FORM PERENCANAAN NUTRITION CARE PROCESS

INSTALASI GIZI

BAGIAN 1. ASSESMEN
A. ANAMNESIS

1. Identitas Pasien
Nama : No RM :
Umur : Ruang :
Sex : Tgl Masuk :
Pekerjaan : Tgl Kasus :
Pendidikan : Alamat :
Agama : Diagnosis :
medis

2. Riwayat Penyakit

Keluhan Utama

Riwayat Penyakit
Sekarang

Riwayat Penyakit
Dahulu

Riwayat Penyakit
Keluarga

3. Riwayat Gizi

Data Sosial ekonomi Penghasilan :

 Jumlah keluarga :
Suku: Bangsa :

Aktifitas fisik Lama kerja: Lama Tidur :

Jenis Olahraga: Frekuensi :

Alergi/ makanan
pantangan

Diet yang pernah Jenis diit :

dijalankan Lamanya :

Makanan kesukaan Jenis :

Frekuensi :

Fungsi gastrointestinal Nyeri ulu hati :

Mual :
Muntah :
Anoreksia :
Diare :
Konstipasi :
Perubahan pengecapan/penciuman :
Gangguan mengunyah:
Gangguan menelan :
Kondisi gigi :

Suplementasi gizi Jenis : Merk :

Frekuensi :

Perubahan berat Berkurang: Bertambah :

badan Kurun waktu :

Cara mengolah
makanan

Kebiasaan makan

Asupan makan di Energi :

rumah Protein:
Lemak :
Karbohidrat :

Kesimpulan :

B. ANTROPOMETRI

Tinggi Badan : Cm
 Tinggi lutut : Cm Rumus Estimasi TB :

Rentang lengan : Cm Rumus Estimasi TB :

Berat badan : Kg BB idaman/ideal :

LLA : Cm
Lingkar Pinggul : Cm
Lingkar Pinggang : Cm

Assesmen berdasarkan antropometri :

C. PEMERIKSAAN FISIK KLINIK

1. Kesan Umum :
2. Vital sign :
Tensi :
Respirasi :
Nadi :
Suhu :
3. Kepala/ abdomen/ extremitas dll :

Assesmen Berdasarkan Pemeriksaan Fisik Klinik:

D. PEMERIKSAAN BIOKIMIA

Pemeriksaan Satuan/ Nilai Normal Awal Masuk RS Awal Kasus

Urin/darah

Assesmen Berdasarkan Pemeriksaan Biokimia:

E. ASUPAN ZAT GIZI

Hasil Recall 24 jam diet : Rumah/Rumah Sakit

Tanggal : ...............................................
Diet RS : ...............................................
 Implementasi Energi Protein Lemak (g) KH
(Kcal) (g) (g)
Asupan Oral
Asupan Enteral
Parrenteral
Kebutuhan
% Asupan

Assesmen Berdasarkan Asupan Zat Gizi::

Pemeriksaan Penunjang:

F. RIWAYAT MEDIS

Jenis Obat/tindakan Fungsi Interaksi dengan

Zat Gizi

Assesmen Berdasarkan Riwayat Medis :

BAGIAN 2. DIAGNOSIS GIZI

Domain Intake:
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Klinis:
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Behaviour:
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 BAGIAN 3. INTERVENSI GIZI

A. PLANNING

1. Tujuan Diet :

2. Syarat/prinsip diet :

3. Perhitungan Kebutuhan Energi dan Zat Gizi :

4. Terapi Diet :
Bentuk Makanan :
Cara Pemberian :
 Pembahasan Preskripsi Diet:

5. Rencana Monitoring dan Evaluasi

Yang Diukur Hasil Pengukuran Evaluasi/Target/

Nilai normal
Anamnesis/Keluhan

Antropometri

Biokimia

Klinik

Asupan Zat Gizi

6. Rencana Konsultasi Gizi

Masalah Gizi Tujuan Materi Konseling Keterangan

B. IMPLEMENTASI
1. Kajian Terapi Diet Rumah Sakit
  Jenis Diet/ Bentuk Makanan/ Cara Pemberian:

 Parrenteral Nutrisi:

Energi Protein Lemak KH

(Kcal) (g) (g) (g)
Standar Diet RS
Infus
Kebutuhan (Planning)
% standar/kebutuhan

Pembahasan Diet RS:

2. Rekomendasi Diet

Standar Diet RS Rekomendasi Standar Diet

Makan Pagi

Selingan Pagi

Makan Siang

Selingan Siang

Makan Malam

Selingan Malam

3. Penerapan Diet Berdasarkan Rekomendasi

Pemesanan Diet:

4. Penerapan Konseling
 BAGIAN 4. MONITORING, EVALUASI DAN TINDAK LANJUT
TGL DIAGNOSIS MONITORING ASSESMEN GIZI MONITORING EVALUASI DAN TINDAK LANJUT
MEDIS ANTROPOMETRI BIOKIMIA FISIK DAN KLINIS ASUPAN DIAGNOSIS GIZI (TERAPI DIET DAN KONSELING
GIZI)
 NUTRITIONAL RISK SCREENING (NRS-2002)
Nama : Usia :

Bangsal : Diagnosis :

Tanggal masuk RS : Tanggal skrining :

1. Skrining Awal
No Kriteria Jawaban
1 Apakah IMT < 20.5 atau LLA < 25 cm untuk wanita Ya Tidak
dan LLA < 26.3 cm untuk pria?
2 Apakah pasien kehilangan BB dalam 3 bulan
terakhir?
3 Apakah asupan makan pasien menurun 1 minggu
terakhir?
4 Apakah pasien dengan penyakit berat ? (ICU)
- Jika tidak untuk semua kriteria skrining diulang 1 minggu kemudian
- Jika ada 1 atau lebih kriteria dengan jawaban ya dilakukan skrining lanjut

2. Skrining Lanjut I
Risiko Gizi Kriteria
Absen (Skor = 0) Status gizi normal
Ringan (Skor = 1) Kehilangan BB > 5% dalam 3 bulan atau asupan 50-75% dari
kebutuhan
Sedang (Skor = 2) Kehilangan BB > 5% dalam 2 bulan atau IMT 18.5-20.5 atau
asupan 25-50% dar kebutuhan
Berat (Skor = 3) Kehilangan BB > 5% dalam 1 bulan (> 15% dalam 3 bulan) atau
IMT < 18.5 atau asupan 0-25% dari kebutuhan.

3. Skrining Lanjut II
Risiko Gizi Kriteria
Absen (Skor = 0) Kebutuhan gizi normal
Ringan (Skor = 1) Fraktur, pasien kronik (sirosis hati, COPD, HD rutin, DM,
kanker)
Sedang (Skor = 2) Bedah mayor, stoke, pneumonia berat, kanker darah
Berat (Skor = 3) Cedera kepala, transplantasi sumsum, pasien ICU
(APACHE>10)