VS (Temp, Pulse, Resp, BP, O2 sat)

NCLEX Review Guide: Nursing Process & Vital Signs

Nursing Process

Five Steps of Nursing Process

Assessment: Collect subjective and objective data through observation, interview, and physical examination
Diagnosis: Analyze data to identify actual or potential health problems using NANDA-I approved nursing diagnoses
Planning: Establish priorities, set measurable goals, and develop interventions with specific timelines
Implementation: Execute the nursing care plan through direct care, teaching, and coordination
Evaluation: Determine effectiveness of interventions and modify care plan as needed

Memory Aid: ADPIE

Assess → Diagnose → Plan → Implement → Evaluate

Key Points

Assessment is ALWAYS the first step - never skip data collection
Goals must be SMART: Specific, Measurable, Achievable, Realistic, Time-bound
Evaluation leads back to assessment - it's a continuous cycle

Documentation Principles

Legal Documentation Standards

Document objectively using factual observations without personal opinions or judgments
Use chronological order with date, time, and signature on every entry
Never leave blank spaces - draw a line through unused areas to prevent tampering
Correct errors with single line through mistake, write "error" and initial - never use white-out

Critical Documentation Rule

If it's not documented, it's not done! This is a legal principle in healthcare.

Vital Signs Assessment

Temperature

Normal range: 96.8-100.4°F (36-38°C) orally
Fever: >100.4°F (38°C) - increases metabolic rate by 10% per degree
Route hierarchy for accuracy: Rectal > Tympanic > Oral > Axillary > Temporal

Temperature Routes Comparison

Route	Normal Range	Considerations
Oral	96.8-100.4°F	Wait 15 min after hot/cold intake
Rectal	97.8-101.4°F	Most accurate core temp
Axillary	95.8-99.4°F	Least accurate but safest

Pulse

Normal adult rate: 60-100 bpm at rest
Assess rate, rhythm, and quality - palpate for full 60 seconds if irregular
Apical pulse required for infants, cardiac patients, and before digoxin administration

Clinical Scenario

Patient has irregular radial pulse. What's your next action? Take apical pulse for full 60 seconds and assess pulse deficit.

Respirations

Normal adult rate: 12-20 breaths per minute
Observe rate, depth, rhythm, and effort without patient awareness
Count for 30 seconds and multiply by 2 if regular; full minute if irregular

Blood Pressure

Normal: <120/80 mmHg; Hypertensive crisis: >180/120 mmHg
Cuff size matters: width should be 40% of arm circumference
Position: arm at heart level, feet flat on floor, back supported

BP Categories Memory Aid

Normal: <120 AND <80
Elevated: 120-129 AND <80
Stage 1 HTN: 130-139 OR 80-89
Stage 2 HTN: ≥140 OR ≥90

Oxygen Saturation

Normal range: 95-100% for healthy adults
Critical threshold: <90% requires immediate intervention
Factors affecting accuracy: nail polish, poor circulation, carbon monoxide poisoning

Commonly Confused Points

Assessment vs Evaluation

Assessment	Evaluation
Initial data collection	Determining intervention effectiveness
Identifies problems	Measures goal achievement
First step of nursing process	Last step of nursing process

Subjective vs Objective Data

Subjective	Objective
Patient's statements ("I feel dizzy")	Observable/measurable (BP 90/60)
Symptoms	Signs
What patient tells you	What you observe/measure

Study Tips & Quick Checks

Vital Signs Memory Tricks

Temperature: "Fever = Fire" (>100.4°F)
Pulse: "60-100 beats, that's the treat"
Respirations: "12-20, that's plenty"
BP: "120/80 is great, don't be late"

Common Pitfalls to Avoid

Don't skip assessment - it's always the priority
Never document care before providing it
Don't use abbreviations that aren't approved
Remember: apical pulse before digoxin administration

Quick Self-Check

☐ Can you list the 5 steps of nursing process in order?
☐ Do you know normal ranges for all vital signs?
☐ Can you differentiate subjective from objective data?
☐ Do you understand proper documentation principles?

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VS (Temp, Pulse, Resp, BP, O2 sat)

NCLEX Review Guide: Nursing Process & Vital Signs

Nursing Process

Five Steps of Nursing Process

Memory Aid: ADPIE

Key Points

Documentation Principles

Legal Documentation Standards

Critical Documentation Rule

Vital Signs Assessment

Temperature

Temperature Routes Comparison

Pulse

Clinical Scenario

Respirations

Blood Pressure

BP Categories Memory Aid

Oxygen Saturation

Commonly Confused Points

Assessment vs Evaluation

Subjective vs Objective Data

Study Tips & Quick Checks

Vital Signs Memory Tricks

Common Pitfalls to Avoid

Quick Self-Check

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제안하기

컨텐츠 수정하기

VS (Temp, Pulse, Resp, BP, O2 sat)

NCLEX Review Guide: Nursing Process & Vital Signs

Nursing Process

Five Steps of Nursing Process

Memory Aid: ADPIE

Key Points

Documentation Principles

Legal Documentation Standards

Critical Documentation Rule

Vital Signs Assessment

Temperature

Temperature Routes Comparison

Pulse

Clinical Scenario

Respirations

Blood Pressure

BP Categories Memory Aid

Oxygen Saturation

Commonly Confused Points

Assessment vs Evaluation

Subjective vs Objective Data

Study Tips & Quick Checks

Vital Signs Memory Tricks

Common Pitfalls to Avoid

Quick Self-Check