FORMULIR ASUHAN GIZI ANAK

Nama : .....................................................................
Tanggal : .....................................................................
Diagnose Medis : .....................................................................
ASESMEN GIZI
Anthropometri
Umur : ............... th ............... bln ............... Hari
BB : ............... kg BB/U : ............... SD, Interpretasi ...................................
TB : ............... cm TB/U : ............... SD, Interpretasi ...................................
LLA : ............... cm BB/TB : ............... SD, Interpretasi ...................................
LK : ............... cm LLA/U : ............... SD, Interpretasi ...................................
BB Ideal : ............... kg Kesimpulan : .............................................................................
Biokimia
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Klinik/Fisik
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Riwayat Gizi
Alergi Makanan : Ya Tidak Ya Tidak
*Telur *Udang
*Susu sapi & produk turunannya *Ikan
*Kacang kedelai/tanah *Halzenut/almond
*Gluten/gandum *Lain Lain : .................................

Perubahan BB (+ / - ) Diare (+ / - ) Kontipasi (+ / - )

Nyeri perut (+ / - ) Mual (+ / - ) Suplemen Tambahan (+ / - )
Nafsu Makan Menurun (+ / - ) Muntah (+ / - )
Sulit Menelan (+ / - ) Sulit Mengunyah (+ / - )
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Pola Makan
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Total Asupan
Zat Gizi Nilai Kebutuhan % Pehitungan Kebutuhan
Energi Energi

Protein
Protein
Cairan

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Riwayat Personal
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DIAGNOSA GIZI
(bisa pilih lebih dari satu sesuai hasil assesmen, atau mengisi yang belum ada pada daftar)
Kode Problem Etyology Sign/Symtomps
NI-1.2 Peningkatan kebutuhan energi disebabkan oleh infeksi/hipermetabolisme ditandai dengan Lekositosis/ suhu tubuh
tinggi/ sepsis
NI-2.1 Kekurangan intake makanan dan minuman oral disebabkan olek faktor fisiologis ditandai dengan intake kurang/
penurunan berat badan/ anorexia/ gangguan absorbsi/ …………………………
NI-3.1 Asupan cairan tidak adekuat disebabkan oleh diare/ muntah/ vomiting/ hipertermi/ gangguan fungsi ginjal/
jantung ditandai dengan kulit keriput, lemas, anuri, balance cairan negatif
NI-5.1 Peningkatan kebutuhan protein disebabkan oleh peningkatan kebutuhan metabolik ditandai dengan Albumin
rendah
NI-5.1 Peningkatan kebutuhan Kalium disebabkan oleh efek obat/ kurang makan buah ditandai dengan Kalium rendah
NI-5.4 Penurunan kebutuhan Natrium disebabkan oleh hipertensi/ odema
NI-5.4 Penurunan kebutuhan Cholesterol/ Purin/ Protein/ Lemak disebabkan oleh perubahan metabolisme/ gagal
jantung/ gagal ginjal/ gagal fungsi hati ditandai dengan Cholesterol tinggi/ Asam Urat tinggi/ Bun Sc tinggi/ SGOT,
SGPT tinggi
NI-5.8.4 Asupan Serat tidak adekuat disebabkan oleh kurangnya pengetahuan, gangguan GI Track ditandai dengan asupan
serat berlebih/ kurang
NI-5.10.1 Kekurangan intake Fe disebabkan oleh faktor fisiologi/ kurang pengetahuan tentang makanan tinggi Fe ditandai
dengan Hb rendah
NI-5.8.3 Konsumsi jenis karbohidrat tidak tepat disebabkan oleh pengetahuan tentang karbohirat sederhana ditandai
dengan hipoglikemia/ hiperglikemia
NC-1.1 Kesulitan menelan disebabkan karena stroke ditandai dengan penolakan makanan/ intake makanan menurun
NC-2.2 Perubahan nilai lab terkait gula darah/ Leukosit/ Kalium/ ……… disebabkan oleh gangguan fungsi endoktrin/
infeksi ditandai dengan gula darah/ Leukosit/ Kalium/………. tinggi
NC-3.1 Berat badan kurang disebabkan oleh pola makan salah/ intake kurang/ peningkatan kebutuhan ditandai dengan
IMT kurang dari standar
NC-3.3 Berat badan lebih disebabkan oleh pola makan salah/ kelebihan intake/ aktivitas kurang ditandai dengan IMT
diatas standar
NB-1.5 Kekeliruan pola makan disebabkan oleh pengetahuan salah tentang makanan sehat ditandai dengan intake makan
berlebih/ kurang

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INTERVENSI GIZI
Tujuan Diet : .........................................................................................................................................................
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Prinsip Diet : TKTP / RS / RG / RL / DM / R PURIN / R PROTEIN/ ..............................................................................
Kebutuhan Zat Gizi : ............................................................................................................................................
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Konsistensi Diet : NASI / TIM / BK / TIM SARING / BH/..........................
Jalur Makan : ORAL / ENTERAL / PARENTERAL/..............................
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MONITORING DAN EVALUASI
TGL

ANTROPOMETRI

BIOKIMIA

CLINIS

DIETERI
HISTORI

LAIN-LAIN

Tanda Tangan,

(………………………………….)
Tenaga Gizi