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Obtaining Vital Signs

Unit 7 Lesson 3

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Explain the process of measuring temperature, respirations, pulse, and blood pressure in clients of various ages
Identify differences between normal and abnormal vital signs
Describe the role of the nurse’s aide in the documentation and reporting of abnormal vital signs

Student Learning Outcomes

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Purpose of Vital Signs

Establish a client’s health baseline
Monitor health trends and changes over time
Detect early signs of health issues
When to Measure

Admission
Routine checks
Condition changes
Post-accident
Medication changes

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Common Vital Signs

Temperature

Indicates body's heat regulation

Pulse

Reflects heart rate and rhythm

Respiration

Measures breathing frequency

Blood Pressure

Assesses circulatory health

Oxygen Saturation

Evaluates oxygen levels in blood

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Measuring Temperature

Methods of Measurement

Oral

Taken under the tongue
Affected by recent eating/drinking

Axillary

Armpit method
Generally lower than oral
Useful for children

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Oral Thermometer

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Measuring Temperature continued…

Methods of Measurement

Tympanic

Ear-based
Shares artery with brain's temperature regulation center

Rectal

Most accurate
Used for infants
Invasive

Temporal

Forehead scanner
Quick and non-invasive

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Rectal Thermometer

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Measuring Temperature continued…

Normal Temperature Ranges

Oral

35.8 – 37.3ºC (96.4 – 99.1ºF)

Axillary

34.8 – 36.3ºC (94.6 – 97.3ºF)

Tympanic

36.1 – 37.9ºC (96.9 – 100.2ºF)

Rectal

36.8 – 38.2ºC (98.2 – 100.7ºF)

Temporal

35.2 – 36.7ºC (95.3 – 98ºF)

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Tympanic Thermometer

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Critical Thinking Question

A nursing assistant is about to take the temperature of an adult client who just drank a cup of hot coffee. Which of the following actions should the nursing assistant take?

A) Take the client's temperature immediately using the oral method.

B) Wait 5 minutes and then take the client's temperature using the oral method.

C) Wait 15 to 25 minutes before taking the client's temperature using the oral method.

D) Use the tympanic method immediately to get an accurate reading.

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Pulse

Pressure wave from heart’s contraction
Common sites

Radial (wrist)
Carotid (neck)
Brachial (arm)

Use index and middle fingers, avoid thumb

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Common Pulse Assessment Locations

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Pulse continued…

Irregular Pulse

Known as arrhythmias
Document and report to nurse

Factors Influencing Pulse

Activity level
Emotional state
Medications
Health conditions

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Normal Pulse Rates by Age

Adults

60–100 beats per minute

Adolescents

60–100 bpm

Children

Varies, generally higher than adults

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Critical Thinking Question

A nursing assistant is checking the pulse of a client who is calm and resting. The assistant counts 110 beats per minute. What should the nursing assistant do next?

A) Report the elevated pulse rate to the nurse immediately.

B) Document the pulse as normal since the client is resting.

C) Recheck the pulse after a few minutes to confirm the reading.

D) Ask the client if they're feeling anxious or have been active.

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Respiration

Respiration Process

Involves air moving in (inspiration) and out (expiration) of lungs
Best measured discreetly to avoid altering breathing pattern

Normal Respiratory Rates by Age

Adults

12–20 breaths per minute

Infants

30–60 breaths per minute

Children

Rates decrease as age increases

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Respiration continued…

Signs of Respiratory Distress

Loud breathing
Nasal flaring
Use of neck muscles
Assume tripod position for better breathing

Factors Affecting Respiration

Illness
Activity
Emotional state
Altitude

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Critical Thinking Question

During routine vital signs assessment, a nursing assistant notices an adult client with a respiratory rate of 24 breaths per minute and is using accessory muscles to breathe. What should the nursing assistant do?

A) Document the findings and continue with other assessments.

B) Reassure the client that everything is fine.

C) Notify the nurse immediately as these are signs of respiratory distress.

D) Ask the client to sit in a more comfortable position and reassess later.

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Measuring Blood Pressure

Procedure Tips

Ensure correct cuff size for accuracy
Position client seated, arm at heart level

When Not to Use Arm for BP

Presence of fistula
IV line
Post-mastectomy

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Measuring Blood Pressure continued…

Systolic

Pressure during heart contraction

Diastolic

Pressure during heart relaxation

Expressed in mmHg (e.g., 120/80)

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Measuring Blood Pressure continued…

Normal and Abnormal Ranges

Normal

91-129/61-89 mmHg

Hypotension

<90/<60 mmHg

Hypertension

≥130/≥90 mmHg

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Different Sizes of Blood Pressure Cuffs

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Critical Thinking Question

A nursing assistant is taking a client's blood pressure and notes it as 140/95 mmHg. How should the assistant proceed?

A) Repeat the measurement on the same arm immediately.

B) Record the reading and report it to the nurse promptly.

C) Measure the blood pressure on the opposite arm for accuracy.

D) Have the client rest for a few minutes, then retake the reading.

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Oxygen Saturation (SpO2)

Assessed with a pulse oximeter
Normal adult range: 94-98%
COPD clients may have lower acceptable ranges

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Oxygen Saturation (SpO2) continued…

Accuracy Considerations

Factors like anemia or poor circulation can affect readings
Remove nail polish for finger measurements

Documentation

Note if supplemental oxygen is used
Include type and amount of oxygen given

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Role of Nurse Aide

Documentation and Reporting

Accurately record all vital signs
Note and report abnormalities promptly
Ensure clear communication with nursing staff

Client Interaction

Explain procedures to clients to ease anxiety
Ensure client comfort during measurements

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Role of Nurse Aide continued…

Scope of Practice

Follow state and facility guidelines
Tasks may vary based on training and policies

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References

Sandquist-Reuter, M. (2023). Nursing Assistant. WisTech Open. https://wtcs.pressbooks.pub/nurseassist/

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