The Nurse, Professional Practice and Scope

In a few months you will walk into a room, put your hands on a stranger, and decide whether what you are seeing is normal. Everything that follows in this book — every technique, every number, every red flag — rests on a license that is granted by a state, defined by a statute, and revocable. This chapter is about that foundation. It explains what a nursing license actually authorizes, where the boundary of your scope sits and how to test whether an action falls inside it, what you may hand to an assistant and what never leaves you, and how the standards of practice, the Code of Ethics and the law of negligence converge at the bedside. It ends where every chapter in this book ends: with the findings that mean stop, escalate now, and the exact words — SBAR — you will use to escalate them.

Section 1Becoming and Staying a Nurse

The credentials, and what each one legally means

Students use the word “nurse” loosely; the law does not. A certified nursing assistant (CNA) holds a certification, not a license, after roughly four to sixteen weeks of training. A CNA is authorized to provide personal care and to collect certain routine data. A licensed practical nurse or licensed vocational nurse (LPN/LVN) completes a twelve- to eighteen-month program and passes the NCLEX-PN. An LPN holds a license and a defined, narrower scope: in most states an LPN may administer most medications, perform sterile dressing changes and tracheostomy care, insert a urinary catheter, and gather data — but works under the direction of an RN or a provider and does not perform the initial comprehensive assessment or independently formulate the plan of care.

The registered nurse (RN) comes from one of three routes: a diploma program, an associate degree in nursing (ADN/ASN), or a bachelor of science in nursing (BSN). All three sit for the same examination, the NCLEX-RN, and all three receive the same license with the same legal scope. The degrees are not legally different; they are professionally different. The BSN adds community health, leadership, research literacy and statistics, and it is the entry point for graduate study and for Magnet-designated employers. An advanced practice registered nurse (APRN) — nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, or certified nurse-midwife — holds a graduate degree, national certification, and a second, separate state authorization that permits diagnosis and, in most states, prescribing.

The Nurse Practice Act and your board of nursing

Every state and territory has a Nurse Practice Act (NPA) — an actual statute passed by that state’s legislature. The NPA defines who may call themselves a nurse, what nursing practice includes, the grounds for discipline, and it creates the board of nursing (BON), the agency that issues your license and can suspend or revoke it. The BON then writes administrative rules and advisory opinions that fill in the detail the statute leaves open. This is the single most important document in your professional life and most students never read it. Read yours before you start clinicals. It is free, it is online, and it is written in plain enough English.

The National Council of State Boards of Nursing (NCSBN) is the organization the boards jointly own; it develops the NCLEX and administers the Nurse Licensure Compact (NLC). A multistate license issued by a compact state lets you practice, physically or by telehealth, in every other compact state without a second license. It does not exempt you from the practice act of the state where the patient is located — the rule is that you practice under the law of the state where the patient is, not where you are sitting. Licenses are renewed on a state-set cycle, usually every two years, generally with continuing education and sometimes practice-hour requirements.

Discipline is real and it is public. The most common paths to a board action are diversion of controlled substances, practicing while impaired, falsification of documentation, patient abandonment (leaving an assignment without transferring care to a qualified person), boundary violations, and practicing outside scope. Most states also make you a mandatory reporter of suspected abuse or neglect of a child, an older adult, or a dependent adult — a duty that belongs to you personally and is not discharged by telling the charge nurse and letting it go.

What professional practice actually asks of you

Licensure is the floor. The profession expects more, and the framework most schools use is QSEN — Quality and Safety Education for Nurses — with six competencies: patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. These are not slogans. Patient-centered care means the plan is built around what the patient values, not around what is convenient for the unit. Evidence-based practice means that when you were taught something in 2018 and the evidence changed in 2024, you change. Informatics means you can find the answer in the chart and in the literature quickly, and that you understand the electronic record is a legal document and a data source, not a typing chore.

Professional practice also means accountability that does not transfer. You are accountable for the assessment you performed, the medication you pushed, the finding you did or did not report, and the task you delegated. “The provider ordered it” is not a defense if the order was clearly unsafe — a nurse who administers an obviously wrong dose shares liability with the prescriber. The correct action when an order looks wrong is to hold it, clarify it with the prescriber, and document the clarification.

Section 2Scope, Delegation and the Team

Three questions before you do anything unfamiliar

New nurses get into trouble not by doing something malicious but by doing something helpful that was not theirs to do. Before you perform a task you have not performed before, run three questions in order. One: is it within my state’s Nurse Practice Act and board rules? If the statute or the board says no, stop — nothing downstream can rescue it. Two: is it within my employer’s policy, and do I have an order or protocol if one is required? Facilities lawfully restrict practice below the statutory ceiling; a hospital may decide RNs do not push a given medication even where the state permits it. Three: am I personally competent — educated, trained, and validated — to do this safely right now? A yes to the first two and a no to the third still means you do not do it; you find someone who can and you arrange to be taught.

The most common scope traps in the first year are administering an IV push medication in a facility that does not credential RNs for it, titrating a drip without a protocol, taking a verbal order in a non-emergency situation when policy forbids it, performing a skill you watched but were never checked off on, and “just” suturing, casting, or adjusting a device because a provider asked and was busy. In every one of these, the safe answer is the same sentence: “I’m not checked off on that — I’ll get someone who is.” No one has ever been disciplined for saying it.

Who may do what

Two words get confused constantly. Assignment is transferring both the responsibility and the accountability for tasks that are already within the receiving person’s own scope and job description — a charge nurse assigning four patients to an RN. Delegation is transferring responsibility for performing a specific task to someone whose scope does not otherwise include it, while you keep the accountability. If a UAP takes a blood pressure you delegated and it is wrong, the number is your problem. Supervision is the ongoing monitoring that follows delegation; you cannot delegate and then disappear.

The five rights of delegation

NCSBN and the ANA describe five checks, and they are worth memorizing because NCLEX tests them relentlessly. Right task — it is repetitive, predictable, low-risk, and does not require nursing judgment. Right circumstance — this patient is stable and the setting is appropriate; the same task on a different patient may not be delegable. Right person — this specific individual has the training and demonstrated competence, not merely the job title. Right direction and communication — you state the task, the patient, the expected method, the deadline, and exactly what to report back and when. Right supervision and evaluation — you follow up, you obtain the result, and you evaluate the outcome yourself.

Vague delegation is unsafe delegation. Compare “Can you get vitals on room 12?” with “Please take a manual blood pressure on Mr. Ruiz in 12 within the next ten minutes, sitting, left arm, and tell me the number right away if the systolic is under 100 or over 160.” The second sentence gives the task, the patient, the method, the timeframe and the reporting threshold. It takes eight seconds longer and it is the difference between delegation and hoping.

Four things never leave the RN, and this is the sentence to carry into the exam and into practice: assessment, nursing diagnosis and planning, teaching, and evaluation — plus anything at all involving an unstable patient. A UAP may gather a number; only the RN decides what that number means. If a UAP reports a blood pressure of 86/50, the delegated task was completed correctly and the clinical problem is entirely yours.

Section 3Standards, Ethics and the Law at the Bedside

The standards you will be measured against

When a case is reviewed, the question is not whether you meant well — it is whether you met the standard of care, defined as what a reasonably prudent nurse with similar preparation would have done in similar circumstances. That standard is built from the ANA Nursing: Scope and Standards of Practice, your state’s NPA, facility policy, manufacturer instructions, and current evidence. The six Standards of Practice map exactly onto the nursing process and are the spine of the next chapter: assessment, diagnosis, outcomes identification, planning, implementation and evaluation. Layered on top are the Standards of Professional Performance — ethics, advocacy, respectful and equitable practice, communication, collaboration, leadership, education, scholarly inquiry, quality of practice, professional practice evaluation, resource stewardship and environmental health.

Standards are not aspirational language. If a patient falls and the record shows no fall-risk screening was documented on admission, the deviation from the assessment standard is the case. This is why documentation is not clerical work: in a legal review, care that was not documented is treated as care that was not given.

Ethical principles and the Code of Ethics

The ANA Code of Ethics for Nurses is the profession’s non-negotiable statement of obligation. Its provisions establish that the nurse practices with compassion and respect for every person, that the nurse’s primary commitment is to the patient, that the nurse advocates for and protects the patient’s rights and safety, and that the nurse owes the same duties to self as to others — a provision that matters when you are asked to take a ninth patient or a third consecutive double shift.

The legal floor: negligence, consent, privacy and restraints

Negligence is failing to act as a reasonably prudent person would; malpractice is professional negligence. A plaintiff must prove four elements, all of them: duty (you had a nurse–patient relationship), breach (you departed from the standard of care), causation (that breach caused the harm), and damages (real injury occurred). Missing one element ends the case. Also know the intentional torts, because they are quieter and easier to commit: assault (threatening unwanted contact — “hold still or I will hold you down”), battery (the contact itself, including performing a procedure a patient refused), false imprisonment (restraining or confining without order or emergency justification), defamation (libel in writing, slander in speech), and invasion of privacy.

Informed consent belongs to the person performing the procedure. The provider must explain the diagnosis, the nature and purpose of the procedure, the risks and benefits, the alternatives, and the consequences of refusing. The nurse’s role is narrow and specific: verify that the consent form is signed, that the signature is voluntary, and that the patient can describe in their own words what is about to happen — then witness the signature. If the patient says “they’re taking out my gallbladder, I think, or maybe part of my colon,” you stop, you do not have them sign, and you page the provider. Consent obtained after a sedating premedication is not valid consent.

HIPAA protects health information; the rule of practice is minimum necessary and need-to-know. The most frequent violations by students are elevator and hallway conversations, looking up a patient you are not assigned to, and photographing anything on a personal phone. Restraints are a last resort, never a response to short staffing, convenience or punishment, and are used only after less restrictive alternatives have been tried and documented. They require a provider order that is never written as needed (no PRN restraint orders) and that is time-limited: for violent or self-destructive behavior, up to 4 hours for an adult, 2 hours for ages 9–17, and 1 hour for children under 9, with a face-to-face evaluation of the patient by a physician or trained licensed independent practitioner within 1 hour of initiation. Use the least restrictive effective type, and monitor frequently with release, repositioning, range of motion, fluids, toileting, circulation and skin checks. Applying restraints without an order, outside an immediate emergency, is false imprisonment.

Section 4The Core Skill: Assessing, Measuring, Documenting

The four techniques and the order they go in

Every regional examination in this textbook uses the same four techniques in the same order. Inspection comes first and is the most underused: you look, deliberately and with adequate light, comparing side to side, before you touch anything. Inspect for color, symmetry, contour, movement, lesions, drainage and effort. Most abnormal findings are visible before they are palpable. Palpation comes second. Use the finger pads for texture, pulses, moisture, tenderness and masses; the ulnar or palmar surface for vibration such as thrills and fremitus; and the dorsum of the hand for temperature, because it is more sensitive to heat. Light palpation depresses about 1 cm; deep palpation depresses about 4–5 cm and is used to identify organs and deep masses. Palpate tender areas last, and warm your hands.

Percussion comes third. Press the distal phalanx of the non-dominant middle finger firmly on the skin, keep the other fingers off the surface, and strike that phalanx sharply with the tip of the dominant middle finger using wrist motion only, withdrawing immediately. You are listening for whether the tissue underneath is air-filled, fluid-filled or solid: resonance over normal lung, hyperresonance over trapped air as in emphysema or pneumothorax, tympany over the gastric bubble and the intestines, dullness over the liver, a full bladder or consolidated lung, and flatness over bone and muscle. Auscultation comes fourth. Use the diaphragm pressed firmly for high-pitched sounds — breath sounds, bowel sounds, normal heart sounds S1 and S2 — and the bell held lightly for low-pitched sounds such as S3, S4, and bruits. Place the stethoscope on skin, never over a gown, and stop moving and talking while you listen.

There is one exception, and it is the abdomen. The abdominal sequence is inspect, auscultate, percuss, palpate. Auscultation is moved ahead of percussion and palpation because pressing on the abdomen mechanically stimulates or suppresses peristalsis and changes the bowel sounds you are about to grade. If you palpate first, the bowel sounds you then document are an artifact you created. Auscultate all four quadrants, beginning in the right lower quadrant near the ileocecal valve where sounds are usually most active; normal is 5–30 gurgles per minute, and before you may document absent bowel sounds you must listen for a full 5 minutes in that quadrant. Sequence errors like this one are exactly the kind of mistake that looks trivial on paper and produces a false finding in a real chart.

The numbers you must know cold

You cannot recognize abnormal until normal is automatic. These are adult values; commit them to memory now, because during a rapid response nobody will let you look them up.

Values shift across the lifespan, and the shift is largest at the extremes. Children run faster and breathe faster; older adults run cooler and stiffer. Memorize the direction of change even if you keep the table handy.

Three lifespan cautions save lives. First, in infants and children hypotension is a late and ominous sign — children compensate with tachycardia and vasoconstriction until they crash; for ages 1–10 years, hypotension is a systolic below 70 plus twice the age in years. Second, in older adults the febrile response is blunted: a temperature of 37.8 °C (100.0 °F), or a rise of 1.1 °C (2 °F) above that person’s own baseline, is a significant fever, and new confusion may be the only sign of infection. Third, in pregnancy heart rate rises 10–20 beats/min, blood volume rises 30–50%, and blood pressure falls slightly through the second trimester before returning to baseline by term; after about 20 weeks, lay the patient in a left lateral tilt rather than supine, because the gravid uterus compresses the inferior vena cava and drops cardiac output.

Seeing findings on every skin tone

Much of the classic physical-examination vocabulary was written for pale skin, and describing findings only as “redness” or “blueness” causes real, documented harm — pulse oximeters overestimate saturation in patients with darker skin, and stage 1 pressure injuries are missed at higher rates. The fix is technique, not vocabulary: assess the areas with the least melanin and the thinnest tissue, use natural or bright white light, compare with the patient’s own unaffected skin, and palpate as well as look.

Charting it so it holds up

Documentation is a clinical intervention and a legal record simultaneously. Chart what you observed and measured, not what you concluded without data; quote the patient in their own words; time everything; and never leave a blank space that another person could fill in. Chart after care, never before. Enter a late entry as a late entry with both the current time and the time the event occurred. In an electronic record, use the amendment function — the audit trail preserves the original anyway, and an attempt to conceal reads far worse in court than the error did.

Section 5Recognizing Trouble and Escalating It

Failure to rescue, and the findings that mean now

Failure to rescue is the term for a patient who deteriorates and dies not because the complication was unpredictable, but because the warning signs were recorded and not acted upon. Reviews of these events consistently find abnormal vital signs documented for six to eight hours before the arrest — most often a rising respiratory rate, which is the earliest and most ignored warning sign in adult medicine. The nurse is the surveillance system. Nobody else is in the room every hour.

SBAR: the escalation script

SBAR — Situation, Background, Assessment, Recommendation — exists because unstructured calls fail. Before you dial, have the chart open, the most recent vital signs in front of you, the allergy list, the pertinent medications and the code status, and have laid eyes on the patient yourself within the last few minutes. Then say it in this order.

S — Situation. “Dr. Okoye, this is Priya Menon, RN, on 4 West. I’m calling about Mr. Daniel Ruiz in room 412, post-op day one from a right hemicolectomy. His respiratory rate has climbed to 28 and his oxygen saturation has dropped to 88% on room air.” B — Background. “He’s 68, with COPD and type 2 diabetes. He came back from the OR yesterday at 1400. He’s had 6 mg of morphine IV in the last four hours, last dose at 0230. He hasn’t been out of bed since surgery.” A — Assessment. “Right now he’s tachypneic and anxious, speaking in three-word sentences. Heart rate 122 sinus tach, blood pressure 98/56, temperature 37.9 °C. Breath sounds are diminished at both bases with no wheeze. His right calf is 3 cm larger than the left and tender. I’m concerned about a pulmonary embolism.” R — Recommendation. “I’ve placed him on 2 liters by nasal cannula and sat him upright. I’d like you to come see him now. Can I get orders for a stat CT pulmonary angiogram, a 12-lead ECG and an arterial blood gas? And what oxygen saturation target do you want, given his COPD?”

Notice four things about that call. It named the nurse and the unit; it gave the numbers rather than adjectives; it stated a concern out loud rather than hinting at one; and it closed with a specific, answerable request. Then document it: “0310 Dr. Okoye notified of RR 28, SpO2 88% RA, HR 122, BP 98/56, right calf tenderness. Verbal orders received for stat CTPA, ECG, ABG; SpO2 target 88–92%. Read back and verified. Provider to bedside.”

Advocacy, the chain of command and speaking up

Escalation does not stop at one phone call. If the provider does not respond, or responds in a way you believe is unsafe, you go up the chain of command: charge nurse, then nursing supervisor or manager, then the attending physician, then the medical director or administrator on call. Most facilities also have a rapid response team that any nurse may activate without a physician’s permission for a patient who is deteriorating but has not arrested, and many now extend that activation to patients and families. Calling a rapid response is never wrong; the near-miss you prevent is invisible, and the arrest you failed to prevent is not.

When you are ignored, use the two-challenge rule: state your concern clearly twice, and if it is still not acknowledged, take it to the next level of the chain. Structured phrases exist for this because in the moment people go quiet. The CUS script escalates the language deliberately: “I am Concerned. I am Uncomfortable. This is a Safety issue — I need us to stop.” That last sentence is the one to memorize, because the moments when you most need it are the moments when you will least want to say it.

Advocacy also runs in the ordinary direction: making sure the patient understands what they consented to, that pain is treated, that the discharge plan matches the home the person is actually going to, and that the frightened family gets an explanation. Two patient identifiers — full name and date of birth, never the room number — before every medication, specimen and procedure. Hand hygiene before and after every patient contact. These are not junior tasks you outgrow; they are the practice.

Words worth knowing

THE NURSING PROCESS AND CLINICAL JUDGMENT

The nursing process is not a school exercise you outgrow after fundamentals — it is the thinking pattern that keeps a patient alive on a night shift when the physician is two floors away and something is quietly going wrong. Assessment, diagnosis, planning, implementation, evaluation: five steps that run as a loop, not a line, and that cycle again every time you touch a patient. Layered on top of that loop is clinical judgment — the ability to notice which of the forty things you observed actually matters, to decide what it means, to act on it, and to check whether your action worked. This chapter teaches the loop with the hands attached: the exact order in which you inspect, palpate, percuss and auscultate; the exact numbers that define normal; the exact words you write in the chart; and the exact moment you stop charting and pick up the phone.

Section 1Assessment — Collecting Data You Can Defend

Five steps, one loop

The nursing process is usually taught as an acronym — ADPIE: Assessment, Diagnosis, Planning, Implementation, Evaluation. That acronym is accurate but it hides the most important feature of the process, which is that it never stops. Evaluation feeds straight back into assessment. You reassess after every intervention, after every position change, after every dose of an analgesic or an antihypertensive, and at the beginning of every shift. A patient who was stable at 0700 is a different data set at 1100, and the plan you built at 0730 is a hypothesis, not a contract.

Assessment is the deliberate, systematic collection of data about a patient’s health status. It comes first for a reason that is not academic: every other step is corrupted by bad data. If you chart a respiratory rate of 18 because that is what the last nurse charted and you did not actually count, the diagnosis is wrong, the plan is wrong, the intervention is wrong, and the evaluation confirms a fiction. Counting respirations takes thirty to sixty seconds. Do it.

There are four kinds of assessment and you will use all four. The initial comprehensive assessment is performed on admission and establishes the baseline every later finding is measured against. The focused or problem-focused assessment targets one system or one complaint — a lung assessment on a patient with pneumonia, a neurovascular check distal to a new cast. The emergency assessment is the rapid primary survey (airway, breathing, circulation, disability, exposure) performed when a patient is decompensating, and it is intentionally incomplete because completeness costs time you do not have. The ongoing or time-lapsed assessment is the reassessment that detects change — and change, more than any single value, is what tells you a patient is in trouble.

Subjective, objective, primary, secondary

Subjective data is what the patient tells you: pain, nausea, dizziness, dyspnea, fear. These are symptoms, and they cannot be measured by you — only reported by the patient. Chart them in the patient’s own words inside quotation marks whenever the wording matters: the patient states, “It feels like someone is standing on my chest.” Objective data is what you observe, measure or elicit: a blood pressure of 88/52, crackles in the right lower lobe, a 3 cm reddened area over the sacrum that does not blanch, a respiratory rate of 28. These are signs. Both types are real data and neither outranks the other — but only objective data can be independently verified, so it carries the weight in documentation and escalation.

The primary source of data is always the patient, when the patient is able and willing to give it. Secondary sources include family members, the medical record, the previous shift’s nurse, laboratory and imaging results, and other members of the team. Secondary data is legitimate but must be flagged as such: the daughter reports the patient has been confused for two days is not the same statement as the patient is confused.

Validation is the step students skip. When subjective and objective data conflict — a patient rates pain at 9 out of 10 while sleeping comfortably with a heart rate of 62, or a monitor reads a heart rate of 148 while the radial pulse is 74 — you do not choose the more convenient number. You recheck. Take an apical pulse for a full minute. Take a manual blood pressure with a correctly sized cuff. Ask the patient again in different words. A finding that surprises you is either an artifact or an emergency, and the only way to tell is to repeat the measurement.

How the hands actually move

Physical examination has four techniques, performed in a fixed order: inspection, palpation, percussion, auscultation. The order exists because each technique disturbs what the next one measures. Inspection is done first because it is the only technique that does not touch the patient and therefore cannot change the findings. Then palpation, then percussion, then auscultation.

There is one exception and you must know it: the abdomen is examined in the order inspect, auscultate, percuss, palpate. Auscultation is moved to second position because pressing on the abdomen mechanically stimulates the bowel and alters bowel sounds — palpate first and you will hear sounds you created rather than sounds the patient had. Listen before you touch. Use the diaphragm of the stethoscope, warmed, and listen in all four quadrants; normal bowel sounds are 5 to 30 per minute and irregular. Before declaring bowel sounds absent you must listen for a full five minutes in each quadrant.

Inspection means looking with intent, in good light, with the area adequately exposed and compared side to side. Symmetry is the single most useful concept in physical assessment: one warm foot and one cool foot means far more than two cool feet. Palpation uses the fingertips for texture, pulsation and size, the palmar surface of the metacarpophalangeal joints for vibration such as fremitus and thrills, and the dorsum of the hand for temperature, because the dorsum is more sensitive to heat. Warm your hands, keep your nails short, and always perform light palpation (about 1 cm) before deep palpation (about 4 to 5 cm). Never deeply palpate a pulsatile abdominal mass, and never test for rebound tenderness casually — both can cause harm.

Percussion strikes the distal interphalangeal joint of the pleximeter finger with the tip of the plexor finger, using wrist motion only, striking twice and withdrawing immediately so the sound is not damped. The note tells you what is under your finger to a depth of roughly 5 to 7 cm. Auscultation uses the diaphragm pressed firmly for high-pitched sounds (breath sounds, bowel sounds, normal S1 and S2) and the bell placed lightly for low-pitched sounds (S3, S4, bruits, some murmurs). Place the stethoscope on skin, never over a gown, and listen for at least one full respiratory cycle at each site.

The numbers you must know cold

Vital signs are the cheapest early-warning system in medicine and the most frequently rushed measurement in nursing. Measure them correctly. Blood pressure: patient seated quietly for five minutes, back supported, feet flat on the floor, legs uncrossed, arm supported at heart level, no talking, no caffeine or nicotine for 30 minutes. The cuff bladder should be about 40 percent of arm circumference in width and encircle 80 percent of the arm; a cuff that is too small produces a falsely high reading, and a cuff that is too large produces a falsely low one. Position the lower cuff edge 2.5 cm (1 inch) above the antecubital fossa. Count an apical pulse for a full 60 seconds in infants, children and any irregular rhythm.

Three lifespan facts change management immediately. First, in children aged 1 to 10 years, hypotension is defined as a systolic pressure below 70 plus twice the age in years — a 4-year-old with a systolic of 74 is already hypotensive, and because children compensate with tachycardia and vasoconstriction until they abruptly do not, hypotension in a child is a late and ominous sign. Second, any infant younger than 3 months with a rectal temperature of 38.0 °C (100.4 °F) or higher is a medical emergency and requires immediate evaluation. Third, older adults often have a lower baseline temperature (frequently 36.0–36.5 °C) and a blunted febrile response, so a temperature of 37.2 °C (99.0 °F), or a rise of 1.1 °C (2 °F) above that patient’s own baseline, may be the only temperature sign of serious infection. In older adults, new confusion is frequently the first sign of infection, before any fever appears at all.

Pregnancy shifts the baseline in predictable ways: circulating blood volume rises 30 to 50 percent, resting heart rate rises 10 to 20 beats per minute, and blood pressure falls in the second trimester before returning toward baseline near term. That physiologic drop means a “normal-looking” blood pressure in late pregnancy can represent a significant rise from that patient’s own first-trimester baseline — which is why a systolic of 140 or a diastolic of 90 after 20 weeks, especially with headache, visual changes or right upper quadrant pain, is escalated, not observed.

Section 2Analysis and Nursing Diagnosis — Turning Cues Into a Problem

From cue to cluster

A cue is a single piece of relevant data: a heart rate of 118, a report of burning on urination, a urine output of 15 mL over two hours. Cues become meaningful when they are clustered — grouped with other cues that share a plausible physiologic explanation. Heart rate 118, temperature 38.4 °C, respiratory rate 24, systolic 96, new confusion in an 82-year-old with an indwelling catheter is not five separate problems. It is one pattern, and the pattern is sepsis until proven otherwise.

Analysis has three moves. First, separate relevant from irrelevant data — the patient’s chronic well-controlled hypothyroidism is not driving today’s picture. Second, identify which cues are expected for this patient’s condition and which are unexpected; the unexpected ones deserve your attention first, because expected findings rarely kill patients and unexpected ones frequently do. Third, compare against two standards: population norms (is this outside 12–20 breaths per minute?) and the patient’s own baseline (was this patient at 12 all week and is now at 22?). A value inside the normal range that has moved sharply from a personal baseline is still a red flag.

Nursing diagnosis versus medical diagnosis

A medical diagnosis names a disease — pneumonia, heart failure, type 2 diabetes mellitus. It is made by a licensed provider and it generally does not change over the hospitalization. A nursing diagnosis names the patient’s human response to that disease — impaired gas exchange, activity intolerance, risk for unstable blood glucose — and it belongs to the RN, is treated by independent nursing interventions, and changes as the patient changes, sometimes within a single shift. Two patients with identical pneumonia may carry entirely different nursing diagnoses: one is short of breath and frightened, the other is dehydrated and falling.

Writing it: PES, and the risk exception

The standard actual (problem-focused) nursing diagnosis is written in PES format: Problem, Etiology, Signs and symptoms, joined by the phrases “related to” and “as evidenced by.” For example: Impaired gas exchange related to alveolar-capillary membrane changes as evidenced by SpO2 88 percent on room air, respiratory rate 28, crackles in bilateral lower lobes and restlessness. The problem is the NANDA-I label, the etiology is the cause you can actually do something about, and the evidence is the objective and subjective data you collected.

Two rules students break constantly. First, the etiology must never be a medical diagnosis, because you cannot independently treat pneumonia — write “related to retained secretions and alveolar inflammation,” not “related to pneumonia.” Second, a risk diagnosis has only two parts: the risk label and the risk factors. There is no “as evidenced by,” because if there were evidence the problem would already exist and would no longer be a risk. Write: Risk for falls as evidenced by — wrong. Write: Risk for falls related to postural hypotension, new zolpidem order and generalized weakness — correct.

Deciding which problem comes first

Once you have several diagnoses, you must rank them, because you cannot do everything at 0800. Use ABC first: an airway problem outranks a breathing problem, which outranks a circulation problem, which outranks everything else. Then Maslow: physiologic needs before safety, safety before love and belonging, and so on — but note that within physiologic needs, oxygenation is always the top priority. Then apply the practical rules: actual problems before risk problems of equal urgency; acute before chronic; unexpected findings before expected ones; and problems that will worsen without immediate action before those that will not.

Section 3Planning — Outcomes, Priorities and the Limits of Your Scope

Outcomes must be measurable or they are wishes

An outcome statement describes what the patient will do or achieve, not what the nurse will do. “Encourage fluids” is an intervention, not an outcome. Outcomes should be SMART: specific, measurable, attainable, relevant and time-bound. Write them in the patient’s voice with an observable behavior and a deadline. If two nurses could disagree about whether the outcome was met, it was not written well enough.

Choosing interventions

Interventions come in three types and the distinction is a scope-of-practice question, not a vocabulary quiz. Independent interventions are within the RN’s own license and require no order: repositioning every two hours, elevating the head of the bed, incentive spirometry coaching, therapeutic communication, oral care, teaching, and assessment itself. Dependent interventions require a provider order: medications, intravenous fluids, wound care protocols, activity orders, diet orders. Collaborative or interdependent interventions are carried out with other disciplines: physical therapy mobility plans, respiratory therapy nebulizer schedules, dietitian-designed feeding plans, pharmacy medication reconciliation.

Every intervention you select should have a stated rationale, because a rationale is what allows you to defend the choice later and to recognize when the intervention is no longer appropriate. “Elevate head of bed 30 to 45 degrees to reduce aspiration risk and improve diaphragmatic excursion” tells the next nurse why the position matters, which means it is more likely to survive the shift change.

Delegation and the boundary of your license

Delegation is transferring the authority to perform a selected nursing task in a selected situation to a competent individual, while the RN retains accountability for the outcome. That last clause is the whole point: you can delegate the task, never the responsibility. The Five Rights of Delegation are the right task, under the right circumstance, to the right person, with the right direction and communication, under the right supervision and evaluation.

The RN never delegates assessment, nursing diagnosis, planning, evaluation, teaching, or any clinical judgment, and never delegates care of an unstable or unpredictable patient. Those five words — assess, diagnose, plan, teach, evaluate — are the ones to memorize. Unlicensed assistive personnel may collect and report data such as a blood pressure reading, but they may not interpret it. If a UAP tells you the pressure is 84/50, the measurement was delegated and the meaning is yours.

When you delegate, communicate specifically. “Take vitals on 12” is a weak instruction. “Please take a full set of vital signs on room 12 within the next fifteen minutes, count the respirations for a full minute, and tell me immediately if the systolic is under 100 or the heart rate is over 110” gives the task, the timeframe, the method and the reporting parameters. Then follow up — supervision and evaluation are the fifth right, and skipping them is the most common delegation failure on real units.

Section 4Implementation and Evaluation — Doing It, Charting It, Re-checking It

Implementation is assessment too

Implementation is not simply executing the plan. Every intervention is bracketed by assessment: you reassess immediately before acting (is the plan still appropriate?), you monitor during the action, and you reassess after to evaluate the response. Before giving a scheduled metoprolol, you check the apical pulse and blood pressure. Before ambulating a post-operative patient, you check orthostatic vital signs, pain level and the surgical site. Before suctioning, you auscultate. The order is never “do the task, then look at the patient.”

Reassessment intervals are not arbitrary. After an intravenous analgesic, reassess pain within 15 to 30 minutes; after an oral analgesic, within 45 to 60 minutes. After an antihypertensive, recheck blood pressure at the drug’s expected peak. After oxygen titration, recheck SpO2 and work of breathing within 15 minutes. After a fall, perform a full head-to-toe assessment plus neurologic checks immediately and per protocol thereafter. Know these intervals for the drugs you give — an intervention without documented reassessment is legally indistinguishable from an intervention that failed.

How to chart it

Documentation must be timely, factual, complete, organized and objective. Chart what you observed and what you did, not what you concluded about the patient’s character. “Patient uncooperative” is an opinion; “Patient declined morning ambulation, stating ‘my chest hurts too much’; pain rated 7/10; RN notified provider at 0915” is a record. Never chart in advance, never chart for someone else, never delete an entry — correct an error by following facility policy for an addendum, with the reason and your initials. Late entries are labeled as late entries with the actual time of the event and the actual time of the entry.

Evaluation closes the loop

Evaluation asks one question about each outcome: was it met, partially met, or not met? You answer with data, not impression — you compare the patient’s current status to the measurable outcome you wrote. Outcome: SpO2 ≥94 percent on 2 L by end of shift. Result: SpO2 92 percent on 3 L with respiratory rate 22. That is not met, and it obligates you to act.

When an outcome is not met, there are only four possible reasons and you should check them in order: the assessment data was incomplete or wrong; the nursing diagnosis or its etiology was wrong; the outcome was unrealistic or the timeframe too short; or the interventions were appropriate but were not actually implemented. Revising the plan is not an admission of failure — it is the process working. What is a failure is carrying an outcome forward unchanged for three shifts while the patient does not improve.

Section 5Clinical Judgment — From Noticing to Escalating

Two models, one habit of mind

Clinical judgment is the observed outcome of critical thinking and decision making — the conclusion you reach about a patient’s needs and the decision to act, modify or withhold action. Tanner’s widely taught model describes four phases: noticing (perceiving that something is different), interpreting (making sense of it), responding (deciding and acting) and reflecting (evaluating in the moment and afterward). Experienced nurses notice faster not because they see more data but because they know which data matters.

The NCSBN Clinical Judgment Measurement Model, which structures Next Generation NCLEX items, breaks the same process into six testable steps: recognize cues (what matters most?), analyze cues (what could it mean?), prioritize hypotheses (what is most likely and most dangerous?), generate solutions (what can I do?), take action (what will I do, and how?) and evaluate outcomes (did it help?). Map those onto ADPIE and they overlap almost perfectly — the difference is that the judgment model makes the reasoning between assessment and action explicit instead of assuming it.

The reason this matters at the bedside has a name: failure to rescue. Patients who deteriorate in hospitals usually show abnormal vital signs for six to eight hours before an arrest, most often a rising respiratory rate. The deterioration is rarely missed because it was invisible. It is missed because it was recorded and not acted upon. Respiratory rate is the most sensitive and the most frequently falsified vital sign on the flowsheet. Count it.

Red flags — findings that require action now

SBAR — how the escalation actually sounds

SBAR (Situation, Background, Assessment, Recommendation) exists because nurses were trained to narrate and providers were trained to expect a headline. SBAR forces the headline first. Prepare before you dial: have the chart, the current vital signs, the relevant medications, allergies, code status and the most recent labs in front of you. State your name and unit, and say the patient’s name and room.

Two habits complete the escalation. First, read back and verify every verbal or telephone order, then document the order, the time, the provider and the read-back. Second, use the chain of command if the response is inadequate: if the provider does not respond within the timeframe your patient’s condition allows, or gives an order you believe is unsafe, notify the charge nurse and then the nursing supervisor, and call the rapid response team — which any nurse may activate without an order. Document each escalation attempt with the time. Chart the call: “0246 Dr. Patel paged. 0254 No response, second page. 0301 Charge nurse notified, rapid response activated.”

Words worth knowing

COMMUNICATION, DOCUMENTATION AND HANDOFF

Everything you find at the bedside is worthless if it dies in your head. The most common root cause of serious patient harm in hospitals is not a missed lab value or a dull stethoscope — it is a communication failure: a nurse who noticed something and said it too softly, a handoff that skipped the one detail that mattered, a chart entry so vague that the next nurse could not tell whether the patient was improving. This chapter teaches the three ways nursing assessment travels: to the patient (therapeutic communication), to the team (escalation, SBAR, closed-loop verification) and to the future (the legal health record and the handoff). You will learn exact phrasing — what to say, what to write, what to refuse to write — and the numeric thresholds that convert an observation into a phone call you make right now instead of at the end of the shift.

Section 1Therapeutic Communication and the Nurse’s Presence

What makes communication therapeutic

Social conversation is symmetrical: two people trade stories and both leave satisfied. Therapeutic communication is deliberately asymmetrical. It is goal-directed, time-limited and centered entirely on the patient’s needs, not yours. You will not tell the patient about your own gallbladder surgery. You will not reassure them that everything will be fine, because you do not know that and saying it ends the conversation. What you will do is create enough safety that a frightened adult tells a stranger in scrubs that they have not taken their blood pressure medication in three months because it costs eighty dollars a month.

Hildegard Peplau described the nurse—patient relationship in three phases, and they hold up at the bedside. In the orientation phase you introduce yourself by name and role, state what you are going to do and how long it will take, and set the frame: “Good morning, Mr. Okonkwo, I’m Dana, I’m the registered nurse taking care of you until seven tonight. I’d like to spend about ten minutes going over how last night went and then listen to your heart and lungs.” In the working phase the actual assessment, teaching and problem-solving happen. In the termination phase you summarize, confirm understanding and say what happens next — including who is coming after you. Skipping orientation is the most common student error, and it is why patients answer their questions in monosyllables.

The techniques below are not scripts to memorize for an exam; they are the moves you will actually make forty times a shift. Practice them until they stop feeling artificial. The single highest-yield one is silence: after you ask a hard question, count to five in your head before you fill the space. Patients disclose in the gap.

Non-verbal communication, environment and body position

Patients decide within seconds whether you are actually available. Sit down. Studies of hospitalized patients consistently show that when the clinician sits, patients estimate the visit as longer than it was and report better communication — even when the actual seated time is shorter. Get your eyes at or below the level of the patient’s eyes. Standing over a supine adult is a power position and it feels like one. If there is no chair, crouch or sit on the edge of the recliner — not on the bed, which invades personal territory and is an infection-control problem.

The classic mnemonic is SOLER: Sit squarely facing the patient, Open posture (arms and legs uncrossed), Lean slightly forward, Eye contact appropriate to culture, Relaxed. Add the practical items SOLER leaves out: silence the television with permission, close the curtain and the door, lower the bed rail on the side you are sitting on while you are there and raise it again before you leave, and put your phone or workstation-on-wheels where it is not between you and the person. If you must type, narrate it — “I’m going to look at the screen for a second to check your last blood pressure, keep talking.”

Personal space matters and varies. Hall’s zones — intimate (0 to 18 inches), personal (18 inches to 4 feet), social (4 to 12 feet) — are a rough North American map, not a rule. Nursing work forces you into the intimate zone constantly, which is exactly why you announce each entry into it: “I’m going to listen to your back now, I’ll lift your gown from behind.” Direct eye contact is a sign of respect and attention in much of the United States and Western Europe, and can be read as confrontational or disrespectful in some East Asian, Indigenous American and traditional Middle Eastern contexts, particularly across gender or age differences. The safe practice is to offer eye contact and follow the patient’s lead rather than to enforce it.

Communicating across the lifespan, language and literacy

Infants and toddlers. Communication is with the caregiver and through the caregiver. Keep the child on the parent’s lap for as much of the exam as possible, save the invasive and distressing parts for last (ears and throat in a toddler always go last), and use the parent’s words for body parts. For preschoolers, expect magical and literal thinking: never say you are going to “take” their blood pressure or “take a little blood,” and never say a procedure will not hurt if it will. Offer real, narrow choices — “Which arm?” not “Can I check your blood pressure?” School-age children want mechanism and honesty; show them the equipment. Adolescents require time alone without the parent, an explicit statement of confidentiality and its legal limits, and a non-reactive face.

Pregnancy. Position matters after roughly 20 weeks: avoid prolonged supine positioning, which can cause aortocaval compression and supine hypotensive syndrome. Interview in a left-lateral tilt or seated. Ask about intimate partner violence privately, with no partner or family member in the room and never through a family interpreter — pregnancy is a period of elevated risk.

Older adults. Presbycusis is high-frequency hearing loss, so shouting (which raises pitch) makes comprehension worse. Lower your pitch, slow down, face the person so they can lip-read, reduce background noise, and confirm with teach-back. Never use elderspeak — “sweetie,” “honey,” “are we ready for our bath?” It is associated with resistance to care and with worse self-rated function. Allow extra processing time; older adults answer accurately, just more slowly. Ask about, and document, the patient’s preferred name.

Limited English proficiency. Use a qualified medical interpreter — in person, by video or by phone. This is a federal civil-rights requirement under Title VI, not a courtesy, and it is a patient-safety intervention: encounters without professional interpretation carry significantly more clinically consequential errors. Do not use family members, and never use a child, as an interpreter except in a life-threatening emergency while a qualified interpreter is being obtained. Speak to the patient, not the interpreter, in the first person and in short segments. Document the interpreter’s name or ID number and the modality used. For patients who are Deaf, ask their preference; American Sign Language is a distinct language and written English is often not equivalent.

Low health literacy. Roughly one in three US adults has difficulty with everyday health information, and it is invisible — people compensate skillfully. Use plain language (“high blood pressure” not “hypertension,” “water pill” not “diuretic”), limit teaching to three key points per encounter, and close with teach-back: “I want to be sure I explained this well. Tell me in your own words how you’ll take this new water pill at home.” Teach-back tests the teaching, not the patient, and you must say so.

Section 2Speaking Up: SBAR, Red Flags and Closed-Loop Communication

SBAR: the structure that makes you sound credible

SBAR — Situation, Background, Assessment, Recommendation — was adapted from nuclear submarine practice for exactly the problem nurses have: transferring urgent information to someone with more authority, over the phone, in under ninety seconds, without being dismissed. Many facilities use ISBAR, adding Introduction at the front, or ISBARR, adding Read-back at the end. Use whichever your employer uses, and use it every time, including when it feels like overkill. Structure is what lets the receiver find the important item.

The part students under-use is the R. New nurses frequently deliver a flawless S, B and A and then stop, leaving the provider to guess what is being asked. State what you want, out loud, even if you are not sure it is the right ask: “I’d like you to come see her now,” “I’m requesting an order for a stat 12-lead and troponin,” “I need a set of blood cultures and an order to start fluids.” If you are wrong, you have still made the request explicit and the conversation moves faster. Also state your time expectation and confirm the plan: “If she isn’t better in thirty minutes, I’ll call you back.”

Red flags: the numbers that mean call now

You cannot escalate what you cannot recognize. Learn the adult normal ranges cold, then learn the thresholds that override everything you had planned for the next hour. Facilities vary slightly — know your unit’s parameters and your rapid response team criteria — but the values below are the common defaults, and a patient meeting any of them needs a provider or rapid response call, not a recheck at the end of your med pass.

Ranges shift dramatically across the lifespan, and a “normal adult” heart rate in an infant is bradycardia. Memorize the pediatric bands well enough to know when a number is wrong for the age in front of you. Note that the wide neonatal band applies only through 28 days of life; from 1 month on, the upper limit is 180, so a rate of 195 in a 2-month-old is not a normal newborn rate but a finding that prompts evaluation for supraventricular tachycardia, pain, fever, hypovolemia or sepsis.

Closed-loop communication, read-back and the chain of command

Closed-loop communication (also called check-back) has three legs: the sender states the message, the receiver repeats it back in their own voice, and the sender confirms it was heard correctly. It is not optional for verbal or telephone orders and for critical laboratory values — it is a National Patient Safety Goal, and it is the practice that catches “fifteen” misheard as “fifty.” For medications, read back the drug name spelled out for sound-alikes, the dose with units, the route and the frequency: “Reading back: hydrALAZINE, h-y-d-r-a-l-a-z-i-n-e, 10 milligrams, IV push, one time now. Correct?”

A critical value is a laboratory result so far outside the expected range that it represents immediate risk — potassium below 2.5 or above 6.5 mmol/L, sodium below 120 or above 160 mmol/L, glucose below 50 or above 400 mg/dL, hemoglobin below 7 g/dL, platelets below 50,000/mm³, INR above 5, or a positive blood culture. When the lab calls one, you write it down, read it back, document the value, the name of the caller and the time, notify the provider, and document that notification with the time and the response. An undocumented notification is, legally, a notification that did not happen.

When you are worried and the person you called is not, you do not drop it. Use the graded assertiveness tools. CUS: “I am Concerned. I am Uncomfortable. This is a Safety issue.” Those words are recognized in most US hospitals as a formal stop signal. The two-challenge rule says that if you voice a concern twice and it is not acknowledged, you are obligated to escalate to the next level — charge nurse, rapid response team, nursing supervisor, attending physician, chief medical officer. You do not need permission to call a rapid response team, and in many facilities the patient or family can call one directly. Then document what you did, when, and to whom.

Section 3Documentation: The Legal Record and How to Write It

What the chart is for, and the formats you will meet

The health record serves five purposes at once: it communicates with the team, it directs and evaluates care, it is the legal account of what happened, it drives reimbursement and coding, and it feeds quality and research data. The legal function is the one students underestimate. In a malpractice claim filed four years from now, the chart is the only witness that remembers. The standard the record is held to is simple and brutal: if it was not documented, it was not done — and the corollary, if it was documented but not done, that is fraud.

Six rules govern every entry regardless of format. Timely: chart as close to the event as possible, and never in advance — charting a medication before you give it is falsification even if you intend to give it in two minutes. Accurate and objective: record what you saw, heard, measured and did, not what you concluded about the patient’s character. Complete: include the assessment, the intervention, the patient’s response and any notification. Legible and permanent: black ink on paper, no pencil, no erasures, no white-out. Attributed: full signature with credentials, or your own EHR login — never share a password, never chart under another person’s login, and never let someone chart under yours. Chronological: use the facility’s clock convention, usually 24-hour time, and use late-entry format when you fall behind.

How to actually chart it: vague versus precise

The difference between a defensible note and a worthless one is specificity. A vague note tells a reader nothing about trend, and trend is the whole point. Read the pairs below and notice that the precise version is not longer than the vague version by much — it is just made of measurements instead of adjectives.

Chart what you assess in the order you assessed it, because the order is part of the technique. The standard sequence for every body region is inspection, palpation, percussion, auscultation. The abdomen is the exception: inspect, then auscultate, then percuss, then palpate — because percussing or palpating first mechanically stimulates the bowel and alters the bowel sounds you are about to report. Charting “abdomen soft, non-tender, bowel sounds present” when you palpated before you listened is documenting a finding you contaminated. A correct entry reads: “1100 Abdomen inspected: flat, symmetric, no distention, scars or visible pulsation. Bowel sounds active ×4 quadrants. Tympany throughout except dullness over liver. Soft, non-tender to light and deep palpation, no masses or guarding.”

Describing skin findings across skin tones. Pallor, cyanosis, jaundice and erythema are described in most textbooks as they appear in lightly pigmented skin, and students then miss them entirely in patients with darker skin. Do not chart “pink and well perfused” as a reflex on every patient. Assess and describe the sites where pigment interferes least — the oral mucosa, conjunctivae, sclerae, tongue, nail beds, palms and soles — and compare with the patient’s own uninvolved skin. Also palpate, because in darkly pigmented skin, erythema and early pressure injury are more reliably detected as warmth, induration, edema or a change in texture than as redness.

Errors, abbreviations, privacy and EHR-specific traps

Correcting an error on paper: draw a single line through the entry so the original remains readable, write “error” or “mistaken entry” above or beside it, add your initials, the date and the time, and then write the correct entry. Never obliterate, erase, use correction fluid or write over. In the EHR: use the built-in amendment or addendum function; the original stays in the audit trail forever regardless, so never attempt to hide anything. A late entry is labeled as such: “1900 Late entry for 1345 — ...” Backdating an entry to make it look contemporaneous is fraud.

The Joint Commission Do Not Use list applies to all orders and all handwritten and free-text documentation: do not write U or u (write “unit”), IU (write “international unit”), Q.D., QD, q.d., qd (write “daily”), Q.O.D., QOD (write “every other day”), a trailing zero (write 1 mg, never 1.0 mg), a missing leading zero (write 0.5 mg, never .5 mg), and MS, MSO₄, MgSO₄ (write “morphine sulfate” or “magnesium sulfate”). Each of these has killed people: 1.0 mg read as 10 mg is a tenfold overdose.

Privacy. Protected health information is anything that identifies the patient combined with health information. Under HIPAA you access only the records of patients in your care — not your neighbor’s, not a celebrity’s, not your own family member’s without authorization — and every access is logged and audited. Do not discuss patients in elevators, hallways or cafeterias. Do not photograph a patient, a wound or a monitor with a personal phone. Do not post anything on social media, including de-identified stories, room numbers or shift complaints; nurses lose licenses for this every year. Log out of the workstation every time you walk away.

Finally, two EHR-specific hazards. Copy-forward propagates yesterday’s assessment into today’s note, which means it propagates yesterday’s errors and makes the record legally indefensible; if you copy anything forward, you must read and edit every line. Wrong-patient charting happens when multiple charts are open; verify the name and date of birth on the banner before every entry. And keep the incident or variance report out of the medical record entirely — document the facts of what happened to the patient and the notification in the chart, complete the incident report separately as a quality-improvement document, and never write “incident report filed” in the nursing note, because doing so drags the report into discovery.

Section 4Handoff and Transitions of Care

Why handoffs fail, and the structures that fix them

A handoff is the transfer of responsibility and accountability for a patient from one clinician to another, along with the information required to act. It happens at shift change, at breaks, at transfer between units, at transport to and from procedures, and at discharge. It is the highest-risk moment in a hospital stay because responsibility can quietly land on nobody. Analyses of sentinel events repeatedly find handoff communication among the leading contributing factors, and the estimated cost of communication failure in US hospitals runs into the billions of dollars annually.

Handoffs fail for predictable reasons: information overload (a fifteen-minute recitation of the entire chart, with the critical item buried in minute eleven), omission of pending items (a culture that has not resulted, a scan that has not been read), interruptions, distraction, no opportunity to ask questions, and no explicit statement of who now owns the patient. The fixes are structural. Use a standardized format every time. Give the receiver protected, uninterrupted time. End with questions and an explicit transfer: “You have her.”

I-PASS is the best-validated structure; its implementation across pediatric residency programs was associated with a roughly 30 percent reduction in preventable adverse events without lengthening handoffs. Many nursing units use ISBAR instead, which is fine — consistency matters more than which acronym.

Bedside shift report: how it is actually done

Bedside shift report moves handoff from the nurses’ station into the room, with the patient and (with the patient’s permission) family present. It is associated with fewer falls during shift change, fewer call-light requests immediately after report, better patient experience scores and earlier catching of errors — because the patient is the only person in the building who was present for the entire admission. Run it like this:

1. Introduce. Both nurses enter together; the off-going nurse introduces the on-coming nurse by name and role. 2. Invite. Ask the patient’s permission for anyone else present to hear the report. 3. Report. Use your standard format, speak to the patient rather than across them, and avoid jargon — say “your kidney function test” rather than “creatinine trending up.” 4. Look. Do a joint visual check together: IV site and what is infusing at what rate, drains and output, oxygen and flow rate, dressings, drips and pumps, the last dose of pain medication, the fall-risk and skin-risk status, the safety items — bed low and locked, call light in reach, non-skid socks. 5. Involve. Ask the patient what their most important goal is for this shift. 6. Close. The on-coming nurse restates the plan, answers questions, and updates the whiteboard with their name and the goal.

Two judgment calls. First, sensitive information — a new cancer diagnosis the patient has not been told, HIV status, substance use, suspected abuse, a psychiatric history — is discussed outside the room or in general terms, then completed privately. Second, if the patient is asleep, you still enter, verify identity and the safety items visually, and keep voices low; you do not skip the room.

Transfers, procedures and discharge

Unit-to-unit transfer requires a nurse-to-nurse verbal report, not just a note. Include everything in I-PASS plus: isolation precautions and why, allergies, code status and any advance directive, lines and tubes with insertion dates, last medication doses (especially opioids, anticoagulants and antibiotics), pending results, and family contact and who has been notified of what. Send the belongings and the assistive devices — glasses, hearing aids, dentures, walker — and document what went with the patient. Procedure and OR handoffs add: NPO status and time, site marking, consent, last anticoagulant dose, and blood availability.

Discharge is a handoff to the patient, and it is where most preventable readmissions are born. Do not deliver it in the last ten minutes while the wheelchair waits. Start discharge teaching on admission. At discharge, cover in plain language: medications (what, why, when, what to stop — reconcile against the home list explicitly), follow-up appointments with date, time and address, activity and diet restrictions, wound or device care demonstrated back to you, and above all the warning signs that mean call the office or come back, written down and specific: a temperature above 38.0 °C (100.4 °F), redness spreading from the incision, calf pain or swelling, shortness of breath, chest pain, or an inability to keep fluids down. Then use teach-back on the two most dangerous items, and document that you did, including the patient’s response.

Section 5Delegation, Difficult Conversations and Conflict

Delegating to UAP: what transfers and what never does

Delegation is the transfer of the authority to perform a selected task in a selected situation to a competent person, while the RN retains accountability for the outcome. That last clause is the one to burn in. You can delegate the task; you can never delegate the accountability, and you can never delegate the thinking steps of the nursing process — assessment, nursing diagnosis, planning, teaching and evaluation. Distinguish delegation from assignment, which is the routine transfer of activities that are already within the receiver’s own scope of practice.

The five rights of delegation are the checklist: the right task (delegable, repetitive, predictable, with a predictable outcome), under the right circumstance (a stable patient, appropriate setting, available resources), to the right person (verified competence for this task with this patient, not just a job title), with the right direction and communication (specific, measurable, with limits and a reporting threshold), and the right supervision and evaluation (you monitor, intervene as needed, evaluate the outcome and give feedback).

Delegate in a sentence with numbers and a threshold, then require a check-back. Weak: “Can you get vitals on 12?” Strong: “Marcus, please take a full set of vitals on Mrs. Marks in 412 within the next fifteen minutes, and come tell me right away if her heart rate is above 110, her systolic is below 100, or her oxygen saturation is below 92 percent. Write them in the flowsheet and let me know when they are in. Does that work with what else you have?” The final question is not politeness — it surfaces the fact that Marcus already has two showers and a transport, which is information you need before you count on those vitals. Licensed practical/vocational nurses have a broader scope than UAP that varies by state; they commonly administer many medications, perform sterile procedures and reinforce teaching, but the initial comprehensive assessment, the care plan, IV push medications in many states, and blood administration typically remain with the RN.

Hard conversations: anger, bad news, refusal

The angry patient or family member. Anger at the bedside is almost always fear, grief, pain or powerlessness in disguise. Do not match volume. Position yourself with a clear exit path behind you, keep your hands visible and open, lower your voice slightly, and use the sequence: acknowledge, apologize for the experience without admitting fault where none is established, ask, and act. “I can see you’re furious, and waiting four hours for pain medicine would make me furious too. I’m sorry that happened. Tell me what is most urgent right now and I’ll deal with that first.” Then actually do the thing and come back when you said you would. If the person becomes threatening, leave, get help and notify security; you are never obligated to remain in a room where you are unsafe, and workplace violence is a reportable event.

Bad news and hard questions. When a patient asks “Am I dying?”, the worst answers are false reassurance and deflection. Explore before you inform: “That’s a big question. What are you most worried about?” Diagnosis and prognosis disclosure belongs to the provider, but the conversation afterward belongs largely to you: silence, presence, permission to cry, and honest answers to the questions you can answer. Do not fill the silence.

Refusal of care. A competent adult may refuse anything, including care you believe is life-saving. Your obligations are to ensure the refusal is informed, to notify the provider, and to document. Document the specific care refused, the education provided, the consequences explained, the patient’s stated reason in their own words, the assessment of decision-making capacity, the provider notified with the time, and any alternative offered and accepted. For discharge against medical advice, document the risks explained, that the patient could state them back, whether they signed the AMA form, and that they were told they may return at any time — refusing to sign the form does not invalidate the departure and does not void insurance coverage, a common and harmful myth.

Conflict with the team, and speaking up in a hierarchy

Conflict on a unit is not a character flaw; it is structural, and unresolved conflict is a patient-safety hazard. The five classic modes are avoiding, accommodating, competing, compromising and collaborating. Collaborating produces the best long-term outcome and takes the most time; competing is appropriate only in an emergency when one person must direct. Most day-to-day disagreement is best handled with an I-statement and a specific request delivered privately: “When the 0800 medications were still in the drawer at 1000, I had to re-time the whole day and the patient missed a dose. I need us to check the drawer together at handoff.” Blame is “you never,” and it ends the conversation.

Disruptive or intimidating behavior — belittling, throwing, refusing to answer a page, public humiliation — is not something to absorb quietly. The Joint Commission considers such behavior a patient-safety issue precisely because it makes people stop speaking up. Document the facts objectively, report through your chain of command, and use CUS language in the moment. If you are a student or a new graduate, this is genuinely hard; use the words anyway, and remember that a rapid response call needs no one’s permission.

Finally, when an error occurs, communication is a duty rather than a choice. Assess and stabilize the patient first, notify the provider, follow the facility’s disclosure policy, complete the incident report, and document in the chart only the objective facts about the patient: what was given or done, the assessment, the notification with the time, the interventions and the response. Never chart speculation, never chart blame, and never chart that a report was filed.

Words worth knowing

SAFETY, ASEPSIS AND INFECTION PREVENTION

Nothing you do at the bedside matters if the patient is harmed by the care itself. Roughly one in every thirty-one hospitalized patients in the United States has a healthcare-associated infection on any given day, and falls, medication errors and misidentification remain among the most common preventable injuries in hospitals. This chapter is about the two habits that prevent most of that harm: a disciplined approach to physical safety, and an equally disciplined approach to breaking the chain of infection. You will learn to identify a patient correctly, screen for fall risk, use restraints only as a last resort and within legal limits, and respond to fire and to a sharps exposure. You will learn the five moments for hand hygiene, when alcohol is not enough, the exact order for donning and doffing personal protective equipment, the three tiers of transmission-based precautions with the diseases that belong to each, and the rules of a sterile field. Every rule here has a body attached to it.

Section 1A Culture of Safety and the Patient Environment

Safety is a system, not a personality trait

Careful people still make errors. The nurse who has never been distracted, never been interrupted mid-task and never worked short-staffed does not exist. Modern patient safety science accepts that human error is inevitable and builds systems that catch it before it reaches the patient: barcode scanning, independent double checks on high-alert medications, standardized handoff, forcing functions that make the wrong move physically impossible. Your job is not to be flawless. Your job is to use the system as designed, every time, and to speak up when the system is failing.

The phrase just culture describes an organization that distinguishes among human error (a slip — console and fix the system), at-risk behavior (drifting from policy because the shortcut usually works — coach), and reckless behavior (conscious disregard of a substantial risk — discipline). This distinction matters to you as a student because it explains why reporting is safe. When you scan a wristband and the system flags the wrong drug, that is a near miss and it is worth reporting. Near misses are free lessons; the alternative is learning the same lesson from an injured patient.

An event report (incident report) is an internal quality document. Complete it for any fall, medication error, near miss, equipment failure or exposure. Two rules students get wrong constantly: first, you still chart the clinical facts of the event and your assessment in the medical record; second, you never write “incident report completed” or “error made” in the medical record. The chart describes what happened to the patient and what you did about it. The event report is the parallel document that feeds quality improvement, and referencing it in the chart can strip its protected status.

The same system gives you a way to summon help before a patient arrests. A rapid response team brings critical care expertise to the bedside for a patient who is deteriorating but has not yet coded, and in most hospitals any staff member — including a student — and often the patient or family may activate it without a practitioner’s order. Typical triggers are an acute change in heart rate to below 40 or above 130, respiratory rate below 8 or above 28, systolic pressure below 90 mm Hg, oxygen saturation below 90 percent despite supplemental oxygen, a new or prolonged seizure, acute chest pain, a sudden fall in level of consciousness or urine output, or simply that a staff member is worried about the patient. That last criterion is a real, written criterion and you are allowed to use it. Call early, do not wait for a returned page, and do not talk yourself out of it because the numbers are only almost at threshold. Failure to rescue — deterioration that was visible in the chart for hours before anyone acted — is one of the most studied preventable causes of hospital death, and the fix is almost always someone calling sooner.

Identifying the right patient, every single time

Wrong-patient events almost always trace back to a shortcut in identification. The Joint Commission’s first National Patient Safety Goal requires two patient identifiers before any medication, blood product, specimen collection, treatment or procedure. Acceptable identifiers are full name, date of birth and medical record number. A room number or bed location is never an identifier — patients move. Whenever the patient is able, use an open-ended question: “Please tell me your full name and date of birth,” not “Are you Mr. Alvarez?” A confused, sedated or hard-of-hearing patient will agree to almost any name.

Compare what the patient says with the wristband and with the order, and stop if any of the three disagree. For a patient who cannot state their name, verify the band against the record and, when policy allows, confirm with a family member or a second nurse. Blood administration adds a two-person verification of the unit, the blood type and the patient identifiers at the bedside. Before an invasive procedure, the team performs a time-out: everyone stops, and the team confirms correct patient, correct procedure, correct site and side (marked by the proceduralist), correct position, availability of implants and imaging, and antibiotic prophylaxis. Anyone in the room, including a student, may halt a time-out that does not match.

Falls: predict, prevent, and if it happens, document precisely

Falls are the most common adverse event reported in hospitals, and about a quarter of inpatient falls cause injury. Screening is done with a validated tool on admission, on transfer, after a change in condition, after a fall, and at least each shift per policy. The Morse Fall Scale scores history of falling, secondary diagnosis, ambulatory aid, intravenous therapy, gait and mental status; a score of 45 or higher is high risk (25 to 44 is moderate). The Hendrich II Fall Risk Model flags confusion, depression, altered elimination, dizziness, male sex, antiepileptics, benzodiazepines, and a timed get-up-and-go; a score of 5 or greater is high risk. Whichever tool your facility uses, the score is not the intervention. The score tells you to act.

Universal fall precautions apply to every patient: bed in the lowest position with wheels locked, call light and personal items within reach, adequate lighting, nonskid footwear, clear pathways, and orientation to the room. High-risk patients add purposeful hourly rounding using the four Ps — pain, potty, position, possessions — because most falls occur when a patient tries to get to the bathroom alone. Add a bed or chair alarm, a visual identifier per policy, a low bed with a floor mat, assistive devices in reach, and a toileting schedule. Review the medication list: benzodiazepines, opioids, antipsychotics, antihypertensives, diuretics, hypoglycemics and anticholinergics all raise risk, and four or more medications of any kind raises risk further. Check orthostatic vital signs in the patient who reports dizziness on standing: a drop of 20 mm Hg or more in systolic pressure, 10 mm Hg or more in diastolic pressure, or a rise in heart rate of 20 beats per minute or more within three minutes of standing is a positive result.

Raising all four side rails is a restraint, not a fall precaution. Two or three rails up for mobility and positioning is standard; four rails up on a bed confines the patient and, if they climb over, converts a two-foot fall into a four-foot fall onto the head. If a patient does fall, do not lift them first. Assess in place: level of consciousness, airway, breathing, circulation, pain, obvious deformity, head strike, and neurologic status. Take a full set of vital signs, and if the patient is anticoagulated or struck their head, escalate immediately for imaging and neurologic checks per protocol.

Restraints: the last option, with hard legal limits

A restraint is any manual method, physical device, material or equipment that immobilizes or reduces the ability of a patient to move freely, or any drug used as a restriction to manage behavior that is not standard treatment for the patient’s condition. Mittens tied to the bed are restraints; mittens alone usually are not. Four side rails up are a restraint. A tucked-in sheet the patient cannot get out of is a restraint. Under the Centers for Medicare and Medicaid Services Conditions of Participation, restraints require a practitioner’s order that is never written as PRN, must use the least restrictive effective method, and must be discontinued at the earliest possible time.

Always try alternatives first and document that you did: reorient the patient, move them closer to the nurses’ station, provide a sitter or family presence, treat pain, address hunger and toileting needs, reduce noise and lighting at night, offer a diversional activity or an activity apron, review deliriogenic medications, and camouflage lines under clothing or a stockinette. Delirium, not defiance, drives most of the pulling at tubes; treat the delirium.

Technique matters. Tie limb restraints to the movable bed frame, never to a side rail — a rail that is lowered will wrench the limb. Use a quick-release knot that unties with a single pull, never a square knot or a bow that can jam. You should be able to slide two fingers between the restraint and the patient’s skin. Never place a patient in restraints in the prone position, and never restrain the arms above the head. Document the specific behavior that necessitated the restraint, the alternatives tried and their outcomes, the type and location of the device, the time applied, every assessment and release, the patient and family education provided, and the time of discontinuation. Restraint documentation is one of the most heavily surveyed records in the hospital.

Section 2Microbes, the Chain of Infection and Assessing the Infected Patient

Six links, six chances to intervene

Infection requires an unbroken chain. An infectious agent (bacterium, virus, fungus, protozoan, prion) must live in a reservoir (a human, an animal, water, equipment, the environment), leave through a portal of exit (respiratory secretions, blood, stool, urine, wound drainage, skin), travel by a mode of transmission (contact — direct or indirect, droplet, airborne, vehicle such as contaminated food or fluid, or vector), enter a new host through a portal of entry (mucous membranes, broken skin, an intravenous catheter, a urinary catheter, the respiratory tract), and find a susceptible host. Remove any one link and there is no infection. Nurses spend their whole careers working links three, four and five.

Two words to keep straight: colonization means the organism is present and multiplying without tissue damage or host response — a patient may be colonized with MRSA in the nares for years. Infection means the organism is causing damage and the host is responding. A positive nasal swab in a patient with no symptoms is colonization and is not treated with antibiotics, although it may still trigger precautions because the patient can shed the organism. A healthcare-associated infection is one that was not present or incubating on admission, most commonly bloodstream, urinary, surgical site, pneumonia and C. difficile infections.

Assessing for infection at the bedside — the correct exam sequence

Physical assessment follows a fixed order: inspection, palpation, percussion, auscultation. Inspect first, because touching changes what you see (pressing on skin blanches it) and because looking costs nothing. Palpate second, using light palpation to about 1 cm before deep palpation to 4 to 5 cm, warm hands, short nails, and always palpating the tender area last so guarding does not contaminate the rest of the exam. Percuss third, listening for the resonance that tells you whether tissue underneath is air-filled, fluid-filled or solid. Auscultate fourth, with the diaphragm for high-pitched sounds and the bell for low-pitched sounds, on skin and never through a gown.

The abdomen is the exception, and it is the exception you will be asked about. For the abdomen the order is inspect, auscultate, percuss, palpate. Auscultation moves ahead of percussion and palpation because pressing on the abdomen mechanically stimulates or suppresses peristalsis and will give you falsely altered bowel sounds. Listen in all four quadrants, beginning in the right lower quadrant over the ileocecal valve, with the diaphragm, for 5 to 20 seconds per quadrant if sounds are present. Normal is 5 to 30 gurgles per minute. Before you may document absent bowel sounds you must listen for a full 5 minutes in a quadrant. This matters clinically in this chapter because the patient with suspected C. difficile colitis needs an abdominal exam, and a nurse who palpates first has destroyed the most useful piece of data they had.

For a wound or an intravenous site, inspect for the classic local signs — erythema, edema, warmth, pain, purulent drainage, loss of function — then palpate for warmth compared with the opposite limb, induration, fluctuance suggesting an abscess, and crepitus, which is an emergency. Measure the area of erythema in centimeters and mark its border with a skin pen and the time, so the next nurse can tell whether cellulitis is advancing. Note the drainage by amount, color and odor: serous (clear), sanguineous (bloody), serosanguineous (pink), or purulent (thick, opaque, yellow, green or brown).

Normal, abnormal and what the abnormal means

Lifespan variation — the numbers actually change

Children are not small adults, and older adults are not simply slower adults. In a neonate under 28 days, a single rectal temperature of 38.0 °C (100.4 °F) or higher is a medical emergency requiring a full sepsis evaluation; do not give an antipyretic and reassess later. Neonates and young infants may present with hypothermia, poor feeding, lethargy, irritability, grunting or a bulging fontanelle rather than fever. In older adults, the febrile response is blunted: up to half of older adults with serious infection never mount a temperature above 38.0 °C. Long-term care criteria therefore define fever as a single oral temperature above 37.8 °C (100 °F), or repeated oral temperatures above 37.2 °C (99 °F), or an increase of more than 1.1 °C (2 °F) over that resident’s baseline. Suspect infection in the older adult who has become confused, stopped eating, started falling or lost function, even with a normal temperature.

Escalating with SBAR

SBAR converts your worry into a clinical request the receiving provider can act on. Situation: who you are, who the patient is and what is wrong right now. Background: the relevant history in two or three sentences. Assessment: what you think is happening. Recommendation: what you want, stated out loud, with a timeframe. Nurses lose ground by stopping after Assessment. Ask for the thing.

Section 3Hand Hygiene, Standard Precautions and PPE

The five moments, and the technique that makes them count

The World Health Organization’s Five Moments for Hand Hygiene are the framework you will be audited against: (1) before touching a patient, (2) before a clean or aseptic procedure, (3) after body-fluid exposure risk, (4) after touching a patient, and (5) after touching patient surroundings. Moments one and two protect the patient; moments three, four and five protect you and everyone else in the environment. Moment two is the one most often missed and the one with the shortest path to harm — the nurse who empties a drain and then adjusts an oxygen cannula without hand hygiene has just inoculated an airway. Beyond the five moments, perform hand hygiene before donning and after removing gloves (gloves leak and hands become contaminated during removal), before eating, after using the restroom, when moving from a contaminated body site to a clean body site on the same patient, and on entering and leaving any patient room.

Alcohol-based hand rub containing 60 to 95 percent alcohol is the preferred method for routine decontamination because it is faster, more effective against most organisms and less drying than soap. Apply the volume the manufacturer specifies — usually a full palmful — and rub over all surfaces for about 20 to 30 seconds until the hands are completely dry. Do not wave, blow or wipe them dry; the contact time is the mechanism. The surfaces people miss are the thumbs, the fingertips, the nail beds and the web spaces, so start there deliberately.

Soap and water is required, and alcohol is inadequate, in five situations: when hands are visibly soiled or contaminated with blood or body fluids; after caring for a patient with Clostridioides difficile; during outbreaks of norovirus; after known or suspected exposure to Bacillus anthracis; and before eating and after using the restroom. The reason is chemistry, not tradition: alcohol does not kill bacterial spores, and non-enveloped viruses such as norovirus are far less susceptible to it. Only the mechanical friction and rinsing of handwashing physically removes spores from the skin. To wash: wet hands with warm — not hot — water, apply soap, lather and rub all surfaces vigorously for at least 20 seconds, rinse with fingertips pointed downward so water runs from clean to dirty, dry thoroughly with a paper towel, and use that towel to turn off the faucet. The whole procedure takes 40 to 60 seconds.

Keep natural nail tips shorter than one-quarter inch (about 0.6 cm). Do not wear artificial nails, extenders, wraps or chipped polish when providing direct care to high-risk patients; artificial nails harbor gram-negative bacilli and yeast and have been traced to fatal neonatal intensive-care outbreaks. Rings increase the microbial load on the hands and interfere with glove fit. If your hands are cracked and dry, use the facility-approved lotion — damaged skin sheds far more organisms, and petroleum-based products degrade latex gloves.

Standard precautions apply to everyone, always

Standard precautions assume that the blood, all body fluids except sweat, non-intact skin and mucous membranes of every patient may be infectious, regardless of diagnosis or known status. You do not need a positive test to justify protecting yourself. The components are hand hygiene; personal protective equipment selected by anticipated exposure; respiratory hygiene and cough etiquette (tissues, a mask for the coughing patient, spatial separation of at least three feet in waiting areas); safe injection practices (one needle, one syringe, one time, and never re-enter a single-dose vial); safe handling of potentially contaminated equipment and linen; environmental cleaning; and sharps safety.

Sharps deserve their own discipline. Never recap a used needle; if recapping is unavoidable, use a one-handed scoop or a mechanical device. Activate the safety mechanism immediately, before your hand leaves the device. Dispose at the point of use into a puncture-resistant container and replace the container when it reaches the three-quarters full line. Never reach into a sharps container, never force an item in, and never place a used sharp on the bed, the tray or your pocket.

If you sustain a needlestick or a mucous membrane splash: wash the site immediately with soap and water, or flush eyes, nose or mouth with water or normal saline for 15 minutes. Do not squeeze the wound or apply bleach. Report to your supervisor and to employee health immediately — not at the end of the shift — so that source testing and post-exposure prophylaxis can begin. HIV post-exposure prophylaxis is most effective when started within hours and should be started no later than 72 hours after exposure. For perspective on why this urgency exists, the average risk of transmission from a percutaneous exposure to infected blood is roughly 0.3 percent for HIV, about 1.8 percent for hepatitis C, and up to 30 percent for hepatitis B in an unvaccinated worker — which is precisely why the hepatitis B vaccine series is required before clinical rotations.

PPE: the order is the safety feature

Personal protective equipment is chosen by what you expect to encounter, not by the label on the door. Gloves for contact with blood, body fluids, mucous membranes, non-intact skin or contaminated items. A fluid-resistant gown when clothing or arms may be soiled. A mask and eye protection — goggles or a full face shield, not personal eyeglasses — when splashing or spraying is possible, which includes suctioning, irrigating a wound, emptying drainage and caring for a patient with a productive cough. Gloves are single-use and single-patient: change them between tasks on the same patient when moving from a dirty site to a clean one, and never wash or re-use them.

Two memory hooks will keep the sequences straight under pressure. Donning moves head-to-toe in size order and ends with gloves: gown, mask, goggles, gloves. Doffing removes the dirtiest item first and the mask last: gloves, goggles, gown, mask. Notice that the gown always comes off before the mask, that hand hygiene belongs between steps and at the end, and that the respirator is the only item ever removed outside the room. Some facilities teach a combined gown-and-glove removal in one motion, rolling the gown forward off the shoulders while the gloves are still on and peeling all of it inside out together; that variation is acceptable when you have been trained in it, and the order of everything else is unchanged.

Section 4Transmission-Based Precautions

Three tiers, layered on top of standard precautions

Transmission-based precautions are added to — never substituted for — standard precautions when a patient is known or suspected to be infected or colonized with an organism that requires extra barriers. Start them on suspicion, before the laboratory confirms anything; waiting for a positive result is how measles gets into a waiting room. Some conditions need more than one tier: chickenpox and disseminated herpes zoster require airborne and contact precautions, and many respiratory viruses require droplet and contact.

Room turnover, air clearance and the details that get missed

After an airborne-precautions patient leaves the room, the room must remain vacant until enough air exchanges have removed the suspended particles. At 12 air changes per hour, 99 percent removal takes about 23 minutes and 99.9 percent takes about 35 minutes; at 6 air changes per hour those figures are about 46 and 69 minutes. Environmental services should not enter before that interval elapses, and neither should you. Post the time the room was vacated so everyone is working from the same clock.

The opposite arrangement, a protective environment, is used for allogeneic hematopoietic stem cell transplant recipients: positive pressure relative to the corridor, 12 or more air changes per hour, HEPA filtration of incoming air, sealed room, and no dried or fresh flowers or potted plants because of Aspergillus. The confusion students carry into practice is the direction of airflow. Negative pressure keeps the organism in the room and protects everyone else. Positive pressure keeps organisms out of the room and protects the patient. A patient who is both immunocompromised and has tuberculosis requires an anteroom, and that is a facility engineering decision, not a bedside one.

A respirator only works if it seals. Fit testing is required annually and whenever facial features change, and a user seal check is required every single time you put one on: cover the respirator with both hands, inhale sharply and feel it collapse slightly toward the face, then exhale and feel for leakage around the edges and at the nose. Facial hair that crosses the seal makes an N95 ineffective, and a surgical mask is not a substitute for a respirator at any time. A patient in an airborne room wears a surgical mask during transport, never an N95, because a respirator has never been fit-tested to that patient’s face, it adds work of breathing to someone who is already ill, and if it carries an exhalation valve it vents unfiltered air and provides no source control at all. Keep the two purposes separate in your head: the patient’s surgical mask contains what they exhale, and your fit-tested respirator filters what you inhale.

Nursing care does not stop at the door. Patients in isolation receive fewer provider visits, report more depression and anxiety, and experience more non-infectious adverse events than comparable patients who are not isolated. Counter that deliberately. Explain to the patient and family, in plain language, what organism is involved, how it travels, why the gown and mask are worn, and what has to happen before precautions can end. Post visiting instructions and teach visitors the same PPE sequence you use. Enter the room for reasons other than tasks, cluster care so that you reduce the number of entries without reducing the amount of contact, and sit down when you are in there. Never let the sign on the door become a reason to stand in the hallway and talk loudly through the doorway.

Charting precautions and educating the patient

Section 5Asepsis, the Sterile Field and Device-Associated Infection

Medical asepsis versus surgical asepsis

Medical asepsis, or clean technique, reduces the number and transfer of pathogens. It includes hand hygiene, gloves, cleaning surfaces, separating clean from dirty, and not shaking linen. Surgical asepsis, or sterile technique, eliminates all microorganisms and spores from an object or area. It is required for entering a normally sterile body cavity or the bloodstream: inserting a urinary catheter, inserting or dressing a central line, performing a sterile dressing change on a fresh surgical wound, tracheostomy care in acute care, and any procedure entering the peritoneum or spinal canal. When you are unsure which applies, ask whether you are crossing into a sterile space. If yes, sterile technique.

Terminology also matters when you clean equipment. Cleaning physically removes soil and organic material and must precede everything else — disinfectants do not work through blood and feces. Disinfection destroys most pathogens on inanimate objects; high-level disinfection is used for semi-critical items that touch mucous membranes, such as endoscopes. Sterilization destroys all microorganisms including spores and is required for critical items that enter sterile tissue or the vascular system, such as surgical instruments and implants. Contact time on the label of a disinfectant wipe is not a suggestion; if the surface dries before the stated wet time, wipe again.

The rules of a sterile field

To apply sterile gloves by the open method, peel the wrapper open on a clean dry surface above waist level without touching the inner surface, pick up the first glove by the folded cuff with your non-dominant hand touching only the inside, and pull it onto the dominant hand. Then slide the gloved fingers under the cuff of the second glove — touching only its outer surface — and pull it on. Adjust with both gloved hands, and keep your hands above your waist and in front of you from that moment until the procedure ends. If a glove tears, or you touch anything unsterile, stop, remove and start with a new pair. Nobody has ever been disciplined for re-gloving; patients have died from a nurse who kept going.

Device-associated infections and the bundles that prevent them

Most healthcare-associated infections in acute care attach to a device or an incision. Prevention is bundled, meaning that the elements are done together, every time, and audited; performing four of five elements does not deliver four-fifths of the benefit.

Delegation and scope: who may do what

Delegation is the transfer of responsibility for performing a task to someone else while the registered nurse retains accountability for the outcome. Use the five rights of delegation: right task, right circumstance, right person, right direction and communication, and right supervision and evaluation. The permanent boundary is this — assessment, teaching, evaluation, nursing judgment and the care of an unstable patient never leave the RN. A task that seems routine on a stable patient may not be delegable on an unstable one, and the same task may be delegable at 0800 and not at 1600 because the patient changed.

When you delegate, be specific and close the loop: “Please take Mr. Ruiz’s vital signs now, before his 1000 medications, and tell me the number right away if the systolic is under 100 or the heart rate is over 110.” That single sentence contains the task, the timeframe, the parameters and the reporting requirement. “Go get vitals when you can” contains none of them. And a final piece of scope that students underestimate: you are permitted — obligated — to stop any team member, at any level, who is about to break sterile technique or skip hand hygiene. Say it plainly, say it kindly, say it out loud.

Words worth knowing

Vital Signs

Vital signs are the only part of the assessment that produces a number every patient, every shift, in every setting — and because they are numbers, they are the first thing anyone deteriorating shows you. Hours before a patient looks septic, the respiratory rate has already climbed. Hours before a patient bleeds out visibly, the pulse pressure has already narrowed and the pulse has quickened. This chapter teaches you to produce numbers that can be trusted: the correct route, the correct cuff, the correct count, the correct position, the correct amount of time. It then teaches you to read them — against the exact adult ranges, against the lifespan variations that make a heart rate of 140 normal in an infant and an emergency in an adult, and against the patient’s own baseline, which almost always matters more than the textbook. It ends with the values that mean stop, call now, and the words you will use to call.

Section 1Vital Signs as a System

What the numbers are actually telling you

The five traditional vital signs — temperature, pulse, respiration, blood pressure and oxygen saturation — are not five unrelated chores. They are five windows onto two questions: is this patient perfusing tissue with oxygenated blood, and is the body’s regulatory machinery still holding the line? Temperature reports the hypothalamic set point and the presence of inflammation. Pulse reports cardiac rate and, in its quality, stroke volume. Respiration reports both gas exchange and, quietly, metabolic acidosis. Blood pressure reports the driving force behind perfusion. Oxygen saturation reports how loaded the hemoglobin is. When one moves, ask what the others are doing, because compensation is a pattern, not a single value.

That pattern is why trend beats snapshot. A blood pressure of 104/62 is unremarkable in a small young adult and alarming in a patient whose baseline is 160/90, because the second patient has lost more than fifty points of driving pressure and may be perfusing a kidney at the edge of failure. Before you decide a number is normal, find the last three sets on the flowsheet. Deterioration almost never announces itself with one wildly abnormal value; it announces itself with three sets that each looked acceptable and that, lined up, point one direction.

Of the five, respiratory rate is the one students underweight and clinicians most often falsify. It is the earliest and most sensitive predictor of deterioration in adults, it rises before blood pressure falls, and it is the value most likely to be charted as 18 because 18 looks reasonable. Counting a real respiratory rate takes thirty to sixty seconds and can be the difference between recognizing early sepsis and finding it in shock four hours later.

The four techniques, and the one exception you must never forget

Every physical assessment in this book is built from four techniques performed in a fixed order: inspection, then palpation, then percussion, then auscultation. Inspection is deliberate looking — adequate light, exposed skin, comparison side to side. Palpation uses the fingerpads for texture, pulsation and tenderness, the ulnar surface of the hand for vibration, and the dorsum of the hand for temperature, because the back of the hand is the most temperature-sensitive surface you have. Percussion strikes the distal interphalangeal joint of the pleximeter finger with the tip of the plexor finger, using wrist motion only, to judge whether the tissue beneath is air-filled, fluid-filled or solid. Auscultation uses the diaphragm for high-pitched sounds (breath sounds, bowel sounds, S1 and S2) and the bell, held lightly, for low-pitched sounds (S3, S4, bruits, murmurs of mitral stenosis).

There is one exception, and it is asked on every examination and matters at every bedside. For the abdomen, the order is inspect, auscultate, percuss, palpate. Auscultation moves ahead of the hands because pressing on the abdomen mechanically stimulates or suppresses peristalsis and changes the bowel sounds you are about to listen for. Palpate first and you have contaminated your own data. Everywhere else on the body, palpation precedes auscultation; on the abdomen it follows it.

Vital signs sit inside these techniques rather than beside them. You inspect while you count respirations, you palpate to find a radial pulse and to estimate a systolic pressure before you inflate a cuff, and you auscultate for Korotkoff sounds and for an apical rate. Treating vital signs as data entry rather than as physical assessment is exactly how bad numbers get charted.

How often, and who may take them

Frequency is set by provider order, facility policy and patient condition, and the last of those overrides the first two upward but never downward. Common patterns: a full set on admission and at the start of every shift; every four hours on a general medical-surgical unit; postoperatively every fifteen minutes for four sets, every thirty minutes for two, every hour for four, then every four hours; every fifteen minutes during the first hour after a blood transfusion begins, with the nurse remaining with the patient for the first fifteen minutes; before and after any procedure, any transfer, any fall, any change in condition, and any patient complaint that could be cardiopulmonary. Certain medications carry their own vital-sign gate: an apical rate before digoxin (hold and notify if under 60 in an adult), a blood pressure before an antihypertensive, a respiratory rate and sedation level before an opioid dose.

Measuring routine vital signs on a stable, predictable patient may be delegated to unlicensed assistive personnel. Interpreting them may not. When you delegate, you must give the assistant the exact numbers to report back to you — not “let me know if anything looks off,” but “tell me immediately if the heart rate is above 110, the systolic is below 100, the respiratory rate is above 24, the temperature is above 38 °C, or the SpO2 is below 92 percent.” The registered nurse retains the baseline admission set, any set on an unstable patient, any set taken because the patient changed, and every act of judgment about what the numbers mean.

The adult numbers, and how they move across the lifespan

Memorize the adult set as exact numbers, not as impressions. Then memorize the direction pediatric values move: as a child grows, heart rate and respiratory rate fall and blood pressure rises. A heart rate of 140 is expected in a two-month-old and is a rapid-response call in a forty-year-old. Pediatric numbers are given here in the ranges used by Pediatric Advanced Life Support; individual textbooks vary by a few beats, so follow your facility’s reference and, above all, the child’s own baseline.

For children over one year, the fifth-percentile (lowest acceptable) systolic pressure is 70 plus twice the age in years; below that value a child aged one to ten is hypotensive, and hypotension in a child is a late, ominous sign because children compensate with tachycardia until they cannot. In pregnancy, heart rate rises 10 to 20 beats per minute by the third trimester, blood pressure falls during the second trimester and returns to baseline near term, and tidal volume rises about 30 to 40 percent while the respiratory rate stays essentially unchanged. In older adults, arterial stiffening produces isolated systolic hypertension and a widened pulse pressure, the febrile response is blunted so that infection may present with confusion or a fall rather than a temperature, and baseline temperature runs lower — a rise of 1.1 °C (2 °F) above that patient’s own baseline is clinically significant even if the absolute number never reaches 38 °C.

Pain is measured with every vital-sign set and is often called the fifth vital sign, though strictly it is a self-reported symptom rather than a measured physiologic value. Use a 0-to-10 numeric rating scale for adults who can self-report, Wong-Baker FACES from about age three, FLACC for children two months to seven years, CRIES for neonates, PAINAD for advanced dementia and CPOT for intubated adults. Self-report is the gold standard and outranks your impression of how comfortable the patient looks. Pain assessment is developed fully in Chapter 7.

Section 2Temperature

Thermoregulation and what counts as a fever

The hypothalamus holds core temperature near 37.0 °C (98.6 °F) by balancing heat production — basal metabolism, muscle activity, shivering, thyroid hormone and catecholamines — against heat loss through radiation, conduction, convection and evaporation. Fever is not a failure of that system. In fever, pyrogens raise the hypothalamic set point, and the body then works to reach the new, higher target: the patient vasoconstricts, feels cold, and shivers during the chill phase while the temperature climbs. At the plateau the patient is hot and vasodilated — on lighter skin this looks flushed, while on brown or black skin the change is easier to feel as warmth and to see in the conjunctivae and oral mucosa than to read as redness. When the set point resets downward, the patient diaphoreses and vasodilates in the defervescence phase. Recognizing these phases keeps you from piling blankets on a shivering patient whose temperature is already 39 °C.

Hyperthermia is different in mechanism and in danger. There the set point is normal but heat gain overwhelms heat loss — heat stroke, malignant hyperthermia, neuroleptic malignant syndrome, anticholinergic toxicity. Hyperthermia does not respond to antipyretics, because there is no raised set point to lower; it requires active cooling and removal of the cause. A temperature above 40 °C (104 °F) with altered mental status and hot dry skin is heat stroke until proven otherwise, and it is an emergency.

Normal temperature also varies predictably. It is lowest between 0400 and 0600 and highest between 1600 and 1800, swinging 0.5 to 1.0 °C across the day; it rises 0.3 to 0.6 °C after ovulation; it rises with exercise, heavy clothing and a hot environment. If you are comparing a morning temperature to an evening one, part of the difference is the clock. To convert, multiply degrees Celsius by 1.8 and add 32; to reverse, subtract 32 and divide by 1.8.

Choosing a route and performing it correctly

Routes are not interchangeable, and the conversions between them are approximations. Chart the route with the number, every time, and compare like with like across the shift.

For infants under three months, rectal temperature is the reference standard and the number that decision rules are built on. For most other patients an oral or temporal reading is enough, and the accuracy you gain from a rectal temperature rarely justifies the invasion. Core temperature from an esophageal, bladder or pulmonary artery probe is used in critical care and during therapeutic hypothermia; if such a probe is in place, it is the number the team will act on.

Fever across the lifespan, and what abnormal temperature means

Two lifespan cautions deserve emphasis. Infants have a large surface-area-to-mass ratio, little insulating fat and no shivering thermogenesis at birth; they lose heat fast and become hypothermic rather than febrile when septic. Older adults may run a baseline temperature of 36.2 °C, so a “normal” 37.8 °C may already represent a 1.6-degree rise and a real infection. In both groups the absolute number lies more often than the change from baseline does.

Section 3The Pulse

What you are feeling, and how to feel it

Each ventricular contraction ejects a stroke volume into an already-full aorta, and the pressure wave that travels down the arterial tree is what your fingers detect. That means the pulse carries information about rate, about the regularity of the electrical rhythm, and about the force of the contraction reaching the periphery. Palpate with the pads of your index and middle fingers, never the thumb, which has a pulse of its own that you will happily count as the patient’s.

Press gently. Heavy pressure occludes the vessel and erases the very finding you are grading. Count for 30 seconds and multiply by two if the rhythm is regular; count a full 60 seconds if the rhythm is irregular, if the rate is very fast or very slow, if the patient is an infant, or if you are taking an apical pulse. Doubling an irregular 30-second count is how a real rate of 96 becomes a charted 120.

Rate, rhythm and amplitude

Report all three. Rate is beats per minute against the expected 60 to 100 in adults, adjusted for age and for the patient’s own baseline — an endurance athlete at 48 and a patient on a beta-blocker at 56 are not necessarily abnormal, while 56 in a patient whose baseline is 88 is a change worth investigating. Rhythm is the spacing between beats: regular, regularly irregular (a repeating pattern, such as every third beat dropped), or irregularly irregular (no pattern at all, the classic finding of atrial fibrillation). Amplitude is the force of the wave, graded on a 0 to 4+ scale; some facilities use a 0 to 3+ scale, so know which one your chart uses before you document a number.

Two special qualities are worth recognizing early. Pulsus paradoxus is an exaggerated fall in systolic pressure — more than 10 mm Hg — during inspiration; the peripheral pulse seems to fade with each breath in. It points toward cardiac tamponade, severe asthma or constrictive pericarditis and warrants immediate escalation. Pulsus alternans alternates strong and weak beats at a regular rhythm and suggests severe left ventricular dysfunction.

The apical pulse and the pulse deficit

The apical pulse is auscultated with the diaphragm at the point of maximal impulse — fifth intercostal space, left midclavicular line in an adult. Each “lub-dub” counts as one beat, and you count for a full minute. Take an apical rather than a radial pulse in any infant or child under two, in any patient with an irregular rhythm, before administering digoxin or another rate-controlling drug, and whenever the peripheral pulse is difficult to feel. In infants the point of maximal impulse sits higher and more lateral — third or fourth intercostal space, at or just lateral to the midclavicular line — because the heart lies more horizontally in the chest.

A pulse deficit is the difference between the apical rate and the radial rate. It exists because some ventricular contractions are too weak, or come too soon after the last one, to fill enough to generate a palpable peripheral wave. You hear them at the apex; the wrist never feels them. The classic causes are atrial fibrillation and frequent premature ventricular contractions, and the size of the deficit is a rough measure of how much of the heart’s work is being wasted.

Measure it properly. The reliable method uses two nurses and one watch: one auscultates the apex, one palpates the radial, both count simultaneously for a full 60 seconds beginning on an agreed signal. Subtract the radial from the apical; the apical is never lower. One nurse taking the two rates sequentially will produce a number, but not a trustworthy one, because the rhythm changes between counts. Document all three values, not just the difference: “Apical 118, irregularly irregular; radial 92; pulse deficit 26. Counted simultaneously for 1 minute with RN Alvarez.”

Section 4Respiration and Oxygen Saturation

Counting a breath without changing it

Breathing is the one vital sign under voluntary control, which means a patient who knows you are counting will breathe differently. Count without announcing it. The standard technique is to finish the radial pulse, keep your fingers on the wrist, and shift your eyes to the chest or abdomen — the patient believes you are still counting the pulse. One full cycle of rise and fall is one respiration. Count for 30 seconds and double if the pattern is regular; count a full 60 seconds if it is irregular, if the rate is abnormal, or if the patient is an infant.

Infants breathe diaphragmatically, so watch the abdomen rather than the chest, and expect an irregular pattern with brief pauses — periodic breathing is normal in newborns, but a pause longer than 20 seconds, or any pause accompanied by bradycardia or cyanosis — judged at the tongue, oral mucosa and conjunctivae rather than by skin color, which is unreliable on brown and black infants — is apnea and is not normal. In older adults, reduced chest wall compliance and lower vital capacity mean a slightly higher resting rate, but a rate above 24 is abnormal at any adult age.

Adult expected values: 12 to 20 breaths per minute, quiet, effortless, with symmetric chest expansion and an inspiration-to-expiration ratio of roughly 1 to 2. Anything that changes that ratio — prolonged expiration in obstructive disease, for example — is a finding even when the rate is normal.

Depth, effort and pattern

Rate alone is half the assessment. Look at depth (shallow, normal or deep), effort (accessory muscle use, nasal flaring, intercostal or subcostal retractions, tripod positioning, pursed-lip breathing, ability to speak in full sentences) and pattern. Retractions and nasal flaring in a child mean respiratory distress regardless of what the number says, and a child who becomes quiet and sleepy after a period of retractions may be tiring toward respiratory failure, not improving.

Pulse oximetry: what it measures and what it misses

A pulse oximeter shines red and infrared light through a pulsating vascular bed and calculates the percentage of hemoglobin binding sites occupied by oxygen, reported as SpO2. Expected value on room air is 95 to 100 percent. Because of the shape of the oxyhemoglobin dissociation curve, an SpO2 of 90 percent corresponds to a PaO2 of about 60 mm Hg, and below that point the curve falls steeply — small further drops in saturation represent large drops in dissolved oxygen. That is why 90 percent is a threshold rather than a gentle slope. In patients with chronic carbon dioxide retention, a target of 88 to 92 percent is deliberate, not an oversight.

Place the probe on a warm, well-perfused digit with the light source and detector facing each other, and confirm that the displayed pulse rate matches the pulse you palpate and that the waveform or signal-strength indicator looks convincing. A saturation reading attached to a heart rate that does not match the patient is not data.

That last row is a patient-safety issue, not a footnote. Occult hypoxemia — a true arterial saturation below 88 percent while the oximeter reads 92 to 96 percent — occurs several times more often in patients with darker skin. Combine that with the fact that cyanosis is harder to appreciate on darkly pigmented skin, and the two tools most likely to catch hypoxemia can fail together in the same patient. Assess the oral mucosa, tongue, conjunctivae, palms and soles, where cyanosis appears as a gray or ashen dullness; count the respiratory rate; listen to whether the patient can finish a sentence; and escalate on the clinical picture even when the number looks acceptable.

Section 5Blood Pressure, and Knowing When to Call

The technique that makes the number trustworthy

Blood pressure is the force the blood exerts against the arterial walls: the systolic peak during ventricular ejection and the diastolic trough during ventricular relaxation. It is determined by cardiac output and systemic vascular resistance, so it falls with hypovolemia, vasodilation and pump failure, and rises with volume overload, vasoconstriction and increased stroke volume. It is also the vital sign most easily corrupted by technique, and a corrupted blood pressure changes medication decisions.

Start with the cuff. The inflatable bladder width should be about 40 percent of the arm circumference at the midpoint of the upper arm, and the bladder length should encircle about 80 percent of the arm. A cuff that is too small requires more pressure to compress the artery and therefore reads falsely high — this is the single most common cause of a spurious hypertension diagnosis, and it happens constantly on patients with large arms. A cuff that is too large reads falsely low. Measure the arm or use the range printed on the cuff; do not eyeball it. If no cuff fits the upper arm, use a correctly sized cuff on the forearm with the radial artery auscultated, and document that you did.

Then prepare the patient. Five minutes of quiet rest, seated, back supported, feet flat on the floor, legs uncrossed, bladder empty, no caffeine or nicotine or exercise in the preceding 30 minutes, and no talking during the measurement — by the patient or by you. Bare the arm; a cuff over a sleeve reads falsely high. Support the arm at heart level, roughly the mid-sternum or fourth intercostal space. An arm hanging below heart level reads falsely high; an arm held above it reads falsely low. Avoid an arm with an arteriovenous fistula or graft, an intravenous infusion or PICC line, lymphedema or axillary node dissection, a cast, injury or paralysis. On first assessment measure both arms and use the higher; a persistent difference greater than 10 to 15 mm Hg between arms is abnormal, and a large acute difference raises the question of aortic dissection.

Now the measurement itself. Palpate the radial pulse and inflate until it disappears, note that number, and deflate fully; wait 30 to 60 seconds. Place the diaphragm (or bell) lightly over the brachial artery in the antecubital fossa, not under the cuff edge. Inflate to 20 to 30 mm Hg above the palpated systolic estimate. Deflate at 2 to 3 mm Hg per second — faster deflation systematically underestimates systolic and overestimates diastolic. The palpation step is not optional: it protects you from the auscultatory gap, a silent interval between the first and second Korotkoff phases seen in some patients with hypertension, which can make you record a systolic pressure 20 to 40 mm Hg too low if you inflated only until sounds vanished.

Automated oscillometric devices calculate systolic and diastolic values from the measured mean arterial pressure. They are accurate on stable patients with regular rhythms and unreliable in atrial fibrillation, tremor, shivering, severe hypotension and extremes of arm size. Any automated reading that would change management — especially a very low one — should be confirmed manually before you act on it.

Reading the number: categories, MAP, pulse pressure and orthostatics

A hypertensive crisis divides on symptoms. Hypertensive urgency is a pressure above 180/120 without evidence of target-organ damage: recheck after five minutes of rest, notify the provider, expect oral therapy and close follow-up. Hypertensive emergency is the same pressure with chest pain, dyspnea, neurologic change, visual change, severe headache, back pain or new oliguria, and it requires immediate intravenous therapy with the mean arterial pressure lowered by no more than about 25 percent in the first hour — dropping it faster can infarct the brain, heart or kidney.

Two derived numbers earn their place at the bedside. Mean arterial pressure approximates the average perfusion pressure across the cardiac cycle and is calculated as the diastolic plus one third of the pulse pressure; normal is 70 to 100 mm Hg, and a MAP below 65 is generally taken as the point at which organ perfusion is threatened. Pulse pressure is systolic minus diastolic, normally 30 to 40 mm Hg. A narrowing pulse pressure — below about 25 mm Hg, or less than 25 percent of the systolic — suggests falling stroke volume from hypovolemia, cardiac tamponade or heart failure, and it often narrows before the systolic pressure falls. A widening pulse pressure suggests arterial stiffening, aortic regurgitation, thyrotoxicosis or, in a head-injured patient, rising intracranial pressure. Cushing triad — rising systolic with a widening pulse pressure, bradycardia and irregular respirations — is a late and emergent sign of brain herniation.

Orthostatic vital signs test whether the patient can maintain pressure against gravity. Perform them when a patient reports dizziness on standing, has fallen, is on antihypertensives or diuretics, is suspected of bleeding or dehydration, or is starting to mobilize after prolonged bed rest. Technique: have the patient lie supine for at least five minutes, then measure blood pressure and heart rate. Assist the patient to sitting, wait one minute, repeat. Assist to standing, and measure at one minute and again at three minutes. Keep a chair behind the patient and a gait belt on; stop immediately and return the patient to bed if symptoms appear. The test is positive when, within three minutes of standing, the systolic falls by 20 mm Hg or more or the diastolic falls by 10 mm Hg or more. A heart-rate rise of 20 beats per minute or more supports volume depletion; a patient who drops pressure without raising the heart rate may have autonomic failure or be beta-blocked. Symptoms — lightheadedness, greying vision, near-syncope — are part of the result and belong in the note.

Charting it so it counts

A vital-sign entry has to let a nurse who has never met the patient reconstruct exactly what you measured, how, and what you did about it. That means values with units, the route or site, the position, the oxygen delivery, the comparison to the prior set, and the action taken. Compare these two entries describing the same patient.

Chart in the moment, not at the end of the shift; chart what you measured rather than what you concluded (“BP 96/54” rather than “BP soft”); never chart a value you did not personally obtain without naming who did; and never chart in advance. If a value is refused or cannot be obtained, say so and say why: “Rectal temperature declined by patient; temporal 37.9 °C obtained instead.”

Red flags and the SBAR call

Some numbers do not wait for the next scheduled set. Learn these as thresholds that trigger a call, and remember that any acute change from a patient’s own baseline can outrank an absolute value.

Escalate in SBAR, and have the chart and the last two sets of vital signs in front of you before you dial. A worked example for the febrile patient above:

S — Situation: “Dr. Nwosu, this is Priya Raman, RN, on 4 West. I’m calling about Mr. Delgado in room 412, a 68-year-old man admitted yesterday with pyelonephritis. His vital signs have changed significantly in the last four hours and I’m concerned he is becoming septic.”

B — Background: “He was admitted at 0900 yesterday, is on IV ceftriaxone, has a history of type 2 diabetes and benign prostatic hyperplasia. At 1000 today he was 37.2 degrees, heart rate 88, respirations 18, blood pressure 124/72, saturation 97 percent on room air.”

A — Assessment: “Right now he is 38.4 oral, heart rate 118 and regular, respirations 26, blood pressure 96/54, saturation 92 percent on room air, and he is more confused than this morning. His mean arterial pressure is 68. He meets all three qSOFA criteria — respiratory rate 26, systolic 96 and altered mentation — and that systolic is down 28 points from this morning. I think he is septic and starting to decompensate.”

R — Recommendation: “I would like you to come and see him now. I am requesting the sepsis order set: blood cultures times two, a lactate, a CBC and chemistry, and a 30 mL/kg crystalloid bolus. I have started oxygen at 2 liters and placed a second large-bore IV. Would you like me to activate the rapid response team while you are on your way? And how often would you like vital signs — I plan on every 15 minutes.”

Then close the loop. Read the orders back, document the time of the call and the response, and if the patient continues to deteriorate or the provider does not respond, move up the chain of command — charge nurse, rapid response team, nursing supervisor. A rapid response team may be activated by any nurse without a provider’s permission, and in most facilities by the patient or family as well.

Words worth knowing

THE HEALTH HISTORY AND THE THERAPEUTIC INTERVIEW

Almost everything you will ever know about a patient arrives first as words. Before you lay a stethoscope on a chest or press a fingertip into an abdomen, the patient tells you where it hurts, when it started, what they took for it, and what they are afraid it means — and study after study finds that the history alone points to the correct diagnosis in the large majority of cases. The interview is therefore not the polite preamble to the “real” assessment; it is assessment, and it is a skill with technique, sequence, and error modes exactly like auscultation has. This chapter teaches you how to prepare the room and yourself, how to open with a question that produces information instead of a yes, how to analyze a symptom with OLDCARTS or PQRSTU, how to move through a review of systems without turning it into an interrogation, how to adapt for a toddler, a teenager, an interpreter, or an eighty-eight-year-old with hearing aids in the drawer — and how to recognize the sentence in the middle of a history that means you stop asking questions and escalate.

Section 1Before You Speak: Preparing for the Interview

Preparing yourself and the room

The interview begins before you enter the room. Review what is already known — the chart, the admission note, the handoff you just received, the medication list, the last set of vital signs, the reason the patient is here. This is the preinteraction phase, and it exists so that you do not spend the patient’s energy asking for data that is already documented. A patient who has told four people in six hours that her mother died of breast cancer will not enjoy telling a fifth. Reviewing first also lets you enter with a hypothesis: if the handoff said “new onset atrial fibrillation,” you already know you will be asking about palpitations, alcohol, thyroid disease, and anticoagulation.

Then prepare the physical space, because environment is technique. Close the door or draw the curtain fully — a curtain that is half open is not privacy, it is theater. Silence or mute the television. Adjust the lighting so the patient can see your face, and position yourself so a light source is not behind you, which turns you into a silhouette. Set the room to a comfortable temperature and offer a blanket; a shivering, half-covered patient is thinking about their body, not your questions. If the patient uses glasses, hearing aids, or dentures, put them in before you begin. Removing the barriers to communication takes ninety seconds and improves the quality of every answer that follows.

Finally, prepare your own attention. Put the phone away or turn it face down. Decide before you start how much time you actually have and tell the patient the truth about it: “I have about fifteen minutes right now, and I want to use it on what matters most to you.” A bounded, honest interview earns more trust than an open-ended one you visibly abandon halfway through. If the patient is in significant pain, nauseated, or urgently needs the bathroom, address that first. Maslow applies to interviewing too — nobody gives a good family history while they need a bedpan.

The phases of the interview

The orientation phase (also called the introduction) is short and it is where credibility is established. Knock, wait, enter. Address the patient by their preferred name and title — ask, do not assume, and never default to “honey,” “sweetie,” or “buddy.” Introduce yourself with name and role: “Good morning, Mr. Alvarez. I’m Dana Whitfield, I’m the registered nurse caring for you until seven tonight.” State the purpose and the plan: “I’d like to ask you some questions about your health so we can plan your care, and then I’ll do a physical assessment.” Ask permission and confirm identity using two identifiers per your facility policy — typically full name and date of birth, checked against the armband, never the room number.

The working phase is the body of the interview: data collection, symptom analysis, and validation. It moves from open to focused. You begin broad (“Tell me what brought you in”), let the patient talk without interruption, then narrow into specific closed questions to fill the gaps (“Has the pain ever woken you from sleep?”). Beginners reverse this order and start firing closed questions, which produces a checklist of yes and no answers and misses the story. Resist the urge. Research on clinician behavior consistently finds that patients are interrupted within roughly eleven to twenty-three seconds of beginning to speak; if you simply stay quiet for sixty to ninety seconds, most patients will hand you the history unprompted.

The termination phase closes the loop. Summarize what you heard in your own words and ask the patient to correct you: “So the pressure in your chest started Tuesday, comes on when you climb stairs, goes away when you rest, and this morning it lasted longer than usual. Did I get that right?” This is not a courtesy — it is error checking, and it routinely catches misunderstandings. Then ask the highest-yield question in all of nursing: “Is there anything else you think I should know?” Tell the patient what happens next and when you will be back. Never end an interview by walking out mid-sentence; if you must leave, name it and give a return time.

Presence, positioning, and the therapeutic use of self

Sit down. A nurse who sits is perceived as having spent substantially more time in the room than a nurse who stands for the identical duration, and the patient discloses more. Sit at the patient’s eye level or slightly below — standing over a supine adult in a bed reproduces a power imbalance that suppresses disclosure. Keep an interpersonal distance of roughly four to five feet, about twice arm’s length, for the conversational portion; that is close enough for warmth and far enough that the patient does not feel cornered. Move into personal and intimate space only for the physical examination, and announce it first: “I’m going to listen to your lungs now, so I’ll be standing close behind you.”

Keep your posture open — uncrossed arms, hands visible, leaning slightly forward, feet toward the patient. Avoid barriers: do not conduct the interview from behind a computer workstation with your back to the bed. If you must chart during the conversation, angle the screen so the patient can see it, and tell them what you are doing: “I’m typing what you said so I get it right.” Eye contact should be comfortable and intermittent, not fixed staring; the culturally appropriate amount varies widely, and in some communities sustained direct eye contact from a younger person to an elder, or across genders, is read as disrespect rather than attentiveness. Follow the patient’s lead.

Therapeutic use of self means deliberately deploying your own presence — voice, pace, face, silence — as an instrument. Speak slightly slower and lower than feels natural. Match your affect roughly to the patient’s: brisk cheerfulness delivered to a frightened person reads as dismissal. Watch your own nonverbals, because patients read them ruthlessly; a nurse who winces at a wound teaches the patient that the wound is disgusting. And protect confidentiality actively, not passively. Under the HIPAA Privacy Rule you must apply reasonable safeguards to limit incidental disclosures, which in practice means you do not take a sexual history through a curtain in a semi-private room. (The separate minimum-necessary standard is about how much information you disclose to any given recipient, not about who can overhear you.) Ask visitors to step out for the sensitive portion — “I ask everyone’s family to step out for a few minutes so I can ask some private questions” — which normalizes the request and, crucially, does not tip off a controlling partner that this patient specifically is being screened.

Section 2Therapeutic Communication: What Opens a Patient Up and What Shuts Them Down

Techniques that open the conversation

Therapeutic communication is a set of named, teachable moves. Open-ended questions invite narrative and cannot be answered with one word: “Tell me about the pain,” “What has your breathing been like at home?” Start here for every new problem. Closed or direct questions pin down specifics and are appropriate later or in an emergency: “Are you allergic to any medication?” “What time did it start?” In a rapid response, closed questions dominate, and that is correct — technique follows acuity.

Silence is the most underused technique in nursing. After a hard question, wait at least three to five seconds. The pause feels enormous to you and normal to the patient, and it is where disclosures live. General leads (“Go on,” “Mm-hm,” “And then?”) keep a narrative moving without steering it. Restating and paraphrasing feed back content so the patient can confirm or correct: “So you stopped the water pill on your own two weeks ago.” Reflection feeds back feeling rather than content: “You sound frightened.” Clarification repairs vagueness — “When you say dizzy, do you mean the room spins, or you feel like you might pass out?” That single clarification separates vertigo from presyncope and changes the entire workup.

Focusing narrows a scattered account (“Let’s stay with the chest pressure for a moment”). Empathy statements name and legitimize the emotion without claiming to share it: “That sounds exhausting,” not “I know exactly how you feel.” Offering self supplies presence without promises: “I’ll sit with you for a few minutes.” Validation confirms that a concern is reasonable. Summarizing ends a segment and checks accuracy. Finally, gentle confrontation surfaces a discrepancy without accusation: “You’re telling me the pain is a two out of ten, and I notice you’re guarding your belly and sweating. Help me understand.”

Responses that close it down

Nontherapeutic responses are usually well-intended, which is exactly why they are hard to unlearn. False reassurance (“Don’t worry, everything will be fine”) ends the conversation and cannot be honored; you do not know that it will be fine. Giving advice substitutes your judgment for the patient’s and blocks problem solving; offer information instead. “Why” questions read as accusation — “Why did you stop taking your insulin?” puts the patient on trial, while “What made it hard to keep taking the insulin?” produces the real answer, which is often that a vial costs more than the electric bill.

Leading and biased questions supply the answer you expect (“You don’t drink much, do you?”) and reliably generate false negatives. Stacked questions — three at once — get one answer and you will not know which. Medical jargon produces polite nodding: patients routinely misinterpret “NPO,” “void,” “hypertension,” and “negative results.” Changing the subject, defensive responses, stereotyped comments (“Everything happens for a reason”), false agreement, and interrupting all communicate the same message: your story is not welcome here. Watch also for distancing language (“the gallbladder in 12B”) and elderspeak — the sing-song, over-loud, diminutive register used with older adults, which is associated with resistance to care and loss of dignity.

Hard conversations: anger, tears, silence, and sensitive topics

An angry patient is usually a frightened or powerless one. Do not match the volume. Keep your voice low and slow, maintain a safe exit path, acknowledge the feeling without conceding facts you do not know (“You’re angry that no one told you about the delay. That’s fair — let me find out what happened”), and set a clear behavioral limit if needed (“I want to help you and I need you to stop shouting so I can hear you”). If you feel unsafe, leave and get help; personal safety precedes data collection, always.

A crying patient does not need to be fixed. Stop talking, offer tissues, stay, and wait. “Take your time” is a complete intervention. Do not rush to the next question and do not leave the room to escape the discomfort. With an anxious patient, shorten sentences, ask one thing at a time, and orient frequently. With a withdrawn or depressed patient, expect long latency — count to five before rephrasing, and use simple open questions with generous pauses.

Sensitive topics — sexual health, substance use, intimate partner violence, incontinence, finances, spiritual distress — require three things: privacy, normalization, and a matter-of-fact tone. Normalize with a preamble: “I ask every patient these questions.” Ask permission: “Is it all right if I ask about your sexual health?” Use the patient’s own words back to them. Ask about behavior, not identity (“Do you have sex with men, women, or both?”), and ask about the specific act rather than assuming from a stated orientation. Keep your face neutral. If a patient declines, document the decline and revisit later — a refusal today is not a refusal forever.

When the barrier is language, hearing, vision, or cognition

For patients with limited English proficiency, use a qualified medical interpreter — in person, by video, or by phone. This is a legal obligation for facilities receiving federal funds under Title VI of the Civil Rights Act and Section 1557 of the Affordable Care Act, and it is a safety issue: ad hoc interpreters produce clinically significant errors at several times the rate of trained ones. Do not use family members, and never use a child. Speak to the patient, not the interpreter; use first person (“Where does it hurt?” not “Ask him where it hurts”); use short segments; allow extra time. Document the interpreter’s name or ID number and the modality used. A bilingual nurse must be formally qualified by the facility before interpreting.

For hearing loss, first check that hearing aids are in and working. Face the patient in good light, do not cover your mouth, lower your pitch rather than raising your volume (high frequencies are lost first in presbycusis), rephrase rather than simply repeating louder, and reduce background noise. Do not rely on lip reading — only a minority of English speech sounds are visible on the lips. For patients who are Deaf and use American Sign Language, ASL is a distinct language and a qualified ASL interpreter is required; writing notes is not an equivalent substitute. For vision loss, announce yourself on entering and before touching, describe what you are doing, and orient the patient to the room and call light.

For aphasia, distinguish the two patterns, because the nursing approach differs. In expressive (Broca) aphasia comprehension is relatively intact but output is effortful — give time, allow gestures, use yes/no or pointing questions, and never finish sentences unless the patient asks you to. In receptive (Wernicke) aphasia speech is fluent but the content is off and comprehension is impaired — use short concrete phrases, gestures, pictures, and demonstration. For dementia or delirium, interview in a calm environment, ask one simple question at a time, avoid open-ended abstraction, use closed questions, and obtain collateral history from a caregiver — while still directing questions to the patient first. Document the source and your judgment of reliability.

Section 3The Complete Health History, Component by Component

Biographic data, source, reliability, and the reason for seeking care

Biographic data anchors the record: full legal name, date of birth, age, sex assigned at birth and gender identity, pronouns, address and phone, occupation (present and past), preferred language, marital or partnership status, emergency contact, and insurance or payer if your facility collects it. Occupation is not administrative trivia — a forty-year history of grain dust, asbestos, or solvent exposure explains a chest film, and a night-shift schedule explains a hemoglobin A1c.

Source of history and reliability come next. Record who provided the information: the patient, a parent, a spouse, a group-home staff member, a prior record, or emergency medical services. A primary source is the patient; anything else is a secondary source. Then state whether the account seems reliable, and why. Reliability is not an insult — it is a flag for whoever reads your note next.

The reason for seeking care — historically called the chief complaint, increasingly called the chief concern — is a brief statement, ideally in the patient’s own quoted words, plus a duration. Write “‘My heart’s been flip-flopping since Saturday’ — 3 days,” not “atrial fibrillation.” The patient’s words are data; your diagnostic label is inference, and inference belongs later. Recording a label instead of the words is one of the most common and most consequential documentation errors students make, because it quietly closes the differential before anyone has examined the patient.

History of present illness, past health history, medications, and allergies

The history of present illness (HPI) is the chronological, detailed story of the current problem from the last time the patient felt well to now. It is built by symptom analysis, which Section 4 covers in full. It should include what the patient has already tried, what happened when they tried it, and their own theory of what is wrong — that last item takes ten seconds and frequently reveals the actual reason they came in (“My brother had the exact same thing and it was his heart”).

Past health history covers childhood illnesses; chronic conditions with dates of diagnosis; hospitalizations and surgeries with dates and facilities; injuries and accidents; blood transfusions; immunization status (including influenza, COVID-19, tetanus/Tdap, pneumococcal, shingles, and HPV as age-appropriate); most recent screening tests and examinations; and, for patients who can become pregnant, an obstetric history. Obstetric history is commonly recorded as GTPAL — Gravida (total pregnancies), Term births (37 weeks 0 days or later), Preterm births (20 weeks 0 days through 36 weeks 6 days), Abortions or losses before 20 weeks, and Living children.

Medication reconciliation is a required, high-risk task. Ask the patient to name every prescription, over-the-counter product, vitamin, herbal supplement, inhaler, eye drop, patch, injectable, and “as needed” medication — and ask about each category explicitly, because patients almost never volunteer eye drops, topicals, or supplements when asked “what medications do you take?” For each, capture drug, dose, route, frequency, indication, and when the last dose was actually taken, which is often not what the label says. Ask about sharing or borrowing medications, and ask about cost as a barrier without judgment. The best practice is to have the patient or family bring in the actual bottles.

Allergies require the reaction, not just the name. “Allergic to penicillin” is nearly useless; “Penicillin — hives and lip swelling within 1 hour, age 22, required epinephrine” is actionable, and “Penicillin — upset stomach as a child” describes an intolerance, not an allergy. That distinction changes antibiotic choice and patient outcomes. Ask separately about food, latex, contrast media, tape and adhesives, and environmental allergens. Document severity and the date of the reaction.

Family history and the genogram

Family history looks for heritable and familial risk across at least three generations — the patient, siblings and children, parents, and grandparents. Ask about age and cause of death for deceased relatives and current age and health for living ones. Screen specifically for cardiovascular disease and early sudden cardiac death, hypertension, stroke, diabetes, cancers (with the organ and the age at diagnosis), kidney disease, seizure disorders, mental illness and suicide, substance use disorder, tuberculosis, and known genetic conditions such as sickle cell disease, cystic fibrosis, or hemophilia.

Age at diagnosis is the part students skip and the part that matters most. A father with a myocardial infarction at 78 is unremarkable; a father with a myocardial infarction at 44 is a premature-family-history risk factor that changes lipid management. Breast cancer in a grandmother at 80 is different from breast cancer in a sister at 35, which may prompt genetic counseling. Bilateral, multiple-primary, or male breast cancer, and clusters of breast with ovarian or pancreatic cancer, raise concern for inherited susceptibility.

A genogram is the drawn version of this: squares for males, circles for females, a diamond when sex is unknown, a slash through the symbol for deceased with the age and cause noted, horizontal lines for partnerships, vertical lines for offspring, and the patient marked with an arrow. It compresses three generations into an image you can read in five seconds and is far more useful at a glance than a paragraph. Also ask about family environment and shared exposures — household smoking, water source, occupational exposures, and who the patient can actually call at two in the morning.

Functional assessment and perception of health

Functional assessment asks what the patient can do, not what is wrong with them, and it is what determines whether discharge is safe. Assess activities of daily living (ADLs) — bathing, dressing, toileting, transferring, continence, and feeding — and instrumental activities of daily living (IADLs) — managing medications, managing money, shopping, cooking, housekeeping, laundry, using the telephone, and transportation. Ask about assistive devices, who helps and how often, and what has changed in the last six months. A patient who could climb their porch steps in March and cannot in June has a story worth chasing.

Extend into the domains that predict outcomes: nutrition (a 24-hour dietary recall, appetite change, unintentional weight loss, food access, chewing and swallowing, dentition); elimination patterns; sleep and rest (hours, insomnia, snoring, witnessed apnea, daytime somnolence); activity and exercise; substance use including tobacco, vaping, alcohol, cannabis, and other drugs, quantified honestly (“How many days a week do you have a drink? On those days, how many?”); sexual health; occupational and environmental hazards; coping and stress; social supports; spiritual and cultural practices that affect care; and advance directives and health care proxy.

Screen for social drivers of health deliberately, because they are more predictive of readmission than most laboratory values: housing stability, food security, transportation, utilities, interpersonal safety, literacy, and ability to afford medications. Ask plainly — “In the last twelve months, did you worry that your food would run out before you got money to buy more?” Close the history with the patient’s perception of health: “How would you describe your health? What do you think is going on? What are you hoping we can do?” Self-rated health is a startlingly strong predictor of outcomes, and the answer tells you exactly where to aim your teaching.

Section 4Symptom Analysis, the Review of Systems, and the Bridge to the Physical Exam

Analyzing a symptom: OLDCARTS and PQRSTU

Every symptom — pain, cough, dizziness, nausea, a rash, palpitations, fatigue — gets the same systematic dissection. Two mnemonics dominate. OLDCARTS: Onset (when did it start, sudden or gradual, what were you doing), Location (point to it with one finger), Duration (how long does an episode last, is it constant or intermittent), Characteristics (in your words — sharp, crushing, burning, tearing), Aggravating and associated factors (what makes it worse; what else happens with it), Relieving factors and radiation (what helps; does it travel), Timing and treatment (pattern across the day; what have you already taken), Severity (0 to 10, and what it stops you from doing).

PQRSTU covers the same ground with a different handle: Provocative and palliative, Quality, Region and radiation, Severity, Timing, and Understanding — the patient’s own interpretation and the impact on daily life. Use whichever your program teaches; use it every single time, including at three in the morning, because completeness is what makes the pattern visible. The character of chest pain distinguishes pleuritic from ischemic; the radiation of flank pain to the groin suggests a ureteral stone; a sudden “thunderclap” onset of the worst headache of a person’s life is a subarachnoid hemorrhage until proven otherwise.

Two additions elevate a student history to a professional one. First, always ask what makes it better or worse in behavioral terms — not just “does anything help” but “does leaning forward help, does eating make it worse, does it wake you at night.” Second, always capture pertinent negatives: the symptoms you deliberately asked about and the patient denies. “Denies fever, cough, hemoptysis, leg swelling, or recent travel” in a patient with chest pain proves you thought about pneumonia and pulmonary embolism. Absent findings, documented, are evidence of clinical reasoning.

The review of systems

The review of systems (ROS) is a head-to-toe screen of subjective symptoms, by body system, to catch problems the patient did not think to mention. It is entirely questions — nothing you observe belongs here. Move in a fixed order so you do not skip a system: general, integumentary, head and neck, eyes, ears, nose and sinuses, mouth and throat, respiratory, cardiovascular, peripheral vascular, gastrointestinal, genitourinary, sexual and reproductive, musculoskeletal, neurologic, hematologic, endocrine, and psychiatric.

Use plain language. Ask “Any trouble swallowing?” not “Any dysphagia?” Ask “Do you ever leak urine when you cough or laugh?” rather than “Any stress incontinence?” A complete ROS is appropriate for a comprehensive admission history; for a focused or emergency assessment, review the system involved plus the systems immediately adjacent to it. Whichever you do, document which it was — “Focused ROS, cardiopulmonary” is honest; implying a complete ROS you did not perform is a documentation integrity problem.

Certain ROS answers are not merely positive — they are stop-signs. Learn them as a set, because they arrive in the middle of an otherwise routine conversation and your job is to recognize them in real time.

Subjective, objective, and the handoff to the physical examination

Subjective data is what the patient (or a proxy) reports — symptoms, feelings, perceptions, history. It cannot be observed by anyone else and is documented as reported: “Pt reports…”, “Pt states…”, “Pt denies…”, or in direct quotation. Objective data is what you observe, measure, or elicit — vital signs, a wound’s dimensions, lung sounds, a laboratory value, an observed limp. Nausea is subjective; emesis of 200 mL of coffee-ground fluid is objective. Pain is uniquely both: the reported score is subjective and is charted as the patient states it, while guarding, grimacing, tachycardia, and diaphoresis are objective corroboration. You never override a reported pain score with your own impression.

When the history is complete, you move to the physical examination, and the sequence there is fixed: inspection, palpation, percussion, auscultation. Inspect first because touching changes what you will see and because looking costs nothing. Palpate second, light before deep, warm hands, painful areas last. Percuss third to assess density and organ borders. Auscultate fourth. Work in an organized head-to-toe order, compare side to side for symmetry, and expose only the region being examined.

There is exactly one region where this order changes, and you must know it cold. For the abdomen, the sequence is inspect, auscultate, percuss, palpate. Auscultation moves ahead of percussion and palpation because manipulating the abdominal wall alters bowel motility and therefore falsifies the bowel sounds you are about to grade. Listen before you touch, in all four quadrants, before percussing or palpating anything. Examine any area the patient identifies as painful last, and stop deep palpation entirely if there is rigidity, rebound, or a known or suspected abdominal aortic aneurysm.

The history also tells you what to expect from the vital signs and how hard to worry when they deviate. Know the adult numbers exactly, and know how they shift across the lifespan, because “a heart rate of 130” is a red flag in an adult that demands an immediate search for a cause, and is unremarkable in a well six-month-old.

Adult oral temperature normally runs 36.5–37.5 °C (97.7–99.5 °F); rectal readings average about 0.5 °C higher and axillary about 0.5 °C lower. Fever in an adult is generally defined at 38.0 °C (100.4 °F) or above. Older adults run a lower baseline, often 35.8–36.6 °C, and may mount no fever at all with serious infection — a single oral temperature of 37.8 °C (100 °F), repeated readings above 37.2 °C (99 °F), or a rise of 1.1 °C (2 °F) over that patient’s own baseline should be treated as fever. Oxygen saturation is 95–100 percent on room air for most adults; patients with chronic carbon-dioxide retention are often targeted to 88–92 percent, so know the ordered target before you adjust anything. Be aware that pulse oximeters can overestimate true arterial saturation in patients with darker skin pigmentation, producing occult hypoxemia — a normal-looking reading in a patient who is genuinely hypoxic. Never let the number override the patient: work of breathing, respiratory rate, mental status, and the patient’s own report of breathlessness come first, and a reading that does not match the patient warrants a repeat on a different site and escalation.

Section 5Lifespan, Culture, Risk Screening, Charting, and Escalation

Adapting across the lifespan

For infants, the history comes entirely from the caregiver and includes prenatal, birth, and neonatal history — gestational age, complications, delivery mode, birth weight, newborn screening, feeding method and volumes, wet diapers per day, sleep position, and developmental milestones. Perform the least invasive parts of any assessment while the infant is calm and in the caregiver’s arms.

Toddlers and preschoolers think concretely and magically; they may believe illness is punishment. Get to eye level, use short words, allow a security object, and offer limited real choices (“left arm or right arm?” — never “may I?” for something that is not optional). Avoid frightening literalisms: “take your blood pressure” and “shot” and “put you to sleep” are heard exactly as spoken. School-age children can give substantial history themselves and want a mechanical explanation; ask them first, then verify with the caregiver.

Adolescents must be given time alone with the clinician. Explain confidentiality and its legal limits up front — you will keep what they say private except where there is risk of harm to themselves or others, or abuse. Use the HEEADSSS framework: Home, Education and employment, Eating, Activities, Drugs, Sexuality, Suicide and depression, and Safety, moving from least to most sensitive. In pregnancy, add GTPAL, prenatal care, fetal movement, and the preeclampsia symptom set. For older adults, allow more time, ask about function and falls, review polypharmacy and who fills the pillbox, screen for cognition and mood, and ask about caregiver strain and elder mistreatment — privately. Do not shout; do not use elderspeak; do not assume confusion until you have ruled out hearing loss, delirium, pain, and hypoxia.

Cultural humility, and findings across skin tones

Cultural humility is a posture, not a body of memorized facts: you assume you do not know this patient’s beliefs and you ask. Useful questions include “What do you think caused this?”, “What do you call it?”, “What have you already tried, including home or traditional remedies?”, and “Who in your family helps make health decisions?” Ask about fasting, dietary law, modesty and same-gender caregiver preferences, and practices around touch, blood products, and end of life. Never generalize from an ethnic label to an individual’s beliefs.

Skin tone changes how findings appear, and describing every abnormality as “redness” is both inaccurate and a documented source of missed pressure injuries and missed hypoxia in patients with darker skin. Assess in natural or bright white light, compare with the patient’s own baseline and adjacent skin, and always use the mucous membranes and palms as a check.

Screening for risk, and the red flags that stop the interview

Several validated screens belong in the history. The PHQ-2 asks about depressed mood and anhedonia over two weeks; a score of 3 or more is positive and should be followed by the PHQ-9. Any positive response to item 9 of the PHQ-9, or any spontaneous statement about wanting to die, triggers a direct suicide risk assessment — ask plainly (“Are you having thoughts of killing yourself?”), then ask about plan, means, timeline, and intent. Asking does not plant the idea; the evidence is clear on this. AUDIT-C screens alcohol use (positive at 4 or more for men, 3 or more for women); the CAGE questionnaire is positive at 2 or more. Screen for intimate partner violence privately, with the partner out of the room, using a brief tool such as HITS, and know your state’s mandatory reporting law for children, dependent adults, and elders.

Some statements end the data-collection phase immediately. Recognize them and act: chest pressure with diaphoresis, dyspnea, or radiation to the jaw or arm; sudden severe headache described as the worst of the patient’s life; new facial droop, one-sided weakness, or speech change (get the last-known-well time before anything else); airway symptoms after a new medication — lip or tongue swelling, throat tightness, stridor, hives; hematemesis, melena, or syncope; suicidal or homicidal ideation with plan or means; disclosure of abuse with immediate danger; and any patient who says they feel a sense of impending doom — which is a genuine clinical sign, not an anxiety symptom, until you have proven otherwise. One tier below these, but still requiring that you notify the provider before the shift moves on rather than charting it and continuing, is a missed dose of insulin, anticoagulant, antiepileptic, or antirejection medication.

Charting the history and escalating with SBAR

Documentation of a history has four requirements: it is timely, objective in tone, specific in measurement, and attributed to a source. Quote the patient for the reason for seeking care and for anything clinically or legally significant. Use “reports,” “states,” and “denies” rather than “complains of,” which reads as judgment. Never chart opinion about character (“drug seeking,” “uncooperative,” “poor historian”); chart the behavior you observed instead. Never chart care before it is given, never chart for another person, and correct errors according to policy — single line, initial, date, addendum — never by erasing or deleting.

When you escalate, use SBAR, and have the chart, the last vital signs, and the medication list in front of you before you dial. Situation: “This is Dana Whitfield, RN, on 4 East calling about Mr. Alvarez in room 412. He has new chest pressure that started 30 minutes ago.” Background: “He’s a 62-year-old admitted yesterday for cellulitis, with a history of type 2 diabetes, hypertension, and a father who died of a myocardial infarction at 51. He’s on metformin and lisinopril, no anticoagulation.” Assessment: “Blood pressure 148/92, heart rate 104 and regular, respirations 24, oxygen saturation 94 percent on room air, temperature 36.8. He’s diaphoretic and describes 7 out of 10 pressure radiating to his jaw. I think this is cardiac.” Recommendation: “I’d like a 12-lead ECG now, cardiac markers, and an order for aspirin. Can you come see him, or should I activate rapid response?” Then read back any orders you receive, and document the call with the time, the person notified, and the response.

Delegation and scope

Interviewing is a professional nursing act. The registered nurse performs the initial and ongoing assessment, analyzes the data, formulates nursing diagnoses, teaches, evaluates responses to interventions, and manages unstable patients. None of that may be delegated. In particular, the health history, the interpretation of a symptom, the suicide risk assessment, patient education, and any judgment about reliability or acuity stay with the RN. Delegation follows the five rights — right task, right circumstance, right person, right direction and communication, right supervision and evaluation — and the RN who delegates retains accountability for the outcome.

Unlicensed assistive personnel may perform standardized, predictable tasks on stable patients: obtaining and recording routine vital signs, height and weight, intake and output, capillary blood glucose where policy allows, bathing, feeding, ambulating, and positioning. UAP may — and should — report what a patient told them, and you should ask them what they noticed; their observations are valuable raw data that you then interpret. What UAP may not do is collect the history, decide what a symptom means, teach the patient, evaluate the effect of an intervention, or take vital signs on an unstable patient whose readings will drive an immediate decision. Give explicit parameters when you delegate: “Please take Mr. Alvarez’s vital signs now and tell me right away if his heart rate is over 110, his systolic is under 100, or his oxygen saturation is under 92.” A licensed practical or vocational nurse can gather focused data and reinforce teaching within state scope, but the comprehensive assessment and the care plan remain the RN’s.

Words worth knowing

General Survey, Pain and Mental Status

Before you place a stethoscope on anyone, you have already collected data. The way a patient sits, whether they finish a sentence without stopping for air, whether they are groomed, whether they meet your eye, whether they shift and wince when they move — all of it is assessment, and all of it is chartable. This chapter teaches the three assessments that frame every other examination in this book: the general survey, the systematic first impression; the pain assessment, which is a symptom only the patient can define and which nurses have historically undertreated; and the mental status assessment, where a change of a single point is often the earliest sign that a patient is deteriorating. You will also learn the four physical examination techniques — inspection, palpation, percussion, auscultation — and the one body region where that order deliberately changes. Get these right and the rest of the head-to-toe becomes a confirmation of what you already suspected.

Section 1The General Survey and the Four Techniques

What the general survey is, and the four domains you scan

The general survey is a deliberate, structured first impression. It is not “eyeballing” the patient. It is a scan that you perform the same way on every patient so that when something is different, you notice it. It begins the moment the patient is in your field of view — in the doorway, in the hallway, in the waiting room — and it continues while you introduce yourself, wash your hands and take vital signs. Experienced nurses do this in under a minute and can tell you, before the monitor is attached, roughly how sick the person is. That skill is not intuition. It is a checklist run so many times that it has become automatic, and you build it by running the checklist consciously until it is.

Scan four domains, always in the same order. Physical appearance: apparent age compared with stated age, level of consciousness, skin color and condition, facial expression and symmetry, hygiene and grooming, dress appropriate to the setting and the weather, and any odor (ketones, alcohol, urine, infected wound, poor hygiene). Body structure: height and build, apparent nutritional state, symmetry of the body, posture, and any obvious deformity, amputation, edema or muscle wasting. Mobility: gait, use of assistive devices, range of motion, how the patient moves from chair to bed, and any involuntary movement such as tremor, tic or restlessness. Behavior: eye contact, facial expression, mood and affect, speech (rate, volume, clarity, articulation), and the relationship between the patient and anyone accompanying them.

Two survey findings deserve special naming because they carry so much weight. Tripod positioning — the patient sitting leaning forward with arms braced on knees or a bedside table — means the patient is recruiting accessory muscles to breathe and should never be laid flat “so you can examine them.” And the number of words a patient can say between breaths is a bedside respiratory measurement you can chart: full sentences, three-to-four-word phrases, or single words. A patient who was speaking in full sentences at 0800 and is speaking in three-word phrases at 1200 has deteriorated, even if the recorded respiratory rate has not changed.

The four techniques, and the order that changes

Every physical examination in this book is built from four techniques, performed in this sequence: inspection, palpation, percussion, auscultation. The logic is that each technique is progressively more disruptive, so the least invasive information is gathered while the body is still undisturbed. There is one deliberate exception. For the abdomen, the sequence is inspect, auscultate, percuss, palpate. Percussing and palpating the abdomen mechanically stimulates the bowel and alters bowel sounds, so listening must happen before you touch. Say that exception out loud until it is reflex, because it is one of the most commonly missed items on both exams and clinical checkoffs — and a nurse who palpates first and then reports “hyperactive bowel sounds” has reported an artifact they created.

Inspection is purposeful looking. Provide adequate light — natural daylight is best, especially for assessing color in darker skin tones — expose only the area being examined, keep the room warm, and compare the side you are examining with its opposite. Inspect before you touch, and give it real time; most nurses under-inspect. Colour findings must be judged where pigment cannot hide them, in every patient and not only in patients with dark skin: look at the oral mucosa and tongue, the palpebral conjunctivae, the lips and nail beds, and the palms and soles. Cyanosis is not reliably “blue” — in richly pigmented skin it shows as grey, ashen or dull darkening, and it is confirmed at the tongue, oral mucosa and conjunctivae rather than at the fingertips. Pallor appears as ash-grey or yellow-brown skin with pale conjunctivae, pale palms and pale mucous membranes. Jaundice is judged at the sclera next to the iris, the hard palate, and the palms and soles, remembering that harmless subconjunctival fat can look yellow in darkly pigmented patients. Erythema and inflammation are frequently invisible in dark skin, so palpate for warmth, induration, tightness and tenderness and compare with the opposite side instead of looking for redness — relying on redness alone is exactly how early pressure injury and cellulitis are missed in patients with dark skin. Palpation uses different parts of the hand for different jobs: finger pads for texture, moisture, pulsation, masses and edema; the dorsum (back) of the hand for temperature, because it is thinner and more sensitive to heat; the ulnar surface and base of the fingers for vibration such as tactile fremitus and thrills. Light palpation depresses the tissue about 1 to 2 cm; deep palpation depresses about 4 to 5 cm and is done with one hand or with two hands stacked. Warm your hands, keep nails short, start light, and palpate tender or painful areas last.

Percussion produces sound that tells you what lies beneath. Hyperextend the middle finger of your non-dominant hand (the pleximeter), press its distal joint firmly against the skin, and keep your other fingers off the surface so they do not damp the vibration. Strike the pleximeter at the distal interphalangeal joint with the tip of your dominant middle finger (the plexor), using a quick, sharp motion from the wrist, two taps, then withdraw immediately. Learn five tones: tympany (drumlike, over the gastric bubble and intestine), resonance (hollow, over normal lung), hyperresonance (booming, over hyperinflated lung as in emphysema or pneumothorax), dullness (thudlike, over liver, spleen, a full bladder or consolidated lung), and flatness (very dull, over muscle and bone). Auscultation uses the diaphragm for high-pitched sounds (breath sounds, bowel sounds, normal S1 and S2) pressed firmly against skin, and the bell for low-pitched sounds (extra heart sounds S3 and S4, the murmur of mitral stenosis, bruits) rested lightly, because pressing the bell hard turns it into a diaphragm. Never auscultate through clothing, and clean the stethoscope with alcohol before and after every patient.

Height, weight, BMI and the numbers that matter

Measure, do not ask. Reported heights and weights are consistently wrong, and in a patient receiving weight-based medications such as heparin, vancomycin or chemotherapy, a guessed weight is a medication error waiting to happen. Weigh adults on the same scale, at the same time of day, in similar clothing, and record in kilograms because that is the unit drug calculations use. For daily weights — the single most sensitive measure of fluid status in heart failure and renal disease — weigh before breakfast, after voiding, in the same gown. A gain of 1 kg corresponds to roughly 1 litre of retained fluid; a gain of more than 1 kg (about 2 lb) in 24 hours or 2.3 kg (about 5 lb) in a week is a reportable finding in a heart failure patient.

Body mass index (BMI) is weight in kilograms divided by height in metres squared. Adult categories: underweight below 18.5; healthy weight 18.5 to 24.9; overweight 25.0 to 29.9; obesity class I 30.0 to 34.9, class II 35.0 to 39.9, class III 40.0 and above. BMI is a screening number, not a diagnosis: it does not distinguish muscle from fat, and it misclassifies very muscular patients, patients with large amounts of ascites or edema, and older adults who have lost lean mass. Pair it with waist circumference, measured at the top of the iliac crest at the end of a normal exhalation; greater than 102 cm (40 in) in men and greater than 88 cm (35 in) in non-pregnant women indicates increased cardiometabolic risk. Unintentional weight loss is significant at greater than 5 percent of body weight in one month or greater than 10 percent in six months, and it should trigger a nutrition referral and a search for cause.

Measurement changes across the lifespan. Infants and children under 24 months are measured as recumbent length on a length board with two people, weighed nude on an infant scale in kilograms, and have head circumference measured at the widest point (just above the eyebrows and around the occipital prominence) at every well visit through 24 to 36 months. All three are plotted on growth charts; a single point means little, but a child who crosses two major percentile lines downward is a concern. In children aged 2 to 20, BMI is interpreted as a percentile for age and sex: underweight below the 5th, healthy 5th to 84th, overweight 85th to 94th, obesity at or above the 95th. In pregnancy, recommended total weight gain depends on pre-pregnancy BMI: 12.5 to 18 kg (28 to 40 lb) if underweight, 11.5 to 16 kg (25 to 35 lb) if healthy weight, 7 to 11.5 kg (15 to 25 lb) if overweight, and 5 to 9 kg (11 to 20 lb) if obese. Older adults lose roughly 1 cm of height per decade after age 40 from disc compression and vertebral change, so a measured height noticeably below the patient’s historic height may reflect osteoporotic vertebral compression fractures rather than measurement error.

Section 2Pain: the Symptom Only the Patient Can Define

The ethical baseline and why pain is measured, not judged

Margo McCaffery’s working definition remains the standard of nursing practice: pain is whatever the experiencing person says it is, existing whenever they say it does. That sentence is not sentiment, it is a rule of practice. Pain is a subjective symptom with no laboratory value and no imaging study that confirms it. Your job is to measure it — consistently, with a validated tool, in the patient’s own words — and to act on the measurement. Your job is not to decide whether the number is deserved. Documented undertreatment of pain in Black and Hispanic patients, in women, in older adults, in patients with substance use disorders and in patients who cannot speak English is one of the best-established disparities in health care. It happens through exactly the mechanism you are guarding against: a clinician substitutes their own judgment for the patient’s report.

Two clinical facts protect patients from that error. First, vital signs do not confirm or refute pain. Acute pain often raises heart rate, blood pressure and respiratory rate and can cause diaphoresis and pupil dilation, but those responses adapt within hours to days. A patient with chronic pain or long-standing severe pain frequently has entirely normal vital signs. Never chart “pain rated 8 out of 10 but vital signs stable, appears comfortable” as if the second half undermines the first. Second, behavior is not a lie detector. Patients smile, joke, watch television and sleep through severe pain; sleep is a coping behavior and an exhausted patient may sleep at a pain score of 8. Chart what you observe alongside what the patient reports, without editorializing.

Use a professional interpreter for any patient with limited English proficiency — never a family member, never a child — and remember that pain expression is culturally patterned. Some patients are raised to bear pain silently and view complaint as weakness; others express pain loudly as a normal signal for help. Neither pattern tells you anything about the intensity of the pain. Ask, in the patient’s language, what word they use for pain: hurt, ache, sore, pressure, discomfort, burning, tight. Patients frequently deny “pain” and then agree readily to “pressure” or “soreness.”

PQRSTU and OLDCARTES: the actual questions

Two mnemonics organize the full symptom analysis, and either is acceptable. PQRSTU: Provocation and palliation — “What brings it on? What makes it better? What makes it worse?” Quality — “Describe the pain in your own words” (ask open-ended first; only offer descriptors such as burning, stabbing, aching, cramping if the patient cannot generate any). Region and radiation — “Point to it with one finger. Does it travel anywhere?” Severity — a number on a validated scale, both now and at its worst and best in the last 24 hours. Timing — onset, duration, frequency, constant or intermittent, and what the patient was doing when it started. Understanding and effect on you — “What do you think is causing it? What can you not do because of it? What is an acceptable level of pain for you?”

OLDCARTES covers the same ground in a different order: Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Treatments tried, Effect on daily life, Severity. The two elements students most often skip are also the two that most change the plan of care: treatments already tried (including what worked at home, over-the-counter drugs, heat, ice, position, cannabis, herbal preparations and prayer) and the patient’s functional goal. “Zero out of ten” is rarely a realistic postoperative goal; “a 3, so I can get up and walk to the bathroom” is a goal you can actually work toward and evaluate against, and it is what belongs in the care plan.

Ask about pain at more than one moment. A patient at rest may report 2 out of 10 and then report 8 out of 10 on standing; incident pain, or pain with movement, is what actually determines whether the patient will ambulate, cough, deep-breathe and avoid pneumonia and venous thromboembolism. Chart both: “3/10 at rest, 8/10 with ambulation.” Also screen for the effect of pain on sleep, appetite, mood, concentration and relationships, because unrelieved pain drives delirium, depression and functional decline, and because those effects justify escalating the plan when a number alone does not persuade a prescriber.

Choosing the right pain scale

Self-report is always the gold standard, so the first question is whether the patient can self-report. If yes, choose a self-report tool matched to development, literacy and language. If no — a preverbal infant, an intubated critically ill adult, a patient with advanced dementia, a patient with a profound intellectual disability — you must use a validated observational tool, and you must not record “denies pain” for a patient who cannot answer. In that situation the sequence is: attempt self-report; look for an obvious cause of pain (surgery, fracture, wound care, positioning, a full bladder); observe behavior with a validated scale; ask a family member or regular caregiver what this person looks like when they hurt; and, when there is a plausible cause, consider an analgesic trial with reassessment of behavior.

Types of pain, reassessment and opioid safety

Classify pain by mechanism, because the words the patient uses point to the treatment. Nociceptive somatic pain arises from skin, muscle, bone and joint; it is well localized and described as aching, throbbing, sharp or gnawing — a fracture, a surgical incision, a pressure injury. Nociceptive visceral pain arises from organs; it is poorly localized, deep, squeezing, cramping or pressure-like, often with nausea and diaphoresis, and it refers to predictable places — diaphragmatic irritation to the shoulder tip, cardiac ischemia to the jaw, left arm, or between the shoulder blades, biliary colic to the right scapula, renal colic from flank to groin. Neuropathic pain arises from damaged nerve tissue; it is burning, shooting, electric, stabbing, or accompanied by numbness, tingling and hypersensitivity to light touch, and it responds poorly to opioids and better to agents such as gabapentin, pregabalin and duloxetine. When a patient says “it feels like electricity” or “the sheet hurts my feet,” those exact words belong in your note because they change the prescription.

Also classify by duration. Acute pain has an identifiable cause, is expected to resolve as tissue heals, and is protective. Chronic (persistent) pain continues beyond expected healing, commonly defined as more than 3 months, is no longer protective, and reshapes sleep, mood and function. Breakthrough pain is a transient flare above otherwise controlled baseline pain and requires a short-acting rescue dose, not a change in the long-acting regimen. Cancer pain and end-of-life pain often combine all of these. And know that pain unrelieved by the ordered regimen is itself a finding to escalate — not a reason to wait for the next scheduled dose.

Reassess after every intervention. The general standard, which your facility policy will specify precisely: reassess roughly 15 to 30 minutes after an intravenous analgesic, 30 to 60 minutes after intramuscular or subcutaneous, and about 60 minutes after an oral dose. An intervention that is not reassessed is not documented care. Reassessment includes the pain score, the patient’s function (did they get up, cough, sleep), and a sedation and respiratory check for any opioid.

The single most important opioid safety concept is this: sedation precedes respiratory depression. By the time the respiratory rate falls, the patient has already been over-sedated for some time. Monitor sedation with a validated tool, most commonly the Pasero Opioid-Induced Sedation Scale (POSS): S — sleep, easy to arouse (acceptable); 1 — awake and alert (acceptable); 2 — slightly drowsy, easily aroused (acceptable, continue to monitor); 3 — frequently drowsy, arousable but drifts off to sleep during conversation (unacceptable: hold or reduce the opioid dose, typically by 25 to 50 percent per order, monitor sedation and respiratory status closely, add supplemental oxygen only per protocol, notify the prescriber); 4 — somnolent, minimal or no response to verbal or physical stimulation (unacceptable and an emergency: stop the opioid, stay with the patient, call for help and rapid response, prepare naloxone, support airway and breathing). Do not confuse POSS with the Richmond Agitation-Sedation Scale (RASS), which measures sedation and agitation for a different purpose in critical care.

Section 3Mental Status and Level of Consciousness

Level of consciousness: AVPU, RASS and the Glasgow Coma Scale

Level of consciousness (LOC) is the most sensitive single indicator of neurologic change, and it is the finding that most often deteriorates first when a patient is becoming hypoxic, septic, hypoglycemic or bleeding into the head. Describe it behaviorally, not with a label. “Lethargic” means different things to different nurses; “opens eyes to loud voice, answers name correctly, falls back asleep within 10 seconds” means the same thing to everyone. The traditional descriptive ladder runs alert, lethargic (drowsy but rousable to voice), obtunded (rousable with difficulty, limited responses), stuporous (rousable only with vigorous or painful stimulus), and comatose (no rousable response). Use those words if your unit does, but always add the behavior.

AVPU is the fast field screen: Alert, responds to Voice, responds to Pain (a central stimulus — trapezius pinch, supraorbital ridge pressure or, where your facility permits it, mandibular pressure — applied only when needed and for no more than about 10 seconds; fingertip pressure on the nail bed is a peripheral stimulus — it is the standard opening stimulus for eye opening and limb response on the GCS, but because a limb can pull away by spinal reflex it cannot establish localization or, by itself, the P of AVPU, so escalate to a central stimulus before you call a patient unresponsive; the sternal rub is no longer recommended, because it bruises and abrades the skin without adding information), Unresponsive. It is quick and coarse, and it belongs in a rapid response or a first look, not in an ongoing neurologic flowsheet. RASS, the Richmond Agitation-Sedation Scale, runs from +4 (combative, violent) through 0 (alert and calm) to −5 (unarousable, no response to voice or physical stimulation); most sedated critical care patients are targeted at 0 to −2. RASS is also the level-of-consciousness input for delirium screening.

The Glasgow Coma Scale scores three independent responses and reports them separately as well as summed — document “E3 V4 M5 = GCS 12,” because the components carry information that the total hides. Always score the best response obtained, and score the best side for motor. Interpretation: 13 to 15 mild, 9 to 12 moderate, 8 or less severe brain injury — and a GCS of 8 or less is the classic threshold at which the airway is considered unprotected and intubation is anticipated (“less than 8, intubate”). The lowest possible score is 3, not 0. If a component cannot be tested — an intubated patient has no testable verbal response, a swollen orbit no testable eye opening — record it as not testable rather than guessing a 1. A drop of 2 or more points is an emergency, and so is any new asymmetry between sides.

Pair LOC with pupils. Normal adult pupils are round, equal and roughly 3 to 5 mm in ambient room light (2 to 6 mm is the usual range — larger in young patients and in a darkened room, smaller in older adults), and briskly reactive to light both directly and consensually — charted as PERRLA. New unequal pupils (anisocoria greater than 1 mm), a sluggish or fixed pupil, or a unilaterally “blown” dilated pupil suggests third cranial nerve compression from rising intracranial pressure and is an emergency. Pinpoint pupils suggest opioid effect or a pontine lesion. The Cushing triad — rising systolic pressure with widening pulse pressure, bradycardia and irregular respirations — is a late sign of increased intracranial pressure; if you wait for it, you have waited far too long.

The components of the mental status examination

Beyond consciousness, the mental status examination has a fixed set of components, and most of them are collected simply by conducting the health history attentively. Appearance and behavior: grooming, hygiene, dress, posture, motor activity, eye contact, cooperation. Speech: rate, volume, fluency, articulation, spontaneity — note dysarthria (slurred, a motor problem) versus aphasia (a language problem: expressive, receptive or global). Mood and affect: mood is the sustained emotional state the patient reports in their own words (“How have your spirits been?”); affect is the emotional expression you observe moment to moment. Describe affect as full, constricted, blunted, flat or labile, and state whether it is congruent with the content of what is being said.

Thought process is how thinking is organized: logical and goal-directed is expected; abnormalities include circumstantial (eventually arrives at the point after excessive detail), tangential (never arrives), flight of ideas, loose associations, perseveration (repeating the same response), neologisms and word salad. Thought content is what the patient is thinking: delusions, obsessions, phobias, and — asked directly of every patient in whom it is a possibility — thoughts of harming self or others. Perception: illusions (a misinterpreted real stimulus) and hallucinations (a perception without a stimulus). Auditory hallucinations are most characteristic of primary psychiatric illness; visual and tactile hallucinations point toward delirium, alcohol or sedative withdrawal, or a drug effect and require a medical work-up, not a psychiatric label. Insight and judgment: does the patient understand they are ill, and can they reason through a realistic problem such as “What would you do if you ran out of your blood pressure medication on a Sunday?”

Cognition is tested actively. Orientation ×4 is person, place, time and situation; ask it conversationally rather than as an interrogation (“Just to make sure I have things right — can you tell me your full name, where we are, what month it is, and what brought you in?”). Orientation is lost in a predictable order: time first, then place, then situation, and person last. Attention is the hallmark of delirium and is tested with digit span (5 to 7 digits forward is normal for an adult), reciting the months of the year backward, spelling “WORLD” backward, or serial sevens. Memory: immediate (register three unrelated words and repeat them at once), recent (recall the same three words after 3 to 5 minutes of distraction), and remote (verifiable historical detail). Language: naming, repetition, comprehension, reading, writing. Higher function: similarities (“how are an apple and an orange alike?”) and simple calculation. Avoid proverb interpretation as a stand-alone test; it is heavily influenced by culture, language and education.

Cognitive screening tools and how to use them honestly

Screening tools give you a number to compare over time, but they are not diagnoses and they perform badly when misapplied. The Mini-Cog is the most practical bedside screen: register three unrelated words, have the patient draw a clock face with all the numbers and set the hands to a specified time such as ten past eleven, then ask for the three words. Recall scores 0 to 3 (one point per word); a normal clock scores 2 and an abnormal clock scores 0, for a total of 0 to 5. A total of less than 3 — that is, 0, 1 or 2 — is a positive screen and warrants full evaluation; 3, 4 or 5 is a negative screen but does not rule out milder impairment. It takes about 3 minutes and is relatively resistant to education and language effects.

The Mini-Mental State Examination (MMSE) scores 0 to 30 across orientation, registration, attention, recall, language and construction; a score below 24 suggests cognitive impairment, though the cut point must be adjusted for education. The Montreal Cognitive Assessment (MoCA) also scores 0 to 30, is more sensitive to mild cognitive impairment and executive dysfunction, defines 26 or above as normal, and adds one point for patients with 12 or fewer years of formal education. Both require training and, in the case of the MMSE and MoCA, permission or certification depending on the version and setting.

Use these tools honestly. A patient who cannot hear you, cannot see the paper, has no glasses, is in severe pain, has just received an opioid, is being tested at 0300, or is being tested in their second language will score poorly for reasons that have nothing to do with cognition. Correct the sensory and comfort barriers first — glasses on, hearing aids in and switched on, lights up, pain treated, an interpreter present — then screen. And never chart a screening score as a diagnosis: “Mini-Cog 2 of 5” is a finding; “patient has dementia” is a medical diagnosis you do not make.

Section 4Delirium, Dementia and Depression

Telling the three apart

Confusion is not a diagnosis; it is a symptom with three common explanations that are treated completely differently. Delirium is an acute, fluctuating disturbance of attention and awareness caused by a medical problem — it is a medical emergency and it is usually reversible. Dementia (major neurocognitive disorder) is a slow, progressive loss of cognitive function that is not reversible. Depression can mimic dementia so closely that it was historically called pseudodementia, and it is treatable. The single question that separates them is: what was this person like two weeks ago? Delirium is defined by acute change from baseline, which means you must find the baseline — from family, from the group home staff, from the long-term care nurse, from the prior admission’s notes. A patient who has been oriented only to person for six years is at their baseline. A patient who was balancing a checkbook last Tuesday and cannot say the month today is delirious until proven otherwise.

Screening for delirium and preventing it

Delirium affects a very large share of hospitalized older adults, is independently associated with prolonged stay, functional decline, new nursing home placement and death, and is missed most of the time. It is missed because the hypoactive subtype — quiet, withdrawn, drowsy, slow, not making trouble — is the most common and carries the worst prognosis, while nurses are trained by experience to notice the hyperactive patient who is pulling at lines. A quiet patient who is not their usual self is the one to worry about.

The Confusion Assessment Method (CAM) is the standard bedside screen and requires four features. Delirium is present when you have Feature 1 AND Feature 2, plus either Feature 3 OR Feature 4. Feature 1: acute onset or fluctuating course — is there evidence of an acute change from baseline, and does the behavior come and go? Feature 2: inattention — does the patient have difficulty focusing, become easily distracted, lose track of what is being said? Feature 3: disorganized thinking — rambling, illogical, unpredictable switching of subject. Feature 4: altered level of consciousness — anything other than alert (vigilant, lethargic, stuporous, comatose). The ICU version (CAM-ICU) uses RASS and a picture and letter task so that intubated patients can be screened without speaking. Screen at least once a shift in any at-risk patient and any time the family says “that is not how she normally is.”

When a screen is positive, look for the cause with a memory aid such as PINCH ME: Pain, Infection (urinary tract infection and pneumonia are the classics), Nutrition, Constipation and urinary retention, Hydration, Medication (benzodiazepines, anticholinergics including diphenhydramine, opioids, steroids, and abrupt withdrawal of alcohol or benzodiazepines), Environment (sensory deprivation, sleep disruption, ICU, restraints). Check a glucose and an oxygen saturation immediately — hypoglycemia and hypoxia are fast, common and correctable. Prevention is largely nursing work: get glasses and hearing aids on the patient, reorient with a visible clock and calendar, keep familiar objects and family present, mobilize early, protect sleep by clustering care and dimming lights, maintain hydration and bowel function, treat pain adequately, avoid deliriogenic drugs, and use physical restraints only as a genuine last resort because they increase agitation, injury and delirium duration.

Depression, mood and suicide risk

Screen for depression routinely, because it is common, treatable and frequently masked by physical complaints. The PHQ-2 asks about the last two weeks: little interest or pleasure in doing things, and feeling down, depressed or hopeless, each scored 0 (not at all) to 3 (nearly every day). A total of 3 or more is a positive screen and should be followed by the PHQ-9, where a score of 10 or more indicates at least moderate depression. In older adults the Geriatric Depression Scale (GDS-15) is better tolerated, and a score of 5 or more suggests depression. Note that in older adults depression more often presents as somatic complaints, memory complaints, irritability or withdrawal than as reported sadness.

Question 9 of the PHQ-9 asks about thoughts of being better off dead or of self-harm, and any positive answer requires immediate action, not a note for the next shift. Ask about suicide directly and plainly: “Are you having thoughts of killing yourself?” Asking does not plant the idea and does not increase risk — that is a myth, and the evidence contradicts it. If the answer is yes, use a structured tool such as the Columbia Suicide Severity Rating Scale (C-SSRS) to assess ideation, intent, plan, means and prior attempts. Do not leave the patient alone, remove means from the environment, initiate your facility’s suicide precautions, and notify the provider and rapid response or behavioral health team immediately. Never promise confidentiality about safety information, and never make a “no-harm contract” a substitute for supervision and a real safety plan. In the United States, patients and families can reach the Suicide and Crisis Lifeline by calling or texting 988.

Warning signs that raise concern include hopelessness, giving away possessions, putting affairs in order, a sudden unexplained calm after a period of severe depression, increased substance use, withdrawal from others, and access to firearms or a stockpile of medication. Risk is elevated in older men, in patients with a prior attempt, in those with serious or painful medical illness, in those recently discharged from psychiatric care and in those who are socially isolated. Document exactly what you asked and exactly what the patient answered, in quotation marks.

Section 5Documenting, Escalating and Delegating

How to chart what you found

Charting rules that apply to everything in this chapter: write objectively, quantify with numbers and named scales, quote the patient when the exact words matter, timestamp every entry, and chart what you did about the finding and what happened next. Avoid conclusions you did not test (“drug-seeking,” “non-compliant,” “appears fine”), avoid words that mean different things to different readers (“lethargic,” “good,” “tolerated well”), and never chart an assessment you did not personally perform. If a finding is abnormal and you notified someone, document the name, the time, what you reported and what was ordered.

Red flags: escalate now

Escalate immediately — call the provider, activate rapid response, or both — for any of the following. Any acute change in level of consciousness or mental status from the patient’s baseline, including new inattention. A GCS drop of 2 or more points, or GCS 8 or less. New pupil asymmetry, a fixed or sluggish pupil, or new unilateral weakness or facial droop. Stroke signs screened with BE-FAST — Balance loss, Eyes (vision change), Face droop, Arm drift, Speech change, Time to call — and always establish and report the last known well time, because thrombolysis and thrombectomy windows depend on it. Sudden severe headache described as the worst of the patient’s life. New chest pain, or pain described as crushing, tearing or ripping. Pain that is severe, unrelieved by the ordered regimen, or disproportionate to the physical findings — this is the classic pattern of compartment syndrome and of mesenteric ischemia. A rigid, board-like abdomen with rebound tenderness. POSS 3 or 4 in a patient receiving opioids, or a respiratory rate below 8 to 10 with sedation. Any suicidal or homicidal ideation. Cushing triad. And any patient whose family says clearly that this is not how the patient normally is.

One more escalation trigger deserves emphasis because it is entirely nursing-driven: the patient just does not look right. Deterioration frequently announces itself as a change in the general survey — a patient who was chatty is now quiet, a patient who was sitting up is now slumped, a patient whose color was good is now gray. That impression is legitimate clinical data. Convert it into specifics (respiratory rate, SpO2, work of breathing, mental status, capillary refill, urine output), then escalate.

Escalating with SBAR

SBAR gives your report a shape the receiving clinician expects, and it forces you to end with a request instead of a description. S — Situation: who you are, who the patient is, and the one-sentence problem. B — Background: the relevant history in three or four sentences, not the whole chart. A — Assessment: your vital signs, your findings, and your clinical impression — nurses are permitted and expected to say what they think is happening. R — Recommendation: what you want, stated explicitly, with a timeframe. Write the numbers down before you call and have the chart, the medication record and the last set of vitals in front of you.

A worked example. S: “Dr. Nunez, this is Amara Boyd, RN, on 4 West. I am calling about Mrs. Ellen Rowe in room 412. She has had an acute change in mental status in the last four hours.” B: “She is 81, admitted two days ago with a right hip fracture, surgery yesterday morning, history of hypertension and hypothyroidism. She has a urinary catheter placed preoperatively and she is on scheduled oxycodone. At 0800 she was alert and oriented ×4 and joking with her daughter.” A: “Right now her CAM is positive — acute onset with fluctuation, inattention, and disorganized thinking. She is oriented to person and place only, thinks the year is 1998, and reports seeing children at the window. Her temperature is 38.1 orally, heart rate 110, blood pressure 102 over 58, respirations 24, oxygen saturation 92 percent on room air, glucose 96. Her urine is cloudy and strong smelling. I think she has a urinary tract infection with delirium, and I am concerned about early sepsis.” R: “I would like you to come assess her within the next 15 minutes. I am requesting orders for blood cultures before antibiotics, a urinalysis with culture, a lactate and CBC, and an order for intravenous fluids. I would also like to discuss holding her oxycodone and switching to a scheduled non-opioid, and removing the catheter if she no longer needs it. Do you want me to activate rapid response while you are on your way?”

Delegation, supervision and scope

The rule that governs everything in this section: the registered nurse may delegate a task, but never the nursing process. Assessment, analysis and nursing diagnosis, planning, patient and family teaching, evaluation of outcomes, and any care of an unstable or unpredictable patient remain with the RN. Unlicensed assistive personnel (UAP) may collect and report data; only the RN interprets it. Apply the five rights of delegation every time: the right task, under the right circumstances, to the right person, with the right direction and communication, and with the right supervision and evaluation. And remember that delegating does not transfer accountability — you remain accountable for the outcome and for verifying that the task was done.

Give direction that is specific and includes the report-back threshold, because “let me know if anything changes” is not a delegation instruction. Say instead: “Please take Mr. Alvarez’s vital signs at 1000 and 1400 and tell me right away if his heart rate is over 110, his respiratory rate is over 24, his systolic is under 100, or his oxygen saturation is under 92 percent. Also tell me immediately if he seems more sleepy than he was this morning, even if the numbers look fine.” Then verify. The UAP who tells you a patient “seems more sleepy” has just handed you the earliest sign of opioid-induced sedation, and your job is to go look.

Words worth knowing

Assessing Skin, Hair and Nails

The integument is the only organ you can examine in full without a single piece of technology, and it is the organ most likely to tell you something before the monitor does. Skin reports perfusion, oxygenation, hydration, hepatic function, nutrition, immune status, medication reactions and — bluntly — the quality of the nursing care a patient has received. A pressure injury is one of the few adverse events that is almost always preventable and almost always attributable, which is why regulators count them. This chapter teaches you to look with intent rather than glance: how to set up the room and the light, how to move through inspection and palpation in a fixed order so you never skip the heel or the sacrum or the skin under the oxygen tubing, how to name a lesion by its primary morphology and size, how to recognize pallor, cyanosis, jaundice and erythema in every skin tone rather than only in pale skin, how to stage a pressure injury without reverse–staging it, how to chart what you saw in words a wound nurse can act on, and when to stop charting and escalate by SBAR right now.

Section 1The Skin as an Organ You Can Actually See

Three layers, and what each one tells you

The epidermis is avascular, thin as tissue paper over the eyelid and thick as a callus over the sole, and it turns over roughly every 28 days. Because it has no blood supply of its own, it is nourished by diffusion from the dermis below — which is exactly why a patient with poor perfusion gets shiny, fragile, slow–healing skin. The basal layer holds melanocytes. Every person has approximately the same number of melanocytes; what differs across skin tones is how much melanin those cells produce and how it is packaged. This single fact matters enormously at the bedside: it means a patient with deeply pigmented skin has the same underlying physiology of pallor, cyanosis and erythema as a patient with pale skin, but the visual signal is filtered through pigment. You do not change the assessment. You change where you look.

The dermis is the working layer: collagen and elastin for tensile strength and recoil, capillary loops for the color you see through the epidermis, sensory nerve endings for touch, pressure, temperature and pain, and the sebaceous and sweat glands. When you assess turgor you are testing dermal elastin and interstitial fluid. When you see erythema you are seeing dilated dermal capillaries. When a Stage 2 pressure injury shows a pink, moist, shiny wound bed, you are looking directly at exposed dermis — and because the dermis holds the nerve endings, that wound hurts. A wound that has destroyed the dermis entirely, on the other hand, may be strangely painless, which is a warning sign rather than a reassurance.

The subcutaneous layer (hypodermis) is adipose and connective tissue. It insulates, cushions bony prominences and stores energy. This is why the cachectic patient, the frail older adult and the critically ill patient who has lost 12 kg in three weeks are at extreme pressure–injury risk: the padding over the sacrum, ischial tuberosities, greater trochanters, heels and occiput is simply gone. When you can see visible adipose in a wound bed, you are looking at a full–thickness injury — at minimum a Stage 3.

The appendages: hair, nails and glands

Hair follicles, nails, eccrine sweat glands, apocrine glands and sebaceous glands are all epidermal derivatives, which is why systemic illness marks all of them at once. Eccrine glands are distributed nearly everywhere and are your thermoregulatory workhorse; diaphoresis in a patient who is not hot is a sympathetic surge and deserves a set of vital signs, not a towel. Apocrine glands sit in the axillae and groin, become active at puberty and produce body odor when bacteria act on their secretions. Sebaceous glands produce sebum, which keeps the stratum corneum pliable; they decline with age, which is one reason older adults develop xerosis (dry, scaling, itchy skin) and why moisturizing is a nursing intervention rather than a courtesy.

Nails are keratinized plates growing from the nail matrix under the proximal fold. Fingernails grow about 0.1 mm per day — roughly 3 mm per month, so a full fingernail replaces itself in about six months. Toenails grow at about a third of that rate and take 12 to 18 months. That growth rate is clinically useful: if you see a transverse groove (a Beau line) 6 mm from the cuticle, the systemic insult that arrested nail growth happened roughly two months ago. Hair likewise grows in cycles, and a diffuse shed two to three months after a major stressor — childbirth, sepsis, surgery, severe illness — is telogen effluvium, not disease.

Functions, and the assessment question each one implies

Teaching the functions of skin as a memorized list wastes them. Each function is really an assessment question. Barrier: is the skin intact, and where is it not? Thermoregulation: is this patient hot, cold, diaphoretic, mottled? Sensation: can this patient feel the pressure of their own heel on the mattress, or has neuropathy, spinal cord injury, sedation or an epidural taken that protective feedback away? Vitamin D synthesis, immune surveillance via Langerhans cells, fluid and electrolyte conservation, excretion, and identity — the face and hands a patient recognizes as their own. That last one is not sentimental. Disfiguring skin disease and visible wounds carry real psychological weight, and a patient who will not look at their own stoma or their own burn is telling you something you must document and address.

Baseline variation across the lifespan

Nothing in skin assessment makes sense until you know what is normal for the age in front of you. A newborn is covered in vernix caseosa and fine lanugo, has pinpoint white milia across the nose and chin, and commonly develops erythema toxicum neonatorum — blotchy erythematous macules with tiny central papules appearing at 24 to 72 hours and resolving on its own. Acrocyanosis (blue hands and feet with a pink trunk and pink mucous membranes) is expected in the first 24 to 48 hours of life. Central cyanosis — blue lips, tongue and oral mucosa — is never normal at any age. Congenital dermal melanocytosis, the blue–gray patches over the sacrum and buttocks seen most often in infants with darker skin tones, is a benign finding that must be documented on admission with location and size so it is never mistaken for bruising.

Older adults lose dermal thickness, elastin, subcutaneous fat, sebum and capillary density. Expect thin, dry, wrinkled, cool skin; solar lentigines (liver spots); seborrheic keratoses (the greasy, stuck–on brown plaques); cherry angiomas; and senile purpura — flat, dark purple patches on the forearms and dorsal hands from fragile vessels and thin dermis, which is not evidence of abuse by itself. Turgor is unreliable over the hand in an older adult; test over the sternum or below the clavicle instead. In pregnancy expect melasma, linea nigra, striae gravidarum, spider angiomas and palmar erythema, all driven by estrogen and increased cutaneous blood flow.

Section 2Technique: How the Examination Is Actually Performed

The order of techniques, and the one exception you must memorize

The standard sequence of physical examination is inspection, palpation, percussion, auscultation — least invasive to most, so that each technique does not corrupt the one after it. For the integument only the first two apply: you inspect, then you palpate. There is nothing to percuss and nothing to auscultate on skin, with the narrow exception of listening over a vascular lesion or graft for a bruit. Learn the four–step order anyway, because it governs every other regional examination in this book.

The exception is the abdomen, and it is the single most tested sequence variation in nursing school: inspect, auscultate, percuss, palpate. Auscultation moves to second position because percussing and palpating the abdomen mechanically stimulates the bowel and alters the frequency and character of bowel sounds. If you palpate first, whatever you hear afterward is an artifact of your own hands. Every other region — skin, thorax, heart, extremities — keeps inspection, palpation, percussion, auscultation.

Two more sequencing rules matter for skin. First, inspect and palpate region by region as you undrape, rather than exposing the whole patient at once; this preserves dignity and warmth and reduces the chance you skip a region. Second, always compare side to side. Symmetry is your control group. A warm, red, swollen left calf means far more when you have just palpated a cool, normal right calf thirty seconds earlier.

Setting up: light, warmth, gloves, ruler

Poor lighting is the most common reason a skin finding is missed. Use natural daylight if you can, or a strong daylight–balanced overhead light plus a penlight; fluorescent light adds a green cast that masks jaundice, and the amber glow of a night light will hide early erythema entirely. Use tangential lighting — shine the penlight across the surface at a low angle — to raise the shadow of a lesion that is flat under direct light and to reveal the subtle contour of a healing wound. Warm the room; a cold patient will be pale, mottled and vasoconstricted, and you will misread perfusion. Perform hand hygiene, wear gloves for any contact with non–intact skin, mucous membrane or drainage, and change gloves and repeat hand hygiene between a wound and clean skin, and between one wound and the next.

Carry a flexible centimeter ruler, not an inch ruler and not your own estimate. “Dime–sized” and “golf–ball–sized” are not measurements and cannot be trended. Carry a penlight, a magnifier if available, and know that a transparent glass slide or clear plastic pressed on a red lesion (diascopy) will tell you whether it blanches — a two–second maneuver that separates a benign erythema from a hemorrhagic rash.

A repeatable head–to–toe route

Use the same route every time so that omission becomes impossible. Scalp and behind the ears, then face, then neck and the skin folds under the chin, then anterior trunk including under the breasts and in the axillae, then arms and hands with the palms and interdigital webs, then abdomen and the panniculus folds, then perineum and the gluteal cleft, then legs, then feet including between every toe and the plantar surfaces, then log–roll and inspect the entire posterior surface: occiput, scapulae, spine, sacrum, ischial tuberosities and heels. Then inspect under and around every device — oxygen tubing over the ears and nares, the nasogastric tube against the nostril, pulse oximeter probes, the collar of a cervical brace, compression sleeves, casts, ID bands, the tubing coiled under the patient’s thigh. Device–related pressure injuries are common and they conform to the shape of the device.

On palpation you are gathering five things: temperature, moisture, texture, turgor and mobility, plus tenderness and any masses. Use the dorsum of your hand for temperature because it is more thermally sensitive than the palm, and compare bilaterally. Test turgor by gently pinching a fold of skin — over the sternum or beneath the clavicle in adults and especially in older adults, over the abdomen or inner thigh in infants. Expected: the fold returns immediately, in under 2 seconds. Tenting that persists 3 seconds or more suggests volume depletion, though it is unreliable in isolation in older adults, so pair it with mucous membranes, urine output, orthostatic vital signs and daily weight. Assess capillary refill by pressing the nail bed or a fingertip pulp for 5 seconds and releasing; expected refill is under 2 seconds in adults and children.

Edema, and the numbers that frame every skin finding

Grade pitting edema by pressing your thumb firmly over a bony prominence — the tibia, the medial malleolus, the dorsum of the foot, or the sacrum in a bedbound patient — for 5 seconds and then observing the indentation. The conventional scale is 1+ = about 2 mm, barely detectable, rebounds immediately; 2+ = about 4 mm, rebounds in a few seconds; 3+ = about 6 mm, deep pit, the limb looks swollen, rebound may take 10 to 30 seconds; 4+ = about 8 mm, very deep pit, gross swelling, indentation lasts more than 30 seconds. Record the grade, the depth, the location and how far up the limb it extends: “3+ pitting edema bilateral lower extremities to mid–calf” is usable data.

Skin findings are interpreted against vital signs, so know the real numbers. In a healthy adult: oral temperature 36.5 to 37.5 °C (97.7 to 99.5 °F) with an average near 37 °C (98.6 °F); pulse 60 to 100 beats per minute; respirations 12 to 20 per minute; blood pressure less than 120/80 mm Hg as normal; oxygen saturation 95 to 100 percent on room air. A hot, red, tender leg with a temperature of 38.6 °C, a heart rate of 118 and a systolic of 88 is not a dermatology consult — it is sepsis until proven otherwise.

Two lifespan cautions. Infants and young children lose heat fast because of a high body–surface–area–to–mass ratio and thin subcutaneous fat, so uncover them briefly and re–cover them. Older adults run a lower baseline temperature and blunt the febrile response, so a reading of 37.8 °C (100 °F), or a rise of 1.1 °C (2 °F) above that person’s own baseline, can represent significant infection — a cellulitis in an 84–year–old may present as new confusion and a temperature of 37.6 °C rather than a spiking fever.

Section 3Color, Lesions and Vascular Findings — Normal Beside Abnormal

Reading color in every skin tone

The traditional description of cyanosis as “bluish skin” and pallor as “white skin” was written for one narrow band of complexions, and students who learn it that way miss hypoxia in patients with deeply pigmented skin. Fix this by changing your viewing windows, not your standards. For cyanosis, examine the oral mucosa, tongue, lips, conjunctivae, nail beds, palms and soles; in darker skin tones cyanosis appears ashen, gray or dusky rather than blue, and the tongue and buccal mucosa are the most reliable sites because they are minimally pigmented in almost everyone. Never wait for cyanosis to diagnose hypoxia; it requires roughly 5 g/dL of deoxygenated hemoglobin, which means a severely anemic patient can be dangerously hypoxic and never turn blue at all.

For pallor, examine the conjunctivae, oral mucosa, nail beds and palmar creases. In brown skin, pallor may look yellow–brown; in black skin, ashen or gray; the underlying skin loses its normal red undertone. For jaundice, examine the sclerae (near the limbus, avoiding the peripheral fat pad, which can look yellow normally in darker–skinned patients), the hard palate under bright light, the sublingual area, and the palms and soles. For erythema, do not rely on redness at all in deeply pigmented skin: it presents as a deeper violet, purple, maroon or eggplant hue and is often invisible under artificial light. Instead palpate — compare the area to the same site on the opposite side for increased warmth, induration, firmness, boggy softness, edema and tenderness, and ask the patient whether that spot itches, burns or hurts. Warmth and induration in a patient reporting pain over a bony prominence is a Stage 1 pressure injury or early cellulitis whether or not you can see red.

Naming the lesion: primary, secondary, size

A primary lesion arises on previously normal skin. A secondary lesion results from a change in a primary lesion — scratching, infection, healing or time. Naming the morphology and giving a measurement in centimeters is what turns your note into data. “Rash on chest” is useless. “Multiple erythematous, blanchable macules 2 to 4 mm, coalescing into patches up to 6 cm, distributed over anterior chest and both upper arms, sparing palms and soles, no mucosal involvement” lets a provider act from the hallway.

Configuration, distribution and blanching

Three modifiers finish the description. Configuration: annular (ring), linear, grouped or herpetiform, target/iris, serpiginous, confluent. Distribution: localized, generalized, symmetric, dermatomal, sun–exposed, intertriginous, acral (hands and feet). Distribution is diagnostic on its own — a painful vesicular eruption in a band on one side of the trunk that stops abruptly at the midline is herpes zoster, following a single dermatome; a symmetric rash on palms and soles carries an entirely different differential than the same rash on the trunk.

Blanching is the fastest and highest–yield maneuver in the entire skin examination. Press a red area with your fingertip or a clear slide for 3 seconds and release. If it whitens and refills, the redness is intravascular — blood inside dilated vessels — and the causes are inflammation, fever, flushing, drug eruption, reactive hyperemia. If it does not blanch, blood has leaked out of the vessels into the tissue, and the differential turns serious: petechiae, purpura, thrombocytopenia, vasculitis, meningococcemia, disseminated intravascular coagulation. Non–blanching erythema over a bony prominence in skin that is still intact is, by definition, a Stage 1 pressure injury — but if that non–blanchable area is deep red, maroon or purple, or is a blood–filled blister, call it a deep tissue pressure injury instead, because it is deeper and can deteriorate within hours.

The lesion you must not walk past: ABCDE

Nurses see more undressed skin than any other clinician, which makes you the most likely person to find a melanoma. Screen every pigmented lesion with ABCDE: Asymmetry (one half unlike the other), Border irregular, notched or blurred, Color varied within a single lesion — brown, black, red, white, blue, Diameter greater than 6 mm (about a pencil eraser), Evolving — changing in size, shape, color, elevation, or newly itching, bleeding or crusting. Add the ugly duckling rule: the mole that looks unlike all the patient’s other moles deserves attention even if it passes ABCDE. Evolution is the most important letter; a patient who says “that one has changed” is reporting a red flag.

Skin cancer is not a light–skin–only disease, and the reason patients with darker skin tones have worse melanoma survival is later detection. The most common melanoma subtype in Black patients is acral lentiginous melanoma, which appears on the palms, soles, and under the nails — sites that get skipped by clinicians who inspect only sun–exposed skin. So examine the soles and the interdigital spaces on every patient, and take a new dark longitudinal band in a nail, especially one that widens or spreads pigment onto the surrounding nail fold, as a finding to report rather than a cosmetic curiosity.

Section 4Hair, Scalp and Nails

Hair and scalp

Inspect and palpate hair for distribution, quantity, texture, color and the condition of the scalp beneath it — separate the hair in several places rather than looking at the surface, and always inspect behind the ears and at the nape, where lice, seborrheic scale and device pressure hide. Expect terminal hair on the scalp, axillae and pubic area after puberty and fine vellus hair elsewhere. Expect gradual thinning, graying and reduced axillary and pubic hair in older adults.

Patterns matter more than amount. Alopecia areata produces sharply defined round bald patches with smooth underlying scalp. Traction alopecia thins the frontal and temporal hairline and follows tight braids, weaves, extensions or a ponytail worn the same way for years; it is reversible early and permanent late, which makes it a genuine teaching opportunity rather than a cosmetic aside. Telogen effluvium is a diffuse shed 2 to 3 months after childbirth, surgery, severe illness or major weight loss and regrows. Tinea capitis gives scaly patches with broken–off hairs and is contagious. Hirsutism — coarse terminal hair in a male pattern on a female patient’s face, chest or abdomen — warrants reporting for endocrine evaluation.

One hair finding is a vascular emergency in slow motion: loss of hair over the lower legs, ankles and toes together with shiny, thin, cool, pale skin and thickened nails is classic peripheral arterial disease. Pair that with dependent rubor, pallor on elevation, diminished pulses and painful, punched–out ulcers on the toes or lateral malleolus, and you have a limb at risk. Contrast it with venous insufficiency: warm limb, brown hemosiderin staining, edema, and a shallow, weepy, irregular ulcer at the medial malleolus. The two are managed in opposite directions — compression helps venous disease and can destroy an arterial limb — so the distinction is not academic.

Nails: angle, surface, color, and the bed beneath

Inspect nail shape, contour, surface, thickness, color and the surrounding folds, and palpate the nail plate for firmness and adherence to the bed. The normal nail base angle (Lovibond angle) is approximately 160 degrees; the nail is firmly adherent, smooth, and the bed is pink with capillary refill under 2 seconds. In clubbing the angle flattens and then exceeds 180 degrees, the nail base becomes spongy or floating, and the fingertip bulbs. Use the Schamroth window test: have the patient place the dorsal surfaces of two matching fingernails together. Normally a small diamond–shaped window of light appears between them; in clubbing the window disappears. Clubbing develops over months and points to chronic hypoxemia or shunting — cystic fibrosis, congenital cyanotic heart disease, bronchiectasis, interstitial lung disease, lung cancer, cirrhosis, inflammatory bowel disease.

Infestations and the findings that change the room

Pediculosis capitis (head lice) shows as intense itching with tiny gray–white nits cemented to hair shafts, most densely behind the ears and at the nape; nits found within about 6 mm (a quarter inch) of the scalp indicate active infestation, while nits far out on the shaft are usually old. Scabies presents as relentless itching that is worst at night with thin, wavy burrows in the finger webs, flexor wrists, axillae, waistband area, and genitals; in infants it involves the palms, soles and scalp. Both findings change nursing practice immediately: initiate contact precautions per facility policy, bag linens, notify the provider and infection prevention, and treat the itching as real distress rather than a complaint. Neither is a marker of poor hygiene, and telling the patient so plainly is part of care.

Section 5Skin Integrity, Documentation, Red Flags and Scope

Risk, prevention and the Braden Scale

Pressure injuries develop where soft tissue is compressed between bone and a surface long enough to occlude capillary flow, and they are accelerated by shear, friction, moisture, poor nutrition and impaired sensation. Assess risk on admission, at every shift change or per facility policy, and with any change in condition, using the Braden Scale. It scores six subscales — sensory perception, moisture, activity, mobility, nutrition, and friction and shear — for a total of 6 to 23, where a lower score means higher risk. Conventional cutoffs: 19 to 23 no risk, 15 to 18 mild, 13 to 14 moderate, 10 to 12 high, 9 or below very high. A score of 18 or less should trigger a prevention bundle, and many facilities use a higher threshold for older adults and patients with darker skin tones because visual detection of early injury is less reliable.

The prevention bundle is nursing work, not an order set: reposition a bedbound patient at least every 2 hours and a chair–bound patient every 1 hour (or teach small shifts every 15 minutes if they can); use a 30–degree lateral tilt rather than direct side–lying on the trochanter; keep the head of bed at 30 degrees or less unless contraindicated, because higher elevation drives shear at the sacrum; float the heels off the bed entirely with a pillow under the calves or a heel offloading boot; use lift sheets and never drag; keep skin clean and dry with a barrier product for incontinence; optimize protein and calorie intake and involve dietitian services; and do not massage over bony prominences or reddened areas — massage over compromised tissue increases damage.

Staging — and the errors that get students in trouble

Four rules save you. First, do not reverse–stage. A healing Stage 4 does not become a Stage 2; it is a “healing Stage 4” forever, because lost muscle and fat are replaced by scar, not by the original tissue. Second, do not stage a wound that is not a pressure injury. Staging language belongs only to pressure injuries; skin tears, surgical wounds, venous ulcers, arterial ulcers, diabetic foot ulcers and burns are described by depth and characteristics instead. Third, do not remove stable eschar on a heel. Dry, adherent, intact eschar on an ischemic heel without erythema, fluctuance, drainage or odor is a biological cover; leave it, offload the heel and report. If it becomes soft, boggy, draining or surrounded by erythema, escalate. Fourth, distinguish pressure injury from moisture–associated skin damage.

How to chart it

Documentation is a clinical intervention. It is how the next nurse detects deterioration, how the wound team plans, and how the record demonstrates that an injury was present on admission rather than acquired on your unit. Chart what you observed and measured, not what you concluded. Wounds are measured in centimeters as length × width × depth, with length head–to–toe and width side–to–side, and undermining or tunneling described by depth in centimeters and by clock position with 12 o’clock toward the patient’s head.

Red flags and the SBAR that follows

Some skin findings buy you hours. These do not.

Escalate with SBAR, which turns anxiety into a plan. Situation: “Dr. Ellis, this is Marcus Reed, RN, on 4 West. I’m calling about Mr. Alvarez in 412 — I’m concerned he has a rapidly spreading soft–tissue infection of the right leg.” Background: “He’s a 62–year–old admitted two days ago for cellulitis after a lawn–mower laceration, on IV vancomycin, with type 2 diabetes and an A1c of 9.4.” Assessment: “At 1800 the erythema was marked at the ankle. It’s now 3 cm past that mark, the skin is dusky with two tense bullae, I feel crepitus over the lateral calf, and his pain is 9 out of 10 and out of proportion to what I see. Temperature 38.9, heart rate 124, respirations 26, blood pressure 92/54 down from 132/78, SpO2 94 percent on room air.” Recommendation: “I need you to see him now. I’ve activated rapid response, held his diet, and I’m requesting surgical consult, blood cultures and fluid resuscitation orders.” Notice the recommendation is specific. “Something is wrong” is not an SBAR.

Delegation and scope

The five rights of delegation — right task, right circumstance, right person, right direction and communication, right supervision and evaluation — apply constantly in skin care, because so much skin work happens during hygiene, which is frequently delegated. The line is simple and absolute: assessment, interpretation, staging, teaching, evaluation and the care of an unstable patient stay with the RN. Unlicensed assistive personnel may observe and report what they see; they may never assess what it means. Delegating a task never delegates accountability, and the RN must give explicit direction about what to report and when.

Words worth knowing

Assessing Head, Neck, Eyes, Ears, Nose and Throat

Everything above the clavicles is crowded, and that is exactly why it matters. In a space the size of your two fists sit the airway, four of the great sensory organs, ten lymph node chains, the thyroid, the carotids and eleven of the twelve cranial nerves. A student who learns this region as a list of parts will chart “HEENT within normal limits” and move on. A nurse who learns it as a system will notice that the uvula has shifted to the left, that one pupil is a millimetre larger than it was two hours ago, that the node above the clavicle is hard and will not move, or that a patient who was hoarse this morning is now making noise on inspiration. Those four findings are, in order, a peritonsillar abscess, a herniating brain, a probable malignancy and an airway that is closing. This chapter teaches the technique first — hands, light, sequence — then the findings, then the numbers, then the words you write and the escalation you call.

Section 1The Head, Face and Neck

The order of the exam, and the one place it changes

Physical assessment has a fixed order: inspection, palpation, percussion, auscultation. You look before you touch, you touch before you tap, and you tap before you listen. The reason is not tradition. Looking costs nothing and biases nothing; touching a tender area first makes the patient guard, tense and stop cooperating; and percussion sets tissue moving in ways that can change what you hear afterward. In the head and neck you will use inspection and palpation constantly, percussion almost never, and auscultation in exactly two places — over the carotid arteries and over an enlarged thyroid.

There is one region of the body where this order is deliberately broken. The abdomen is the exception: inspect, then AUSCULTATE, then percuss, then palpate. Bowel sounds are produced by peristalsis, and pressing on the abdomen mechanically stimulates or suppresses that peristalsis. If you palpate first, the bowel sounds you then auscultate are sounds you created, not sounds the patient had. Memorize the exception now, because it is the single most commonly missed sequencing item on licensure examinations and the single most commonly botched sequence at the bedside. Everywhere else — head, neck, thorax, extremities — the standard order holds.

Before you touch the patient, set the stage. Perform hand hygiene, introduce yourself, use two identifiers, explain what you are about to do, and position the patient sitting upright with their head at your eye level. Sitting matters: it lets you compare both sides of the face and neck simultaneously, and symmetry is the single most powerful assessment tool you have in this region. Almost every abnormality above the clavicles announces itself first as an asymmetry.

Skull, face and the temporomandibular joint

Inspect the skull for size, shape and symmetry. The expected finding is normocephalic and atraumatic — a rounded, symmetric skull with no depressions, bossing or lesions, and no evidence of injury. Then palpate the entire scalp with the pads of your fingers in small circles, front to back, feeling for tenderness, masses, depressions and step-offs in the bone. Part the hair to look at the scalp itself; you are checking for lesions, scaling, lice and, in an older adult who has fallen, a boggy hematoma hidden under thick hair. Palpate the temporal arteries just anterior to each ear: they should be smooth, non-tender and equally pulsatile.

Inspect the face at rest and in motion. At rest, look at the palpebral fissures, nasolabial folds and mouth corners for symmetry. Then test the muscles of facial expression, which is cranial nerve VII (facial): ask the patient to raise their eyebrows, close their eyes tightly while you try to open them, smile, show their teeth and puff out their cheeks. A drooping mouth corner with an intact forehead points to a central lesion such as a stroke; a droop that includes the forehead on the same side points to a peripheral seventh nerve palsy such as Bell palsy. That distinction — forehead spared or not — changes the entire escalation pathway, and you can make it in eight seconds. While you are there, test cranial nerve V (trigeminal): palpate the masseter and temporalis muscles while the patient clenches, and check light touch sensation on the forehead, cheek and jaw bilaterally.

Palpate the temporomandibular joint by placing your index fingertips just anterior to the tragus of each ear and asking the patient to open and close the mouth slowly. You should feel a smooth, symmetric glide. The mouth should open 3 to 6 cm between the incisors, roughly the width of three of the patient’s own fingers held vertically. Audible clicking is common and by itself not alarming. Crepitus, pain, locking, or an opening of less than 3 cm is abnormal. An inability to open the mouth at all — trismus — in a patient with a sore throat is not a dental problem; it is a deep neck space infection until proven otherwise, and it belongs in Section 4 and in your escalation list.

Lymph nodes: the ten chains and what a bad node feels like

Palpate the cervical nodes using the pads of your index and middle fingers, both hands at once, moving the skin over the underlying tissue in gentle circles. Use light pressure — heavy pressure pushes a small node out of your way and you will miss it. Work in a fixed order every time so you never skip a chain: preauricular (in front of the ear), posterior auricular (over the mastoid), occipital (base of the skull), tonsillar (angle of the mandible), submandibular (halfway between the angle and the tip of the jaw), submental (behind the tip of the chin, one hand), superficial cervical (over the sternocleidomastoid), deep cervical chain (under the sternocleidomastoid — hook your fingers around the muscle and ask the patient to tilt the head toward the side you are examining to relax it), posterior cervical (along the anterior edge of the trapezius) and supraclavicular (in the hollow above the clavicle; ask the patient to shrug and then relax, and have them take a deep breath and hold it to bring a deep node up under your finger).

Most healthy adults have no palpable nodes at all, and many have a few small nodes that are less than 1 cm, soft, mobile, discrete and non-tender. When you find a node, describe six things: location, size in centimetres, shape, consistency, mobility and tenderness. Those six words separate a viral pharyngitis from a lymphoma. The pattern that reassures is tender, warm, soft, mobile and bilateral — that is inflammation, and it usually has an obvious source such as a throat, ear or scalp infection. The pattern that worries is hard, fixed, matted, painless and unilateral — that is how malignancy presents, and painlessness is a feature, not a reassurance.

Two rules override everything else. First, a palpable supraclavicular node is abnormal at any size, in any patient, at any age. The left supraclavicular node — the Virchow node — drains the thoracic duct and can be the first sign of a gastric, pancreatic, esophageal or pulmonary malignancy. Second, size is not the only trigger for referral. Any node that is hard, fixed, matted or painless needs a provider evaluation at any size; so does any node that has been enlarging for more than two to four weeks without an infectious explanation, any node larger than 1 cm that does not settle as the infection settles, and any node larger than 2 cm regardless of how it feels. Do not wait for a suspicious node to reach 2 cm before you report it.

Thyroid, trachea and carotids

Confirm the trachea is midline before anything else. Place your index finger in the suprasternal notch and slip it gently to each side of the trachea; the space between the trachea and the sternocleidomastoid should be equal on both sides. A deviated trachea is never a minor finding. Air or fluid under pressure pushes the trachea away from the affected side — that is tension pneumothorax and large pleural effusion. Loss of lung volume pulls the trachea toward the affected side — that is atelectasis, fibrosis and pneumonectomy. A patient who is short of breath with a trachea deviated away from the side with absent breath sounds is a rapid-response call, not a documentation entry.

Now the thyroid. The isthmus lies across the second and third tracheal rings, with a lobe curving back on either side. Inspect first: with the patient’s neck slightly extended, hand them a cup of water and watch them swallow. Thyroid tissue rises with the swallow; lymph nodes and most other neck masses do not. That single manoeuvre — watch it move with the swallow — is the most useful thing you will do at the neck. For the posterior approach, stand behind the seated patient, place the fingers of both hands on the neck with your index fingers just below the cricoid cartilage, ask the patient to flex the neck slightly forward and tilt it toward the side you are palpating (this relaxes the sternocleidomastoid), displace the trachea gently toward that side with the opposite hand, and ask for a sip of water. For the anterior approach, stand in front, use the same displacement and swallow, and palpate with your thumbs. Use whichever you can do reliably; consistency beats elegance.

A normal thyroid is often not palpable at all. When it is, the lobes feel smooth, firm, non-tender and roughly the size of the distal phalanx of the patient’s thumb. Enlargement is a goiter. If you feel any enlargement, place the bell of your stethoscope over each lobe and ask the patient to hold their breath. A soft blowing swishing sound is a thyroid bruit, and it means increased vascularity — classically hyperthyroidism and Graves disease. Palpate gently; vigorous manipulation of a hyperactive gland is avoided. Finally, auscultate each carotid with the bell while the patient holds their breath, listening for a bruit. Never palpate both carotid arteries at the same time and never massage the carotid sinus; you can drop the heart rate and the cerebral perfusion of the patient in front of you.

Section 2Assessing the Eyes

Visual acuity and visual fields

Visual acuity is the vital sign of the eye, and like any vital sign it is measured, not estimated. Use a Snellen chart at 20 feet (6 metres) in good light. Test each eye separately with the other eye covered by an occluder or the patient’s palm — never by their fingers, because patients peek — then test both eyes together. If the patient wears glasses or contacts for distance, leave them on and chart the result as corrected. Record the smallest line the patient reads correctly, plus the number of letters missed on that line: 20/30 − 1 means they read the 20/30 line and missed one letter. The numerator is your testing distance; the denominator is the distance at which a person with normal vision could read that line. So 20/20 is expected adult acuity, and 20/40 means your patient must stand at 20 feet to see what a normal eye sees at 40 feet. Legal blindness in the United States is 20/200 or worse in the better eye with best correction. If a patient cannot read the largest letter, move them closer and record the distance; if they still cannot, test counting fingers, then hand motion, then light perception, in that order.

Test near vision with a handheld Jaeger card held at 14 inches (35 cm); normal is J1 or 14/14. Difficulty with near vision beginning in the forties is presbyopia, a normal age-related stiffening of the lens, and it is the reason your fifty-year-old patient holds the discharge instructions at arm’s length. That is a teaching moment about large-print materials, not a pathology.

Screen peripheral vision by confrontation. Sit facing the patient at eye level about 60 cm (2 feet) away. Cover your right eye and have them cover their left, so you and the patient are looking directly at one another with the opposite eyes. Keep your eyes locked, then bring a wiggling finger in from the far periphery in each of four quadrants, midway between you and the patient, and ask them to say “now” the moment they see it. Because you are the control, you should see the finger at the same instant. Normal fields extend approximately 50° superiorly, 60° nasally, 70° inferiorly and 90° temporally. A quadrant the patient consistently misses is a field cut and needs a provider — and it also needs a safety plan, because a patient with a left field cut will walk into the left side of the doorway and will not see the food on the left half of the tray.

The external eye, the pupils and extraocular movement

Inspect the eyebrows, lids and lashes for symmetry, ptosis, edema, lesions and lid margin inflammation. The upper lid normally covers the top 1 to 2 mm of the iris; the sclera should not be visible above the iris. Inspect the conjunctivae by having the patient look up while you pull the lower lid down: the palpebral conjunctiva should be pink and moist, and the bulbar conjunctiva clear with fine visible vessels. Sclera should be white. In patients with darker skin, small tan or brown melanin deposits are commonly seen in the sclera near the limbus and are a normal variant — do not mistake them for jaundice. When you are screening for jaundice, look at the sclera immediately adjacent to the iris, at the hard palate and under the tongue; the peripheral sclera can carry a yellowish tint from fat and carotene in perfectly healthy people.

Assess the cornea by shining a penlight obliquely across it; it should be smooth, clear and glossy, with no cloudiness or abrasion. A thin greyish-white ring around the outer iris in an adult over 60 is arcus senilis and is a normal aging finding; the same ring in a patient under 40 warrants a lipid evaluation. Test the corneal light reflex by shining a penlight at the bridge of the nose from about 30 cm: the reflection should land on exactly the same spot of each cornea. Asymmetry means the eyes are not aligned.

Pupils are round, equal and, in normal room light, 3 to 5 mm in diameter (the full normal range is roughly 2 to 6 mm depending on light and age). Chart the actual millimetre size using the gauge printed on your penlight or pupil card — “pupils equal” is not data. Darken the room, bring the light in from the side, and check four things: direct constriction of the lit eye, consensual constriction of the other eye, then accommodation and convergence as the patient shifts gaze from a distant object to your finger 10 cm from their nose. That is PERRLA: pupils equal, round, reactive to light and accommodation. About one in five people has a benign difference of up to 1 mm between pupils that is stable over time — physiologic anisocoria. What is never benign is a new difference, especially a unilateral dilated pupil that reacts sluggishly or not at all in a patient with a declining level of consciousness. That is third nerve compression from an expanding intracranial mass, and it is a call to the rapid response team while you are still standing at the bedside.

Assess extraocular movement through the six cardinal fields of gaze, which test cranial nerves III, IV and VI together. Hold your finger about 30 cm away, ask the patient to hold their head still and follow with their eyes only, and move slowly through an H pattern — lateral, up-and-lateral, down-and-lateral on each side. Both eyes should move together, smoothly and fully, with parallel alignment. A few beats of nystagmus at extreme lateral gaze are normal; sustained nystagmus in any other position is not.

The internal eye, the red reflex and eye emergencies

The funduscopic examination is performed by advanced practice providers in most settings, but you need to understand it because you will assist with it, position for it and read the results. Darken the room. Hold the ophthalmoscope in your right hand, use your right eye, and examine the patient’s right eye; then switch everything for the left. Start about 25 cm away and 15° lateral to the patient’s line of sight, find the orange glow of the red reflex, then follow it in to within 3 to 5 cm. The optic disc is creamy yellow-orange with sharp margins and a cup that occupies no more than about half of the disc diameter. Arterioles are lighter and narrower than venules, in roughly a 2:3 ratio. The macula lies about two disc diameters temporal to the disc. Blurred disc margins — papilledema — indicate raised intracranial pressure.

The red reflex is the finding nurses genuinely own, because it is checked at every newborn and well-child assessment. It should be present, equal and symmetric in both eyes. A white reflex — leukocoria — is an urgent referral: retinoblastoma, congenital cataract and retinopathy of prematurity all present this way, and retinoblastoma is a childhood cancer where time to treatment determines whether the child keeps the eye and the life. If a parent shows you a phone photo in which one of their baby’s eyes glows white while the other glows red, you escalate that photo.

Three ocular situations demand action before assessment. A chemical splash is irrigated immediately — do not stop to test acuity, do not look for the bottle first. Remove contact lenses, hold the lids open and irrigate with normal saline or lactated Ringer solution for at least 15 to 20 minutes, or until the conjunctival pH is 7.0 to 7.4, directing flow from the inner to the outer canthus so you do not wash the chemical into the other eye. Alkali burns penetrate deeper and irrigate longer than acid. Never attempt to neutralize a chemical with another chemical. An impaled foreign body is never removed at the bedside: stabilize it, shield both eyes to stop conjugate movement, keep the patient still and call. And sudden painless loss of vision in one eye — a curtain coming down, a shower of floaters, a shade closing — is a retinal artery occlusion or a retinal detachment and is a same-hour emergency.

Section 3Assessing the Ears and Hearing

The external ear: inspection and the two-second diagnosis

Inspect both auricles for size, shape, symmetry, position and skin condition. The top of the auricle should meet an imaginary line drawn from the outer canthus of the eye to the occiput, and the auricle should sit within 10° of vertical. Low-set or rotated ears in an infant are associated with congenital renal and chromosomal anomalies and are reported, not just noted. Inspect the external canal opening for discharge, redness, swelling and cerumen. Note the colour and character of any discharge: purulent drainage suggests infection, and clear or blood-tinged watery drainage after head trauma is cerebrospinal fluid until proven otherwise.

Then palpate. Move the auricle up and down, press the tragus inward, and press over the mastoid process. This takes two seconds and does real diagnostic work. Pain when you move the pinna or press the tragus points to otitis externa, an infection of the canal. Ear pain with no tenderness on external manipulation points to otitis media, behind the drum. And tenderness, redness or swelling over the mastoid, especially with an auricle that is pushed forward and outward, is mastoiditis — a complication that can extend intracranially and needs urgent evaluation.

Otoscopy: how to hold it, what you should see

Choose the largest speculum that will fit the canal comfortably; a speculum that is too small gives you a keyhole view and is more likely to touch the sensitive canal wall. Hold the otoscope like a pencil, upside down, braced against the patient’s head with the ulnar side of your hand, so that if the patient moves suddenly your hand moves with them and the speculum does not lacerate the canal. Straighten the canal by pulling the auricle: up and back for adults and children 3 years and older, down and back for infants and children under 3, because their canal points upward. Insert slowly, downward and forward, about 1 to 1.5 cm in an adult, watching your path the whole way in.

The normal tympanic membrane is pearly grey, translucent, intact and slightly concave. You should identify the cone of light — the triangular light reflex that points anteroinferiorly, at roughly 5 o’clock in the right ear and 7 o’clock in the left — along with the umbo, the handle of the malleus and the short process. On pneumatic insufflation the membrane moves. Cerumen is normal and protective and does not need removal unless it blocks the view or the hearing; when irrigation is ordered, it is contraindicated if there is any suspicion of perforation, tympanostomy tubes, current infection or a history of ear surgery.

In children, the ear examination and the throat examination are performed last, after everything that requires cooperation, because both are intrusive and both end cooperation. Infants and toddlers have shorter, wider, more horizontally oriented eustachian tubes, which is why otitis media peaks between 6 and 24 months and why a bottle-propped supine feeding raises the risk.

Testing hearing: whisper, Weber and Rinne

Start with the simplest and most sensitive screen: the whispered voice test. Stand about an arm’s length (roughly 60 cm) behind and to the side of the patient so they cannot read your lips. Occlude the non-tested ear by pressing and gently rubbing the tragus. Exhale fully — this ensures you are truly whispering — then whisper a combination of three numbers and letters, such as “4–K–2.” A patient with normal hearing repeats all three correctly. If they miss any, repeat with a different set; failing to repeat at least three of six items is a failed screen. Test each ear separately.

Tuning fork tests separate conductive loss (a problem in the outer or middle ear — cerumen, effusion, perforation, otosclerosis) from sensorineural loss (a problem in the cochlea or eighth nerve — aging, noise exposure, ototoxic drugs). Use a 512 Hz fork. For the Weber test, strike the fork, place the base on the midline of the top of the skull or the mid-forehead, and ask where the sound is heard. Normal is equal in both ears with no lateralization. Sound that lateralizes to the bad ear means conductive loss in that ear (blocking room noise makes bone conduction seem louder there). Sound that lateralizes to the good ear means sensorineural loss in the other ear.

For the Rinne test, place the vibrating fork on the mastoid process, ask the patient to say when the sound disappears, then immediately move the still-vibrating tines about 2 cm in front of the ear canal. Normally, air conduction is better than bone conduction by about a 2:1 time ratio, so the patient hears the fork again in front of the ear — charted as AC > BC, positive Rinne. When bone conduction is equal to or better than air conduction, the Rinne is negative and there is conductive loss on that side. Nurses do not diagnose from these tests; nurses use them to decide how urgently to route a patient and to communicate a precise finding.

Two hearing changes need speed. Sudden sensorineural hearing loss — hearing that disappears in one ear over hours to a day or two, often with the patient describing fullness and tinnitus — is an emergency, not a wait-and-see. Outcomes are best when corticosteroids begin as early as possible — ideally within about 72 hours — and treatment is still offered up to two weeks from onset, so a patient who calls the clinic reporting that one ear stopped working overnight is triaged as urgent, and a patient who reports it five days later is still worked in today rather than dismissed as too late. And any patient on an ototoxic medication — aminoglycosides, high-dose loop diuretics, cisplatin, high-dose salicylates, vancomycin — who reports new tinnitus, hearing loss or vertigo needs the medication reported and levels reviewed before the next dose.

Section 4Nose, Sinuses, Mouth and Throat

Nose and sinuses

Inspect the external nose for symmetry, deformity and lesions. Test patency one side at a time: occlude one naris, ask the patient to close their mouth and sniff, then repeat on the other side. Then use an otoscope with a wide short speculum, or a nasal speculum with a penlight, tilting the patient’s head back slightly. You should see a midline septum, pink moist mucosa, and the inferior and middle turbinates as smooth reddish-pink ridges on the lateral wall. Do not confuse a turbinate with a polyp; polyps are pale, grey, glistening and mobile, and they do not hurt when touched.

Abnormal nasal findings are unusually informative. Pale, boggy, bluish-grey turbinates with clear watery discharge indicate allergic rhinitis. Bright red swollen mucosa suggests infection. A perforated septum raises questions about intranasal cocaine use, chronic topical decongestant use or trauma. Unilateral foul-smelling purulent discharge in a toddler is a nasal foreign body until someone looks. And clear watery drainage from one nostril after head trauma may be cerebrospinal fluid — do not pack it, do not insert a nasogastric tube, and report it immediately.

Only the frontal and maxillary sinuses are accessible. Palpate the frontal sinuses by pressing up under the bony brow ridges, never directly on the eyes, and the maxillary sinuses by pressing up under the cheekbones. Expected finding: no tenderness. Sinuses may also be transilluminated in a darkened room, but this is a low-yield technique in practice. The ethmoid and sphenoid sinuses cannot be examined at the bedside. Cranial nerve I (olfactory) is tested only when there is a reason — head trauma, suspected neurologic disease, new anosmia — by occluding one nostril and asking the patient to identify a familiar non-irritating odour such as coffee or vanilla with their eyes closed.

For epistaxis, sit the patient upright and leaning forward — never tilted back, which sends blood into the airway and the stomach and causes vomiting. Pinch the soft compressible part of the nose just below the nasal bones firmly and continuously for 10 to 15 minutes without releasing to check. Apply ice to the bridge. Bleeding that continues beyond 20 to 30 minutes of correct pressure, occurs in a patient on anticoagulants, or is accompanied by hemodynamic change requires provider evaluation.

Mouth, tongue and the oral cancer check

Put on gloves. Inspect the lips for colour, moisture, cracking and lesions. Then use a tongue blade and a good light to inspect the buccal mucosa, gums, teeth, hard and soft palate, tongue and floor of the mouth. Expected findings: mucosa pink, smooth and moist; gums pink with tight margins and no bleeding; teeth intact with no obvious caries; palate intact; tongue midline, pink, with a papillated dorsal surface and a smooth ventral surface. The parotid (Stensen) duct opens on the buccal mucosa opposite the second upper molar; the submandibular (Wharton) ducts open on either side of the frenulum under the tongue.

Now do the part students skip. Wrap the tip of the tongue in a gauze square, pull it gently forward and to each side, and inspect the lateral borders and the floor of the mouth, then palpate the floor of the mouth bimanually. Those two areas are where oral cancers most commonly begin, and they are the two areas that a quick “say ahh” never shows you. A thick white patch that does not scrape off is leukoplakia, a precancerous lesion requiring biopsy, and it is strongly associated with tobacco, smokeless tobacco and alcohol. By contrast, white curd-like plaques that do scrape off, leaving a red raw base that may bleed, are oral candidiasis. It is common in infants but it is never a normal finding: report it, expect an antifungal order such as nystatin, and assess feeding, bottle and pacifier hygiene and maternal nipple candidiasis. Distinguish it from milk residue, which wipes away without leaving a raw base, and treat thrush that persists or recurs beyond infancy as a reason to ask about immune status. In an adult it demands a question about inhaled corticosteroids without rinsing, recent antibiotics, diabetes or immunosuppression. Any oral ulcer or lesion present for more than two weeks is referred.

Several normal variants are commonly mistaken for pathology, and most of them are more frequent in patients with darker skin. Leukoedema is a filmy greyish-white translucent appearance of the buccal mucosa that disappears when the mucosa is stretched. Physiologic melanin pigmentation produces brown or blue-grey patches on the gingiva, buccal mucosa or tongue, present for years and asymptomatic. Torus palatinus is a hard bony midline ridge on the hard palate. Fordyce granules are small yellow-white sebaceous spots on the buccal mucosa. None require action; all require that you not chart them as lesions. What does require action is new pigmentation, a pigmented lesion that is changing, or a lesion that bleeds.

Pharynx, tonsils and the airway you are protecting

Depress the middle third of the tongue with a blade — pressing too far back triggers gagging — and ask the patient to say “ahh.” Inspect the tonsils, anterior and posterior pillars, uvula and posterior pharyngeal wall. Expected: mucosa pink and moist, tonsils without exudate, uvula midline, soft palate rising symmetrically and the uvula staying midline as it rises. That rise tests cranial nerves IX and X; a uvula that deviates to one side on phonation indicates weakness on the opposite side. Then ask the patient to stick out their tongue: it should protrude midline, which tests cranial nerve XII. Deviation of the protruded tongue points toward the side of the lesion.

Grade the tonsils on a standard scale, because “big tonsils” means nothing to the next clinician. 1+ tonsils are just visible beyond the pillars. 2+ extend halfway to the uvula. 3+ touch the uvula. 4+ touch each other in the midline — so-called kissing tonsils. Note colour, symmetry and exudate separately from size. In a sore throat, the findings that raise the probability of group A streptococcus are the Centor criteria: fever above 38°C, tonsillar exudate, tender anterior cervical adenopathy and the absence of cough. Cough, hoarseness, coryza and conjunctivitis point toward a virus. Nurses do not prescribe from this — but nurses do decide who gets seen this afternoon and who gets fluids and a follow-up call.

The throat exam has one absolute stop rule. If a patient — particularly a child — presents with sudden high fever, severe sore throat, drooling, muffled “hot potato” voice, refusal to lie down, sitting forward in a tripod position, and any stridor, do not put a tongue blade in that mouth. Do not lie them down. Do not draw blood or start an IV. Do not agitate the child. This picture is epiglottitis or another airway-threatening infection, and instrumenting the pharynx can precipitate complete obstruction. Keep the patient upright and calm, ideally in the parent’s arms, give oxygen in the least disturbing way possible, and get the airway team — anaesthesia and ENT — to the bedside immediately. The same restraint applies to a patient with a rapidly swelling tongue or lips from angioedema, and to a patient with severe unilateral throat pain, trismus and a uvula pushed to the opposite side, which is a peritonsillar abscess.

Section 5Numbers, Variation, Charting, Red Flags and Delegation

The numbers, across the lifespan

HEENT complaints rarely stand alone. A sore throat with a respiratory rate of 16 is a clinic visit; the same sore throat with a respiratory rate of 34 and a heart rate of 128 is a different problem entirely. You cannot make that distinction without knowing expected values cold, and expected values change dramatically with age. Adult resting norms are a temperature of 36.5–37.5°C (97.7–99.5°F), heart rate 60–100 beats per minute, respiratory rate 12–20 breaths per minute, blood pressure less than 120/80 mmHg, and oxygen saturation 95–100% on room air. Pain is assessed and documented alongside them.

A few structural numbers belong with these. Newborn head circumference is 32–38 cm, measured over the widest point just above the eyebrows and pinnae, and is tracked routinely to about 24–36 months. The anterior fontanel is 2.5–4 cm at its widest and closes between 12 and 18 months; the posterior fontanel is 0.5–1 cm and closes by 1 to 2 months. Assess a fontanel with the infant calm and upright: a bulging, tense fontanel at rest suggests increased intracranial pressure, and a sunken fontanel suggests dehydration. Transient bulging while crying is normal.

Variation across skin tone and life stage

Colour changes are described in most textbooks as if every patient were pale. That is a patient-safety problem, because cyanosis, jaundice, pallor and erythema are all harder to see in richly pigmented skin and are all routinely missed. The solution is to move your assessment to sites where pigmentation is minimal and vascularity is high — and almost all of those sites are in this chapter’s territory.

Life stage changes the exam as much as skin tone does. In pregnancy, estrogen-driven mucosal edema causes nasal congestion and epistaxis, and the gums become hyperemic and bleed easily; the thyroid may enlarge modestly. What is never normal in pregnancy is new blurred vision, scotomata or photophobia with headache after 20 weeks — that combination with a blood pressure of 140/90 mmHg or higher is preeclampsia, and 160/110 mmHg or higher is severe-range and requires immediate escalation. In older adults, expect presbyopia, presbycusis, arcus senilis, decreased tear and saliva production (often worsened by anticholinergic medications), thinner drier nasal mucosa, reduced smell and taste, and drooping upper lids. Expect them — but do not dismiss them. Xerostomia causes caries, poor denture fit, altered nutrition and impaired swallowing, and it is very often a medication side effect that can be reduced.

Charting it: vague versus precise

Documentation is not paperwork; it is the instrument by which your assessment reaches the next nurse and the provider at 3 a.m. The test of a good HEENT entry is simple: could a colleague who has never seen this patient reconstruct exactly what you found and detect a change tomorrow? Objective findings, measured values, laterality and negatives that matter — those are what make an entry usable.

Red flags, SBAR and who may do what

Some findings are charted. Some findings are called. Learning which is which is the difference between a nurse who documents an event and a nurse who prevents one. The following list is not exhaustive, but every item on it means you stop what you are doing and escalate.

Escalate with SBAR, because a structured report gets a decision and an unstructured one gets questions. Here is a HEENT escalation written out in full, the way you would actually say it into the phone:

Finally, delegation. The rule is a rule of scope, not of workload. The nursing assessment, the interpretation of findings, patient teaching, evaluation of outcomes, and the care of any unstable or unpredictable patient stay with the registered nurse and cannot be delegated. Unlicensed assistive personnel may perform tasks that are routine, standardized and have a predictable outcome on a stable patient, and they may — and must — report what they observe. Delegating well means being specific: not “keep an eye on him,” but “tell me right away if his voice changes, if he starts drooling, or if he says his throat feels tight.”

Words worth knowing

Assessing the Thorax and Lungs

The chest is the one region where a nurse can detect a patient deteriorating before any monitor announces it. Respiratory rate is the earliest vital sign to change in sepsis, in hemorrhage, in opioid oversedation and in heart failure — and it is the vital sign most often invented rather than counted. This chapter teaches the thoracic exam the way it is actually performed at the bedside: the bony landmarks you find with your fingertips, the lobes lying underneath them, and then the four steps in their fixed order — inspection, palpation, percussion, auscultation. You will learn what resonance sounds like against dullness, why bronchial breath sounds in the periphery mean consolidation, why a wheeze that disappears is worse than a wheeze that does not, and how to write a lung note precise enough that the next nurse can tell whether the patient improved. Every finding here has an escalation threshold attached, because a chest exam that ends in your head instead of in an SBAR call helps no one.

Section 1Landmarks, Lobes and the Respiratory Baseline

Reference lines and the bony landmarks you can find in the dark

A lung finding without a location is nearly useless. “Crackles in the chest” tells the next nurse nothing; “fine end-inspiratory crackles, bilateral posterior bases, below the level of the scapular tips” tells them exactly where to listen at 0300 to see whether the patient got better. Naming a location requires two coordinates: a horizontal one from the ribs and intercostal spaces, and a vertical one from a reference line. Learn to find both by touch, because you will often be assessing in a dim room with a patient who does not want to sit forward.

Start at the suprasternal notch, the hollow at the top of the sternum. Walk your fingers down about 5 cm until you feel a firm ridge — the sternal angle, or angle of Louis, where the manubrium meets the body of the sternum. The second rib articulates here, so the space just below your finger is the second intercostal space. From that single landmark you can count every rib on the anterior chest. Count in the intercostal spaces, not on the ribs, and remember that the costal cartilages of ribs eight through ten fuse rather than attach to the sternum, so anterior counting becomes unreliable below about the seventh rib. The sternal angle also marks the level where the trachea bifurcates into the right and left mainstem bronchi (roughly T4 to T5) — useful, because that is exactly where normal breath sounds are loudest and most tubular.

Posteriorly, ask the patient to flex the neck forward and find the vertebra prominens, the prominent spinous process of C7. Below it lies T1. The inferior angle of the scapula sits at approximately the seventh rib or seventh intercostal space and is the practical marker for “the bases.” The vertical reference lines are: midsternal, midclavicular and anterior axillary anteriorly; anterior, mid- and posterior axillary laterally; and vertebral (midspinal) and scapular posteriorly. The costal angle, formed where the two costal margins meet at the xiphoid, is normally less than 90 degrees and widens in chronic air trapping.

What lies beneath: lobes, fissures and lung borders

The right lung has three lobes, the left has two plus the lingula, which is the left lung’s anatomic answer to the right middle lobe. The clinically important fact is where those lobes sit relative to the skin. The oblique (major) fissures run from about the T3 spinous process posteriorly, around the chest, to the sixth rib at the midclavicular line. Everything you auscultate on the posterior chest below the scapular tips is lower lobe. The right horizontal (minor) fissure runs from the fourth rib at the sternum to the fifth rib at the midaxillary line, so the right middle lobe is heard on the anterior and right lateral chest only — never on the back. This is why nurses who auscultate only the posterior chest miss right middle lobe pneumonia and aspiration, and why the lateral chest wall at the midaxillary line is a mandatory part of the exam, not an optional one.

The lung apices extend 2 to 4 cm above the inner third of the clavicles, so a finding “above the clavicle” is still lung. The lower borders sit at roughly the sixth rib at the midclavicular line, the eighth rib at the midaxillary line, and the level of T10 posteriorly, descending to about T12 on deep inspiration. Below those borders you are percussing liver on the right and stomach or spleen on the left, which is why a dull note at the right base near the sixth rib is normal liver and not consolidation.

The respiratory baseline and the order of the exam

Count respirations for a full 30 seconds and multiply by two when the pattern is regular, and for a full 60 seconds when it is irregular, when the patient is an infant, or when the rate is at either extreme. Count without announcing it — keep your fingers on the radial pulse and watch or feel the chest, because a patient who knows you are counting breathes differently. Document rate, depth (shallow, normal, deep) and rhythm (regular, irregular), plus effort and oxygen saturation with the delivery device and flow rate. “RR 18” alone is an incomplete vital sign.

Oxygen saturation by pulse oximetry is normally 95% to 100% on room air. A saturation of 90% corresponds roughly to a PaO2 of 60 mmHg — the shoulder of the oxyhemoglobin dissociation curve, below which small further drops in saturation mean large drops in PaO2. For most patients with chronic carbon dioxide retention the prescribed target is 88% to 92%, because excess oxygen worsens ventilation-perfusion matching and can blunt ventilatory drive; titrate only within the ordered range. That target is never a reason to withhold oxygen — a patient who is acutely and severely hypoxemic is given oxygen first, and the target range is re-established once they are safe. Always chart saturation with its context: “SpO2 94% on 2 L/min nasal cannula” means something entirely different from “SpO2 94% on room air.”

Section 2Inspection and Palpation of the Thorax

Inspection: what the first ten seconds tell you

Inspection begins before you touch anything, and often before you speak. Expose the chest with the patient sitting upright, gown open, room warm and light good. Stand back far enough to see the whole thorax and watch a full minute of breathing. Note position first: a patient sitting bolt upright, leaning forward on their elbows, is in the tripod position and is recruiting every accessory muscle they have. Note speech: a patient who can speak only three or four words between breaths is in significant distress regardless of the number on the pulse oximeter.

Look at shape. The normal adult chest is wider than it is deep; the anteroposterior to transverse diameter ratio is about 1:2 (ranging to 5:7). In a barrel chest the ratio approaches 1:1, the ribs run horizontally rather than sloping down at roughly 45 degrees, and the costal angle exceeds 90 degrees — the configuration of chronic air trapping in emphysema and long-standing asthma, and an expected finding in infants under about two years and in some older adults with kyphosis. An increased anteroposterior diameter is a chronic finding, so it never explains a new symptom — do not let it talk you out of an acute change. Note also pectus excavatum (a sunken sternum), pectus carinatum (a protruding sternum), kyphosis, scoliosis and any surgical scars or chest tube sites.

Look at effort. Normal quiet breathing is almost invisible: the chest rises symmetrically, the accessory muscles are silent, and the ratio of inspiration to expiration is about 1:2. Abnormal effort shows as retractions (skin sucking in above the clavicles, between the ribs, or below the xiphoid), nasal flaring, grunting (an infant generating their own positive end-expiratory pressure — always ominous), head bobbing in an infant, use of the sternocleidomastoid, scalene and trapezius muscles, and pursed-lip breathing. Watch for paradoxical movement, where a segment of chest wall moves inward on inspiration — flail chest after trauma. Finally, look at the fingers: the normal nail-bed angle is about 160 degrees, and clubbing (angle 180 degrees or more, with a spongy nail bed) signals months to years of hypoxemia, not an acute event.

Breathing patterns worth naming

Palpation: tenderness, expansion, fremitus and crepitus

Palpate with warm hands and a stated purpose. First, palpate for tenderness, masses and lesions with the finger pads over the anterior, lateral and posterior chest wall, and note whether pain is reproducible with pressure — reproducible chest wall tenderness suggests a musculoskeletal or costochondral source, but it never rules out a cardiac or pulmonary cause on its own. Confirm the trachea is midline by placing an index finger in the suprasternal notch and slipping it gently to each side to compare the spaces between the trachea and the sternocleidomastoid. Deviation is a late and dangerous sign.

Next assess chest expansion. Standing behind the seated patient, place your thumbs along the spine at about the level of the tenth rib with your palms lightly on the posterolateral chest, and slide medially just enough to raise a small skin fold between your thumbs. Ask for a deep breath. Your thumbs should move apart symmetrically, separating about 3 to 5 cm. Asymmetry is the finding that matters: the side that lags is the abnormal side — think pneumothorax, pleural effusion, lobar pneumonia, atelectasis, splinting from rib fracture, or post-operative guarding.

Then assess tactile fremitus, the palpable vibration of the voice transmitted through lung tissue. Use the ball of the palm or the ulnar surface of one hand, move in a side-to-side ladder pattern, and ask the patient to repeat “ninety-nine” or “one-one-one” in a low voice each time you move. Fremitus is normally strongest near the large airways — the second intercostal spaces anteriorly and between the scapulae posteriorly — and fades toward the bases. Compare sides, not absolute intensity. Solid, consolidated lung conducts sound better, so fremitus increases in pneumonia. Air, fluid or fat between your hand and the lung conducts it worse, so fremitus decreases in pneumothorax, pleural effusion, emphysema, bronchial obstruction and simply in a thick chest wall or a very muscular back.

Finally, feel for crepitus — subcutaneous emphysema. It feels like fine bubble wrap or crackling tissue paper under the skin, usually over the upper chest, neck or around a chest tube insertion site. It means air has escaped into the subcutaneous tissue and demands immediate assessment for pneumothorax, a disconnected or malpositioned chest tube, or airway injury. Mark the borders with a skin pen, note the time, and escalate.

Section 3Percussion and Diaphragmatic Excursion

How to percuss so the note means something

Percussion is the step students skip and experienced nurses use to answer one question quickly: is there air where there should be air? Sound produced by tapping the chest wall penetrates only about 5 to 7 cm, so percussion assesses the outer lung, not deep structures — a small central lesion will be silent to your fingers.

Use indirect percussion. Hyperextend the middle finger of your non-dominant hand — the pleximeter — and press its distal interphalangeal joint firmly into an intercostal space, keeping the rest of that hand off the chest wall so it does not damp the vibration. With the dominant hand, flex the wrist (not the elbow or shoulder) and strike the pleximeter’s DIP joint sharply with the tip of your middle finger — the plexor — using a quick, bouncing motion. Deliver two taps, then withdraw immediately; a finger left in place absorbs the sound you are trying to hear. Keep your fingernail short, or you will hurt both of you.

Percuss over intercostal spaces only. Bone gives a dull, useless note, so avoid the sternum, ribs, scapulae and vertebrae. Work in the same side-to-side ladder as the rest of the exam: right apex, left apex, right second interspace, left second interspace, and downward, comparing each pair before moving on. Anteriorly, percuss from above the clavicles to the sixth rib. Posteriorly, ask the patient to cross their arms in front to swing the scapulae laterally, then percuss from C7 down to T10, staying medial to the scapular borders and finishing along the lateral chest.

The five percussion tones

Two normal findings trip up beginners. Dullness at the right base at about the fifth to sixth intercostal space anteriorly is liver, and tympany in the left lower anterior chest is the gastric air bubble — neither is pathology. Cardiac dullness is expected from the third to fifth interspaces left of the sternum. Anything else that is dull where it should be resonant deserves a careful auscultation of that exact spot.

Diaphragmatic excursion

Diaphragmatic excursion measures how far the diaphragm travels between full expiration and full inspiration, and it is the cleanest bedside test of ventilatory mechanics available without equipment. With the patient sitting and leaning slightly forward, ask them to exhale fully and hold. Percuss down the posterior chest along the scapular line until resonance changes to dullness, and mark that spot. Let them breathe, then ask them to inhale deeply and hold. Percuss down again until the note changes, and mark the second spot. The distance between the two marks is the excursion, and it is measured on both sides.

Expected excursion in a healthy adult is 3 to 5 cm, and up to 7 to 8 cm in a tall, well-conditioned adult. The right side may sit slightly higher than the left because of the liver. Reduced excursion appears in emphysema (a flattened, already-depressed diaphragm), atelectasis, pleural effusion, severe obesity, ascites, late pregnancy, phrenic nerve injury and simple splinting from pain. Asymmetry — one side moving well and the other barely at all — is the more alarming pattern and points to unilateral disease or a paralyzed hemidiaphragm.

Section 4Auscultation and Voice-Transmitted Sounds

Technique and sequence

Use the diaphragm of the stethoscope, pressed firmly enough to leave a light ring on the skin, and always on bare skin — auscultating through a gown produces rustling artifact that beginners confuse with crackles. Ask the patient to sit upright and breathe slowly and a little more deeply than usual through an open mouth. Nose breathing adds turbulence; mouth breathing gives clean sounds. Listen to at least one full inspiration and expiration at every site, and stop and let the patient rest if they become dizzy or lightheaded from hyperventilating.

Move in the same side-to-side ladder used for percussion: apices first, then downward, comparing each pair before descending. Posteriorly, listen at approximately eight to ten paired sites from above the scapulae down to the level of T10, staying medial to the scapular borders. Then listen laterally at the midaxillary lines from the axilla to the seventh or eighth rib — this is where the right middle lobe and the lingula live. Then listen anteriorly from above the clavicles down to the sixth rib, moving the breast tissue aside rather than listening through it. If a patient cannot sit up, listen posteriorly with them rolled to each side and document their position, because gravity changes findings.

Describe what you hear along four axes: location, timing in the respiratory cycle (inspiratory, expiratory or both, early or late), quality, and whether it clears with coughing. A crackle that clears after two deep breaths and a cough is atelectatic and usually resolves with mobilization and incentive spirometry; a crackle that persists is not.

Normal breath sounds

Adventitious sounds

Two distinctions carry the most clinical weight. First, rhonchi versus crackles: ask the patient to cough and listen again. Sounds that clear were secretions sitting in an airway; sounds that persist reflect fluid or disease in the tissue. Second, wheeze versus stridor: a wheeze is expiratory and comes from the lower airways; stridor is inspiratory, comes from obstruction of the extrathoracic upper airway — anywhere above the thoracic inlet, whether supraglottic (epiglottitis), glottic (laryngospasm, vocal cord edema) or subglottic (croup, post-extubation edema) — and buys the patient minutes rather than hours. Confusing them delays an airway response.

Voice-transmitted sounds

When percussion is dull and breath sounds are bronchial where they should be vesicular, three quick maneuvers confirm consolidation. Perform each with the stethoscope diaphragm over the suspicious area, comparing to the same spot on the opposite side.

Bronchophony: ask the patient to say “ninety-nine” repeatedly. Normally the words are muffled and indistinct. Over consolidated lung they become louder and clearer. Egophony: ask the patient to say a long “eeee.” Normally you hear a muffled “eeee.” Over consolidation it converts to a nasal “aaaa” — the classic E-to-A change, also heard just above the fluid level of a pleural effusion where lung is compressed. Whispered pectoriloquy: ask the patient to whisper “one-two-three” or “ninety-nine.” Normally the whisper is faint and unintelligible. Over consolidation the whispered words come through crisply, as if the patient were speaking directly into your stethoscope. All three are increased in consolidation and decreased or absent over a pneumothorax or a large effusion, for the same reason fremitus behaves that way: solids conduct sound, air and fluid do not.

Section 5Red Flags, Lifespan Variation, Documentation and Escalation

Findings that mean escalate now

The earliest sign of hypoxia is not cyanosis. It is restlessness, anxiety, agitation or new confusion, because the brain is the first organ to complain. A patient who was oriented at 0800 and is now pulling at their lines at 1000 is hypoxic until you prove otherwise. Cyanosis is a late sign requiring roughly 5 g/dL of deoxygenated hemoglobin, which means a profoundly anemic patient may never become visibly cyanotic despite dangerous hypoxemia.

Lifespan and skin-tone variation

Infants and children. The infant chest is round, with an anteroposterior to transverse ratio near 1:1 until about age two, so a “barrel chest” in a toddler is normal. Infants breathe primarily with the diaphragm, so watch the abdomen rise; thoracic breathing establishes around age six or seven. Count for a full 60 seconds, ideally while the infant is quiet or asleep. The chest wall is thin and sounds transmit widely, so bronchovesicular sounds throughout the lung fields are normal in children and would be abnormal in an adult. Retractions, nasal flaring, grunting and head bobbing form the visual distress score you should chart every time. Infants in the early months breathe preferentially through the nose, so nasal congestion alone can cause real distress.

Pregnancy. The enlarging uterus elevates the diaphragm by up to 4 cm, the transverse chest diameter increases about 2 cm and the costal angle widens. Tidal volume rises 30% to 40% under progesterone, so minute ventilation increases while the respiratory rate stays essentially normal. Physiologic dyspnea affects most pregnant patients and is typically mild, gradual and present at rest but not worsening. Sudden dyspnea, tachypnea, chest pain or hypoxemia in pregnancy is never physiologic — pregnancy is a hypercoagulable state and pulmonary embolism is a leading cause of maternal death.

Older adults. Costal cartilage calcifies, kyphosis increases the anteroposterior diameter, respiratory muscles weaken and elastic recoil falls, so chest expansion and diaphragmatic excursion decrease. Cough strength and ciliary clearance decline, which is why immobility so quickly produces atelectasis and pneumonia. Fine crackles at the bases that clear after several deep breaths and a cough are usually atelectatic, not heart failure. Critically, older adults often do not mount a fever or a productive cough with pneumonia — new confusion, a fall, anorexia or simply a rising respiratory rate may be the only presentation. Take a respiratory rate over 24 in an older adult seriously.

Skin tone. Cyanosis, pallor and erythema are unreliable when assessed only on the outer skin of patients with richly pigmented skin. Assess oral mucosa, the tongue, the conjunctivae, the palms and soles and the nail beds in natural or full-spectrum light. Central cyanosis appears as a gray or ashen cast to the lips, tongue and oral mucosa rather than a blue tint. Pallor may present as ashen, gray or yellow-brown rather than white. Erythema is often easier to feel than to see — compare warmth and induration to the opposite side. Be aware also that pulse oximetry systematically overestimates arterial saturation in patients with darker skin pigmentation, producing occult hypoxemia; when the number looks acceptable but the patient is working hard, believe the work of breathing and request an arterial or venous blood gas.

Charting the lung exam

Document what you observed and measured, not what you concluded. Include location, timing, quality, response to cough, position of the patient, oxygen device and flow, saturation, and the patient’s own words in quotation marks. Compare the two entries below.

Delegation, scope and the SBAR call

Apply the five rights of delegation: right task, right circumstance, right person, right direction and communication, right supervision and evaluation. The registered nurse may delegate data collection tasks on a stable patient but never delegates assessment, interpretation, teaching, evaluation, or any aspect of care for an unstable or deteriorating patient.

When a red flag appears, escalate with SBAR. Have the chart, the last two sets of vitals and the medication list in front of you before you dial. A worked example: Situation — “This is Marcus Ellis, RN, on 4 West. I am calling about Mrs. Alvarez in room 412, a 74-year-old two days post right hip arthroplasty. She has new shortness of breath and her oxygen saturation has fallen to 88% on room air.” Background — “She has a history of heart failure and COPD, home oxygen 2 L at night. She has been on bed rest since surgery and has not ambulated today. Baseline saturation on admission was 95% on room air.” Assessment — “Respirations 30 and shallow, heart rate 118, blood pressure 104 over 62, temperature 37.9 Celsius. She is using accessory muscles and speaking in short phrases. Fine crackles at both bases that do not clear with cough, decreased breath sounds at the right base, dullness to percussion there. No stridor, trachea midline. She is more confused than this morning. I have her upright and on 2 L nasal cannula under the standing hypoxia protocol, which brought her to 92%.” Recommendation — “I think she needs to be seen now. I am requesting a chest x-ray, arterial blood gas and an oxygen order, and I would like to know whether you want a rapid response called. Can you come to the bedside?” Then close the loop: repeat the orders back, document the time of the call and the response, and reassess.

Words worth knowing

Assessing the Heart and Peripheral Vascular System

Cardiovascular disease is the leading cause of death in this country, and the nurse at the bedside is the person most likely to notice it turning. This chapter teaches the cardiac and peripheral vascular exam the way it is actually performed: where the valve areas sit on the chest wall, how to find the apical impulse with your fingertips, how to tell a jugular pulsation from a carotid one, when to use the bell and when the diaphragm, and how to grade a pulse, an edema and a murmur so the next nurse can tell whether the patient improved. You will learn the four-step order — inspection, palpation, percussion, auscultation — and the single exception to it. You will learn the real numbers: heart rate and blood pressure across the lifespan, capillary refill, ankle-brachial index, the size and location of a normal apical impulse. And you will learn which findings do not wait for morning rounds, because a cold pulseless foot and a new S3 in a patient gaining weight are both clocks that have already started.

Section 1The Pump, the Cycle and the Cardiac Baseline

Chambers, valves and the direction of flow

The heart sits in the mediastinum behind the sternum, roughly two thirds of it to the left of the midline, with its broad base up under the second intercostal spaces and its pointed apex down and to the left at about the fifth intercostal space. That orientation is upside down from how students first picture it, and it matters: the valves closest to the base are the ones you hear best at the top of the chest, and the apex — the tip of the left ventricle — is what taps your fingers low on the left chest wall.

Deoxygenated blood returns from the body through the superior and inferior vena cava into the right atrium, crosses the tricuspid valve into the right ventricle, and is pumped through the pulmonic valve into the pulmonary artery and on to the lungs. Oxygenated blood returns through the four pulmonary veins into the left atrium, crosses the mitral valve into the left ventricle, and is ejected through the aortic valve into the aorta. The tricuspid and mitral valves are the atrioventricular valves; the pulmonic and aortic are the semilunar valves. The left ventricle does the systemic work and is therefore the thickest chamber, which is why it is the chamber you can feel and the chamber that hypertrophies under a lifetime of high blood pressure.

The heart is wrapped in the pericardium, a two-layered sac with a thin film of fluid between the layers. When those layers inflame they scrape against each other and produce a friction rub; when fluid accumulates rapidly between them the ventricles cannot fill, which is cardiac tamponade. The coronary arteries branch off the aorta immediately above the aortic valve and fill during diastole, not systole, which is why a very fast heart rate — by shortening diastole — worsens myocardial ischemia even when nothing else changes.

The cardiac cycle and what makes the sounds

Systole is ventricular contraction and ejection; diastole is ventricular relaxation and filling. Diastole is normally the longer of the two at rest, occupying roughly two thirds of the cycle. The heart sounds are not made by valves opening — opening is silent — but by the abrupt deceleration of blood and the vibration of structures when valves close.

S1, the “lub,” is closure of the mitral and tricuspid valves and marks the beginning of systole. It is lower pitched, slightly longer, and loudest at the apex. S2, the “dub,” is closure of the aortic and pulmonic valves and marks the end of systole. It is higher pitched, shorter, and loudest at the base. The interval between S1 and S2 is systole; the longer interval between S2 and the next S1 is diastole. If you cannot tell which sound is which — and at a rate over about 120 you often cannot — palpate the carotid pulse while you listen: the carotid upstroke coincides with S1.

Two more facts turn this into usable clinical information. First, S2 normally splits during inspiration, because negative intrathoracic pressure increases venous return to the right heart, prolongs right ventricular ejection and delays pulmonic closure behind aortic closure. Physiologic splitting is heard best at the second left intercostal space, appears on inspiration and vanishes on expiration, and is a normal finding, most obvious in children and thin young adults. Splitting that persists through expiration, or that widens on expiration, is not normal. Second, the atria contribute a final “atrial kick” of about 20 to 30 percent of ventricular filling at the very end of diastole. When the atria fibrillate, that kick disappears — which is why patients who go into atrial fibrillation often drop their blood pressure, and why an S4, which is generated by atrial contraction, can never exist in atrial fibrillation.

Precordial landmarks and the auscultatory areas

The five listening areas are not directly over their valves. They are the spots on the chest wall where blood flow carries each valve’s sound most clearly, so you must learn them as surface locations, counted from the sternal angle (angle of Louis) exactly as you learned to count ribs in the chest exam.

A common mnemonic runs All People Enjoy Time Magazine — aortic, pulmonic, Erb’s, tricuspid, mitral — and it tracks the standard base-to-apex sequence. Move in that order or its reverse, but move in an order and use the same one every time. Do not skip from spot to spot; slide the stethoscope in small steps so you do not miss a murmur that lives between two named areas.

The cardiac baseline: rate, rhythm and pressure

The apical pulse is auscultated at the mitral area with the diaphragm and counted for a full 60 seconds whenever the rhythm is irregular, whenever the patient is an infant or young child, and before administering any medication with a heart-rate parameter. Digoxin is the classic example: hold the dose and notify the provider if the apical rate is under 60 in an adult, under 70 in a child or under 90 in an infant, and always follow the parameters actually written in the order.

A pulse deficit is the difference between the apical rate and the radial rate counted over the same minute. It is measured by two clinicians counting simultaneously, or by counting apical then radial back to back if only one nurse is available, and it means that some ventricular contractions are too weak to generate a peripheral pulse. A deficit is common in atrial fibrillation and with frequent premature ventricular contractions, and it is always the apical rate — never the radial — that is the true heart rate.

Pulse pressure is systolic minus diastolic and is normally about 30 to 40 mmHg, up to roughly 50. A narrow pulse pressure suggests reduced stroke volume — hypovolemia, heart failure, aortic stenosis, tamponade. A wide pulse pressure suggests stiff arteries in an older adult, or aortic regurgitation, thyrotoxicosis, anemia or fever. Cuff technique changes the number: the bladder width should be about 40 percent of the arm circumference and the bladder length about 80 percent, the arm must be supported at heart level, and the patient should sit quietly for five minutes with the back supported, feet flat on the floor, legs uncrossed, and should not talk during the measurement. An unsupported back raises the diastolic reading and crossed legs raise the systolic reading. A cuff that is too small or too loose reads falsely high; an arm held below heart level reads falsely high; an arm held above heart level reads falsely low.

Orthostatic vital signs are a cardiovascular test, not a courtesy. Measure blood pressure and heart rate after the patient has been supine at least five minutes, then repeat sitting and again standing at one minute and at three minutes. Orthostatic hypotension is a drop of 20 mmHg or more in systolic pressure, or 10 mmHg or more in diastolic pressure, within three minutes of standing; a compensatory rise in heart rate of 20 beats per minute or more is corroborating. Stay with the patient. If they become dizzy or pale, sit them down and abandon the test — you have your answer.

Section 2Inspecting and Palpating the Precordium and Neck Vessels

Setting up, and the order of the exam

The cardiovascular exam follows the same fixed sequence as the rest of the body: inspection, palpation, percussion, auscultation. The abdomen is the single exception — there you inspect, then auscultate, then percuss, then palpate, because pressing on the abdomen first alters bowel motility and produces falsely absent or falsely hyperactive bowel sounds. Nothing about the heart uses that modified order.

Position matters more here than anywhere else in the physical exam. Begin with the patient supine with the head of the bed at 30 to 45 degrees, chest exposed, room warm, and stand on the patient’s right side if you can. You will use two more positions later: the left lateral decubitus position, which rolls the apex of the heart toward the chest wall and brings out low-pitched apical sounds such as S3, S4 and the rumble of mitral stenosis; and sitting upright and leaning forward, which brings the base of the heart forward and brings out the soft early-diastolic murmur of aortic regurgitation and a pericardial friction rub. Tell the patient what you are doing and drape a female patient so that only the area being examined is uncovered; when breast tissue overlies the apex, ask the patient to lift the breast or displace it upward yourself with the back of your hand.

Inspection and palpation of the precordium

Inspect with tangential light across the chest so that movement casts a shadow. Look for the apical impulse, which is visible in roughly half of adults and in most thin patients and children, and for any other pulsation, lift or retraction. Note the chest wall itself: pectus excavatum can displace the heart, a median sternotomy scar tells you about prior surgery, and a firm rectangular bulge below the left clavicle is a pacemaker or defibrillator generator, which should be documented along with the site’s appearance.

Now palpate. Use the finger pads for pulsations and the ball of the hand at the base of the fingers for the low-frequency buzzing of a thrill. Palpate systematically at the apex, the left lower sternal border, the left and right second intercostal spaces and the epigastrium. The point of maximal impulse, or PMI, is the apical impulse and normally sits at the fifth intercostal space at or just medial to the left midclavicular line. It is small — about 1 to 2 cm across, no more than the size of a quarter, roughly one interspace — it is a brief gentle tap occupying the first half of systole, and it is easiest to feel with the patient rolled to the left side or in full expiration. If you cannot find it, that alone is not abnormal: obesity, a muscular chest wall, emphysema and large breasts all conceal it.

Percussion of the heart is the third step in the sequence, and honesty is owed to students here: it is now rarely performed and has largely been replaced by chest radiography and echocardiography, because percussing the left cardiac border is imprecise and unreliable. It is still taught, and if you perform it you percuss from resonance in the left anterior axillary line medially toward the sternum at the third, fourth and fifth interspaces, listening for the change to dullness, which normally occurs at or medial to the midclavicular line. Cardiac dullness extending well past the midclavicular line suggests cardiac enlargement. Chart what you did and did not perform; do not chart a percussion you skipped.

The neck vessels: carotids and jugular venous pressure

The carotid arteries and internal jugular veins are the two windows onto the heart that sit outside the chest. Assess the carotid arteries one at a time, never both simultaneously — simultaneous compression can reduce cerebral perfusion, and pressure over the carotid sinus can trigger a reflex bradycardia or even asystole in a susceptible patient. Palpate low in the neck, medial to the sternocleidomastoid, below the level of the thyroid cartilage, using light pressure. The normal carotid upstroke is brisk, smooth and symmetric, graded 2+, and it coincides with S1. A weak, slow-rising and delayed upstroke suggests aortic stenosis; a bounding upstroke suggests aortic regurgitation, fever, anemia or hyperthyroidism.

Auscultate the carotids before you palpate them in any patient over about 50, or with known atherosclerosis, hypertension, diabetes, or a history of stroke or transient ischemic attack. Place the bell lightly over each carotid at the angle of the jaw, at the midcervical level and at the base of the neck, and ask the patient to hold their breath briefly so tracheal sounds do not mask what you are listening for. A bruit is a blowing, swishing sound of turbulent flow and requires reporting. Be aware that a bruit does not reliably indicate the degree of stenosis: a tightly narrowed artery may be silent because so little blood is moving through it.

Jugular venous pressure is a direct bedside estimate of right atrial filling pressure and volume status, and it is one of the most useful skills in this chapter. Position the patient at 30 to 45 degrees, turn the head slightly away from the side you are examining, and use tangential lighting. Look for the flickering pulsation of the internal jugular between the two heads of the sternocleidomastoid. Identify the highest point at which the pulsation is visible, then measure the vertical distance in centimeters from that point up from the horizontal plane of the sternal angle. Normal is 3 cm or less above the sternal angle; because the sternal angle sits about 5 cm above the right atrium in any position, that corresponds to a central venous pressure of roughly 8 cm of water or less. A jugular pulsation visible with the patient sitting fully upright at 90 degrees is markedly elevated.

Elevated jugular venous pressure, commonly charted as jugular venous distention, means the right side of the heart cannot handle its returning volume: right-sided heart failure, fluid overload, tricuspid regurgitation, pulmonary hypertension, cardiac tamponade, constrictive pericarditis or tension pneumothorax. Flat neck veins in a patient lying supine suggest the opposite — hypovolemia. Hepatojugular reflux refines the finding: with the patient at 30 to 45 degrees and breathing normally through an open mouth, press firmly over the right upper quadrant for 10 to 15 seconds. A sustained rise in jugular pressure of more than 3 cm that persists throughout the pressure suggests the right ventricle cannot accommodate additional volume. Stop if the patient reports pain.

Section 3Auscultating the Heart: Normal Sounds, Extra Sounds and Murmurs

Technique: bell, diaphragm, position and sequence

Auscultate on bare skin in a quiet room. Clothing and gowns generate rustling that beginners mistake for murmurs and rubs. Warm the endpiece. Then use both sides of the stethoscope deliberately, because they filter different frequencies: the diaphragm, pressed firmly enough to leave a light ring, transmits high-pitched sounds — S1, S2, most murmurs, and friction rubs. The bell, applied lightly enough that it barely dimples the skin, transmits low-pitched sounds — S3, S4 and the diastolic rumble of mitral stenosis. Pressing the bell firmly stretches the skin beneath it into a diaphragm and eliminates exactly the sounds you were trying to hear, which is why so many students never hear an S3.

Go through all five areas with the diaphragm first, then repeat all five with the bell. At every site, listen for one thing at a time rather than trying to hear everything at once. Identify S1, then S2, then the systolic interval between them, then diastole, and only then listen for extra sounds. Note the rate and the rhythm: regular, regularly irregular (a repeating pattern, as in bigeminy or second-degree block) or irregularly irregular (no pattern at all, the hallmark of atrial fibrillation).

Finally, use the two special positions. Roll the patient into the left lateral decubitus position and listen at the apex with the bell — this is where S3, S4 and mitral stenosis appear. Then sit the patient up, ask them to lean forward and exhale fully and hold, and listen along the left sternal border and at the base with the diaphragm — this is where aortic regurgitation and a pericardial friction rub appear. Skipping these two maneuvers is why soft diastolic murmurs get missed on the unit and found in the cath lab.

S1, S2 and normal variation

At the apex, S1 is louder than S2; at the base, S2 is louder than S1. Both should be crisp. Muffled or distant heart sounds occur with obesity, emphysema, a thick chest wall, and — urgently — with pericardial effusion and cardiac tamponade, where muffled sounds join hypotension and jugular distention to form Beck’s triad. An accentuated S1 occurs with tachycardia, fever, anemia, exercise and mitral stenosis; a diminished S1 occurs with first-degree heart block and with mitral regurgitation. Variable S1 intensity from beat to beat is a clue to atrial fibrillation or complete heart block, because the relationship between atrial and ventricular contraction keeps changing.

Physiologic splitting of S2, described earlier, is normal when it appears on inspiration and disappears on expiration at the pulmonic area. Persistent splitting through both phases, fixed splitting that never varies with respiration (classically atrial septal defect) and paradoxical splitting that appears on expiration and disappears on inspiration (left bundle branch block, severe aortic stenosis) are all abnormal and reportable. A nurse is not expected to name the lesion; a nurse is expected to notice that the second sound is doing something it should not and to describe it accurately.

S3, S4, and the other extra sounds