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Andrew Pollack-Gray

Nursing Notes

Vital Signs

3 min read

What Am I Assessing?

Vital signs provide measurements of essential physiological functions.
Common Vital Signs:

  • Temperature: Body temperature and thermoregulation.
  • Pulse: Heart rate and rhythm.
  • Respirations: Breathing rate, rhythm, and effort.
  • Blood Pressure: Arterial pressure during circulation.
  • Oxygen Saturation (SpO₂): Estimate of blood oxygen saturation.
  • Pain: Often assessed alongside vital signs.
    Key Principle: Compare measurements with the resident’s usual baseline, current condition, and care plan.

What Should I Look For?

Temperature

  • Elevated or abnormally low temperature.
  • Chills, sweating, or unusual warmth.
  • Changes from the resident’s normal temperature.
  • Measurement site and method.

Pulse

  • Rate: Fast, slow, or within expected range.
  • Rhythm: Regular or irregular.
  • Strength: Strong, weak, or difficult to detect.
  • Changes from baseline.

Respirations

  • Rate: Breaths per minute.
  • Rhythm: Regular or irregular.
  • Depth: Shallow or deep.
  • Effort: Relaxed or labored.
  • Associated coughing, wheezing, or visible distress.

Blood Pressure

  • Systolic and diastolic measurements.
  • Unexpectedly high or low readings.
  • Dizziness or weakness associated with position changes.
  • Changes from baseline.

Oxygen Saturation

  • SpO₂ reading and whether it is consistent with the resident’s condition.
  • Poor signal quality or movement affecting measurements.
  • Signs of breathing difficulty despite a seemingly acceptable reading.

Pain

  • Resident-reported pain score when appropriate.
  • Location, severity, and changes.
  • Nonverbal indicators of discomfort.

What Could It Mean?

ObservationPossible Concern
Elevated temperatureInfection, inflammation, or other illness
Low temperatureHypothermia or impaired temperature regulation
Rapid pulsePain, fever, dehydration, or physiological stress
Slow pulseMedication effect, normal variation, or cardiac conduction changes
Rapid or labored breathingRespiratory distress or other acute illness
Low blood pressureDehydration, blood loss, medication effects, or circulatory problems
Elevated blood pressureStress, pain, or hypertension
Low SpO₂Possible impaired oxygenation or measurement error

Important: These are possible explanations, not diagnoses.

What Should I Do?

  1. Review the care plan and required measurement schedule.
  2. Explain the procedure and prepare equipment.
  3. Obtain measurements using trained methods.
  4. Record the values, units, time, and relevant measurement details.
  5. Compare with the resident’s baseline and reporting parameters.
  6. Notify the nurse about unexpected or concerning results.
  7. Follow directions for repeat measurements and ongoing observation.

Urgent Findings

Activate the appropriate emergency response for:

  • Severe breathing difficulty.
  • Unresponsiveness or sudden significant mental-status changes.
  • Chest pain with concerning symptoms.
  • Signs of stroke or shock.
  • Other critical findings identified by the facility’s emergency protocol.

Important Considerations

  • Vital signs must be interpreted in context.
  • A change from baseline may be important even when the reading falls within a typical adult range.
  • Pain, activity, medications, positioning, and illness can affect readings.
  • Report symptoms alongside numeric measurements.
  • CNAs observe, measure, document, and report; licensed clinicians perform clinical interpretation and treatment planning.

Sources

Flashcards

Which features of respiration should be observed beyond rate?01-foundations / assessment
Answer

Rhythm, depth, effort, and signs of distress.

Why is baseline more useful than a normal-range table alone?02-mechanisms / assessment
Answer

A meaningful change may occur within a typical reference range.

What should accompany an abnormal vital-sign report?03-application / assessment
Answer

Symptoms, context, and relevant changes from baseline.

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