This document provides information on measuring and recording various vital signs including temperature, pulse, respiration, blood pressure, height and weight. It describes normal ranges for each vital sign and situations that could cause variations. Proper techniques are outlined for measuring each vital sign safely and accurately. All abnormal readings or difficulties taking measurements should be reported to the nurse.

1. Vital Signs
Unit 12
Taking a Radial Pulse and
Counting Respirations
Measuring Blood Pressure
Measuring Weight and Height

2. Vital Signs
• Measuring vital signs is one means of
getting information about body condition.
Included in vital signs are
– Temperature(T)
– Pulse (P)
– Respiration (R)
– Blood Pressure (BP)
Measuring height (ht) is included in this unit
although it is not a vital sign.
Weight is covered in Unit 10.

3. Temperature
• Is a measurement of the amount of heat in the
body. The healthy body maintains a balance
between heat produced and lost.
• Is created as the body changes food to energy.
• Is lost from the body to the environment by
contact, perspiration, breathing and other
means.

4. Types of Thermometers
• Electronic thermometer
– Types: Simple digital, probe-style digital, tympanic.
– Battery powered, usually rechargeable
Chemically treated paper or plastic strips-change color to
register temperature reading .
Glass thermometer
-glass tube with measurement markings
-easily broken, present potential for injury
-Mercury, galinstan or colored alcohol within thermometer
shows temperature.
MERCURY-CONTAINING THERMOMETERS NO LONGER USED IN
MOST LONG-TERM CARE FACILITIES BECAUSE OF
ENVIRONMENTAL HAZARDS WHEN THERMOMETER BREAKS

6. Types of Thermometers
– Types (shapes): oral, security, rectal.
– Oral thermometers are marked with blue
while rectal thermometers are marked with
red.
• DO NOT PUT RED TIPPED THERMOMETERS
IN MOUTH!!!!!

7. Normal Range Key Points
• Oral-98.6 ‘ (F) Fahrenheit
– Range 97.6-99.6 (F)
Rectal-99.6 (F)
- Range 98.6-100.6 (F)
Axillary-97.6 (F)
- Range 96.6-98.6 (F)
Tympanic-98.6 (F)
- Range 97.6-99.6 (F)

8. Temperature
• Variations from “normal” temperature range
before assuming that the temperature reading
is out of acceptable range.
– Situations causing higher than normal readings:
eating warm food, time of day, infection or other
disease.
– Situations causing lower readings: faulty technique,
eating cold food, time of day, dry mouth.

9. Checking Body Temperature-
Oral
• Used in almost all situations, except when
contraindicated.
• Key points for glass or digital thermometers.
– Preparing thermometer for accurate reading
Must be shook down
– Infection control and disinfection
Disposable sheath cover in place
– Placement
– Resident safety
– Time to register(follow facility procedure)

11. Checking Body Temperature-
Rectal Route
• Used when oral route is unsafe or inaccurate
– Resident is not reliable
– Resident cannot hold mouth closed around
thermometer
– Resident’s mouth is dry or inflamed
Key points
-Preparing thermometer for accurate reading
-Infection Control and disinfection
-Placement
-Resident safety
-Time to register (follow facility procedure)

13. Checking Body Temperature-
Tympanic (ear) Route
• Most accurate route, IF PROPERLY DONE. If
technique is not correct, errors in reading will
result.
• Key points
– Preparing thermometer for accurate reading
– Infection control and disinfection
– Placement
– Time to register (follow facility policy)

15. Checking Body Temperature-
Axillary Route
• Used when other methods are unsafe or
inaccurate. This method can provide less
consistent readings than the other routes.
• Key Points
– Preparing thermometer for accurate reading
– Infection control and disinfection
– Placement
– Resident safety
– Time to register (follow facility policy)

17. Reporting and Recording-
Temperature
• Notify nurse immediately if:
– Oral temperature below 97 (F) or above 100 (F)
– Rectal temperature below 98 (F) or above 101 (F)
– Axillary temperature below 96 (F) or above 99 (F)
– Tympanic temperature below 97 (F)or above 100(F)
Notify nurse if CNA has difficulty obtaining
temperature.
Record or document temperature reading, using the
following symbols:
Oral=O Tympanic=T
Rectal=R Axillary=Ax

19. Pulse
• Measurement of number of times the
heart beats, a basic observation of the
functioning of the heart and circulatory
system.
• “Normal” or average pulse
– 60-100 beats per minute. Each person has a
rate that is “normal” for him/her.
– Should be regular in rate, rhythm and
strength of force.

20. Variation in pulse pressure
• All variations in pulse should be reported
to the nurse.
• Elder pulses are often irregular.
– Abnormal rate can be distinguished by
• Pulse beat of less than 60, counted for one full
minute.
• Pulse beat of more than 100, counted for one
minute
• Pulse rate may be increased by such things as
exercise, activity, emotional distress, fever.

21. Pulse
• Abnormal rhythm can be described as:
– Beats that are not evenly spaced apart such as
skipped beats, extra beats or an erratic pattern of
beats.
Abnormal strength or force can be described as:
-Bounding-pulse cannot be occluded by mild
pressure.
-Weak and thready -pulse can be occluded by slight
pressure. Often has fast rate.

22. Checking Pulse
Radial Pulse
Key points
– Location to palpate
Wrist – thumb side
– Placement of CNA’s fingers
Middle three finger tips
using only light pressure
Apical Pulse
Key points
-Equipment needed
Stethoscope
-Location to listen
Left side of chest
-Time interval
Must count for 1 full minute

25. Pulse
• Reporting and recording
– Report changes in resident’s pulse from what
is “normal” for him/her
– Report pulses <60 or >100
– All variations in pulse should be reported to
the nurse.
– Notify nurse if CNA has difficulty obtaining
pulse.
– Record or document pulse measurement.
– Identify Apical pulse measurement with (AP)

26. Respiration
• Counting the inspiration and expiration of
air.
• “Normal” or average respiratory rate is
14-20 per minute for average adult. Each
person has a rate that is “normal” for
him/her.

27. Respiration
• Variations-all variations in respiratory rate
should be reported to the nurse.
– Rate
• Increased by exercise, fever, lung disease, heart disease,
emotional distress.
• Decreased by sleep, inactivity, pain medication.
Character and rhythm
-Dyspnea- difficult or labored breathing, extra muscles
used for breathing.
-Shallow- small amounts of air exchanged.
-Noisy- gurgling, wheezing, or snoring sounds.
-Irregular- such as cycles of dyspnea followed by apnea.

28. Respiration
• Counting respiratory rate
• Key points
– Counting without residents awareness
Reporting and recording
-Report changes in resident’s respiratory rate from what is
“normal” for him/her.
-Report respiratory rates <14 or >24
-All variations in respiratory rate should be reported to the
nurse.
-Notify nurse if CNA has difficulty counting respiratory rate
-Record or document respiratory rate

29. Blood Pressure
• Blood pressure is the force of blood
against artery walls
• Pressure level depends on:
– Rate and strength of heart beat
– Ease with which blood flows through the
arteries
– Amount of blood within the circulatory system

30. Blood Pressure
Systolic Pressure
• The force within arteries
when the heart contracts
• The highest pressure
within the arteries
• The top number of BP
• The first sound heard
when measuring BP.
Diastolic Pressure
• The force within arteries
when heart relaxes
between beats
• The lower number of BP
• The level at which pulse
sounds change or cease.

31. Blood Pressure
• “Normal” or average blood pressure for
the older adult.
– Systolic pressure <120, Diastolic<90
– Resident previous measurements identify
“normal” or expected BP level for that
individual.

32. Blood Pressure
• Variations
– Blood pressure may increase slightly with age, due
to various factors. BP may be temporarily elevated
by exercise or emotional distress.
– Hypertension-High Blood Pressure
• Systolic BP >140, Diastolic BP >90
– Postural Hypotension (orthostatic hypotension)-
elderly person’s body is unable to rapidly adjust to
maintain normal blood pressure in the head and
upper body when the person moves from lying to
sitting, or sitting to standing. The person will
complain of dizziness or feeling faint.

33. Measuring BP
• Equipment used
– Sphygmomanometer (BP cuff) and gauge
– Stethoscope
• Technique/Key points
– Choosing cuff of appropriate size
Correct size range indicated on inside of cuff
– Positioning cuff, gauge and stethoscope
Snug fit about 1 inch above bend in elbow
on bare upper arm

34. Measuring BP
• Technique/Key points (continued)
– Positioning stethoscope
Place diaphragm firmly over brachial artery
located little finger side above bend in elbow
– Interpreting sounds heard
First sound heard – systolic
Point where sound disappears/changes –
diastolic
– Time and interval with rechecking
Wait 30-60 seconds before rechecking

38. Blood Pressure
• Reporting and recording
– Report to nurse changes in resident’s BP
from what is “normal” for him/her.
– Report systolic pressure <100 or >190
– Report diastolic pressure <60 or > 100
– Notify nurse if CNA has difficulty hearing or
measuring BP.
– Record and document BP measurement.
– Write as systolic over diastolic (120/80)

39. Height
• Frequency of measurement
– On admission
– May be measured annually. Changes such as osteoporosis
can decrease the resident’s height.
• Method
– Resident who is able to stand can be measured using the
height bar of the standing balance scale.
– Resident who is unable to stand may be measured in bed.
Position resident flat on back.
– Measure from top of head to soles of feet. Nurse will guide
CNA in performing in-bed measurement.
• Record or document measurement, using standard or
metric measurement, according to facility policy.