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01.04 Adult Vital Signs (VS)

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Overview

  1. Vital signs
    1. Temperature
    2. Pulse
    3. Respirations
    4. Blood Pressure
    5. SpO2
    6. Pain
  2. Proper technique is required to ensure accuracy of results
  3. Equipment needed
    1. Stethoscope
    2. Blood Pressure Cuff  & Sphygmomanometer
      1. Or automated BP cuff
    3. Thermometer
    4. Pulse Oximeter
    5. Watch with second hand

Nursing Points

General

  1. Temperature
    1. 97.8 – 99.1°F
    2. Oral – place probe in pocket under tongue, have pt close mouth
      1. Not accurate if pt has eaten or drank in the last 15 minutes
    3. Axillary – place probe in axilla and have pt put arm by their side
      1. Least accurate
    4. Temporal – swipe across forehead or place on temple (follow manufacturer instructions)
    5. Rectal – Apply small amount of lubricant jelly to probe, place probe in rectum and wait for result.
      1. Do not use excessive amounts of lubricant or results will be inaccurate
  2. Pulse
    1. 60 – 100 beats per minute
    2. Apical – place stethoscope over the apex of the heart (5th intercostal space, left midclavicular line). Listen for a full minute
    3. Radial – locate the groove below the thumb on the inside of the wrist to find the radial pulse. Count pulse for 30 seconds, multiply by 2
      1. Can also count for a full minute for more accuracy
    4. Carotid – place two fingers on the thyroid cartilage, slide to the side into the groove, approximately 2 inches. Count pulse for 30 seconds and multiply by 2
      1. Never palpate bilateral carotid pulses at the same time
  3. Respirations
    1. 12 – 20 breaths per minute
    2. Count breaths for 30 seconds, multiply by 2
    3. TIPS:
      1. Do not tell the patient you are counting their breaths – they’ll breath differently
      2. After counting pulse for 30 seconds, continue holding pulse but count respirations for another 30 seconds
      3. Some thermometers have a timer function that will beep every 15 seconds. You can count respirations while waiting for the thermometer to result
  4. Blood Pressure
    1. <120 / <80 mmHg
    2. Equipment required – stethoscope, cuff, sphygmomanometer
    3. Position patient – sitting, legs uncrossed, arm at heart level
    4. Ensure proper sizing of cuff
      1. Follow range lines on cuff
    5. Steps for Manual:
      1. Feel for brachial pulse
      2. Wrap cuff around upper arm, leaving room for 2 fingers under cuff
        1. Arrow should point to the brachial pulse
      3. Place diaphragm of stethoscope over the brachial artery/pulse
      4. Tighten the valve on the bulb inflator
      5. Inflate the cuff until:
        1. Unable to hear brachial pulse (160 – 180 mmHg)
        2. 30-40 mmHg above patient’s baseline
      6. Slowly release the air from the cuff by opening the valve
        1. Should release 2-3 mmHg per second
      7. Listen for “boof” sound of pulse – the FIRST sound you hear is the Systolic BP
      8. The pulse sound will begin to fade – the LAST sound you hear is the Diastolic BP
      9. Do NOT watch the bouncing of the arm on the meter – only count based on what you hear
    6. Document Systolic BP / Diastolic BP
  5. SpO2 (Pulse Oximetry)
    1. 95 – 100%
    2. Ensure fingernail free of polish, warm hands with a warm towel if needed to improve circulation
    3. Place probe with UV light on top of fingernail.  Result will show within 3-5 seconds
    4. Special probes also available for ears, noses, and foreheads
  6. Pain
    1. Subjective – whatever the patient says it is
    2. Use appropriate pain scale to quantify the patient’s pain
    3. Use PQRST or OLDCARTS to assess more details about pain

Assessment

  1. Temperature
    1. High
      1. Fever
      2. Infection
      3. Neurologic injury
      4. Hyperthyroidism
    2. Low
      1. Exposure to cold
      2. Drug/alcohol abuse
      3. Diabetes
      4. Hypothyroidism
  2. Pulse
    1. High
      1. Fear/Anxiety
      2. Arrhythmia
      3. Hypovolemia
      4. Exertion/Activity
    2. Low
      1. Arrhythmia
      2. Coronary artery disease
      3. Infection
      4. Electrolyte imbalance
      5. *May also be low baseline in very athletic patients
  3. Respirations
    1. High
      1. Fear/pain
      2. Asthma
      3. Pneumonia
      4. Neurologic injury
    2. Low
      1. Alkalosis
      2. Neurologic injury
      3. Opioid overdose
      4. Oversedation
  4. Blood Pressure
    1. High
      1. Pain
      2. Heart failure
      3. Volume overload
      4. Kidney failure
      5. Neurological injuries
    2. Low
      1. Medication reaction
      2. Shock
      3. Hemorrhage
      4. Arrhythmias
      5. *May also be low baseline in very athletic patients
  5. SpO2
    1. High
      1. O2 toxicity
    2. Low
      1. Hypoxia
      2. Asthma/COPD
      3. ARDS
      4. Pneumonia
      5. Collapse
        1. Atelectasis
        2. Pneumothorax
        3. Hemothorax

Therapeutic Management

  1. Note trends in vital signs
  2. Report abnormal vitals to healthcare provider
  3. Treat cause

Patient Education

  1. Purpose for vital signs
  2. Frequency of vital signs

Reference Links

Study Tools

Video Transcript

In this video we’re going to walk you through proper technique on obtaining vital signs. It’s so important that you use the correct technique in order to obtain accurate results! The 5 vital signs we’ll review are Temperature, Pulse, Respirations, Blood Pressure, and SpO2 or Pulse Oximetry.

To take an oral temperature, remove the probe from the thermometer and attach a probe cover. Place the probe in the pocket under the tongue and have the patient close their mouth. Make sure they haven’t had anything to eat or drink in at least 15 minutes. Normal temperature for an adult is 97.8 to 99.1 degrees Fahrenheit.

To take an axillary temperature, place the covered probe under the patient’s arm, in the axilla, and have them place their arm by their side. While this isn’t the most accurate temperature, and usually runs a full degree lower than oral, it is a good option if the other routes are unavailable. You could also use a temporal thermometer or rectal temperature when appropriate.

Next, we check the pulse, which is the number of times the heart beats in one minute. Normal for an adult is 60 – 100 beats per minute. When checking a pulse, you have a few options. The first is the apical pulse. To get an apical pulse, place the diaphragm of your stethoscope over the apex of the heart – which is the 5th intercostal space, midclavicular line. Always listen for a full minute for an apical pulse.

To obtain a radial pulse, locate the groove just below the thumb on the inside of the patient’s wrist. Palpate the pulse and count for 30 seconds, then multiply by two. This will give you your beats per minute.

To obtain a Carotid pulse, place two fingers on the thyroid cartilage in the front of the neck, then slide your fingers to the side into the groove just below the jaw line. Again, you will want to palpate the pulse for 30 seconds and multiply that number by two. One important thing to know here is you should never palpate both carotid arteries at the same time.
When obtaining a patient’s respiratory rate, it’s important that you don’t tell them you are counting their breaths – otherwise they will breathe differently. One trick is to count the radial pulse for 30 seconds, then – while still holding the patient’s wrist, count the respirations for another 30 seconds, then multiply by two. The patient will think you’re still counting their pulse. You can also count respirations while waiting for the temperature to result. Some thermometers even have a timer function that will beep every 15 seconds so you can count respirations!

Getting a blood pressure isn’t always as simple as slapping a cuff on and pressing start. Sometimes we have to take the blood pressure manually. First things first, your patient should be sitting upright, legs uncrossed, with their arm at heart level – if that means you need to prop their arm up on a pillow, then do that. Then you want to make sure you have the right size cuff. Wrap the cuff around the top of their arm and look at the range markings. If the cuff is in range, you can use it – otherwise get a bigger or smaller size as needed.

Now you can get started. The first thing you need to do is feel for the patient’s brachial pulse on the inside of their elbow. Then you’re going to wrap the blood pressure cuff around their upper arm with the indicator line or arrow pointing to their brachial artery.

Make sure that you have the sphygmomanometer where you can see it and place your stethoscope over the Brachial artery.
Make sure the valve on the bulb inflator is closed. You’ll want to inflate the cuff by squeezing the bulb until you can’t hear the brachial pulse anymore, which on average is usually between 160 and 180 mmHg. OR inflate to about 30 to 40 mmHg above the patient’s baseline blood pressure.

Then, carefully open the valve very slowly and begin deflating the cuff at about 2-3 mmHg per second. As the pressure drops you will begin to hear a ‘boof’ pulse sound. Take note of the pressure at that moment – that is your systolic blood pressure.
Continue deflating until the pulse sound fades and you no longer hear it. The point at which you no longer hear the pulse is your diastolic blood pressure. Careful that you aren’t just watching the needle bounce, that won’t be accurate – it has to be what you hear. Once you have your numbers you can fully deflate and remove the cuff. This is a skill that takes a lot of practice, so grab a friend and practice on each other!

Last is pulse oximetry – first, make sure your patient’s fingers are nice and warm, you can even wrap them in a warm towel if you need to – because we need good circulation for the pulse ox. We also want them to have no nail polish on.
All you have to do is apply the probe with the red light on top of the fingernail and wait! You should get a result in about 5 seconds and that’s the number you’ll document. If you’re still having trouble with circulation, try a different hand, a toe, or you can even use probes for ears and noses as well!
Last, but certainly not least – DOCUMENT the vital signs!

We hope that was a helpful review on how to take a set of vital signs on an adult! The more you practice, the better you’ll get at it! Now, go out and be your best self today. And, as always, happy nursing!

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