Basic Nursing Skills and Vital Signs
Numbers to know
Temperature: about 97.6–99.6°F orally; report above 100.4°F. Pulse: 60–100 beats per minute in adults; report below 60 or above 100. Respirations: 12–20 per minute; report below 12 or above 20. Blood pressure: about 120/80; report a systolic under 90 or a significant change from baseline. Pain is the fifth vital sign - ask and record it.
Skills and traps
Count respirations without announcing it; a resident who knows is being counted will change the rate. Count a full 60 seconds if the rhythm is irregular. Do not take an oral temperature on an unconscious, confused, or mouth-breathing resident or one who has just had hot or cold fluids; use another route. The radial pulse is at the wrist on the thumb side; count 30 seconds and multiply by two when regular, a full minute when irregular. Orthostatic blood pressure: measure lying, then sitting, then standing. A drop of 20 mmHg systolic or 10 mmHg diastolic on standing is significant, and the resident is a fall risk. Weight: same scale, same time of day, same clothing, recorded in the facility's unit.
Rule of thumb
Compare every reading with the resident's usual baseline, not just the textbook range. A pulse of 58 in a fit older adult who is always 58 may be normal; a jump from 72 to 110 is not.
Worked example
You count a pulse of 48 and the resident is dizzy. Do not simply record it. Leave the resident seated or lying safely, stay with them, and report the rate and the symptom to the nurse immediately.