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Vital Signs Assessment
Vital Signs Assessment
Assessment of Temperature, Pulse, Respiration, Blood Pressure, Pulse Oximetry, Pain
Rubric Code:
R247953
By
ginilynm28
Ready to use
Public Rubric
Subject:
Health
Type:
Assessment
Grade Levels:
Undergraduate
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Vital Signs Assessment
Excellent
10 pts
Good
8 pts
Poor
5 pts
Failure
0 pts
Verify Orders/Gather Equipment
Excellent
Check orders in MAR: note baseline VS assessments
Gather Equipment:
Stethoscope
Second Hand watch
B/P cuff
Thermometer,
Pulse Oximeter
Good
Failure to check MAR or Note baseline
Has Stethoscope/Watch
Failure to bring some of equipment
Poor
Failure to Check MAR
Failure to bring proper equipment
Has watch or stethoscope
Failure
NO watch/stethoscope
NO MAR check
Missing equipment
Standard Steps Before Proced
Excellent
1. Purell on entry
2. Provided privacy for pt.
3. introduce yourself
4. identify patient w/ 2 identifiers: ask patient name and DOB while checking band or MAR
5. Explained procedure (vital sign check) and allowed pt to ask questions.
Purell/full intro /identify/explanation
Good
1. purell on entry
2. Did not provided privacy for pt
3. introduce themselves
4. identify procedure: improper
did not ask 2 questions OR
did not check against band or MAR
5. Explained to pt purpose of visit (No questions)
Purell/introduce/improper identify/"vitals"
Poor
1. Purell
2. Did not provide privacy for pt.
3. Failure to introduce
4. Failure to identify pt
5. Explained part of the procedure/Did not allow pt to ask questions
Purell/"Im here to take your vitals"
Failure
1. Failure to Purell
2. failure to identify self
3. failure to identify patient
Pain Assessment / Position
Excellent
1. Assessed pain: provide pain scale 0-10, follow up questions for any + pain.
2. Placed pt in correct position:
sitting or supine, comfortable
arm relaxed at heart level
palm up
legs uncrossed
Good
1. did not follow up on pain assessment: Ask but did not provide pain scale, did not ask follow up questions
3. did not positioned pt correctly: one or some
arm/side table too far up
arm hanging down
palm down
pt uncomfortable
Poor
1. Assess for pain
2. Pt not positioned correctly/comfortable.
Failure
1. Failure to Assess Pain
Pulse Oximetry
Excellent
1. Had equipment ready,
2. pt. hands clean and checked for cap refill and remove nail polish
3. able to use oximeter effectively and got correct reading.
Obtained correct reading on 1st try with confidence.
Good
1.Had oximeter and knew how to use equipment
2. Did not varify capp refill or remove nail polish prior to taking the reading.
2. Required some cues from instructor.
Obtained the correct reading on the 2nd try with confidence.
Poor
1. Did not have pulse oximeter
2. Did not check pt. to verify if pt. was wearing nail polish
3. Needed cues from instructor.
Failure to Obtain correct reading on the second try/demonstrated little confidence.
Failure
Temperature
Excellent
1. Had correct equipment.
2. Place correctly on pt
3. was able to report findings on 1st attempt without instructor's help.
Obtained correct reading on 1st try with confidence.
Good
1. Had correct equipment
2. Did not place or use correctly
3. required some cues from instructor but was able to report findings after 1st attempt.
Obtained the correct reading on the 2nd try with confidence.
Poor
1. Did not have correct equipment
2. Did not place correctly on pt
3. was not able to report findings on 2 attempt.
Failure to Obtain correct reading on the second try/demonstrated little confidence.
Failure
Pulse
Excellent
1. Found indicated pulse site quickly,
2. findings were correct
3. required no help from instructor.
Obtained correct reading on 1st try with confidence.
Good
1. Found the indicated pulse site
2. Had correct finding after 2nd attempt.
3. Required very little cues from instructor.
Obtained the correct reading on the 2nd try with confidence.
Poor
1. Was not able to locate/identify radial
pulse without assistance
2. correct pulse rate After more than 2x
3. Needed help from instructor
Failure to Obtain correct reading on the second try/demonstrated little confidence.
Failure
Respirations
Excellent
1. Was able to count correctly on 1st attempt
2. No instructor's help
Obtained correct reading on 1st try with confidence.
Good
1. Able to count respirations correctly on 1st attempt
2. Required some cues from instructor.
Obtained the correct reading on the 2nd try with confidence.
Poor
1. Was not able to count rate on 1st try
2. Needed to repeat more than 2x to get correct respiration rate
3. Needed help from instructor.
Failure to Obtain correct reading on the second try/demonstrated little confidence.
Failure
Blood Pressure
Excellent
1. Correct cuff size
2. Palpate pulse point
3. Apply cuff correctly (evenly and snuggly)
4. Cuff was inflated correctly
5. Deflated correctly: Let the air out 2-3mm Hg/not painfully slow.
Obtained correct reading on 1st try with confidence.
Good
1. correct cuff size
2. Finds Brachial pulse with assistance
3. fumbles with the cuff, but applies it correctly
4. the cuff inflated correctly
5. Lets air out too fast initially
but Gets correct value
Obtained the correct reading on the 2nd try with confidence.
Poor
1. Wrong cuff size
2. Needs several tries to adjust BP cuff
3. Need several attempts to get cuff inflated
4. Cuff Left inflated to long causing some pain to the pt.
5. gets incorrect value or unable to determine correct value on first attempt
Failure to Obtain correct reading on the second try/demonstrated little confidence.
Failure
Standard Steps After Procedure
Excellent
Purell
inform patient of values/allows for questions
reassess pain/comfort/repositions pt
Provides safety
gathers/disinfects equipment for reuse
Good
Purell
informs patient of values/no questions
no reassessment of pain/comfort
provides safety
gathers/disinfects equipment for reuse
Poor
Purell
No patient interaction/Pain reassessment
No Safety assessment
gathers/disinfects equipment for reuse
Failure
NO Purell upon leaving
NO disinfection of equipment
Documentation
Excellent
Documents Vital Signs properly: Example
B/P = 120/80 R brachial
Pulse = 70 R +2 Right radial
Temp = 98.7 Tympanic
Pulse Ox = 98% Room Air
Pain = pt denies pain
Good
Documents correct Vital sign values
without complete descriptive explanations
120/80, 70, 98.7, 98%, 0pain
Poor
Fails to transcribe all values or
Failure to transcribe correct vital signs values at documentation time
Needs cues
Failure
Failure to document Values
Keywords:
TPR, BP, O2 Sat
Subjects:
Health
Nursing
Types:
Exam
Assessment
(Other)
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