Nurses Notes

Nurses's
Notes
Tanya Hughes, RN, BSN
[copyright page]
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 response

4. Spontaneously
3. To speech
2. To pain
1. None
Motor response
6. Obeys request
5. Localizes
4. Withdraws from painful stimuli
3. Abnormal flexion - decorticate posture (toward
spine)
2. Abnormal extension - decerebrate posture (away
from spine)
1. None
Verbal response
5. Oriented
4. Confused
3. Inappropriate words
2. Incomprehensible
1. 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 Scale
5. Normal power or strength in extremities
4. Weak extremities, but can overcome resistance
applied by the examiner
3. Patient can overcome gravity, but cannot overcome
resistance applied by the examiner
2. Weak muscle contraction, but cannot overcome
gravity
1. Palpable or visible muscle flickr or twitch, but no
movement
0. No response to stimulus, complete paralysis
PULMONARY
Modes of Ventilator Support
Assist-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 MI
elevation in V1, V2, V3, V4; depression may be
present in II, III, aVF (left anterior descending branch
of left coronary artery, aka LAD)
Inferior MI
elevation in II, III, aVF; depression may be present in
I, aVL, V2-V4 (right coronary artery, aka RCA)
Lateral MI
elevation in I, aVL, V5, V6 (circumflex branch of left
coronary artery, aka Circ)
Posterior MI
depression in V1, V2, V3 (could be RCA branch or
Circ branch)
Classification of Cardiac Murmurs by
Degree of Intensity
I - Barely audible
II - Audible after a few seconds of auscultation, low
intensity
III - Immediately audible, moderate intensity
IV - Loud intensity without a precordial thrill
V - Loud intensity with a precordial thrill
VI - 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 8-12
High values - Overload, Pericarditis, Pulmonary
HTN/Embolus, Ventricular Septal Defect, LV Failure,
PEEP, Cardiac Tamponade/Effusion
Low 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: 6-12
High values - Overload, Pulmonary Embolus, LV
Failure, Cardiac Tamponade/Effusion, Pericarditis,
PEEP
Low 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= CI
Normal Cardiac Output: 4-8 L/min
Normal Cardiac Index : 2.5-4.0 L/min/m2
High values - Sepsis
Low 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: 2-6
High values - Ascites, Pericarditis, ARDS, COPP,
Pulmonary Embolus, Cardiac Tamponade/Effusion,
LV Failure, Mitral Stenosis, PEEP, Pneumothorax,
Pulmonary HTV, RV Infarct, Sepsis, Volume
Overload
Low values - Hypovolemia, Shock
SVR (Systemic Vascular Resistance)

Normal: 900-1600
(MAP - CVP)/CO x 80=SVR
ENDO
Possible Treatment of DKA Patients

Restoration 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 DKA
Glucose (300-800mg/100ml) Concentration not
related to severity of DKA
pH (6.8-7.3)
Na+ (low, normal or high) Total body depletion;
concentration dependent on relative H2O loss
K+ (low, normal or high) Total body depletion; heart
responsive to extracellular concentration
WBC (usually increased) Possibility of leukemoid
reaction (even in absence of infection)
Hgb/Hct (often increased) Secondary to contracted
plasma volumes.
Insulin Pumps
Basal Dose
1. 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 doses
1. 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 units
c. Dinner dose is 15% (or 0.15) x 44 = 7 units
d. Bedtime snack dose is 5% (or 0.05) x 44 = 2 units.
RENAL
TRAUMA
Revised Trauma Score (RTS)

GCS
4. GCS 13-15
3. GCS 9-12
2. GCS 6-8
1. GCS 4-5
0. GCS 3
Respiratory Rate (number of respirations in 15 sec

multiplied by 4)
4. Resp rate 10-29
3. Resp rate >29
2. Resp rate 6-9
1. Resp rate 1-5
0. Resp rate 0
Systolic BP
4. SBP >89
3. SBP 76-89
2. SBP 50-75
1. SBP 1-49
0. No pulse
Total RTS 1-12
[Lefort Fractures]
[Rules of Nine]
SURGICAL
FLACC Scale
Face
2. Frequent to constant quivering chin, clenched jaw
1. Occasional grimace or frown, withdrawn,
disinterested
0. No particular expression or smile
Legs
2. Kicking or legs drawn up
1. Uneasy, restless, tense
0. Normal position or relaxed
Activity
2. Arched, rigid or jerking
1. Squirming, shifting back and forth, tense
0. Lying quietly, normal position, moves easily
Cry
2. Crying steadily, screams or sobs, frequent
complaints
1. Moans or whimpers; occasional complaint
0. No cry (awake or asleep)
Consolability
2. Difficult to console or comfort
1. Reassured by occasional touching, hugging or
being talked to
0. Content, relaxed
Central Venous Catheter Protocol,
Adult
Peripheral
Dressing Change: q72 hrs transparent, q48 hrs
(gauze/tape dressing)
Flush for used ports: 3ml NS q12 hrs
PICC (nontunneled) peripheral or central

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
hrs
Flush after blood draw: 10 ml NS
Groshong (tunneled)
Flush for used ports: 10 ml NS per week
Flush after blood draw: 10-20 ml NS
Hickman/Broviac (tunneled)
hrs
Flush after blood draw: 10ml NS, 3ml Heparin (100
units/ml), if not accessed and in use
Hohn (tunneled)
hrs
Flush 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 accessed
Flush 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 weeks
Flush 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 hrs
Flush after blood draw: 10ml NS
Reminder: Dialysis Catheter care should be done by

the Dialysis nurse
FACILITY PROTOCOLS MAY BE DIFFERENT,
FOLLOW YOUR FACILITY PROTOCOL OR
DOCTOR ORDERS
Common procedural sedation
medications and reversal agents
Benzodiazepines
Midazolam (Versed)
1-5 min/immediate
Duration: 2-6 hr
Dose: 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 min
Duration: 15-60 min
Dose: 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 min
Duration: 6-8 hr
Dose: 0.5-2 mg slow IV to a maximum of 4 mg total
Opiods
Morphine
2-5 min/20 min
Duration: 4-5 hr
Dose: 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 hr
Dose: 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 min
Duration: 45-90 min, but can vary
Dose: 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 sedation

Flumazenil (Romazicon)
1-2 min/6-10 min
Duration: 45-90 min, but can vary
Reversal 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 min
Duration: 1-4 hr, but can vary
Reversal 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 Sedation
Activity
2. Voluntary movement of all limbs to command
1. Voluntary movement of two extremities to
command
0. Unable to move
Respiration
2. Breathe deeply and cough
1. Dyspnea, hypoventilation
0. Apneic
Circulation
2. BP +/- 20 mmHg of pre-anesthesia level
1. BP >20-50 mmHg of pre-anesthesia level
0. BP >50 mmHg of pre-anesthesia level
Consciousness
2. Fully awake
1. Arousable
0. Unresponsive
Color
2. Pink
1. Pale, blotch
0. Cyanotic
Total score must be > 8 at conclusion of monitoring.

Ramsey Sedation Scale
I. Anxious and agitated
II. Cooperative, oriented, tranquil
III. Responds only to verbal commands
IV. Asleep with brisk response to light
stimulation
V. Asleep with sluggish response to
stimulation
VI. Asleep without response to stimulation
MULTI
Vital Signs (Normal Range According
to Age)
Age: Newborn
Resting Respiratory Rate: 30-50
Resting Heart Rate: 100-170
Blood Pressure: 65-95/30-60
Age: 1 Year
Age: 3 Years
Age: 6 Years
Age: 10 Years
Age: 14 Years
Age: Adult
MISC
NANDA Nursing Diagnoses
Activity/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 min
Peak: 0.75-2.0 hrs
Duration: 4-5 hrs
Route of Administration: SubQ
Regular (Humulin or Novolin R)

Onset: 30-60 min
Peak: 1-4 hrs
Duration: 4-8 hrs
Route of Administration: SubQ or IV
NPH (Humulin or Novolin N)

Onset: 1-3 hrs
Peak: 5-7 hrs
Duration 12-18 hrs
Glargine (Lantus)
Onset: 2-4 hrs
Peak: None
Duration: ~24 hrs
Angiotensin - Converting Enzyme
Inhibitors
Captopril (Capoten)
Initial dose: 6.125 mg tid
Goal dose: 50 mg bid
Side 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 bid
Goal dose: 20 mg/d or bid
Benazepril (Lotensin)
Initial dose: 10 mg/d or bid
Goal dose: 40 mg/d or bid
Quinapril (Accupril)
Initial dose: 5 mg bid
Goal dose: 20 mg bid
Ramipril (Altace)
Initial dose: 2.5 mg/d
Goal dose: 20 mg/d in single or divided dose
Lisinopril (Prinivil, Zestril)

Initial dose: 10 mg/d po
Goal dose: 40 mg/d po
Beta- Blocking Agents
Carvedilol (Coreg)
Initial dose: 3.125 mg bid
Goal dose: 25-50 mg bid
Side effects: dizziness, nightmares, depression,
fatigue, wheezing, decreased sex drive, itching,
memory loss, fluid retention, worsening diabetes,
diarrhea
Monitoring: pulse, blood pressure
Metoprolol (Lopressor)
Initial dose: 12.5 mg po bid
Goal dose: 50-100 mg po bid
diarrhea
Long-acting metoprolol (Toprol XL)

Initial dose: 25 mg/d
Goal dose: 200 mg/d
diarrhea
Bisoprolol (Zebeta)
Initial dose: 1.25 mg/d
Goal dose: 10 mg/d
diarrhea

Nurses Notes

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Nurses's

Cath Lab _________________

Long Distance Code __________

Eye - opening response

Total score ranges from 3-15. A total of 7 or less

[Los Angeles Stroke Scale]

Continuous Positive Airway Pressure (CPAP)

Continuous mandatory ventilation (CMV)

Intermittent mandatory ventilation (IMV)

Mandatory minute ventilation (MMV)

Pressure support ventilation (PSV)

Synchronized IMV (SIMV)

PCWP (Pulmonary Cap Wedge Pressure)

SVR (Systemic Vascular Resistance)

Possible Treatment of DKA Patients

Prompt recognition and treatment of complications

Prevention of future episodes

Signs & Symptoms of DKA

Revised Trauma Score (RTS)

Respiratory Rate (number of respirations in 15 sec

Total RTS 1-12

PICC (nontunneled) peripheral or central

Implanted ports (Port-a-cath) (tunneled implanted)

Percutaneous (triple/double lument) Arrow/Cook

Reminder: Dialysis Catheter care should be done by

Reversal agents for procedural sedation

Total score must be > 8 at conclusion of monitoring.

Properties of Different Types of Insulin

Regular (Humulin or Novolin R)

NPH (Humulin or Novolin N)

Lisinopril (Prinivil, Zestril)

Long-acting metoprolol (Toprol XL)

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