3.1 Vital Signs
Key Takeaways
- Memorize the normal adult ranges: oral temperature 97.6-99.6 F (98.6 F average), pulse 60-100 bpm, respirations 12-20 breaths/min, blood pressure below 120/80 mmHg, and SpO2 95-100%
- Report a temperature of 100.4 F or higher (fever), a pulse below 60 (bradycardia) or above 100 (tachycardia), respirations below 12 or above 20, BP of 130/80 or higher, and SpO2 below 90%
- Site changes the reading: rectal and tympanic run about 1 F HIGHER than oral; axillary and temporal run about 1 F LOWER than oral - always chart the site used
- Count the radial pulse for a full 60 seconds, then count respirations right after without telling the resident so the breathing rate stays natural
- The nurse aide measures and records vital signs but never diagnoses or treats; abnormal values are reported to the licensed nurse
What Vital Signs Are
Vital signs are objective measurements of the body's most basic functions: temperature (T), pulse (P) or heart rate, respirations (R) or breathing rate, and blood pressure (BP). Most facilities add oxygen saturation (SpO2) measured with a pulse oximeter, and many treat pain as a "fifth vital sign" the resident self-reports on a 0-10 scale.
On the Georgia CNA exam, Basic Nursing Skills is the single largest content area at about 35% (roughly 21 of the 60 written questions), and vital signs sit at its core. Measuring and recording vital signs is also one of the most common skills assigned during the NNAAP (National Nurse Aide Assessment Program) skills evaluation.
Vital signs are objective data (signs) because you measure them with an instrument - this is different from subjective data (symptoms) the resident only tells you about, like pain or nausea. A baseline set of vitals lets the team catch change early, which is why accuracy matters so much.
Normal Ranges and Report Thresholds
These ranges are the most testable facts in the whole chapter. Learn the normal range AND the value that means "tell the nurse." The aide measures and records; the aide does not decide what a reading means or change care because of it.
| Vital Sign | Normal Adult Range | Report to the Nurse If |
|---|---|---|
| Oral temperature | 97.6-99.6 F (98.6 F average) | 100.4 F or higher (fever); or below 97.6 F |
| Pulse (heart rate) | 60-100 beats/min | Below 60 (bradycardia) or above 100 (tachycardia); irregular |
| Respirations | 12-20 breaths/min | Below 12 or above 20; labored or noisy |
| Blood pressure | Below 120/80 mmHg | 130/80 mmHg or higher; or a sudden drop |
| Oxygen saturation (SpO2) | 95-100% | Below 90% |
| Pain | Resident-reported 0-10 | New, severe, or unrelieved pain |
Key vocabulary the exam uses
- Bradycardia - a slow heart rate, pulse below 60 beats/min.
- Tachycardia - a fast heart rate, pulse above 100 beats/min.
- Hypertension - high blood pressure (generally 130/80 mmHg or higher).
- Hypotension - low blood pressure, which can cause dizziness and falls.
- Febrile - having a fever; afebrile means no fever.
- Apnea - no breathing; dyspnea - difficult or labored breathing.
Where You Take the Temperature Changes the Reading
Body temperature can be measured at five sites, and each site reads a little differently, so you must always document which site you used. Rectal is the most accurate (closest to true core temperature), but it is rarely used by aides and never on combative or post-rectal-surgery residents. Tympanic (ear) and temporal (forehead) are fast and noninvasive. Axillary (armpit) is the safest and least invasive but the least accurate.
| Site | Reads vs. Oral | When to Use / Avoid |
|---|---|---|
| Oral (mouth) | Baseline / reference | Most common; avoid if resident is confused, on oxygen, mouth-breathing, or just ate/drank |
| Rectal | About 1 F HIGHER | Most accurate; nurse-directed only; never if rectal surgery, diarrhea, or combative |
| Tympanic (ear) | About 1 F HIGHER | Fast; affected by earwax or ear infection |
| Temporal (forehead) | About 1 F LOWER | Quick, noninvasive; affected by sweat or hats |
| Axillary (armpit) | About 1 F LOWER | Safest/least invasive; least accurate; hold thermometer in a dry armpit |
A simple memory aid: rectal and tympanic run hot; axillary and temporal run cool; oral is the middle reference. If you take an axillary temperature of 99.0 F, the true reading is roughly a degree higher - which matters when you are deciding whether something crosses the 100.4 F fever line.
Factors That Affect Vital Signs
Many normal things move vitals, and the exam expects you to recognize them so you do not over-report or under-report:
- Exercise, anxiety, pain, fever, and caffeine all raise pulse, respirations, and BP.
- Rest and sleep lower pulse, respirations, and BP.
- Hot food/drink, smoking, or chewing gum raise an oral temperature falsely - wait 15-20 minutes.
- Position change: BP and pulse can shift when a resident stands (let them sit a moment first).
- Age and medications: older adults often run slightly cooler; some heart drugs slow the pulse.
How to Measure Each Vital Sign
Pulse. The usual site is the radial pulse at the thumb side of the wrist. Press gently with two or three fingertips - never the thumb, which has its own pulse - and count for a full 60 seconds to catch any irregular beats. The apical pulse, heard with a stethoscope over the heart's apex, is used for residents on certain heart medications and for any irregular pulse.
Respirations. Count breaths immediately after the pulse, while your fingers stay on the wrist, so the resident does not realize you are counting. Do not tell the resident you are counting their breathing - if they know, they may unconsciously speed up or slow down. One full rise and fall of the chest equals one respiration; count for a full minute.
Temperature. Choose the safest accurate site, clean the probe, use a fresh cover, and wait for the signal/beep. Document the site.
Blood pressure. Use a correctly sized cuff on a bare upper arm supported at heart level; the resident should be seated and rested. A cuff that is too small reads falsely high. Place the stethoscope over the brachial artery, inflate, and listen as you slowly deflate.
SpO2. Clip the pulse oximeter on a clean, warm fingertip without dark nail polish; cold or poorly perfused fingers give low readings.
Worked Example: Mr. Alvarez just finished walking back from the dining hall and sat down. You immediately take his radial pulse and get 104 bpm, his respirations are 22/min, and his oral temperature is 99.4 F. Before you report anything, you recall that walking raises pulse and respirations and hot soup raises an oral temperature. You let him rest quietly for several minutes and recheck: pulse 86, respirations 16, and a tympanic temperature of 99.0 F. The recheck values are within normal limits. Because the tympanic site reads about 1 F high, his true temperature is around 98 F - no fever. You record the resting values, note the site, and have nothing abnormal to report. Rushing the first set would have triggered a false alarm.
While taking a resident's radial pulse, a nurse aide counts 54 beats in one full minute. What should the aide do?
Match each temperature site to how its reading compares with an oral temperature.
Match each item on the left with the correct item on the right
Why does a nurse aide count a resident's respirations without telling the resident it is being done?
A resident's oral temperature reads 100.8 F. How should the nurse aide respond?