7.1 Temperature, Pulse & Respiration Measurement
Key Takeaways
- Normal baseline vital signs in adults include oral temperature of 97.6°F–99.6°F (36.5°C–37.5°C), resting radial pulse of 60–100 beats per minute, and respiratory rate of 12–20 breaths per minute.
- When obtaining an oral temperature, the nursing assistant must wait 10 to 20 minutes if the resident has recently consumed hot or cold beverages, eaten food, chewed gum, or smoked.
- Rectal temperature measurement uses a dedicated red-probe thermometer inserted 1 inch into the adult rectum with water-soluble lubricant, but is strictly contraindicated in residents with active cardiac disease, rectal surgery, bleeding, or diarrhea.
- Apical pulse is auscultated over the 5th intercostal space at the left midclavicular line for one full minute (60 seconds); a pulse deficit exists when the apical pulse exceeds the radial pulse.
- Respirations must be counted unobtrusively immediately following radial pulse assessment without alerting the resident, ensuring the natural breathing pattern is not consciously altered.
Last updated: August 2026
Temperature, Pulse & Respiration Measurement
Vital signs—temperature, pulse, respirations, blood pressure, and oxygen saturation—are the primary physiological indicators of a resident's internal homeostasis and cardiorespiratory stability. In long-term care, assisted living, and acute hospital environments, the Certified Nursing Assistant (CNA) or Licensed Nursing Assistant (LNA) is often the first healthcare team member to detect subtle physiological changes. Accurate measurement, meticulous technique, and prompt reporting of abnormal findings are vital competencies mandated by the Arizona State Board of Nursing (AZBN) and evaluated on the D&SDT-Headmaster clinical skills examination.
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| VITAL SIGNS CLINICAL OVERVIEW |
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| | TEMPERATURE | | PULSE | |
| | Oral: 97.6°F–99.6°F | | Normal: 60–100 bpm | |
| | Rectal: 98.6°F–100.6°F| | Bradycardia: < 60 bpm | |
| | Axillary: 96.6°F–98.6°F| | Tachycardia: > 100 bpm| |
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| | RESPIRATIONS | | PULSE OXIMETRY | |
| | Normal: 12–20 br/min | | Normal SpO2: 95%–100% | |
| | Bradypnea: < 12 br/min| | Hypoxemia: < 90% | |
| | Tachypnea: > 20 br/min| | COPD Target: 88%–92% | |
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1. Body Temperature: Physiology, Routes & Ranges
Body temperature represents the precise balance between heat produced by cellular metabolism and muscular activity versus heat lost through the skin, lungs, and bodily eliminations. The thermoregulatory center in the hypothalamus maintains core temperature within a narrow physiological window.
Clinical Thermometry Routes and Equipment
Modern electronic thermometers utilize color-coded interchangeable probes to prevent cross-contamination:
- Blue Probe: Designated exclusively for oral (sublingual) and axillary measurements.
- Red Probe: Designated exclusively for rectal measurements.
- Disposable Sheaths: A single-use plastic probe cover must be snapped securely over the probe before every measurement and ejected directly into a waste receptacle afterward.
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| TEMPERATURE MEASUREMENT COMPARISON |
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| [ORAL (Blue Probe)] -----> 97.6°F – 99.6°F (36.5°C – 37.5°C) |
| * Sublingual pocket; wait 10-20 min post hot/cold intake or smoking. |
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| [RECTAL (Red Probe)] -----> 98.6°F – 100.6°F (37.0°C – 38.1°C) |
| * Most accurate core route; lubricate 1 inch; Sims' position. |
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| [TYMPANIC (Ear)] -----> 97.6°F – 99.6°F (36.5°C – 37.5°C) |
| * Pull pinna up & back (adult); fast, non-invasive core estimate. |
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| [TEMPORAL (Forehead)]-----> 97.2°F – 100.1°F (36.2°C – 37.8°C) |
| * Infrared scan across forehead and behind earlobe. |
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| [AXILLARY (Blue Probe)]---> 96.6°F – 98.6°F (35.9°C – 37.0°C) |
| * Least accurate; pat axilla dry; hold arm tight against chest. |
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Detailed Route Specifications & Clinical Rules
| Measurement Route | Normal Range (°F / °C) | Placement & Technique | Clinical Contraindications & Safety Rules |
|---|---|---|---|
| Oral (Sublingual) | 97.6°F–99.6°F<br>(36.5°C–37.5°C) | Place covered blue probe deep under the tongue into the sublingual pocket on either side of the frenulum. Resident must keep lips closed firmly around the probe without biting down. | Contraindicated in unconscious, confused, agitated, or seizure-prone residents; mouth breathers; oxygen via face mask; recent oral surgery. Mandatory Rule: Wait 10 to 20 minutes if resident recently ate, drank hot/cold liquids, chewed gum, or smoked. |
| Rectal | 98.6°F–100.6°F<br>(37.0°C–38.1°C) | Position resident in left Sims' position (side-lying with right knee flexed). Apply water-soluble lubricant to covered red probe (approx. 1 inch). Gently insert 1 inch into the adult rectum (0.5 inch for infants). Hold firmly in place throughout reading; never let go. | Most accurate core reflection. Strictly Contraindicated in: Active cardiac conditions (insertion can stimulate the vagus nerve, causing profound bradycardia, cardiac arrhythmias, and syncope); recent rectal surgery; rectal bleeding; hemorrhoids; severe diarrhea; low platelet count (thrombocytopenia). |
| Axillary (Armpit) | 96.6°F–98.6°F<br>(35.9°C–37.0°C) | Ensure axilla is clean and completely dry; pat dry gently with a towel (do not rub vigorously, which creates frictional heat). Place covered blue probe in the deepest center of the armpit. Fold resident's arm tightly across the chest to maintain contact. | Least accurate non-invasive route (reads ~1°F lower than oral). Used when oral, rectal, and tympanic routes are clinically unsafe or refused. |
| Tympanic (Aural) | 97.6°F–99.6°F<br>(36.5°C–37.5°C) | Place disposable cover on ear probe. For adults, gently pull the external ear pinna up and back to straighten the acoustic auditory canal. (For infants/toddlers < 3 years, pull pinna down and back). Insert probe gently until snug and press activate button. | Fast core temperature reading (1–2 seconds) from the tympanic membrane blood supply. Contraindicated if ear canal is impacted with excessive cerumen (earwax), active ear drainage, otitis externa/media, or recent ear surgery. |
| Temporal Artery | 97.2°F–100.1°F<br>(36.2°C–37.8°C) | Clean infrared sensor lens. Place flush against the center of the forehead, press scan button, slide smoothly straight across the forehead to the hairline, lift, and touch the probe to the soft depression behind the earlobe (to account for diaphoresis). | Fast, comfortable, non-invasive. Inaccurate if forehead is heavily covered with sweat without scanning behind ear, or if covered by thick bangs, hats, or bandages. |
Clinical Terminology & Reporting Standards
- Pyrexia / Febrile: Core body temperature elevated above normal physiological limits (generally > 100.4°F / 38.0°C). In geriatric residents, blunted immune responses may mean a modest rise (e.g., 99.5°F or a 2°F increase above baseline) signifies a severe systemic infection.
- Afebrile: Body temperature within the normal range.
- Hypothermia: Core body temperature dropping below 95.0°F (35.0°C), leading to decreased cellular metabolism, shivering, confusion, and cardiac arrhythmias.
- Reporting Trigger: Immediately report any temperature reading above 100.0°F (37.8°C) or below 96.0°F (35.6°C) to the supervising nurse.
2. Pulse Measurement: Assessment, Sites & Rhythm
The pulse is the tactile, rhythmic expansion and recoil of an artery resulting from the surge of blood ejected into the systemic circulation with each contraction of the left ventricle.
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| ANATOMICAL PULSE ASSESSMENT SITES |
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| [Temporal] - Above & lateral to eye |
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| [Carotid] - Neck groove lateral to trachea (CPR) |
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| [Apical] - 5th ICS Left Midclavicular Line (60 sec) |
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| [Brachial] - Antecubital fossa (BP assessment) |
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| [Radial] - Thumb side of inner wrist (Routine) |
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| [Femoral] - Inguinal groin crease |
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| [Popliteal]- Posterior knee fossa |
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| [Post. Tibial] - Medial ankle posterior to malleolus |
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| [Dorsalis Pedis] - Dorsum of foot between metatarsals |
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Clinical Assessment Parameters
When assessing a pulse, the CNA must evaluate three distinct characteristics:
- Rate: Number of pulsations felt or heard per minute.
- Normal Adult Range: 60 to 100 beats per minute (bpm).
- Bradycardia: Heart rate less than 60 bpm (common in conditioned athletes, but pathological in heart block, digoxin toxicity, or severe hypothermia).
- Tachycardia: Heart rate greater than 100 bpm (triggered by fever, pain, anxiety, hemorrhage, hypovolemia, infection, or heart failure).
- Rhythm: Regularity of the interval between successive beats (Regular vs. Irregular/Arrhythmia).
- Volume / Quality / Amplitude: Strength of the arterial pulse wave:
0: Absent / non-palpable.+1: Weak, thready, feeble (easily obliterated with slight finger pressure; indicates hypovolemia or shock).+2: Normal, expected pulse volume.+3: Full, bounding (difficult to obliterate; indicates fluid overload, hypertension, or high cardiac output).
Radial Pulse Assessment (AZBN & Headmaster Skill Protocol)
- Position the resident in a comfortable seated or supine position with the forearm supported.
- Place the pads of your first two or three fingers (index, middle, and ring) gently over the radial artery on the thumb side of the resident's inner wrist.
- CRITICAL RULE: NEVER use your thumb to palpate a pulse, because the thumb contains its own strong arterial pulsation that can easily be mistaken for the resident's heartbeat.
- Apply gentle pressure until pulsations are clearly distinct. Pressing too hard obliterates the arterial lumen and eliminates the pulse.
- Timing Standard:
- If the pulse is regular, count the beats for 30 seconds and multiply by 2.
- If the pulse is irregular, if taking an initial baseline on admission, or if evaluating cardiac medications, count for a full 60 seconds (one full minute).
Apical Pulse Assessment Protocol
The apical pulse represents the direct auscultation of the mechanical contraction of the heart at the apex.
[!IMPORTANT] Apical Pulse Anatomical Landmark: Located at the 5th intercostal space (ICS) along the left midclavicular line (MCL) (the Point of Maximal Impulse - PMI).
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| APICAL PULSE AUSCULTATION |
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| [Clean Earpieces & Diaphragm with Alcohol Wipe] |
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| v |
| [Warm Diaphragm in Palm to Prevent Resident Startle Reflex] |
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| v |
| [Locate 5th Intercostal Space at Left Midclavicular Line] |
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| v |
| [Place Diaphragm & Listen for 'Lub-Dub' Sounds (S1 + S2 = 1 Beat)] |
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| v |
| [Count Continuously for ONE FULL MINUTE (60 Seconds)] |
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- Auscultation Technique: Each heartbeat produces two distinct acoustic sounds: "lub" (S1 - closure of AV valves) and "dub" (S2 - closure of semilunar valves). The combined "lub-dub" constitutes ONE single heartbeat.
- Full Minute Standard: On the Arizona Headmaster examination and in clinical practice, an apical pulse must ALWAYS be counted for a full 60 seconds.
- Medication Significance: Often required prior to administering cardiac medications such as Digoxin (Lanoxin); nurses typically hold the dose if apical pulse is < 60 bpm.
Understanding the Pulse Deficit
A pulse deficit occurs when there is a numerical difference between the apical heart rate and the peripheral radial pulse rate.
- Physiological Mechanism: In conditions like atrial fibrillation or premature ventricular contractions (PVCs), some cardiac contractions are too weak to eject sufficient stroke volume to propagate a detectable pulse wave to the distant radial artery.
- Assessment Protocol: Two healthcare providers measure simultaneously using one synchronizing watch over 60 full seconds—one provider counting the apical pulse with a stethoscope while the second provider counts the radial pulse.
- Clinical Rule: The apical pulse will never be lower than the radial pulse. A pulse deficit indicates compromised cardiac output and must be reported immediately.
Peripheral Pedal Pulses (Dorsalis Pedis & Posterior Tibial)
In residents with peripheral vascular disease (PVD), diabetes mellitus, arterial occlusive disorders, or localized lower extremity edema, the CNA checks pedal pulses to verify tissue perfusion. Always compare bilateral feet for symmetry in pulse strength, skin temperature, and capillary refill.
3. Respiration Measurement: Physiology, Rates & Patterns
Respiration is the vital mechanical and metabolic process of gas exchange, consisting of inspiration (inhalation) of oxygen and expiration (exhalation) of carbon dioxide. One complete respiratory cycle equals one breath (one chest rise + one chest fall).
Normal Range and Assessment Technique
- Normal Adult Resting Respiratory Rate: 12 to 20 breaths per minute.
- Quality Assessment: Respirations should be regular, effortless, quiet, symmetrical, and unlabored.
[!WARNING] The Unobtrusive Measurement Technique: Breathing is under both voluntary and autonomic nervous control. If a resident knows their breathing is being counted, they will involuntarily or consciously alter their breathing rate, depth, and rhythm. Headmaster / AZBN Skill Standard: Count respirations immediately after completing the radial pulse assessment. Keep your fingers resting on the resident's wrist or your stethoscope resting on the chest, pretend to continue counting the pulse, and unobtrusively observe the resident's chest or abdominal excursions. Count for 30 seconds x 2 (or 60 seconds if irregular/labored).
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| UNOBTRUSIVE RESPIRATION COUNTING FLOW |
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| [Step 1: Locate Radial Pulse & Count Beats for 30 or 60 Seconds] |
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| v |
| [Step 2: Maintain Fingers Firmly on Wrist - DO NOT Announce Switch] |
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| v |
| [Step 3: Shift Gaze to Chest/Abdomen; Observe Rises & Falls] |
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| v |
| [Step 4: Count 1 Full Rise + 1 Full Fall as ONE Breath (30s x 2)] |
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| v |
| [Step 5: Record Pulse & Respiration Values in Resident Chart] |
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Clinical Respiratory Patterns and Terminology
| Term | Clinical Definition | Common Causes / Significance |
|---|---|---|
| Eupnea | Normal, quiet, rhythmic breathing (12–20 breaths/min). | Healthy baseline resting state. |
| Tachypnea | Abnormally rapid respiratory rate (> 20 breaths/min). | Fever, hypoxemia, acute pain, anxiety, pulmonary embolism, pneumonia. |
| Bradypnea | Abnormally slow respiratory rate (< 12 breaths/min). | Opioid/sedative toxicity, elevated intracranial pressure, coma. |
| Dyspnea | Difficult, painful, or labored breathing; shortness of breath. | COPD, asthma, congestive heart failure, airway obstruction. |
| Apnea | Complete, temporary, or prolonged cessation of breathing. | Sleep apnea, respiratory arrest, brainstem ischemia. |
| Cheyne-Stokes | Rhythmic cycles of slow, shallow breathing that progressively increase in rate and depth, peak, then diminish to shallow breathing followed by a period of apnea (10–60 seconds). | End-of-life/terminal states, severe congestive heart failure, severe stroke, metabolic encephalopathy. |
| Orthopnea | Inability to breathe comfortably unless sitting upright or standing. | Left-sided congestive heart failure, pulmonary edema, severe emphysema. |
| Kussmaul | Abnormally deep, rapid, sighing respirations without apnea. | Diabetic Ketoacidosis (DKA) — body attempting to blow off excess carbonic acid. |
| Stridor | High-pitched, harsh musical sound heard on inspiration. | Acute upper airway obstruction, laryngeal spasm, croup (medical emergency). |
4. Pulse Oximetry ($SpO_2$ Monitoring)
A pulse oximeter is a non-invasive optical sensor that measures the percentage of arterial hemoglobin saturated with oxygen ($SpO_2$), providing continuous hemodynamic insight.
Clinical Targets & Sensor Application
- Normal Range: 95% to 100% on room air.
- COPD / Chronic Hypercapnia Range: 88% to 92% (as specified by individualized physician order to maintain hypoxic drive).
- Hypoxemia Alert: Any reading below 90% (or falling below the resident's prescribed care plan baseline) indicates clinical hypoxemia and must be reported immediately to the nurse.
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| PULSE OXIMETRY ARTIFACT FACTORS |
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| [Dark/Metallic Nail Polish] ----> Interferes with optical light beams. |
| [Cold / Vasoconstricted Digits]-> Inadequate pulsatile capillary flow. |
| [Tremors / Restlessness] -------> Motion artifact creates false lows. |
| [Severe Hypotension / Shock] ---> Insufficient peripheral pulse wave. |
| [Bright Ambient Lighting] ------> Ambient sunlight/fluorescent saturation.|
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Nursing Assistant Precautions for Pulse Oximetry
- Site Selection: Place the sensor clip on a warm, dry, clean finger, earlobe, or toe. If fingers are cold, gently warm the hand between your palms or use an earlobe sensor.
- Nail Polish Removal: Dark blue, black, or metallic nail polish and acrylic nails absorb infrared wavelengths and create falsely low readings. Polish must be removed with an acetone pad, or the sensor placed laterally across the finger or on the earlobe.
- Correlate with Pulse: Always compare the pulse rate displayed on the oximeter screen with the resident's manually palpated radial pulse. If the oximeter heart rate matches the palpated radial pulse, the oximeter has captured a reliable pulsatile wave.
Test Your Knowledge
A nursing assistant enters a resident's room to take morning vital signs and notes that the resident is finishing a hot cup of black coffee. What is the correct clinical action for obtaining an oral temperature?
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Test Your Knowledge
When auscultating an apical pulse on an adult resident, where must the nursing assistant place the stethoscope diaphragm, and for how long should the heart rate be counted?
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Test Your Knowledge
A licensed nurse and a nursing assistant assess a resident with atrial fibrillation and obtain an apical pulse of 92 beats per minute and a radial pulse of 76 beats per minute. What is the calculated pulse deficit?
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