STANDART OPERATIONAL PROCEDURE

MEASUREMENT OF VITAL SIGN

A. Examination of axillary temperature

The purpose is :
To knows the temperature of the human body
 Materials
1. Thermometer
2. Alcohol swab
3. Tissue
4. Handscun
5. Notebook
6. Pen
 Methode
1. Explain the procedure to the patient
2. Wash your hands (with 6 steps)
3. Use the handscun
4. Adjust the position of the patient as comfortable as possible (sitting / lying)
5. Specify the axillary position and clean up with tissue
6. Make the thermometer’s temperature between 34oC – 35oC
7. Put the thermometer in the axillary and make sure the patient’s arm in the
flexion’s position on the chest
8. After 3-5 minute see the results of the temperature
9. Write the results
10. Clean up the thermometer with tissue
11. Clean the thermometer with alcohol swab
12. Wash your hand after doing the procedure
B. Pulse Examination
The purpose is :
1. To find out the pulsation
2. Assess cardiovascular system
 Materials
1. Watch
2. Notebook
3. Bulpoin
 Methode
1. Explain the procedure
2. Wash your hands (6 steps)
3. Set the patient’s position
4. Place both hands on your sides
5. Determine the location of the arteries (the pulsation will be calculated)
6. Check the pulse using the tip of the index finger, middle finger, and ring
finger. Determine the frequency per minute and the regularity of the rhytm
and the strength of the pulsation
7. Write the results
8. Wash your hand (6 steps) after doing the procedure
C. Respiratory Rate Examination
The purpose is :
1. To knows the frequency, rhytm, and depth breathing
2. Assess the ability of respiration function
 Materials
1. Watch
2. Notebook
3. Pen
 Methode
1. Washing hands
2. Bringing all the tools to close the patient.
3. Explain procedures to patients
4. Adjust the position of the patient as comfortable as possible (sitting / lying)
5. Putting a patient's arm in a relaxed position crosses the abdomen / 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 starts counting the respiratory
rate and 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. Set back comfortable patient positioning
8. Inform the result of the examination to the patient and informed that the action
has been completed
9. Washing hands
10. Documentation
D. Examination of Blood Pressure
The purpose is
To knows the blood perssure’s value
 Materials
1. Sphygnomanomater
2. Stethoscope
3. Notebook
4. Pen
 Methode
1. Explain the procedure
2. Wash your hands (6 steps)
3. Set the patient’s position
4. Put the hand that will measured in the supine position
5. Open the patient’s sleeves
6. Hold the pressure gauge in your left hand and the bulb in your right.
7. Close the airflow valve on the bulb by turning the screw clockwise.
8. Inflate the cuff by squeezing the bulb with your right hand. You may hear your
pulse in the stethoscope.
9. Watch the gauge. Keep inflating the cuff until the gauge reads about 30 points
(mm Hg) above your expected systolic pressure. At this point, you should not
hear your pulse in the stethoscope.
10. Keeping your eyes on the gauge, slowly release the pressure in the cuff by
opening the airflow valve counterclockwise. The gauge should fall only 2 to 3
points with each heartbeat. (You may need to practice turning the valve
slowly.)
11. Listen carefully for the first pulse beat. As soon as you hear it, note the
reading on the gauge. This reading is your systolic pressure (the force of the
blood against the artery walls as your heart beats).
12. Continue to slowly deflate the cuff.
13. Listen carefully until the sound disappears. As soon as you can no longer hear
your pulse, note the reading on the gauge. This reading is your diastolic
pressure (the blood pressure between heartbeats).
14. Allow the cuff to completely deflate.
15. Hold the bulb in your right hand.
16. Press the power button. All display symbols should appear briefly, followed
by a zero. This indicates that the monitor is ready.
17. Inflate the cuff by squeezing the bulb with your right hand. If you have a
monitor with automatic cuff inflation, press the start button.
18. Watch the gauge. Keep inflating the cuff until the gauge reads about 30 points
(mm Hg) above your expected systolic pressure.
19. Sit quietly and watch the monitor. Pressure readings will be displayed on the
screen. For some devices, values may appear on the left, then on the right.
20. Wait for a long beep. This means that the measurement is complete. Note the
pressures on the display screen. Systolic pressure (the force of the blood
against the artery walls as your heart beats) appears on the left and diastolic
pressure (the blood pressure between heartbeats) on the right. Your pulse rate
may also be displayed in between or after this reading.
21. Allow the cuff to deflate.
22. Write the result of the manometer (mmHg) when you first hear the pulse and
when it last sounds
23. Wash your hand (6 steps) after doing the procedure