alleen PHINMA Name: Yr.& Sec. Date: ch. ASSESSING VITAL SIGNS RUBRICS T _| CRITERIA : T 4 T 3 2 ] 1 T_ | Proficient | Approachin | Developing | Beginning | Rating | } g | | 2h ___| proficiency | joes | PROCEDURE Independently | Performs Performs [| Performs | performs all ‘skills with skills with | _ skills with | i | skills fluently | assistance of | assistance of | assistance | andwithout | faculty 1-2 | faculty3-4 | of facutty | difficulty, times during | times during greater than | ] simulation, | simulation 4 times | i | | | | during L | |_ simulation le INITIAL STEPS: T | 1. Identify the patient. Discuss | | procedure with patient and assess | | Patient's ability to assist with the | | procedure. | | | 2. Prepare ail the equipment needed | 1 and ensure they are alll in good | | condition. : 3. Provide privacy. i 4, Perform hand hygiene. BODY TEMPERATURE 41. Helps the client toassumea | | | position of comfort for axillary | | | temperature. t ‘ | 2. Takes the thermometer out of its | | holder. | 3. Tums on the thermometer and | places it in the armpit. '4. Removes the thermometer when | it beeps and reads at the digital | | display. | | Cleans the thermometer using | alcohol swabs before placing it back. | |G. Places the thermometer | its holder. PULSE 1. Positions the client so that his arms are relaxed and supported | | 2. Places fingertips index and middle finger on the inner surface of the wrist. (radial artery)the thumb side of the wrist against the adjacent bone so that the client's pulsating artery can be felt distinctly. (Using a watch with a second hand count the number of pulsation for one full minute, RESPIRATION =| 1. Assumes the same position in taking pulse rate. 2. Keeps fingertips in place after | counting the pulse, but note the rise | and fall of the client's chest with | each inspiration and expiration without patient's awareness | |3. Counts the number of respirations for one full minute. I ~ BLOOD PRESSURE | 1. Assists patient assume a correct position | 2. Removes or rearranged clothing | to expose the area where the cuff | | will be applied | | 3. Extends the arm with the paim | | facing upward {4 | inches above the inner aspects of the elbow with bladder over the brachial artery. 'S. Arranges the manometer gauge | at eye level | 6, Palpates the brachial artery or radial pulse by pressing gently with | the fingertips. Tighten the screw | valve on the air pump and Inflate the | cuff while continuing to palpate the | artery. Note the point on the gauge | where the pulse disappears. Deflate | the cuff and wait for 15 seconds. | 7. Place the stethoscope earpieces | in the ears properly. Then position | the diaphragm of the stethoscope | firmly but with as litle pressure as | possible over the artery where the | pulse is felt. Do not aliow the | stethoscope to touch clothing or the cuff. "8 Pump the pressure 30mm Hg _ ‘above the point at which the pulse disappeared "9. Note the point on the gauge at which there is an appearance of the | first faint, but clear, sound, which | | slowly increases in intensity. Note | this number as the systolic pressure. | Read the pressure to the closest.10, Releases air entirely from the cuff and remove the cuff from patient arm ‘AFTER PROCEDURE 1. Perform hand hygiene. 2. Records the temperature, respiratory rate, pulse rate and Blood Pressure reading on a flow sheet and indicate the time. Report | any abnormal findings to the appropriate person. poo TOTAL POINTS: 116 Signature over Printed name of the Student Signature over Printed name of the Clinical instructor Prepared: Marie Christiné N. Mercado, RN, MAN, Ed.D Level Il - RLE Coordinator Noted: Jilt Marie C. Helmogenes, RN, MAN, Ed.D Assistant Dean Approved: Michelle B. Yu, Fl, MAN, DM Dean