Vital Signs, Observation and Basic Clinical Measurement
This domain tests correct measurement, correct technique and correct reporting of temperature, pulse, respiration, blood pressure, oxygen saturation and pain.
Normal adult values
- Temperature: oral 36.5–37.5 °C (97.7–99.5 °F); axillary about 0.5 °C lower; rectal about 0.5 °C higher.
- Pulse: 60–100 beats/min, regular, good volume.
- Respiration: 12–20 breaths/min, regular, quiet.
- Blood pressure: normal below 120/80 mmHg.
- SpO₂: 95% or above on room air.
- Pain: the fifth vital sign; use a 0–10 numeric scale or a faces scale for children.
Pulse sites include radial, carotid, brachial, femoral, popliteal, dorsalis pedis and apical. Count a regular pulse for 30 seconds and double it; count an irregular pulse, or an apical pulse, for a full minute. Count respirations for a full minute without telling the patient, so breathing does not change.
Blood pressure technique
Patient rested 5 minutes, seated, back supported, feet flat, arm supported at heart level, correct cuff size (bladder about 40% of arm circumference), cuff over bare skin, deflate slowly and take two readings 2 minutes apart.
Worked example
A GDA records 150/95 mmHg using a cuff that is too small, with the patient's arm hanging down. Reasoning: an undersized cuff and a dependent arm both falsely raise the reading. Correct action is to let the patient rest, support the arm at heart level, use the right cuff, and repeat; if it is still high, report it rather than writing the first number in the chart.
Traps that cost marks
- Measuring over a sleeve or with an unsupported arm.
- Counting respirations for 15 seconds - count a full minute.
- Using the thumb to feel a radial pulse (your own pulse is felt).
- Recording a value you did not actually measure.