PAMANTASAN NG CABUYAO

Katapatan Ville Banay-Banay Cabuyao Laguna

COLLEGE OF HEALTH AND ALLIED SCIENCES

Bachelor of Science in Nursing

Checklist Evaluation

Vital Signs

Name: _______________________________ Yr./Section/Grp: Rate:

______________
Objective:
 Demonstrate proper measuring of vital signs.
 Document normal findings of vital signs.

Rating Scale:

5 – The student demonstrates the procedure with thorough in independent manner

4 – Demonstrate the procedure with minimal guidance and supervision

3 – Demonstrate the procedure with frequent guidance and supervision

2 – Demonstrate the procedure with errors even with frequent guidance and supervision

1 – Does not demonstrate the procedure even under close supervision and guidance

Assessing Body Temperature

Performance
Preparation Remarks
5 4 3 2 1

1. Assess:

 Clinical signs of fever

 Clinical signs of hypothermia

 Site most appropriate for measurement

 Factors that may alter core body temperature

2. Assemble equipment and supplies:

 Digital Thermometer

 Thermometer sheath or cover

 Water-soluble lubricant for a rectal temperature

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  Disposable gloves

 Towel for axillary temperature

 Tissues/wipes
 Cotton balls with alcohol/cotton pads

Procedure

1. Explain to the client what you are

going to do, why it is necessary, and how he can cooperate.

2. Wash hands and observe other appropriate infection control

procedures.
3. Provide for client privacy.
4. Place the client in the appropriate position.
5. Place the thermometer.
Rectal
Apply clean gloves.
Apply a protective sheath or probe cover if appropriate.
Lubricate a rectal thermometer.
Instruct the client to take a slow deep breath during insertion.
Insert 3.5 cm (1.5 in.) in adults.

Never force the thermometer if resistance is felt.

Oral
Place the tip on either side of the frenulum.
Axillary
Pat the axilla dry if very moist.
The tip is placed in the center of the axilla.
Tympanic
Pull the pinna slightly upward and backward for an adult.
Point the probe slightly anteriorly, toward the eardrum.
Insert the probe slowly using a circular motion until snug.
6. Wait the appropriate amount of time.
Electronic and tympanic thermometers will indicate that
the reading is complete through a light or tone.
Check package instructions for length of time to wait prior to
reading chemical dot or tape thermometers.

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 7. Remove the thermometer and discard the cover or wipe with
a tissue if necessary.

8. Read the temperature

If the temperature is obviously too high, too low, or

inconsistent with the client’s condition, recheck it with a
thermometer known
to be functioning properly.

9. Wash the thermometer if necessary and return

it to the storage location.

10. Document the temperature in the client record.

A rectal temperature may be recorded with an “R” next

to the
value, or with the mark on a graphic sheet circled.

An axillary temperature may be recorded with “AX,” or

marked
on a graphic sheet with an X.

Total Score
To compute for the Total Score: Add each item’s
rating.
Ave.

To compute for the Average: Divide the total

SCORE by total number of items, multiply by 100
----------/60

Comments:

____________________________________________________________________________________

Student’s Signature Over Printed Name CI’s Signature Over Printed Name

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 Assessing a Peripheral Pulse

Performance
Preparation Remarks

3 2 1

1. Assess:

 Clinical signs of cardiovascular alterations, other than

pulse rate, rhythm, or volume

 Factors that may alter pulse rate

 Site most appropriate for assessment

2. Assemble equipment and supplies:

 Watch with a second hand or indicator.

 If using Doppler ultrasound stethoscope (DUS), obtain the

transducer probe, the stethoscope headset, transmission
gel,
and tissues/wipes

Procedure

1. Explain to the client what you are to do, why it is necessary,

and how she can cooperate.

2. Wash hands and observe other appropriate infection control

procedures.
3. Provide for client privacy.
4. Select the pulse point.
5. Assist the client to a comfortable resting position.
6. Palpate and count the pulse. Place two or three middle
fingertips
Lightly and squarely over the pulse point.

Count for 15 seconds and multiply by 4. Record the pulse in

beats per minute on your worksheet. If taking a client's pulse
for the first time, when obtaining baseline data, or if the pulse
is

irregular, count for a full minute. An irregular pulse also requires

taking the apical pulse. Is irregular, count for a full minute.

7. Assess the pulse rhythm and volume.

Assess the pulse rhythm.
Assess the pulse volume.

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 8. Document the pulse rate, rhythm, and volume and your actions
in the client record.

Variation: Using a Doppler Ultrasound Stethoscope (DUS)

Procedure

If used, plug the stethoscope headset into one of the two

outputs jacks located next to the volume control.

Apply transmission gel either to the probe at the narrow end of

the plastic case housing the transducer or to the client's skin.
Press the "on" button.
Hold the probe against the skin over the pulse site. Use a light
pressure and keep the probe in contact with the skin.

Adjust the volume if necessary. Distinguish artery sounds

from vein sounds. If arterial sounds cannot be easily heard,
then
reposition the probe.

After assessing the pulse, remove all the gel from the probe to
prevent damage to its surface. Clean the transducer with
aqueous
solutions.

Total Score
To compute for the Total Score: Add each item’s rating.

Ave.
To compute for the Average: Divide the total SCORE by
total number of items, multiply by 100

----------/50

Comments:

____________________________________________________________________________________

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Student’s Signature Over Printed Name CI’s Signature Over Printed Name

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 Assessing an Apical Pulse

Performed
Preparation Remarks
5 4 3 2 1

1. Assess:

 Clinical signs of cardiovascular alterations, other than

pulse rate,
rhythm, or volume

 Factors that may alter pulse rate

2. Assemble equipment and supplies:

 Watch with a second hand or indicator

 Stethoscope

 Antiseptic wipes
 If using DUS, the transducer probe, obtain the
stethoscope headset, transmission gel, and
tissues/wipes

Procedure

1. Explain to the client what you are going to do, why it is

necessary, and how he can cooperate.

2. Wash hands and observe other appropriate infection control

procedures.
3. Provide for client privacy.
4. Position the client appropriately in a comfortable supine
position or a sitting position.
Expose the area of the chest over the apex of the heart.
5. Locate the apical impulse.

Palpate the angle of Louis, located just below the suprasternal

notch and felt as a prominence.
Slide your index finger just to the left of the client's sternum,
and
palpate the second intercostal space.
Place your middle or ring finger in the third intercostal space,
and continue palpating downward until you locate the
fifth intercostal space.
Move your index finger laterally along the fifth intercostal space
towards the MCL. Normally, the apical impulse is palpable at or
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 just medial to the MCL.

6. Auscultate and count heartbeats.

Use antiseptic wipes to clean the earpieces and diaphragm of

the
stethoscope.

Warm the diaphragm of the stethoscope by holding it in the

palm of the hand for a moment.

Insert the earpieces of the stethoscope into your ears in the

direction of the ear canals, or slightly forward, to facilitate
hearing.

Tap your finger lightly on the diaphragm to be sure it is

the active side of the head.

Place the diaphragm of the stethoscope over the apical

impulse and listen for the normal S1 and S2 heart sounds.
If the rhythm is regular, count the heartbeats for 30 seconds and
multiply by 2. If the rhythm is irregular, count the beats for
60 seconds.

7. Assess the rhythm and the strength of the heartbeat.

Assess the rhythm of the heartbeat by noting the pattern

of intervals between the beats.
Assess the strengths (volume) of the heartbeat.

Total Score
To compute for the Total Score: Add each item’s rating.

Ave.
To compute for the Average: Divide the total SCORE by
total number of items, multiply by 100

----------/45

Comments:

____________________________________________________________________________________

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Student’s Signature Over Printed Name CI’s Signature Over Printed Name

9|Page
Assessing an Apical−Radial Pulse

Performance
Preparation Remarks

5 4 3 2 1

1. Assess:
 Clinical signs of hypovolemic shock

2. Assemble equipment and supplies:

Watch with a second hand or indicator

 Stethoscope
 Antiseptic wipes

Procedure

1. Explain to the client what you are going to do, why it is

necessary, and how she can cooperate.

2. Wash hands and observe other appropriate infection control

procedures.
3. Provide for client privacy.
4. Position the client appropriately.
5. Locate the apical and radial pulse sites.
In the two-nurse technique, one nurse locates the apical impulse
by palpation or with the stethoscope while the other nurse
palpates the radial pulse site.

6. Count the apical and radial pulse rates.

Two -Nurse Technique

Place the watch where both nurses can see it. The nurse who is
taking the radial pulse may hold the watch.

Decide on a time to begin counting. The nurse taking the radial pulse
says "Start" at that time.

Each nurse counts the pulse rate for 60 seconds. Both nurses end
the count when the nurse taking the radial pulse says "Stop."
The nurse who assesses the apical rate also assesses the apical
pulse rhythm and volume.
The nurse assessing the radial pulse rate also assesses the radial

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 pulse rhythm and volume.

One-Nurse Technique
Assess the apical pulse for 60 seconds.
Assess the radial pulse for 60 seconds.

7. Document the apical and radial (AR) pulse rates, rhythm,

volume, and any pulse deficit in the client record. Also record
related data.

Total Score
To compute for the Total Score: Add each item’s
rating.
Ave.

To compute for the Average: Divide the total SCORE

by total number of items, multiply by 100
----------/45

Comments:

____________________________________________________________________________________

Student’s Signature Over Printed Name CI’s Signature Over Printed Name

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Assessing Respirations

Performance
Prepar Remarks
ation
5 4 3 2 1

1. Assess:

 Skin and mucous membrane color

 Position assumed for breathing

 Signs of cerebral anoxia

 Chest movement

 Activity tolerance

 Chest pain

 Dyspnea

 Medications affecting respiratory rate

2. Assemble equipment and supplies:

 Watch with a second hand or indicator

Proce
dure

1. Explain to the client what you are going to do, why it is

necessary, and how he can cooperate.

2. Wash hands and observe other appropriate infection

control procedures.
3. Provide for client privacy.
4. Observe or palpate and count the respiratory rate.

If you anticipate the client’s awareness of respiratory

assessment, place a hand against the client's chest to feel
the chest movements with breathing, or place the client's
arm across

the chest and observe the chest movements while

supposedly taking the radial pulse.

Count the respiratory rate for 30 seconds if the respirations

are regular. Count for 60 seconds if they are irregular. An
inhalation
and an exhalation count as one respiration.

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 Observe the depth, rhythm, and character of respirations.
5.

Observe the respirations for depth by watching the

movement of
the chest.
Observe the respirations for regular or irregular rhythm.
Observe the character of respirations—the sound they
produce
and the effort they require.

6. Document the respiratory rate, depth, rhythm,

and character on the appropriate record.

Total Score
To compute for the Total Score: Add each
item’s rating.
Ave.

To compute for the Average: Divide the

total SCORE by total number of items,
multiply by 100 ----------/35

Comments:

____________________________________________________________________________________

Student’s Signature Over Printed Name CI’s Signature Over Printed Name
Printed Name

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Assessing Blood Pressure

Performance

Remarks

Preparation 5 4 3 2 1

1. Assess:

 Signs and symptoms of hypertension

 Signs and symptoms of hypotension

 Factors affecting blood pressure

2. Assemble equipment and supplies:

 Stethoscope or DUS

 Blood pressure cuff of the appropriate size

 Sphygmomanometer

Procedure

1. Explain to the client what you are going to do, why it is

necessary, and how she can cooperate.

2. Wash hands and observe other appropriate infection control

procedures.
3. Provide for client privacy.
4. Position the client appropriately.
The adult client should be sitting unless otherwise specified.
Both feet should be flat on the floor.
The elbow should be slightly flexed with the palm of the hand
facing up and the forearm supported at heart level.
Expose the upper arm.
5. Wrap the deflated cuff evenly around the upper arm.
Locate the brachial artery. Apply the center of the bladder
directly over the artery.
For an adult, place the lower border of the cuff approximately
2.5 cm (1 inch) above the antecubital space.

6. If this is the client's initial examination, perform a preliminary

palpatory determination of systolic pressure.
Palpate the brachial artery with the fingertips.
Close the valve on the pump by turning the knob clockwise.

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 Pump up the cuff until you no longer feel the brachial pulse. At
that pressure, the blood cannot flow through the artery. Note
the pressure on the sphygmomanometer at which pulse is no
longer

felt.
Release the pressure completely in the cuff, and wait one to two
minutes before making further measurements.

7. Position the stethoscope appropriately.

Cleanse the earpieces with alcohol or recommended
disinfectant.
Insert the ear attachments of the stethoscope in your ears so
that
they tilt slightly forward.
Ensure that the stethoscope hangs freely from the ears to the
diaphragm.
Place the bell side of the amplifier of the stethoscope over the
brachial pulse. Hold the diaphragm with the thumb and index
finger.

8. Auscultate the client's blood pressure.

Pump up the cuff until the sphygmomanometer reads 30 mm Hg

above the point where the brachial pulse disappeared.
Release the valve on the cuff carefully so that the pressure
decreases at the rate of 2–3 mm Hg per second.
As the pressure falls, identify the manometer reading at each of
the five phases, if possible.
Deflate the cuff rapidly and completely.
Wait one to two minutes before making further determinations.
Repeat the above steps once or twice as necessary to confirm
the
accuracy of the reading.
9. If this is the client’s initial examination, repeat the procedure
on the client’s other arm.

Variation: Obtaining a Blood Pressure by the Palpation Method

Procedure

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 If it is not possible to use a stethoscope to obtain the blood
pressure, or if the Korotkoff’s sounds cannot be heard, palpate
the radial or brachial pulse site as the cuff pressure is released.
The manometer reading at the point where the pulse
reappears represents a blood pressure between what would be
the

auscultated systolic and diastolic values.

Variation: Taking a Thigh Blood Pressure

Procedure

Help the client to assume a prone position. If the client cannot

assume this position, measure the blood pressure while the
client is in a supine position with the knee slightly flexed. Slight
flexing of the knee will facilitate placing the stethoscope on the
popliteal space. Expose the thigh, taking care not to expose the

client unduly.
Locate the popliteal artery.

Wrap the cuff evenly around the mid-thigh, with the

compression bladder over the posterior aspect of the thigh
and
the bottom edge above the knee.
If this is the client's initial examination, perform a preliminary
palpatory determination of systolic pressure by palpating the
popliteal artery.
In adults, the systolic pressure in the popliteal artery is usually
20–30 mm Hg higher than that in the brachial artery because of
use of a larger bladder; the diastolic pressure is usually the
same.

Variation: Using an Electronic Indirect Blood Pressure Monitoring Device

Procedure

Place the blood pressure cuff on the extremity according to

the manufacturer’s guidelines.
Turn on the blood pressure switch.

If appropriate, set the device for the desired number of minutes

between blood pressure determinations.

When the device has determined the blood pressure reading,

note the digital results.
10. Remove the cuff.

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 11. Wipe the cuff with an approved disinfectant.

12. Document and report pertinent assessment data according to

agency policy.

Total Score
To compute for the Total Score: Add each item’s rating.

Ave.
To compute for the Average: Divide the total SCORE by
total number of items, multiply by 100
----------/70

Comments:

____________________________________________________________________________________

Student’s Signature Over Printed Name CI’s Signature Over Printed Name
Printed Name

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 Measuring Oxygen Saturation

Performance
Preparation Remarks

5 4 3 2 1

1. Assess:

 Based on the client’s age and physical condition,

determine the best location for a pulse oximeter sensor

 The client’s overall condition, including risk factors for

development of hypoxemia and hemoglobin level

 Vital signs, skin and nailbed color, and tissue perfusion

of extremities as baseline data

 For allergy to adhesive

2. Assemble equipment and supplies:

 Nail polish remover as needed

 Alcohol wipe

 Sheet or towel
 Pulse oximeter

Procedure

1. Explain to the client what you are going to do, why it is

necessary, and how he can cooperate.

2. Wash hands and observe other appropriate infection control

procedures.
3. Provide for client privacy.
4. Choose a sensor appropriate for the client’s weight, size, and
desired location.

If the client is allergic to adhesive, use a clip or sensor without

adhesive. If using an extremity, assess the proximal pulse and
capillary refill at the point closest to the site.

If the client has low tissue perfusion due to peripheral vascular

disease or therapy using vasoconstrictive medications, use a
nasal sensor or a reflectance sensor on the forehead. Avoid
using lower extremities that have a compromised circulation,
or

extremities that are used for infusions or other invasive

monitoring.

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 5. Prepare the site.
Clean the site with an alcohol wipe before applying the sensor.
Remove client’s nail polish or acrylic nails.
6. Apply the sensor, and connect it to the pulse oximeter.
Make sure the LED and photodetector are accurately aligned.
Attach the sensor cable to the connection outlet on the
oximeter. Turn on the machine.

Ensure that the bar of light or waveform on the face of the

oximeter fluctuates with each pulsation and reflects the pulse
volume or strength.

7. Set and turn on the alarm.

Check the preset alarm limits for high and low oxygen
saturation and high and low pulse rates. Change these alarm
limits as indicated. Ensure that the audio and visual alarms are
on before
you leave the client.

8. Ensure client safety.

Inspect and/or move or change the location of an adhesive toe

or
finger sensor every four hours and a spring-tension sensor
every two hours.
Inspect the sensor site tissues for irritation from adhesive
sensors.

9. Ensure the accuracy of measurement.

Minimize motion artifacts by using an adhesive sensor, or

immobilize the client’s monitoring site.
If indicated, cover the sensor with a sheet or towel to block
large
amounts of light from external sources.

10. Document the oxygen saturation on the appropriate record

at designated intervals.

Total Score
To compute for the Total Score: Add each item’s rating. .

Ave
To compute for the Average: Divide the total SCORE by ----------/60
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 total number of items, multiply by 100

____________________________________________________________________________________

Student’s Signature Over Printed Name CI’s Signature Over Printed Nam

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