Basic Nursing Skills: Measuring, Observing, Reporting
What you must understand
Vital signs are the backbone of this domain: temperature (oral, axillary, tympanic, temporal, rectal), pulse (rate, rhythm, force), respirations (rate, depth, rhythm, effort), blood pressure, and oxygen saturation by pulse oximetry. Know which route suits which resident - oral temperatures are unsafe for a resident who is confused, coughing, or likely to bite, and rectal temperatures are avoided with diarrhea or recent rectal surgery. Count respirations without announcing it; people change their breathing when they know they are being watched. Blood pressure technique matters: correct cuff size, arm supported at heart level, and repeat an abnormal reading before you report it.
Also in this domain: height and weight (same scale, same time of day, shoes off), intake and output in milliliters, and specimen collection - clean-catch midstream urine, first-morning sample when ordered, stool and sputum specimens handled as infectious material.
Traps that show up on questions
- Confusing what the aide may do (gather, measure, observe, report) with what the nurse does (interpret, decide, medicate).
- Believing that charting an abnormal value is the same as reporting it. It is not.
- Trusting a machine when the resident is cold, shivering, or moving.
- Recording guesses. If you did not measure it, you do not chart it.
Rule of thumb
Measure, compare against the resident's usual range, and tell the nurse immediately about any value outside that range or any change from the last reading. What you write in the chart is a record; what you say to the nurse is the intervention.