FN - Vital Sign
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Page 1Powerpoint Templates
VITAL SIGN
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'slevel 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 hadthe 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 memonitorstatus fisik seseorang. Hasil pemeriksaan hrs
diinterpretasikan kedalam nilai normal seseorang,
diagnosa medis, riw penyakit, riw pengobatan
dan hasil laboratorium
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Manfaat
Pemeriksaan TTV berguna untuk:
- mengetahui status fisik seseorang
- mengetahui respon seseorang terhadapnyeri, ansietas, takut dan toleransiaktivitas.
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Jika hasil pemeriksaan mengalamipenyimpangan/deviasi dari normal maka perawat
harus :
1. Evaluasi beberapa deviasi dari normal pada nilainormal seseorang
contoh : TD 90/60 mmHg : deviasi dari range normaltekanan darah sistolik secara umum, namun bisa juganormal untuk orang tsb.
2. Evaluasi deviasi dengan status fisik seseorang.
contoh : TD 90/60 mmHg yang disertai dengandingin, 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 100o C = 212o F
Rumus merubah celcius ke fahrenheit
= (Celcius x 1,8) + 32 E. Rumus merubah fahrenheit ke celcius
= (Fahrenheit - 32) / 1,8
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PENGUKURANSUHU
RECTAL
ORAL
AXILLA
EAR
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Rectally
Temperatures taken
rectally (using a mercury or
digital thermometer) tendto be 0.5 to 0.7
(Fahrenheit) higher than
when taken by mouth.
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Oral temperature
can be taken bymouth 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 tobe 0.3 to 0.4
(Fahrenheit) lower
than those
temperatures takenby mouth.
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By ear a special
thermometer canquickly measure the
temperature of the ear
drum, which reflects the
body's coretemperature
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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 demamatau sakit, saat menghitung
RR, observasi juga adanya
kesulitan bernapas
RR normalnya 12 -20x/menitsaat 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 dipergelangan tangan
sehingga tangan
pemeriksa melingkari
pergelangan klien
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How to check your pulse
Beri tekanan ringan pada
awal pemeriksaan jikaklien gemuk dan sulitterdeteksi adanya arteri.Jangan menekan terlalu
dalam, karenamenyebabkan alirandarah terhambat danterjadi 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 ruanganyang tenang dengan
suhu ruangan normal
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Position of the Patient
Posisikan duduk
Lengan dan punggung
rileks
Kaki diletakkan dilantai, jangan
menggantung
Pengukuran sebaiknyadi 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 pengukuranlebih 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 (Clothesartificially raises
blood pressure )
Position lower cuffborder 2.5 cmabove antecubital
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