kul_TANDA TANDA VITAL

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

 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

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

MEKANISME KEHILANGAN

PANAS

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

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 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 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 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 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.