Vital Signs: Temperature, Pulse & Respiration

Quick Answer: Measure temperature, pulse, and respirations accurately, record immediately, and report abnormal values to the nurse—never treat or diagnose. Count respirations for one full minute without alerting the resident.

Vital Signs in the NY CNA Role

Vital signs are objective data the nurse uses to assess condition. Your job: correct technique, accurate numbers, timely documentation, and immediate reporting of out-of-range findings.

In New York nursing homes, vital signs are often taken on admission, quarterly, when condition changes, and per physician orders. A single abnormal reading can signal infection, cardiac compromise, or medication reaction—your prompt report initiates nursing assessment.

Temperature

Report fevers per policy—often ≥101°F (38.3°C) oral. Wait 15 minutes after hot/cold fluids before oral temps.

Factors That Alter Temperature Readings

Technique (Oral Electronic)

1. Explain procedure; wash hands
2. Cover probe with disposable sheath
3. Place under tongue in posterior sublingual pocket
4. Wait for signal; read and record
5. Remove sheath into trash; disinfect per policy

Pulse

Normal adult pulse: 60–100 beats per minute.

Do not use your thumb—it has its own pulse.

Apical Pulse

Place stethoscope on bare skin at apex; count one full minute. Required when pulse is irregular or ordered post-cardiac medication.

Pulse Quality Terms (Report Objectively)

Respirations

Normal adult: 12–20 breaths per minute, effortless and regular.

Critical technique: Count for one full minute while resident is unaware—observe chest/abdominal rise without stating you are counting breaths (knowing causes altered breathing).

What Counts as One Respiration

One complete cycle: inhalation + exhalation. Observe the chest or abdomen rise and fall. Cheyne-Stokes or apnea periods require immediate nursing notification.

Documentation and Reporting

Record: value, route/site, time, position. Compare to baseline. Never delay reporting abnormal vitals to finish linen change.

Worked Scenario

Radial pulse 48 bpm, regular, resident alert. First action?

Report to nurse immediately—bradycardia is abnormal. Do not wait for next round; do not exercise the resident without orders.

Prometric Measurement Skill Tips

If assigned radial pulse or respirations:

• Introduce self; explain; privacy
• Position resident comfortably
• Perform hand hygiene
• Count correctly; record on form
• Unrecorded measurement can fail skill even if technique looked correct

Combining Vital Sign Rounds Efficiently

Many facilities group temperature, pulse, and respirations in one round. Take temperature first (may affect pulse if resident is anxious), then pulse, then respirations while resident remains still and unaware of breath count.

Exam Traps

• Counting respirations 15 seconds × 4 (too short—use 1 minute)
• Using thumb on radial pulse
• Oral temp immediately after hot coffee
• Diagnosing "anxiety" instead of reporting tachypnea
• Reporting only verbally without documenting per facility policy

NY Nursing Home Vital Sign Protocols

Vital signs are often obtained on admission, quarterly, when condition changes, before/after procedures, and per physician orders. Know your facility parameter sheet for automatic reporting thresholds.

Tympanic and Temporal Thermometers

Many New York units use tympanic or temporal artery thermometers for speed. Follow manufacturer technique—incorrect angle gives false lows. Report equipment malfunction.

Oxygen and Oral Temperature

Residents on supplemental oxygen often mouth-breathe or have nasal cannula interference—use axillary or tympanic route instead of oral unless policy specifies.

Apical vs Radial Pulse Discrepancy

If apical rate is higher than radial (pulse deficit), report immediately—may indicate atrial fibrillation or other cardiac issue. This is nursing assessment data you supply through accurate measurement.

Respiration Character Quality

Count rate and note quality: shallow, labored, Cheyne-Stokes pattern, use of accessory muscles. Objective description: "Respirations 28, labored, resident using accessory neck muscles."

Fever Workup Support

When you report fever, nurse may order blood cultures, urine, or monitoring. Retake temperature per schedule; offer comfort measures within scope (cool cloth to forehead if ordered); do not give antipyretic unless nurse delegates specific medication administration—which is outside standard CNA scope in NY.

Pediatric and Geriatric Variations

Elderly residents may not mount fever with infection—report subjective chills, confusion, or hypothermia as equally urgent. Know facility parameters for reporting low temperatures.

Antipyretic Timing and Vitals

If resident recently received acetaminophen, note time on vital sign record—nurse interprets trending. Retake temperature per schedule after medication if ordered.

End-of-Life Vital Sign Changes

Slowing respirations, irregular pulse, and cool extremities near end of life require comfort-focused reporting per plan. Still report changes promptly—family and hospice team rely on CNA observations.