Nurses Notes

Nurses's Notes

Tanya Hughes, RN, BSN

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Phone Numbers Frequently Needed

Cath Lab _________________CT ______________________CVICU __________________ER ______________________ICU _____________________Lab _____________________Respiratory ________________PACU ____________________Pharmacy _________________Supply ___________________

Long Distance Code __________Door Code ________________Overhead page _____________

NEURO

Glasgow Coma Scale

Eye - opening response4. Spontaneously3. To speech2. To pain1. None

Motor response6. Obeys request5. Localizes4. Withdraws from painful stimuli3. Abnormal flexion - decorticate posture (toward spine)2. Abnormal extension - decerebrate posture (away from spine)1. None

Verbal response5. Oriented4. Confused3. Inappropriate words2. Incomprehensible1. None

Total score ranges from 3-15. A total of 7 or less indicates server neurological damage.

[Los Angeles Stroke Scale][Cincinnati Stroke Scale]

Muscle Strength Scale5. Normal power or strength in extremities4. Weak extremities, but can overcome resistance applied by the examiner3. Patient can overcome gravity, but cannot overcome resistance applied by the examiner2. Weak muscle contraction, but cannot overcome gravity1. Palpable or visible muscle flickr or twitch, but no movement0. No response to stimulus, complete paralysis

PULMONARY

Modes of Ventilator SupportAssist-control (AC)Pt or ventilator triggered breaths either volume or pressure controlled.

Continuous Positive Airway Pressure (CPAP)Positive pressure applied during spontaneous breathing and maintained throughout the entire respiratory cycle; decreases intrapulmonary shunting.

Continuous mandatory ventilation (CMV)Ventilator delivers the breaths at a preset rate and volume or pressure.

Intermittent mandatory ventilation (IMV)Ventilator delivers breaths at a set rate and volume or pressure. Patient is able to breathe spontaneously between machine breaths.

Mandatory minute ventilation (MMV)Patient breathes spontaneously, yet a minimum level of minute ventilation is ensured.

Pressure-controlled/inverse-ratio ventilation (PC/IRV)Provides inspiratory time greater than expiratory time, thereby improving distribution of ventilation and preventing collapse of stiffer alveolar units (auto-PEEP). Patient is unable to initiate an inspiration.

Positive end-expiratory pressure (PEEP)Positive pressure applied during machine breathing and maintained at end-expiration; decreases intrapulmonary shunting.

Pressure support ventilation (PSV)Patient’s inspiratory effort is assisted by the ventilator. PSV decreases work of breathing caused by demand flow valve, IMV circuit, and narrow inner diameter of ETT.

Synchronized IMV (SIMV)Intermittent ventilator breaths synchronized to spontaneous breaths to reduce competition between ventilator and patient. If no inspiratory effort is sensed, the ventilator delivers the breath.

CARDIAC

Myocardial Infarctions

Anterior MIelevation in V1, V2, V3, V4; depression may be present in II, III, aVF (left anterior descending branch of left coronary artery, aka LAD)

Inferior MIelevation in II, III, aVF; depression may be present in I, aVL, V2-V4 (right coronary artery, aka RCA)

Lateral MIelevation in I, aVL, V5, V6 (circumflex branch of left coronary artery, aka Circ)

Posterior MIdepression in V1, V2, V3 (could be RCA branch or Circ branch)

Classification of Cardiac Murmurs by Degree of IntensityI - Barely audibleII - Audible after a few seconds of auscultation, low intensity III - Immediately audible, moderate intensityIV - Loud intensity without a precordial thrillV - Loud intensity with a precordial thrillVI - Loudest intensity, precordial thrill, audible with stethoscope slightly away from thoracic wall

Hemodynamic Data

PAP (Pulmonary Artery Pressure)PAP is the systolic and mean pressure of the pulmonary artery.Normal: Systolic 20-30 Diastolic 8-12High values - Overload, Pericarditis, Pulmonary HTN/Embolus, Ventricular Septal Defect, LV Failure, PEEP, Cardiac Tamponade/EffusionLow values - Hypovolemia, RV Failure, Pulmonary Stenosis, Shock

PCWP (Pulmonary Cap Wedge Pressure)The pressure measured is that of the pulmonary vein and, indirectly, that of the left atrium and the left ventricle during diastole.Normal: 6-12High values - Overload, Pulmonary Embolus, LV Failure, Cardiac Tamponade/Effusion, Pericarditis, PEEPLow Values - Hypovolemia, Shock, RV Failure, Pulmonary Stenosis/Embolus

CO (Cardiac Output)Cardiac Output is the amount of blood ejected by the Left Ventricle into the Aorta in one minute.(SV x HR = CO) CO/BSA= CINormal Cardiac Output: 4-8 L/minNormal Cardiac Index : 2.5-4.0 L/min/m2High values - SepsisLow values - Shock, LV Failure, Pulmonary Embolus, Cardiac Tamponade

CVP (Central Venous Pressure)CVP is the measurement of the Right Atrial pressure or pressure of the great veins within the thorax.Normal: 2-6High values - Ascites, Pericarditis, ARDS, COPP, Pulmonary Embolus, Cardiac Tamponade/Effusion, LV Failure, Mitral Stenosis, PEEP, Pneumothorax, Pulmonary HTV, RV Infarct, Sepsis, Volume OverloadLow values - Hypovolemia, Shock

SVR (Systemic Vascular Resistance)Normal: 900-1600(MAP - CVP)/CO x 80=SVR

ENDO

Possible Treatment of DKA PatientsRestoration of fluid & electrolyte balance-NS or 1/2 NS given quickly if no CV problems-Administer K+ replacement because the K+ may be high in the plasma concentration only

Reduction of Hyperglycemia-Use of low-dose insulin infusion-Intravenous insulin-Intramuscular insulin

Prompt recognition and treatment of complications- Infection- Arrhythmias- Hypoglycemia

Prevention of future episodes- Education is the Key

Signs & Symptoms of Diabetes Mellitus-Increased Thirst-Increased Urination-Increased Hunger-Fatigue-Weight Loss-Blurred Vision-Frequent Infections-Dry Skin-Numbness/Tingling In Hands/Feet

Signs & Symptoms of DKA-Dehydration-Hyperventilation (acetone breath)-GI Symptoms (abd pain, N&V)-Alteration in Mentation-Hypothermia-Hyporeflexia-Hypotonia

Initial Laboratory Values for Patients Experiencing DKAGlucose (300-800mg/100ml) Concentration not related to severity of DKApH (6.8-7.3)Na+ (low, normal or high) Total body depletion; concentration dependent on relative H2O lossK+ (low, normal or high) Total body depletion; heart responsive to extracellular concentrationWBC (usually increased) Possibility of leukemoid reaction (even in absence of infection)Hgb/Hct (often increased) Secondary to contracted plasma volumes.

Insulin PumpsBasal Dose1. Identify the total amount of insulin (rapid- or short-acting) that the patient administered daily by injection (prepump dose); for example, 49 units (31 units NPH and 18 units regular insulin)2. To find the total daily insulin pump dose, multiply the total prepump daily dose by 90% (49 x 0.9 = 44). This patient's total daily dose via the pump is 44 units of rapid or short acting insulin.3. To find the basal dose, multiply this number by 50% (44 x 0.5 = 22). The basal insulin pump dose for this patient is 22 units.4. Divide the basal insulin pump dose by 24 to get the hourly basal pup dose and rate (22/24 = 0.9 units/hr).

Bolus doses1. To calculate bolus doses, take the remaining 50% of insulin and divide it by four doses according to the patient's meal plan for the day. For example the remaining 50% could be divided thus: 20% at breakfast, 10% at lunch, 15% at dinner, and 5% with a bedtime snack.2. To calculate the units for each of these four daily bolus doses, multiply the percent of each meal bolus times the total daily insulin pump dose. For example, for 44 units for a total daily dose:a. Breakfast dose is 20% (or 0.2) x 44 units = 9 units.b. Lunch dose is 10% (or 0.1) x 44 = 4 unitsc. Dinner dose is 15% (or 0.15) x 44 = 7 unitsd. Bedtime snack dose is 5% (or 0.05) x 44 = 2 units.

RENAL

TRAUMA

Revised Trauma Score (RTS)GCS4. GCS 13-153. GCS 9-122. GCS 6-81. GCS 4-50. GCS 3

Respiratory Rate (number of respirations in 15 sec multiplied by 4)4. Resp rate 10-293. Resp rate >292. Resp rate 6-91. Resp rate 1-50. Resp rate 0

Systolic BP4. SBP >893. SBP 76-892. SBP 50-751. SBP 1-490. No pulse

Total RTS 1-12

[Lefort Fractures]

[Rules of Nine]

SURGICAL

FLACC ScaleFace2. Frequent to constant quivering chin, clenched jaw1. Occasional grimace or frown, withdrawn, disinterested0. No particular expression or smile

Legs2. Kicking or legs drawn up1. Uneasy, restless, tense0. Normal position or relaxed

Activity2. Arched, rigid or jerking1. Squirming, shifting back and forth, tense0. Lying quietly, normal position, moves easily

Cry2. Crying steadily, screams or sobs, frequent complaints1. Moans or whimpers; occasional complaint0. No cry (awake or asleep)

Consolability2. Difficult to console or comfort1. Reassured by occasional touching, hugging or being talked to0. Content, relaxed

Central Venous Catheter Protocol, Adult

PeripheralDressing Change: q72 hrs transparent, q48 hrs (gauze/tape dressing)Flush for used ports: 3ml NS q12 hrs

PICC (nontunneled) peripheral or centralDressing Change: 24 hrs post-insertion, then q7 days (transparent dressing), q48 hrs (gauze/tape dressing)Flush for used ports: 3ml Heparin (100 units/ml), q24 hrsFlush after blood draw: 10 ml NS

Groshong (tunneled)Dressing Change: 24 hrs post-insertion, then q7 days (transparent dressing), q48 hrs (gauze/tape dressing)Flush for used ports: 10 ml NS per weekFlush after blood draw: 10-20 ml NS

Hickman/Broviac (tunneled)Dressing Change: 24 hrs post-insertion, then q7 days (transparent dressing), q48 hrs (gauze/tape dressing)Flush for used ports: 3ml Heparin (100 units/ml), q24 hrsFlush after blood draw: 10ml NS, 3ml Heparin (100 units/ml), if not accessed and in use

Hohn (tunneled)Dressing Change: 24 hrs post-insertion, then q7 days (transparent dressing), q48 hrs (gauze/tape dressing)

Flush for used ports: 3ml Heparin (100 units/ml), q24 hrsFlush after blood draw: 10ml NS, 3ml Heparin (100 units/ml), if not accessed and in use

Implanted ports (Port-a-cath) (tunneled implanted)Dressing Change: Needle & Dsg change q week when accessedFlush for used ports: 5 ml NS & 5 ml of Heparin (100 units/ml) after infusions, *Terminal flush 5-7 ml Heparin (100 units/ml) q 4 weeksFlush after blood draw: 5 ml NS, 5 ml Heparin (100 units/ml), *if not accessed and in use

Percutaneous (triple/double lument) Arrow/Cook (non-tunneled)Dressing Change: q7 days (transparent dressing), q48 hrs (gauze/tape dressing)Flush for used ports: 3 ml Heparin (100 units/ml), q24 hrsFlush after blood draw: 10ml NS

Reminder: Dialysis Catheter care should be done by the Dialysis nurseFACILITY PROTOCOLS MAY BE DIFFERENT, FOLLOW YOUR FACILITY PROTOCOL OR DOCTOR ORDERS

Common procedural sedation medications and reversal agentsBenzodiazepinesMidazolam (Versed)1-5 min/immediateDuration: 2-6 hrDose: 0.5-2 mg IV over 2 min; may repeat every 5 min with 2 mg increments to a maximum of 10 mg total

Diazepam (Valium)1-5min/ 1-5 minDuration: 15-60 minDose: 2-5 mg IV over 5 min; may repeat every 5 min with 2 mg increments to a maximum of 10 mg total

Lorazepam (Ativan)5 min/10-15 minDuration: 6-8 hrDose: 0.5-2 mg slow IV to a maximum of 4 mg total

OpiodsMorphine2-5 min/20 minDuration: 4-5 hrDose: 2-5 mg IV over 5 min; may repeat every 5 min with 2-5 mg increments

Meperidine (Demerol)1 min/5-7 min

Duration: 2-4 hrDose: 25-50 mg IV over 2 min; may repeat every 5 min with 10-15 mg increments to a maximum of 150 mg total

Fentanyl (Sublimaze)1-2 min/6-10 minDuration: 45-90 min, but can varyDose: 25-50 mcg IV over 2 min; may repeat every 5 min with 25 mcg increments to a maximum of 500 mcg in 4 hr

Reversal agents for procedural sedationFlumazenil (Romazicon)1-2 min/6-10 minDuration: 45-90 min, but can varyReversal dose: 0.2 mg IV every min as needed to a max of 1 mg; may repeat series at 20 min intervals to a max of 3 mg/hr. For overdose: 0.2 mg IV over 30 sec to a max of 3 mg; consider an alternate if no response in 3-5 min.

Naloxone (Narcan)2 min/5-15 minDuration: 1-4 hr, but can varyReversal dose: 0.02-0.04 mg over 30 sec; may repeat at 1 min intervals to a maximum of 10 mg. (Dilute 0.4 mg in 10 ml to make 0.04 mg/ml.) For overdose: 0.4-2 mg SC/IV q 2-3 min.

Aldrette Scoring System for Conscious SedationActivity2. Voluntary movement of all limbs to command1. Voluntary movement of two extremities to command0. Unable to move

Respiration2. Breathe deeply and cough1. Dyspnea, hypoventilation0. Apneic

Circulation2. BP +/- 20 mmHg of pre-anesthesia level1. BP >20-50 mmHg of pre-anesthesia level0. BP >50 mmHg of pre-anesthesia level

Consciousness2. Fully awake1. Arousable0. Unresponsive

Color2. Pink1. Pale, blotch0. Cyanotic

Total score must be > 8 at conclusion of monitoring.

Ramsey Sedation ScaleI. Anxious and agitatedII. Cooperative, oriented, tranquilIII. Responds only to verbal commandsIV. Asleep with brisk response to light

stimulationV. Asleep with sluggish response to

stimulationVI. Asleep without response to stimulation

MULTI

Vital Signs (Normal Range According to Age)Age: NewbornResting Respiratory Rate: 30-50Resting Heart Rate: 100-170Blood Pressure: 65-95/30-60

Age: 1 YearResting Respiratory Rate: 20-40Resting Heart Rate: 80-160Blood Pressure: 65-115/42-80

Age: 3 YearsResting Respiratory Rate: 20-30Resting Heart Rate: 80-120Blood Pressure: 76-122/46-84




Age: AdultResting Respiratory Rate: 14-20Resting Heart Rate: 60-100Blood Pressure: 100-140/60-90

MISC

NANDA Nursing DiagnosesActivity/Rest

- Activity intolerance- Activity intolerance, risk for- Disuse Syndrome, risk for- Diversional Activity Deficit- Fatigue- Sleep Deprivation- Sleep Pattern Disturbance

Circulation- Adaptive capacity: intercranial, decreased- Autonomic dysreflexia- Autonomic dysreflexia, risk for- Cardiac Output, decreased- Tissue Perfusion, altered (specify): renal,

cerebral, cardiopulmonary, gastrointestinal, peripheral

Ego integrity- Adjustment, impaired- Anxiety, death- Anxiety (specify level)- Body Image Disturbance- Coping, defensive- Coping, individual, ineffective- Decisional Conflict (specify)- Energy Field Disturbance- Fear- Grieving, anticipatory

- Grieving, dysfunctional- Hopelessness- Personal Identity Disturbance- Post-Trauma Syndrome- Post-Trauma Syndrome, risk for- Powerlessness- Rape-Trauma Syndrome- Rape-Trauma Syndrome: compound reaction- Rape-Trauma Syndrome: silent reaction- Relocation Stress Syndrome- Relocation Stress Syndrome, risk for- Self-Esteem, chronic low- Self-Esteem Disturbance- Self-Esteem, situational low- Self-Esteem, situational low, risk for- Sorrow, chronic- Spiritual distress- Spiritual distress, risk for- Spiritual well-being, enhanced, potential for

Elimination- Bowel incontinence- Constipation- Constipation, perceived- Constipation, risk for- Diarrhea- Urinary incontinence, functional- Urinary incontinence, reflex- Urinary incontinence, stress- Urinary incontinence, total- Urinary incontinence, urge - Urinary incontinence, urge, risk for - Urinary elimination, altered

- Urinary retention (acute/chronic)

Food/Fluid- Breastfeeding, effective- Breastfeeding, ineffective- Breastfeeding, interrupted- Dentition, altered- Failure to thrive, adult- Fluid volume deficit (active loss)- Fluid volume deficit (regulatory failure)- Fluid volume deficit, risk for- Fluid volume excess- Infant feeding pattern, ineffective- Nutrition: altered, less than body requirements- Nutrition: altered, risk for more than body

requirements- Oral mucous membrane, altered- Swallowing, impaired- Health Maintenance, altered

Hygiene- Self care deficit (specify level): feeding, bathing/hygiene, dressing/grooming, toileting

Neurosensory- Confusion, acute- Confusion, chronic- Infant behavior, disorganized- Infant behavior, disorganized, risk for- Infant behavior, organized, potential for

enhanced- Memory, impaired

- Peripheral neurovascular dysfunction, risk for- Sensory perception alterations (specify): visual,

auditory, kinesthetic, gustatory, tactile, olfactory

- Thought processes, altered- Unilateral neglect

Pain/Comfort- Nausea- Pain, acute- Pain, chronic

Respiration- Airway Clearance, ineffective- Aspiration, risk for- Breathing Pattern, ineffective- Gas Exchange, impaired- Ventilation, spontaneous, inability to sustain- Ventilatory Weaning Response, dysfunctional

(DVWR)

Safety- Body Temperature, altered, risk for- Environmental interpretation syndrome,

impaired- Falls, risk for- Home Maintenance Management, impaired- Hyperthermia- Hypothermia- Infection, risk for- Injury, risk for- Latex Allergy Response- Latex Allergy Response, risk for

- Mobility, impaired bed- Mobility, impaired physical- Mobility, impaired wheelchair- Perioperative Positioning Injury, risk for- Poisoning, risk for- Protection, altered- Self-Mutilation- Self-Mutilation, risk for- Skin Integrity, impaired- Skin Integrity, impaired, risk for- Suffocation, risk for- Suicide, risk for- Surgical recovery, delayed- Thermoregulation, ineffective- Tissue integrity, impaired- Transfer ability, impaired wheelchair- Trauma, risk for- Violence, risk for, directed at self/others- Walking, impaired- Wandering (specify): sporadic, continual

Sexuality- Sexual Dysfunction- Sexuality Patterns, altered

Social Interaction- Caregiver Role Strain- Caregiver Role Strain, risk for- Communication, impaired, verbal- Community Coping, enhanced, potential for- Community Coping, ineffective- Family Coping, ineffective: compromised- Family Coping, ineffective: disabling

- Family Coping, potential for growth- Family Process, altered: alcoholism- Family Processes, altered- Loneliness, risk for- Parent-Infant Attachment, insecure, risk for- Parent-Infant Attachment, altered, risk for- Parental Role Conflict- Parenting, altered- Parenting, altered, risk for- Relocation Stress syndrome- Role performance, altered- Social interaction, impaired- Social isolation

Teaching/Learning- Development, altered, risk for- Growth and Development, altered- Health – Seeking Behaviors (specify)- Knowledge Deficit (specify)- Noncompliance (specify)- Therapeutic Regimen: Community, ineffective

management- Therapeutic Regimen: Families, ineffective

management- Therapeutic Regimen: Individual, effective

management- Therapeutic Regimen: Individual, ineffective

management

MEDICATIONS

Properties of Different Types of Insulin

Lispro (NovoLog)Onset: 5-15 minPeak: 0.75-2.0 hrsDuration: 4-5 hrsRoute of Administration: SubQ

Regular (Humulin or Novolin R)Onset: 30-60 minPeak: 1-4 hrsDuration: 4-8 hrsRoute of Administration: SubQ or IV

NPH (Humulin or Novolin N)Onset: 1-3 hrsPeak: 5-7 hrsDuration 12-18 hrsRoute of Administration: SubQ

Glargine (Lantus)Onset: 2-4 hrsPeak: NoneDuration: ~24 hrsRoute of Administration: SubQ

Angiotensin - Converting Enzyme Inhibitors

Captopril (Capoten)Initial dose: 6.125 mg tidGoal dose: 50 mg bidSide effects: dry cough, dizziness, rash, high potassium levels, low blood pressure, angioedema (swelling of hand, face, throat)Monitoring: potassium, BUN, Creatine levels

Enalapril (Vasotec)Initial dose: 2.5 mg/d or bidGoal dose: 20 mg/d or bidSide effects: dry cough, dizziness, rash, high potassium levels, low blood pressure, angioedema (swelling of hand, face, throat)Monitoring: potassium, BUN, Creatine levels

Benazepril (Lotensin)Initial dose: 10 mg/d or bidGoal dose: 40 mg/d or bidSide effects: dry cough, dizziness, rash, high potassium levels, low blood pressure, angioedema (swelling of hand, face, throat)Monitoring: potassium, BUN, Creatine levels

Quinapril (Accupril)Initial dose: 5 mg bidGoal dose: 20 mg bidSide effects: dry cough, dizziness, rash, high potassium levels, low blood pressure, angioedema (swelling of hand, face, throat)

Monitoring: potassium, BUN, Creatine levels

Ramipril (Altace)Initial dose: 2.5 mg/dGoal dose: 20 mg/d in single or divided doseSide effects: dry cough, dizziness, rash, high potassium levels, low blood pressure, angioedema (swelling of hand, face, throat)Monitoring: potassium, BUN, Creatine levels

Lisinopril (Prinivil, Zestril)Initial dose: 10 mg/d poGoal dose: 40 mg/d poSide effects: dry cough, dizziness, rash, high potassium levels, low blood pressure, angioedema (swelling of hand, face, throat)Monitoring: potassium, BUN, Creatine levels

Beta- Blocking Agents

Carvedilol (Coreg)Initial dose: 3.125 mg bidGoal dose: 25-50 mg bidSide effects: dizziness, nightmares, depression, fatigue, wheezing, decreased sex drive, itching, memory loss, fluid retention, worsening diabetes, diarrheaMonitoring: pulse, blood pressure

Metoprolol (Lopressor)Initial dose: 12.5 mg po bidGoal dose: 50-100 mg po bidSide effects: dizziness, nightmares, depression, fatigue, wheezing, decreased sex drive, itching, memory loss, fluid retention, worsening diabetes, diarrheaMonitoring: pulse, blood pressure

Long-acting metoprolol (Toprol XL)Initial dose: 25 mg/dGoal dose: 200 mg/dSide effects: dizziness, nightmares, depression, fatigue, wheezing, decreased sex drive, itching, memory loss, fluid retention, worsening diabetes, diarrheaMonitoring: pulse, blood pressure

Bisoprolol (Zebeta)Initial dose: 1.25 mg/dGoal dose: 10 mg/d

Side effects: dizziness, nightmares, depression, fatigue, wheezing, decreased sex drive, itching, memory loss, fluid retention, worsening diabetes, diarrheaMonitoring: pulse, blood pressure

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