• What it is: temperature (heat balance), pulse (heart rate/rhythm/circulation), respirations (gas exchange), and blood pressure (force of blood on artery walls during systole and diastole) — the fastest, cheapest window into a patient's physiologic status.
• Why the nurse does it: a trending or acutely abnormal vital sign is usually the first sign something is wrong, often before the patient can tell you.
• Whose job / where it lives: a UAP may collect routine vital signs on a stable patient, but the RN interprets abnormal findings and reassesses — because interpreting and acting on the number is nursing judgment, not data collection.

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• "12–20, 60–100, below 90 means go" → the three numbers that trigger action fastest: respirations 12–20/min, pulse 60–100/min, and SpO₂/SBP below 90 = act now.
• VEAL vs the four heat-loss words — "CCER" → Conduction (direct contact), Convection (air currents), Evaporation (water vapor/sweat), Radiation (no contact) — the four ways the body loses heat.
• "Small cuff, big number; big cuff, small number" → a cuff that's too small gives a falsely high reading; a cuff that's too large gives a falsely low reading.

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Picture it: vital signs are your car's dashboard gauges — you don't diagnose the engine from the gauge alone, but a gauge in the red tells you to stop and look immediately.

The purpose: temperature reflects the balance between heat produced and heat lost; pulse reflects heart rate/rhythm and circulatory status; respirations reflect the exchange of O₂ and CO₂; blood pressure reflects the force blood exerts on artery walls during systole (contraction) and diastole (relaxation). Pulse oximetry (SpO₂) and pain are also treated as vital signs at most facilities.

Normal numbers — adult:

• Temperature: oral 36–38°C (96.8–100.4°F), average 37°C (98.6°F). Rectal runs 0.5°C (0.9°F) higher than oral/tympanic; axillary runs 0.5°C (0.9°F) lower; temporal runs close to rectal — about 0.5°C (1°F) higher than oral and 1°C (2°F) higher than axillary.
• Pulse: 60–100/min at rest, regular rhythm, equal and symmetrical bilaterally, strength graded 0 (absent) to 4+ (bounding), with 2+ (brisk) as the expected finding.
• Respirations: 12–20/min, regular rhythm (eupnea) with an occasional sigh, normal depth.
• Blood pressure: normal is <120/80 mm Hg (BP = cardiac output × systemic vascular resistance — anything that raises CO or SVR raises BP, and anything that lowers them lowers BP).
• SpO₂: 95–100%, though a client with chronic lung disease may tolerate as low as 85% per provider-prescribed parameters. The commonly prescribed target in COPD is 88–92% 🚨 — because a COPD client's drive to breathe can be blunted by over-oxygenation, so "fix" a saturation of 90% in COPD and you may stop them breathing. Read the client's ordered parameters before you touch the flowmeter.

The full blood pressure classification (the exam grades by the HIGHER of the two numbers):

Watch the connectors: Normal and Elevated need BOTH numbers to qualify; the hypertension stages need only ONE. That is why 124/92 is Stage 2 — the diastolic alone carries it. Hypertensive crisis is the one that isn't a category, it's an event — reassess in 5 minutes and, if it holds, escalate immediately.

Words to know: core temperature sites = rectum, tympanic membrane, temporal artery, pulmonary artery, esophagus, bladder; surface sites = skin, mouth, axillae; pulse deficit = the difference between the apical rate and the radial rate (heart contracts but doesn't perfuse to the periphery); pulse pressure = the difference between systolic and diastolic readings.

Bottom line: know the exact normal number and site-adjustment for every vital sign — every abnormal finding in Step 3 is graded against these.

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Do it right: wrong technique gives you a wrong number, and a wrong number can trigger the wrong intervention — treat the technique as part of patient safety, not a formality.

Temperature

• Oral — place probe under the tongue in the posterior sublingual pocket lateral to the center of the lower jaw; use for clients ≥4 years old; do not use for clients who breathe through their mouth or have facial/mouth trauma. Wait 20–30 min after food, fluids, or smoking before measuring because recent intake alters the local temperature reading.
• Rectal — most accurate site; Sims' position, insert 2.5–3.5 cm (1–1.5 in) toward the umbilicus; stop immediately if you meet resistance 🚨. Never use on clients with diarrhea, bleeding precautions/low platelets, or rectal disorders, and never on infants <3 months (AAP). Use this site to verify any other-site reading >37.2°C (99°F).
• Axillary — probe centered in a clean, dry axilla, arm lowered over it; least accurate, but safest for clients where rectal/oral are contraindicated.
• Tympanic — pull the ear up and back (adult) or down and back (child <3 years); do not use electronic ear thermometers on infants ≤3 months (AAP) because readings are unreliable at that age; excess earwax also skews the result.
• Temporal — wipe the lens clean, hold flush against the forehead while scanning, then touch the probe behind the earlobe before reading.

Pulse

1. Locate the radial pulse at the wrist, radial/thumb side; palpate with the pads of two fingers (not your thumb, because your thumb has its own pulse and will mislead you).
2. If regular, count 30 sec × 2. If irregular, count a full 60 sec and compare to the apical rate 🚨 because an irregular peripheral pulse can miss beats that never make it to the periphery (pulse deficit).
3. Use the apical site (5th intercostal space, left midclavicular line, stethoscope diaphragm) for infants, before cardiac medications, or to verify a rate >100/min or an irregular rate — count 1 full minute if irregular or the client is on cardiovascular medications.
4. To find a true pulse deficit, two clinicians count apical and radial simultaneously.

Respirations

1. Do not tell the client you're counting 🚨 because awareness changes breathing pattern and gives a false rate.
2. Semi-Fowler's position, chest visible (or a hand/arm resting on the abdomen).
3. Observe one full cycle first, then start the timer.
4. Count 30 sec × 2 if regular; count a full 60 sec if irregular, >20/min, or <12/min. Note depth and rhythm along with rate.

Blood pressure (auscultatory method)

1. Client rests ≥5 min, no nicotine/caffeine in the prior 30 min, seated with feet flat, back and arm supported, arm at heart level.
2. Measure both arms initially; if they differ by >10 mm Hg, use the higher arm going forward because the gap itself can flag a vascular problem.
3. Never cuff an arm with an IV infusing, a mastectomy, or an AV shunt/fistula 🚨.
4. Cuff bladder should encircle 80% of adult arm circumference (whole arm for a child); cuff width 40% of arm circumference. Too small = falsely high; too large = falsely low.
5. Palpate the radial pulse while inflating to estimate systolic, then inflate 30 mm Hg above where the pulse disappeared; deflate, wait 1 min.
6. Stethoscope over the brachial artery, inflate to 30 mm Hg above the palpated systolic, release 2–3 mm Hg/sec. First clear sound = systolic; sounds muffle/disappear = diastolic.
7. Average two readings ≥2 min apart; if they differ by >5 mm Hg, take more and average.
8. Deflate completely and wait a full minute before reinflating because trapped air gives a falsely high reading.

The safety rules baked in: never measure BP on an arm with an IV/mastectomy/AV access; count a full minute on any irregular rhythm; don't announce you're counting respirations; verify a high other-site temperature rectally when appropriate; stop rectal insertion at resistance.

Bottom line: the technique itself is tested — the "obvious" step (regular vs. full-minute counting, cuff sizing, which arm) is usually the trap answer.

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Read the patient: a number alone never tells the whole story — always pair the value with how the patient looks.

Normal vs Abnormal

• Tachycardia — Normal: 60–100/min. Abnormal: >100/min because of exercise, fever, epinephrine/levothyroxine/albuterol, position change, acute pain, hyperthyroidism, anemia/hypoxemia, stress, or hypovolemia/shock/heart failure/hemorrhage. → Nurse: watch for low-cardiac-output signs (fatigue, dizziness, hypotension, chest pain, low SpO₂), monitor for med adverse effects, protect from injury.
• Bradycardia — Normal: 60–100/min. Abnormal: <60/min because of long-term fitness, hypothermia, digoxin/beta-blockers/calcium channel blockers, lying down from standing, chronic severe pain, hypothyroidism, or relaxation. → Nurse: watch for low-cardiac-output signs (dizziness, hypotension, chest pain, syncope, diaphoresis, dyspnea, altered mental status).
• Tachypnea — Normal: 12–20/min, regular. Abnormal: regular pattern >20/min because of pain, anxiety, illness, or compensation for impaired O₂-carrying capacity. → Nurse: assess work of breathing, oxygenation.
• Bradypnea / Hypoventilation — Abnormal: regular pattern <12/min (bradypnea) or shallow + abnormally low rate (hypoventilation) because of opioids, sedatives, general anesthetics, or neurologic injury to the brainstem. → Nurse: monitor for respiratory depression, have reversal/resuscitation ready.
• Apnea — Abnormal: periods of no breathing because ongoing spells can progress to respiratory arrest. → Nurse: stimulate, prepare to intervene immediately 🚨.
• Cheyne-Stokes — Abnormal: cyclical shallow-to-normal-to-fast-then-slowing pattern ending in apnea because of severe illness/neurologic compromise. → Nurse: recognize as an ominous pattern, escalate.
• Kussmaul — Abnormal: rapid, regular, abnormally deep breathing because the body is trying to blow off CO₂ to compensate for metabolic acidosis (e.g., DKA). → Nurse: check glucose/ketones, correlate with cause.
• Hypertension — Normal: <120/80. Abnormal: Stage 1 = 130–139/80–89; Stage 2 = ≥140/≥90 because of increased CO and/or SVR; classify by the higher of the two numbers (a BP of 124/92 is Stage 2 because of the DBP). → Nurse: assess for tachy/bradycardia, pain, anxiety; identifiable causes (kidney/thyroid disease, medications); usually asymptomatic, so trend matters more than a single reading.
• Hypotension — Abnormal: SBP <90 mm Hg because of fluid depletion, heart failure, or vasodilation. → Nurse: assess perfusion (mental status, skin, urine output), protect from falls.
• Fever — Normal: 37°C. Abnormal: ≥38°C (100.4°F); usually not harmful unless it exceeds 39°C (102.2°F) because it signals infectious/inflammatory response (increases WBCs, decreases plasma iron to slow bacterial growth, stimulates interferon). → Nurse: obtain cultures before antibiotics, monitor WBC/ESR/electrolytes, give antipyretics, prevent shivering, offer fluids and rest.

Early Clues / Common Errors

• Aspirin given for pediatric viral fever — Why: risk of Reye's syndrome. → Nurse: use acetaminophen/ibuprofen instead in children/adolescents with viral illness (influenza, chickenpox).
• Cold, motion, or nail polish on the SpO₂ finger — Why: falsely low reading. → Nurse: choose an intact, well-perfused, nonedematous site; use earlobe/nose bridge for peripheral vascular disease.
• BP taken right after activity or in a stressful first encounter — Why: transiently elevated reading. → Nurse: let the client rest 5 min; recall initial readings run high from clinical-setting stress.

🔑 Differentiators — Orthostatic Hypotension vs Routine Hypotension

Bottom line: normal = the range plus a stable trend; abnormal = a value outside the range or a sudden change from the client's own baseline, and either one earns a look at how the patient actually looks.

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Your move: assess the patient before you trust the monitor, and never let ABCs wait on a repeat measurement.

Nursing Actions — In Priority Order

1. Assess airway, breathing, circulation, and mental status first (Airway/Breathing) — because an unstable ABC finding outranks confirming the exact number.
2. Keep the patient safe (Safety) — sit a dyspneic patient upright; never leave a dizzy or orthostatic-positive patient to stand alone — because falls and airway compromise are the immediate, preventable harms.
3. Repeat the measurement correctly (Verification) — while beginning urgent care if the patient is unstable — because technique errors (30-sec count on an irregular rhythm, wrong cuff size) produce false alarms and false reassurance alike.
4. Compare to baseline, meds, pain, and recent activity (Clinical reasoning) — because context tells you whether the number is expected or new.
5. Report the value, symptoms, trend, actions taken, and response (Communication) — because the provider needs the whole picture, not just a number.

Protect the Patient (safety / infection control)

• Obtain cultures before starting antibiotics for a fever (Infection control) — because antibiotics sterilize the sample and hide the causative organism.
• Use continuous cardiac monitoring for hypothermia (Safety) — because cold myocardium is prone to dysrhythmias.
• Assist orthostatic-positive patients to sit at the edge of the bed ≥1 min before standing (Fall prevention) — because a slow position change lets the vasculature compensate.

Patient & Family Teaching

• Teach hypertensive clients lifestyle modification (DASH diet, sodium restriction, exercise, smoking cessation, stress reduction) (Health promotion) — because primary hypertension is usually asymptomatic and controlled long-term through behavior plus medication.
• Teach clients to activate the call light rather than get up alone after a dizzy spell (Safety) — because orthostatic symptoms recur and falls are the preventable harm.

Document / Report

• Chart the exact value, site/method used, and client position — because rectal/axillary/tympanic/temporal readings aren't interchangeable, and the next clinician needs to know what they're comparing against.
• Report any UAP-collected abnormal vital sign to the RN for interpretation — because collecting the number is within UAP scope, but deciding what it means is not.

Bottom line: look at the patient, verify the number with correct technique, protect ABCs and safety first, then trend and report.

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Don't Confuse

Escalate / Never-Do Now

• SpO₂ <90%, severe dyspnea, or cyanosis → hypoxemia, act immediately.
• Hyperthermia >40°C (104°F) → thermoregulatory failure.
• Hypothermia <35°C (95°F) → cardiac dysrhythmia risk.
• SBP <90 mm Hg with symptoms → possible shock.
• Orthostatic drop with dizziness → fall risk, do not leave the patient standing alone.
• Aspirin ordered for a febrile child with a viral illness → Reye's syndrome risk, clarify the order.