lOMoARcPSD|25973474
ATI Comprehensive
Nursing Research (Concordia University
Wisconsin)
,
,LAB VALUES
ABG:
pH 7.35 7.45
CO2 35 45
HCO3 22 26
Fully Compensation pH in range
Partial Compensation ALL out of range
Non-compensation pH out of range &
CO2 OR HCO3 in range
ELECTROLYTE:
Potassium K (heart) 3.5 5 mEq/L
Sodium Na (brain) 135 145 mEq/L
Calcium Ca (bone/muscle) 9 10.5 mg/dL
Magnesium Mg 1.3 2.1 mg/dL
Chloride Cl 98 106 mEq/L
Phosphorus P 3 4.5 mg/dL
BLOOD:
WBC 5k 10k
RBC 4.2 6.1
Platelets 150k 400k
Hemoglobin (Hgb) F: 12 16
M: 14 18
Hematocrit (Hct= Hgb x3) F: 37 47
M: 42 52
PT/INR (Warfarin) Normal INR: 0.7 1.8
Therapeutic: 2 3
aPTT (Heparin) Normal: 30s 40s
Therapeutic= 2x baseline: 60s 80s
RENAL:
GFR 120
Urine Output >30 ml/hour, >1.5 L/day
BUN 10 20 mg/dL
Creatinine (CK) 0.6 1.2 mg/dL
Specific gravity 1.005 1.025
Plasma osmolarity 270 300
LIVER:
AST 0 35 units/L
ALT 4 36 units/L
ALP 30 120 units/L
Bilirubin 0.3 1
Albumin 3.5 5 g/dL
Ammonia 10 80
PANCREAS:
Amylase 30 220
Lipase 0 160
Glucose 70 105 mg/dL
HbA1c < 6.5%: NO/PRE diabetics
BRAIN:
Intracranial pressure (ICP) 10 15
HEART:
Capillary refill < 3sec: Arterial sufficiency
Brain natriuretic peptide (BNP) <100: NO Heart failure
CHOLESTEROL:
Total cholesterol 130 200 mg/dL
Triglycerides < 150 mg/dL
HDL > 60 mg/dL
LDL < 100 mg/dL
Digoxin 0.5 2
Lithium 0.8 1.5
Dilantin / Theophylline 10 20
, 2. Latex allergies
a. Note that clients allergic to bananas, apricots, cherries, grapes, kiwis, passion fruit,
avocados, chestnuts, tomatoes, and/or peaches may experience latex allergies as well
3. Order of assessment → Inspection, palpation, percussion, auscultation
a. Except with abdomen it is IAPP-inspect, auscultate, percuss and palpate.
4. Cane walking → COAL (Cane, Opposite, Affected, Leg)
5. Crutch walking → Remember the phase "step up" when picturing a person going up stairs with crutches. The
good leg goes up first followed by the crutches and the bad leg. The opposite happens going down the
stairs….OR "up to heaven…down to hell"
6. S point gait → Allows pt to be mobile without bearing weight on affected extremity
a. Used when pt is non-weight bearing on a leg
7. Delegation → RNs DO NOT delegate what they can EAT (Evaluate, Assess, Teach)
a. A nursing assistant can perform tasks such as taking vital signs, range of motion exercises,
bathing, bed making, obtaining urine specimens, enemas and blood glucose monitoring. Nursing
assistants cannot interpret results or perform any task beyond the skill level of the certification
they received.
i. Performing gastrostomy feeding thru an established gastrostomy tube
b. The PN is managed under the supervision of the RN. Certain higher level skills can be delegated
after competency has been established by the RN (e.g., dressing changes or suctioning).
8. Medical asepsis is "clean technique" and surgical asepsis is sterile technique
9. Isolation Precautions
a. AIRBORNE → "My chicken hez TB"
i. Measles, chicken pox, herpes zoster, TB
ii. Management → Neg pressure room, private room, mask, n95 for TB
b. DROPLET → SPIDERMAn
i. Sepsis, scarlet fever, strep, pertussis, pneumonia, parvovirus, influenza, diphtheria, epiglottitis,
rubella, mumps, adenovirus
ii. Management → private room, mask
c. CONTACT → MRS WEE
i. MRSA, VRSA, RSV, skin infection (herpes zoster, cutaneous diphtheria, impetigo,
pediculosis, scabies, and staphylococcus), wound infections, enteric infection (C diff), eye
infections (conjunctivitis)
ii. Management → gown, gloves, goggles, private room
10. Venturi mask (4-10L/min) is most precise O2 delivery. Best for pt w/ chronic lung disease (i.e. COPD)
11. Aerosol mask/Face tent good for pt w/ facial trauma or burns
12. Dysphagia is difficulty swallowing; Dysphasia is difficulty speaking
a. Dysphagia → Aspiration precautions; Avoid thin liquids and sticky food and provide oral care
prior to eating (helps to enhance taste of food)
13. Home oxygen education → Avoid synthetic or wool fabrics (encourage wearing cotton)
a. Educate to apply a water-soluble lubricant to soothe irritation of the mucous membranes
14. Incentive Spirometer use → Instruct pt to keep a tight mouth seal around mouthpiece and to inhale
and hold breath for S-5 secs
15. Restraints → Assess and document pt physical needs, safety and comfort q 15-30 mins
a. Renew of perscription → Adults - q4h, 9-17 y/o - q2h, under 9 y/o - q1h
b. Staff member must remain continuously w/ pt or view the pt via camera
2
ATI Comprehensive
Nursing Research (Concordia University
Wisconsin)
,
,LAB VALUES
ABG:
pH 7.35 7.45
CO2 35 45
HCO3 22 26
Fully Compensation pH in range
Partial Compensation ALL out of range
Non-compensation pH out of range &
CO2 OR HCO3 in range
ELECTROLYTE:
Potassium K (heart) 3.5 5 mEq/L
Sodium Na (brain) 135 145 mEq/L
Calcium Ca (bone/muscle) 9 10.5 mg/dL
Magnesium Mg 1.3 2.1 mg/dL
Chloride Cl 98 106 mEq/L
Phosphorus P 3 4.5 mg/dL
BLOOD:
WBC 5k 10k
RBC 4.2 6.1
Platelets 150k 400k
Hemoglobin (Hgb) F: 12 16
M: 14 18
Hematocrit (Hct= Hgb x3) F: 37 47
M: 42 52
PT/INR (Warfarin) Normal INR: 0.7 1.8
Therapeutic: 2 3
aPTT (Heparin) Normal: 30s 40s
Therapeutic= 2x baseline: 60s 80s
RENAL:
GFR 120
Urine Output >30 ml/hour, >1.5 L/day
BUN 10 20 mg/dL
Creatinine (CK) 0.6 1.2 mg/dL
Specific gravity 1.005 1.025
Plasma osmolarity 270 300
LIVER:
AST 0 35 units/L
ALT 4 36 units/L
ALP 30 120 units/L
Bilirubin 0.3 1
Albumin 3.5 5 g/dL
Ammonia 10 80
PANCREAS:
Amylase 30 220
Lipase 0 160
Glucose 70 105 mg/dL
HbA1c < 6.5%: NO/PRE diabetics
BRAIN:
Intracranial pressure (ICP) 10 15
HEART:
Capillary refill < 3sec: Arterial sufficiency
Brain natriuretic peptide (BNP) <100: NO Heart failure
CHOLESTEROL:
Total cholesterol 130 200 mg/dL
Triglycerides < 150 mg/dL
HDL > 60 mg/dL
LDL < 100 mg/dL
Digoxin 0.5 2
Lithium 0.8 1.5
Dilantin / Theophylline 10 20
, 2. Latex allergies
a. Note that clients allergic to bananas, apricots, cherries, grapes, kiwis, passion fruit,
avocados, chestnuts, tomatoes, and/or peaches may experience latex allergies as well
3. Order of assessment → Inspection, palpation, percussion, auscultation
a. Except with abdomen it is IAPP-inspect, auscultate, percuss and palpate.
4. Cane walking → COAL (Cane, Opposite, Affected, Leg)
5. Crutch walking → Remember the phase "step up" when picturing a person going up stairs with crutches. The
good leg goes up first followed by the crutches and the bad leg. The opposite happens going down the
stairs….OR "up to heaven…down to hell"
6. S point gait → Allows pt to be mobile without bearing weight on affected extremity
a. Used when pt is non-weight bearing on a leg
7. Delegation → RNs DO NOT delegate what they can EAT (Evaluate, Assess, Teach)
a. A nursing assistant can perform tasks such as taking vital signs, range of motion exercises,
bathing, bed making, obtaining urine specimens, enemas and blood glucose monitoring. Nursing
assistants cannot interpret results or perform any task beyond the skill level of the certification
they received.
i. Performing gastrostomy feeding thru an established gastrostomy tube
b. The PN is managed under the supervision of the RN. Certain higher level skills can be delegated
after competency has been established by the RN (e.g., dressing changes or suctioning).
8. Medical asepsis is "clean technique" and surgical asepsis is sterile technique
9. Isolation Precautions
a. AIRBORNE → "My chicken hez TB"
i. Measles, chicken pox, herpes zoster, TB
ii. Management → Neg pressure room, private room, mask, n95 for TB
b. DROPLET → SPIDERMAn
i. Sepsis, scarlet fever, strep, pertussis, pneumonia, parvovirus, influenza, diphtheria, epiglottitis,
rubella, mumps, adenovirus
ii. Management → private room, mask
c. CONTACT → MRS WEE
i. MRSA, VRSA, RSV, skin infection (herpes zoster, cutaneous diphtheria, impetigo,
pediculosis, scabies, and staphylococcus), wound infections, enteric infection (C diff), eye
infections (conjunctivitis)
ii. Management → gown, gloves, goggles, private room
10. Venturi mask (4-10L/min) is most precise O2 delivery. Best for pt w/ chronic lung disease (i.e. COPD)
11. Aerosol mask/Face tent good for pt w/ facial trauma or burns
12. Dysphagia is difficulty swallowing; Dysphasia is difficulty speaking
a. Dysphagia → Aspiration precautions; Avoid thin liquids and sticky food and provide oral care
prior to eating (helps to enhance taste of food)
13. Home oxygen education → Avoid synthetic or wool fabrics (encourage wearing cotton)
a. Educate to apply a water-soluble lubricant to soothe irritation of the mucous membranes
14. Incentive Spirometer use → Instruct pt to keep a tight mouth seal around mouthpiece and to inhale
and hold breath for S-5 secs
15. Restraints → Assess and document pt physical needs, safety and comfort q 15-30 mins
a. Renew of perscription → Adults - q4h, 9-17 y/o - q2h, under 9 y/o - q1h
b. Staff member must remain continuously w/ pt or view the pt via camera
2
