3.1 Vital Signs Assessment

Vital Signs Assessment

Vital signs are the most basic and essential clinical measurements that indicate a patient's physiological status. As a medical assistant, you will measure vital signs at nearly every patient encounter. The CCMA exam tests your knowledge of normal ranges, measurement techniques, equipment, and interpretation.

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Temperature

Normal Ranges by Site:

Temperature Abnormalities:

• Fever (pyrexia): >100.4°F (38°C) — body's response to infection
• Hypothermia: <95°F (35°C) — dangerously low body temperature
• Febrile: Having a fever
• Afebrile: Without fever

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Pulse

Normal Pulse Rates by Age:

Pulse Assessment Sites:

Pulse Characteristics:

• Rate: Number of beats per minute
• Rhythm: Regular or irregular
• Volume (strength): Strong (bounding), weak (thready), normal

Counting the Pulse:

• Count for 30 seconds and multiply by 2 for regular pulses
• Count for 60 seconds (full minute) for irregular pulses
• Apical pulse: use stethoscope; count for 60 seconds

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Respiration

Normal Adult Respiratory Rate: 12-20 breaths/min

Assessment Tips:

• Count respirations without the patient's knowledge (they may alter their breathing)
• Best technique: Count while appearing to still take the pulse
• One respiration = one inhalation + one exhalation
• Count for 30 seconds × 2 for regular breathing; 60 seconds for irregular

Respiratory Abnormalities:

Blood Pressure

Blood pressure measures the force of blood against the walls of the arteries.

Components:

• Systolic pressure — Pressure during ventricular contraction (the higher number)
• Diastolic pressure — Pressure during ventricular relaxation (the lower number)
• Measured in mmHg (millimeters of mercury)

Blood Pressure Classifications (Adult):

Measurement Procedure:

1. Patient seated, arm at heart level, feet flat on floor, back supported
2. No talking or crossing legs during measurement
3. Use proper cuff size — bladder should cover 80% of arm circumference
4. Apply cuff 1 inch above the antecubital space (inner elbow)
5. Palpate the brachial artery and inflate cuff 20-30 mmHg above the point where the pulse disappears
6. Place stethoscope bell/diaphragm over the brachial artery
7. Deflate at 2-3 mmHg per second
8. First Korotkoff sound heard = systolic pressure
9. Last Korotkoff sound heard = diastolic pressure

Common Blood Pressure Errors:

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Pain Assessment

Pain is considered the "fifth vital sign" and must be assessed and documented at every visit.

Pain Scales:

• Numeric Rating Scale (NRS): 0-10 scale (0 = no pain, 10 = worst pain imaginable)
• Wong-Baker FACES Scale: Facial expressions for children and non-verbal patients
• FLACC Scale: For infants — Face, Legs, Activity, Cry, Consolability

Pain Assessment (OLDCARTS/OPQRST):

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Pulse Oximetry (SpO2)

• Measures the percentage of hemoglobin saturated with oxygen
• Normal: 95-100%
• Below 90%: Hypoxemia — report to provider immediately
• Device is placed on fingertip, toe, or earlobe
• Factors affecting accuracy: Nail polish, cold extremities, poor circulation, anemia, dark skin pigmentation, movement, carbon monoxide exposure

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Orthostatic (Postural) Vital Signs

Measured to detect orthostatic hypotension (blood pressure drop when changing position):

1. Measure BP and pulse with patient lying down (supine) for 3-5 minutes
2. Have patient sit up; wait 1-3 minutes; repeat measurements
3. Have patient stand up; wait 1-3 minutes; repeat measurements

Positive orthostatic finding: Drop in systolic BP ≥20 mmHg OR diastolic BP ≥10 mmHg, OR increase in heart rate ≥20 bpm upon standing