ENGLISH PAPERS

VITALS SIGNS
Supporting lecturer : Nurul Arifah, S.Kep.,Ns.,S. Pd., M. Telf

Arranged by :
1. Cindy Anggita Putri (191141012)
2. Deonizio Cajusticolo (191141014)
3. Lailatul Mafruhah (191141037)
4. Rizki Ridha Alief Yana (191141055)
5. Satya Julianti Anggraeini (191141060)
6. Suciana (191141066)
7. Ziyanatur Roziqoh (191141069)

S1-Nursing semester IV
INSTITUT KESEHATAN DAN BISNIS SURABAYA

Academic Year 2020-2021

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 FOREWORD

Gratitude for the presence of ALLAH SWT, who has always bestowed His Grace and
Hidayah so that we are all in good health in carrying out our daily activities. The compilers also
proclaim the presence of ALLAH SWT, because only with His wisdom this paper with the title
"Vital Signs" can be completed. We are fully aware that without the help of various parties, this
paper will not be realized and is still far from perfect, therefore with all humility the author hopes
for suggestions and criticism for further improvements.

Finally, the authors hope that this paper can be of benefit to all readers and those in need.

Surabaya, 20 May 2021

Compiler

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 TABLE OF CONTENT
Cover
Foreword .......................................................................................................................................ii

Table of
Content............................................................................................................................iii

Chapter I Introduction
1.1 Background ....................................................................................................................1
1.2 Formulation of the problem...............................................................................................1
1.3 Destination.........................................................................................................................1

Chapter II Discussion
2.1. Definition of Vital Sign / TTV
examination.....................................................................2
2.2. Types of vital examination Sign / TTV and examination
procedures..............................2
2.3. Role Play Vital
Signs........................................................................................................11
Chapter III Clossing
3.1 Conclusion........................................................................................................................12
3.2 Suggestion .......................................................................................................................12
Bibliography

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 CHAPTER I
INTRODUCTION
1.1 Background
The measurements most often taken by health practitioners are temperature, pulse, blood
pressure and respiratory rate measurements. As indicators of health status, these measures
indicate the effectiveness of circulation, respiration, neural and endocrine functions of the
body, because they are so important they are called vital signs. Vital sign measurements
provide data to determine the client's usual health status. Changes in vital signs can also
indicate the need for nursing and medical interventions.
In the medical world, the vital sign is a value used to measure basic body functions. The
patient's vital sign is very important for monitoring. Vital sign monitoring is done to
determine or analyze a person's physical health in general, show illnesses that a person may
have, and show progress in one's health. Usually differences in the patient's normal vital sign
are based on differences in age, sex, or body weight. The patient's vital sign was observed
periodically by the paramedics every hour.
Vital sign examination is a way to detect changes in body systems. Vital signs include
blood pressure, pulse, body temperature, respiratory rate, body temperature, body weight,
and height. Vital signs have a very important value for bodily functions. Paramedics make
vital sign reports that are running at the time of observation. The vital sign was reported to
the doctor for further analysis. Elliott and Conventry explained that there are eight vital signs
that can be used to monitor patient health, but there are four vital signs that are most
important, namely body temperature, blood pressure, and breath.

1.2 Formulation of the problem

1. What is the meaning of examination of vital signs?
2. What are the Vital sign checks / TTV examination and how are the procedures for the
examination.
1.3 Destination
1. To know the meaning of a vital sign / TTV examination.
2. To find out the Vital sign / TTV examination and the inspection procedure

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 CHAPTER II
DISCUSSION
2.1. Definition of Vital Sign / TTV Examination.
Vital Sign Examination is a way to detect changes in body systems. Vital signs include
body temperature, pulse, respiratory rate and blood pressure. Vital sign examinations
performed by nurses are used to monitor the patient's progress. This action is not only a
routine activity for the client, but is an act of monitoring for changes and disorders of the
body's systems. Examination of vital signs on all clients is different from others. The level of
emergency of the patient as in a critical patient condition will require monitoring of changes
or disorders of body systems.
Vital signs are a fast and efficient way to monitor the client's condition or identify
problems and evaluate the client's response to intervention. Vital signs or basic signs include
temperature, pulse, respiration and blood pressure. As indicators of health status, these
measures indicate the effectiveness of circulation, respiration, neural and endocrine
functions of the body, because they are so important they are called vital signs.
According to Potter and Perry (2005) vital sign measurements are needed when:
1. When a client enters a Health care facility
2. In the hospital or nursing facility on a regular schedule according to the doctor's program
or standard practice of the institution.
3. Before and after the surgical procedure.
4. Before and after administering medications that affect cardiovascular, respiratory and
temperature control functions.
5. Before and after nursing interventions that affect vital signs.
6. When clients report symptoms of non-specific physical disters.
2.2. Types of vital examination Sign / TTV and examination procedures
There are four types of vital Sign / TTV examinations, namely :
1. Examination of Body Temperature
Body temperature is the difference between the amount of heat produced by
bodily processes and the amount of heat lost to the outside environment. Surface
temperature fluctuates depending on blood flow to the skin and the amount of heat lost
to the outside environment. Examination of body temperature can be measured in several

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easily accessible places, including in the armpit (axilla), mouth (oral), ear (tympanic),
rectum (rectal), and on the forehead (forehead). The instrument used to check body
temperature is a thermometer, of which there are two types, namely a digital
thermometer and a mercury thermometer.
a. Digital Thermometer

With the advancement of technology, mercury thermometers, which have been

the standard in measuring human body temperature for hundreds of years, both in
clinics and at home, are slowly being replaced by digital thermometers. Digital
thermometers are becoming popular because the time required to measure temperature
is relatively fast. For a digital thermometer, a thermocouple is usually used as the
sensor. In detail, the working principle of a digital thermometer can be explained as
follows: A sensor in the form of a PTC or NTC with a high sensitivity level will
change its resistance value if there is a change in temperature that hits it. Changes in
resistance value are linear with changes in current, so that the value of this current can
be converted into a display form. Before being converted, the current value is
compared with the reference value and the offset value on the comparator, its function
is to translate each ampere unit into volts to be converted to the display.
b. Mercury Thermometer

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 On a mercury thermometer, there is a narrow indentation on the top of the
container. When used to measure a person's body temperature, the mercury in the
container expands through the narrow indentation and shows the position of that person's
body temperature. When the thermometer is removed from the measuring site, the
mercury cannot return to its original position because the gap is too narrow. Thus, the
position of the mercury will continue to show the person's temperature until the
examiner has finished reading the temperature. The mercury can return to its original
position by shaking the thermometer several times.
Factors that affect body temperature include:
Many factors affect body temperature including :
a. Age
The body temperature of women and men 60 and older is lower than that of
younger people, and their tolerance for temperature extremes is more limited.
Regulation of body temperature does not depend on a single organ, but involves
almost all body systems. As we age, the systems in the body will decline in function,
as well as the systems that regulate body temperatur. it involves almost all body
systems. As we age, the systems in the body will decline in function, as well as the
systems that regulate body temperature
b. Weather changes
Changes in weather, climate or season affect evaporation, radiation, convection,
conduction and thus affect metabolism and body temperature.
c. Gender
Gender In men, there is a high testosterone hormone. This results in an increase in
the metabolic rate in the body. In women, the temperature tends to increase during
menstruation or menstruation, and when ovulating occurs an increase in temperature
of 0.3 - 0.5 ° C in the morning due to the production of the hormone progesterone.
d. Food intake
One that affects the body's metabolic rate is food intake. Food-induced heat
generation increases over 12 hours due to increased metabolic activity associated
with nutrient processing and storage, particularly by biochemical processes.
e. Stress

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 Thermoregulation in humans is a complex process under the control of the central
nervous system, and core and peripheral temperatures in humans will respond
differently to exposure to stress.30 According to the theory, when stressed, post
ganglion neurons will release norepinephrine (NE) and will also trigger the release of
the hormones epinephrine and 10 NE so that there is an increase in cell metabolism
in the body which results in an increase in body temperature.

Normal body temperature between 36 ° C-37.5 ° C An abnormal body

temperature can be called :
a. Hypothermia, namely body temperature less than normal
b. Hyperthermia, namely body temperature more than normal
Temperature measurement place :
Core temperature :
1) Rectum
2) tympani membrane
3) Esophagus
4) Pulmonary artery
5) Bladder
Surface temperature :
1) Rectal
2) Axillary
3) Oral
4) Tympanic / Auricular
Procedure for Measuring axillary temperature using a mercury thermometer:

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 1. Lower the mercury on the thermometer so that the mercury in the thermometer
points to 35 ° C or below.
2. Place the thermometer in the axillary crease. The axillary fold must be dry. Make
sure the thermometer is against the skin and not obstructed by the patient's clothes.
3. Pinch the axilla by pressing the patient's arm against the body
4. Wait 3-5 minutes. Read the temperature on the thermometer.
5. Wash the thermometer with soapy water and then clean water. Then lower the aksa
water back in the thermometer.
2. Pulse Check
Pulse (ulse) is a vibration / pulse of blood in the arteries due to contraction of the
left verticle of the heart. This pulse can be felt by palpation, namely using the fingertips
along the way the arteries run, especially in places where the bone protrudes slightly
above the arterial blood vessels. In general, there are 9 places to feel the pulse, namely
temporal, carotid, apical, brankial, femoral, radial, popliteal, dorsalis pedis, and
posterior, but what is often done is :
Radial artery: is located along the radial bone, more easily over the wrist on the side of
the thumb. Relatively easy and often used regularly.
Branchial Artery : Located in the biceps ptot of the arm or medial in the crease of the
elbow (antecubital fossa) It is used to measure blood pressure in cases of cardiac arrest
in infant.
Carotid Artery: Located in the neck below the ear lobe, where there is a carotid artery
running between the trachea and the sternocleidomastoid muscle. Often used for bayo,
cardiac arrest cases and to monitor blood circulation to the brain.
The frequency of the human pulse varies, depending on the many factors that influence
it, during normal activities:
- Normal: 60-100 x / minute
- Bradikardi: <60 times / minute
- Takhikardi:> 100 x / minute
Pulse Frequency Check Procedure :
Destination :
1. Knowing the frequency, rhythm, and depth of breathing.

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 2. Assess the ability of respiratory function.
Tools and Materials :
1. The watch (clock) or stop-watch
2. Notebook
3. Pen
Work procedures :
1. Explain the procedure to the client.
2. Wash your hands.
3. Position the patient (human trials).
4. Calculate the frequency and rhythm of breathing.
5. Record the results.
6. Wash hands after the procedure.
3. Blood Pressure Check
Blood pressure checks are obtained from measurements of the arterial circulation.
Blood flow due to pumping the heart creates a wave, namely a high wave called systolic
pressure and a wave at the lowest point, which is called diastolic pressure. The unit of
blood pressure is expressed in millimeters of mercury (mmHg). In normal healthy adults,
normal systolic pressure ranges from 90-140 mmHg and generally increases with age.
The normal value of diastolic pressure ranges from 60-90 mmHg. Pulsus pressure varies
between systolic and diastolic pressures. Hypertension in adults is characterized by a
blood pressure equal to or greater than 140/100 mmHg.
Things that must be considered before doing blood pressure checks :
It is better if before doing the examination make sure the patient's bladder is empty and
avoid consuming coffee, alcohol and cigarettes, because all these things will increase the
blood pressure from the actual value. We recommend that you rest and sit quietly for 5
minutes before the examination and do not speak during the examination. Calm the
patient's mind, because tense and stressful thoughts will increase blood pressure.

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 Blood Pressure Check Procedure :

Some steps are taken to check blood pressure using a mercury sphygmomanometer:
1. Place the cuff on the upper arm, with the lower limit of the cuff 2-3 cm from the fold
of the elbow and note the position of the cuff tube that will press just above the
pulsation of the folded artery of the elbow (brachial artery).
2. Place the stethoscope directly over the brachial artery.
3. Feel for the pulsation of the artery in the wrist (radial artery).
4. Inflate the cuff until the cuff pressure reaches 30 mmHg after the radial artery pulse
has disappeared. 5. Open the cuff valve and allow the cuff pressure to decrease slowly
at a rate of 2-3 mmHg / s.
5. When you hear the first sound, remember it and record it as systolic pressure.
6. The last sound that is still heard is recorded as the diastolic pressure
4. Examination of respiratory frequency
Respiration is the body's mechanism of using air exchange between the
atmosphere and blood and blood and cells. The respiratory mechanisms include:

1) Ventilation, namely the movement of air into the outside of the lungs.
2) Diffusion, namely the exchange of O2 & CO2 between alveoli & red blood cells.
3) Perfusion, namely the distribution by red drh cells to and from blood capillaries.
Things that need to be considered in the assessment of breathing:
1) Respiratory frequency
The nurse observes full inspiration and expiration when calculating the
frequencyventilation and breathing. Normal respiratory rate drops t hroughout life.
2) Depth of exhalation

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 Depth is assessed by observing the degree of deviation or movement of the walls
chest. The nurse described ventilator movements as deep, normal and shallow. Deep
breathing involves the full expansion of the lungs with exhalation full.
3) The rhythm of breathing
With normal breathing regular intervals occur after each breathing cycle. Baby tend
to lack regularity in breathing. Little children may have a parent slowly for a few
seconds and then suddenly breathe rapidly. Regular and irregular breathing rhythm.
Respiratory rate is normal according to age.

Respiration Rate Average Normal by Age

Age Frequency
Newborn baby 35-40 x/minute
Infant (6 Months) 30-50 x/minute
Toodler (2 Years) 25-32 x/minute
Children 20-30 x/minute
Youth 16-19 x/minute
Adult 12-20 x/minute

Disturbances in breathing pattern :

1) Bradipnea: Breathing is regular but abnormally slow (breathing less than 12x / minute).
2) Tachypnea: Breathing regularly but abnormally fast (breathing more than 20x / minute).
3) Hypernea: Difficulty breathing, deep, more than 20x / minute. Normally occurs after
exercise.
4) Apnea: Breath stops for a few seconds.
5) Hyperventilation: Increased frequency and depth of breath.
6) Hypoventilation: Abnormal breathing rate in rate and depth.
7) Cheyne stokes inhalation: Irregular breathing frequency and depth is characterized by
changing periods of apnea and hyperventilation.
8) Kussmaul's inhalation: abnormal deep breathing with an increased frequency of breaths.
9) Biot inhalation: Abnormally shallow breathing followed by periods of irregular apnea
(stopping breathing).

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 Respiratory examination procedure:

1) Inspection examination: Pay attention to the patient's breathing movements as a whole

(do an inspection without affecting the patient's psychology). On inspiration, pay
attention to: movement of the ribs to the lateral direction, widening of the epigastric
angle, the presence of chest wall retraction (supraclavicular, suprasternal, intercostal,
epigastric), use of accessory breathing muscles and increasing anteroposterior size in the
chest cavity. On expiration, note: Re-insertion of the ribs, narrowing of the epigastric
angle and a reduction in the anteroposterior diameter in the thoracic cavity.
2) Palpation examination: the examiner places the palm of the hand to feel it rising
decreased chest wall motion.
3) Auscultation examination: using a stethoscope membrane that is placed on chest wall
outside the location of the heart sound.

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2.3 Role Play Vitals Signs
Role Play Vitals Signs
07.00
Nurse 1: Good morning mom.
Patient: Good morning.
Family 1: Early morning.
Nurse 1: Is this true with Ziyan’s mother?
Family 1: Yes, that’s right. I’m his family. What’s up, Sus?
Nurse 1: OK, here I am nurse ____. Here I am on a morning shift, ma’am, from 7 am to 2
pm.
Family 1: Oh, yes sus.
Nurse 1: Good ziyan mom. This morning I will do a TTV examination, as a reference for
the next nursing action. Is ziyan mother willing.
Patient: Good sus. I am willing?
Nurse 1: For this TTV check, I will check your blood pressure, body temperature, pulse,
and breath. Did you ask Ziyan’s family or mother?
Patient: None
Family 1: No thanks.
Nurse 1: Very well then. Immediately, ma’am.
The examination was carried out ................
Nurse 1: Fine mom, this is over. Later my colleague will come here again around 3 pm,
Ma’am, to see your development. Is there anything you want to ask mom?
Patient: Not successful. Thank you
Nurse 1: Fine, then I’ll say goodbye, ma’am. Good morning.
Patient: Morning
Family 1: Early morning. Thank you.

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 CHAPTER III
CLOSING
3.1 Conclusion
Vital signs are a fast and efficient way to monitor the client's condition or identify
problems and evaluate the client's response to intervention. Vital sign assessment enables
the nurse to identify nursing diagnoses, implement an intervention plan and evaluate
success when vital signs are returned to acceptable values.
3.2 Suggestion
Hopefully the results of this paper can be of benefit to readers both now and in the
future. The author apologizes if there are errors and deficiencies in this paper, because the
author is still in the learning stage. The author asks readers for criticism and suggestions
for the perfection of this paper.

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 BIBLIOGRAPHY

Potter & Perry. 2005. Textbook of Nursing Fundamentals. Concepts, processes and practices.
Jakarta: EGC.
Vital Signs Examination Procedure. Keperawatan.umm.ac.id, accessed on 11 October 2015.
Kozier, et al. 2016 Nursing Fundamentals Textbook. Concepts, Processes and Practices. Jakarta:
EGC.
Writers Team of Poltekkes Depkes Jakarta III. (2009). Practical Guidelines for Basic Human
Needs I.
Competency-Based. Jakarta: Salemba Medika. Muttaqin, Arif. (2011). Nursing Assessment.
Application in Clinical Practice. Jakarta: Salemba Medika.

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