Vital signs and physical assessment

Foundations items ask whether you measured the right vital the right way and whether the number matches the client in front of you. This chapter owns temperature, pulse, respirations, blood pressure, SpO2, pain, vital-sign craft, and drug-level timing. Head-to-toe technique, lung and heart findings, and abdomen red flags live in Adult physical assessment. Chest-pain perfusion mapping and focused stroke neuro exams stay in Acute coronary syndromes and Stroke and neuro assessment.

What counts as a vital-sign set

A vital sign is a decision tool, not chart decoration. The usual set is temperature, pulse, respirations, blood pressure, oxygen saturation, and pain. Tachycardia with fever means something different from tachycardia with bleeding. Hypotension with cool clammy skin is perfusion failure until proven otherwise. Always pair the number with symptoms, baseline, and trend. A “normal” BP that is 40 points below the client’s usual is still a finding.

Assistive personnel may collect many routine vitals, but interpretation, abnormal response, and deciding how often to recheck stay with the nurse. Document clearly and escalate unexpected values with the clinical picture attached.

When to measure

• On first contact / admission and during physical assessment
• Before and after invasive procedures or surgery
• Before, during, and after meds that change heart rate, BP, breathing, or temperature control
• Before, during, and after transfusion
• When the client’s condition changes or they report feeling “different” or sick
• Before/after interventions that stress the system (for example, first ambulation)
• With fever or known infection on a tighter schedule (often every 2 to 4 hours per protocol)

Temperature

Body temperature reflects heat production and heat loss. It runs lower on waking, often peaks in late afternoon or evening, and shifts with environment, exercise, stress, infection, the menstrual cycle, pregnancy, and age. Infants do not regulate heat as tightly as older children and adults. An inability to obtain any temperature reading is not a documentation annoyance. In the very young or older adult it can signal hypothermia, which is an emergency path.

Rectal technique, when it is the right choice: left side-lying, lubricated probe aimed toward the umbilicus, about 1.5 inches (3.8 cm) in an adult and no more than about 0.5 inch (1.25 cm) in an infant. Fever care treats the cause and comfort. Shivering and heavy chilling raise oxygen demand, so warm lightly while you follow antipyretic orders rather than forcing a cold bath that triggers more shivering.

• Fahrenheit to Celsius: (°F − 32) × 5/9
• Celsius to Fahrenheit: (°C × 9/5) + 32
• Follow the device’s instructions. Electronic probes are not interchangeable by guesswork.

Pulse

A peripheral pulse is a palpable pressure wave. Rate alone is not enough. Note rhythm, strength (amplitude), and equality side to side. Changes after ambulation, bathing, or exercise tell you whether the client tolerated the work. When BP falls or circulating volume falls, the heart rate usually rises as compensation. Pain, fever, stimulants, emotions, and hemorrhage push the rate up; many cardiac depressants and aging slow it.

Know the common sites well enough to choose them on sight. Radial at the thumb side of the wrist is the routine count. Apical at the left midclavicular line, fifth intercostal space, is for accuracy. Carotid sits in the groove beside the trachea (never massage both at once). Brachial at the antecubital fossa is for infant counts and BP. Femoral, popliteal, posterior tibial, and dorsalis pedis map limb perfusion. If a pedal pulse is hard to feel, a Doppler ultrasound probe with gel can confirm flow that fingers miss.

Apical count and pulse deficit

Count the apical pulse for a full minute when the radial pulse is irregular, when a heart condition is on the stem, before digoxin or beta blockers as ordered, and in children younger than 2 years. Hold and notify for bradycardia per parameters. A pulse deficit means the apical rate is higher than the radial rate: some ventricular beats are not generating a peripheral wave. One nurse can count apical then radial back to back; two nurses can count simultaneously. Either way, a real deficit is reported.

• Irregular rhythms: count a full minute at the apex when the stem demands accuracy.
• Compare right and left pulses when perfusion or arterial disease is the question.
• Document rate, rhythm, quality, and which site you used.

Respirations

One respiration is one inspiration plus one expiration. Assess rate, depth, pattern, and sounds. Adult baseline is usually 12 to 20 breaths per minute; age changes the expected range. High CO2 or low oxygen drives the rate up. Opioids and other CNS depressants slow it. Head injury or rising intracranial pressure can shallow or slow breathing because the brainstem drive is impaired. Exercise, pain, anxiety, smoking, and body position also move the number.

Count after the radial pulse while you still hold the wrist, or rest your hand lightly on the chest, so the client does not consciously change their breathing. Thirty seconds times two is fine when breathing is regular and the client is stable. Count a full minute when the client is very ill or the pattern is irregular.

Blood pressure

Systolic pressure is the peak during ventricular ejection. Diastolic pressure is the force remaining while the heart rests. Pulse pressure is the difference between them. Adult categories from ACC/AHA are the pattern most exams expect you to recognize, even though treatment thresholds also weigh cardiovascular risk.

BP tends to rise with age and stress, runs lower in the early morning, and can read high after smoking or exercise. Have the client rest about 5 minutes, sit with feet flat or lie as protocol says, and stay quiet during the reading. Choose the right site. Avoid an arm with an AV fistula or shunt, the side of mastectomy or axillary node dissection as taught, a traumatized or diseased limb, and an arm with infusing IV fluids when another site exists. The thigh with a popliteal artery is a fallback when both arms are unusable.

• Cuff too small → falsely high BP. Cuff too large → falsely low BP.
• First Korotkoff sound (phase 1) = systolic. Beginning of phase 5 silence = diastolic in most adults.
• If an electronic machine reading looks wrong for the client, confirm with a manual cuff.
• No smoking or exercise in the 30 minutes before a reading when you need accuracy.

Orthostatic (postural) vitals

Orthostatic hypotension is a drop in BP with position change that produces symptoms such as dizziness or near-syncope. Measure BP and pulse supine, then sitting, then standing, waiting the protocol interval (commonly 1 to 3 minutes) after each change. Stop if the client is about to faint. Teaching is slow position change, dangle, and call for help, not “push through the dizziness.” Review antihypertensives and volume status when orthostasis appears.

Pulse oximetry (SpO2)

Pulse oximetry estimates the percent of hemoglobin carrying oxygen. It can warn you about hypoxemia before cyanosis is obvious. A usual adult target is 95% to 100%. Values under about 90% generally need provider notification unless the client already has an established chronic target. Agency parameters win when they are on the stem.

Place the sensor on a vascular pulsatile site: finger, toe, earlobe, nose, or forehead per device. Skip a cold extremity or one with impaired flow. Anything that blocks light transmission can spoil the number: sensor motion, dark nail polish, hypotension, anemia, and peripheral vascular disease. When a reading is low, look at the client first. Support oxygenation as indicated, coach deep breathing when appropriate, and recheck rather than trusting a single odd digit in isolation.

Pain: the sixth piece of the set

Pain is subjective. Ask timing, location, severity, quality, what worsens or relieves it, and what the client already tried. Older adults may show pain as sleep change, gait change, withdrawal, or depression rather than a dramatic report. Clients with dementia or who are unresponsive still hurt. Watch nonverbal cues and use an appropriate behavioral or faces-style scale.

Wong-Baker FACES pain rating scale

When a child or a client who cannot give a clean 0 to 10 number needs a severity score, offer a faces scale. The client points to the face that matches their pain. Wong-Baker FACES uses even numbers from 0 to 10 so the score still lands on the same 0 to 10 band used for adults. Document the number, not a vague “looked uncomfortable.” FLACC (face, legs, activity, cry, consolability) is the behavioral alternative when the client cannot point.

Reassess after pharmacologic and nonpharmacologic measures. Heat, cold, positioning, binders, and ordered TENS can help selected pains, but crushing chest pain or a client who cannot breathe is not a “finish the pain scale first” moment. Those stems move into cardiac and respiratory chapters once you recognize the emergency.

Vital signs that change the plan

Once technique is solid, the exam asks whether you notice the trend that means bleeding, sepsis, respiratory failure, or drug effect.

Where technique order lives

Abdominal sequence (listen before you poke), lung and heart findings to report, capillary refill, LOC change, and rigid-abdomen emergencies are taught in Adult physical assessment. Keep that chapter open when the stem is about hands and stethoscopes rather than the vital-sign number itself.

Therapeutic drug monitoring

Some drugs need blood levels because the gap between help and harm is narrow: digoxin, vancomycin, aminoglycosides, and similar agents on exams. A trough is usually drawn immediately before the next dose (lowest level). A peak is drawn after a dose or infusion finishes on a drug-specific clock. If timing is wrong, the lab number cannot guide the next dose safely.

Nursing responsibilities: hold or give as parameters say, draw from the correct line (not from the same lumen that is infusing the drug when that contaminates the sample), label time accurately, and notify for levels outside the ordered band with the clinical picture attached. Lithium and other psych levels also appear in mental-health stems. Same timing discipline.

Priority map