A.

Preparation Tool
1. Stethoscope
2. Tensimeter/Sphygmomanometer
3. Alcohol Swab
4. Termometer Digital
5. Gauze
6. Stationery
B. Phase Orientation

1. Greeting

2. Introduction

3. Explain The Purpose of Examination

4. Explain The Procedure Of Examination

5. Create a Comfortable Environment

C. Phase accupation

a. Examination of temperature and frequency of respiration

1. Hand washing

2. Assist the patient for sit or lie down

3. Open the upper clothes patient

4. Clean the axila with gauze

5. Push the button and put thermometer in the middle axila. Then ask patient to lower
upper arm and put the under arm above the chest

6. Explain to patient that the thermometer will beep and a number will appear,
indicating in degrees Fahrenheit the temperature of the patients body

7. Then, inspection or palpation with hands on upper chest for count of respiration and
when the chest rises start count to a full minute. Once the counting is finished then
record how many times the chest rises

8. Take the thermometer and read the result

9. Clean the thermometer with alcohol swab

 10 . Neat the patient

11. Documentation of examination result

b. Examination the pulse

1. Assist the patient for sit or lie down
2. Use two fingers and place it on the patient wrist or in the area arteries until you
feel the pulsation
3. And then use wristwatch to count the pulse for 1 minute or 15 seconds multiplied
by four
4. Documentation of examination result
c. Examination the blood pressure
1. Assist the patient for sit or lie down. Make sure the arm is being relaxed and
patient is comfortable
2. Palpation Artery Brachialis and Pair the cuff
3. Closed Bulb Srew Tensimeter
4. Place the stethoscope in the ear then place the diaphragm underneath the cuff on
the artery.
5. Pumping tensimeter with quickly until 180 mmhg
6. Relegated pressure the cuff is slowly until artery pulsation feel and listen the first
sound Dug as systolic pressure and the last sound Dug as diastolic pressure.
7. Neat the tools and patient
8. Hand washing
9. Documentation of examination result
D. Phase Termination

1. Evaluation response of patient

2. Conclusion

3. Greeting

4. Documentation

VITAL SIGN

Compiled By :
 Created By :

Name : Mia Audina

Grade : II.A

NIM : PO.71.20.1.13.014

Lecturer :

1. Ira Kusumawati, S.Kp.,M.Kep,MPH

2. Luci Fransiska Situmorang, S.Kep.,Ners,M.Kep

MINISTRY OF HEALTH THE REPUBLIC OF INDONESIA

POLYTECHNIC OF HEALTH PALEMBANG

DEPARTMENT OF NURSING

2014/2015