TPR Monitoring

KESHLATA COLLEGE OF NURSING
OBJECTIVE STRUCTURED CLINICAL

EXAMINATION
(OSCE)
Venue- Nursing Foundation lab
Presented By
Mr. Himanshu Pal
Nursing Tutor
TEMPERATURE/PULSE/RESPIRATION
INTRODUCTION OF TPR
Measurement of vital signs data determines the client’s level of health and response to physical and psychological stress as
well medical , surgical and nursing therapy.
Definition: - Temperature pulse respiration readings are known as a vital sign because these are governed by vital organs.
Purposes and indication
 To assess the normal functioning of vital organs.

 To assess the condition and progress made by the patient.
 It helps in the formulation of disease, diagnosis, and assessment.
 To assess the emotional status of the patient.
Indications
 On admission
 Any change in health status e.g. The client complains of chest pain.
 Before and after surgical procedure.
 Before and after the administration of drugs or nursing intervention that affects vital organs.
 As a routine procedure to assess the health status of admitted patients.
Temperature:-
The temperature may be defined as the degree of heat maintained by the body. It is the balance between heat produced and
heat loss from the body.
Sites - oral, axilla, rectal.
Pulse: -
Pulse is the palpable bounding of the blood flow noted at various points on the body where the artery is near the surface
and passes over the bone. When blood is pumped into the arteries by the contraction of the left ventricle.
Normal pulse rate of an adult is 70 – 80 b/min
Sites of pulses-
1. Temporal
2. Carotid
3. Apical
4. Radial pulse
5. Ulnar
6. Brachial
7. Femoral
8. Popliteal
9. Posterior tibial
10. Dorsalis pedis
Respiration: -
Respiration is the act of breathing. It involves two processes i.e. inspiration and expiration followed by a pause.
Respiration may be external or internal.
External respiration is the movement of air between the environment and lungs.
Internal respiration is the movement of Oxygen between hemoglobulin and cells
In respiration, the diaphragm moves about 1 cm down and ribs retract upwards about 1.2 to 2.5 cm.
KESHLATA COLLEGE OF NURSING
PROCEDURE CHECKLIST
MONITORING TPR
S.NO PROCEDURE STEPS 1 2 3 4 5
A PREPARATORY PHASE
(I) PREPARATION OF PATIENT
1.  Check Physician’s Order
2.  Identify the patient
3.  Explain the procedure to the patient
 Ensure that patient has not been involved physical and mental activity within
4.
30 minutes prior to the procedure
5.  Place the patient Comfortable position.
6.  Check for contraindication of taking temperature by the specified route
(II) PREPARATION OF ARTICLES
7.  Clinical Oral/axilla/rectal thermometer (1)
8.  A bottle containing lotion for disinfect the thermometer (1) – Dettol
9.  A bottle containing plain water (1)
10.  Small size towel (1)
11.  Sprit Cotton swab and Dry swab in the container (1)
12.  A kidney tray and a paper bag (1)
13.  A feeding cup with water (1)
14.  T.P.R Sheets
15.  Ball point pens: - Blue (1) black (1) Red Pen (1)
16.  Steel tray (1)
(III) PREPARATION OF SELF
17. Wash Hands
18. Dry our hands
19. Wear Gloves
B PERFORMANCE PHASE
TEMPERATURE
20. Remove the thermometer from an antiseptic solution and rinse with cold water.
21. Wipe the thermometer from the bulb toward the stem.
Read the level of mercury by holding with fingers, slowly rotate until silvery mercury
22.
line come in view.
Shake if mercury level is above 35⁰C or 95⁰F with quick movement of wrist by
23.
holding it by stem.
For Oral:
Ask the patient to open his/her mouth and place the thermometer at the base of
24.
tongue/ the posterior sublingual pocket.
25. Ask the patient to hold the thermometer by closing his/her lips for 2 minutes.
For axilla:
26. Wipe the axilla with a towel. Place the thermometer in the armpit for 5 minutes.
27. Place the thermometer in the armpit for 5 minutes.
For rectal:
28. Place the inside lying position, screen the patient.
29. Apply lubricant about 2 to 5 cm on thermometer.
30. Ask the client to take deep breaths and insert the thermometer and place for 5 min.
PULSE
Place the patient hands over the chest with the wrist extended and palm facing down
31.
ward.
32. Felt the radial pulse and check the rhythm, volume and tension.
33. Once the beat is regular, count pulse rate for full minutes.
RESPIRATION
After counting pulse note the rise and fall of the client’s chest- inspiration and
34.
expiration.
35. Count the number of respirations for 30 sec and calculated for 1 minute.
Remove the thermometer from the site, and wipe it from stem to bulb with a clean
36.
cotton swab.
37. Read the level of mercury at the eye level facing toward the good light.
Clean the thermometer with the soap solution and rinse with water and disinfect it
38.
before use of another patient.
C TERMINATION PHASE
39. Replace all articles.
40. Hand Wash
41. Document the TPR on the patient file
Total score
Obtained Score
Percentage
Remark
Name of the student__________________ Date_________

Course___________________________________ Class________
Name of Instructor/ evaluator. _____________________ Ward/Unit___________
Signature: - _____________________
Satisfactory – 85- 100 %
Moderate Satisfactory- 66 to 84 %
Moderately unsatisfactory 44 to 65 %
Unsatisfactory 22- 43 %
Not Observed – 0 to 21 %
Note: -
1. 1, 2, 3, 4, 5 denoting attempted made by the student
2. Each statement will be score by yes/no and yes contain a 1point and no contain 0 point
3. Students who get 85% or above will get full satisfactory and below be have to make attempt till the candidate get 85 % and above.
Remakes by evaluator_____________________
Principal
Keshlata College of Nursing

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KESHLATA COLLEGE OF NURSING

OBJECTIVE STRUCTURED CLINICAL

Venue- Nursing Foundation lab

Purposes and indication

 To assess the normal functioning of vital organs.

Sites - oral, axilla, rectal.

Normal pulse rate of an adult is 70 – 80 b/min

Respiration may be external or internal.

Internal respiration is the movement of Oxygen between hemoglobulin and cells

(I) PREPARATION OF PATIENT

1.  Check Physician’s Order

2.  Identify the patient

3.  Explain the procedure to the patient

5.  Place the patient Comfortable position.

6.  Check for contraindication of taking temperature by the specified route

(II) PREPARATION OF ARTICLES

7.  Clinical Oral/axilla/rectal thermometer (1)

8.  A bottle containing lotion for disinfect the thermometer (1) – Dettol

9.  A bottle containing plain water (1)

10.  Small size towel (1)

12.  A kidney tray and a paper bag (1)

13.  A feeding cup with water (1)

14.  T.P.R Sheets

16.  Steel tray (1)

(III) PREPARATION OF SELF

17. Wash Hands

18. Dry our hands

19. Wear Gloves

27. Place the thermometer in the armpit for 5 minutes.

28. Place the inside lying position, screen the patient.

29. Apply lubricant about 2 to 5 cm on thermometer.

39. Replace all articles.

40. Hand Wash

41. Document the TPR on the patient file

Name of the student__________________ Date_________

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Name of the student__________ Date_