8.1 Understanding Vital Signs and Normal Ranges
Key Takeaways
- The five vital signs are temperature, pulse, respirations, blood pressure, and pain
- Normal ranges: T: 97.6-99.6°F, P: 60-100 bpm, R: 12-20/min, BP: 90-120/60-80 mmHg
- Report immediately: T >101°F or <96°F, P >100 or <60, R >24 or <10, BP >160 or <90 systolic
- Vital signs are affected by age, activity, stress, medications, pain, and time of day
- Always document date, time, method, position, abnormal findings, and who was notified
- Vital signs measurement is part of INACE Duty Area 2 and several mandated skills
Last updated: March 2026
Understanding Vital Signs and Normal Ranges
Vital signs are measurements of the body's most basic functions. They are called "vital" because they indicate whether essential life processes are functioning within normal limits. Vital signs are part of Duty Area 2 (Performing Basic Nursing Skills) on the INACE, and several of the 21 mandated performance skills involve taking and recording vital signs.
The Five Vital Signs
| Vital Sign | Abbreviation | Normal Adult Range | Unit |
|---|---|---|---|
| Temperature | T or Temp | 97.6°F - 99.6°F (36.4°C - 37.6°C) | Degrees Fahrenheit or Celsius |
| Pulse | P or HR | 60-100 beats per minute | beats/min (bpm) |
| Respirations | R or RR | 12-20 breaths per minute | breaths/min |
| Blood Pressure | B/P or BP | Systolic: 90-120 / Diastolic: 60-80 mmHg | mmHg |
| Pain | Often called the "5th vital sign" | 0-10 scale (0 = no pain, 10 = worst) | Numeric rating |
When to Take Vital Signs
| Timing | Reason |
|---|---|
| On admission | Establish baseline values |
| At scheduled times | Per care plan (e.g., every shift, twice daily) |
| Before and after procedures | Monitor for adverse effects |
| When condition changes | Detect deterioration early |
| When resident complains | Validate symptoms objectively |
| Before giving PRN medications | Nurse needs baseline before treatment |
| As ordered by physician | Specific monitoring orders |
Factors That Affect Vital Signs
| Factor | Effect |
|---|---|
| Age | Elderly may have lower temperature, higher blood pressure |
| Activity | Exercise increases pulse, respirations, and temperature |
| Stress/Anxiety | Increases pulse, blood pressure, and respirations |
| Medications | Blood pressure meds lower BP; beta-blockers lower pulse |
| Pain | Increases pulse, blood pressure, and respirations |
| Illness/Infection | Increases temperature, pulse, and respirations |
| Time of day | Temperature lowest in morning, highest in late afternoon |
| Dehydration | Increases pulse; may decrease blood pressure |
What to Report Immediately
Report these vital sign findings to the nurse immediately:
| Vital Sign | Report If |
|---|---|
| Temperature | Above 101°F (38.3°C) or below 96°F (35.6°C) |
| Pulse | Above 100 bpm (tachycardia) or below 60 bpm (bradycardia), or irregular |
| Respirations | Above 24/min (tachypnea) or below 10/min, or labored/difficult |
| Blood Pressure | Systolic above 160 or below 90; Diastolic above 90 or below 60 |
| Pain | Any new pain or sudden increase in pain level |
| Oxygen saturation | Below 90% (if taking pulse oximetry readings) |
Vital Signs Documentation
Always record vital signs with:
- Date and time of measurement
- Method used (e.g., oral temperature, right arm blood pressure)
- Position (sitting, standing, lying down — especially for blood pressure)
- Any abnormal findings reported to the nurse and nurse's response
- Your name and title (CNA)
Test Your Knowledge
What is the normal range for an adult resting pulse rate?
A
B
C
D
Test Your Knowledge
Which of the following vital sign findings should be reported to the nurse IMMEDIATELY?
A
B
C
D