Basic Nursing Skills and Observation/Reporting
Skills and the numbers behind them
Vital signs are core exam territory. Temperature: know the routes and when oral is not appropriate (confusion, coughing, recent hot or cold fluids, oxygen by mask). Pulse: count 30 seconds and multiply by two if regular, a full minute if irregular; never use your thumb. Respirations: count without announcing it - residents change their breathing when they know; count 30 seconds and multiply by two, or a full minute if abnormal. Blood pressure: correct cuff size, arm supported at heart level. Pain is the fifth vital sign - ask the resident and use the scale. Also know pulse oximetry and weight (same scale, same time of day, shoes off).
Other skills - specimen collection, hot and cold applications, TED hose, catheter and ostomy care, enemas, oxygen, range of motion, ambulation with a gait belt - each has safety checkpoints. Remember the scope: a CNA does not assess, diagnose, give medications, or perform sterile procedures.
Observation and reporting
Separate objective data (what you see, hear, smell, measure) from subjective data (what the resident tells you). Report immediately: chest pain, difficulty breathing, sudden weakness or facial droop, change in level of consciousness, bleeding, any fall, fever, no urine output, vomiting, or a refusal that concerns you. Chart at the time of care, never in advance, and never for another person.
Traps the questions set
- "The resident seemed fine" is not charting.
- "I think she had a stroke" is a diagnosis, not an observation.
Rule of thumb
If it is new, sudden, or different from the resident's baseline, report it now - not at the end of the shift.