NOC : fluid overload severity, fluid balance

No. Indikator 1 2 3 4 5
1 Edema
2 MAP
3 Albumin
4 Nilai Natrium

 NOC : Respiratory status

No. Indikator 1 2 3 4 5
1 Dyspnea/RR
2 SaO2

NOC : shock severity: sepsis

No. Indikator 1 2 3 4 5
1 TD sistol
2 TD diastol
3 Leukosit
4 Status kesadaran

TD sistolik Tingkat kesadaran

1: <80 mmHg 1: Coma (GCS 3)
2: 80 mmHg 2: Sopor (GCS 6-5)
3: 90 mmHg 3: Somnolen (GCS 7-9)
4: 100 mmHg 4: Delirium-apatis (GCS 11-13)
5: compos mentis (GCS 15-14)
5: 110-120 mmHg
TD diastolic Leukosit
1: <50 mmHg 1: >20.000
2: 50 mmHg 2: 15.000-20.000
3: 60 mmHg 3: 12.000-15.000
4: 10300-12.000
4: 70 mmHg 5: 4300-10.300
5: 70-80 mmHg
Keterangan Penilaian : SaO2
Dyspnea /RR 1 : <<80%
1 : ≥30x/m 2 : <90%
2 : 28-30x/m 3 : 90-94%
3 : 24-28x/m 4 : 95-99%
4 : 22-24x/m 5 : 100%
5 : 14-22x/m
Keterangan Penilaian :
Edema
Albumin
1 : edema anasarka
1 : >1.5
2 : edema bagain tubuh atas
2 : 1.6-2.0
3 : edema bagian ekstremitas atas
3 : 2.1-2.9
4 : edema bagian ekstremitas bawah
4 : 2.9-3.4
5 : tdak ada edema
5 : 3.5-5.5
MAP
Natrium
1 : >130, <40
1 : >170
2 : 121-130, 40
2 : 161-170
3 : 111-120, 50-60
3 : 151 - 160
4 : 106-110, 60-75
4 : 146 - 150
5 : 75-105
5 : 136-145