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Nursing Care Assessment and Delegation

Sodium 136-145 mEq/L Potassium 3.5-5.0 mEq/L Total Calcium 9.0-10.5 mg/dL Magnesium 1.3-2.1 mg/dL Phosphorus 3.0 -4.5 mg/dL BUN 10-20 mg/dL Creatinine 0.6 - 1.2mg/dL males, 0.5 - 1.1 mg/dL females Glucose 70 -105 mg/dL HgbA1c <6.5% WBC 5,000-10,000/mm3 RBC Men 4.7-6.1 million/mm3, Women 4.2-5.4 million/mm3 Hemoglobin Men 14-18g/100 mL, Women 12-16 g/100 mL Hematocrit Men 42-52%,Women 37-47% Platelet 150,000-400,000/mm3 pH 7.35-7.45 pC02 35 to45 mm Hg p02 80-100 mmHg HCO3 21-26mmol/L Normal PT = 11-12.5 sec, Normal INR = 0.7-1.8 (Therapeutic INR 2-3) Normal PTT = 30-40 sec (Therapeutic PTT 1.5 -- 2 x normal or control values) Digoxin 0.5 to 2.0ng/mL Lithium 0.8 to 1.4 mEq/L Dilantin 10-20 mcg/mL Theophylline 10 to 20mcg/mL Latex Allergies: Note that clients allergic to bananas, apricots, cherries, grapes, kiwis, passion fruit. avocados, chestnuts, tomatoes, and/or peaches may experience latex allergies as well Order of assessment: I-inspection P-palpation P-percussion A-auscultation Except with abdomen it is IAPP-inspect, auscultate, percuss and palpate. Cane walking: C-cane O-opposite A-affected L-leg Crutch walking: Remember the phase "step up" when picturing a person going up stairs with crutches. happens going down the stairs...OR "up to heaven...down to hell" Delegation: RNs DO NOT delegate what they can EAT - evaluate, assess, teach Helpful tool to remember Isolation Precautions: AIRBORNE: "My Chicken Hez TB" -Measles -Chicken pox -Herpes zoster -TB Management: neg. pressure room, private room, mask, n-95 for TB. DROPLET: "SPIDERMAn" -Sepsis -Scarlet Fever -Strep -Pertussis -Pneumonia -Parvovirus -Influenza -Diphtheria -Epiglottitis -Rubella sdwnw- -Adenovirus Management: Private room/mask CONTACT: "MRS WEE" -MRSA -VRSA -RSV -Skin infections (herpes zoster, cutaneous diphtheria, impetigo, pediculosis. scabies, and staphylococcus) -Wound infections -Enteric infections (Clostridium difficile) -Eye infections (conjunctivitis) Management: gown, gloves, goggles, private room Test taking tip: Slow Down!