Laura Adinda Putri (19112239)

Rossy Amarthia Lasfi

Febi Melsi Monalisa

Drafting Nursing Intervention : Checking Patients Vital Signs

A grandfather comes to hospital after he fell down in the bathroom because not high
hypertension. Then he went into hospital

Nurse 1 : Hello sir, can I help you ?

Grandfather : I fell down in the bathroom because of high hypertension. And now I feel a lot
of pain in my head and my neck. Can you check my vital signs ?
Nurse1 : oh my goodness. Let me take you to the emergency room to check your vital signs
Two nurses welcome the patient and took the patient into bed and talked a little one
nurse asked some questions of admission
Nurse 1 : Ok sir. First I want to fill out the patient admission form. Can you mention the data
I provided ?
Grandfather :Yes nurse. Sure
Nurse 1 : What is your name and when your date of ?
Grandfather : My name is Boy. I waa born in Padang on August 18,1886
Nurse 1 : What is your religion ?
Grandfather : I’m Muslim
Nurse 1 : What are you complaints ?
Grandfather : I feel dizzy and have pain in my head and my neck. Lately I feel my blood
pressure is high
Nurse 1 : Do your parents have a history of hipertention ?
Grandfather : Yes. My mother has a history of hipertention
Nurse 1 : Ok Tn. Boy. Next, nurse Laura will check your vital signs and I will complete this
data. Thank you tn. Boy
Grandfather : You are welcome nurse

The nurses started to do checking vital signs

Nurse 2 : Morning Tn. Boy. Introduce my name is Laura. Well, at this time I will do a vital
sign check on you. This check takes a few minutes. Are you ready ?
Grandfather : Yes, I’m ready
Nurse 2 : First , I will measure blood pressure using a tensimeter dan stethoscope, can you
raise your hand and roll up your sleeves ?
Grandfather : Yes please
Nurse 2 : The second, I will measure body temperature using thermometer, and will put in the
armpits of you. Excuse me, can you lift your arms ??
Grandfather : Yes I can lift it
Nurse 2 : Do you find it hard to breathe ??
Grandfather : Yes I feel tight on my breath
Nurse 2 : Ok I will check your respiration with a stethoscope and please open two buttons on
your shirt
Grandfather : Ok nurse
Nurse 2 : And the last, I Will measure the pulse using a stethoscope. Please straighten your
hand and make a fist.
Grandfather : Yes nurse
Nurse 2 : I have finished checking vital signs. According to the results of the examination of
your blood pressure is 140/80 mmHg, your body temperature is 39°C, your respiration is 22/
minutes, and your pulse rate is 84/ minutes.
The nurse give some advice
Nurse 2 : Ok Tn Boy, you should control the number if calories eaten each day and balance it
with regular exercise. Limit foods that contain high level of salt, and simply add a little salt to
the food. Well, then let me go out first
Grandfather : Ok. Nurse. Thank you nurse.