Good morning my name is Juvel C.

Orquinaza and I will be performing the Assessing

Temperature, Pulse, and Respiration (TPR) of the patient. Vital signs indicate the
function of the body’s homeostatic mechanisms and it is important components of
assessment to know the underlying health status of the patient.

Purposes:

Assessing Temperature
 To establish baseline data for future comparisons.
 To identify whether the body temperature is within normal range.
 To determine changes and abnormalities in the body temperature in
response
to specific therapies.

Assessing Pulse Rate

 To determine number of heartbeats in a minute.
 To gather information about heart rhythm and pattern of beats.
 To evaluate the strength of the pulse.
 To determine the body’s response to cardiac medications, activity, blood
volume and gas exchange.
 To assess vascular status of limbs/extremities.

Assessing Respiratory Rate

 To determine the number of client’s respirations per minute.
 To gather information about the rhythm and depth of client’s respiration.
 To assess the client’s respiratory response to any related therapy or
medication.

Materials Needed:
• Digital Thermometer • Note pad and pen
• Antiseptic Wipes/ Cotton • Watch with a second hand
Balls with Alcohol • Cotton Balls
Procedures Ginagawa Rationale

(2) ASSESMENT What is your name Ask their name to

1. Identify the client.
po? I am Nurse know if the
Juvs procedure is
intended for the
patient.

2. Explain the procedure. I will be taking your To encourage

vital sign by cooperation and
assessing your alleviate anxiety.
temperature first
by using axillary
thermometer and
your pulse, to know
your health status.

(4) PLANNING Pakita na nagwash To diminish the

1. Wash your hands.
hands remove watch microorganism of
lagay sa pocket. the hands.

2. Gather materials needed Nakaayos na ung The nurse can

gamit sa isang work at ease and
table. promotes
efficiency to save
time and effort.
3. Ensure the privacy of the client Close the curtain To promote
and door. comfort and lessen
anxiety
4. Assist the client to a sitting position,
if possible.
IMPLEMENTATION
Temperature Reading
1. Take the thermometer from its pack Kunin ung From cleanest (tip)
and wipe with cotton balls with alcohol thermometer to the least clean
or antiseptic wipes from the kuhanin yung bulak (Body)
tip that will come in contact with the punasan ung tip up
patient to the area where you hold it. to thermometer’s
body.

2. Turn it on. Kuhanan ng

temperature si
patient.
3. Pat dry the axilla and place the Pat dry the axilla We know axillary
thermometer in the hollow of axilla with paper towel. thermometer is
horizontally. Keep the arm flexed Flexed the arms. the least accurate
across the chest. and least reliable
site because
several factors
such as Excessive
moisture will cool
the skin and could
result in an
inaccurate
temperature
reading. Be sure
to pat the area
dry. Rubbing the
axillary area could
cause an
inaccurate reading
due to the heat
caused by friction.

Para di mahulog
yung thermometer
kaya flexed ung
arms sa chest.

4. Leave thermometer in place until a Iwan mona si

signal
is heard. thermometer.
Deretso kuha ka na
pulse

FOR WHOLE 2 MINUTES ISABAY MO ITAKE YUNG PULSE AT RESPIRATION.

RECORD MO AGAD SA NOTE PAD.
AFTER MONG ITAKE YUNG TEMP, PULSE AND RESPIRATION SABIHIN MO
IMPLEMENTATION NILA ISA ISA

5. Remove the thermometer and read the

result

6. Disinfect the thermometer from Pag tumunog I-clean

the area where you hold it to the tip
that come in contact with the patient gamit ng alcohol ulit
and return it to the storage location. bago ibalik sa
lagayan.
7. Record the temperature reading on Axillary Look at the eye
your notepad.
temperature varies level prevent ung
among people, and strain ng neck.
temperatures
 ranging from 36.2
to 37.5 °C are
accepted as normal
Pulse (Radial) Rate Counting

1. Either in supine or siting position,

position client's arm next to his body
with palm facing downward.

2. Place the index, middle and ring Proximal finger

fingers along the radial artery and (Ring) is used to
press gently against the radius. check condition of
Rest the thumb on the back of client's arterial wall and
wrist. tention of wall.

Middle finger is
used to count
pulse rate and
volume.

Distal finger
(Index) to
obliterate ulnar
pulse
3. Apply enough pressure so that the Lagyan ng pressure
client's pulsating artery can be para maramdaman
distinctly felt. mo

4. Using a watch with a second hand, Habang tumitingin

count the number of pulsations felt on
the client's artery for one full minute. ka sa watch eye
level lang dapat

5. Record the pulse rate on your notepad Isulat sa note pad For adults 60 -
100 beat per
minute yung
normal.
Respiratory Rate Counting

1. While fingertips still in place observe

client's respiration.

2. Observe the rise and fall of the chest Observe mo lang Look on their
and count this as one cycle.
shoulder not on
their chest you
put the patient on
uncomfortable
situation.

3. Count the number of cycles in one full Look ka sa watch Make sure not to
minute
mo nakalagay sa tell the patient
 pocket. Eye level. you are taking
their respiration.
There are chances
they will change
the rhythm of
their breathing.
Your based line
will not be
accurate.

4. Record the respiratory rate on your Isulat sa note pad For adults 12-20
notepad
breath/cycle per
minute. Yung
normal.
EVALUATION
1. Evaluate temperature measurement,
pulse rate and respiratory rate in
relation to baseline data and normal
range for client.

DOCUMENTATION
1. Document vital signs on TPR Sheet
according to hospital's policy.

2. Note for any observed abnormalities

and unusual findings.