3.1 Measuring and Recording Vital Signs

Measuring and Recording Vital Signs

Vital signs (often abbreviated as TPR & BP) are fundamental physiological measurements that reflect the performance of a resident's vital organs—specifically the heart, lungs, and brain. Because long-term care residents often have complex or chronic medical conditions, accurate measurement of vital signs provides early warnings of infection, heart failure, respiratory distress, and medication side effects. Nursing assistants are responsible for measuring baseline vital signs upon admission and monitoring them routinely according to the resident's individualized care plan.

Body Temperature Measurement Routes and Normal Ranges

Body temperature represents the balance between the heat produced by body tissues and the heat lost to the environment. Temperature can be measured using several anatomical routes, each with specific normal ranges, equipment requirements, and clinical indications.

Contraindications for Temperature Routes

1. Oral Route Contraindications: Do not take an oral temperature if the resident is confused, disoriented, unconscious, prone to seizures, receiving oxygen therapy, breathing primarily through the mouth, experiencing severe coughing spells, or recovering from oral surgery.
2. Rectal Route Contraindications: Do not take a rectal temperature if the resident has cardiac disease or a heart condition (rectal stimulation can stimulate the vagus nerve, causing sudden bradycardia), severe diarrhea, rectal bleeding, hemorrhoids, recent rectal surgery, or severe confusion/agitation.

Recognizing Abnormal Changes and Reporting

Vital signs are one part of observation. CNAs must also watch for and immediately report abnormal changes in body function to the supervising nurse, including:

• Sudden confusion, lethargy, or change in level of consciousness
• Shortness of breath, chest pain, or bluish lips/nail beds
• New weakness, facial droop, or slurred speech (possible stroke signs)
• Fever, uncontrolled bleeding, vomiting, or severe pain
• Skin color changes, new wounds, or increasing edema
• Refusal to eat/drink or a sudden drop in urine output

Document objective facts (what you saw, measured, and when) and notify the nurse without delaying care for urgent changes. Do not diagnose; report.

Measuring Pulse and Respiration Rates

The pulse rate represents the expansion and recoil of an artery as the heart contracts and pumps blood throughout the body. Respiration rate measures the mechanical process of breathing, supplying oxygen to cells and removing carbon dioxide.

Pulse Measurement Protocols

• Normal Adult Pulse Range: 60 to 100 beats per minute (bpm).
• Pulse Assessment Attributes: When assessing a pulse, the nursing assistant evaluates rate (beats per minute), rhythm (regular or irregular), and force/volume (weak/thready, normal, or bounding).
• Radial Pulse: Located on the thumb side of the inner wrist. This is the most common site for routine pulse measurement in adult residents. Place the tips of your first two or three fingers (never use your thumb, which has its own pulse) over the radial artery, press gently, and count for 30 seconds multiplied by 2 if regular, or 60 full seconds if irregular.
• Apical Pulse: Located over the apex of the heart at the 5th intercostal space along the left midclavicular line. Measured using a stethoscope for 1 full minute (60 seconds). An apical pulse measurement is required for residents with irregular cardiac rhythms, infants/children, or prior to administering cardiac medications such as digoxin.
• Medical Terminology: Tachycardia refers to a pulse rate persistently above 100 bpm. Bradycardia refers to a pulse rate persistently below 60 bpm. Both conditions must be reported to the charge nurse.

Respiration Measurement Protocols

• Normal Adult Respiration Range: 12 to 20 breaths per minute (rpm).
• Respiration Attributes: Assess for rate, rhythm, and depth (shallow, normal, deep). One complete respiration consists of one inspiration (chest rising) and one expiration (chest falling).
• Discreet Measurement Technique: Residents frequently change their breathing patterns unconsciously when aware their breathing is being observed. Therefore, the nursing assistant should keep their fingers in place on the resident's radial wrist after counting the pulse, discreetly observing and counting chest rises for 30 seconds (multiplied by 2) or 1 full minute.
• Medical Terminology: Tachypnea (respirations >20 rpm), Bradypnea (respirations <12 rpm), Dyspnea (difficult or painful breathing), and Apnea (absence of breathing).

Blood Pressure Measurement and Pain Rating

Blood pressure (BP) measures the force exerted by circulating blood against the walls of the body's arteries. It is recorded as two distinct numbers in millimeters of mercury (mmHg): Systolic over Diastolic pressure.

Blood Pressure Categories and Normal Parameters

• Systolic Pressure: The top number; represents the maximum pressure exerted against arterial walls when the heart's ventricles contract. Normal adult systolic pressure is less than 120 mmHg.
• Diastolic Pressure: The bottom number; represents the baseline pressure within arteries when the heart relaxes between beats. Normal adult diastolic pressure is less than 80 mmHg.
• Hypertension: High blood pressure defined as systolic pressure ≥130 mmHg or diastolic pressure ≥80 mmHg. Hypertension places severe stress on the heart, kidneys, and blood vessels.
• Hypotension: Low blood pressure defined as systolic pressure <90 mmHg or diastolic pressure <60 mmHg. Symptoms include dizziness, lightheadedness, and syncope (fainting).

Equipment and Step-by-Step Sphygmomanometer Procedure

1. Select the correct cuff size (an oversized cuff yields falsely low readings; an undersized cuff yields falsely high readings).
2. Position the resident comfortably sitting or lying down with the arm supported at heart level and palm facing upward.
3. Expose the upper arm and locate the brachial artery on the inner aspect of the elbow.
4. Wrap the deflated cuff smoothly around the upper arm, placing the artery marker directly over the brachial artery, approximately 1 inch above the antecubital space (elbow bend).
5. Place the stethoscope earpieces in your ears tilted forward toward your face. Position the diaphragm over the brachial artery.
6. Inflate the cuff to 30 mmHg above the point where the radial pulse was no longer felt. Deflate the valve slowly at a rate of 2 to 3 mmHg per second.
7. Record the exact number on the pressure gauge when you hear the first faint tapping sound (Systolic), and record the exact number when the sound completely disappears (Diastolic).

CRITICAL CLINICAL PRECAUTION: NEVER apply a blood pressure cuff to an arm that has an active intravenous (IV) infusion line, a renal dialysis arteriovenous (AV) shunt or fistula, a cast/splint, severe edema, paralysis, or on the affected side of a resident who has undergone a radical mastectomy.

Pain Rating: The Fifth Vital Sign

Pain is recognized as the fifth vital sign because it directly impacts physical recovery, mobility, and psychological well-being. Nursing assistants must routinely ask residents about pain using a standardized 0 to 10 scale (0 indicating no pain, 10 indicating the worst possible pain). For non-verbal or cognitively impaired residents, observe for physical indicators of pain such as facial grimacing, moaning, crying, guarding a body part, restlessness, rapid breathing, sweating, or sudden aggressive behavior.