Vital Signs Checklist PDF

Body Temperature Axillary Route Checklist Student Name: ____________________________________ Date: ___________ Student ID: ________________________Level: __________Group No: ___________ PROCEDURE STEPS Grade Student’...

Body Temperature Axillary Route Checklist Student Name: ____________________________________ Date: ___________ Student ID: ________________________Level: __________Group No: ___________ PROCEDURE STEPS Grade Student’s grade 1 Assess patient's record as name, diagnosis, if there is any contraindication for 1 measuring body temperature routes. 2 Perform hand hygiene and prepare equipment. 1 3 Put on disposable gloves. 1 4 Wash the thermometer with soap and water from tip to bulb 1 5 Rinse well with running water not hot water 1 6 Dry the thermometer from bulb to tip with tissue paper 1 7 Wipe the thermometer with alcohol sponge from bulb to tip 1 8 Introduce yourself and explain procedures to the patient. 1 9 hold the thermometer between thumb and index fingers from the tip of 1 thermometer at the eye level. 10 Shake down the thermometer below 35c by holding it from tip between thumb 2 and forefingers and shake wrist sharply. 11 Close door , put patient in comfort position with exposing axilla 1 12 Dry axilla with tissue paper gently 1 13 Put thermometer in the center of axilla. 1 14 Left thermometer on axilla for 5 minutes then remove it. 1 15 Remove the thermometer then wipe it from any secretions with tissue paper from 2 tip to bulb and read at eye level, rotate slowly until it is mercury visible. 16 Wash the thermometer with soap from tip to bulb then rinsing under running 1 water. 17 Remove disposable gloves and wash hands. 1 18 record temperature reading if there is any abnormality notifying doctor. 1 Total grade 20 Student signature Instructor signature  Body Temperature Oral Route Checklist Student Name: ____________________________________ Date: ___________ Student ID: ________________________Level: __________Group No: ___________ PROCEDURE STEPS Grade Student’s grade 1 Assess patient's record as name, diagnosis, if there is any contraindication for 1 measuring body temperature routes. 2 Perform hand hygiene and prepare equipment. 1 3 Put on disposable gloves. 1 4 Wash the thermometer with soap and water from tip to bulb 1 5 Rinse well with running water not hot water 1 6 Dry the thermometer from bulb to tip with tissue paper 1 7 Wipe the thermometer with alcohol sponge from bulb to tip 1 8 Introduce yourself and explain procedures to the patient. 1 9 hold the thermometer between thumb and index fingers from the tip of 1 thermometer at the eye level. 10 Shake down the thermometer below 35c by holding it from tip between thumb 2 and forefingers and shake wrist sharply. 11 Ask the patient if he smokes, chews gum, drank cold or hot drinks, wait 15 1 minutes before measuring temperature. 12 Ask patient to open mouth and put the glass thermometer under tongue in the 1 posterior sublingual pocket at the right or left sides of the tongue. 13 Tell patient to close his lips to avoid biting down the thermometer with his teeth. 1 14 Leave the thermometer under tongue for 3 minutes. 1 15 Remove the thermometer then wipe it from any secretions with tissue paper from 2 tip to bulb and read at eye level, rotate slowly until it is mercury visible. 16 Wash the thermometer with soap from tip to bulb then rinsing under running 1 water. 17 Remove disposable gloves and wash hands. 1 18 record temperature reading if there is any abnormality notifying doctor. 1 Total grade 20 Student signature Instructor signature  Assessing the Apical Pulse Checklist Student Name: ____________________________________ Date: ___________ Student ID: _______________________Level: __________Group No: ___________ PROCEDURE STEPS Grade Student’s grade 1 Introduce self and verify the client's identity using agency policy. 1 2 Explain to the patient what you are going to do. 1 3 Perform hand hygiene and observe other appropriate standard precautions. 1 4 Prepare equipment 1 5 Provide for client privacy. 1 6 Assists patient to a supine or sitting position (preferably sitting); exposes the left 1.5 side of the chest, only as much as necessary. 7 Clean the stethoscope with alcohol, wipe before using. 1.5 8 Select, correctly locates, and palpates the apical site (5th intercostal space at the 3 midclavicular line). 9 Warms the stethoscope in the hands for 10 seconds. 2 10 place the stethoscope over the apex of the heart. 1 11 Counts for 60 seconds 2 12 Notes rate, rhythm, and depth. 2 13 Report any abnormalities 1 14 Again cleans the stethoscope with a 70% alcohol 1 Total grade 20 Student signature Instructor signature  Assessing Peripheral Pulses and Respiration Checklist Student Name: ____________________________________ Date: ___________ Student ID: ________________________Level: __________Group No: ___________ PROCEDURE STEPS Grade Student’s grade 1 Introduce self and verify the client's identity using agency policy. 1 Explain to the patient what you are going to do. 2 Perform hand hygiene and observe other appropriate standard precautions. 1 3 Provide for client privacy. 1 4 Prepare equipment 1 5 Examine the patient's previous pulse and respiratory rate recording, medical 2 diagnosis and any prior history of arrhythmia or respiratory difficulty 6 Determine if the patient is taking any medications that may affect his or her 2 pulse rate or respiratory rate or depth 7 Assist the patient in a position of comfort (sitting or lying position), resting the 1 hand in a comfortable, relaxed position 8 locate the patient radial pulse and palpate with your first three fingers 2 9 Count pulse for one minute. 2 10 Notes rate, rhythm, and depth. 1 11 With fingers still on the wrist count respiration for one minute by looking at the 2 chest as the chest rises and falls 12 Observe patient color, depth of respiration, presence of nasal flaring, retraction, 2 and rhythm of respiration. also observe the body position he or she assume. 13 Hand washing. 1 14 Record the results 1 -Pulse (rate, rhythm, force) -Respiration (rate, rhythm, depth) - report any abnormalities  Total grade 20 Student signature Instructor signature Measuring palpatory Blood Pressure Checklist Student Name: ____________________________________ Date: ___________ Student ID: _______________________Level: __________Group No: ___________ PROCEDURE STEPS Grade Student’s grade 1 Introduce self and verify the client's identity using agency policy. 1 Explain to the patient what you are going to do. 2 Perform hand hygiene and prepare equipment. 1 3 Provide for client privacy. 1 4 Assess the following measures: 1 - Patient's previous blood pressure recording. - Patient's medical diagnosis and history of problems that may affect BL. P - If the patient is taking any medications that may affect his\her BL. P 5 Place the client in a comfortable position, either sitting or lying in bed 1 - Both feet should be flat on the floor 6 Expose the upper arm by rolling sleeves up (does not auscultate through clothing). 2 7 Locate the brachial pulse at antecubital space and wrap the deflated cuff evenly around 2 the upper arm. lower border of the cuff approximately 2.5 cm (1 in.) above the antecubital space. 8 Palpate radial pulse as you inflate the cuff. 2 9 Inflate the cuff gradually and determine the point at which the pulse disappear. 2 10 Elevate 30 mmHg higher than the point at which you last felt the patient's pulse. 2 11 Slowly deflate the cuff and identify the point at which you feel the pulse return. 1 12 Release air from cuff completely, repeat the procedure if needed (wait 30-60 seconds 1 before taking the blood pressure again). 13 Check to see that the patient is comfortable. 1 14 16-Wipe the earpiece and diaphragm with alcohol and -Return the equipment to 1 proper place 15 Record (time, reading, position, site of measurement). 1 Total grade 20 Student signature Instructor signature Measuring Auscultatory Blood Pressure Checklist Student Name: ____________________________________ Date: ___________ Student ID: _______________________Level: __________Group No: ___________ PROCEDURE STEPS Grade Student’s grade 1 Introduce self and verify the client's identity using agency policy. 1 Explain to the patient what you are going to do. 2 Perform hand hygiene and prepare equipment. 1 3 Provide for client privacy. 1 4 Assess the following measures: 1 - Patient's previous blood pressure recording. - Patient's medical diagnosis and history of problems that may affect BL. P - If the patient is taking any medications that may affect his\her BL. P 5 Place the client in a comfortable position, either sitting or lying in bed 1 - Both feet should be flat on the floor 6 Expose the upper arm by rolling sleeves up (does not auscultate through clothing). 2 7 Locate the brachial pulse at antecubital space and wrap the deflated cuff evenly around 2 the upper arm. lower border of the cuff approximately 2.5 cm (1 in.) above the antecubital space. 8 Wipe the diaphragm and earpiece of stethoscope with alcohol and place the stethoscope 1 in the ear with the earpiece directed forward. 9 Apply the diaphragm of the stethoscope firmly over the patient's brachial artery. Place 2 the stethoscope directly on the skin, not on clothing over the site. 10 Close valve and inflate cuff rapidly about 30 mmhg above point at which pulse disappear 2 and auscultate the client’s blood pressure by listening to Korotkoff sounds. 11 Deflate the cuff by slowly opening the valve at a rate of 2 to 3 mmHg per second. 2  Note when you hear the first strong(thumbing) sound this is systolic pressure (1st Korotkoff sound) and the last beat heard sound, this is diastolic pressure (5th Korotkoff sound). 12 Release air from cuff completely, repeat the procedure if needed (wait 30-60 seconds 1 before taking the blood pressure again). 13 Check to see that the patient is comfortable. 1 14 16-Wipe the earpiece and diaphragm with alcohol and -Return the equipment to 1 proper place 15 Record (time, reading, position, site of measurement). 1 Total grade 20 Student signature Instructor signature