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
Preparation of patient, nurse and the environment:
1. Introduce yourself to the client, including name, job title or role, andexplain 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

Preparation
• watches with a second needle.
• Pen and notebook.
Do not tell the client that the nurse would calculate the frequency ofrespiratory
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