3.b. penilaian penderita tanda vital
TRANSCRIPT
5/17/2018 3.b. Penilaian Penderita Tanda Vital - slidepdf.com
http://slidepdf.com/reader/full/3b-penilaian-penderita-tanda-vital 1/24
Tanda Vital
5/17/2018 3.b. Penilaian Penderita Tanda Vital - slidepdf.com
http://slidepdf.com/reader/full/3b-penilaian-penderita-tanda-vital 2/24
Tanda vital
Pernapasan
NadiKulit
Tekanan Darah
5/17/2018 3.b. Penilaian Penderita Tanda Vital - slidepdf.com
http://slidepdf.com/reader/full/3b-penilaian-penderita-tanda-vital 3/24
Pernapasan
Tanda Vital
5/17/2018 3.b. Penilaian Penderita Tanda Vital - slidepdf.com
http://slidepdf.com/reader/full/3b-penilaian-penderita-tanda-vital 4/24
Pernapasan
• Amati gerakan naik turunnya dada
• Tentukan berapa kali, teratur atau tidak dankualitas (kedalaman)
• Hitung jumlah gerakan naik turun dada selama 30detik, hasilnya kalikan dua
5/17/2018 3.b. Penilaian Penderita Tanda Vital - slidepdf.com
http://slidepdf.com/reader/full/3b-penilaian-penderita-tanda-vital 5/24
Menilai pernapasan pada bayi
5/17/2018 3.b. Penilaian Penderita Tanda Vital - slidepdf.com
http://slidepdf.com/reader/full/3b-penilaian-penderita-tanda-vital 6/24
Nilai normal pernapasan
• Bayi : 25 - 50 x/ menit
• Anak : 15 - 30 x/ menit
•
Dewasa : 12 - 20 x/ menit
5/17/2018 3.b. Penilaian Penderita Tanda Vital - slidepdf.com
http://slidepdf.com/reader/full/3b-penilaian-penderita-tanda-vital 7/24
Nadi
Tanda Vital
5/17/2018 3.b. Penilaian Penderita Tanda Vital - slidepdf.com
http://slidepdf.com/reader/full/3b-penilaian-penderita-tanda-vital 8/24
Nadi
• Tentukan jumlah, irama dan kualitas
• Hitung selama 15 detik, hasilnya dikalikan 4
5/17/2018 3.b. Penilaian Penderita Tanda Vital - slidepdf.com
http://slidepdf.com/reader/full/3b-penilaian-penderita-tanda-vital 9/24
Memeriksa nadi radial
5/17/2018 3.b. Penilaian Penderita Tanda Vital - slidepdf.com
http://slidepdf.com/reader/full/3b-penilaian-penderita-tanda-vital 10/24
Memeriksa nadi karotis
5/17/2018 3.b. Penilaian Penderita Tanda Vital - slidepdf.com
http://slidepdf.com/reader/full/3b-penilaian-penderita-tanda-vital 11/24
Memeriksa nadi brakialis
5/17/2018 3.b. Penilaian Penderita Tanda Vital - slidepdf.com
http://slidepdf.com/reader/full/3b-penilaian-penderita-tanda-vital 12/24
Denyut Nadi Normal
• Bayi : 120 - 150 x/menit
• Anak : 80 - 150 x/menit
•
Dewasa : 60 - 90 x/menit
• pada keadaan istirahat
5/17/2018 3.b. Penilaian Penderita Tanda Vital - slidepdf.com
http://slidepdf.com/reader/full/3b-penilaian-penderita-tanda-vital 13/24
Kulit
Tanda Vital
5/17/2018 3.b. Penilaian Penderita Tanda Vital - slidepdf.com
http://slidepdf.com/reader/full/3b-penilaian-penderita-tanda-vital 14/24
Kulit
Tentukan warna, suhu dan kondisi
PINK = Normal PUCAT / PUTIH, ABU-ABU = Shock
MERAH = CO, TD ↑, Demam
BIRU = Hipoksia ( O 2, ) KUNING = Cedera/gagal hati, Hepatitis,Sirosis
5/17/2018 3.b. Penilaian Penderita Tanda Vital - slidepdf.com
http://slidepdf.com/reader/full/3b-penilaian-penderita-tanda-vital 15/24
Suhu kulit relatif
5/17/2018 3.b. Penilaian Penderita Tanda Vital - slidepdf.com
http://slidepdf.com/reader/full/3b-penilaian-penderita-tanda-vital 16/24
Tanda Vital
Tekanan Darah
5/17/2018 3.b. Penilaian Penderita Tanda Vital - slidepdf.com
http://slidepdf.com/reader/full/3b-penilaian-penderita-tanda-vital 17/24
Tekanan darah
Angka besar = Sistolik
jantung memompa darah
Angka kecil = Diastoliktekanan diantara dua denyut jantung
5/17/2018 3.b. Penilaian Penderita Tanda Vital - slidepdf.com
http://slidepdf.com/reader/full/3b-penilaian-penderita-tanda-vital 18/24
Gunakan stetoskop dan pengukur tekanan darah
5/17/2018 3.b. Penilaian Penderita Tanda Vital - slidepdf.com
http://slidepdf.com/reader/full/3b-penilaian-penderita-tanda-vital 19/24
Cari nadi brakialis
5/17/2018 3.b. Penilaian Penderita Tanda Vital - slidepdf.com
http://slidepdf.com/reader/full/3b-penilaian-penderita-tanda-vital 20/24
Pasang manset
5/17/2018 3.b. Penilaian Penderita Tanda Vital - slidepdf.com
http://slidepdf.com/reader/full/3b-penilaian-penderita-tanda-vital 21/24
Pompa manset
5/17/2018 3.b. Penilaian Penderita Tanda Vital - slidepdf.com
http://slidepdf.com/reader/full/3b-penilaian-penderita-tanda-vital 22/24
Keluarkan udara secara perlahan
5/17/2018 3.b. Penilaian Penderita Tanda Vital - slidepdf.com
http://slidepdf.com/reader/full/3b-penilaian-penderita-tanda-vital 23/24
Tekanan darah cara palpasi
5/17/2018 3.b. Penilaian Penderita Tanda Vital - slidepdf.com
http://slidepdf.com/reader/full/3b-penilaian-penderita-tanda-vital 24/24
Tekanan Darah Normal
Dewasa
• Sistolik : 100 - 140 mmHg
•
Diastolik : 60 - 90 mmHgAnak
• Sistolik : 2 x umur + 80
• Diastolik : 50 - 80