Basic Data Collection (Measurements and Vital Signs)

1. Height, weight, and temperature

Weight changes can signal fluid gain or loss, poor nutrition, or illness. Height and weight are measured with a standing scale (the resident stands) or a wheelchair scale (the resident is weighed while seated in the wheelchair, and the wheelchair's weight is subtracted). Accuracy matters because medications and nutrition are sometimes based on weight. Report sudden weight gain (possible fluid retention) or loss (possible under-nutrition).

Temperature reflects body heat. Normal average is about 98.6°F (37°C), with a normal oral range of roughly 97.6-99.6°F. Routes include oral (mouth), tympanic (ear), axillary (armpit), rectal (rectum), and temporal (forehead). The axillary route reads about one degree lower than oral, while rectal and tympanic read about one degree higher. A fever is a sign to report. Route choice and technique follow facility policy and nurse direction.

2. Pulse, respirations, and blood pressure

Pulse is the heartbeat felt in an artery. The radial pulse is felt at the wrist, and the apical pulse is heard at the chest with a stethoscope. Normal adult resting pulse is 60-100 beats per minute. The aide counts for a full 60 seconds to catch irregular rhythms, and reports a rate outside the normal range or an irregular rhythm. The apical pulse is used when the rhythm is irregular or the nurse directs it.

Respirations are breaths per minute. Normal adult breathing is 12-20 breaths per minute. The aide counts respirations discreetly — without letting the resident know — because people change their breathing when they are aware it is being watched. Report an abnormal rate, rhythm, depth, or difficulty (dyspnea).

Blood pressure has two numbers: systolic (pressure when the heart contracts) over diastolic (pressure when the heart relaxes). Normal is generally below 120/80 mmHg. Report readings outside the resident's usual range, or any reading the nurse or facility defines as concerning.

3. Pain, intake, and output

Pain is the "fifth vital sign" and is subjective — only the resident knows how it feels. The 0-10 scale rates pain from 0 (no pain) to 10 (worst pain imaginable). The Wong-Baker FACES scale uses pictures of faces from smiling to crying, which is useful for children and residents who cannot use numbers. Report new or worsening pain, and its location and character as the resident describes it.

Intake is everything that goes in (fluids, foods that melt, tube feedings); output is everything that comes out (urine, emesis, diarrhea, drainage). Volumes are recorded in milliliters (mL), and 1 ounce (oz) equals 30 mL. Urine output is measured by pouring it into a graduated container (a "graduate") and reading the level, then recording and reporting. Tracking intake and output helps detect dehydration or fluid overload.

How it works

1. The nurse directs which measurements are needed and how often.
2. The aide measures accurately using the appropriate equipment and route.
3. The aide records the value in the right place on the chart or flowsheet.
4. The aide compares the value to the resident's baseline and normal ranges.
5. The aide reports any change or abnormal value promptly.

Common confusions

Memory aids

Remember "T-P-R-BP-Pain" — Temperature, Pulse, Respirations, BP (blood pressure), Pain — the vital signs as commonly charted. Add the tag "1 oz = 30 mL" for intake and output.

Quick review

Topic Recap

The aide collects and reports baseline data — height, weight, temperature, pulse, respirations, blood pressure, pain, and intake/output — so the nurse can detect changes early. Normal adult ranges are temperature about 98.6°F (route-dependent), pulse 60-100 beats per minute, respirations 12-20 per minute, and blood pressure below about 120/80. Pain is subjective and is respected as the resident reports it. Intake and output are recorded in milliliters with 1 ounce = 30 mL, and urine output is measured in a graduate. Accuracy and prompt reporting — never guessing — are the aide's responsibilities.

Knowledge Check

1. What is the normal adult pulse range, and for how long should it be counted?
2. How many milliliters are in 2 ounces?
3. Why are respirations counted without the resident's awareness?
4. Name two temperature routes and how each compares to oral.
5. Which scale uses pictures of faces, and for whom is it useful?

Answers and Rationales

1. 60-100 beats per minute, counted for a full 60 seconds to detect irregular rhythms.
2. 60 mL, because 1 ounce equals 30 mL (2 x 30 = 60).
3. People change their breathing when they know it is being watched; counting discreetly gives a natural rate.
4. Axillary (about one degree lower than oral) and rectal or tympanic (about one degree higher than oral), among the routes; report which route was used.
5. The Wong-Baker FACES scale, useful for residents who cannot use a 0-10 number scale, such as children or non-verbal residents.