SOP Signs - Vital Signs

N Rated aspect Ye No
o s
I TOOLS PREPARATION
1. Thermometer in its place (axila, oral, rectal)
2. Three bottles containing a solution of soap, disinfectant,
and clean water
3. Crooked
4. tissue
5. Watches ticking
6. Full sphygmomanometers (manometer, mercury, electrically)
7. Stethoscope
8. Pen and notebook
9. sheath hand
10. vaseline in its place

II PATIENT PREPARATION AND ENVIRONMENT

1. Provides information about actions will be done
2. prepare patients in a state of rest / relax
3. Setting up the environment a safe and comfortable
4. Provide privacy to clients

III PROCEDURE FOR IMPLEMENTATION

 MEASURING TEMPERATURE axilla

1. Wash hand
2. Bring tools close to the patient
3. Explaining the procedure in patients
4. Set the position of the patient as comfortable as possible
(sitting / lying)
5. ask client opens a sleeve (if you need help)
6. When the wet armpits dry with a tissue
7. Take the thermometer out of place (when the thermometer
from grab disinfectant solution and wipe with tissue from the
base of the reservoir with the direction of play, then insert it
into clean water and wipe with tissue)
8. Check the thermometer make sure the temperature is below 35
0C

9. Place the thermometer right in the axial arm of the patient,

the patient's arm flexion on the chest
10. Wait up to 10 minutes then remove, wash and read the
result
11. Inform the examination results to the patient
12. Tidy up the back clothes patient and helpful to a
comfortable position
13. put in into a soap solution to clean with tissue from the base of
the reservoir with a circular motion, enter a disinfectant solution
to wipe with tissue from the base of the reservoir with a circular
motion, then insert it into clean water and wipe with tissue from
the base of the reservoir with a circular motion
14. lower mercury to the reservoir and then insert the
thermometer in place
15. Wash hand
16. record pengukran result of temperature on notebook

 MEASURING TEMPERATURE ORAL

1. Wash hand
2. Bring tools close to the patient
3. Explaining the procedure in patients
4. Set the position of the patient as comfortable as possible
(sitting / lying)
5. Take the thermometer out of place (when the thermometer
from grab disinfectant solution and wipe with tissue from the
base of the reservoir with the direction of play, then insert it
into clean water and wipe with tissue)
6. Check the thermometer make sure the temperature is below 35
C
7. ask patient opened her mouth, gently place the
thermometer under the tongue
8. ask mengatubkan patient's lips
9. Wait up to 3-5 minutes then remove, wash and read the result
10. Inform the examination results to the patient
11. Tidy up the back clothes patient and helpful to a
comfortable position
12. put in into a soap solution to clean with tissue from the base of
the reservoir with a circular motion, enter a disinfectant solution
to wipe with tissue from the base of the reservoir with a circular
motion, then insert it into clean water and wipe with tissue from
the base of the reservoir with a circular motion
13. lower mercury to the reservoir and then insert the
thermometer in place
14. Wash hand
15. record pengukran result of temperature on notebook

 MEASURING TEMPERATURE Rectal

1. Wash hand

2. Bring tools close to the patient

3. Explaining the procedure in patients

4. Closing the curtains / doors

5. Wear gloves

6. Help patients in the sim's position (client child can lie on his
stomach)

7. ask lower the patient down clothing to below the gluteal

(if you need help)

8. Open ass to release visible from the outside, when the

release looks dirty, wipe with a tissue

9. Take the thermometer out of place (when the thermometer

from grab disinfectant solution and wipe with tissue from the
base of the reservoir with the direction of play, then insert it
into clean water and wipe with tissue)

10. Check the thermometer make sure the temperature is below 35

C

11. Smearing vaseline / lubrication at the tip of the thermometer (2.5

- 4 cm for adults and 1.5 - 2.5 cm for infants / children)

12. With The dominant left hand not elevate the buttocks
 on patients

13. Insert the thermometer into rectal slowly (if there is any
resistance thermometer immediately pull)

14. Keep the thermometer

15. Wait up to 2-3 minutes then remove, wash and read the result

16. Inform the examination results to the patient

17. Tidy up the back clothes patient and helpful to a

comfortable position

18. put in into a soap solution to clean with tissue from the base of
the reservoir with a circular motion, enter a disinfectant solution
to wipe with tissue from the base of the reservoir with a circular
motion, then insert it into clean water and wipe with tissue from
the base of the reservoir with a circular motion

19. lower mercury to the reservoir and then insert the

thermometer in place

20. take the gloves hand

21. Wash hand

22. record pengukran result of temperature on notebook

 REVIEWING pulse PULSE

1. Wash hand
2. Bring tool - tool close to the patient
3. Explaining the procedure in patients
4. Set the position of the patient as comfortable as possible
(sitting / lying)
5. Fingering / specify the location of the artery / pulse to be
counted
6. pulse pulse by placing the tip of the index finger, middle
finger and ring finger on top of the artery to be counted
7. When the already palpable pulse regularly, hold a watch
with a second date on the other hand
8. Counting pulse for ¼ minute pulse (if pulse regularly) the
result is multiplied by 4, if irregular pulse count for a full
minute
9. Tidy up the patient's back and help the patient to a
comfortable position
10. Inform the examination results to the patient and telling
the patient the action has been completed
11. Wash hand
12. mencata the results of temperature measurements at notebook

 REVIEWING BREATHING
1. Wash hand
2. Bring tool - tool close to the patient
3. Explaining the procedure in patients
4. Set posii patients as comfortable as possible (sitting /
lying)
5. meletakkn the patient's arm in a relaxed position crosses
 abdominal / lower chest and put your hands on the abdomen /
chest on the patient and then observe the movement
6. observing one complete respiratory cycle then begins counting
respiratory rate danmem note the depth, rhythm and character
of breathing for 30 seconds the result is multiplied by 2 when
breathing regularly but if breathing is irregular or patient babies
/ small children count for a full minute
7. Rearrange comfortable patient positioning
8. mengiformasikan the examination results to the patient
and informed that the action has been completed
9. Wash hand
10. record the results of temperature measurements at notebook

 MEASURING BLOOD PRESSURE

1. Wash hand
2. Bring tool - tool close to the patient
3. Explaining the purpose and procedures on patients
4. Disinfect handles stethoscope which will be attached to the ear
and also disinfect the diaphragm
5. Set the position of the patient as comfortable as possible
(sitting / lying)
6. laying tensimeter in addition to the patient's upper arm
7. Request / help patient rolling / opening the sleeve to be
checked
8. installing cuff on the upper arm about - about 2.5 cm above the
fossa antecubiti (not too strong) and the arrow on the cuff is
parallel to the brachial artery
9. Palpate the brachial artery with the index and middle fingers
10. wearing a stethoscope on the ears, put part of the
diaphragm on the brachial artery and memegangganya
with your thumb or a few fingers
11. Close valve / balloon pump by turning the screw
clockwise and unlock menggukana tension mercury if
mercury
12. Pump air balloon about - about 30 mmHg above the point of
missing pulses
13. Open couplers balloon slowly - slowly (mercury down around
- about 2-3 mmHg / sec)
14. Listen carefully reading the scale mercury which arterial pulse
sound first heard until it disappears (the first is the systolic
pressure pulse and the last pulse noise is the sound of
diastolic pressure)
15. Mengempeskan with quickly after the throbbing sound is not
heard until the mercury to zero (if you want to repeat the
examination wait about - about 2 minutes)
16. Open cuff, rolled / folded neatly and then cuff and balloon put
in place, the mercury is locked, closed tensimeter
17. Rearrange comfortable patient positioning
18. Inform the examination results to the patient and informed
that the action has been completed
19. Wash hand
20. record the results of temperature measurements at notebook

 ASSESSING apical pulse

1. Wash hand
2. Cleaning the hilt and the diaphragm with
 disinfectant
3. Explaining the purpose and procedures for actions to be
taken
4. Close doors and curtains
5. help organize the patient's position (sitting / lying)
6. Request / help unlock / release clothes on the client to
expose the sternum and left side of the chest
7. Fingering / specify the point of maximal impulse (TIM)
8. Warms the diaphragm by putting a diaphragm on the palms
about - about 5
- 10 seconds
9. Put diaphragm above TIM
10. Listening to heart sounds (When the regular audible count
for 30 seconds the result is multiplied by 2, if not regularly
count for 1 minute)
11. Tidy up the back pkaian patient and help the patient
desired position / cozy
12. Wash hand
13. record the examination results on the record books

 EVALUATION
1. Trim the patient and tighten up tool
2. convey sign measurement results - the patient's vital signs
and interpret
3. Place patient in a comfortable position
TOTAL NUMBER

Lamongan, 200

examiner