Pemeriksaan Status Mental,

Antropometri, dan TTV

Oleh:
Ns. Gst. Kade Adi Widyas Pranata, S.Kep., M.S.
Pemeriksaan
Status Mental
 Defining Mental Status
• Mental status  a person’s emotional
(feeling) and cognitive (knowing) function
• Mental health  a state of well-being in
which every individual:
 realizes his or her own potential,
 can cope with normal stresses of life,
 can work productively and fruitfully, and
 able to make a contribution to community
 Relative and ongoing
 Defining Mental Status
• Mental disorder:
 Apparent when a person’s response is much greater than
the expected reaction to a traumatic life event
 Clinically significant behavioral, emotional, or cognitive
syndrome that is associated with significant distress (a
painful symptom) or disability (impaired functioning)
involving social, occupational, or key activities
 Include:
• Organic disorders  caused by brain disease of known
specific organic cause (e.g., delirium, dementia, alcohol
and drug intoxication, and withdrawal)
• Psychiatric mental disorder  in which an organic
etiology has not yet been established (e.g., anxiety
disorder or schizophrenia)
 Mental Status  inferred through assessment
No Individual’s Key Point
behaviors
1 Consciousness Being aware of one’s own existence, feelings, and
thoughts and of the environment
2 Language Using the voice to communicate one’s thoughts and
feelings
3 Mood and Affect  a temporary expression of feelings or state
Affect of mind
Mood  a prolonged display of feelings that color the
whole emotional life (more durable)
4 Orientation The awareness of the objective world in relation to
the self (Person, place, and time)
5 Attention The power of concentration, the ability to focus on
one specific thing without being distracted by many
environmental stimuli
 Mental Status  inferred through assessment
No Individual’s Key Point
behaviors
6 Memory The ability to lay down and store experiences and
perceptions for later recall
Recent memory  evokes day-to-day events
Remote memory  brings up years’ worth of
experiences
7 Abstract Pondering a deeper meaning beyond the concrete
reasoning and literal
8 Thought The way a person thinks; the logical train of thought
process
9 Thought What the person thinks - specific ideas, beliefs, and
content the use of words
10 Perceptions An awareness of objects through the five senses
Components of The Mental Status Examination

A
Appearance B Behavior

C
T
Thought processes
Cognitive Function
& Perception
Parameters Normal Abnormal findings
1. Appearance
a. Posture Erect and Anxiety: sitting on edge of chair or curled in bed, tense
position is muscles, frowning, darting and watchful eyes, restless
relaxed pacing
Depression: sitting slumped in chair, slow walk, dragging
feet
b. Body Voluntary, Anxiety: Restless, fidgety or hyperkinetic appearance
Movements deliberate, Depression and dementia: Apathy & psychomotor slowing
coordinated, Schizophrenia: abnormal posturing and bizarre gestures
smooth and even

c. Dress Appropriate for Organic brain syndrome: Inappropriate dress

setting, season, Schizophrenia or manic syndrome: Eccentric dress
age, gender, combination and bizarre make up
social group
d. Grooming Clean and well Strokes: Unilateral neglect
and hygiene groomed Depression and severe Alzheimer disease: inappropriate
dress, poor hygiene, and lack of concern with appearance
Obsessive compulsive disorders: Meticulously dressed and
groomed appearance and fastidious manner
Parameters Normal
2. Behavior
a. Level of Awake, alert, and aware of
Consciou stimuli from the environment
sness and within the self, respond
appropriately and reasonably
soon to stimuli
b. Facial Appropriate to the situation
Expression and changes appropriately
with the topic
c. Speech Laryngeal sounds effortlessly;
The pace is moderate, and
stream of talking is fluent;
Articulation is clear and
understandable; Word choice
is effortless and appropriate to
educational level, complete
sentences
d. Mood Appropriate to the person’s
and affect place and condition and
change appropriately with
topics
Abnormal findings
Lethargic (or Somnolent), Obtunded, Stupor
or Semi-Coma, Coma, Delirium (Acute
Confusional State)
Parkinsonism and depression: Flat, masklike
expression
Dysphonia: disorder of voice
Dysarthria: disorder of articulation
Aphasia: disorder of language
comprehension and production secondary to
brain damage
Depression: Slow, monotonous speech
Manic Syndrome: rapid-fire, pressured, and
loud talking
Flat affect: lack of emotional response, no
expression of feelings, voice monotonous
Euphoria: excessive well-being, unusually
cheerful or elated
GCS ( Kuantitatif )
Parameter Respon Nilai
Mata Secara spontan 4
Terhadap suara 3
Terhadap nyeri 2
Tidak berespon 1
Verbal Orientasi baik 5
Bingung 4
Penggunaan kata2 tdk tepat 3
Suara tdk dimengerti (mengerang) 2
Suara tdk ada 1
Motorik Mematuhi perintah 6
Melokalisir nyeri 5
Menarik dng fleksi 4
Fleksi abnormal 3
Ekstensi abnormal 2
Tidak berespon 1
 Interpretasi
• Hasil pemeriksaan tingkat kesadaran berdasarkan GCS
disajikan dalam simbol E…V…M…
• Selanjutnya nilai-nilai dijumlahkan. Nilai GCS yang tertinggi
adalah 15 yaitu E4V5M6 dan terendah adalah 3 yaitu
E1V1M1
• Setelah dilakukan scoring maka dapat diambil kesimpulan:
 Compos Mentis (GCS: 15-14)
 Apatis (GCS: 13-12)
 Delirium (GCS: 11-10)
 Somnolen (GCS: 9-7)
 Sporo coma (GCS: 6-4)
 Coma (GCS: 3)
 Interpretasi
• Compos mentis/ conscious: kesadaran normal, sadar sepenuhnya,
dapat menjawab semua pertanyaan tentang keadaan sekelilingnya
• Apatis: keadaan kesadaran yang segan untuk berhubungan dengan
sekitarnya, sikapnya acuh tak acuh
• Delirium: gelisah, disorientasi (orang, tempat, waktu), memberontak,
berteriak-teriak, berhalusinasi, kadang berhayal
• Somnolen (Obtundasi, Letargi): kesadaran menurun, respon
psikomotor yang lambat, mudah tertidur, namun kesadaran dapat
pulih bila dirangsang (mudah dibangunkan) tetapi jatuh tertidur lagi,
mampu memberi jawaban verbal.
• Stupor (soporo koma): keadaan seperti tertidur lelap, tetapi ada
respon terhadap nyeri.
• Coma (comatose): tidak bisa dibangunkan, tidak ada respon
terhadap rangsangan apapun (tidak ada respon kornea maupun
reflek muntah.
Parameters Normal Abnormal findings
3. Cognitive Functions
a. Orientation Fully oriented by time, place Delirium and dementia: disorientation from
and person time  place  person

b. Attention Fully concentrate, can Confusion, negativism

Span complete a thought without Digression from initial thought
wandering Anxious, fatigued: attention span impaired
c. Recent Fully remember recent event Delirium, dementia, amnestic syndrome or
memory in the last 24-hour or a Korsakoff syndrome in Chronic Alcoholism:
passed week recent memory deficit
d. Remote Fully remember verifiable Alzheimer dementia or any disease that
memory past event (e.g., past health, damages the cerebral cortex: lost remote
first job, birthday and memory
anniversary dates, and
historical events)
e. New People < 60 is an accurate Alzheimer dementia: score zero- or one-word
learning – the three- or four-word recall recall
four unrelated after a 5-. 10-, and 30- Anxiety (inattention and distractibility) and
words test minute delay depression (lack of effort mobilized to
remember): impaired new learning ability
Parameters Normal Abnormal findings
4. Thought Processes and Perceptions
a. Thought The way a person thinks Illogical, unrealistic thought processes
processes should be logical, goal Blocking
directed, coherent, and Flight of ideas
relevant, complete a
thought
b. Thought What the person says Phobia
content should be consistent and Obsession, Compulsion
logical Hypochondriasis
c. Consistently aware of Hallucination  visual, auditory
Perceptions reality, congruent with (psychiatric and organic brain disease),
examiner tactile (alcohol withdrawal), olfactory,
gustatory
Illusion
 Supplemental Mental Status Examination
The Mini Mental Sate Examination (MMSE)
•Is a simplified scored form of the cognitive functions of the mental status
examination
•Is used with caution with people with low education
•It requires paper and pencil; the person must be able to write and have no
vision impairment
•It concentrates only on cognitive functioning, not on mood or thought
processes  good screening tool to detect dementia and delirium, and to
differentiate from pyschiatric mental illness
Score
•24 – 30  normal/ no cognitive impairment
•18 – 23  mild cognitive impairment
•8 – 17  moderate cognitive impairment
•0 – 7  severe cognitive impairment
 Developmental Competence
Infant and Children
•Emotional and cognitive functioning mature progressively from
simple reflex behavior into complex logical and abstract thought
•Consciousness gradually develops along with language by 18 to 24
months
•Language as a social tool communication occurs around 4 – 5 years of
age
•Attention gradually increases in span through preschool years
•Thought process become more logical, systematic, able to reason and
understand  around age 7
•Abstract thinking, the ability to consider a hypothetical situation 
ages 12 – 15 years
 Developmental Competence
Infant and Children
•The Denver II screening test 
•Designed to detect developmental delays in infants and preschoolers within
four functions: gross motor, language, fine motor-adaptive, and personal-
social skills
•Helps to identify young children who may be slow in development in
behavioral, language, cognitive, and psychosocial areas
•Childhood mental disorders
•ADHD (Attention-Deficit/Hyperactivity Disoder)
•ASD (Autism Sydrome Disorder)
•ODD (Oppositional Defiant Disorder
•Anxiety
•Depression
•Eating disorder  anorexia nervosa, bulimia nervosa, binge eating
 Childhood Mental Disorders

ADHD ODD

Autism spectrum
disorder
Eating disorders
 Characteristic of Eating Problems

Anorexia Nervosa Bulimia nervosa

Binge eating disorder

 Developmental Competence
The Aging Adult
•The aging process leaves the parameters of mental status mostly intact
•No decrease in general knowledge and little or no loss in vocabulary
•Response time is slower than in youth  take longer to process information
and react to it  affects new learning
•Recent memory which requires some processing is somewhat decreased
•Remote memory is not affected
•Changes in sensory perception can affect mental status
Vision loss  apathy, social isolation, and depression
Hearing loss  problem with normal conversation  frustration, suspicion,
social isolation and confused
•The grief and despair because of loss of loved one, job status and prestige,
income, energic and resilient body, chronic disease  disorientation,
disability, or depression
•Common disorder in Aging Adult: confusion, delirium, dementia
 Developmental Competence for Aging Adult
No Objective data Findings
1 Behavior  level The Glasgow Coma Scale is quantitative tool give the
of consciousness numeric value to the person’s response in eye opening,
best verbal response, and best motor response

2 Cognitive Experience social isolation, loss of structure without

functions  job, or short-term memory loss
orientation
3 New learning An age-related decline occurs in performance in the
Four Unrelated Words Test
4 Supplemental • Newly develop, reliable, quick, and easily available
Mental Status instrument to screen for cognitive impairment.
Examnination  • Consist of 3 item recall test and a clock drawing test
The Mini-Cog • Test the person’s executive function, including the
ability to plan, manage time, organize activities, and
managing working memory.
Abnormal Findings
 Level of Consciousness
No Level of Keypoint
Consciousness
1 Alert Awake; oriented, fully aware of internal-external stimuli;
conducts meaningful interpersonal interactions
2 Lethargic Not fully alert; drifts off to sleep when not stimulated;
(somnolent) can be aroused to name when called in normal voice but
looks drowsy
3 Obtunded Sleep most of the time; difficult to arouse (transitional
state between lethargy and stupor)
4 Stupor or Semi Spontaneously unconscious; responds only to persistent
Coma and vigorous shake or pain
5 Coma Completely unconscious; no response to pain or any
external or internal stimuli
6 Delirium Clouding of consciousness (dulled cognition, impaired
alertness); inattentive; incoherent conversation;
disoriented; impaired recent memory
No Mood and affect Key point
1 Flat affect Lack of emotional response
2 Depression Sad, gloomy, dejected
3 Depersonalization Loss of identify, feels estranged
4 Elation Joy and optimism, overconfidence
5 Euphoria Excessive well-being, unusually cheerful
6 Anxiety Worried, uneasy, apprehensive from anticipatio n
7 Fear Worried, uneasy, apprehensive, external danger is
known and identified
8 Irritability Annoyed, easily provoked, impatient
9 Rage Furious, loss of control, expressed violent behavior
10 Ambivalence The existence of opposing emotions toward an
idea, object, person
11 Lability Rapid shift of emotions
12 Inappropriate Affect clearly discordant with content of person’s
affect speech
No Anxiety disorders Key point
1 Panic attack Defined period of intense fear, anxiety, and dread
accompanied by signs of dyspnea, choking, chest pain
2 Specific phobia A pattern of debilitating fear when faced with a particular
object or situation
3 Generalized A pattern of excessive worrying and morbid fear about
anxiety disorders anticipated “disasters” in the job, personal relationships,
(GAD) health, or finances
4 Agoraphobia An irrational fear of being out in the open or in a place
from which escape is difficult
5 Social anxiety A persistent and irrational fear of speaking or performing
disorders (Social in public in which the person anticipates being judged or
phobia) criticized, feeling/ looking foolish
6 Obsessive A pattern of recurrent obsessions (intrusive,
compulsive uncontrollable thoughts) and compulsions (repetitive
disorder (OCD) ritualistic actions) done to decrease anxiety
7 Posttraumatic Follow a traumatic event outside the range of human
stress disorder experience involving actual or threatened death
 Delirium, Dementia, and Depression
Delirium Dementia Depression
Onset Sudden, over hour Slowly, over Gradual,
to days months exacerbation
during crisis or
stress
Contributing Hypoglychemia, Alzheimer, Lifelong history,
factors fever, vascular disease, losses, loneliness,
dehydration, chronic crises, declining
Change in alcoholism, head health, medical
environment (e.g., trauma conditions
hospitalization)
Cognition Impaired memory, Impaired Difficulty
judgment, memory, concentrating,
attention span, judgment, forgetfulness,
fluctuate through attention span, inattention
 Delirium, Dementia, and Depression
Delirium Dementia Depression

Level of Altered Not altered Not altered

consciousness
Activity level Can be Not altered Usually
increased or decreased,
reduced lethargy, fatigue
Emotional state Rapid swings, Flat; agitation Extreme
can be fearful, sadness, apathy,
anxious irritability
Speech Rapid, Incoherent, Slow, flat, low
inappropriate slow, repetitious
Prognosis Reversible Not reversible, Reversible
progressive
 Thought Process Abnormalities
No Type of process Key point

1 Blocking Sudden interruption in train of thought

2 Confabulation Fabricates events to fill in memory gaps
3 Neologism Coining a new word
4 Circumlocution Round-about expression
5 Circumstantiality Talks with excessive and unnecessary detail
6 Loosening Shifting from one topic to an unrelated topic;
associations unware that topics are unconnected
7 Flight idea Abrupt change, rapid skipping from topic to topic
8 Word salad Incoherent mixture of word, phrases, & sentences
9 Perseveration Persistent repeating of verbal or motor response
10 Echolalia Imitation, repeats others words or phrases
11 Clanging Word choice based on sound, not meaning
 Thought Content Abnormalities
No Type of content Keypoint
1 Phobia Strong, persistent, irrational fear of an
object or situation
2 Hypochondriasis Morbid worrying about his or her own
health; feels sick with no actual basis for
that assumption
3 Obsession Unwanted, persistent thoughts or
impulses
4 Compulsion Unwanted repetitive, purposeful act,
driven to do it
5 Delusions Firm, fixed, false beliefs, irrational;
person clings to delusion despite
objective evidence to contrary
 Perception Abnormalities

No Type of Key point

perception
1 Hallucination Sensory perceptions for which there are
no external stimuli; may strike any sense:
visual, auditory, tactile, olfactory,
gustatory
2 Illusion Misperception of an actual existing
stimulus, by any sense
Pemeriksaan Antropometri
 Antropometri

Penilaian pertumbuhan
• Berat badan
• Tinggi badan
• Kepala
• Lengan dan lipatan kulit (jaringan lemak)
a. Berat Badan
Bayi
Triwulan I 700 – 1000 gram/ bulan
Triwulan II 500 – 600 gram/ bulan
Triwulan III 350 – 450 gram/ bulan
Triwulan IV 250 – 350 gram/ bulan
Atau
6 bulan I (0 – 6 bulan) 1 kg/ bulan
6 bulan II (7 – 12 bulan) : 0,5 kg/ bulan
Atau
Bayi umur 5 bulan 2x BB waktu lahir
Bayi umur 1 tahun 3x BB waktu lahir
Toddler
1 tahun 0,25 kg/bulan
2 tahun 4x BB waktu lahir
> 2 tahun Tidak tentu (2,3 kg/ tahun)
Pre school kenaikan BB rata2 2 kg/tahun
Pre – adolescent growth spurt kenaikan BB 3 – 3,5 kg/th, pertumbuhan konstan

Adolescent growth spurt anak perempuan > anak laki2 (perempuan mulai
usia 8 – 18 tahun, laki2 mulai usia 10 – 20 tahun)
a. Berat Badan

Perkiraan BB (kg) menurut Behrman, 1992

Lahir : 3,25 kg
3 – 12 bulan : umur (bulan) + 9 /2
1 – 6 tahun : umur (tahun) x 2 + 8
6 – 12 tahun : umur (tahun) x 7 – 5/ 2
Lanjutan…………….
•Penilaian status gizi :
(BB aktual : BB ideal) x 100%

Klasifikasi status gizi :

•Status gizi normal : BB anak 90 – 100%
•Status gizi kurang : BB anak 80 – 90%
•Status gizi buruk : BB anak = / < 80 %
•Status gizi berlebih : BB anak > 100 %
b. Tinggi badan
• Laju Pertumbuhan anak :
– Deselerasi : sejak lahir sampai usia 4-5 tahun atau 9 tahun
(tahun ke 1, yaitu 1,25 cm/bulan, menurun sampai tahun ke 9 yaitu 5
cm/tahun)
– Akselerasi : usia 13 – 15 tahun (adolescent growth spurt)
Wanita: 5 – 25 cm/tahun, laki-laki: 10 – 30 cm/tahun

• Rata-rata laju pertumbuhan anak laki-laki 10,3 cm/tahun dan anak perempuan
9 cm/tahun

Rumus prediksi tinggi akhir anak sesuai dengan potensi genetik oleh Titi, 1993
dlm Soetjiningsih 1995
• TB anak perempuan : (TB ayah – 13 cm) + TB ibu / 2 ± 8,5 cm
• TB anak laki-laki : (TB ibu + 13 cm) + TB ayah / 2 ± 8,5 cm
b. Tinggi badan
Secara garis besar perkiraan TB :
•Waktu lahir : 50 cm
•1 tahun : 1,5 x TB lahir
•4 tahun : 2 x TB lahir
•6 tahun : 1,5 x TB setahun
•13 tahun : 3 x TB lahir
•Dewasa : 3,5 x TB lahir atau (2x TB 2 tahun)

Menurut rumus Behrman, 1992

•Perkiraan lahir : 50 cm
•Umur 1 tahun : 75 cm atau 1,5 x TB lahir
•Umur 2 – 22 tahun : umur (tahun) x 6 + 77
BMI
c. Kepala
Pertambahan ukuran lingkar kepala pada setiap tahap relatif
konstan dan tidak dipengaruhi o/ faktor ras, bangsa
•Saat lahir : 34 – 35 cm (> dari Lingkar dada)
•Bulan berikutnya : ± 0,5 cm / bulan
•6 bulan pertama : LK ± 10 cm LK lahir (± 44 cm)
•1 tahun : 47 cm (tidak lebih dari 5 cm/ tahun)
•2 tahun : 49 cm
•Dewasa : 54 cm

•50% penambahan LK dari lahir sampai dewasa terjadi 6 bulan

pertama kehidupan

•Tahun-tahun pertama, LK bertambah tidak > dr 5 cm/tahun dan

sampai dewasa LK bertambah ± 10 cm
• Pengukuran LK dimaksudkan untuk menaksir
pertumbuhan otak
• Pertumbuhan otak tercepat terjadi pada trimester 3
kehamilan sampai 5-6 bulan pertama setelah lahir
• Waktu lahir berat otak bayi ¼ org dewasa (350 gram)
dengan jumlah sel otak 2/3 jumlah sel otak org dewasa

Kenaikan berat otak anak menurut Lazuardi, 1984

• 6 – 9 bulan kehamilan : 3 gram / 24 jam
• Lahir – 6 bulan : 2 gram / 24 jam
• 6 bulan – 3 tahun : 0,35 gram / 24 jam
• 3 tahun – 6 tahun : 0,15 gram / 24 jam
d. Jaringan lemak
Meningkat Trimester III kehamilan – pertengahan
usia bayi

Tidak banyak bertambah Usia 7 bulan – 6 tahun

Meningkat kembali Usia 8 tahun pada wanita

10 tahun pada pria sampai pubertas

> pubertas pada pria menurun lagi,

pada wanita terus bertambah dan
mengalami reorganisasi hingga
membentuk tubuh wanita dewasa

Cara penilaian :
1)Lingkar lengan atas (LLA/ Lila)
2)Lipatan kulit
3)Lingkar pinggang
1) Lingkar lengan atas (LLA atau Lila)
• Pengukuran dilakukan terutama kepada: bayi &
anak-anak, remaja, ibu hamil dan menyusui, serta
pasangan usia subur
• Ambang batas pita Lila:
 Bayi baru lahir : 9,5 cm
• Nilai normal saat lahir: 11 cm
• Tahun pertama: 16 cm  kemudian relative konstan
(pengukuran efektif < 3 tahun)
 Dewasa : 23,5 cm
• Laki-laki : 29,3 atau 29,5 cm
• Perempuan : 28,5 cm
2) Lipatan kulit
• Tebalnya lipatan kulit pada daerah triceps dan
subscapular  refleksi pertumbuhan jaringan lemak di
bawah kulit  mencerminkan kecukupan energi
– Lipatan kulit menipis : defisiensi kalori
– Lipatan kulit menbal : kelebihan energi

Lingkar dada :
• Saat lahir : diameter transversal dan anteroposterior
dari lingkar dada hampir sama besarnya (34 – 35 cm,
bentuk dada silinder)
• Usia bertambah : ukuran diameter transversal > besar
dari diameter anteroposterior (bentuk dada gepeng)
3) Lingkar Pinggang
• Wanita: ≤35 inches
• Pria: 40 inches
Pemeriksaan TTV
Pengukuran Tanda-tanda Vital
• Suhu Tubuh
• Denyut Nadi
• Pernafasan
• Tekanan Darah
 Pandahuluan
• Perubahan fungsi tubuh seringkali
tercermin pada suhu tubuh, denyut nadi,
pernafasan, tekanan darah

• Setiap perubahan yang berbeda dengan

keadaan normal dianggap sebagai indikasi
penting mengenai kesehatan seseorang
TANDA – TANDA VITAL
 Tujuan
• Memberikan data untuk menentukan
keadaan kesehatan klien sebagai respon
terhadap stres fisik dan psikologis serta
medis, keperawatan ataupun terapi
psikologis
 Waktu
• Ketika klien 1x mrs
• Secara rutin
• Sebelum dan sesudah pembedahan
• Sebelum dan sesudah prosedur invasif
• Sebelum, selama dan sesudah pemberian
obat yang berefek pada sistem
kardiovaskuler, pernafasan dan suhu
PENGUKURAN SUHU TUBUH

• Menilai kondisi metabolisme tubuh

• Diatur oleh hipotalamus:

– Anterior  bag pembuangan panas dengan
vasodilatasi pembuluh darah

– Posterior  mengatur penyimpanan panas

dgn vasokontriksi
 TEMPAT PENGUKURAN
SUHU ORAL (3-4 menit)
 Kontra indikasi bila epilepsi, post op bedah mulut,
pingsan, terapi oksigen

SUHU REKTAL (2-3 menit)

 Mrp suhu inti tubuh, lebih akurat , tidak dilakukan pada
bayi, diare, Ca anus

SUHU AKSILA (5-10 menit)

 Kurang akurat, mudah dipengaruhi suhu lingkungan

Aksila 1° C lebih rendah daripada suhu rectum,

Suhu oral 0,5° C lebih rendah daripada suhu rectum
 RENTANG SUHU TUBUH
• Normal 36-37° C,
• Hypothermia (< 35° C ),
• Pyreksi ( 38-40 ° C),
• Hyperthermia (> 41 - 42° C)
 PEMERIKSAAN NADI
• Denyut nadi merupakan denyutan/
dorongan yang dirasakan dari proses
pemompaan jantung
• Setiap kali bilik kiri jantung menegang untk
menyemprotkan darah ke aorta, maka
dinding arteri akan mengembang untuk
mengimbangi bertambahnya tekanan
• Pengembangan aorta menghasilkan
gelombang dinding aorta yg menimbulkan
denyutan
Nadi
• Denyut nadi dapat dibedakan menjadi 2
nadi apical dan nadi perifer
 Denyut nadi APICAL adalah denyut nadi
yang dirasakan pada daerah apek jantung

 Denyut nadi PERIFER adalah denyut nadi

yang dirasakan di perifer tubuh seperti
kepala, leher, pergelangan tangan, paha
dan ketiak
Nadi
Denyut nadi dipengaruhi oleh factor
aliran darah (hemodinamik):
 Elastisitas arteri,
 Tekanan pembuluh darah,
 Viskositas darah, dan
 Bentuk aliran (laminar atau turbulen)
 TEMPAT PENGUKURAN
• Arteri Karotis,
• Arteri Apical,
• Arteri Brachial,
• Arteri Radial,
• Arteri Pemoral,
• Arteri Poplitea,
• Arteri Dorsalis pedis
• Arteri Temporal,
 FREKUENSI
• Baru Lahir : ±140 x/mnt
• 1-6 bl : ±130 x/mnt
• 6-12 bl : ±115 x/mnt
• 1-2 thn : ±110 x/mnt
• 2-4 thn : ±105 x/mnt
• 6-10 thn : ±95 x/mnt
• 10-14 thn : ±85 x/mnt
• 14 – 18 thn : ±82 x/mnt

Sumber : Joyce Engel, 1995

Hal yg perlu diperhatikan :
• Dewasa normal 70-80 x/mnt atau 60 – 100 x/mnt
• Denyut < 60 x/mnt (bradikardia)
• Denyut nadi > 100 x/mnt (takikardia)
• Ritme (pola gelombang) denyut nadi relative
konstan dengan interval yang teratur.

• Kekuatan denyut nadi:

– Skala 0 : tidak kuat
– skala 1 : lemah sulit dirasakan
– skala 2 : normal
– skala 3 : kuat
 IRAMA NADI
• Jika normal iramanya teratur
• Irama tidak teratur disebut Aritmia
• Jika nadi teraba sangat kuat dan
turun dengan cepat (akibat
perbedaan tekanan sistolik dan
diastolik yang sangat besar)
disebut Pulsus Seller
 IRAMA NADI
• Pulsus Parvus et Tardus ditandai denyut
nadi rendah dan teraba lambat
• Pulsus Alternans denyut nadi berselang
seling kuat dan lemah
• Pulsus Paradoksus ditandai
lemah/normal saat inspirasi dan kuat
saat ekspirasi
• Pulsus Bigeminus denyutan
berpasangan yang berhubungan
dengan denyut prematur
Faktor yang Mempengaruhi Nadi
• Usia,
• Latihan fisik,
• Demam,
• Pengobatan,
• Perdarahan,
• Stres,
• Perubahan posisi,
• Makanan,
• Penyakit,
 CARA PEMERIKSAAN
• Nadi dihitung selama satu menit
• Komponen yang harus dilaporkan
frekuensi, irama/ ritme, dan kekuatan
 PEMERIKSAAN PERNAFASAN
• Kegiatan masuknya 02 dan keluarnya Co2
• Pengkajian pernafasan meliputi :
– Respiratory rate
• Pernafasan normal : 16-20 x/mnt,
• Takipneu ( > 24x/mnt),
• Bradipnea ( < 10x/mnt),
• Apnea ( pernafasan berhenti )
– Kedalaman pernafasan
– Irama pernafasan (keteraturan : regular
atau tidak regular).
 POLA NAFAS
1. Dyspnea  susah bernafas O/k retraksi
2. Bradipnea  frek nafas lambat , abnormal dan tidak
teratur
3. Tacypnea  frek pernafasan cepat
4. Hiperpnea  pernafasan cepat dan dalam
5. Apnea  tidak ada pernafasan
6. Cheyne stokes  periode nafas cepat dan dalam yang
bergantian dengan periode apnea
7. Kusmaul  Nafas dalam yang abnormal bisa cepat,
normal atau lambat
8. Biot  Nafas tidak teratur
 CARA PENGUKURAN
• Inspeksi, melihat gerakan nafas dan
menghitung frekuensinya.
• Palpasi, tangan pemeriksa diletakan pada
dinding abdomen/dada pasien, kemudian
hitung gerakan pernafasan yang terasa
pada tangan, sementara pemeriksa
memperhatikan jarum jam
• Cara auskultasi  dengan stetoskop
didengarkan dan dihitung bunyi pernafasan
 TEKANAN DARAH
• Pengukuran tekanan darah secara langsung dan tidak
langsung
• Pengukuran langsung
– Menghubungkan pembuluh darah arteri dengan suatu
selang plastic (kanula) dan ujung selang yang lain
dihubungkan dengan alat pengukur tekanan yaitu
manometer air raksa atau dengan alat “pressure
producers”
• Pengukuran TD tidak langsung
– menentukan tekanan darah systole, yaitu tekanan tinggi
saat kontraksi ventrikel dan tekanan diastole
– memakai stetoskope Korokoff sound
 TEKANAN DARAH

KOROTKOFF SOUND
1. Bunyi korotkoff I  bunyi yang pertama kali
terdengar, berupa bunyi detak jantung yang
perlahan
2. Bunyi korotkoff II  seperti korotkoff I tetapi
disertai bunyi desis
3. Bunyi korotkoff III  seperti bunyi korotkoff II
tetapi lebih keras
4. Bunyi korotkoff IV  bunyi tiba-tiba melemah
5. Bunyi korotkoff V  bunyi terakhir dan
menghilang
 PENILAIAN TEKANAN DARAH

• Tekanan sistolik adalah tekanan darah pada

puncak gelombang saat ventrikel kiri
kontraksi

• Tekanan diastolic adalah teknan diantara

dua kontraksi ventrikel saat jantung pada
kondisi istirahat

• Hasil pengukuran  sistolik/ diastolic

yaitu bunyi Korotkoff I / Korotkoff V