I have just begun nursing school and one of our assignments is to practice taking vitals and to document them correctly on our assignment to turn in. Does anyone have any advice on how to document the vital signs or a good resource that has an explanation? I know that for Blood Pressure I will need to document systolic/diastolic (plus any abnormalities); for pulse I will need to document the rate, rhythm and strength (plus any abnormalities); for respirations I will need to document the rate, rhythm, quality, and sounds (plus any abnormalities); and for temperature I will need to document the temp and the route taken. What I don't know if there is any particular order that I should use and if I'm missing anything. I've searched through my texts and so far all I can figure is that I just need to make sure that the things I've already mentioned are documented. I appreciate any advice or resources anyone can provide on this question. :)
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I have just begun nursing school and one of our assignments is to practice taking vitals and to document them correctly on our assignment to turn in. Does anyone have any advice on how to document the vital signs or a good resource that has an explanation? I know that for Blood Pressure I will need to document systolic/diastolic (plus any abnormalities); for pulse I will need to document the rate, rhythm and strength (plus any abnormalities); for respirations I will need to document the rate, rhythm, quality, and sounds (plus any abnormalities); and for temperature I will need to document the temp and the route taken. What I don't know if there is any particular order that I should use and if I'm missing anything. I've searched through my texts and so far all I can figure is that I just need to make sure that the things I've already mentioned are documented. I appreciate any advice or resources anyone can provide on this question. :)