Draft Sistematika Penyusunan Laporan Kasus-2
Draft Sistematika Penyusunan Laporan Kasus-2
KEMENTERIAN KESEHATAN RI
POLTEKKES KEMENKES MATARAM
JURUSAN GIZI
2023
A.PENGKAJIAN GIZI (NUTRITION ASESSMENT)
1. DATA RIWAYAT PASIEN/KLIEN (CLIENT HISTORY/CH)
CH.1.Riwayat Personal
CH.1.1 Data Personal
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CH.2. 1 Riwayat Medis/Kesehatan Pasien/Klien dan Keluarga
Kode
Jenis Data Hasil
IDNT
Keluhan utama pasien/klien
yang berkaitan dengan gizi
Riwayat Penyakit Sekarang
CH-2.1 Riwayat Penyakit Dahulu
Kode
Jenis Data Hasil
IDNT
Terapi medis yang
pernah dilakukan
(chemotherapy, dialysis,
CH-2.2.1
penggunaan ventilator/oksigen,
radiasi, obat-obatan untuk
terapi dll)
Perawatan bedah
(coronary artery bypass, gastric
CH-2.2.2 bypass, bedah saluran
pencernaan, transpanlantasi
organ, dll.)
Perawatan paliatif/end life care
CH-2.2.3 (pasien/klien dengan kondisi
terminal atau mengancam jiwa)
Kesimpulan Riwayat Medis/Kesehatan Pasien/Klien dan Keluarga :
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CH.3 Riwayat Sosial Pasien/Klien
Kode
Jenis Data Hasil
IDNT
Faktor sosio ekonomi/penghasilan
keluarga
CH-3.1.1
(apakah ada mengalihkan uang
makan untuk kebutuhan lain)
CH-3.1.2 Situasi rumah/hidup
(tinggal sendiri/bersama
keluarga/tunawisma)
(keluarga/pengasuh/komunitas)
CH-3.1.5 Letak geografis rumah
(perkotaan/pedesaan/pencahayaan
dan sanitasi rumah)
CH-3.1.6 Pekerjaan/kesibukan
CH-3.1.7 Agama
(kehilangan pekerjaan/kehilangan
anggota keluarga/trauma/bedah)
CH-3.1.9 Tingkat stres sehari-hari
Asupan Enteral
(bila ada)
Infus (bila ada)
Kebutuhan*
(Comparative
Standar-CS)
% Asupan
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(Gambaran makanan minuman yang biasa disediakan atau dikonsumsi, diet masalalu yang dijalani
atau preskripsi diet/konseling yang pernah diterima, serta lingkungan makan)
Kode
Data Hasil
IDNT
FH-2.1 Riwayat Diet
Frekuensi makanan utama: kali/hr, selingan/snack: kali/hr
(riwayat pola
makan) Form SQ-FFQ
Bahan Frekuensi Porsi/kali Cara Pemasakan
Makanan makan
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Kode Data Hasil
IDNT
FH-4.1 Pengetahuan/keterampilan
terkait makanan dan zat gizi
(ukur tentang pengetahuan gizi
sebelumnya)
FH-4.2 Kepercayaan dan perilaku terkait
makanan dan zat gizi
(misalnya kepercayaan tertentu
tentang makanan, obsesi pada
makanan tertentu, obsesi tentang
berat badan, kepercayaan yang
tidak ilmiah, kesukaan pada
makanan tertentu, kesiapan untuk
mengubah perilaku yang
berhubungan dengan makanan)
FH 5 Perilaku
(binge behavior, kebiasaan
memuntahkan kembali makanan,
penggunaan obat laxative, puasa
berlebihan, olah raga berlebihan,
perilaku saat makan, durasi
makan.)
Kesimpulan Pengetahuan/kepercayaan/perilaku
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FH 7 Aktivitas dan fungsi fisik
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3. DATA ANTROPOMETRI (AD)
Kode
Jenis Data Hasil
IDNT
- Panjang Badan/Tinggi badan (cm)
- Panjang Badan lahir (cm), pada
AD-1.1.1 anak
- Rentang lengan (cm)
- Tinggi lutut (cm)
AD-1.1.2 - Berat Badan Aktual (kg) CS-5.1.1 Ideal/reference body
- Berat Badan lahir (cm), pada anak weight (IBW)
- Berat Badan Ideal (kg)
- Adjusted Body Weight (kg)
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4. DATA BIOKIMIA, TES MEDIS, DAN PROSEDUR (BD)
KODE Pemeriksaan urin/darah Satuan/ Hasil Interpretasi
IDNT Nilai Normal
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Kode
Data Fisik Hasil
IDNT
PD-1.1.1 Penampilan keseluruhan
(keadaan umum)
PD-1.1.3 Cardiovascular-pulmonary
(edema pulmo, sesak napas dll.)
PD-1.1.4 Ekstremitas, otot, tulang
(edema ekstrimitas, penampakan lemak
subkutan, massa otot, penampakan
kuku/tangan, ada/tidaknya gangguan otot
dan sendi)
PD-1.1.5 Sistem pencernaan
(gangguan gigi, stomatitis, kesulitan
mengunyah, menelan, perubahan
pengecapan dan penciuman, nafsu makan,
nyeri ulu hati, mual,muntah,diare
,konstipasi,dll.)
Kode
Data Fisik Hasil
IDNT
PD-1.1.6 Kepala dan mata
(pusing, penampakan rambut, sklera
ikterik,bintik bitot, conjunctiva anemis
dll.)
PD-1.1.7 Saraf dan kognitif
(gangguan sistem saraf cranial tertentu,
loss of consentration, dizziness, gangguan
motoric)
PD-1.1.8 Kulit
(dermatitis, kulit kering bersisik, erythema,
kuning (jaundice), terdapat luka, ulcer,
gangren, dll)
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B. DIAGNOSIS GIZI
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C. INTERVENSI GIZI
1. PLANNING: PEMBERIAN MAKAN DAN ATAU ZAT GIZI (NUTRITION
DELIVERY/ND)
a. Tujuan: untuk mengatasi masalah gizi dengan strategi yang diarahkan pada etiologi (akar
masalah)
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b. Prinsip Diet:
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c. Syarat Diet: Dijelaskan secara singkat dan jelas per item zat gizi, termasuk cara menghitung,
tujuan/alasan, contoh bahan makanan yang digunakan, BM yang dianjurkan, dibatasi, dll.
Penjelasan syarat berdasarkan literature yang digunakan
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e. Preskripsi Diet
NP .1.1 Preskripsi Diet
- Rute/cara pemberian:
- ND-5 Lingkungan makan (apakah pasien/ klien membutuhkan suasana lingkungan khusus
saat makan)
- ND-6 Tata laksana gizi berkaitan dengan obat (apakah apakah ada obat yang
berpengaruh pada pemberian makan dan status gizi
RENCANA EDUKASI GIZI (E)
(proses formal dalam melatih keterampilan atau membagi pengetahuan yang membantu
pasien/klien mengelola atau memofifikasi diet dan perialku secara sukarela untuk menjaga atau
meningkatkan kesehatan)
(kegiatan dietisien melakukan konsultasi, rujukan atau koordinasi pemberian asuhan gizi
dengan tenaga kesehatan/institusi/dietisien lain yang dapat membantu dalam merawat atau
mengelola masalah yang berkaitan dengan gizi)
AD
BD
PD
18
DOKUMENTASI ASUHAN GIZI
Nama : Tanggal Pengkajian :
No. Register : Usia :
Ruang : JK :
Diagnosis Penyakit : Tgl MRS :
SKRINING GIZI LANJUT/ NUTRITIONAL SCREENING
Alat Skrining : Skor : Kesimpulan Interpretasi :
Berisiko malnutrisi / tidak
PENGKAJIAN GIZI / NUTRITIONAL ASSESMENT
1. Data Antropometri
Kesimpulan Interpretasi :
4. Riwayat Makan dan Diet % Asupan (hasil Recall makanan 1x24 Kesimpulan Interpretasi :
jam/ hasil SQ-FFQ):
- Pola makan harian : kali Energi:
Protein
- Alergi :
Lemak:
- Pantangan : KH:
- Obat/Suplemen /herbal :
19
- Riwayat Edukasi Gizi :
5. Riwayat Klien
Riwayat Medis:
RENCANA INTERVENSI
Perhitungan Kebutuhan Gizi Pasien : BB yang digunakan
20
Intervensi Kolaborasi : bentuk kolaborasi)
1
Biokimia :
Fisik-Klinis :
Asupan Makan :
Lain – Lain :
( )
DAFTAR PUSTAKA
21
Berat (gram)
BDD Harga Satuan Harga total
No. Nama Bahan Makanan Berat Berat
(%) (Rp.) (Rp.)
Bersih Kotor
22