FA17 Vital Signs Check off PDF

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Vital Signs practice sheet...

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Lone Star College-Montgomery Vocational Nursing Program

PERFORMANCE CHECK LIST – VITAL SIGNS

Oral Temperature, Pulse, Respirations, Blood Pressures & AP Student ____________________________________________ Date: ________ RECOMMENDED TECHNIQUE 1. Explains procedure to patient and encourages patient to participate as appropriate. Promotes self-esteem. 2. Assembles appropriate equipment, before obtaining vital signs. Appropriate thermometer, stethoscope, and sphygmomanometer with correct cuff size. Promotes efficiency. 3. Provides for privacy as indicated. Preserves dignity for the patient.

Pass

Fail

Comments

4. Cleans hands appropriately and applies clean gloves before procedure. Reduces spread of microorganisms.

ORAL TEMPERATURE 5.

Determines if the patient has had any hot or cold substances, or smoked within 30 minutes of oral temperature assessment. Assists with accurate assessment of temp/ contraindication of oral temperature assessment 6. Removes thermometer from electronic charging base to clear previous temp  Allows for accurate assessment of temperature. 7. Covers thermometer with protective barrier cover.  Reduces spread of microorganisms. 8. Inserts thermometer correctly into client’s mouth, under tongue (to the left or right of the frenulum)  Allows for accurate assessment of temperature. 9. Leaves the thermometer in place for at least (three minutes or until audible sound occurs), with lips closed. Ensures adequate time for the thermometer to reach maximum measurement 10. Removes the thermometer (probe) from mouth and aseptically removes protective covering disposing in trash.  Removing cover makes it easier to see the numeric markings. 11. Cleans the thermometer with an alcohol swab from end to bulb  Reduces spread of microorganisms. 12. Student records correct temperature.  Assures accuracy of information/data. Student______________Instructor____________

Key: Rationale Rev FA17 faculty

Critical elements in bold. Failure to meet critical elements requires the student to retest. One critical element not met = Failure Two non-critical elements not met = Failure

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Lone Star College-Montgomery Vocational Nursing Program

PERFORMANCE CHECK LIST – VITAL SIGNS

Oral Temperature, Pulse, Respirations, Blood Pressures & AP RECOMMENDED TECHNIQUE

Pass

Fail

Comments

RADIAL PULSE: 13. Locates the radial pulse by placing pads of index and middle fingers over the radial artery and applies light but firm pressure until pulse is palpated.  Ensures accuracy because the nurse may feel his or her own pulse if the thumb is used. 14. Counts pulse for 30 seconds x 2 or 60 seconds if irregular, using a watch with a second hand.  Ensures for accuracy 15. Records pulse rate, rhythm and volume/strength. Student’s recorded rate is within + or – 2 beats of instructor’s recorded rate.  Assures accuracy of information/data. Student______________Instructor___________

RESPIRATORY RATE: 18. While fingertips are in place after counting the pulse rate, observes the patient’s respirations.  Patient will be unaware of being watched and will discourage control of breathing during the assessment. Counts and records the patient’s respiratory rate for 30 seconds x 2, or 60 seconds, using a watch with a second hand. Instructor should ask student for length of time he or she will count and check patient’s respiration while the student does so. Adjusts time according to normal or abnormal breathing patterns.  Ensures accuracy. Records respiratory rate + or – 2 respirations of instructors recorded rate.  Assures accuracy of information/data Student______________Instructor____________

APICAL PULSE: 16. Locates the pulse by placing the stethoscope on the chest at the point of maximum impulse/apex of the heart, (fifth intercostal space at midclavicular line) Student’s recorded rate is within + or – 2 beats of instructor’s recorded rate.  Ensures accuracy 17. Counts the rate for one full minute and evaluates the rhythm as regular or irregular.  Ensures accurate rate and identifies any abnormalities. Student______________Instructor____________

Key: Rationale Rev FA17 faculty

Critical elements in bold. Failure to meet critical elements requires the student to retest. One critical element not met = Failure Two non-critical elements not met = Failure

2

Lone Star College-Montgomery Vocational Nursing Program

PERFORMANCE CHECK LIST – VITAL SIGNS

Oral Temperature, Pulse, Respirations, Blood Pressures & AP

RECOMMENDED TECHNIQUE

Pass

Fail

Comments

BLOOD PRESSURE: 23. Removes clothing on upper arm, positions arm at heart level with elbow extended and palm turned upward.  Facilitates locating the brachial artery and ensures accuracy in collecting data. 24. Places the cuff around the upper arm so that the inflatable bladder is centered over the brachial artery. The lower edge of the cuff should be 1 –2 inches above the inner aspect of the elbow.  Places the cuff in the best position for occluding the blood flow through the brachial artery. 25. Locates brachial artery, places bell or diaphragm of stethoscope over brachial artery  Determines the most accurate location for assessment. 26. Tightens valve attached to air bulb, and inflates up to 30mmHg over patient’s baseline if known  Provides estimation of blood pressure 28. Slowly releases air, so that the mercury falls at a rate of 2-3mmHg per second. Notes the point at which the first sound is heard and the point at which the sound disappears. Determines systolic and diastolic pressure. 29. Allows remaining air to escape quickly from the cuff and removes the cuff from the patient’s arm.  Demonstrates patient safety and comfort. 30. Records systolic and diastolic blood pressure. Both systolic and diastolic varies no more than 4mmHg from the instructor’s blood pressure measurement.  Ensures accuracy. Student______________Instructor____________ 31. Washes hands after pt contact with soap and water or antiseptic cleanser.  Reduces spread of microorganisms. 31. Remains effective during skill in front of instructor

Key: Rationale Rev FA17 faculty

Critical elements in bold. Failure to meet critical elements requires the student to retest. One critical element not met = Failure Two non-critical elements not met = Failure

3

Lone Star College-Montgomery Vocational Nursing Program

PERFORMANCE CHECK LIST – VITAL SIGNS

Oral Temperature, Pulse, Respirations, Blood Pressures & AP

Student Name: Skill T Test est #1 Date: ________ P Pass/F ass/F ass/Fail: ail: Comments: ___________________ _______________________________________________________ ____________________________________ _____________________________________________________________ _________________________ ______________________________ _____________________________________________________________ _______________________________ ___________________________________________________________________ ____________________________________ _______________________________________ ___ Student Signature: ________________________________________ Instructor Signature: ____________________________

Date: _________

Remediation#1: Student Signature: __________________________ Instructor Signature: ____________________________ Date: _________

Skill T Test est #2 Date: ________ P Pass/F ass/F ass/Fail: ail: Comments: ___________________ _______________________________________________________ ____________________________________ _____________________________________________________________ _________________________ ______________________________ _____________________________________________________________ _______________________________ ___________________________________________________________________ ____________________________________ _______________________________________ ___ Student Signature: ________________________________________ Instructor Signature: ____________________________

Date: _________

Remediation#2: Student Signature: __________________________ Instructor Signature: ____________________________ Date: _________ Skill T Test est #3 Date: ________ P Pass/F ass/F ass/Fail: ail: Comments: ___________________ _______________________________________________________ ____________________________________ _____________________________________________________________ _________________________ ______________________________ _____________________________________________________________ _______________________________ ___________________________________________________________________ ____________________________________ _______________________________________ ___ Student Signature: _____________________________________ Instructor #1 Signature: ____________________________ Instructor #2 Signature: ____________________________

Key: Rationale Rev FA17 faculty

Date: _________

Date: _________

Critical elements in bold. Failure to meet critical elements requires the student to retest. One critical element not met = Failure Two non-critical elements not met = Failure

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