Nursing Cheat Sheets for the NCLEX, Cheat Sheet of Nursing

Download Nursing Cheat Sheets for the NCLEX and more Cheat Sheet Nursing in PDF only on Docsity! 0 4 Vital Signs Hematology Labs Heart rate: 80-100 bpm ) Respiratory rate: 12-20 pm Blood pressure: 110-120/60 mmHg Temperature: 37 °C (98.6 F) © Serum Electrolytes XK p , ° \ Sodium (Na): 135-145 mEq D H + ABG Values Potassium (K): 3.5-5.5 mEq/L Calctum (Ca): 8.5-10.9 mEq/L Chloride (Ci): 95-105 mEq/L Magnesium (Mg): 1.5-2.5 mEq/L Phosphorus (P): 2.51.5 mEq . CHe Conversions / \ T grain (gr) = 60 mg | teaspoon () = 5 ml , Ss OC . 1 gram (¢) = 1,000 mg { tablespoon (T) = 3t= 15 ml cy. - CJ e 1 kilogram (kg) = 2.2 Ibs lor=d0 nl 1 Ib = 16.02 Leup=8 07 Chemistry Lab Values Couvat to F.C amiplyby 95 and bac 101 quant = 2 pints Convert Fto C2 F140 mulpiyby 59 and sbact | pnt = 2 cups Jarbamazepine (Tegretol): 1-10 meg/ml Digoxin (Lanoxin): 0.8-2.0 ng/ml Gentamycn (Garamycin): 5-10 meg/tul (peak), <2.0 meg/mnl (valley) Lithium (Eskalith): 0.8-1.5 mEqL. Phenobarbital (Solfoton): 15-10 meg/mL. Phenytom (Dilantin): 10-20 meg/dL Theophylline (Ammophylline): 10-20 meg/dL, Tobramycin (Tobrex): 5-10 meg/ml. (peak), 0.5-2.0 meg/mL, (valley) Valproic Acid (Depakene): 50-100 meg/ml ‘ancomycin (Vancocin): 20-40 meg/ml (peak), 5 to 15 meg/ml (trough) Aen Therapy Sodium warfarin (Coumadin) PT: 10-12 seconds (control). The antidote is Vitamin K. INR (Coumadin): 0.9—1.2 Heparin PTT: 30—45 seconds (control). The antidote is protamine sulfate. APTT: 23.3-319 seconds Fibrinogen level: 203-377 mg/dLa Anticoagulation Therapy -Antacids—reduces hydrochloric acid in the stomach -Antianemics—increases blood cell production -Anticholinergics-decreases oral secretions -Anticoagulants—prevents clot formation -Anticonvulsants—used for management of seizures and/or bipolar disorders. -Antidiarrheals—decreases gastric motility ! and reduce water in bowel. (ch) -Antihistamines—block the release of histamine. -Antihypertensives—lower blood pressure and increases blood flow. Anti-infectives—used for the treatment of infections -Bronchodilators—dilates large air passages in asthma or lung diseases (eg., COPD). -Diuretics—decreases water/sodium from the Loop of Henle. -Laxatives—promotes the passage of stool. -Miotics—constricts the pupils. -Mydriatics—dilates the pupils. -Narcotics/analgesics—relieves moderate to severe pai -Rule of Nine’s For Calculating Rule of Nine's For Calculating Total Surface Area of Burns Head: 9% Arms: 18% (9% each) Back: 18% Legs: 36% (18% each) Genitalia: 1% Medications Digoxin (Lanoxin)—Assess pulses for a full minute, if < 60 bpm hold dose. Check digitalis and K+ levels. Aluminum Hydroxide (Amphojel)—Treatment of GERD and kidney stones. May cause constipation. Hydroxyzine (Vistaril)— Treatment of anxiety and itching. May cause H + OO p May cause respiratory — depression and hypotension. Amiodarone (Cordarone)— May cause diaphoresis, dry mouth. Midazolam (Versed)— given for conscious sedation. dyspnea, lethargy. Take missed dose in the day or skip it entirely. Do not take double dose. Warfarin (Coumadin)—Watch for signs of bleeding, diarrhea, fever, or rash. Methylphenidate (Ritalin)— Treatment of ADHD. Assess for heart related side effects. Child may need a drug holiday because the drug stunts growth. Dopamine—Treatment of hypotension, shock, and low cardiac output. Monitor ECG for arrhythmias and BP. Rifampicin—causes red-orange tears and urine. Ethambutol—causes problems with vision, liver problem. Isoniazid—can cause peripheral , take vit Bé to counter. Ho+%— Goo —_—_~ “y (ttm Common Diets | © Acute Renal Disease—protein-restricted, high-calorie, fluid-controlled, sodium and potassium controlled. © Addison's disease—increased sodium, low K+ diet. ®@ ADHD and Bipolar—high-calorie & provide finger foods. © Burns—high protein, high caloric, increase in Vitamin C. @ Cancer—high-calorie, high-protein ® Celiac Disease—gluten-free diet (no BROW: barley, rye, oat, and wheat). @ Chronic Renal Disease—protein restricted, low-sodium, fluid-restricted, potassium-restricted, phosphorus » restricted. Cirrhosis (stabble)—normal protein. © Cirrhosis with hepatic insufficiency— restrict protein, fluids, and sodium. q @ Constipation—high-fiber, increased fluids ® COPD-soft, high-calorie, low carb, high-fat, small frequent feedings @ Cystic Fibrosis—increase in fluids, high cal, high fat @ Gallbladder diseases—low-fat, calorie restricted, regular © Gastritis—low-fiber, bland diet © Hepatitis—regular, high-calorie, high protein @ Hyperlipidemias—fat-controlled, calorie restricted @ Hypertension, heart failure, CAD—low sodium, “\ \ \ calorie-restricted, fat-controlled @ Kidney Stones—increased fluid intake, calcium-controlled, low-oxalate @ Nephrotic Syndrome—sodium-restricted, high-calorie, high-protein, potassiumrestricted. @ Pancreatitis—low-fat, regular, small frequent feedings; tube feeding or TPN @ Peptic ulcer—bland diet ® Pernicious Anemia—increase Vitamin B12 (Cobalamin), ( found in high amounts on shellfish, beef liver, and fish. @ Sickle Cell Anemia—increase fluids to maintain hydration since sickling increases when patients become dehydrated. . @ Stroke—mechanical soft, regular, or tube-feeding. ) Lo gn Mental Health @ Delegate sterile skills to the RN or LPN. @ The LPN can monitor clients with IV therapy, insert urinary catheters, feeding tubes, and apply restraints. @ Assessment, teaching, medication adminis- tration, evaluation, unstable patients cannot be delegated to an unlicensed assistive personnel. e@ Weight is the best indicator of dehydration. e@ When patient is in distress, administration of medication is rarely the best choice. @ Neutropenic patients should not receive vaccines, fresh fruits, or flowers. @ Nitroglycerine patch is administered up to three times with intervals of five minutes. @ Morphine is contraindicated in pancreatitis because it causes spasms of the Sphincter of Oddi. Demerol should be given. @ Never give potassium (K+) in IV push. @ The first nursing intervention in a quadriple- gic client who is experiencing autonomic dysreflexia is to elevate his head as high as possible. e@ Usually, patients who have the same infec- tion and are in strict isolation can share a room. A —> Hbbde e _ eAsthma— patient is sitting up and bent forward with arms supported on a table @ Post Bronchoscopy-— flat on bed with head hyper- extended. e@Cerebral Aneurysm—high Fowler's. eHemorrhagic Stroke: HOB elevated 30 degrees elIschemic Stroke: HOB flat. ®@ Cardiac Catheterization—keep site extended. @ Epistaxis—lean forward. ®@ Above Knee Amputation—elevate for first 24 hrs on pillow, position prone daily e@Below Knee Amputation—foot of bed elevated for first 24 hrs, position prone daily Tube feeding for patients with decreased LOC—position patient on right side to promote emptying of the stomach with HOB elevated to prevent aspiration. e Air/Pulmonary embolism—turn patient to left side and lower HOB. e Postural Drainage—Lung segment to be drained should be in the uppermost position to allow gravi- ty to work. e@ Post Lumbar puncture— patient lie flat in supine to prevent headache and leaking of CSF. e Continuous Bladder Irrigation (CBI)— catheter taped to thigh so legs should be kept straight. ®@ After myringotomy—position on the side of affect- ed ear after surgery e Post cataract surgery—patient sleep on unaffect- ed side with a night shield for 1-4 wks Detached retina—area of detachment should be in the dependent position. Post thyroidectomy—low or semiFowlers, support head, neck and shoulders. co (oot/s40m— Positioning Clients e Thoracentesis—sitting on the side of the bed and leaning over the table (during procedure); affected side up (after proce- dure). Vy e@ Spina Bifida— position infant on prone so that sac does not rupture. e@ Buck's Traction— elevate foot of bed for counter-traction. © Post 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. @ Prolapsed cord—knee-chest position or Trendelenburg. e Cleft-lip—position on back or in infant seat to prevent trauma to the suture line. While feeding, hold in upright position. © Cleft-palate—prone. e@Hemorrhoidectomy-—assist to lateral posi- tion. e@ Hiatal Hernia—upright position. @ Preventing Dumping Syndrome—eat in reclining position, lie down after meals for 20-30 minutes (also restrict fluids during meals, low fiber diet, and small frequent meals). e@Enema Administration—position patient in left-side lying (Sim's position) with knees flexed. e Post supratentorial surgery (incision behind hairline)—elevate HOB 30-45 degrees. © Post infratentorial surgery (incision at nape of neck)—position patient flat and 2 us. lateral on either side. e@Increased ICP—high Fowler's. ioning Clients Continued e Laminectomy—back as straight as possi- ble; log roll to move and sand bag on sides. ‘¢ @ Spinal Cord Injury—immobilize on spine board, with head in neutral position. Immobilize head with padded C-collar, maintain traction and alignment of head manually. Log roll client and do not allow client to twist or bend. e Liver Biopsy—right side lying with pillow or small towel under puncture site for at least 3 hours. \ e Paracentesis—flat on bed or sitting. @ Intestinal Tubes—place patient on right side to facilitate passage into duode- num. e Nasogastric Tubes— elevate HOB 30 degrees to prevent aspiration. Maintain elevation for continuous feeding or 1 hour after intermittent feedings. @ Pelvic Exam—lithotomy position. @ Rectal Exam—knee-chest position, Sim's, or dorsal recumbent. © During internal radiation— patient should be on bed rest while implant is in place. @ Autonomic Dysreflexia— place client in sitting position (elevate HOB) first before any other implementation. e@ Shock—bed rest with extremities elevated 20 degrees, knees straight, head slightly elevated (modified Trendelenburg). ®@ Head Injury—elevate HOB 30 degrees to decrease intracranial pressure. @ Peritoneal Dialysis when outflow is inade- quate—turn patient side to side before checking for kinks in the tubing. Common Signs & Symptoms @ Pulmonary Tuberculosis (PTB)—low grade afternoon fever. © Pneumonia—rust-colored sputum. e@ Asthma—wheezing on expiration. e@ Emphysema—barrel chest. © Kawasaki Syndrome—strawberry tongue. @ Pernicious Anemia—red beefy tongue. @ Down syndrome—protruding tongue. ®@ Cholera—rice-watery stool and washer wom- an's hands (wrinkled hands from dehydration). @ Malaria—stepladder like fever with chills. @ Typhoid—rose spots in the abdomen. @ Dengue—fever, rash, and headache. Positive Herman's sign. @ Diphtheria— pseudo membrane formation. @ Measles—Koplik's spots (clustered white lesions on buccal mucosa). @ Systemic Lupus Erythematosus— butterfly rash. @ Leprosy—leonine facies (thickened folded facial skin). Ne Bulimia—chipmunk facies (parotid gland swell- ing). @ Appendicitis—rebound tenderness at McBur- ney’s point. @ Meningitis—Kernig's sign (stiffness of ham- strings causing inability to straighten the leg when the hip is flexed to 90 degrees), Brudzins- ki's sign (forced flexion of the neck elicits a reflex flexion of the hips). ‘@ Tetany—hypocalcemia, [+] Trousseau's sign; Chvostek sign. @ Tetanus— Risus sardonicus or rictus grin. @ Pancreatitis—Cullen's sign (ecchymosis of the umbilicus), Grey Turner's sign (bruising of the flank). Pyloric Stenosis—olive like mass.