Vital Signs
Vital signs are the fundamental measurements of basic body functions: temperature, pulse (heart rate), respirations (breathing rate), blood pressure, and pain (often called the "5th vital sign"). They provide critical data about a patient's physiological status and are assessed by all levels of nursing staff.
Exam Tip
Normal adult VS: T 98.6°F, P 60-100, R 12-20, BP <120/<80. Rectal is most accurate temperature. Apical pulse is most accurate heart rate. Hold digoxin if apical pulse <60. Report abnormal VS to RN immediately. Always check VS before medications that affect them.
What Are Vital Signs?
Vital signs are the most basic and essential clinical measurements used to assess a patient's physical condition. They reflect the functioning of the body's vital organs and are used to detect medical problems, monitor treatment effectiveness, and guide clinical decisions.
The Five Vital Signs
| Vital Sign | Normal Adult Range | Unit |
|---|---|---|
| Temperature (T) | 97.8-99.1°F (36.5-37.3°C) oral | Degrees F or C |
| Pulse (P/HR) | 60-100 beats per minute | bpm |
| Respirations (R/RR) | 12-20 breaths per minute | breaths/min |
| Blood Pressure (BP) | Systolic <120, Diastolic <80 mmHg | mmHg |
| Pain | 0-10 scale (0 = no pain, 10 = worst pain) | Numeric or descriptive |
Temperature Measurement
| Route | Normal Range | Time | Considerations |
|---|---|---|---|
| Oral | 98.6°F (37°C) | 3-5 min | Most common; wait 15-30 min after eating/drinking |
| Rectal | 99.6°F (37.5°C) | 2-3 min | Most accurate; contraindicated in neutropenia, cardiac conditions |
| Axillary | 97.6°F (36.4°C) | 5-10 min | Least accurate; used for screening |
| Tympanic | 98.6°F (37°C) | Seconds | Quick; pull ear up and back (adult) |
| Temporal artery | 98.6°F (37°C) | Seconds | Non-invasive; good for screening |
Blood Pressure Categories (AHA)
| Category | Systolic | Diastolic |
|---|---|---|
| Normal | <120 | AND <80 |
| Elevated | 120-129 | AND <80 |
| Stage 1 Hypertension | 130-139 | OR 80-89 |
| Stage 2 Hypertension | >=140 | OR >=90 |
| Hypertensive Crisis | >180 | AND/OR >120 |
Pulse Assessment
| Location | When Used |
|---|---|
| Radial | Routine vital signs (most common) |
| Apical | Before administering cardiac medications (digoxin); most accurate |
| Carotid | Emergency assessment (CPR) |
| Pedal (dorsalis pedis) | Assessing peripheral circulation |
| Brachial | Blood pressure measurement; infant pulse |
Key Nursing Considerations
- Assess vital signs on admission, before/after procedures, before/after medication administration, and with any change in condition
- Report abnormal vital signs to the RN immediately
- Do NOT administer medications that affect vital signs without checking the relevant vital sign first (e.g., check apical pulse before digoxin; hold if <60 bpm)
- Document trends, not just individual readings
- Consider the patient's baseline when interpreting results
- Oxygen saturation (SpO2) is often assessed alongside traditional vital signs (normal: 95-100%)
Exam Alert
Vital signs questions appear throughout the NCLEX-PN, especially in Reduction of Risk Potential and Pharmacological Therapies. Know normal ranges, when to hold medications (digoxin: hold if apical pulse <60), and when to report findings to the RN. Always check vital signs BEFORE administering medications that affect them.
Study This Term In
Related Terms
Focused Assessment
A focused assessment is a detailed nursing assessment of a specific body system or complaint, performed after the initial comprehensive assessment to gather more information about a particular health concern or to monitor a known condition.
Nursing Process
The nursing process is a systematic, five-step problem-solving framework used by nurses to provide patient-centered care: Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE). It is the foundation of all nursing practice and the organizing framework for the NCLEX.
Glasgow Coma Scale (GCS)
The Glasgow Coma Scale (GCS) is a standardized neurological assessment tool that evaluates a patient's level of consciousness by scoring three responses: eye opening (1-4), verbal response (1-5), and motor response (1-6), for a total score of 3-15.
Intake and Output (I&O)
Intake and Output (I&O) is a nursing measurement that tracks all fluids entering (intake) and leaving (output) a patient's body over a specified period, typically 24 hours. Accurate I&O monitoring is essential for assessing fluid balance, kidney function, and hydration status.
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