SOP FOR MEASURING VITAL SIGNS

STANDARD VITAL SIGNS EXAMINATION

OPERSIONAL
PROCEDURE

Vital sign examination (Vital Sign) is a way to detect changes in the

body system. Vital signs include body temperature, pulse, respiratory
rate and blood pressure. Vital signs have a very important value in
bodily functions. A change in vital signs, for example body temperature
DEFINITION can indicate the state of metabolism in the body; The pulse can show
changes in the cardiovascular system; Respiratory frequency can
indicate respiratory function; and Blood pressure can assess the ability
of the cardiovascular system which can be attributed to pulse.

 To find out any abnormalities in the patient

 Knowing the condition and development of the patient's vital
signs
PURPOSE
 Knowing the patient's frequency, respiratory rhythm, pulse rate,
blood pressure and body temperature

 The patient has just been admitted to the hospital

 Patients with pain associated with vital signs
 All patients were treated
POLICY
 Patients with disorders of the respiratory system, cardiovascular,
and body temperature

OFFICERS Nurse

1. Handscoon
2. Mercury thermometer
3. 3 bottles each contains: Soap liquid, disinfectant liquid, clean
water.
4. Tissue
5. Tensimeter: Spingomanometer / mercury tension
EQUIPMENT 6. Stethoscope
7. Wristwatch / stopwatch
8. Tray and base
9. Crooked
10. Graph of vital sign progress
11. Writing tools
IMPLEMENTAA.Pre-Interaction Stage
TION
PROCEDURES 1. Prepare tools and patients properly
2. Verify the previous data if any
3. Place the instrument near the patient correctly and position the
examiner correctly

B.Orientation Stage

1. Giving greetings as a therapeutic approach

2. Explain the purpose and procedure of action to the family /
patient
3. Give the patient the opportunity to ask questions
4. Asking the client's readiness before the activity is carried out

C.Work Stage

1. Washing hands
2. Maintain patient privacy
3. Get into a comfortable position: sit or lie down with your hands
relaxed
4. Put on gloves
5. Position the nurse on the right side of the patient
6. Dry the tip of the thermometer. Then lower the mercury to zero.
Before placing it on the axilla, clean / dry the patient's left axilla
first using a tissue.
7. Place the diacillary thermometer on the left. Then while waiting
for the mercury to rise on the thermometer, check your pulse,
respiration and blood pressure by:
8. Place the tips of the three fingers except the thumb on the
artery / pulse to be measured, (starting from the radiialis,
brachialis, carotid, and temporalis) gently press
9. Count the pulse frequency from zero (0) for 30 seconds
(multiply by 2x to get the frequency in one minute). If the pulse
is irregular, count it for one minute. Continue counting the
breaths
10. Then while holding the radial artery (as if still counting the
pulse), count the number of breaths of the client for 1 minute
(the rise and fall of the client's chest)
11. Next, prepare the patient for blood pressure checks (blood
pressure meter preparation).
12. free the brachial area by rolling the client's sleeve.
13. Palpate the brachial artery. Place the cuff 2.5 cm above the
brachial pulse (antecubital space).
 14. Increase the pressure in the cuff while feeling the radial artery
until the pulse disappears then the pressure is increased again by
approximately 30 mmHg.
15. Carefully place the stethoscope on the brachial artery at the
cubit fossa and determine the systolic pressure
16. Record the I and V korotkoff sounds or the sound of the first
(systole) and last (diastole) beats on the manometer as the
pressure drop
17. Lower the cuff pressure at a rate of 4 mmhg / s while listening
for vessel loss following the 5 corotary phases
18. Repeat the measurement one more time with the mercury in the
spignomanometer returned to 0. Perform the action as above.
19. Then open the cuff, remove the cuff and straighten it back.
20. Remove the thermometer from the axilla reading the
temperature rise, then wash the thermometer into soapy water
then the final disinfectant water into clean water
21. Dry the thermometer and lower the mercury again
22. Replace the patient and equipment.
23. Remove the handscoon
24. Washing hands

D.Termination Stage

1. Perform action evaluation

2. Contracts for further activities
3. Saying goodbye to clients
4. Tidy up the tools
5. Record activities in nursing note sheets