4.1 Measuring & Recording Vital Signs

Vital signs are essential indicators of a resident's physiological status and overall wellbeing. As a Certified Nursing Assistant (CNA), measuring, recording, and reporting vital signs accurately is a core clinical responsibility. Shifts in vital signs can signal acute illness, infection, or medication reactions, requiring prompt reporting to the licensed nurse.

Body Temperature Measurement

Body temperature reflects the balance between heat produced by metabolic body processes and heat lost to the external environment. Normal body temperature varies depending on the measurement route used:

Clinical Guidelines & Contraindications

Oral temperatures are contraindicated for residents who are confused, unconscious, experiencing seizures, or breathing through their mouth.

Rectal measurement provides the most accurate core reading but carries specific risks. Always position the resident in Sims' position (left side-lying with right knee flexed), apply a probe cover, lubricate the tip with water-soluble jelly, and gently insert it 1 inch into the adult rectum. Rectal insertion is strictly contraindicated in residents with cardiac conditions (vagus nerve stimulation can cause severe bradycardia), rectal bleeding, recent rectal surgery, or severe diarrhea.

Pulse Rate & Assessment

Pulse is the palpable wave of blood created by left ventricular contraction. When measuring pulse, assess rate (beats per minute), rhythm (regularity), and force (strong, weak, or thready).

• Normal Adult Range: 60 to 100 beats per minute (bpm).
• Bradycardia: A pulse rate below 60 bpm. Can occur in conditioned athletes or indicate heart block or digitalis toxicity.
• Tachycardia: A pulse rate above 100 bpm. Caused by fever, pain, anxiety, hemorrhage, or exertion.

Assessment Procedures

• Radial Pulse: Locate on the thumb side of the inner wrist. Compress gently with the index and middle fingertips (never the thumb). Count for 30 seconds and multiply by 2 if regular; count for 1 full minute if irregular.
• Apical Pulse: Measured using a stethoscope placed over the apex of the heart at the fifth intercostal space at the left midclavicular line. Listen to the "lub-dub" sound (counted together as one beat) for 1 full minute. Required before administering certain cardiac drugs or when the radial pulse is irregular.

Respiration Rate & Patterns

Respiration involves one complete cycle of inhalation and exhalation. The normal adult rate is 12 to 20 breaths per minute. Count respirations immediately after measuring pulse without releasing the wrist so the resident does not alter their natural breathing pattern. Count for 30 seconds x 2 if regular, or 1 full minute if irregular.

Abnormal Breathing Patterns

• Dyspnea: Painful or difficult breathing.
• Apnea: Absence of breathing.
• Cheyne-Stokes Respirations: Pattern of alternating deep, rapid breathing followed by shallow breaths and periods of apnea (10–60 seconds), common near the end of life or in severe brain injuries.

Blood Pressure Measurement

Blood pressure (BP) measures the force of circulating blood against arterial walls, recorded in millimeters of mercury (mmHg).

• Systolic Pressure: Top number; pressure during ventricular contraction (Normal: 100–120 mmHg).
• Diastolic Pressure: Bottom number; pressure when the heart relaxes between beats (Normal: 60–80 mmHg).
• Hypertension: Persistently elevated BP of 130/80 mmHg or higher.
• Hypotension: Abnormally low BP below 90/60 mmHg.

Technique & Cuff Sizing

Palpate the brachial artery in the inner elbow (antecubital fossa) and place the cuff bladder directly over it, 1 inch above the bend of the elbow. Ensure proper cuff size: the bladder width must cover 40% of arm circumference and length must encircle 80%. An undersized cuff gives a falsely high reading, while an oversized cuff yields a falsely low reading. Do not take BP on an arm with an IV, dialysis shunt, or side of mastectomy.