4.2 Vital Signs & Measurement
Key Takeaways
- Normal adult ranges: temperature 97.6-99.6°F (oral), pulse 60-100 bpm, respirations 12-20/min, blood pressure under 120/80 mmHg
- Count respirations without telling the resident, immediately after taking the pulse, while keeping a hand on the wrist
- Report a pulse below 60 or above 100, respirations below 12 or above 20, oral temperature above 101°F, or BP above 140/90 unless it is the resident's baseline
- Take blood pressure with the arm at heart level, the correct cuff size, and on the arm WITHOUT an IV, dialysis access, or affected side
- Pain is the 'fifth vital sign' — the resident's self-report is the most reliable measure and must be recorded and reported, not judged
Vital signs are measurements of the body's most basic functions. Because a change can signal a serious problem early, accurate measurement and prompt reporting are among the most heavily tested New Jersey CNA skills. The four primary vital signs are temperature (T), pulse (P), respirations (R), and blood pressure (BP).
Normal Adult Ranges
| Vital Sign | What It Measures | Normal Adult Range | Report If |
|---|---|---|---|
| Temperature | Body heat | Oral 97.6-99.6°F (36.4-37.6°C) | Over 101°F or under 97°F |
| Pulse | Heartbeats per minute | 60-100 beats/min | Under 60 or over 100 |
| Respirations | Breaths per minute | 12-20 breaths/min | Under 12 or over 20 |
| Blood Pressure | Force on artery walls | Under 120/80 mmHg | Over 140/90 or under 90/60 |
A reading outside the range is not automatically an emergency — always compare it to the resident's baseline (their usual values) and report the change to the nurse.
Temperature Sites
Sites read differently. Oral is the common baseline. Rectal runs about 1°F higher and is the most accurate; axillary (armpit) runs about 1°F lower and is the least accurate. Use the site ordered in the care plan and never take an oral temperature on a confused resident or one who just had hot or cold fluids.
Measuring Pulse and Respirations
The radial pulse at the wrist is the routine site; the apical pulse, heard with a stethoscope over the heart, is used for irregular rhythms or before certain medications. Count a regular pulse for 30 seconds and multiply by 2; count an irregular pulse for a full 60 seconds.
Immediately after counting the pulse, keep your hand on the wrist and count respirations for 30 seconds (or 60 if irregular). Do not tell the resident you are counting breaths — awareness changes the breathing rate. Note depth and whether breathing is labored or noisy.
Measuring Blood Pressure
Blood pressure has two numbers: systolic (heart contracting, the top number) over diastolic (heart at rest, the bottom number). Accurate technique:
- Resident seated and rested at least 5 minutes, legs uncrossed, feet flat.
- Bare upper arm supported at heart level.
- Correct cuff size — a cuff too small gives a falsely high reading; too large gives a falsely low one.
- Never use an arm with an IV line, a dialysis shunt, a cast, or the affected (paralyzed) side.
Common Error Sources
| Error | Effect on Reading |
|---|---|
| Cuff too small / loose | Falsely high |
| Arm below heart level | Falsely high |
| Deflating the cuff too fast | Inaccurate (often low) |
| Resident talking or not rested | Falsely high |
| Recent caffeine, smoking, exercise | Falsely high |
Height, Weight, and Pain
Measure weight at the same time of day, on the same scale, in similar clothing, after the resident voids — a sudden gain may signal fluid retention and must be reported. Measure height with the resident standing straight or, if bedbound, using a tape measure from head to heel.
Pain is called the fifth vital sign. The resident's own report (often a 0-10 scale) is the most reliable measure. The CNA records exactly what the resident says and reports it; the CNA never decides whether the pain is 'real.'
Recording
Record every value immediately — do not rely on memory or 'eyeball' a number. Document the actual reading, the site or arm used, and report any abnormal value or change from baseline to the nurse right away. Accurate documentation is a legal record.
A New Jersey CNA finishes counting a resident's radial pulse and, while still holding the wrist, begins counting the resident's breathing. The resident asks, 'Are you checking my breathing now?' What should the CNA do?
A CNA is about to take a blood pressure on a New Jersey resident who had a right-side mastectomy and has an IV in the left forearm. Both arms are otherwise available. What is the BEST action?