Clinical Nursing: free practice, theory and problems

1. Vital signs and normal values

What is it about?

Vital signs are the measurements that most quickly tell whether a patient is stable: respiratory rate, oxygen saturation, blood pressure, pulse, consciousness and temperature. Changes in respiratory rate often come first.

Approximate normal values in adults at rest

• Respiratory rate: 12–20 per minute.
• Oxygen saturation (SpO₂): 96–100% (lower targets may apply in chronic lung disease, as decided by the doctor).
• Pulse: 60–100 beats per minute (51–90 scores 0 points in NEWS2).
• Blood pressure: about 120/80 mmHg. A systolic blood pressure below 90–100 mmHg can be serious.
• Temperature: about 36.1–38.0 °C.
• Consciousness: awake and oriented.

How to measure

• Count the respiratory rate for a full minute, without the patient noticing.
• Feel the pulse for regularity, not just rate.
• Always look at the measurements together and compare with the patient's own previous values.

Practise vital signs and normal values in the app →

2. NEWS2 and the acutely ill patient

What is it about?

NEWS2 (National Early Warning Score 2) turns vital signs into a score, so deterioration is detected early and everyone responds the same way. ABCDE is the order for assessing an acutely ill patient, and ISBAR is a fixed way of reporting to a doctor.

NEWS2 (SpO₂ scale 1)

• Respiratory rate: ≤8: 3 · 9–11: 1 · 12–20: 0 · 21–24: 2 · ≥25: 3
• SpO₂: ≤91: 3 · 92–93: 2 · 94–95: 1 · ≥96: 0
• Supplemental oxygen: yes: 2 · no (room air): 0
• Systolic blood pressure: ≤90: 3 · 91–100: 2 · 101–110: 1 · 111–219: 0 · ≥220: 3
• Pulse: ≤40: 3 · 41–50: 1 · 51–90: 0 · 91–110: 1 · 111–130: 2 · ≥131: 3
• Consciousness: alert: 0 · new confusion, responds to voice, pain or not at all: 3
• Temperature: ≤35.0: 3 · 35.1–36.0: 1 · 36.1–38.0: 0 · 38.1–39.0: 1 · ≥39.1: 2

A total of 0–4 is low risk (but a 3 in a single parameter needs urgent assessment), 5–6 medium (urgent), and 7 or more high risk (emergency assessment).

ABCDE

Airway, Breathing, Circulation, Disability (consciousness and neurology) and Exposure (examine the whole body). Treat what is life-threatening before moving on.

ISBAR

Identify, Situation, Background, Assessment and Recommendation (what you need).

Practise nEWS2 and the acutely ill patient in the app →

3. Fluid balance, nutrition and BMI

What is it about?

Many patients are at risk of getting too little or too much fluid and nutrition. You follow this with fluid balance charts, weight and nutritional screening.

Concepts and formulas

• Fluid balance = everything that goes in (drinks, food, intravenous) minus everything that goes out (urine, vomit, drains, stool). In addition about 0.5–1 litre a day is lost through the skin and breathing, which is not measured.
• Approximate fluid requirement in adults: 30–35 mL per kg per day (more with fever and heat).
• BMI (body mass index): $BMI = \text{weight (kg)} / \text{height (m)}^2$.
• Normal BMI for adults: 18.5–24.9. In people over 70, a BMI below 22 is considered a risk of undernutrition.
• Unintentional weight loss (for example more than 5% in three months) is an important warning sign.
• Weight is the best single measurement for following fluid balance over days: a 1 kg weight gain over a short time is often 1 litre of fluid.

Practise fluid balance, nutrition and BMI in the app →