U N I V E R S I T A S B O N D O W O S O

PROGRAM STUDI DIII KEPERAWATAN

Jalan Diponegoro No. 247 Tlp/Fax. (0332) 427022 Bondowoso

FORMAT PENGKAJIAN
KEBUTUHAN NUTRISI
Rumah sakit :………………………………………………………………………………..
Ruangan :………………………………………………………………………………..
Tgl/Jam MRS :………………………………………………………………………………..
Dx. Medis :………………………………………………………………………………..
No. Register :………………………………………………………………………………..

Pengkajian Oleh :..............................................................................................................

Tgl/Jam pengkajian :..............................................................................................................
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
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b. Saat Pengkajian
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2. Riwayat Penyakit Sekarang :
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3. Riwayat Penyakit Dahulu :
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.
 4. Riwayat Penyakit Keluarga :
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5. Genogram :
Ket :.......................................

III. POLA FUNGSI KESEHATAN

1. Pola Persepsi dan Tata Laksana Kesehatan
……………………………………………………………………………………………………….
.………………………………………………………………………………………………………
2. Pola Nutrisi dan Metabolisme
a. Kebutuhan kalori basal ( KKB )
Aktifitas tetap : KKB X 3
Aktifitas sedang : KKB X 5
Aktifitas berat : KKB X 10
Anak usia < 12 thn : 1000kal + (100 x Usia)
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b. Pola makan
Keterangan Sebelum Sakit Saat sakit
Frekuensi
Jenis
Cara Makan
Nafsu makan
Porsi
Total konsumsi (kkal/hari)

Keluhan:
- Mual
- Muntah(..x/hari,...cc)
- Sariawan
- Masalah mengunyah
- Kesulitan menelan
- ................................

Deskripsikan singkat mengenai keluhan yang dirasakan :

……………………………………………………………………………………………...........
 ……………………………………………………………………………………………...........
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

4. Pola Aktifitas dan Kebersihan Diri

Keterangan Sebelum Sakit Saat Sakit
Mobilitas Rutin
Waktu Senggang
Mandi
Berpakaian
Berhias
Toileting
Makan-minum
Keterangan :
0 : mandiri
1 : dengan alat bantu
2 : dibantu oleh orang lain
3 : dibantu oleh orang lain dan alat
4 : tergantung secara total

5. Pola Istirahat – Tidur

Keterangan Sebelum Sakit Saat Sakit
Lama tidur siang
Lama tidur malam
Pengantar tidur
 Gangguan tidur
IV. PEMERIKSAAN FISIK
 Keadaan umum :……………………………………………………………………………
 Kesadaran : ………………………………………………………………………….
 Tensi : ……………………… mmHg
 Nadi : ……………………… x/ menit
 Suhu : ……………………… oC
 RR : ……………………… x/menit,
 Antropometri : TB :……………………………………cm
BB sebelum sakit:……………………………….kg
BB saat ini : …………………………………....kg
BB ideal : ……………………………………kg
TSF :....................................................cm
LLA :....................................................cm
LOLA : LLA – (3,14 x TSF)
......................................................cm
- Analisis Kecukupan Nutrisi
 Kebutuhan :………………………………………………………kkal
 Masukan :……………………………………………………….kkal
Keseimbangan nutrisi = Masukan – Masukan
=……………………………………………….kkal
1. Kepala
 Rambut : ……………………………………………………………………………….....
 Wajah : ……………………………………………………………………………….....
 Mata : ……………………………………………………………………………….....
 Hidung : ……………………………………………………………………………….....
 Mulut : ……………………………………………………………………………….....
 Gigi : ……………………………………………………………………………….....
 Telinga : ……………………………………………………………………………….....

2. Leher
I............................................................................................................................................
.P..........................................................................................................................................
.

3. Payudara dan ketiak

I.............................................................................................................................................
P..........................................................................................................................................

4. Dada
Paru-Paru
I……………………………………………………………………………………………………
 P...........................................................................................................................................
P...........................................................................................................................................
A………………………………………………………………………………………………….
Jantung
I……………………………………………………………………………………………………
P...........................................................................................................................................
P...........................................................................................................................................
A………………………………………………………………………………………………….

5. Abdomen
I………………………………………………………………………………………………………
A…………………………………………………………………………………………………….
P…………………………………………………………………………………………………….
P…………………………………………………………………………………………………….

6. Ekstremitas
Atas
I………………………………………………………………………………………………………
P……………………………………………………………………………………………………
Gerakan Sendi……………………………………………………………………………………
……………………………………………………………………………………………………..
Kekuatan Otot…………………………………………………………………………………….
Bawah
I………………………………………………………………………………………………………
P……………………………………………………………………………………………………
Gerakan Sendi……………………………………………………………………………………
……………………………………………………………………………………………………..
Kekuatan Otot…………………………………………………………………………………….

7. Tulang Belakang/ Punggung-pinggang

I ……………………………………………………………………………………………………..
P……………………………………………………………………………………………………..

8. Anus – Genetalia
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9. Pemeriksaan Neurologis
Kesadaran…………………………………………………………………………………………
Meningeal Sign……………………………………………………………………………………
……………………………………………………………………………………………………….
 Refleks
 Fisiologis………………………………………………………………………………….
 Patologis…………………………………………………………………………………
Pemeriksaan Saraf Kranial (I-XII)
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V. Pemeriksaan Diagnostik ( cantumkan tanggal pemeriksaan )

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VI. Pemeriksaan Laboratorium (cantumkan tanggal dan nilai normal)
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VII. Terapi ( disertai dosis tiap pemberian )
Oral
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Parenteral
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Mahasiswa

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NIM…………………………