Status Cairan L.03028 |
|
Definisi Kondisi volume cairan intravascular,interstisiel,dan/atau intraseluler. |
|
Ekspetasi Membaik |
|
Kriteria Hasil |
|
Menurun |
Cukup Menurun |
Sedang |
Cukup Meningkat |
Meningkat |
Kekuatan nadi |
1 |
2 |
3 |
4 |
5 |
Output urine |
1 |
2 |
3 |
4 |
5 |
Membran mukosa lembap |
1 |
2 |
3 |
4 |
5 |
Pengisian vena |
1 |
2 |
3 |
4 |
5 |
|
Meningkat |
Cukup Meningkat |
Sedang |
Cukup Munurun |
Menurun |
Otopnea |
1 |
2 |
3 |
4 |
5 |
Dispnea |
1 |
2 |
3 |
4 |
5 |
Paroxysmalnocturnal dyspnea (PND) |
1 |
2 |
3 |
4 |
5 |
Edema anasarka |
1 |
2 |
3 |
4 |
5 |
Edema perrifer |
1 |
2 |
3 |
4 |
5 |
Berat badan |
1 |
2 |
3 |
4 |
5 |
Distensi vena jugularis |
1 |
2 |
3 |
4 |
5 |
Suara napas tambahan |
1 |
2 |
3 |
4 |
5 |
Kongesti paru |
1 |
2 |
3 |
4 |
5 |
Perasaan lemah |
1 |
2 |
3 |
4 |
5 |
Rasa haus |
1 |
2 |
3 |
4 |
5 |
Konsentrasi urine |
1 |
2 |
3 |
4 |
5 |
|
Memburuk |
Cukup Memburuk |
Sedang |
Cukup Membaik |
Membaik |
Frekuensi nadi |
1 |
2 |
3 |
4 |
5 |
Tekanan darah |
1 |
2 |
3 |
4 |
5 |
Tekanan nadi |
1 |
2 |
3 |
4 |
5 |
Turgor kulit |
1 |
2 |
3 |
4 |
5 |
Jugular Venous Pressure (JVP) |
1 |
2 |
3 |
4 |
5 |
Hemoglobin |
1 |
2 |
3 |
4 |
5 |
Hematokrit |
1 |
2 |
3 |
4 |
5 |
Cental Venous Pressure |
1 |
2 |
3 |
4 |
5 |
Refleks hepatojugular |
1 |
2 |
3 |
4 |
5 |
Berat badan |
1 |
2 |
3 |
4 |
5 |
Hepatomegali |
1 |
2 |
3 |
4 |
5 |
Oliguria |
1 |
2 |
3 |
4 |
5 |
Intake cairan |
1 |
2 |
3 |
4 |
5 |
Status mental |
1 |
2 |
3 |
4 |
5 |
Status tubuh |
1 |
2 |
3 |
4 |
5 |