Republic of the Philippines

ISABELA STATE UNIVERSITY

Ilagan Campus

COLLEGE OF NURSING

NAME: Andrea Monique R. Galasinao COURSE: FUNDA RLE

YR. & SEC: BSN-1A DATE: 4/26/2022

VITAL SIGNS CHECKLIST

BODY TEMPERATURE CHECKLIST (AXILLARY)

1. Introduce yourself and verify client RATIONALE: This is to
ensure that you are
performing the procedure to
the right patient.
2. Identity with 2 identifiers and establish rapport. RATIONALE: Establishing
rapport is important for the
patient to fully trust you
throughout the procedure.
3. Ask consent for the procedure RATIONALE: This is to
ensure that you are
performing the procedure to
the right patient.
4. Hand hygiene and infection control procedure. RATIONALE: Hand hygiene
is important to prevent disease
causing microorganism to
invade the patient’s body as
well as the nurse.
5. Provide privacy. RATIONALE: Privacy
maintains the patient’s
dignity.
6. Position accordingly/Make patient comfortable. RATIONALE: Patient’s
comfort is the utmost priority
of nurses.
7. Check for adequate lighting. RATIONALE: To ensure
accuracy of the result.
8. Check the digital thermometer if it is functioning well. RATIONALE: To ensure
accuracy of the result also.
 9. Wipe thermometer with cotton ball soaked with alcohol RATIONALE: To reduce the
from cleanest to dirtiest. likelihood of spreading
contamination.
10. Lift up patients arm to expose axilla. Assess if there’s any RATIONALE: To make sure
lesion present. that you are not hitting any
skin abnormalities.
11. Place the thermometer in axilla and fold the patient’s arm RATIONALE: Leave for 30
over and unto his chest and wait for appropriate amount of seconds for more accurate
time/ wait for the beep sound results.
12. Remove and read temperature.
13. Disinfect thermometer with cotton ball soaked with RATIONALE: To reduce the
75% alcohol & return to receptacle. likelihood of spreading
contamination.
14. Document the procedure in the patient’s record. RATIONALE: It is important
to document the results in
order to take note of accurate
reflection of the patient’s
state.
15. Perform hand hygiene. RATIONALE: To maintain
hygiene and prevent any
diseases to spread.

RECTAL (Use if the patient is in the state of comatose, confused, critically ill, in shock
and unable to close the patient’s mouth)
1. Introduce yourself and verify client
2. Identity with 2 identifiers and
establish rapport.
3. Ask consent for the procedure
4. Hand hygiene and infection control
procedure.
5. Provide privacy.
6. Position accordingly (Sim’s Position
with upper leg bent) /Make patient
comfortable.
RATIONALE: This is to ensure that you are
performing the procedure to the right patient.
RATIONALE: Establishing rapport is
important for the patient to fully trust you
throughout the procedure.
RATIONALE: This is to ensure that you are
performing the procedure to the right patient.
RATIONALE: Hand hygiene is important to
prevent disease causing microorganism to
invade the patient’s body as well as the nurse.
RATIONALE: Privacy maintains the
patient’s dignity.
RATIONALE: This is to safely secure the
patient to the table for assessment and this
allows access to the anus.
7. Check for adequate lighting.
8. Wear gloves.
9. Attach the red rectal probe stem to the
thermometer.
10. Slide over a disposable probe stem
cover and apply plenty of lubricant.
11. With one hand separate the patient’s
buttocks. Ask the patient to breathe
slowly
12. Insert the lubricated probe about 3 cm
just over an inch deep into the
direction of the umbilicus
13. When the thermometer chimes,
remove the probe and read
temperature.
14. Document the procedure in the
patient’s record.
15. Perform hand hygiene.
RATIONALE: To ensure accuracy of the
result.
RATIONALE: This serves as a barrier
between the patient and the nurse incase of
having open portals to the skin, especially
when the procedure is invasive.
RATIONALE: Lubricants will help the
thermometer slide smoothly.
RATIONALE: Gently insert it to prevent any
discomfort.
RATIONALE: Do not put any farther than 3
cm.
RATIONALE: It is important to document
the results in order to take note of accurate
reflection of the patient’s state.
RATIONALE: To maintain hygiene and
prevent any diseases to spread.
PULSE RATE CHECKLIST
1. Perform hand hygiene before patient contact. RATIONALE: Hand hygiene
is important to prevent
disease causing
microorganism to invade the
patient’s body as well as the
nurse.
2. Verify the correct patient using two identifiers. RATIONALE: Establishing
rapport is important for the
patient to fully trust you
throughout the procedure.
3. Assess the patient for risk factors for an abnormal radial RATIONALE:
pulse.
4. Assess the patient for signs and symptoms of altered
cardiac function.
5. Determine the patient’s previous baseline pulse rate
from the patient’s record
6. Encourage the patient to relax as much as possible.
7. If the patient has been active and his or her condition RATIONALE: Let the patient
permits, wait several minutes before assessing the pulse rest for several minutes
because assessing the patient
righ after a rigorous activity
can affect the results.
8. Perform hand hygiene RATIONALE: Hand hygiene
is important to prevent
disease causing
microorganism to invade the
patient’s body as well as the
nurse.
9. Help the patient assume a supine or sitting position RATIONALE: This is to help
the patient to relax.
10. If the patient is supine, place his or her forearm straight RATIONALE: Placing the
alongside the body or across the lower chest or upper patient in comfort is the
abdomen with the wrist extended straight. If the patient utmost priority of every nurse.
is sitting, bend the elbow 90 degrees and support the
lower arm on a chair or the nurse’s arm
11. Place the tips of the first two or three fingers over the RATIONALE: Apply enough
groove along the radial (or thumb) side of the patient’s pressure to feel the beat.
inner wrist. Slightly extend or flex the patient’s wrist
with the palm down until the pulse is strongest
12. Lightly compress the artery against the radius,
obliterating the pulse initially. Then ease the pressure so
the pulse becomes easily palpable.
13. Determine the strength of the pulse (e.g., 0, 1+, 2+, 3+, RATIONALE: Use this
4+). Note whether the thrust of the vessel against the subjective scale as accurately
fingertips is absent, thready, weak, strong, or bounding. as possible, especially if the
If this is a repeat assessment, note any changes in the presence or absence of pulses
intensity of the pulse. is a concern. Consider having
another nurse assess the
patient at the same time
14. After palpating a regular pulse, note the position of the
second hand on a wristwatch and then begin to count the
rate. Begin counting with the first beat felt after the
second hand has moved toward the next number on the
dial; count as one, then two, and so on.
15. If the pulse is regular, count the rate for 30 seconds and RATIONALE: For more
multiply the total by 2. accurate results, count pulse
for 1 whole minute.
16. If the pulse is irregular, count the rate for a full 60
seconds. Assess the pattern of irregularity.
17. Compare the radial pulses bilaterally. If a marked
difference between the sides exists, assess the
extremities for perfusion. Notify the practitioner if signs
of decreased perfusion, including a change in skin color,
edema, a change in skin temperature, and decreased
pulse palpability, are present.
18. Help the patient to a comfortable position. RATIONALE: Patient’s
comfort is the utmost priority
of nurses.
19. Discuss the findings with the patient as needed. RATIONALE: Make the
patient be aware of the results
in order to discuss any
discussions needed.
20. Perform hand hygiene RATIONALE: Hand hygiene
is very important before and
after the procedure.
21. Document the procedure in the patient’s record RATIONALE: It is important
to document the results in
order to take note of accurate
reflection of the patient’s
state.
RESPIRATORY RATE CHECKLIST
1. Check record for baseline and factors (age, illness, RATIONALE: There are
medications, etc.) influencing vital signs factors that may influence
the results, so it is important
to look out for these.
2. Gather equipment, including paper and pen, for recording RATIONALE: This is to
vital signs ensure that the assessment
flows smoothly.
3. Perform hand hygiene before patient contact. RATIONALE: Hand hygiene
is important to prevent
disease causing
microorganism to invade the
patient’s body as well as the
nurse.
4. Prepare participant by telling them what you will be doing. RATIONALE: Make sure
the patient is aware of the
procedure to establish
rapport.
5. Check the accuracy of participant’s name and birthdate per RATIONALE: This is to
identification policy before starting the procedure ensure that the you are with
the right patient.
6. Be sure light is adequate for the procedure. RATIONALE: To ensure
accuracy of the result.

7. Observe rise and fall of chest or abdomen. Count RATIONALE: Make sure to
respirations for 30 seconds and multiply by 2. focus on the rise and fall of
the abdomen to measure it
accurately.

8. Observe for signs of respiratory distress (retractions, nasal RATIONALE: These factors
flaring, grunting, use of accessory muscles). may affect the results, ask
the patient if there’s any
existing conditions she/he
have.

9. Wash hands. RATIONALE: Hand hygiene

is important to prevent
disease causing
microorganism to invade the
 patient’s body as well as the
nurse.
10. Document the following: RATIONALE: It is
important to document the
• Rate of respirations.
results in order to take note
• What would be the parameters to report in an urgent of accurate reflection of the
fashion? patient’s state.
• Who should you report the urgent findings to?
BLOOD PRESSURE CHECKLIST
1. Check the physician’s order RATIONALE: To make sure
you have the authority given to
you to perform the procedure.
2. Check record for baseline and factors (age, illness, medications, etc.) RATIONALE: There are
influencing vital signs. factors that may influence the
results, so it is important to
look out for these.
3. Gather equipment, including paper and pen, for recording vital signs. RATIONALE: This is to
ensure that the assessment
flows smoothly.
4. Perform hand hygiene. RATIONALE: Hand hygiene
is important to prevent disease
causing microorganism to
invade the patient’s body as
well as the nurse.
5. Prepare participant by telling them what you will be doing. RATIONALE: Make sure the
patient is aware of the
procedure to establish rapport.
6. Check the accuracy of participant’s name and birthdate per RATIONALE: This is to
identification policy before starting the procedure ensure that the you are with the
right patient.
7. Cleanse ear pieces and bell/diaphragm of stethoscope with an alcohol RATIONALE: To make sure
wipe. there isn’t any existing bacteria
that can touch the patient’s
skin.
8. Position the arm in Sitting or recumbent position with forearm RATIONALE: Positioning can
supinated and slightly flexed and supported at heart level. affect the result, so it is
important to make sure the
patient is comfortable.
9. Remove clothing as necessary to expose extremity. RATIONALE: Certain factors
can greatly affect the results,
such as clothings.
10. Place correct size cuff around the extremity with the center of the RATIONALE: Correct cuff
cuff over the artery. size would provide comfort to
the patient especially the obese
a. Arm: Cuff should be placed around upper arm with the lower edge
ones and provide accurate
about 3 cm above the antecubital fossa.
results.

11. Locate the artery by palpation. RATIONALE: With your first

2 fingers, locate the artery.
12. Palpate a pulse distal to the cuff, e.g., brachial or radial. Close air RATIONALE: Locate with
valve and rapidly inflate cuff to 30 mm Hg above where pulse no your index and middle finger
longer felt or above expected systolic blood pressure. and press lightly on the inside
of the patient’s wrist.

13. Place stethoscope gently over artery.

14. NOTE: To obtain a blood pressure reading by palpation, keep fingers
on a distal pulse.
15. Open the valve and slowly release the air, permitting the pressure to RATIONALE: When inflating
drop 2–3 mm Hg per heart beat while auscultating for BP sounds or the blood pressure cuff for
palpating for a pulse. actual measurement, you
should inflate the cuff to 30
16. NOTE: Do not reinflate cuff without letting cuff totally deflate.
mmHg greater than the
estimated systolic value. This
avoids over-inflation and
subsequent patient discomfort
from increased pressure. It also
avoids the error of an
auscultatory gap.
17. Obtain a blood pressure reading. RATIONALE: You should
note when the sounds first
a. Auscultation.
appear with two consecutive
b. Systolic pressure: The pressure at which you first hear sounds. beats; this is the systolic
c. Diastolic pressure: The pressure when sounds become inaudible is the pressure. Continue to lower the
diastolic pressure pressure at a rate of 2-3 mmHg
per second until the sounds are
muffled and disappear; this is
the diastolic pressure. To
confirm that this is the correct
value, continue to deflate the
cuff for another 10-20 mmHg,
and then deflate the cuff
completely.
18. Do not leave the cuff inflated for a prolonged period RATIONALE: Prolonged
inflation of the cuff may cause
discomfort to the patient.
19. Deflate the cuff rapidly and completely and remove from the arm. RATIONALE: The cuff may
be too uncomfortable for
several patients, so remove it
immediately.
20. Inform the patient of the result of her blood pressure and let him/her RATIONALE: Let the patient
ask questions be aware of her results in order
to maintain transparency.
21. Do after care of equipment RATIONALE: It is important
to maintain the equipment
organized and clean for future
purposes.