Vital Signs, Observation and Reporting
10% of the exam 4 min
Ten percent of the exam: temperature, pulse and respiration (named in the federal rule itself), blood pressure, weight, pain, what to report right away, and how to write an objective note.
The normal adult ranges
A resting adult pulse is 60 to 100 beats per minute and respirations are 12 to 20 breaths per minute. Distractors swap these two ranges on purpose. Normal blood pressure, by American Heart Association categories, is a systolic below 120 and a diastolic below 80; elevated is 120 to 129 with a diastolic below 80; stage 1 high blood pressure starts at 130 or 80; above 180 and/or 120 is a crisis. A temperature of 100.4°F (38°C) or higher is the common definition of fever, but older adults can have a serious infection with only a small rise, or with new confusion instead of fever. A healthy adult's pulse oximeter reading is usually 95% to 100%; some clients with lung disease have a lower usual range set by their doctor. Always compare a reading with the range in the client's care plan.
Measuring correctly
Wait about 15 minutes after the client eats, drinks, chews gum or smokes before taking an oral temperature. Do not take an oral temperature on a client who is confused or unconscious, has a seizure history, receives oxygen by mask, breathes through the mouth, or had recent mouth surgery. Axillary readings run about 1°F lower than oral and are the least accurate; rectal readings run about 1°F higher. Record the method. For a tympanic reading on an adult, pull the ear gently up and back. Feel the radial pulse with two or three fingertips on the thumb side of the inner wrist, never with your thumb, which has its own pulse. Count an irregular pulse for a full minute. Count respirations right after the pulse, fingers still on the wrist, so the client does not change their breathing. For blood pressure, support the arm at heart level, palm up, and avoid an arm with a dialysis fistula, IV, cast or injury, or on the side of a mastectomy.
Weight, pain and the body's warning signs
Daily weights only mean something when taken the same way: same time (usually morning, after urinating, before breakfast), same scale, similar clothing. In heart failure, a gain of 2 to 3 pounds in a day or 5 pounds in a week commonly signals fluid buildup and is reported, unless the care plan sets another number. Pain is what the client says it is. On a 0 to 10 scale, 7 to 10 is severe. Clients who cannot describe pain, such as those with advanced dementia, show it through grimacing, moaning, guarding a body part, restlessness, refusing to move or new agitation. Other signs to watch: bluish lips or nail beds (possible low oxygen), a fruity breath odor in a person with diabetes (possible ketoacidosis), dark or cloudy or foul-smelling urine, and black, tarry stool (possible upper digestive bleeding).
What to report, and how fast
Reporting is telling the nurse; recording is writing it in the record. Important changes get both. Report immediately, and call 911 first if agency policy calls for it: sudden confusion or slurred speech, chest pain or pressure, trouble breathing, bluish color, a fall, uncontrolled bleeding, a client who cannot be roused, signs of stroke, and readings far outside the normal or care-plan range. Report promptly but routinely: small changes in appetite, sleep, mood, bowel or bladder habits, and new minor complaints. Federal rules list 'changes in body function that must be reported' as a training subject in itself, so the exam rewards the aide who reports a change rather than the one who decides it is probably nothing.
Writing the note
Objective observations, also called signs, are what you can see, hear, smell, feel or measure, such as 'vomited about one cup of green fluid'. Subjective observations, or symptoms, are what the client tells you. Record them in the client's own words: Client states, "My chest feels tight." Never diagnose ('has a heart problem') or label ('was difficult all day'). Be specific and measurable: 'refused lunch; ate 2 crackers and drank 4 oz juice'. Many agencies use 24-hour time: add 12 to PM hours, so 3:30 PM is 1530. Know the common abbreviations: NPO means nothing by mouth, PRN as needed, BID twice a day, TID three times a day, q every (q2h, every 2 hours), c/o complains of, SOB shortness of breath, I&O intake and output.
Where people lose points
✗ "Normal adult respirations are 60 to 100."
✓ 60 to 100 is the pulse. Respirations are 12 to 20.
✗ "A digital thermometer reads correctly right after a hot drink."
✓ It reads faster, but it cannot correct a warm mouth. Wait about 15 minutes.
✗ "An irregular pulse can be counted for 30 seconds and doubled."
✓ Count an irregular pulse for a full 60 seconds.
✗ "An arm hanging down gives the most relaxed, accurate blood pressure."
✓ An arm below heart level reads falsely high. Support it at heart level.
✗ "'Client states she feels dizzy' is an objective observation."
✓ It is subjective: something the client reports. Objective is what you observe or measure.
✗ "Small changes are not worth bothering the nurse with."
✓ Reporting changes in body function is a federal training subject. Report, and let the nurse decide.
Numbers to memorize
| Adult pulse | 60-100 per minute |
| Adult respirations | 12-20 per minute |
| Normal blood pressure (AHA) | Under 120 and under 80 |
| Fever | 100.4°F (38°C) or higher |
| Oral temperature wait | About 15 minutes after eating, drinking or smoking |
| Axillary vs oral | About 1°F lower; rectal about 1°F higher |
| Pulse oximeter, healthy adult | 95-100%, or the care-plan range |
| Heart failure weight gain to report | 2-3 lb in a day or 5 lb in a week, unless the plan says otherwise |
| Severe pain | 7-10 on a 0-10 scale |
| 1 fluid ounce | About 30 mL |
| 3:30 PM in 24-hour time | 1530 |
| NPO / PRN / q2h | Nothing by mouth / as needed / every 2 hours |
Test yourself
No answers here on purpose — retrieving them is the practice. Drill this domain if any of these stall you.
- Give the normal ranges for adult pulse, respirations and blood pressure.
- List four clients who should not have an oral temperature taken.
- Explain how to make daily weights comparable from day to day.
- Name five changes the aide reports immediately.
- Write one objective and one subjective observation about the same client.
- Convert 9:15 PM to 24-hour time and explain NPO.