Sop Fix

UNIVERSITAS KATOLIK WIDYA MANDALA SURABAYA
FAKULTAS KEPERAWATAN
JL. Raya Kalisariselatan No. 1, lantai 8, Tower B, Pakuwon City, Surabaya Email :
keperawatan@mail.wima.ac.idfkep.wima@yahoo.co.id
PROCEDURE
GIVE MEDICINE (ORAL)
Prepare and provide medicines for clients

DEFINITION
which can be given by mouth and swallowed.
Giving medicine to the patient by mouth correctly and
PURPOSE correctly, according to the program
treatment.
As a reference for nurses in the implementation of
steps of nursing care on the implementation of actions
POLICY
or methods of administration of drugs
by mouth
PROCEDURE 1. Preparation of tools and medicines
a. Tray
b. Glass of medicine / measuring cup.
c. A complete card with writing:
Name of patient.
The patient's room and bed.
Type of medication / drug name.
Drug dosage.
Time of administration.
Date ordered and signature working.
d. Wipe the wipe (to divide the liquid medicine).
e. Drinking water / banana (for taking
medicine).
f. Medicine needed
2. Patient preparation
1. Explain to the patient about the procedure for
the action to be taken.
A. Implementation
Washing hands
a. About half an hour before the drug is given, take
the medicine card from the medicine box.
b. Match medication cards with patient lysts, doctor
messages and nurse records by date. If it's not
suitable, return it to the doctor's message.
c. Prepare medicine according to the method
ordered.
d. Prepare the tools needed.
e. Don't talk to anyone when providing medicine.
g. With a medicine card, check the label for the name

h. the dosage of the drug in the bottle when taking it
from the cupboard. Before pouring the required
medication, read the etiquette again for the name of
the drug and the dose of the drug.
i. Place the medicine cups on the medicine card in the
tray.
j. The drug is brought to the patient by the nurse who
prepared the drug.
k. Determine the patient, read the patient's name and
call the patient's name.
l. Give the drug directly to the patient and wait until
the drug is thoroughly taken / swallowed if the
patient needs to be helped by observing the 5
principles correctly.
m. Turn over the patient's medicine card.
n. Return the tools to the study, wash the tools and
store them in place.
o. Bring the medicine card to the patient's lyst as soon
as possible and check it on the medication column
and note the patient's response to the drug
administration. By checking and signing the nurse
prove it has given medicine with

the correct size according to the hour and date. The
graffiti becomes official if there is an initial scratch
on it.
o. Writing is only made by nurses who have
prepared and given the drug.
p. If the patient does not want to take medication / is
delayed due to fasting for examination, circle the
hours of the medicine and write the initial.
q. After checking, the drug card is returned to the
medicine box, according to the time of the next drug
administration
r. Washing hands
UNIT Inpatient installation, outpatient installation,

emergency room, ICU
PROCEDUR GIVING MEDICINE (EYES)

E
Giving certain drugs / fluids into the eye
DEFINITION
by dripping / rubbing on the eyes.
1. 1. Carry out eye treatment measures, according to
the therapy program.
PURPOSE
2. Speed up the healing process in the affected eye.
As a reference for nurses in implementation

POLICY steps of nursing care on eyes
1. Preparation of tools and medicines

a. Eye ointment / eye drops.
b. Sterile / gauze cotton.
c. Scissors and plaster (prn).
d. Sterile tweezers / gloves.
e. Kom sterile.
f. Crooked.
B. Patient preparation
Explain to patients about the actions to be taken.
C. Implementation
a. Match the medication card with the patient's lyst.
b. Explain to the patient about the procedure for the
action to be taken.
c. Washing hands.
d. Prepare the medication needed.
e. Position the patient as needed.
f. Wear gloves.
PROCEDURE g. Clean the eyes with sterile cotton.
h. The tube tip is rubbed with sterile cotton then
ointment is poured a little on the cotton.
i. Open the conjunctiva of the lower eyelid with the
thumb / two fingers by applying downward pressure
on the prominent part of the cheek and the patient is
encouraged to look up.
j. Apply along the inner side of the lower eyelid, in
the lower conjunctiva and advise the patient to close
and blink the petals
eye.
k. Cleanse the remaining ointment / drops

around the eyes with cotton.
l. If necessary, the eyes are closed with sterile
gauze and plastered.
m. Take off the gloves.
n. Take care of tools, and wash hands
o. Documenting the patient's standardized
procedure.
Attention :
1. 1. Wash hands before and after giving
medication.
2. 2. Read etiquette before giving to prevent
mistakes.

emergency room, ICU
PROCEDUR Giving Medicine (Vagina)

E
Giving medications through the vagina by applying it,
DEFINITION
suppositorium, irrigation.
PURPOSE To treat and clean the vagina.

As a reference for nurses in applying the steps of
nursing care to the implementation of the action of
POLICY
administering drugs through
vagina
1. Preparation of tools and medicines

Tray contains:
a. Medication according to the doctor's order.
b. Sterile hand shirt.
Explain to the patient about the procedure for the
action to be taken.
3. Implementation
a. Match the yellow medicine card on the doctor's
order.
b. Washing hands
c. Prepare medicine according to the doctor's order.
d. Prepare the tools in the tray and bring them to the
PROCEDURE side where they sleep
patient (the drug has been opened and put into a
sterile gauze).
e. Adjust the position of the dorsa recumbent patient.
f. Enter the medicine slowly using a hand shirt
and have a long breath patient.
g. Return the client in a pleasant position.
h. Clean the tools.
i. Wash hands and check on patient lysts

emergency room, ICU
Giving Medicine (Ear)

PROCEDURE
Giving medicine into the outer cavity by dripping or

DEFINITION
irrigation.
Clean the ear cavity from pus, dirt
PURPOSE
ears or foreign objects.
steps of nursing care on the implementation of the action
POLICY
of administering drugs through the ear
1. Preparation of tools
a. Ear irrigation device.
b. Warm water in its place.
c. Crooked.
d. It is necessary and the base.
e. Towel.
f. Twisted tweezers / tweezers.
g. Cotton sticks.
a. Patients are prepared to sit.
b. Explain the procedure for the action to be taken
3. Implementation
a. Washing hands
b. It is necessary and the base is placed above the
PROCEDURE shoulder.
c. Patients are recommended to hold a bent under
the ear
to be cleaned.
d. With the left hand the earlobe is pulled up and
slightly to
back
f. The tip of the irrigation device is placed not in
the ear canal
to cover the ear cavity.
g. Spraying is done carefully but is rather strong
on
the upper side of the ear canal.
h. The liquid that comes out is accommodated by
bending.
i. Spraying was repeated several times

clean.
j. Once clean, the ear hole is cleaned with cotton sticks,
the surrounding is cleaned with a towel.
k. If necessary, drug drops.
l. The tools were taken care of and the patient was tidied
up.
m. Wash hands and record actions in patient status

emergency room, ICU.
Giving Drug (Nose)

PROCEDURE
An action of giving drugs to patients through breathing.

DEFINITION
1. Relieve breathing.
2. Reducing the swelling of the respiratory tract.
3. Treating inflammation.
4. Dilute and facilitate the discharge of mucus.
5. Reduce coughing.
6. Prevent dryness of the mucous membranes.
7. Performed on patients:
PURPOSE - Out of breath.
- Bronchial asthma.
- Post tracheostomy.
- Upper respiratory tract is blocked by mucus
As a reference for nurses in implementing the steps of

nursing care on the implementation of the action of
POLICY administering drugs through the nose
PROCEDURE 1. Preparation of tools and drugsa.

a. Tissue
b. Crooked
c. Medicine needed
Explain the procedure for the action to be taken
3. Implementation
a. Match drug cards with patient status
b. Washing hands
c. Prepare medicine
d. Bring medicine to the patient
e. Drop certain drugs into the nostrils.
f. Tidy up the patient and tidy up the equipment
g.Washing hands
Inpatient installation, outpatient installation,

UNIT
Giving Meidicne Inj INTRA MUSCULAR

PROCEDURE
DEFINITION Injecting drugs into muscle tissue.
1. To give stimulating drugs that are not easily

sucked / can cause pain when given under the skin.
2. To give medicines which we expect to see more
PURPOSE quickly than we give under the skin.

nursing care to
POLICY
implementation of the action of administering drugs
through intra muscular injections
a. Tray.
b. Medicine card.
c. Drugs to be given
d. Disposable syringes as needed
e. Miser ampoule
f. Sterile needle.
g. 70% alcoholic cotton.
action to be taken
3. Implementation
a. Washing hands
c. Pay attention to aseptic techniques
d. Match the yellow medicine card to the doctor's
order and the nurse's note.
e. Prepare medicine according to the
PROCEDURE
doctor'sorder.
f. Take the disposible syringe according to the
amount of medicine to be given, tear the plastic
tip marked, take the syringe in the plastic.
g. Read the etiquette and dosage of the drug and
put the drug into the syringe, then the air in the
syringe is removed
A. On ampules
a) Make sure the medicine is under the ampoule.
b) Saw on the ampoule neck marked / not.
c) Ampoule held with one hand and ampoule
handle
held with the right hand

dialed to break it.
d) To take the drug in the ampule: insert the syringe into
the ampoule and pull the solution, be careful not to
touch the side of the glass with a syringe, to prevent
contamination.
B. In the vial
a. Add air to the amount of solution to be taken and
before the vial rubber is cleaned with anti-septic
(alcoholic cotton).
b. Take medicine to the patient.
c. Position the patient.
d. Determine the area to be injected
C. When injections in the buttocks:

a. At the musculus glutus, set the patient on his stomach
with a limp body lying face down and covering the
patient, choose the place for the injection in the middle
of the upper quadrant.
b. Disinfecting the skin to be injected with alcohol in a
circular motion from the inside out
c. Inserting a needle quickly into a perpendicular muscle
(90º angle), hold the tissue firmly when inserting the
needle with the left hand.
d. Make aspirations by pulling a little syringe stamper
and if there is no blood entering the syringe, enter the
liquid medicine slowly. When there is blood, pull the
needle
come out, then replace with the needle
new, then choose another place to inject
back.
e. Pay attention to the patient's response
f. Pull out the needle slowly
g. Disinfect skin with 70% alcohol cotton
h. Washing hands
i. Record patient response and drug administration
Attention:
1. The injection site must be correct if it is wrong,

because it can affect the ischiadeous nerve.
2. Location of intra muscular injection:
The right buttocks muscle is 1/3 part of the anterior

superior spina illiaka, (dorso-gluteal area / back waist).
The gluteal dorso area located at the waist has a

commonly used IM injection area.
The injection is carried out between 5 - 7.5 cm below

the illium peak in the upper quarters of the hip.
Another method for determining the injection point at

the hip can be by drawing a line from the posterior
superior illium bone to the base of the outer femur.
The outer thigh muscle is 1/3 the middle of the outer

thigh (the area of the vestus lateris muscle). The third
middle part, if measured up from the top of the knee,
and down from the lower end of the base, here as the
injection area.
Forearm muscle / deltoid da pasterior triceb muscle

(shoulder and upper arm).
This muscle can also be used for IM injection,
This muscle is rarely used for use
injection, because the client feels more pain and
sore in the muscles, when injection position

patients can lie down / sit down
Attention:
1. The injection site must be correct if it is wrong,
because it can affect the ischiadeous nerve.
2. Location of intra muscular injection:
The right buttocks muscle is 1/3 part of the anterior
superior spina illiaka, (dorso-gluteal area / back waist).
The gluteal dorso area located at the waist has a
commonly used IM injection area.
The injection is carried out between 5 - 7.5 cm below the
illium peak in the upper quarters of the hip.
Another method for determining the injection point at the
hip can be by drawing a line from the posterior superior
illium bone to the base of the outer femur.
The outer thigh muscle is 1/3 the middle of the outer
thigh (the area of the vestus lateris muscle). The third
middle part, if measured up from the top of the knee, and
down from the lower end of the base, here as the injection
PROCEDURE area.
Forearm muscle / deltoid da pasterior triceb muscle
(shoulder and upper arm).
This muscle can also be used for IM injection,
this muscle is rarely used for injection purposes,
because the client feels more aches and pains in
the muscles, when the injection position the
patient can lie down / sit.
Inpatient installation, outpatient installation,

UNIT
emergency room, ICU .
PROCEDURE Inj INTRA CUTAN
DEFINITION Injecting drugs into the skin tissue.
1. To conduct a trial of skin / skin tests of certain

drugs, for example: antibiotics, ATS, etc.
2. For certain drugs which are given specifically in
PURPOSE
this way, for example: BCG.
3. For observation of TB disease (Tuberculin test /
PPD test).
POLICY steps of nursing care on the implementation of intra
cutaneous administration
a. Tray.
b. Medicine card.
c. Drugs to be given
d. Disposable syringes as needed
e. Miser ampoule
f. Sterile needle.
g. 70% alcoholic cotton.
3. Implementation
a. Match the medicine card to the doctor's order
and note
nurse / read doctor's message on patient lyst.
b. Washing hands.
c. Prepare tools and medicine
d. The skin is disinfected, then stretched /
stretched / stretched
with left hand.
e. The needle is inserted with a pinhole
facing up
and make an angle of 15º - 20º with
skin surface, then
the drug is sprayed until a bubble occurs
at that place.
f. Then the needle is pulled quickly, no
deleted with alcohol and massase should not be
done.
g. Washing hands.
CARA MEMBERIKAN OBAT INTRA

PROCEDURE SUBCUTAN
Injecting drugs under the skin, for example: injecting

DEFINITION
insulin with a client diabetes militus.
PURPOSE To treat patients.

steps of nursing care on the implementation of intra-
POLICY
sub cutaneous drug administration
PROCEDURE 1. Preparation of tools

Same with IM injections.
3. Implementation
a. Match the medicine card to the doctor's order and
nurse's note /
read the doctor's message to the patient's lyst.
b. Washing hands.
c. Prepare the tools according to the doctor's order.
d. Bring medicine to patients while reading TT cards.
e. The injection site is disinfected, which has been
confirmed.
f. The injection site is slightly removed with the left
hand.
g. With the pinhole facing up, the needle is inserted
into a 45º angle to the surface of the skin.
h. The stamper is pulled slightly if there is blood
medicine not to be inserted,
i. if there is no blood, the drug is slowly inserted.
j. After the drug has entered completely, the needle
is pulled out quickly, the puncture marks are held
with alcohol cotton and massase is carried out.
k. Tidy up equipment
l. Wash hands and take notes on actions
patient status
UNIT Inpatient installation, outpatient installation, emergency

room, ICU.
MEASURING THE TEMPERATURE OF

PROCEDURE
AGENCY
Measure the patient's body temperature using a
DEFINITION
temperature thermometer.
Know the patient's body temperature to help:

PURPOSE 1. Determine the diagnosis.
2. Determine treatment steps.
POLICY steps of nursing care on the implementation of
measures to measure body temperature
a. The thermometer is clean and in place.
b. Crooked.
c. Cut tissue.
d. Vaselin in his place.
e. Notebook.
Patients are explained about the procedure of the
action to be taken
3. Implementation
a. Measurement of temperature in the armpit
a) Wash hands
b) The tools are brought near the patient.
PROCEDURE
c) If you need to open the patient's arm, the
armpit is wiped (using a tissue with a pat on the
motion) and dried.
d) Take the thermometer from the storage area,
broom it with tissue
e) Check and lower mercury at the lowest
position.
f) Put it right on the reservior, pin it in the
middle of the armpit and the patient's arm is
placed on the chest
g) After 8-10 minutes the thermometer is lifted
and read the numbers on the thermometer with
the position parallel to the eye, and the results
are recorded in the book
h) The thermometer is cleaned with alcohol
cotton and dried with tissue
i) Mercury is lowered back and the thermometer

is put into place
j) Wash hands
b. Temperature measurement in the mouth
The patient must have his own
thermometer.
Washing hands
Tools are placed on the patient's table.
The patient is told to open his mouth, the
thermometer is checked again, then the tip
until the limit of the reservoir is placed under
the patient's tongue
Mouth added 5 minutes and breathe through
the nose.
As long as the thermometer is installed the
patient cannot talk.
PROCEDURE For 3-5 minutes the thermometer is lifted,
wiped with tissue and read and recorded.
The tools are cleaned with running water then
wiped with alcohol cotton, dried with tissue,
and returned to its place
Washing hands
c. Temperature measurement at rectal
a) Wash hands
b) Tools are placed on the patient's table.
c) After the patient is notified, the patient is tilted
(SIM attitude).
d) The patient's clothes are lowered below the
buttocks.
e) The thermometer is examined, the tip is
smeared with vaseline, then inserted through
the anus, to the limit of the mercury reservoir.
a) f) The thermometer is still held.
g) g) After 3-5 minutes the thermometer is

removed, wiped with tissue, read and the
results are recorded.
h) The thermometer is cleaned with running
water then wiped with alcohol cotton,
dried with tissue, and returned to its place
i) Wash hands
Nursing ,
UNIT
Installation
ICU, IGD, IKO.
PROCEDUR
CALCULATING NADI AND BREATHING
E
Calculate pulse and amount of breathing (inspiration

DEFINITION
followed by expiration) in one minute.
1. To find out the amount of breathing in 1
2. minute.
PURPOSE 3. To find out the work of the heart
4. To find out the general condition of the patient.
5. To determine the diagnosis.
POLICY steps of nursing care on the implementation of the
action of calculating pulse and respiration
a. Wristwatch with seconds instructions.
b. Note the patient's pulse and respiration.
Patients are told to be calm and relaxed, may
PROCEDURE while lying or sitting.
3. Implementation
a. Washing hands
b. Calculate the pulse for one minute on the radial
artery.
c. Observe frequency, rhythm, and volume
d. Calculate breathing for one minute.
e. Record the results of the patient's actions and
responses
f. Washing hands
Instalasi Rawat Jalan, hospitaliz rawat inap,
UNIT
ICU,IGD,IKO. ed
PROCEDURE MEASURING BLOOD PRESSURE
DEFINITION Measuring blood pressure on the arterial wall.
1. To know the work of the heart.

PURPOSE 2. To determine the diagnosis.
3. To determine the steps of nursing.

POLICY steps of nursing care on the implementation of actions
in measuring blood pressure
PROCEDURE
a. Tensimeter.
b. Stethoscope.
c. Notebook.
Patients are explained about the procedure of
action to be taken and adjust the position of the
patient as needed
3. Implementation
a. Washing hands
b. The sleeve is opened / rolled up.
c. The tensimeter cuff is mounted on the upper arm
with the rubber pipe on the outside of the arm. The
cuff is not too tight or too loose.
d. Tensimeter pump installed.
e. The branchial artery pulse is palpated, then the
stethoscope is placed in the area.
f. Rubber balloon screw closed, mercury lock is
opened Then balloons are pumped until the arterial
pulse is not heard again and mercury in the glass
pipe rises.
g. The balloon screw is opened slowly so that the
mercury drops slowly. While noting the drop in
mercury listen to the first throb / systole,
listen until the diastole pulses
h Record patient measurement results and

responses
i. Patients and tools trimmed
j. Washing hands
Outpatient Installation, Inpatient Installation, ICU,
UNIT
IGD, IKO.
PROCEDURE
GIVE COLD COMPRESSES
DEFINITION Give patients cold compresses to help lower body

temperature and provide comfort
1. Helps reduce body temperature

PURPOSE 2. Giving comfort to patients.

POLICY nursing care to the implementation of actions in giving
compresses
Cold
a. Washcloth
b. Not small and the base
c. Waskom contains cold water / ice or ice cream
The patient is given an explanation of the things
to be done and the position is adjusted according
to need
PROCEDURE
3. Implementation
a. Washing hands
b. Bring equipment to patients
c. It is necessary and the base is installed in the
place to be compressed
d. Wash the cloth moistened with cold water / ice
to taste and put it in a place to be compressed
e. Observation of patient responses
f. Washing hands
g. Record patient response and results of action
Outpatient Installation, Inpatient Installation, ICU,

UNIT
IGD, IKO.
GIVING INHALATION DRUGS WITH

NEBULIZER
PROCEDURE
Provision of steam inhalation with drugs / without drugs
DEFINITION using a nebulator
Dilute secretions to make them easier to remove,
PURPOSE loosen the airway
As a reference for nurses in the implementation of

steps of nursing care on the implementation of actions
POLICY
or methods of administration of drugs
Inhalation with a nebulizer
a. Set nebulizer
b. Bronchodilator
c. Crooked 1 fruit
d. Tissue
e. 5cc spuit
f. Aquades
action to be taken.
3. Management
a. Maintain client privacy
b. Set
C. Implementation
1. Maintain patient privacy
2. Arrange the patient in a sitting position
3. Place the table / troly in front of the patient
containing the set of nebulizer
4. Fill the nebulizer with aquades according to
the dosage
5. Make
Instalasi sure
rawat theInstalasi
inap, tool can rawat
function properly
jalan, IGD, ICU
6. Enter the drug according to the dose
7. Install the mask on the patient
8. Turn on the nebulizer and ask the patient to
breathe deeply until the medicine runs out
9. Clean the mouth and nose with tissue
Termination Stage
1. Perform an action evaluation
2. Goodbye to patients / families
3. Tidy up the tool
4. Wash hands
5. Record activities on the nursing record sheet
UNIT Outpatient Installation Unit, Inpatient Installation,

IGD, OK.
GIVING OXYGEN WITH A SIMPLE MASK

PROCEDURE
A simple face mask is a tool for oxygen therapy that covers the
DEFINITION client's nose and mouth, used for oxygen inhalation of 40-60% at
speeds of 5-8 liters / minute,
To launch the airway so that the respiratory flow is

PURPOSE regular.
As a reference for nurses in the application of steps of

nursing care on the implementation of actions or ways
POLICY
of administering oxygen with a simple mask.

a. Simple face masks, according to patient's needs
and size
b. Oxygen hose
c. Humidifier
d. Sterile water
e. Oxygen tube with flowmeter
f. Elastic tape or cord
action to be taken.
A. Implementation
a. Washing hands
b. Prepare tools
c. Assess for signs and clinical symptoms and
secretions on the airway.
d. Connect the mask to the source and oxygen
e. Give oxygen flow according to the flow rate in
the medical program and make sure it functions
properly.
• The hose is not bent and the connection is
patent.
• There are air bubbles in the humidifier.
• Feel the oxygen coming out of the mask.
f. Point the mask to the client's face and attach it
from the nose down (adjust to the contour of the
client's face).
Elastic fixation of the client's head brush so that
the mask is comfortable and not narrow.
Check the mask, oxygen flow every 2 hours or
faster, depending on the patient's general
condition and condition
g. Keep the water level on the humidifier bottle
every time
h. Check the amount of oxygen flow rate and
treatment program every 8 hours.
i. Assess the nasal mucous membrane for
irritation and give jelly to moisturize the mucous
membrane if needed.
j. Washing hands.
k. Evaluate patient response.
l. Record the results of the actions taken.
GIVING OXYGEN WITH REBREATHING MASK

PROCEDURE
Rebreathing mask is a face mask that has a reservoir bag and mask
DEFINITION without a valve. The oxygen reservoir bag that is connected allows
the client to take a breath back about a third of that air exhaled
together with oxygen. Rebreathing masks flow oxygen with an O2
flow rate of 8-12 liters / minute and O2 concentration of 60-80%.

PURPOSE regular.
A.
B. a reference for nurses in implementing steps of
As
C.
nursing
D. care on the implementation of measures or
POLICY
methods
E. of administering oxygen with rebreathing
masks.
F.
PROCEDURE G. 1. Preparation of tools and medicines
H. a. Oxygen set (O2, O2 tube, flowmeter, humidifier)
I. b. Sterile water
J. c. Non irritant plaster
K. d. Antiseptic (if needed)
L. e. Rebreathing mask
M. f. Clean gloves
action to be taken.
A. Implementation
a. Washing hands
b. Using clean gloves
c. Prepare equipment
d. Assess the presence of clinical signs and
symptoms and secretions on the airway
e. Connect the mask to the hose and to the oxygen
source
f. Provides oxygen flow according to the flow rate
in the medical program and ensures that it functions
properly.
g. The hose is not bent and the connection is patent.
h. There are air bubbles in the humidifier.
i. Oxygen comes out of the mask.
j. Ensure that the reservoir bag is not totally folded
or deflated when inspiring
k. Direct the mask to the client's face and attach it
client's face)
l. Circular elastic tape to the patient's head to make
it comfortable and not narrow
m. Check the mask, oxygen flow every 2 hours or
faster, depending on the patient's general condition
and condition
n. Maintain the water level on the bottle of the
humidifier at all times.
o. Check the amount of oxygen flow rate
p. Assess the nasal mucous membrane from
irritation and give jelly to moisturize the mucous
membrane if needed.
a. R: avoid irritation caused by canal nasal
installation and dryness due to oxygen boost
a. Washing hands.
R: maintain cleanliness and avoid nosocomial infections
b. Evaluating patient responses
R: avoid actions that result in clients feeling sick and anxious
about further actions
c. Record the results of the actions taken and the results
R: as a documentation and monitoring tool for the development
of the client's physical condition
.
Outpatient Installation, Inpatient Installation, ICU, IGD,

UNIT
IKO.
GIVING OXYGEN WITH NON-REBREATHING

PROCEDURE
MASK
Nonrebreathing masks flow oxygen with the highest concentration
DEFINITION
Giving Oxygen Through Nonrebreathing Masks reaches 99% by
means of intubation or mechanical ventilation, at a flow volume of
10 to 12 L per minute. The one-way valve on the mask and between
the reservoir bag and mask, prevents the air from air and the exhaled
air from entering the bag so that only oxygen in the bag is inhaled.
PURPOSE regular.

nursing care to the implementation of measures or
POLICY
methods of administering oxygen with a Non-
Rebreathing mask
a. Nonrebreathing face masks, according to
patient's needs and size
b. Oxygen hose
c. Humidifier
d. Sterile water
e. Oxygen tube with flowmeter
f. Elastic tape or cord
action to be taken.
N. Implementation
a. Washing hands
b. Prepare tools
c. Assess for signs and clinical symptoms and
secretions on the airway
d. Connect the mask to the source and oxygen
e. Give oxygen flow according to the flow rate in
the medical program and make sure it functions
properly.
1. The hose is not bent and the connection is patent.
2. There are air bubbles in the humidifier.
3. Feel the oxygen coming out of the mask.
f. Point the mask to the client's face and attach it
client's face) ..
g. Elastic fixation of the client's head brush so that
the mask is comfortable and not narrow.
h. Give oxygen flow according to the flow rate
i. Check the mask, oxygen flow every 2 hours or
faster, depending on the patient's general condition
and condition
j. Try to keep the reservoir bag completely deflated
when the client is inspiring
k. Keep the water level on the humidifier bottle
every time
l. Check the amount of oxygen flow rate and
treatment program every 8 hours
m. Assess the nasal mucous membrane for irritation
and give jelly to moisturize the mucous membrane
if needed
n. Washing hands
o. Evaluate patient response
p. Record the results of the actions taken and the
results
Outpatient Installation, Inpatient Installation, ICU, IGD,

UNIT
IKO.

Sop Fix

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Sop Fix

Uploaded by

Copyright:

Available Formats

UNIVERSITAS KATOLIK WIDYA MANDALA SURABAYA

Prepare and provide medicines for clients

g. With a medicine card, check the label for the name

prove it has given medicine with

UNIT Inpatient installation, outpatient installation,

PROCEDUR GIVING MEDICINE (EYES)

As a reference for nurses in implementation

1. Preparation of tools and medicines

k. Cleanse the remaining ointment / drops

UNIT Inpatient installation, outpatient installation,

PROCEDUR Giving Medicine (Vagina)

PURPOSE To treat and clean the vagina.

1. Preparation of tools and medicines

UNIT Inpatient installation, outpatient installation,

Giving Medicine (Ear)

Giving medicine into the outer cavity by dripping or

i. Spraying was repeated several times

UNIT Inpatient installation, outpatient installation,

Giving Drug (Nose)

An action of giving drugs to patients through breathing.

As a reference for nurses in implementing the steps of

PROCEDURE 1. Preparation of tools and drugsa.

Inpatient installation, outpatient installation,

Giving Meidicne Inj INTRA MUSCULAR

DEFINITION Injecting drugs into muscle tissue.

1. To give stimulating drugs that are not easily

As a reference for nurses in applying the steps of

held with the right hand

C. When injections in the buttocks:

new, then choose another place to inject

e. Pay attention to the patient's response

f. Pull out the needle slowly

g. Disinfect skin with 70% alcohol cotton

i. Record patient response and drug administration

1. The injection site must be correct if it is wrong,

2. Location of intra muscular injection:

The right buttocks muscle is 1/3 part of the anterior

The gluteal dorso area located at the waist has a

The injection is carried out between 5 - 7.5 cm below

Another method for determining the injection point at

The outer thigh muscle is 1/3 the middle of the outer

Forearm muscle / deltoid da pasterior triceb muscle

This muscle can also be used for IM injection,

This muscle is rarely used for use

injection, because the client feels more pain and

sore in the muscles, when injection position

Inpatient installation, outpatient installation,

PROCEDURE Inj INTRA CUTAN

DEFINITION Injecting drugs into the skin tissue.

1. To conduct a trial of skin / skin tests of certain

CARA MEMBERIKAN OBAT INTRA

Injecting drugs under the skin, for example: injecting

PURPOSE To treat patients.

As a reference for nurses in implementation

PROCEDURE 1. Preparation of tools

UNIT Inpatient installation, outpatient installation, emergency

MEASURING THE TEMPERATURE OF

Know the patient's body temperature to help:

i) Mercury is lowered back and the thermometer

g) g) After 3-5 minutes the thermometer is

Calculate pulse and amount of breathing (inspiration

PROCEDURE MEASURING BLOOD PRESSURE