Procedure Checklist: VITAL SIGNS

ASSESSING BODY TEMPERATURE

Able to Able to Unable to

Perform Perform Perform
Preparation with
Assistance
1. Assess:
a. Clinical signs of fever and hypothermia
b. Appropriate site
c. Factors that may affect body temperature
2. Assemble equipment and supplies:
a. Thermometer
b. Thermometer sheet cover
c. Cotton balls with alcohol
d. Tissue/wipes
e. Disposable gloves
f. Water soluble lubricant
g. Towel
Procedure
1. Explain the procedure to the client.
2. Wash hands.
3. Provide client privacy.
4. Place client in appropriate position.
5. Wear disposable gloves.
6. Grasp the thermometer firmly with your
thumb and forefingers.
7. Clean using cotton ball with alcohol. Wipe
from tip to stem in circular motion then dry.
8. Insert thermometer into plastic sleeve
cover.
ORAL METHOD
1. Place the thermometer under the clients
tongue, directed towards the side.
2. Ask the client to hold thermometer with
lips closed.
3. Leave thermometer in place for 2-3 mins
(mercury) or until tone is heard (digital).
AXILLARY METHOD
1. Pat the axilla with towel.
2. Place the thermometer into the axilla with
the bulb directed towards client’s head.
3. Place client’s forearm across the chest.
4. Leave thermometer in place for 6-9 mins.
(mercury) or wait until tone is heard (digital).

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RECTAL METHOD
1. Lubricate the bulb area about 1 inch
above for an adult; 0.5 inch for an infant.
2. With non-dominant hand, retract client’s
buttocks to expose anus.
3. Ask the client to take a deep breath upon
insertion of thermometer.
4. Hold the thermometer in place for 2
min.(mercury) or until the tone is heard
(digital).
5. Wipe the client’s anal area with tissue.
9. Remove the thermometer. Discard plastic
sheet cover.
10. Cleanse from stem to bulb.
11. Read the thermometer at eye level.
12. Document the temperature in the client’s
record.

____________________________
Clinical Instructor

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 ASSESSING PULSE

Preparation Performed
Yes No Comments
1. Assess:
a. Clinical signs of cardiovascular alteration
b. Appropriate site
c. Factors that may alter pulse rate

2. Assemble equipment and supplies:

a. Watch with second hand indicator
b. Stethoscope
c. Antiseptic swipes
Procedure
1. Explain the procedure to the client.
2. Wash hands.
3. Provide client privacy.
4. Select the pulse point.
5. Assist the client in comfortable position.
PERIPHERAL PULSE
1. Palpate and count the pulse. Place two to three
middle fingertips over the pulse point.
2. Count pulse for one full minute.
3. Assess the pulse rhythm and volume.
APICAL PULSE
1. Expose the area of the chest over the apex of
the heart.
2. Locate the apical pulse. Move your index finger
laterally along the fifth intercostals space
towards the MCL.
3. Use antiseptic wipes to clean the earpiece and
diaphragm of the stethoscope.
4. Warm the diaphragm of the stethoscope by
holding it in the palm of the hand.
5. Insert the earpiece of the stethoscope into your
ears in the direction of the ear canals, or slightly
forward to facilitate hearing.
6. Tap your finger lightly on the diaphragm to be
sure it is the active side of the head.
7. Place the diaphragm of the stethoscope over the
apical impulse and listen to the normal heart
sounds.
8. If the rhythm is regular, count heart beats for
30 sec. and multiply by two. If the rhythm is
irregular, count the beats for 60 seconds.
9. Assess the rhythm and the strength of the
heartbeat.
10. Document the pulse rate, rhythm, and volume
in the clients record.

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 ASSESSING RESPIRATION

Preparation Performed
Yes No Comments
1. Assess:
a. Assess mucous membrane
b. Position assumed for breathing
c. Chest movement
d. Activity tolerance
e. Dyspnea
f. Medications affecting respiratory rate.
2. Assemble equipment and supplies:
a. Watch with second hand indicator
Procedure
1. Explain the procedure to the client.
2. Wash hands.
3. Provide client privacy.
4. Place the clients arm across the chest and
observe the chest movements while supposedly
taking the radial pulse.
5. Count the respiratory rate for 30 sec. and
multiply by two if the respirations are regular. If
irregular, count for 60 seconds.
6. Observe the depth of respiration by watching the
movement of the chest.
7. Observe respiratory rhythm if regular or irregular.
8. Observe the character of respiration- the sound
they produce and the effort they require.
9. Document the respiratory rate, depth, rhythm,
and character on the appropriate record.

____________________________
Clinical Instructor

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 ASSESSING BLOOD PRESSURE

Preparation Performed
Yes No Comments
1. Assess:
a. Signs and symptoms of hypertension
b. Signs and symptoms of hypotension
c. Factors affecting blood pressure
2. Assemble equipment and supplies:
a. Blood pressure cuff of appropriate size
b. Stethoscope
c. Sphygmomanometer
Procedure
1. Explain the procedure to the client.
2. Wash hands.
3. Provide client privacy.
4. Position the client appropriately.
5. Expose the upper arm.
6. Wrap the deflated cuff evenly around the upper arm
approximately 2.5 cm above the antecubital space.
7. Locate the brachial artery.
8. Cleanse the ear pieces with alcohol.
9. Insert the ear attachment of the stethoscope in your
ears so that they are tilted slightly forward.
10. Ensure that the stethoscope hangs freely from the
ears to the diaphragm.
11. Place the bell side over the brachial pulse. Hold the
diaphragm with thumb and index finger.
12. Pump up the cuff until the sphygmomanometer
reads 30 mm Hg above the point where the brachial
pulse disappeared.
13. Release the valve on the cuff carefully so that the
pressure decreases at the rate of 2-3 mm Hg per sec.
14. As the pressure falls, deflate the cuff rapidly and
completely.
15. Wait one to two minutes before making further
determinations.
16. If this is the client’s initial examination, repeat the
procedure on the client’s other arm.
17. Remove the cuff.
18. Wipe the cuff with an approved disinfectant.
19. Document and report pertinent assessment data.

____________________________
Clinical Instructor

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