PEMERIKSAAN PERNAFASAN ( SOP )

LAMBANG RS. ………………. Jl. ……………… ……………………..	PEMERIKSAAN PERNAFASAN
	No. Dokumen: …../…./…………./…….	No. Revisi :	No. Halaman : 1
	Tanggal terbit ………………………….	Ditetapkan Oleh: dr. ………………….. Direktur
STANDAR OPERASIONAL PROSEDUR KEPERAWATAN
Pengertian	Nilai pemeriksaan pernafasan merupakan salah satu indikator untuk mengetahui fungsi sistem pernafasan yang terdiri dari mempertahankan pertukaran oksigen dan karbon dioksida dalam paru dan pengaturan keseimbangan asam-basa
Tujuan	Mengetahui frekuensi, irama dan kedalaman pernafasan Menilai kemampuan fungsi pernafasan. Mengikuti perkembangan jalannya penyakit. Membantu menentukan salah satu pendukung diagnose.
Kebijakan	Melakuakn tindakan dengan tujuan mendukung sempurnanya pelayanan kesehatan yang diberikan dalam ketepatan Assesment pasien.
Prosedur	1.     Tahap pra interaksi : a.    Verifikasi program terapi b.    Siapkan alat -          Arloji (Jam) atau stop-watch -          Buku catatan nadi -          Pena /  Bolpoint c.    Jaga privacy klien; bila perlu tutup pintu dan jendela / gorden

LAMBANG RS. ………………. Jl. ……………… ……………………..	PEMERIKSAAN PERNAFASAN
	No. Dokumen: …../…./…………./…….	No. Revisi :	No. Halaman : 2
	1.    Tahap orientasi : a.    Berikan salam 2.    Tahap kerja. a.    Mencuci tangan. b.    Mempersilakan pasien berbaring atau duduk dengan tenang di tempat tidur. c.    Jangan beritahu klien jika frekuensi pernafasannya dihitung d.   Hitung frekuensi dan irama pernafasan e.    Jelaskan pada klien bahwa saudara telah menghitung frekuensi dan irama pernafasan klien f.     Cuci tangan g.    Nilai standar pemeriksaan nafas -          Neonatus : 30 – 60  ( Saat tidur : 35 ) -          1 bulan – 1 tahun : 30 – 60   ( Saat tidur : 30 ) -          1 tahun – 2 tahun : 25 – 50 ( Saat tidur : 25 ) -          3 tahun – 4 tahun : 20 – 30 ( Saat tidur : 22 ) -          5 tahun – 10 tahun : 15 – 30 ( Saat tidur : 18 ) -          10 tahun lebih : 15 – 30 ( Saat tidur : 15 ) 3.    Tahap terminasi : a.    Ucapkan terima kasih atas kerjasama dengan pasien b.    Evaluasi respon klien c.    Simpulkan hasil kegiatan d.   Pemberian pesan e.    Kontrak waktu kegiatan selanjutnya f.     Atur posisi klien senyaman mungkin 4.    Dokumentasikan : Nama klien Tanggal dan jam Tindakan yang dilakukan Respon klien Nama petugas

LAMBANG RS. ………………. Jl. ……………… ……………………..	PEMERIKSAAN PERNAFASAN
	No. Dokumen: …../…./…………./…….	No. Revisi :	No. Halaman : 3
Unit Terkait	Seluruh personil Dokter, Keperawatan & Bidan RS. ......................

MEASURE BODY TEMPERATURE ( SOP ) STANDARD OPERATING PROCEDURE

SYMBOL

. ………………. HOSPITAL

Jl. ………………

……………………..

MEASURE BODY TEMPERATURE

No. Document:

…../…./…………./…….

No. Revision:

  

Date of issue

…………………………

Determined by:

dr. ………………….

director

STANDARD OPERATING PROCEDURE

NURSING

MEASURE BODY TEMPERATURE

No. Page :

1

 

 

Understanding

To examine the degree of heat produced by the human body as a balance in the body burning with heat dissipation through sweating, breathing, remnants disposal [eksresi] and irradiation [radiation], conductivity [conduction] and convection [convection]

Aim

1.      Knowing the patient's general condition.

2.      Knowing the temperature of the hot body.

3.      Knowing abnormalities in the body is used as a backstop to help make the diagnosis

4.      Knowing the progression of the disease.

Policy

Take action with the aim of supporting imperfect health services provided in the accuracy Assessment of patients.

 

Procedure

1.      Examination melelui axillary temperature

a.       Describe the purpose and implementation procedures

b.      Washing hands

c.       Use gloves (handscond)

d.      Adjust the position of the client (sitting / lying down)

e.       When using a mercury thermometer, then lower the temperature on the thermometer prior to the figure of 35 ° c

No. Page :

2

 

f.       Place the thermometer in the axillae then tell the patient clamped to 3-5 minutes.

g.      When using a digital thermometer, then wait until the thermometer reads and wait until the sound stops then the results can be seen printed on the thermometer

h.      Noting the results of the investigation

i.        Clean the thermometer

2.     Measure the temperature of the body through the rectum

a.       Describe the purpose and implementation procedures

b.      Washing hands

c.       Use gloves (handscond)

d.      Adjust the position by asking the patient to tilt left

e.       When using a rectal thermometer mercury, then lower the temperature on the thermometer until the number 0 ° C and apply Vaslin / gelly taste

f.       Lower the patient's clothing to parts of the gluteal and maintaining patient privacy.

g.      Place the palms on the side of the gluteal patient and insert the thermometer into the rectum, have the patient hold up to 3-5 minutes and try not to change its position.

h.      After completion of the lift thermometer and read / record results

i.        Clean the thermometer

No. Page :

3

3.     Examination of body temperature through oral

a.       Describe the purpose and implementation procedures

b.      Washing hands

c.       Use gloves (handscond)

d.      Adjust the position of the client (sitting / lying down)

e.       When using a mercury thermometer, then lower the temperature on the thermometer prior to the figure of 35 ° c

f.       Tentukkan lies under the tongue

g.      Place the thermometer under the tongue and gums aligned with

h.      Instruct the clenched mouth for 3-5 minutes

i.        Pick up and read the results (in reading straighten and align it with the eyes of the reader and then read the results carefully the extent where the mercury stops, log results)

Related unit

All personnel Doctor, Nursing and Midwife, .....................HOSPITAL

MEASURE BODY TEMPERATURE ( SOP ) STANDARD OPERATING PROCEDURE

SYMBOL

. ………………. HOSPITAL

Jl. ………………

……………………..

MEASURE BODY TEMPERATURE

No. Document:

…../…./…………./…….

No. Revision:

  

Date of issue

…………………………

Determined by:

dr. ………………….

director

STANDARD OPERATING PROCEDURE

NURSING

MEASURE BODY TEMPERATURE

No. Page :

1

 

 

Understanding

To examine the degree of heat produced by the human body as a balance in the body burning with heat dissipation through sweating, breathing, remnants disposal [eksresi] and irradiation [radiation], conductivity [conduction] and convection [convection]

Aim

1.      Knowing the patient's general condition.

2.      Knowing the temperature of the hot body.

3.      Knowing abnormalities in the body is used as a backstop to help make the diagnosis

4.      Knowing the progression of the disease.

Policy

Take action with the aim of supporting imperfect health services provided in the accuracy Assessment of patients.

 

Procedure

1.      Examination melelui axillary temperature

a.       Describe the purpose and implementation procedures

b.      Washing hands

c.       Use gloves (handscond)

d.      Adjust the position of the client (sitting / lying down)

e.       When using a mercury thermometer, then lower the temperature on the thermometer prior to the figure of 35 ° c

No. Page :

2

 

f.       Place the thermometer in the axillae then tell the patient clamped to 3-5 minutes.

g.      When using a digital thermometer, then wait until the thermometer reads and wait until the sound stops then the results can be seen printed on the thermometer

h.      Noting the results of the investigation

i.        Clean the thermometer

2.     Measure the temperature of the body through the rectum

a.       Describe the purpose and implementation procedures

b.      Washing hands

c.       Use gloves (handscond)

d.      Adjust the position by asking the patient to tilt left

e.       When using a rectal thermometer mercury, then lower the temperature on the thermometer until the number 0 ° C and apply Vaslin / gelly taste

f.       Lower the patient's clothing to parts of the gluteal and maintaining patient privacy.

g.      Place the palms on the side of the gluteal patient and insert the thermometer into the rectum, have the patient hold up to 3-5 minutes and try not to change its position.

h.      After completion of the lift thermometer and read / record results

i.        Clean the thermometer

No. Page :

3

3.     Examination of body temperature through oral

a.       Describe the purpose and implementation procedures

b.      Washing hands

c.       Use gloves (handscond)

d.      Adjust the position of the client (sitting / lying down)

e.       When using a mercury thermometer, then lower the temperature on the thermometer prior to the figure of 35 ° c

f.       Tentukkan lies under the tongue

g.      Place the thermometer under the tongue and gums aligned with

h.      Instruct the clenched mouth for 3-5 minutes

i.        Pick up and read the results (in reading straighten and align it with the eyes of the reader and then read the results carefully the extent where the mercury stops, log results)

Related unit

All personnel Doctor, Nursing and Midwife, .....................HOSPITAL