Lesson 2: Fundamentals of Nursing Care & Vital Signs 🩺

Introduction

Welcome to the core of nursing practice! As an LPN/LVN, you'll spend significant time assessing patients through vital signs (VS) monitoring. This isn't just about recording numbers—it's about recognizing patterns, identifying when a patient is deteriorating, and knowing what to do about it. On the NCLEX-PN, you'll face scenarios where vital signs tell a story, and you must choose the priority action based on those clues.

This lesson builds on your understanding of scope of practice from Lesson 1. Now we'll focus on the "how" and "why" of fundamental nursing assessments and interventions. 🎯

---

Core Concepts: The Vital Signs Framework 📊

What Are Vital Signs and Why Do They Matter?

Vital signs are physiological measurements that reflect the body's most essential functions. They include:

• Temperature (T) 🌡️
• Pulse (P) 💓
• Respirations (R) 🫁
• Blood Pressure (BP) 🩸
• Pain (considered the "5th vital sign") 😣
• Oxygen Saturation (SpO₂) 💨

💡 Think of vital signs as your patient's "dashboard"—just like a car's speedometer and fuel gauge warn you of problems, vital signs alert you to physiological changes before they become critical.

Normal Adult Ranges (Know These Cold!) 📋

⚠️ NCLEX TIP: Pediatric and geriatric ranges differ! Infants have higher pulse/respirations, elderly may have lower baseline temps.

---

Temperature: The Body's Thermostat 🌡️

Thermoregulation is the body's ability to maintain core temperature. Deviations indicate infection, inflammation, or environmental exposure.

Key Terms:

• Afebrile: No fever (normal temperature)
• Febrile: Fever present (typically >100.4°F/38°C)
• Pyrexia: Medical term for fever
• Hypothermia: Dangerously low body temperature (<95°F/35°C)
• Hyperthermia: Dangerously high body temperature (>105°F/40.5°C)

Temperature Sites & Accuracy:

Site	Accuracy	When to Use	When to AVOID
Rectal	Most accurate core temp	Infants, unconscious patients	Rectal surgery, neutropenia, diarrhea
Oral	Accurate if done correctly	Alert, cooperative adults	Mouth breathing, recent hot/cold intake, O₂ mask
Tympanic (ear)	Quick, fairly accurate	Fast screening	Ear infection, impacted cerumen
Axillary (armpit)	Least accurate (-1°F from oral)	When other routes contraindicated	When precision critical
Temporal (forehead)	Quick, non-invasive	Children, screening	Sweating, environmental heat

💡 Nursing Judgment: A patient post-bowel surgery with fever? Use oral or axillary, NOT rectal (risk of perforation).

Fever Phases & Nursing Care:

FEVER PROGRESSION

Phase 1: ONSET (Chills)
    ↓
    🥶 Patient feels cold
    ↓
    Shivering, blanket requests
    ↓
    🧥 Nursing Action: ADD blankets, warm fluids

Phase 2: PLATEAU (Fever peak)
    ↓
    🔥 Temperature elevated
    ↓
    Patient hot, flushed
    ↓
    🌡️ Nursing Action: Monitor, antipyretics if ordered

Phase 3: DEFERVESCENCE (Fever breaks)
    ↓
    💧 Diaphoresis (sweating)
    ↓
    Risk of dehydration
    ↓
    🧊 Nursing Action: REMOVE blankets, cool cloths, fluids

⚠️ Common Mistake: Giving blankets during defervescence! The patient is sweating and cooling down—don't trap heat.

---

Pulse: The Heart's Rhythm 💓

Pulse reflects heart rate and rhythm. You're assessing:

• Rate: Beats per minute (bpm)
• Rhythm: Regular vs. irregular
• Quality: Strong (bounding) vs. weak (thready)

Pulse Abnormalities:

• Tachycardia: >100 bpm (causes: fever, anxiety, hypovolemia, hypoxia)
• Bradycardia: <60 bpm (causes: athletic conditioning, beta-blockers, increased ICP)
• Irregular: Skipped beats or no pattern (atrial fibrillation common in elderly)

Pulse Sites & When to Use Them:

Site	Location	Best Use
Radial	Thumb side of wrist	Routine VS checks (most common)
Apical	5th intercostal space, midclavicular line (heart apex)	Irregular rhythms, cardiac meds, infants
Carotid	Neck, beside trachea	Emergencies (CPR pulse check)
Brachial	Inner elbow	Infants, blood pressure
Femoral	Groin	Lower extremity circulation assessment
Pedal (dorsalis pedis)	Top of foot	Peripheral vascular disease, diabetes monitoring

💡 NCLEX Strategy: If the question mentions "irregular pulse" or "cardiac medication" (digoxin, beta-blockers), you should count an apical pulse for a FULL MINUTE. Don't count for 15 seconds and multiply by 4—you'll miss irregularities!

The Apical-Radial Pulse (Pulse Deficit):

Some heartbeats don't generate enough force to create a peripheral pulse. This creates a pulse deficit:

Pulse Deficit = Apical Rate - Radial Rate

Example: Apical = 88 bpm, Radial = 76 bpm → Pulse deficit of 12

🩺 Procedure: Two nurses simultaneously count apical and radial for 1 minute. Report deficits >10 to the RN/provider.

---

Respirations: The Breath of Life 🫁

Respirations measure breathing rate, depth, and effort. Unlike pulse, patients can voluntarily control breathing, so count without them knowing (count immediately after pulse while still holding wrist).

Normal Breathing Characteristics:

• Rate: 12-20 breaths/minute (adult)
• Rhythm: Regular, even intervals
• Depth: Moderate chest rise
• Effort: Effortless, quiet, no accessory muscle use

Respiratory Abnormalities (Know These!):

Term	Definition	Possible Causes
Tachypnea	Fast breathing (>20/min)	Fever, anxiety, hypoxia, pain
Bradypnea	Slow breathing (<12/min)	Opioid overdose, increased ICP, sedation
Apnea	Absence of breathing	Airway obstruction, cardiac arrest
Dyspnea	Difficulty breathing (subjective)	Asthma, COPD, heart failure, anxiety
Orthopnea	Difficulty breathing when lying flat	Heart failure, COPD
Cheyne-Stokes	Cycles of deep/shallow, then apnea periods	End of life, increased ICP, stroke
Kussmaul	Deep, rapid, labored breathing	Diabetic ketoacidosis (DKA)

Oxygen Saturation (SpO₂) 💨

Pulse oximetry measures the percentage of hemoglobin saturated with oxygen:

• Normal: 95-100%
• Mild hypoxia: 91-94%
• Moderate hypoxia: 86-90%
• Severe hypoxia: <85% (CRITICAL—notify RN/provider immediately!)

⚠️ Factors Affecting Accuracy:

• Nail polish (remove or use earlobe/toe)
• Poor circulation (cold hands, peripheral vascular disease)
• Carbon monoxide poisoning (falsely high readings)
• Anemia (fewer red blood cells carrying O₂)

💡 NCLEX Pearl: SpO₂ <90% = Priority! This means inadequate oxygenation to tissues. Immediate interventions: raise HOB, give O₂ (if ordered), assess airway/breathing, notify RN.

---

Blood Pressure: The Force of Circulation 🩸

Blood pressure measures the force of blood against arterial walls during heart contraction (systolic) and relaxation (diastolic).

BP Categories (American Heart Association):

Category	Systolic	Diastolic
Normal	<120	AND <80
Elevated	120-129	AND <80
Hypertension Stage 1	130-139	OR 80-89
Hypertension Stage 2	≥140	OR ≥90
Hypertensive Crisis	>180	AND/OR >120

⚠️ Hypertensive Crisis = EMERGENCY! Risk of stroke, heart attack, organ damage. Notify provider immediately, stay with patient, recheck in 5 minutes.

Hypotension (Low BP):

• Systolic <90 mmHg or MAP <65 mmHg (Mean Arterial Pressure)
• Causes: Bleeding, dehydration, shock, medications (antihypertensives, vasodilators)
• Symptoms: Dizziness, fainting, confusion, cool/clammy skin

💡 Orthostatic Hypotension (Postural hypotension): BP drops ≥20 systolic or ≥10 diastolic when changing position (lying→sitting→standing). Common with bedrest, dehydration, certain meds. FALL RISK!

Proper BP Measurement Technique:

BLOOD PRESSURE MEASUREMENT CHECKLIST

✓ Patient rested 5 minutes before measurement
✓ Bladder empty (full bladder ↑ BP)
✓ Arm supported at heart level
✓ Feet flat on floor, legs uncrossed
✓ No talking during measurement
✓ Correct cuff size:
   - Width = 40% of upper arm circumference
   - Length = 80% of upper arm circumference
   - Too small cuff → falsely HIGH reading
   - Too large cuff → falsely LOW reading
✓ Cuff placed 1 inch above antecubital fossa
✓ Inflate 30 mmHg above palpated systolic
✓ Deflate 2-3 mmHg per second

⚠️ Common Mistakes:

1. Wrong cuff size (obese patients need large/thigh cuff)
2. Arm below heart level (falsely elevated reading)
3. Patient talking (increases BP)
4. Taking BP on mastectomy side or arm with IV/shunt (NEVER do this!)

---

Pain Assessment: The 5th Vital Sign 😣

Pain is subjective—"Pain is whatever the patient says it is, existing whenever they say it does." You cannot see pain on a monitor; you must believe the patient's report.

Pain Scales:

Scale	Population	How It Works
0-10 Numeric	Adults, older children	0 = no pain, 10 = worst imaginable
Wong-Baker FACES	Children 3+, non-verbal adults	6 faces from smiling to crying
FLACC	Infants, non-verbal	Face, Legs, Activity, Cry, Consolability (0-10)
PAINAD	Dementia patients	Breathing, Vocalization, Facial expression, Body language, Consolability

PQRST Pain Assessment Mnemonic 🧠

P - Provocation/Palliation: What makes it better/worse?
Q - Quality: Sharp, dull, burning, aching, stabbing?
R - Region/Radiation: Where is it? Does it spread?
S - Severity: Rate 0-10
T - Timing: When did it start? Constant or intermittent?

💡 NCLEX Strategy: Questions about pain management test your understanding that:

1. Assessment before intervention (always assess characteristics first)
2. Non-pharmacological interventions matter (positioning, ice/heat, distraction, relaxation)
3. Opioids require close monitoring (respiratory depression risk)
4. Pain medications given BEFORE painful procedures (premedicate!)

---

Priority Setting Using Vital Signs 🎯

On the NCLEX-PN, you'll get scenarios with multiple patients. Who do you see first? Use the ABC priority framework:

PRIORITY FRAMEWORK

   🔴 IMMEDIATE (Life-threatening)
        |
        A - Airway (obstructed, stridor)
        |
        B - Breathing (SpO₂ <90%, severe dyspnea, apnea)
        |
        C - Circulation (severe hypotension, hemorrhage, chest pain)
        |
   🟡 URGENT (Potential complications)
        |
        Pain (severe, uncontrolled)
        Abnormal VS (hypertensive crisis, high fever)
        |
   🟢 NON-URGENT (Stable)
        |
        Normal VS, routine care, patient teaching

---

Clinical Scenarios & Examples 🏥

Example 1: Recognizing Shock

Scenario: You're monitoring a post-operative patient who had abdominal surgery 6 hours ago. Initial VS: BP 128/76, P 72, R 16, T 98.2°F. Current VS: BP 92/58, P 118, R 24, T 98.0°F. The patient reports feeling "dizzy and thirsty."

Analysis:

• Decreasing BP (128→92 systolic) = hypotension
• Increasing pulse (72→118) = tachycardia (compensation)
• Increasing respirations (16→24) = tachypnea (compensation)
• Symptoms: dizziness, thirst (dehydration/hypovolemia)

Pattern Recognition: These are classic signs of hypovolemic shock (bleeding/fluid loss). The body compensates by increasing heart rate and respirations to maintain perfusion.

Priority Action:

1. Check surgical dressing for bleeding
2. Notify RN/provider immediately (potential hemorrhage)
3. Lay patient flat with legs elevated (modified Trendelenburg for shock)
4. Prepare for IV fluid bolus/transfusion

💡 Why not get more vital signs first? Because the PATTERN already indicates shock. Delaying notification risks patient deterioration.

---

Example 2: Respiratory Distress

Scenario: An elderly patient with COPD has these VS: BP 142/88, P 96, R 28, SpO₂ 86% on room air, T 99.1°F. The patient is using accessory muscles to breathe and appears anxious.

Analysis:

• SpO₂ 86% = severe hypoxia (critical finding!)
• R 28 = tachypnea
• Accessory muscle use = increased work of breathing
• Anxiety = common with hypoxia ("air hunger")

Priority Actions (in order):

1. Elevate head of bed (improve lung expansion)
2. Apply oxygen per protocol/standing orders (COPD patients typically need low-flow O₂, 1-2L)
3. Stay with patient, encourage pursed-lip breathing
4. Notify RN immediately
5. Reassess SpO₂ after interventions

⚠️ COPD Caution: High-flow O₂ can suppress the hypoxic drive in chronic COPD patients. Typically start low (1-3L nasal cannula) unless severely hypoxic.

---

Example 3: Fever vs. Hypothermia Decision

Scenario A: Pediatric patient with T 103.2°F (oral), flushed, lethargic.
Scenario B: Homeless patient brought in from cold weather, T 93.8°F (rectal), shivering, confused.

Which requires immediate intervention?

Answer: Both are urgent, but hypothermia (B) is more immediately life-threatening. Core temperature <95°F can cause cardiac arrhythmias and death.

Actions for Hypothermia (B):

• Remove wet clothing
• Apply warm blankets (start peripherally, not core—prevents "afterdrop" shock)
• Warm IV fluids if ordered
• Monitor cardiac rhythm (risk of ventricular fibrillation)
• Warm slowly (1-2°F per hour)

Actions for Fever (A):

• Antipyretics if ordered (acetaminophen, ibuprofen)
• Tepid bath (NOT ice bath—causes shivering, raises core temp)
• Encourage fluids
• Light clothing/bedding
• Monitor for febrile seizures (common in children)

💡 Key Difference: Hypothermia affects cardiac function immediately. High fever, while serious, has more time before critical complications (seizures typically >105°F).

---

Example 4: Medication and Vital Signs

Scenario: You're preparing to administer digoxin 0.125 mg PO to a heart failure patient. Standing orders state: "Hold if apical pulse <60 or >100."

You count the apical pulse for 1 minute: 58 bpm, regular rhythm.

What do you do?

Correct Action: Hold the medication and notify the RN/provider. Digoxin slows heart rate; giving it when pulse is already bradycardic (<60) could cause dangerous further slowing or heart block.

Documentation: "Digoxin 0.125 mg PO held per protocol. Apical pulse 58 bpm, regular. RN Smith notified at 0900."

⚠️ NEVER give a medication outside parameters without provider clarification, even if the patient took it yesterday. Vital signs change!

---

Common Mistakes to Avoid ⚠️

---

Priority & Delegation with Vital Signs 👥

As an LPN/LVN, you can:

• ✅ Obtain vital signs on stable patients
• ✅ Report abnormal findings to RN
• ✅ Reinforce teaching about BP monitoring

You cannot:

• ❌ Perform initial admission assessment (RN role)
• ❌ Independently change care plan based on VS (must report to RN)
• ❌ Make medical diagnoses ("This patient has sepsis")—you report findings

You can delegate to UAP/CNA (Unlicensed Assistive Personnel):

• ✅ Routine VS on stable patients
• ✅ Recording intake/output
• ✅ Positioning patients

You cannot delegate to UAP:

• ❌ Initial VS on new admission
• ❌ VS on unstable/critical patients
• ❌ Interpreting abnormal findings
• ❌ Any assessment requiring nursing judgment

💡 Delegation Rule of Thumb: UAP can do tasks that are predictable, routine, and on stable patients. If critical thinking is needed, it's YOUR responsibility.

---

Key Takeaways 🎓

---

Mnemonic Device: TEMP for Fever Assessment 🧠

T - Temperature measured accurately (correct site/method)
E - Etiology (infection? inflammation? heat exposure?)
M - Medications (antipyretics ordered? Timing of last dose?)
P - Prevent complications (febrile seizures in kids, dehydration)

---

Quick Reference Card 📋

---

📚 Further Study Resources

1. American Heart Association - Understanding Blood Pressure Readings
   https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings

2. CDC - Measuring Vital Signs (Healthcare Providers)
   https://www.cdc.gov/nchs/nhanes/measuring_guides/vitals/manual_pulse.pdf

3. RegisteredNursing.org - Vital Signs NCLEX Review
   https://www.registerednursing.org/nclex/vital-signs/

---

Ready to apply your knowledge? Let's test your critical thinking with realistic NCLEX-style scenarios! 💪🩺