Section 3.1: Measuring & Recording Vital Signs (Temp, Pulse, Resp, BP)

Measuring & Recording Vital Signs

Vital signs are the clinical foundation of resident monitoring in Iowa long-term care facilities. As a Certified Nursing Assistant (CNA) operating under the supervision of a Licensed Practical Nurse (LPN) or Registered Nurse (RN), you serve as the front-line observer. Under Iowa Administrative Code (IAC) 441 Chapter 81, CNAs must accurately measure, record, and report vital signs, as these measurements are critical indicators of a resident’s cardiorespiratory and metabolic status. Any sudden or significant deviation from a resident's baseline can signal a life-threatening change in condition, requiring immediate notification of the nurse.

Normal Vital Sign Ranges in Older Adults

Understanding the normal physiological parameters is vital for identifying abnormal findings. While individual baselines vary, the standard clinical ranges tested on the Iowa CNA competency exam are as follows:

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Temperature Measurement: Clinical Protocols

Body temperature reflects the balance between heat produced and heat lost. CNAs utilize five primary routes, each requiring strict adherence to clinical steps to ensure safety and accuracy:

1. Oral Route (Blue/Green Probe): The most common route. Place the disposable sheath over the probe and position it in the sublingual pocket (the 'hot pocket' at the base of the tongue, to the left or right of the frenulum). The resident must close their lips firmly around the probe and breathe through their nose. Before measuring, ask the resident if they have consumed hot or cold liquids, eaten, smoked, or chewed gum within the last 15 to 20 minutes. If yes, you must wait a full 15 to 20 minutes to prevent artificially altered readings.
2. Rectal Route (Red Probe): The most accurate route, as it measures core body temperature. It is indicated when the resident is unconscious, confused, or unable to close their mouth. Position the resident in the Sims' position (left side-lying with the right leg flexed). Apply a generous amount of water-soluble lubricant to the probe sheath. Gently insert the probe 1/2 to 1 inch into the rectum, pointing toward the umbilicus. Safety Warning: You must hold the thermometer in place the entire time it is in the rectum. Never release your grip, as sudden movement could cause rectal perforation.
3. Tympanic Route: Measures heat from the tympanic membrane in the ear. To ensure an accurate reading in adults and older residents, gently pull the ear pinna up and back to straighten the external auditory canal before inserting the probe.
4. Axillary Route: The least accurate method, used only when other routes are contraindicated. Ensure the axilla (armpit) is dry. Place the probe in the center of the armpit and hold the resident’s arm tightly against their side for the duration of the reading.

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Pulse and Respiration: Assessment Techniques

The pulse rate measures the wave of blood created by the contraction of the left ventricle of the heart.

• Radial Pulse: Located on the thumb side of the inner wrist. Use the tips of your index and middle fingers to palpate the artery. Press gently. Never use your thumb, as it has its own pulse and can lead to an inaccurate count. Count for a full 60 seconds if the pulse is irregular, or for 30 seconds and multiply by 2 if it is regular.
• Apical Pulse: Located at the apex of the heart (left side of the chest, at the fifth intercostal space, midclavicular line). This method requires a stethoscope. You must count the apical pulse for one full minute (60 seconds) to ensure accuracy. This route is mandatory for residents with known cardiac arrhythmias or those taking medications such as digoxin.
• Respirations: A single respiration consists of one inspiration (chest rise) and one expiration (chest fall). Do not inform the resident you are counting their breaths. If they know, they may consciously alter their breathing pattern. Instead, immediately after counting the radial pulse, keep your fingers on their wrist as if you are still taking the pulse. Observe the rise and fall of the chest. Count for 30 seconds (multiply by 2) or a full 60 seconds if irregular.

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Blood Pressure: Clinical Guidelines and Precautions

Blood pressure is the force exerted by the blood against the arterial walls.

• Contraindicated Arms: Never apply a blood pressure cuff to an arm that has an intravenous (IV) line, a peripherally inserted central catheter (PICC) line, a dialysis shunt or fistula, a cast, or on the side of a radical mastectomy (due to the risk of lymphedema). In stroke residents with hemiplegia (paralysis), avoid the weak or paralyzed arm.
• Cuff Sizing and Placement: A cuff that is too small yields a falsely high reading, while a cuff that is too large yields a falsely low reading. The bladder of the cuff must encircle at least 80% of the resident's arm circumference, and the width must be approximately 40% of the arm circumference. Center the arrow of the cuff over the brachial artery, which is located in the antecubital space (inner elbow). Place the lower edge of the cuff 1 to 2 inches above the bend of the elbow.
• Measurement Steps:
  1. Palpate the radial or brachial pulse. Inflate the cuff until you can no longer feel the pulse (the obliteration point). Note this number.
  2. Deflate the cuff and wait 60 seconds.
  3. Place the stethoscope earpieces in your ears facing forward, and position the diaphragm directly over the brachial artery. Do not tuck the diaphragm under the cuff, as this creates frictional noise and alters the reading.
  4. Inflate the cuff to 30 mmHg above the noted obliteration point.
  5. Deflate the cuff slowly and steadily at a rate of 2 to 3 mmHg per second.
  6. The point where you hear the first clear, rhythmic tapping sound is the systolic pressure (Phase I Korotkoff sound). The point where the sound disappears completely is the diastolic pressure (Phase V Korotkoff sound).
  7. Deflate the cuff completely and remove it.

Common Exam Traps to Avoid

• The Thumb Pulse Trap: Never use your thumb to feel a resident's pulse. The thumb contains a strong arterial pulse of its own, which can lead to counting your own heartbeats instead of the resident's.
• The Hot Coffee Wait: If a resident has just finished drinking a warm beverage or smoking, you must wait 15 to 20 minutes before taking an oral temperature. Skipping this wait time leads to a falsely elevated reading.
• The Cuff Diaphragm Tuck: Do not tuck the stethoscope diaphragm under the blood pressure cuff. Tucking it under the cuff creates pressure on the stethoscope head, resulting in friction sounds that obscure the true systolic and diastolic sounds.