Basic Nursing Skills: Vital Signs, Positioning, Specimens, Wounds, and Catheters
What you must know
Vital signs: oral temperature roughly 97.6–99.6 F, radial pulse 60–100 beats per minute and regular, respirations 12–20 per minute, blood pressure below 120/80, and oxygen saturation 95% or higher. You measure and report; you do not interpret or decide treatment.
Positioning: supine, lateral, Sims (side-lying), Fowler's at 45–60 degrees, semi-Fowler's at about 30 degrees, prone, and Trendelenburg. Reposition at least every two hours and whenever the resident asks, keeping heels off the mattress and the body aligned.
Specimens: midstream clean-catch urine, 24-hour urine (discard the first void, then collect everything including the final void), sputum, stool. Label at the bedside, do not touch the inside of the container, and send promptly.
Wounds: you observe and report - drainage color, amount, odor, plus redness, swelling, warmth, or separation. Change only dressings that facility policy permits you to change.
Catheters: keep the bag below the level of the bladder and off the floor, keep tubing unkinked and free of tension, give perineal care, and empty the bag before it is full into a separate container.
Traps
- Wait about 15 minutes after a hot or cold drink and 30 minutes after smoking before taking an oral temperature. Avoid rectal temperatures with diarrhea or recent rectal surgery.
- Count respirations without telling the resident; people change their breathing when they know it is being counted.
- If a pulse, respiration, or rhythm is irregular or abnormal, count for a full minute.
Worked example
You count 9 respirations in 30 seconds. Multiply by 2 for 18 per minute - normal. But if the breathing looks shallow, irregular, or labored, start over and count the full minute, then report the character of the breathing as well as the number.