Ahmad Faridi_2021

PENGKAJIAN STATUS
GIZI
AHMAD FARIDI
Pengkajian status gizi
 Data umum meliputi; nama, umur, jenis kelamin,
suku bangsa, sosekbud, pendidikan, status
perkawinan, dsb

 Subjektif, Objektif, Assessment dan Planning

(SOAP)

Ahmad Faridi_2021
Subjektif (S)
4 (empat) kelompok informasi :
 Informasi berkaitan dengan diet

 Informasi Gaya hidup/psikososial atau emosional

 Informasi riwayat medis

 Informasi motivasi/pembelajaran

Ahmad Faridi_2021
 Lanjut...S
Diet related :
 Eating habit and feeding abilities
 Use and fit dentures
 Appetite and digestion problems
 Nausea, vomiting, constipation, diarrhea, heartburn, physical problems interfering with adequate
oral intake
 Recent weight change
 Diet history/previous diet modification or Rx
 Usual pattern of food intake
 Food allergies/aversion
 Vitamin, mineral and nutrient supplement intake
 Complementary/alternative nutrition therapy
 Nutritional history and family nutritional history
 Adequacy of prior dietary intake
 Method of obtaining foods/nutrients
 Previous nutrition education/counseling Ahmad Faridi_2021
 Lanjut...S
Lifestyle/psychosocial/emotional :
 Economic situation/income

 Ability to purchase/prepare/store food

 Living or eating alone

 Health promotion and exercise practices

 exercise

 smoking

 Interaction with/between other family members or caretakers

 Support system

 Coping mechanisms

 occupation Ahmad Faridi_2021

 Lanjut...S
Medically related :
 Personal and family medical history

 Especially, disease with nutritional implication (DM

tipe 2)
 Use of complementary/alternative medical therapies

(CAM)
 Medication, previous to admission or current PE

 Prescriptions, OTC (antasid, laxatif, dll) and any CAM

medications
 Other physically related problems
Ahmad Faridi_2021
 Lanjut...S
Learning and motivation related :
 Ability to communicate
 Patient’s comments about previous prescribed diets/medical treatment and compliance issues
 Psychosocial problems, including addiction
 Perception of health status/reasons for seeking health care
 Desire to improve health or be involved in their own trreatment or treatment decisions
 Learning style/problem-solving abilities
 Intelectual performance
 Educational level
 Communication patterns
 Attention span
 Long term and recent memory
 Readiness to learn
 Barriers to change
 Growth and maturation Ahmad Faridi_2021
 Objektif (O)
 Menjelaskan :
A age, ethnicity, gender, height/weight, BMI; any
antropometric measurement in addition to height and
weight
B biochemical lab results that are of nutritional relevance
C clinical diagnosis, medication, treatment oreders
(including diet orders), any additional clinical findings
of nutritional relevance
D dietary information, including current intake that has
been observed (not subjective) or analysis of diet
quality; protein/kkal requirements
Ahmad Faridi_2021
Assessment (A)
 The nutrition diagnosis or interpretation of the patient’s
nutrition problems
 Kesimpulan berdasarkan data subjektif (S) dan Objektif (O)

Meliputi :
 Current nutrition Problems, etiology and signs/symptoms

(PES)
 Potential nutritional problems (due to prognosis or clinical

course of the disease, noncompliance and/or drug nutrient

interactions)
 Prioritization of the nutrition diagnoses

Ahmad Faridi_2021
 Planning (P)

GATHER Additional information you need or would like (for

current and potential nutritional problems; for
instance, whether the patient is lactointolerant)
REFERR Referral to other health or social professional (examples:
AL psychologist for an eating disorder or depression; social
worker if patient is homeless)
NUTRITI Specific nutritional recommendations for the client/patient
ON to address current nutrition problem(s)
(these may be different than those stated under
Assessment: for example, fewer kcalories to help achieve
weight loss)

Ahmad Faridi_2021
 Planning (P)
GOALS/ED • what is/are your short term goal(s) for this client/patient?
UCATION • For each goal, state the expected outcome(s) of dietary
compliance as behavioral objective for change, or expected
outcomeof the nutrition support. (remember that outcome
should be measurable; specify a time frame and criterion[by
how much], and encourage client participation, if possible)
• Nutrition support to be recommended (when it is medical
procedure)
• Visuals, models, printed material to be given or used, if
appropriate
Example :
(goal) patient will increase dietary fiber consumption
1. Patient will eat whole grain bread instead of white bread and
increase consumption by one additional fruit and vegetable
every day
2. Patient will be given a handout on whole grain products
EVALUA- Timeline and measures for nutrition monitoring and evalution (when
TION and how will you evaluate the outcome of your nutrition plan goals?)
Ahmad Faridi_2021
Planning (P)
 Menjelaskan tentang :
1. Tujuan Diet
2. Prinsip dan syarat diet
3. Faktor penyulit yang mungkin terjadi
4. Perhitungan/total kebutuhan gizi
5. Bahan Makanan Penukar (BMP)
6. Distribusi BMP
7. Penyuluhan/konsultasi
8. Monitoring evaluasi (monev)
Ahmad Faridi_2021
 Contoh
Nutrition
11/10/2016 jam 11.30
S : Patient’s mother relates that Denise’s mouth hurts so badly that she can hardly
talk. She has had limited oral intake. Patient’s mother also describes an “anti
cancer” diet that Denise’s aunt and uncle introduced them to. Denise states that
she doesn’t want to make anyone mad, but those foods on the anti cancer diet
make her mouth hurt worse, and she doesn’t know what to believe
O: 21 th Dx : stage II diffuse large B-cell lymphoma. Admitted with
immunosuppression, fungal infection, dehydration R/O pneumonia, s/p first
round of chemotherapy/CHOP
TB 165 cm; BB 54 kg; saat pendaftaran 60 kg; sebelum sakit 65 kg
Hsl Lab : albumin 3; sel drh putih 1100mm3
Kebutuhan Energi 1700-1800 kkal; protein 75-80 g
A: Penurunan BB disebabkan karena asupan energi dan protein yang tidak adekuat.
Kehilangan BB sejak 3 bulan lalu. Tidak dapat makan/minum secara oral karena
mengalami mukositis
Percaya pada diet anti kanker yang tidak tepat
Ahmad Faridi_2021
 Contoh
Nutrition
11/10/2016 jam 11.30
P: 1. Modifikasi diet lunak, mudah dikunyah. Meningkatkan asupan
zat gizi dengan menggunakan suplemen dan suplemen makanan
cair yang tinggi kalori dan protein. Porsi kecil 6-8 kali/hari
2. Menghitung asupan energi untuk memantau apakah asupan per
oral sudah terpenuhi
3. Merekomendasikan obat antibakteri
4. Mengkonsultasikan dengan perawat/dokter untuk menjamin
pasien mampu makan per oral
5. Menyediakan informasi tentang makanan yang dianjurkan
kepada anggota keluarga pasien
6. Memantau setiap hari, melihat asupan energi dan menimbang
BB tiap hari untuk melihat apakah diet yang diberikan sudah
cukup adekuat
Ahmad Faridi_2021