Vital Signs, Observation, and Reporting
Measuring vital signs
Typical adult ranges to know: temperature about 97.6 to 99.6 F orally, pulse 60 to 100 beats per minute, respirations 12 to 20 per minute, and blood pressure around 120 over 80, with pain as the fifth vital sign rated 0 to 10. For an oral temperature, wait 15 minutes after hot or cold drinks or smoking. Count the pulse for 30 seconds and multiply by two, or a full minute if it is irregular, and never use your thumb. Count respirations without telling the resident, keeping your hand on the wrist as if still counting the pulse. For blood pressure, use the correct cuff size, support the arm at heart level, and keep the resident quiet.
Observation
Objective information is what you can see, hear, smell, or measure; subjective is what the resident tells you. Observe skin, breathing, appetite, urine, stool, mood, mobility, and mental status, and compare with what is usual for that resident. Report immediately for chest pain, difficulty breathing, sudden confusion, bleeding, fainting, fever, a fall, or severe pain.
Documentation and reporting
Chart promptly, objectively, in black ink, with date, time, and signature. No erasures or white-out; correct with a single line, initials, and date. Never chart for someone else, never chart before care is given, and never chart opinions such as "resident seems fine." Report to the nurse, not to housekeeping or the family.
Rule of thumb
If it would change what the nurse does in the next hour, report it now rather than at the end of the shift.