Vital Signs
Vital signs are the fundamental measurements of basic body functions: temperature, pulse (heart rate), respirations (breathing rate), blood pressure, and pain (often called the "5th vital sign"). They provide critical data about a patient's physiological status and are assessed by all levels of nursing staff.
Exam Tip
Record actual measurements, units, route and symptoms; follow reporting limits. No fixed temperature-route conversion. Medication hold decisions belong to authorized clinicians.
Vital Signs and CNA Observations
Traditional vital signs are temperature, pulse, respirations and blood pressure. Pain and oxygen saturation are commonly measured alongside them. CNAs measure assigned observations, document the route, units and conditions, and promptly report changes.
| Measurement | Adult reference |
|---|---|
| Resting pulse | Usually 60-100 beats/min; individual baselines vary |
| Resting respirations | Common teaching range 12-20 breaths/min |
| Oral temperature | Average near 98.6 F (37 C); normal range varies by person, time and device |
| Normal blood pressure | Less than 120 systolic AND less than 80 diastolic mmHg |
| Pain | Person's report using an appropriate validated scale |
Use the thermometer manufacturer's instructions. Do not use fixed 3-10 minute timings for modern electronic devices or add a fixed degree to convert one temperature route to another. Report the actual reading and route.
AHA Blood Pressure Categories
| Category | Systolic and diastolic mmHg |
|---|---|
| Normal | Less than 120 AND less than 80 |
| Elevated | 120-129 AND less than 80 |
| Stage 1 | 130-139 OR 80-89 |
| Stage 2 | 140 or higher OR 90 or higher |
| Severe | Higher than 180 and/or higher than 120 |
A single reading is not an independent diagnosis. Severe blood pressure with chest pain, breathlessness or neurological symptoms needs emergency response. Follow the nurse's reporting instructions without delaying help for a symptomatic resident.
A nurse or prescriber decides medication administration and hold parameters. A CNA does not independently hold or give digoxin based on a generic pulse threshold.
Use the current care plan and the applicable state rules. Official guidance.
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