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VITAL SIGN

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Ns. Hevi Mulia Putri, S.Kep


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Vital Signs /TTV disebut juga cardinal signs meliputi temperatur tubuh, nadi, respirasi dan tekanan darah These signs may be observed, measured, and monitored to assess an individual's level of physical functioning

Normal vital signs change with age, sex, weight, exercise tolerance, and condition.

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Hal yang perlu diperhatikan :


All measurements are made while the patient is seated Prior to measuring vital signs, the patient should have had the opportunity to sit for approximately five minutes Before diving in, take a minute or so to look at the patient in their entirety TTV merupakan dasar untuk melakukan pemeriksaan fisik (langkah pertama pada pemeriksaan fisik) untuk menentukan keadaan kardiorespirasi seseorang. Perawat secara rutin mengevaluasi TTV untuk memonitor status fisik seseorang. Hasil pemeriksaan hrs diinterpretasikan kedalam nilai normal seseorang,

diagnosa medis, riw penyakit, riw pengobatan Powerpoint Templatesdan hasil laboratorium

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Manfaat
Pemeriksaan TTV berguna untuk: - mengetahui status fisik seseorang - mengetahui respon seseorang terhadap nyeri, ansietas, takut dan toleransi aktivitas.

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Jika hasil pemeriksaan mengalami penyimpangan/deviasi dari normal maka perawat harus : 1. Evaluasi beberapa deviasi dari normal pada nilai normal seseorang contoh : TD 90/60 mmHg : deviasi dari range normal tekanan darah sistolik secara umum, namun bisa juga normal untuk orang tsb. 2. Evaluasi deviasi dengan status fisik seseorang. contoh : TD 90/60 mmHg yang disertai dengan dingin, berkeringat, nadi cepat, dan penurunan kesadaran merupakan tanda-tanda syok.
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TEMPERATURE
Old people, people with disabilities, babies and young children typically feel more comfortable at higher temperatures. Women notice that they are feeling cool quicker than men, which may be related to their different body size The normal body temperature of a person varies depending on gender, recent activity, food and fluid consumption, time of day, and, in women, the stage of the menstrual cycle Temperature is measured in either Celcius or Farenheit, with a fever defined as greater then 38-38.5 C or 101-101.5 F
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0o C = 32o F
= (Celcius x 1,8) + 32

100o C = 212o F

Rumus merubah celcius ke fahrenheit E. Rumus merubah fahrenheit ke celcius = (Fahrenheit - 32) / 1,8

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RECTAL

EAR

PENGUKURAN SUHU

ORAL

AXILLA

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Rectally Temperatures taken rectally (using a mercury or digital thermometer) tend to be 0.5 to 0.7 (Fahrenheit) higher than when taken by mouth.

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Oral temperature can be taken by mouth using classic glass mercury-filled or digital thermometers.

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Axillary temperatures can be taken under the arm. Temperatures taken by this route tend to be 0.3 to 0.4 (Fahrenheit) lower than those temperatures taken by mouth.

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By ear a special thermometer can quickly measure the temperature of the ear drum, which reflects the body's core temperature

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FEVER VS HYPOTHERMIA
A fever is indicated when body temperature rises above 98.6 F orally or 99.8 F rectally Hypothermia is defined as a drop in body temperature below 95 F.

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RESPIRATORY RATE
RR adalah jumlah napas manusia selama 1 menit Sebaiknya dihitung dalam 30 detik u/ menghindari kesalahan penghitungan RR meningkat saat demam atau sakit, saat menghitung RR, observasi juga adanya kesulitan bernapas RR normalnya 12 -20x/menit saat ISTIRAHAT RR abnormal jika < 12 x/menit atau > 25x/menit
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Pulse rate (Nadi)


N : 60 100 x/menit Nadi meningkat krn exercise, sakit, dan emosi Atlit (pelari) bs meningkat 40 x lbh cepat tanpa ada keluhan

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How to check your pulse


Rasakan denyutan dengan menekan ringan arteri yang dekat dengan permukaan kulit Nadi dapat dihitung di area a. radialis, a. brakhialis atau a. carotis

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How to check your pulse


Letakkan ujung telunjuk dan jari tengah di atas arteri radialis, dan ibu jari di pergelangan tangan sehingga tangan pemeriksa melingkari pergelangan klien

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How to check your pulse


Beri tekanan ringan pada awal pemeriksaan jika klien gemuk dan sulit terdeteksi adanya arteri. Jangan menekan terlalu dalam, karena menyebabkan aliran darah terhambat dan terjadi kesalahan penghitungan

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Pulse: Quantity
If the rate is particularly slow or fast, it is probably best to measure for a full 60 seconds in order to minimize the error. Ukur kuantitas, regularitas dan volumenya

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TEKANAN DARAH
Pasien sebaiknya tidak makan, minum, merokok dan mengkonsumsi obat, 1 jam sebelum pengukuran Pasien diminta mengosongkan bladder

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Preparation for measurement


Painful procedures and exercise should not have occurred within one hour. Patient should have been sitting quietly for about 5 minutes. Dilakukan di ruangan yang tenang dengan suhu ruangan normal
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Position of the Patient


Posisikan duduk Lengan dan punggung rileks Kaki diletakkan di lantai, jangan menggantung Pengukuran sebaiknya di lengan kanan Lengan diletakkan di meja
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Position of the arm

Naikkkan a. brakhialis sejajar dengan jantung. Jika lebih tinggi, akan menyebabkan pengukuran lebih rendah dari asli.
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In order to measure the Blood Pressure (equipment)


Adult Cuff size
Cuff Width: 40% of limb's circumference Cuff Length: Bladder at 80% of limb's circumference

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In order to measure the Blood Pressure (Cuff Position)


Patient's arm slightly flexed at elbow Push the sleeve up, wrap the cuff around the bare arm

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In order to measure the Blood Pressure (Cuff Position)


Cuff applied directly over skin (Clothes artificially raises blood pressure ) Position lower cuff border 2.5 cm above antecubital

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Measurement of the pulse rate


The manometer scale should be at eye level, and the column vertical. The patient should not be able to see the column of the manometer

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