6.1 Measuring & Recording Temperature, Pulse & Respirations
Key Takeaways
Measure and report vital signs against the resident's baseline and the nurse's specified limits; normal-looking numbers do not exclude deterioration.
Temperature route, device, recent intake, and technique affect readings; record the route and follow manufacturer instructions.
A typical resting adult pulse is 60–100 beats/minute; report new irregularity or values outside assigned limits.
Measure an assigned apical pulse for a full minute; a simultaneous apical-minus-radial difference is a pulse deficit to report.
Count complete respiratory cycles unobtrusively and report difficulty breathing immediately, regardless of the rate.
6.1 Measuring & Recording Temperature, Pulse & Respirations
Vital signs are objective indicators of systemic homeostasis, reflecting cardiovascular, respiratory, and neurological stability. In long-term care, certified nursing assistants (CNAs) gather, document, and report these baseline parameters. Because elderly residents often exhibit blunted physiological responses—such as severe infection without high fever—monitoring an individualized baseline is essential. Deviations from baseline provide the earliest clinical warnings of infection, decompensation, or physiological decline.
Body Temperature Measurement Sites, Norms & Procedures
Body temperature balances metabolic heat production with heat dissipation through conduction, convection, radiation, and evaporation. Thermometer routes and techniques are device-specific. The nurse and care plan determine which route is appropriate; the aide does not choose an invasive route simply because it seems more accurate.
| Route | Practical technique | Important limitation |
|---|---|---|
| Oral | Use the correct covered probe in the sublingual pocket | Recent hot/cold intake, smoking, oxygen delivery, or inability to cooperate may affect suitability |
| Rectal | Only if assigned, trained, permitted, and appropriate for this resident | Invasive; use the designated device, lubricant, position, and insertion limit in its instructions; never force or leave unsupported |
| Axillary | Position the approved probe in the dry axilla with the arm supported | Technique and device affect accuracy; do not add an assumed correction factor |
| Tympanic | Use the ear-specific cover and positioning technique | Ear obstruction, drainage, or incorrect positioning may affect suitability |
| Temporal | Follow the particular scanner's contact or noncontact instructions | Not every device uses the same forehead/earlobe scanning motion |
Preparing and Recording Temperature
Check the assigned route, clean equipment, cover the probe as instructed, explain the procedure, and obtain cooperation. After hot/cold food, drinks, or smoking, follow the device's stated waiting interval or ask the nurse about an alternative route; 15–20 minutes is not a universal instruction for all devices. Probe colors are common equipment conventions, not a substitute for reading the label.
Report pain, resistance, bleeding, or inability to cooperate rather than completing an invasive measurement by force. The nurse considers rectal disease/surgery, bleeding risk, and other conditions before assigning a rectal route. A history of any cardiac disease is not by itself a universal prohibition for every thermometer, and rectal readings do not perfectly measure core temperature in every circumstance.
Document the actual number, units, route, time, and relevant circumstances. Do not automatically add or subtract one degree to convert between sites. Compare repeated measurements using the same appropriate route when possible. Older residents may have serious infection without a high fever; a new rise above baseline, chills, new confusion, or marked weakness still needs prompt reporting. If a reading seems implausible, check technique and tell the nurse rather than inventing a replacement value.
Radial and Apical Pulse Measurement
The pulse represents the rhythmic arterial pressure wave created by left ventricular contraction during cardiac systole.
- Normal Adult Pulse: 60 to 100 beats per minute (bpm).
- Tachycardia: Heart rate exceeding 100 bpm, caused by fever, pain, dehydration, infection, hypoxia, or anxiety.
- Bradycardia: Heart rate below 60 bpm, seen in athletic conditioning, hypothermia, heart block, or cardiotonic drugs like digoxin or beta-blockers.
Radial Pulse Assessment
The radial pulse is assessed on the thumb side of the wrist over the radius bone. Place the pads of the first two fingers gently over the radial artery. Never use your thumb, which has its own arterial pulse. If regular, count beats for 30 seconds and multiply by two. If irregular or an admission baseline, count for a full 60 seconds while assessing rhythm regularity and strength (normal, bounding, or thready).
Apical Pulse & Pulse Deficit
When the plan assigns an apical pulse and the aide is trained, use the prescribed technique; report an irregular radial pulse promptly and obtain nurse direction rather than deciding medication-related assessments independently. Place the stethoscope diaphragm over the apex of the heart at the fifth intercostal space (5th ICS) at the left midclavicular line (LMCL). Count heartbeats for a full 60 seconds.
A pulse deficit occurs when cardiac contractions are too weak to transmit a pulse wave to peripheral arteries, commonly seen in atrial fibrillation. Two clinicians measure simultaneously for 60 seconds: one auscultates the apical pulse while the other palpates the radial pulse. Subtracting the radial rate from the apical rate determines the pulse deficit:
An apical rate of 92 bpm with a radial rate of 76 bpm yields a pulse deficit of 16 bpm, indicating beats not detected as peripheral pulse waves that must be reported to the supervising nurse immediately.
Respiratory Assessment & Breathing Patterns
Respiration involves oxygen and carbon dioxide exchange. One breath consists of one chest rise (inhalation) and one chest fall (exhalation). Normal resting adult respiration is 12 to 20 breaths per minute, characterized by a quiet, regular rhythm.
Measure respirations unobtrusively by maintaining fingers on the resident radial wrist following the pulse count as if still taking the pulse, while observing chest rises. Count for 30 seconds and multiply by two if regular, or count for a full 60 seconds if irregular or shallow.
Key Respiratory Parameters & Abnormalities
- Eupnea: Normal breathing at 12 to 20 breaths per minute.
- Tachypnea: Rapid respirations exceeding 20 breaths per minute.
- Bradypnea: Slow respirations below 12 breaths per minute.
- Dyspnea: Difficult, labored, or painful breathing, often with accessory muscle use.
- Apnea: Absence of breathing.
- Cheyne-Stokes Respirations: An abnormal pattern of shallow breaths that gradually increase in depth and rate (crescendo), followed by a gradual decrease (decrescendo), ending in 10 to 60 seconds of apnea. Commonly seen in stroke, heart failure, and during active dying.
Reporting Vital Sign Abnormalities & Documentation
Document all vital signs promptly in the medical record with date, time, value, and route (e.g., "T 99.8°F R, P 84 apical, R 18"). Never record estimated numbers. Report readings outside the nurse's assigned limits, new irregularity, a pulse deficit, or a change from baseline promptly. Typical adult reference ranges are learning guides, not universal emergency thresholds. Acute dyspnea, unresponsiveness, or abnormal breathing requires immediate emergency escalation, even when another number appears within range.
Sources checked October 16, 2026
AHA blood pressure measurement; FDA pulse oximeter limitations; MedlinePlus vital signs.
The nurse assigns a temperature using a particular electronic device. Which practice best ensures an accurate record?
Follow the device's instructions, use the assigned route, and document the measured value with route, units, and time
Add one degree to every axillary measurement without telling the nurse
Use any probe color for any route because covers eliminate all contamination
Choose a rectal route independently whenever another reading seems low
Under an assigned protocol, two trained aides simultaneously count a full-minute apical pulse of 94 and radial pulse of 78. What should be reported?
The resident's heart rate is normal and stable, and the documented pulse rate should be averaged to 86 bpm in the electronic medical record
The resident exhibits a pulse deficit of 16 bpm, indicating beats not detected as peripheral pulse waves that must be reported immediately to the charge nurse
The radial pulse is falsely low due to excessive artery compression, requiring the assistants to repeat the assessment using the carotid pulse
The apical pulse is tachycardic, and the CNA should administer an extra dose of prescribed cardiotonic medication before rechecking
During the nurse-directed care of a resident with a known end-of-life breathing plan, the aide observes breaths waxing and waning in depth with pauses. Which pattern should be reported?
Eupneic ventilation with transient periods of exertion-induced tachypnea
Kussmaul breathing with continuous, rapid, deep, and labored hyperventilation
Cheyne-Stokes respirations requiring immediate reporting to the charge nurse
Orthopneic breathing relieved by repositioning the resident in a flat supine position
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