Basic Nursing Skills, Vital Signs, and Measurements
What you measure and what is normal
Temperature: oral about 98.6°F (37°C), axillary about one degree lower, rectal about one degree higher. Pulse: adult 60-100 beats per minute, regular and strong. Respirations: 12-20 per minute for adults. Blood pressure: normal below 120/80, with hypertension generally at 130/80 and above. Pulse oximetry: 95-100%. Pain is the fifth vital sign, and the resident's own report is the standard.
Technique points that show up on tests
Count respirations for a full minute without telling the resident, because awareness changes breathing. Take an apical pulse for a full minute with the stethoscope at the fifth intercostal space, left midclavicular line. Avoid an arm with an IV, dialysis fistula, mastectomy, or lymphedema for blood pressure, keep the cuff at heart level and correctly sized, and wait 15 minutes after smoking, eating, or exercise for an oral temperature. Do not take a rectal temperature with diarrhea, rectal surgery, or cardiac history.
Measurements and reporting
Record intake and output in milliliters (1 ounce = 30 mL). Weigh at the same time of day, on the same scale, in similar clothing. Report any value outside the ordered range, any change from baseline, chest pain, shortness of breath, or a resident who seems suddenly different.
Traps
Items that hide the requirement for a full-minute count, and items offering to wait and see instead of reporting an abnormal value.
Rule of thumb
Compare the reading to the resident's baseline and the ordered parameters, then report - the aide measures and reports; the nurse interprets.