Patient Care Fundamentals

Normal adult resting ranges: pulse 60-100 bpm, respirations 12-20 breaths/min, oral temperature about 98.6°F (37°C), and blood pressure below 120/80 mmHg.

A pulse oximetry (SpO2) reading of 95-100% is normal on room air; readings below 90% indicate hypoxemia and require prompt reporting.

Count an irregular pulse or respirations for a full 60 seconds; a regular radial pulse may be counted for 30 seconds and multiplied by 2.

The apical pulse is auscultated at the fifth intercostal space, left midclavicular line, and is the most accurate site for irregular rhythms.

Check orthostatic vital signs lying, then sitting or standing; a drop of 20 mmHg systolic or 10 mmHg diastolic suggests orthostatic hypotension.

High-Fowler's position (head of bed 60-90 degrees) eases breathing; supine is flat on the back, prone is face-down, and lateral is side-lying.

Apply a gait belt snugly around the waist over clothing before transferring or ambulating a weight-bearing patient; never place it under the arms or around the neck.

A patient holds a cane on the strong side, opposite the weak leg, moving the cane and weak leg forward together.

Dangle the legs at the bedside before ambulating a patient on bed rest to prevent dizziness from orthostatic hypotension.

Perform passive range-of-motion exercises slowly through the normal range, stopping at pain or resistance, to prevent contractures.

If a patient becomes dizzy or begins to fall, ease them to the floor or a chair using the gait belt, protect the head, and stay with them.

Reposition immobile patients at least every 2 hours to relieve pressure over bony prominences such as the sacrum, heels, and hips.

A Stage 1 pressure injury is intact skin with non-blanchable redness; report it immediately and relieve pressure.

Provide perineal care front to back on female patients to avoid moving bacteria toward the urethra, using a clean section of cloth each stroke.

Give oral care to unconscious patients in a side-lying position with the head turned to prevent aspiration.

Check bath water temperature (about 100-105°F) with a thermometer or inner wrist before the patient enters to prevent scald burns.

Intake includes oral fluids, IV fluids, and foods liquid at room temperature (gelatin, ice cream); output includes urine, emesis, liquid stool, and drainage.

Convert household measures for I&O: 1 ounce equals about 30 mL and 1 cup (8 oz) equals about 240 mL.

Keep the urinary drainage bag below the level of the bladder and off the floor to prevent backflow and infection.

Feed patients with dysphagia sitting fully upright at 90 degrees, placing food on the stronger side, and keep them upright at least 30 minutes after eating.

Honor NPO orders strictly (no food, fluids, or ice chips); explain the reason and report requests to the nurse.

Restorative care promotes the highest possible level of independence; encourage patients to do as much self-care as they safely can.

Encourage fluids, fiber-rich foods, and activity as allowed to support normal bowel elimination and relieve constipation.

Measure daily weights at the same time each day, ideally before breakfast, using the same scale and similar clothing.

Support proper body alignment and pad pressure points such as the hip, shoulder, and ankles in the lateral position.