Professional Documents
Culture Documents
Nutrition
Assessment
Nutrition
Nutrition
Monitoring
Diagnosis
Evaluation
Nutrition
Intervention
Nutrition Care Process and
Nutritional Assessment
Sign
problem etiology
symptom
Relationships
1 2 3
4. Nutrition-
5. Client History
Focused Physical
(E/CH)
Findings (C/PD)
1. Food Nutrition-
related history
▪ Food and Nutrient Intake includes factors such as composition and adequacy of food and nutrient
intake, and meal and snack patterns
▪ Food and Nutrient Administration includes current and previous diet and/or food modifications,
eating environment, and enteral and parenteral nutrition administration
▪ Medication and herbal supplement Use includes prescription and over-the counter medications,
including herbal preparations and complementary medicine product used
▪ Knowledge/Belief/Attitudes includes understanding of nutrition-related concepts and conviction of
the truth and feeling/emotions toward some nutrition-related statement or phenomenon, along with
readiness to change nutrition-related behaviors
1. Food Nutrition-
related history
▪Behavior includes patient/client activities and actions which influence achievement of nutrition-
related goals
▪Factors Affecting Access to Food and Food/Nutrition-Related Supplies includes factors that affect
intake and availability of sufficient quantity of safe, healthful food and water as well as food/ nutrition-
related supplies
▪Physical activity and function includes physical activity, cognitive and physical ability to engage in
specific taks, e.g., breasfeeding and self feeding
▪Nutrition-related patient/client-centered measures consists of patient/client’s perception of his or
her nutrition intervention and its impact on life
Intake makanan dan zat gizi
Aktifitas fisik FH-7.3 Tingkat aktifitas fisik dan kemampuan atau jumlah
dalam melakukan olahraga
Faktor yang FH-7.4 Faktor-faktor yang mempengaruhi akses dalam
mempengaruhi akses melakukan kegiatan aktifitas fisik (olahraga) atau ikut
terhadap aktifitas fisik dalam program olahraga
UKURAN KEBERHASILAN PASIEN TERKAIT GIZI
•Include height, weight, body mass index (BMI), growth pattern indices/percentile
ranks, and weight history
•Include laboratory data, (e.g electrolytes, glucose, and lipid panel), tests (e.g gastric
emptying time, resting metabolic rate)
Sub kelompok Kode Definisi Indikator Pengkajian Status Gizi
dan Monitoring Evaluasi
Inlude findings from an evaluation of body systems, muscle and subcutaneous fat
wasting, oral health, suck/swallow/breathe ability, appetite, and affect
Sub kelompok Kode Definisi
Pemeriksaan fisik klinis terkait AD-1.1 Karakteristik fisik klinis terkait dengan
gizi penyakit pasien ditunjukkan dengan hasil
pemeriksaan fisik, wawancara atau rekam
medis
Indikator Pengkajian Status Gizi dan Monitoring Indikator Pengkajian Status Gizi dan Monitoring
Evaluasi Evaluasi
• Penampakan secara umum • Ekstremitas, otot dan tulang
- Posisi tubuh, seperti konstruksi otot - Tulang, spesifik, menonjol, rapuh, melebar
- Amputasi, spesifik - Edema, peripheral, spesifik
- Kemampuan berkomunikasi - Lemak subkutan, spesifik, hilang atau
- Lainnya bertambah
- Fatique
• Bahasa tubuh (dapat dipengaruhi suku), spesifik - Terasa dingin sepanjang waktu
• System kardiovaskular dan pernafasan - Tangan/kaki, spesifik, merasa geli, sianosis,
- Odema, suara nafas mati rasa
- Nafas pendek - Persendian, arthralgia, efusi
Indikator Pengkajian Status Gizi dan Monitoring Indikator Pengkajian Status Gizi dan Monitoring
Evaluasi Evaluasi
• System pencernaan (mulut – rectum) - Polidipsi
- Bersendawa - Stomatitis
- Cheilosis - Gangguan merasakan
- Merasa makanan berhenti di tenggorokan - Perut kembung
- Gingivitis - Asites
- Dada terasa terbakar - Fungsi bowel, seperti tipe, frekuensi dan volume
- Suara serak flatus
- Nafas berbau keton - Nausea
- Lesi, oral atau esophageal - Vomiting
- Bibir, spesifik (kering, pecah-pecah, basah) - Rasa kenyang
- Malformasi, oral, contoh langit-langit pecah - Nyeri epigastric
- Gangguan mengunyah
- Edema mucosal
Indikator Pengkajian Status Gizi dan Monitoring Indikator Pengkajian Status Gizi dan Monitoring Evaluasi
Evaluasi
• Mata • Kulit
- Bitot spot - Dermatitis
- Kabur dimalam hari - Jaundis
- Sklera, jaundis - Xanthoma
- Xerophthalmia - Kering
- Calcinosis
• Kepala - Lainnya
- Pusing
- Mucosa hidung basah • Tanda vital
- Tekanan darah (mmHg)
• Syaraf dan kognitif - Nadi, detak jantung
- Kebingunagn, kehilangan konsentrasi - Respiratory rate / RR
- Pusing - Suhu
- Gangguan neurologis
5. Client History
•Consists of current and past information related to personal, medical, family, and
social history
▪ Personal History includes general patient/client information such as age, gender,
race/ethnicity, language, education, and role in family
▪Patient/Client/Family Medical/Health History includes patient/client or family
disease states, conditions, and illnesses yhat may have a nutritional impact
▪Social History includes items such as socioeconomic status, housing situation,
medical care support, and involvement in social groups
Latihan Soal
Tn A baru saja berobat ke dokter penyakit dalam dan terdiagnosa Diabetes Mellitus tipe 2. Tn. A saat
ini datang ke poli gizi agar dapat mengatur pola makannya dengan baik karena Tn A belum
mendapatkan edukasi terkait dengan Diabetes mellitus. Hasil asessment menunjukkan bahwa Tn. A
memiliki BB = 78 kg dengan TB= 170 cm. Tn A berusia 50 tahun dan masih aktif bekerja sebagai guru
SMA. Tn. A bekerja selama 7 jam sehari dan tidak pernah melakukan olahraga karena merasa sudah
lelah setelah bekerja. Tn. A menyampaikan bahwa setiap malam sering bangun untuk buang air kecil,
sering lapar dan mudah haus. Pola makan dirumah dengan rata-rata intake energi 140% dari
kebutuhan, lemak 120% dari kebutuhan, protein 100% dan karbohidrat 80% dari kebutuhan. Pasien
menyukai makanan seperti jeroan dan masakan padang, pasien hampir tidak pernah makan buah (2-3
kali per bulan). Hasil pemeriksaan laboratorium lab menunjukkan Glukosa darah puasa 150 mg/dl
(Normal = <90 mg/dl); Glukosa darah post prandial 335 mg/dl(Normal = 120 mg/dl); Hb A1C 8.5%
(Normal 6%), Kolesterol total 250 md./dl (Normal <200 mg/dl).
Semangat