KGMU COLLEGE OF NURSING, LUCKNOW

PROCEDURE CHECKLIST
SUBJECT TOPIC
ADVANCE NURSING PRACTICE VITAL SIGNS

TEMPERATURE
S.NO STEPS 1 2 3 4 5
1. Ascertain method of taking temperature and explain the procedure to
the patient and instruct him how to cooperate.

A. In case of oral method ensures that patient had not taken any
hot or cold food and fluids orally or smoked in 15-30 minutes
prior to procedure.

B. For rectal method, provide privacy and position the patient in a

Sims position. In young children position laterally with knees
flexed or prone across lap.

C. For axillary method, expose axilla and pat dry with a towel.
Avoid vigorous rubbing.

2. wash hands

3. prepare equipment

a. If glass thermometer is in disinfectant solution, transfer it to

container with plain water using dominant hand.

b. Wipe thermometer dry, using a clean cotton swab using rotator

motion from bulb to stem.

c. Shake down the mercury (if needed) by holding thermometer

between thumb and forefinger at the tip of stem. Shake till
mercury is below 35 degree centigrade.

4. Check temperature.

a. for oral method

i. place bulb of thermometer at base of tongue on the side of fraenulum
in the posterior sublingual pocket.
ii. Instruct patient to close the lips and not teeth around thermometer.
 iii. Leave thermometer in place for 2-3 minutes.

b. for rectal method

i.don clean gloves
ii. Apply lubricant on the bulb of thermometer using cotton ball.
iii. With non-dominant hand, expose the anus raising upper buttocks.
iv. Instruct patient to breathe deeply and insert thermometer into anus.
3.5-4cm in adults
1.5 cm in infant
2.5 cm in child
Do not force insertion.
v. hold thermometer in place for 1-2 minutes.

c. for axillary method

i. place bulb in the centre of axilla
ii. Place arm tightly across chest to hold thermometer in place.
iii. Hold thermometer in place for 3-5 minutes.

Remove the temperature, holding thermometer at eye level and rotate

it till reading is visible and read it accurately.

7. Shake down the mercury level.

8. Clean thermometer using soap and water.

9. Dry it and store it in disinfectant solution.

10. Document temperature

11. Wash hands.

PULSE
1. Explain procedure to patient and check if the patient had just been
involved in any activity. If so allow the patient to rest for 10 mins
before taking pulse.

2. a. Select the pulse site.

b. Assist the patient to a comfortable position. For radial pulse, keep
the arm, resting over chest or on the side with palm facing downward.

3. Palpate and check pulse.

a. place tips of 3 fingers other than thumb lightly over pulse site.
b. after getting the pulse regularly, count the pulse for one whole
minute looking at the second hand on the wrist watch.
c. assess for rate, rhythm and volume of pulse and condition of blood
vessel.

4. Document and report pertinent data in the appropriate record.

5. Wash hands.
 RESPIRATION
1. Ensure that patient is relaxed assess other vital signs such as pulse or
temperature prior to counting respirations.

2. Assess for factors that may alter respiration.

3. Wait for 5-10 mins before assessing respirations if patient had been
active.

4. Position patient in sitting or supine position with head elevated at 45-

60 degree.

5. Keep your fingers over the wrist as if checking pulse and position
patients hand over his lower chest or abdomen.

6. Observe one complete respiratory cycle-inspiration.

7. Assess rate, depth, rhythm and character of respiration.

8. Count respiration for one whole minute.

9. Wash hands.

10. Record the findings and report any abnormal findings.

BLOOD PRESSURE
1. Check physicians order nursing care plan and progress notes.

2. Explain the procedure and reassure the patient. Ensure that patient has
not smoked ingested caffeine or involved in strenuous physical and
mental activity within 30 minutes prior to procedure.

3. wash and dry hands

4. Assist the patient to either sitting or king down position and ensure that
legs are not crossed.

5. Collect and check equipment.

6. Position the sphygmomanometer at approximately heart level of the

patient ensuring that mercury level is at zero.

7. Select a cuff of appropriate size.

8. Expose the arm to make sure that there is no constrictive clothing

above the placement of cuff.

9. Apply the cuff approximately 2.5 cm above the point where brachial
artery can be palpated. The cuff should be applied smoothly and firmly
 with the middle of the rubber bladder directly over the artery.

10. Secure the cuff by tucking the end under or by fixing the Velcro
fastener.

11. Place the entire arm at the patient’s heart level.

12. Keep the arm well rested and supported.

13. Place yourself in a comfortable position.

14. Connect the cuff tubing to the manometer tubing and close the valve of
the inflation bulb.

15. Palpate the radial pulse and inflate the cuff until pulse is obliterated.

16. Inflate the compression bag a further 20-30 mm of mercury and then
deflate cuff slowly. Note the point at which pulse reappears. Release
the valve.

17. Palpate brachial artery and place diaphragm of the stethoscope lightly
over the brachial artery. Ensure that ear pieces of the stethoscope are
placed correctly. Raise mercury level 20-30 mm of mercury above the
point of systolic pressure obtained by means of palpatory method.

18. Release the valve of the inflation bulb, so that mercury column falls at
the rate 2-4 mm of mercury/sec.

19. When first sound is heard, the mercury level is noted, this denotes
systolic pressure.

20. Continue to deflate the cuff, note the point on manometer at which
sound nuffles. This is diastolic pressure.

21. Deflate cuff completely. Disconnect the tubing and remove the cuff
from the patients arm.

22. Repeat the procedure after one minute if there is any doubt about the
reading.

23. Ensure that patient is comfortable.

24. Remove equipment and clean ear piece with a spirit swab.

25. Wash and dry hands.

26. Document the reading in appropriate observation chart or flowchart.