FAQIH RUHYANUDIN

TERMASUK:
1. 2. 3. 4. SUHU TUBUH NADI PERNAFASAN TEKANAN DARAH 5. (NYERI : sering disebut tandatanda vital yang ke-5) Status fisiologis fungsi tubuh seseorang dapat direfleksikan oleh indikator TTV perubahan TTV indikasikan

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 :

Hilang : melalui kulit, paru, dan produk sisa melalui proses radiasi, konduksi,konveksi, evaporasi

exercise dan metabolisme makanan

Suhu tubuh mencerminkan keseimbangan antara produksi panas dan kehilangan panas, dan diukur dalam unit panas yang disebut derajat. Ada 2 macam suhu tubuh:
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
1.

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

F) Suhu inti

Permukaan : 36,8o 37,4o C (96,6o 99,3o : 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 hilangnya panas
Posterior produksi dan menyimpan panas

Vasodilatasi dan bengkak

1. Menyesuaikan dengan sirkulasi darah 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 1C oleh perubahan suhu permukaan tubuh dan darah
Suhu > 41C, dan < 34C 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. 2. 3. 4. 5. 6. 7.

Klien tidak kooperatif Bayi atau toodler Tidak sadar Dalam keadaan menggigil orang yang biasa bernafas dengan mulut Pembedahan pada mulut 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

0,1C dengan

suhu inti Kontraindikasi Diare Pembedahan rektal Clotting disorders Hemorrhoids

3. Aksila
Hasil pengukuran 0,6C 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 PENGUKURAN Oral Rektal (setara) Aksila (setara) CELCIUS 37 37,5 36,4

4. Telinga (Aural)

Riset menunjukkan suhu ditelinga pada membran timpani paling mendekati suhu inti tubuh Kesimpulan ini diddasarkan pada 2 fakta anatomi:
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
1.

Tympanic Thermometer

PENINGKATAN SUHU TUBUH yang digunakan untuk 1. Pyrexia : istilah

2.
-

menggambarkan suhu tubuhlebih tinggi dari set point normal Fever (demam) : suhu tubuh > 37,4C, 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 > 40,6C sangat beriko terjadi kerusakan otak bahkan kematian kerusakan pusat pernafasan

TAHAPAN DEMAM (FEVER)

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
1.

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. 2. 3. 4. 5.

Resiko Trauma Hyperthermia Hypothermia Resiko ketidakseimbangan suhu tubuh Ineffektif termoregulasi

PROSEDUR PEMERIKSAAN SUHU

1.

2. 3. 4. 5. 6.

Pastikan frekuensi dan cara pemeriksaan suhu sesuai dengan permintaan dokter atau rencana keperawatan (nursing care plan) Identifikasi pasien Jelaskan prosedur pemeriksaan kepada pasien Pastikan termometer dalam keadaan siap pakai Cuci tangan dan gunakan sarung tangan bila ada indikasi 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. 2.

3.

Usia; peningkatan usia, nadi berangsur-angsur menurun Jenis Kelamin; pria sedikit lebih rendah daripada wanita (P=60-65 x/mnt ketika istirahat, W=7-8 x/mnt lebih cepat) 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 1F nadi meningkat 10x/mnt, peningkatan 1C 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 1 12 BL 1 2 TH 3 6 TH 7 12 TH REMAJA DEWASA

120 160 80 140 80 130 75 120 75 110 60 100 60 100

140 120 110 100 95 80 80

IRAMA NADI
1.

2.

REGULER; pola dan jarak waktu denyutan pada tiap denyutan teraba sama/teratur NORMAL 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
0 1+ 2+ 3+ 4+

definisi
Tidak ada nadi Nadi sangat lemah (thready Pulse) Nadi lemah Normal

Deskripsi
Tidak teraba, meskipun ditekan dengan kuat Pulsasi susah dirasakan, dengan tekanan ringan tidak teraba Denyutan Lebih kuat dibanding Thready Dapt teraba dengan mudah,dengan palpasi ringan denyutan tidak teraba Denyutan kuat dan teraba dengan palpasi sedang

PENGUKURAN NADI
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
1.

5. Radial; on the thumb side of 6. 7. 8. 9.

the inner aspect of the wrist Femoral; alongside the inguinal ligaments Popliteal; behind the knee Posterior tibial; on the medial surface of the ankle Pedal dorsalis pedis; over the bones of the feet

 Adalah

jumlah frekuensi pernafan 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 breaths per minute (when at rest) may be considered abnormal

under 12 breaths

over 25 breaths

Respiratory Rate
Normal

respiration rates at rest range from 15 to 20 breaths per minute. In the cardiopulmonary illness, it can be a very reliable marker of disease activity.

15

20

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) slightly Patient's arm

flexed at elbow Push the sleeve up, wrap the cuff around the bare arm

In order to measure the Blood Pressure (Cuff Position) directly Cuff applied

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 thumbscrew.

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 1015 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 pressure: systolic pressure consistently 120 to 139, or diastolic 80 to 89

Stage 1 high blood pressure: systolic pressure consistently 140 to 159, or diastolic 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 cardiopulmonary disorders, Oxygen Saturation can help quantify the degree of impairment.