8.1 Vital Signs

Why Vital Signs Matter

Vital signs are objective measurements of the body's most basic functions. A change in a vital sign is often the first warning that a resident's condition is changing, which is why the nursing assistant (NA) who takes them must be accurate and must know when to report. On the Montana knowledge exam, expect questions on normal ranges, correct technique, and which findings are urgent. On the Montana skills test administered by Headmaster, vital-signs tasks — manual blood pressure; radial pulse and respirations; or temperature, radial pulse and respirations — are drawn from the published 26-task listing (four mandatory hand-washing-embedded tasks plus 22 others), and you must perform every key (critical) step plus at least 80% of the non-key steps to pass a task.

Temperature

Normal adult body temperature varies by route. Memorize the normal ranges and the route-specific cautions:

Mercury glass thermometers are no longer used in healthcare because of mercury's toxicity; electronic and digital thermometers are standard. Always use a probe cover, clean the device per policy, and report a fever — generally an oral temperature above 100.4°F — or an unusually low reading promptly.

Pulse

The radial pulse, felt on the thumb side of the wrist, is the routine adult site. Use the pads of your first two or three fingers — never your thumb, which has its own pulse you could mistake for the resident's. Note three qualities:

• Rate: normal adult range is 60-100 beats per minute. Count for 30 seconds and multiply by two if the rhythm is regular; count a full 60 seconds if irregular.
• Rhythm: regular or irregular (report irregularity).
• Strength (force): strong, weak, thready, or bounding.

A rate below 60 is bradycardia; above 100 is tachycardia. The apical pulse — counted with a stethoscope over the apex of the heart for a full minute — is used when the radial pulse is irregular or hard to feel, and before certain heart medications.

Respirations

Count respirations without telling the resident. The moment people know their breathing is being watched, they change it. The standard trick is to keep your fingers on the wrist as if you are still counting the pulse, then silently watch the chest rise and fall. One rise plus one fall equals one respiration. Normal adult rate is 12-20 breaths per minute, regular, quiet, and effortless. Count 30 seconds and multiply by two when regular; a full minute if irregular.

Report and document abnormal patterns: tachypnea (over 20), bradypnea (under 12), dyspnea (difficult or labored breathing), orthopnea (breathlessness when lying flat, relieved by sitting up), and Cheyne-Stokes respirations (cycles of speeding up and slowing down with pauses, often seen near death). Also note the use of accessory muscles, flaring nostrils, wheezing, or bluish color (cyanosis) of the lips or nail beds.

Blood Pressure

Blood pressure is the force of blood against artery walls, measured in millimeters of mercury (mm Hg) over the brachial artery in the upper arm. The systolic pressure (top number) is the pressure when the heart contracts; the diastolic pressure (bottom number) is the pressure when the heart rests between beats. A normal adult reading is about 120/80 mm Hg. Readings persistently at or above 140/90 suggest hypertension; a systolic below 90 with symptoms suggests hypotension.

Technique points the exam loves:

• Cuff sizing matters. The cuff bladder should encircle about 80% of the arm. A cuff too small gives a falsely high reading; a cuff too large gives a falsely low reading.
• Position the resident seated or lying, arm supported at heart level, palm up; wrap the cuff snugly about one inch above the elbow.
• The resident should rest five minutes first and avoid caffeine, smoking, and exercise for 30 minutes before measurement.
• Do not take blood pressure on an arm with a dialysis fistula, an IV line, a mastectomy on that side, or an injury.
• When measuring manually, inflate about 30 mm Hg past where the radial pulse disappears, deflate slowly (2-3 mm Hg per second), and note the first sound (systolic) and the point the sound disappears (diastolic).

Pain: The Fifth Vital Sign

Pain is assessed along with the four classic vital signs and is called the fifth vital sign. Pain is subjective — whatever the resident says it is. Ask the resident to rate pain on a 0-10 scale (0 = no pain, 10 = worst imaginable), and ask about location, quality (sharp, dull, burning), onset, and what makes it better or worse. Report pain that is new, severe, or unrelieved.

Reporting and Documenting

Report immediately to the nurse: fever or abnormally low temperature; pulse under 60 or over 100, or an irregular rhythm; respirations under 12 or over 20 or any breathing difficulty; blood pressure outside the resident's usual range; and new or severe pain. Record what you measured, the route or site used, and the time — accurately and promptly. Never document a value you did not actually measure, and never "round" a concerning number into a normal one. Accurate documentation is a legal record and a core data-collection duty.