Basic Nursing Skills, Vital Signs, and Observation/Reporting
Know the numbers, then report the change
Normal adult ranges: temperature about 97.6–99.6°F orally, pulse 60–100 beats per minute and regular, respirations 12–20 per minute, blood pressure under about 120/80, and oxygen saturation 95–100% on room air. A single number matters less than a change from that resident's baseline.
Technique questions are common. Count respirations for a full minute - or 30 seconds times two if regular - without telling the resident you are counting, so breathing stays normal. Count an irregular pulse for a full minute. Take the blood pressure in the correct arm: avoid an arm with an IV, dialysis fistula, or on the side of a mastectomy. Report an orthostatic drop when you check lying, sitting, and standing pressures. Use the pain scale the resident can use, including faces or behavioral scales for residents with dementia.
Chart objectively and promptly: what you saw, heard, measured, and did - not opinions like "resident seems fine" or "was good today." Never chart before care is given. If you make an error, draw a single line through it, write "error," initial, and re-document per policy. Use a late entry if you remember something afterward.
Reporting is the heart of the job. Any change in condition - new confusion, refusal to eat, a fall, skin breakdown, abnormal vital sign, or complaint of pain - goes to the licensed nurse immediately, and you document what you found and whom you told. Reporting to a coworker instead of the nurse is a classic wrong answer.
Rule of thumb: a change from baseline goes to the nurse now, not at the end of the shift.