4.2: Vital Signs Measurement and Reporting

Introduction to Vital Signs

Vital signs are the body's dashboard. They provide a quick and objective snapshot of how well the body is functioning. The four primary vital signs are Temperature, Pulse, Respirations, and Blood Pressure. In modern healthcare, Pain is routinely assessed alongside them as the fifth vital sign.

As an LNA, you will measure and record vital signs frequently. Absolute accuracy is mandatory. If you are ever unsure of a reading, take it again or ask the nurse to check it. Never guess or fabricate a number. Most importantly, any vital sign that falls outside the normal range, or represents a significant change for that specific resident, must be reported to the charge nurse immediately.

Temperature Measurement and Routes

Body temperature represents the balance between the heat the body produces and the heat it loses. Normal body temperature varies slightly depending on the route used to measure it and the time of day (temperatures are usually lower in the morning).

1. Oral (Mouth): The most common route. The normal baseline is 98.6°F (normal range 97.6°F - 99.6°F). Place the thermometer probe under the tongue, to the side (in the sublingual pocket). Safety Constraints: Do not take an oral temperature if the resident is unconscious, confused, has a history of seizures, breathes through their mouth, or is receiving oxygen therapy. If the resident has eaten, consumed a hot/cold beverage, or smoked, wait 10-20 minutes before taking an oral temperature.

2. Axillary (Armpit): The safest, but least accurate route. The normal baseline is 97.6°F (runs one degree lower than oral). The probe must be in the center of a dry armpit, with the arm held firmly against the body.

3. Rectal (Rectum): The most accurate, but most invasive route. The normal baseline is 99.6°F (runs one degree higher than oral). The resident is placed in the Sims' position (left side-lying). The thermometer must be lubricated and inserted only ½ to 1 inch into the rectum. Never force the thermometer, and never leave the resident alone. Rectal temps are contraindicated for residents with diarrhea, rectal surgery, bleeding disorders, or certain heart conditions (vagus nerve stimulation can drop the heart rate).

4. Tympanic (Ear): Fast and common. Normal range is similar to oral. For an adult, gently pull the ear pinna up and back to straighten the ear canal before inserting the probe.

5. Temporal (Forehead): Measures heat over the temporal artery. Very non-invasive and increasingly common in facilities.

Pulse: The Heart's Rhythm

The pulse is the beat of the heart felt at an artery as blood is pumped through it. The normal pulse rate for an adult is 60 to 100 beats per minute (bpm).

• Bradycardia: A slow heart rate (under 60 bpm).
• Tachycardia: A fast heart rate (over 100 bpm).

When taking a pulse, you are assessing three things: Rate (number of beats), Rhythm (regular or irregular), and Force (strong/bounding or weak/thready).

Pulse Sites:

• Radial Pulse: Located on the thumb side of the inner wrist. This is the most common site for routine vital signs. Use two or three fingers, never your thumb, as your thumb has its own pulse. Count for 30 seconds and multiply by 2 (or a full 60 seconds if the pulse is irregular).
• Apical Pulse: Listened to directly over the heart using a stethoscope on the left side of the chest, just below the nipple. An apical pulse is always counted for a full 60 seconds. It is used for infants, residents with heart disease, or those with irregular radial pulses.
• Carotid Pulse: Located on the neck, next to the trachea. Primarily used during emergency CPR.
• Brachial Pulse: Located inside the elbow. Used for blood pressure measurement.

Respirations: The Breath of Life

Respiration is the process of breathing air into the lungs (inspiration) and exhaling air out (expiration). One inspiration plus one expiration equals one respiration. The normal respiratory rate for an adult is 12 to 20 breaths per minute.

• Tachypnea: Rapid breathing (over 20 breaths per minute).
• Bradypnea: Slow breathing (under 12 breaths per minute).
• Dyspnea: Difficulty or labored breathing.
• Apnea: Absence of breathing.
• Cheyne-Stokes Respirations: Alternating periods of slow, irregular breathing and rapid, shallow breathing, often with periods of apnea. This is common during the dying process.

Measurement Technique: People can consciously control their breathing if they know you are watching. The trick is to count respirations seamlessly after taking the radial pulse, keeping your fingers on the resident's wrist so they think you are still counting their heart rate. Observe the chest rise and fall. Count for 30 seconds and multiply by 2 (or a full minute if abnormal).

Blood Pressure: The Force of Blood

Blood pressure is the force of the blood pushing against the walls of the arteries. It is measured in millimeters of mercury (mmHg) and recorded as a fraction.

• Systolic (Top Number): The pressure when the heart muscle contracts and pumps blood. The normal range is 90 to 119 mmHg.
• Diastolic (Bottom Number): The pressure when the heart relaxes and fills with blood. The normal range is 60 to 79 mmHg.

Abnormal Values:

• Hypertension (High Blood Pressure): Consistently elevated BP. Often defined clinically as 130/80 or higher, but reporting thresholds in facilities are usually 140/90 or as defined in the care plan.
• Hypotension (Low Blood Pressure): Typically below 90/60 mmHg. Orthostatic hypotension is a sudden drop in blood pressure when a person stands up, which can cause severe dizziness and falls.

Measurement Technique (Sphygmomanometer and Stethoscope): The resident should be seated quietly with their arm resting at heart level, palm up, and legs uncrossed.

1. Wrap the correctly sized cuff around the upper arm, about 1 inch above the elbow. (A cuff that is too small gives a falsely high reading; too large gives a falsely low reading).
2. Locate the brachial artery pulse with your fingers, then place the stethoscope diaphragm over it.
3. Inflate the cuff until you can no longer hear the pulse (usually around 160-180 mmHg).
4. Slowly release the valve to deflate the cuff.
5. Note the number on the dial when you hear the first clear tapping sound. This is the systolic pressure.
6. Continue listening. Note the number when the sound completely disappears. This is the diastolic pressure.

Never take a blood pressure on an arm with an IV line, a dialysis shunt, a cast, or on the side where a resident has had a mastectomy or stroke paralysis.

Pain: The Fifth Vital Sign

Pain is entirely subjective; it is whatever the resident says it is. Because you cannot measure it with a device, you must ask. Often, pain is rated on a scale of 0 to 10, where 0 is no pain and 10 is the worst pain imaginable. For residents who are non-verbal or cognitively impaired, observe for objective signs like grimacing, groaning, pacing, guarding a body part, or sudden behavioral changes. LNAs do not give medication, but they must report complaints of pain to the nurse promptly.