KwikKlips.nursingbro..

Transcription

KwikKlips.nursingbro..
2
EDI 006
TIO
N
GET THE JUMP
ON YOUR CLINICALS
WITH THE ULTIMATE
NURSING REFERENCE CLIPBOARD
• Calculator with calendar and clock including second hand function.
• Cardiovascular assessment information including EKG intervals, heart
sounds, hemodynamic norms and calculations, pulse scale, edema
scale, murmur scale.
• Integumentary assessment information including skin breakdown areas, skin
integrity scale and descriptors for skin temperature, moisture and color.
• Elimination assessment information including urinalysis values and
descriptors for urinary and bowel function, sounds, patterns and color.
• Neurological assessment information including pain intensity scale,
pupil scale, muscle testing scale, deep tendon reflex scale, glasgow
coma scale, descriptors for pupil reaction, motor response, behavior
and level of consciousness.
• Respiration assessment information including common respiratory patterns,
breath sound assessment, descriptors for breath quality, rate, sputum
and cough.
• IV infusion information including IV infusion rate calculation, hourly
dosage IV flow chart, multiple hour IV dosage flow chart.
• Injection information for needle length, gauge, maximum volume and
insertion degree.
• Normals for serum electrolytes, arterial blood gases, complete blood
count, urinalysis.
• Vital sign normals for children through seniors for temperature, pulse,
respiration and blood pressure.
• Assessment chart for respiratory and metabolic acidosis and alkalosis.
• Conversion formulas for volume, weight, temperature and length.
• BMI weight management guidelines and formulas.
• Dosage calculation formulas for both pills and liquids.
• Metric and standard rulers.
ORDER FORM
WITH CALCULATOR: $21.95
25+ ..................$18.95 per clipboard
50+ ..................$16.95 per clipboard
WITHOUT CALCULATOR: $18.95
25+ ..................$15.95 per clipboard
50+ ..................$13.95 per clipboard
STORAGE TRAY: $8.00
FREE laminated sheet included with every clipboard
outlining common healthcare abbreviations,
documentation tips, unsafe abbreviations and
patient care planning, a $9.00 value.
SHIPPING CHARGES: Please add the following
amounts to your order for shipping charges:
1 - 5 ..................$2.50 per clipboard
6 - 24 ................$1.25 per clipboard
25+ ....................$0.75 per clipboard
For trays in any quantity, add $0.75
QUESTIONS?
Contact us at:
Clipboards by Kwik Klip
Phone: 800-653-7017
Fax: 954-212-2411
E-mail: clipboards@earthlink.net
Website: www.clipboards.org
❑ Check
❑ VISA
❑ MASTERCARD
0
Enclosed is $_________________
C L I P B OA R D P R I C E S :
12
COMPREHENSIVE NURSING
CLIPBOARD INCLUDES:
1
11
2
DAILY PATIENT ASSESSMENT INFORMATION
8
7
7
8
13
14
6
MOTOR
RESPONSE
Flexion & Withdrawl
Oriented
Localizes Pain
5
Obeys Commands
LIQUID
D
____
xQ=X
H
MD order: Digoxin 0.25 mg
Drug available: Digoxin
0.125 mg per tablet
D=0.25 H=0.125
X=2 tablets
MD order: Dilantin 50 mg
Drug available: Dilantin
125 mg/5ml
D=50 H=125
Q=5 X=2 ml
IV INFUSION RATE CALCULATION
Total Volume (ml) x IV Drip Factor = Drip Rate (gtts/min)
Time (mins)
BMI
WEIGHT MANAGEMENT
Below 18.5
18.5 - 24.9
25.0 - 29.9
Above 30
Underweight
Normal
Overweight
Obese
4
BMI = Weight (kg) / (Height (m) x Height (m))
20
D = MD order H= Dose on hand
Q = Amt of liquid
X = Amt of medication to administer
19
Flexion Posture
Disoriented
18
Extension Posture
Inappropriate
17
Unintelligible
Spontaneously
6
PILLS
D
____
=X
H
None
None
To Pain
To Command
4
16
+
AMOUNT TO ADMINISTER
15
VERBAL
RESPONSE
None
3
21
PAIN INTENSITY SCALE
CRANIAL NERVES
COMMON RESPIRATORY PATTERNS
Normal rate and rhythm
3
NORMAL
ABNORMAL
[Central airways] Bubbling, rumbling sound
[Main stem-bronchi] Soft, blowing, medium
pitched; inspiration = expiration
Hyperpnea
Deep respirations at normal rate
Vision
Oculomotor
Eye Movement,
Pupil Dilation
4
Trochlear
5
Trigeminal
6
Abducens
Eye Movement
7
Facial
Taste, facial movement
8
Vestibulocochlear
9
Glossopharyngeal
Taste, gag, swallow,
saliva secretion
10
Vagus
FUNCTION
Sensory, motor, autonomic
control of viscera
Smell
Eye Movement
Chewing, sensation in face
and head
Kussmaul’s
Fast [> 20 bpm], deep [sigh like], labored respirations
without pause
Hearing, balance
11
Spinal Accessory
Head and shoulder movement
12
Hypoglossal
Tongue movement
27
[Anywhere] High pitched musical squeaks
Rhonchi
[Lung periphery] Soft, swishing, breezy, low
pitched; inspiration > expiration
Bronchovesicular
Slow regular respirations [< 12 bpm]
Optic
3
26
Wheezes
Vesicular
Bradypnea
Olfactory
2
25
[Trachea] Loud, high pitched & harsh;
expiration > inspiration
NAME
1
24
DESCRIPTION
Bronchial
Rapid respirations; Rate rises 4 bpm for every degree > than
normal body temp.
23
BREATH SOUNDS
2
Eupnea
Tachypnea
#
22
Worst Pain Possible
LOCATION
Cheyne-Stokes
[Lateral lung field; client in upright position]
Grating, creaking or squeaking sound
Fast deep respirations [30-170 secs] with periods of apnea
[20-60 secs]
[Anywhere; usually during inspiration]
Soft crackling, popping, or bubbling sound
Apnea
Absence of breathing
●
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This Clipboard serves as a reference guide only and
should not be relied on in providing medical care. Kwik
Klip Enterprises is not responsible for the use of this
information in the provision of medical care.
30
Pleural
friction rub
Rales
Copyright © 2006
Kwik Klip Enterprises, all rights reserved.
2901 Ellsworth Road, Nortonville, KS 66060
Phone 800-653-7017 FAX 954-212-2411
email clipboards@earthlink.net
ORDER ONLINE AT www.clipboards.org
29
0
1
Apneustic
Prolonged gasping inspiration followed by very short & ineffecient
expiration
28
School Attending: ____________________________________________________________________________________________
QUALITY
■ WNL
■ Deep
■ Shallow
■ Labored
■ Unlabored
SOUNDS
■ Clear
■ Cough
■ Moist
RATE
■ WNL
■ Slow
■ Rapid
SPUTUM
■ Clear
■ White
■ Yellow
■ Green
■ Frothy
■ Brown
■ Blood - tinged
COUGH QUALITY
P Productive
N Nonproductive
W Weak
S Strong
6
reactive to light, accomodation normal
MOTOR RESPONSE
■ Obeys commands
■ Localizes pain
■ Withdraws to pain
■ No motor response
LEVEL OF
CONSCIOUSNESS (LOC)
A Alert
V Voice Response
P Pain Response
U Unresponsive
BEHAVIOR
■ Agitated ■ Calm ■ Restless
■ Anxious ■ Withdrawn
12
+
EYES
OPEN
2
1
No Pain
______________________________________________________________________________________________________________
RESPIRATION
PUPIL SCALE (mm)
1 2
3
4
5
PUPIL REACTION
± Sluggish
+ Reactive
– Non-Reactive
(PERRLA) pupils equal, round,
11
GLASGOW COMA SCALE
5
______________________________________________________________________________________________________________
BOWEL PATTERNS
■ Regular
■ Constipation
■ Diarrhea
■ Impaction
ABDOMEN
■ Firm ■ Soft
■ Rigid ■ Tender
■ Flat
■ Distended
NEUROLOGICAL
10
BREAKDOWN AREAS
■ Hip bones, tailbone, ischium
■ Knees, heels, ankles, toes
■ Spine, shoulder blades, elbows
■ Ears, side/back of head
BOWEL SOUNDS
+ Present
0 Absent
Hyperactive
Hypoactive
9
SKIN INTEGRITY
I Reddened
II Broken skin, superficial
III Crater, involves fat layer
IV Crater, involves
muscle & bone
ELIMINATION
URINE COLOR
■ Yellow ■ Amber
■ Milky ■ Tea
■ Straw ■ Pink
■ Red
URINARY FUNCTION
■ Frequency ■ Urgency
■ Polyuria
■ Dysuria
■ Hematuria ■ Nocturia
■ Calculi
■ Retention
■ Incontinence
8
Ship to: _______________________________________________________________________________________________________
SKIN COLOR
■ Ashen ■ Ruddy
■ Dusky ■ Mottled
■ Pale
■ Cyanotic
■ Pink
■ Flushed
■ Jaundiced
7
Credit Card #: ____________________________________________________________ Exp. Date ____________________________
INTEGUMENTARY
SKIN TEMP.
■ Warm ■ Hot
■ Cool ■ Cold
SKIN MOISTURE
■ Clammy
■ Dry
■ Diaphoretic ■ Moist
TURGOR
■ Elastic
■ Firm
■ Fragile
■ Edema
6
9
10
CARDIOVASCULAR
HEART SOUNDS
■ Distinct ■ Murmur ■ Rub
■ Distant ■ Extra Sounds
■ Muffled ■ Gallop
PULSES
0 Absent
+1 Weak, Thready
+2 Normal
+3 Strong
+4 Bounding
MUMUR SCALE
I/VI Barely audible
II/VI Audible, low intensity
III/VI Immediately audible, mod intensity
IV/VI Loud intensity without thrill
V/VI Loud intensity with thrill
VI/VI Loudest intensity, thrill,
audible with stethoscope
slightly off chest
EDEMA
0 No edema
+1 Barely discernible pit; normal foot
& leg contours
+2 Deeper pit [<5mm]; fairly normal
foot & leg contours
+3 Deep pit [5-10mm]; foot & leg
swelling
+4 Even deeper pit [>1cm]; severe
foot & leg swelling
5
______ Storage Tray(s)
4
______ Nursing Clipboard(s) with standard clip
3
_____ Nursing Clipboard(s) with calculator
Phone: _______________________________________ Email: _________________________________________________________
Mail order form to Clipboards by Kwik Klip, 2901 Ellsworth Road, Nortonville KS, 66060, or FAX to 954-212-2411
You may order online, at www.clipboards.org, using a Visa or Mastercard. We also accept checks,
money orders, or purchase orders. Please allow ten business days for shipment of your order.
An optional storage tray is available, for both the
standard clip as well as the calculator clipboards, at
$8.00 plus $0.75 shipping for each tray in any quantity.