Basic Nursing Skills and Vital Signs
Vital signs basics
Temperature, pulse, respirations, blood pressure, and pain are the core measurements. Know the adult norms: oral temperature about 97.6-99.6°F, pulse 60-100 beats per minute, respirations 12-20 per minute, and blood pressure around 120/80. Report anything outside the resident's usual range promptly and record the exact numbers.
Technique points
Wait 15-20 minutes after hot or cold drinks or smoking before an oral temperature. Avoid rectal temperatures with diarrhea, rectal surgery, or per policy with cardiac conditions. Count respirations without telling the resident, since people change breathing when they know. Count an irregular pulse or respiration for a full minute; otherwise 30 seconds times two is acceptable. Radial pulse is at the thumb side of the wrist. Take blood pressure with the cuff at heart level and the correct cuff size, and avoid an arm with an IV, dialysis fistula, or on the side of a mastectomy. Pulse oximetry measures oxygen saturation; report low readings and check for a cold or polished nail interfering.
Measurements and applications
Weigh residents at the same time of day on the same scale. Measure intake and output in milliliters (1 ounce = 30 mL, 1 cup = 240 mL). When applying heat or cold, check the skin frequently, place a barrier between the device and skin, and limit time per policy.
Traps
Examiners like the number that should be reported rather than recorded and forgotten, and the resident whose pulse was taken right after ambulation. Also watch for questions about choosing the wrong arm or the wrong cuff size.
Rule of thumb
Measure, compare to the resident's normal, record exactly, and report any meaningful change.