🩺 Nursing Notes

📋 Nursing Fundamentals

Core concepts, skills, and frameworks every nursing student must master.

Vital Signs

ParameterNormal Adult RangeCritical Values
Temperature36.1 – 37.2 °C (97 – 99 °F)<35 °C or >41 °C
Heart Rate60 – 100 bpm<40 or >150 bpm
Respiratory Rate12 – 20 breaths/min<8 or >30 breaths/min
Blood Pressure90–120 / 60–80 mmHgSBP <90 or >180 mmHg
SpO₂95 – 100 %<90 %

ADPIE Nursing Process

  1. Assessment – Collect subjective & objective data (health history, physical exam, diagnostics).
  2. Diagnosis – Identify nursing diagnoses using NANDA-I taxonomy (PES format: Problem, Etiology, Signs/Symptoms).
  3. Planning – Set SMART goals and expected outcomes; prioritize using Maslow's hierarchy.
  4. Implementation – Carry out interventions: independent, dependent, and collaborative.
  5. Evaluation – Compare outcomes to goals; revise plan as needed.

SBAR Communication

S
Situation

What is happening right now with the patient?

B
Background

Relevant history, diagnosis, medications, labs.

A
Assessment

Your clinical interpretation of the situation.

R
Recommendation

What action do you think should be taken?

Infection Control

  • Standard Precautions – Hand hygiene, PPE, safe sharps disposal; apply to ALL patients.
  • Contact Precautions – Gown + gloves; MRSA, C. diff, VRE.
  • Droplet Precautions – Surgical mask; influenza, pertussis, meningococcal disease.
  • Airborne Precautions – N95 respirator + negative-pressure room; TB, measles, varicella.
  • Hand Hygiene – Soap & water preferred for C. diff; alcohol-based hand rub for most others.

Maslow's Hierarchy in Nursing Priority

  1. Physiological – Airway, breathing, circulation, nutrition, elimination (always first).
  2. Safety & Security – Fall prevention, medication safety, infection control.
  3. Love & Belonging – Family support, therapeutic communication.
  4. Esteem – Patient autonomy, dignity, culturally sensitive care.
  5. Self-Actualization – Patient education, chronic disease self-management.