Pangasinan State University

Bayambang Campus
Institute of Nursing

NAME:_______________________________ DATE:_______________ COURSE & SEC: ______________________

RLE GROUP: _________

Purposes:

1. To establish baseline data for subsequent evaluation

2. To identify whether the core temperature is within normal range
3. To determine changes in the core temperature in response to specific therapies (e.g.
antipyretic medication,

Skill: Assessing Body Temperature

Preparation

1. Assess:
● Clinical signs of fever
● Clinical signs of hypothermia.
● Site most appropriate for measurement.
● Factors that might alter core body temperature.
2. Assemble equipment:
● Thermometer
● Thermometer sheath or cover
● Water-soluble lubricant for a rectal temperature
● Disposable gloves
● Towel for axillary temperature
● Tissues/wipes
Procedure Rationale
1. Introduce yourself, and verify the client’s identity. ● To ensure correct procedure to the patient
Explain to the client what you are going to do, why it is
● Explaining procedure reduces anxiety and fear
necessary, and how the client can cooperate.
thus promoting cooperation from the client.

2. Performed hand hygiene, and observe other appropriate ● Reduces transmission of microorganisms
infection control procedures.
3. Provide for client privacy. ● To provide a secure environment for patients
and reinforces confidence in health care and
emphasizes the importance of respect for
patient.

4. Place the client in the appropriate position. * To promote client`s comfort

5. Place the thermometer.

Apply protective sheath or probe cover, if appropriate ● Reduces transmission of microorganisms

6. Remove the thermometer, and discard the cover or wipe ● To prevent cross contamination.
with a tissue, if necessary.
● Wipe from area with least contamination to the
area that is most contaminated.

7. Read measurement on digital display the temperature * Promotes client’s participation in care.
and inform client about the reading.
If the temperature is obviously too high, too low, or
inconsistent with the client’s condition, recheck it with a
thermometer known to be functioning properly.
8. Wash the thermometer, if necessary, and return it to the ● Protective storage prevent breakage.
storage location.
9. Document the temperature in the client record. ● Serves as baseline data for health care providers.
Remarks:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
_______________________________________________________________________

Grade: ___________________
 Skill: Assessing a Radial Pulse
Purpose:

1. To determine the adequacy of peripheral circulation or presence of pulse deficit.

Preparation

1 Assess:
● Clinical signs of cardiovascular alterations.
● Factors that might alter pulse rate.
● Site most appropriate for assessment.

2. Assemble equipment:
● Watch with a second hand or indicator
Procedure Rationale
1. Introduce yourself, and verify the client’s identity. ● To ensure correct procedure to the patient
Explain to the client what you are going to do, why it is
● Explaining procedure reduces anxiety and fear
necessary, and how the client can cooperate.
thus promoting cooperation from the client.

2. Performed hand hygiene, and observe other appropriate ● Reduces transmission of microorganisms
infection control procedures.
3. Provide for client privacy. ● To promote client`s comfort
4. Select the pulse point.

5. Assist the client to a comfortable resting position.

6. Palpate and count the pulse. Place two or three middle ● Finger tips are sensitive to touch and will feel the
fingertips lightly and squarely over the pulse point. pulsation of the patient`s artery
● Thumb should not be used because it has pulse to
avoid confusion
Count for 1 full minute. Record the pulse in beats per minute
on your worksheet. If taking a client’s pulse for the first time,
if obtaining baseline data, or if the pulse is irregular, count
for a full minute. An irregular pulse also requires taking the
apical pulse.
7. Assess the pulse rhythm and volume.

8. Document the pulse rate, rhythm, and volume, and your ● To serve as baseline data for health care providers.
actions in the client record

Remarks:

________________________________________________________________________________________________________
________________________________________________________________________________________________________
_______________________________________________________________________

Grade: ___________________

Rating Scale:

5- Performed well without assistance (recited step by step)

4- Performed with minimal assistance
3- Performed with assistance
2- Performed recited but not done & explain or vice versa
1- Did not performs & recite

_________________________________ _________________________________
Clinical Instructor Student’s Signature

Skill: Assessing Respirations

Purposes:

1. To acquire baseline data against which future measurements can be compared

2. To monitor abnormal respirations and respiratory patterns and identify changes
3. To monitor respirations before or after the administration of a general anesthetic or any
medication that influences respirations
4. To monitor clients at risk for respiratory alterations
Preparation

1. Assess:
● Skin and mucous membrane color.
● Position assumed for breathing.
● Signs of cerebral anoxia.
● Chest movements.
● Activity tolerance. ● Chest pain.
● Dyspnea
Medications affecting respiratory rate.

2. Assemble equipment:
● Watch with a second hand or indicator
Procedure Rationale
1. Identify yourself, and verify the client’s identity. Explain ● To ensure correct procedure to the patient
to the client what you are going to do, why it is necessary,
● Explaining procedure reduces anxiety and fear
and how the client can cooperate.
thus promoting cooperation from the client.

2. Performed hand hygiene, and observe other appropriate ● Reduces transmission of microorganisms
infection control procedures.
3. Provide for client privacy. ● To promote client`s comfort
4. Observe or palpate and count the respiratory rate.

If you anticipate the client’s awareness of respiratory
assessment, place a hand against the client’s chest to feel
the chest movements with the breathing, or place the
client’s arm across the chest and observe the chest
movements while supposedly taking the radial pulse.
● To count a respiratory rate, you want the
patient to be unaware that you’re counting
their breathing rate until after you are done.
If they are aware that you are counting their
breathing, they might alter their breathing.

Count the respiratory rate for 1 full minute. An inhalation
and an exhalation count as one respiration.
● A measurement of respiratory rate for 1 full
minute means to assess the respiratory
condition and to detect clinical deterioration.
This helps to determine the level of care
required.

5. Observe the depth, rhythm, and character of

respirations.
Observe the respirations for depth by watching the ● During deep respirations,a large volume of air is
movement of the chest. exchanged; during shallow respirations, a small
volume is exchanged.

Observe the respirations for regular or irregular rhythm.
Observe the character of respirations- the sound they
produce and the effort they require.
6. Document the respiratory rate, depth, rhythm, and
character on the appropriate record.
● Normally, respirations are evenly spaced.
● Normally, respirations are silent and effortless.
● To serve as baseline data for health care providers.

Remarks:

________________________________________________________________________________________________________
________________________________________________________________________________________________________
_______________________________________________________________________

Grade: ___________________

Skill: Assessing Blood Pressure

Purposes:
 1. To obtain a baseline measurement of arterial blood pressure for subsequent evaluation.
2. To determine the client`s hemodynamic status
3. To identify and monitor changes in blood in pressure resulting from a disease process or
medical therapy.
Preparation

1. Assess:
● Signs and symptoms of hypertension.
● Signs and symptoms of hypotension.
● Factors affecting blood pressure.
Client for allergy to latex cuff.
2. Assemble equipment:
● Stethoscope or DUS
● Blood pressure cuff of the appropriate size
● Sphygmomanometer
Procedure Rationale
1. Identify yourself, and verify the client’s identity. Explain To ensure correct procedure to the patient
to the client what you are going to do, why it is necessary, Explaining procedure reduces anxiety and fear thus
and how the client can cooperate. promoting cooperation from the client.
2. Performed hand hygiene, and observe other appropriate Reduces transmission of microorganisms
infection control procedures.
3. Provide for client privacy. To promote client`s comfort
4. Position the client appropriately.

The adult client should be sitting unless otherwise specified.
Both feet should be flat on the floor.
The elbow should be slightly flexed, with the palm of the
hand facing up and the forearm supported at heart level.
Expose the upper arm.
* Legs crossed at the knee results in elevated systolic and
diastolic blood pressure
The blood pressure increases when the arm is below heart
level and decreases when the arm is above heart level.

5. Wrap the deflated cuff evenly around the upper arm.
Locate the brachial artery. Apply the center of the bladder
directly over the artery.
For an adult, place the lower border of the cuff
approximately 2.5 cm (I inch) above the antecubital space.
6. If this is the client’s initial examination, perform a
preliminary palpatory determination of systolic pressure.
Palpate the brachial artery with the fingertips.
The bladder inside the cuff must be directly over the artery
to be compressed if the reading is to be accurate.
The initial estimate tells the nurse the maximal pressure to
which the sphygmomanometer needs to be elevated in
subsequent determinations. It also prevents
underestimation of the systolic pressure or overestimation
of the diastolic pressure should an auscultatory gap occur.

Close the valve on the bulb.

Pump up the cuff until you no longer feel the brachial pulse. This gives an estimate systolic pressure.
Note the pressure on the sphygmomanometer at which the
pulse is no longer felt.
Release the pressure completely in the cuff, and wait 1-2 A waiting period gives the blood trapped in the veins time
minutes before taking further measurements. to be released. Otherwise, false high systolic will occur.
7. Position the stethoscope appropriately.

Cleanse the earpieces with antiseptic wipe.

Insert the era attachments of the stethoscope in your ears so
that they tilt slightly forward.
Ensure that the stethoscope hangs freely from the ears to
diaphragm.
Place the bell side of the amplifier of the stethoscope over
the brachial pulse. Place stethoscope directly on skin, not on
clothing over the site. Hold the diaphragm with the thumb
and index fingers.
8. Auscultate the client’s blood pressure.
Sounds are heard more clearly when the ear attachment
follow the direction of the ear canal.
If the stethoscope tubing rubs against an object, the noise
can block the sounds of the blood within the artery.
Because the blood pressure is a low-frequency sound, it is
best heard with the bell-shaped diaphragm.
This is to avoid noise made from rubbing the amplifier
against cloth.

Pump up the cuff until the sphygmomanometer is 30 mmHg

above the point where the brachial pulse disappeared.
Release the valve on the cuff carefully so that the pressure If the rate is faster or slower, an error in measurement may
occur.
 decreases at the rate of 2-3 mm Hg per second.

As the pressure falls, identify the manometer reading at There is no significance to phases 2 and 3.
Korotkoff phases I, IV, and V.
Deflate the cuff rapidly and completely.

Wait 1-2 minutes before making further determinations. This permits blood trapped in the veins to be released.
Repeat the above steps once or twice as necessary to
confirm the accuracy of the reading.
9. If this is the client’s initial examination, repeat the
procedure on the client’s other arm.
10. Remove the cuff.

11. Wipe the cuff with an approved disinfectant. Cuffs can become significantly contaminated. Many
institutions use disposable blood pressure cuffs. This
decreases the risk of spreading infection by sharing
cuffs.
12. Document and report pertinent assessment data
according to agency policy.
Remarks:

________________________________________________________________________________________________________
________________________________________________________________________________________________________
_______________________________________________________________________

Grade: ___________________

Rating Scale:

5- Performed well without assistance (recited step by step)

4- Performed with minimal assistance
3- Performed with assistance
2- Performed recited but not done & explain or vice versa
1- Did not performs & recite
_________________________________ _________________________________ Clinical
Instructor Student’s Signature