I.02060 Pemantauan Tanda Vital

Definisi : Mengumpulkan dan menganalisis data hasil pengukuran fungsi vital kardiovaskuler, pernapasan dan suhu tubuh

Tindakan

Observasi

  1. Monitor tekanan darah
  2. Monitor nadi (frekuensi, kekuatan, irama)
  3. Monitor pernapasan (frekuensi, kedalaman)
  4. Monitor suhu tubuh
  5. Monitor oksimetri nadi
  6. Monitor tekanan nadi (selisih TDS dan TDD)
  7. Identifikasi penyebab perubahan tanda vital

Terapeutik

  1. Atur interval pemantauan sesuai kondisi pasien
  2. Dokumentasikan hasil pemantauan

Edukasi

  1. Jelaskan tujuan dan prosedur pemantauan
  2. Informasikan hasil pemantauan, jika perlu

Daftar Pustaka

PPNI (2018). Standar Intervensi Keperawatan Indonesia.

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