Assessment & Core Skills

Vital Signs

Know the normals and when to report abnormals.

Temperatureoral standard

97.8–99.1°F (36.5–37.3°C). Oral is standard. Rectal is most accurate (+1°F). Axillary is least accurate (-1°F). Tympanic = core temp.

Heart Rate (Pulse)60–100 bpm

Apical pulse for 1 full minute before digoxin. Radial is routine. Pedal pulse assessed for circulation.

Respiratory Rate12–20 breaths/min

Count for 1 full minute. Do NOT tell patient you're counting (they'll change their breathing).

Blood Pressure<120/80 mmHg

Cuff width = 40% of arm circumference. Too small cuff = false high reading. Too large = false low.

SpO₂95–100%

<90% = hypoxemia → administer O₂. COPD: target 88–92%. Remove nail polish for accurate reading.

Orthostatic Hypotension

A drop of ≥20 mmHg systolic or ≥10 mmHg diastolic when moving from lying → sitting → standing, with symptoms (dizziness, lightheadedness). Common with dehydration, antihypertensives, prolonged bed rest. Teach patients to rise slowly.

Pain Assessment

Pain is the 5th vital sign — the patient's self-report is the most reliable indicator.

Pain Assessment Tools

• Numeric Rating Scale (0–10): Standard for verbal adults
• Wong-Baker FACES: Children age 3+ and non-verbal adults
• FLACC: Infants and children under 3 (Face, Legs, Activity, Cry, Consolability)
• PAINAD: Dementia patients who cannot self-report

OLDCARTS Assessment

• Onset — when did it start?
• Location — where is the pain?
• Duration — how long does it last?
• Characteristics — sharp, dull, burning, aching?
• Aggravating factors — what makes it worse?
• Relieving factors — what makes it better?
• Treatment — what have you tried?
• Severity — rate 0–10

Non-Pharmacological Pain Interventions

• Repositioning, heat/cold therapy, elevation
• Distraction, guided imagery, deep breathing
• Massage (if not contraindicated)
• Music therapy, relaxation techniques

Patient Positioning

The right position for the right situation.

Fowler's (45–60°)

HOB elevated 45–60°. Used for cardiac/respiratory patients, eating, tube feeding.

High-Fowler's (60–90°)

HOB elevated 60–90°, nearly sitting. Used for severe respiratory distress, COPD, after thoracic surgery.

Semi-Fowler's (30–45°)

HOB elevated 30–45°. Used for post-op, GERD, increased ICP, tube feeding.

Supine (Dorsal)

Lying flat on back. Used for post-lumbar puncture, spinal anesthesia, CPR.

Prone

Lying face down. Used for ARDS, post-amputation (prevents hip contracture), back assessment.

Lateral (Side-lying)

On the side. Used for unconscious patient, seizure (recovery position), enema administration.

Sims'

Semi-prone (left side, right knee flexed). Used for rectal examination, enema, rectal temperature.

Trendelenburg

Head lower than feet. Used for shock (increase venous return), air embolism (left side + Trendelenburg).

Reverse Trendelenburg

Feet lower than head. Used to reduce ICP, promote venous drainage from head.

Lithotomy

On back, legs in stirrups. Used for pelvic exam, vaginal delivery, urinary catheter insertion.

Nutrition & Therapeutic Diets

Know which diet goes with which condition.

Low sodium (<2,000 mg)

Heart failure, HTN, renal disease, ascites. Avoid processed foods, canned soups, deli meats.

Low potassium

CKD, hyperkalemia. Avoid bananas, oranges, potatoes, tomatoes, avocados.

High potassium

Hypokalemia (loop diuretics). Eat bananas, oranges, potatoes, spinach.

Low protein

Hepatic encephalopathy, early CKD. Reduce ammonia production. May ↑ protein if on dialysis.

High protein

Wound healing, burns, dialysis. Meat, eggs, beans, dairy.

DASH diet

Hypertension. High fruits/veggies, low-fat dairy, low sodium.

Diabetic diet (consistent carb)

Diabetes. Consistent carb intake at each meal. Avoid simple sugars.

Low residue/low fiber

IBD flare, bowel obstruction, pre-op. Avoid raw fruits/veggies, whole grains, nuts, seeds.

Clear liquid

Post-op (first diet), bowel prep. Broth, Jell-O, clear juice, popsicles, tea. No milk, no pulp.

Dysphagia diet

Stroke, Parkinson's, elderly. Thickened liquids, pureed/mechanical soft foods. Upright during/after meals.

Tube Feedings (Enteral Nutrition)

Placement verification, aspiration prevention, and complications.

• Verify placement BEFORE every feeding: X-ray is gold standard (before first use). Check gastric aspirate pH (<5.5 = gastric). Auscultation is the LEAST reliable method.
• Elevate HOB 30–45° during feeding AND for 30–60 minutes after (prevents aspiration)
• Check gastric residual before intermittent feedings (hold if >250–500 mL per facility policy — return aspirate to stomach)
• Flush tube with 30 mL water before and after each feeding and medication
• For continuous feedings: hang formula for no more than 4–8 hours (bacteria growth). Change tubing every 24 hours.
• Do NOT add food coloring to formula (no longer recommended)
• Medications: crush separately, flush between each, never mix with formula. Check if medication can be crushed (no enteric-coated, sustained-release, or sublingual)

Complications

• Aspiration — #1 complication. Prevent with HOB elevation, placement verification, residual checks.
• Diarrhea — may indicate too fast a rate, formula intolerance, or contamination. Slow the rate.
• Clogged tube — flush with warm water. Do NOT use cranberry juice or cola (outdated practice).
• Dumping syndrome — give feeding at room temperature, avoid bolus feedings that are too fast.

Intake & Output (I&O)

What counts as intake, what counts as output, and when to monitor closely.

Intake Includes

• All oral fluids (water, juice, coffee, soup, ice cream, gelatin, popsicles)
• IV fluids, IV medications, blood products
• Tube feedings and flushes
• Ice chips (count as half the volume — 100 mL ice ≈ 50 mL water)

Output Includes

• Urine, emesis, diarrhea/liquid stool
• Drainage from NG tube, surgical drains (JP, Hemovac), chest tube, T-tube
• Wound drainage

Key Values

• Normal adult urine output: ≥30 mL/hr (≥0.5 mL/kg/hr)
• <30 mL/hr → possible renal impairment or dehydration → report to provider
• Average daily adult fluid intake: ~2,000–2,500 mL/day

Documentation

If it wasn't documented, it wasn't done.

• Document objectively and factually — what you see, hear, measure, and do. Avoid subjective opinions.
• Use quotes for patient statements: "I feel like my chest is tight."
• Document in real time (as close to the event as possible) — never pre-chart
• Use approved abbreviations only (follow facility policy and Joint Commission "Do Not Use" list)
• Late entries: document as "late entry" with the current date/time and reference the original event time
• Errors in documentation: draw a single line through the error, write "error," initial, date, and write the correct information. NEVER use white-out, scratch out, or erase.
• Incident/variance reports are NOT part of the medical record — they go to risk management for quality improvement.

Do Not Use Abbreviations (Joint Commission)

• U or u (units) → write "units"
• IU → write "international units"
• Q.D. / Q.O.D. → write "daily" / "every other day"
• Trailing zero (1.0 mg) → write "1 mg"
• Lack of leading zero (.5 mg) → write "0.5 mg"
• MS, MSO₄, MgSO₄ → write "morphine sulfate" / "magnesium sulfate"

Delegation & Scope of Practice

Know what the LPN can do, what the LPN cannot do, and what can go to a UAP.

LPN/LVN Scope of Practice

• CAN: Collect data (focused assessment), reinforce teaching, administer medications (PO, IM, SubQ — IV varies by state), perform wound care and dressing changes, monitor and report changes, perform sterile procedures (catheter insertion, sterile dressing changes), assist with ADLs, document, supervise UAPs
• CANNOT: Perform initial comprehensive assessment, create or modify the nursing care plan, provide initial patient education (can reinforce), administer IV push medications (in most states), receive phone orders (in many states — varies by state), triage, manage unstable patients independently

What Can Be Delegated to a UAP (CNA/Nursing Aide)

• CAN delegate: Bathing, feeding, ambulating STABLE patients, measuring vital signs (stable patients), I&O measurement, daily weights, specimen collection, bed making, toileting assistance, transport
• CANNOT delegate: Assessment, evaluation, patient teaching, medication administration, care of unstable patients, sterile procedures, any task requiring clinical judgment

The 5 Rights of Delegation

1. Right task — is it appropriate to delegate?
2. Right circumstance — is the patient stable enough?
3. Right person — is the UAP trained and competent for this task?
4. Right direction/communication — did you give clear instructions?
5. Right supervision/evaluation — did you follow up?

Body Mechanics

Protect your back and your patient.

• Maintain a wide base of support (feet shoulder-width apart)
• Bend at the knees, not the waist — use your legs, not your back
• Keep the load close to your body (center of gravity)
• Avoid twisting — turn your whole body by pivoting your feet
• Use assistive devices when available (slide boards, draw sheets, mechanical lifts)
• Get help — if you need to move a heavy or immobile patient, use 2+ people or a lift device
• Lock bed wheels before transferring a patient
• When using a draw sheet: roll it close to the patient, lift (don't pull) on the count of 3

Frequently Asked Questions

Common student questions on this topic.

Quick-Reference Cheatsheet

Every key point from this guide on a single printable page.