pemeriksaan fisik tanda vital
DESCRIPTION
Pemeriksaan FisikTRANSCRIPT
-
TANDA-TANDA VITALYASIN WAHYURIANTO
-
TujuanPengamatan kondisi umumIdentifikasi masalahEvaluasi respon untuk pengobatan
-
GuidelinesPulse : 96.8100.4RR : 12-16/minBlood Pressure :120/80mmHgPulse pressure: 3050mmHgBASELINE---REALIZE--INDIVIDUALIZE!
-
When to takeWhen you think they should be takenProtocolMD ordersBefore and after med administration
-
Temperature
Temperature alterationsPyrexia (fever)Hyperthermia Heatstroke Heat exhaustionHypothermia Frostbite
Mosby items and derived items 2005 by Mosby, Inc.
-
Temperature
Nursing diagnosesRisk for imbalanced body temperature HyperthermiaHypothermiaIneffective thermoregulation
Mosby items and derived items 2005 by Mosby, Inc.
-
Temperature (cont'd)
ImplementationPrevention of alterationsInterventions for feverInterventions for hyperthermiaInterventions for hypothermia
Mosby items and derived items 2005 by Mosby, Inc.
-
FeverBacteria or viruses stimulate immune systemChills, shivers, feeling coldTemp increasesFeeling warm and dryWarm, flushed, diaphoreticTemp returns to normal
-
FeverUp to 102.2 F (39 degrees Celsius) is beneficialWBC Suppresses bacterial growthStimulates interferonIncreased metabolic demands=pulse, respirations
-
FeverEnergy conservationMonitoringFluidsOxygenMedsEnvironmentNursing diagnosis
-
Pulse (the beat of the heart)
Character of the pulseRateRhythmStrengthEquality
Mosby items and derived items 2005 by Mosby, Inc.
- Pulse problemsIf irregular: count apical one minuteCount apical and radial x 1 minutePulse deficit: >2 differenceTachycardia: >100 beats/minBradycardia:
-
PulsePulse rate x Stroke volume= cardiac outputCardiac output= tissue perfusion/oxygenationStrength of muscle, volume, 30 second x 2 count is alright for slow, rapid, regular pulse rates
-
Pulse
Nursing diagnosesActivity intoleranceDecreased cardiac outputIneffective tissue perfusion
Mosby items and derived items 2005 by Mosby, Inc.
-
Respiration
Physiological controlOxygenCarbon dioxideMechanics of breathingInspirationExpirationTidal volume
Mosby items and derived items 2005 by Mosby, Inc.
-
RespirationVentilationgases in and outDiffusionOxygen and carbon dioxide between alveoli and red blood cellsPerfusionred blood cells to and from pulmonary capillaries
-
RespDeep NormalshallowLaboredunlaboredRateDyspnea
-
Cheyne Stokes Breathing
-
Respiration (cont'd)
Nursing diagnosesActivity intoleranceIneffective airway clearanceIneffective breathing patternImpaired gas exchangeIneffective tissue perfusion
Mosby items and derived items 2005 by Mosby, Inc.
-
Blood Pressure12080 is magical number
Depends on: blood volume; greater heart muscle contractility; arterial wall resistance; heart rate
-
Blood Pressure
PhysiologyCardiac outputPeripheral resistanceBlood volumeViscosityElasticity
Mosby items and derived items 2005 by Mosby, Inc.
-
Blood pressure is the force exerted on the blood vessel walls by the blood
-
Systolic Ventricles are contractingCondition of heart and great arteriesMax pressure
-
DiastolicVentricles are relaxedMinimum pressureIndicates arteriolar or peripheral vascular resistance
-
Pulse pressureDifference between systolic and diastolicNormally 30-50 mm/Hg.
-
Correct procedureNot crossing legs!Palpate brachialCorrect cuff sizelook at yours
-
Blood Pressure (cont'd)
Nursing diagnosesAnxietyDecreased cardiac outputDeficient/Excess fluid volumeRisk for injuryAcute painIneffective tissue perfusion
Mosby items and derived items 2005 by Mosby, Inc.
-
Pulse oximetryP. 519> 90% is okay but higher is better!Remove nail polish!!
-
Last but not least Potter & Perry
P. 666 client teaching
P. 667 Focus on older adults
-
THANK
YOU