FAQIH RUHYANUDIN

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)
Vital sign
 Normal vital
signs berubah
dipengaruhi oleh
: umur, sex,
berat badan,
Aktivitas, dan
kondisi
(sehat/sakit)
Pengukuran TTV
 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
lanjutan
 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
 SUHU TUBUH MENUNJUKKAN
KEHANGATANTUBUH MANUSIA
 Panas tubuh
Diproduksi :
exercise dan
Hilang : melalui kulit, metabolisme
paru, dan produk makanan
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
FAKTOR-FAKTOR YANG
MEMPENGARUHI PRODUKSI
PANAS
1. BMR : jumlah energi yang digunakan
tubuh 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
MEKANISME KEHILANGAN
PANAS
Radiasi adalah pemindahan panas dari
permukaan objek tertentu ke permukaan
objek 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
FAKTOR YANG
MEMPENGARUHI SUHU
TUBUH
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 tubuh 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 TUBUH NORMAL
 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
PENGATURAN SUHU
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
Pengaturan Suhu Tubuh oleh
HIPOTALAMUS
PENGUKURAN SUHU
1. ORAL
Termometer diletakkan di
dibawah lidah
sublingual artery
- biasanya hasil
pengukuran 0,5 – 0,8 °C
dibawah suhu inti
KONTRA INDIKASI
PENGUKURAN SUHU DI ORAL:

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
Untuk menjamin keakuratan hasil
pengukuran perlu dikaji:
Pengukuran dilakukan 30 menit setelah klien :
1. Mengunyah permen/permen karet
2. Merokok
3. Makan dan minum panas atau dingin
2. Rektal
 Berbeda 0,1°C dengan
suhu inti

Kontraindikasi
 Diare
 Pembedahan rektal
 Clotting disorders
 Hemorrhoids
3. Aksila
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 °
4. Telinga (Aural)
 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
Tympanic Thermometer
PENINGKATAN SUHU
TUBUH
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
TAHAPAN DEMAM
(FEVER)
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
Nursing Interventions for Client's
with fever:
• 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
DIAGNOSA KEPERAWATAN
BERHUBUNGAN DENGAN SUHU TUBUH

1. Resiko Trauma
2. Hyperthermia
3. Hypothermia
4. Resiko ketidakseimbangan suhu
tubuh
5. Ineffektif termoregulasi
PROSEDUR PEMERIKSAAN
SUHU
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
PEMERIKSAAN NADI

 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
KECEPATAN NADI (PULSE
RATE)
 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
FACTOR YANG MEMPENGARUHI
NADI
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
Penghitungan Nadi Normal
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
IRAMA NADI
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
 ISI DENYUTAN
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
 PENGUKURAN NADI
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
pernapasan
seseorang selama
satu menit
 Frekuensi
pernafasan dihitung
setiap satu gerakan
inhalasi dan
ekshalasi
Mechanics and regulation of breathing
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.
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.
Abnormal Respiratory Rate

 Respiration rates
over 25 or under 12
under 12 breaths
breaths per minute
(when at rest) may
be considered over 25 breaths
abnormal
Respiratory Rate
 Normal respiration
rates at rest range 15
from 15 to 20
breaths per minute.
In the cardio-
pulmonary illness, it
can be a very
reliable marker of
20
disease activity.
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
Preparation for measurement
 Patient should
abstain from eating,
drinking, smoking
and taking drugs that
affect the blood
pressure one hour
before
measurement.
Remember the following for accuracy of
your readings
 Instruct your patients
to avoid coffee,
smoking or any other
unprescribed drug
with
sympathomimetic
activity on the day of
the measurement
Preparation for measurement

 Because a full
bladder affects the
blood pressure it
should have been
emptied.
Preparation for measurement
 Painful procedures
and exercise should
not have occurred
within one hour.
 Patient should have
been sitting quietly
for about 5 minutes.
Preparation for measurement
 BP take in quiet room
and comfortable
temperature, must
record room
temperature and time
of day.
Position of the Patient
 Sitting position
 Arm and back are
supported.
 Feet should be
resting firmly on the
floor
 Feet not dangling.
Position of the arm

 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)
Position of the arm

 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.
Position of the arm

 Palm is facing up.

 The arm should remain somewhat bent and
completely relaxed
In order to measure the Blood Pressure
(equipment)
 Pediatric Cuff size
Minimum Cuff Width:
2/3 length of upper
arm
Minimum Cuff length:
Bladder nearly
encircles arm
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
In order to measure the Blood Pressure
(equipment)
 Adult Cuff size
Indications for large
cuff or thigh cuff
○ Upper arm
circumference >34 cm
Indications for forearm
cuff (with radial
palpation)
○ Upper arm
circumference >50 cm
Blood Pressure
 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.
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
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
 Center inflatable
bladder over
brachial artery
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
In order to measure the BP
 Feel for a pulse
from the artery
coursing through
the inside of the
elbow
(antecubital
fossa).
In order to measure the BP
 Wrap the cuff around
the patient's upper
arm
 Close the thumb-
screw.
In order to measure the BP
 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.
Technique of BP measurement
 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
Technique of BP measurement

 If you immediately
hear sound, pump up
an additional 20
mmHg and repeat
Technique of BP measurement

 Deflate cuff slowly at

a rate of 2-3 mmHg
per second until you
can again detect a
radial pulse
Technique of BP measurement
 Listen for auditory
vibrations from artery
"bump, bump, bump"
(Korotkoff)
In order to measure the BP
 Systolic blood
pressure is the
pressure at which
you can first hear the
pulse.
 In order to measure the BP

 Diastolic blood pressure is the last pressure at

which you can still hear the pulse
In order to measure the BP
 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.
Technique of BP measurement
 BP must take
in both arms
and one lower
extremity.
In order to measure the BP
 The two arm
readings should be
within 10-15 mm Hg.
Differences greater
then 10-15 imply
differential blood flow.
In order to measure the BP
 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.
Remember the following for accuracy
of your readings
 If the BP is
surprisingly high or
low, repeat the
measurement
towards the end of
your exam
(Repeated blood
pressure
measurement can
be uncomfortable).
In order to measure the BP

 You can verify the

SBP by palpation.
Place the index and
middle fingers of
your right hand over
the radial artery.
In order to measure the BP
 Diastolic blood
pressure allow free
flow of blood without
turbulence and thus
no audible sound.
These are known as
the Sounds of
Koratkoff.
Blood pressure
 The minimal SBP
required to maintain
perfusion varies with
the individual.
Interpretation of low
values must take into
account the clinical
situation.
Blood pressure for adult
 Physician will want to
see multiple blood
pressure
measurements over
several days or
weeks before making
a diagnosis of
hypertension and
initiating treatment.
What Abnormal Results Mean

 Pre-high blood  Stage 1 high blood

pressure: systolic pressure: systolic
pressure consistently pressure consistently
120 to 139, or diastolic 140 to 159, or diastolic
80 to 89 90 to 99
What Abnormal Results Mean
 Stage 2 high blood
pressure: systolic
pressure consistently
160 or over, or
diastolic 100 or over
What Abnormal Results Mean
 Hypotension (blood
pressure below
normal): may be
indicated by a
systolic pressure
lower than 90, or a
pressure 25 mmHg
lower than usual
Hypertension

 High blood pressure greater

than 139-89..
Blood pressure (mm Hg)
 Normal blood
pressure 100/60 and
139/89.
 Prehypertension
120,139-80,89…
Blood pressure may be affected by
many different conditions
 Cardiovascular
disorders
 Neurological
conditions
 Kidney and urological
disorders
Blood pressure may be affected by
many different conditions
 Pre eclampsia in
pregnant women
 Psychological factors
such as stress,
anger, or fear

Eclampsia
Blood pressure may be affected by
many different conditions

 Various medications
 "White coat hypertension" may occur if the
medical visit itself produces extreme anxiety
Remember the following for accuracy
of your readings
 Orthostatic (postural)
measurements of
pulse and blood
pressure are part of
the assessment for
hypovolemia.
Remember the following for accuracy
of your readings
 First measuring BP
when the patient is
supine and then
repeating them after
they have stood for
2 minutes, which
allows for
equilibration.
Remember the following for accuracy
of your readings
 Systolic blood
pressure does
not vary by more
then 20 points
when a patient
moves from
lying to standing.
Remember the following for accuracy
of your readings
 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
Oxygen Saturation
 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
 Oxygen Saturation
provide important
information about
cardio-pulmonary
dysfunction and is
considered by many
to be a fifth vital sign.
Oxygen Saturation
 For those suffering
from either acute or
chronic cardio-
pulmonary disorders,
Oxygen Saturation
can help quantify the
degree of
impairment.