Copyright © 2004 F.A Davis REFERENCE VALUES FOR LABORATORY TESTS—BLOOD OR SERUM These values are for some of the more common laboratory tests done on blood or serum See pp 172–198 for a more complete list, including possible causes of increased and decreased values Test Conventional Units Albumin Adult: 3.5–5.0 g/dL or 52–68% of total protein Child: 4.0–5.8 g/dL Adult: 20–90 U/L Child: 60–270 U/L Infant: 40–300 U/L Adult: 15–70 μg/dL Newborn: 40–120 μg/dL Adult: 4–25 U/mL Child: 25–125 U/L Newborn: Up to 65 U/L Direct: Up to 0.4 mg/dL Indirect: Up to 0.8 mg/dL Total: Up to 1.0 mg/dL Newborn: 1–12 mg/dL Adult: 5–25 mg/dL Child: 5–20 mg/dL Infant: 4–18 mg/dL Adult: 8.5–10.5 mg/dL Child: Slightly higher 95–107 mEq/L 40–50 yr: 140–240 mg/dL Ͻ age 25: 125–200 mg/dL Infant: 70–175 mg/dL Ͼ age 65: Up to 200 mg/dL To age 40: Up to 180 mg/dL To age 25: Up to 138 mg/dL 32–75 mg/dL (varies with age) Alkaline phosphatase (ALP) Ammonia Amylase Bilirubin Blood urea nitrogen (BUN) Calcium (serum) Chloride Cholesterol Cholesterol, low density (LDL) Cholesterol, high density (HDL) CO2, venous Creatinine 23–30 mEq/L Adult: 0.6–1.5 mg/dL Child: 0.3–0.7 mg/dL Newborn: 0.3–1.0 mg/dL Male: 55–170U/L Creatine kinase Female: 30–135 U/L or creatine Child: 15–50 U/L phosphokinase Newborn: 30–100 U/L (CK or CPK) Adult: 60–100 mg/dL Glucose, whole Newborn (1 day): 25–51 mg/dL blood (fasting) Men: 60–170 μg/dL Iron Women: 50–130 μg/dL Child: 40–200 μg/dL Newborn: 350–500 μg/dL Iron-binding capac- 300–360 μg/dL ity, total (TIBC) Adult: 14–280 U/L Lipase Child: 20–136 IU/L Infant: 9–105 IU/L SI Units 11–32 μmol/L 64–107 μmol/L 1.36–3.0 μkat/L 1.88–5.03 μkat/L 1.7–6.8 μmol/L 5.0–19.0 μmol/L 5–20 μmol/L 34–102 μmol/L 1.8–7.1 mmol/L 2.5–6.4 mmol/L 1.4–6.4 mmol/L 2.25–2.75 mmol/L 95–105 mmol/L 4.37–6.35 mmol/L 3.27–5.20 mmol/L 2.69–5.12 mmol/L 2.30–4.60 mmol/L 1.87–3.53 mmol/L 0.82–1.92 mmol/L 24–30 mmol/L 53–133 μmol/L 0.94–2.89 μkat/L 0.51–2.30 μkat/L 0.26–0.85 μkat/L 0.51–1.70 μkat/L 3.3–5.6 mmol/L 1.4–2.8 mmol/L 10.7–30.4 μmol/L 9.0–23.3 μmol/L 7.2–35.8 μmol/L 62.7–89.5 μmol/L 54–64 μmol/L 0.2.72 μkat/L (continued on inside back cover) Copyright © 2004 F.A Davis Nurse’s Fast Facts: Your Quick Source for Core Clinical Content Copyright © 2004 F.A Davis This page intentionally left blank Copyright © 2004 F.A Davis Nurse’s Fast Facts: Your Quick Source for Core Clinical Content Third Edition BRENDA WALTERS HOLLOWAY, CRNP, FNP, MSN Clinical Assistant Professor University of South Alabama College of Nursing Mobile, Alabama F A DAVIS COMPANY Philadelphia Copyright © 2004 F.A Davis F A Davis Company 1915 Arch Street Philadelphia, PA 19103 Copyright © 2004 by F A Davis Company Copyright © 1996, 2001 by F A Davis Company All rights reserved This book is protected by copyright No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher Printed in Canada Last digit indicates print number: 10 Acquisitions Editor: Robert G Martone Developmental Editor: Alan Sorkowitz Art & Design Manager: Joan Wendt As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes The author and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication The author, editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug Caution is especially urged when using new or infrequently ordered drugs Library of Congress Cataloging-in-Publication Data Holloway, Brenda Walters, 1949Nurse’s fast facts : your quick source for core clinical content / Brenda Walters Holloway.—3rd ed p ; cm Includes index ISBN 0-8036-1161-7 Nursing—Handbooks, manuals, etc [DNLM: Nursing Care—Handbooks Nursing Process—Handbooks Specialties, Nursing—methods—Handbooks WY 49 H745n 2004] I Title RT51.H65 2004 610.73—dc22 2004043215 Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F A Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.10 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923 For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged The fee code for users of the Transactional Reporting Service is: 8036–0599/01 ϩ $.10 Copyright © 2004 F.A Davis This book is dedicated to my parents, Juanice and J M Walters, who provided me with the opportunity to obtain an education, and to Harry, Jason, Shanda, and Scott, who have provided me with many opportunities to use it Copyright © 2004 F.A Davis This page intentionally left blank Copyright © 2004 F.A Davis Preface Through years of clinical practice and teaching, I have observed that orientation to each major clinical nursing specialty usually leads the novice to ask a somewhat predictable set of questions ranging from specialty-related communication, to assessment and anatomy, physiology, and pathology involved in frequently seen conditions to questions related to the planning and implementation of patient care Many excellent texts are available to provide in-depth information related to these topics Although the use of such texts is essential to the acquisition of a thorough knowledge of comprehensive patient care, these texts are frequently too cumbersome to carry to the clinical area, where on-the-spot information may be needed My goal in writing this book has been to provide a portable and easy-to-use source for quick answers to questions I have frequently heard from students and practicing nurses The sections of this book pertain to each major clinical nursing specialty and are identified by printed tabs to speed access to the information At the end of each section are blank pages, which allow users to “customize” the book by adding information that they find helpful for each specialty It is hoped that the handy availability of information in this pocket-sized reference book not only will improve the accuracy and quality of patient care, but also will relieve some of the stress that students and graduate nurses experience when they must move from one clinical specialty area to another vii Copyright © 2004 F.A Davis This page intentionally left blank Copyright © 2004 F.A Davis K Kava-kava, potential hazard of, 530 Kehr’s sign, 469t Kernig’s sign, 469t Kidneys frontal section of right, 17f renal failure and, 297–298 Knee-chest/genupectoral positioning, 140, 141f L Labor See also Pregnancy comparison of true and false, 318–320 external fetal monitoring in interpretation of, 321–322 methods of, 321 terminology, 321 fetal presentations categories of, 319–320f possible, 318t mechanism of normal, 324f preliminary events to, 316–317 preterm, 315 stages of, 325–328t station in, 316, 317f terminology in, 316 Labyrinthectomy, 78 Lactic or lactate dehydrogenase (LDH), 187 Lactose intolerance, therapeutic diet for, 598 Laminectomy, 78 Laparotomy, 78 Laryngotracheobronchitis (croup), 293–294 Laser, 78 Latent phase, in labor, 325–326t Lateral recumbent positioning, 140, 142f Laxatives, potential hazard of, 531 LDH See Lactic or lactate dehydrogenase (LDH) Lead, 187 Learned dependence, as problem in long-term care, 540t Left ventricular diastolic pressure, adult norm for, 497 Left ventricular mean pressure, adult norm for, 497 Left ventricular stroke work index (LVSWI) adult norm for, 497 Left ventricular systolic pressure, adult norm for, 497 Legal aspects, home health patient care and, 556–557 Legionella, incubation and isolation periods in, 166t 623 Index safety precautions for hospitalization, 398 Infections control of, 133–134 group B streptococcal, in pregnancy, 314 as problem in long-term care, 540t Influenza adult immunization schedule, 152 incubation and isolation periods in, 165t recommended immunization schedule, 385 transmission of, 159t vaccination, 154 Infusion rates, of fluids, 116–117t Inhaled poisons, 468 In-hospital assessment, guidelines of, 69–70 Injection sites intramuscular, 96f subcutaneous, 95f INR, 185 Insight-oriented therapy, 425 Instructions, emergency, for patient/family, 556 Insulin diabetes and, 289t time/action profile of, 97f Integumentary system assessment of See Skin; Hair; Nails age-related changes in, and nursing implications, 507–509 functions and organs of, 27t Intellectualization, as defense mechanism, 411 Intensity, in labor and delivery, 316 Internal fetal monitoring, 321 Introjection, as defense mechanism, 411 Iodine, 576t Iron drugs and, 581 iron-binding capacity, 186–187 reference values for lab tests, 186, 575t rich foods, 584 Iron deficiency anemia physical assessment and, 292–293 therapeutic diet for, 588 Irritable bowel syndrome, therapeutic diet for, 598 Isolation, as problem in long-term care, 540t IV admixture compatibility, 110–111 IV fluids, uses of, 113–114t IV rates, calculation of, 116 IV therapy, adults, 112 Index Copyright © 2004 F.A Davis Legs See also Extremities bones of, 6f movements of, 29f Length equivalents, 85 growth charts for boys, from birth to 36 months, 367f growth charts for girls, from birth to 36 months, 368f Leprosy, transmission of, 159t Lesions in health assessment, 226 skin, 227t types of, 227t Leukemia, 294–295 Leukocytes See White blood cell count (WBCs or leukocytes) Licorice root, potential hazard of, 531 Lie, in labor and delivery, 316 Life review therapy, 425 Ligation, 78 Lipase, 187 Lipectomy, 78 Lipids, 187 Liposuction, 78 Lips, in adult assessment, 243 Liquid equivalents, 84 Lithotomy, defined, 78 Lithotomy/dorsosacral positioning, 140, 141f Lithotripsy, 78 Lobectomy, 78 Lobotomy, 78 Long-term care, problems in, 539–541t Loss of privacy, as problem in longterm care, 540t Low-sodium foods, 583 Lumpectomy, 78 Lungs See also Respiration; Respiratory system in health assessment, 248–252 in newborn assessment, 335 pneumonia and, 296–297 in postpartum assessment, 345 LVSWI See Left ventricular stroke work index (LVSWI) Lyme disease, incubation and isolation periods in, 166t Lymphatic system, functions and organs of, 27t Lymph nodes, of head and neck, 11f M Macule lesion, 227t Magnesium, 188, 567t, 575t, 582 624 Magnet reflex, 340 Maintenance, chest tube, 126–128 Maintenance fluid calculation, 390–392 Maladaptive behavior, characteristics and management of individuals with, 413–420 Malaria, incubation and isolation periods in, 166t Male See also Men aspartate aminotransferase (AST or SGOT), 175 breasts, 263 pediatric caloric requirements for, 388 reproductive system, 26f sexuality, in health history, 219 Malignant hyperpyrexia, 78 Mammoplasty, 78 Manic behavior, 417 Manipulative behavior, 417–418 MAP See Mean arterial pressure (MAP) Marshall-Marchetti-Krantz procedure, 79 Marsupialization, 79 Mastectomy, 79 Maturation, 356 McBurney’s sign, 470t McDonald procedure, 78 Mean arterial pressure (MAP), adult norm for, 497 Measles adolescent and children immunization schedule, 385, 386 immunization doses, 153 incubation and isolation periods in, 166t transmission of, 160t vaccination, 155–156 Measurements abbreviations, 83 in newborn assessment, 331 normal pressure in adults, 497–499 Meat, in DASH diet, 605 Meconium aspiration, 343 Medicare certification (acceptance), for home care, 549–550 Medication administration See also Drug(s) blood levels of drugs, 98–107t blood products, 119–120 calculation of dosages fraction format, 91 pediatric, 388–389 ratio and proportions, 92 solving for x, 90–91 Copyright © 2004 F.A Davis defense (coping) mechanisms in, 411–413 delusional behavior in, 415 dependent behavior in, 415 depressed behavior in, 416 family violence in, 421 hallucinatory behavior in, 416 hyperactive behavior in, 417 hypochondriacal behavior in, 417 manipulative behavior in, 417– 418 monitoring for reactions, 425– 428 obsessive-compulsive behavior in, 418 passive aggressive behavior in, 418 phobic behavior in, 419 post-traumatic stress syndrome, 421 psychotherapeutic treatment modalities, 424–425 suicidal behavior in, 419 suspiciousness in, 419–420 therapeutic communication techniques in, 409–410 withdrawn behavior in, 420 Mental status in health assessment, 222–224 altered, in the older adult, 526–527 delirium in the older adult, 526 dementia in the older adult, 526 depression in the older adult, 526 Metabolic acidosis, 465t Metabolic alkalosis, 466t MI See Myocardial infarction (MI) Milieu therapy, 425 Milk anemia, 588 Milligrams, equivalents for, 86–87 Minerals, 575–576t negative interactions between drugs and, 580–582 Modeling, 425 Mononucleosis, infectious, incubation and isolation periods in, 166t Moro (startle) reflex, 340 Morphine, potential hazard of, 530 Motor system, in adult assessment, 276 Mouth See also Sensory system in health assessment, 243–245 in newborn assessment, 334 Multifocal atrial tachycardia, 487t Multiple electrolyte solutions, 115t Multiple trauma patient in emergency department adult trauma score, 452–453t 625 Index calculation of IV rates, 116–117 common IV fluids and their uses, 113–114t intramuscular injection sites, 96f IV admixture compatibility, 110–111 IV therapy, adults, 112 nomograms for estimating body surface area of infants and young children, 93f for estimating body surface area of older children and adults, 94f parenteral administration, 117–119 for pediatric IV 389–390 , psychotropic, 425–428 rules and routes of, 90 side effects and/or interactions, as problem in long term care, 540 subcutaneous injection sites, 95f syringe compatibility, 108–109 time/action profile of insulin, 97 Medication side effects and/or interactions, as problem in long-term care, 540t Men See also Male number of calories needed for, 565 recommended dietary allowances for, 567t, 569t recommended fat-soluble vitamins for, 572t recommended water-soluble vitamins for, 573–574t Meningitis, 295–296 Brudzinski’s sign in, 469t incubation and isolation periods in, 166t Kernig’s sign in, 469t transmission of, 160t Meningococcal immunization, 153 vaccine for, 156 Meniscectomy, 79 Mental health addictive behavior in, 413 aggressive behavior in, 413 alcohol withdrawal in, 421 altered eating behavior in, 413–414 anxious behavior in, 414 assertive behavior in, 413 characteristics and management of maladaptive behavior, 413–420 codependent behavior, 414–415 crisis situation in, 421 Index Copyright © 2004 F.A Davis Multiple trauma patient (Cont’d.) Glasgow Coma scale for infants and toddlers, 451t primary survey, 437 secondary survey, 437, 448 Mumps adolescent and children immunization schedule, 385, 386 immunization doses, 153 incubation and isolation periods in, 167t transmission of, 160t Murmurs, cardiac See Cardiac murmurs Murphy’s sign, 470t Muscular system functions and organs of, 27t major muscles in, 7–8f Musculoskeletal system See also Muscular system; Neuromuscular system in adult assessment, 271–273 Myectomy, 79 Myocardial infarction (MI), 295–296 Myoglobin, 188 Myomectomy, 79 Myopia, 521 Myotomy, 79 Myringotomy with pressureequalizing (PE) tubes, 79 N Nailing, 79 Nails, in health assessment, 229 NANDA nursing diagnoses, 57–68 Narcotics, blood levels of, 104–105t Narrative charting, 73 Narrow-complex tachycardia, 446–447 Nasoduodenal route continuous tube feeding, 139 intermittent (bolus) tube feeding, 137–138 tube feeding, 137 Nasogastric tube continuous feeding, 139 feeding with, 137 intermittent (bolus) feeding, 137–138 Nasogastric tube insertion method of securing tube and tape, 132f overview, 134–136 pediatric adaptation, 136 Nausea, as presumptive sign of pregnancy, 307 Nausea/vomiting, therapeutic diet for, 599 626 Neck in health assessment, 246–247 lymph nodes of, 11f midsagittal section of, 12f in newborn assessment, 334 Neonates See also Newborns Apgar scoring for, 329, 330t complications of ABO incompatibility, 342 infant of diabetic mother (IDM), 342 meconium aspiration, 343 neonatal sepsis, 343 physiologic jaundice, 343 respiratory distress syndrome, 344 RH incompatibility, 344 CPR guidelines, 436t delivery room care for, 329 nursery admission care of, 330 reflexes in, 340–341 respiratory distress syndrome/hyaline membrane disease (RDS) in, 298–299 sepsis, 343 weight conversion table for, 338–339t Nephrectomy, 79 Nephron with associated blood vessels, 18f Nephrosis, therapeutic diet for, 599 Nephrotic syndrome, therapeutic diet for, 599 Nervous system functions and organs of, 27t Neurogenic shock, 457t Neuroleptic malignant syndrome (NMS), 427 Neurologic conditions, rigid postural responses to, 454f Neurologic system, in health assessment, 274–276 Neuromuscular system, age-related changes and nursing implications in, 517–519 Neurosensory system in health history, 218 in NANDA nursing diagnoses, 62 Newborns See also Neonates physical assessment of abdomen, 335 chest, 334 ears, 332 extremities, 337 eyes, 333 genitalia, 336 gestational age, 337 head, 333 Copyright © 2004 F.A Davis O Obesity body mass index and, 578–579t therapeutic diet for, 599 Obsessive-compulsive behavior, 418 Obstetrics See Pregnancy Older adults See Adults Oophorectomy, 79 Ophthalmia neonatorum, transmission of, 160t Opisthotonos, 454f Orchiectomy, 79 Orchiopexy, 79 Osmolality, 188 Osteomalacia, Trousseau’s sign in, 469t Osteoporosis, therapeutic diet for, 599 Ostomy, therapeutic diet for, 599–600 Otoplasty, 79 Ovaries, 23t Over-the-counter medicines, potential hazards of, 530–531 Oxygen consumption (VO2), adult norm for, 498 Oxygen content of blood, adult norm for, 498 Oxygen delivery, adult norms for, 498 P PaCO2, 189 Pain evaluation of abdominal, 472t evaluation of chest, 472t in health history, 218 in NANDA nursing diagnoses, 63 Palate, in health assessment, 244 Palmar grasp, 340 Palpations, 249–251, 253, 268, 307 Pancreas, 21t Pancreatitis, therapeutic diet for, 600 Pantothenic acid, 569–570t PaO2, 189 Papule lesion, 227t Paranasal sinuses, 233f Parathyroid, 22t Paratyphoid fevers, incubation and isolation periods in, 167t Parenteral nutrition, 117–119 Paroxysmal supraventricular tachycardia (PVST), 488t PARS (postanesthesia recovery score) See Postanesthesia recovery score (PARS) Partial thromboplastin time (PTT), 189 Passive aggressive behavior, 418 Patient assessment, in home health care, 553 PCW See Pulmonary capillary mean wedge pressure (PCW) Pediatrics See also Children; Infants; Neonates; Toddlers 627 Index heart, 335 lungs, 335 measurements, 331 mouth, 334 neck, 334 nose, 334 reflexes, 337 skin, 332 vital signs, 331 variations in respiration in, 375 Niacin, 569–570t, 572t Nissen fundoplication, 79 NMS See Neuroleptic malignant syndrome (NMS) Nodule lesion, 227t Nomograms for estimating body surface area of adults, 94f for estimating body surface area of infants and young children, 93f North American Nursing Diagnosis association See NANDA Nursing Diagnoses Nose See also Sensory system in health assessment, 231–232 in newborn assessment, 334 Nursing change-of-shift report, 74–75 Nutrition anorexia nervosa and, 413–414 body mass index (BMI), 577–579 DASH diet, 603–606 deficit, as problem in long-term care, 541t dietary guidelines for food sources, 582–585 dietary guidelines for healthy adults, 565 encouraging children to eat, 397–398 fat soluble vitamins, 572t minerals, 575–576t parenteral, 117–119 peripheral parenteral nutrition (PPN), 117 total parenteral nutrition (TPN), 117–118 water-soluble vitamins, 573–574t Nuts, in DASH diet, 605 Index Copyright © 2004 F.A Davis Pediatrics (Cont’d.) age-appropriate play and diversional activities for, 395–397 age-related stages to categorize children, 358 blood pressure assessment, 151, 375 caloric requirements, 388 catheter irrigation, open method, 126 catheterization, 124 developmental assessment, 357 developmental milestones, 359–372 development theories Erikson’s psychosocial development, 357–358 Freud’s stages of psychosexual development, 357–358 Piaget’s cognitive theory, 358 encouraging to eat, 397–398 fears related to hospitalization, 394 Glasgow Coma score for infants and toddlers, 451t growth and development terminology in, 356 head circumference growth chart for boys from birth to 36 months, 371f head circumference growth chart for girls from birth to 36 months, 372f height growth chart for boys from to 20 years, 369f height growth chart for girls from to 20 years, 370f IV administration tips, 392–394 IV medication administration methods, 389–390 length growth chart for boys from birth to 36 months, 367f length growth chart for girls from birth to 36 months, 368f maintenance fluid calculation, 390–392 medication dosage calculation and administration guidelines, 388–389 nasogastric tube insertion, 136 recommended adolescent immunization schedules, 385t recommended childhood immunization schedules, 385t respiratory and cardiac monitoring in, 402 628 routine immunization schedule, 384 weight growth chart for boys from birth to 36 months, 363f from to 20 years, 365f weight growth chart for girls from birth to 36 months, 364f from to 20 years, 366 well-child assessment, 373 Peptic ulcer, therapeutic diet for, 599–600 Perineum, in postpartum assessment, 346–347 Peripheral parenteral nutrition (PPN), 117 Peristalsis, in health assessment, 266 Peritoneal irritation, Ballance’s sign in, 468t Pernicious anemia, therapeutic diet for, 588 Personal safety, in home health care, 556 Perstalsis, in abdomen, 266 Pertussis adolescent and children immunization schedule, 385, 386 transmission of, 160t Petechial lesion, 227t pH, 189 Phenylketonuria, therapeutic diet for, 601 Phobic behavior, 419 Phone numbers, agency, 81–82 Phosphorus, 189, 575t Physiologic jaundice, 343 Piaget’s cognitive theory, 358 Pituitary gland anterior, function and disorders of, 22t posterior, function and disorders of, 23t target organs and hormones of, 20f Placenta praevia in the emergency department, 477 in pregnancy, 313 Plague, incubation and isolation periods in, 167t Plan of care (POC), in home health care, 554 Plantar grasp, 340 Platelet count, 190 Play therapy, 425 Copyright © 2004 F.A Davis ectopic Cullen’s sign in, 469t in the emergency department, 477 Kehr’s sign in, 469t emergency department assessment of, 477 estimating expected date of delivery, 308–309t fundal height assessment causes of deviation from usual, 310 classic milestones, 210 usual height, 311f positive signs of, 307 presumptive signs of, 307 probable signs of, 307 recommended dietary allowances, 568t, 570t signs of imminent birth, 472 Premature, variations in respiration in, 375 Premature complexes, 493t Preoperative care, 143–144 Presbyopia, 521 Preschoolers See also Children; Pediatrics; Toddlers nasogastric tube insertion, 137 Prescription medications, potential hazards of, 529–530 Presentation categories of, 319–320f in labor and delivery, 316 possible, fetal, 318t Pressure ulcers (decubitus) prevention of, 542 as problem in long-term care, 539t therapeutic diet for, 593 treatment of, 543 Preterm labor (PTL), in pregnancy, 315 Primary lesions, 227t Privacy, in home health care, 557 Projection, as defense mechanism, 411 Prolapsed cord, in the emergency department, 477 Prone positioning, 140, 142f Prostatectomy, 79 Prosthesis, 79 Protein, total, 191 Prothrombin time (pro time or PT), 191 Proximodistal, 356 Psoas sign, 470t Psyche, in postpartum assessment, 347 629 Index Pneumococcal immunization schedule recommended adult, 152 recommended pediatric, 385 revaccination, 155 vaccination, 154 Pneumonectomy, 79 Pneumonia, 296–297 transmission of, 161t Pneumonia, pneumococcal, incubation and isolation periods in, 167t Pneumothorax, Hamman’s crunch sign in, 469t POC See Plan of care (POC) Pocket vision screener, 237f Poisoning management, 467–468 Poison, inhaled, 468 Poliomyelitis incubation and isolation periods in, 167t transmission of, 161t Polypectomy, 79 Position, in labor and delivery, 316 Positioning dorsal recumbent, 138, 140f Fowler’s, 139, 140f knee-chest/genupectoral, 140, 141f lithotomy/dorsosacral, 140, 141f prone, 140, 142f Sims, 140, 142f supine, 140, 142f Trendelenburg (modified), 140,142f Trendelenburg’s, 140, 142f Postanesthesia recovery score (PARS), 79 Postoperative care, 140–143 Postpartum assessment and nursing considerations, 345–347 Post-traumatic stress syndrome, 421 Potassium (K+), 190 Potassium-rich foods, 582 Potts-Smith procedure, 79 Poultry, in DASH diet, 605 PPN See Peripheral parenteral nutrition (PPN) Pre-eclampsia, 314–315 Pregnancy See also Labor complications of abruptio placentae, 312 eclampsia, 312 gestational onset diabetes, 313 group B streptococcal infection, 314 HELLP syndrome, 314 placenta praevia, 313 pregnancy-induced hypertension, 314 preterm labor (PTL), 315 Index Copyright © 2004 F.A Davis Psychiatric drugs, 106–107t Psychoeducation, 425 Psychopharmacology, 425 Psychotherapy, 425 Psychotropic medications, monitoring for reactions to, 425–428 PTT See Partial thromboplastin time (PTT) Puerperal fever, streptococcal, incubation and isolation periods in, 167t Pulmonary artery diastolic pressure, adult norm for, 498 Pulmonary artery mean pressure, adult norm for, 498 Pulmonary artery systolic pressure, adult norm for, 498 Pulmonary capillary mean wedge pressure (PCW), adult norm for, 498 Pulmonary ventricular stroke, adult norm for, 498 Pulsations, in abdomen, 266 Pulseless electrical activity algorithm, 440–441 Pulses adult trauma score, 452t Doppler, 148 in health assessment, 148 rate, 148 rhythm, 148 sites, 259f volume, 148 Purpura lesion, 227t Pustule lesion, 227t PVST See Paroxysmal supraventricular tachycardia (PVST) Pyeloplasty, 79 Q QRST complex of electrocardiogram, 482f Quickening, as presumptive sign of pregnancy, 307 R Rabies, incubation and isolation periods in, 167t Raccoon eyes sign, 470t Radial keratotomy, 79 Radical, 80 Radical neck dissection, 80 Ramstedt-Fredet procedure, 80 Ranitidine, potential hazard of, 530, 531 Rapid plasma reagin (RPR), 191 Rashkind procedure, 80 630 Rationalization, as defense mechanism, 411 RDAs See Recommended dietary allowances (RDAs) RDS See Respiratory distress syndrome/hyaline membrane disease (RDS) Reaction formation, as defense mechanism, 411 Reactive airway disease See Asthma (reactive airway disease) Reality therapy, 425 Rebounding, as probable sign of pregnancy, 307 Reciprocal inhibition, 425 Recommended dietary allowances (RDAs), 567–571t Record, home health, 552–553 Red blood cell count (RBC) See Erythrocyte count distribution width (RDW), 193 indices, 191–192 Reduction, 80 Reflexes in adult assessment, 277 neonatal, 337, 340–341 Regression, as defense mechanism, 411 Relaxation therapy, 425 Renal calculi (kidney stones), therapeutic diet for, 601 Renal dialysis, therapeutic diet for, 601 Renal failure, 297–298, 601, 602 Report, nursing change-of-shift, 74–75 Reporting guidelines, 75 incident, in home health care, 557 Repression, as defense mechanism, 411 Reproductive system See also Labor; Pregnancy age-related changes in, and nursing implications, 515–517 female anterior view, 25f external genitalia, 24f functions and organs of, 28t male, 26t midsagittal section, 26f Resection, 80 Resection and pull through, 80 Respiration assessment character, 149–150 norms, 149 rate, 149, 452t Copyright © 2004 F.A Davis immunization doses, 153 immunization schedule, 385 incubation and isolation periods in, 168t transmission of, 159t vaccination, adult, 155–156 S Safety in health history, 218–219 home health, 556 in NANDA nursing diagnoses, 64 precautions for hospitalized infants and toddlers, 398 Salicylates, blood levels of, 104t Saline solutions, 113t, 114t Salmonellosis, incubation and isolation periods in, 168t Salpingo-oophorectomy, 80 Scabies, incubation and isolation periods in, 168t Scale lesion, 227t Scarlet fever, incubation and isolation periods in, 168t Scleral buckling, 80 Scrub nurse, 80 Secondary lesions, 227t Second degree (partial thickness) burns, 459–460 Section, 80 Seeds, in DASH diet, 605 Seizures documentation of, 455 emergency care of patients during, 455 SSRI use and, 427 Selenium, 576t Sensory cortex, in adult assessment, 277 Sensory system See also Ears; Eyes; Mouth; Nose in adult assessment, 276 age-related changes in, and nursing implications, 520–522 Sepsis, neonatal, 343 Septic shock, 457t Septoplasty, 80 Serotonin syndrome (SS), 427 Setup, chest tube, 126–128 Sexuality in health history, 219 in NANDA nursing diagnoses, 65 SGOT See Aspartate aminotransferase (AST or SGOT) SGPT See Alanine aminotransferase (ALT/SGPT) 631 Index rhythm, 149 volume, 149 disorders of, causes of, 473t in health history, 218 in NANDA nursing diagnoses, 63 variations with age, 375 Respiratory acidosis, 465t Respiratory alkalosis, 466t Respiratory distress syndrome/hyaline membrane disease (RDS), 298–299 in neonates, 344 Respiratory failure, Hamman’s crunch sign in, 469t Respiratory monitoring, 402 Respiratory system See also Lungs age-related changes in, and nursing implications, 510 anterior view of the upper and lower tracts, 13f functions and organs of, 28t microscopic view of alveoli and pulmonary capillaries, 13f monitoring of, in pediatrics, 402 Rest See also Activity in health history, 216 in NANDA nursing diagnoses, 57–58 Restitution, as defense mechanism, 411 Reticulocyte count, 193 Retina, of right eye, 10f Retroperitoneal hematoma, Grey Turner’s sign in, 469t Review of systems, 216–221 Rheumatoid factor (RF), 193 Rh incompatibility, 344 Rhinoplasty, 80 Rhizotomy, 80 Rhytidectomy (facelift), 80 Rib cage, 4f Riboflavin, 567t, 573t Right atrial mean pressure, adult norm for, 498 Right ventricular pressure, adult norm for, 498 Rigidity, neurologic conditions and, 454 Roman numerals, 84 Rooting reflex, 340 Rosenbaum pocket vision screener, 237f Rovsing’s sign, 470t RPR See Rapid plasma reagin (RPR) Rubella (German measles) adolescent and children immunization schedule, 385, 386 Index Copyright © 2004 F.A Davis Shirodkar’s procedure, 80 Shock in emergency and critical care, 456–457 signs in children, 401 Shoulder girdle, bones of, 5f Show, in labor and delivery, 316 Shunt, 80 Sickle cell anemia physical assessment in, 299–300 therapeutic diet for, 589 Sickle cell prep, 194 Sickledex, 194 Sims positioning, 140, 142f Sinus arrest/SA exit block, 486t Sinus bradycardia, 486t Sinus dysrhythmia, 486t Sinuses in health assessment, 231 paranasal, 233f Sinus tachycardia, 486t Sinus tachycardia /AV junctional tachycardia, 488t Skeletal system anterior view of skeleton, 3f functions and organs of, 27t Skin abdomen, in health assessment, 266 in health assessment, 224–226 changes in, as presumptive sign of pregnancy, 307 in newborn assessment, 332 Skull anterior view of, 233f fracture, Battle’s sign in, 468t lateral view of, 4f, 233f SMR (submucous resection of nasal septum) See Submucous resection of nasal septum (SMR) Snellen eye chart, 240 SOAP charting, 71–72 Soave procedure, 80 SOB, evaluation of, 471–472t Social interaction in health history, 219 in NANDA nursing diagnoses, 65–67 Sodium, 194, 580 Sodium-rich foods, 582 Spinal fusion, 80 Spinal instrumentation, 80 Spine, in health assessment, 271– 272 Splenic rupture, Kehr’s sign in, 469t Squint repair, 80 SS See Serotonin syndrome (SS) 632 Station(s) in labor and delivery, 316, 317f of the presenting part, 317f Stenosis, 80 Stepping reflex, 340 Streptococcal infection, group B, in pregnancy, 314 Streptococcal pharyngitis, transmission of, 161t Sublimation, as defense mechanism, 411 Submucous resection of nasal septum (SMR), 80 Sucking reflex, 341 Suicidal behavior, 419 Superior vena cava pressure (SVC), 498 Supine positioning, 140, 142f Suppression, as defense mechanism, 411 Supraventricular tachycardias, 487–488t Surgery terms, 75–81 therapeutic diet for, 602 Suspiciousness, 419–420 SVC See Superior vena cava pressure (SVC) SVO2 See Systemic venous oxygen saturation (SVO2) Swallowing reflex, 341 Sweets, in DASH diet, 606 Symbols, medical, 38–39 Sympathectomy, 80 Syphilis incubation and isolation periods in, 168t transmission of, 161t Syringe compatibility, 108–109 Systemic vascular resistance, adult norm for, 499 Systemic venous oxygen saturation (SVO2), 499 Systolic blood pressure adult trauma score, 452t variations with age for boys, 380–383t variations with age for girls, 376–379t T T & A, 80 Tachycardia defined, 321 narrow-complex, 446–447 overview algorithm, 444–445 Tardive dyskinesia (TD), 428 Copyright © 2004 F.A Davis Toxemia, in pregnancy, 314–315 Toxic shock syndrome, incubation and isolation periods in, 169t TPN See Total parenteral nutrition (TPN) Tracheal tear, Hamman’s crunch sign in, 469t Tracheostomy suctioning, 144–146 Trachoma incubation and isolation periods in, 169t transmission of, 162t Traction reflex, 341 Transition phase, in labor, 325–326t Transurethral resection (TUR, TURP), 81, 90 Trauma patient adult score, 452–453t predictable injuries in, 448–449t primary survey for, 437 secondary survey for, 437, 448 Trendelenburg (modified) positioning, 140, 142f Trendelenburg positioning, 140, 142f Trephination, 81 Triage See also Emergency and critical care basic emergency, 435 Tricyclics, potential hazard of, 530 Triglycerides, 195 Triiodothyronine RIA (T3), 195 Troponin I, 196 Troponin T, 195 Trousseau’s sign, 470t TSH See Thyroid stimulating hormone (TSH) Tube feeding continuous, 139 intermittent (bolus), 137–138 Tube insertion, nasogastric, 134–136, 136f Tuberculosis incubation and isolation periods in, 169t transmission of, 162t Tularemia, incubation and isolation periods in, 169t Tumor lesion, 227t TUR See Transurethral resection (TUR, TURP) TURP See Transurethral resection (TUR, TURP) Tylectomy, 81 Tympanic membrane (TM), 241, 242f 633 Index Teaching/learning in health history, 220 in NANDA nursing diagnoses, 67–68 Teeth, in health assessment, 244 Temperature assessment, 146–147 causes of abnormal, 473t equivalents, 86 norms, 147 Terminology for growth and development, 356 of home health care, 549 Terminology and symbols, 29–55 Terms for body parts and areas, 30–32t for labor and delivery, 316 surgical, defined, 75–81 Testes, 23t Tetanus adolescent and children immunization schedule, 385, 386 adult immunization schedule, 152 doses of, 154 incubation and isolation periods in, 169t prophylaxis, 462, 464 recommended immunization schedule, 464 wound classification, 462t Tetany Chvostek’s sign in, 469t Trousseau’s sign in, 470t Thiamin, 567t, 573t Third degree (full thickness) burns, 460 Thoracotomy, 81 Thorax, in health assessment, 248–252 Thyroid gland, 23t, 247 Thyroid stimulating hormone (TSH), 194 Thyroxine RIA (T4), 195 Time conversions, 89 Toddlers See also Children; Pediatrics cardiac murmurs in, 399 Glasgow Coma score for, 451t nasogastric tube insertion, 137 safety precautions for hospitalization, 397 Tongue, in health assessment, 245 Tonic neck reflex, 341 Torsades de pointes, 492t Total parenteral nutrition (TPN), 119–120 guidelines for administration, 120–121 Index Copyright © 2004 F.A Davis Tympanoplasty, 81 Typhoid fever incubation and isolation periods in, 170t transmission of, 162t Typhus fever, incubation and isolation periods in, 170t U Ulcerative colitis, therapeutic diet for, 602 Ulcer lesion, 227t Umbilicus, 264 Undoing, as defense mechanism, 411 UPJ repair, 81 Ureterolithotomy, 81 Ureteroneocystostomy, 81 Ureteropelvioplasty, 81 Uric acid, 196 Urinalysis (UA), 199–202 Urinary frequency increase, as presumptive sign of pregnancy, 307 Urinary retention, 541t Urinary system See also Genitourinary system functions and organs of, 28t organs of, 16f Urine foods that acidify, 583 foods that alkalinize, 584 Usual maintenance, of fluid, 391 Uterine changes, as probable sign of pregnancy, 307 V Vaginal changes, as presumptive sign of pregnancy, 307 Vagotomy, 81 Variability, 321–322 Varicella immunization doses, adult, 153 immunization schedule, pediatric, 385, 386 vaccination, adult, 156 Vasectomy, 81 Vegetables, in DASH diet, 604 Ventilation compression ratio, 436t Ventricular fibrillation, 492t Ventricular fibrillation/pulseless ventricular tachycardia (VF/VT) algorithm, 438–439 Ventricular idioventricular rhythm, 491t Ventricular tachycardia, 491t Vesicle lesion, 227t VF/VT algorithm See Ventricular fibrillation/pulseless ventricular tachycardia (VF/VT) algorithm 634 Violence, domestic See Domestic violence Visits, home health and, 551–552 Vital signs abnormal, causes of, 473–474t average heart rates for infants and children at rest, 374 blood pressure assessment, 150–151 causes of abnormal, 473–474t in newborn assessment, 331 norms, 147 in postpartum assessment, 345 pulse assessment, 148 respiration assessment, 148–150 temperature assessment, 146–147 timing of assessment, 146 Vitamin A, 572t, 580 Vitamin B1, 580 Vitamin B2, 580 Vitamin B6, 569–570t, 574t, 580 Vitamin B12, 569–570t, 574t, 580 Vitamin C, 581 Vitamin D, 572t, 585 Vitamin E, 572t, 581 Vitamin K, 581, 583 Vitamins fat soluble, 572t negative interactions between drugs and, 580–582 recommended dietary allowance, 567t water-soluble, 573t Vitrectomy, 81 Vomiting See also Dehydration as presumptive sign of pregnancy, 307 W Warfarin, potential hazard of, 530 Water-soluble vitamins, 573–574t, 574–575t Waterson shunt, 81 Web sites for contraindications to immunizations, 384 DASH eating plan, 603–606 NANDA, 57 Weight conversion table, for neonates, 338–339 equivalents, 85 growth chart for boys, from birth to 36 months, 363f growth chart for boys, from to 20 years, 365f Copyright © 2004 F.A Davis Women See also Female lactating, recommended dietary allowances for, 568t, 570t number of calories needed for, 565 pregnant, recommended dietary allowances for, 568t, 570t recommended fat-soluble vitamins for, 572t Word elements, and meaning, 32–37 Wound, tetanus-prone vs non–tetanus-prone, 463t Written documentation, 71–73 X Xenograft, 81 Z Zinc, 576t 635 Index growth chart for girls, from birth to 36 months, 363f growth chart for girls, from to 20 years, 366f Well-child assessment, 373 Wheal lesion, 227t Wheezing, evaluation on, 472–473t White blood cell count (WBCs or leukocytes), 197 White blood cell differential, 197 bands (stabs), 197 basophils, 198 eosinophils, 197 lymphocytes, 198 monocytes, 198 neutrophils (polys or segs), 198 Whooping cough, incubation and isolation periods in, 170t Withdrawn behavior, 420 Copyright © 2004 F.A Davis This page intentionally left blank Copyright © 2004 F.A Davis REFERENCE VALUES FOR LABORATORY TESTS—BLOOD OR SERUM (continued) Test Conventional Units SI Units Magnesium Adult: 1.4–2.4 mEq/L Child: 1.2–1.9 mEq/L 285–310 mOsm/Kg Adult: 2.5–4.5 mg/dL Child: 4–6 mg/dL Infant: 4.5–6.7 mg/dL 150,000–450,000/mm3 Adult: 3.5–5.0 mEq/L Child: 3.4–4.7 mEq/L Infant: 4.1–5.3 mEq/L Adult: 6–8 g/dL 15 yr: 6.5–8.6 g/dL yr: 5.0–7.5 g/dL Male: 4.6–6.2 million/mm3 Female: 4.2–5.4 million/mm3 Newborn: Up to 7.1 million/mm3 MCV Male: 80–94 μm3 Female: 81–99 μm3 Newborn: 96–108 μm3 MCH Male: 27–31 pg Female: 27–31 pg Newborn: 32–34 pg MCHC Male: 32–36% Female: 32–36% Newborn: 32–33% Adult: 135–145 mEq/L Infant: 134–150 mEq/L Adult: Ͻ10 mIU/mL By days old: Ͻ25 μIU/mL 0.61–1.03 mmol/L 0.65–1.07 mmol/L 280–300 mmol/kg 0.78–1.50 mmol/L 1.45–1.78 mmol/L 1.45–2.16 mmol/L Adult: 10–150 mg/dL 40–60 yr: 10–190 mg/dL Child: 10–140 mg/dL Ͻ2 yr: 5–40 mg/dL Male: 4.0–8.5 mg/dL Female: 2.7–7.3 mg/dL Child: 2.5–5.5 mg/dL Adult: 4300–10,800/mm3 1–10 yr: 5000–13,000/mm3 mo: 6000–16,000/mm3 Newborn: 9000–30,000/mm3 Neutrophils (polys or segs): 54–75% (lower up to age yr) Bands (stabs): 0–5% Eosinophils: 1–4% Basophils: 0–1% Lymphocytes: 25–40% (higher up to age yr) Monocytes: 2–8% 0.11–1.68 mmol/L 0.11–2.21 mmol/L 0.11–1.58 mmol/L 0.06–0.45 mmol/L 0.24–0.51 mmol/L 0.16–0.43 mmol/L 0.15–0.33 mmol/L 4.3–10.8 ϫ 109/L 5.0–13.0 ϫ 109/L 6.0–16.0 ϫ 109/L 9.0–30.0 ϫ 109/L 0.54–0.75 Osmolality Phosphorus Platelet count Potassium (K+) Protein, total Red blood cell count Red blood cell indices Sodium (Na+) Thyroidstimulating hormone (TSH) Triglycerides Uric acid White blood cell count White blood cell count differential 3.5–5.0 mmol/L 3.4–4.7 mmol/L 4.1–5.3 mmol/L 66–79 g/L 65–86 g/L 50–75 g/L 4.6–6.2 ϫ 1012/L 4.2–5.4 ϫ 1012/L 4.8–7.1 ϫ 1012/L 135–145 mmol/L 134–150 mmol/L Ͻ10 mU/L Ͻ25 mU/L 0.03–0.08 0.01–0.04 0–0.01 0.25–0.40 0.02–0.08 ... Davis Nurse’s Fast Facts: Your Quick Source for Core Clinical Content Copyright © 2004 F.A Davis This page intentionally left blank Copyright © 2004 F.A Davis Nurse’s Fast Facts: Your Quick Source. .. Congress Cataloging-in-Publication Data Holloway, Brenda Walters, 194 9Nurse’s fast facts : your quick source for core clinical content / Brenda Walters Holloway.—3rd ed p ; cm Includes index ISBN... © 2004 F.A Davis Nurse’s Fast Facts: Your Quick Source for Core Clinical Content Third Edition BRENDA WALTERS HOLLOWAY, CRNP, FNP, MSN Clinical Assistant Professor University of South Alabama