VITAL SIGNS TAKING RUBRICS

PROCEDURE CHECKLIST

Scale Description
4 Able to recite and perform correctly
3 Able to recite and perform moderately with less mistakes/Unable to recite but perform
2 Able to recite and perform with assistance
1 Unable to recite and perform
Mastered Repetitively done until the procedure is mastered

VITAL SIGNS

Procedure 1. Assessing Body Temperature 4 3 2 1 Mastered

Preparation

1.Assessment:
 Assess for clinical signs of fever
 Clinical signs of hypothermia
 Site of most appropriate measurement
 Factors that may alter core body temperature

2. Assemble equipment and supplies:

 Digital thermometer,
 Lubricant for rectal temperature,
 Disposable gloves,
 Tissue wipes and/or towel for axillary temperature

Procedure
1.Explain to the client about the procedure to be done and how
he/she can cooperate
2. Wash hands and observe other appropriate infection control
procedures.
3. Provide the client privacy.
4. Place the client in appropriate position, sitting or lying with head
elevated unless taking a rectal or tympanic temperature.
5. Expose the client’s arm and shoulder from sleeve or gown and
make sure axillary skin is dry, if necessary, pat dry.
6. Prepare and set the digital thermometer
7. Place the thermometer appropriately, apply a protective sheath if
necessary, and apply lubricant if rectal thermometer is to be done.
8. Leave the digital thermometer until the signal is heard and/or
check package instructions for length of time to wait prior to reading
thermometer.
9. Remove and read thermometer, if the reading is too high or too
low or inconsistent with the client’s condition, recheck using a well-
functioning one.
10. Inform client of temperature reading.
11. Wash or cleanse the thermometer and return it to the proper
storage.
12. Document the temperature in the client record and the site
taken.
13. Wash hands.

Procedure 2. Assessing a Peripheral Pulse 4 3 2 1 Mastered

Preparation
1.Assessment
 Assess for signs for cardiovascular alterations, other than
pulse rate, rhythm, or volume
 Factors that may affect the character of the pulse rate
 Assess for appropriate site for obtaining pulse
2. Assemble equipment and supplies
 Watch with second hand or indicator
 If using Doppler ultrasound stethoscope, obtain the
transducer probe, handset, transmission gel, and
tissues/wipes

Procedure
1.Explain to the client about the procedure to be done and how
he/she can cooperate
2. Wash hands and observe other appropriate infection control
procedures.
3. Provide the client privacy.
4. Select the pulse point at which you will measure the pulse rate.
5. Assist the client in a comfortable resting position, flex client’s
elbow and place lower part of arm across chest.
6. Place your index and middle finger over the radial artery, palpate
and count the pulse and record the beats in full minute. Recheck if
the pulse is irregular and count for a full minute.
7. Assess the rhythm and volume.
8. Inform the findings with the client.
9. Document the pulse rate, rhythm, and volume and your action in
the client record.
10. Wash hands.

Assessing an Apical Pulse

1.Assessment
 Assess for signs for cardiovascular alterations, other than
pulse rate, rhythm, or volume
 Factors that may affect the character of the pulse rate
 Assess for appropriate site for obtaining pulse
2. Assemble equipment and supplies
 Watch with second hand or indicator
  Stethoscope
 Antiseptic swipes
 If using Doppler ultrasound stethoscope, obtain the
transducer probe, handset, transmission gel, and
tissues/wipes

Procedure
1.Explain to the client about the procedure to be done and how
he/she can cooperate.
2. Wash hands and observe other appropriate infection control
procedures.
3. Provide the client privacy.
4. Position the client appropriately in a comfortable supine position
or a sitting position.
5. Expose the area of the chest over the apex of the heart.
6. Locate the apical pulse
 Palpate the angle of Louis, located just below the
suprasternal notch and felt as 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 just medial to the MCL
7. Auscultate and count heartbeats.
 Prepare the stethoscope, use antiseptic wipes to clean the
earpieces and diaphragm.
 Warm the diaphragm of the stethoscope by holding it in 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 heart sounds or
regularity of the rhythm.
8. Assess the rhythm and strength of the heart beat by noting the
pattern of intervals and strength of the heartbeat.
9. Start to count the heart beat while looking at second hand of
watch for one (1) full minute.
10. Inform the findings with the client.
8. Document the pulse rate, rhythm, and volume and your action in
the client record.
9. Wash hands.

Procedure 3. Assessing Respirations 4 3 2 1 Mastered

 Preparation
1.Assessment
 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 second hand or indicator

Procedure
1.Explain to the client about the procedure to be done and how
he/she can cooperate.
2. Wash hands and observe other appropriate infection control
procedures.
3. Provide the 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.
 An inhalation and an exhalation count s one respiration.
Count the respiratory rate in a full minute.
5. Observe the depth, rhythm, and character of respiration.
 Observe the respirations for depth by watching the
movement of the chest
 Observe the respirations for regular or irregular rhythm
 Observe the character of the respirations, the sound they
produce and the effort they require
6. Inform the findings with the client.
7. Document the respiratory rate, depth, rhythm, and character on
the appropriate client record.
8. Wash hands.

Procedure 4. Assessing Blood Pressure 4 3 2 1 Mastered

Preparation
1.Assessment:
 Signs and symptoms of hypertension and hypotension
 Factors affecting blood pressure
 Assess the condition of the potential blood pressure site
 Determine the client’s baseline blood pressure

2. Assemble equipment and supplies:

 Stethoscope or DUS
 Blood pressure cuff of the appropriate size
 Sphygmomanometer

Procedure
1.Explain to the client about the procedure to be done and how
he/she can cooperate.
2. Wash hands and observe other appropriate infection control
procedures.
3. Provide the 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. Apply the deflated cuff snugly and smoothly around the upper
arm. Locate the brachial artery. Apply the center of the cuff bladder
over the artery.
 For an adult, place the lower border of the cuff
approximately1 inch (2.5) above the antecubital space.
6. For the 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.
 Pump up the cuff until you no longer feel the brachial
pulse. At that pressure, the blood cannot flow the 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 earpieces of stethoscope into ears with a
forward tilt.
 Ensure that the stethoscope hangs freely from the ears to
the diaphragm.
 Place the bell side or diaphragm 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
mmHg above the point where the brachial pulse
disappeared.
  Release the valve on the duff carefully to decrease the
pressure at the rate of 2-3 mmHg per second.
 As the pressure falls, note the manometer readings when
sounds appear and disappear.
 After the final sound disappeared, 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. Remove the cuff properly and assist the client in comfortable
position.
10. Wipe the cuff with a recommended disinfectant.
11. Inform the findings with the client.
12. Document and report pertinent assessment data to the client
record.
13. Wash hands.