Vital Signs, Intake and Output, and Clinical Documentation

Why Accurate Vital Signs and Documentation Matter

As a nursing assistant, you will measure vital signs and record intake and output (I&O) every shift. These numbers are the earliest warning system for a resident's or patient's condition. A blood pressure that has dropped, a pulse that has become irregular, or a fluid balance that has tipped into deficit can signal a medical emergency. Because the registered nurse (RN) and the care team act on the data you record, accuracy is not optional — it is a patient safety obligation and a legal one. Falsifying, guessing, or copying a previous value is grounds for removal from the state CNA registry.

The Five Vital Signs You Will Measure

Temperature. Normal oral temperature for an adult is approximately 97.8–99.1 °F (36.5–37.3 °C). Use a digital oral thermometer with a disposable probe cover. Ask the resident not to eat, drink, or smoke for at least 15 minutes before an oral reading. Wait for the audible beep before reading. Discard the probe cover without touching it and return the thermometer to its holder.

Pulse. Count radial pulse (at the wrist, thumb side) for a full 60 seconds using a watch with a second hand. Normal adult pulse is 60–100 beats per minute (bpm). Note the rhythm (regular or irregular) and strength. Report any irregular rhythm to the nurse immediately — never estimate or count for 15 seconds and multiply when rhythm is irregular.

Respiration. Count breaths for a full 60 seconds while keeping your fingers on the wrist so the resident does not change their breathing pattern. One rise and fall of the chest equals one breath. Normal adult range is 12–20 breaths per minute. Report any rate below 12 or above 20, or any labored breathing, at once.

Blood pressure (BP). Manual BP uses an aneroid sphygmomanometer and stethoscope. Apply the cuff over bare skin, two finger-widths above the antecubital space (inner elbow). The resident should be seated or supine, arm at heart level, and rested for at least five minutes. Inflate the cuff approximately 30 mmHg above the estimated systolic, then release at about 2–3 mmHg per second. Record the first sound (systolic) and the point sounds disappear (diastolic) as two numbers, e.g., 118/76 mmHg. Normal adult BP is generally below 120/80 mmHg; always report a systolic above 140 or below 90 to the nurse. Automated cuffs follow the manufacturer's directions and are useful for monitoring, but manual technique remains a core skill.

Pulse oximetry (SpO2). Clip the pulse oximeter to a fingertip that is warm, dry, and free of nail polish. Wait for the waveform to stabilize, then read the SpO2 percentage. Normal is 95–100 % for most adults; report any reading below 95 % to the nurse promptly.

Intake and Output

I&O tracks the fluids a resident takes in and puts out over a shift or 24 hours. It helps the nurse detect dehydration, fluid overload, or kidney problems. Intake includes all oral fluids (water, juice, soup broth, ice chips counted as roughly half their volume in mL), IV fluids, and tube feedings. Output includes urine (measured in a graduate or read from a urinary catheter drainage bag), emesis (vomit), wound drainage, and other measurable losses.

Facility flow sheets use milliliters (mL). Because residents describe intake in household measures, you must convert. Common conversions: 1 fl oz = 30 mL; 1 cup (8 fl oz) = 240 mL; 1 pint = 480 mL. A small juice glass is often 4 oz (120 mL); a standard hospital cup is often 8 oz (240 mL). Learn your facility's specific container sizes because they vary. Record each item as it occurs, not from memory at the end of the shift.

Clinical Documentation: Rules Every CNA Must Follow

1. Write in real time. Document after you perform — never before.

2. Use only approved abbreviations. Your facility provides an approved abbreviation list. When in doubt, write it out.

3. Use objective language. Record what you see, hear, smell, or measure — not what you think it means. Write "resident ate 75 % of lunch tray" not "resident seemed to enjoy lunch."

4. Never leave blank spaces. Draw a single line through unused space on paper forms.

5. Correct errors properly. On paper: draw one straight line through the error, write your initials and the date, and write the correct information. Never use correction fluid (white-out), erase, or scribble out.

6. In an EHR: follow the system's correction or addendum function. Never delete an entry.

7. Sign every entry with your name and title (e.g., J. Smith, CNA).

8. Confidentiality. All documentation is protected health information under HIPAA. Never share, photograph, or discuss resident records with unauthorized persons.

Safety Points for This Lab

• Perform hand hygiene before and after contact with each resident or partner.
• Use a fresh probe cover for every temperature reading; discard immediately.
• Never apply a BP cuff over a dialysis access site, an IV, or on the side where a mastectomy has been performed — ask the nurse if you are unsure.
• If any vital sign is outside normal limits during the lab, treat it as you would in a real setting: report to the instructor (acting as the nurse) before continuing.
• Comparing your reading with a partner's helps catch technique errors — a difference of more than 2 mmHg in BP or more than 1 beat or breath per minute means one or both readings need to be repeated.

Entering Data: Flow Sheets and the EHR

A paper flow sheet has a grid: residents in rows, time slots in columns (or vice versa). Enter values in the correct cell and sign the signature line. An electronic health record (EHR) works similarly but the system time-stamps each entry automatically. During this lab you will practice both. Accuracy matters equally in both formats. A number entered in the wrong cell or the wrong field carries the same risk as a number never recorded.