Archdiocese of Tuguegarao

Lyceum of Aparri
COLLEGE OF HEALTH

Name: ___________________________________________________ Score: ____________________

Course and Year Level: ____________________ Date of Assessment: ____________________

PERFORMANCE CHECKLIST
Assessing Blood Pressure

Procedure S U NP Remarks
ASSESSMENT
1. Identify factors that would likely interfere with the
accuracy of the client’s blood pressure
2. Observe for signs and symptoms indicating
hypertension or hypotension
3. Assess the client for latex allergy and obtain a latex –
free cuff if indicated
4. Determine baseline blood pressure from the client’s
record
IMPLEMENTATION
5. Prepare all necessary supplies and equipment. Ensure
that the equipment is intact and functioning properly
6. Introduce self and verify the client’s identity using
agency protocol
7. Explain to the client what you are going to do, why it
is necessary, and how he or she can participate
8. Perform hand hygiene and observe other appropriate
infection control procedures
9. Provide for client privacy
10. Position the client appropriately
a. The adult client should be sitting unless otherwise
specified. Both feet should be flat on the floor
b. The elbow should be slightly flexed with the palm of
the hand facing up and the arm supported at heart
level
c. Expose the upper arm
11. Unroll the cuff, loosen the screw and squeeze the cuff
with your hands to remove air completely
12. Wrap the deflated cuff evenly around the upper arm.
Locate the brachial artery
13. Preliminary Palpatory Systolic Pressure Determination
(Initial Examination)
a. Palpate the brachial artery with the fingertips
b. Close the valve on the bulb
c. Pump up the cuff until you no longer feel the brachial
pulse. Note the pressure on the sphygmomanometer
at which pulse is no longer felt
d. Release the pressure completely in the cuff, and wait
1 to 2 minutes before making further measurements
14. Position the stethoscope appropriately
a. Cleanse the earpieces with an antiseptic wipe
b. Insert the ear attachments of the stethoscope in your
ears so that they tilt slightly forward
c. Ensure that the stethoscope hangs freely from the ears
to the diaphragm
d. Place the bell side of the amplifier of the stethoscope
over the brachial pulse site
e. Place the stethoscope directly on the skin, not on
clothing over the site
f. Hold the diaphragm with the thumb and index finger
 Archdiocese of Tuguegarao
Lyceum of Aparri
COLLEGE OF HEALTH

Procedure S U NP Remarks
IMPLEMENTATION (continued)
15. Pump up the cuff until the sphygmomanometer reads
30 mmHg above the preliminary palpatory systolic
pressure
16. Release the valve on the cuff carefully so that the
pressure decreases at the rate of 2 to 3 mmHg per
second
17. As the pressure falls, take note of the calibration that
the pointer passes as you hear a clear tapping or
thumping sound (Korotkoff phase 1 – systolic
pressure)
18. Continue releasing the air from the cuff. When you
hear the sounds change to something softer and
faster and disappear, take note of the calibration
(Korotkoff phase 4 and 5 – diastolic pressure)
19. Deflate the cuff rapidly and completely. Remove the
cuff from the client’s arm
20. Wait 1 to 2 minutes before making further
determinations. Repeat the above steps to confirm
the accuracy of the reading
21. Wipe the cuff with an approved disinfectant
22. Perform hand hygiene and institute completion
protocol
EVALUATION
23. Document assessment data according to agency
policy
24. Relate blood pressure to other vital signs, to baseline
data, and to health status
25. Report any significant change in the client’s blood
pressure

Evaluated by: ________________________

Course Instructor
 Archdiocese of Tuguegarao
Lyceum of Aparri
COLLEGE OF HEALTH

Name: ___________________________________________________ Score: ____________________

Course and Year Level: ____________________ Date of Assessment: ____________________

PERFORMANCE CHECKLIST
Assessing Body Temperature

Procedure S U NP Remarks
ASSESSMENT
1. Identify factors that would likely to may alter core
body temperature
2. Determine site and method most appropriate for
measurement
3. Observer for clinical signs of fever or hypothermia
4. Determine baseline temperature readings from the
client’s record
IMPLEMENTATION
5. Prepare all necessary supplies and equipment. Check
that all equipment is functioning normally
6. Introduce self and verify the client’s identity using
agency protocol
7. Explain to the client what you are going to do, why it
is necessary, and how he or she can participate
8. Perform hand hygiene and observe other appropriate
infection control procedures
9. Provide for client privacy
10. Place the client in the appropriate position
11. Clean the probe (pointed end) of the thermometer or
apply a protective sheath or probe cover if
appropriate
12. Place the thermometer to intended site
13. Leave the thermometer in place and wait for the
appropriate amount of time. Electronic and tympanic
thermometers will indicate that the reading is
complete through a light or tone.
14. Remove the thermometer and discard the cover or
wipe the probe with a tissue or cotton balls soaked in
alcohol if necessary
15. Read the temperature
16. Wash the thermometer if necessary and return it to
the storage location
17. Perform hand hygiene and implement completion
protocol
EVALUATION
18. Document the temperature in the client record
19. Compare the temperature measurement to baseline
data, normal range for age of client, and client’s
previous temperatures
20. Conduct appropriate follow – up such as notifying the
primary care provider if a temperature is outside of a
specific range or is not responding to interventions
medication, or altering the client’s environment

Evaluated by: ________________________

Course Instructor
 Archdiocese of Tuguegarao
Lyceum of Aparri
COLLEGE OF HEALTH

Name: ___________________________________________________ Score: ____________________

Course and Year Level: ____________________ Date of Assessment: ____________________

PERFORMANCE CHECKLIST
Assessing for Pulses

Procedure S U NP Remarks
ASSESSMENT
1. Identify factors that may alter pulse rate
2. Determine which site is most appropriate for
assessment based on the purpose
3. Assess for clinical signs and symptoms of
cardiovascular alterations
4. Determine baseline pulse rate and characteristics
from the patient’s record
IMPLEMENTATION
5. Prepare all necessary equipment and check their
functionality
6. Introduce self and verify the client’s identity using
agency protocol
7. Explain to the client what you are going to do, why it
is necessary, and how he or she can participate
8. Perform hand hygiene and observe other appropriate
infection control procedures
9. Provide for client privacy
Auscultating the Apical Pulse
10. Position the client appropriately in a comfortable
supine position or in a sitting position. Expose the
area of the chest over the apex of the heart
11. Locate the apical impulse
a. Palpate the angle of Louis
b. Slide your index finger just to the left of the sternum,
and palpate the 2nd intercostal space
c. Place your middle or next finger in the 3rd intercostal
space, and continue palpating downward until you
locate the 5th intercostal space
d. Move your index finger laterally along the 5 th
intercostal space toward the MCL
e. Normally, the apical impulse is palpable at or just
medial to the MCL
12. Auscultate and count heartbeats
a. Use antiseptic wipes to clean the earpieces and
diaphragm of the stethoscope
b. Warm the diaphragm of the stethoscope by holding it
in the palm of the hand for a moment
c. Insert the earpieces of the stethoscope into your ears
in the direction of the ear canals, or slightly forward
d. Tap your finger lightly on the diaphragm
e. Place the diaphragm of the stethoscope over the
apical impulse and listen for the normal S1 and S2
heart sounds, which are heard as “lub – dub.”
13. If you have difficulty hearing the apical pulse, ask the
supine client to roll onto his or her left side or the
sitting client to lean slightly forward
14. If the rhythm is regular, count the heartbeats for 30
seconds and multiply by 2
 If the rhythm is irregular count the beats for 60
seconds
15. Assess the rhythm and the strength of the heartbeat
 Archdiocese of Tuguegarao
Lyceum of Aparri
COLLEGE OF HEALTH

Procedure S U NP Remarks
IMPLEMENTATION (continued)
Palpating for the Radial Pulse
16. Assist the client to a comfortable resting position.
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
17. Place two or three middle fingertips lightly and
squarely over the pulse point. Rest the thumb of the
back of the client’s wrist
18. Count for 15 seconds and multiply by 4
 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
19. Assess the pulse rhythm and volume
EVALUATION
20. Document the pulse rate, rhythm, and volume and
your actions in the client record
21. Compare the pulse rate to baseline data or normal
range for age of client
22. Relate pulse rate and volume to other vital signs
23. If assessing peripheral pulses, evaluate equality, rate,
and volume in corresponding extremities
24. Report to the primary care provider any abnormal
findings
25. Conduct appropriate follow – up such as
administering medication ordered

Evaluated by: ________________________

Course Instructor
 Archdiocese of Tuguegarao
Lyceum of Aparri
COLLEGE OF HEALTH

Name: ___________________________________________________ Score: ____________________

Course and Year Level: ____________________ Date of Assessment: ____________________

PERFORMANCE CHECKLIST
Assessing Respirations

Procedure S U NP Remarks
ASSESSMENT
1. Identify factors that would likely to interfere with
the accuracy of assessing the patient’s
respirations
2. Assess for indications of respiratory compromise
3. Determine baseline respiratory rate and
characteristics from the patient’s record
IMPLEMENTATION
4. Prepare all necessary supplies and equipment
5. Introduce self and verify the client’s identity
using agency protocol
6. Explain to the client what you are going to do,
why it is necessary, and how he or she can
participate
7. Perform hand hygiene and observe other
appropriate infection control procedures
8. Provide for client privacy
9. Observe or palpate and count the respiratory
rate. If you anticipate that the client may be
aware that you are counting his or her
respirations, place the client’s arm across the
chest and observe the chest movements while
supposedly taking the radial pulse
10. Count the respiratory rate for 30 seconds if the
respirations are regular
 Count for 60 seconds if they are irregular
11. Observe the depth, rhythm, and character of
respirations
EVALUATION
12. Document the respiratory rate, depth, rhythm,
and character on the appropriate record
13. Relate respiratory rate to other vital signs, in
particular pulse rate
14. Report to the primary care provider a respiratory
rate significantly above or below the normal
range and any notable change in respirations
from previous assessments
15. Conduct appropriate follow – up such as
administering oxygen or other appropriate
medications or treatments and interventions

Evaluated by: ________________________

Course Instructor
 Archdiocese of Tuguegarao
Lyceum of Aparri
COLLEGE OF HEALTH

Name: ___________________________________________________ Score: ____________________

Course and Year Level: ____________________ Date of Assessment: ____________________

PERFORMANCE CHECKLIST
Measuring Oxygen Saturation

Procedure S U NP Remarks
ASSESSMENT
1. Determine the best location for a pulse oximeter
sensor based on the client’s age and physical
condition
2. Assess vital signs, skin color and temperature,
nail bed color, and tissue perfusion of extremities
as baseline data
3. Determine the client’s overall condition including
risk factors for the development of hypoxemia
and hemoglobin level
4. Identify if client has allergies to adhesives
IMPLEMENTATION
5. Prepare all necessary supplies and equipment.
Check that the oximeter equipment is
functioning normally
6. Introduce self and verify the client’s identity
using agency protocol
7. Explain to the client what you are going to do,
why it is necessary, and how he or she can
participate
8. Perform hand hygiene and observe other
appropriate infection control procedures
9. Provide for client privacy
10. Choose a sensor appropriate for the client’s
weight, size, and desired location
11. Clean the site with an alcohol wipe before
applying the sensor. It may be necessary to
remove a client’s dark nail polish
12. Apply the sensor, and connect it to the pulse
oximeter
13. Set and turn on the alarm when using continuous
monitoring
14. Ensure client safety
15. Ensure the accuracy of measurement
EVALUATION
16. Document the oxygen saturation on the
appropriate record at designated intervals
17. Compare the oxygen saturation to the client’s
previous oxygen saturation level
18. Conduct appropriate follow-up such as notifying
the primary care provider, adjusting oxygen
therapy, or providing breathing treatments

Evaluated by: ________________________

Course Instructor