1. LAPORAN PENDAHULUAN
UNIT KOMPETENSI KE-11
“MENGUKUR TANDA-TANDA VITAL”
TAHUN PELAJARAN 2021/2022
DISUSUN OLEH:
Kharisma Nur Idalasari
0522 / 3172044404030004
SEKOLAH MENENGAH KEJURUAN KESEHATAN GLOBAL CENDEKIA
JALAN GADANG NO. 83-85 KEL. SUNGAI BAMBU KEC. TANJUNG PRIOK
JAKARTA UTARA
2020
2. 11th
Competency Unit
MEASURES VITAL SIGNS
I. PRE-INTERACTIONSTAGE
1.1 Program Verification
“I will take Vital Sign to Tn./Ny./Nn./An. atau Mr. Mrs. Miss. in ward 3, bed 1.”
1.2 Wash Hand (sebelum melakukan tindakan)
1.3 Preparing of the nursing tools
Trolly
Baki & Alas Baki
APD (Apron, Masker, Handscoen)
Handrub
Note book & pen
Arloji/Jam Tangan
Tensimeter
Stetoskop
Thermometer Air Raksa/Digital
Small Kom
Kom Tertutup
Tissu
Alkohol swab
Bengkok/Nierbekhen/Piala Ginjal/Kidneydish
1.4 Wash Hand (sebelum kontak dengan klien/pasien)
3. II. ORENTATION STAGE
N :”Assalammualaikum, Good Morning… Can I look at your ID bracelet please?”
P :”Yes, of course ners…”
N :”Can you tell me your full name, please?”
P :”Yes, my name is Fitri Wahyuni.”
N :”What is your date of birth?”
P :”My birthday is September 9, 1981.”
N :”I will just checking that on the identity bracelet. Your bracelet ID is 09091981,
that’s right.”
N :”Okay Mrs. Fitri, introduce my self, my name is Ni Nyoman Rosa Sari Anastasya,
you can call me Suster Rosa. I am in service from 7 a.m to 2 p.m. How are this
morning Mrs. Fitri?
P :”I am not good feeling.”
N :”Okay, now, I will take your Vital Sign, to find out if your condition is normal or
not. Are you willing?
P :”Yes, I am willing.”
N :”Alright…. I will prepare the tools first, excuse me…”
III. WORK STAGE
N :”I close the curtain, so that your privacy is maindtained.”
Wash hand with handrub (mencuci tangan sebelum melakukan tindakan)
Using APD: Handscoen
N :”First, I will take your temperature. Before I put the thermometer in your armpit,
I clean it first. This temperature measurement is 5-10 minutes. (until you hear a
sound)”
P :”Okay ners…”
N :”Second, I will measure your blood pressure. I roll up your sleeves.”
N :”Your blood pressure is 150/100 mmHg. This is normal.”
P :”Alhamdulillah/be better…”
N :”and your temperature is 39°C. This is so high result.”
4. N :”Third, I will measure your pulse. Can I feel your pulse?”
P :”Yes, please…”
N :” Your pulse is 88 x/minute.”
N :”The last, I will measure your breathing.”
N :” Your breathing is 23 x/minute. This is normal.”
P :”Thank you suster Rosa.”
Wash hand (mencuci tangan sesudah kontak dengan pasien/sesudah terpapar
dengan cairan tubuh pasien)
IV. TERMINATION STAGE
N :”How are you feeling now?
P :”I am not feeling well.”
N :”After this, another nurse will do a warm compress. Okay… Mrs. Fitri, my duty
is finish, get well soon, if you need something, you can call me or press the button
on the back of your bed excuse me…”
P :”Thank you…”
Tidy up equipment
Wash hand (mencuci tangan sesudah kontak dengan lingkungan pasien)
Doing Nursing Documentation
5. No. Date Implementation Sign
1. Aug 27, 2021 Measure of Vital Sign Mrs. Fitri in ward 3, bed 1
(Mengukur tanda-tanda vital Ny. Fitri di kamar 3
bed 1)
Respon:
DS:” I am not feeling well.”
DO: - BP : 150/100 mmHg
- T : 39°C
- P : 88 x/minute
- RR : 23 x/minute
- body feel warm
Ni Nyoman
Rosa Sari
Anastasya
