4.1 Vital Signs
Key Takeaways
- Normal adult oral temperature is 97.6-99.6°F (avg 98.6°F); rectal reads ~1°F higher and axillary ~1°F lower than oral
- Report fever ≥100.4°F (38.0°C) or hypothermia <97°F (36.1°C) to the licensed nurse
- Normal adult resting pulse is 60-100 bpm; count an apical pulse for one full minute when irregular or before digoxin
- Hypertension Stage 1 is 130-139/80-89 mm Hg and Stage 2 is ≥140/90 mm Hg per 2017 ACC/AHA guidelines
- SpO₂ below 92% on room air, respirations <12 or >20/min, or BP <90/60 with symptoms must be reported
Vital signs are the fastest objective indicator of a resident's condition. North Carolina CNAs measure them every shift, before and after activity, and any time a resident's status changes. The NNAAP skills exam tests blood pressure, pulse, respirations, and weight directly; the written exam tests normal ranges and reportable thresholds.
The core vital signs are:
- Temperature (T)
- Pulse (P)
- Respirations (R)
- Blood pressure (BP)
- Pulse oximetry / SpO₂
- Pain (the "5th vital sign")
Temperature
Body temperature reflects the balance between heat produced and heat lost. CNAs in NC long-term care most often take oral, axillary, or tympanic temperatures; rectal is used only when ordered and never on residents with rectal injury, diarrhea, recent rectal surgery, or heart conditions.
| Site | Normal Range (°F) | Average | Notes |
|---|---|---|---|
| Oral | 97.6 – 99.6 | 98.6 | Wait 15 min after hot/cold drinks or smoking |
| Rectal | 98.6 – 100.6 | 99.6 | ~1°F higher than oral; lubricate, insert 1 inch |
| Axillary | 96.6 – 98.6 | 97.6 | ~1°F lower than oral; dry axilla first |
| Tympanic | 98.6 – 100.6 | 99.6 | ~1°F higher than oral; pull pinna up & back |
| Temporal | 98.6 – 100.6 | 99.6 | Forehead scanner; quick screening |
Reportable thresholds:
- Fever: oral temperature ≥100.4°F (38.0°C) — the CDC's clinical fever threshold used to start infection workup.
- Hypothermia: oral temperature <97.0°F (36.1°C).
- Any sudden change ≥1°F from the resident's baseline.
Pulse
The pulse is the wave of blood pushed through the arteries each time the left ventricle contracts. CNAs measure pulse by rate, rhythm, and force (strength).
- Normal adult resting pulse: 60 – 100 beats per minute (bpm)
- Bradycardia: <60 bpm
- Tachycardia: >100 bpm
Sites
| Site | When Used |
|---|---|
| Radial (wrist) | Routine adult pulse — most common |
| Apical (5th intercostal space, mid-clavicular line) | Irregular rhythm, infants/children, before digoxin |
| Carotid | Emergencies (CPR); never press both sides at once |
| Brachial | Infants, BP measurement |
| Pedal/dorsalis pedis | Circulation checks in legs |
Counting rules
- Regular radial pulse: count for 30 seconds × 2.
- Irregular rhythm, apical, or before digoxin: count for one full minute.
- Apical pulse requires a stethoscope placed at the 5th intercostal space, mid-clavicular line on the left side.
Respirations
One respiration = one inhalation + one exhalation. Because residents may alter their breathing if they know they're being watched, count respirations without telling the resident — keep your hand on the wrist as if still taking the pulse.
- Normal adult: 12 – 20 breaths per minute
- Bradypnea: <12/min — report
- Tachypnea: >20/min — report
- Apnea: absence of breathing — report immediately
Observe rate, rhythm, depth, and effort (use of accessory muscles, nasal flaring, retractions, noisy breathing). Count for 30 seconds × 2 if regular; one full minute if irregular or abnormal.
Blood Pressure
Blood pressure (BP) is reported as systolic/diastolic in millimeters of mercury (mm Hg). The 2017 ACC/AHA categories the NNAAP follows are:
| Category | Systolic | Diastolic | |
|---|---|---|---|
| Normal | <120 | and | <80 |
| Elevated | 120 – 129 | and | <80 |
| Stage 1 hypertension | 130 – 139 | or | 80 – 89 |
| Stage 2 hypertension | ≥140 | or | ≥90 |
| Hypertensive crisis | >180 | and/or | >120 |
| Hypotension | <90 | or | <60 (if symptomatic) |
Cuff Sizing & Technique
- The cuff bladder must cover about 80% of the arm's circumference and roughly 40% of its width. A cuff that is too small gives a falsely high reading; one that is too large gives a falsely low reading.
- Position the arm at heart level, palm up, supported.
- The lower edge of the cuff sits 1 inch (2.5 cm) above the antecubital space.
- Place the stethoscope diaphragm over the brachial artery.
- Inflate 30 mm Hg above the point the radial pulse disappears, then deflate at 2 – 3 mm Hg per second.
- First Korotkoff sound = systolic; last sound = diastolic.
- Never take BP on an arm with an IV, dialysis shunt/fistula, mastectomy on that side, or injury/cast.
Pulse Oximetry (SpO₂)
Pulse oximetry measures the percentage of hemoglobin saturated with oxygen via a finger or earlobe sensor.
- Normal on room air: ≥95%
- Report: SpO₂ <92% (many facilities call the nurse immediately at <90%)
- Cold extremities, dark nail polish, motion, and poor circulation cause falsely low readings.
Pain — the 5th Vital Sign
Pain is subjective: whatever the resident says it is. Always document the resident's own words.
| Scale | Use For |
|---|---|
| 0 – 10 numeric | Alert adults |
| Wong-Baker FACES | Children ≥3, adults with language/cognition barriers |
| PAINAD | Advanced dementia (breathing, vocalization, facial expression, body language, consolability) |
| FLACC | Non-verbal residents and young children (Face, Legs, Activity, Cry, Consolability) |
Report any new pain, pain rated ≥7/10, or pain unrelieved by current measures.
Reportable Findings — Quick Reference
| Vital Sign | Report If |
|---|---|
| Temperature | ≥100.4°F or <97.0°F oral; ≥1°F change from baseline |
| Pulse | <60 or >100 bpm; new irregular rhythm; weak/thready |
| Respirations | <12 or >20/min; labored, noisy, or absent |
| Blood pressure | ≥140/90 or <90/60; sudden ≥20 mm Hg change |
| SpO₂ | <92% on room air |
| Pain | New onset; ≥7/10; unrelieved |
Document immediately after measuring. Record the value, time, site/method, and resident position.
A CNA takes an oral temperature of 100.6°F on a resident in a North Carolina long-term care facility. Which action should the CNA take FIRST?
A CNA prepares to measure blood pressure on a resident whose mid-arm circumference is 14 inches. The cuff bladder is 7 inches long. What is the MOST likely effect of using this cuff?