ASSESSING TEMPERATURE (AXILLA)

Materials:
Thermometer dry tissue clean gloves cotton ball with alcohol

CHECKLIST 1 2 3 4 5
1. Introduced self and verified client’s identity.
2. Explained procedure to client and discussed how results will be used.
3. Gathered appropriate equipment.
4. Performed hand hygiene and observed other appropriate infection prevention
procedures.
5. Provided for client privacy.
6. Placed the client in the appropriate position.
7. Wear gloves.
8. Expose axilla and pat dry if very moist.
9. Wipe the thermometer using cotton moistened with alcohol from the tip to
base and discard the cotton ball in the appropriate receptacle.
10. Placed the tip of the thermometer in the center of the axilla.
11. Waited the appropriate amount of time.
12. Removed the thermometer and wiped with a cotton moistened with alcohol
from the base to tip and discard the cotton ball in the appropriate receptacle.
13. If gloves were applied, removed and discarded gloves. Performed hand
hygiene.
14. Read the temperature and recorded it on a worksheet.
15. Washed the thermometer if necessary and returned it to storage location
16. Document the temperature in the client record.

TOTAL SCORE = = %
16
 ASSESSING PULSE RATE (RADIAL PULSE)

Materials:
watch with second hand

CHECKLIST 1 2 3 4 5
1. Introduced self and verified client’s identity.
2. Explained procedure to client and discussed how results will be used.
3. Performed hand hygiene and observed other appropriate infection
prevention procedures.
4. Provided for client privacy.
5. Selected pulse point.
6. Assisted client to a comfortable resting position. When the radial pulse is
assessed, with the palm facing downward, the client’s arm can rest
alongside the body or the forearm can rest at a 90-degree angle across the
chest. For
the client who can sit, the forearm can rest across the thigh, with the palm of
the hand facing downward or inward.
7. Palpated and counted the pulse. Placed two or three middle fingertips lightly
and squarely over pulse point. Count for 15 seconds and multiply by 4.
Record the pulse in beats per minute on your worksheet. If taking a client’s
pulse for the first time, when obtaining baseline data, or if the pulse is
irregular, count for a full minute. If an irregular pulse is found, also take
the apical pulse.
8. Assessed pulse rhythm and volume.
9. Document the pulse rate, rhythm, and volume and your actions in the client
record.
TOTAL SCORE = = %
9
 ASSESSING RESPIRATORY RATE

Materials:
watch with second hand

CHECKLIST 1 2 3 4 5
1. Introduced self and verified client’s identity.
2. Explained procedure to client and discussed how results will be used.
3. Gathered appropriate equipment.
4. Performed hand hygiene and observed other appropriate infection
prevention procedures.
5. Provided for client privacy.
6. Observed or palpated and counted respiratory rate. Count the respiratory
rate for 30 seconds if the respirations are regular. Count for 60 seconds if
they are irregular. An inhalation and an exhalation count as one
respiration.
7. Observed depth, rhythm, and character of respirations.
8. Document the respiratory rate, depth, rhythm, and character on the
appropriate record.
TOTAL SCORE = = %
8
 ASSESSING BLOOD PRESSURE

Materials:
Sphygmomanometer stethoscope cotton balls with alcohol (antiseptic wipe)

CHECKLIST 1 2 3 4 5
1. Introduced self and verified client’s identity.
2. Explained procedure to client and discussed how results will be used.
3. Gathered appropriate equipment.
4. Performed hand hygiene and observed other appropriate infection
prevention procedures.
5. Provided for client privacy.
6. Positioned the client appropriately.
7. Wrapped the deflated cuff evenly around the upper arm. Applied the center
of the bladder directly over the brachial artery.
8. Performed a preliminary palpatory determination of systolic pressure,
if client’s initial examination.
a. Palpated the brachial artery with the fingertips.
b. Pumped up the cuff until brachial pulse was no longer felt.
c. Released the pressure completely in the cuff, and waited 1 to 2
minutes before making further measurements.
9. Positioned stethoscope appropriately.
a. Cleanse the earpieces with antiseptic wipe.
b. Inserted the ear attachments of the stethoscope in ears so that
they tilted slightly forward.
c. Ensured that the stethoscope hung freely from the ears to
the diaphragm.
d. Placed the bell side of the amplifier of the stethoscope over the
brachial pulse site.
e. Placed the stethoscope directly on the skin, not on clothing over the
site.
10. Auscultated client’s blood pressure.
a. Pumped up the cuff until the sphygmomanometer read 30 mm
Hg above the point where the brachial pulse disappeared.
b. Released the valve cuff carefully so that the pressure decreased at
rate of 2 to 3 mm Hg per second.
c. Identified the manometer reading at Korotkoff phases 1, 4, and 5
as pressure fell.
d. Deflated the cuff rapidly and completely.
e. Waited 1 to 2 minutes before making further determinations.
f. Repeated above steps to confirm the accuracy of the reading.
11. Removed the cuff from the client’s arm.
12. Wiped the cuff with an approved disinfectant.
13. Document and report pertinent assessment data according to agency policy.

TOTAL SCORE = = %
13