Nursing Memory Notes
Nursing Memory Notes
Nursing Memory Notes Nursing Memory Notes Nursing Memory Notes Nursing Memory Notes
Vital Signs Burn Rule of NIne Pregnancy category Drugs Drug Considerations
Heart rate: 60—100 bpm Head: 9% Digoxin (Lanoxin)—Assess pulses for a full minute, if less than 60
Category A—No risk in controlled human studies
Respiratory rate: 12-20 rpm Arms: 18% (9% each) bpm hold dose. Check digitalis and potassium levels.
Blood pressure: 110-120/60 mmHg
Category B—No risk in other studies.
Back: 18% Aluminum Hydroxide (Amphojel)— Treatment of GERD and kidney
Temperature: 37 °C (98.6 °F) Legs: 36% (18% each) Examples: Amoxicillin, Cefotaxime. stones. WOF constipation.
Genitalia: 1% Category C—Risk not ruled out. Hydroxyzine (Vistaril)—Treatment of anxiety and itching. WOF
Hematology values Serum electrolytes Examples:Rifampicin(Rifampin),Theophylline dry mouth.
RBCs: 4.5—5.0 million Sodium: 135—145 mEq/L (Theolair). Midazolam (Versed)—given for conscious sedation. WOF
WBCs: 5,000—10,000
Conversions respiratory depression and hypotension.
Potassium: 3.5—5.5 mEq/L 1 teaspoon (t) = 5 ml Category D—Positive evidence of risk.
Amiodarone (Cordarone)—WOF diaphoresis, dyspnea, lethargy.
Platelets: 150,000— Calcium: 8.5—10.9 mEq/L Examples: Phenytoin, Tetracycline.
1 tablespoon (T) = 3 t = 15 ml Take missed dose any time in the day or to skip it entirely. Do not
450,000 Chloride: 95—105 mEq/L 1 oz = 30 ml Category X—Contraindicated in Pregnancy. take double dose.
Hemoglobin (Hgb): 12—16 Magnesium: 1.5—2.5 Warfarin (Coumadin)—WOF for signs of bleeding, diarrhea, fever,
1cup=8oz Examples:Isotretinoin (Accutane), Thalidomide
gm (female); 4—18 gm mEq/L or rash. Stress importance of complying with prescribed dosage
(male). (Immunoprin), etc.
Phosphorus: 2.5—4.5 1 quart = 2 pints and follow-up appointments.
Hematocrit (Hct): 37—47 Pregnancy Category N—Not yet classified Methylphenidate (Ritalin)—Treatment of ADHD. Assess for heart
mEq/L 1pint=2cups
(female); 40— 54 (male) related side- effects and reported immediately. Child may need a
1grain(gr)=60mg
drug holiday because the drug stunts growth.
1 gram (g) = 1,000 mg Drug Schedules Dopamine—Treatment of hypotension, shock, and low cardiac
Therapeutic Drug Levels 1 kilogram (kg) = 2.2 lbs output. Monitor ECG for arrhythmias and blood pressure.
Schedule I—no currently accepted medical use and Rifampicin—causes red-orange tears and urine.
Carbamazepine (Tegretol): 4—10 mcg/ml 1lb=16oz
Digoxin (Lanoxin): 0.8—2.0 ng/ml for research use only (e.g., heroin, LSD, MDMA). Ethambutol—causes problems with vision, liver problem.
Convert C to F: C+40 multiply by 9/5 Isoniazid—can cause peripheral neuritis, take vitamin B6 to
Gentamycin (Garamycin): 5—10 mcg/ml Schedule II—drugs with high potential for abuse and
and subtract 40 counter.
(peak), <2.0 mcg/ml (valley) requires written prescription (e.g., Ritalin,
Lithium (Eskalith): 0.8—1.5 mEq/L
Convert F to C: F+40 multiply by 5/9
hydromorphone (Dilaudid), meperidine (Demerol), and
Phenobarbital (Solfoton): 15—40 and subtract 40
fentanyl).
mcg/mL
Schedule III—requires new prescription after six
Phenytoin (Dilantin): 10—20 mcg/dL
Maternal Health Normal Values months or five refills (e.g., codeine, testosterone,
Theophylline (Aminophylline): 10—20
mcg/dL Fetal Heart Rate: 120—160 bpm ketamine).
Tobramycin (Tobrex): 5—10 mcg/mL Variability: 6—10 bpm Schedule IV—requires new prescription after six
(peak), 0.5—2.0 mcg/mL (valley) Amniotic fluid: 500—1200 ml months (e.g., Darvon, Xanax, Soma, and Valium).
Valproic Acid (Depakene): 50—100 Contractions: 2—5 minutes apart with Schedule V—dispensed as any other prescription or Developmental Milestone
mcg/ml duration of < 90 seconds and intensity of <100 mmHg. without prescription (e.g., cough preparations, 2—3 months: able to turn head up, and can
Vancomycin (Vancocin): 20—40 mcg/ml APGAR Scoring: Appearance, Pulses, turn side to side. Makes cooing or gurgling
Lomotil, Motofen).
(peak), 5 to 15 mcg/ml (trough) Grimace, Activity, Reflex Irritability. Done at 1 and 5 noises and can turn head to sound.
minutes with a score of 0 for absent, 1 for decreased, and 4—5 months: grasps, switch and roll over
2 for strongly positive. Scores 7 and above are generally Acid-Base Balance tummy to back. Can babble and can mimic
Anticoagulant therapy ABG Values
normal, 4 to 6 fairly low, and 3 and below are generally sounds.
Sodium warfarin (Coumadin) PT: 10—12 Remember ROME
regarded as critically low. pH: 7.35—7.45 6—7 months: sits at 6 and waves bye- bye.
seconds (control). The antidote is respiratory
AVA: The umbilical cord has two arteries and one vein. HCO3: 24—26 mEq/L Can recognize familiar faces and knows if
Vitamin K. opposite
STOP—Treatment for maternal hypotension after an CO2: 35—45 mEq/L someone is a stranger. Passes things back
INR (Coumadin): 0.9—1.2 metabolic
epidural anesthesia: PaO2: 80%—100% and forth between hands.
Heparin PTT: 30—45 seconds (control). equal 8—9 months: stands straight at eight, has
Stop infusion of Pitocin. SaO2: >95%
The antidote is protamine sulfate. Turn the client on her left side. that in respiratory favorite toy, plays peek-a-boo.
APTT: 23.3—31.9 seconds Administer oxygen. acid/base disorders the pH is 10—11 months: belly to butt.
Fibrinogen level: 203—377 mg/dL push IV fluids, if hypovolemia is present. opposite to the other 12—13 months: twelve and up, drinks from a
components. cup. Cries when parents leave,
uses furniture to cruise.
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Nursing Memory Notes Nursing Memory Notes Nursing Memory Notes Nursing Memory Notes
Common Signs & Symptoms (Pathognomonic sign)
Diets Positioning patients Positioning patients (Cont.)
Prolapsed cord—knee-chest position or Trendelenburg. Pulmonary Tuberculosis (PTB)—low- grade afternoon fever.
Acute Renal Disease—protein-restricted, high-calorie, fluid- Pneumonia—rust-colored sputum.
Cleft-lip—position on back or in infant seat to prevent trauma
controlled, sodium and potassium controlled. Asthma—wheezing on expiration.
to the suture line. While feeding, hold in upright position.
Addison’s disease—increased sodium, low potassium diet. Emphysema—barrel chest.
Cleft-palate—prone.
ADHD and Bipolar—high-calorie and provide finger foods. Asthma—orthopneic position Kawasaki Syndrome—strawberry tongue.
Hemorrhoidectomy—assist to lateral position.
Burns—high protein, high caloric, increase in Vitamin C. Bronchoscopy (Post)—flat on bed Pernicious Anemia—red beefy tongue.
Hiatal Hernia—upright position. Down syndrome—protruding tongue.
Cancer—high-calorie, high-protein. with head hyperextended.
Preventing Dumping Syndrome—eat in reclining position, lie Cholera—rice-watery stool and washer woman’s hands
Celiac Disease—gluten-free diet (no BROW: barley, rye, oat, Cerebral Aneurysm—high Fowler’s.
down after meals for 20-30 minutes (also restrict fluids during Malaria—stepladder like fever with chills.
and wheat). Autonomic Dysreflexia—place client in sitting position
meals, low fiber diet, and small frequent meals). Typhoid—rose spots in the abdomen.
Chronic Renal Disease—protein- restricted, low-sodium, (elevate HOB) first before any other implementation. Dengue—fever, rash, and headache. Positive Herman’s sign.
Enema Administration—position patient in left-side lying (Sim’s
fluid-restricted, potassium-restricted, phosphorus- Hemorrhagic Stroke— HOV elevated 30 degrees to reduce ICP Diphtheria—pseudo membrane formation.
position) with knees flexed.
restricted. and facilitate venous drainage. Measles—Koplik’s spots
Post supratentorial surgery (incision behind hairline)—elevate
Cirrhosis (stable)—normal protein Ischemic Stroke— HOB flat. Systemic Lupus Erythematosus— butterfly rash.
HOB 30-45 degrees.
Cirrhosis with hepatic insufficiency— restrict protein, Cardiac Catheterization—keep site extended. Leprosy—leonine facies (thickened folded facial skin).
Post infratentorial surgery (incision at nape of neck)—position Bulimia—chipmunk facies (parotid gland swelling).
fluids, and sodium. Epistaxis—lean forward.
patient flat and lateral on either side. Appendicitis—rebound tenderness at McBurney’s point. Rovsing’s
Constipation—high-fiber, increased fluids Above Knee Amputation—elevate for first 24 hours on pillow,
Increased ICP—high Fowler’s. sign (palpation of LLQ elicits pain in RLQ). Psoas sign (pain from flexing
COPD—soft, high-calorie, low- carbohydrate, high-fat, small position on prone daily for hip extension.
Laminectomy—back as straight as possible; log roll to move and the thigh to the hip).
frequent feedings Below Knee Amputation—foot of bed elevated for first 24 Meningitis—Kernig’s sign, Brudzinski’s sign
sand bag on sides.
Cystic Fibrosis—increase in fluids. hours, position prone daily for hip extension. Tetany—hypocalcemia, [+] Trousseau’s sign; Chvostek sign.
Spinal Cord Injury—immobilize on spine board, with head in
Diarrhea—liquid, low-fiber, regular, fluid and electrolyte Tube feeding for patients with decreased LOC—position Tetanus— Risus sardonicus or rictus grin.
neutral position. Immobilize head with padded C-collar,
replacement patient on right side to promote emptying of the stomach with Pancreatitis—Cullen’s sign, Grey Turner’s sign
maintain traction and alignment of head manually. Log roll
Gallbladder diseases—low-fat, calorie- restricted, regular HOB elevated to prevent aspiration. Pyloric Stenosis—olive like mass.
client and do not allow client to twist or bend. Patent Ductus Arteriosus—washing machine-like murmur.
Gastritis—low-fiber, bland diet Air/Pulmonary embolism—turn patient to left side and lower
Liver Biopsy—right side lying with pillow or small towel under Addison’s disease—bronzelike skin pigmentation.
Hepatitis—regular, high-calorie, high- protein HOB.
puncture site for at least 3 hours. Cushing’s syndrome—moon face appearance and buffalo hump.
Hyperlipidemias—fat-controlled, calorie- restricted Postural Drainage—Lung segment to be drained should be in
Paracentesis—flat on bed or sitting. Grave’s Disease (Hyperthyroidism)— Exophthalmos
CAD—low- sodium, calorie-restricted, fat-controlled the uppermost position to allow gravity to work.
Intestinal Tubes—place patient on right side to facilitate Intussusception—Sausage-shaped mass.
Kidney Stones—increased fluid intake, calcium-controlled, Post Lumbar puncture—patient should lie flat in supine to Multiple Sclerosis—Charcot’s Triad: nystagmus, intention tremor,
passage into duodenum.
low-oxalate prevent headache and leaking of CSF. and dysarthria.
Nasogastric Tubes—elevate HOB 30 degrees to prevent
Nephrotic Syndrome—sodium-restricted, high-calorie, high- Continuous Bladder Irrigation (CBI)— catheter should be Myasthenia Gravis—descending muscle weakness, ptosis
aspiration. Maintain elevation for continuous feeding or 1hour
protein, potassium- restricted. taped to thigh so legs should be kept straight. Guillain-Barre Syndrome—ascending muscles weakness.
after intermittent feedings. Deep vein thrombosis (DVT)—Homan’s Sign.
Obesity, overweight—calorie-restricted, high-fiber After myringotomy—position on the side of affected ear after
Pelvic Exam—lithotomy position. Angina—crushing, stabbing pain relieved by NTG.
Pancreatitis—low-fat, regular, small frequent feedings; surgery (allows drainage of secretion).
Post cataract surgery—patient will sleep on unaffected side
Rectal Exam—knee-chest position, Sim’s, or dorsal recumbent. Myocardial Infarction (MI)—crushing, stabbing pain radiating to left
tube feeding or total parenteral nutrition.
with a night shield for 1-4 weeks. radiation,During internal —patient should be on bed rest while shoulder, neck, and arms. Unrelieved by NTG.
Peptic ulcer—bland diet Parkinson’s disease—pill-rolling tremors.
Detached retina—area of detachment should be in the implant is in place.
Pernicious Anemia—increase Vitamin B12 (Cobalamin) Cytomegalovirus (CMV) infection—Owl’s eye appearance of cells
dependent position. Shock—bed rest with extremities elevated 20 degrees, knees
Sickle Cell Anemia—increase fluids to maintain hydration Glaucoma—tunnel vision.
Post thyroidectomy—low or semi- Fowlers, support head, straight, head slightly elevated (modified Trendelenburg).
since sickling increases when patients become dehydrated. Retinal Detachment—flashes of light, shadow with curtain across
neck and shoulders. Head Injury—elevate HOB 30 degrees to decrease intracranial
Stroke—mechanical soft, regular, or tube-feeding. vision.
Thoracentesis—sitting on the side of the bed and leaning pressure. Basilar Skull Fracture—Raccoon eyes (periorbital ecchymosis) and
Underweight—high-calorie, high protein
over the table (during procedure); affected side up (after Peritoneal Dialysis when outflow is inadequate—turn patient Battle’s sign (mastoid ecchymosis).
Vomiting—fluid and electrolyte replacement
procedure). side to side before checking for kinks in the tubing. Buerger’s Disease—intermittent claudication
Spina Bifida— position infant on prone so that sac does not Myelogram Diabetic Ketoacidosis—acetone breathe.
Water-based dye—semi Fowler’s for at least 8 hours. Pregnancy Induced Hypertension (PIH)—proteinuria, hypertension,
rupture.
Oil-based dye—flat on bed for at least 6-8 hours to prevent edema.
Buck’s Traction—elevate foot of bed for counter-traction. Diabetes Mellitus—polydipsia, polyphagia, polyuria.
Post Total Hip Replacement—don’t sleep on operated side, leakage of CSF.
Gastroesophageal Reflux Disease (GERD)—heart burn.
don’t flex hip more than 45-60 degrees, don’t elevate HOB more Air dye—Trendelenburg.
Hirschsprung’s Disease (Toxic Megacolon)—ribbon-like stool.
than 45 degrees. Maintain hip abduction by separating thighs
with pillows.