Vital Signs FNC 1
Transcript of Vital Signs FNC 1
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Key Terms
Afebrile
Apnea
Blood pressure
Bradycardia
Bradypnea
Diastolic pressure
Dyspnea
Dysrhythmia
Eupnea
Febrile
Fever
Hypertension
Hyperthermia
Hypotension
Hypothermia
Korotkoff sounds
Orthopnea
Orthostatic hypotension
Pulse
Pulse deficit
Pulse pressure
Respiration
Systolic pressure
Tachycardia
Tachypnea
Temperature
Vital signs
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VITAL SIGNS
Created by: Yenni Ferawati Sitanggang, S.Kp., BN., RNDeveloped by: Siska Natalia
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OBJECTIVES
Lima Tanda-tanda vital (TTV)
Nyeri adalah tanda vital kelima
Teknik yang benar memeriksa TTV
Nilai Normal TTV
Dokumentasi TTV dengan benar
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Normal Vital Signs(Taylor, 2008)
Keterangan (Dewasa) Nilai Normal
Tensi Darah (BP) 110/70 ?120/80 mmHg
Nadi (P) 60 – 100 x/menit
Pernapasan (RR) 12 – 20 x/mnt
Suhu 36.5 – 37.5 C ? 37?
Nyeri 1 - 10
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Komponen Stetoskop
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Key Terms•
Afebrile• Apnea
• Blood pressure
• Bradycardia
• Bradypnea
• Diastolic pressure• Dyspnea
• Dysrhythmia
• Eupnea
• Febrile
• Fever• Hypertension
• Hyperthermia
• Hypotension
• Hypothermia
•
Korotkoff sounds• Orthopnea
• Orthostatic hypotension
• Pulse
• Pulse deficit
• Pulse pressure• Respiration
• Systolic pressure
• Tachycardia
• Tachypnea
• Temperature• Vital signs
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Hipotensi
Merujuk padatekanan sistolikkurang dari 90mmHg
Hipertensi
Merujuk padatekanansistolik lebihdari 135atau 140mmHg, dandiastoliklebih dari 90
mmHg
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Tekanan Darah Normal(http://www.nhlbi.nih.gov)
Blood Pressure Level (mmHg)
Category Systolic Diastolic
Normal < 120 and < 80
Prehypertension 120-139 or 80-89
High Blood Pressure
Stage 1 Hypertension 140–159 or 90–99
Stage 2 Hypertension 160 or 100
http://www.nhlbi.nih.gov/http://www.nhlbi.nih.gov/
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Memeriksa Suhu
Pastikan alat yang akan dipakai berfungsi
Pastikan sesuai kebutuhan: oral, rectal, axilla,
tympani, infra red, digital, raksa
Pastikan di O atau 35 C pada yang raksa
Perhatikan cara memegang supaya tidakberbahaya
Keringkan ketiak klien
Pakai temp sheet atau alkohol swab
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Oral atau Rectal Thermometer
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Oral thermometer:Glass thermometer
Tempatkan thermometerdi mulut klien atau
dibawah lidah Instruksikan klien untuk
menutup mulut
Tunggu selama 3-5
menit
Baca sejajar mata
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Oral temperature :electronic thermometer
Tempatkan thermometer dimulut klien atau dibawah lidah
Instruksikan klien untukmenutup mulut
Termometer akan berbunyibeep saat temperaturmaksimal tertulis
Baca pengukuran pada layaryang terdapat padathermometer
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Rectal Thermometer
Bersihkan area
Beri lubrikasi di ujungthermometer
Instruksikan klien untukmenarik napas panjang
Masukan thermometerperlahan
Tunggu 2 menit
Bersihkan sekret yangterdapat di thermometer
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Axillary temperature
Lepaskan atau naikan lenganbaju klien
Pastikan ketiak kering
Tempatkan thermometer di
ketiak klien, dan minta klienmenekuk tangannya
Normal 35.9 – 37.4C
Baca hasil di thermometer
Digital thermometer:beberapa detik akan berbunyibeep
Glass thermometer:3-5 mnt
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Tympanic thermometer
Klien posisi duduk atausims
Ambil alat dan tempelkanpenutup plastik untuk
menutupi thermometer
Tempatkan di sisi kepalaklien. Dewasa: tarik pinnakeatas dan belakang.Anak: tarik pinna kebawah
dan belakang. Masukan sisi termometer
dengan perlahan di lubangtelinga.
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Temporal thermometer
Tidak biasa dipakai diIndonesia
Mengukur temperatur denganinfra merah dari aliran arteritemporalis
Biasanya digunakan pada anak
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Denyut Arteri
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Cara mengukur Denyut Nadi
Tempatkan 2 sampai 3 jari diatas nadi, dan tekanperlahan. Gunakan jempol untuk menopangpergelangan tangan. Hitung nadi selama 60 detik.
Di tiap nadi arteri kita perlu memeriksa kualitas,irama, frekuensi, dan volume/kekuatan
Nadi normal 60-100x/menit
Takikardi
Bradikardi
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Mengukur Denyut Nadi
Radialis
Brachialis
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MENGUKUR PERNAPASAN
Observasi satu siklus pernapasan
Tempatkan tangan klien melintang diatas perutdan tangan pemeriksa diatas pergelangantangan klien. Place clients hand acrossabdomen and your hand over clients’ wrist
Mulai menghitung (Ekspirasi dan Inspirasidalam satu hitungan)
Observasi: kedalaman, irama, frekuensi
Observasi pergerakan dada Tidak adanya pernapasan: Apnea, dyspnea,
kesulitan bernapas
Bradypnea: RR < 10 x/menit
Tachypnea : RR > 24x/mnt
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Pengkajian Nyeri Komprehensif
O ONSET When did it start?
How long?
How often?
P PROVOCATING/
PALLIATING
What caused the pain?
What reduced the pain?
Q QUALITY Can you describe the quality of your pain?
What do you feel looks like?
Can you describe it? (sharp, punctured, burning, pressed)
R REGION/
RADIATION
Does the pain radiate?
Where does it radiate?
S SEVERITY How bad is your pain?
Used the Numeric-Rating Scale, Wong-Baker Faces Scale, FLACC, CRIES or COMFORT
Pain Scale
T TREATMENT Have you done any treatment or intervention?
How effective is the current treatment ?
Do you feel any side effects of the treatment?
What kind of pain medication are you taking?
U UNDERSTANDING/
IMPACT ON YOU
What do you believe caused the pain?
How the pain effects you and/or your family?
V VALUES What is your expectation for the pain you are having?
What is the level of comfort that you desired (in the scale of 0-10)?
Do you have any other expectation regarding your pain?
How important is your comfort for you and/or your family?
Referensi: VIHA Quality Council July 2008. http://www.viha.ca/NR/rdonlyres/PrinciplesOfPainAssessment.pdf
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Skala Nyeri (Wong Baker, 2010)
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References Berman, A & Snyder, S. (2012). Kozier & Erb’
Fundamentals in nursing, concept, process and practice(9th Ed). New Jersey
Daniels, R., Grendell, & Wilkins, F. (2010). NursingFundamentals, Caring & clinical decision making(2nd Ed). Delmar
Taylor, C., Lilis, C & LeMone, P. (2008).Fundamental of nursing (2008), The art & scienceof Nursing care (6th Ed). Lippincot Williams &Wilkins
___. (2015) http://www.crozerkeystone.org/
healthcare-professionals/nursing/pqrst-pain-assessment-method/ retreived 23rd April 2015
http://www.crozerkeystone.org/healthcare-professionals/nursing/pqrst-pain-assessment-method/http://www.crozerkeystone.org/healthcare-professionals/nursing/pqrst-pain-assessment-method/http://www.crozerkeystone.org/healthcare-professionals/nursing/pqrst-pain-assessment-method/http://www.crozerkeystone.org/healthcare-professionals/nursing/pqrst-pain-assessment-method/http://www.crozerkeystone.org/healthcare-professionals/nursing/pqrst-pain-assessment-method/http://www.crozerkeystone.org/healthcare-professionals/nursing/pqrst-pain-assessment-method/http://www.crozerkeystone.org/healthcare-professionals/nursing/pqrst-pain-assessment-method/http://www.crozerkeystone.org/healthcare-professionals/nursing/pqrst-pain-assessment-method/http://www.crozerkeystone.org/healthcare-professionals/nursing/pqrst-pain-assessment-method/http://www.crozerkeystone.org/healthcare-professionals/nursing/pqrst-pain-assessment-method/http://www.crozerkeystone.org/healthcare-professionals/nursing/pqrst-pain-assessment-method/http://www.crozerkeystone.org/healthcare-professionals/nursing/pqrst-pain-assessment-method/http://www.crozerkeystone.org/healthcare-professionals/nursing/pqrst-pain-assessment-method/
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