TANDA-TANDA VITAL

YASIN WAHYURIANTO

Tujuan
Pengamatan kondisi umum
Identifikasi masalah
Evaluasi respon untuk pengobatan

Guidelines

Pulse : 96.8100.4
RR : 12-16/min
Blood Pressure :120/80mmHg
Pulse pressure: 3050mmHg
BASELINE---REALIZE--INDIVIDUALIZE!

When to take
When you think they should be
taken
Protocol
MD orders
Before and after med administration

Temperature (cont'd)
Implementation
Prevention of alterations
Interventions for fever
Interventions for hyperthermia
Interventions for hypothermia

Mosby items and derived items 2005 by Mosby, Inc.

Fever
1. Bacteria or viruses stimulate immune
system
2. Chills, shivers, feeling cold
3. Temp increases
4. Feeling warm and dry
5. Warm, flushed, diaphoretic
6. Temp returns to normal

Fever
Up to 102.2 F (39 degrees Celsius) is
beneficial
WBC
Suppresses bacterial growth
Stimulates interferon
Increased metabolic demands=
pulse, respirations

Fever

Energy conservation
Monitoring
Fluids
Oxygen
Meds
Environment
Nursing diagnosis

Pulse problems

If irregular: count apical one minute

Count apical and radial x 1 minute
Pulse deficit: >2 difference
Tachycardia: >100 beats/min
Bradycardia: <60 beats/min
Abnormal rhythm: dysrhythmia

Pulse
Pulse rate x Stroke volume= cardiac
output
Cardiac output= tissue
perfusion/oxygenation
Strength of muscle, volume,
30 second x 2 count is alright for slow,
rapid, regular pulse rates

Respiration
Physiological control
Oxygen
Carbon dioxide

Mechanics of breathing
Inspiration
Expiration
Tidal volume
Mosby items and derived items 2005 by Mosby, Inc.

Respiration
Ventilationgases in and out
DiffusionOxygen and carbon dioxide
between alveoli and red blood cells

Perfusionred blood cells to and from

pulmonary capillaries

Resp

Deep
Normal
shallow
Laboredunlabored
Rate
Dyspnea

Cheyne Stokes Breathing

Respiration (cont'd)
Nursing diagnoses
Activity intolerance
Ineffective airway clearance
Ineffective breathing pattern
Impaired gas exchange
Ineffective tissue perfusion

Mosby items and derived items 2005 by Mosby, Inc.

Blood Pressure
12080 is magical number
Depends on:
blood volume; greater heart muscle
contractility; arterial wall resistance; heart
rate

Blood Pressure
Physiology
Cardiac output
Peripheral resistance
Blood volume
Viscosity
Elasticity

Mosby items and derived items 2005 by Mosby, Inc.

Blood pressure is
the force exerted on
the blood vessel
walls by the blood

Systolic
Ventricles are contracting
Condition of heart and great arteries
Max pressure

Diastolic
Ventricles are relaxed
Minimum pressure
Indicates arteriolar or peripheral vascular
resistance

Pulse pressure
Difference between systolic and diastolic
Normally 30-50 mm/Hg.

Correct procedure
Not crossing legs!
Palpate brachial
Correct cuff sizelook at yours

Blood Pressure (cont'd)

Nursing diagnoses
Anxiety
Decreased cardiac output
Deficient/Excess fluid volume
Risk for injury
Acute pain
Ineffective tissue perfusion
Mosby items and derived items 2005 by Mosby, Inc.

Pulse oximetry
P. 519
> 90% is okay but higher is better!
Remove nail polish!!

Last but not least

Potter & Perry
P. 666 client teaching
P. 667 Focus on older adults

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