CALAMBA DOCTORS’ COLLEGE

Virborough Subdivision, Parian, Calamba City, Laguna

Performance Evaluation Checklist

Name: ________________________ Date: _______________

Year and Section: _______________

Instruction: Rate the nursing skill performance of the student based as follows: 5 = Perfect (91-100), 4 = Very
Satisfactory (85-90), 3 = Satisfactory (80-84), 2 = Poor (79-75), 1 = Need Improvement (74 and below)

Vital Signs

Measuring Body Temperature
Equipment
 Thermometer
 Soft tissue or wipe
 Alcohol swab
 Water-soluble lubricant (for rectal measurements only)
 Pen and vital sign flow sheet, record form
 Clean gloves (optional
Assessment
 Determine need to measure patient’s body temperature
 Determine appropriate measurement site and device for patient
 Determine previous baseline temperature and measurement site
(if available
 Assess patient’s knowledge of procedure
Procedures
1. Perform hand hygiene.
2. Assist patient to comfortable position that provides easy
access to temperature measurement site
3. Obtain temperature reading by:
Oral temperature (electronic):
1. Provide privacy
2. Apply clean gloves (optional)
3. Ask patient to open mouth; gently place thermometer
probe under tongue in posterior sublingual pocket lateral
to center of lower jaw
4. Ask patient to hold thermometer probe with lips close
5. Leave thermometer probe in place until audible signal
indicates completion
6. Return thermometer probe stem to storage position of
thermometer unit.

Rectal temperature
1. Assist patient to side-lying or Sims’ position with upper
leg flexed.
2. Perform hand hygiene and apply clean gloves. Cleanse
anal region when feces and/or secretions are present
3. Lubricate thermometer blunt end 2.5 to 3.5 cm for adult.
4. With nondominant hand separate patient’s buttocks to
expose anus. Ask patient to breathe slowly and relax.
5. Gently insert thermometer into anus in direction of
umbilicus 3.5 cm (112 inches) for adult
6. Do not force thermometer.
7. Once positioned, hold thermometer probe in place until
audible signal indicates completion
8. Wipe patient’s anal area with soft tissue to remove
lubricant or feces and discard tissue

Axillary temperature
1. Assist patient to supine or sitting position.
2. Move clothing or gown away from shoulder and arm.
3. Raise patient’s arm away from torso and inspect for skin
lesions and excessive perspiration
4. Insert thermometer probe into center of axilla lower arm
over probe, and place arm across patient’s chest
5. Hold thermometer in place until audible signal indicates
completion
6. Clean the thermometer
 Tympanic membrane temperature
1. Assuming comfortable position with head turned toward
side, away from you
2. Note if there is an obvious presence of cerumen
(earwax) in patient’s ear canal
3. Insert speculum into ear canal following manufacturer
instructions for tympanic probe positioning:
4. Pull ear pinna backward, up, and out for an adult (see
illustration). For children less than 3 years of age, pull
pinna down and back, point covered probe toward
midpoint between eyebrow and sideburns. For children
older than 3 years, pull pinna up and back
5. Fit speculum tip snug in canal, pointing toward the nose
6. Once positioned, press scan button on handheld unit.
Leave speculum in place until audible signal indicates
completion

Assessing Pulse
Assessment
 Determine need to assess radial pulse
 Determine patient’s previous baseline pulse rate (if available)
Procedure 5 4 3 2 1 Comments
Radial pulse
 Assist patient with assuming a supine or sitting position
1. If patient is supine, place his or her forearm straight
alongside or across lower chest or upper abdomen with
wrist extended straight
2. If sitting, bend patient’s elbow 90 degrees and support
lower arm on chair or on nurse’s arm. Place tips of first
two or middle three fingers of hand over groove along
radial or thumb side of patient’s inner wrist
3. Slightly extend or flex wrist with palm down until you note
strongest pulse.
 Lightly compress against radius, obliterate pulse initially, and
relax pressure so pulse becomes easily palpable.
 Determine strength of pulse. Note whether thrust of vessel
against fingertips is bounding (4+); full increased, strong (3+);
expected (2+); barely palpable, diminished (1+); or absent, not
palpable (0).
 After palpating a regular pulse, look at watch second hand and
begin to count rate
 If pulse is regular, count rate for 30 sec. and multiply total by 2.
 If pulse is irregular, count rate for a full 60 seconds. Assess
frequency and pattern of irregularity
 When pulse is irregular, compare radial pulses bilaterally
Apical pulse
 Assist patient to supine or sitting position. Move aside bed linen
and gown to expose sternum and left side of chest
 Locate anatomic landmarks to identify point of maximal impulse
(PMI), also called apical impulse
1. Slip fingers down each side of angle to find second intercostal
space (ICS)
2. Carefully move fingers down left side of sternum to fifth ICS
and laterally to left midclavicular line (MCL)
3. A light tap felt within area 1 to 2.5 cm (12 to 1 inch) of PMI is
reflected from apex of heart
 Place diaphragm of stethoscope in palm of hand for 5 to 10
second
 Place diaphragm of stethoscope over PMI at fifth ICS, at left
MCL, and auscultate for normal S1 and S2 heart sounds
 When you hear S1 and S2 with regularity, use second hand of
watch and begin to count rate
 If apical rate is regular, count for 30 seconds and multiply by 2.
 If HR is irregular or patient is receiving cardiovascular
medication, count for a full 1 minute (60 seconds).
 Note regularity of any dysrhythmia (S1 and S2 occurring early or
late after previous sequence of sounds) (e.g., every third or
every fourth beat is skipped).
 Perform hand hygiene
 Clean earpieces and diaphragm of stethoscope with alcohol
swab routinely after each use.
 Assessing Respirations
Assessment
 Determine need to assess patient’s respirations
 Assess pertinent laboratory values (ABG, Pulse Oxymetry, CBC)
 Determine previous baseline respiratory rate
Procedure
Radial pulse
 Be sure that patient’s chest is visible. If necessary, move bed
linen or gown
 Place patient’s arm in relaxed position across abdomen or lower
chest or place your hand directly over patient’s upper abdomen
 Observe complete respiratory cycle (one inspiration and one
expiration).
 Look at second hand of watch and begin to count rate: when
sweep hand hits number on dial, begin time frame, counting one
with first full respiratory cycle.
 If rhythm is regular, count number of respirations in 30 seconds
and multiply by 2. If rhythm is irregular, less than 12, or greater
than 20, count for 1 full minute.
 Note depth of respirations by observing degree of chest wall
movement while counting rate. Describe depth as shallow,
normal, or deep
 Note rhythm of ventilatory cycle. Normal breathing is regular and
uninterrupted. Do not confuse sighing with abnormal rhythm

Assessing blood pressure

Preparation
Before measuring the blood pressure, consider the following behavioral
and environmental conditions that can affect the reading:
1. Room temperature
2. Exercise
3. Alcohol intake
4. Nicotine use
5. Muscle tension
6. Bladder distention
7. Background noise
8. Talking
9. Arm position

Equipment
 Aneroid sphygmomanometer
 Pressure cuff of appropriate size for patient’s extremity
 Stethoscope
 Alcohol swab
 Pen and vital sign flow sheet
Steps for Measuring Blood Pressure
1. Assemble your equipment so that the sphygmomanometer,
stethoscope, and your pen and recording sheet are within easy
reach
2. Assist the client into a comfortable, quiet, restful position for 5 to
10 minutes. Client may lie down or sit
3. Remove client’s clothing from the arm and palpate the pulsations
of the brachial artery.
4. Place the blood pressure cuff so that the midline of the bladder is
over the arterial pulsation, and wrap the appropriate-sized cuff
smoothly and snugly around the upper arm, 1 inch above the
antecubital area so that there is enough room to place the bell of
the stethoscope. The bladder inside the cuff should encircle 80%
of the arm circumference in adult and 100% of the arm
circumference in children younger than age 13 years.
5. Support the client’s arm slightly flexed at heart level with the
palm up
6. Put the earpieces of the stethoscope in your ears, then palpate
the brachial pulse again and place the stethoscope lightly over
this area. Position the mercury gauge on the manometer at eye
level.
7. Adjust the screw above the bulb to tighten the valve on the air
pump, and make sure that the tubing is not kinked or obstructed.
8. Inflate the cuff by pumping the bulb to about 30 mmHg above the
point at which the radial pulse disappears or estimated systolic.
Pressure. This will help you avoid missing an auscultatory gap.
9. Deflate the cuff slowly—about 2 mm per second—by turning the
 valve in the opposite direction while listening for the first of
Korotkoff’s sounds
10. Read the point, closest to an even number, on the mercury
gauge at which you hear the first faint but clear sound. Record
this number as the systolic blood pressure. This is phase I of
Korotkoff’s sounds.
11. Next, note the point, closest to an even number, on the mercury
gauge at which the sound becomes muffled (phase IV of
Korotkoff’s sounds). Finally, note the point at which the sound
subsides completely (phase V of Korotkoff’s sounds). When
both a change in sounds and a cessation of the sounds are
heard, record the numbers at which you hear phase I, IV, and V
sounds. Otherwise, record the first and last sounds
12. Deflate the cuff at least another 10 mmHg to make sure you
hear no more sounds. Then deflate completely and remove.
13. Record readings to the nearest 2 mmHg
14. Perform hand hygiene

Cuff Selection Guidelines

1. The “ideal” cuff should have a bladder length that is 80% and a
width that is at least 40% of the arm circumference (a length-to-
width ratio of 2:1).
2. A recent study comparing intra-arterial and auscultatory blood
pressure concluded that the error is minimized with a cuff of 46%
of the arm circumference.
The recommended cuff sizes are:
 12 × 22 cm for arm circumference of 22 to 26 cm, which is the
“small adult” size
 16 × 30 cm for arm circumference of 27 to 34 cm, which is the
“adult” size
 16 × 36 cm for arm circumference of 35 to 44 cm, which is the
“large adult” size
 16 × 42 cm for arm circumference of 45 to 52 cm, which is the
“adult thigh” size

Ave. Score =

Grade: __________
Evaluated by:

__________________________
Clinical Instructor

Rating Scale
Range Descriptive Rating
4.51 - 5.00 Perfect
3.51 - 4.50 Very Satisfactory
2.51 - 3.50 Satisfactory
1.51 - 2.50 Poor
1.00 - 1.50 Need Improvement