Section 5.1: Vital Signs: Temperature, Pulse, & Respirations

Vital Signs: Temperature, Pulse, and Respirations

Vital signs are the baseline measurements of a resident’s essential body functions. They provide immediate, objective data about a resident's physical condition and are a critical tool for detecting physiological changes or distress. As a Certified Nursing Assistant (CNA) in Utah, you are the "eyes and ears" of the healthcare team. You will measure and record vital signs frequently, and it is your legal and professional responsibility to recognize and report any deviations from the normal range immediately.

Body Temperature

Body temperature represents the balance between the heat produced by the body and the heat lost to the environment. Temperature can be measured using several different routes, each with its own normal range, equipment, and technique.

Normal Temperature Ranges by Route

Temperature varies depending on where it is measured on the body. Rectal and tympanic measurements are closer to the core body temperature and run slightly higher than oral measurements, while axillary measurements are external and run lower.

Color-Coded Thermometers and Probes

Electronic thermometers use interchangeable, color-coded probe covers to prevent cross-contamination.

• Blue or Green probes are designated for oral and axillary measurements.
• Red probes are designated exclusively for rectal measurements.
• Exam Alert: Never use a red probe in a resident's mouth, and never use a blue probe in a resident's rectum. This is a critical infection control safety concept.

Measuring Techniques and Key Safety Steps

1. Oral Temperature: Place the probe under the tongue in the sublingual pocket (to either side of the frenulum at the back of the mouth). The resident must keep their mouth closed around the probe.
   • Critical Wait Time: If a resident has recently eaten, drank hot or cold liquids, smoked, or chewed gum, you must wait 15 to 20 minutes before taking an oral temperature. Failing to wait will result in an inaccurate reading.
2. Rectal Temperature: Considered the most accurate measurement of core body temperature. However, it is invasive and poses risks.
   • Safety Steps: Always explain the procedure, provide maximum privacy, and position the resident in the Sims' position (left side-lying with the right knee flexed). Apply a water-soluble lubricant to the tip of the red probe cover. Gently insert the probe 1/2 to 1 inch into the rectum. Never force the thermometer. You must hold the thermometer in place the entire time it is in the rectum; never let go of a rectal thermometer while it is inserted.
3. Axillary Temperature: Place the probe in the center of the clean, dry axilla (armpit). Have the resident hold their arm close to their chest. Because this is an external measurement, it is the least reliable.
4. Tympanic Temperature: Insert the covered ear probe gently into the ear canal. For an adult resident, gently pull the pinna (outer ear) up and back to straighten the ear canal.

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Radial Pulse

The pulse is the rhythmic expansion and contraction of an artery as the heart pumps blood through the body. The most common site for a CNA to measure a resident's pulse is the radial pulse, located on the thumb side of the wrist.

Normal Pulse Parameters

For a healthy adult, the normal resting heart rate (pulse) is 60 to 100 beats per minute (bpm).

• Tachycardia is a rapid heart rate, defined as a pulse over 100 bpm.
• Bradycardia is a slow heart rate, defined as a pulse under 60 bpm.

Technique for Measuring Radial Pulse

To measure the radial pulse accurately, follow these steps:

1. Locate the radial artery on the inside of the resident's wrist, just below the thumb.
2. Use the pads of your index and middle fingers to press gently against the artery. Never use your thumb to measure a pulse, as your thumb has its own strong pulse, and you may accidentally count your own heartbeats instead of the resident’s.
3. Note the rhythm (regular or irregular) and force (strong, bounding, weak, or thready).
4. Count the beats. For the Utah clinical skills exam, you must count the pulse for one full minute to ensure accuracy.

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Respirations

Respiration is the process of breathing air into the lungs (inspiration) and expelling air out of the lungs (expiration). One respiration cycle consists of one inhalation and one exhalation.

Normal Respiration Parameters

For a healthy adult, the normal respiratory rate is 12 to 20 breaths per minute.

• Tachypnea is a rapid respiratory rate, defined as more than 20 breaths per minute.
• Bradypnea is a slow respiratory rate, defined as fewer than 12 breaths per minute.
• Dyspnea is difficult, labored, or painful breathing.

The "Stealth" Technique for Counting Respirations

People tend to alter their breathing patterns if they know they are being observed. Therefore, CNAs use a "stealth" technique to count respirations without the resident's awareness:

1. Immediately after you finish counting the radial pulse, keep your fingers on the resident's wrist as if you are still counting the pulse.
2. Direct your eyes to the resident's chest or abdomen to observe the rise and fall of the chest.
3. Count each rise and fall as one single breath.
4. Count for one full minute. Note the depth (normal, shallow, or deep) and character (quiet, wheezing, or congested) of the breathing.

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Reporting Deviations & Clinical Scenarios

You must immediately report any vital sign measurement that falls outside the normal range, or any sudden change from a resident's baseline, to the supervising nurse.

Immediate Notification Triggers

• Temperature below 96°F or above 101°F.

• Pulse below 60 bpm or above 100 bpm.

• Respiratory rate below 12 or above 20 breaths per minute.

• Any signs of respiratory distress, such as gasping, cyanosis (blue tint to lips or nail beds), or audible wheezing.

• Scenario: Mr. Davis is a 78-year-old resident recovering from a hip replacement. While measuring his vital signs, you find a radial pulse of 104 bpm and a respiratory rate of 24. He appears slightly flushed and is breathing rapidly.

• CNA Action: You must immediately report these values to the charge nurse. Do not wait until the end of your shift. These findings could indicate an underlying infection, dehydration, or cardiovascular strain.