Vital signs and assessment
Vital signs are the most basic measurements of a patient's condition. Changes often give the earliest warning of deterioration. For study only, not clinical guidance: always follow your programme, current local protocols, and supervising clinicians.
The vital signs
The classic vital signs are temperature, pulse, respiratory rate, and blood pressure. Oxygen saturation (SpO2) and pain are often added. They should be measured accurately, compared with the patient's baseline, and interpreted in context, not in isolation.
Typical adult ranges
Commonly taught adult reference ranges are: heart rate 60-100 beats per minute; respiratory rate 12-20 breaths per minute; blood pressure below 120/80 mmHg considered normal; oral temperature about 36.5-37.5 degrees C (97.7-99.5 F); and SpO2 about 95-100% for most healthy adults. Ranges vary by age, condition, and local policy.
Pulse
The pulse is usually counted at the radial artery for 30 seconds (doubled) if regular, or a full minute if irregular. The apical pulse, heard with a stethoscope at the heart's apex, is used for infants and before giving certain cardiac medications. Note rate, rhythm, and strength.
Respirations
Count respirations without telling the patient, since awareness changes breathing, often while appearing to still take the pulse. Note rate, depth, rhythm, and effort, including use of accessory muscles. A rising respiratory rate is one of the most sensitive early signs of deterioration.
Blood pressure
Use the correct cuff size: too small gives falsely high readings, too large falsely low. Position the arm at heart level with the patient seated and relaxed. Systolic pressure is the first sound heard as the cuff deflates; diastolic is when the sounds disappear. Orthostatic hypotension is a drop in pressure on standing.
Head-to-toe assessment
A systematic physical assessment uses inspection (looking), palpation (feeling), percussion (tapping), and auscultation (listening). For the abdomen, the order changes: inspect, auscultate, then percuss and palpate, because touching can alter bowel sounds.
Early warning scores
Many hospitals use early warning scores, such as the National Early Warning Score (NEWS2) in the UK, which combine vital signs into a single score. Rising scores trigger escalation to senior clinicians or rapid response teams, helping catch deterioration before cardiac arrest.
Worked example
A patient's baseline heart rate is 72 and respiratory rate 16. Two hours later they are 112 and 26, with new confusion, though blood pressure is still normal. These changes suggest deterioration, possibly early sepsis, even before blood pressure falls. The nurse should escalate promptly according to protocol.
Key takeaways
Vital signs are temperature, pulse, respirations, blood pressure, often plus SpO2 and pain. Common adult ranges include HR 60-100, RR 12-20, BP under 120/80, and SpO2 95-100%. Use correct technique, cuff size, and baseline comparison. Respiratory rate is a sensitive early warning sign. Assessment uses inspection, palpation, percussion, and auscultation (abdomen: auscultate before palpating). Early warning scores guide escalation.
Flashcard
Temperature, pulse, respirations, blood pressure
Check your understanding
Why is the abdomen auscultated before it is palpated?