FORMAT PENGKAJIAN
KEBUTUHAN NUTRISI
Rumah sakit :………………………………………………………………………………..
Ruangan :………………………………………………………………………………..
Tgl/Jam MRS :………………………………………………………………………………..
Dx. Medis :………………………………………………………………………………..
No. Register :………………………………………………………………………………..
I. BIODATA
PENANGGUNG JAWAB
Nama Klien :..............................................................................................................
Nama :……………………........
Umur :..............................................................................................................
Umur :………………………….
Jenis Kelamin :..............................................................................................................
Pendidikan :………………………….
Pendidikan :..............................................................................................................
Pekerjaan :………………………….
Pekerjaan :..............................................................................................................
Alamat :………………………….
Agama :..............................................................................................................
Hubungan dengan klien
Gol. Darah :..............................................................................................................
Suami/ Istri/Orangtua/…………………..
Alamat :................................................
.................................................
II. RIWAYAT KESEHATAN
1. Keluhan Utama :
a. Saat MRS
.......................................................................................................................................
.......................................................................................................................................
b. Saat Pengkajian
.......................................................................................................................................
.......................................................................................................................................
2. Riwayat Penyakit Sekarang :
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
............................................................................................................................................
3. Riwayat Penyakit Dahulu :
.............................................................................................................................................
.............................................................................................................................................
..............................................................................................................................................
4. Riwayat Penyakit Keluarga :
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
5. Genogram :
Ket :.......................................
c. Pola Minum
Keterangan Sebelum Sakit Saat Sakit
Jenis
Jumlah (….cc/ hari)
Keluhan
3. Pola Eliminasi
a. Eliminasi Urine
Keterangan Sebelum Sakit Saat Sakit
Frekuensi
Jumlah
Warna
Bau.
b. Eliminasi Alvi
Keterangan Sebelum Sakit Saat Sakit
Frekuensi
Konsistensi
Warna
Bau
Keterangan :
0 : mandiri
1 : dengan alat bantu
2 : dibantu oleh orang lain
3 : dibantu oleh orang lain dan alat
4 : tergantung secara total
5. Dada
Paru-Paru
I……………………………………………………………………………………………………
P...........................................................................................................................................
P...........................................................................................................................................
A………………………………………………………………………………………………….
Jantung
I……………………………………………………………………………………………………
P...........................................................................................................................................
P...........................................................................................................................................
A………………………………………………………………………………………………….
6. Abdomen
I………………………………………………………………………………………………………
A…………………………………………………………………………………………………….
P…………………………………………………………………………………………………….
P…………………………………………………………………………………………………….
7. Ekstremitas
Atas
I………………………………………………………………………………………………………
P……………………………………………………………………………………………………
Gerakan Sendi……………………………………………………………………………………
……………………………………………………………………………………………………..
Kekuatan Otot…………………………………………………………………………………….
Bawah
I………………………………………………………………………………………………………
P……………………………………………………………………………………………………
Gerakan Sendi……………………………………………………………………………………
……………………………………………………………………………………………………..
Kekuatan Otot…………………………………………………………………………………….
………………,…………20........
Mahasiswa
(
) NIM…………………………