Ambulatory Services Orientation & Skill Review Skill Performance Checklist: Vital Signs. Name: Date:

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1 Evaluation Levels Behavior Level 3 Met Performed all skills competently. No behaviors omitted. Level 2 Satisfactory Omitted no more than three (3) non-critical behaviors. Level 1 Unsatisfactory Omitted more than three (3) non-critical behaviors or one (*) critical behavior. Pulse Radial Pulse Apical Blood Pressure Comments:. Evaluator s Signature Date: ****CRITICAL BEHAVIORS ARE NOTED BY BOLD TYPE**** 03/2013 dk 1

2 (Circle the number of all OMITTED behaviors) 1. Performed hand hygiene upon entering room and before touching patient. 2. Welcomed patient using AIDET. Provided privacy for patient. 3. Identified patient appropriately. 4. Asked patient questions about affects in last 30 minutes: caffeine, smoking/nicotine, hot or cold liquids, chewing gum, mints, cough drops, activity/exercise, pain 1. Removed probe from well, observed oral mode on display and applied a new probe cover to thermometer probe. 2. Probe position: placed probe under tongue deep in posterior sublingual pocket. Asked patient to hold probe in place and instructed patient to close lips around it during measurement. 3. Reading: left probe in place until heard audible signal and temperature displayed. Noted reading before removed probe. Rationales for Behaviors 1. See Hand Hygiene policy. 2. Best practice process for increased patient satisfaction. 3. Complies with The Joint Commission requirements. 4. Helps to determine if any affects are present which could affect the patient s vital signs. These should be documents and reported to the MD/NP/RN. 1. For accurate oral temperature, the oral mode must be displayed. 2. Probe must be positioned properly to allow for the machine to accurately sense and calculate reading. 3. Signal determines adequate time for measurement. reading changes when probe is removed from mouth. 4. Discarded plastic probe cover and replaced probe to well. Pulse Pulse 1. Positioned patient s arm relaxed with wrist extended 1. Best position to accurately find pulse. 2. Gently palpated artery with tips of first two or middle three fingers. If pulse weak or difficult to palpate on one wrist, checked pulse on opposite wrist and made a note. 3. Counted pulse for 30 seconds and multiplied by 2 for rate; if irregular, counted for one full minute. 4. Determined rhythm and strength of pulse 5. Accurately identified the pulse rate within 4 beats of competency monitor 1. Positioned patient for comfort in sitting or lying position 2. Observed rise and fall of chest or upper abdomen 3. Counted respirations for 30 seconds and multiplied by 2 for rate; if irregular, less than 12 or greater than 20, counted for one full minute 4. Determined depth and rhythm of respirations 5. Accurately identified the respiratory rate within 4 respirations of competency monitor. 2. The radial artery is accessible and usually one of the easiest pulses to palpate. Gentle pressure is recommended because pressing too hard may occlude the artery. 3. For accuracy, pulse must be counted for 30 seconds and if irregular, for 60 seconds to pick up all irregular beats. 5. Must be able to accurately count and calculate pulse rate. 3. For accuracy, respirations must be counted for 30 seconds and if irregular, less than 12 or greater than 20, for 60 seconds to pick up all respirations 5. Must be able to accurately count and calculate respiratory rate. 03/2013 dk 2

3 Blood Pressure 1. Positioned patient properly with arm supported and at heart level and feet/legs uncrossed 2. Used appropriate sized cuff and stated how they would determine size needed. 1. Improper position may change the results of the blood pressure reading. 2. Improper size causes inaccurate readings; Too wide of a bladder cuff may cause false low readings; Too narrow of a bladder cuff may cause a false high reading. 3. Loose fitting cuff can cause a false high reading. 3. Wrapped deflated cuff snugly and evenly over exposed upper arm all clothing removed. Removing clothing ensures proper cuff application. 4. Appropriately centered cuff bladder over brachial artery 4. The most accurate results are best determined by (palpated brachial artery) at one inch above antecubital space proper cuff placement. 5. Manometer positioned at eye level 5. Looking up or down at scale can result in distorted readings 6. Baseline unknown; determined baseline systolic reading Palpated artery distal to cuff with fingertips of non dominant hand while inflating cuff rapidly to a pressure 30mm HG above point at which pulse disappears Slowly deflated cuff, noted point when pulse reappears. This is the estimated systolic or palpated systolic reading. Deflated cuff fully and waited 30 seconds to measure reading 7. Placed stethoscope ear pieces in ears and bell or diaphragm over brachial artery 8. Closed pump valve and inflated cuff rapidly to 30mm Hg above baseline systolic 9. Opened valve on cuff and deflated cuff gradually at constant rate of 2-3 mm Hg per second mm Hg past last sound. 10. Deflated cuff rapidly & completely and did not attempt another reading for 30 seconds. Removed cuff from patient s arm when finished. 11. Accurately identified blood pressure reading within 6 mm Hg of competency monitor. 6. The 2-step blood pressure is performed to determine the palpated systolic reading to prevent unnecessary inflation of the cuff above the systolic number and not enough inflation of the cuff below the systolic number. It also prevents unnecessary pressure on the artery which is more comfortable for the patient and results in a more accurate reading. Completely deflating cuff prevents venous congestion and false high readings. Making repeated BP attempts restricts circulation and may result in an inaccurate BP reading as well as numbness and tingling of the patient s extremity. 7. Placement of the bell or diaphragm over the brachial artery ensures hearing the beats more clearly. Improperly positioned stethoscope causes muffled sounds that often result in false low systolic and false high diastolic readings. 8. Ensures accurate detection of true systolic pressure once pressure valve is released. 9. If cuff is deflated too fast or too slow and not allowed to go low enough, a false reading may be the result. 10. Completely deflating cuff prevents venous congestion and false high readings. Making repeated BP attempts restricts circulation and may result in an inaccurate BP reading as well as numbness and tingling of the patient s extremity. 11. Must be able to accurately measure and determine blood pressure reading. 03/2013 dk 3

4 Apical Pulse Apical Pulse 1. Positioned patient supine or sitting with chest area exposed. Maintained privacy. Asked patient to be quiet and relax. 2. Locate landmarks for apex of heart: 5 th ICS and midclavicular 2. Use of landmarks allows for correct placement of line. stethoscope over apex of heart. 3. Placed stethoscope over apex of heart. 3. Apex of heart at point of maximal impulse is the best place to hear the apical pulse. 4. Counted pulse for 30 seconds and multiplied by 2 for rate; if 4. For accuracy, pulse must be counted for 30 seconds irregular OR if patient taking cardiac medications, counted pulse and if irregular, for 60 seconds to pick up all irregular for one full minute. beats. 5. Determined rhythm of pulse 6. Accurately identified the pulse rate within 4 beats of competency monitor 6. Must be able to accurately count and calculate pulse rate. 1. Calibrated scale if platform 2. Had patient stand still 3. Measured weight 1.Asked patient to remove shoes and stand on floor (paper towel under feet if bare to remain clean) 2. Asked patient to stand erect, both feet flat on floor, eyes looking straight ahead, chin parallel to floor 3. Placed measuring stick flat on crown of head, horizontally at a 90 degree angle to scale or wall 4. Measured height 1. Recorded readings and documented all findings 2. Performed hand hygiene Per Policy Per Policy 1. Accurate and complete documentation if one of the six patient rights. Critical behaviors are noted by bold type. 03/2013 dk 4

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