Vital Signs FNC 1

8/17/2019 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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Documents

Vital Signs FNC 1