Vital Signs: Temperature, Pulse, Respiration, Blood Pressure & Pain

Vital Signs: Temperature, Pulse, Respiration, Blood Pressure & Pain

Vital signs provide immediate, objective data regarding a resident's core body functions and physiological stability. The five primary vital signs monitored by Nursing Assistants are Temperature, Pulse, Respiration, Blood Pressure, and Pain (often designated the "fifth vital sign"). Height, weight, and intake and output are covered in the next section. CNAs must perform measurements with absolute accuracy and immediately report any values outside normal ranges or sudden baseline changes to the licensed nurse.

Baseline Values & Normal Adult Ranges

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Temperature Routes & Measurement Procedures

Body temperature reflects the balance between heat produced by the body's metabolic processes and heat lost to the environment. Temperature can be measured at five anatomical routes, each with specific average values, probe colors, and clinical contraindications.

Temperature Routes Comparison

1. Oral Route (Mouth)

   • Average: 98.6°F (37.0°C) (Range: 97.6°F - 99.6°F).
   • Probe Color: Blue or green probe cover.
   • Procedure: Place covered probe under tongue in sublingual pocket to the side of the frenulum. Resident closes lips tightly around probe (not teeth).
   • Contraindications: Unconscious, confused, or disoriented residents; seizure disorders; infants/young children; oxygen mask users; oral surgery/sores; or residents who have ingested hot/cold fluids, eaten, or smoked within the last 15 to 20 minutes (must wait 15-20 min before measuring).

2. Rectal Route (Rectum)

   • Average: 99.6°F (37.5°C) (Range: 98.6°F - 100.6°F) — 1°F higher than oral.
   • Probe Color: Red probe cover.
   • Accuracy: Most accurate measure of core body temperature.
   • Procedure: Position resident in Sims' position (left side-lying). Apply water-soluble lubricant to covered probe tip. Insert gently 1 inch into adult rectum (1/2 inch for infants). Hold probe in place continuously throughout measurement.
   • Contraindications: Cardiac residents (stimulation of vagus nerve can slow heart rate to dangerous levels—vagal response); severe diarrhea; rectal bleeding, hemorrhoids, or recent rectal surgery; bleeding disorders or low platelet counts.

3. Axillary Route (Armpit)

   • Average: 97.6°F (36.5°C) (Range: 96.6°F - 98.6°F) — 1°F lower than oral.
   • Accuracy: Least accurate route; used when other routes are contraindicated.
   • Procedure: Ensure axilla is dry. Place covered probe in center of armpit. Lower arm down snugly over chest.

4. Tympanic Route (Ear)

   • Average: 98.6°F (37.0°C).
   • Procedure: Fast, non-invasive core temperature measurement. For adults, pull pinna (outer ear) up and back to straighten ear canal (for children <3 years, pull ear down and back). Insert covered probe gently into ear canal.

5. Temporal Artery Route (Forehead)

   • Average: 98.6°F (37.0°C).
   • Procedure: Gently slide electronic scanner flat across forehead to hair line or tap behind earlobe per device instructions.

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Pulse Measurement & Pulse Sites

Pulse is the wave of blood created by heart contractions as blood is pumped into the arterial system. When measuring pulse, the Nursing Assistant evaluates three distinct characteristics: Rate (number of beats per minute), Rhythm (regularity of beats), and Volume/Force (strong/bounding vs. weak/thready).

Pulse Anatomical Sites

• Radial Pulse: Located on the thumb side of the inner wrist. The most common site for routine vital sign measurement in adults.
• Apical Pulse: Located at the apex of the heart (left 5th intercostal space at the midclavicular line). Measured directly using a stethoscope.
• Carotid Pulse: Located in the neck alongside the trachea; used during CPR and emergency resuscitation.
• Brachial Pulse: Located in the inner bend of the elbow (antecubital fossa); used to position the stethoscope during blood pressure measurement and to assess infant pulses.
• Femoral, Popliteal, Posterior Tibial, Dorsalis Pedis: Peripheral arterial sites used to assess lower extremity circulation.

Radial Pulse Measurement Technique

1. Place resident's arm in a comfortable, supported position.
2. Place tips of your index and middle fingers over the radial artery on the thumb side of the wrist. (Never use your thumb, as it has its own pulse).
3. Apply gentle pressure until pulse is felt.
4. If pulse is regular, count beats for 30 seconds and multiply by 2. If pulse is irregular, count for 1 full minute (60 seconds).

Apical Pulse Measurement Technique

1. An apical pulse is ordered for residents with cardiac conditions, irregular radial pulses, or prior to administering cardiac medications (e.g., digoxin).
2. Clean stethoscope earpieces and diaphragm with alcohol wipes.
3. Warm diaphragm in hand and place over left 5th intercostal space, midclavicular line.
4. Count heartbeats (each "lub-dub" sounds counts as ONE beat) for 1 full minute (60 seconds).

Respiration Measurement

Respiration is the process of inhaling oxygen into the lungs (inspiration) and exhaling carbon dioxide (expiration). One full respiration consists of one inspiration plus one expiration.

Measurement Technique & Key Rules

• Normal Rate: 12 to 20 breaths per minute in adults.
• Covert Counting Technique: Because breathing is under voluntary control, residents will unconsciously alter their breathing rate if they know they are being observed. The CNA must count respirations without telling the resident.
• Immediately after counting the radial pulse, leave your fingers on the wrist and observe the rise and fall of the resident's chest.
• Count respirations for 30 seconds and multiply by 2 (or count for 60 seconds if breathing is irregular, shallow, or labored).
• Note breathing depth (deep, normal, shallow), rhythm (regular or irregular), and effort (quiet, unlabored vs. dyspnea, wheezing, or stertorous).

Respiratory Terminology

• Dyspnea: Difficult, painful, or labored breathing.
• Apnea: Absence of breathing.
• Tachypnea: Rapid breathing (>20 breaths/min).
• Bradypnea: Abnormally slow breathing (<12 breaths/min).
• Cheyne-Stokes: Pattern of breathing characterized by alternating periods of deep, rapid breathing followed by shallow breathing and periods of apnea; common near end of life.

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Blood Pressure Measurement

Blood pressure (BP) is the force exerted by circulating blood against the arterial vessel walls. It is measured in millimeters of mercury (mmHg) and recorded as a fraction: Systolic / Diastolic.

Systolic vs. Diastolic Pressure

• Systolic Pressure: The higher number (top number). Measures arterial pressure during ventricular contraction (systole). Marked by the first clear tapping sound (Korotkoff Phase I). Normal range: 90 - 119 mmHg.
• Diastolic Pressure: The lower number (bottom number). Measures arterial pressure during ventricular relaxation and filling (diastole). Marked by the disappearance of sound (Korotkoff Phase V). Normal range: 60 - 79 mmHg.

Equipment & Cuff Sizing Rules

• Equipment includes a sphygmomanometer (blood pressure cuff with pressure gauge) and a stethoscope.
• Cuff Sizing: Selecting the proper cuff size is critical. The inflatable bladder must be about 40% of the arm's circumference in width and long enough to encircle about 80% of the arm's circumference.
  • Cuff too small/narrow: Yields a falsely high reading.
  • Cuff too large/wide: Yields a falsely low reading.

Manual BP Procedure Step-by-Step

1. Ensure resident has been resting comfortably for at least 5 minutes. Position arm supported at heart level with palm up.
2. Expose upper arm completely. Do not roll up tight sleeves that compress the arm.
3. Locate brachial artery in antecubital fossa. Wrap deflated cuff smoothly 1 inch above antecubital space, centering bladder over brachial artery.
4. Position stethoscope earpieces angled forward into ears. Place stethoscope diaphragm lightly over brachial artery.
5. Inflate cuff to 30 mmHg above estimated systolic pressure (or above point where radial pulse disappeared).
6. Deflate cuff slowly at a rate of 2 to 3 mmHg per second while listening carefully.
7. Note reading when first clear tapping sound is heard (Systolic). Continue deflating smoothly.
8. Note reading when sound disappears completely (Diastolic). Deflate cuff completely and remove.

⚠️ Contraindicated Arms for Blood Pressure Never take blood pressure on an arm that has: an IV line, a dialysis arteriovenous (AV) shunt/fistula, a history of mastectomy on that side, recent trauma/fracture, or paralysis.

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Pain: The Fifth Vital Sign

Pain is a subjective experience. The Nursing Assistant must assess pain whenever vital signs are checked and report complaints immediately to the nurse.

• 0 - 10 Numeric Rating Scale: Ask resident to rate pain from 0 (no pain) to 10 (worst imaginable pain).
• Wong-Baker FACES Scale: Visual face scale used for residents with cognitive impairment, language barriers, or pediatric patients.
• Non-Verbal Indicators of Pain: CNAs must observe for non-verbal pain cues: grimacing, moaning, sighing, guarding a body part, restlessness, sweating, rapid breathing, or sudden refusal to move.