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TEAM 8 5

Arbainah
Devi Anggraeni
Ginti Mei Istiqomah
Isti Rahayuni
M. Zaunul Arief
Pransiska Aprilia
Vital signs are measurements of the body's most basic
functions. The four mainvital signs routinely
monitoredby medical professionals and health
care providers include the following:
 Body temperature
 Pulse rate
 Respiration rate
 Blood pressure
TEMPRATURE

The pulse is throbbing or perceived encouragement from the pumping of


the heart. Temperature probe used to assess the condition of the metabolism in the
body, which the body produces a chemical heat through metabolism of blood.
Equilibrium temperature should be regulated in the disposal and storage in the
body are regulated by the hypothalamus.
Someone said normal body temperature, if temperature is at 36 ºC -
37,5˚C. Someone said low body temperature (hypopirexia / hypopermia), if body
temperature <36ºC
 Kinds of a temperature measurement
 Kinds of a temperature measurement
1, axillary temperature 1, axillary temperature
a temperature measurement techniques are less accurate than the third
a temperature measurement
measurement technique
techniquesbecause
are lessthe thermometer
accurate than theshould
third be placed
outsidetechnique
measurement the bodybecause
than in the
the body. Normalshould
thermometer temperature: 36º C - 37.5º c
be placed
outside the body than in the body. Normal temperature: 36º Cpreparation
- 37.5º c tools:
a. Thermometer
preparation tools: b. Three bottles
a. Thermometer c. The first bottle containing a solution of soap
b. Three bottles d. second bottle containing a disinfectant solution
c. The first bottle containing a solution of soap e. third bottle containing water
d. second bottle containing a disinfectant solution f. Crooked
e. third bottle containing water g. Paper / wipes
f. Crooked h. Vaseline
g. Paper / wipes i. Book temperature records
h. Vaseline j. Gloves
i. Book temperature records
j. Gloves
work procedures
1. Explain the procedure to the client
2. Wash your hands
work 3.
procedures
Use gloves
4. Adjust the position of the patient
1. Explain the procedure
5. Determine to the
the location client
of the axilla (armpits) and clean the axillary
2. Wash yourregionhands
by using tissue
Lower the temperature of the thermometer under anatara 34C - 35˚C.
3. Use 6.gloves
7. Put
4. Adjust thethe thermometer
position of theinpatient
the axilla region and the patient's arm flexed
5. Determineover the
the chest (chestofclasp)
location the axilla (armpits) and clean the axillary
8. After 3-5 minutes, remove the thermometer and read the result
region by using tissue
9. record results
6. Lower the temperature of the thermometer under anatara 34C -
10. Clean the thermometer with a paper / tissue
35˚C. 11. Wash thermometer with soapy water, disinfectant, rinse with clean
7. Put the water
thermometer
and dry. in the axilla region and the patient's arm
flexed 12. Wash hands after the procedure is done
over the chest (chest clasp)
8. After 3-5 minutes, remove the thermometer and read the result
9. record results
10. Clean the thermometer with a paper / tissue
11. Wash thermometer with soapy water, disinfectant, rinse with clean
water and dry.
12. Wash hands after the procedure is done
2. RECTAL TEMPRATURE
is through a rectal measurement. This measurement was conducted in patients infants, clients
2. rectal temperature
with surgery or rectal disorder, clients in traction or cast pelvic or lower extremity. normal rectal
temperature: 36.1 to 37.5
is through a rectal measurement. This measurement was conducted in
patients infants, clients with surgery or rectal disorder, clients in traction or
working procedures
cast pelvic or lower extremity. normal rectal temperature: 36.1 to 37.5
1. Explain the procedure to the client
2. Wash your hands working procedures
3. Use gloves 1. Explain the procedure to the client
4. Replace drapes or cover (curtain / door) room. 2. Wash your hands
5. Go to clothes that cover the buttocks client, clothing lowered to below 3. Use gloves
gluteal (buttock below) 4. Replace drapes or cover (curtain / door) room.
6. Adjust 5. Go to clothes
the position that cover
of the patient the
on his buttocks client, clothing lowered to below
side
7. Determine the location rectally, then apply Vaseline around 2.5gluteal -3.5 (buttock below)
6. Adjust the position of the patient on his side
cm for adults and 1.2 to 2.5 cm for infants / children
7. Determine the location rectally, then apply Vaseline around 2.5 -3.5
8. Lower the temperature of the thermometer
cm for adults under
andthe
1.2340C
to 2.5- 350C.
cm for infants / children
9. Place the 8.palms on the gluteal patients, enter into a rectal thermometer
Lower the temperature of the thermometer under the 340C - 350C.
slowly,
9. notPlace
to change the position
the palms on theand temperature
gluteal measuring
patients, enter into a rectal thermometer
slowly,thenot
10. After 3-5 minutes, remove to change and
thermometer the read
position and temperature measuring
the result
11. Record results10. After 3-5 minutes, remove the thermometer and read the result
11. Record results
3. 3. ORALTEMPRATURE
ORAL TEMPRATURE
3. oral temperature
oral temperature
 oral temperature measurements.
measurements. Normal
Normal oraltemperature:
oral temperature: 35.5
35.5 to
to 37.5
oral37.5
temperature measurements. Normal oral temperature: 35.5 to 37.5
work procedures :
work procedures : 1. Explain the procedure to the client.
 work procedures :
1. Explain the procedure to the client. 2. Wash your hands.
1. Explain the procedure to the client. 3. Use gloves.
2. Wash your hands.
2. Wash your hands. 4. Adjust the position of the patient.
3. Use
3. Use gloves.gloves.
5. Determine the location under the tongue
4. Adjust the
4. Adjust the position position
6.of
Lower of the patient.
the temperature of the thermometer under 34ºC - 35ºC.
the patient.
5. Determine
5. Determine the7.location
the location Place
under theunder
the the tongue
thermometer
tongue under the tongue parallel to the gums
6. Lower
6. Lower the temperature
the temperature of the 8.
of the thermometer Encourage
under 34ºCclenched
thermometer -under mouth
35ºC. 34ºC for 3-5 minutes
- 35ºC.
7. Place
7. Place the thermometer
the thermometer under9.the
Remove
under
tonguethe the thermometer
tongue
parallel gumscarefully
parallel
to the to the and
gums read the result
8. Encourage clenched mouth for 3-5 minutes 10. a note results
8. Encourage clenched mouth for 3-5 minutes
11. Clean the thermometer with a paper / tissue
9. Remove
9. Removethe thermometer
12. Wash carefully
the thermometer
the thermometer and readsoapy
carefully
with the result
and read the
water, result rinse with clean
disinfectant,
10. a10.
note resultsresults
a note water and dry.
11. Clean the thermometer with a paperor / tissue thermometer return to the initial scale.
11.13. Lower
Clean thelevels of
thermometermercury with adigital
paper / tissue
12. Wash the thermometer with soapy water, 14. Wash hands
disinfectant, rinse after the procedure
with clean water and is done
dry.
12. Wash the thermometer with soapy
13. Lower levels of mercury or digital thermometer return water, disinfectant,
15.toDocument rinse with clean
in nursing records.
the initial scale.
waterhands
14. Wash and after
dry. the procedure is done
13. Lowerinlevels
15. Document nursingofrecords.
mercury or digital thermometer return to the initial
scale.
B. Pulse Rate B. PULSE RATE
Is a way checks are performed to determine the pulse. The
Is a way checks areisperformed
pulse an indicatortofordetermine
assessing thethe pulse. The system.
cardiovascular pulse
is an indicator formeasured
Speed assessing the
pulse cardiovascular
is measured system.
at several points eg the radial
Speed measured pulse is measured at several points eg the
arterial pulse at the wrist, the brachial artery in the upper arm, the carotid
radial arterial pulse at the wrist, the brachial artery in the upper
arterythe
arm, in the neck, on
carotid the back
artery of the
in the kneeon
neck, popliteal
the backartery,
of the
theartery
kneedorsalis
popliteal artery, the artery dorsalis pedis
pedis or or posterior
posterior tibial
tibial arteries in the legs.
arteries in the legs.
Normal pulse: 60-80 times per minute
Normal pulse: 60-80 times per minute
PULSE RATE
 Tools and materials

1. Watches (clock) or stopwatch


2. Logbook pulse
3. Pena

work procedures

1. Explain the procedure to the client


2. Wash your hands
3. Adjust the position of the patient (humans try)
4. Put both arms stretched out on the side of the body
5. Determine the location of the artery (the pulse to be counted)
6. Check the pulse (arteries) with meng¬gunakan tip of the index finger,
middle finger and ring finger. Determine the frequency per minute and
regularity of the rhythm, and the strength of pulses.
7. Record the results.
8. Wash hands after the procedure is done
RESPIRATION RATE
RESPIRATION RATE
The respiration rate is the number of
The respiration rate is the number of breaths a person takes per minute. The
breaths a person takes per minute. The rate
rateisisusually
usually measured
measuredwhen when a person is at is
a person restatand
restsimply involves counting the
and of
number simply
breathsinvolves counting
for one minute the number
by counting how many times the chest rises.
of breaths
Respiration ratesfor
mayone minute
increase withby counting
fever, howwith other medical conditions.
illness, and
many times the chest rises. Respiration
When checking respiration, it is important to also note whether a person has any
rates may increase with fever, illness, and
difficulty
with breathing.
other medical conditions. When
checking respiration,
Normal respiration it is important
rates for an adult to also at rest range from 12 to 16
person
note whether a person has any difficulty
breaths per minute.
breathing.
Normal respiration rates for an
adult person at rest range from 12 to 16
breaths per minute.
Tools and materials
1. Watches (h) or stop-watch
 Tools and materials 2. Logbook
Watches (h) or stop-watch 3. Pena
Logbook
Pena work procedures
1. Explain the procedure to the client
 work procedures 2. Wash your hands
3.Explain
Adjust the
the position
procedureof the
topatient (humans try).
the client
4. Calculate
Wash your hands the rate and rhythm of breathing.
5. Record the results.Wash
Adjust hands after
the position ofthe
theprocedure
patientis(humans
done.
try).
Calculate the rate and rhythm of breathing.
Record the results.Wash hands after the
procedure is done.
BLOOD BLOODPRESSURE
PRESSURE
Blood pressure, measured with a blood pressure cuff and
Blood pressure,bymeasured
stethoscope a nursewith a blood
or other pressure
health carecuff and stethoscope
provider, is the
by aofnurse
force the or otherpushing
blood health care provider,
against theisartery
the force of theEach
walls. blood
pushing against the artery walls. Each time the heart beats, it pumps
time the heart beats, it pumps blood into the arteries,
blood into the arteries, resulting in the highest blood pressure as the
resulting in the highest blood pressure as the heart contracts.
heart contracts.
The number of normal blood pressure is based on a person's age is:
 The number of normal blood pressure is based on a person's
age is: - Infants under the age of 1 month: 85/15 mmHg
- Infants under the age of 1 month: 85/15 mmHg - Age 1-6 months: 90/60 mmHg
- Age 1-6 months: 90/60 mmHg - Age 6-12 months: 96/65 mmHg
- Age 6-12 months: 96/65 mmHg
- Age 1-4 years: 99/65 mmHg
- Age 1-4 years: 99/65 mmHg
- Age 4-6 years: 160/60 mmHg - Age 4-6 years: 160/60 mmHg
- Age 6-8 years: 185/60 mmHg - Age 6-8 years: 185/60 mmHg
- Age 8-10 years: 110/60 mmHg - Age 8-10 years: 110/60 mmHg
- Age 10-12 years: 115/60 mmHg
- Age 10-12 years: 115/60 mmHg
- Age 12-14 years: 118/60 mmHg
- Age 14-16 years: 120/65 mmHg - Age 12-14 years: 118/60 mmHg
- Age 16 years and over: 130/75 mmHg - Age 14-16 years: 120/65 mmHg
- Elderly: 130-139 / 85-89 mmHg - Age 16 years and over: 130/75 mmHg
- Elderly: 130-139 / 85-89 mmHg
Tools and materials
1, sphygmomanometer (tensimeter) consisting of
 Tools and materials 2. Stethoscope
1, sphygmomanometer (tensimeter) consisting of
3. Logbook vital signs
2. Stethoscope
3. Logbook vital signs 4. Pena
4. Pena
The working procedure
 The working procedure (How palpation)
Explain the procedure to the client.
 How palpation
Wash your hands.
1. Explain the procedure to the client.
2. Wash your hands. Adjust the position of the patient
3. Adjust the position Placeof thethe arm to be measured in the supine position.
patient
4. Place the arm to be measured in the supine position. sleeve in the open.
Put the5.cuff
sleeve in right
on the the open.
arm / left over approximately 3 cm above the cubital fossa
6. Put the cuff on the right arm / left over approximately 3 cm
(not too tight or too loose)
7.above the cubital fossa (not too tight or too loose)
Determine the radial artery pulse dekstra / sinister
8. Determine the radial artery pulse dekstra / sinister
9. Wash hands after the procedure Wash hands after the procedure is done.
is done.
10. Pump air balloon cuff until the radial artery pulse was not
palpable
9. Pump air 11.balloon
Pump cuff until the
continues radial
until artery pulse
manometer wasasnot
as high 20 palpable
mm Hg
10. Pump continues
higheruntil
than manometer
the point ofasnohigh as 20 radial,
palpable mm HgPut higher than the of
the diaphragm
the stethoscope over the brachial pulsepoint and
of noballoon
palpable radial
cuff is
11. Put the diaphragmslowly
of the and
stethoscope over the
continuously brachialthe
by turning pulse andonballoon
screw the air cuff
pump
is slowly and continuously by turning the screw on the air pump anticlockwise.
anticlockwise.
12. Write down the first
12. time
WritemmHg manometer
down the first timepalpable pulse back. palpable
mmHg manometer This value pulse
back. This value indicates
indicates the
the systolic
systolic pressure
pressure by
by palpation.
palpation.
13. Record the results. 13. Record the results.
14. Wash hands14. afterWash hands after
the procedure the procedure is done.
is done.

 How to auscultation How to auscultation


1. Explain the procedure to thethe
1. Explain client.
procedure to the client.
2. Wash your hands. 2. Wash your hands.
3. Adjust the position3. of Adjust
the patient
the position of the patient
4. Place the arm to be measured in the supine position.
4. Place the arm to be measured in the supine position.
5. Open sleeves.
6.Put the cuff on the right arm / left over 5. approximately
Open sleeves.3 cm
6. Put the cuff on the the
above rightcubital
arm / fossa
left over
(notapproximately
too tight or too3 loose).
cm above the
cubital fossa (not too tight or too loose).
7. radial artery pulse deks¬tra / the left.
8. Pump air balloon cuff until the radial artery pulse was not palpable.
7. 9.
Radial artery
Pump pulse dekstra
continues / the left. as high as 20 mm Hg from the radial
until manometer
8. Pump air balloon cuff until the radial artery pulse waspoint not palpable.
is not palpable.
9. Pump continues until manometer as high as 20 mm Hg from the radial
10. Put the diaphragm of the stethoscope over the brachial artery and listen.
point is not palpable.
10. 11. balloon
Put the cuff is of
diaphragm slowly and continuously
the stethoscope over the bybrachial
turning artery
the screw
and on the air
listen.
11. balloon cuff is slowly and continuously by turning the pump screwanticlockwise.
on the air
12. Record
pump high mercury manometer when per¬tama times heard back beats.
anticlockwise.
12. Record high mercury manometer when 13. first timeshigh
Record heard back beats.
mercury manometer
13. Record14. highSound
mercury manometer
Korotkoff I: shows the systolic pressure by auscultation
14. Sound Korotkoff I: shows the systolic pressure by auscultation
15. Sound Korotkoff IV / V: shows the diastolic pressure by auscultation.
15. Sound Korotkoff IV / V: shows the diastolic pressure by auscultation.
16. Record the results in the patient 16.record.
Record the results in the patient record.
17. Wash hands after the procedure 17.is done.
Wash hands after the procedure is done.
VITAL SIGNS
THE END

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