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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$s #on%ition
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7/24/2019 ppt b.ing ttv
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&ONTENTS
Body teme!"t#!e
P#$%e
Re%&!"t&o'
B$ood !e%%#!e
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' O*+ TEM,E-AT.-E
alan#e !eteen heat pro%u#e% an% heat lost !y the !o%y
He"t !e(#$"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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7/24/2019 ppt b.ing ttv
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Types o2 thermometers
* Ele#troni#
Thermometers* Glass Thermometers
* Thermometer
/an%les
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7/24/2019 ppt b.ing ttv
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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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7/24/2019 ppt b.ing ttv
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A a"e o2!loo% 2lo
#reate% !y a
#ontra#tion o2the heart
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&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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7/24/2019 ppt b.ing ttv
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,.LSE
PULSE RATE
No!m"$ 09 * 59 6m&'
B!"dy)"!d&" /
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7/24/2019 ppt b.ing ttv
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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"#$% +!e"t-&'(dee
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7/24/2019 ppt b.ing ttv
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= LOO* ,-ESS.-E (,)
loo% pressure(,)is the pressure or
tension e4erte% on the arterial alls as!loo% pulsates through them
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E4pe#te% loo% ,ressure Values* E4pe#te% S,: '77 to '=7 mm /g* E4pe#te% *,: 97 to >7 mm /g* /ypotension: hen the !loo% pressure %rops
!elo e4pe#te% le"els* /ypertension: high !loo% pressure
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Sites 2or loo% ,ressure Assessment
* ra#hial
* -a%ial
* ,opliteal
* *orsalis pe%is an% posterior ti!ial
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Euipment 2or Measuring loo% ,ressure
* loo% pressure is measure% using a
sphygmomanometer5 also #alle% a , #u225 or
#u22
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7/24/2019 ppt b.ing ttv
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A%%e%%me't:
Normal 1291960979 mmH(
/ypertension 1
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-E,ETITION
1. W-"t &% " >&t"$ %&('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.