GBSN Program (Year One) Skill Checklist

TEMPERATURE

PURPOSES:
• To obtain baseline data for subsequent evaluation.
• To determine changes in body temperature in response to specific therapies.
• To monitor patients at risk for elevated temperature.

EQUIPMENTS: (ORAL)
• Rectangular tray containing
a) Thermometer (oral).
b) Gallipots (4).
c) Tissue/cotton balls.
d) Small kidney tray.
e) Jar of antiseptic
solution. (Dettol 1%,
savlon 2% or alcohol
70%) or Jar of
f) Soapy solution.
g) Jar of clean water.

Additional equipment for Axillary temperature:

1. Towel/tissue for drying the axilla.

Additional equipment for rectal temperature:

1. Thermometer (rectal).
2. Lubricant (KY jelly).
3. Disposable gloves.
4. Tissue paper
 PROCEDURE:

S.NO STEPS RATIONALE S1 S2

1. Identify the patient. To give care to the correct patient.

2. Assess the site for temperature. Helps in identifying the most appropriate
 site for reading temperature.

S.NO STEPS RATIONALE S1 S

2
3. Wash hands. Reduces risk of cross infection.
4. Collect equipment. Saves time and energy.
5. Check thermometer for damaged bulb Mercury may leak through cracks and
broken glass and may cause injury.
6. Explain the procedure to the patient. Relieves patient’s fears and anxiety
and gains cooperation.
7. If the thermometer is in the case

i. Take out thermometer from the case.

ii. Wash the thermometer with soap and

water from bulb end to finger end in firm Cleans the thermometer and
twisting motion. decreases the chance of infection.

iii. Rinse it with cold water.

iv. Dry with cotton swab/ tissue from blub

end towards finger end using firm Cleans the thermometer from least
twisted motion. contaminated to most contaminated
area.

8. Read thermometer at eye level.

9. Lower the level of mercury below 35C by Mercury should be below 35C.
gently shaking it with firm grip. Thermometer reading must be
below client's actual temperature
before use. Gentle shake lowers
mercury level in glass tube.
10. ORAL METHOD:

a) Ensure the patient has not taken hot/ cold Ensures correct reading.
fluids and not smoked for at least10- 15
minutes.
b) Place thermometer under the tongue at a
45C angle in a position that allows the The thermometer needs to reflect
bulb to rest against the tongue tissue. the core temperature of the blood in
larger blood vessels of the posterior
pocket.
c) Instruct the patient to : To ensure accurate results and
• Close his/ her mouth carefully with prevent the thermometer from
lips held firmly together. falling out or breaking.
• Avoid biting down the
thermometer.
• Refrain from speaking.

d) Leave the thermometer in place for 2- 3 Less likely to chip on the patients
minutes. teeth or break the thermometer.

e) Grasp the stem of the thermometer, asks

the patient to open his/ her mouth,
remove the thermometer.

f) Wipe off any secretion from thermometer

Wiping allows clear reading of
with cotton swab/ tissue. Wipe in rotating
thermometer. Wiping is done from
fashion from finger to bulb end.
area of least contamination to area
g) Read the thermometer at eye level (by of greater contamination.
slowly rotating)
Ensure accurate reading
AXILLARY METHOD:

a) Put the curtains around patients bed or

close door (as required)
b) Ensure that axilla is dry. Provides privacy and comfort.
c) Move clothing or gown away from
patient's shoulder and arm. Moisture conducts heat, and may give
d) Place the thermometer in the centre of an in accurate reading.
axilla, lower the patient's arm over the Provides optimal exposure of axilla.
thermometer, and place the forearm
across the chest.
e) Gently hold the arm in place (if Maintains proper position of
required). thermometer against blood vessels.
f) Leave the thermometer in place for a Movement can displace thermometer
minimum of 3-5 minutes. can give false reading and
thermometer can fall and break.
Ensure accurate reading
 g) Remove the thermometer, Ensure accurate reading
raise it to eye level, and note
the reading.
11. Wash thermometer with soap and Avoid contact of microorganism
warm water using firm twisted with nurse’s hand.
motion.
12. Rinse with cold water. Provides exposure to genitalia.
13. Dry it with a cotton swab/ tissue Provides easy access to the
using firm twisted motion. genitalia and prevents
unnecessary exposure.
14. Inform the client of temperature Promotes participation in care and
reading understanding of health status.
15. Replace the thermometer in the Storage container prevents
provided case/ antiseptic breakage.
solution.
16. Wash hands. Reduce transmission of
microorganisms.
17. Document accurately on the flow
sheet.

GBSN Program (Year One) Skill Checklist

ASSESSING PULSE

PURPOSES:
• Verbalize the purpose of taking pluses.
• Verbalize the normal ranges of pulses.
• Demonstrate the proper technique of assessing pulses.

EQUIPMENTS:
• Watch with second hand.
• Paper or flow sheet
• Pen (red ink).
PROCEDURE:

S.NO STEPS RATIONALE S1 S2

1. Identify the patient. To give care to correct patient.
2. Wash hands. Reduces risk of cross infection.
3. Collect equipment. Easy access to equipment prevents
delay, saves time and energy and
prevents interruption during
procedure.
4. Explain the procedure to the Gains cooperation reduces patient's
patient. anxiety.
5. Place the patient in a comfortable Relaxed position of the lower
position. arm and extension of the wrist
permits full exposure of the
• Rest the patient's arm artery for palpation.
alongside his body with the
wrist extended and the palm of
the hand downward or inward.
• Patient can sit with his
forearm at a 90 angle to the
body resting on a support and
with the wrist extended and
the palm of the hand
downward.
 6. Place tips of first two or middle Fingertips are most sensitive parts
three fingers of dominant hand of hand to palpate arterial
over groove along radial or pulsation.
thumb side of patient’s inner Thumb has pulsation that may
wrist. interfere with accuracy.
7. Lightly compress against radius; Pulse is more accurately assessed
press pulse initially, and then relax with moderate pressure. Too
pressure so pulse becomes easily much pressure occludes pulse
palpable. and impairs blood flow.
8. Using a watch with a second hand, Sufficient time is necessary to
count the number of pulsations felt assess the rate, rhythm and
for 1 minute. amplitude of the pulse.
9. Assess the pulse, rhythm, and Irregularity in heart rate may disrupt
amplitude while counting rate. the cardiac output. Amplitude of
pulse indicates the quality of the
heart's contraction.
10. Wash hands. Prevents risk of cross infection.
11. Record pulse on vital sheet with Promote continuity of care.
red pen and rhythm and amplitude
in nurse's notes (if abnormal).
Document the following findings:
site, Rate, rhythm,
volume/amplitude and other.

Assess the following peripheral pulses

• Temporal
• Carotid
• Brachial
• Radial
• Femoral
• Popliteal
• Posterior tibial
• Dorsalis pedis

Faculty Comments:

Faculty name & signature: Date:

 GBSN Program (Year One) Skill Checklist

ASSESSING RESPIRATION

PURPOSES:
• To acquire base line data for subsequent evaluation.
• To monitor abnormal respiratory status and identify changes.
• To monitor patients at risk for respiratory alterations.
• To evaluate effects of medication and activity on respiratory status.

EQUIPMENTS:
• Watch with second hand.
• Flow sheet
• Pen (black)

PROCEDURE:

S.NO STEPS RATIONALE S1 S2

1. Identify the patient. To give care to correct patient.
2. Wash hands. Reduces risk of cross infection.
3. Collect equipment. Easy access to equipment prevents
delay, saves time and energy and
prevents interruption during
procedure.
4. Be sure client's chest is visible Saves time and energy.
remove bed linen or gown.
5. Assess patient's activity prior to A patient who has been exercising
checking respiration. will need to rest for few minutes to
permit the accelerated respiratory
rate return to normal.
6. Place patient in a comfortable
position.
 7. a) Place hand against patient's Awareness of respiratory rate
chest to feel his chest assessment would cause the patient
movement or voluntarily to alter the respiratory
pattern.
b) Place patient's arm across the
chest and observe the chest
movement while supposedly
taking the radial pulse.
8. Read thermometer at eye level.
9. Lower the level of mercury below Mercury should be below 35C.
35C by gently shaking it with firm Thermometer reading must be
grip. below client's actual temperature
before use. Gentle shake lowers
mercury level in glass tube.
10. Check the respiratory rate, rhythm Accuracy of reading.
and depth for 1 minute.
11. Wash hands. Prevents the risk of cross infection.
12. Document inflow sheet and nurse's Promotes continuity of care.
notes (if required)

Faculty Comments:

Faculty name & signature: Date:

 GBSN Program (Year One) Skill Checklist
BLOOD PRESSURE

PURPOSES:
• To maintain a base line measure of arterial pressure.
• To assess the hemodynamic (i.e. the study of movement of
blood and the forces concerned) status of a patient.
• To monitor response of the circulatory system to various disease conditions and
therapies.

EQUIPMENTS:
• Sphygmomanometer (B.P apparatus)
• B.P cuff (appropriate size).
• Stethoscope
• Spirit swabs.
• Vital sheet.
• Black/ blue pen

CONTRAINDICATION:
• Arterial-venous shunt
• Any deformity or surgical history

PROCEDURE:

S.NO STEPS RATIONALE S1 S2

1. Identify the patient. To give care to correct patient.
2. Explain procedure to patient. Reduces anxiety and gains cooperation.
3. Collect & check equipment. Ensures proper functioning of
apparatus.
4. Have patient in sitting or supine Promotes comfort and relaxes patient.
position. Provides accurate reading.
5. Wash hands. Prevents cross infection.
6. Clean the ear piece of stethoscope Prevents transmission of
with the spirit swab. microorganisms.
7. Be sure that the manometer is Ensures accurate reading of mercury
positioned vertically at eye level. level.
8. Support patient's fore-arm at heart Blood pressure increases when the
level, with palm turned up. arm is below heart level and
decreases when the arm is above
heart level.
9. Expose patient's left upper Ensures proper cuff application. Tight
arm by removing sleeves interfere with the ability to
constructing clothing. hear pulsations and may cause
inaccurate reading.
10. Wrap the deflated cuff evenly Even wrapping produces equal
around the upper arm by placing pressure. Too loose/ tight cuff will give
the lower edge of the cuff 2.5-cm inaccurate reading. The bladder
(1-2 inches) above the antecubital directly over the brachial artery gives
space. Ensure the center of the accurate reading.
bladder is applied directly over the
medial aspect of the upper arm.
11. Place the stethoscope in your ears Tapping is done to check whether the
and check the diaphragm by sound is audible.
tapping.
12. Make sure to unlock the mercury
column before inflating.
13. Palpate brachial or radial pulse Indicates approximate systolic
with one hand. Close the value of pressure (Done if it is the initial
the bulb: Inflate the cuff noting examination)
the level of mercury where pulse
disappears.
14. Deflate cuff quickly and wait for 30 Prevents venous congestion and false
secs; tighten the value. high reading.
15. Relocate brachial artery and place Proper stethoscope placement
the diaphragm of stethoscope over ensures optional sound reception.
the brachial pulse and hold it in Improper position of diagram causes
place (Do not let the diaphragm muffled sounds and often results in
touch the cuff or patient's false low systolic and false high
clothing). diastolic readings.
16. Inflate the cuff to 30mm Hg above Ensures accurate measurement of
where the pulse disappeared. systolic pressure.
17. Slowly release the value and allow Too rapid or too slow decline of
mercury to fall at the rate of 2-3 mercury level can cause
mm Hg per sec. inaccurate readings.
18. Note point on manometer when First Korotkoff sound indicates the
first clear sound is heard. systolic pressure.
19. Continue to deflate cuff gradually This is noted as the diastolic pressure.
nothing point at which sounds
disappear.
 20. Deflate cuff rapidly and Prevents arterial occlusion resulting in
completely. Remove cuff from numbness and tingling of patient's arm.
patient's arm. Lock mercury column
unless measurement must be
repeated.
21. Assist patient to a comfortable Ensures patient's comfort.
position. Cover the upper arm.
22. Inform client of B.P reading Promotes participation in care and
(depends on patient's conditions) understanding of health status.
23. Clean stethoscope with spirit swab Prevents spread of microorganism
and return equipment to appropriate and safety of equipment.
place.
24. Wash hands. Prevents transmission of
microorganisms.
25. Record accurately in the flow sheet Timely documentation ensures
according to hospital policy. accurate therapeutic intervention, if
needed.

Faculty Comments:

Faculty name & signature: Date: