Patient Assessment, Monitoring and Vital Signs
What the exam tests
This domain tests systematic patient assessment, accurate vital-sign measurement, recognition of deterioration, and timely escalation, including documentation and reassessment.
Core rules
- Assess in a structured sequence: airway, breathing, circulation, disability, exposure (ABCDE), then focused history and pain.
- Adult resting values commonly used: respiratory rate 12–20/min, heart rate 60–100/min, systolic BP 90–140 mmHg, temperature 36.0–37.5 °C, SpO2 94–98% on room air. Interpret against the patient’s baseline and condition.
- Measure BP with the cuff at heart level, correct cuff size, and the patient seated and rested. Check orthostatic BP when falls or dizziness are reported.
- Count respiratory rate for a full 60 seconds; it is the most neglected early warning sign.
- Pulse oximetry is a trend tool, not a diagnosis. It can be normal in carbon monoxide poisoning, poor perfusion, or severe anemia.
- Use the facility early warning score, escalate according to the response protocol, and document the time and actions.
Worked example
A 70-year-old on postoperative day 1 has HR 118/min, BP 92/58 mmHg, RR 24/min, temperature 38.2 °C, SpO2 93% on room air, and new confusion. The nurse repeats the observations, checks glucose and urine output, starts oxygen per protocol, and calls the physician urgently. Reasoning: the combination suggests hypovolemia or sepsis, not “normal postoperative pain.” A single low BP is less informative than the trend plus confusion and tachypnea.
Traps
Recording vital signs without acting on abnormal values; using a cuff that is too small (falsely high BP); trusting SpO2 alone; checking a pulse for 15 seconds and multiplying; and documenting “stable” without values. Also do not attribute new confusion in an older adult to age alone.