3.b. penilaian penderita tanda vital
TRANSCRIPT
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Tanda Vital
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Tanda vital
Pernapasan
NadiKulit
Tekanan Darah
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Pernapasan
Tanda Vital
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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
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Menilai pernapasan pada bayi
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Nilai normal pernapasan
• Bayi : 25 - 50 x/ menit
• Anak : 15 - 30 x/ menit
•
Dewasa : 12 - 20 x/ menit
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Nadi
Tanda Vital
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Nadi
• Tentukan jumlah, irama dan kualitas
• Hitung selama 15 detik, hasilnya dikalikan 4
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Memeriksa nadi radial
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Memeriksa nadi karotis
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Memeriksa nadi brakialis
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Denyut Nadi Normal
• Bayi : 120 - 150 x/menit
• Anak : 80 - 150 x/menit
•
Dewasa : 60 - 90 x/menit
• pada keadaan istirahat
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Kulit
Tanda Vital
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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
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Suhu kulit relatif
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Tanda Vital
Tekanan Darah
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Tekanan darah
Angka besar = Sistolik
jantung memompa darah
Angka kecil = Diastoliktekanan diantara dua denyut jantung
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Gunakan stetoskop dan pengukur tekanan darah
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Cari nadi brakialis
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Pasang manset
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Pompa manset
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Keluarkan udara secara perlahan
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Tekanan darah cara palpasi