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Nursing Field Notes / Nursing Core · Fundamentals of Nursing

Vital Signs 🌡️

Temp · Pulse · Respirations · BP · SpO2 — and Pain, the "extra" vital sign

NG-079 Nursing Core ADHD-friendly visual edition

Vital signs are the baseline data every assessment starts with — one number, one set of locations, one reason it moves. This page is the foundation card for the whole Nursing Core batch: NG-082 Assessment Locations zooms into exactly where you find these, and NG-190 Head-to-Toe puts them inside the full physical exam.

📄 Simple Nursing original — opens in Drive →

🖐️ 5 vitals, 1 baselineTemp · Pulse · Respirations · BP · SpO2 — all measured, all compared to the client's own trend.
🚨 SpO2 <85%Severe hypoxia — this is an emergency, not a "recheck it" number.
⏱️ Irregular pulse?Count apical for a full 60 seconds — never estimate an irregular rhythm.
😖 Pain = 5th/6th vitalAsk every time, 0–10 scale — it's subjective, and it's still data.
🌡️

THE 5 VITALS

STEP 1 · KNOW THE BASELINE

One number, one set of locations, one reason it moves — learn all three together and the rest of nursing school gets easier.

🫀 Where these vitals live on the body

Pulses can be palpated at seven classic sites; the apical pulse and lung sounds are auscultated, not palpated. Full landmark detail lives on NG-082 Assessment Locations — this is the quick map.

Where the pulse points are on the body A front view of a person with nine points marked: temporal at the temple, carotid at the side of the neck, apical on the left chest at the fifth intercostal space, brachial at the inner elbow, radial at the thumb side of the wrist, femoral in the groin crease, popliteal behind the knee, dorsalis pedis on the top of the foot, and posterior tibial behind the inner ankle bone. Because this is a front view the patient's left side is on our right, which is why the apical point sits right of the midline. Temporal Carotid Brachial Radial Dorsalis pedis Apical Femoral Popliteal Post. tibial The four that catch people out Apical — listened to, never felt. 5th intercostal space, mid-clavicle. Popliteal — BEHIND the knee. Post. tibial — behind the inner ankle bone. Carotid — one side at a time, never both.
SEE ALSO NG-082 Assessment Locations — exact landmark technique for every point above, plus heart, lung & bowel auscultation.

📋 The vitals at a glance

Vital SignTypical adult reference rangeCommon sitesWhat moves itHow we classify it
💓 Pulse60–100 bpmRadial, carotid, brachial, femoral, popliteal, dorsalis pedis, posterior tibial, apicalExercise, cardiac output changes, fluid volume shiftsAbsent, weak, normal, increased, bounding
🩸 BP<120/<80 mmHgBrachial (standard), radial, popliteal, posterior tibialAcid–base balance, activity, fluid volume shiftsNormal, hypotensive, hypertensive (staged)
🫁 Respirations12–20 breaths/minAnterior & posterior chest (auscultation + observed rate/effort)Acid–base balance, activity, fluid volume shiftsNormal, adventitious sounds present
🌡️ Temperature~98.6°F / 37°C (typical, varies by site)Temporal, rectal, oral, axillaryInfection, fluid balance, hyper/hypothermia, metabolism, thyroid diseaseFebrile, afebrile
🌬️ SpO295–100%Pulse oximeter — finger, earlobe, foreheadOxygenation, ventilation, perfusionNormal → mild → moderate → severe hypoxia

Exact cutoffs vary slightly by textbook and facility policy — treat these as typical adult teaching ranges, not a single hard law, and always trend against the client's own baseline.

🌡️ Temperature

~98.6°F / 37°C is the commonly-cited average — real "normal" is a range, roughly 97.8–99.1°F, and it shifts with time of day, age, and site measured.

  • Febrile = has a fever
  • Afebrile = no fever
  • Sites, most → least invasive-accurate: rectal ≈ temporal > oral > axillary
🧠 Cross-ref: hypothermia is core temp <95°F (35°C) — full pathophysiology on NG-041 Hypothermia.

💓 Pulse

60–100 bpm at rest. Always note rate, rhythm, AND quality — three data points, one vital sign.

  • 0 = absent
  • 1+ = weak / thready
  • 2+ = normal
  • 3+ = increased / full
  • 4+ = bounding
🧠 Irregular rhythm? Count the apical pulse for a full 60 seconds — never a 15-second count ×4.

🫁 Respirations

12–20 breaths/min, counted for a full minute without the client knowing (they'll change their pattern if they notice you counting).

  • Eupnea = normal, unlabored
  • Tachypnea = fast, >20
  • Bradypnea = slow, <12
  • Apnea = absent breathing
🧠 "Count the chest, not the story." Keep your fingers on the pulse site while you covertly watch the chest rise — the client relaxes their breathing when they think you're still counting pulse.

🩸 Blood pressure — systole vs diastole

Systole = max contraction of the left ventricle (top number). Diastole = pressure of the resting ventricles (bottom number).

SYSTOLE squeezed — top number 120 DIASTOLE relaxed — bottom number 80
🧠 "Systole = Squeeze." Both start with S — the squeeze makes the top number.

🌬️ SpO2 — pulse oximetry & hypoxia levels

95–100% is the typical adult reference range. Below that, hypoxia is commonly taught in tiers:

<85% 86–90% 91–94% 95–100% NORMAL 🚨 Severe Moderate Mild Hedge: exact cutoffs vary by source/policy — trend matters more than one reading.
🧠 "85 = call for backup." Under 85% is severe hypoxia — that's an emergency escalation, not a "recheck in an hour."

😖 Pain — the 5th (or 6th) vital sign

Pain is assessed at every vitals check using a 0–10 numeric scale (or a validated behavioral/faces scale for nonverbal clients).

  • It's subjective — the client's report is the data
  • Ask location, quality, timing, aggravating/relieving factors
  • Reassess after every intervention
🧠 "Pain is what the patient says it is." Never substitute your own judgment of how much pain "looks right."
🔎

SPOT THE PATTERN

STEP 2 · READ THE CLUES

Individual numbers matter less than the pattern they make together — a fast pulse plus a rigid belly tells a very different story than a fast pulse alone.

🫁 Adventitious (abnormal) breath sounds

Crackles salt on a hot pan / velcro tearing Rhonchi low-pitched, rattling — like snoring Wheezes high-pitched, whistling — narrowed airway Diminished / Absent fluid or air where lung should be (PNA, HF, effusion)
🧠 "HF = Heavy Fluid." Crackles at the lung bases = think fluid overload / heart failure.
SEE ALSO NG-082 Assessment Locations — exact anterior/posterior auscultation sequence & ladder pattern.

🧪 ABG quick pairing (typical teaching pattern)

ValueResp. acidosisResp. alkalosis
pH↓ low↑ high
pCO2↑ high↓ low
HCO3normal (acute)normal (acute)

Respiratory problems move pH and pCO2 in opposite directions; verify the full ROME/Tic-Tac-Toe method your program teaches.

🌡️ Temperature abnormal patterns

  • 🔥 Fever (febrile) — above the client's typical baseline
  • 🧊 Hypothermia — core temp <95°F (35°C)
SEE ALSO NG-041 Hypothermia — full stages, rewarming priorities, at-risk populations.

🩸 Commonly-cited BP categories

CategoryTypical range (mmHg)
Hypotension<90/60
Normal<120/80
Elevated120–129/<80
Hypertension (staged)≥130/80, higher stage ≥140/90

Category cutoffs are updated periodically by clinical guidelines — verify the current version your program/facility uses.

💓 Pulse quality + the pattern trap

A pulse can be the "right number" and still be abnormal — rate is only 1 of 3 things you must chart: rate, rhythm, quality.

🧠 "Number's fine, pattern's not." A rate of 88 with a thready, irregular, weak quality is NOT a normal finding — always chart all three.
🩺

PRIORITY ACTIONS

STEP 3 · ACT ON IT

Vital signs exist to trigger an action — know what each red-flag pattern means you do next.

🚨 Airway → Breathing → Circulation — the universal priority order

1
🫁 Airway — is it open/patent? Position, suction, anticipate advanced airway if needed
2
💨 Breathing — rate, effort, SpO2, adventitious sounds
3
🫀 Circulation — pulse, BP, cap refill, cardiac monitor if unstable
🧠 ABC never changes. Whatever the diagnosis, the priority framework for an unstable vital sign pattern is always Airway → Breathing → Circulation.

✅ When one abnormal vital = escalate

  • SpO2 <85% — severe hypoxia
  • New irregular pulse — get a full apical minute + notify
  • Temp <95°F — hypothermia protocol
  • Rigid, board-like abdomen + fever + tachycardia — think peritonitis

⚠️ NCLEX trap: "normal" ≠ "stable"

A single normal-range vital sign doesn't rule out deterioration — always compare to the client's own trend, not just the textbook range.

🧠 "Trend beats snapshot." A BP of 110/70 is reassuring for most people — but it's a red flag if their baseline is 160/95.

🗺️ Where this page fits in the batch

NG-082 Assessment Locations — precise pulse points, lung/heart/bowel auscultation landmarks.
NG-190 Head-to-Toe Assessment — the full systematic exam sequence, using this page's normal ranges as its baseline.
NG-041 Hypothermia — deep dive on the temperature vital sign gone dangerously low.
⚡

QUICK RECALL

SAY IT OUT LOUD
🌡️ 98.6°F / 37°Ctypical average temp — real range ~97.8–99.1°F
💓 60–100 bpmrate + rhythm + quality, every time
🫁 12–20/mincount a full minute, don't let them notice
🌬️ 95–100% SpO2<85% = severe hypoxia, escalate now
🎯 Cover & check — 4 rapid-fire questions
Q1: A client's pulse is irregular. How should the nurse count it?
Count the apical pulse for a full 60 seconds — never estimate an irregular rhythm from a partial count.
Q2: SpO2 reads 83%. What tier of hypoxia is this and what's the priority?
Severe hypoxia (typically taught as <85%) — this is an emergency; assess airway/breathing immediately and escalate, don't just recheck later.
Q3: What three things must be charted for a pulse, not just the number?
Rate, rhythm, and quality (e.g., 0 absent to 4+ bounding).
Q4: Why is pain called the "5th (or 6th) vital sign"?
Because it's assessed at every vitals check just like temp/pulse/RR/BP/SpO2 — and because it's subjective, the client's report is treated as the data.