Vital Signs, Pain, Intake, Output, and Weight
Key Takeaways
- The CNA measures and reports vital signs but does not diagnose the reason for abnormal findings.
- Temperature, pulse, respirations, blood pressure, oxygen saturation, pain, intake, output, and weight are most useful when measured accurately and compared with the resident's usual baseline.
- Pain is whatever the resident says it is, and new or worsening pain must be reported even when the CNA cannot see an injury.
- Intake and output should be recorded in milliliters, with urine, emesis, wound drainage, and liquid stool reported according to facility policy.
- A sudden weight change, abnormal vital sign, low blood pressure, fever, breathing difficulty, chest pain, or new confusion requires prompt reporting to the nurse.
Data collection within CNA scope
Vital signs and measurements are part of data collection, not independent diagnosis. A CNA may measure temperature, pulse, respirations, blood pressure, oxygen saturation, pain level, intake, output, and weight when trained and delegated. The nurse interprets the data and decides the clinical response. On the Kansas CNA exam, an answer is unsafe if it asks the aide to ignore an abnormal value, change oxygen settings, decide that a resident is stable without reporting, or explain a medical cause as fact.
Accuracy starts with preparation. Identify the resident, explain the measurement, provide privacy, use the correct equipment, and follow facility policy. Compare the result to the resident's usual baseline when available. A blood pressure that looks ordinary for one resident may be unusual for another. If a result seems inconsistent, repeat the measurement if appropriate and report the concern rather than guessing.
| Measurement | CNA exam focus |
|---|---|
| Temperature | Fever, chills, low temperature, route used |
| Pulse | Rate, rhythm, strength, sudden change |
| Respirations | Count before telling the resident if possible |
| Blood pressure | Correct cuff, arm position, reporting parameters |
| Oxygen saturation | Probe placement, cold fingers, shortness of breath |
| Pain | Resident report, location, number, behavior changes |
Vital signs and urgent reporting
Common adult reference ranges help with exam questions: pulse about 60 to 100 beats per minute, respirations about 12 to 20 per minute, and oral temperature around the normal adult range near 98.6 degrees Fahrenheit. Facilities may set exact reporting parameters, and residents may have individualized limits. Report fever, very low temperature, irregular pulse, very fast or slow pulse, labored breathing, oxygen saturation outside the ordered range, blood pressure much higher or lower than usual, dizziness, fainting, chest pain, sudden weakness, or new confusion.
Respirations require special care. If residents know their breathing is being counted, they may change the pattern. Count quietly while appearing to continue the pulse check when appropriate. Report noisy breathing, wheezing, cyanosis, shortness of breath, or use of accessory muscles. Never withhold a report because the resident says they do not want to bother the nurse.
Pain is subjective
Pain is not proven or disproven by how the resident looks. The CNA should ask about pain using the facility's scale, record the resident's words or number, observe nonverbal cues, and report new, severe, or worsening pain. Do not promise medication, give medication, massage a painful area without direction, or tell the resident the pain is normal aging. If pain occurs with chest pressure, shortness of breath, fall, fracture concern, sudden headache, or abdominal rigidity, get the nurse immediately.
Intake, output, and weight
Intake and output (I&O) must be measured carefully because small errors can hide dehydration, fluid overload, urinary problems, or bleeding. Intake includes fluids taken by mouth, ice chips converted per policy, tube feeding, and other ordered fluids when the CNA is responsible for recording them. Output includes urine, emesis, liquid stool, and drainage measured under policy. Record in milliliters, not guesses such as good or normal.
Weight should be measured with the same scale, similar clothing, and the same time of day when possible. A sudden increase, such as several pounds in a short period, can signal fluid retention. A sudden loss may suggest dehydration or poor intake. The CNA should report the change, not diagnose heart failure, kidney disease, or malnutrition.
Exam traps
Reject choices that estimate output without measuring, chart values before taking them, count respirations after telling the resident to breathe normally, dismiss pain because the resident is smiling, or fail to report abnormal findings. The safest answer is usually: measure correctly, document accurately, compare with usual status, and report changes promptly.
A resident's blood pressure is much lower than usual and the resident says, "I feel dizzy when I sit up." What should the CNA do?
Which entry is the best example of objective intake documentation?
A resident rates new hip pain as 8 out of 10 after a transfer. Which response is within CNA scope?