L.06053 Status Neurologis

Definisi : Kemampuan sistem saraf perifer dan pusat untuk menerima, mengolah, dan merespon stimulus internal dan eksternal

Ekspektasi :

Meningkat

Kriteria Hasil :

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

  1. Tingkat kesadaran (……..)
  2. Reaksi pupil (……..)
  3. Orientasi kognitif (……..)
  4. Status kognitif (……..)
  5. Kontrol motorik pusat (……..)
  6. Fungsi sensorik kranial (……..)
  7. Fungsi sensorik spinal (……..)
  8. Fungsi motorik kranial (……..)
  9. Fungsi motorik spinal (……..)
  10. Fungsi otonom (……..)
  11. Komunikasi (……..)

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

  1. Sakit kepala (……..)
  2. Frekuensi kejang (……..)
  3. Hipertermia (……..)
  4. Diaforesis (……..)
  5. Pucat (……..)
  6. Kongesti konjungtiva (……..)
  7. Kongesti nasal (……..)
  8. Parestesia (……..)
  9. Sensasi logam di mulut (……..)
  10. Sindrom horner (……..)
  11. Pandangan kabur (……..)
  12. Penile erection (……..)

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

  1. Tekanan darah sistolik (……..)
  2. Frekuensi nadi (……..)
  3. Ukuran pupil (……..)
  4. Gerakan mata (……..)
  5. Pola napas (……..)
  6. Pola istirahat tidur (……..)
  7. Frekuensi napas (……..)
  8. Denyut jantung apikal
  9. Denyut nadi radialis
  10. Refleks pilomotorik (……..)

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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