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VS check off - Outline for how to properly assess
Vital signs.
Health Assessment (Liberty University)
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My name is Christal Weaver, I am going to be preforming the vital signs check off for health
assessment, section 4. I have closed the door to provide patient privacy and preformed hand
hygiene. *Put gloves on*
To patient:
Hi, my name is Christal. I’m a liberty university nursing student and will be taking your vitals
today. Will you please state your name and DOB? Perfect, thank you. Are you currently
experiencing any pain? Could you rate that on a pain scale of 0-10, 0 being no pain at all and 10
being the worst pain you’ve ever had? Okay, I need to get your weight and height. Please
remove your shoes and step on the scale for me. Your weight is 140lbs. Now, stand up straight
for me *measure from grown of head to feet*, your height is 5’6”. You can step off the scale
now, thank you. Doing this allows me to look at the BMI chart and determine if you are at a
healthy weight.
First, I will be taking your temperature. Have you had anything to drink in the last 15 min? Okay,
perfect, if you had had something to drink in the past 15 min, I could take your temperature via
axillary or rectal. We do this because anything you drank in the last 15 min could affect the
reading of the oral temperature. An axillary temperature is obtained by putting the
thermometer under your armpit for 3-5 min. If I were to take your temperature rectally, I would
have you lay in a left sims position and using lube, I would insert the probe 1-1.5 inches deep for
3 min. I could also use an analog thermometer if provided, I would just have to shake it first to
reset it to 96 degrees or lower. Then you would hold the thermometer in your mouth for 3-5
min. *Put thermometer in pt. mouth for 3-5 min or till you hear a beep* Your temperature is
98.5, which is within the normal range of
Next, I am going to check your oxygen saturation. Your 02 is 98% which is within the normal
range of 95-100%.
Now I am going to assess your radial pulse and respirations. *Count for 1 min for each* Your
heart rate is regular and strong at 88 bpm which is within the normal range of 60-100bpm. Your
respirations are even and nonlabored at 17 respirations a min which is also within the normal
range of 12-20.
Lastly, I will assess your auscultatory gap and blood pressure, do you have a preference of which
arm I use? *Palpate brachial or radial pulse and inflate cuff until pulse disappears, then deflate
cuff. Your palpated systolic bp is 120mmhg. *Inflate cuff 20-30mmhg above palpated systolic
bp* Your pulse did not return after inflating the cuff to 140mmhg, therefore there is no
auscultatory gap present. Now I will assess your bp. *Inflate cuff to 140mmhg and take note of
first number pulse is heard and last number pulse is heard* Your bp is 125/90mmhg which is
within the normal range of 110/70-120/80mmhg. I could have taken your bp on both arms just
to be sure there is no discrepancy.
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If I had obtained any vs that were not within the normal range, I would notify my instructor or
primary nurse immediately.
That is all I needed from you today, do you have any questions or concerns? Okay, thank you
and have a nice day.
