COLLEGE OF NURSING

1/1

Obtaining Temperature, Pulse, Respiration and Blood Pressure

Instruction: check on the column of your choice as to what level is the performance of the student in the following procedure. Be
guided in the scoring with the legend below:
Respirations
Legend: Level of performance
1 Assess patient’s condition. Determine the client’s activity schedule.
4 Very satisfactory (Performed all the procedures correctly)
2 Place the patient in a comfortable position. Lying down with the head of the bed at 45-
3 Satisfactory
60o angle. (Needs minimal assistance in performing the procedure)
23 Good (Needs more practice in performing the procedure)
1 Place a hand againstinthe
Fair (inappropriate theclient’s chest orofposition
performance the patient’s arm over the abdomen.
the procedure)
4 While supposedly taking the radial pulse, count respirations by observing the rise and
STEPS fall of the patient’s chest for one whole PROCEDURE
minute. 4 3 2 1
Temperature
5 Note rate, depth, rhythm, and character.
16 Wash hands.
Document findings.
27 Rinse thermometer
Wash hands. in cold water if kept in a disinfectant solution.
3
Blood Pressure Wipe dry with tissue moving from bulb to stem using a firm twisting motion.
41 Grasp thermometer
Wash hands. Clean off the with thumb and forefinger
stethoscope diaphragmand shake
or bell0vigorously
with antisepticby snapping
wipes. wrist in
0
2 downward motion to lower mercury level to below 95-96 F (35.5 C)
5 Determine
Pat dry axilla which extremity
of patient. is most
Place appropriate
thermometer for center
in the reading. Do axilla
of the not take anda lower
blood patient’s
pressure
reading
arm down on across
an injured or painful extremity or one in which an intravenous line is running.
the chest.
63 Leave
Select aincuffplace forthat
size 8-10 minutes. encircles the upper arm without overlapping. The
completely
7 Remove thermometer
bladder must encircle at least and wipe it once with
two-thirds tissue
of the arm.from fingers down the bulb, using a
4 firm twisting motion.
Explain procedure to the patient.
85 Read
Place temperature
the patient inbya relaxed
rotating reclining
thermometer until the
or sitting mercury
position withlevel
arm is at clearly
the levelvisible
of theand
at eye level. Shake thermometer down, cleanse and return to storage
heart and with the palm of hand facing upward. Expose the upper part of patient’s arm. container.
9 Dispose used tissue
Blood pressure shouldwipes
not in
beataken
container
over for contaminated items.
clothes.
10 6 Wash hands.
Palpate the brachial artery.
11 Document
Wrap cuff snuglytemperature reading. around the upper part of the arm (about one inch above
and smoothly
Pulse 7 the antecubital space) with the center of the bladder over the brachial artery.
18 Assess
Place the thegauge
patient’s
at eyecondition.
level, closeDetermine
enough to theread.
client’s
(Notactivity schedule.
more than three feet away from
2 Place patient
the manometer). in a comfortable position. Ask about activity within the last half hour.
39 Palpate
Palpate over the pulsing
the brachial artery
artery, close(radial or peripheral)
the valve and compressusingbulb
padstoofinflate
the three
cuffmiddle
to 30 mmHg
fingers.the point where palpated pulse disappears, then slowly release the valve to deflate
above
4 Apply light but firm pressure.
cuff.
10 5 Countdiaphragm
Place pulse for one whole
or bell minute.
of stethoscope on the medial antecubital fossa where brachial
6 Note rhythm
artery is felt. and volume of the pulse.
11 7 Leavethe
Place thestethoscope
patient in a ear comfortable
pieces in position.
your ears, tighten the screw valve and inflate the cuff
8 Document
rapidly (7 secfindings.
or less) by pumping up bulb until manometer registers 30 mmHg above the
Taking an Apical Pulse pulse point or at which pulsations are no longer heard.
diminished
12 1 Place the client in a supine or left-sided position.
Loosen valve slightly to release air at a rate of 2-4 mmHg per second for normal adult.
2 Warm diaphragm with hands.
13 3 Listen for a faint, clear
Place stethoscope on thetapping
apex ofsound that appears
the heart. The apex andisincreases
normallyin intensity.
located on the fifth
14 intercostals
Continue to space
deflatejust
cuffbelow the nipple
(sounds and three
will change inches toRecord
in quality). the leftdiastolic
of the sternum.
BP as the
sound disappears (Korotkoff’s V sound). If sounds are continuously heard at a very low
4 reading,
Count therecordrate fortheone
abrupt muffling
minute when of sound,
taking an phase
apical IV (muffling is often recorded for
pulse.
5 children)
Assess rhythm and any unusual heart sounds.
15 6 Release
Leave the airclient
from in cuff after sound position.
a comfortable ceases. Wait 2 minutes before taking a second reading.
7 Document findings.
16 Leave the patient in a comfortable position.
17 Clean the diaphragm and bell of the stethoscope with antiseptic wipes. Wash hands.
18 Record and report findings.

UC-VPAA-CON-FORM-48 Page 1 of 2
JUNE 2012 REV. 00
 Subtotal:
Total Score:
Perfect Score:
Remarks:

Name / Signature of Student Name / Signature of RD Instructor

UC-VPAA-CON-FORM-48 Page 2 of 2
JUNE 2012 REV. 00