General Nursing

  Vital Signs 120/80 60-100 bpm 95-100% or 88-92% for COPD 36.5-37.5 C or 96.8 F - 100.4 12-20 rpm BP HR SPO2 T RR  General Nursing Therapeutic Medication Levels Acetaminophen 10-30 mcg/mL Carbamazepine 5-12 mcg/mL Digoxin 0.5-2 ng/mL Gentamicin 5-10 mcg/mL Lithium 0.5-1.2 mEq/L Magnesium Sulfate 4-7 mg/dL Phenobarbital 10-30 mcg/mL Phenytoin 10-20 mcg/mL Salicylate 100-250 mcg/mL Valproic acid 50-100 mcg/mL Head Arms Back Chest Legs Genitalia BURNS: Rule of 9s 9% 18% (9% each) 18% 18% 36% (18% each) 1% Parkland Formula: used to determine amount of fluid resuscitation needed in 24hrs after a burn o 4 mL x BSA (% of body burned) x kg ▪ Give half of this in the first 8 hours ▪ Remaining half is given over 16 hours K Na Ca Cl Mg Phos RBC WBC Plt Hgb pH CO2 HCO3 PaO2 Glucose HBA1C Specific Gravity BUN Creatinine LDH Triglycerides Total chol Bilirubin Protein Albumin PTT PT INR Lab Values 3.5-5.0 mEq/L 135-145 mEq/L 8.5-10.5 mg/L 95-105 mEq/L 1.5-2.5 mEq/L 2.5-4.5 mg/dL 4.5-5.0 million 5K-10K 200K-400K 12-16 g (female) 14-18 g (male) 7.35-7.45 35-45 mEq/L 24-26 mEq/L 80-100% 70-110 mg/dL or 4-6 mmol/L <7% 1.010-1.030 7-22 mg/dL 0.6-1.35 mg/dL 100-190 U/L 40-50 mg/dL 130-200 mg/dL <1.0 mg/dL 6.2-8.1 g/dL 3.4-5.0 g/dL 20-36 seconds If on heparin: 1.5-2.5x normal 9-11 s 0.9-1.8 2-3 if on warfarin Fluids and Electrolytes: Intravascular: fluid inside a blood vessel Intracellular: fluid inside a cell (most bodily fluids are inside the cells) Extracellular: fluid outside the cells (includes interstitial fluid [fluid in between cells], blood, bone, connective tissue, water) Isotonic Hypotonic 0.9% NS, D5W, Lactated Ringers 0.45% NS, 0.33% NS Hypertonic 3% NS, 5% NS, D10W, D5W with ½ NS, D5LR Colloid Dextran, Albumin No osmotic force = cells neither swell nor shrink More dilute solutions (more water than solute) = causes water to enter cells *watch for edema More concentrated solution (more solute than water) = water is removed from cells Fluid moves from interstitial to intravascular compartment *given in severe hypovolemia Monitor your patients with severe diarrhea and vomiting for electrolyte imbalance* 5 Electrolyte Sodium Foods that will increase the electrolyte bacon, butter, canned food, cheese, milk, condiments, salt, bread Potassium avocado, banana, carrots, fish, oranges, potatoes, pork/beef, spinach, tomato Calcium cheese, milk, spinach, yogurt, tofu, sardines, greens Magnesium avocado, leafy greens, milk, wheat, peanut butter, pork/beef/chicken, potatoes, yogurt fish, pumpkin, nuts, pork/beef/chicken, whole grain, dairy Phosphorus ECG changes Notes Low Na = Low H20 (dry mucous membranes High Na = High H20 Low: ST dep., shallow/flat/ Potassium is never given by IV inverted T wave, U wave push (IVP)!! It is always diluted High: tall peaked T wave, flat P in a minibag!! wave, wide QRS *never given greater than 10meq/hr Low: prolonged ST + QT Low calcium = Positive High: shortened ST, wide T Trousseau’s and Chvostek’s wave Low: tall T wave, depressed ST Antidote for magnesium toxicity High: prolonged ST, wide QRS = calcium gluconate Decrease in phosphorus levels results in increase in calcium lvls Sodium/Potassium – inverse relationship; high Na = low K Calcium/Phosphorus – inverse relationship; high Ca = low Phos Calcium/Vit D – similar relationship; high Ca = high Vit D Magnesium/Calcium – similar relationship; low Mg = low Ca Magnesium/Potassium – similar relationship; low Mg = low K Magnesium/Phosphorus – inverse relationship; low Mg = high Phos Acid and Base Balance: 1. Look at pH – is it too low or too high? • Too low = acidosis • Too high = alkalosis 2. Look at CO2 and see if it’s an opposite relationship from the pH (e.g. if pH was low and CO2 was high, or if pH was high and CO2 was low) • If YES, you have a respiratory imbalance • If NO (pH and CO2 have same relationship – either both are high or both are low) move to #3 3. Look at HCO3 and see if it has the same relationship as pH (both pH + bicarb are high both pH + bicarb are low) • If YES, you have a metabolic imbalance 4. COMPENSATED: pH will be within the normal range (body has corrected the problem) 5. PARTIALLY COMPENSATED: pH is not normal. Look at the system that is supposed to fix the problem (if you have a respiratory problem, the metabolic system will try to compensate and vice versa) and see if it is abnormal, which means it is trying to compensate • If YES, then you have PARTIAL compensation • If NO, then you have UNCOMPENSATION Low pH + high CO2 = respiratory acidosis • Any condition causing airway obstruction or depression Acidosis: RR increases to try and exhale acids Low pH + low HCO3 = metabolic acidosis Alkalosis: RR decreases to try and retain CO2 in • Insufficient insulin in pt w DM = DKA order to neutralize + decrease the strength of • Severe diarrhea can cause metabolic acidosis excess bicarb High pH + low CO2 = respiratory alkalosis • Any condition causing overstimulation of the respiratory system (e.g. hyperventilation, hysteria, overventilation, etc.) 6 High pH + high HCO3 = metabolic alkalosis • GI suctioning or severe vomiting can cause metabolic alkalosis Lungs control carbonic acid lvls (CO2 will either be retained or blown off) Kidneys control bicarb concentration (will retain or excrete bicarb) - Correcting acid/base balance by the kidneys takes hours to days Conversions 1 oz = 30 ml 1 cup = 8oz 1 kilogram (kg) = 2.2 lbs 1 mg = 1000 mcg or 0.001 g 1 teaspoon (t) = 5 ml 1 tablespoon (T) = 3 t = 15 ml 1 gram (g) = 1,000 mg 1 mcg = 0.000001 g 1 quart = 2 pints 1 pint = 2cups 1 lb = 16oz        Medication Calculations: * Remember to convert your units first* Standard formula for medication dosage: Desired (dose prescribed) Available (dose available) x Quantity E.g. There is an order for 18,000,000 mcg of Ampicillin. Ampicillin is available as 0.012 kg tablets. What should the nurse administer? 1. 0.012 kg = 12,000,000 mcg 2. 18,000,000 mcg 12,000,000 mcg x 1 tablet 3. 1.5 tablets Flow rate: [total volume x drop factor] time in minutes = drops per minute E.g. Calculate the IV flow rate for 0.61 L of 0.9% NaCl IV over 21.5 hr. Infusion set has drop factor of 62 gtts/mL. What is the IV flow rate in gtts/min? 1. Convert 0.61L to 610 mL and 21.5 hrs = 1290 minutes 2. 610 mL x 62 = 37,820 gtts 3. 37,820 gtts 1290 minutes = 29 gtts/minute mL per hour: total V in mL number of hours = mL per hour E.g. Ordered 49 mL NS IV to infuse in 12.5 hr by infusion pump. What is the IV flow rate in mL/hr? 1. 49 mL 12.5 hrs = 3.92 mL/hr Infusion time: total volume to infuse mL per hour being infused = infusion time ABC’s: ABC’s are ALWAYS the priority Airway – Is it clear? Breathing – If this isn’t possible, O2 won’t reach the lungs and be circulated around the body Circulation – Without circulation = hypoxia and cardiac arrest will ensue Nursing Process: 1. Assessing – Collecting data. 2. Diagnosing – Figuring out what is the problem. 3. Planning – How to best manage the problem. 4. Implementing – Putting the plan into action. 5. Evaluating – Did the plan work? Blood Transfusions: Universal donor = O neg Universal recipient = AB pos *Rh neg pt should not receive Rh pos blood Transfusion Reactions: 1. Hemolytic 2. Allergic 3. Febrile S/S: SOB, chest pain/tightness, fever, back pain, anxiety, tachycardia, hypotension 7 IF REACTION OCCURS = Stop transfusion, change IV tubing down to IV site and keep IV open with NS, notify MD + blood bank, stay with pt to monitor S/S, return blood bag/tubing/labels to blood bank, document *First 15 minutes of transfusion = stay with pt Adventitious Lung Sounds Fine crackles - High pitched crackling/popping noise heard @ end of inspiration Coarse crackles (worse than fine crackles) – low pitched gurgling sound during inspiration and expiration High pitched musical sound similar to a squeak Priority: 1. Relieve bronchoconstriction (give short acting bronchodilator – Albuterol) Low pitched, coarse, loud, snoring tone during expiration Low pitched coarse grating sound during inspiration and expiration Crackles Wheeze Ronchi Pleural friction rub Stridor Harsh high pitched breathing due to obstruction in upper airway *Life threatening Pneumonia, heart failure, pulmonary edema Asthma Chronic bronchitis Aspiration of foreign object, anaphylaxis, epiglottitis                               Positioning NGT placement High Fowlers Shortness of Breath High Fowlers Hypotension Trendelenburg Myocardial Infarction Semi-Fowlers Air/Pulmonary Embolism Left lateral + lower the head of Head Injury elevate HOB 30 degrees to decrease bed (Trendelenburg) intracranial pressure Woman in Labor w/ Un-reassuring FHR Left lateral After Total Hip Replacement don't sleep on operated side, don't flex hip more than 45- 60 degrees, don't elevate HOB more than 45 degrees. Maintain hip abduction by separating thighs with pillows Tube Feeding w/ Decreased LOC Right lateral + elevated Infant w/ Spina Bifida Prone (to avoid sac rupture) HOB During Epidural Puncture Lateral Prolapsed Cord Trendelenburg or knee-chest position During Lumbar Puncture aide lying with head, back, and After Lumbar Puncture Supine (prevents CSF leakage) knees flexed After Myringotomy Position on side of affected ear after Infant w/ Cleft Lip Supine to prevent trauma to suture line surgery (allows drainage of secretions) After Cataract Surgery Pt will sleep on unaffected side To Prevent Dumping Syndrome Eat in low Fowlers position, with a night shield for 1-4 weeks lie supine after meals for 20-30 minutes After Thyroidectomy Low or semi-Fowler's Above Knee Amputation elevate amputation for first 24 hours on pillow, position prone daily for hip extension Detached Retina area of detachment should be in the Below Knee Amputation foot of bed elevated for first 24 dependent (lower) position hours, position prone daily to provide for hip extension Administration of Enema Sim’s After Supratentorial Surgery (incision behind hairline) semi Fowlers Autonomic Dysreflexia/Hyperreflexia High Fowlers After Infratentorial Surgery (incision at nape of neck) Lateral Paracentesis high Fowlers + empty bladder Chest tube insertion arm raised above head After liver biopsy lie on R side for 2 hrs and then supine Neutropenic Precautions: Used for immunocompromised pts Hand hygiene, visitors should be free of illness, private room if possible, avoid sources of potential infection (crowds, raw fruit/vegetables, flowers/plants) 8 Contact Gloves, gown, *water + soap for c.diff Mrs. WEE 1. M - multidrug resistant organism 2. R - respiratory infection 3. S - skin infections (varicella zoster, cutaneous diphtheria, herpes simplex, impetigo, pediculosis, scabies) 4. W - wound infection 5. E - enteric infection - clostridium difficile 6. E - eye infection - conjunctivitis Infection Control Droplet Gloves, gown, face mask + eye shield SPIDERMAN 1. Sepsis 2. Scarlet fever 3. Streptococcal pharyngitis 4. P - parvovirus B19 5. P – pneumonia 6. P – pertussis 7. I – influenza 8. D - diphtheria (pharyngeal) 9. E – epiglottitis 10. R – rubella 11. M – mumps 12. M – meningitis 13. M - mycoplasma or meningeal pneumonia 14. An - Adenovirus Airborne Gloves, N95 mask MTV 1. Measles 2. Tuberculosis 3. Varicella Zoster *Pts with suspected infections (increased secretions/excretions) should NOT be in the same room as pts with fresh wounds or immunocompromised pts Fall Prevention: Orient to room, teach how to use call bell and when to use call bell, keep bed in lowest position, raise 3 of 4 side rails, lock wheels on all equipment, keep floor dry and free of cords, wear slip resistant footwear, stay with pt during shower Fire Safety: RACE – rescue pts in danger, activate alarm, contain fire (close windows/doors), extinguish fire if small Pulse Grades: 1+ weak & barely palpable, 2+ normal & easily palpable, 3+ full pulse & increased, 4+ strong & bounding Eye Opening Response 4 = Spontaneous 3 = To verbal stimuli 2 = To pain 1 = None Glasgow Coma Scale Verbal Response 5 = Oriented 4 = Confused 3 = Inappropriate words 2 = Incoherent 1 = None Motor Response 6 = Obeys commands 5 = Localizes to pain 4 = Withdraws from pain 3 = Flexion to pain (decorticate) 2 = Extension to pain (decerebrate) 1 = None Deep Tendon Reflexes: 0 = no response, 1+ = diminished, 2+ = active/expected response, 3+ = slightly hyperactive, 4+ = brisk/hyperactive with intermittent clonus Ambulating with cane: Going up stairs: 1. Strong leg 2. Cane 3. Weak leg Going down stairs: 1. Cane 2. Weak leg 3. Strong leg *Cane always moves before the weak leg 9