Importance of Vital Signs
Certified Nursing Assistant Guide to
Vital Signs
2 hours Continuing Nurse Education
Credits upon completion
R. VAN DEE RN, MSN PROCARE HOSPICE
2015
Why take vital signs for hospice
patients
• Hospice is palliative medicine helps patients
manage pain and symptoms
• Improve quality of life .
• Patients receive appropriate care in the last
phase of life.
• Changes in vital signs can indicate infection in
early stages, preventing hospital admits
R. VAN DEE RN, MSN PROCARE HOSPICE
2015
Cleaning equipment
• Cleaning your equipment prevents
transmission of infection.
• If equipment does not touch mucus
membranes use an EPA-registered low- or
intermediate-level disinfectant before an after
use with each patient.
• Recommended use of PDI super sani-cloth
germicidal disposable wipes for disinfecting
equipment
R. VAN DEE RN, MSN PROCARE HOSPICE
2015
Temperature
(report temperatures under 96 or over 99
degrees
• Taking temperature in the ear (tympanic): Read instructions
depending on the type/brand of thermometer. Method
involves placing instrument gently into ear canal.
• Temporal: Follow manufacture instructions. Always clean
equipment before use. Method involves sliding
thermometer across patients forehead.
• Oral: Method involves placing thermometer in patient’s
mouth. Avoid using glass that can break. If patient is a
mouth breathing, reading will not be accurate.
• Axillary: Method is used using oral thermometer placed
under patient’s armpit. This is an inaccurate method
measuring lower than actual temperature.
• Rectal: We do not do rectal temperatures at our company
R. VAN DEE RN, MSN PROCARE HOSPICE
2015
Pulse Rate and Respirations
• Using finger tips not your thumb place
underneath patient’s wrist until you feel their
pulse. Begin counting for 60 seconds
• Report pulse rate under 50 or over 100
• Respirations can be done immediately after or
before taking the pulse. Observe patient’s
chest moving as they breath, count for 60
seconds. Respirations under 16 or over 30
need to be reported
R. VAN DEE RN, MSN PROCARE HOSPICE
2015
Blood Pressure
• Digital: is easy but can be inaccurate as irregular heart beat
or patient movement can change accuracy.
• Manual: Using correct size for patient, Measure patients
arm 7-9 inches use small cuff, 9-13 inches use regular cuff,
13-17 inches use large cuff.
• Line up artery marker on cuff points to brachial artery, wrap
cuff around arm
• Palpate antecubital for pulse , place stethoscope over pulse
• Inflate cuff to 200 then slowly release pressure listening for
systolic pressure the first sound you hear, then continue
listening until you cannot hear heart beat, the last sound
you hear is the diastolic
R. VAN DEE RN, MSN PROCARE HOSPICE
2015
Reporting Blood Pressure
• Report blood pressure that is significantly
higher or lower than patient’s baseline
• Systolic pressure over 200 patient is dizzy
complaining of headache
• Systolic pressure under 90
• Diastolic pressure over 90
R. VAN DEE RN, MSN PROCARE HOSPICE
2015
Reference
• Guidelines for disinfection and sterilization in
healthcare (2008) Centers for Disease Control
http://www.cdc.gov/hicpac/disinfection_steril
ization/3_4surfacedisinfection.html
R. VAN DEE RN, MSN PROCARE HOSPICE
2015
Post Test
• After you have reviewed the handout you will
need to actually take vital signs you have two
choices:
• 1. Take patient’s vital signs with nurse present
to observe and sign you off
• 2. Take another staff member’s vital signs to
be checked off
R. VAN DEE RN, MSN PROCARE HOSPICE
2015
Observed Skill
Nurse to observe skill set, circle pass or requires further
training (put in Rose’s mailbox when complete)
• Temperature pass needs further training
• Pulse pass needs further training
• Respirations pass needs further training
• Blood pressure
Manual pass needs further training
digital pass needs further training
• CNA (print) ___________________ Date_______
Nurse (print)_______________ Signature________
R. VAN DEE RN, MSN PROCARE HOSPICE
2015