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newSchoolWorks.com › VoTechWorks › Health & Personal Services › Nursing Assistant (CNA) › Vital Signs Measurement and Documentation for Nursing Assistants › Lesson 2
HLT-CNA36-03 · Lesson 2 · 6 clock hours · demo

Temperature and Pulse: Equipment, Technique, and Documentation

Objective. Students will demonstrate proper step-by-step technique for measuring oral, axillary, and tympanic temperature and radial pulse, and record findings accurately on a paper flow sheet.

⚠ Pending professional review

This lesson, its worked examples and its practice questions has not yet been verified by a licensed clinician in the field or by a certification or approval body. It is a study draft and may contain errors. Do not use it to make decisions about any patient or medication. Always follow your instructor, your supervising professional, and current official references and regulations.

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Why Vital Signs Matter

Temperature and pulse are two of the four classic vital signs. They give the care team an early warning when a patient's condition changes. As a nursing assistant, you will measure these signs many times every shift. Accurate measurement and clear documentation protect patients and are required for your state CNA registry credential. An error in technique or recording can delay treatment or cause harm, so every step counts.

Body Temperature: Normal Ranges and Routes

Normal oral body temperature is generally accepted as approximately 98.6 °F (37 °C), though individual baseline values vary slightly. A reading above 100.4 °F (38 °C) is commonly considered a fever; a reading below 96.8 °F (36 °C) may indicate hypothermia. Always compare a patient's reading to their documented baseline and report changes to the nurse.

Three routes are covered in this lesson:

Contraindications

| Route | Do NOT use when… |

|---|---|

| Oral | Patient is unconscious, confused, on seizure precautions, has had recent oral surgery, or is receiving oxygen by mask or nasal cannula at high flow |

| Axillary | Axillary region is injured, has a rash, or has a recent surgical incision |

| Tympanic | Ear drainage is present, recent ear surgery, or ear canal is blocked by wax |

Always check the care plan and ask the nurse before selecting a route.

Equipment and Infection Control

Digital thermometers used orally and axillary require a disposable probe cover placed on the probe before each use. Tympanic thermometers require a disposable speculum cover snapped on before inserting into the ear. Never reuse a probe cover. After removing the cover, dispose of it without touching the used surface. Perform hand hygiene before and after every vital-signs measurement—this protects both the patient and you.

Step-by-Step: Oral Temperature

1. Perform hand hygiene.

2. Identify the patient using two identifiers (name and date of birth or ID band).

3. Explain the procedure.

4. Apply a disposable probe cover to the oral thermometer.

5. Ask the patient to open their mouth; place the probe tip under the tongue in the posterior sublingual pocket (to one side of the frenulum).

6. Ask the patient to close their lips gently around the probe without biting.

7. Hold in place until the thermometer signals (typically a beep).

8. Remove, read the display, and note the number.

9. Eject the probe cover without touching it; dispose properly.

10. Perform hand hygiene.

11. Record immediately on the flow sheet.

Step-by-Step: Axillary Temperature

1. Perform hand hygiene and apply a probe cover.

2. Expose the patient's axilla; pat it dry with a towel if moist (moisture affects accuracy).

3. Place the probe tip in the center of the axilla against the skin.

4. Ask the patient to lower their arm over the thermometer and hold it snugly against the chest.

5. Hold until the thermometer signals.

6. Remove, read, eject the cover, and perform hand hygiene.

7. Record, noting that the reading is axillary (abbreviation: T(ax)).

Step-by-Step: Tympanic Temperature

1. Perform hand hygiene and snap a new speculum cover onto the tympanic probe.

2. For an adult, gently pull the ear pinna up and back to straighten the ear canal.

3. Insert the probe snugly (seal the canal) and press the scan button.

4. Remove after the signal (measurement is nearly instant).

5. Eject the cover; perform hand hygiene.

6. Record, noting the route (abbreviation: T(tym)).

Radial Pulse: Technique and Counting

The radial pulse is felt at the inner wrist at the base of the thumb. Use the pads of your index and middle fingers—never your thumb, because the thumb has its own pulse and may cause an inaccurate count.

1. Perform hand hygiene.

2. Position the patient's arm comfortably, palm facing down.

3. Press lightly on the radial artery until you feel the pulse.

4. Using a watch or clock with a second hand, count the beats for a full 60 seconds.

5. Note the rate, rhythm (regular or irregular), and strength (strong, weak, thready).

6. Perform hand hygiene.

7. Document all findings.

Normal adult resting pulse range is approximately 60–100 beats per minute. Report values outside this range, an irregular rhythm, or a weak or bounding quality to the nurse promptly.

Documentation: Accuracy and Format

Document vital signs immediately—do not rely on memory. Use the correct abbreviations on the flow sheet:

Record the date and time in the facility's required format (often MM/DD/YYYY and 24-hour or AM/PM clock). Write legibly in ink. Sign with your initials and title (e.g., SNA for student nursing assistant, or per facility policy). Never document a measurement you did not actually take. If you make an error, draw a single line through it, write "error," and initial—do not erase or use correction fluid.

Safety Reminders

Key terms10

Vital signsMeasurable indicators of a patient's basic body functions: temperature, pulse, respirations, and blood pressure (SpO₂ is often added as a fifth sign).
Sublingual pocketThe area under the tongue on either side of the frenulum where the oral thermometer probe is placed to obtain an accurate oral temperature reading.
AxillaryRelating to the armpit; the axillary route measures temperature by placing the thermometer probe in the center of the armpit against the skin.
Tympanic thermometerAn infrared thermometer inserted into the ear canal that reads temperature rapidly by detecting heat from the tympanic membrane.
Probe coverA disposable plastic sleeve or speculum cover placed on a thermometer probe before use to prevent cross-contamination between patients.
Radial pulseThe pulse felt at the radial artery on the inner aspect of the wrist near the base of the thumb; the most common site for routine pulse assessment by nursing assistants.
FeverAn elevated body temperature, generally defined as above 100.4 °F (38 °C), that may indicate infection or other illness.
Rhythm (pulse)The pattern of heartbeats; a normal pulse is regular (evenly spaced beats), while an irregular pulse has uneven intervals and must be reported to the nurse.
Flow sheetA pre-printed documentation form used to record vital signs, intake and output, and other recurring data in a column format organized by date and time.
ContraindicationA condition or factor that makes a particular procedure or route inadvisable because it could harm the patient or produce an inaccurate result.

Worked examples4

1. A patient's tympanic temperature reads 101.2 °F. The nurse asks you to re-check using the oral route. The oral reading is 100.8 °F. Which reading do you document, and how do you write each on the flow sheet?
  1. Document both readings because each was taken and each reflects a different route and time.
  2. For the tympanic reading, write: T(tym) 101.2 °F, followed by the time taken and your initials.
  3. For the oral reading taken afterward, write on the next line (or next time column): T 100.8 °F, followed by the new time and your initials.
  4. Report both readings and the route difference to the nurse immediately because both values are above 100.4 °F, indicating fever.
Answer: Both readings are documented separately with route, value, time, and initials. Both are reported to the nurse because fever is present on both routes.
2. You count a patient's radial pulse and tally 23 beats in 30 seconds. The patient's rhythm is regular. What is the pulse rate you record?
  1. The standard technique requires counting for a full 60 seconds; however, if a 30-second count was taken (for practice understanding), the rate is calculated by multiplying the 30-second count by 2.
  2. 23 beats × 2 = 46 beats per minute.
  3. Note: Because the result of 46 bpm is below the normal adult range of 60–100 bpm, this is abnormal (bradycardia range) and must be reported to the nurse immediately.
  4. For documentation: P 46, regular — and notify the nurse before leaving the patient.
Answer: 46 beats per minute. Document P 46, regular, and report the low value to the nurse at once.
3. You are documenting five vital-sign readings on a paper flow sheet. One entry reads: temperature 98.2 °F oral, taken at 8:15 AM on 06/10/2025. Write the correct entry as it should appear on the flow sheet.
  1. Write the date in the required format: 06/10/2025.
  2. Write the time: 0815 (24-hour format) or 8:15 AM per facility policy.
  3. Write the abbreviation and value: T 98.2 °F (no route notation needed when oral is the default, but T(oral) is also acceptable and clear).
  4. Sign with your initials and title in ink directly after the entry or in the signature column.
Answer: 06/10/2025 | 0815 | T 98.2 °F | [initials/title] — all entries in ink, legible.
4. A patient had a stroke and cannot close her lips around a thermometer. She breathes through her mouth. Which temperature route should you use, and why?
  1. Oral route is contraindicated: the patient cannot keep her lips closed and is breathing through her mouth, both of which prevent an accurate oral reading.
  2. Tympanic route is appropriate if there are no ear contraindications (no drainage, no recent ear surgery, no canal blockage).
  3. Check the care plan and ask the nurse to confirm the preferred route before proceeding.
  4. If tympanic is approved, use the tympanic thermometer with a new speculum cover, pull the adult pinna up and back, seal the canal, and scan.
Answer: Use the tympanic route (after confirming with the nurse and care plan), because oral is contraindicated due to the patient's inability to maintain lip closure.
In class: Instructor live demonstration at the skills station: each temperature route is shown in real time on a manikin and a volunteer student; instructor narrates rationale for probe cover use, placement, hold time, and when each route is contraindicated · Paired practice: each student practices all three temperature routes and radial pulse on their lab partner at least twice per route, using a skills checklist to give peer feedback step by step · Documentation drill: students receive a set of five fictitious measurement results and transcribe them onto a paper vital-signs flow sheet using correct date/time format, correct abbreviations (T, P, R, BP, SpO2), and initials; instructor reviews for legibility and accuracy
Materials: Oral/axillary digital thermometers, tympanic thermometer with probe covers, disposable probe covers, watch or clock with second hand, paper vital-signs flow sheets, skills checklist (steps listed per state CNA exam task list), Mosby's Textbook for Nursing Assistants Chapter on vital signs
Check: Instructor observes each student perform one complete oral temperature and one radial pulse using the skills checklist; student must complete all critical steps (hand hygiene before and after, correct placement, 60-second pulse count, accurate reading, correct documentation) with zero critical-step omissions and 80% of total steps correct

Practice check8

Answer each question, then check it. Nothing is recorded; this is your own practice.

Basic Nursing Skills – Vital Signs
1. When measuring an oral temperature, where should the nursing assistant place the thermometer probe?
Basic Nursing Skills – Vital Signs
2. A nursing assistant is preparing to take an axillary temperature. The patient's axilla feels damp with perspiration. What should the nursing assistant do before placing the thermometer?
Basic Nursing Skills – Vital Signs
3. Which of the following patients is MOST appropriate for a tympanic temperature measurement?
Basic Nursing Skills – Vital Signs
4. Why should a nursing assistant use the pads of the index and middle fingers—not the thumb—when palpating a radial pulse?
Basic Nursing Skills – Vital Signs / Patient Safety
5. A student nursing assistant counts 18 beats in a 60-second radial pulse count. The rhythm is regular. What should the student do next?
Basic Nursing Skills – Documentation
6. On a paper vital-signs flow sheet, the nursing assistant notices she wrote 'T 97.6' in the wrong patient's column. What is the correct way to correct this error?
Basic Nursing Skills – Vital Signs
7. A nursing assistant is about to measure a tympanic temperature on an adult patient. Before inserting the probe, what must she do to the ear pinna?
Infection Control / Basic Nursing Skills
8. Which action by a nursing assistant BEST demonstrates understanding of infection control during vital-signs measurement?
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