Lower extremity monitoring (3480)

Wound healing : primary intention

Peripheral sensation management

Neurogical monitoring (2620)
Jaringan

Wound healing : secondary

Teaching : foot care (5603)

severity (0703)
Neurogical status (0909)

Wound irrigation (3680)

Sensory function (2405)

Incision site care (3440)

Wound care (3660)
: Gg. Integritas

intention (1103)
Infection

(1102)

(2660)
NOC :
Dx : Gg. Pertukaran Hiperosmolalita

NIC :
Dx : Gg. Keseimbangan
gas s

Dx
asam basa & elektrolit
ALGORITMA DKA (DIABETIC KETOACIDOSIS)

NOC : Gas exchange

Anion
(0402)Gap me Celah osmosis NOC : Electrolyte & Kronik Dx : Ketidakseimbangan

Makroangiopati
Cl-, SO -, PO4-
4
Acid/Base Balance (0600) cairan

- Warna Hitam
AsamNIClaktat NOC : Fluid Balance

- Akral Dingin
apas bau buah, Hiperventilasi : Glikosuria

Gangren
Keton NIC : Reduksi Urin (+) (0601)
Kerusakan sel pankreas
Resspirasi > O2 Therapy (3220)

Nekrotik
- Luka (+)
Gula

- Jaringan
- Nadi (-)
pirasi, Frek > 30 Respiration Monitoring (3350) Acid base management (1910)
Berat <
Jenis Urine: Acidosis NIC :
(Kusmaul). HCO3- < 22-26 Acid base management
Fluid management (4120)

(+)
mMol/L 1,0020
acid base – 1,0035(1911)
management
Glukagon (-), Epinefrin (-)
Output > Intake Volume Cairan Hypercalemia management (2120)
pH < 7,35 Acid base monitoring (1920)
Turgor Kulit Jelek Fluid monnitoring (4130)
Electrolyte management (2000)
Kelembaban Kulit Hypovolemic management (4180)

Antibiotik
Neuropati
Hipoglikemia

Ulkus
Kadar Gula Darah
Eelectrolyte monitoring (2020)
Menurun Intra vein therapy (4200)

300-800 mg/dL
Hypercalemia electrolyte
Shock prevention (4260)
management (2002)Takikardia Venous acces device maintenance
Dehidrasi (2440)
Mual muntah
Sadar

Sesak napas
Kelelahan
Peningkatan rasa haus

Hiperglikemia

Nekrotomi
Amputasi
DKA

Termo regulation (3900)

Hypovolemic management (4180)

Kesadaran
Haemodynamic regulation (4150)
Consiousness monitoring (2620)
Positioning (0840)
Bed rest care (0740)
NIC :
Vital sign (0802)
kesadaran (0912)