health assessment vital signs taking

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Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY
General Tinio, Cabanatuan City, Nueva Ecija
ClinicalLearningSkillsLaboratory
HEALTH ASSESSMENT (NCM 101)
CHECKLIST:
vital signs:
temperature
Name: ______________________________________________________________ Score:
Block: ________________________ Date:____________________________
PROCEDURE
Assessing Body Temperature Performed Comments
YES NO
ASSESSMENT
1. Assess:
 Clinical signs of fever
 Clinical signs of hypothermia
 Site most appropriate for measurements
 Factors that may alter core body temperature
2. Determine:
 The policies and procedures for the facility
 The client’s record for medications that may increase
or decrease the present temperature
PLANNING
1. Assembleequipmentandsupplies:
 Thermometer
 Thermometer sheath or cover
 Water-soluble lubricant for a rectaltemperature
 Disposable gloves (if necessary)
 Towel for axillary temperature
 Tissue/wipes
IMPLEMENTATION
1. Priorto performingtheprocedure,introduceselfand
verifythe client’sidentityusingagencyprotocol.
Explain to the client what youare going to do, why it is
necessary, and how he or she can participate.
2. Wash handsand observeotherappropriateinfection
control procedures.
3. Provideforclientprivacy.
4. Place the client in the appropriate position.
5. Clean the thermometer
Place the thermometer to appropriate route/site
Wait the appropriate amount of time.

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Remarks:
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
RatingScale:
Excellent : 96 – 100%
Very Satisfactory : 90 – 95%
Very Good : 85 – 89%
Good : 80 – 84%
Fair : 75 – 79%
Poor : 74 and below
_______________________________________________
Student’sPrintedName and Signature
_______________________________________
SkillsLaboratoryInstructor
Electronic and tympanic thermometer will indicate that the
reading is complete through a light or tone.
6. Remove the thermometer and discard the cover or wipe with
a tissue ifnecessary.
7. Read the temperature.
If the temperature is obviously too high, too low or consistent
with the client’s condition, recheck it with a thermometer known
to be functioning properly.
EVALUATION AND DOCUMENTATION
8. Document the temperature in the vital signs record sheet.
9. Report abnormal results to the primary care provider.
10. Document the procedure in the client’s record
TOTAL: