Vital Sign Rubric

Each student will automatically begin the testing with 100%.

Marks will be deducted as follows - If a single bolded item is missed during the testing, there is an
automatic deduction of grade to a 60%.

Any subsequent missed bolded or non-bolded items is a 5% deduction.

Evaluation: /100%

Item Descriptor Yes No

No.
Pre -Assessment
1 Review/ state prescription/prescriber order for vital sign measurement. ☐ ☐
2 Performs/ states hand hygiene. ☐ ☐
3 Verify the client using 2 identifiers. Compare client’s name and another identifier  ☐ ☐
(i.e., hospital ID number, DOB) from client’s arm band to order.
4 Introduce self, role and procedure using non-, medical terminology ☐ ☐
5 Provide for client privacy. ☐ ☐
Perform an Assessment Radial Pulse – minimally 30 seconds
6 Assess for signs and symptoms of altered stroke volume and cardiac output, such ☐ ☐
as dyspnea, fatigue, chest pain, orthopnea, syncope, palpitations (unpleasant
awareness of heartbeat), jugular venous distension, edema of dependent body
parts, and cyanosis or pallor of skin.
7 Landmark ☐ ☐
8 Strength scale (1+,2+,3+,4+) ☐ ☐
9 Rhythm – regular or irregular ☐ ☐
10 Equality – compare right to left ☐ ☐
11 Rate with 5 % (round up) e.g. hr 70 + or – 4 beats ☐ ☐
Perform Assessment – Respirations - minimally 30 seconds

12 Assess for signs and symptoms of respiratory alterations, such as bluish (cyanotic) ☐ ☐
appearance of nail beds, lips, mucous membranes, and skin; restlessness,
irritability, confusion, and reduced level of consciousness; pain during inspiration;
laboured or difficult breathing; adventitious breath; inability to breathe
spontaneously; thick, frothy, blood-tinged, or copious sputum produced on
coughing.
13 Rhythm – regular or irregular ☐ ☐
14 Quality – laboured, non laboured ☐ ☐
15 Rate - with 5 % (round up) e.g. 12 + or – 1 breath ☐ ☐
Perform Assessment – Manual Blood Pressure
16 Identify factors likely to interfere with accuracy of blood pressure measurement ☐ ☐
(e.g., acute anxiety, stress, pain). Encourage the patient to avoid caffeine, and
tobacco for 60 minutes before blood pressure is assessed, and avoid exercise 30
minutes before assessment.
17 Explain to patient that blood pressure is to be assessed, and have patient rest at ☐ ☐
least 5 minutes before blood pressure is measured in sitting or lying position; wait
1 minute if patient is standing. Ask patient not to speak when blood pressure is
being measured
18 Place stethoscope earpieces in your ears, and be sure sounds are clear, not ☐ ☐
muffled.
19 Relocate patient's brachial artery, and place bell or diaphragm chest pieces of ☐ ☐
stethoscope over it. Do not allow chest piece to touch cuff or clothing.
20 Quickly inflate cuff between 150- 180 mmHg above palpated systolic pressure. ☐ ☐
21 Slowly release the pressure bulb valve, and allow the needle of the manometer ☐ ☐
gauge to fall at rate of 2 to 3 mm Hg/second.
22 Note point on manometer when first clear sound is heard . The sound will slowly ☐ ☐
increase in intensity.
23 Continue to deflate cuff, noting point at which disappears ☐ ☐
24 Remove cuff from extremity ☐ ☐
25 Measurement systolic and diastolic within 5% ☐ ☐
27 State wipes the blood pressure cuff with disinfectant ☐ ☐
After Assessment

26 Perform hand hygiene (verbal) ☐ ☐

27 Document (verbal).  ☐ ☐