Vital Signs Checklist

Performed
Performed Performed Not
but needs
PROCEDURE well Poorly Performed
improvement Remarks
(3) (1) (0)
(2)
Prepare needed materials:
• BP set (Sphygmomanometer and
Stethoscope)
• Thermometer
• Watch with second hand
1. Wash hands and ensure that necessary
equipment are complete and working
properly.
Rationale: Handwashing reduces transmission
of microorganisms and gathering need
materials aids in organization and efficiency.
2. Introduce self, explain the procedure, and
provide privacy.
Rationale: Helps minimize anxiety and
privacy minimizes embarrassment and
promotes comfort.
3. Determine which extremity is most
appropriate for blood pressure reading.
Rationale: Determines if patient’s status
contraindicates selection of a specific
method or site.
TEMPERATURE

4. Wipe digital thermometer starting from

the tip to the stem using an antiseptic
swab/cotton ball.
Rationale: Reduces transmission of
microorganisms.
5. Turn on thermometer and place it into the
axilla of the arm NOT to be used for
blood pressure monitoring. Ensure the tip
of the thermometer or probe is at the
center of the axilla and directly touching
the skin.
Rationale: Maintains proper position of
thermometer against blood vessels in
axilla.
6. Leave electronic thermometer in place
and instruct client to hold arm down
tightly on his/her side.
Rationale: Thermometer probe must
stay in place until signal occurs to ensure
accurate reading.
7. Once the thermometer beeps, remove
and read measurement on digital display
of the digital thermometer and clean from
stem/display area to tip/bulb.
Rationale: Beeping of the thermometer
means that the temperature reading has
 been completed. Cleaning reduces the
transmission of microorganisms.
RADIAL PULSE

8. Support and fold the opposite

forearm(same arm to be used for blood
pressure reading) across the client’s
abdomen or chest. Slightly extend or flex
wrist with palm down until you note
strongest pulse.
Rationale: Relaxed position of the arm and
extension of wrist permits full exposure of
artery to palpation.
9. Place your index finger and middle
fingers over the radial artery and apply
light but firm pressure until pulse is
palpated.
Rationale: Fingertips are the most
sensitive parts of the hand to palpate
arterial pulsations. Nurse’s thumb has
pulsation that interferes with accuracy.
Pulse assessment is more accurate
when using moderate pressure. Too
much pressure occludes pulse and
impairs blood flow.
10. Count number of beats for 1 minute while
noting the strength and rhythm of the
pulse. For an irregular pulse note the
number of irregular beats.
Rationale: Rate is determined accurately
only after pulse has been palpated.
RESPIRATION

11. Without informing the client, count

number of respiration for 1 minute by
observing or feeling the movement of the
chest or abdomen. Note the depth and
rhythm of the respiration.
Rationale: Patient’s or nurse’s hand
rises and falls during respiratory cycle.
Rate is accurately determined only after
nurse has viewed respiratory cycle.
Respirations occur more slowly than
pulse; thus timing does not begin with
zero.
BLOOD PRESSURE

12. Position the same arm at the level of the

heart with the elbow extended and palm
facing upward. Instruct patient to keep
feet flat on the floor without legs crossed.
Rationale: If arm is extended and not
supported, patient will perform isometric
exercise that can increase diastolic pressure.
Placement of arm above the level of the heart
causes false low pressure effort up to 3 or 4
 mmHg can occur for each 5 cm change in
heart level. Leg crossing can falsely increase
systolic and diastolic BP.
13. Wrap deflated cuff snugly over the upper
arm approximately 2.5 cm(1 inch) above
the antecubital space with center of cuff
over the brachial artery.
Rationale: Loose -fitting cuff causes
false readings.
14. Perform preliminary palpatory
determination of systolic pressure.
a. Palpate brachial artery with the
fingertips
b. Inflate the cuff
c. Note the pressure until pulse is no
longer felt
d. Deflate and remove the cuff
completely
Rationale: Estimating prevents false low
reading by palpation. Completely
deflating cuff prevents venous congestion
and false high readings.
15. Disinfect the stethoscope. Then,
auscultate the client’s blood pressure by
placing the ear piece of the stethoscope
into your ears and the diaphragm directly
on the skin over the brachial artery.
Rationale: Proper stethoscope placement
ensures optimal sound reception. Stethoscope
improperly positioned causes muffled sounds
that often result in false low systolic and false
high diastolic readings. The diaphragm is
easier to secure with fingers and covers a
larger area.
16. With the dominant hand, close the valve
inflate the cuff until the
sphygmomanometer reads 30 mm Hg
above the point where the brachial pulse
disappeared.
Rationale: Tightening of valve prevents
air leak during inflation. Inflation above
systolic level ensures accurate
measurement of systolic measurement.
17. Slowly open valve so that pressure falls
at a rate if 2 – 3 mmHg per second.
Rationale: Too rapid or slow a decline in
mercury level causes inaccurate readings.
The first Korotkoff sound reflects systolic
pressure.
18. Listen for the Korotkoff’s sounds while
noting manometer reading. Deflate cuff
rapidly and completely after the last
Korotkoff sound is heard. Remove cuff
and clean diaphragm and earpiece.
 Rationale: The last Korotkoff sound
heard is the diastolic pressure. Cleaning
of diaphragm and earpiece reduces
transmission of microorganisms.
19. Inform client of vital signs reading.
Document properly and wash hands.
Rationale: Promotes participation in care
and understanding of health status. Makes
patient accountable for follow-up assessment.
Rationale Question 1: Answer Answer Answer Answer
correctly correctly but correctly but incorrectly
and with some with some
completely. incomplete incorrect (0)
information. information
(3)
(2) (1)

Rationale Question 2: Answer Answer Answer Answer

correctly correctly but correctly but incorrectly
and with some with some
completely. incomplete incorrect (0)
information. information
(3)
(2) (1)

Perfect Score: 66

Passing Score: 53