Name: _____________________________________________________ Date: _____________ Section/Group:________

Measuring Body Temperature

CHECKLIST
Legend:
3-Very Satisfactory 0- Did not perform the procedure
2- Satisfactory 1- Needs Improvement
PROCEDURES 3 2 1 0
1. Review medical record for baseline factors that influence vital signs.
2. Explain to the client that vital signs will be assessed. Encourage client to remain still and refrain
from drinking, eating, and smoking to avoid mouth breathing, if possible.
3. Assess client’s toileting needs and proceed as appropriate.
4. Gather equipment.
5. Provide for privacy.
6. wash hands/hand hygiene and apply gloves, when appropriate.
Oral temperature:
7. Repeat Actions 1-6.Place disposable protective sheath over probe.
8. Grasp top of probe’s stem.
9. Place tip of thermometer under the client’s tongue and along gumline to posterior sublingual pocket
lateral to lower jaw.
10. Instruct client to keep mouth closed around thermometer.
11. Thermometer will signal (beep) when a constant temperature registers.
12. Read measurement on digital display of electronic thermometer. Push ejection button to discard
disposable sheath into receptacle and return probe to storage well.
13. Inform client of temperature reading.
14. remove gloves and perform hand hygiene.
Tympanic Temperature: Infrared Thermometer. Repeat actions 1-6
Position client in Sim’s or Sitting Position.
Remove the probe from container and attach probe cover to tympanic thermometer unit.
Turn the client’s head to one side. Gently insert probe with firm pressure into ear canal.
Remove probe after the reading is displayed on digital u nit (usually 2 seconds).
Remove probe cover and replace in storage container.
Return tympanic thermometer to storage unit.
Record reading according to institution policy.
Hand hygiene.
Rectal temperature. Repeat actions 1-6
Place client in Sim’s position with upper knee flexed. Adjust sheet to expose only anal area.
Place tissues in easy reach. Apply gloves.
Lubricate rectal probe tip.
With dominant hand, grasp top of the probe’s stem. With other hand, separate buttocks to expose anus.
Instruct client to take deep breath. Insert probe gently into anus.
Repeat actions 11-14.
Axillay temperature. Repeat actions 1-6
Remove client’s arm and shoulder from one sleeve of gown. Avoid exposing chest.
Make sure axillay skin is dry, if necessary, pat dry.
Place probe into center of axilla. Fold client’s upper arm straight down, and place arm across client’s
chest.
Repeat actions 11-14

For the next items, evaluate the students in general according to the criteria. (5 as the highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.
Student’s signature: __________________
Evaluator’s Signature: __________________

Comments:________________________________________________________________________________________
__________________________________________________________________________________________________
Name: ____________________________________________________ Date: _____________ Section/Group:________
Assessing Pulse Rate
CHECKLIST
Legend:
3-Very Satisfactory 0- Did not perform the procedure
2- Satisfactory 1- Needs Improvement
PROCEDURES 3 2 1 0
1. Wash hands/hand hygiene.
2. inform client of site(s) where pulse will be measures.
3. Flex client’s elbow and place lower part of arm across chest.
4. Support client’s wrist by grasping outer aspect of thumb.
5. Place index and middle fingers on inner aspect of client’s wrist over the rasial artery, and apply
light but firm pressure until pulse is palpated.
6. Identify pulse rhythm.
7. Determine pulse volume.
8. Count pulse rate by using second hand of watch.
Taking apical pulse.
9. Wash hands/hand hygiene.
10. Raise client’s gown to expose sternum and left side of chest.
11. Cleanse earpiece and stethoscope diaphragm with an alcohol swab.
12. Put stethoscope around the neck.
13. Locate the apex of the heart.
• With the client lying on left side, locate suprasternal notch.
• Palpate second intercostal space to left sternum.
• Place index finger in intercostal space, counting downward until fifth intercostal space is
located.
• Move index finger along fourth intercostals left of sternal border and to fifth intercostals
space, left of midclavicular line to palpate the point of maximal impulse (PMI)
• Keep index finger of nondominant hand on PMI.
14. Inform client that client’s heart will be listened to. Instruct client to remain silent.
15. With dominant hand, put earpiece of the stethoscope in ears and grasp diaphragm of stethoscope
in palm of the hand for 5-10 seconds.
16. Place diaphragm of stethoscope over PMI and auscultate for sounds S1 and S2 to hear lubdub
sound.
17. Note the regularity of the rhythm.
18. Start to count while looking at second hand of watch. Count lub-dub sound as one beat.
19. share findings with patient.
20. Record by site, rate,rhythm, and, if applicable, number of irregular beats.
21. Wash hands/hand hygiene.

For the next items, evaluate the students in general according to the criteria. (5 as the highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.

Student’s signature: __________________

Evaluator’s Signature: __________________

Comments:________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Name: ____________________________________________________ Date: _____________ Section/Group:________

Assessing Blood Pressure

CHECKLIST
Legend:
3-Very Satisfactory 0- Did not perform the procedure
2- Satisfactory 1- Needs Improvement
PROCEDURES 3 2 1 0
1. Wash hands/ hand hygiene.
2. Determine which extremity is most appropriate for reading.
3. Select a cuff size appropriate for the client.
4. Rest client’s bare arm on a support so the midpoint of the upper arm is at the level of the heart.
Extend elbow with palm turn upward.
5. Make sure bladder cuff is fully deflated and pump valve moves freely. Place manometer at eye
level and easily visible.
6. palpate brachial artery in antecubital space, and place cuff so that midline of bladder is over arterial
pulsation. Wrap and secure off snugly around the client’s bare upper arm. Lower edge of cuff should
be 1 inch above antecubital fossa where head of stethoscope is to be placed.
7. Inflate cuff rapidly to 70 mmHg and increase by 10 mm increments while palpating radial pulse.
Note level of pressure at which pulse disappears and subsequently reappears during deflation.
8. Insert stethoscope earpieces into ear canals.
9. Relocate brachial artery with nondominat hand, and place stethoscope bell over brachial artery
pulsation.
10. With dominant hand, turn valve clockwise to close. Compress pump to inflate cuff rapidly and
steadily until manometer registers 20-30 mmHg above the level previously determined by palpation.
11. Partially unscrew (open) valve counter clockwise to deflate bladder at 2mm/sec while listening
for the 5 phases of the Korotkoff sounds. Note manometer reading for these sounds.
12. After the last Korotkoff’s sound is heard, deflate cuff slowly fot at least another 10 mmHg then
deflate rapidly and completely.
13. Allow client to rest for at least 30 seconds and remove cuff.
14. Inform client of reading.
15. Record the BP reading.
16. if appropriate, lower bed, rasie side rails, and place call light in easy reach.
17. Put all equipment in proper place.
18. wash hands/hand hygiene.

For the next items, evaluate the students in general according to the criteria. (5 as the highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.

Student’s signature: __________________

Evaluator’s Signature: __________________

Comments:________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Name: _____________________________________________________ Date: _____________ Section/Group:________
Assessing Respiratory Rate
CHECKLIST
Legend:
3-Very Satisfactory 0- Did not perform the procedure
2- Satisfactory 1- Needs Improvement
PROCEDURES 3 2 1 0
1. Wash hands/hand hygiene.
2. be sure chest movement is visible. Remove clothing, if necessary.
3. Observe one complete respiratory cycle.
4. Start counting with first inspiration while looking at the second hand of watch.
5. Observe character of respiration.
6. Replace client’s gown, if needed.
7. Record rate and character of respiration.
8. Was hands/hand hygiene.

For the next items, evaluate the students in general according to the criteria. (5 as the highest score)
5 4 3 2 1
Mastery
Orderliness
Proper attitude in assessing the client followed.
Ability to answer questions
Proper reporting observed.

Student’s signature: __________________

Evaluator’s Signature: __________________

Comments:________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________