Fundamentals of Nursing Notes: Vital Signs, Infection Control, BMW, Procedures and Safety

These fundamentals of nursing notes bring together the bedside basics that every nursing recruitment exam tests: vital signs, the nursing process, infection control, biomedical waste, positions, tubes, oxygen, IV therapy, medication safety and documentation. The content follows standard texts such as Potter and Perry and the INC syllabus, arranged for quick revision before AIIMS NORCET, staff nurse, CHO and ANM exams.

Fundamentals is one of the highest-scoring subjects because the questions are practical and the answers are fixed by standard protocols. Most mistakes come from mixing up numbers, such as injection angles, drop factors or waste bag colours, so the tables below are worth memorising.

Vital signs and normal ranges

Vital sign	Adult normal	Newborn normal
Temperature (oral)	About 36.5 to 37.5 degrees C (average 37 degrees C / 98.6 degrees F)	36.5 to 37.5 degrees C (axillary)
Pulse	60 to 100 beats/min	About 120 to 160 beats/min
Respiration	12 to 20 breaths/min	About 30 to 60 breaths/min
Blood pressure	About 120/80 mmHg	Much lower, rises with age
SpO2	95 to 100 percent	95 percent or more after the first minutes of life

• Rectal temperature reads about 0.5 degrees C higher and axillary about 0.5 degrees C lower than oral.
• Hyperpyrexia: above about 41 degrees C (105.8 degrees F). Hypothermia: below 35 degrees C.
• Radial pulse is the routine site; apical pulse is used for infants and before giving digoxin (count a full minute). Carotid is checked in adult CPR, brachial in infant CPR.
• Pulse deficit = apical rate minus radial rate, measured by two nurses at the same time.
• BP: the first Korotkoff sound is systolic pressure; disappearance of sounds (phase V) is diastolic pressure. A cuff that is too narrow gives a falsely high reading; too wide gives a falsely low reading.

Nursing process

The nursing process has five steps: Assessment, Diagnosis, Planning, Implementation and Evaluation (ADPIE). It is cyclical, client-centred and goal-directed.

• Assessment: subjective data (what the patient says) and objective data (what is observed or measured).
• Nursing diagnosis: NANDA-I format, often written as PES: Problem, Etiology, Signs and symptoms.
• Planning: set priorities and SMART goals. Priorities follow Maslow’s hierarchy (physiological needs first) and ABC (airway, breathing, circulation).
• Implementation: independent, dependent and collaborative interventions.
• Evaluation: compare outcomes with goals and modify the plan.

Infection control and asepsis

Chain of infection

Infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host. Breaking any link prevents infection; hand hygiene breaks the mode of transmission and is the single most effective measure.

Hand hygiene

• WHO “My 5 Moments”: before touching a patient, before a clean or aseptic procedure, after body fluid exposure risk, after touching a patient, after touching patient surroundings.
• Handwash with soap and water takes about 40 to 60 seconds; alcohol hand rub about 20 to 30 seconds.

Transmission-based precautions

Type	Examples	Key measures
Contact	MRSA, scabies, wound infections	Gloves and gown, dedicated equipment
Droplet (particles larger than 5 microns)	Influenza, diphtheria, pertussis, meningococcal infection	Surgical mask within about 1 m, private room or cohorting
Airborne (particles smaller than 5 microns)	Tuberculosis, measles, chickenpox	N95 respirator, negative pressure isolation room

PPE order (CDC): donning is gown, mask or respirator, goggles or face shield, gloves. Doffing is gloves, goggles or face shield, gown, mask or respirator, then hand hygiene.

Medical and surgical asepsis

Medical asepsis (clean technique) reduces the number of microorganisms; surgical asepsis (sterile technique) eliminates them. In a sterile field, a 2.5 cm (1 inch) border is considered unsterile, anything below waist level is unsterile, and if in doubt, consider it contaminated.

Method	Standard parameters
Autoclave (moist heat)	121 degrees C at 15 psi for 15 minutes (most widely taught cycle)
Hot air oven (dry heat)	160 degrees C for 2 hours; for glassware and powders
Glutaraldehyde 2 percent	High-level disinfectant for endoscopes and heat-sensitive items
Sodium hypochlorite 1 percent	Blood and body fluid spills, surface disinfection

Biological indicator for the autoclave: spores of Geobacillus stearothermophilus. The Bowie-Dick test checks air removal in pre-vacuum autoclaves.

Biomedical waste colour coding in India

Segregation follows the Bio-Medical Waste Management Rules, 2016 (with later amendments), notified by the Ministry of Environment, Forest and Climate Change.

Category	Type of waste	Treatment and disposal
Yellow (non-chlorinated bag)	Human anatomical waste, animal waste, soiled waste (dressings, cotton, plaster casts soiled with blood or body fluids), expired or discarded medicines, cytotoxic drug waste, chemical waste, discarded contaminated linen, pre-treated microbiology lab waste	Incineration, plasma pyrolysis or deep burial (as permitted)
Red (non-chlorinated bag)	Contaminated recyclable plastic waste: tubing, bottles, IV sets, catheters, urine bags, syringes without needles, gloves	Autoclaving or microwaving or hydroclaving, then shredding and recycling
White (translucent, puncture-proof, leak-proof, tamper-proof container)	Sharps: needles, syringes with fixed needles, scalpels, blades	Autoclaving or dry heat sterilisation, then shredding or encapsulation
Blue (cardboard box with blue marking)	Glassware: broken or discarded contaminated glass, medicine vials and ampoules (except those contaminated with cytotoxic waste), metallic body implants	Disinfection or autoclaving, then recycling

Untreated biomedical waste should not be stored beyond 48 hours. Vials contaminated with cytotoxic drugs go in the yellow category, not blue, which is a common MCQ trap.

Patient positions

Position	Description	Common use
Fowler’s	Head of bed 45 to 60 degrees (high Fowler’s 60 to 90, semi-Fowler’s 30 to 45)	Breathing difficulty, feeding, after thyroid surgery
Orthopnoeic	Sitting, leaning forward over an overbed table	Severe dyspnoea, COPD, thoracentesis
Sims’ (semi-prone)	Left lateral with upper knee flexed	Enema, rectal examination, suppository
Dorsal recumbent	Supine with knees flexed	Perineal care, catheterisation in females
Lithotomy	Supine, hips and knees flexed, legs in stirrups	Vaginal examination, delivery, cystoscopy
Knee-chest (genupectoral)	Kneeling with chest on the bed	Rectal or sigmoid examination, cord prolapse relief
Trendelenburg	Head lower than feet on a tilted bed	Some pelvic surgeries; for hypotension, a passive leg raise is now preferred

A pregnant woman in late pregnancy should lie in the left lateral position to avoid supine hypotension.

Bed making

• Closed bed: unoccupied bed ready for a new admission.
• Open bed: for a patient who can get in and out of bed.
• Occupied bed: made with the patient in it, rolling the patient side to side.
• Post-operative (surgical) bed: top linen fan-folded to one side for easy transfer from the trolley.
• Cardiac bed, fracture bed, amputation bed: special beds for those conditions.

Pressure ulcer (pressure injury) staging

Stage	Features
Stage 1	Intact skin with non-blanchable redness
Stage 2	Partial-thickness skin loss with exposed dermis; may look like an intact or ruptured blister
Stage 3	Full-thickness skin loss; fat may be visible, but no bone, tendon or muscle
Stage 4	Full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage or bone
Unstageable	Base obscured by slough or eschar, so depth cannot be judged
Deep tissue pressure injury	Persistent non-blanchable deep red, maroon or purple discolouration

The sacrum is the most common site. The Braden scale (6 subscales, score 6 to 23) assesses risk: a lower score means higher risk, and 18 or below indicates risk. Reposition at least every 2 hours.

Urinary catheterisation

• Use strict aseptic technique; CAUTI is one of the most common healthcare-associated infections.
• Common adult Foley sizes: about 12 to 14 Fr for women and 14 to 16 Fr for men. The balloon is inflated with sterile water (usually 10 mL), never saline or air.
• Female position: dorsal recumbent. Insert about 5 to 7.5 cm until urine flows. Male: insert about 17 to 22 cm, holding the penis at about 90 degrees to the body.
• Keep the drainage bag below bladder level and off the floor, and maintain a closed system.

Nasogastric tube insertion

• Measure using NEX: tip of the nose to the earlobe to the xiphisternum.
• Position the patient in high Fowler’s with the head slightly flexed, and ask the patient to swallow as the tube is advanced.
• Confirm placement before every feed: chest X-ray is the most reliable method; aspirate pH of 5.5 or below supports gastric placement. The air “whoosh” test is not reliable.
• Keep the head of bed raised 30 to 45 degrees during feeding and for at least 30 minutes after to prevent aspiration.

Oxygen therapy

Device	Flow rate	Approximate FiO2
Nasal cannula	1 to 6 L/min	24 to 44 percent (about 4 percent per litre)
Simple face mask	5 to 10 L/min (at least 5 to flush CO2)	40 to 60 percent
Venturi mask	As marked on the adaptor	Fixed, precise 24 to 60 percent
Non-rebreather mask	10 to 15 L/min, reservoir bag kept inflated	About 60 to 90 percent

• For COPD patients with CO2 retention, target SpO2 is 88 to 92 percent; the Venturi mask is the device of choice.
• In India, a medical oxygen cylinder is black with a white shoulder.
• Oxygen supports combustion: no smoking or open flames nearby. High oxygen in preterm babies can cause retinopathy of prematurity.

IV therapy and drop rate formula

Drop rate (drops/min) = Volume (mL) x Drop factor (drops/mL) / Time (minutes)

Worked example: 1000 mL of normal saline over 8 hours with a 20 drops/mL set. 1000 x 20 / 480 = 41.6, so about 42 drops/min. The infusion pump rate would be 1000 / 8 = 125 mL/hour. With a microdrip set (60 drops/mL), drops per minute equal mL per hour.

Cannula gauge	Colour	Typical use
14 G	Orange	Rapid large-volume infusion, trauma
16 G	Grey	Trauma, rapid transfusion
18 G	Green	Blood transfusion, surgery
20 G	Pink	Routine infusions
22 G	Blue	Small veins, elderly, children
24 G	Yellow	Neonates and infants

• Isotonic fluids: 0.9 percent NaCl, Ringer’s lactate. Hypotonic: 0.45 percent NaCl. Hypertonic: 3 percent NaCl, D10. D5W is isotonic in the bag but acts as hypotonic once the glucose is metabolised.
• Phlebitis: stop the infusion and resite. Infiltration: stop, elevate the limb. Suspected air embolism: clamp the line and place the patient in left lateral Trendelenburg position.

Medication administration

The classic 5 rights are right patient, right drug, right dose, right route and right time. Many texts expand these to 10 by adding right documentation, right reason, right response, right to refuse and right education. Check the label three times and use two patient identifiers.

Injection	Angle	Common sites
Intradermal (ID)	10 to 15 degrees, bevel up, raises a wheal	Inner forearm (Mantoux, test dose); BCG on the left upper arm
Subcutaneous (SC)	45 degrees (90 degrees if an adequate fold can be pinched or with short needles)	Abdomen at least 5 cm from the umbilicus, outer upper arm, anterior thigh
Intramuscular (IM)	90 degrees	Ventrogluteal (preferred in adults), vastus lateralis (preferred in infants), deltoid (small volumes), dorsogluteal (risk to sciatic nerve)
Intravenous (IV)	About 15 to 30 degrees for venepuncture	Peripheral veins of the forearm and hand

• Z-track technique is used for irritant drugs such as iron dextran to prevent leakage into subcutaneous tissue.
• Do not aspirate or rub after heparin or insulin SC injections.
• Mantoux test is read at 48 to 72 hours by measuring induration, not redness.

Drug calculations, high-alert drugs and antidotes are covered in the pharmacology notes for nursing.

Documentation and record keeping

• Records must be factual, accurate, complete, current, organised and confidential. Write in ink, date, time and sign each entry.
• To correct an error, draw a single line through it, write “error” or “mistaken entry” with your initials; never erase, use correction fluid or leave blank spaces.
• Formats: SOAP / SOAPIE, PIE, focus charting (DAR: data, action, response) and charting by exception.
• Incident reports are filled for unusual events but are not filed in the patient’s chart.
• Under the Indian Medical Council (Professional Conduct) Regulations, 2002, inpatient records are maintained for at least 3 years.

Patient safety basics

• Identify patients with at least two identifiers (name and date of birth or hospital number), never the bed number.
• Use structured handover such as SBAR (Situation, Background, Assessment, Recommendation) and read back verbal orders.
• Fall prevention: fall risk assessment (for example the Morse Fall Scale), bed in lowest position, call bell in reach, side rails as per policy, non-slip footwear.
• Fire safety: RACE (Rescue, Alarm, Contain, Extinguish) and PASS for extinguishers (Pull, Aim, Squeeze, Sweep).

Quick revision points

1. Nursing process steps: Assessment, Diagnosis, Planning, Implementation, Evaluation.
2. Most effective way to prevent hospital infection: hand hygiene.
3. Airborne precautions need an N95 respirator and negative pressure room.
4. First item removed while doffing PPE: gloves.
5. Autoclave standard: 121 degrees C, 15 psi, 15 minutes.
6. Sharps go in a white translucent puncture-proof container.
7. Glass vials and ampoules go in the blue-marked cardboard box.
8. Soiled dressings and anatomical waste go in the yellow bag.
9. Enema position: left Sims’.
10. Foley balloon is inflated with sterile water.
11. NG tube length is measured by the NEX method.
12. Non-rebreather mask delivers the highest FiO2 among common masks.
13. COPD target SpO2: 88 to 92 percent.
14. Intradermal angle: 10 to 15 degrees; IM angle: 90 degrees.
15. Stage 2 pressure ulcer: partial-thickness loss with exposed dermis.
16. Count apical pulse for a full minute before digoxin.

Fundamentals overlaps strongly with clinical subjects, so revise the medical surgical nursing notes and the anatomy and physiology notes alongside this page. Exam-specific weightage and planning are explained in the NORCET exam pattern and syllabus guide.

For structured coaching, see the AIIMS NORCET courses and staff nurse and nursing officer courses. Practise MCQs in the NORCET test series and staff nurse test series, and download the free nursing PDF notes.

Frequently asked questions

Is fundamentals of nursing important for NORCET?

Yes. Fundamentals questions appear in almost every nursing officer paper, often as practical bedside scenarios on infection control, positions, injections and safety.

Which book is best for fundamentals of nursing notes?

Potter and Perry’s Fundamentals of Nursing is the standard reference. Use it for concepts and revise from short notes and tables like these.

What is the current biomedical waste colour coding in India?

Under the Bio-Medical Waste Management Rules, 2016, waste is segregated into yellow, red, white (translucent) and blue categories, as shown in the table above.

How do I calculate IV drop rate quickly?

Multiply volume in mL by the drop factor and divide by time in minutes. With a microdrip set (60 drops/mL), drops per minute equal mL per hour.