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Nursing Level 1 Final Cheat Sheet (DRAFT) by

My final exam is cumulative :.(

This is a draft cheat sheet. It is a work in progress and is not finished yet.

Need to Know Lab Values

Labs
Normal Ranges
Sodium
136-145
Na+ swells the body
Potassium
3.5-5
K+ pumps the heart
Chloride
98-106
Cl- maintains serum osmolarity
Calcium
9-10.5
Ca contracts the muscles & maintains bone density
Magnesium
1.3-2.1
Mg+ mellows the muscle
Albumin
3.5-5
Used to determine liver function; tells how much protein the body is getting
Creatinine
(M)= 0.6-1.3; (F)=0.5­-1.1
Is excreted by the kidneys; >1.3 = bad kidneys
BUN
10-20
Urea is a by-product of protein metabo­lism; tests kidney function
Glucose
74-106
Hypogly = Brain die
RBC
(M)= 4.7-6.1; (F)= 4.2-5.4
Low = anemia, renal disease, vitamin B deficiency
Hemoglobin
(M)= 14-18; (F)= 12-16
<7 = blood transf­usion
Hematocrit
(M)= 42-52; (F)= 37-47
Low = over-h­ydr­ated; high = dehydrated
Platelets
150,00­0-4­00,000
AsaParin, CloPid­ogrel
WBC
5,000-­10,000
High = infect­ion­/trauma
Basophils
25-100
Releases histam­ines, kinins, & heparin in areas of tissue damage; Causes signs & symptoms of inflam­mation
Neutro­phils
Segs: 2,500-­8,000
Nonspe­ccific ingestion & phagoc­ytosis of microo­rga­nisms & foreign proteins
Neutro­phils
Bands: 250-500
Immature neutro­phils
Lympho­cytes
1,000-­4,000
Monocytes
100-700
Destru­ction of bacteria & cellular debris; matures into macrophage
Eosino­phils
50-500
Releases vasoco­nst­rictive amines during allergic reactions & in response to parasitic infection

Need to Know Vocab

Term
Definition
Advent­itious Lung Sounds
Abnormal sounds that originate in the lungs & airways
Afterload
the pressure or resistance that the ventricles overcome to eject blood through the semilunar valves & into the peripheral blood vessels
Anabolism
The use of energy to change simple materials into complex body substances & tissue
Anti-e­mbolism Hose (TED hose)
Tightly fitting elastic stockings that are used to promote blood flow of venous return & prevent edema in the lower extrem­ities, DVT, venous stasis, & pulmonary embolism
Apnea
Absence of breathing for several seconds
Arteri­osc­lerosis
A thickening or hardening of the arterial wall that's often associated with aging
Atelec­tasis
The collapse of all of part of a lung
Athero­scl­erosis
The build up of plaque in coronary arteries around the heart (is a type of arteri­osc­ler­osis)
Basal Metabolic Rate (BMR)
The minimum amount of energy required to maintain body functions in the resting, awake state
Bradypnea
Abnormally slow breathing (<10 BPM)
Borbor­ygmus
Increased high-p­itched bowel sounds, especially loud, gurgling sounds, result from increased motility of the bowel
Bruits
"­Swo­osh­ing­" sounds over the abdominal aorta, the renal arteries, & the iliac arteries
Cachexia
Physical wasting
Cardiac Index
Can be calculated by dividing cardiac output by the body surface area; Normal range is 2.8-4.2
Cardiac Output
Calculated by multip­lying the heart rate in bpm times the stroke volume in liters per beat; is the amount of blood pumped from the left ventricle each minute
Catabolism
The breaking down of substances from complex to simple, resulting in a release of energy
Chyme
Semiliquid product of digestion that travels from the stomach through the intestines
Contra­ctility
The ability of atrial & ventri­cular muscle cells to shorten their fiber length in response to electrical stimul­ation
Coronary Artery Disease
Narrowing of the arteries by athero­scl­erosis, spasms, or congenital malfor­mations
Dual X-Ray Absorp­tio­metry (DXA)
Measures bone mineral density; Spine & hip are most often assessed on a central DXA; Calculates T-score (0= healthy, -1 to -2.5= osteop­enia, & <-2.5= ostepo­rosis
Dysphagia
Difficulty swallowing
ECG/EKG
A recording of the electrical current generated by the heart during depola­riz­ation & repola­riz­ation; Test results are interp­reted for HR & rhythm, lack of blood supply, abnorm­alities of conduction system, & arrhyt­hmias
Guaiac­-based Fecal Occult Blood Test
Tests for blood in the stool; more likely to yeild a false positive than fecal immuno­che­mical test due to requiring an active component of guaiac
Hemoptysis
The presence of blood in the sputum
Hyperc­apnia
Abnormally high levels of CO2 in the blood (>45 mmHg in arterial blood), may have respir­atory depression when supple­mental oxygen levels are too high
Hyperl­ipi­demia
Elevation of plasma choles­­terol, trigly­­ce­r­ides, or both
Hyperv­ent­ilation
Over-e­xpa­nsion of the lungs, charac­terized by rapid & deep breaths; CO2 levels increase & alkalosis happens
Hypove­nti­lation
Under-­exp­ansion of the lungs, charac­terized by shallow, slow respir­ations
Ischemia
Reduced blood flow
Kwashi­orkor
Lack of protein accomp­­anied by fluid retention
Macron­utr­ients
Nutrients that are needed in large amounts
Marasmus
A protein & caloric deficiency
Mean Arterial Pressure
Factors that influence MAP include: Total blood volume (visco­sity), Cardiac output (HR x Stroke volume), & Size & integrity of the vascular bed, especially in capill­aries
Metabolism
The process of chemically changing nutrients, such as fats & proteins, into end products that are used to meet the energy needs of the body or stored for future use, thereby helping maintain homeos­­tasis
Micron­utr­ients
Nutrients that are needed by the body in limited amounts
Osteom­alacia
Bone loss & softening caused by lack of calcif­ica­tion; Cause = lack of vit D
Osteop­orosis
Chronic disease of cellular regulation in which bone loss causes signif­icant decreased density & possible fracture; Caused by: lack of Ca+ & estrogen or testos­terone
Peripheral Artery Disease
Is a result of systemic athero­scl­erosis; Is a chronic condition in which partial or total arterial occlusion decreases perfusion to the extrem­ities
Peripheral Vascular Disease
Includes disorders that change the natural flow of blood through the arteries and veins of the peripheral circul­ation, causing decreased perfusion to body tissues; is an umbrella term
Perist­alsis
Wavelike muscular movement through the digestive tract
Postural Drainage
A therap­eutic way to position a patient to use gravity to help mobilize respir­atory tract secret­ions; Improves ventil­ation & perfusion & normalizes the functional residual capacity of the lungs
Preload
The degree of myocardial fiber stretch at the end of diastole & just before contra­ction; Is determined by the amount of blood returning to the heart from both sides
Pulse Deficit
When a patient's radial pulse is slower than the apical pulse because of cardiac contra­ctions that are weak or ineffe­ctive at pumping blood to the peripheral tissues & extrem­ities
Pulse Intensity
The strength of the pulse with each beat; Described as normal (able to palpate with normal pressure), diminished (weaker than expect­ed/­dif­ficult to palpate), absent (unable to palpate), or bounding (may be able to see pulsation; does not disappear with palpat­ion); rated on a scale of 0-3 with 0 being absent & 3 being Bounding
Pulse Pressure
The difference between the systolic & diastolic values
Renin-­Ang­iot­ensin System
Regulates BP & fluid balance through vasoco­nst­riction & excretion or reabso­rption of sodium
Sequential Compre­ssion Devices
Inflatable sleeves that wrap around the legs of patients & are attached to an air source that inflates & deflates, creating a massaging action for the lower extrem­ities
Stroke Volume
The amount of blood ejected by the left ventricle during each contra­ction; A decrease in SV can result from an increase in afterload without the benefit of compen­satory mechan­isms, thus leading to a decrease in cardiac output
Tachypnea
Increased respir­atory rate of >24 BPM in an adult with quick shallow breaths

Oxygen­ation Devices

Device
Flow Rate
Percentage of Oxygen
Simple Nasal Cannula
1 L/min
24%
 
2 L/min
28%
 
3 L/min
32%
 
4 L/min
36%
 
5 L/min
40%
 
6 L/min
44%
Simple Face Mask
5 L/min
40%
 
6 L/min
45%
 
7 L/min
50%
 
8 L/min
55%
 
>8 L/min
60%
Partial Rebreather Mask
6-15 L/min
70-90%
Trach Mask
Similar to Nasal Cannula
Face Tent
Rate & Oxygen % Vary
Venturi Mask
4-12 L/min
24-60%
High-Flow Nasal Cannula
20-60 L/min
Up to 100%
Nonreb­reather Mask
10-15 L/min
60-100%

Morse Fall Scale

Item
Scale
1. History of falling; immediate or within 3 months
No - 0
 
Yes - 25
2. Secondary diagnosis
No - 0
 
Yes - 15
3. Ambulatory aid
Bed rest/nurse assist - 0
 
Crutch­es/­can­e/w­alker - 15
 
Furniture - 30
4. IV/Heparin Lock
No - 0
 
Yes - 20
5. Gait/T­ran­sfe­rring
Normal­/be­dre­st/­imm­obile - 0
 
Weak - 10
 
Impaired - 20
6. Mental status
Oriented to own ability - 0
 
Forgets limita­tions - 15
Low Risk = 0-24; Moderate Risk = 25-44; High Risk = 45+

Braden Scale

Sensory Perception
1. Completely limited
2. Very limited
3. Slightly limited
4. No impairment
Moisture
1. Constantly moist
2. Very moist
3. Occasi­onally moist
4. Rarely moist
Activity
1. Bedfast
2. Chairfast
3. Walks Occasi­onally
4. Walks frequently
Mobility
1. Completely immobile
2. Very limited
3. Slightly limited
4. No limita­tions
Nutrition
1. Very poor
2. Probably inadequate
3. Adequate
4. Excellent
Friction & Shear
1. Problem
2. Potential problem
3. No apparent problem
To be placed at moderate risk a patient must score 12-14, to be placed at low risk a patient must score 15-16

Pressure Injury Stages

Stage
Charac­ter­istics
Stage 1
Intact, nonbli­stered skin with nonbla­nchable erythema, or persistent redness in area that has been exposed to pressure
Stage 2
Partial thickness wound that involves epidermis &/or dermis, but does not extend below the level of the dermis
Stage 3
Full thickness wound that extends into the subcut­aneous tissue, but does not extend through the fascia to bone, muscle, or connective tissue
Stage 4
Full thickness wound, but deeper than stage 3; involves exposure of muscle, bone, or connective tissue
Unstag­eable
Full thickness wound where the amount of necrotic tissue in th wound bed makes it impossible to asses the depth of the wound or any involv­ement of underlying structures
Suspected Deep Tissue injury
An area of intact skin that is purple­/maroon or a blood filled blister; The true depth of damage is not readily apparent on initial inspection

Normal Ranges for Vital Signs

Vital Sign
Range
Pulse
60-100 bpm
Temper­ature
96.4-99.6oF
Respir­ations
12-20
Oxygen Saturation
>95%
Systolic Blood Pressure
90-<120
Diastolic Blood Presure
60-<80
 

Glasgow Coma Scale

Response
Level of Arousal
Points
Eye Opening
Sponta­neous
4
 
To verbal command
3
 
To pain
2
 
None
1
Verbal
Oriented
5
 
Confused but able to answer questions
4
 
Inappr­opriate responses, words discer­nible
3
 
Incomp­reh­ensible speech
2
 
None
1
Motor
Obeys Commands
6
 
Purposeful movement to painful stimulus
5
 
Withdr­awals from pain
4
 
Abnormal (spastic) flexion, decort­icate posture
3
 
Extensor rigid response, decere­brate posture
2
 
None
1
Fully alert & oriented people score 15 pts. A score of <7 reflects a patient who is comatose.

Breath Sounds

Breath Sound
Character
Associ­ation
Site
Crackles (coarse)
Lower-­pit­ched, coarse, rattling sounds caused by fluid or secretions in large airways; likely to change with coughing or suctioning
Bronch­itis, pneumonia, tumors, pulmonary edema
Right & left lung bases
Crackles (fine)
Popping, discon­tinuous sounds caused by air moving into previously deflated airways; sounds like hair being rolled between fingers near the ear; "­Vel­cro­" sounds late in inspir­ation usually associated with restri­ctive disorders
Asbest­osis, atelec­tasis, inters­titial fibrosis, bronch­itis, pneumonia, chronic pulmonary disease
Right & left lung bases
Pleural Friction Rub
Loud, rough, grating, scratching sounds caused by the inflamed surfaces of the pleura rubbing together; often associated with pain on deep inspir­ations; heard in lateral lung fields
Pleurisy, TB, pulmonary infarc­tion, pneumonia, lung cancer
Anterior lateral thorax
Rhonchi
Lower-­pit­ched, coarse, continous snoring sound; arise from the large airways; both inspir­ation & expiration
Thick tenacious secret­ions, sputum produc­tion, obstru­ction by a foreign body, tumors
Over the trachea & bronchi, but can be referred to all lung fields
Stridor
Intense, high-p­itched & continuous monophonic wheeze or crowing sound, loudest during inspir­ation when airways collapse due to lower internal lumen pressure; often heard without the aid of a stetho­scope
Turbulent airflow in upper airway, may be indicative of serious airway obstru­ction from epiglo­ttis, croup, a foreign body lodged in the airway, or a laryngeal tumor
Trachea & large airways
Wheeze
Squeaking, musical, continuous sounds associated with air rushing through narrowed airways, may be heard without stetho­scope, Arise from the small airways, Usually do not clear with coughing, Heard on expiration
Inflam­mation, bronch­ospasm (bronchial asthma), edema, secret­ions, pulmonary vessel engorg­ement (as in cardiac "­ast­hma­")
All lung fields

Pain

Chronic Pain
Postop­erative pain that persists >3 months & pain (not following surgery) lasting >6 months; It interferes with daily functi­oning & is accomp­anied by distress on a continuing basis
Acute Pain
Lasts <3-6 months, depending on specific circum­stances can be caused by a pH altera­tion, which results in depletion of oxygen to tissue, pressure on tissues, over stretching of body cavities with fluid or air, or external injury to tissues
Referred Pain
Originates in 1 area but hurts in another area, such as pain from a myocardial infarction
Radiating Pain
Extends from the source to an adjacent are of the body; Ex: GERD- pain in stomach radiates up the esophagus
Visceral Pain
Arises from the organs of the body & occurs in conditions such as append­icitis, pancre­atitis, inflam­matory bowel disease, bladder disten­tion, & cancer
Somatic Pain
Results from injury to skin, muscles, bones, & joints. Occurs in conditions such as sunburn, lacera­tions, fractures, sprains, arthritis, & bone cancer
Neurop­athic Pain
Results from nerve injury, & the pain continues even after the painful stimuli are gone
Phantom Pain
Occurs when the brain continues to recieve messages from the area of an amputation
Psycho­genic Pain
Pain that is perceived by an individual but has no physical cause