Basic Nursing Skills and Restorative Care
Measure carefully, restore actively
Vital signs: adult temperature 97.6–99.6 F orally; pulse 60–100 and regular; respirations 12–20; blood pressure under 120/80; oxygen saturation 95–100 percent. Count respirations for 30 seconds and double if regular, but do it without announcing it - people change their breathing when watched. Count an irregular pulse or respiration for a full minute. Report a pulse deficit, a systolic drop of 20 mm Hg or more on standing (orthostatic hypotension), or an SpO2 below the ordered threshold. Avoid taking blood pressure on an arm with a dialysis fistula, a mastectomy, or an IV, and use the correct cuff size. Do not take a rectal temperature on a resident with diarrhea, recent rectal surgery, or cardiac disease.
Intake and output: record every fluid in and out in milliliters, including ice chips, IV fluids, and urine in the catheter bag measured at the same time daily. Weigh on the same scale, same time, same clothing.
Restorative care means practicing function, not doing for: range-of-motion exercises within the ordered limits, stop at pain or resistance; ambulation with the ordered device and gait belt; splints and positioning to prevent contractures; bladder and bowel retraining with scheduled toileting; and prompting the resident to feed or dress themselves. Restorative programs are ordered by a therapist or nurse - do not invent exercises.
Traps. Counting respirations while telling the resident you are doing it; starting ROM past the point of pain; performing a skill outside your scope.
Rule of thumb. Count breathing quietly for 30 seconds and double it; stop range of motion at pain.