UNIVERSITY OF CALOOCAN CITY

(formerly Caloocan City Polytechnic College)

Gen. San Miguel St., Sangandaan, Caloocan City
Tel. Nos. 324-6855 (Main)
324-6843 (Tandang Sora Annex)
962-9799 (Camarin Annex)

PERFORMANCE CHECKLIST
NAME:
DATE:
SCORE:
COURSE AND SECTION:
INSTRUCTOR:
I.
ASSESSING VITAL SIGNS : TEMPERATURE
Purpose:
ASSESSMENT
Assess
To establish baseline data for subsequent
Clinical signs of fever
evaluation
Clinical signs of hypothermia
To identify whether the core temperature is
Site and method most appropriate for
within normal range
measurement
To determine changes in the core
Factors that may alter core body
temperature in response to specific
temperature
therapies (e.g., antipyretic medication,
Equipment
immunosuppressive therapy, invasive
Thermometer
procedure)
Thermometer sheath or cover
To monitor clients at risk for imbalanced
Water-soluble lubricant for a rectal
body temperature (e.g., clients at risk for
temperature
infection or diagnosis of infection; those
Clean gloves for a rectal temperature
who have been exposed to temperature
Towel for axillary temperature
extremes)
Tissues/wipes
cotton balls (w and w/o alcohol )

Performance Points

Don

Score

e
1. Check if all equipment is functioning normally.

2. Introduce self

3. Verify the clients identity using agency protocol.

4. Explain to the client what you are going to do,

why it is necessary, and how he or she can
participate.

5. Discuss how the results will be used in

planning further care or treatments.

6. Perform hand hygiene and observe appropriate

infection control procedures.
(Apply gloves if performing a rectal temperature)

7. Provide for client privacy.

8. Place the client in the appropriate position

9. Wipe thermometer with cotton ball w/ alcohol

from bulb to stem
10. Wipe thermometer with dry cotton ball in the
same manner

5
5

11. Place the thermometer

20

12. Wait the appropriate amount of time

15

13. Remove the thermometer

10

14. Read the temperature and record it on your

worksheet

10

10

15. Wipe again the thermometer with wet and dry

cotton ball

Total

100

Remarks:

UNIVERSITY OF CALOOCAN CITY

(formerly Caloocan City Polytechnic College)
Gen. San Miguel St., Sangandaan, Caloocan City
Tel. Nos. 324-6855 (Main)
324-6843 (Tandang Sora Annex)
962-9799 (Camarin Annex)

PERFORMANCE CHECKLIST
NAME:
DATE:
SCORE:
COURSE AND SECTION:
INSTRUCTOR:
II.
ASSESSING VITAL SIGNS : ASSESSING A PERIPHERAL PULSE
Purpose:
ASSESSMENT
Assess
To establish baseline data for subsequent
Clinical signs of cardiovascular alterations such as
evaluation
dyspnea (difficult respirations), fatigue, pallor, cyanosis
To identify whether the pulse rate is within
(bluish discoloration of skin and mucous membranes),
normal range
palpitations, syncope (fainting), or impaired peripheral
To determine the pulse volume and
tissue perfusion (as evidenced by skin discoloration and
cool temperature)
whether the pulse rhythm is regular

Factors that may alter pulse rate (e.g., emotional status

To determine the equality of corresponding
and activity level)
peripheral pulses on each side of the body
Which site is most appropriate for assessment based on
To monitor and assess changes in the
the purpose
clients health status
Equipment
To monitor clients at risk for pulse
Watch with a second hand or indicator
alterations (e.g., those with a history of
heart disease or experiencing cardiac
arrhythmias, hemorrhage, acute pain,
infusion of large volumes of fluids, or fever)
To evaluate blood perfusion to the
extremities

Performance Points

Don

Score

e
1. Check if all equipment is functioning normally.

2. Introduce self

3. Verify the clients identity using agency protocol.

4. Explain to the client what you are going to do, why

it is necessary, and how he or she can participate.

5. Discuss how the results will be used in planning

further care or treatments.

6. Perform hand hygiene and observe appropriate

infection control procedures.

7. Provide for client privacy

8. Select the pulse point. Normally, the radial pulse is

taken, unless it cannot be exposed or circulation to
another body area is to be assessed.

9. Assist the client to a comfortable resting position.

10. When the radial pulse is assessed, with the palm

facing downward, the clients arm can rest alongside
the body or the forearm can rest at a 90-degree
angle across the chest.

11. Palpate and count the pulse. Place two or three

middle fingertips lightly and squarely over the pulse
point.

30

12. Assess the pulse rhythm and volume.

10

13. Document the pulse rate, rhythm, and volume and

your actions in the client record

10

Total

100

Remarks:

UNIVERSITY OF CALOOCAN CITY

(formerly Caloocan City Polytechnic College)
Gen. San Miguel St., Sangandaan, Caloocan City
Tel. Nos. 324-6855 (Main)
324-6843 (Tandang Sora Annex)
962-9799 (Camarin Annex)

NAME:
COURSE AND SECTION:
III.
Purpose:
To

PERFORMANCE CHECKLIST
DATE:
INSTRUCTOR:
ASSESSING VITAL SIGNS : RESPIRATORY RATE
ASSESSMENT

acquire baseline data against which future

measurements can be compared
To monitor abnormal respirations and respiratory patterns
and identify changes
To monitor respirations before or following the
administration of a general anesthetic or any medication
that influences respirations
To monitor clients at risk for respiratory alterations
(e.g., those with fever, pain, acute anxiety, chronic
obstructive pulmonary disease, asthma, respiratory
infection, pulmonary edema or emboli, chest trauma or
constriction, brainstem injury)

SCORE:

Assess
Skin and mucous membrane color (e.g., cyanosis or pallor)
Position assumed for breathing (e.g., use of orthopneic
position)
Signs of cerebral anoxia (e.g., irritability, restlessness,
drowsiness, or loss of consciousness)
Chest movements (e.g., retractions between the ribs or
above or below the sternum)
Activity tolerance
Chest pain
Dyspnea
Medications affecting respiratory rate

Equipment
Watch

Performance Points

with a second hand or indicator

Don

Score

e
1. Check if all equipment is functioning normally.

2. Introduce self

3. Verify the clients identity using agency protocol.

4. Explain to the client what you are going to do, why it is

necessary, and how he or she can participate.

5. Discuss how the results will be used in planning

further care or treatments.

6. Perform hand hygiene and observe appropriate infection

control procedures.

7. Provide for client privacy

8. Observe and count the respiratory rate.

35

9. Observe the depth, rhythm, and character of respirations

20

10.Document the respiratory rate, depth, rhythm, and character

on the appropriate record

10

100

TOTAL

Remarks:

UNIVERSITY OF CALOOCAN CITY

(formerly Caloocan City Polytechnic College)
Gen. San Miguel St., Sangandaan, Caloocan City
Tel. Nos. 324-6855 (Main)
324-6843 (Tandang Sora Annex)
962-9799 (Camarin Annex)

NAME:
COURSE AND SECTION:
IV.
Purpose:
To

PERFORMANCE CHECKLIST
DATE:
INSTRUCTOR:
ASSESSING VITAL SIGNS : BLOOD PRESSURE
ASSESSMENT

obtain a baseline measure of arterial blood pressure for

subsequent evaluation
To determine the clients hemodynamic status (e.g.,
cardiac output: stroke volume of the heart and blood vessel
resistance)
To identify and monitor changes in blood pressure
resulting from a disease process or medical therapy (e.g.,
presence or history of cardiovascular disease, renal disease,
circulatory shock, or acute pain; rapid infusion of fluids or
blood products)

SCORE:

Assess
Signs and symptoms of hypertension (e.g., headache, ringing in
the ears, flushing of face, nosebleeds, fatigue)
Signs and symptoms of hypotension (e.g., tachycardia,
dizziness, mental confusion, restlessness, cool and clammy skin,
pale or cyanotic skin)
Factors affecting blood pressure (e.g., activity, emotional stress,
pain, and time the client last smoked or ingested
caffeine)
Some blood pressure cuffs contain latex. Assess the client for
latex allergy and obtain a latex-free cuff if indicated.

Performance Points

Don
e

Ensure that the equipment is intact and functioning

properly.

Introduce self

Verify the clients identity using agency protocol.

Introduce self and Explain to the client what you are going
to do, why it is necessary, and how he or she can
participate.

Discuss how the results will be used in planning further

care or treatments.

Make sure that the client has not smoked or ingested

caffeine within 30 minutes prior to measurement.

Perform hand hygiene and observe appropriate infection

control procedures.

Provide for client privacy.

Position the client appropriately.

Wrap the deflated cuff evenly around the upper arm.

Locate the brachial artery

Apply the center of the bladder directly over the artery.

Place the lower border of the cuff approximately 2.5 cm (1

in.) above the antecubital space.

If this is the clients initial examination, perform a preliminary

palpatory determination of systolic pressure:

20

Palpate the brachial artery with the fingertips.

Close the valve on the bulb.
Pump up the cuff until you no longer feel the brachial pulse.
At that pressure the blood cannot flow through the artery.
Note the pressure on the sphygmomanometer at which pulse
is no longer felt.
Release the pressure completely in the cuff, and wait 1 to 2
minutes before making further measurements.

Position the stethoscope appropriately

Cleanse the earpieces with antiseptic wipe.

Insert the ear attachments of the stethoscope in your ears so

that they tilt slightly forward.

Ensure that the stethoscope hangs freely from the ears to the
diaphragm.

Place the bell side of the amplifier of the stethoscope over the
brachial pulse site.

Place the stethoscope directly on the skin, not on clothing over

the site.

Hold the diaphragm with the thumb and index finger.

Pump up the cuff until the sphygmomanometer reads 30 mmHg

above the point where the brachial pulse disappeared.

Release the valve on the cuff carefully so that the pressure

decreases at the rate of 2 to 3 mmHg per second.

As the pressure falls, identify the manometer reading at

Korotkoff phases 1, 4, and 5.

25

Deflate the cuff rapidly and completely.

Remove the cuff from the clients arm.

Document and report pertinent assessment data according to

agency policy.

120

TOTAL

Remarks:

Patient Name:
Vital Sign
Temperature
Pulse Rate
Respiratory Rate
Blood Pressure

Normal Values

UNIVERSITY OF CALOOCAN CITY

(formerly Caloocan City Polytechnic College)
Gen. San Miguel St., Sangandaan, Caloocan City
Tel. Nos. 324-6855 (Main)
324-6843 (Tandang Sora Annex)
962-9799 (Camarin Annex)

NAME:

PERFORMANCE CHECKLIST
DATE:

SCORE:

COURSE AND SECTION:

V.
Purpose:
To

reduce
To reduce
Clients
To reduce
To reduce
to oneself

the number of microorganisms on the hands

the risk of transmission of microorganisms to
the risk of cross contamination among clients
the risk of transmission of infectious organisms

INSTRUCTOR:
HAND WASHING
ASSESSMENT
Determine the clients
Presence of factors increasing susceptibility to infection
and possibility of undiagnosed infection (e.g., HIV)
Use of immunosuppressive medications
Recent diagnostic procedures or treatments that
penetrated the skin or a body cavity
Current nutritional status
Signs and symptoms indicating the presence of an infection:
Localized signsswelling, redness, pain or tenderness
with palpation or movement, palpable heat at site, loss
of function of affected body part, presence of exudate
Systemic indicationsfever, increased pulse and
respiratory rates, lack of energy, anorexia, enlarged
lymph nodes
Equipment
Soap
Warm running water
Paper towels

Performance Points

Done SCORE

Assess the hands:

Nails should be kept short.

Removal of all jewelry is recommended

Check hands for breaks in the skin, such as hangnails or cuts.

If you are washing your hands where the client can observe you, introduce
yourself and explain to the client what you are going to do and why it is
necessary.
Turn on the water and adjust the flow.

10

Wet the hands thoroughly by holding them under the running water and apply
soap to the hands.
Thoroughly wash and rinse the hands:

Use firm, rubbing, and circular movements to wash

The palm, back, and wrist of each hand.

Be sure to interlacing the fingers during hand washing.

Include the heel of the hand.

Interlace the fingers and thumbs, and move the hands back and forth.

Rub the fingertips against the palm of the opposite hand.

Thoroughly pat dry the hands and arms.

10

Turn off the water

10

TOTAL

Remarks:

10
10
40

10