Nursing Fundamentals

Approximately 36.1°C to 37.2°C (97.0°F to 99.0°F). Average is 37.0°C (98.6°F). Values above 38.0°C (100.4°F) typically indicate fever.

12 to 20 breaths per minute. Bradypnea is below 12; tachypnea is above 20. Assess rate, depth, and rhythm for one full minute.

60 to 100 beats per minute. Bradycardia is below 60; tachycardia exceeds 100. Apical pulse should be assessed for one full minute.

Systolic below 120 mmHg and diastolic below 80 mmHg define normal. Elevated: 120–129/

Respirations, pulse, blood pressure, temperature, pain (often remembered by acronym). Respirations are counted first so patient does not consciously alter them.

Use the thigh or upper arm with an appropriately sized cuff. Width should be ~40% of limb circumference; length ~80%. Auscultate or use oscillometric device.

The percentage of hemoglobin saturated with oxygen (SpO2). Normal is 95–100%. It does not measure ventilation, so CO2 retention may still occur.

Count for one full minute (60 seconds) to detect dysrhythmias and accurately capture rate. Document rhythm, rate, and any deficits.

Measure BP and pulse with patient supine, then sitting, then standing—waiting 1–3 minutes between positions. Positive if SBP drops ≥20 mmHg or HR rises ≥20 bpm.

Subjective data is what the patient reports (symptoms, pain, feelings). Objective data is measurable/observable by the nurse (signs, vital signs, lab results).

Includes chief complaint, history of present illness, relevant body system review, vital signs, and targeted physical exam using inspection, palpation, percussion, auscultation.

P: Provocation/Palliation, Q: Quality, R: Region/Radiation, S: Severity (0–10), T: Timing (onset, duration, frequency). Guides comprehensive pain evaluation.