FAQIH RUHYANUDIN

TERMASUK:SUHU TUBUHNADIPERNAFASANTEKANAN DARAH(NYERI : sering disebut tanda-tanda vital yang ke-5)Status fisiologis fungsi tubuh seseorang dapat direfleksikan oleh indikator TTV perubahan TTV indikasikan perub. kesehatan

Vital sign

Normal vital signs berubah dipengaruhi oleh : umur, sex, berat badan, Aktivitas, dan kondisi (sehat/sakit)

Pengukuran TTVSesuai permintaan, untuk melengkapi data dasar pengkajianSesuai permintaan dokterSekali sehari klien stabilSetiap 4 jam 1 /> TTV abnormalSetiap 5 15mnt klien tidak stabil atau resiko perubahan fisiologi secara cepat post opKetika kondisi klien tampak berubah

Setiap menit atau lebih sering, bila ada perubahan signifikan dari hasil pengukuran sebelumnyaKetika klien merasa tidak seperti biasaSebelum,selama dan setelah transfusiSebelum pemberian obat efek perubahan TTV

SUHU TUBUHSUHU TUBUH MENUNJUKKAN KEHANGATANTUBUH MANUSIAPanas tubuhDiproduksi : exercise dan metabolisme makananHilang : melalui kulit, paru, dan produk 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:Suhu inti jaringan dalam tubuh: rongga abdomen dan rongga pelvic Relatif konstanSuhu permukaan suhu kulit, SC, dan lemak SC naik dan turun merespon thd lingkungan

FAKTOR-FAKTOR YANG MEMPENGARUHI PRODUKSI PANAS1. BMR : jumlah energi yang digunakan ubuh untuk melakukan aktivitas utama seperti bernafas2. AKTIVITAS OTOT: termasuk menggigil, meingkatkan metabolisme rate3. TYROXINE OUTPUT: meningkatnya output tyroxine akan meningkatkan metabolisme sel seluruh tubuh

4. Stimulasi/respon Epineprin, norephinephrine, simpatis. Hormon ini dengan seketika meningkatkan metabolisme sel dibeberapa jaringan tubuh 5. Fever, meningkatkan jumlah metabolisme tubuh

MEKANISME KEHILANGAN PANASRadiasi adalah pemindahan panas dari permukaan objek tertentu ke permukaan objek 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 kulitKonveksi adalah penyebaran panas oleh karena pergerakan udara dengan kepadatan yang tidak sama. orang yang menggunakan kipas angin

Mekanisme perpindahan panas

FAKTOR YANG MEMPENGARUHI SUHU TUBUHCircadian 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 24jamUsia suhu tubuh bayi dan anak-anak berubah lebih cepat dalam merespon perubahan panas dan dingin

Hormonal perempuan cenderung lebih fluktuatif dibandingkan dengan laki-laki, karena perubahan hormonStress respon tubuh terhadap stress fisik dan emosi akan meningkatkan produksi epineprin dan nor epineprin sehingga mengakibatkan peningkatan metabolisme rate peningkatan suhu tubuh

SUHU TUBUH NORMALSuhu 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), dgn perbandingan antara satu dan lainnya mengikuti: C:R:(F-32) = 5:4:9Contoh: oC=5/9(F-32) dan F=9/4R+32

PENGATURAN SUHU Suhu manusia dikendalikan oleh HIPOTHALAMUSAnterior hilangnya panasVasodilatasi dan bengkakPosterior produksi dan menyimpan panasMenyesuaikan dengan sirkulasi darahPiloerectile (mengatur konstriksi atau dilatasi pori-pori kulit)Respon menggigil

Hipotalamus meningatkan produksi panas dengan cara meningkatkan metabolisme melalui sekresi hormon thyroid, yaitu epinephrin dan norepinephrin medulla adrenalisDalam keadaan normal, hipotalamus menjaga suhu inti set point(suhu tubuh optimal) sebesar 1C oleh perubahan suhu permukaan tubuh dan darahSuhu > 41C, dan < 34C indikasi kerusakan di pusat pengaturan hipotalamus

Pengaturan Suhu Tubuh oleh HIPOTALAMUS

PENGUKURAN SUHUORALTermometer diletakkan di dibawah lidah sublingual artery- biasanya hasil pengukuran 0,5 0,8 C dibawah suhu inti

KONTRA INDIKASI PENGUKURAN SUHU DI ORAL:Klien tidak kooperatifBayi atau toodlerTidak sadarDalam keadaan menggigilorang yang biasa bernafas dengan mulutPembedahan pada mulutPasien tidak bisa menutup mulut

Untuk menjamin keakuratan hasil pengukuran perlu dikaji:Pengukuran dilakukan 30 menit setelah klien :Mengunyah permen/permen karetMerokokMakan dan minum panas atau dingin

2. RektalBerbeda 0,1C dengan suhu inti

KontraindikasiDiarePembedahan rektalClotting disordersHemorrhoids

3. Aksila Hasil pengukuran 0,6C lebih rendah dibandingkan suhu oral Paling sering dilakukan mudah, nyaman

Contraindication of axillary temperaturePasien kurusInflamasi Lokal daerah aksila Tidak sadar, shockKonstriksi pembuluh darah perifer

Ekuivalen Pengukuran suhu

TEMPAT PENGUKURANCELCIUSOral37Rektal (setara)37,5Aksila (setara)36,4

4. Telinga (Aural)Riset menunjukkan suhu ditelinga pada membran timpani paling mendekati suhu inti tubuhKesimpulan ini didasarkan pada 2 fakta anatomi:Membran tympani hanya berjarak 3,8 cm dari hipotalamusDarah pada arteri karotis internadan eksterna, adalah pembuluh darah yang menyuplai hipotalamus dan membran tympani

Tympanic Thermometer

PENINGKATAN SUHU TUBUHPyrexia : istilah yang digunakan untuk menggambarkan suhu tubuh lebih tinggi dari set point normalFever (demam) : suhu tubuh > 37,4C, tanda dan gejala:Kulit kemerahanGelisah, irratibilitas (lekas marah)Tidak nafsu makanPandangan menurun dan sensitif terhadap cahaya

Banyak KeringatSakit kepalaNadi dan RR meningkatDisorientasi dan bingung (jika suhu terlalu tinggi)Kejang pada infant dan anak-anak

3. Hiperthermi : suhu tubuh > 40,6Csangat beriko terjadi kerusakan otak bahkan kematian kerusakan pusat pernafasan

TAHAPAN DEMAM (FEVER)Prodromal phase : gejala tidakspesifik sebelumpeningkatan suhuOnset or invasion phase (fase serangan)peningkatan suhu tubuh, menggigil3. Stationary phase : demam menetap4. Resolution phase : suhu kembali normal

Penanganan pasien dengan panas:Monitor vital signsAssess skin color and temperatureMonitor WBC, HCT, and other laboratory reports for indications of infection or dehydrationRemove excess blanket when the client feels warm, but provide extra warmth when the client feels chilled.Measure intake and outputProvide adequate nutrition and fluidReduce physical activity to limit heat production.

Administer antipyreticProvide 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 lossInadequate heat production to counteract heat lossImpaired hypothalamic thermoregulation

The clinical signs of hypothermia:Decreased body temperature, pulse, and respirationSevere shiveringFeelings of cold and chillsPale, cool skinHypotensionDecreased urinary outputLack of muscle coordinationDisorientationDrowsiness progressing to comaFrostbite(nose, fingers, toes)

Nursing Interventions for Client's with HypothermiaProvide a warm environmentProvide dry clothingApply warm blanketKeep limbs close to bodyCover the client's scalp with a cap Supply warm oral or intravenous fluidsApply warming pads

DIAGNOSA KEPERAWATAN BERHUBUNGAN DENGAN SUHU TUBUHResiko TraumaHyperthermiaHypothermiaResiko ketidakseimbangan suhu tubuhIneffektif termoregulasi

PROSEDUR PEMERIKSAAN SUHUPastikan frekuensi dan cara pemeriksaan suhu sesuai dengan permintaan dokter atau rencana keperawatan (nursing care plan)Identifikasi pasienJelaskan prosedur pemeriksaan kepada pasienPastikan termometer dalam keadaan siap pakaiCuci tangan dan gunakan sarung tangan bila ada indikasiPilih letak pemasangan termometer

7. Ikuti tahap-tahap pengukuran sesuai pedoman secara berurutan menyesuaikan dengan jenis termometer8. Cuci tangan 9. catat hasil pengukuran

PEMERIKSAAN NADINadi 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 jantungPada orang dewasa kontraksi jantung 60 100 x/mnt saat istirahatCardiac output; adalah volume darah yang dipompakan kedalam arteri oleh jantung dan = SVxHRNadi Perifer; nadi yang berada jauh dari jantung, ex: kaki, radialis, leherNadi 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 jariTachycardia: nadi >100 -150 x/mnt jantung overwork oksigenasi sel tidak adequatPalpitasi : perasaan berdebar-debar, sering menyertai tachycardi

Denyut Nadi sangat fluktuatif dan meningkat dengan :exercise, illness, injury, and 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 NADIUsia; peningkatan usia, nadi berangsur-angsur menurunJenis 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 gemuk5. Aktivitas dan exercise; nadi akan meningkat dengan aktivitas dan exercise dan menurun dengan istirahat6. 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 menurun8. Volume darah; kehilanngan darah yang berlebihan akan menyebabkan peningkatan nadi9. 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

USIARENTANG NORMALRATA-RATABBL120 1601401 12 BL80 1401201 2 TH80 1301103 6 TH75 1201007 12 TH75 11095REMAJA60 10080DEWASA60 10080

IRAMA NADIREGULER; pola dan jarak waktu denyutan pada tiap denyutan teraba sama/teratur NORMALIRREGULER (arrhythmia/dysrhythmia); pola dan jarak waktu denyutan pada tiap denyutan teraba tidak sama/tidak teratur

ISI DENYUTANAdalah kualitas denyutan yang teraba yang berhubungan dengan julah darah yang dipompakan oleh jantung ketika berkontraksi

KualitasdefinisiDeskripsi0Tidak ada nadiTidak teraba, meskipun ditekan dengan kuat1+Nadi sangat lemah (thready Pulse)Pulsasi susah dirasakan, dengan tekanan ringan tidak teraba2+Nadi lemahDenyutan Lebih kuat dibanding Thready3+NormalDapt teraba dengan mudah,dengan palpasi ringan denyutan tidak teraba4+Denyutan kuat dan teraba dengan palpasi sedang

PENGUKURAN NADITemporal; passes over the temporal bone of the head. The site is superior and lateral to the eye.Carotid; at the side of the neck between the trachea and the sternocleiodomastoid muscle.Apical; at the apex of the hearty. About 8cm to the left of the sternum and at the fourth and sixth intercostals space.Brachial; at the inner aspect of the biceps muscle of the arm

Radial; on the thumb side of the inner aspect of the wristFemoral; alongside the inguinal ligamentsPopliteal; behind the kneePosterior tibial; on the medial surface of the anklePedal dorsalis pedis; over the bones of the feet

Adalah jumlah frekuensi pernafan seseorang selama satu menitFrekuensi pernafasan dihitung setiap satu gerakan inhalasi dan ekshalasi

Mechanics and regulation of breathingDuring 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 breathsover 25 breaths

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

15 20

Factors affecting RespirationsFactors increase the rate:ExerciseIncrease metabolismStressIncreased environmental temperatureLowered oxygen concentration

Factors decrease respiration rate:Decreased environmental temperatureCertain medications such as narcoticsIncreased 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 tissueHyperventilation; 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 measurementPatient 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 readingsInstruct 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 measurementPainful procedures and exercise should not have occurred within one hour. Patient should have been sitting quietly for about 5 minutes.

Preparation for measurementBP take in quiet room and comfortable temperature, must record room temperature and time of day.

Position of the PatientSitting position Arm and back are supported. Feet should be resting firmly on the floorFeet 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)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 antecubitalCenter 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 BPFeel for a pulse from the artery coursing through the inside of the elbow (antecubital fossa).

In order to measure the BPWrap the cuff around the patient's upper armClose the thumb-screw.

In order to measure the BPWith 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 measurementUse 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 measurementListen for auditory vibrations from artery "bump, bump, bump" (Korotkoff)

In order to measure the BPSystolic blood pressure is the pressure at which you can first hear the pulse.

In order to measure the BPDiastolic blood pressure is the last pressure at which you can still hear the pulse

In order to measure the BPAvoid 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 measurementBP must take in both arms and one lower extremity.

In order to measure the BPThe two arm readings should be within 10-15 mm Hg. Differences greater then 10-15 imply differential blood flow.

In order to measure the BPIf 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 readingsIf 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 BPDiastolic blood pressure allow free flow of blood without turbulence and thus no audible sound. These are known as the Sounds of Koratkoff.

Blood pressureThe minimal SBP required to maintain perfusion varies with the individual. Interpretation of low values must take into account the clinical situation.

Blood pressure for adultPhysician 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 MeanStage 2 high blood pressure: systolic pressure consistently 160 or over, or diastolic 100 or over

What Abnormal Results MeanHypotension (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 conditionsCardiovascular disorders Neurological conditions Kidney and urological disorders

Blood pressure may be affected by many different conditionsPre eclampsia in pregnant women Psychological factors such as stress, anger, or fear Eclampsia

Blood pressure may be affected by many different conditionsVarious medications "White coat hypertension" may occur if the medical visit itself produces extreme anxiety

Remember the following for accuracy of your readingsOrthostatic (postural) measurements of pulse and blood pressure are part of the assessment for hypovolemia.

Remember the following for accuracy of your readingsFirst 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 readingsSystolic 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 readingsOrthostatic 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 SaturationOver 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 SaturationOxygen Saturation provide important information about cardio-pulmonary dysfunction and is considered by many to be a fifth vital sign.

Oxygen SaturationFor those suffering from either acute or chronic cardio-pulmonary disorders, Oxygen Saturation can help quantify the degree of impairment.

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