KEYNURSING

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Author:
TomWruble
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207921
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KEYNURSING
Updated:
2013-03-18 12:32:10
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keynursing
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Key Nursing Knowledge
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  1. Hold BP meds for?
    • S <= 100 or
    • D <= 60 or
    • HR <= 60

    Unless specific Rx "hold" info given
  2. For Pts on coumadin or warfarin, pt teaching includes
    Excess leafy greens (any foods rich in vitamin K) should be avoided because they reduce the effectiveness of drug.

    They work by inhibiting the hepatic synthesis of vitamin K.

    Prior to use as blood thinner, it was used to kill rats by causing hemmorage.
  3. Minimum Pt urine output?
    30 mL/hr

    or 720 mL/day
  4. Signs of Stroke?
    → Facial weakness judges whether the person can smile without their mouth or eyes dropping.

    → Arm weakness is whether the person can hold up both arms successfully.

    → Speech difficulty is about whether the person can speak clearly and understand speech.
  5. BP Ranges
    • Normal: 90–119 / 60–79
    • Prehypertension: 120–139 / 80–89
    • Stage 1 hypertension: 140–159 / 90–99
    • Stage 2 hypertension: ≥160 / ≥100
  6. For Pts beginning coumadin or warfarin therapy, until a therapeutic level is reached ...
    Check INR (International Normalized Ratio), the current lab results that monitor PT prothrombin time (clotting), BEFORE next dose.
  7. Metabolic syndrome (CV-cardiovascular) risk factors?
    BP of 130/85 or higher or taking drugs for

    • HDL <40 mg="" dl="" for="" men="" or="" 50="" women="" taking="" drugs="" br="">
    • triglycerides of 150 mg/dL or higher or taking drugs for

    BS of 110 mg/dL or higher or taking drugs for

    Waist > 40"(102cm) men, or 35"(89cm) women

    Inc fibrinogen or plasma activator inhibitor

    Inc C-reactive protein , a marker for inflammation
  8. Hypertensive Crisis (Malignant Hypertension)
    • Sys > 200
    • Dia > 150
  9. Catecholamine
    The most abundant catecholamines are epinephrine (adrenaline), norepinephrine (noradrenaline) and dopamine, all of which are produced from phenylalanine and tyrosine. Release of the hormones epinephrine and norepinephrine from the adrenal medulla of the adrenal glands is part of the fight-or-flight response.
  10. RAA Renin-Angiotensin-Aldosterone?
    → Reduced blood flow to kidneys cause them to produce Renin.

    → Renin causes angiotensinogen to split off angiotensin I, which is converted by an enzyme in the lungs to form angiotensin II, which is both a strong vasoconstrictor as well as the controlling mechanism for aldosterone release.

    → Aldosterone causes the kidney tubules to reabsorb sodium, which in turn inhibits fluid loss.

    → Aldosterone also causes potassium to be excreted by the kidneys, so as sodium is retained, potassium is lost leading to possible hypokalemia @ < 3.2 mEq/L
  11. Cholesterol targets?
    fasting total cholesterol < 200mg/dL

    For high-risk or exisitng CAD, CVD or diabetic: LDL < 70 mg/dL

    For low/moderate-risk: LDL < 100 mg/dL

    HDL > 40 mg/dL (soon to get higher...)

    Triglycerides < 135 mg/dL women, 150 mg/dL men

    Controversial but elevated Homocysteine may block nitric oxide production making the cell walls less elastic.
  12. Ascites
    is a gastroenterological term for an accumulation of fluid in the peritoneal cavity. The medical condition is also known as peritoneal cavity fluid, peritoneal fluid excess, hydroperitoneum or more archaically as abdominal dropsy. Although most commonly due to cirrhosis, severe liver disease or metastatic cancer, its presence can portend other significant medical problems. Diagnosis of the cause is usually with blood tests, an ultrasound scan of the abdomen, and direct removal of the fluid by needle or paracentesis (which may also be therapeutic). Treatment may be with medication (diuretics), paracentesis, or other treatments directed at the cause.
  13. Key cardiac electrlytes & normal ranges?
    • Mg 1.3 - 2.1 mEq/L
    • K    3.5 - 5.0 mEq/L
    • Calcium 9 - 10.5 mg/dL
    • Cl 98 - 106 mEq/L
    • Sodium 135 - 145 mEq/L
  14. Pts on steroids, e.g. for COPD

    (Side effects of steroids?)
    Can raise BS. An accucheckorder is not required for nursing discretion to check BS of Pts on steroids.
  15. TSS
    Toxic shock syndrome (TSS) is a potentially fatal illness caused by a bacterial toxin. Different bacterial toxins may cause toxic shock syndrome, depending on the situation. The causative bacteria include Staphylococcus aureus and Streptococcus pyogenes.

    In either case, diagnosis is based strictly upon CDC criteria modified in 1981 after the initial surge in tampon-associated infections.

    • Body temperature > 38.9 °C (102.02 °F)
    • Systolic blood pressure < 90 mmHg
    • Diffuse rash, intense erythroderma, blanching with subsequent desquamation, especially of the palms and soles
    • Involvement of three or more organ systems:
    • Gastrointestinal (vomiting, diarrhea)
    • Mucous membrane hyperemia (vaginal, oral, conjunctival)
    • Renal failure (serum creatinine > 2 times normal)
    • Hepatic inflammation (AST, ALT > 2 times normal)
    • Thrombocytopenia (platelet count < 100,000 / mm³)
    • CNS involvement (confusion without any focal neurological findings)
  16. Hemoptysis
    the expectoration (coughing up) of blood or of blood-stained sputum from the bronchi, larynx, trachea, or lungs (e.g., in tuberculosis or other respiratory infections or cardiovascular pathologies).
  17. Subcutaneous Needle
    • 3/8 - 5/8
    • 1 inch if obese

    • 24 - 26
    • 26 - 30 for insulin

    0.5 - 1.0 mL
  18. Deltoid IM
    1 inch

    23 - 25

    0.5 - 1.0 mL
  19. Dorsal Gluteal, Ventral Gluteal or Vastus Lateralis
    • 1 1/2
    • 2 inch if obese

    20 - 22

    Up to 3.0 mL
  20. Intradermal
    1/4 - 5/8

    25 - 27

    up to 0.1 mL
  21. Deltoid landmarks
    • 1. Acromion Process
    • 2. Top of axilla
  22. Dorsal Gluteal landmarks
    • 1. Posterior superior iliac spine (note: towards the spine)
    • 2. Greater trochanter (note: lateral side of leg)
  23. Ventrogluteal landmarks
    • 1. Greater trochanter
    • 2. Anterior superior iliac spine (note: towards umbilicus)
    • 3. Iliac crest (note: lateral leg above greater trochanter)
  24. Vastus lateralis landmarks
    • 1. Greater trochanter
    • 2. Lateral femoral condyle
  25. Subcutaneous upper arm landmarks
    • 1. Acromion process (hand breath below)
    • 2. Elbow (hands breath above)
  26. Subcutaneous abdomen landmarks
    • 1. 2 inches away from umbilicus
    • 2. Above level of iliac crest
  27. General
    Level of consciousness: alert, sedate, unconcious

    Orientation: person, place and time (AAOx3)

    Affect: afraid, irritable, distressed, attentive, ashamed, sad, happy, confident, shy, sleepy,  calm

    Skin color:

    Obvious distress:

    Ease of respirations and use of accessory muscles.

    Observe skin throughout assessment.
  28. Vital Signs
    • Temp
    • → Normal oral, resting: 37/98.6
    • → Range: 35.8 - 37.3 or 96.4 - 99.1
    • → 15 after hot/cold, 2 after smoke

    • Pulse
    • → Normal resting 50-90 BPM

    • Respirations
    • → 10-20

    • BP
    • → 120/80

    Sa02:
  29. Pain
    • Assess
    • location,
    • quality,
    • severity (0-10 scale),
    • radiation,
    • duration,
    • precipitating and alleviating factors,
    • associated symptoms,
    • level of sedation.
  30. Primary Symptom
    Assess client’s chief complaint and progress since hospitalization.
  31. Head & Neck
    • Check pupils for equality and reaction to light. (PERRL)
    • Check oral mucosa for color and moisture.
    • Observe for facial symmetry and tracheal deviation.
    • Check for neck vein distention at 45 degrees.
  32. Chest
    • Auscultate S1 and S2 at aortic, pulmonic, tricuspid and mitral areas for rate and rhythm and location of extra sounds.
    • Listen at apex for full minute.
    • Auscultate anterior and lateral lung sounds.
  33. Abdomen
    • Auscultate all quadrants for bowel sounds.
    • Palpate for distention of bladder and abdominal tenderness.
    • Ask about last BM, problems with urinating.
  34. Upper Extremities
    • Inspect arms.
    • Palpate radial pulses bilaterally and capillary refill;
    • assess grip strength and equality.
  35. Lower Extremities
    • Inspect legs.
    • Palpate dorsalis pedis pulses bilaterally.
    • Palpate legs and feet for edema.
    • 0: none
    • +1: slight pitting
    • +2: Deeper, countours still present
    • +3: Deep pittin, mpuffy appearance
    • +4: Deep persistent pitting, frankly swollen
    • Check foot presses.
    • Check feet for resistance.
    • Observe feet for lesions.
  36. Back
    • Turn to side or sit up;
    • auscultate posterior lung fields.
    • Observe skin on back and coccyx.
    • Palpate for sacral edema.
  37. Tubes and Equipment
    • Check all tubes from origin to insertion.
    • Verify correct oxygen flow,
    • correct IV solutions and flow rates.
    • Verify Foley draining and other equipment functioning appropriately.
    • Check dressings if present.
  38. Potassium (K+)
    3.5-5.0 mEq/L
  39. Sodium (Na+) 91+
    132-146 mEq/L
  40. Sodium (Na+) <= 90
    136-145 mEq/L
  41. Chloride (Cl-) <= 90
    98-106 mEq/L
  42. Chloride (Cl-) 91+
    98-111 mEq/L
  43. Carbon dioxide (C02) <= 60
    23-30 mEq/L
  44. Carbon dioxide (C02) 60-90
    23-31 mEq/L
  45. Carbon dioxide (C02) 91+
    20-29 mEq/L
  46. Glucose (fasting) <= 60
    70-110 mg/dL

    4.1-5.9 mmol/L
  47. Glucose (fasting) 60-90
    82-115 mg/dL

    4.6-6.4 mmol/L
  48. Glucose (fasting) 91+
    75-121 mg/dL

    4.2-6.7 mmol/L
  49. Creatinine - Females <= 60
    0.5-1.1 mg/dL

    44-97 µmol/L
  50. Creatinine - Females 60-90
    0.6-1.2 mg/dL

    53-106 µmol/L
  51. Creatinine - Females 91+
    0.6-1.3 mg/dL

    53-115 µmol/L
  52. Creatinine - Males <= 60
    0.6-1.2 mg/dL

    53-106 µmol/L
  53. Creatinine - Males 60-90
    0.8-1.3 mg/dL

    71-115 µmol/L
  54. Creatinine - Males 91+
    1.0-1.7 mg/dL

    88-150 µmol/L
  55. Blood urea nitrogen (BUN) <= 60
    10-20 mg/dL

    2.1- 7.1 mmol/L
  56. Blood urea nitrogen (BUN) 60-90
    8-23 mg/dL

    2.9- 8.2 mmol/L
  57. Blood urea nitrogen (BUN) 91+
    10-31 mg/dL

    3.6-11.1 mmol/L
  58. INR
    0.9 - 1.3

    A high INR level such as INR=5 indicates that there is a high chance of bleeding, whereas if the INR=0.5 then there is a high chance of having a clot. Normal range for a healthy person is 0.9–1.3, and for people on warfarin therapy, 2.0–3.0, although the target INR may be higher in particular situations, such as for those with a mechanical heart valve, or bridging warfarin with a low-molecular weight heparin (such as enoxaparin) perioperatively.

    The prothrombin time (PT) and its derived measures of prothrombin ratio (PR) and international normalized ratio (INR) are measures of the extrinsic pathway of coagulation. This test is also called "ProTime INR" and "INR PT". They are used to determine the clotting tendency of blood, in the measure of warfarin dosage, liver damage, and vitamin K status. PT measures factors I (fibrinogen), II (thrombin), V, VII, and X. It is used in conjunction with the activated partial thromboplastin time (aPTT) which measures the intrinsic pathway.
  59. Prothrombin time (pro time, PT) seconds
    11-12.5

    The reference range for prothrombin time is usually around 10-14 seconds, and the INR in absence of anticoagulation therapy is 0.8-1.2. The target range for INR in anticoagulant use (e.g. warfarin) is 2 to 3. In some cases, if more intense anticoagulation is thought to be required, the target range may be 2.5-3.5.

    The prothrombin time (PT) and its derived measures of prothrombin ratio (PR) and international normalized ratio (INR) are measures of the extrinsic pathway of coagulation. This test is also called "ProTime INR" and "INR PT". They are used to determine the clotting tendency of blood, in the measure of warfarin dosage, liver damage, and vitamin K status. PT measures factors I (fibrinogen), II (thrombin), V, VII, and X. It is used in conjunction with the activated partial thromboplastin time (aPTT) which measures the intrinsic pathway.
  60. Prothrombin time (pro time, PT) percent
    85%-100%
  61. Prothrombin time (pro time, PT) ratio
    1:1.1 patient-control ratio
  62. Partial thromboplastin time, activated (aPTT)
    30-40 sec

    The prothrombin time (PT) and its derived measures of prothrombin ratio (PR) and international normalized ratio (INR) are measures of the extrinsic (fibrin in bloood) pathway of coagulation. This test is also called "ProTime INR" and "INR PT". They are used to determine the clotting tendency of blood, in the measure of warfarin dosage, liver damage, and vitamin K status. PT measures factors I (fibrinogen), II (thrombin), V, VII, and X. It is used in conjunction with the activated partial thromboplastin time (aPTT) which measures the intrinsic (collogen on cell wall) pathway.
  63. White blood cell (WBC, leukocyte count)
    5,000-10,000/mm3
  64. Hemoglobin, total - Females 18-44
    117-155 g/L

    aka 11.7 or 12 g/dL
  65. Hemoglobin, total - Females 45-64
    117-160 g/L

    aka 11.7 or 12 g/dL
  66. Hemoglobin, total - Females 65-74
    117-161 g/L

    aka 11.7 or 12 g/dL
  67. Hemoglobin, total - Males 18-44
    132-173 g/L
  68. Hemoglobin, total - Males 45-64
    131-172 g/L
  69. Hemoglobin, total - Males 65-74
    126-174 g/L

    aka 12.6 or 13 g/dL
  70. Hematocrit - Females 18-44
    35%-45%
  71. Hematocrit - Females 45-74
    37%-47%
  72. Hematocrit - Males18-44
    42%-52%
  73. Hematocrit - Males 45-64
    39%-50%
  74. xHematocrit - Males 65-74
    37%-51%

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