Nurs 202 OSCE Checklist
Upon Entering - answer- Hello, my name is ___, I am a second year student Nurse and
I am going to be working with you today
- wash hands
- check armband, ask pt name and birthday
- pull the curtain for privacy
- raise bed to working height
VItals: 6 components - answer- Heart rate
- Respiratory rate
- Blood Pressure
- Temperature
- O2 Saturation
- Pain (pt self-report 0-10)
Vitals: Heart rate - answerNormal range = 60-100 bpm
- pulse, rhythm, force, equality
- should be 2+, normal rhythm, equal bilaterally
- take radial pulse (thumb side on inner wrist) with pads of first 2-3 fingers
- count for 30 sec, double # (full min if irregular)
- Force:
--- 3+= Bounding
--- 2+= Strong/normal
--- 1+= Weak/thready
--- 0= Absent
- check bilaterally for equality
*Ratio of pulse rate to respiratory rate should be approximately 4:1*
Vitals: Respiratory rate - answerNormal range: 10-20 per minute
- rate, rhythm, depth
- should be unlaboured, normal depth, regular pattern
- count 30 sec, double # (irregular count full min)
- watch chest rise and fall
- don't tell patient you are doing this as it may affect rate
*Ratio of pulse rate to respiratory rate should be approximately 4:1*
Vitals: Blood Pressure - answerNormal range: 120-139/80-89 mmHg
, Prep:
- pt at rest at least 5 minutes
- no exercise for 30 minutes
- no caffeine for 60 minutes
- Sit supported, feet flat on floor or lay on bed
- Have arm at level of heart, palm upward
- legs uncrossed
- ensure no IVs, mastectomies, fistulas, injured areas
- no speaking during measurement
- ensure cuff is appropriate size
-- - Cuff width = 40% of pt's arm circumference
--- Cuff bladder length = 80% of arm circumference
- hand hygiene!
- palpate brachial artery: medial to bicep tendon
- place artery marker on cuff 2.5 cm above artery
- wrap cuff even and comfortably tight
- stethoscope in ears, ON
- BELL SIDE on artery
- inflate to 30mmHg above pulse gone/last systolic
- inflate 2-3mmHg/sec
- note 1st korotkoff sound (systolic)
- note 5th korotkoff sound (diastolic)
- listen 10-20 mmHg below 5th, release rest
- remove and Disinfect cuff! hand hygiene
- if first admission, measure bilaterally
Vitals: Temperature - answerNormal range: 36-38 degrees C
- under tongue
- mouth closed around probe
- WAIT 20 min after pt drank hot/cold drink, 5 min if pt just chewed gum, 2 min if pt just
smoked
- rectal: 0.5 C higher, axillary 0.5 C lower than oral
Vitals: O2 Saturation - answerNormal Range: 95-100%
- appropriate size
- check for nail polish or artificial nails
- hold hand still
- use opposite hand of BP cuff
Vitals: Pain - answerNormal: 0
- ask pt to rate on scale
Upon Entering - answer- Hello, my name is ___, I am a second year student Nurse and
I am going to be working with you today
- wash hands
- check armband, ask pt name and birthday
- pull the curtain for privacy
- raise bed to working height
VItals: 6 components - answer- Heart rate
- Respiratory rate
- Blood Pressure
- Temperature
- O2 Saturation
- Pain (pt self-report 0-10)
Vitals: Heart rate - answerNormal range = 60-100 bpm
- pulse, rhythm, force, equality
- should be 2+, normal rhythm, equal bilaterally
- take radial pulse (thumb side on inner wrist) with pads of first 2-3 fingers
- count for 30 sec, double # (full min if irregular)
- Force:
--- 3+= Bounding
--- 2+= Strong/normal
--- 1+= Weak/thready
--- 0= Absent
- check bilaterally for equality
*Ratio of pulse rate to respiratory rate should be approximately 4:1*
Vitals: Respiratory rate - answerNormal range: 10-20 per minute
- rate, rhythm, depth
- should be unlaboured, normal depth, regular pattern
- count 30 sec, double # (irregular count full min)
- watch chest rise and fall
- don't tell patient you are doing this as it may affect rate
*Ratio of pulse rate to respiratory rate should be approximately 4:1*
Vitals: Blood Pressure - answerNormal range: 120-139/80-89 mmHg
, Prep:
- pt at rest at least 5 minutes
- no exercise for 30 minutes
- no caffeine for 60 minutes
- Sit supported, feet flat on floor or lay on bed
- Have arm at level of heart, palm upward
- legs uncrossed
- ensure no IVs, mastectomies, fistulas, injured areas
- no speaking during measurement
- ensure cuff is appropriate size
-- - Cuff width = 40% of pt's arm circumference
--- Cuff bladder length = 80% of arm circumference
- hand hygiene!
- palpate brachial artery: medial to bicep tendon
- place artery marker on cuff 2.5 cm above artery
- wrap cuff even and comfortably tight
- stethoscope in ears, ON
- BELL SIDE on artery
- inflate to 30mmHg above pulse gone/last systolic
- inflate 2-3mmHg/sec
- note 1st korotkoff sound (systolic)
- note 5th korotkoff sound (diastolic)
- listen 10-20 mmHg below 5th, release rest
- remove and Disinfect cuff! hand hygiene
- if first admission, measure bilaterally
Vitals: Temperature - answerNormal range: 36-38 degrees C
- under tongue
- mouth closed around probe
- WAIT 20 min after pt drank hot/cold drink, 5 min if pt just chewed gum, 2 min if pt just
smoked
- rectal: 0.5 C higher, axillary 0.5 C lower than oral
Vitals: O2 Saturation - answerNormal Range: 95-100%
- appropriate size
- check for nail polish or artificial nails
- hold hand still
- use opposite hand of BP cuff
Vitals: Pain - answerNormal: 0
- ask pt to rate on scale
