key information

Oral temperature range ; 35.8–37.3°C (mean 37°C)

Rectal temperature ; 0.4–0.5°C higher than oral

Factors affecting temperature ; Exercise, hormones, environment, age

Hyperthermia ; Temperature >37.3°C caused by pyrogens, tissue breakdown, or neurological thermostat reset

Hypothermia ; Temperature <35.8°C caused by cold exposure, wet skin, or induced to reduce oxygen demand

Pulse rhythm ; Even tempo, regular or irregular

Pulse force ; Strength of heart stroke volume

3+ pulse ; Full, bounding pulse (hyperkinetic state, exercise, anxiety, fever, anemia)

2+ pulse ; Normal pulse

1+ pulse ; Weak, thready pulse (decreased circulatory volume)

0 pulse ; Absent pulse (decreased circulatory volume)

Expected adult pulse ; 50–95 bpm, regular rhythm, force 2+

Bradycardia ; HR <50 bpm, stronger efficient heart, decreased metabolism

Tachycardia ; HR >95 bpm, increased metabolism

Pulse-respiration ratio ; 4:1

Expected adult respiratory rate ; 10–20 breaths/min

Bradypnea ; RR <10 breaths/min, drug induced, increased ICP, diabetic coma

Tachypnea ; RR >24 breaths/min, fever, fear, exercise, pneumonia, alkalosis, pleurisy, pontine lesion

Hyperventilation ; Increased rate and depth, decreased CO₂, respiratory alkalosis

Hypoventilation ; Irregular, shallow breathing pattern

Normal pediatric respiratory rate ; Higher than adults

Normal RR ages 0–2 ; Up to 40 breaths/min

Tachypnea newborn ; >60 breaths/min

Tachypnea 2–12 months ; >50 breaths/min

Older adult respirations ; Shallower and increased due to decreased vital capacity and inspiratory reserve

Hypotension ; BP <95/60 mmHg

Hypertension ; BP >140 systolic or >90 diastolic

Arm above heart level ; Falsely low BP

Arm below heart level ; Falsely high BP

Leg BP positioning ; Falsely high systolic and diastolic

Incorrect meniscus viewing ; Looking up falsely high, looking down falsely low

Orthostatic hypotension ; Drop in systolic >20 mmHg or pulse increase >20 bpm

OPQRSTU ; Initial pain assessment framework

Brief Pain Inventory ; Rates pain over past 24 hours and impact on ADLs

General survey ; Overall observation of health and physical characteristics

Physical appearance ; Age, sex, LOC, skin color, facial features

Normal appearance findings ; Appears stated age, appropriate sexual development, alert, even skin tone, symmetrical facial movement, no acute distress

Edema ; Fluid accumulation in intercellular spaces

1+ edema ; Mild pitting, slight indentation, no visible swelling

2+ edema ; Moderate pitting, indentation subsides rapidly

3+ edema ; Deep pitting, indentation remains briefly, leg swelling

4+ edema ; Very deep pitting, indentation lasts long, gross distortion

Skin mobility ; Ease of skin rising

Skin turgor ; Ability to return to place when released

Ecchymosis ; Purplish patch >3 mm from blood extravasation

Petechiae ; Tiny round hemorrhages

Purpura ; Confluent petechiae/ecchymoses, flat red-purple >3 mm

Hematoma ; Palpable bruise

ABCDE² melanoma rule ; Asymmetry, Border irregularity, Colour variation, Diameter, Elevation/enlargement

Primary lesion ; Growth on previously normal skin

Secondary lesion ; Lesion that changes over time

Cyanosis ; Bluish discoloration from decreased oxygenated blood

Pallor ; Pale skin from loss of oxygenated hemoglobin

Seborrhea ; Oily skin/hair

Xerosis ; Dry skin

Vellus hair ; Fine hair covering most of body

Terminal hair ; Thick dark hair on scalp, eyebrows, post-puberty areas

Hirsutism ; Excessive male-pattern hair in females indicating endocrine abnormalities

UAP ; Unlicensed Assistive Personnel (PSW)

UCP ; Unregulated Care Provider (PSW)

PCP ; Primary Care Provider (physician, NP)

Nose subjective assessment ; Rhinorrhea, frequency of colds, sinus pain, trauma, epistaxis, allergies, altered smell

Mouth/throat subjective data ; Sores, sore throat, bleeding gums, toothache, sugar intake, bruxism, halitosis

Papillae ; Taste bud elevations on dorsal tongue

Tonsil grade 1 ; Visible

Tonsil grade 2 ; Halfway between pillars and uvula

Tonsil grade 3 ; Touching uvula

Tonsil grade 4 ; Touching each other

Normal tonsils ; Grade 1 or 2

Amplitude ; Loudness of sound

Pitch ; Frequency of vibrations

Quality (timbre) ; Subjective sound tone differences

Duration ; Length sound lingers

Resonant ; Medium loud, low pitch, hollow, moderate duration, normal lung tissue

Hyperresonant ; Louder, lower pitch, booming, longer duration, normal in children

Fine crackles ; High-pitched popping during inspiration

Coarse crackles ; Low-pitched bubbling/gurgling from secretions

Atelectatic crackles ; Fine crackles that do not last due to alveoli collapse

High-pitched wheeze ; Narrowed airways, inspiratory or expiratory

Low-pitched wheeze ; Obstructed airflow, more prominent on expiration

Stridor ; High-pitched inspiratory sound from upper airway obstruction

Bronchial breath sounds ; High pitch, loud, harsh, trachea/larynx

Bronchovesicular breath sounds ; Moderate pitch, equal I:E, major bronchi

Vesicular breath sounds ; Low pitch, soft, inspiration longer, peripheral lungs

Bronchial location ; Anterior only

Bronchovesicular location ; Upper sternum anterior, upper thoracic spine posterior

Vesicular location ; Peripheral lung fields

Dyspnea ; Shortness of breath

Infant thorax ratio ; 1:1 at birth, 1:2 by age 6

Infant breathing pattern ; Nose breathing predominates

Infant thorax movement ; Minimal expansion, bulging abdomen

Infant apnea ; Brief apnea 10–15 seconds is normal

Sinus arrhythmia ; Normal variation in heart rate with breathing (HR increases with inspiration and decreases with expiration), common in children and young adults