Chapter 1 of 528% of exam

Patient Care: Vital Signs, Intake, and Direct Assistance

Patient care is the single largest domain on the CCMA exam and covers everything you do in the exam room: measuring vital signs, collecting a history, positioning and draping, moving patients safely, and caring for wounds. Learn the normal adult ranges cold, because most questions ask whether a value or a technique falls inside or outside them.

Vital signs and normal adult ranges

Vital signs are the objective baseline measurements taken at nearly every visit: temperature, pulse, respirations, blood pressure, and often pulse oximetry and pain. A medical assistant measures and records them accurately but does not interpret them or diagnose from them. Your job is to recognize a value outside the expected range and report it to the provider before the patient leaves the room.

Adult oral temperature
Average 98.6 degrees F (37 degrees C), with a normal range of roughly 97.0 to 99.0 degrees F. Rectal readings run about 1 degree higher and axillary readings about 1 degree lower than oral.
Adult resting pulse
60 to 100 beats per minute. Below 60 is bradycardia and above 100 is tachycardia. Count a regular pulse for 30 seconds and double it, but count an irregular pulse for a full 60 seconds.
American Heart Association
Adult respirations
12 to 20 breaths per minute. Count them without telling the patient, because awareness changes the breathing rate, and remember that one respiration equals one full inhalation plus exhalation.
Blood pressure categories
Normal is less than 120/80 mmHg, elevated is 120 to 129 systolic with diastolic under 80, stage 1 hypertension is 130 to 139 or 80 to 89, and stage 2 is 140/90 or higher.
ACC/AHA Hypertension Guideline
Cuff size changes the reading
The inflatable bladder should cover about 80 percent of the arm circumference, with a width near 40 percent. A cuff that is too small falsely raises the reading and one that is too large falsely lowers it.
American Heart Association
Pulse oximetry
Normal oxygen saturation on room air is 95 to 100 percent. Nail polish, artificial nails, cold fingers, and poor perfusion all produce falsely low or unreadable results.

Patient intake, history, and the chief complaint

Intake begins with correct patient identification and ends with a clean, usable record for the provider. You gather the chief complaint, the history of present illness, current medications, allergies, and pertinent past history. Everything you write must be objective, dated, and attributable to you.

Two patient identifiers
Verify identity with two identifiers such as full name and date of birth before any specimen collection, medication, or procedure. A room number or bed location is never an acceptable identifier.
The Joint Commission National Patient Safety Goals
Chief complaint in the patient's own words
Record the chief complaint briefly and in quotation marks using the patient's own language, such as burning when I urinate for three days, rather than substituting a diagnosis like dysuria or urinary tract infection.
Subjective versus objective data
Subjective data is what the patient reports and cannot be measured, such as nausea, dizziness, or pain. Objective data is what you can measure or observe, such as a temperature of 101.4 degrees F or visible swelling.
Medication reconciliation
List every medication with name, dose, route, and frequency, including over-the-counter products, vitamins, and herbal supplements, because these interact with prescription drugs.
Allergies must include the reaction
Document what the substance is and what it did, for example penicillin causing hives and throat swelling. Flag allergies prominently in the chart so the provider sees them before prescribing.
Ask open-ended questions
Use open-ended prompts such as tell me about the pain during history taking, and avoid leading questions that suggest an answer. Reserve closed yes or no questions for confirming specific details.

Assisting with the physical exam and patient positioning

You prepare the room, position and drape the patient, hand instruments to the provider, and stay available for chaperone and safety needs. Choosing the correct position is a frequently tested skill because each exam type has a standard position. Always drape so that only the area being examined is exposed.

Supine and dorsal recumbent
Supine is flat on the back and is used for general, chest, and abdominal exams. Dorsal recumbent is supine with knees flexed and feet flat, used for abdominal or genital exams when the patient cannot tolerate lithotomy.
Lithotomy
The patient lies supine with feet in stirrups and buttocks at the table edge, which is the standard position for pelvic exams and Pap collection. Drape in a diamond shape and never leave the patient alone in this position.
Sims position
Left lateral with the left leg slightly flexed and the right knee drawn up toward the chest, used for rectal exams, enemas, and rectal temperature.
Fowler's variations
High Fowler's is roughly 90 degrees, standard Fowler's is 45 to 60 degrees, and semi-Fowler's is 30 to 45 degrees. Any Fowler's position eases breathing and is preferred for patients in respiratory distress.
Prone and Trendelenburg
Prone is face down and is used for exams of the back and posterior legs. Trendelenburg tilts the head lower than the feet and is used in some shock states and abdominal procedures.
Draping and privacy
Expose only the area under examination, keep the drape in place while the patient moves, and knock before entering. Patients should be given time and privacy to change into a gown.

Ambulation, transfers, and fall prevention

Moving a patient safely protects the patient from falls and protects you from a back injury that can end your career. Use a gait belt, plan the move before you start, and always tell the patient what you are going to do and count out loud. Never lift a patient under the arms, because that can dislocate a shoulder or injure the brachial plexus.

Gait belt technique
Apply the belt snugly around the waist over clothing with two fingers of space, and grasp it underhand from below. Never pull a patient up by the arms or under the axillae.
Body mechanics
Stand with feet shoulder-width apart, bend at the knees and hips rather than the waist, keep the load close to your body, and pivot with your feet instead of twisting your spine.
Transfer toward the strong side
Position the wheelchair on the patient's stronger side, lock both brakes, and raise or remove the footrests before any transfer.
Cane and walker rules
A cane is held on the strong side and advanced together with the weak leg. With a walker the patient moves the walker first, then the weak leg, then the strong leg.
Crutch fitting
The axillary pad should sit two to three finger widths below the armpit, with the elbows flexed about 20 to 30 degrees. Weight rests on the hands, not the armpits, to avoid nerve damage.
If a patient starts to fall
Do not try to hold the patient upright. Widen your stance, pull the patient toward your body, and ease them slowly to the floor while protecting the head, then call for help and do not move them until they are assessed.

Wound care and dressing changes

Medical assistants clean wounds, change dressings, assist with suture and staple removal, and teach patients home care. Open wounds require sterile technique, and any change in drainage or appearance of infection must be reported. Documentation should describe size, location, drainage, and the patient's response.

Phases of wound healing
Healing proceeds through the inflammatory phase with redness and swelling, the proliferative phase where granulation tissue forms, and the maturation or remodeling phase where scar tissue strengthens over months.
Clean from clean to dirty
Wipe from the center of the wound outward, or from the least contaminated area to the most contaminated, and use a new sterile gauze for each stroke. Never return a used swab to the wound.
Signs of wound infection
Report increasing redness, warmth, swelling, worsening pain, purulent drainage, foul odor, red streaking, or fever, because these indicate infection rather than normal healing.
Drainage terminology
Serous drainage is clear and watery, sanguineous is bright red blood, serosanguineous is thin and pink, and purulent is thick and opaque, often yellow or green, indicating infection.
Sterile field integrity
The outer one inch of a sterile field is considered contaminated, anything below waist level or out of your line of sight is contaminated, and moisture soaking through a sterile drape contaminates the field.
Pressure injury staging
Stage 1 is intact skin with nonblanchable redness, stage 2 is partial-thickness loss with a shallow open ulcer, stage 3 extends into subcutaneous fat, and stage 4 exposes muscle, tendon, or bone.
National Pressure Injury Advisory Panel
Test your knowledge
Practice questions on Patient Care: Vital Signs, Intake, and Direct Assistance
Practice now →
Next →
Clinical Procedures: Injections, EKG, Phlebotomy, and Instrument Processing

Last updated: July 2026

Report