VITAL SIGNS & PAIN ASSESSMENT
SKILL
VALIDATION
Student Name: _____________________________________ Date: _____________________
Points Allowed
1
st
Attempt
2
nd
Attempt
Preparation
Perform I-CHECK: Introduce yourself,
Check armband (two patient identifiers),
Hand hygiene, Explain procedure, Check order, Keep privacy
+1
Determine the appropriate arm
for blood pressure measurement (i.e., consider presence of IV-line, mastectomy, fistula, or injury)
+1
Manual Blood Pressure
Apply appropriately sized sphygmomanometer with a snug fit, correct alignment, and cuff placed 2-5 cm above the brachial artery
+1
Position patient with arm supported at heart level and feet flat on the floor
+1
Ask patient what their BP typically is
(this step prevents overinflation of cuff & avoids auscultatory gaps)
+1
Obtain the patient’s blood pressure:
· Put on the stethoscope with earpieces angled forward, place the diaphragm over the brachial artery & inflate cuff 30mmHg above estimated systolic pressure to avoid missing an auscultatory gap
· Deflate cuff 2mmHg per second while listening for Korotkoff sounds noting when first Korotkoff sound appears (systolic BP) & the last audible Korotkoff sound (diastolic BP)
· Continue to slowly deflate the cuff for a bit longer to make sure the Korotkoff sounds don’t reappear, and then rapidly deflate the cuff
+3
Correctly state blood pressure measurement (within 4 mmHg)
+1
Heart Rate
Place fingertips on radial artery and press lightly until pulse is felt
+1
Count beats for 30 seconds if regular (then double it) or 60 seconds if irregular
+1
Correctly state the heart rate (within 2 bpm),
noting rate, rhythm, and force
(3+ = full, bounding, 2+ = normal, 1+ = weak, thread, 0 = absent)
+1
Respiratory Rate
Watch the rise and fall of the chest or abdomen
without letting the patient know
you are counting (e.g., pretend to still be checking the pulse)
+1
Count breaths for 30 seconds if regular (then double it) or 60 seconds if irregular
+1
Obtain oxygen saturation
+1
Correctly state the respiratory rate (within 1 breath per minute)
+1
Temperature (Oral)
Ask patient if they have recently eaten, consumed hot or cold liquids, or smoked. If yes, wait 15 minutes prior to assessing an oral temperature
+1
Attach a disposable cover to the thermometer and position the thermometer at the base of the tongue in either of the posterior sublingual pockets and ask the patient to close their lips around it
+1
Wait for the thermometer to beep, indicating the reading is complete and dispose of the cover and read the temperature accurately
+1
Pain
Ask if the patient is experiencing any pain (the “patient” should report a common ailment like a headache) and assess using the OPQRST method:
· Chief Complaint: Are you having any pain? Where is it located?
· Onset: When the pain began?
· Provocation: What makes the pain worse?
· Quality: How do you describe the pain?
· Radiation: Does the pain spreads elsewhere?
· Severity Scale: Explain and use the 0-10 scale to assess intensity
· Timing: Is the pain constant or intermittent? How long does it last?
+7
Post-Procedure
Document patient’s vital signs (blood pressure, heart rate, respiratory rate, temperature) and pain assessment
No points but required
Total Points (successful/Unsuccessful) 21 out of 26 needed to be successful
Comments
Evaluator Initials or Signature: _____________________________________ Date: _____________________
1
ST
Attempt Pass ____________/Needs Remediation___________________
Evaluator Initials or Signature: _____________________________________ Date: _____________________
2
nd
Attempt Pass ____________/Lab Fail_____________________________
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