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7/24/2019 ppt b.ing ttv

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ASSESSMENT OF VITAL SIGNS

PRESENTED BY :

1.NONIK GINANJARSARI

2.SITI SHOLIKHAH

3.TIKA WAHYU WARDANI


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Vital sign ?

Vital Signs (VS) are the most important

measurements you ill o!tain hen youe"aluate or assess a #lient$s #on%ition


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&ONTENTS

Body teme!"t#!e

P#$%e

Re%&!"t&o'

B$ood !e%%#!e


4/21

' O*+ TEM,E-AT.-E

alan#e !eteen heat pro%u#e% an% heat lost !y the !o%y

He"t !e(#$"t&'( )e't!e * hypothalamus

Heat production)"#%ed +y &')!e"%&'( )e$$ met"+o$&%m

Tye% o, t-e!momete!%:

me!)#!y&'($"%%

e$e)t!o'&)

)-em&)"$


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O*+ TEM,E-AT.-E

O*+ TEM,E-AT.-E S+M,TOMS

/ypothermia

/ 30

S&' "$e'e%%

T&!ed'e%%

Normal

30 * 3045 6 57.08 * 199. 8

Lo;e%t < * 0"m

H&(-e%t * 0m

Py!e=&" 6 %$&(-t ,e>e!

3?49 * 3?45

Pe!%&!"t&o'

S&' !ed'e%%

He"d")-eFe"er

37

P!e%e')e o, &',e)t&o' @ +ody de,e')e

Ge'e!"$ ;e"'e%%

T")-y)"!d&" 6 -ye!'e"

S&' "$e'e%%6!ed'e%%

S-&>e!%

Pe!%&!"t&o'


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O*+ TEM,E-AT.-E

-O.TES FO- MEAS.-ING T/E O*+ TEM,E-AT.-E

0 O-AL

A1ILLA-+

0T+M,ANI&

I' t-e e"! )"'"$

0 -E&TAL

T-!o#(- t-e "'#%4 &' t-e !e)t#m.


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Types o2 thermometers

* Ele#troni#

Thermometers* Glass Thermometers

* Thermometer

/an%les


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3 ,.LSE

E4pansion o2 an artery ith ea#h hart !eat

e"%#!&'( te)-'e% 6 $")e% o, "%%e%%&'(:

PALPATION

". )"!ot&%

". +!")-&"$&%4 ra%ialis

". ,emo!"$&%4 o$&te" et).

AUSULTATION

%tet-o%)oe


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A a"e o2!loo% 2lo

#reate% !y a

#ontra#tion o2the heart


10/21

&hara#teristi#s o2 the ,ulse

* ,ulse -ate

Assesse% as !eats per minute5 or ,M &ounte% 2or '65 375 875 or 97 se#on%s Ta#hy#ar%ia: a pulse rate 2aster than

normal ra%y#ar%ia: a pulse rate sloer than

normal


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,.LSE

PULSE RATE

No!m"$ 09 * 59 6m&'

B!"dy)"!d&" /


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8 -ES,I-ATION

-espiration(-)is the a#t o2 !reathing*

-ate o2 -espiration: the num!er o2 !reathsper minute

Normal range is '3 to 37 !reaths per minute

2or an a%ult

-ate ill "ary ith age an% si;e o2 #lient


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* -ate o2 -espiration (#ont) An in#rease% respiratory rate is #alle%

hyper"entilation A %e#rease in respiratory rate an% %epth is

#alle% hypo"entilation* -hythm o2 -espiration: shoul% !e regular*


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-ES,I-ATION

NORAL RESPIRATIONS E,,o!t$e%%

Re(#$"! Smoot-

AFERAGE RESPIRATIONS

I',"'t to 2 ye"!% 2*36m&' To #+e!ty 29206m&' Ad#$t% 12176m&'

RESPIRATORY RATE No!m"$ 12 * 29 6 m&'

B!"dy'e" / 19 6 m&' T")-y'e" 2< 6 m&' A'e"

RESPIRATORY RHYTH

No!m"$ Dy%'e" e=e!t&o'6!e%t -ey'e%Stoe% !e%&!"t&o'

&!!e(#$"! dee6%$o;6%-"$$o; K#%%m"#$% +!e"t-&'(dee


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= LOO* ,-ESS.-E (,)

loo% pressure(,)is the pressure or

tension e4erte% on the arterial alls as!loo% pulsates through them


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E4pe#te% loo% ,ressure Values* E4pe#te% S,: '77 to '=7 mm /g* E4pe#te% *,: 97 to >7 mm /g* /ypotension: hen the !loo% pressure %rops

!elo e4pe#te% le"els* /ypertension: high !loo% pressure


17/21

Sites 2or loo% ,ressure Assessment

* ra#hial

* -a%ial

* ,opliteal

* *orsalis pe%is an% posterior ti!ial


18/21

Euipment 2or Measuring loo% ,ressure

* loo% pressure is measure% using a

sphygmomanometer5 also #alle% a , #u225 or

#u22


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A%%e%%me't:

Normal 1291960979 mmH(

/ypertension 1


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-E,ETITION

1. W-"t &% " >&t"$ %&('2. e't&o'ed )o'te't% " >&t"$ %&('

3. e't&o'ed tye% o, t-e!momete!%

. W-"t &% " B$ood !e%%#!e A'd me't&o'ed E=e)ted B$oodP!e%%#!e F"$#e%


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T/AN@ +O.

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