.3.
Cara
Penularan
Hepatitis B umumnya menular jika darah dan aliran tubuh lainnya seperti semen (air mani) atau sekresi vagina dari seseorang yang terinfeksi memasuki tubuh orang yang belum terinfeksi. Penularan biasanya melalui : 1. Kontak seksual dengan penderita 2. Gigitan atau melalui mulut 3. Pemakaian jarum suntik bersama, sikat gigi, pisau cukur, alat tindik telinga, alat tato dan akupuntur 4. Dari ibu yang terinfeksi kepada bayinya pada saat melahirkan Virus hepatitis B tidak ditemukan dalam keringat, air mata, urin atau
sekresi
pernafasan.
Hepatitis
B
tidak
ditularkan
melalui
pemakaian bersama perkakas makan, pelukan, batuk, bersin dan pegangan tangan. Penelitian menunjukkan hepatitis B tidak menular melalui makanan dan minuman. Sebagian besar orang dewasa dewasa yang terinfeksi hepatitis B akan sembuh tanpa masalah, akan tetapi tidak pada bayi dan anak -anak. Semakin muda seseorang terinfeksi pertama kali, maka semaki besar kemungkinan berkembang menjadi kronis. a) Jika orang dewasa terinfeksi : 10% akan berkembang menjadi kronis b) Jika seorang anak terinfeksi : 50% akan berkembang menjadi kronis c) Jika seorang bayi terinfeksi : 90% akan berkembang menjadi infeksi kronis d) Cara mengetahui apakah seseorang terinfeksi hepatitis B atau tidak adalah melalui pemeriksaan darah. Ada 3 pemeriksaan standar yang biasa dilakukan yaitu: 1. HBsAg ( hepatitis B surface antigen) :
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2. Anti HBc ( antibodi hepatitis B core ) : Adalah antibodi terhadap antigen inti hepatitis B. Antibodi ini terdiri dari 2 tipe yaitu : IgM ( imunoglobulin M ) anti HBc dan IgG anti HBc. y
Anti-HBc IgM : Muncul 2 minggu setelah HBsAg terdeteksi, dapat bertahan hingga 6 bulan. Berperan pada core window ( fase jendela ) yaitu masa masa dimana HBsAg sudah hilang, tetapi anti HBsAg belum muncul 10% hepatitis akut tidak terdeteksi hanya dengan memeriksa HBsAg.
y
Anti-HBc IgG : Muncul sebelum anti-HBc IgM hilang, Terdeteksi pada hepatitis akut dan kronik Dapat bertahan pada fase penyembuhan ( kadar rendah ), Tidak mempunyai efek protektif.
Interpretasi
hasil
positif
anti-HBc
biasanya
tergantung hasil pemeriksaan HBsAg dan anti -HBs. 3. Anti-Hbs (antibodi terhadap terhadap hepatitis hepatitis B surface antigen ) Jika hasilnya positif atau reaktif menunjukkan adanya imunitas atau kekebalan terhadap infeksi virus hepatitis B baik dari imunisasi maupun dari proses penyembuhan infeksi masa lampau. Seseorang yang terinfeksi masa lampau tidak dapat menularkan penyakitnya kepada orang lain. ( Zubair, 2010 ) a.4. Patofisiologi
Masa inkubasi bervariasi, tergantung pada agennya, refleksi virus dalam hati meningkat, yang di ikuti oleh penampilan komponen virus dan nekrosis sel hati bersama respons peradangan yang menyertai. Antibodi non spesifik dapat meningkat sama seperti pada infeksi virus lainnya. Perubahan morfologi hati pada hepatitis A, B, C
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kekacauan hepatoseluler, cedera dan necrosis hati, dan peradangan perifer. Perubahan reversible bila fase akut penyakit mereda. Pada beberapa kasus, necrosis sub masif atau masif dapat mengakibatkan payah hati yang berat dankematian. Hepaptitis virus D merupakan hibrid DNA virus hepatitis B. virus ini dapat menular sendiri secara langsung dan bersifat hepatoksit. Bentuk ini akan memperbanyak bentuk hepatitis kronik. (Saputra, 2010) a.5. Manifestasi Klinis
Infeksi HBV dapat menimbulkan akibat klinis yang berbedabeda bagi setiap individu, penderita dapat mengalami salah satu dari beberapa keadaan seperti dibawah ini ; 1. Tetap sehat. Terjadi bagi mereka yang memiliki kekebalan ( anti HBS ), Mengidap tetapi tetap sehat, Bila HBS Ag menetap ( persistem ) selama lebih dari 6 bulan tanpa disertai kelainan virus. 2. Hepatitis akut ikterik. Ditandai masa prodromal selama 3 ± 6 hari, kadang-kadang sampai 3 minggu, pasien merasa tidak sehat, anorexia, mual, kadang demam ringan, ras sakit pada bagian kanan atas perut, rasa lesu, cepat lelah & sakit lemah. Gejala prodromal mereda saat timbul ikterus yang dimulai dengan perubahan perubahan warna urein menjadi
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pemeriksan flopia lesi positife dan bilirubinuria, urein secara makroskopis berwarna seperti teh pekat. 4. Hepatitis akut tulminan. Bentuk ini hampir semuanya mempunyai prognosis jelek, kematian biasanya terjadi dalam 7 ± 10 hari ssejak mulai sakit. Pada waktu yang singkat terhadap gangguan neorologik, faktor hepatik dan muntah yang peresisten, terdapat demam dan ikterus yang menghebat dalam waktu yang singkat, pada pemeriksaan didapatkan
hati
yang
mengecil
purpura,
dan
perdarahan
gastrointestinal. 5. Hepatitis Kronik. Diduga bahwa pasien Hepatitis B kronik mengalami episode subklinis dari hepatits akut dengan gejala yang sangat ringan sehingga luput dari perhatian. Dugaa kearah kromositas dimulai manakala keadaan SGOT & SGPT tidak pernah menjadi normal selama 6 bulan dari awal hepatitis akut disertai dengan peresistensi HBS Ag serum. Seringkali dijumpai ikterus hepatoseluler yang hilang timbul pada saat general chek- up, tampak adanya ikterus, spider nevi, hepato splenomegali, eritema palmar dan kelainan biokimiawi serta serologi diagnostik hanya dapat dipastikan dengan pemeriksaan biopsi dan gambaran PA. Pada hepatitis kronik aktif umumnya berakhir menjadi sirosis hepatis. (Saputra, 2010)
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Dewasa ini diagnosis untuk sebagian besar pasie n Hepatitis B kronik ditegakkan berdasarkan gejala klinis, peningkatan kadar SGOT, SGPT dan Gama GT, dengan tanpa Hiperbilirubinemia, HBS
Ag
(+),
menetap
dan
gambaran
Ultrasonography.
(Saputra, 2010)
a.7. Pengobatan Medis
Penderita yang diduga Hepatitis B, untuk kepastian diagnosa yang ditegakkan maka akan dilakukan periksaan darah. Setelah diagnosa ditegakkan sebagai Hepatitis B, maka ada cara pengobatan untuk hepatitis B, yaitu pengobatan telan (oral) dan secara injeksi. a. Pengobatan oral yang terkenal adalah : 1. Pemberian obat Lamivudine dari kelompok nukleosida analog, yang dikenal dengan nama 3TC. Obat ini digunakan bagi dewasa maupun anak-anak, Pemakaian obat ini cenderung meningkatkan enzyme hati (ALT) untuk itu penderita akan mendapat monitor bersinambungan dari dokter. 2. Pemberian obat Adefovir dipivoxil ( Hepsera). Hepsera). Pemberian secara oral akan lebih efektif, tetapi pemberian dengan dosis yang tinggi akan berpengaruh buruk terhadap fungsi ginjal. 3. Pemberian obat Baraclude ( Entecavir ). ). Obat ini diberikan pada penderita Hepatitis B kronik, efek samping dari pemakaian obat ini
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pemberian obat ini adalah depresi, terutama pada penderita yang memilki riwayat depresi sebelumnya. Efek lainnya adalah terasa sakit pada otot-otot, cepat letih dan sedikit menimbulkan demam yang hal ini dapat dihilangkan dengan pemberian paracetamol. (Anonim,2009)
a.8. Pencegahan
Vaksinasi sedini mungkin adalah upaya pencegahan yang paling tepat, khususnya di Indonesia karena prevalensinya cukup tinggi. Vaksinasi dapat melindungi sekitar 90 -95% populasi dewasa muda. muda. Vaksin hepatitis B aman diberikan pada bayi, anak -anak maupun orang orang dewasa. Untuk mencegah penularan secara vertikal, setiap ibu hamil dianjurkan periksa HBsAg, agar dokter dapat mengambil keputusan dalam penanganan ibu hamil selanjutnya, dan agar bayi yang baru lahir dari ibu pengidap segera diberi imunisasi hepatitis B. Secara umum cara-cara yang dapat dilakukan untuk menghindari tertular hepatitis B adalah sebagai berikut : a. Selalu menjaga menjaga kebersihan diri dan lingkungan lingkungan b. Hindari jajan jajan makanan disembarang disembarang tempat atau "jajan" "jajan" yang lain c. Hindari
penularan
melalui
makanan
dan
minuman
yang
terkontaminasi, jarum suntik, alat tato, akupuntur yang tidak steril d. Gunakan jarum suntik sekali pakai pakai (disposable)
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b.2. Tujuan
Memberikan makanan yang tepat dan secukupnya pada penderita penyakit hati dengan biaya murah, guna mempercepat perbaikan faal hati tanpa memberatkan pekerjaannya, dengan cara : 1.
Meningkatkan regenerasi regenerasi jaringan hati dan mencegah kerusakan lebih lanjut dan dan meningkatkan fungsi jaringan hati yang tersisa.
2.
Mencegah katabolisme p rotein
3.
Mencegah penurunan berat badan atau meningkatkan meningkatkan berat badan bila kurang.
4.
Mencegah atau mengurangi mengurangi asites, varises esovagus, dan hipertensi portal.
5.
Mencegah koma hepatik.
b.3. Prinsip
Tinggi Energi Protein diberikan cukup Lemak diberikan cukup Karbohidrat diberikan cukup b.4. Syarat
Syarat-syarat diet hepatitis adalah : 1. Energi tinggi untuk mencegah pemecahan protein, yang diberikan bertahap sesuai dengan kemampuan pasien, yaitu 30-40 kkal/kg BB.
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mengalami steatorea, gunakan asam lemak dengan asam lemak rantai sedang Mediun Chain Triglyceridel (MCT). Jenis makanan ini tidak membutuhkan aktivitas lipase dan asam empedu dalam proses absorbsinya. Pemberian lemak sebanyak 45 gram dapat mempertahankan fungsi imun dan proses sintesis lemak. 4. Vitamin dan mineral diberikan sesuai dengan tingkat defisiensi. Bila perlu diberikan suplemen B kompleks, C, dan K serta mineral seng dan zat besi bila ada anemia. 5. Natrium diberikan rendah, tergantung tingkat edema dan asites. Bila pasien mendapat diuretika, garam natrium dapat diberikan lebih leluasa. 6. Cairan diberikan lebih dari biasa, kecuali bila ada kontraindikasi. 7. Bentuk makanan lunak bila ada keluhan mual dan muntah, atau makanan
biasa
( Almatsier, 2007 )
sesuai
dengan
kemampuan
saluran
cerna.
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Jonathan Wright, M.D menyarankan: y
Diet rendah protein untuk meminimalkan tekanan pada liver.
y
Pola makan dengan porsi kecil sepanjang hari.
y
Menghindari makanan-makanan yang memberi tekanan seperti gula buatan, alkohol, dan kafein.
y
Mengkonsumsi banyak air yang difilter.
y
Minum jus lemon segar setiap pagi dan sore yang diikuti dengan jus sayuran adalah salah satu yang paling disarankan untuk liver.
y
Lakukan ini secara konsisten selama dua sampai empat minggu dan kemudian setiap pagi beberapa kali dalam seminggu untuk beberapa bulan, kemudian setiap kali gejala timbul.
y
Makan banyak sayuran setiap hari.
y
Yang ideal adalah paling tidak satu salad dan satu porsi sayuran yang dikukus atau ditumis ringan setiap hari.
y
Biji-bijian mudah dicerna, seperti padi -padian, gandum, dll sangat
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4)
Bahan makanan yang menimbulkan gas, seperti ubi, kacang merah, kool, sawi, lobak, mentimun, durian, nangka.
5)
Bumbu yang merangsang, seperti cabe, bawang, merica, cuka, jahe.
6)
Minuman yang mengandung alkohol dan soda. (Anonim, 2007)
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BAB III METODOLOGI
A. Waktu
Pengambilan data dilakukan pada tanggal 7 Juni 2010 dan asuhan gizi dilaksanakan dilaksanakan selama selama 3 hari bert urut-turut, yaitu pada pada tanggal 8 Juni 2010 sampai dengan tanggal 10 Juni 2010. B. Tempat
Asuhan gizi dilakukan di Ruang Pandan Wangi kelas III RSUD Dr. Soetomo Surabaya. C.
Metode pengambilan pengambilan data
Metode yang digunakan dalam pengambilan data adalah 1) Observasi/ pengamatan Observasi dilakukan dengan pengamatan langsung kepada pasien
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BAB VI GAMBARAN UMUM PASIEN
A. Identitas Pasien
1. Nama
: Nn. E
2. No. Register Register
: 11.05.52.52
3. Ruangan
: Ruang Pandan Wangi. Wangi .
4. Umur
: 16 tahun
5. Jenis kelamin
: Perempuan
6. Alamat
: Tambak Pring Timur 5 No. 27, 27 , Surabaya
7. Agama
: Islam
8. Pendidikan
: SMP
9. Tgl MRS
: 06 Juni 2010
10. Diagnosa MRS
: Hepatitis Virus Akut ( Suspect Hepatitis A )
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b.2. Riwayat gizi y
Pola makan pasien Tabel 1. Pola makan pasien
No
1
Sumber
KH
Bahan makanan Nasi
Frekuensi >=1x/hr
1-3x/mg 1-3x/mg
<1x/mg
Tidak
Keterangan
pernah @ 100 gr/ 1 entong
V
Roti
V
@40 gr/ 2 ptng sdg
Mie
V
@80 gr/ 1 bgkus
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Pasien mempunyai kebiasaan makan di luar dan hanya makan masakan rumah pada saat makan malam saja.
b.4
Kebiasaan Hidup y
Merokok
y
Obat-obatan yang biasa diminum : Promag
y
Minum alcohol
: tidak
y
Olah raga
: Ya ( 1x/ minggu )
b.5. Skrining Gizi
:-
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c.2. Pemeriksaan fisik/klinis
-
Data klinis Tabel 3. Data Klinis tanggal 07 Juni 2010 Pengukuran
Hasil
Normal
Suhu
36,70C
360-370C
RR
18x/menit
20-30/menit
Nadi
80x/menit
80-100x/menit
Tensi
100/60 mmHg
120/80 120/ 80 mmHg
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c.5. Analisa zat gizi
Tabel 5. Analisa zat gizi pasien Pengamatan
Energi
Protein
Lemak
Karbohidrat
(Kkal)
(gram)
(gram)
(gram)
a. Anamnese
2185,7
68,95
82,66
263,9
b. Kebutuhan
1800
45
50
292,5
c. Recall 24 jam
1074,7
36,06
35,48
141,63
% asupan (a/b)
121,4%
150,01%
165,3 %
90,1%
% asupan (c/b)
59,7%
80,1%
78,96%
48,4%
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Peningkatan nilai laboratorium SGOT, SGPT dan Bilirubin yang disebabkan oleh adanya gangguan pada organ hepar yang dialami pasien yang ditandai dengan dengan nilai hasil pemeriksaan kadar S GOT mencapai 906 U/L, SGPT 1348 U/L, bilirubin direct (0,83 mg/dl), bilirubin indirect (0,66 mg/dl), mg/dl), dan bilirubin total (1,49 mg/dl) (NC ± 2.2) Kurangnya informasi yang berhubungan dengan makanan bergizi yang disebabkan oleh adanya kebiasaan makan sehari-hari yang salah yang ditandai dengan suka makan/ jajanan di luar dan menyukai
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2. Protein Protein cukup, yaitu yaitu 1,-1,2 g/kg BB agar terjadi terjadi anabolis anabolisme me Protein Protein . Pada kasus Hepatitis Fluminan dengan nekrosis dan gejala
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2) Kebutuhan Energi
BEE
= 655,1 + ( 9,46 X BBA) + ( 1,96 x TB) - ( 4,68 x U)
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e.7. Rencana penyuluhan
-
Topik
: Diet Hati I
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e.9. Evaluasi
-
Antropometri status gizi
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BAB V HASIL DAN PEMBAHASAN
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