Basic Nursing Skills and Observation
Know the numbers
Typical adult ranges: pulse 60–100 beats per minute, respirations 12–20 per minute, oral temperature about 98.6°F (37°C), blood pressure under 120/80, and oxygen saturation 95–100%. Pain is often called the fifth vital sign and is whatever the resident says it is. Count respirations without telling the resident, since breathing changes when people know it is being counted. Report a pulse deficit (apical minus radial), a blood pressure that drops when the resident stands (orthostatic hypotension), a temperature elevation, or any change from the resident's normal - report, do not diagnose.
Observation and reporting
Observation is objective (what you see, hear, smell, measure) versus subjective (what the resident tells you). Report immediately any change in mental status, breathing, skin color, intake and output, vomiting, bleeding, pain, or refusal of care. Measure intake and output accurately and record the time.
Charting rules
Chart promptly, factually, and objectively, in ink, with the time, your signature, and your title. Record only what you did or personally observed - never chart care you did not give or for another aide. Do not chart in advance, do not erase or use correction fluid, and do not chart by memory at the end of the shift. If you remember something later, follow facility policy for a late entry.
Rule of thumb: if it is new, worse, or worries you, report it now - the nurse, not the aide, decides what it means.