This is the hands-on heart of CNA work and the largest slice of the written test, and most of the skills you demonstrate on the manual exam come from this chapter: measuring vital signs, height, and weight; assisting with activities of daily living; positioning, transferring, and ambulating residents; feeding; and preventing pressure injuries. The numbers here — normal vital-sign ranges, reporting thresholds, positioning schedules, water temperatures — are the most heavily tested facts in the whole exam. Two ideas run through everything: learn the exact sequence of each skill (the skills evaluation grades order and safety steps, not just the result), and remember the CNA's lane — you measure, observe, and report; the licensed nurse assesses and decides.
Vital signs: the numbers that protect the resident
A CNA measures and records vital signs and reports abnormal values to the licensed nurse; the nurse interprets them and decides on action (nursing assessment is the nurse's job under 42 CFR §483.35, not the aide's). The four classic vital signs are temperature, pulse, respirations, and blood pressure; oxygen saturation (SpO2) is now commonly measured as a fifth. Vital signs are called "vital" because they are the body's early-warning system — a rising temperature or falling oxygen level often shows a problem hours before the resident can describe it. Standard adult normal ranges taught in nurse-aide training:
- Temperature: average 98.6 °F orally; a normal oral range is roughly 97.6–99.6 °F. The axillary (armpit) route reads about a degree lower; the rectal route about a degree higher and is the most accurate; tympanic (ear) and temporal (forehead) are quick and close to oral. Match the route to the resident (never oral for a confused resident or one who is unconscious, on oxygen, or unable to hold the thermometer), and record which route you used.
- Pulse: 60–100 beats per minute, regular and strong, in an adult at rest. Note the rate, rhythm (regular or irregular), and force (strong, weak, thready). The radial pulse (wrist) is usual; the apical pulse (over the heart with a stethoscope) is used for irregular or hard-to-feel pulses and is counted for a full minute.
- Respirations: 12–20 breaths per minute. Count respirations without telling the resident — people change their breathing when they know they are being watched — so count them right after the pulse while you still appear to be holding the wrist. One rise and fall of the chest is one breath.
- Blood pressure: a normal adult reading is roughly 90–120 systolic over 60–80 diastolic, and current guidelines call under 120/80 "normal." The systolic (top) number is the pressure when the heart beats; the diastolic (bottom) is between beats. Use the correct cuff size — a cuff too small reads falsely high, a cuff too large reads falsely low — and never take a BP on an arm with a dialysis shunt, a fresh mastectomy side, or an IV.
- SpO2 (oxygen saturation): 95–100% on room air is normal; the sensor clips on a clean, warm finger (remove dark nail polish).
Report immediately — before finishing your round — any of these: temperature over 100.4 °F, pulse under 60 or over 100, respirations under 12 or over 20, systolic over 180 or under 90, or SpO2 under 90%. Count for a full 60 seconds whenever a pulse or breathing is irregular. Never chart a rounded guess ("about 80"); write the exact reading and the route or site. (Blood-pressure category labels are periodically revised by national guidelines; teach the normal range above and report per your facility's thresholds and the nurse's orders.)
Measuring height and weight
Weight is one of the most important numbers in long-term care because a change flags fluid retention (heart or kidney trouble) or malnutrition. Weigh the resident at the same time of day, on the same scale, in similar clothing, after voiding so the comparison is fair, and report a sudden change (a common alert is a gain or loss of several pounds in a short period) to the nurse. Balance a standing scale at zero before use, guard the resident for safety, or use a chair or bed scale for a resident who cannot stand. Height is usually measured standing against the scale's rod, or by a measured supine length for a resident who cannot stand. Record in the units your facility uses and note how the measurement was taken.
Body positions — and why each is used
The exam expects you to name the common positions and know when they are used, and correct positioning prevents pressure injuries, aids breathing and digestion, and keeps the airway safe:
- Supine — flat on the back; a resting/neutral position.
- Fowler's — semi-sitting with the head of the bed raised about 45–60°, used for eating, breathing comfort, and many procedures. Semi-Fowler's is lower (~30°); high-Fowler's is ~60–90° (upright, best for a resident short of breath).
- Lateral — lying on the side, used for rest and to relieve pressure off the back; support the top arm and leg with pillows.
- Prone — lying on the stomach, used less often in the elderly.
- Sims' — a left side-lying position with the top knee drawn up, used for enemas and rectal care.
For every position, use pillows and wedges to keep the body in good alignment, keep joints slightly flexed and supported, and change the position on a schedule to protect the skin.
Activities of daily living: bathing, dressing, grooming, toileting
ADL care is governed by 42 CFR §483.24, which requires that a resident's ability to perform ADLs not decline unless it is clinically unavoidable. Translation: if your resident loses the ability to feed or dress themselves on your watch with no medical reason, the facility owes surveyors an explanation. Core principles that apply to every ADL:
- Privacy and dignity first — door and curtain closed, body kept covered except the part you are working on, supplies gathered before you start so you never leave a resident exposed or unattended.
- Water temperature for bathing about 105 °F, no hotter — elderly skin burns easily and feels heat poorly; check the water before the resident gets in, and wash from cleanest to dirtiest, changing water when it cools or becomes soiled.
- Perineal care goes clean-to-dirty — front to back for women (to keep bowel bacteria away from the urethra and prevent UTIs); for an uncircumcised man, retract the foreskin, clean the tip first, then return the foreskin to prevent constriction.
- Encourage the resident to do what they can — hand them the washcloth, let them choose the clothes — to preserve function and dignity (this ties directly to restorative care, Chapter 5).
- Inspect the skin during every bath and report any reddened, broken, bruised, or new area.
- Oral care at least twice a day, including for residents who are NPO (nothing by mouth) and those with dentures — dry mouth and inhaled mouth bacteria are leading causes of nursing-home pneumonia. For an unconscious resident, do mouth care with the head turned to the side to prevent aspiration.
- Dress the weak (affected) side first and undress it last, and support the joint you are moving — this avoids forcing a stiff or paralyzed limb.
Denture care, step by step: put on gloves; line the sink with a towel or fill it with water so a dropped denture does not break; remove the dentures (rock the upper gently to break the seal); brush them over the cushioned sink with denture cleaner and cool water (hot water warps them); rinse; store in a labeled cup of cool water or denture solution when out of the mouth; provide mouth care to the gums and tongue before reinserting.
Toileting, elimination, and specimen basics
Assist residents to the bathroom or commode on a schedule, answer the call light promptly, provide privacy, and observe and record what you see — amount, color, and any blood, pain, or unusual odor — then report anything abnormal.
For a resident who cannot get up, know the equipment and its exam-tested details. A standard bedpan goes wide end (the seat) under the buttocks, with the head of the bed raised afterward so the resident sits in as natural a position as possible. A fracture pan is the flatter, thinner pan with a low wedge end — used for residents with a hip fracture, recent hip surgery, casts, or very limited movement, because it slides under with far less lifting; the thin, flat end goes under the buttocks. Warm a cold metal pan with water first, place a protective pad, give the resident privacy and the call light, and return promptly — a resident left sitting on a bedpan is both a dignity problem and a pressure-injury risk. A male resident who can use a urinal should be positioned comfortably (standing if safe, or in bed), given privacy, and never left with the urinal in place between uses. After any use: gloves on, perineal care as needed, measure and observe the contents before discarding, empty into the toilet, rinse per policy, and wash your hands and the resident's. The CNA records intake and output (I&O) in milliliters and may collect certain specimens within scope: a routine or clean-catch (midstream) urine specimen (clean the perineal area, have the resident start the stream, then catch the middle portion in a sterile container) and a stool specimen (catch it without urine or toilet-paper contamination). Label every specimen at the bedside, use Standard Precautions, and deliver it promptly. Inserting or removing catheters and any sterile collection are outside CNA scope.
Transfers, ambulation, and range of motion
Transfers are the most common moment of injury for both resident and CNA, so follow the care plan's transfer level exactly: independent, supervision, one-person assist with a gait belt, two-person assist, or mechanical lift (sit-to-stand or full sling/Hoyer-type). Before any transfer: lock the bed and wheelchair brakes, raise the bed to a safe working height and then to where the resident's feet reach the floor, position the chair on the resident's strong side, apply the gait belt around the waist (never over a colostomy, feeding tube, or fresh surgical site), have the resident wear non-skid shoes, and count out loud ("on three") so the resident moves with you. Let the resident dangle (sit on the edge of the bed with feet down) for a moment first to prevent dizziness from a blood-pressure drop.
For ambulation, walk slightly behind and to the weak side, holding the gait belt from underneath — never grip the resident's arm, which tears fragile skin and gives you no control. If a resident starts to fall, do not try to catch the full weight. Ease them down along your body/leg to the floor, protecting the head, and call for help; trying to hold up a falling adult is how aides injure their backs and residents break hips.
Range-of-motion (ROM) exercises keep joints mobile and prevent contractures (permanent tightening). Active ROM = the resident moves the joint; active-assisted = you help; passive = you move the joint for a resident who cannot. Move each joint gently, only to the point of resistance — never past pain, supporting the limb above and below the joint, and do each motion the ordered number of times.
Anti-embolism stockings and circulation aids
Anti-embolism (TED) stockings are elastic stockings that promote blood return and help prevent clots. Apply them in the morning before the resident gets up, while the legs are elevated and not yet swollen; turn the stocking partly inside out, ease it over the toes and heel, and smooth it up with no wrinkles, twists, or rolled-down tops (a rolled top acts like a tourniquet). Remove them periodically per orders to check the skin and circulation, and report any coolness, color change, numbness, or new pain in the leg.
Warm and cold applications
Applied heat and cold are ordered treatments; the CNA applies them only per policy and with care, because frail skin and reduced sensation make burns and frostbite injuries easy. Never apply a heat or cold pack directly to bare skin, always place a cloth barrier, follow the ordered time limit (usually short), and check the skin often. Stop and report immediately any redness, blistering, paleness, blue color, numbness, or a complaint of pain — a resident who cannot feel the application cannot warn you.