Basic Nursing Skills and Vital Signs
The vital signs
Temperature, pulse, respirations, blood pressure, and pain - with oxygen saturation often treated as a sixth. Know the adult norms: oral temperature 97.6–99.6°F; pulse 60–100 beats per minute and regular; respirations 12–20 per minute; blood pressure under 120/80; SpO2 95–100%.
Temperature: axillary is safest and reads about a degree lower; rectal is most accurate but is contraindicated with diarrhea, recent rectal surgery, or cardiac history; tympanic and temporal are quick alternatives.
Pulse: count the radial pulse for 30 seconds and multiply by 2 only if the rhythm is regular. Count a full minute if it is irregular. An apical pulse is heard at the fifth intercostal space, left midclavicular line, and is always counted for a full 60 seconds.
Respirations: count without announcing it, because awareness changes breathing. Count a full minute if irregular.
Blood pressure: use the correct cuff size, support the arm at heart level, and avoid an arm with an IV, dialysis fistula, mastectomy, or lymphedema. Report a systolic below 90 or above 180, or any major change from baseline.
Intake and output: 1 ounce = 30 mL and a standard cup = 240 mL. Read the graduate at eye level.
Traps
- Counting respirations for 15 seconds and multiplying.
- Taking a rectal temperature on a resident with heart disease.
- Charting a value you did not actually measure.
Rule of thumb
If a value is irregular or unexpected, count or measure for a full minute, then report it.