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





