2.1 Vital Signs Measurement & Normal Ranges

Vital Signs Measurement & Normal Ranges

Vital signs are the primary physiological indicators of a resident's physical status, autonomic regulation, and internal homeostasis. The Certified Nursing Assistant (CNA) is often the first healthcare team member to detect subtle changes in a resident's baseline measurements. In long-term care facilities and skilled nursing environments regulated by the North Dakota Department of Health and Human Services (ND HHS) and tested through Headmaster/D&S Diversified Technologies, precise measurement, meticulous recording, and prompt reporting of abnormal findings are vital to resident safety.

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|                        THE FIVE CARDINAL VITAL SIGNS                        |
|                                                                             |
|   [TEMPERATURE]      ---> Core & surface thermal regulation (Oral: 98.6°F)  |
|   [PULSE]            ---> Heart rate, rhythm, and cardiac output (60-100 bpm)|
|   [RESPIRATIONS]     ---> Pulmonary ventilation & gas exchange (12-20 bpm)   |
|   [BLOOD PRESSURE]   ---> Hemodynamic vascular resistance (<120/<80 mmHg)  |
|   [PAIN (5th SIGN)]  ---> Subjective sensory & emotional comfort level (0-10)|
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1. Body Temperature Measurement Sites & Protocols

Body temperature reflects the balance between heat produced by metabolic processes and heat lost to the external environment. Temperature fluctuates slightly throughout the day—lowest in the early morning and highest in the late afternoon.

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|                   TEMPERATURE SITES & CLINICAL ACCURACY                     |
|                                                                             |
|   [RECTAL]    ---> 98.6°F - 100.6°F (Avg: 99.6°F) [MOST ACCURATE / CORE]    |
|   [TYMPANIC]  ---> 96.6°F - 99.7°F  (Avg: 98.6°F) [Fast, Core Reflection]   |
|   [TEMPORAL]  ---> 97.2°F - 100.1°F (Avg: 98.6°F) [Non-invasive, Fast]      |
|   [ORAL]      ---> 97.6°F - 99.6°F  (Avg: 98.6°F) [Standard Clinical Site] |
|   [AXILLARY]  ---> 96.6°F - 98.6°F  (Avg: 97.6°F) [LEAST ACCURATE / SURFACE]|
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Clinical Comparison of Temperature Routes

[!IMPORTANT] Clinical Terminology & Reporting Thresholds:

• Afebrile: Normal body temperature (without fever).
• Febrile / Pyrexia: Elevated body temperature (>100.4°F or according to facility policy).
• Hypothermia: Core body temperature dropping below 95.0°F (35.0°C), causing slowed metabolic processes, shivering, confusion, and lethargy. Report immediately to the charge nurse.

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2. Pulse Assessment & Cardiac Monitoring

A pulse is the palpable rhythmic expansion and recoil of an artery resulting from the contraction of the left ventricle of the heart. Pulse assessment evaluates three primary qualities: rate (beats per minute), rhythm (regular vs. irregular), and force/volume (pulse amplitude).

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|                      PRIMARY CLINICAL PULSE SITES                           |
|                                                                             |
|   [TEMPORAL]       ---> Side of head above and lateral to eye               |
|   [CAROTID]        ---> Lateral neck groove (Emergency CPR / Code Blue)     |
|   [APICAL]         ---> 5th ICS, Left Midclavicular Line (Auscultation 1 min)|
|   [BRACHIAL]       ---> Antecubital fossa (Blood pressure measurement)      |
|   [RADIAL]         ---> Radial wrist at base of thumb (Standard assessment)  |
|   [FEMORAL]        ---> Groin crease (Central circulation & shock)          |
|   [POPLITEAL]      ---> Posterior knee crease (Lower extremity perfusion)   |
|   [POSTERIOR TIB]  ---> Inner ankle behind medial malleolus                 |
|   [DORSALIS PEDIS] ---> Top ridge of foot between 1st & 2nd metatarsal (DP)  |
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Pulse Terminology & Characteristics

• Normal Resting Adult Heart Rate: 60 to 100 beats per minute (bpm).
• Tachycardia: A resting heart rate exceeding 100 bpm (triggered by pain, fever, hypoxia, anxiety, dehydration, or heart failure).
• Bradycardia: A resting heart rate below 60 bpm (normal in conditioned athletes, but concerning if accompanied by dizziness, weakness, or fainting).
• Pulse Amplitude / Force Scale:
  • 0: Absent (non-palpable)
  • 1+: Thready, weak, easily obliterated by slight pressure
  • 2+: Normal, easily palpable with moderate pressure
  • 3+: Full, bounding, robust stroke volume

Step-by-Step Radial Pulse Procedure (Headmaster Testing Standard):

1. Perform hand hygiene, greet the resident, verify identity, and provide privacy.
2. Ensure the resident is resting in a comfortable seated or supine position with the forearm supported and palm facing upward.
3. Locate the radial artery on the thumb side of the inner wrist using the tips of your first two or three fingers.

   [!CAUTION] Never Use Your Thumb to Measure a Pulse: Your thumb contains its own strong arterial pulse (princeps pollicis artery). Using your thumb causes you to count your own pulse rather than the resident's heart rate.

4. Apply gentle pressure. For normal regular rhythm, count for 30 seconds and multiply by 2 (on state skill testing examinations, ND Headmaster requires counting for one full minute / 60 seconds).
5. Note rate, regularity of rhythm, and pulse strength. Record immediately.

Auscultating the Apical Pulse

The apical pulse represents the actual mechanical contraction of the heart apex. It is auscultated using a stethoscope in residents with known cardiac arrhythmias, prior to administering cardiac medications (such as digoxin/Lanoxin), or when radial pulses are weak/irregular.

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|                        APICAL PULSE AUSCULTATION                            |
|                                                                             |
|   1. Clean stethoscope earpieces and diaphragm with 70% isopropyl alcohol.  |
|   2. Locate the 5th Intercostal Space (ICS) on the left chest.              |
|   3. Trace laterally to the Left Midclavicular Line (MCL) below the nipple. |
|   4. Warm the stethoscope diaphragm in your palm to avoid startling resident|
|   5. Place diaphragm firmly over the apex; listen for "lub-dub" (S1-S2).    |
|   6. Count for ONE FULL MINUTE (60 SECONDS). Each "lub-dub" counts as 1 beat|
|   7. If apical rate is <60 bpm (bradycardia) or >100 bpm, notify nurse.     |
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[!NOTE] Pulse Deficit: A pulse deficit occurs when the apical pulse rate is higher than the peripheral radial pulse rate. It indicates that premature or weak ventricular beats fail to pump sufficient blood volume to generate a palpable peripheral pulse wave. It is measured simultaneously by two healthcare providers (one counting apical for 60 seconds, one counting radial for 60 seconds). $\text{Pulse Deficit} = \text{Apical Pulse} - \text{Radial Pulse}$

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3. Respiration Assessment & Respiratory Patterns

Respiration is the mechanism of pulmonary ventilation, supplying oxygen to tissues and removing carbon dioxide. One complete respiratory cycle consists of one inspiration (inhalation/chest rise) and one expiration (exhalation/chest fall).

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|                   NORMAL & ABNORMAL RESPIRATORY PATTERNS                    |
|                                                                             |
|   [EUPNEA]         ---> Normal unlabored breathing (12-20 breaths/min)      |
|   [TACHYPNEA]      ---> Rapid shallow breathing (>20 breaths/min)           |
|   [BRADYPNEA]      ---> Abnormally slow breathing (<12 breaths/min)         |
|   [APNEA]          ---> Temporary or complete cessation of breathing       |
|   [DYSPNEA]        ---> Difficult, painful, or labored breathing            |
|   [ORTHOPNEA]      ---> Inability to breathe easily unless sitting upright   |
|   [CHEYNE-STOKES]  ---> Cyclic pattern of crescendo-decrescendo breathing   |
|                         followed by 10-60 sec apnea (End-of-life/dying)     |
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Clinical Respiratory Parameters

• Normal Adult Range: 12 to 20 breaths per minute.
• Discreet Measurement Technique: Because breathing is under voluntary nervous control, residents who know their breathing is being counted will unconsciously alter their respiratory rate and depth.
  • The CNA Stealth Method: Immediately after counting the radial pulse, keep your fingers positioned on the resident's wrist. Shift your gaze to the resident's chest or abdomen and count respirations for one full minute (or 30 seconds multiplied by 2 if regular).
• Observations Beyond Rate: Note depth (shallow, normal, deep), symmetry of chest expansion, use of accessory neck/intercostal muscles, and respiratory sounds (wheezing, stridor, stertorous snoring, or rattling secretions).

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4. Blood Pressure Measurement Principles & Procedures

Blood pressure (BP) measures the lateral hydrostatic force exerted by circulating blood against the walls of the arterial system. It is expressed in millimeters of mercury (mmHg) as a fraction:

$\text{Blood Pressure} = \frac{\text{Systolic Pressure (Ventricular Contraction)}}{\text{Diastolic Pressure (Ventricular Relaxation)}}$

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|              AMERICAN HEART ASSOCIATION (AHA) BP CLASSIFICATIONS            |
|                                                                             |
|   [NORMAL BP]             ---> Systolic < 120  AND  Diastolic < 80 mmHg     |
|   [ELEVATED BP]           ---> Systolic 120-129 AND Diastolic < 80 mmHg     |
|   [STAGE 1 HYPERTENSION]  ---> Systolic 130-139  OR Diastolic 80-89 mmHg    |
|   [STAGE 2 HYPERTENSION]  ---> Systolic ≥ 140    OR Diastolic ≥ 90 mmHg     |
|   [HYPERTENSIVE CRISIS]   ---> Systolic > 180   and/or Diastolic > 120 mmHg |
|   [HYPOTENSION]           ---> Systolic < 90    and/or Diastolic < 60 mmHg  |
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Blood Pressure Equipment & Cuff Sizing Rules

Using an incorrectly sized blood pressure cuff produces major diagnostic errors:

• Cuff Width: Must cover 40% of the upper arm circumference.
• Cuff Bladder Length: Must encircle 80% to 100% of the upper arm.
• Diagnostic Impact:
  • Cuff Too Small / Narrow: Causes a falsely elevated (HIGH) reading.
  • Cuff Too Large / Wide: Causes a falsely decreased (LOW) reading.
  • Cuff Wrapped Too Loosely: Causes a falsely elevated (HIGH) reading.

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|                    BLOOD PRESSURE CUFF SIZING CHECK                         |
|                                                                             |
|       +-------------------------------------------------------------+       |
|       |                      BP CUFF BLADDER                        |       |
|       +-------------------------------------------------------------+       |
|       |<----------------- Width = 40% Arm Circ -------------------->|       |
|       |<================ Length = 80-100% Arm Circ ================>|       |
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Contraindications for Blood Pressure Arm Selection

Never apply a blood pressure cuff to an extremity with:

1. An intravenous (IV) infusion line or saline lock.
2. An arteriovenous (AV) fistula, shunt, or graft used for hemodialysis.
3. The ipsilateral side of a mastectomy or axillary lymph node dissection (due to severe risk of lymphedema).
4. A cast, splint, burn, or open surgical wound.
5. Severe hemiplegia or flaccid paralysis from a stroke (use the unaffected arm for optimal accuracy).

Step-by-Step Manual Auscultation Procedure:

1. Ensure the resident has rested for at least 5 minutes. Position the resident seated or supine with the bare arm supported at heart level and palm facing up.
2. Clean stethoscope earpieces and diaphragm with alcohol wipes.
3. Locate the brachial artery via palpation in the antecubital space (inner elbow).
4. Wrap the deflated cuff smoothly and snugly around the upper arm, placing the lower edge 1 inch (2.5 cm) above the antecubital fossa, aligning the cuff arrow with the brachial artery.
5. Determine Estimated Systolic Pressure (Palpatory Method): Palpate the radial pulse while rapidly inflating the cuff until the pulse disappears. Note the gauge reading (e.g., 110 mmHg). Deflate the cuff rapidly and completely. Wait 30 to 60 seconds.
6. Place the stethoscope earpieces into your ears (pointing forward toward the nose). Place the diaphragm flat and lightly over the brachial artery (never tuck it beneath the cuff edge).
7. Inflate the cuff to 30 mmHg above the estimated systolic reading (e.g., 110 + 30 = 140 mmHg).
8. Open the thumb valve slowly to deflate the cuff at a steady rate of 2 to 4 mmHg per second.
9. Note the gauge reading at the first clear, rhythmic tapping sound (Korotkoff Phase 1)—this is the Systolic Pressure.
10. Continue slow deflation until the sound completely disappears (Korotkoff Phase 5)—note this reading as the Diastolic Pressure.
11. Deflate the cuff completely, remove it from the arm, and immediately document the value (e.g., 124/76 mmHg, Right Arm, Seated).

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5. Pain Assessment: The Fifth Vital Sign

Pain is recognized by clinical accrediting bodies as the 5th vital sign. Pain is an entirely subjective sensation: "Pain is whatever the experiencing person says it is, existing whenever they say it does."

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|                         PAIN ASSESSMENT SCALES                              |
|                                                                             |
|   [NUMERIC RATING SCALE (0-10)]                                             |
|   0 = No Pain | 1-3 = Mild | 4-6 = Moderate | 7-9 = Severe | 10 = Worst Pain|
|                                                                             |
|   [WONG-BAKER FACES SCALE]                                                  |
|   (0) No Hurt  (2) Little Hurt  (4) Hurts More  (6) Even More  (8/10 Worst) |
|   *Used for pediatric, non-English speaking, or mildly impaired residents*  |
|                                                                             |
|   [PAINAD SCALE (Dementia Assessment)]                                      |
|   Evaluates: Breathing, Vocalization, Facial Expression, Body Language,     |
|              and Consolability in non-verbal residents with dementia.       |
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Non-Verbal Indicators of Pain:

Residents with cognitive impairment, expressive aphasia, or advanced dementia often cannot articulate pain numerically. The CNA must remain vigilant for behavioral indicators:

• Facial grimacing, furrowed brow, wincing, or clenching the jaw.
• Moaning, whimpering, crying, groaning, or calling out.
• Guarding, clutching, or protecting a specific body part.
• Restlessness, pacing, fidgeting, or constant shifting in bed/chair.
• Clenched fists, rigid posturing, or pulling knees to chest.
• Sudden combativeness, agitation, or refusal to participate in morning care.
• Autonomic changes: Diaphoresis (sweating), tachycardia, tachypnea, and hypertension.

[!TIP] The CNA's Clinical Role in Pain Management: Certified Nursing Assistants do not administer prescription analgesics or adjust medication dosages. However, the CNA is legally and ethically responsible for asking residents about comfort levels prior to transfers/care, documenting pain ratings and locations, utilizing non-pharmacological comfort interventions (repositioning, back rubs, soothing environments), and reporting complaints of pain immediately to the charge nurse.