NURSE DOJO Cheat Sheet
Lesson 7.1 · Reduction of Risk Potential
Vital Signs: Changes, Trends, and Abnormalities
Must-know rules
- Technique determines accuracy. • Wrong cuff size → wrong BP. • Radial instead of apical before digoxin → wrong decision.
- Normal ranges are the baseline, not the rule. • An HR of 98 is "normal", but if that client was 72 four hours ago, something changed.
- Tachycardia is the earliest warning sign. Before the BP drops, before the SpO₂ falls, before the LOC changes: the heart rate rises.
- Respiratory rate is the most undervalued vital sign. A change in RR is the single best predictor of clinical deterioration on a medical-surgical unit.
- Cushing's triad = neurosurgical emergency. Hypertension (widening pulse pressure) + bradycardia + irregular respirations = critically elevated ICP. Recognize it instantly.
- Know your shock patterns. Hypovolemic: ↑HR, ↓BP, cool/clammy. Cardiogenic: ↑HR, ↓BP, crackles/JVD. Septic (early): ↑HR, ↓BP, warm/flushed.
- Orthostatic hypotension: Drop ≥20 mmHg systolic OR ≥10 mmHg diastolic on standing, with HR rise ≥20 bpm. Causes: dehydration, hemorrhage, medications, prolonged bed rest.
- Trend the data. Trust the pattern. • The deterioration cascade: ↑HR first → ↑RR second → ↓BP late → ↓SpO₂ → ↓LOC last.
VITAL SIGN MEASUREMENT: TECHNIQUES & NORMAL RANGES
| Vital Sign | Adult Normal Range | Key Measurement Notes |
|---|---|---|
| Temperature | 97.8–99.1°F (36.5–37.3°C) | Oral: most common. Rectal |
| Pulse (HR) | 60–100 bpm | Radial: routine assessment. |
| Respirations (RR) | 12–20 breaths/min | Count WITHOUT telling the client (they'll... |
| Blood Pressure | Systolic <120 / Diastolic <80 mmHg | Cuff width = 40% of arm circumference. |
| SpO₂ | 95–100% | Pulse oximetry measures peripheral oxygen... |
| Pain | Subjective: 0/10 is goal | Use age-appropriate scales: numeric (0–10) |
BP MEASUREMENT: THE TECHNIQUE THE NCLEX LOVES TO TEST
- Select correct cuff size. A cuff that's too small is the #1 cause of falsely elevated readings.
- Position the client correctly. Seated for 5 minutes, back supported
- Avoid these measurement errors: • Reading over clothing (cuff directly on skin).
- First visit: • Measure in BOTH arms.
- Orthostatic vitals: • Measure supine → sitting → standing (wait 1–3 minutes between positions).
- VITAL SIGN CHANGES IN PREGNANCY: Heart rate: Increases 15–20 bpm above baseline by the third trimester due to...
DOJO RULE
Never document vital signs you didn't actually take. • The NCLEX tests correct TECHNIQUE, not just the number. • Cuff too small? Correct it before accepting the reading.
PATHOPHYSIOLOGY OF ABNORMAL VITAL SIGNS
CUSHING'S TRIAD: THE ICP EMERGENCY
- Hypertension (widening pulse pressure): systolic rises while diastolic stays the same or drops.
- Bradycardia: the body's reflex response to rising intracranial pressure (Cushing reflex).
- Irregular respirations: as the brainstem herniation progresses
- This is a LATE sign of increased ICP. • If you see Cushing's triad, the brainstem is being compressed
SHOCK: VITAL SIGN PATTERNS BY TYPE
- Hypovolemic (hemorrhage/dehydration): • ↑HR, ↓BP, ↑RR, ↓urine output, cool/clammy skin.
- Cardiogenic (pump failure): ↑HR, ↓BP, ↑RR, crackles, JVD, ↓cardiac output.
- Septic: EARLY (warm/distributive): • ↑HR, ↓BP, ↑RR, warm/flushed skin, widened pulse pressure, fever.
- Anaphylactic: • ↑HR, ↓BP, ↑RR, bronchospasm, urticaria, angioedema.
- Neurogenic (spinal cord injury): • ↓HR (BRADYCARDIA: unique to this type), ↓BP
NCLEX FAVORITE
Tachycardia is the body's FIRST compensatory response: • to almost every crisis: hemorrhage, hypovolemia, infection, pain, hypoxia, fever.
DOJO RULE
Vital signs never lie, but they need context. • An HR of 55 bpm in a marathon runner is normal. • An HR of 55 bpm in a client on digoxin is a red flag for toxicity.
VITAL SIGN TREND ANALYSIS & CLINICAL JUDGMENT
DOJO RULE
A normal vital sign doesn't mean a safe client. • The client whose HR went from 72 to 98 is technically still "within normal limits"
FINAL DOJO RULE
Vital signs aren't checkboxes: they're a conversation with the body. • Every heartbeat, every breath, every reading is the body telling you something.
Memory hooks
Heart Rate Rises First 1 Heart rate rises · 2 Respiratory rate rises · 3 Urine output drops · 4 Confusion · 5 Blood pressure drops (late)
Cushing's Triad: Wide, Slow, Odd Wide Widening pulse pressure (high · Slow Bradycardia · Odd Irregular respirations
Count Without Telling Cuff Right cuff size · Apical Apical pulse before digoxin · Secret Count respirations without the · Minute Irregular rhythm