Vital Signs: Temperature, Pulse and Respiration

This is Unit Twelve of Medical Assistant Prep. Unit Eleven gathered the patient's own words. This unit begins the measured half of the record, the first three vital signs: temperature, pulse and respiration. Carry one idea through this lecture. A number means something only against the right reference: the route, the patient's age and the patient's own baseline, and the medical assistant records and reports it without explaining it away. Two constructed scenes at the end apply that idea to an anxious adult and an infant. By the end you will be able to take a temperature by four routes. To read each against its own range. To take and describe a pulse. And to count respirations and report readings at once.

Eight entries on temperature: the order of vital signs, observation, the four routes, and what changes a reading.

Five measurements.

MAS 276 Vital Signs and Their Order

Vital signs are objective measurements of temperature, pulse, respiration, blood pressure and oxygen saturation. The order depends on the patient and the situation; often the oximeter probe goes on first, and pulse, respirations, blood pressure and temperature follow. Measure, record, and then compare each reading with the expected range.

From the waiting room.

MAS 277 Notice From the Waiting Room

Observation starts the moment you call a patient from the waiting room. Notice how the patient walks, how steady they are, and how they speak and respond as they come back to the room. If anything signals distress, such as labored breathing or confusion, tell the provider before routine measurements.

Chosen by the patient.

MAS 278 Four Temperature Routes

Body temperature can be measured by four main routes: oral, tympanic, axillary and rectal. The route is chosen by the patient's age, ability to cooperate, level of consciousness and the practice's policy. Record the route with every reading, because each route has its own normal range.

Under the tongue.

MAS 279 Taking an Oral Temperature

An oral temperature is taken with an electronic thermometer under the tongue. Slide on a probe cover without touching it, place the tip in the pocket under the tongue, slightly off-center toward the back, and ask the patient to keep their mouth closed. A patient who cannot keep their mouth closed needs another route.

Food, drink and smoking.

MAS 280 Wait After Food, Drink or Smoking

Recent food, drinks, gum or smoking can make an oral reading falsely high or low. Wait fifteen to twenty-five minutes after a hot or cold food or drink, and about five minutes after chewing gum or smoking, before taking an oral temperature. Ask before you measure; a patient who finished an iced coffee minutes ago will read low.

In the ear canal.

MAS 281 Tympanic Temperature

A tympanic thermometer reads temperature in the ear canal. Put on a probe cover, ask the patient to hold still, and for an adult or older child gently pull the outer ear up and back to open the canal. Tympanic readings typically run about three to six tenths of a degree Celsius higher than oral.

In the armpit.

MAS 282 Axillary Temperature

An axillary temperature is taken in the armpit and is a minimally invasive method often used with children. The covered probe goes high in the armpit on bare skin, with the arm then lowered to hold it in place. Axillary readings can be as much as one degree Celsius lower than oral.

Most accurate for infants.

MAS 283 Rectal Temperature

A rectal temperature is invasive, but it is considered the most accurate method for infants. Provide privacy, clean your hands and put on gloves; an infant lies on their back with the legs raised toward the chest, and a parent may hold the child still. Rectal readings usually run about one degree Celsius higher than oral.

Two entries on reference ranges: temperature by route, and heart rate by age.

Lowest to highest.

MAS 284 Normal Temperature Ranges by Route

Each route has its own normal range, which is why the route is recorded. In degrees Celsius, the reference text gives oral about thirty-five point eight to thirty-seven point three; axillary about thirty-four point eight to thirty-six point three, the lowest; tympanic about thirty-six point one to thirty-seven point nine; and rectal about thirty-six point eight to thirty-eight point two, the highest. A rectal reading of thirty-eight is within its range, while the same number taken orally is above the oral range. Never compare readings without the route, and use the practice's reference ranges.

Fastest in the youngest.

MAS 285 Pulse Rate by Age

Normal heart rate varies with age, and it is fastest in the youngest patients. The reference ranges run from about one hundred to one hundred sixty beats a minute in newborns, to eighty to one hundred forty in infants, to sixty to one hundred in adolescents and adults. A rate normal for an infant would be very fast for an adult.

Five entries on the pulse: its four characteristics, counting, grading force, the radial technique, and other sites.

Rhythm, rate, force, equality.

MAS 286 Four Things to Note About a Pulse

A pulse is described by four characteristics: rhythm, rate, force and equality. Rhythm is whether the beats come at even intervals; rate is beats per minute; force is the strength of each beat; equality compares the pulse on both sides of the body. Document all four, not only the rate.

When it is irregular.

MAS 287 Count a Full Minute When It Is Irregular

Counting a pulse for a full sixty seconds is considered best practice, especially when the rhythm is irregular. Count the first beat you feel as one, and keep counting until the minute ends. An irregular rhythm is itself a finding, so report it to the provider along with the full-minute count.

Absent to bounding.

MAS 288 Grading Pulse Force

Pulse force is graded on a short scale, from absent to bounding. Zero means absent; one-plus means weak, diminished or thready; two-plus means normal and strong; three-plus means full and bounding. An absent or weak pulse is reported at once; a device called a Doppler can confirm blood flow.

Fingertips at the wrist.

MAS 289 Taking a Radial Pulse

The radial pulse at the wrist is the most common site. Clean your hands and explain what you are doing. Place the pads of your first three fingers along the thumb side of the wrist, near where it bends. Press gently until you feel the pulse, since pressing too hard can block it. Count from one on the first beat, for a full minute if irregular, otherwise as the practice directs. Note rhythm and force, and compare both wrists if asked about equality. Record the rate with your observations. In newborns and children under five the radial pulse is hard to feel, so the brachial or apical pulse is used.

Neck, elbow, chest.

MAS 290 Other Pulse Sites

Different pulse sites suit different situations. The carotid pulse in the neck is checked in emergencies, one side at a time; the brachial pulse above the inner elbow suits infants; the apical pulse, heard over the heart, is the most accurate. Never press both carotid arteries at once, because it can reduce blood flow to the brain.

Seven entries on breathing and reporting: rate and quality, counting, reporting, baselines, and two constructed scenes.

Signs of distress.

MAS 291 Watching Respiration

Respirations are assessed for rate, rhythm and quality. Normal breathing is relaxed and quiet with a regular rhythm; loud breathing, flaring nostrils or use of neck muscles to breathe are signs of distress. Signs of breathing distress are reported to the provider right away, before you finish the rest of the vital signs.

Fastest in infants.

MAS 292 Respiratory Rates by Age

Normal breathing rates vary by age and are fastest in infants. One reference gives about ten to twenty breaths a minute for adults and thirty to sixty for infants under a year; references differ slightly for adults. Use the practice's reference ranges, and consider sleep, pain or crying when judging a child's rate.

Especially infants.

MAS 293 Count Respirations for a Full Minute

Obtain the respiratory rate over a full minute. This matters most for infants, whose breathing in the first weeks of life is often irregular, so a short count can mislead. Record the rate together with anything unusual about how the patient was breathing, such as pauses or noisy breaths.

Compare at once.

MAS 294 Analyze and Report Right Away

After taking vital signs, compare the results with the expected ranges at once and report deviations appropriately. A reading outside the range is reported to the provider, along with how the patient looked and what they said. Recording an abnormal reading without telling anyone leaves it unseen.

The patient's own normal.

MAS 295 Compare With the Patient's Baseline

Compare findings with the patient's own known baseline whenever it is available. A patient whose blood pressure always runs low may be well at a reading that would worry you in someone else, while confusion in a usually alert patient is a change worth reporting. The baseline helps the provider interpret; it is not permission for you to dismiss a reading.

Fast and uneven, in a nervous patient.

MAS 296 Vital Signs on an Anxious Patient

A constructed scene shows vital signs on an anxious young woman. She finished an iced drink ten minutes ago, so the assistant uses the tympanic route the practice allows and records it. The pulse is fast and seems uneven, so she counts a full minute; she counts respirations for a full minute too, still watching the wrist so the patient does not change her breathing. Both rates are above the adult range. Nervousness can speed the heart, but she does not decide that nerves explain it. She records the numbers, the irregular feel and the patient's own word anxious, and tells the provider about the uneven pulse before the provider enters. An irregular rhythm is something the provider must hear about, whatever the likely cause.

An infant, measured against infant ranges.

MAS 297 An Infant's Vital Signs

A constructed scene pays off the opening idea. A father brings his four-month-old daughter, who has felt warm. The assistant explains each step, takes the temperature by the route policy calls for with infants, with the father helping hold her still, and records the route. She uses the brachial pulse, since a radial pulse is hard to feel in an infant, and counts respirations for a full minute. Against infant ranges, a heart rate of one hundred thirty and a breathing rate of forty are normal, though fast for an adult. The temperature is above the range for its route. She records everything, tells the provider, and lets the father know the provider will talk with him. Adult ranges would have flagged two normal numbers and misread the one that mattered.

Look at what you can now do. You can choose a temperature route, take each of the four correctly, and wait after food, drink or smoking. You can read a temperature against its own route's range, and a pulse against the patient's age. You can take a radial pulse and describe its rhythm, rate, force and equality, counting a full minute when it is irregular. And you can count respirations for a full minute, compare every reading with the range and the baseline, and report at once. Unit Thirteen continues with blood pressure, oxygen saturation and body measurements.