L.02011 Perfusi Perifer

Definisi : Keadekuatan aliran darah pembuluh darah distal untuk menunjang fungsi jaringan

Ekspektasi :

Meningkat

Kriteria Hasil :

Skor : Menurun 1, Cukup Menurun 2, Sedang 3, Cukup Meningkat 4, Meningkat 5

  1. Denyut nadi perifer (……..)
  2. Penyembuhan luka (……..)
  3. Sensasi (……..)

Skor : Meningkat 1, Cukup Meningkat 2, Sedang 3, Cukup Menurun 4, Menurun 5

  1. Warna kulit pucat (……..)
  2. Edema perifer (……..)
  3. Nyeri ekstremitas (……..)
  4. Paraestesia (……..)
  5. Kelemahan otot (……..)
  6. Kram otot (……..)
  7. Bruit femoralis (……..)
  8. Nekrosis (……..)

Skor : Memburuk 1, Cukup Memburuk 2, Sedang 3, Cukup Membaik 4, Membaik 5

  1. Pengisian kapiler (……..)
  2. Akral (……..)
  3. Turgor kulit (……..)
  4. Tekanan darah sistolik (……..)
  5. Tekanan darah diastolik (……..)
  6. Tekanan arteri rata-rata (……..)
  7. Indeks ankle brachial (……..)

NOTE : Jika menggunakan metode pendokumentasian manual atau tulisan, maka setiap kriteria hasil perlu dituliskan angka atau nilai yang diharapkan untuk dicapai, sedangkan jika menggunakan metode pendokumentasian berbasis komputer maka setiap kriteria hasil ditetapkan dalam bentuk skor dengan skala 1 s.d 5.

Daftar Pustaka

PPNI (2019). Standar Luaran Keperawatan Indonesia.

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