Tap chi Tai Mui Hpng Vi$t Nam - Volume (58-16). N°4 - June, 2013
SV^ KHAC NHAU VE CAC CHI SO LIEN QUAN TOI DINH DU^OnVG CUA BENH NHAN DU^6l 65 TUOI CUA KHOA N O I
VA KHOA NGOAI TAI BENH VIEN 198
Nguyen Dd Huy*
T6M TAT
Nghien cuu cd muc tieu mo td vd do sdnh cdc ddc diim liin quan tai dinh dudng cua binh nhdn mdi nhgp vien trong vdng 48 gid ddu o Khoa Npi vd Khoa Ngoai cua binh vien 198-Bp cdng an. Thiet ki nghien cuu tien cuu tit thdng 2 din thdng 4 ndm 2012 tren 411 cdn bp vd chiin sy ngdnh cdng an Id binh nhdn nhgp vi^n diiu tri trong vdng 48 gid ddu tgi Benh vien 198 cho thdy: Trie ty li chdn dn cua binh nhdn khoa Npi cao hon so vdi binh nhdn khoa Ngoai (18,4 vd 1 %), cdc chi sd liin quan toi dinh duong khdc cua benh nhdn khoa Ngoai diu cao hon so voi khoa NpiTy li gidm cdn tie 5 din 10% trong 6 thdng cao hem gdp 3 lan. ty le benh nhdn gidm khau phdn dn khi nhgp vi^n cao gan gdp 1,5 ldn(p<0,01), ty le phdi nhin ddi cao hon 10 ldn(p < 0,001). ty le b^nh nhdn gidm chirc ndng van dpng cao gan gdp doi vd ty le phdi ndm tgi giudng cao gdp hon 7 lan.
Tit khda: chi sd lien quan dinh duong. Khoa Ndi, Khoa Ngogi, suy dinh duong.
SUIVIMARY
THE D I F E R E N T I A T I O N OF INDICATORS AT RISK OF MALNUTRITION OF PATIENTS
< 65 YEAR OLD AT INTERNAL AND SURGERY WARDS IN 198 HOSPITAL The purpose of ihe study was to describe the nutrition related factors of hospitalized patients of Internal ward and surgery ward in 198 hospital of Ministry of Police. A prospective study conducted from February to April 2012 in 411 patients hospitalized within 24 hours in the Hospital 198 showed that: Except the percentage of anorexia of patient in Internal ward was higher than that of patients in Surgery ward (18,4 and 1 %), other related lo risk of malnutrition indicators in Surgery ward were much higher than that in Internal ward:Percantage of unintentional weight loss from 5 to 10 % was 3 times higher, percantage of dietary intake change was 1 5 times higher(p<0.01). percantage of fasting was 10 times higher(p<0.001). percantage of reduction of functional capacity was
2 times higher and percantage of bedridden was 7 times higher.
Key words: the at risk indicators of malnutrition, Internal ward, surgery ward, malnutrition status
I. B A T VAN 0 E '^'^* ^'^ ^ ^ ^ " ^ ^ ^^ " ^ ^ ^" '^^^ ^ ^ ^^
trp dinh dudng tich cue. Hien nay, viec Vide xdc dinh tinh trang dinh dudng d ddnh gia tinh trang dinh duong ciia benh benh nhdn nhap vien la rat cdn thiit, dac nhdn trong benh vien chua dupe coi trpng, n l u cd thi chi danh gia tinh trgng dinh
*Vien Dinh duong Quoc gia.
Nhan bai 22/5. Duyet in 5/6/2013
Tgp chl Tai MOi Hpng Vifet Nam - Volume (58-16). N°4-June, 2013
duong qua cdc chi sd nhdn trac (chieu cao, can n|ng va chi sd BMI). Trong khi cdng cu danh gia tinh trang dinh dudng nhu ddnh gid d6i tupng todn di$n (Subjective Global Assessment) (SGA) cho ngudi benh tir 16 din < 65 tudi dupe su dpng rpng rdi trong benh vien cua cdc nude tren the gidi thi vide sii dung cac cdng cu nay cdn rat xa la vdi hdu het cac benh vien d nude ta [1],[2].
Hien nay van de dinh dudng trong benh vien van chua dupe quan tdm dung miic. Chi cd mdt sd benh vien trien khai cdc boat ddng dinh dudng lam sang. Nhieu benh nhdn khi nhap vien chua dupe ddnh gid tinh trang dinh dudng, va che dp dn phii hpp chua dupe dua vao thudng quy trong cdng tdc dieu tri. Thdng tin ve tinh hinh dinh dudng ciia benh nhdn mdi nhap vien ndi chung va theo timg khoa phdng ndi rieng cdn rdt han che. Do dd, nghien ciiu nay dupe thuc hien vdi muc tieu xac dinh lien quan giiia cdc chi sd dinh dudng nhu:
thay ddi cdn ndng thay ddi can nang, thay ddi khdu phdn dn, cdc trieu chiing da day mdt, thay ddi chirc nang van ddng, cac sang chan, cdc ddu hieu SDD... ciia ngudi benh d cac khoa Ndi va Khoa Ngoai tai Benh vien 198.
IL D 6 I TU'ONG VA PHU^OOVG PHAP NGHIEN CLTU
2.L Thiet ke nghien cihi: nghien curu tiin ciiu
2.2. Boi tirpng nghien cihi
Todn bd benh nhdn la cdn bd, chien sy ngdnh cdng an tir 18-65 tudi mdi nhap vien diiu tri npi tm trong 48 gid ddu tai Benh vien 198 tii thdng 2 din thdng 4 ndm 2012 dupe dua vdo nghien ciiu.
2.3. Co* mau
p ( i - p )
n Id sd lupng can dieu tra; Z (].aj2):
Dp tin cay 95% thi Z -1,96
p la ti 1? suy dinh dudng trong benh vien udc tinh la lay p = 37,0 % trong mdt nghien ciiu trudc [1].
d la sai sd cho phep la 5%; cd mdu tinh dupe Id 398.
2.4. Cac phinmg phap thu thap so lieu Tinh trang dinh dudng ciia benh nhdn dupe ddnh gia trong vdng 48 gid sau khi nhap vien bang 2 phuong phap: Danh gia theo BMI va phuong phap danh gia dinh dudng toan dien (SGA) ap dung cho benh nhan < 65 tudi. Thdi diem xac dinh cho nhiing thay ddi nay la trong vong 6 thang va 2 tudn trudc khi nhap vien.
Phuong phap danh gia dinh dudng toan thi SGA (Subjective Global Assessment - SGA) dupe xay dung bdi Detsky vd cdng su nam 1980 va dupe Hiep hdi dinh dudng dudng mieng va dudng tinh mach cua My (ASPEN) khuyin cao su dung [3-5]. De danh gia tinh trang dinh dudng bdng SGA dua vdo each tinh diem theo cac tieu chi:
thay ddi can nang (danh gia tir 0-2 diem), thay ddi khdu phdn an (danh gia tir 0-2 diim), cd cac trieu chiing da day - rupt keo dai tren 2 tudn (danh gia tir 0-2 diem), thay ddi chiic ndng van ddng (danh gid tu 0-2 diim), cac benh mdc phai dnh hudng den cdc stress chuyin hda (ddnh gid tir 0-2 diim), va khdm lam sang: mdt Idp md dudi da, phu, cd chudng (danh gia tir 0-2 diem).
Cac mirc dp dinh dudng gdm: i) Dinh
Tgp chl Tai Mui Hpng Vi$t Nam - Volume (58-16). N°4 - June. 2013
dudng tot (9-12 diim), ii) Nguy co suy dinh dudng (4-8 diim) vd iii) Suy dinh dudng (0-3 diem).
Luu y: Sang chan chuyen hda do bpnh kem theo (stress) la cac bieu hi^n sang chan do bpnh kem theo lam tdng nhu cau dinh dudng: stress nhe: cac benh man tinh..., stress vicaxkc b?nh suy tim, cd thai, bpnh khdng on dinh, hda tri lieu... stress ndng:
cac benh nhu chdn thuong Idn, dai phau, suy da tang
2.5. Khong che sai so va xur ly so lieu Sai so do thu thap so lieu tir phia ngudi thu thap va dung cu thu thap dupe han che bdng tap huan ky luong, sir dung cac dung cu thiet bi cd miic sai sd thap da dupe kiem tra va chuan hda. Sai sd do hdi tudng, nhd lai duoc gidi han bang each hdi trong khoang thdi gian khdng qua xa de han che sai sd, hdi theo trinh tu thdi gian vdi nhiing mdc nhdt dinh de ddi tupng de nhd lai.
Cdc bien dinh lupng dupe kiem tra
phdn bo chudn trudc khi phan tich va su dyng kiim dinh tham sd hoac phi tham sd.
So sanh cac ty I? bdng kiim dinh Chi square test ho^c Fisher Exact tes. Cdc phan tich thong ke dupe th\rc hi?n tren phdn mim SPSS 16.0. Y nghia thdng ke dupe xac djnh vdi gid tri p < 0.05 theo 2 phia.
Bao dij-c nghien cuu: Trudc khi tiin hanh nghien ciiu, cac cdn bp nghien ciiu sg lam vipc chi tiet ve npi dung, muc dich nghien ciiu vdi Idnh dao Benh vien, cung vdi can bp cua cac Khoa ldm sang, trinh bay vd gidi thich ndi dung, muc dich nghien ciiu vdi ngudi b?nh. Cac ddi tupng tham gia phdng vdn mpt each tu nguyen, khdng bat budc va cd quyen tu bd khdng tham gia nghien ciiu ma khdng can bat cii ly do nao.
Vdi benh nhan suy dmh dudng se dupe tu van dinh dudng, tu van siic khoe. Cdc thdng tin ve ddi tupng dupe giii bi mat va chi dupe su dung vdi muc dich nghien ciru, dem lai loi ich cho cdng ddng.
HL KET QUA NGHIEN ClTU
Bang 1. Ode diem cdn ndng cua ddi tuong theo Khoa Idm sdng
Cac bien Khoa N0i Khoa Ngoai Chung Gid trip (n = 315) (n = 96) (n = 411) Giam cdn trong 6 thdng qua, n(%)
Dudi 5% 298(94,6) Tii 5-10% 13(4,1)
>10% 4(1,3) 81(84,4)
14(14,6) 1(1.0)
379(92,2) 27(6,6)
5(1.2) Thay doi cdn trong 2 tuan qua, n(%)
Tdng cdn 5(16) Giam cdn 94(29,8) Khdng thay doi 216(68,6)
4(4,2) 28(29,2) 64(66,7)
9(2,2) 122(29,7)
U ) 0,319
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T^p chl Tai MOi Hpng Vi$t Nam - Volume (58-16). N°4- June, 2013
Bang 1 cho thiy b?nh nhan 6 cac khoa "S^a th6ng ke voi p<0,01. Ngupclai, muc Npi CO muc giam cto tit 5-10% ttong 8>am can ttong 2 tuan qua cua b?nh nhan luong CO thS trong 6 thang vua qua la ^ " ^ ; f ' ? i ' t ' ^ " : t K ' - ! ^ \ ° ' '"•" T 4,1%, thip hon ty le nay a benh nhan ciia 2 9 * " ?° ^'' 'I ^ ' >"" '^"^ •"" ^ "^hia khoa Ngoai (14,6%), su khac bi$t co y *ongke vo.p>0,05.
Bang 2. 0$c diim thay ddi khSu phdn theo Khoa Idm sdng CSc bi^n
Thay aoi k h i u phJn, n(%) KhCng thay a6i Thay doi
Thay a6i kh4u ph^n, n(%) Chdo d$c
Dich, (Ju nang lup'ng Dich, n^ng lupng th^p Nhin dpi KhPng thay doi
Khoa NOi (n = 316)
251(79,7) 64(20,3)
41(13,0) 18(5,4)
4(1,3) 2(0,6) 261(79,4)
Khoa Ngoai (n = 96)
61(63,5) 35(36,5)
9(9,4) 3(3,1) 2(2,1) 21(21,9) 61(63,5)
Chung (n = 411)
312(75,9) 99(24,1)
50(12,2) 21(4,9)
6(1,5) 23(5,6) 311(75,9)
G/d tnp
0,01
0,001
Bang 2 cho thay, chi co 20,3% benh khau phan an, ty le benh nhan phai nhin doi nhan 6 khoa Noi co thay d6i khiu phin an ciia khoa Npi chi la 0,6%, trong khi do ty le khi mic benh, trong khi do ty le nay la nay a benh nhan cua khoa Ngoai len toi 36,5% ddi voi benh nhan ciia khoa Ngoai, 21,9%, su khac biet co y nghia th6ng ke vcti su khac biet co y nghia thing ke voi p<O,O0r.
p<0,01. Trong s6 benh nhan co thay doi
Bang 3. Tri#u tinintg da day-ruSt, thay doi chile nSng van dpng theo Khoa 14m sang Ccic bien
Trifeu chLPng da d4y-ru6t, n(%) Khong c6 tri$u chirng Bu5n ndn N6n Chdn i n Ti6u chay
Khoa NPi (fi = 315)
234(74,3) 12(3,8)
3(1,0) 58(18,4)
8(2,5) Thay doi cSc chijc nSng v§n dpng, n(%) KhPng thay doi
Giam
Thay doi chu'C nSng vdn dpng , n(%) Di lai d u o c
Giam chiFC nSng 50%
Ndm tai giup-ng
218(69,2) 97(30,8)
137(67,8) 52(26,7) 13(6,4)
Khoa Ngoai (n = 96)
88(91,7) 2(2,1) 2(2,1) 1(1,0) 3(3,1)
43(44,8) 53(56,2)
17(25,8) 18(27,3) 31(47,0)
Chung (n = 411)
322(78,3) 14(3,4)
5(1,2) 59(14,4)
11(2,7)
261(63,5) 150(36,5)
154(57,5) 70(26,1) 44(16,4)
Gia tri p
0,01
0,001
0,001
Tgp chl Tai MOi Hpng Vi$t Nam - Volume (58-16). N°4 - June, 2013
Bang 3 cho thdy chi cd 74,3% b?nh nhan d khoa Npi xuat hien trieu chiing da ddy-rupt, ty 1? nay d b?nh nhan khoa Ngo^i la 91,7%. Ty le chdn dn ciia bpnh nhan khoa Npi chiem t6i 18,4 %, trong khi dd ty le chdn dn cua cdc b?nh nhan khoa Ngoai chi la 1%, sy khac biet cd y nghia thong ke voi p<0,01. Ty le bpnh nhan gidm cac chiic
ndng van dpng cua benh nhan khoa Ndi la 30,8%, ty le nay 6 cdc bpnh nhdn khoa Ngo^i la 55,2%. Ty Ip ndm tai giudng ciia b?nh nhan khoa Npi chi la 6,4%, trong khi dd ty 1? nay 6 b?nh nhan ciJa khoa Ngoai len t6\ 47,0%, su khac bi?t cd y nghia thong kevdrip<0,()01.
Bdng 4 Mirc dd stress chuy§n h6a do b$nh k6m theo vd ddu hi$u thg-c t h i v i dinh dud-ng theo Khoa Idm sdng
Cdc b i i n Khoa NOl (n = 315)
Khoa Ngoai (n = 96)
Chung (n = 411)
G/d trip
Ddu hi6u stress chuyen hda do benh kdm theo, n(%)
Khdng c6 triSu chiing 82(26,0) Muc dp nhe 159(50,5) MLFC dp viia 69(21,9) Miic dp ndng 5(1,6)
42(43,8) 12(12,5) 39(40,6) 3(3,1)
94(97,9) 0(0,0) 0(0,0) 2(2,1)
124(30,2) 171(41,6) 108(26,3) 8(1,9)
361(87,8) 34(8,3)
2(0,5) 14(3,4) Dau hieu thuc the ve dinh d u o n g , n(%)
Khong cp dau hieu gi 267(84,8) Giam lap m p d u p i da 34(10,8) Phil, giu nupc 2(0,6) Giam khoi c o 12(3,8)
Bang 4 cho thiy co toi 50% benh nhan a khoa Npi co diu hieu stress chuySn hoa do benh kem theo 6 mirc do nhe, trong khi do 6 benh nhan khoa Ngoai co toi 43,7%) CO dau hieu stress chuySn hoa do benh kem theo 6 mirc dp vira va nang, su khac biet co y nghia th6ng ke vcri p<0,001. Ty le benh nhan co cac dau hieu thuc thS vk suy dinh duong cua benh nhan khoa Npi la 15,2%,,
ty le nay 6 cac benh nhan khoa Ngoai chi la 2,1%, sir khac biet co y nghia thdng ke voi p<0,05.
IV. BAN LUAN
Danh gia SDD ciia nguoi benh theo phirong phap SGA chu yeu dua vao cac yeu to: thay doi cSn nSng khong mong muon, thay ddi vk khau phan an, cac trieu
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Tap chl Tai Mui Hpng Vi^t Nam - Volume (58-16) N''4 - June, 2013
chiing da day rupt, thay ddi chiic nang van ddng, cac benh mac phdi va dnh hudng cua cac sang chin chuyen hda, cac dau hieu SDD (mdt lop mo duoi da, phii, cd chuong) [4,5],
Ket qud trong nghien ciiu nay cho thay ty 1? giam can tii 5 den 10% trong 6 thdng ciia benh nhan khoa Ngoai cao hon gap 3 lan so voi ty le nay 6 b?nh nhan khoa Ndi.
Ty le bpnh nhan gidm khau phan dn khi nhap vien a nhdm benh nhan 6 Khoa Ngoai cao gan gap 1,5 lan so vdi khoa Ndi(p<0,01). Nhdm benh nhan khoa Ngoai phai nhin ddi Id 21,9 %, cao hon ty le phdi nhin ddi ciia khoa Ndi tdi hon 10 lan (0,6%)(p < 0,001). Nhdm benh nhan khoa Ndi cd ty le chdn dn cao hon rat nhieu lan so vdi benh nhan khoa Ngoai (18,4 va 1
%). Didu nay cho thdy neu khdng cd che dp can thiep dinh duong kip thdi ddc biet cac ddi tupng chan an thi nguy co thieu dinh duong 6 benh nhdn khoa Ndi se chi cdn la van de thdi gian.Ty le benh nhan giam chiic nang van dpng ciia khoa Ngoai cao gdn gap 2 Idn so vdi ty le nay o khoa Ndi, dac biet la ty le phdi ndm tai giudng ciia khoa Ngoai cao gdp hon 7 Idn so voi ty le nay d khoa Npi (p<0,001). Cdn cd ke hoach cham soc dinh dudng ddc hieu cho nhimg benh nhdn cd giam kha ndng tu cham sdc do mdc cac benh lien quan tdi dieu tri Ngoai khoa. Ty le suy dinh duong cua benh nhan khoa Ngoai ddu cao hon 2 Idn ty le nay d benh nhan khoa Ndi dii danh gid bdng BMI hay SGA, nhu vay cdn dac biet luu y tdi phdng chdng suy dinh duong cho cac benh nhan trong benh vidn, ddc biet cho cdc benh nhan NgoEii khoa.
Ty le benh nhan giam can tir 5% trd len trong nghien ciiu ciia chiing tdi la 7,8%
(khoa Npi:5,4% va. khoa Ngoai:14,6%), thap hon ty le nay (27,5%) trong nghien ciiu tren benh nhan ung thu dang dupe hda hi lieu tai Han quoc (20]0)[6]. Ty le benh nhdn cd thay ddi ve khau phan an udng trong thai gian mac benh trong nghien ciiu tai Han qudc (2010) la 33,2 % cao hem ty Je ndy tai Ichoa Ndi(20,3%), nhung thap hon ty le nay d khoa Ngoai (36,5%), trong nghien ciiu cua chung tdi [6].
Trong nghien ciiu cua chiing tdi, ty le benh nhan cd xuat hien sang chan chuyen hda do benh kem theo la 68,8% (khoa Ndi:74,0% va khoa Ngoai:56,2%), cao hon rat nhieu so voi cac ty le nay (12,3%) trong nghien ciiu tai Han qudc (2010), cd the do ddi tupng benh nhdn ung thu[6]. Ngupc lai, trong nghien ciiu ciia chiing tdi, ty le benh nhan cd xuat hien trieu chiing suy dinh duong tren lam sang d khoa Npi (5,4%) la thdp hon nhung ty le nay tai khoa Ngoai (14,6%) lai cao hon so vdi cdc ty le nay (9,5%) trong nghien ciiu tai Han qudc (20I0)[6].
V. KET LUAN VA KHUYEN NGHI Didu tra tren 411 doi tupng nhap vien trong vdng 48 gid dau tai benh vien 198 thdy: Trir ty le chan an ciia benh nhan khoa Ndi cao hon so vdi benh nhan khoa Ngoai (18,4 va 1 %), cac chi sd lien quan tea dinh duong khdc ciia benh nhan khoa Ngoai deu cao hon so voi khoa Ndi: Ty le giam can tii 5 den 10% trong 6 thang cao hon gap 3 Ian, ty le benh nhan giam khau phdn an khi nhap vien cao gan gdp 1,5 lan (p<0,01), ty le phai nhin ddi cao hon 10 lan(p < 0,001).
Tgp chl Tai MQi Hpng Vigt Nam - Volume (58-16). N°4 - June, 2013
ty le benh nhan giam chiic ndng v^n dpng cao gan gap 2 lan va ty 1? phdi ndm tai giucmg cao gap hon 7 lan.
Khuyen nghj
Can dp dung cdc phuong phdp ddnh gid tinh trang dinh duong bang phuong phdp ddnh gid todn dien (SGA) cho benh nhan nhap vien de phdt hien sdm nhiing benh nhan cd nguy co thieu dinh duong vd cd bien phap can thiep kip thdi.
Loi cdm on: Xin trdn thdnh cdm on cdc bdc sy, dieu duong vd ky thuat vien ciia binh vien 198 da tham gia vd ddng gop quan trong cho thdnh cdng ciia nghien ciru nay.
TAI LIEU THAM KHAO Pham Thu Huong va cdng su (2006) Tinh trang dinh dudng ciia benh nhan nhap vien khoa tieu hda va ndi tiet tai Benh vien Bach Mai. Tap chi Dinh Dudng va Thuc pham, sd 3+4, trang 85.
M.Shirodkar, K.Mohandas (2005) Subjective Global Assessment: a simple
and reliable screening tool for malnutrition among Indian. Indian Journal of Gastroenterology, 24:
246-250.
3. Jane A.Read et al (2005) Nutritional Assessment in cancer: Comparing the Mini Nutritional Assessment (MNA) with the Scored Patient - Generated Subjective Global Assessment (PG- SGA). Nutrition and Cancer, 53(1):
51-56.
4. J Kondrup et al, ESPEN. Guidelines for Nutrition Screening 2002. Clinical Nuhition(2003)22(4), 415-421.
5. K.W. Loh, M.R. Vriens, et al.
Unintentional weight loss is the most important indicator of malnutrition among surgical cancer patients. The Netherland journal of medicine, October 2012, vol.70, No.8,pp.366-369.
6. Woong Sub Koom, MDI, Seung Do Ahn, et al. Nutritional status of patients treated with radiotherapy as determined by subjective global assessment. Radiat OncolJ2012;30(3):132-139
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