Performance Form – your instructor will have a copy of this to check you off in lab.

INTEGRATED TEMPERATURE, PULSE, RESPIRATION and BLOOD PRESSURE

Name: , UW Student Nurse

Client Initials: ___________________________________ Date: _____________

Exam set-up: The student acting as the patient should be reclining in bed as if he/she were an
inpatient. When doing the safety check, act as if this were an uncomplicated inpatient (for
example, a client who is still in the hospital but likely to be discharged that day).

Physical Examination Guidelines:

__ 1. Gathered equipment needed and wash/gel hands.
__ 2. Identified self, and verified client with two patient identifiers.
__ 3. Performed safety check of room, visually inspecting for any safety concerns and
addressing as needed (personal items within reach, path clear of hazards, bed low &
locked, code status, allergies, noting any tubes, lines, and drains.
__4. Informed and explained the procedure to client.
__ 5. Invited client to discuss any questions or concerns about taking vital signs.
__ 6. Correctly positioned the client.
__ 7. Asked client if experiencing any pain. If yes, assessed on 10 point numeric scale and
ascertained the location(s).
__ 8. Take BP step 1 (palpation for obliteration of pulse to estimate systolic blood pressure).
9. Used temporal thermometer correctly and read temperature.
__ 10. Took and noted characteristics of radial pulse.
__ 11. After taking pulse, kept fingers resting on client's wrist and observed (or felt by putting
the client's wrist over their chest) the rising and falling of the chest to obtain respiratory
rate. Noted depth and rhythm with each cycle.
__ 12. Performed step 2 of the BP, taking an accurate reading.
__ 13. Recorded Pain, Temp, Pulse, Respiration Rate and BP (including arm and client position)
using correct terminology and abbreviations.
__ 14. Discussed findings with client as appropriate.

**BP within ±4 mmHg, pulse within ± 2 BPM, Resp ± 1, temp must be exact, temporal
thermometer technique must include forehead AND behind the ear.

Evaluation Comments (what was done well, what could be improved):

Evaluator: ______________________________________________________________

Summer 2016