6.1 Vital Signs
Key Takeaways
- Vital signs include temperature, pulse, respirations, blood pressure, oxygen saturation when assigned, and pain reporting.
- Know normal adult ranges, but always follow facility-specific reporting thresholds.
- Respirations should be counted without causing the resident to consciously alter breathing.
- Blood pressure measurement requires correct cuff placement and quiet positioning.
- Abnormal or sudden vital-sign changes must be reported promptly.
Vital Signs Basics
Vital signs are measurements that help the nurse assess resident condition. CNAs collect and report them; they do not diagnose based on them.
| Vital Sign | Common Adult Reference |
|---|---|
| Oral temperature | About 98.6 F, varies normally |
| Pulse | 60-100 beats per minute |
| Respirations | 12-20 breaths per minute |
| Blood pressure | Often around 120/80 mmHg, varies by resident |
| Oxygen saturation | Follow facility range and nurse direction |
Temperature
Report fever, low temperature, or sudden change according to policy. Also report symptoms that go with temperature change, such as chills, sweating, confusion, or weakness.
Pulse
Measure pulse rhythm and rate. Report very fast, very slow, irregular, weak, or bounding pulse. If the resident has chest pain or shortness of breath, report immediately.
Respirations
Respirations should be counted quietly. If the resident knows you are counting, they may change the pattern.
Report labored breathing, noisy breathing, shallow breathing, bluish color, or inability to speak in full sentences.
Blood Pressure
Place the cuff on the bare upper arm unless policy or equipment indicates otherwise. The arm should be supported and relaxed.
Do not use an arm with an IV, injury, dialysis access, or other restriction. Ask the nurse if unsure.
Exam Tip
Vital signs questions often combine measurement with judgment. The correct CNA action is usually to measure accurately, record correctly, and report abnormal findings.
Why should respirations be counted without telling the resident?
Where should a blood pressure cuff usually be placed?