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HLT-PSYC90-05 · Lesson 3 · 10 clock hours · lab

Vital Signs: Measurement, Documentation, and Reporting

Objective. Students will measure temperature, pulse, respirations, blood pressure, oxygen saturation, and pain level on a peer or simulation manikin, record results accurately, and correctly identify which values fall outside normal adult ranges and require escalation.

⚠ Pending professional review

This lesson, its worked examples and its practice questions has not yet been verified by a licensed clinician in the field or by a certification or approval body. It is a study draft and may contain errors. Do not use it to make decisions about any patient or medication. Always follow your instructor, your supervising professional, and current official references and regulations.

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Why Vital Signs Matter in Psychiatric Settings

Vital signs are objective measurements of the body's most basic functions. In a psychiatric setting, monitoring vital signs is every psychiatric technician's responsibility, not just nursing staff. Many psychiatric medications—including antipsychotics, mood stabilizers, and sedatives—can affect heart rate, blood pressure, temperature, and respiratory rate. Recognizing an abnormal value early and reporting it promptly can prevent serious patient harm or death.

The Six Vital Signs You Will Measure

1. Temperature

Normal adult oral temperature is approximately 97.8°F to 99.1°F (36.5°C to 37.3°C). Use a digital thermometer according to the manufacturer's instructions. Place the probe under the tongue with the patient's lips closed and wait for the beep. Document the route (oral, axillary, tympanic) alongside the reading, because each route has slightly different normal ranges. A temperature above 100.4°F (38°C) is considered a fever and should be reported. A very high temperature—especially combined with muscle rigidity—can signal Neuroleptic Malignant Syndrome (NMS), a rare but life-threatening reaction to certain psychiatric medications that requires immediate emergency response.

2. Pulse

Count radial pulse (at the wrist, thumb side) by placing two fingers over the artery and counting beats for 60 seconds, or count for 30 seconds and multiply by two. Normal adult resting pulse is 60–100 beats per minute (bpm). Note the rhythm (regular or irregular) as well as the rate. A pulse below 60 bpm (bradycardia) or above 100 bpm (tachycardia) at rest warrants notification of the charge nurse. An irregular rhythm is always reportable.

3. Respirations

Count the number of times the chest rises in 60 seconds. Do this without telling the patient—people unconsciously change their breathing rate when they know it is being watched. Normal adult respirations are 12–20 breaths per minute. Fewer than 12 (bradypnea) or more than 20 (tachypnea) at rest should be reported. Respirations below 10 or accompanied by changes in consciousness require immediate action.

4. Blood Pressure

Use an aneroid sphygmomanometer and stethoscope. Apply the cuff to the upper arm (patient seated, arm at heart level, back supported, legs uncrossed, no talking). Inflate to approximately 20–30 mmHg above the point where the radial pulse disappears, then release slowly at about 2–3 mmHg per second, listening for Korotkoff sounds. The first sound is systolic pressure; the last audible sound is diastolic pressure. Normal adult blood pressure is less than 120/80 mmHg. A reading of 130–139/80–89 mmHg is elevated; 140/90 mmHg or higher on repeated measurement is hypertension. A systolic below 90 mmHg may indicate hypotension, which can cause falls—a serious concern in psychiatric units. A single reading of 180/110 mmHg or higher is a hypertensive urgency and requires immediate escalation.

5. Oxygen Saturation (SpO₂)

Attach a pulse oximeter to a clean, well-perfused fingertip. Allow it to stabilize for a few seconds. Normal SpO₂ in a healthy adult is 95–100%. A reading of 94% or below is abnormal and should be reported promptly. Below 90% is a potential emergency. Note that nail polish, poor circulation, and motion artifact can cause falsely low readings—remove nail polish and reposition the probe if the reading seems inconsistent with the patient's appearance.

6. Pain Level

Pain is assessed as a vital sign using a validated scale. The 0–10 Numeric Rating Scale (0 = no pain, 10 = worst imaginable pain) is standard for adults who can self-report. Document the patient's own words whenever possible. Any pain rated 7 or above, or any sudden new report of severe pain, should be reported to the charge nurse.

Accurate Documentation

Record vital signs immediately after measurement—never from memory later. On a paper graphic flowsheet, plot values at the correct time column and use facility-approved abbreviations. In an electronic health record (EHR), enter values in the correct field; double-check before saving. Include the date, time, route (for temperature), and your initials or login. Transcription errors can lead to incorrect clinical decisions.

When to Escalate

Know your facility's escalation policy. As a psychiatric technician, you observe and report—you do not diagnose or independently treat. A general framework:

Examples of immediately concerning values in adults: temperature above 104°F, pulse below 40 or above 150 bpm, respirations below 10 or above 30 per minute, systolic BP below 80 or above 180 mmHg (especially with symptoms), SpO₂ below 90%.

Safety Points

Key terms8

Systolic pressureThe top number in a blood pressure reading; represents the pressure in the arteries when the heart beats and pumps blood.
Diastolic pressureThe bottom number in a blood pressure reading; represents the pressure in the arteries between heartbeats when the heart is at rest.
SpO₂Peripheral oxygen saturation; the percentage of hemoglobin in arterial blood that is carrying oxygen, measured non-invasively by a pulse oximeter.
BradycardiaA resting heart rate below 60 beats per minute in an adult.
TachycardiaA resting heart rate above 100 beats per minute in an adult.
Neuroleptic Malignant Syndrome (NMS)A rare, life-threatening reaction associated with certain psychiatric medications, characterized by high fever, severe muscle rigidity, altered consciousness, and unstable vital signs.
Korotkoff soundsThe sounds heard through a stethoscope over the brachial artery during blood pressure measurement; the first sound marks systolic pressure and the last audible sound marks diastolic pressure.
EscalationThe process of promptly notifying a charge nurse or emergency response team when a patient's vital signs fall outside acceptable ranges or change significantly.

Worked examples4

1. You count a patient's radial pulse for 30 seconds and count 19 beats. What is the pulse rate in beats per minute, and is it within the normal adult range?
  1. Multiply the 30-second count by 2 to convert to beats per minute: 19 × 2 = 38 bpm.
  2. Compare to the normal adult resting range of 60–100 bpm.
  3. 38 bpm is below 60 bpm, which is the lower limit of normal.
Answer: The pulse rate is 38 bpm, which is bradycardia. This is significantly below normal and requires immediate notification of the charge nurse.
2. A patient's blood pressure reads 176/98 mmHg. Your facility policy says to notify the charge nurse for any reading at or above 140/90 mmHg, and to initiate an immediate emergency response for any systolic at or above 180 mmHg. What action do you take?
  1. Compare the systolic reading: 176 mmHg is below the 180 mmHg threshold for an immediate emergency response.
  2. Compare to the notification threshold: 176 systolic is above 140 mmHg, and 98 diastolic is above 90 mmHg.
  3. The reading falls in the 'notify charge nurse' category, not the 'immediate emergency' category.
  4. Stay with the patient, notify the charge nurse promptly, and document the reading and the notification.
Answer: Notify the charge nurse promptly. Document the BP reading, the time, and that you reported it. Do not leave the patient until the nurse has been informed.
3. You document the following vital signs on the flowsheet: Temp 98.6°F oral, Pulse 88 bpm, Respirations 18, BP 122/78, SpO₂ 97%, Pain 3/10. Your reference card lists normal adult ranges. Which values, if any, require escalation?
  1. Temperature 98.6°F is within 97.8–99.1°F — normal.
  2. Pulse 88 bpm is within 60–100 bpm — normal.
  3. Respirations 18 breaths/min is within 12–20 — normal.
  4. BP 122/78 mmHg: systolic 122 is slightly elevated above 120 but below the 140 notification threshold; diastolic 78 is below 80 — no escalation required at this single reading, but document accurately.
  5. SpO₂ 97% is within 95–100% — normal.
  6. Pain 3/10 is below the reportable threshold of 7/10 — document and monitor.
Answer: No values require immediate escalation. All readings are within or near normal adult ranges. Document all values accurately and continue routine monitoring.
4. You take a patient's oral temperature and get a reading of 103.2°F. The patient is also agitated, diaphoretic (sweating heavily), and appears confused. What do you do, and why is the temperature especially concerning in a psychiatric setting?
  1. Recognize that 103.2°F is above the fever threshold of 100.4°F and is a high fever.
  2. Note the accompanying symptoms: agitation, diaphoresis, and confusion — these combined with high fever can indicate Neuroleptic Malignant Syndrome (NMS), especially if the patient is on antipsychotic medications.
  3. Do not leave the patient alone.
  4. Immediately notify the charge nurse and report all observations: temperature, symptoms, and any known medications.
  5. Be prepared to assist with emergency response if directed.
Answer: Call the charge nurse immediately and stay with the patient. The combination of high fever, agitation, sweating, and confusion in a patient on psychiatric medication raises concern for NMS, which is a medical emergency requiring urgent physician evaluation.

The math in this lesson1

Learners convert a 30-second pulse count to beats per minute and compare to normal range.
6.RP.3
In class: Practice vital-sign measurement on peers in rotating pairs using aneroid sphygmomanometers, digital thermometers, pulse oximeters, and stopwatches; instructor checks each student's readings against a reference device to calculate accuracy. · Enter a complete set of fabricated vital-sign data into a sample paper graphic flowsheet and into a training instance of a basic EHR module, then answer three interpretation questions about trend changes across a 24-hour period. · Review a set of 10 vital-sign values (print cards) and sort them into 'within normal adult range,' 'notify charge nurse,' and 'immediate emergency response required' categories, defending each decision with written rationale.
Materials: Aneroid sphygmomanometers, stethoscopes (student-supplied or school-provided), digital thermometers, pulse oximeters, stopwatches, paper graphic flowsheet forms, EHR training module (computer lab), vital-sign reference card, sorting cards.
Check: Vital-sign readings compared to instructor's reference device: BP within ±6 mmHg systolic/diastolic, pulse within ±4 bpm, SpO2 within ±2%. All 10 sort-card decisions correct. EHR entry matches source data with no transcription errors. Pass mark: 80% on all components.

Practice check8

Answer each question, then check it. Nothing is recorded; this is your own practice.

Patient Care and Clinical Skills
1. A psychiatric technician counts a patient's respirations for 30 seconds and counts 8 breaths. What is the respiratory rate per minute, and how should this be classified?
Patient Care and Clinical Skills
2. When measuring blood pressure with an aneroid sphygmomanometer, the first Korotkoff sound heard as you slowly release cuff pressure represents which value?
Patient Safety and Emergency Response
3. A patient on antipsychotic medication develops a temperature of 104.6°F, severe muscle rigidity, and altered consciousness. Which condition should the psychiatric technician consider as a possible cause, and what is the priority action?
Patient Safety and Emergency Response
4. A patient's pulse oximeter reads 88% after the probe has been repositioned and nail polish has been removed. The patient appears pale and short of breath. What is the correct action?
Documentation and Health Information
5. When documenting vital signs on a paper graphic flowsheet, which practice best ensures accuracy and accountability?
Patient Safety and Emergency Response
6. A psychiatric technician obtains a blood pressure of 182/114 mmHg in a patient who reports a sudden severe headache. According to a general escalation framework, this reading requires:
Infection Control and Safety
7. To prevent infection transmission during vital-sign measurement, which practice is correct?
Patient Care and Scope of Practice
8. A patient rates their pain as 8 out of 10 on the Numeric Rating Scale and states, 'It started suddenly about 10 minutes ago.' What is the psychiatric technician's appropriate response?
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