Ns. Machmudah, M.Kep, Sp. Kep.

Mat
 Tanda-tanda vital  indicator status
kesehatan  menandakan keefektifan
sirkulasi, respirasi, fungsi neural dan
endokrin tubuh
 TTV  menentukan status kesehatan pasien
 TTV  data dasar
 TERMASUK:
1. SUHU TUBUH Status fisiologis
2. NADI fungsi tubuh
seseorang dapat
3. PERNAFASAN
direfleksikan oleh
4. TEKANAN DARAH indikator TTV
5. (NYERI : sering perubahan TTV
disebut tanda- indikasikan perub.
tanda vital yang kesehatan
ke-5)
 Normal vital
signs berubah
dipengaruhi
oleh : umur, sex,
berat badan,
Aktivitas, dan
kondisi
(sehat/sakit)
 Sesuai permintaan, untuk melengkapi data
dasar pengkajian
 Sesuai permintaan dokter
 Sekali sehari  klien stabil
 Setiap 4 jam  1 /> TTV abnormal
 Setiap 5 – 15mnt  klien tidak stabil atau
resiko perubahan fisiologi secara cepat post op
 Ketika kondisi klien tampakberubah
 Setiap menit atau lebih sering, bila ada
perubahan signifikan dari hasil pengukuran
sebelumnya
 Ketika klien merasa tidak seperti biasa
 Sebelum,selama dan setelah transfusi
 Sebelum pemberian obat  efek perubahan
TTV
 SUHU TUBUH MENUNJUKKAN KEHANGATANTUBUH
MANUSIA
 Panas tubuh
Diproduksi :
exercise dan
Hilang : melalui metabolisme
kulit, paru, dan makanan
produk sisa melalui
proses radiasi,
konduksi,konveksi,
evaporasi
 Suhu tubuh mencerminkan keseimbangan
antara produksi panas dan kehilangan
panas, dan diukur dalam unit panas yang
disebut derajat.
 Ada 2 macam suhu tubuh:
1. Suhu inti  jaringan dalam tubuh: rongga
abdomen dan rongga pelvic  Relatif konstan
2. Suhu permukaan  suhu kulit, SC, dan lemak
SC  naik dan turun merespon thd lingkungan
1. BMR : jumlah energi yang digunakan ubuh
untuk melakukan aktivitas utama seperti
bernafas
2. AKTIVITAS OTOT: termasuk menggigil,
meingkatkan metabolisme rate
3. TYROXINE OUTPUT: meningkatnya output
tyroxine akan meningkatkan metabolisme sel
seluruh tubuh
4. Stimulasi/respon Epineprin,
norephinephrine, simpatis. Hormon ini
dengan seketika meningkatkan metbolisme
sel dibeberapa jaringan tubuh
5. Fever, meningkatkan jumlah metabolisme
tubuh
Radiasi adalah pemindahan panas dari
permukaan objek tertentu ke permukaan onjek
yang lain tanpa adanya kontak antara kedua
objek, yang paling sering adalah dengan sinar
inframerah. (atau penyebaran panas dengan
gelombang elektromagnetik)
Konduksi adalah perpindahan panas ke objek lain
melalui kontak langsung
Evaporasi (penguapan) adalah perubahan dari
cairan menjadi uap. Seperti cairan tubuh
dalam bentuk keringat menguap dari kulit
Konveksi adalah penyebaran panas oleh karena
pergerakan udara dengan kepadatan yang
tidak sama. orang yang menggunakan kipas
angin
Mekanisme perpindahan panas
 Circadian Rhythms perubahan fisiologis, seperti
perubahan suhu dan TTV yang lain secara fluktuatif :
pagi hari lebih rendah dibandingkan sore hari, suhu
tubuh berfluktuasi 0,28o – 1,1oC selama periode
24jam
 Usia  suhu tuuh bayi dan anak-anak berubah
lebih cepat dalam merespon perubahan panas
dan dingin
 Hormonal  perempuan cenderung lebih
fluktuatif dibandingkan dengan laki-laki,
karena perubahan hormon
 Stress  respon tubuh terhadap stress fisik
dan emosi akan meningkatkan produksi
epineprin dan nor epineprin sehingga
mengakibatkan peningkatan metabolisme
rate peningkatan suhu tubuh
 Suhu Permukaan : 36,8o – 37,4o C (96,6o – 99,3o F)
 Suhu inti : 36,4o – 38o C (97,5o – 100,4o F)

Suhu diukur dengan termometer.

Termometer yang paling dikenal Celsius (C),
Reaumur (rankine) (R), Fahrenheit (F),
Kelvin (K), dengan perbandingan antara
satu dan lainnya mengikuti:
C:R:(F-32) = 5:4:9
Contoh: oC=5/9(F-32) dan F=9/4R+32
 Suhu manusia dikendalikan oleh
HIPOTHALAMUS

Anterior  Posterior  produksi dan

menyimpan panas
hilangnya panas

1. Menyesuaikan dengan
Vasodilatasi dan sirkulasi darah
bengkak 2. Piloerectile (mengatur
konstriksi atau dilatasi
pori-pori kulit)
3. Respon menggigil
 Hipotalamus meningatkan produksi panas
dengan cara meningkatkan metabolisme
melalui sekresi hormon thyroid, yaitu
epinephrin dan norepinephrin medulla
adrenalis.
 Dalam keadaan normal, hipotalamus menjaga
suhu inti “set point”(suhu tubuh optimal)
sebesar 1˚C oleh perubahan suhu permukaan
tubuh dan darah

Suhu > 41°C, dan < 34°C

indikasi kerusakan di
pusat pengaturan
hipotalamus
1. ORAL
Termometer diletakkan di
dibawah lidah sublingual
artery
- biasanya hasil pengukuran
0,5 – 0,8 °C dibawah suhu
inti
1. Klien tidak kooperatif
2. Bayi atau toodler
3. Tidak sadar
4. Dalam keadaan menggigil
5. orang yang biasa bernafas dengan mulut
6. Pembedahan pada mulut
7. Pasien tidak bisa menutup mulut
Pengukuran dilakukan 30 menit setelah klien :
1. Mengunyah permen/permen karet
2. Merokok
3. Makan dan minum panas atau dingin
 Berbeda 0,1°C dengan suhu
inti

Kontraindikasi
 Diare
 Pembedahan rektal
 Clotting disorders
 Hemorrhoids
Hasil pengukuran 0,6°C lebih rendah dibandingkan
suhu oral
Paling sering dilakukan mudah, nyaman

Contraindication of axillary temperature

 Pasien kurus
 Inflamasi Lokal daerah aksila
 Tidak sadar, shock
 Konstriksi pembuluh darah perifer
Ekuivalen Pengukuran suhu

TEMPAT CELCIUS
PENGUKURAN
Oral 37°
Rektal (setara) 37,5°
Aksila (setara) 36,4 °
 Riset menunjukkan suhu ditelinga pada
membran timpani paling mendekati suhu
inti tubuh
 Kesimpulan ini diddasarkan pada 2 fakta
anatomi:
1. Membran tympani hanya berjarak 3,8 cm dari
hipotalamus
2. Darah pada arteri karotis internadan
eksterna, adalah pembuluh darah yang
menyuplai hipotalamus dan membran tympani
1. Pyrexia : istilah yang digunakan untuk
menggambarkan suhu tubuhlebih tinggi dari
set point normal
2. Fever (demam) : suhu tubuh > 37,4°C, tanda
dan gejala:
- Kulit kemerahan
- Gelisah,
- irratibilitas (lekas marah)
- Tidak nafsu makan
- Pandangan menurun dan sensitif terhadap
cahaya
  Banyak Keringat
 Sakit kepala
 Nadi dan RR meningkat
 Disorientasi dan bingung (jika suhu terlalu
tinggi)
 Kejang pada infantdan anak-anak

3. Hiperthermi : suhu tubuh > 40,6°C

sangat beriko terjadi kerusakan otak bahkan
kematian  kerusakan pusat pernafasan
1. Prodromal phase : gejala tidakspesifik
sebelumpeningkatan suhu
2. Onset or invasion phase (fase serangan)
peningkatan suhu tubuh, menggigil
3. Stationary phase : demam menetap
4. Resolution phase : suhu kembali normal
• Monitor vital signs
• Assess skin color and temperature
• Monitor WBC, HCT, and other laboratory reports for
indications of infection or dehydration
• Remove excess blanket when the client feels warm, but
provide extra warmth when the client feels chilled.
• Measure intake and output
• Provide adequate nutrition and fluid
• Reduce physical activity to limit heat production.
 Administer antipyretic
 Provide oral hygiene to keep the mucous membrane
moist.
 Provide a tepid sponge bath to increase heat loss through
conduction.
 Provide dry clothing and bed linens.
Hypothermia; is a core body temperature below the
lower limit of normal. The three physiologic
mechanisms of hypothermia are:
 Excessive heat loss
 Inadequate heat production to counteract heat loss
 Impaired hypothalamic thermoregulation
The clinical signs of hypothermia:
Decreased body temperature, pulse, and
respiration
Severe shivering
Feelings of cold and chills
Pale, cool skin
Hypotension
Decreased urinary output
Lack of muscle coordination
Disorientation
Drowsiness progressing to coma
Frostbite(nose, fingers, toes)
Nursing Interventions for Client's with
Hypothermia
1. Provide a warm environment
2. Provide dry clothing
3. Apply warm blanket
4. Keep limbs close to body
5. Cover the client's scalp with a cap
6. Supply warm oral or intravenous fluids
7. Apply warming pads
1. Resiko Trauma
2. Hyperthermia
3. Hypothermia
4. Resiko ketidakseimbangan suhu tubuh
5. Ineffektif termoregulasi
1. Pastikan frekuensi dan cara pemeriksaan
suhu sesuai dengan permintaan dokter atau
rencana keperawatan (nursing care plan)
2. Identifikasi pasien
3. Jelaskan prosedur pemeriksaan kepada
pasien
4. Pastikan termometer dalam keadaan siap
pakai
5. Cuci tangan dan gunakan sarung tangan bila
ada indikasi
6. Pilih letak pemasangan termometer
7. Ikuti tahap-tahap pengukuran sesuai pedoman
secara berurutan menyesuaikan dengan jenis
termometer
8. Cuci tangan
9. catat hasil pengukuran
 Nadi adalah sensasi denyutan
seperti gelombang yang dapat
dirasakan/ dipalpasi di arteri
perifer, terjadi karena gerakan
atau aliran darah ketika konstraksi
jantung
 Nadi adalah gelombang darah yang
dibuat oleh kontraksi ventrikel kiri
jantung
 Pada orang dewasa kontraksi jantung
60 – 100 x/mnt saat istirahat
 Cardiac output; adalah volume darah
yang dipompakan kedalam arteri oleh
jantung dan = SVxHR
 Nadi Perifer; nadi yang berada jauh
dari jantung, ex: kaki, radialis, leher
 Nadi apical; nadi central, lokasinya di
apex jantung
 Pulse Rate (jumlah denyutan perifer yang
dirasakan selama 1 menit)  dihitung
dengan menekan arteri perifer dengan
menggunakan ujung jari
 Tachycardia: nadi >100 -150 x/mnt
jantung overwork  oksigenasi sel tidak
adequat
 Palpitasi : perasaan berdebar-debar, sering
menyertai tachycardi
Denyut Nadi sangat fluktuatif dan
meningkat dengan :
1.Exercise ,
2.Illness ,
3.Injury , and
4.Emotions .
wanita cenderung dibandingkan
laki-laki.
Athlets, mis. Pelari, bisa jadi heart
rates-nya 40 x/mnt dan tidak
masalah.
 Bradycardia : denyut nadi < 60 x/mnt
kejadian lebih sedikit dibandingkan
tachycardia
1. Usia; peningkatan usia, nadi berangsur-
angsur menurun
2. Jenis Kelamin; pria sedikit lebih rendah
daripada wanita (P=60-65 x/mnt ketika
istirahat, W=7-8 x/mnt lebih cepat)
3. Circadian rhythm; rata-rata menurun pada
pagi hari dan meningkat pada siamg dan
sore hari
4. Bentuk tubuh; tinggi, langsing biasanya denyut
jantung lebih pelan dan nadi lebih sedikit
dibandingkan orang gemuk
5. Aktivitas dan exercise; nadi akan meningkat
dengan aktivitas dan exercise dan menurun dengan
istirahat
6. Stress dan emosi; rangsangan syaraf simpatis dan
emosi seperti cemas, takut, gembira meningkatkan
denyut jantung dan nadi.
Nyeri, adalah stressor yang dapat memacu nadi
lebih cepat
7. Suhu Tubuh; setiap peningkatan 1°F  nadi
meningkat 10x/mnt, peningkatan 1°C  nadi
meningkat 15x/mnt. Sebaliknya bila terjadi
penurunan suhu tubuh maka nadi akan menurun
8. Volume darah; kehilanngan darah yang berlebihan
akan menyebabkan peningkatan nadi
9. obat-obatan; beberapa obat dapat menurunkan
atau meningkatkan kontraksi jantung. Golongan
digitalisdan sedatifmenurunkan HR, Caffeine,
nicotine,cocaine, hormon tyroid, adrenalin
meningkatkan HR
 USIA RENTANG RATA-RATA
NORMAL
BBL 120 – 160 140
1 – 12 BL 80 – 140 120
1 – 2 TH 80 – 130 110
3 – 6 TH 75 – 120 100
7 – 12 TH 75 – 110 95
REMAJA 60 – 100 80
DEWASA 60 – 100 80
1. REGULER; pola dan jarak waktu denyutan
pada tiap denyutan teraba sama/teratur
 NORMAL
2. IRREGULER (arrhythmia/dysrhythmia);
pola dan jarak waktu denyutan pada tiap
denyutan teraba tidak sama/tidak teratur
 Adalah kualitas denyutan yang teraba yang
berhubungan dengan julah darah yang dipompakan
oleh jantung ketika berkontraksi

Kualitas definisi Deskripsi

0 Tidak ada nadi Tidak teraba, meskipun ditekan dengan
kuat
1+ Nadi sangat lemah Pulsasi susah dirasakan, dengan tekanan
ringan tidak teraba
(thready Pulse)
2+ Nadi lemah Denyutan Lebih kuat dibanding Thready

3+ Normal Dapt teraba dengan mudah,dengan

palpasi ringan denyutan tidak teraba
4+ Denyutan kuat dan teraba dengan
palpasi sedang
1. Temporal; passes over the
temporal bone of the head. The
site is superior and lateral to the
eye.
2. Carotid; at the side of the neck
between the trachea and the
sternocleiodomastoid muscle.
3. Apical; at the apex of the hearty.
About 8cm to the left of the
sternum and at the fourth and
sixth intercostals space.
4. Brachial; at the inner aspect of
the biceps muscle of the arm
5. Radial; on the thumb side
of the inner aspect of the
wrist
6. Femoral; alongside the
inguinal ligaments
7. Popliteal; behind the knee
8. Posterior tibial; on the
medial surface of the ankle
9. Pedal “dorsalis pedis”; over
the bones of the feet
 Adalah jumlah
frekuensi pernafan
seseorang selama satu
menit
 Frekuensi pernafasan
dihitung setiap satu
gerakan inhalasi dan
ekshalasi
Mechanics and regulation
 During inhalation, the diaphragm contracts the ribs
move upward and outward, and the sternum moves
outward, thus enlarging the thorax and permitting the
lungs to expand.
 During exhalation. The diaphragm relaxes, the ribs
move downward and inward, and the sternum moves
inward, thus decreasing the size of the thorax as the
lungs are compressed.
of breathing
Respiration is controlled by (a) respiratory
centers in the medulla oblongata and the pons
of the brain and (b) by chemo receptors
located centrally in the medulla and
peripherally in the carotid and aortic bodies.
External respiration; the interchange of oxygen
and carbon dioxide between the alveoli of the
lungs and the pulmonary blood.
Internal respiration; the interchange of these
same gases between the circulating blood and
the cells of the body tissues.
The respiratory rate is normally described in breaths
per minute, normal in depth and rate called
eupnea. Bradypnea; abnormally slow respirations.
Tachypnea; abnormally fast respirations. Apnea;
the absence of breathing.
 Respiration rates over
25 or under 12 breaths under 12 breaths
per minute (when at
rest) may be considered
abnormal
over 25 breaths
 Normal respiration
15

rates at rest range
from 15 to 20 breaths
per minute. In the
cardio-pulmonary
illness, it can be a
very reliable marker of
disease activity. 20
Factors affecting Respirations
Factors increase the rate:
 Exercise

 Increase metabolism

 Stress

 Increased environmental temperature

 Lowered oxygen concentration

 Factors decrease respiration rate:
 Decreased environmental temperature
 Certain medications such as narcotics
 Increased intra cranial pressure
 
Respiration depth; is generally described as
normal, deep, or shallow. Deep
respirations; large volume of air is
inhaled and exhaled, inflated most of the
lungs.
Shallow breathing involve the exchange of
a small volume of air and often the
minimal use of a lung tissue
Hyperventilation; refers to very deep, rapid
respiration.
Hypoventilation; refers to very shallow
respirations
Respiratory rhythm refers to the regularity of the
expirations and the inspirations .An respiratory
rhythm can be described as regular or irregular.
- Cheyne-stokes breathing, from very deep to very
shallow breathing and temporary apnea.
 
Breath sounds
- Stridor, harsh sound heard during inspiration with
laryngeal obstruction
- Stertor, snoring respiration usually due to a partial
obstruction of the upper airway.
- Wheeze, continuous, high pitched musical sound
occurring on expiration when air moves through
narrowed or partially obstructed air way.
Secretions and coughing
- Hemoptysis, the presence of blood in the sputum
- Productive cough, a cough accompanied by
expectorated secretions
- Nonproductive cough, a dry, harsh cough without
secretions
 Patient should
abstain from eating,
drinking, smoking and
taking drugs that
affect the blood
pressure one hour
before measurement. 
 Instruct your patients
to avoid coffee,
smoking or any other
unprescribed drug
with
sympathomimetic
activity on the day of
the measurement
 Because a full bladder
affects the blood
pressure it should
have been emptied.
 Painful procedures
and exercise should
not have occurred
within one hour. 
 Patient should have
been sitting quietly
for about 5 minutes.
 BP take in quiet room
and comfortable
temperature, must
record room
temperature and time
of day.
 Sitting position
 Arm and back are
supported.
 Feet should be
resting firmly on
the floor
 Feet not
dangling. 
 The measurements should be made on the right arm
whenever possible. 
 Patient arm should be resting on the desk and raised (by
using a pillow)
 Raise patient arm so that the brachial artery is roughly
at the same height as the heart. If the arm is held too
high, the reading will be artifactually lowered, and vice
versa.
 Palm is facing up. 
 The arm should remain somewhat bent and
completely relaxed
 Pediatric Cuff size
 Minimum Cuff Width:
2/3 length of upper arm
 Minimum Cuff length:
Bladder nearly encircles
arm
 Adult Cuff size
 Cuff Width: 40% of
limb's circumference
 Cuff Length: Bladder at
80% of limb's
circumference
 Adult Cuff size
 Indicationsfor large
cuff or thigh cuff
 Upper arm circumference
>34 cm
 Indicationsfor forearm
cuff (with radial
palpation)
 Upper arm circumference
>50 cm
 If it is too small, the
readings will be
artificially elevated.
The opposite occurs if
the cuff is too large.
Clinics should have at
least 2 cuff sizes
available, normal and
large.
 Patient's arm
slightly flexed at
elbow
 Push the sleeve up,
wrap the cuff
around the bare
arm
 Cuff applied
directly over skin
(Clothes artificially
raises blood
pressure )
 Position lower cuff
border 2.5 cm
above antecubital
 Center inflatable
bladder over
brachial artery
 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
 Feel for a pulse
from the artery
coursing through
the inside of the
elbow
(antecubital
fossa).
 Wrap the cuff around
the patient's upper
arm
 Close the thumb-
screw.
 With your left hand
place the stethoscope
head directly over the
artery you found.
Press in firmly but not
so hard that you block
the artery.
 Use your right hand to
pump the squeeze
bulb several times
and Inflate the cuff
until you can no
longer feel the pulse
to level above
suspected SBP
 If you immediately
hear sound, pump up
an additional 20
mmHg and repeat
 Deflate cuff slowly at
a rate of 2-3 mmHg
per second until you
can again detect a
radial pulse
 Listen for auditory
vibrations from artery
"bump, bump, bump"
(Korotkoff)
 Systolic blood
pressure is the
pressure at which you
can first hear the
pulse.
 Diastolic blood pressure is the last pressure at
which you can still hear the pulse
 Avoid moving your
hands or the head of
the stethescope while
you are taking
readings as this may
produce noise that
can obscure the
Sounds of Koratkoff.
 BP must take in
both arms and
one lower
extremity.
 The two arm readings
should be within 10-
15 mm Hg.
Differences greater
then 10-15 imply
differential blood
flow.
 If you wish to repeat
the BP measurement
you should allow the
cuff to completely
deflate, permit any
venous congestion in
the arm to resolve
and then repeat a
minute or so later.
 If the BP is
surprisingly high or
low, repeat the
measurement towards
the end of your exam
(Repeated blood
pressure measurement
can be uncomfortable).
 You can verify the SBP
by palpation. Place the
index and middle
fingers of your right
hand over the radial
artery.
 Diastolic blood
pressure allow free
flow of blood without
turbulence and thus
no audible sound.
These are known as
the Sounds of
Koratkoff.
 The minimal SBP
required to maintain
perfusion varies with
the individual.
Interpretation of low
values must take into
account the clinical
situation.
 Physician will want to
see multiple blood
pressure
measurements over
several days or weeks
before making a
diagnosis of
hypertension and
initiating treatment.
 Pre-high blood  Stage 1 high blood
pressure: systolic pressure: systolic
pressure consistently pressure consistently
120 to 139, or 140 to 159, or
diastolic 80 to 89 diastolic 90 to 99
 Stage 2 high blood
pressure: systolic
pressure consistently
160 or over, or
diastolic 100 or over
 Hypotension (blood
pressure below
normal): may be
indicated by a systolic
pressure lower than
90, or a pressure 25
mmHg lower than
usual
 Highblood pressure greater
than 139-89..
 Normal blood pressure
100/60 and 139/89.
 Prehypertension
120,139-80,89…
 Cardiovascular
disorders
 Neurological
conditions
 Kidney and urological
disorders
 Pre eclampsia in
pregnant women
 Psychological factors
such as stress, anger,
or fear

Eclampsia
 Various medications
 "White coat hypertension" may occur if the
medical visit itself produces extreme anxiety
 Orthostatic (postural)
measurements of
pulse and blood
pressure are part of
the assessment for
hypovolemia.
 First measuring BP
when the patient is
supine and then
repeating them after
they have stood for 2
minutes, which allows
for equilibration.
 Systolic blood
pressure does
not vary by more
then 20 points
when a patient
moves from lying
to standing.
 Orthostatic
measurements may
also be used to
determine if postural
dizziness (diabethic
autonomic nervous
system dysfunction) is
the result of a fall in
blood pressure.
Vital signs
 Over the past decade,
Oxygen Saturation
measurement of gas
exchange and red
blood cell oxygen
carrying capacity has
become available in
all hospitals and many
clinics.
 Oxygen Saturation
provide important
information about
cardio-pulmonary
dysfunction and is
considered by many
to be a fifth vital
sign.
 For those suffering
from either acute or
chronic cardio-
pulmonary disorders,
Oxygen Saturation
can help quantify the
degree of
impairment.