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