CNA TASK LIST

A001 OBSERVE AND REPORT RESIDENT DATA

B029 MEASURE AND RECORD BLOOD PRESSURE
B030 MEASURE AND RECORD PULSE
B031 MEASURE AND RECORD TEMPERATURE
B032 MEASURE AND RECORD RESPIRATION
B033 MEASURE AND RECORD HEIGHT AND WEIGHT
C033 ENCOURAGE FLUID INTAKE
C041 PROVIDE CARE FOR RESIDENT WITH FEVER
D003 APPLY A COLD COMPRESS
D008 ADMINISTER A TEPID BATH

TEMPERATURE

PULSE
RESPIRATIONS

BLOOD PRESSURE
VITAL SIGNS MUST BE MEASURED, REPORTED, AND
RECORDED ACCURATELY
IF YOU ARE NOT SURE OF A MEASUREMENT,
RECHECK IT

o WHEN A PERSON IS ADMITTED TO A HEALTH CARE

FACILITY
o SEVERAL TIMES A DAY FOR HOSPITALIZED PATIENTS
o BEFORE AND AFTER SURGERY
o AFTER SOME NURSING PROCEDURES

o BEFORE MEDICATIONS ARE GIVEN THAT AFFECT THE

RESPIRATORY OR CIRCULATORY SYSTEM
o WHENEVER THE PERSON COMPLAINS OF PAIN,
SHORTNESS OF BREATH, RAPID HEART RATE, OR NOT
FEELING WELL
o WITH THE PERSON AT REST IN A LYING OR SITTING
POSITION

o ILLNESS
o EMOTIONS ANGER, FEAR, ANXIETY, PAIN
o EXERCISE AND ACTIVITY
o AGE
o SEX
o ENVIRONMENT - WEATHER
o FOOD AND FLUID INTAKE
o MEDICATIONS
o TIME OF DAY IN THE MORNING, IN THE AFTERNOON/EVENING
o NOISE

A CHANGE IN ONE VITAL SIGN WILL CAUSE A CHANGE IN

THE OTHERS

o ANY VITAL SIGN IS CHANGED FROM A PREVIOUS

MEASUREMENT
o VITAL SIGNS ARE ABOVE THE NORMAL RANGE

o VITAL SIGNS ARE BELOW THE NORMAL RANGE

MANY AGENCIES HAVE TEMP BOARDS OR TPR BOOKS

RECORD VITAL SIGN MEASUREMENTS AS SOON AS

POSSIBLE
CARRY A SMALL NOTEBOOK IN YOUR POCKET SO YOU
CAN RECORD THEM AS YOU TAKE THEM
ABBREVIATIONS
TEMPERATURE T

PULSE P
RESPIRATIONS R
BLOOD PRESSURE - BP

RESPOND TO PATIENT OR VISITOR

QUESTIONS ABOUT VITAL SIGNS
ACCORDING TO FACILITY POLICY

REFER THEIR QUESTIONS TO THE

NURSE

BODY TEMPERATURE IS THE AMOUNT OF HEAT IN THE

BODY
IT IS A BALANCE BETWEEN THE AMOUNT OF HEAT
PRODUCED AND THE AMOUNT OF HEAT LOST
HEAT IS PRODUCED BY :
THE CONTRACTION OF MUSCLES DURING EXERCISE
THE BREAKDOWN OF FOOD DURING DIGESTION
THE ENVIRONMENTAL TEMPERATURE

HEAT IS LOST THROUGH :

URINE
RESPIRATIONS

FECES
PERSPIRATION

BODY TEMPERATURE IS MEASURED IN ONE OF FOUR

AREAS OF THE BODY

THE MOUTH ORAL

THE RECTUM RECTAL
THE AXILLA (UNDERARM) AXILLARY

THE EAR TYMPANIC

WE NOW ALSO HAVE THE TEMPORAL SITE - FOREHEAD
MOST TEMPERATURES ARE TAKEN ORALLY
RECTAL TEMPERATURES ARE THE MOST ACCURATE
AXILLARY TEMPERATURES ARE THE LEAST ACCURATE

SITE

NORMAL

RANGE

ORAL

98.6

97.6 TO 99.6

RECTAL

99.6

98.6 TO 100.6

AXILLARY

97.6

96.6 TO 98.6

TYMPANIC

98.6

98.6

TEMPORAL

98.6

98.6

TEMPERATURE IN AN OLDER PERSON IS USUALLY LOWER

BECAUSE OF SLOWER METABOLISM. THE AVERAGE BODY
TEMPERATURE IN OLDER ADULTS IS 96.8. RANGE IS 96: TO 98:

A SMALL HOLLOW GLASS TUBE THAT CONTAINS

MERCURY OR A MERCURY-FREE SUBSTANCE IN A BULB
AT ONE END.WHEN HEATED THE MERCURY RISES IN
THE TUBE.

Pear shaped tip

o THE SCALE IS MARKED FROM 94 TO 108

o THE LONG LINES REPRESENT ONE DEGREE

o THE SHORT LINES REPRESENT TWO TENTHS OF A DEGREE

o ONLY EVERY OTHER DEGREE IS MARKED WITH A NUMBER

o BATTERY OPERATED
o HAVE AN ORAL PROBE AND A RECTAL PROBE

o DISPOSABLE PROBE COVER IS PLACED ON THE PROBE

o THE TEMPERATURE REGISTERS IN ABOUT 30 SECONDS

USE A DISPOSABLE SHEATH

o MEASURES THE TEMPERATURE IN THE TYMPANIC MEMBRANE (EARDRUM)

o FAST AND ACCURATE - 1 TO 3 SECONDS
INFANTS PULL
THE EAR
STRAIGHT BACK

ADULTS AND
CHILDREN OVER
ONE YEAR
PULL THE EAR UP
AND BACK

THE TEMPORAL THERMOMETER IS SLOWLY SWEPT

ACROSS THE FOREHEAD, FROM MID-FOREHEAD TO
HAIR LINE.
TEMPORAL TEMPERATURE IS READ THE SAME AS AN
ORAL TEMPERATURE.

GLASS
THERMOMETER
o RINSE WITH COLD WATER

o CHECK THE THERMOMETER

FOR BREAKS AND CHIPS
o SHAKE DOWN THE
THERMOMETER SO THE
MERCURY IS BELOW THE LINES
AND NUMBERS
o PLACE A DISPOSABLE COVER
ON THE THERMOMETER
o PLACE THE THERMOMETER
UNDER THE PERSONS TONGUE
o LEAVE THE THERMOMETER IN
PLACE FOR 2 3 MINUTES
o IF THE PERSON HAS BEEN
EATING, DRINKING, OR
SMOKING, WAIT 15 MINUTES
BEFORE TAKING TEMPERATURE

DO NOT TAKE AN ORAL TEMPERATURE ON:

o AN INFANT OR YOUNG CHILD ( UNDER AGE 6)
o AN UNCONSCIOUS PATIENT
o A PATIENT THAT HAS HAD ORAL SURGERY OR AN INJURY TO THE FACE,
NECK, NOSE, OR MOUTH
o A PERSON RECEIVING OXYGEN
o A PATIENT WITH A NASOGASTRIC TUBE IN PLACE
o A PATIENT WHO IS CONFUSED OR RESTLESS

o A PATIENT WHO IS PARALYZED ON ONE SIDE OF THE BODY

o HAS A HISTORY OF SEIZURES
o A PATIENT WHO BREATHES THROUGH THE MOUTH

o LUBRICATE THE THERMOMETER BEFORE INSERTING INTO THE RECTUM

o PLACE THE PERSON IN A SIDE-LYING POSITION

o INSERT THE THERMOMETER 1 INCH INTO THE RECTUM

o HOLD THE THERMOMETER IN PLACE FOR 2 MINUTES
o REMOVE THE DISPOSABLE COVER AND READ THE THERMOMETER

DO NOT TAKE A RECTAL TEMPERATURE ON:

o A PERSON WHO HAS HAD RECTAL SURGERY OR RECTAL INJURY
o IF THE PERSON HAS DIARRHEA
o IF THE PERSON IS CONFUSED OR AGITATED
o IF THE PERSON HAS HEART DISEASE ( STIMULATES THE VAGUS NERVE
WHICH SLOWS THE HEART RATE )

o TAKEN ONLY WHEN NO OTHER SITE CAN

BE USED

o MAKE SURE THE UNDERARM IS CLEAN

AND DRY
o THE ARM IS HELD CLOSE TO THE BODY
o YOU NEED TO HOLD THE THERMOMETER
IN PLACE WHILE THE TEMPERATURE IS
BEING TAKEN
o THE THERMOMETER IS LEFT IN PLACE
FOR 10 MINUTES

AN ELDERLY PERSON MAY NOT EXHIBIT AN ELEVATED

TEMPERATURE UNTIL THE INFECTION HAS BECOME
MORE SEVERE.
IN THE ELDERLY PATIENT FEVER IS ABSENT 20 30%
OF THE TIME AN INFECTION IS PRESENT
THE PRESENCE OF A FEVER IN THE ELDERLY PATIENT
IS MORE LIKELY TO BE ASSOCIATED WITH A SERIOUS
VIRAL OR BACTERIAL INFECTION
THE ELDERLY PATIENT MAY HAVE A NORMAL
TEMPERATURE READING BELOW THE NORMAL FOR A
YOUNGER PERSON

o GIVE A TEPID (WARM) SPONGE BATH

o INCREASE ORAL FLUID INTAKE
o PUT COLD COMPRESS ON FOREHEAD, AXILLA, AND
GROIN
o GIVE A TEPID TUB BATH

o INFORM THE NURSE OF ELEVATED TEMPERATURE

THE PULSE IS:

o THE BEAT OF THE HEART FELT AT AN ARTERY AS A WAVE OF BLOOD PASSES
THROUGH THE ARTERY
o A PULSE IS FELT EVERY TIME THE HEART BEATS
o MORE EASILY FELT IN ARTERIES THAT COME CLOSE TO THE SKIN AND CAN
BE GENTLY PRESSED AGAINST A BONE
o THE PULSE SHOULD BE THE SAME IN ALL PULSE SITES ON THE BODY
o THE PULSE IS AN INDICATION OF HOW THE CARDIOVASCULAR SYSTEM IS
MEETING THE BODYS NEEDS
o THE PULSE RATE IS AFFECTED BY MANY FACTORS AGE, FEVER,
EXERCISE, FEAR. ANGER, ANXIETY, EXCITEMENT, HEAT, POSITION, AND PAIN.
o MEDICATIONS CAN BE TAKEN THAT EITHER INCREASE OR DECREASE A
PERSONS PULSE RATE.

WE USUALLY COUNT A PULSE FOR 30 SECONDS AND

MULTIPLY THE NUMBER TIMES 2 TO GET THE PULSE
RATE FOR 1 MINUTE
WE NOTE THE RHYTHM (PATTERN)
OF THE HEART BEAT IF THE HEART
BEAT IS IRREGULAR WE COUNT THE
PULSE FOR A FULL MINUTE
WE ALSO OBSERVE THE FORCE
(STRENGTH) OF THE HEARTBEAT.

DOES THE PULSE FEEL :

STRONG

FULL

BOUNDING

WEAK

THREADY

FEEBLE

o MOST COMMON SITE USED FOR

TAKING A PULSE
o CAN BE TAKEN WITHOUT
DISTURBING OR EXPOSING THE
PERSON
o PLACE THE FIRST TWO OR THREE
FINGERS OF ONE HAND AGAINST THE
RADIAL ARTERY
o THE RADIAL ARTERY IS ON THE
THUMB SIDE OF THE WRIST
o DO NOT USE YOUR THUMB TO TAKE
A PERSONS PULSE
o USE GENTLE PRESSURE
o COUNT THE PULSE FOR 30 SECONDS
AND MULTIPLY BY TWO

ALWAYS CLEAN THE

EARPIECES OF THE
STETHOSCOPE WITH
ALCOHOL BEFORE AND AFTER
USE
WARM THE DIAPHRAGM IN
YOUR HAND BEFORE
PLACING IT ON THE PERSON
HOLD THE DIAPHRAGM IN
PLACE OVER THE ARTERY
DO NOT LET THE TUBING
STRIKE AGAINST ANYTHING
WHILE THE STETHOSCOPE IS
BEING USED

o TAKEN WITH A STETHOSCOPE

o COUNTED BY PLACING THE STETHOSCOPE
OVER THE HEART
o COUNTED FOR ONE FULL MINUTE
o THE HEART BEAT NORMALLY SOUNDS LIKE A
LUB-DUB. EACH LUB-DUB IS COUNTED AS ONE
HEARTBEAT.
o DO NOT COUNT THE LUB AS ONE HEARTBEAT
AND THE DUB AS ANOTHER.
o THE APICAL PULSE IS TAKEN ON PATIENTS
WHO HAVE HEART DISEASE , AN IRREGULAR
PULSE RATE, OR TAKE MEDICATIONS THAT CAN
AFFECT THE HEART.

THE APICAL AND RADIAL PULSE RATES SHOULD BE EQUAL

SOMETIMES THE HEART BEAT IS NOT STRONG ENOUGH TO CREATE A PULSE IN
THE RADIAL ARTERY
THIS WOULD CAUSE THE RADIAL PULSE TO BE LESS THAN THE APICAL PULSE
ONE PERSON COUNTS THE APICAL WHILE THE OTHER PERSON COUNTS THE
RADIAL
THE DIFFERENCE IN PULSES IS CALLED THE PULSE DEFICIT

NORMAL ADULT PULSE RATE IS 60 TO 100 BEATS PER MIN.

TACHYCARDIA HEART RATE OVER 100
BRADYCARDIA HEART RATE BELOW 60

REPORT ABNORMAL HEART RATES TO THE NURSE

IMMEDIATELY

ONE RESPIRATION CONSISTS OF ONE INSPIRATION AND

ONE EXPIRATION
o THE CHEST RISES DURING INSPIRATION (BREATHING
IN) AND FALLS DURING EXPIRATION (BREATHING OUT)
o COUNT EACH TIME THE CHEST RISES
o COUNT FOR 30 SECONDS AND MULTIPLY X 2
o DO NOT LET THE PERSON KNOW YOU ARE COUNTING
THEIR RESPIRATIONS

o COUNT AFTER TAKING THE PULSE KEEP YOUR

FINGERS ON THE PULSE SITE
o NORMAL RESPIRATORY RATE FOR ADULT IS 12 20
BREATHS PER MIN.

TACHYPNEA RESPIRATORY RATE OVER 20

BRADYPNEA RESPIRATORY RATE BELOW 12

DYSPNEA SHORTNESS OF BREATH DIFFICULTY IN
BREATHING

APNEA NO BREATHING
HYPERVENTILATION FAST AND DEEP RESPIRATIONS
HYPOVENTILATION SLOW AND SHALLOW
RESPIRATIONS
CYANOSIS BLUE TINGE TO SKIN FROM LACK OF
OXYGEN

THE MEASUREMENT OF THE AMOUNT OF FORCE THE

BLOOD EXERTS AGAINST THE ARTERY WALLS
o SYSTOLIC PRESSURE PRESSURE EXERTED WHEN THE
HEART MUSCLE IS CONTRACTING
o DIASTOLIC PRESSURE PRESSURE EXERTED WHEN THE
HEART MUSCLE IS RELAXING BETWEEN BEATS
BLOOD PRESSURE IS RECORDED AS A FRACTION WITH THE
SYSTOLIC PRESSURE ON TOP AND THE DIASTOLIC PRESSURE
ON THE BOTTOM

SYSTOLIC

SYSTOLIC /DIASTOLIC

DIASTOLIC

120/80

BP IS MEASURED IN MM (MILLIMETERS) OF HG (MERCURY)

AVERAGE ADULT SYSTOLIC RANGE 100 TO 140

AVERAGE ADULT DIASTOLIC RANGE 60 TO 90

HYPERTENSION MEASUREMENTS ABOVE THE NORMAL

SYSTOLIC OR DIASTOLIC PRESSURES

HYPOTENSION MEASUREMENTS BELOW THE NORMAL

SYSTOLIC OR DIASTOLIC PRESSURES

o AGE BLOOD PRESSURE INCREASES AS A PERSON GROWS OLDER.

o GENDER WOMEN USUALLY HAVE LOWER BLOOD PRESSURE THAN MEN
o BLOOD VOLUME SEVERE BLEEDING LOWERS THE BLOOD PRESSURE
o STRESS HEART RATE AND BLOOD PRESSURE INCREASE AS PART OF THE
BODYS RESPONSE TO STRESS
o PAIN INCREASES BLOOD PRESSURE
o EXERCISE INCREASES HEART RATE AND BLOOD PRESSURE
o WEIGHT BLOOD PRESSURE IS HIGHER IN OVERWEIGHT PERSONS
o RACE BLACK PERSONS GENERALLY HAVE HIGHER BLOOD PRESSURE
THAN WHITE PERSONS DO
o DIET A HIGH-SODIUM DIET INCREASES THE FLUID VOLUME IN THE BODY
WHICH INCREASES BLOOD PRESSURE
o MEDICATIONS CAN BE TAKEN TO RAISE OR LOWER BLOOD PRESSURE

o POSITION BLOOD PRESSURE IS LOWER WHEN LYING DOWN

THE PROPER NAME FOR A BLOOD PRESSURE CUFF IS

SPHYGMOMANOMETER
MERCURY

ANEROID

o DO NOT TAKE A BLOOD PRESSURE ON AN ARM WITH AN IV, A CAST, OR A

DIALYSIS SHUNT.
o DO NOT TAKE A BLOOD PRESSURE ON THE SIDE THAT A PERSON HAS HAD
BREAST SURGERY ON.
o MEASURE BLOOD PRESSURE WITH THE PERSON SITTING OR LYING.

o APPLY THE CUFF TO THE BARE UPPER ARM. DO NOT APPLY THE CUFF
OVER CLOTHING.
o MAKE SURE THE CUFF IS SNUG.
o USE A LARGE CUFF IF NECESSARY.

o MAKE SURE THE ROOM IS QUIET.

o IF YOU DO NOT HEAR THE BLOOD PRESSURE, WAIT 30 TO 60 SECONDS
AND TRY AGAIN. IF YOU STILL CAN NOT HEAR IT OR ARE UNSURE OF
YOUR READINGS, HAVE THE NURSE CHECK YOUR MEASUREMENTS.

FIRST STEPS IN MEASURING BLOOD PRESSURE

1. WRAP THE CUFF ABOVE THE ELBOW WITH THE ARROW POINTING TO THE
BRACHIAL ARTERY. FASTEN THE CUFF SO IT FITS SNUGLY.

2. CLOSE THE VALVE ON THE BP CUFF BY TURNING IT TO THE RIGHT

(CLOCKWISE).
1. LOCATE THE RADIAL PULSE.

2. PUMP UP THE CUFF AS YOU PALPATE THE RADIAL PULSE. PAUSE ABOUT
EVERY 20 MM TO ASSURE THAT THE PULSE IS STILL PALPABLE.
3. NOTE WHERE YOU STOP FEELING THE PULSE BEAT.

4. OPEN THE VALVE AND RELEASE THE AIR FROM THE CUFF.

1.

CLEAN THE STETHOSCOPE EARPIECES AND DIAPHRAGM WITH ALCOHOL.

2.

LOCATE THE BRACHIAL PULSE. THIS IS WHERE THE STETHOSCOPE WILL BE PLACED.

3.

WRAP THE CUFF ABOVE THE ELBOW WITH THE ARROW POINTING TO THE BRACHIAL
ARTERY. FASTEN THE CUFF SO IT FITS SNUGLY.

4.

PLACE THE DIAPHRAGM OF THE STETHOSCOPE FLAT ON THE PULSE SITE, HOLDING IT
IN PLACE WITH THE INDEX AND MIDDLE FINGERS OF ONE HAND.

5.

INFLATE THE CUFF 30 MM HG BEYOND THE NUMBER YOU DETERMINED IN THE FIRST
STEP.

6.

DEFLATE THE CUFF SLOWLY BY OPENING THE VALVE SLIGHTLY AND TURNING IT
COUNTERCLOCKWISE (TO THE LEFT) WITH YOUR THUMB AND INDEX FINGER. ALLOW
THE AIR TO ESCAPE SLOWLY WHILE LISTENING FOR A PULSE SOUND.

7.

NOTE THE READING AT WHICH YOU HEAR THE FIRST CLEAR, REGULAR PULSE SOUND.
THIS NUMBER IS THE SYSTOLIC PRESSURE. REMEMBER THIS NUMBER!

8.

CONTINUE LISTENING UNTIL THE SOUND DISAPPEARS. THIS IS THE DIASTOLIC

PRESSURE. NOTE THIS READING.

9.

OPEN THE VALVE COMPLETELY TO DEFLATE THE CUFF. REMOVE THE CUFF FROM THE
PATIENT.

10.

REPORT THE NUMBERS YOU NOTED. THE SYSTOLIC GOES FIRST AND THEN THE
DIASTOLIC.

MEASURING WEIGHT AND HEIGHT

Standing, chair, and lift scales are used.

Measuring weight and height

The person only wears a gown or pajamas.

The person voids before being weighed.
Weigh the person at the same time of day.
Use the same scale.
Balance the scale at zero before weighing the
person.

PAIN

Pain means to ache, hurt, or be sore.

Pain is a warning from the body.
Pain is personal.
Types of pain
Acute pain felt suddenly from an injury,
disease, trauma, or surgery
Chronic pain lasts longer than 6 months. Pain
can be constant or occur on and off.
Radiating pain felt at the site of tissue damage
and in nearby areas.
Phantom pain felt in a body part that is no
longer there.

 Signs and symptoms

Location Where is the pain?
Onset and duration When did the pain start?
Intensity Rate the pain on a scale of 1 to 10, with 10 as
the most severe
Description Can you use words to describe the pain?
Factors causing pain What were you doing when the pain
started?
Vital signs Take the persons vital signs when they
complain of pain.
Other signs and symptom
Body responses - vital signs, nausea, pale skin,
sweating, vomiting
Behaviors crying, groaning, holding affected body
part, irritability, restlessness