TANDA TANDA VITAL

SUHU TUBUH DAN NADI

Oleh
Devi Permata Sari S.Kep.,Ns.,MAN

STIKES Muhammadiyah KLaten

VITAL SIGN

Blood Temperature Pulse Respiratory

Pressure Rate

 Vital Sign

 Indicate
the function of some of the body’s homeostatic
mechanism
 Indicate health status
 Humans could maintain a consistent internal body temperature independent of
the outside environment
 Body temperature depends on :
1. Environmental condition
2. Physical activity

1. BODY TEMPERATURE
BODY TEMPERATURE
MEASURENMENT
 Body temperature regulation requires the
coordination of many body system.
 Thermoregulatory center in the ANTERIOR
HYPOTALAMUS
 It can sense small changes in body temp
and stimulates the responses in the nervous
system, circulatory system, skin, and sweet
glands to maintain homeostasis.

Heat production = heat loss

REGULATION OF BODY TEMPERATURE

Produces heat known as metabolism

BMR reflect the amount of energy the body uses

Physical exercise, increase production of thyroid hormones

and stimulation of the sympathetic nervous system can
increase heat production

1. HEAT PRODUCTION
 Radiation Conduction

2. HEAT LOSS
Convection
 Age Environment Time of day

Exercise Stress Hormones

FACTOR AFFECTING BODY

TEMPERATURE
1. ORAL

 A common site is the mouth

 Adventages :
 Easy access
 Patient comfort
 Drinking Cold or hot liquid can affect
temperature measurenment
 Not safe for infant, young children ,
unconscious patient, seizure disorder

ASSESSING BODY
TEMPERATURE
SITES
2. RECTAL

 Most accurate
 Commonly used clinically
 Less invasive procedures
 Petient feels discomfort and embarrassement
 Avoid placing into fecal material
 Contraindicated: Diarrhea, rectal surgery, rectal cancer

ASSESSING BODY TEMPERATURE

SITES
3. EAR

 Easily and safely

 Reflect core body temperature  membrane tympanic
receive its blood supply from the same vasculature that
supplies the hypothalamus
 Accessible for very young, confused or unconscious patient

ASSESSING BODY TEMPERATURE

SITES
4. FOREHEAD (TEMPORAL ARTERY)

 Fast, safe measurenment

 Tolerated by infants and young children
 Consistent when taken on either the right or left site
 Affected by air blowing over the face

ASSESSING BODY TEMPERATURE

SITES
5. AXILLARY

 Least reliable
 Many factor thet influence the reading

ASSESSING BODY TEMPERATURE

SITES
 Oral Axillary Rectal Tympanic
97.6 ° – 99.6° F 96.6° - 98.6° F 98.6° - 100.6° F 98.2° - 100.2°F
36.5° – 37.5 °C 35.8° - 37.0° C 37.0° - 38.1° C 36.8° - 37.9°C

NORMAL ADULT TEMPERATURE RANGES

FROM DIFFERENT BODY SITES
 Contraction of the ventricles of the heart eject blood into the arteries
 The force of blood entering the aorta from the left ventricle causes stretching or
distention of the elastic aortic wall
 Pulse created when the aorta first expands and then contract
 Pulse can be felt as tap where the arteries lie close to the skin surface

2. PULSE
 Frequency : number of pulse per minute

Rhythm : regularity

Quality : strength of the palpated pulsation

CHARACTERISTIC OF PULSE
 Autonomic
Age Nervous System Medication
Depend on ages Stimulation of Digoxin : decrese
parasympathetic pulse
nervous system Diuretic : increase
(resting state) pulse
decrease the
pulse
Sympathetic
system (pain,
activity, anxiety,
fever) pulse
increased

FACTORS AFFECTING PULSE RATE

 Ages Pulse (beat/minutes)
Newborn (>96h) 70 – 190
Infant (>1mo) 80 – 160
Toddler 80 – 130
Preschool 80 – 120
School Ages 75 – 110
Adolescent 60 – 90
Adult 60 - 100
Older Adult (>70yo) 60 – 100

PULSE RANGE ACROSS THE LIFESPAN

ASSESSING THE PULSE
1. SITES
 Stethoscope
Auscultation at the apical pulse
 Doppler ultrasound device
To detect peripheral pulses

ASSESSING THE PULSE

2. EQUIPMENT
Palpation
 Palpated using second or third fingers of one hand
 Count the number of pulses for 30 or 60 seconds
 Patient with irregular or abnormal slow or fast pulse assessed for 1
full minute

ASSESSING THE PULSE

3. METHODS
Rate
 Adults normal rate : 60 – 100 beat/minutes
 Tachychardia >100 beat/minutes
 Bradycardia <60 beat/minutes

ASSESSING THE PULSE

CHARACTERISTIC
Rhytm
 Normally , Cardiac contraction occurs at evenly spaced intervals  Regular
Rhythm
 Infants and children increased pulse rates during inspiration and decreased rates
during expiration
 Regularly Irregular : irregular pulse rhythm that still display a consistant pattern
 Irregularly irregular : pulse has no pattern

ASSESSING THE PULSE

CHARACTERISTIC
Quality
Strength of pulsation

ASSESSING THE PULSE

CHARACTERISTIC