SIRKULASI PERIFER

dr M.Arman Nasution SpPD

Pemeriksan Tanda _tanda vital

Tensi Nadi

Suhu Respirasi
 Pemeriksaan Tekanan Darah

Bertujuan menilai kelainan pd gangguan system kaardiovaskuler

Darah mengalir mengalir melalui system sirkulasi krn jantung
memompanya kedlm arteri dibawah tekanan tinggi
Tekanan darah arteri menggambarkan 2 hal yaitu :
* Angka systolik besar tekanan yg dihasilkan
ventrikel kiri sewaktu kontriksi
* Angka diastolik besar tekanan yg dihasilkan ventrikel
kiri saat istirahat
 Tekanan Darah Normal Rata 2

USIA TEKANA DARAH ( mmHg )

1 bulan 40

1 tahun 85 / 54

6 tahun 95 / 65

10 -13 tahun 105 / 65

14 – 17 tahun 110 / 65

dewasa tengah 120 /75

Lansia 120 / 80

140 /90
Alat tekanan darah / tensimeter
Alat tensimeter & stetoskop
 Tempat Untuk Melakukan Tensi

Arteri brakhialis
Arteri radialis
Arteri popliteal
Arteri dorsalis pedis
Arteri tibialis posterior
 Pemeriksaan nadi

Menggambarkan tekanan pada ventrikel kiri jantung

Curah jantung : volume drh yg dipompa jantung selama 1 menit
Curah jantung = frekuensi nadi x volume sekuncup
Volume sekuncup = pd setiap kontraksi ventrikel darah masuk ke aorta
sekitar 60 -70 ml
Tekanan darah = curah jantung x tahanan vaskular perifer
 Lokasi Titik Nadi Pd Tubuh

Brakialis
Radialis
Ulnaris
Temporalis
Karotis
Apikal
Femoralis
Popiteal
Tibialis posterior
Dorsalis pedis
Lanjutan........
Lanjutan ........
Arteri & vena
 Perabaan nadi carotis
dari tengah ke-lateral

10 DETIK

1-2-3-4-5
boleh diulang
1-2-3-4-5

Awam : tidak perlu

meraba carotis
 Karakteristik Nadi Menurut
Berbagai Usia
Usia Kecepatan irama Amplitudo
/menit
< 1 bulan 90 s/d 170 Teratur Kuat mudah
diraba
< 1 tahun 80 s/d 160

2 tahun 80 s/d 120

6 tahun 75 s/d 115

10 tahun 70 s/d 110

14 tahun 65 s/d 100

> 14 tahun 60 s/d 100

 Pemeriksaan nadi

TAKIKARDIA : frekuensi jantung yg meningkat secara tdk normal >

100 x/mt
Bradikardia : frekuensi yg lambat < 60 x / mt
Disritmia ; irama tidak normal
• Dihasilkan dari kontraksi ventrikel kiri jantung
• Denyutan nadi menunjukkan volum strok keluaran dan jumlah darah yang
memasuki arteri setiap kontraksi ventrikel

NADI
 • Cardiac output
• Volum darah yang dipam ke dalam arteri oleh jantung
• Sebanyak 5 liter darah akan dipam setiap minit
• Peripheral pulse
• Nadi yang terletak jauh dari jantung contoh pada kaki, lengan atau
leher
• Apical pulse
• Nadi sentral, terletak pada apeks di jantung
NADI
 • Umur
• Jantina
• Senaman
• Demam
• Ubatan
• Hipovulemia
• Tekanan
• Berubah posisi
• Patologi

FAKTOR MEMPENGARUHI NADI

 • Temporal
• Karotid
• Apeks
• Brakial
• Radial
• Femoral
• Popliteal
• Posterior tibia
• Dorsalis pedis

LOKASI NADI
• Palpasi
• Auskaltasi
• Doppler ultrasound

MENGAMBIL NADI
• Takikardia
• Nadi yang laju (>100/min)
• Bradikardia
• Nadi yang lemah/perlahan (<60/min)
• Ritma nadi
• Corak denyutan dan sela masa antara denyutan
• Disritma/aritma
• Nadi yang tidak sama/sekata
• Volum nadi (kekuatan nadi)
• Tekanan darah bagi setiap denyutan nadi

PENILAIAN NADI
Pulse Rate
Pulse
Is a wave of blood created by contraction of left
ventricle of the heart
Generally, the pulse wave represents the stroke
volume output and the compliance of arteries.
Stroke volume output is the amount of blood
that enters the arteries with each ventricular
contraction.
Compliance its the ability of the arteries to
contract andexpand.
When adult is resting, the heart pumps 4 to 6
liters of blood per minute. This volume is called
cardiac output,
The cardiac output (CO) is the result of the
stroke volume (SV) times the heart rate (HR)
per minute
CO= SV x HR
Note: in healthy person the pulse reflects the
heartbeat
Peripheral pulse- is a pulse located in the
periphery of the body.
Apical pulse- is a central pulse located at the
apex of the heart.
Pulse site
1. Temporal- it is where the temporal artery
located, between the upper, lateral part of the
eye and upper medial part of the ear
2. Carotid- at the side of the neck, at the
carotid triangle. Located between the
Anterior/front of SCM and below the angle of
the mandible
3. Apical- at the apex of the heart.
◦ In adult this is located on the left side of the chest, no
more than 8 cm (3 in) to the left sternum under the
Carotid pulse
◦ 4th, 5th or 6th intercostal space.
◦ In Children 7 to 9 years old, the apical pulse is
located between the 4th and 5th intercostal space.
◦ In Young Children below 4 years old , it is located at
the left side of midclavicular line and
◦ In Children between 4 and 6 years old it is at the
midclavicular line.
4. Brachial- at the anterior part of the arm in
children and at the ante-cubital space (elbow
crease) in adult.
5. Radial – located at the wrist (anterior part),
along with the thumb. It is where the radial
artery is located
6. Femoral – at the inguinal ligament, the
femoral artery is located.
Radial and Brachial pulse
7. Popliteal- at the popliteal region, located at
the back of the knee
8. Posterior Tibial- at the medial aspect of
the ankle, it is where the posterior tibial artery is
located
9. Dorsalis pedis- where the dorsalis pedis
artery passes over the bones of the foot, at the
space between the big toe and the 2nd toe.
Posterior tibial & Dorsalis pedis Pulse
 Pulse site Reasons for Use

Radial Readily accessible & routinely used

Temporal Used when radial pulse is not accessible

Carotid Used for infants, in cases of cardiac arrest and to determine the
circulation to the brain

Apical Routinely used in infants and children up to 3 years of age, Used to

determine the discrepancies with radial pulse, and Used in
conjunction with some medication
Brachial Used to measure blood pressure, used for cardiac arrest for infants

Femoral Used in cases of cardiac arrest, for infants and children, determine
circulation in the leg
Popliteal Used to determine the circulation in the lower leg and leg blood
pressure
Posterior tibial Used to determine the circulation in the foot

Pedal Used to determine circulation in the foot

Assessing the Pulse
1.A pulse is commonly assessed by palpation or
auscultation.
2. 3 middle fingers are used for palpating all
pulse site, except for apical pulse.
3. Stethoscope is used in assessing apical pulse
and fetal heart tones.
4. Doppler ultrasound is used for pulses that is
to difficult to assess.
5. The pulse is normally palpated by 6. The pads of the most distal aspect of
applying are moderate pressure with the fingers are the most sensitive areas
the three fingers of the hand. of detecting the pulse.
7. When assessing the pulse, there is a need to
take note of the following
1. rate
2. rhythm
3. volume
4. arterial wall elasticity
5. presence or absence of bilateral equality.
Variations in Pulse Rate

Age Average Range

Newborn to 1 130 80-180
month
1 year 120 80-140
2 years 110 80- 130
6 years 100 75- 120
10 years 70 50-90
Adult 80 60- 100
Pulse rate/
Minute
Kozier Barbara, et.al. Fundamentals of Nursing , 5 th ed. (US Addison-Wesley Publishing
Company, Inc. 1995) p. 438
Rate- referred to tachycardia- (over 100
beats/ minute) bradycardia –(60
beats/minute or less)
Rhythm- is the patterns of beat and the
interval between the beats.
Dysrhythmia or arrhythmia is an example of
irregular rhythm.
Volume- is the pulse strength or the amplitude,
refers to the force of blood with each beat. E.g.
bounding/full; weak/feeble/thready pulse

Scale Description of pulse

0 Absent
1 Thready or weak; difficult to feel

2 Normal, detected readily, obliterated

by strong pressure
3 Bounding; difficult to obliterate
Kozier Barbara, et.al. Fundamentals of Nursing , 5 th ed. (US Addison-Wesley Publishing
Company, Inc. 1995) p. 440
Elasticity of the arterial wall
It reflects the expansibilityof the arterial wall.
A healthy, normal artery feel straight, smooth,
soft and pliable
While, elderly people often have inelastic
arteries that feels twisted or tortuous and
irregular upon palpation
Factors affecting pulse rate
1. Age
2. Sex- after puberty the man’s pulse rate is
slightly lower than the female
3. Exercise
4. Fever- pulse rate increases when metabolic
rate increases
5. Medications
6. Hemorrhage- loss of blood increase pulse rate
7. Stress
Pulse

 Pulse is a wave of blood created by the contraction of left

ventricle.
 pulse reflects the heart beat
 Stroke volume and the compliance of arterial wall are the two
important factors influencing pulse rate.
 Pulse rate is regulated by autonomic nervous system.

42
Cont.…

 Peripheral Pulse: is a pulse located in the periphery of the

body e.g. in the foot, and or neck
 Apical Pulse (central pulse): it is located at the apex of the
heart
 The PR is expressed in beats/ minute (BPM)
 The difference between peripheral and apical pulse is called
pulse deficit, and it is usually zero.

43
Cont.…

 Pulse is assessed for

 rate (60-100bpm),
 rhythm (regularity or irregularity),
 Volume,
 elasticity of arterial wall.
 The pulse is commonly assessed by palpation (feeling) and
auscultation (hearing using a stethoscope).

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Factors Affecting Pulse Rates

 Age
 The average pulse rate of an infant ranges from 100 to 160 BPM
 The normal range of the pulse in an adult is 60 to 100 BPM
Sex: Sex: after puberty the average males PR is slightly
lower than female

45
Cont.….

 Autonomic Nervous system activity

 Stimulation of the parasympathetic nervous system results in decrease
in the PR
 Stimulation of sympathetic nervous system results in an increased
pulse rate
 Sympathetic nervous system activation occurs on response to a variety
of stimuli including
▪ Pain ,anxiety ,Exercise ,Fever
▪ Ingestion of caffeinated beverages
▪ Change in intravascular volume
46
Cont.…

 Exercise: PR increase with exercise

 Fever: increases PR in response to the lowered B/P that
results from peripheral vasodilatation – increased metabolic
rate
 Heat: increase PR as a compensatory mechanism
 Stress: increases the sympathetic nerve stimulation

47
Cont.…

*Position changes:
 a sitting or standing position blood usually pools in
dependent vessels of the venous system. B/c of
decrease in the venous blood return to heart and
subsequent decrease in BP increases heart rate.

48
Cont.…

* Medication
o Cardiac medication such as digoxin decrease heart rate
o Medications that decrease intravascular volume such as divretics may

increase pulse rate

o Atropine in hibits impusses to the heart from the parasympathetic

nervous system, causing increased pusse rate

o Propranolol blocks sympathetic nervous system action resulting in

decreased heart trate sites used for measuring pulse rate

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Pulse Sites

 Carotid: at the side of the neck below tube of the ear (where
the carotid artery runs between the trachea and the
sternocleidomastoid muscle)
 Temporal: the pulse is taken at temporal bone area.
 Apical: at the apex of the heart: routinely used for infant and
children < 3 yrs
 In adults – Left mid-clavicular line under the 4th, 5th, 6th
intercostal space

50
Cont.….

 Brachial: at the inner aspect of the biceps muscle of the arm or

medially in the antecubital space (elbow crease)
 Radial: on the thumb side of the inner aspect of the wrist – readily
available and routinely used
 Femoral: along the inguinal ligament. Used or infants and children
 Popiliteal: behind the knee. By flexing the knee slightly
 Posterior tibial: on the medial surface of the ankle
 Pedal (Dorsal Pedis): palpated by feeling the dorsum (upper
surface) of foot

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Pulse Points
Pulse Points
 A. E.

Pulse
B. F.

 A wave of
C. G.
blood flow
created by a
contraction D. H.
of the heart.

.
.
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Method

 Pulse: is commonly assessed by palpation (feeling) or

auscultation (hearing)
 The middle 3 fingertips are used with moderate pressure for
palpation of all pulses except apical;
 Assess the pulse for
 Rate
 Rhythm
 Volume
 Elasticity of the arterial wall
55
Cont…

56
Cont.…

Pulse Rate
 Normal 60-100 b/min (80/min)
 Adult PR > 100 BPM is called tachycardia
 Adult PR < 60 BPM is called bradycardia

57
Cont.…

Pulse Rhythm
 The pattern and interval between the beats, random, irregular
beats – dysrythymia
Pulse Volume
 the force of blood with each beat
 A normal pulse can be felt with moderate pressure of the fingers
 Full or bounding pulse forceful or full blood volume destroy with
difficulty
 Weak, feeble readily destroy with pressure from the finger tips

58
Cont.…

Elasticity of arterial wall

 A healthy, normal artery feels, straight, smooth, soft, easily
bent
 Reflects the status of the clients vascular system

59
Cont.…

 If the pulse is regular, measure (count) for 30

seconds and multiply by 2
 If it is irregular count for 1 full minute.
 Each heart beat consists of two sounds
 s1 - is caused by closure of the mitral and tricuspid
valves separating the atria from the ventricles
 S2 – is caused by the closure of the plutonic and
aortic values
 The sounds are often described as a muffled “lub –
bub”
60
Cont.…

61
 Palpasi
 Tekan ujung jari untuk memeriksa Capila Refill Time (CRT)
yaitu waktu pengisian balik kapiler. Normalnya akan kembali
dalamwaktu <2 detik.

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Blood Pressure:

 It is the force exerted by the blood against the walls of the

arteries in which it is flowing.
 It is expressed in terms of millimeters of mercury (mm of Hg).

63
There are two types of Bp.

 Systolic pressure is the maximum of the pressure against the

wall of the vessel following ventricular contraction.
 Diastolic pressure is the minimum pressure of the blood
against the walls of the vessels following closure of aortic
valve (ventricular relaxation).

64
Cont.….

 BP is measured by using an instrument called Bp cuff

(sphygmomanometer) & stethoscope and
 the average normal value is 120/80mmHg for adults.
 brachial artery and popliteal artery are most
commonly used.
 It is measured by securing the Bp cuff to the upper arm
& thigh placing the stethoscope on brachial artery in
the antecubital space & popliteal artery at the back of
the knee.
 Pulse pressure: is the difference between the systolic
and diastolic pressure
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Factors Affecting Blood Pressure

 Fever
 Stress
 Arteriosclerosis
 Exposure to cold
 Obesity
 Hemorrhage
 Low hematocrit
 External heat

66
Sites for Measuring Blood Pressure

 Upper arm (using brachial artery (commonest)

 Thigh around popliteal artery
 Fore -arm using radial artery
 Leg using posterior tibial or dorsal pedis

67
Cont.….

 A persistently high Bp, measured for greater than

three times is called hypertension & that
persistently less than normal range is called
hypotension.
 Because of many factors influencing Bp a single
measurement is not necessarily significant to
confirm hypertension.
 When the cause of hypertension is known it is called
secondary hypertension and when the cause is
unknown is called primary/essential hypertension.
68
Assessing Blood pressure

Purpose
 To obtain base line measure of arterial blood pressure for
subsequent evaluation
 To determine the clients homodynamic status
 To identify and monitor changes in blood pressure.

69
Cont..

70
Equipment

 Stethoscope
 Blood pressure cuff of the appropriate size
 Sphygmomanometer

71
Cont…

Earpieces
Binaurals

Rubber or plastic
tubing

Bell
Chestpiece
Diaphragm

72
Procedure to measure BP

 Explain the procedure to the patient & remove any light cloth
from patient’s arm
 Make sure that the client has not smoked or ingested caffeine,
within 30 minutes prior to measurement.
 Position the patient on lying, sitting or standing position, but
always ensure that the sphygmomanometer is at the level of
the heart with the arm supported & the palm facing upwards.

73
Cont.….

 apply cuff snugly/securely around the arm , 2.5cm above the

antecubital space/fossa, at the level of the heart (for every cm
the cuff sites above or below the level of the heart the BP
varies by 0.8mmHg)
 Palpate the radial pulse and inflate the cuff until the radial
pulse can no longer be felt, this provides an estimation of
systolic pressure.
 Inflate cuff 30mmHg higher than estimated systolic pressure.

74
Cont.….

 palpate the brachial artery & place the bell of the stethoscope
over the site & the ear pieces on ear, apply enough pressure to
keep the stethoscope in place (the bell of the stethoscope is
designed to amplify/intensify low frequency sounds)
 Deflate the cuff 2-4mmHg per second.
 The first pulse heard is the systolic reading, continue to
deflate until there is a change in tone to a muffled beat, this is
the diastolic reading.

75
Cont.….

 Deflate & remove cuff roll neatly and replace.

 Record the systolic and diastolic pressure on vital sing sheet
and compare the present reading with previous reading.
 report or treat any change
 Clear ear pieces and bell of the stethoscope with antiseptic
swab and return all equipments.

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Terima kasih

 ASS WR WB

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