SOP Vital Sign
Blood Presure
Goal
a)
Knowing the patient's hemodynamic state
b)
Knowing the patient's overall
state of health
Preparation
of patient, nurse and environmental
1.
Introduce yourself to the client,
including name, job title or role, and explain what you will do.
2.
Verify the identity of the client
3.
Explain the procedure and the reasons
for such action, explained in a language that can be understood by the client.
4.
Prepares equipment
5.
Wash hands before contact with new
clients. wear PPE
6.
Ensure that clients are comfortable and
that you had were pretty good and have adequate lighting for the task.
7.
Provide privacy for the client, or the
client's position and closed as needed.
8.
Ditch patients at least 5 minutes before
the measurement. And make sure patients feel relaxed and comfortable.
Prosedure
1.
Ask the patient to open the upper arms
to be checked, so there is no pressure on the brachial artery.
2.
Positioning the patient can lie,
half-sitting or sitting comfortably with the volar forearm above.
3.
Use cuffs that fit the size of the
patient's arm
4.
Fit a circular cuff on the arm at heart
level checkpoints, with the bottom cuff 2-3 cm above the cubital fossa and
which parts tapping rubber balloon just above the brachial artery.
5.
Sure the hoses are not bent or pinched
cuff.
6.
Connect sphymomanometer cuff with
mercury, upright position and the level of the mercury level of the heart
7.
Feel brachial arterial pulse in the
cubital fossa and the radial artery with the index finger and middle finger (to
ensure no emphasis)
8.
Ensure eye examiner must be parallel to
the surface of the mercury (so that the proper reading of the measurement
results)
9.
Close control valve on the pump cuff
10.
Ensure proper entry into the stethoscope
ear examiner, palpating the radial artery pulse
11.
Pump the cuff until no palpable radial
artery pulse again
12.
Then pump again until 20-30 mm hg (not
higher, because it will cause pain to the patient, the pain will increase
tension)
13.
Put the head of the stethoscope over the
brachial artery
14.
Disconnect the control valve slowly so
that the mercury drops with the speed of 2-3 mm hg per second per second or 1
scale
15.
Ensure high mercury when the first beats
sound the brachial artery is the systolic pressure
16.
Ensure high mercury in the event of
changes in the sound suddenly weakened throbbing latter diastolic pressure
17.
Disconnect from ear examiner stethoscope
and cuff from the patient's arm.
18.
Clean earpieces and diaphragm stestokop
with disinfectant.
19.
If the retry wait at least 30 seconds.
AFTER
THE PROCEDURE:
1.
Say thank you to clients
2.
Immediately report the presence of
abnormal findings
3.
Clean and return equipment that is used
in place
4.
Open PPE and wash hands
5.
Document the results of the procedure.
Temperature
Goal
a) Knowing
the patient's body temperature to determine nursing
actions
b)
Assist the
diagnosis
Preparation
1.
Washing hands
2.
Clean the thermometer with clean water (when stored in
a disinfectant solution) and then dry with a paper towel. How to clean the
thermometer is driven twist of tissue paper from the base (near the finger
hold) towards the end / reservoir.
3.
Check the mercury in thermometers and lower the
mercury, by way of flick / shake (with a stomping movement) towards the bottom
of the thermometer. Performed many times until the mercury is below 350C scale
Oral Examination
1.
Invite the client open reservoir mouth and place it
under the tongue (sublingual). Navigate to the corner of the mouth thermometer
and encourage clients to shut his mouth tightly. During the measurement the
client is not allowed to speak / open mouth.
2.
Allow thermomether for 3-5 minutes
3.
Remove the thermometer and wipe with tissue paper
towards the reservoir, so that the mercury can be read / seen.
4.
Read and record the results obtained
Axilla
examination
1. Encourage
clients to clean the armpits / underarms dry with a paper towel client
2. Put the
reservoir right in the middle of the armpit, close the upper arm to the body
and sleeves client down on the chest client
3. Allow the
thermometer for 5-10 minutes
4. Raise the
thermometer
5. Read and
record the results obtained
Rectal
examination
1. Rub jelly /
vaseline on thermomether approximately 2-3 cm from the tip of the reservoir
2. Adjust the
position of the client with sim position and reveal little blankets clients to
stretch the buttocks buttocks clients to look sphinchter ani. In infants, the
supine position and lift both legs
3. Insert the
thermometer into the rectum reservoir 3.8 cm (at the adult client): 2.5 cm (in
children); 1.25 cm (in infants)
4. Allow to
stand for 2-3 minutes
5. Thermomether
Remove and wipe with tissue paper towards the reservoir, so the water looks
clear mercury
6. Read and
record the results obtained
Pulse
Goal
a) Knowing the pulse
during the vulnerable period of 1 minute
b) Knowing the patient's general condition
c) Knowing intgritas kardiovaskulr system
d) follow course of the disease
b) Knowing the patient's general condition
c) Knowing intgritas kardiovaskulr system
d) follow course of the disease
Preparation of patient,
nurse and the environment:
1. Introduce yourself to the client, including name, job title or role, and explain what you will do.
2. Verify the identity of the client
3. Explain the procedure and the reasons for such action Prepare equipment
4. Wash hands before contact with a new client, wear PPE
5. Provide privacy for the client, or the client's position and closed as needed.
6. When a new client activity, wait 5-10 minutes to check pulse
1. Introduce yourself to the client, including name, job title or role, and explain what you will do.
2. Verify the identity of the client
3. Explain the procedure and the reasons for such action Prepare equipment
4. Wash hands before contact with a new client, wear PPE
5. Provide privacy for the client, or the client's position and closed as needed.
6. When a new client activity, wait 5-10 minutes to check pulse
Prosedure
1.
Arrange clients with supine sleeping position, or sit
semifowler
2.
Put 3 fingers (index, middle finger and ring finger)
just above the artery being examined (radial or other). Use your index finger
to press the artery while the middle and ring finger to assess the quality of
rhythm and a pulse
3.
Perform checks for one minute
4.
Record for the measurement:
a.
Pulse frequency in a minute
b.
Rhythm (regular / irregular)
c.
Pulse quality (strong / weak)
d.
Perceived abnormalities.
Respiration
Goal
1.
Knowing the patient's general kesdaan
2.
Determine the
size and fragile
nature of breathing in 1 minute
3. Following the development of the disease
4. Assist the diagnosis
3. Following the development of the disease
4. Assist the diagnosis
Preparation
• watches with a second needle.
• Pen and notebook.
Do not tell the client that the nurse would calculate the frequency of respiratory
Make sure the client sitting in a comfortable position better
• watches with a second needle.
• Pen and notebook.
Do not tell the client that the nurse would calculate the frequency of respiratory
Make sure the client sitting in a comfortable position better
Prosedure
1.
Place your hands crossed to the patient's chest
2.
Observation movement of the chest wall during
inspiration and exspirasi (one respiration)
3.
Calculate the amount of respiration in a minute
4.
Record the results obtained include:
a.
frequency minute
b.
Chest wall motion abnormalities
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