Basic Nursing Skills Summary

Importance of Vital Signs Monitoring

• Monitor and report vital signs to ensure proper functioning of vital organs.

Vital Signs Definition

• Vital signs: Measurements of temperature, pulse, respiration, and blood pressure.

Reporting Changes

• Report the following to a nurse:
  • Fever
  • Abnormal respiratory or pulse rates
  • Blood pressure fluctuations
  • Unrelieved pain

Normal Ranges for Adult Vital Signs

• Temperature (°F): Oral: 97.6° - 99.6°, Rectal: 98.6° - 100.6°, Axillary: 96.6° - 98.6°
• Blood Pressure:
  • Normal: Systolic 90–119 mm Hg, Diastolic 60–79 mm Hg
  • Hypotension: Systolic < 90 mm Hg, Diastolic < 60 mm Hg
  • Elevated: Systolic 120–129 mm Hg, Diastolic < 80 mm Hg
  • Hypertension: Stage 1: Systolic 130–139 mm Hg, Stage 2: Systolic ≥ 140 mm Hg

Guidelines for Measuring Body Temperature

• Factors affecting temperature: age, illness, stress, environment, exercise, circadian rhythm.
• Precautions for oral temperature: Avoid if resident is unconscious, recently had oral surgery, etc.

Guidelines for Measuring Pulse and Respirations

• Pulse: Normal rate (adults) is 60-100 bpm. Affected by factors such as exercise, anxiety, heat.
• Respiration: Normal rate (adults) is 12-20 breaths/minute. Report irregularities.

Blood Pressure Measurement Guidelines

• Use equipment like sphygmomanometer and stethoscope.
• Measure correctly to avoid misinterpretation of readings. Do not measure on arms with medical equipment.

Pain Management Guidelines

• Pain monitoring is essential; subjective experience differs for each individual.
• Report any observations regarding changes in behavior or additional symptoms.

Warm and Cold Applications

• Heat: Relieves pain, reduces swelling, increases blood flow.
• Cold: Stops bleeding, reduces swelling and pain.

Safety Measures

• Ensure privacy and comfort for patients when taking measurements.
• Clean equipment between uses.

Documentation

• Accurately record measurements and observations promptly after assessments.