NLE Fundamentals of Nursing & the Nursing Process — Vital Signs & Basic Physiologic MonitoringRevision Notes

Exam tips

• NLE questions often ask WHEN to assess vital signs — memorize all five trigger situations.
• Remember: a TREND is more important than a single reading — watch for progressive changes.
• RA 9173 accountability context: the nurse is legally responsible for accurate assessment and timely reporting.

Key points

• Vital signs — Temperature (T), Pulse (P), Respiration (R), Blood Pressure (BP), and Pain — reflect the effectiveness of circulatory, respiratory, neural, and endocrine function.
• They are the first data collected during nursing assessment (Assessment phase of the Nursing Process).
• Assess vital signs on admission, before and after surgery or invasive procedures, before and after medications that affect CV/respiratory function, with any change in patient condition, and before and after nursing interventions affecting vital signs.
• Always compare readings to the PATIENT'S OWN BASELINE — not just population norms.
• Document route/site for each reading (e.g., T 38.2°C axillary, BP 130/84 right arm, sitting).
• A rising heart rate and respiratory rate with falling BP and SpO₂ is an EARLY WARNING of deterioration — escalate immediately.
• Under RA 9173, the nurse is responsible for accurate data collection and timely reporting of abnormal findings to the physician.

Definitions

Common mistakes

• Comparing vital signs ONLY to population norms without considering the patient's personal baseline.
• Forgetting to document the route or site of measurement (e.g., axillary vs. rectal temperature).
• Skipping vital sign assessment before giving cardiovascular or respiratory medications.

Formulas

Exam tips

• NLE CLASSIC QUESTION: Rectal is most accurate; axillary is safest. Know WHICH to use and WHY.
• Antipyretic first-line = PARACETAMOL; max adult dose = 4 g/day — this is frequently tested.
• Fever phases: ONSET = provide warmth (patient feels cold); COURSE = cooling measures + fluids; DEFERVESCENCE = monitor for dehydration.
• Temperature conversion is tested: memorize 37°C = 98.6°F and know the formulas.
• Circadian rhythm: body temperature is LOWEST at 4–6 AM and HIGHEST in late afternoon/evening (4–8 PM).

Key points

• Regulated by the HYPOTHALAMUS (thermoregulatory center).
• Normal adult oral temperature: 36.5–37.5°C (average 37.0°C = 98.6°F).
• Rectal temperature is ~0.5°C HIGHER than oral — most accurate for core temperature.
• Axillary temperature is ~0.5°C LOWER than oral — safest but LEAST accurate.
• Tympanic and temporal artery temperatures approximate core temperature.
• PYREXIA (fever) = elevated temperature; HYPERPYREXIA = >41°C (very dangerous).
• HYPOTHERMIA = core temperature below ~35°C.
• Four fever patterns: Intermittent, Remittent, Relapsing (recurrent), Constant/Sustained.
• Three phases of fever: ONSET (chill/cold phase), COURSE (plateau phase), DEFERVESCENCE (flush/crisis phase).
• Nursing management: tepid sponge bath (NOT cold water or alcohol — causes shivering/vasoconstriction), increase fluids, light clothing, administer antipyretics as ordered.
• PARACETAMOL (acetaminophen) is the FIRST-LINE antipyretic: 500 mg–1 g every 4–6 hours, max 4 g/day for adults (lower max in hepatic impairment).
• Factors: age (infants and elderly regulate poorly), circadian rhythm (lowest in early AM, highest late PM), exercise, hormones (ovulation raises), stress, environment.

Definitions

Common mistakes

• Using cold water or alcohol for sponge baths — this triggers shivering, which INCREASES heat production. Always use TEPID water.
• Not adjusting the paracetamol maximum dose for patients with liver disease.
• Confusing which route is higher/lower: Rectal = HIGHEST, Oral = MIDDLE, Axillary = LOWEST.
• Forgetting to specify the measurement route when documenting (axillary vs. oral vs. rectal changes the clinical interpretation).
• Missing that in the ONSET phase, the patient feels COLD (chills, shivering) — do NOT remove blankets prematurely; provide warmth during this phase.

Formulas

Exam tips

• DIGOXIN RULE is HEAVILY TESTED: Hold digoxin → apical HR <60/min adult → notify MD.
• Pulse deficit requires TWO nurses at the same time — one at apex, one at radial.
• APICAL pulse site = 5th ICS, LEFT midclavicular line — memorize the exact location.
• Fever effect on pulse: +1°C temperature = approximately +10 beats/min in pulse rate.
• Newborn pulse (120–160) is much higher than adult (60–100) — expect comparison questions.

Key points

• The pulse reflects CARDIAC OUTPUT and HEART RATE.
• The RADIAL pulse is the most common assessment site for adults.
• The APICAL pulse (5th intercostal space, left midclavicular line) is the MOST ACCURATE — use for infants, irregular rhythms, and before cardiac medications.
• Normal adult pulse: 60–100 beats/min; Newborn: 120–160 beats/min.
• TACHYCARDIA: >100 beats/min (adult); BRADYCARDIA: <60 beats/min (adult).
• Assess pulse for RATE, RHYTHM, VOLUME/AMPLITUDE, and bilateral equality.
• PULSE DEFICIT = apical rate minus radial rate; assessed by TWO nurses simultaneously; indicates weak/ineffective contractions.
• Amplitude grading: 0 = absent; 1+ = weak/thready; 2+ = normal; 3+ = bounding.
• NEVER palpate BOTH carotids simultaneously — risk of decreased cerebral perfusion.
• In cardiac arrest: assess CAROTID pulse in adults; BRACHIAL pulse in infants.
• Count REGULAR pulse for 30 seconds × 2; count IRREGULAR pulse for a FULL MINUTE.
• DIGOXIN RULE: Hold digoxin and notify MD if apical HR <60/min (adult) or <90–100/min (infant, per facility policy); ALWAYS count apical pulse for 1 full minute before giving digoxin.
• Fever RAISES pulse rate (~10 beats/min per 1°C rise in temperature); beta-blockers LOWER it.

Definitions

Common mistakes

• Counting an irregular pulse for only 30 seconds — always count for a FULL MINUTE when rhythm is irregular.
• Palpating both carotid arteries simultaneously — this can reduce cerebral blood flow.
• Forgetting to count the APICAL (not radial) pulse before giving digoxin.
• Giving digoxin when the apical pulse is <60/min in an adult — this is a HOLD and NOTIFY situation.
• Confusing the carotid (adult cardiac arrest) and brachial (infant cardiac arrest) pulse sites.

Exam tips

• KUSSMAUL = DKA/metabolic acidosis; CHEYNE-STOKES = serious illness/end-of-life/ICP — this pairing is classic NLE material.
• SpO₂ <90% = hypoxemia = ACT NOW. This threshold is frequently tested.
• COPD exception: SpO₂ target is 88–92% — giving too much O₂ can be harmful.
• Assess respirations WHILE APPEARING to still count the pulse — keep your fingers on the wrist so the patient does not realize you have moved to counting breaths.
• Respiratory rate is the MOST SENSITIVE early indicator of patient deterioration — a rising RR is a red flag.

Key points

• Assess rate, DEPTH, and RHYTHM — and assess WITHOUT the patient's awareness (count discreetly after taking the pulse while appearing to still count the pulse).
• Normal adult respiratory rate: 12–20 breaths/min; Newborn: 30–60 breaths/min.
• TACHYPNEA: >20 breaths/min (adult); BRADYPNEA: <12 breaths/min; APNEA: absence of breathing.
• DYSPNEA: labored/difficult breathing; ORTHOPNEA: dyspnea when lying flat (relieved by sitting up — HOB elevated).
• CHEYNE-STOKES: alternating cycles of apnea and hyperpnea — seen in serious illness, end-of-life, and increased ICP.
• KUSSMAUL: deep, rapid breathing — hallmark of metabolic acidosis, especially DIABETIC KETOACIDOSIS (DKA).
• Assess by observing chest rise and fall; one complete cycle = one inhalation + one exhalation = one breath.
• NORMAL SpO₂: 95–100%; SpO₂ <90% = hypoxemia → INTERVENE.
• COPD patients (chronic CO₂ retainers): target SpO₂ = 88–92% to avoid suppressing hypoxic drive.
• Pulse oximetry limitations: inaccurate with poor peripheral perfusion, dark nail polish, carbon monoxide poisoning.

Definitions

Common mistakes

• Alerting the patient that you are counting their breaths — conscious breathing alters the rate. Count discreetly.
• Giving high-flow oxygen to a COPD patient without a prescription — may suppress their hypoxic drive; target SpO₂ is 88–92% for known CO₂ retainers.
• Confusing Cheyne-Stokes (end-stage illness, ICP) with Kussmaul (DKA/metabolic acidosis) — they are distinct patterns with different causes.
• Counting one inhalation only as one breath — a complete breath = one inhale + one exhale.

Formulas

Exam tips

• CUFF SIZE memory aid: SMALL cuff = HIGH reading (overestimates); LARGE cuff = LOW reading (underestimates).
• ARM POSITION: At HEART LEVEL = accurate; BELOW heart = FALSELY HIGH; ABOVE heart = FALSELY LOW.
• ORTHOSTATIC HYPOTENSION threshold: SBP drop ≥20 OR DBP drop ≥10 on standing — memorize these numbers.
• Normal pulse pressure = 30–40 mmHg — widening or narrowing both indicate pathology.
• Do NOT measure BP on: IV arm, AV fistula arm, mastectomy side — all are NLE-tested contraindications.
• Auscultatory gap prevention: PALPATE systolic first, inflate 30 mmHg ABOVE palpated value, then auscultate.

Key points

• BP = Cardiac Output × Peripheral Vascular Resistance.
• NORMAL adult BP: systolic <120 mmHg AND diastolic <80 mmHg.
• ELEVATED: systolic 120–129 and diastolic <80.
• HYPERTENSION: persistently elevated; Stage 1 begins at 130/80 mmHg (current guidelines); classic NLE reference cites ≥140/90 mmHg — follow what the exam uses.
• HYPOTENSION: systolic <90 mmHg, or a clinically significant drop from baseline.
• ORTHOSTATIC (POSTURAL) HYPOTENSION: SBP drops ≥20 mmHg OR DBP drops ≥10 mmHg upon standing.
• PULSE PRESSURE = Systolic − Diastolic; normal range = 30–40 mmHg.
• Accurate technique: patient seated, back supported, feet flat on floor, arm at HEART LEVEL, rested 5 minutes, no caffeine or smoking beforehand.
• CUFF SIZE RULE: Cuff TOO SMALL = FALSELY HIGH reading; Cuff TOO LARGE = FALSELY LOW reading.
• Do NOT measure BP on an arm with IV line, dialysis fistula (AV fistula), or on the side of mastectomy.
• Arm BELOW heart level = FALSELY HIGH; arm ABOVE heart level = FALSELY LOW.
• KOROTKOFF SOUNDS: First sound heard = SYSTOLIC pressure; disappearance of sounds = DIASTOLIC pressure.
• AUSCULTATORY GAP: temporary disappearance of Korotkoff sounds; can cause underestimation of systolic — ALWAYS palpate the systolic first, then inflate 30 mmHg above it.
• Regulation: baroreceptors, renin-angiotensin-aldosterone system (RAAS), blood volume.

Definitions

Common mistakes

• Using a cuff that is too small for the arm — gives a FALSELY HIGH reading (biggest NLE trap for BP).
• Positioning the arm BELOW heart level — gives a FALSELY HIGH reading.
• Not palpating the systolic first — can miss the auscultatory gap and record a falsely LOW systolic.
• Measuring BP on the arm with an AV fistula — never do this; it can damage the fistula and give inaccurate results.
• Measuring BP immediately after exercise, stress, or caffeine intake without waiting 5 minutes of rest.
• Deflating the cuff too rapidly — can cause diastolic BP to be read too low.

Exam tips

• Pain is SUBJECTIVE — the NURSE MUST BELIEVE the patient. NLE questions will test if you would question or verify the patient's pain report. Always trust the patient.
• FLACC = infants/nonverbal; FACES (Wong-Baker) = children ≥3 years; NUMERIC 0–10 = adults — match the scale to the patient.
• WHO Ladder sequence: Paracetamol/NSAIDs → Weak opioids → Strong opioids — always start at the lowest effective step.
• Opioid + respiratory depression = NALOXONE (Narcan) is the antidote — this combination is frequently tested.
• Reassessment after analgesia is a nursing responsibility: 30–60 minutes after oral/parenteral analgesic.

Key points

• Pain is SUBJECTIVE: 'Whatever the patient says it is, existing whenever the patient says it does' (McCaffery).
• Pain must be assessed, BELIEVED, documented, and treated like any other vital sign.
• Use the PQRST or OLDCARTS mnemonic for pain assessment.
• Pain scales: 0–10 NUMERIC scale (adults/older children); WONG-BAKER FACES scale (children ≥3 years); FLACC scale (infants and nonverbal patients); PAINAD scale (cognitively impaired adults).
• ACUTE pain: protective, short-term, resolves with healing.
• CHRONIC pain: persists >3–6 months beyond normal healing; may have no identifiable physical cause.
• NOCICEPTIVE pain: somatic (sharp, well-localized) or visceral (dull, crampy, poorly localized).
• NEUROPATHIC pain: burning, shooting, or electric — caused by nerve injury (e.g., diabetic neuropathy, post-herpetic neuralgia).
• WHO ANALGESIC LADDER: Step 1 = Non-opioids (paracetamol, NSAIDs); Step 2 = Mild-moderate opioids (codeine, tramadol) + non-opioids; Step 3 = Strong opioids (morphine) + non-opioids ± adjuvants.
• Combine PHARMACOLOGIC and NON-PHARMACOLOGIC methods (positioning, relaxation, distraction, heat/cold, guided imagery, massage, TENS).
• REASSESS pain 30–60 minutes after analgesic administration.
• OPIOID RISK: respiratory depression — monitor RR; ANTIDOTE = NALOXONE (Narcan).
• The nurse MUST BELIEVE the patient's self-report of pain — it cannot be verified objectively.

Definitions

Common mistakes

• Doubting or dismissing the patient's pain report because no physical cause is visible — pain is SUBJECTIVE; the patient's self-report is the gold standard.
• Using the 0–10 numeric scale for nonverbal patients or infants — use FLACC for these populations.
• Forgetting to REASSESS pain after the analgesic has had time to work (30–60 minutes).
• Withholding analgesics due to fear of addiction — undertreated pain is unethical and a patient safety issue.
• Not monitoring respiratory rate after opioid administration — respiratory depression is the most dangerous opioid side effect.

Exam tips

• NLE TRICK: An afebrile elderly patient can still have a serious infection — the hypothalamus becomes less responsive with age.
• Infant cardiac arrest pulse site = BRACHIAL; Adult cardiac arrest pulse site = CAROTID.
• For elderly patients at risk for falls: ALWAYS instruct them to change position slowly and dangle feet before standing.

Key points

• INFANTS/NEWBORNS: Higher HR (120–160 bpm), higher RR (30–60 bpm), lower BP — assess RESPIRATION and APICAL pulse FIRST before disturbing the infant; count for a FULL MINUTE.
• OLDER ADULTS: May have BLUNTED febrile response (normal temp does NOT rule out infection); stiffer arteries cause wider pulse pressure; greater risk for orthostatic hypotension and falls.
• Children have HIGHER HR and RR and LOWER BP than adults — rates decrease progressively toward adult values with age.
• Always assess against the PATIENT'S OWN BASELINE — a temp of 37.8°C may be significant for a patient who normally runs 36.0°C.
• Elderly patients on antihypertensives are at HIGH RISK for orthostatic hypotension — instruct them to rise SLOWLY from sitting/lying to standing (dangle feet first).
• In infants, the BRACHIAL pulse is used to assess cardiac arrest (not the carotid).
• Pain assessment in pediatric and elderly patients requires age-appropriate and cognitive-status-appropriate tools (FLACC, FACES, PAINAD).

Common mistakes

• Assuming an elderly patient without fever has no infection — blunted febrile response means they may be severely infected with a normal temperature.
• Using the adult carotid pulse assessment technique in infants — always use the BRACHIAL site in infants for cardiac arrest assessment.
• Not dangling the feet before ambulating an elderly patient or anyone at risk for orthostatic hypotension.

Exam tips

• NLE documentation questions often test whether you know to include the route/site and clinical context for each vital sign.
• Early warning of deterioration: Rising HR + Rising RR + Falling BP + Falling SpO₂ — this pattern requires IMMEDIATE escalation.
• RA 9173 context: accurate documentation is a legal and ethical nursing responsibility under Philippine nursing law.

Key points

• Record EACH value with its ROUTE/SITE: e.g., 'T 38.2°C axillary,' 'P 96 apical regular,' 'BP 130/84 right arm sitting.'
• Document DATE, TIME, and relevant context (before/after activity, before/after medication).
• Plot values on GRAPHIC FLOW SHEET to visualize trends at a glance.
• REPORT ABNORMAL OR TRENDING VALUES IMMEDIATELY to the physician/senior nurse.
• Recognize early deterioration pattern: rising HR + rising RR + falling BP + falling SpO₂ = ESCALATE NOW.
• Under RA 9173, the nurse is professionally accountable for accurate documentation and timely reporting — failure to report abnormal VS is a breach of safe nursing practice.
• Pain documentation should include: scale used, score before and after intervention, and any non-pharmacologic measures applied.

Common mistakes

• Recording vital signs without specifying the route (e.g., writing 'T 38°C' without stating 'axillary' or 'oral').
• Delaying the reporting of abnormal vital sign trends — time-sensitive deterioration can be missed.
• Documenting only a single set of vital signs without noting the trend over time.