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  • Model Adaptasi Roy

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    puspita
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    The document contains progress notes for a patient over two days assessing indicators for three nursing diagnoses: 1) Decreased cardiac output, 2) Impaired gas exchange, and 3) Activity intolerance. For each diagnosis and indicator, the patient's condition is scored from 1 to 5 based on measurements taken in the morning, afternoon, and evening with 1 being the lowest score and 5 being the highest. Overall the scores show some improvement from the first to second day for most indicators.

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    The document contains progress notes for a patient over two days assessing indicators for three nursing diagnoses: 1) Decreased cardiac output, 2) Impaired gas exchange, and 3) Activity intolerance. For each diagnosis and indicator, the patient's condition is scored from 1 to 5 based on measurements taken in the morning, afternoon, and evening with 1 being the lowest score and 5 being the highest. Overall the scores show some improvement from the first to second day for most indicators.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    5 views3 pages

    Model Adaptasi Roy

    Uploaded by

    puspita
    The document contains progress notes for a patient over two days assessing indicators for three nursing diagnoses: 1) Decreased cardiac output, 2) Impaired gas exchange, and 3) Activity intolerance. For each diagnosis and indicator, the patient's condition is scored from 1 to 5 based on measurements taken in the morning, afternoon, and evening with 1 being the lowest score and 5 being the highest. Overall the scores show some improvement from the first to second day for most indicators.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    of 3

    CATATAN PERKEMBANGAN (PROGRESS NOTE)

    Diagnosa keperawatan no. 1 Penurunan curah jantung

    NOC : Cardiac Pump Effectiveness, Circulation Status

    Tanggal 11-02-2015
    No Indikator Pagi Siang Malam
    1 2 3 4 S 1 2 3 4 S 1 2 3 4 S
    1. TD sistol - - + + 3 - - + + 3 - + + + 4

    2. TD diastol + + + + 5 + + + + 5 + + + + 5

    3. MAP + + + + 5 + + + + 5 + + + + 5

    4. Balance cairan - - - + 2 - - - + 2 - - - + 2

    5. Nadi - - + + 3 - - + + 3 - + + + 4

    Tanggal 12-02-2015
    No Indikator Pagi Siang Malam
    1 2 3 4 S 1 2 3 4 S 1 2 3 4 S
    1. TD sistol - - + + 3 - - - + 2 - + + + 4

    2. TD diastol + + + + 5 + + + + 5 + + + + 5

    3. MAP + + + + 5 + + + + 5 + + + + 5

    4. Balance cairan - - - + 2 - - - + 2 - - - + 2

    5. Nadi - - - + 2 - - + + 3 - + + + 4

    Keterangan Penilaian :
    - : tidak sesuai
    + : sesuai yang diharapkan
    S : scoring

    Keterangan Skoring :
    1 :-
    2 : 1+
    3 : 2+
    4 : 3+
    5 : 4+
    CATATAN PERKEMBANGAN (PROGRESS NOTE)

    Diagnosa keperawatan no. 2 Gangguan pertukaran gas

    NOC : Respiratory Status : Gas Exchange

    Tanggal 11-02-2015
    No Indikator Pagi Siang Malam
    1 2 3 4 S 1 2 3 4 S 1 2 3 4 S
    1. SaO2 + + + + 5 + + + + 5 + + + + 5

    2. pH - - + + 3 - - + + 3 - + + + 4

    3. pCO2 + + + + 5 + + + + 5 + + + + 5

    4. HCO3 - - + + 3 - - + + 3 - + + + 4

    5. BE - - - + 2 - - + + 3 - + + + 4

    6. RR - - - + 2 - - - + 2 - - - + 2

    Tanggal 12-02-2015
    No Indikator Pagi Siang Malam
    1 2 3 4 S 1 2 3 4 S 1 2 3 4 S
    1. SaO2 + + + + 5 + + + + 5 + + + + 5

    2. pH - - + + 3 - - + + 3 + + + + 5

    3. pCO2 - - - - 1 - - - - 1 - - - - 1

    4. HCO3 - - + + 3 - - + + 3 - - - + 2

    5. BE - - - + 2 - - + + 3 + + + + 5

    6. RR - - + + 3 - + + + 4 + + + + 5

    Keterangan Penilaian :
    - : tidak sesuai
    + : sesuai yang diharapkan
    S : scoring

    Keterangan Skoring :
    1:-
    2 : 1+
    3 : 2+
    4 : 3+
    5 : 4+
    CATATAN PERKEMBANGAN (PROGRESS NOTE)

    Diagnosa keperawatan no. 3 Intoleransi aktivitas

    NOC : Activity Tolerance

    Tanggal 11-02-2015
    No Indikator Pagi Siang Malam
    1 2 3 4 S 1 2 3 4 S 1 2 3 4 S
    1. TD Sistol - - + + 3 - - + + 3 - + + + 4

    2. TD Diastol + + + + 5 + + + + 5 + + + + 5

    3. Nadi - - + + 3 - - + + 3 - + + + 4

    4. RR - - - + 2 - - - + 2 - - - + 2

    5. Level kelemahan - + + + 4 - + + + 4 - + + + 4

    Tanggal 12-02-2015
    No Indikator Pagi Siang Malam
    1 2 3 4 S 1 2 3 4 S 1 2 3 4 S
    1. TD Sistol - - + + 3 - - - + 2 - + + + 4

    2. TD Diastol + + + + 5 + + + + 5 + + + + 5

    3. Nadi - - - + 2 - - + + 3 - + + + 4

    4. RR - - + + 3 - + + + 4 + + + + 5

    5. Level kelemahan + + + + 5 + + + + 5 + + + + 5

    Keterangan Penilaian :
    - : tidak sesuai
    + : sesuai yang diharapkan
    S : scoring

    Keterangan Skoring :
    1 :-
    2 : 1+
    3 : 2+
    4 : 3+
    5 : 4+

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