Key Takeaways
- Four primary vital signs: Temperature, Pulse, Respirations, and Blood Pressure
- Normal adult vital signs: T 97.6-99.6°F, P 60-100, R 12-20, BP 90-120/60-80
- Always compare readings to the patient's baseline (their normal values)
- Report abnormal findings to the nurse immediately
- Ensure patient has rested 5 minutes before measuring vital signs
Vital Signs Overview
Vital signs are measurements that indicate the basic functions of the body. They are called "vital" because changes in these measurements can indicate serious health problems. CNAs measure vital signs regularly and must report abnormal findings immediately.
The Four Primary Vital Signs
| Vital Sign | What It Measures | Normal Adult Range |
|---|---|---|
| Temperature (T) | Body heat | 97.6°F - 99.6°F (36.4°C - 37.6°C) |
| Pulse (P) | Heart rate | 60-100 beats per minute |
| Respirations (R) | Breathing rate | 12-20 breaths per minute |
| Blood Pressure (BP) | Force of blood on artery walls | Systolic: 90-120 / Diastolic: 60-80 mmHg |
Additional Measurements Often Considered "Vital":
- Pain - Sometimes called the "5th vital sign"
- Oxygen saturation (SpO2) - Measured with pulse oximeter
- Height and weight - Baseline measurements
When to Measure Vital Signs
Routine Measurement:
- On admission to facility
- At beginning of each shift
- Before and after certain procedures
- Before giving certain medications (nurse may ask)
- According to care plan schedule
Additional Measurement When:
- Patient complains of feeling unwell
- Change in level of consciousness
- Before and after transfers or activity
- After a fall or injury
- Per nurse's request
Factors Affecting Vital Signs
| Factor | Effect |
|---|---|
| Age | Vital signs change with age (children have faster rates) |
| Exercise | Increases temperature, pulse, respirations, BP |
| Emotions | Anxiety and stress increase vital signs |
| Medications | Some raise, some lower vital signs |
| Pain | Generally increases vital signs |
| Time of day | Temperature lowest in morning, highest in evening |
| Position | BP may differ between lying, sitting, standing |
| Disease | Infections, heart problems, respiratory conditions |
Accurate Measurement Principles
Before Measuring:
- Ensure patient has rested for 5 minutes
- Check if patient has eaten, smoked, exercised, or bathed recently
- Position patient comfortably
- Use appropriate equipment for the patient
During Measurement:
- Follow facility procedures exactly
- Use correct technique
- Count for the full time period required
- Don't round numbers—record actual readings
After Measurement:
- Record immediately (don't rely on memory)
- Report abnormal values to nurse right away
- Compare to patient's baseline
Understanding "Baseline" Vital Signs
A baseline is the patient's normal vital signs when healthy. Some patients have vital signs outside the "normal" range that are normal for them.
Example:
- A 90-year-old patient may have a normal blood pressure of 145/85
- An athlete may have a resting pulse of 50
- These would be their baselines
Always compare current readings to:
- The patient's baseline values
- Recent previous readings
- Standard normal ranges
Reporting Abnormal Vital Signs
Report to the nurse IMMEDIATELY if vital signs are:
| Vital Sign | Report If |
|---|---|
| Temperature | Above 101°F (38.3°C) or below 97°F (36.1°C) |
| Pulse | Above 100 or below 60 (unless baseline) |
| Respirations | Above 24 or below 10 per minute |
| Blood Pressure | Systolic above 160 or below 90; Diastolic above 100 or below 60 |
| Oxygen saturation | Below 95% (or per patient's baseline) |
Also report:
- Significant change from previous reading
- Patient complaints of pain, dizziness, difficulty breathing
- Irregular pulse
- Labored or noisy breathing
What is the normal resting pulse rate for an adult?
Which factor would cause an INCREASE in vital signs?