Midwife Licensure Exam Fundamentals of Care & the Health-Care Process — Vital Signs & Basic Physiologic MonitoringCheat Sheet
Cheat sheet for Midwife Licensure Exam Fundamentals of Care & the Health-Care Process — Vital Signs & Basic Physiologic Monitoring. Compact, printable, and organised around the concepts Professional Regulation Commission (PRC) — Board of Midwifery tests most frequently in the Midwife Licensure Exam 2026. Perfect for the week before exam day.
Exam context
For the Midwife Licensure Examination, Professional Regulation Commission (PRC) — Board of Midwifery tests Fundamentals of Care & the Health-Care Process under a "Core" label, with Vital Signs & Basic Physiologic Monitoring in the 3rd slot across 8 chapters. Midwife Licensure Exam candidates must clear the 75% weighted average cut on the 2026 paper, which draws about a meaningful share of Fundamentals of Care & the Health-Care Process questions. Date to watch: April and November 2026 (expected).
Vital Signs & Basic Physiologic Monitoring - Cheat Sheet
Your last-minute revision companion for vital signs assessment, normal ranges, deviations, and critical nursing interventions. This is exam-ready reference material organized for rapid recall during the final 30 minutes before the NLE.
Sections
Formulas
Formula
°F = (°C × 9/5) + 32
Meaning
°F = Fahrenheit; °C = Celsius
Watch Out
Do NOT confuse the order — multiply by 9/5 FIRST, then add 32. Reverse for Celsius: subtract 32, then multiply by 5/9.
When To Use
Convert between temperature scales on any NLE question
Formula
Fever pattern identification: Oral temp baseline ~36.5°C
Meaning
Normal adult oral temperature reference point
Watch Out
Remember: rectal is ~0.5°C HIGHER; axillary is ~0.5°C LOWER than oral — this is heavily tested.
When To Use
Use as anchor for calculating deviations and fever severity
Common Values
Value
36.5–37.5°C (average 37.0°C)
Symbol
T
Quantity
Normal adult oral temperature
Value
~37.5–38.0°C (0.5°C higher than oral)
Symbol
T_rectal
Quantity
Normal adult rectal temperature
Value
~36.0–36.5°C (0.5°C lower than oral)
Symbol
T_axillary
Quantity
Normal adult axillary temperature
Value
>41°C
Symbol
Danger zone
Quantity
Hyperpyrexia threshold
Value
<35°C
Symbol
T_hypo
Quantity
Hypothermia threshold
Value
4 grams/day
Symbol
Max_acetaminophen
Quantity
Paracetamol maximum daily dose (adult)
Section Title
Temperature Assessment & Management
Important Facts
- Normal adult oral temperature: 36.5–37.5°C (average 37.0°C); rectal ~0.5°C higher; axillary ~0.5°C lower.
- Hypothalamus is the body's thermostat; acts to restore temperature to set point.
- Three phases of fever: (1) Onset/Chill — shivering, vasoconstriction, pallor; provide warmth. (2) Plateau — sustained fever, flushed skin, thirst; increase fluids, cooling measures. (3) Defervescence/Crisis — diaphoresis, set point drops; monitor for dehydration.
- Fever patterns: Intermittent (fever then normal), Remittent (fluctuates but stays above normal), Relapsing (fever-free days in between), Constant (persistently elevated).
- Paracetamol (acetaminophen): Adult dose 500 mg–1 g every 4–6 hours; MAX 4 g/day (use lower max in hepatic disease).
- Tepid sponge baths use WARM water (~29–32°C), NOT cold or alcohol — cold causes shivering and vasoconstriction (counterproductive).
- Fever is NOT a disease — it is a symptom of infection, malignancy, or immune response; address underlying cause.
- Older adults and infants may have blunted febrile response — a normal temp does NOT rule out serious infection.
- Monitor for febrile seizures in children (usually 6 months–5 years); risk peaks at T >39°C; ensure airway safety.
- Circadian rhythm: Temperature is lowest in early morning (~6 AM) and highest in late afternoon/evening (~4–6 PM); account for timing when interpreting single readings.
Key Definitions
Term
Pyrexia/Fever (Hyperthermia)
Example
Patient with pneumonia presenting with T 38.8°C oral = moderate fever
Definition
Elevation of core body temperature above normal set point (>37.5°C oral); protective response to infection or pathology.
Term
Hypothermia
Example
Elderly patient exposed to cold environment, T 33.2°C rectal
Definition
Core body temperature <35°C; impaired thermoregulation; medical emergency if <30°C.
Term
Hyperpyrexia
Example
Child with meningitis, T 41.5°C — emergency intervention required
Definition
Dangerously high fever, typically >41°C; risk of febrile seizures and delirium.
Term
Diaphoresis
Example
Patient drenched in sweat as fever breaks — provide dry linens and fluids
Definition
Profuse sweating; occurs during defervescence (crisis/flush phase) of fever as set point normalizes.
Diagrams To Know
- Three phases of fever (Onset → Plateau → Defervescence) with nursing interventions for each
- Temperature conversion nomogram or mental anchor: 37°C = 98.6°F
Formulas
Formula
Pulse rate count: Regular pulse = count for 30 sec × 2; Irregular pulse = count for 60 sec × 1
Meaning
Counting method to determine beats per minute (bpm)
Watch Out
If ANY irregularity is detected, ALWAYS count for 60 seconds — do NOT use the 30-second shortcut.
When To Use
Every pulse assessment; irregular rhythms REQUIRE full 60-second count
Formula
Pulse deficit = Apical rate − Radial rate
Meaning
Difference indicates weak or ineffective cardiac contractions
Watch Out
Two nurses must count simultaneously — apical for 60 sec, radial for 60 sec; any deficit warrants investigation.
When To Use
Assess in atrial fibrillation, heart failure, or before giving digoxin
Formula
DIGOXIN RULE: Hold if apical pulse <60 bpm (adult); <90–100 bpm (infant per facility protocol)
Meaning
Critical safety parameter for cardiac glycoside administration
Watch Out
This is a direct-from-memory NLE question — ALWAYS count apical for 60 sec; if HR <60, HOLD and notify physician immediately.
When To Use
Before EVERY digoxin dose; count apical pulse for 1 FULL MINUTE
Common Values
Value
60–100 bpm
Symbol
HR
Quantity
Normal adult resting pulse
Value
120–160 bpm
Symbol
HR_neonate
Quantity
Normal newborn heart rate
Value
<60 bpm
Symbol
Critical
Quantity
Digoxin hold threshold (adult apical)
Value
<90–100 bpm (facility-specific)
Symbol
Critical_infant
Quantity
Digoxin hold threshold (infant apical)
Value
5–10 seconds (carotid or brachial)
Symbol
Assessment
Quantity
Cardiac arrest pulse check duration
Section Title
Pulse Assessment & Cardiac Monitoring
Important Facts
- Normal adult resting heart rate: 60–100 bpm; athletes may be 40–60 bpm.
- Newborn HR: ~120–160 bpm; decreases with age to adult values.
- Assess pulse at RADIAL (wrist) site most commonly; APICAL (listen at 5th ICS, midclavicular line) for accuracy and before cardiac drugs.
- Peripheral pulse sites: temporal, carotid, apical, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis.
- NEVER palpate BOTH carotids simultaneously — risk of decreasing cerebral blood flow.
- In cardiac arrest: palpate CAROTID pulse (adults); BRACHIAL pulse (infants) for 5–10 seconds.
- Pulse amplitude grading: 0 (absent), 1+ (weak/thready), 2+ (normal), 3+ (bounding), 4+ (full/strong).
- Assess pulse for RATE, RHYTHM (regular vs irregular), VOLUME (amplitude), and EQUALITY (compare left/right sides).
- Irregular pulses REQUIRE full 60-second count and apical assessment.
- Digoxin toxicity risk: Hold if apical HR <60 bpm; also monitor for nausea, vomiting, arrhythmias, visual disturbances (halo effect).
- Fever increases heart rate ~10 bpm per 1°C elevation.
- Medications: Beta-blockers LOWER HR; epinephrine/sympathomimetics RAISE HR.
Key Definitions
Term
Tachycardia
Example
Patient post-surgery with HR 118 bpm, BP dropping — assess for shock
Definition
Heart rate >100 bpm in adults; may indicate fever, anxiety, pain, hemorrhage, or cardiac pathology.
Term
Bradycardia
Example
Trained runner with resting HR 52 bpm = normal; bedridden patient with HR 48 bpm on digoxin — assess drug toxicity
Definition
Heart rate <60 bpm in adults; seen in athletes, hypothermia, hypothyroidism, or cardiac block.
Term
Pulse Deficit
Example
Apical rate 92, radial rate 78 = pulse deficit of 14 bpm (some beats too weak to palpate peripherally)
Definition
Difference between apical (auscultated) and radial (palpated) rates; indicates weak/uncoordinated contractions.
Term
Apical Pulse
Example
Listen at the point of maximal impulse (PMI); count 'lub-dub' as one beat for 60 seconds
Definition
Heart rate auscultated directly over the apex of the heart (5th intercostal space, midclavicular line); most accurate; required before digoxin.
Diagrams To Know
- Pulse sites on the body (9 peripheral sites plus apical location)
- 5th intercostal space location for apical pulse (PMI anatomy)
- Pulse amplitude grading scale (0–4+)
Formulas
Formula
Respiratory rate count: Regular breathing = count for 30 sec × 2; Irregular = count for 60 sec × 1
Meaning
Number of breaths per minute (breaths/min)
Watch Out
Count respirations IMMEDIATELY after taking pulse while keeping fingers on wrist — patient must NOT know you are counting.
When To Use
Every respiratory assessment; count DISCREETLY without patient awareness (awareness alters breathing)
Formula
Pulse oximetry (SpO₂) interpretation: Normal ≥95%; Hypoxemia <90% = INTERVENTION
Meaning
Percentage of hemoglobin saturated with oxygen
Watch Out
In COPD patients with CO₂ retention, target SpO₂ may be 88–92% to preserve hypoxic respiratory drive — do NOT automatically target 95%.
When To Use
Continuous monitoring in hospitalized patients; before/after procedures
Common Values
Value
12–20 breaths/min
Symbol
RR
Quantity
Normal adult respiratory rate
Value
30–60 breaths/min
Symbol
RR_neonate
Quantity
Normal newborn respiratory rate
Value
95–100%
Symbol
SpO₂
Quantity
Normal SpO₂ (room air, sea level)
Value
<90% SpO₂
Symbol
Critical
Quantity
Hypoxemia threshold
Value
88–92%
Symbol
SpO₂_COPD
Quantity
Target SpO₂ in COPD with CO₂ retention
Value
>20 breaths/min
Symbol
Abnormal
Quantity
Tachypnea threshold (adult)
Value
<12 breaths/min
Symbol
Abnormal
Quantity
Bradypnea threshold (adult)
Section Title
Respiration Assessment & Oxygen Saturation
Important Facts
- Normal adult respiratory rate: 12–20 breaths/min; count as one complete inspiratory-expiratory cycle.
- Newborn RR: ~30–60 breaths/min; decreases with age.
- Count respirations DISCREETLY — the moment a patient knows you are counting, breathing becomes voluntarily altered.
- Assess RATE, DEPTH (shallow vs deep), RHYTHM (regular vs irregular), and EFFORT (use of accessory muscles, retractions).
- Normal SpO₂ in healthy adults: 95–100% on room air; <90% = hypoxemia requiring intervention.
- COPD patients with chronic CO₂ retention: target SpO₂ = 88–92% ONLY — do NOT give high-flow O₂ (suppresses hypoxic respiratory drive).
- Breath sounds: Clear bilateral = normal; crackles (rales) = pulmonary edema/pneumonia; wheezes = obstruction/asthma; stridor = upper airway obstruction.
- Fever increases RR ~4 breaths/min per 1°C; pain and anxiety increase RR.
- Abnormal breathing patterns: Apnea (cessation), Tachypnea (>20/min), Bradypnea (<12/min), Cheyne-Stokes (alternating apnea/hyperpnea), Kussmaul (deep, sighing — DKA).
- Pulse oximetry limitations: Affected by poor perfusion, carbon monoxide poisoning, methemoglobinemia, dark skin pigmentation (older machines), and motion artifact.
- SpO₂ <90% is an URGENT finding — immediately assess airway, breathing, circulation; apply oxygen; notify physician.
- In end-of-life care, Cheyne-Stokes is expected and does NOT require emergency intervention.
Key Definitions
Term
Tachypnea
Example
Child with asthma exacerbation: RR 38 breaths/min + SpO₂ 88% = emergency
Definition
Rapid breathing >20 breaths/min in adults; indicates fever, hypoxia, pain, anxiety, metabolic acidosis.
Term
Bradypnea
Example
Post-operative patient on morphine: RR 8 breaths/min = respiratory depression risk; assess for hypoxemia
Definition
Slow breathing <12 breaths/min in adults; indicates CNS depression (opioids, sedatives), respiratory fatigue.
Term
Dyspnea
Example
Patient reports SOB with minimal exertion, SpO₂ 92%, RR 26 — evaluate for cardiac/pulmonary pathology
Definition
Subjective sensation of difficult or labored breathing; assess severity on 0–10 scale.
Term
Orthopnea
Example
Heart failure patient: 'I cannot sleep without 3 pillows' = orthopnea → fluid overload
Definition
Dyspnea when lying flat; relieved by sitting upright; classic sign of pulmonary edema or heart failure.
Term
Cheyne-Stokes Respiration
Example
Dying patient: 20 seconds of apnea, then 30 seconds of deep rapid breathing, repeat — normal in end-stage disease
Definition
Alternating pattern of apnea (no breathing) and hyperpnea (deep, rapid breathing); indicates serious illness, CNS dysfunction, or end of life.
Term
Kussmaul Respiration
Example
Uncontrolled diabetic patient with DKA: RR 32, deep sighing breaths, fruity breath odor (ketones)
Definition
Deep, rapid, labored breathing without dyspnea; pathognomonic for metabolic acidosis (especially DKA).
Term
Hypoxemia
Example
Post-operative patient: SpO₂ drops to 87% on room air → provide supplemental O₂, assess positioning
Definition
Inadequate oxygen in arterial blood; SpO₂ <90% or PaO₂ <60 mmHg; requires intervention.
Diagrams To Know
- Abnormal breathing patterns (visual comparison: Cheyne-Stokes vs Kussmaul vs Normal)
- Respiratory assessment flowchart (Rate → Depth → Rhythm → Effort → SpO₂)
Formulas
Formula
Blood Pressure Interpretation (American College of Cardiology/AHA current guidelines): Normal: SBP <120 AND DBP <80 | Elevated: SBP 120–129 AND DBP <80 | Hypertension Stage 1: SBP 130–139 OR DBP 80–89 | Hypertension Stage 2: SBP ≥140 OR DBP ≥90
Meaning
SBP = Systolic BP; DBP = Diastolic BP (in mmHg)
Watch Out
Different organizations (ACC/AHA vs older hypertension guidelines) have different thresholds — know BOTH current and classic definitions for exam.
When To Use
Interpret BP readings in clinical context; note: some older references cite ≥140/90 as hypertension — follow exam reference
Formula
Pulse Pressure = Systolic BP − Diastolic BP
Meaning
Difference reflects arterial compliance and cardiac function
Watch Out
Widened pulse pressure (>50 mmHg) seen in aortic regurgitation, hyperthermia, exercise; narrow pulse pressure (<20 mmHg) in cardiogenic shock, tamponade.
When To Use
Calculate to assess vascular elasticity; normal ~30–40 mmHg
Formula
Orthostatic Hypotension Criteria: SBP drop ≥20 mmHg OR DBP drop ≥10 mmHg on moving from lying to standing
Meaning
Positional blood pressure changes indicating inadequate cerebrovascular compensation
Watch Out
Symptoms (dizziness, syncope) may or may not accompany BP changes — assess both objective BP and subjective symptoms.
When To Use
Assess in elderly, post-operative, or volume-depleted patients; obtain readings supine, then 1–3 minutes standing
Formula
Mean Arterial Pressure (MAP) = (Systolic + 2×Diastolic) / 3
Meaning
Average pressure throughout cardiac cycle; MAP ≥65 mmHg required for organ perfusion
Watch Out
MAP <65 mmHg = inadequate tissue perfusion; indicates shock requiring intervention.
When To Use
Clinical settings (ICU); not typically required for NLE but useful concept
Common Values
Value
<120/80 mmHg
Symbol
BP_normal
Quantity
Normal adult BP (current guidelines)
Value
SBP 120–129 AND DBP <80 mmHg
Symbol
BP_elevated
Quantity
Elevated BP
Value
SBP 130–139 OR DBP 80–89 mmHg
Symbol
HTN_1
Quantity
Hypertension Stage 1 (current)
Value
SBP ≥140 OR DBP ≥90 mmHg
Symbol
HTN_2
Quantity
Hypertension Stage 2 (current)
Value
≥140/90 mmHg
Symbol
HTN_classic
Quantity
Hypertension threshold (older guideline)
Value
<90 mmHg systolic
Symbol
BP_low
Quantity
Hypotension threshold
Value
≥20 mmHg
Symbol
Orthostatic_SBP
Quantity
Orthostatic hypotension SBP drop
Value
≥10 mmHg
Symbol
Orthostatic_DBP
Quantity
Orthostatic hypotension DBP drop
Value
30–40 mmHg
Symbol
PP_normal
Quantity
Normal pulse pressure
Value
≥65 mmHg
Symbol
MAP_min
Quantity
Minimum MAP for organ perfusion
Value
SBP >180 OR DBP >120 mmHg
Symbol
Emergency
Quantity
Hypertensive urgency/emergency threshold
Section Title
Blood Pressure Assessment & Measurement Accuracy
Important Facts
- Normal adult BP: SBP <120 mmHg AND DBP <80 mmHg (newer guidelines); classic cutoff ≥140/90 mmHg for hypertension (older references).
- BP is regulated by: baroreceptors, renin-angiotensin-aldosterone system (RAAS), sympathetic/parasympathetic nervous system, blood volume, and peripheral vascular resistance.
- Measure BP with patient SEATED, back supported, feet flat on floor, arm at HEART LEVEL, rested ≥5 minutes, no talking, no caffeine/smoking 30 min prior.
- CUFF SIZE MATTERS: Too small → falsely HIGH reading; Too large → falsely LOW reading; bladder should encircle 80% of arm.
- DO NOT measure BP on: arm with IV, dialysis fistula, post-mastectomy side, or area of lymphedema.
- Systolic = force during ventricular contraction (top number); Diastolic = force during ventricular relaxation (bottom number).
- Pulse pressure (SBP − DBP) normal ~30–40 mmHg; reflects arterial compliance.
- Orthostatic hypotension: measure supine, then standing after 1–3 minutes; ≥20 mmHg SBP drop or ≥10 mmHg DBP drop = positive finding.
- Palpate systolic first to avoid auscultatory gap error: use radial pulse as reference, inflate 30 mmHg above palpated systolic, then listen.
- Korotkoff sounds: Phase 1 (first sound) = systolic; Phase 2–4 (muffling, softening); Phase 5 (disappearance) = diastolic.
- Common measurement errors: cuff too loose/tight, arm above/below heart, patient not rested, talking during measurement, deflating cuff too quickly.
- Arm positioning: above heart level → falsely LOW BP; below heart level → falsely HIGH BP.
- Systolic >180 mmHg or Diastolic >120 mmHg = Hypertensive urgency/emergency; notify physician immediately.
- Older adults: stiffer arteries → wider pulse pressure and greater orthostatic hypotension risk.
Key Definitions
Term
Hypertension
Example
Patient with three BP readings >140/90 over 3 weeks = diagnosed hypertension; start antihypertensive therapy
Definition
Persistently elevated blood pressure (Stage 1: ≥130/80 or ≥140/90 depending on guideline; Stage 2: ≥140/90); major cardiovascular risk factor.
Term
Hypotension
Example
Post-operative patient: BP drops from 128/76 to 88/52, lightheaded, pale, diaphoretic = shock; IV fluids/vasopressor needed
Definition
Systolic BP <90 mmHg or clinically significant drop from baseline; indicates inadequate perfusion if symptomatic.
Term
Orthostatic (Postural) Hypotension
Example
Elderly patient: lying BP 138/80, standing BP 116/70 = orthostatic hypotension; assist with ambulation, advise slow position changes
Definition
Drop in BP on assuming upright position (≥20 mmHg systolic or ≥10 mmHg diastolic); may cause syncope; common in elderly and volume depletion.
Term
Korotkoff Sounds
Example
Inflate to 200 mmHg, release slowly; first sound at 128 mmHg (SBP), last sound at 76 mmHg (DBP) = 128/76
Definition
Audible sounds heard via auscultation during BP measurement; first sound = systolic, disappearance = diastolic pressure.
Term
Auscultatory Gap
Example
Palpate radial pulse to estimate systolic first; inflate 30 mmHg above palpated systolic, then auscultate for true SBP
Definition
Temporary disappearance of Korotkoff sounds during deflation, risking underestimation of systolic BP; palpate before auscultating.
Diagrams To Know
- Proper BP measurement technique and patient positioning
- Cuff size selection chart (bladder encirclement 80% of arm circumference)
- Korotkoff sounds phases (I–V) during deflation
- Hypertension classification flowchart (Normal → Elevated → Stage 1 → Stage 2)
Formulas
Formula
Pain assessment mnemonic: PQRST | P = Provoking/Palliating | Q = Quality | R = Region/Radiation | S = Severity (0–10 scale) | T = Timing/onset
Meaning
Structured approach to comprehensive pain evaluation
Watch Out
Do NOT skip severity rating — use numeric 0–10, FACES (children), or FLACC (nonverbal) scale consistently.
When To Use
Document ALL dimensions of pain in patient's own words; use for every pain complaint
Formula
WHO Analgesic Ladder: Step 1 (Non-opioids: paracetamol, NSAIDs) → Step 2 (Weak opioids: codeine, tramadol) → Step 3 (Strong opioids: morphine, fentanyl) + Adjuvants at each step
Meaning
Escalating pain management strategy based on pain severity
Watch Out
Start at appropriate step based on pain severity; do NOT skip steps; add adjuvants (antidepressants, anticonvulsants) for neuropathic pain or to reduce opioid dose.
When To Use
Titrate analgesics from non-opioid to opioid based on pain severity and patient response
Common Values
Value
0
Symbol
NPS
Quantity
Numeric pain severity: No pain
Value
1–3
Symbol
NPS
Quantity
Numeric pain severity: Mild
Value
4–6
Symbol
NPS
Quantity
Numeric pain severity: Moderate
Value
7–9
Symbol
NPS
Quantity
Numeric pain severity: Severe
Value
10
Symbol
NPS
Quantity
Numeric pain severity: Worst pain imaginable
Value
500 mg–1 g
Symbol
Acetaminophen_dose
Quantity
Paracetamol single dose
Value
4 g/day
Symbol
Acetaminophen_max
Quantity
Paracetamol maximum daily dose
Value
<12 breaths/min
Symbol
Critical_RR
Quantity
Opioid-induced respiratory depression threshold
Value
0.4–0.8 mg IV/IM
Symbol
Naloxone
Quantity
Naloxone adult dose
Section Title
Pain — The Fifth Vital Sign
Important Facts
- Pain is subjective — ALWAYS believe the patient's report; do NOT minimize or question pain severity.
- Pain assessment tools: Numeric Rating Scale 0–10 (adults), FACES (children 3–8 years), FLACC (nonverbal infants/patients with cognitive impairment), Wong-Baker.
- Reassess pain 30–60 minutes after analgesic administration — document effectiveness and need for dose escalation.
- Paracetamol (acetaminophen): Adult 500 mg–1 g every 4–6 hours, MAX 4 g/day; contraindicated in severe hepatic disease; toxicity → liver necrosis.
- NSAIDs (ibuprofen, naproxen, ketorolac): Anti-inflammatory, analgesic; risk: GI ulceration, renal dysfunction, bleeding — contraindicated in renal failure, active GI bleeding, severe cardiovascular disease.
- Opioids: Morphine, fentanyl, codeine, tramadol; most effective for moderate-severe pain; respiratory depression = #1 serious adverse effect → monitor RR; naloxone is opioid antagonist/reversal agent.
- Opioid-induced respiratory depression: Monitor RR <12/min = urgent; administer naloxone 0.4–0.8 mg IV/IM; repeat every 2–3 minutes if needed.
- Non-pharmacologic pain management: Positioning, heat/cold therapy, massage, TENS, guided imagery, relaxation, distraction, music therapy, cognitive-behavioral techniques.
- Combination therapy: Pharmacologic + non-pharmacologic often more effective and allows lower analgesic doses.
- Adjuvant medications for neuropathic pain: Gabapentin, pregabalin, amitriptyline, duloxetine, carbamazepine.
- Pain-related NANDA diagnoses: Acute Pain, Chronic Pain; related to surgery, trauma, disease, inflammation, neuropathy.
- Nursing interventions: Assess pain PQRST systematically; administer analgesics promptly (do NOT undertreat); position for comfort; provide environmental comfort (quiet, cool); use therapeutic touch and distraction.
Key Definitions
Term
Pain (Definition per International Association for the Study of Pain)
Example
Patient with no visible injury but reports 8/10 pain = BELIEVE and TREAT; pain is real to the patient
Definition
Subjective sensory and emotional experience associated with actual or potential tissue damage; whatever the patient says it is, existing when the patient says it exists.
Term
Acute Pain
Example
Post-operative pain, acute myocardial infarction, trauma — resolves with healing
Definition
Protective, short-duration pain (minutes to <6 weeks) with identifiable cause; often has autonomic signs (↑HR, ↑BP, diaphoresis, anxiety).
Term
Chronic Pain
Example
Chronic low back pain, fibromyalgia, cancer pain — different management approach than acute pain
Definition
Persistent pain lasting >3–6 months beyond normal healing; lacks protective function; often accompanied by depression, sleep disturbance, decreased activity.
Term
Nociceptive Pain
Example
Post-surgical incision pain (somatic), pancreatitis (visceral)
Definition
Pain from tissue damage (somatic: musculoskeletal, integument; visceral: organs); responds well to NSAIDs and opioids.
Term
Neuropathic Pain
Example
Diabetic neuropathy, post-herpetic neuralgia, phantom limb pain — NSAIDs/opioids alone often ineffective
Definition
Pain from nerve injury or dysfunction (not caused by nociceptor activation); described as burning, tingling, 'electric'; requires adjuvants (gabapentin, pregabalin, amitriptyline).
Diagrams To Know
- WHO Analgesic Ladder (3-step escalation with examples)
- PQRST pain assessment framework
- Pain severity scales comparison (0–10, FACES, FLACC)
Common Values
Value
120–160 bpm
Symbol
HR_neonate
Quantity
Newborn heart rate
Value
30–60 breaths/min
Symbol
RR_neonate
Quantity
Newborn respiratory rate
Value
100–160 bpm
Symbol
HR_infant
Quantity
Infant (6 months) heart rate
Value
90–150 bpm
Symbol
HR_toddler
Quantity
Toddler (1–3 years) heart rate
Value
80–120 bpm
Symbol
HR_preschooler
Quantity
Preschooler (3–6 years) heart rate
Value
70–110 bpm
Symbol
HR_schoolage
Quantity
School-age (6–12 years) heart rate
Value
>37.2°C oral or any elevation above baseline
Symbol
Elderly_fever
Quantity
Fever threshold in older adults (increased risk)
Section Title
Vital Signs in Special Populations & Documentation
Important Facts
- Infants and children: Assess respirations and APICAL pulse FIRST before disturbing child (distress elevates all vital signs); count for FULL MINUTE.
- Newborn HR: 120–160 bpm; increases with crying/feeding; baseline must be measured at rest.
- Newborn RR: 30–60 breaths/min; count for 60 seconds; normal to have brief apneic pauses <10 seconds.
- Pediatric BP: Lower than adults; varies by age and height; use pediatric cuff appropriately sized.
- Older adults: Stiffer arteries → wider pulse pressure; increased risk of orthostatic hypotension; blunted febrile response to infection.
- Older adults temperature: May not mount typical fever response (no temp >38°C) even with serious infection → look for subtle signs: confusion, weakness, incontinence.
- Chronic illness: Compare current vital signs to patient's OWN BASELINE, not population norms — an HR of 50 is normal for an athlete but concerning for a previously healthy adult.
- Document vital signs with ROUTE/SITE: 'T 38.2°C oral,' 'HR 92 apical,' 'BP 142/88 right arm, sitting,' 'SpO₂ 96% RA (room air)'.
- Record date, time, and CONTEXT (before/after medication, activity, or procedure).
- Plot values on graphic chart to show TRENDS — rising HR + RR with falling BP and SpO₂ = early warning of deterioration; escalate immediately.
Key Definitions
Term
Pediatric vital signs (general pattern)
Example
Neonate HR 140 bpm, RR 40/min, BP 65/40; 8-year-old HR 90 bpm, RR 20/min, BP 105/60
Definition
Heart rate, respiratory rate, and blood pressure decrease with age toward adult values; infants have highest rates, older children approach adult norms by puberty.
Term
Fever assessment in older adults
Example
Elderly nursing home resident with 'normal' oral temp 37.1°C but altered mental status, confusion → assume infection; culture and treat empirically until ruled out
Definition
Older adults often have blunted febrile response; a 'normal' temperature may mask serious infection; oral temp >37.2°C or any temp elevation above baseline warrants investigation.
Diagrams To Know
- Pediatric vital signs by age (table format: age groups with expected HR, RR, BP ranges)
- Documentation format example with correct terminology
Must Remember
- ADULT VITAL SIGN NORMALS: Temperature (oral) 36.5–37.5°C; Pulse 60–100 bpm; Respiration 12–20 breaths/min; BP <120/<80 mmHg; SpO₂ 95–100% — these are the absolute baseline you MUST know for every NLE question.
- TEMPERATURE CONVERSION ANCHOR: 37°C = 98.6°F; remember this one conversion to derive others using the formula °F = (°C × 9/5) + 32.
- RECTAL ≈ +0.5°C; AXILLARY ≈ −0.5°C COMPARED TO ORAL — this is heavily tested; know that rectal is most accurate, axillary is safest.
- APICAL PULSE + DIGOXIN RULE: ALWAYS count apical pulse for 1 FULL MINUTE before administering digoxin; HOLD if <60 bpm (adult) and notify physician immediately — this is a direct safety rule tested on the NLE.
- IRREGULAR PULSE = 60-SECOND COUNT: Never use the 30-second shortcut for irregular rhythms; you MUST count the full minute and consider apical assessment for accuracy.
- SpO₂ <90% = HYPOXEMIA = INTERVENTION: Immediately assess airway, provide oxygen, and notify physician — this is an urgent clinical finding. Exception: COPD patients may target 88–92% to preserve hypoxic respiratory drive.
- ORTHOSTATIC HYPOTENSION CRITERIA: SBP drop ≥20 mmHg OR DBP drop ≥10 mmHg when moving from lying to standing; measure supine then standing after 1–3 minutes; high fall risk in elderly.
- CUFF SIZE RULE: Too small = falsely HIGH BP; Too large = falsely LOW BP — this is a guaranteed NLE question; know proper sizing (bladder encircles 80% of arm).
- PAIN IS THE FIFTH VITAL SIGN AND IS SUBJECTIVE: Whatever the patient says it is, existing when the patient says it exists — BELIEVE and TREAT pain; use 0–10 scale (adults), FACES (children 3–8), FLACC (nonverbal).
- PARACETAMOL MAX DOSE: 4 g/day in adults (lower in hepatic disease); administered 500 mg–1 g every 4–6 hours — opioid-induced respiratory depression antidote is naloxone 0.4–0.8 mg IV/IM.
Last Minute Tips
- FEVER PHASES MATTER: The NLE will ask about nursing interventions for each phase (Onset = provide warmth; Plateau = increase fluids + cooling measures; Defervescence = monitor for dehydration). Know these cold.
- AUSCULTATORY GAP TRAP: If an NLE question mentions 'sounds disappear then reappear,' it's asking about auscultatory gap — ALWAYS palpate systolic first, inflate 30 mmHg above palpated systolic, then listen to avoid underestimating systolic BP.
- KUSSMAUL = ACIDOSIS (especially DKA): Deep, rapid, SIGHING breathing without dyspnea sensation in a patient with altered glucose or ABG = call this pattern by name; it's a guaranteed recognition question.
- CHEYNE-STOKES IN END-OF-LIFE: If the NLE presents a patient in palliative care with Cheyne-Stokes respiration, the correct answer is NOT to intervene with emergency measures — it's NORMAL and expected at end of life; reassure family.
- OLDER ADULTS + BLUNTED FEVER: An elderly nursing home resident with a 'normal' temperature (37.1°C) but acute confusion or weakness = assume infection (UTI, pneumonia) and treat empirically until ruled out; do NOT be reassured by the normal-looking temperature number.
Comparison Tables
Rows
Values
- 36.5–37.5°C (baseline)
- Non-invasive, convenient, comfortable, patient cooperative
- Contraindicated: altered LOC, oral surgery, chemotherapy mouth ulcers, NPO, seizure risk
- 3–5
Property
Oral
Values
- 37.5–38.0°C (~0.5°C higher)
- Most accurate core temperature, preferred in infants/children
- Invasive, embarrassing, contraindicated: rectal surgery/trauma, diarrhea, immunocompromised, prematurity (perforation risk)
- 2–3
Property
Rectal
Values
- 36.0–36.5°C (~0.5°C lower)
- Safest, non-invasive, preferred in newborns and unconscious patients
- Least accurate, affected by ambient temperature, requires 5–10 minute contact
- 5–10
Property
Axillary
Values
- ~Core temp (37.0–37.5°C)
- Rapid, non-invasive, approximates core temp, good for screening
- Affected by cerumen impaction, incorrect probe angle, environmental temperature, variable accuracy
- 1–2
Property
Tympanic/Temporal
Columns
- Route
- Temperature Range (°C)
- Advantages
- Disadvantages
- Timing (minutes)
Table Title
Temperature Routes — Comparison of Accuracy, Safety & Timing
Rows
Values
- Temperature alternates between fever and normal; spikes in morning/evening
- Tuberculosis, lymphoma, some bacterial infections
- Monitor for diaphoresis during crisis; provide warm covers during chill phase; monitor fluid intake/output
Property
Intermittent
Values
- Temperature fluctuates but stays above normal throughout day; never reaches baseline
- Acute bacterial infection (pneumonia, abscess), sepsis
- Continuous cooling measures; increased fluids; antipyretics as ordered; monitor for septic shock signs
Property
Remittent
Values
- Alternating febrile and afebrile days; fever-free period between 1–2 days
- Malaria, rat-bite fever, leptospirosis
- Educate patient about expected pattern; prevent dehydration during afebrile days; monitor for complications
Property
Relapsing (Tertian)
Values
- Temperature remains persistently elevated with minimal daily variation (<0.5°C)
- Typhoid fever, meningitis, acute streptococcal pharyngitis
- Aggressive cooling measures; frequent monitoring; prepare for potential complications (seizures, delirium); antipyretics as ordered
Property
Constant/Sustained
Columns
- Pattern
- Definition & Graph Appearance
- Clinical Examples
- Nursing Interventions
Table Title
Fever Patterns — Clinical Recognition & Nursing Response
Rows
Values
- Rapid breathing, >20 breaths/min (adult)
- Fever (+4 breaths/°C), hypoxia, pain, anxiety, acidosis, pulmonary embolism, asthma, pneumonia
- Assess SpO₂, oxygenation; position upright; provide O₂ if SpO₂ <90%; calm and reassure patient
Property
Tachypnea
Values
- Slow breathing, <12 breaths/min (adult)
- Opioid overdose, CNS depression, anesthesia, increased intracranial pressure, hypothermia, metabolic alkalosis
- URGENT: Assess level of consciousness, airway patency; prepare for naloxone if opioid-induced; check SpO₂; notify physician immediately
Property
Bradypnea
Values
- Alternating apnea (10–20 sec) then hyperpnea; crescendo-decrescendo pattern
- Heart failure, stroke, CNS injury, dying patient (normal in end-of-life care), severe hypoxia
- In acute setting: assess for shock, heart failure; arrange ICU monitoring. In palliative care: reassure family, do NOT intervene; expected finding
Property
Cheyne-Stokes
Values
- Deep, rapid, sighing breaths (may be >20/min); no dyspnea sensation
- Metabolic acidosis (DKA, uremia, lactic acidosis), sepsis, salicylate toxicity
- URGENT: Check blood glucose, ABG, serum ketones; prepare for IV fluids, insulin; notify physician; monitor closely for respiratory failure
Property
Kussmaul
Values
- Cessation of breathing; >10 sec constitutes clinically significant apnea
- Cardiac arrest, airway obstruction, medication overdose, CNS disorder, sleep apnea
- If cardiac arrest: initiate CPR, call code. If awake: assess airway, respiratory effort, oxygenation; prepare for intubation if needed
Property
Apnea
Columns
- Pattern
- Description & Rate
- Associated Conditions
- Nursing Action
Table Title
Abnormal Respiration Patterns — Recognition & Associated Conditions
Rows
Values
- Falsely HIGH systolic and diastolic
- Cuff bladder <80% arm circumference; using pediatric cuff on obese adult
- Select cuff appropriate for arm circumference; obese arm may need large/thigh cuff
Property
Cuff too small
Values
- Falsely LOW systolic and diastolic
- Cuff bladder >80% arm circumference; using adult cuff on thin child
- Right-size cuff; measure arm circumference if unsure
Property
Cuff too large
Values
- Falsely LOW reading
- Measuring with arm elevated on pillow above cardiac level
- Place arm at heart level (4th intercostal space, midaxillary line); support arm at same level as heart
Property
Arm above heart level
Values
- Falsely HIGH reading
- Measuring while arm hangs at side below cardiac level
- Support arm at heart level; sitting position with feet flat, back supported, arm at 90 degrees
Property
Arm below heart level
Values
- Loose: HIGH reading; Tight: LOW reading
- Not snug against skin; improper application
- Cuff should fit snugly with 1 finger space between cuff and arm; inflate smoothly
Property
Cuff too loose/too tight
Values
- Falsely HIGH reading (white coat effect)
- Conversation, stress, full bladder, physical discomfort
- Quiet environment, rest 5 minutes before measurement, empty bladder, reassure patient
Property
Patient talking/anxious
Values
- Falsely LOW diastolic; miss auscultatory gap
- Deflating >2 mmHg/second
- Deflate cuff slowly (~2 mmHg/second); do NOT rush; listen carefully throughout
Property
Deflating cuff too quickly
Values
- Underestimation of systolic pressure
- Korotkoff sounds disappear then reappear during deflation; not palpating first
- Always palpate systolic first using radial pulse; inflate 30 mmHg above palpated systolic; then auscultate
Property
Auscultatory gap (not recognized)
Columns
- Error Type
- Effect on Reading
- Cause/Example
- Correction
Table Title
Blood Pressure Measurement Errors — Common Mistakes & Correction
Rows
Values
- Cooperative adults and children >8 years
- Ask: 'On a scale of 0 to 10, where 0 is no pain and 10 is the worst pain imaginable, how much pain are you having?'
- Quick, reliable, quantifiable, allows trends, verbal expression
- Requires patient cooperation and cognitive ability; not suitable for nonverbal/very young
Property
Numeric Rating Scale (0–10)
Values
- Children 3–8 years, older adults with dementia, non-English speakers
- Show pictures of faces (smiling to crying) with number ratings; ask child to point to face matching their pain
- Visual, non-verbal, culturally accepted, validated in pediatrics, simple
- May not correlate with NPS in older children; interpretation varies; requires picture availability
Property
Wong-Baker FACES Scale
Values
- Nonverbal infants and children 2 months–7 years; cognitively impaired adults
- Observe 5 behavioral indicators, score 0–2 each; total 0–10 score = pain intensity
- Objective behavioral assessment, validated, no verbal ability needed, useful for sedated/intubated patients
- Requires trained observer, time-consuming, may be affected by pain medication, sedation, developmental stage
Property
FLACC Scale (Face, Legs, Activity, Cry, Consolability)
Values
- Post-operative neonates and infants <2 years
- Score 5 parameters (0–2 each); total 0–10 = post-op pain level
- Specific for post-operative pain in neonates, validated, includes vital signs component
- Limited to post-op setting, neonatal population only; time-intensive; requires vital sign data
Property
CRIES Scale (Crying, Requires O₂, Increased vital signs, Expression, Sleeplessness)
Columns
- Scale Name
- Age/Population
- How to Use
- Advantages
- Limitations
Table Title
Pain Assessment Scales — Appropriate Use by Age/Cognition
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