Vital Signs, Observation and Basic Clinical Assistance
Normal adult values
Temperature 36.5-37.5 degrees Celsius orally (axillary about 0.5 degrees lower). Pulse 60-100 beats per minute, regular. Respiration 12-20 per minute. Blood pressure 120/80 mmHg; hypertension is generally 140/90 or above in clinic readings. SpO2 95-100% on room air. Pain scored 0-10.
Technique matters
Pulse: use two or three fingers, never the thumb, on the radial artery; count a full minute if irregular. Respiration: count without telling the patient, watching the chest rise; one rise plus fall equals one breath. Blood pressure: patient seated and rested, arm supported at heart level, cuff 2.5 cm above the antecubital fossa, deflate 2-3 mmHg per second. Temperature: oral for adults, not for an unconscious or confused patient. Record actual values, never a guess.
Intake and output
1 mL equals 1 cc. Intake includes oral fluids, IV fluids and tube feeds; output includes urine, vomit and drains. Measure urine in a graduated container; never estimate for the chart.
What must be escalated
Respiratory rate 25 or above, SpO2 below 92%, systolic pressure below 90, pulse above 120, temperature 39 degrees or above, urine output below 0.5 mL/kg/hour, new confusion or chest pain. Report these immediately; the GDA does not wait for the next round.
Worked example
A patient's chart shows respiration 28, SpO2 90% and new confusion. The GDA does not assume he is sleeping. She reports to the nurse at once and records the time. Reasoning: this is a deteriorating-patient pattern, and early escalation is the tested behaviour.
Traps
- Counting respirations aloud so the patient changes breathing.
- Using the thumb for a pulse.
- Recording a cuff reading taken over clothing.
- Rounding numbers to make them look normal.