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Reference Guide

Nursing I - Reference Guides

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Department
ANAT - Anatomy
Course Code
ANAT 14
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Nursing I
Nursing I
ASS E SSM E NT O F L U NG S OUN D S
GRA D ING HEA R T M U RMU R S HEA R T S O UND S
MET R I C C ONV E RSI O N FACTO R S
CAL C U LATIO N OF IV D RIP RATES
• During auscultation, move the diaphragm of
the stethoscope according to the numbered
positions on the diaphragm
NORMAL BREATH SOUNDS
ANTERIOR VIEW
bronchial 
(tracheal)
vesicular
v
bronchovesicular
b
Stethescope
placement
S 
vesicular
b
bronchovesicular
S 
Stethescope
placement
POSTERIOR VIEW
• Intensity of a heart murmur is graded using the
Levine scale
• Most obvious heart sounds are the first (S1) and second (S2) heart sounds
• Characteristic of systole and diastole
LENGTH
VOLUME
BOD Y TE M PER ATU R E C O NVE R SIO N S
°C °F
39.6 103.3
39.0 102.2
38.4 101.1
37.8 100.0
37.0 98.6
Absolute 0
-273.15 -459.67
˚C ˚F
39.6
39.0
38.4
37.8
37.0
103.3
102.2
101.1
100.0
98.6
°F = (°C ¥1.8) + 32
°C = (°F – 32) ÷ 1.8
CONVERSION FACTOR
BODY TEMPERATURE RANGES
Ear 35.8˚ - 38˚C (96.4˚ - 100.4˚F)
Rectal 36.6˚ - 38˚C (97.9˚ - 100.4˚F)
Oral 35.5˚ - 37.5˚C (93.9˚ - 99.5˚F)
Armpit 34.7˚ - 37.3˚C (94.5˚ - 99.1˚F)
Total number of mL Drip factor (gtt/mL) = Drip rate (gtt/min)
Total number of minutes
(no. hrs × 60 min/hr)
EQUATION Example: The doctor has written an order for 3600 mL D5W to be infused over
24 hours The IV equipment being used is Travenol straight tubing 10 drops
per milliliter What is the drip rate? Given the following information, the
equation is set up as follows:
300 mL
(24 hrs × 60 min/hr)
10 gtt.mL = 25 gtt/min
Grade Description
ILowest intensity Difficult to hear
II Low intensity Normally audible
III Medium to moderate intensity
• No palpable thrill
IV Medium intensity Palpable thrill
VLoud intensity Palpable thrill Audible
with stethoscope on chest
VI Loudest intensity Palpable thrill Audible
with stethoscope held over the chest
S1Characteristic of systole • Sound is created when an increase in the
intraventricular pressure during contraction exceeds the pressure in
the atria, causing closure of the AV valves (tricuspid and mitral
valves) • Contraction continues throughout the course of systole,
forcing blood through the semilunar valves (aortic and pulmonary
valves)
S2Characteristic of diastole • Produced when the ventricles relax
• Pressure within the heart is less than pressure of the aorta and
pulmonary artery • This results in a brief backflow of blood, which
causes the semilunar valves to close
Bronchial breath Heard over the trachea
sounds and bronchi
Bronchovesicular Heard over the major bronchi
breath sounds where there are fewer alveoli
• Posterior = between scapulae
• Anterior = around upper
sternum in first and second
intercostal spaces
Vesicular breath Heard over areas where
sounds the air flows through alveoli
and bronchioles
1 kilogram (kg) 1000 grams (g)
1 gram (g) 1000 milligrams(mg)
1 milligram (mg) 1000 micrograms (µg)
1 meter (m) 1000 millimeters (mm)
100 centimeters (cm)
10 decimeters (dm)
1 liter (L) 1000 milliliters (mL)
1 teaspoon (tsp) 4.9289 milliliters
1 tablespoon (tbsp) 14.7868 milliliters
NURSING I • 1-55080-734-X 1© 1998-2012 Mindsource Technologies Inc.
2nd EDITION
www.permacharts.com
TM
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Description
b permacharts TM NNursing I 2nd EDITION ASSESSMENT OF LUNG SOUNDS • During auscultation, move the diaphragm of ANTERIOR VIEW POSTERIOR VIEW the stethoscope according to the numbered positions on the diaphragm Stethescope Stethescope placement placement NORMAL BREATH SOUNDS bronchial Bronchial breath Heard over the trachea vesicular (tracheal) bronchovesicular vesicular sounds and bronchi bronchovesicular Bronchovesicular Heard over the major bronchi breath sounds where there are fewer alveoli • Posterior = between scapulae • Anterior = around upper sternum in first and second intercostal spaces Vesicular breath Heard over areas where sounds the air flows through alveoli and bronchioles S GRADING HEART MURMURS HEART SOUNDS • Intensity of a heart murmur is graded using the • Most obvious heart sounds are the first1(S ) and second2(S ) heart sounds Levine scale • Characteristic of systole and diastole b v Grade Description S Characteristic of systole • Sound is created when an increase in the I Lowest intensity • Difficult to hear 1 intraventricular pressure during contraction exceeds the pressure in the atria, causing closure of the AV valves (tricuspid and mitral II Low intensity • Normally audible III Medium to moderate intensity valves) • Contraction continues throughout the course of systole, • No palpable thrill forcing blood through the semilunar valves (aortic and pulmonary valves) IV Medium intensity • Palpable thrill S Characteristic of diastole • Produced when the ventricles relax V Loud intensity • Palpable thrill • Audible 2 • Pressure within the heart is less than pressure of the aorta and with stethoscope on chest pulmonary artery • This results in a brief backflow of blood, which VI Loudest intensity • Palpable thrill • Audible causes the semilunar valves to close with stethoscope held over the chest METRIC CONVERSION FACTORS BODY TEMPERATURE CONVERSIONS 1 kilogram (kg) 1000 grams (g) ˚C ˚F °C °F CONVERSION FACTOR 1 gram (g) 1000 milligrams(mg) 39.6 103.3 39.6 103.3 °F = (°C ¥ 1.8) + 32 1 milligram (mg) 1000 micrograms (µg) 39.0 102.2 39.0 102.2 °C = (°F – 32) ÷ 1.8 38.4 101.1 38.4 101.1 LENGTH 37.8 100.0 37.8 100.0 37.0 98.6 1 meter (m) 1000 millimeters (mm) 37.0 98.6 100 centimeters (cm) 10 decimeters (dm) BODY TEMPERATURE RANGES VOLUME Ear 35.8˚ - 38˚C (96.4˚ - 100.4˚F) Rectal 36.6˚ - 38˚C (97.9˚ - 100.4˚F) 1 liter (L) 1000 milliliters (mL) Oral 35.5˚ - 37.5˚C (93.9˚ - 99.5˚F) 1 teaspoon (tsp) 4.9289 milliliters -273.15 -459.67 Armpit 34.7˚ - 37.3˚C (94.5˚ - 99.1˚F) 1 tablespoon (tbsp) 14.7868 milliliters Absolute 0 CALCULATION OF IV DRIP RATES EQUATION Example: The doctor has written an order for 3600 mL D5W to be infused over 24 hours • The IV equipment being used is Travenol straight tubing 10 drops Total number of mL Drip factor (gtt/mL) = Drip rate (gtt/min)er milliliter • What is the drip rate? Given the following information, the Total number of minutes equation is set up as follows: 300 mL (no. hr¥ 60 min/hr) 10 gtt.mL = 25 gtt/min (24 hrs 60 min/hr) 1 NURSING I • 1-55080-734-X w w w.permacharts.com © 1998-2012 Mindsource Technologies Inc. permachartsMT ELECTROCARDIOGRAMS (ECGS) Normal Arrhythmia Bradycardia Tachycardia Sinus Arrest Sinus Rhythm Sinus Rhythm Sinus Rhythm Sinus Rhythm Sinus Rhythm Atrial rhythm Regular Irregular Regular Regular Regular except for the missing complex Ventricular Regular Irregular Regular Regular Regular except for the rhythm missing complex Atrial rate 60-100 beats/min 60-100 beats/min Less than 60 100-180 beats/min 60-100 beats/min (normal (normal limits) (normal limits) beats/min (higher in infants) limits) but variation due to the pauses Ventricular 60-100 beats/min 60-100 beats/min Less than 60 100-180 beats/min 60-100 beats/min (normal rate (normal limits) (normal limits) beats/min (higher in infants) limits) but variation due to the pauses P wave Normal shape Normal shape Normal shape Normal size; as sinus rate Normal shape but one reaches approx. 150 beats/min, P wave precedes each QRS the P wave merges with complex and is absent preceding T wave and may during pause be difficult to identify PR interval 0.12-0.20 seconds 0.12-0.20 seconds 0.12-0.20 0.12-0.20 seconds Normal limits and constant (normal limits) (normal limits) seconds (normal limits) when P wave is present; (normal limits) not measurable when P wave is absent QRS complex 0.06-0.10 seconds 0.06-0.10 seconds 0.06-0.10 0.06-0.10 seconds Normal limits but QRS (normal limits) (normal limits) seconds (normal limits) complex is absent during a (normal limits) pause T wave Normal shape Normal shape Normal shape Normal shape Normal shape but absent during a pause QT interval 0.36-0.44 seconds 0.36-0.44 seconds 0.36-0.44 0.36-0.44 seconds Normal limits but not (normal limits) (normal limits) seconds (normal limits) measurable during a pause (normal limits) Other Phases show aslowing There is a gradual onset and and quickening of cessation the rhythm – irregular PRESSURE CHANGES IN LEFT HEART 120 aortic pressure 100 aortic valve closes 80 aortic valve opens 60 40 AV valve closes AV valve opens 20 atrial pressure mg Hg 0 venticular pressure HEART SOUNDS S3 S4 S1 S2 R ELECTROCARDIOGRAM P T Q S c o c n Rapid Diastole t c Systole t t Diastole Filling Slow Presystole m t Ejection e x Rapid (Protodiastolic) Filling s o s e Filling I C I R 2 NURSING I • 1-55080-734-X w w w . permacharts.com © 1998-2012 Mindsource Technologies Inc. permachartsMT CLASSIFICATION OF CRANIAL NERVES Cranial Nerve Type Function Assessment I Olfactory Sensory Smell Occlude (block) one nostril • Hold a familiar smell (e.g., mint, coffee, tobacco) under the client’s nose • Repeat with other nostril II Optic Sensory Vision Check the client’s visual acuity with a Snellen chart • Use ophthalmoscope to check the ocular fundus III Oculomotor Motor Extraocular eye movement Assess direction of gaze and elevation of eyelid Parasympathetic Pupil constriction Check pupil size, shape, and reaction to light and dilation IV Trochlear Motor Upward and downward Ask the client to look up and down motion of eyeball V Trigeminal Sensory Somatic sensations of Ask the client to close eyes • Gently
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