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iRubric: Vital Signs Assessment rubric

iRubric: Vital Signs Assessment rubric

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Vital Signs Assessment 
Assessment of Temperature, Pulse, Respiration, Blood Pressure, Pulse Oximetry, Pain
Rubric Code: VXA648X
Ready to use
Public Rubric
Subject: Health  
Type: Assessment  
Grade Levels: Undergraduate

Powered by iRubric 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







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