Goodmorning Ma’am, I am your student
nurse Clarissa Joy Venancio for today’s
ASSESSING BODY TEMPERATURE
assessment, so first thing to know ma’am
may I know your first name and last name Assessment:
po?
- Upon assessing, I observe that
Age there is no any presence of signs
Date of birth of fever and hypothermia naman
po sa inyo, I assess it po through
your facial expression, presence
of redness of skin, visible chills
and sweating.
So before we proceed po no let me inform
- I’ll be assess also appropriate
you that all the data that we will be
part of your body for the
collected remain confidential between you
measurement. And upon
and me and other corresponding healthcare
observing there is no any factor
providers.
that may alter the measurement
of body temperature din po.
So I’ll be performing first a hand hygiene, (procedure)
and provide you a privacy by closing the
So I already did a hand hygiene to
door and as well as the window curtains
avoid cross contamination, since you
and I already gathered the tools and
are already in a sitting position ill be
equipment that I’ll be using.
now conduct your body temperature
through your axillary part.
(explain procedure) (get thermometer with cotton and
alcohol to sterile).
First thing that I’ll be doing po is to conduct
the body temperature po no, followed by May I ask your permission po to lift
peripheral pulse, respiratory rate and lastly your sleeves po to put this
your blood pressure. Throughout the thermometer in your axillary po.
process I’ll be asking your cooperation Let just wait for a moment po for
ma’am to conduct this assessment po, is beeping sound to get the accuarate
that okay po maam? ----- Thank you data po.
(once may beeping sound na, remove)
Ang temperature natin ma’am ay Within 1 min and pulse rate natin
(35.6) po which indicate normal, maam is (ex. 72 beat per min).
kapag umabot po to ng 38 pataas it Within the rhythm regular naman po
indicates the means of fever naman since consistent and interval and
na po. equal time per beats. As well as sa
volume, the pulse is moderate
(clean the thermometer with cotton and
strength and easily felt but not
alcohol)
forceful which indicate normal.
(document the data)
(record data..)
PERIPHERAL PULSE
ASSESSING RESPIRATION
Assessment:
Assessment:
(notepad)
Upon observing there is no any
May I ask ma’am if nakakaramdam indication for unusual color of your
po ba tayo ngayon ng pagkahilo? skin and mucous membrane.
How about chest pain or discomfort? For the 3rd vital sign we will be
May shortness of breathing po ba conducting it in sitting position padin
tayo ngayon? po no.
May I ask ma’am ilan po ito? (hand
So upon checking po there is no any sign
gesture)
and symptoms sa cardiovascular alteration
Ano po ang huli nating kinain
po no, I observe aswell that there is no
maam?
presence of edema and cyanosis color in
Kilala po ba natin si self maam?
your skin or paleness.
Okay, I ask few question to measure
po if there confusion, measure your
responsiveness, and or memory loss
PROCEDURE
to check if there is any signs for
May I ask for your comfortable cerebral anoxia, and upon checking
sitting position po maam inorder to naman there is no any visible signs
conduct this assessment po naman po noh.
accurately po, so to this part I’ll be Chest movement are symmetrical
assessing your radial artery to get and may limit po ba tayo while doing
your pulse rate. any activity at home or outside? Like
(conduct pulse rate for 1 min) nahihilo po ba tayo? Mabilis tayong
mapagod or nagkakaroon ng
discomfort while doing the activity?
May I know if you are currently (check the patient position, feet should b
under medication po maam? If yes flat on surface)
state your medication that youre
So to conduct this blood prsssure
currently taking.
need po ulit natin maam iexpose ang
upper arm.
PROCEDURE (ilagay ang sphyg)
So I already got your Respiratory rate
po maam during pulse rate
So ma’am first thing that I will be
procedure po no, ang respiratory
doing is for initial examination to
rate po natin maam is 15 breaths per
determine your systolic pressure po
min po which is a normal range.
no.
Ang depth is in a moderate volume,
while the rhythm is also regular and (conduct the process)
character of respiration is quiet and
So ang ating systolic rate is 150 + 30
effortless w/o using muscle
is 180 po, kaya po tayo nag add ng
accessory.
30 if nag tataka po tayo it is because
(document findings) to properly detect your systolic
measrurement po, and ensuring a
accurate and reliable measurement,
BLOOD PRESSURE mag wawait lang po tayo for 1 min
to conduct a blood pressure napo.
Assessment:
(while waiting linisin na ang earpiece ng
So I already ask a few question
stet with alcohol)
throughout the other procedure
which also help to indicate if there is Okay napo ma’am proceed na po
a presence of signs and symptoms tayo sa BP.
for hypo and hypertension, so I
(conduct the process)
might say that there is no visible of it
po since wala naman po tayong (after tanggalin ang sphyg)
nararamdaman na pagkahilo, or
So ma’am ang blood pressure po
rapid breathing or kaya naman
natin is 120/80 po.
confusion.
(document data)
(clean the tools)
PROCEDURE
PERTINENT ASSESSMENT
So maam to summarize po no
starting from our body temperature
the data we got is 35.6 C
Our Pulse rate is 72 per min
And Respiratory rate is 15 breaths
per min.
Lastly blood pressure is 120/80
So again ma’am all information and
data that we collected remain
confidential between you and me
and other healthcare providers to
ensure your safety and security,
thank you po maam.
