clinical readiness test Flashcards
normal ranges:
-temperature: 97.6-99.6
-pulse: 60-100
-respiratory rate: 12-20
-blood pressure: systolic 90-120, diastolic 60-80
-O2 saturation: 95-100 (ideal)
-blood glucose: 70-100
different levels of BP:
Pre-HTN = 120-139 / 80-89
Stage 1 = 140-159/90-99
Stage 2 = >160/>100
PERRLA:
Pupils Equal, Round, React to Light, and Accommodation
abnormal breath sounds:
-rales: crackling sounds in the lungs that occur when you inhale
-rhonchi: low-pitched sounds that resemble snoring and are usually heard when you exhale
-stridor: high pitch inspiration crowing sound caused by upper airway obstruction louder over the neck than the chest wall
-crackle: abnormal discontinuous adventicious lung sound heard on inspiration
-wheeze: high pitch musical squeaking adventicious lung sound also used with low pitched adventicious sounds
anatomical location of heart sounds: aortic, pulmonic, tricuspid, mitral, and ERBs point
-Second right interspace: aortic valve area
-Second left interspace: pulmonic valve area
-Left lower sternal border: tricuspid valve area
-Fifth interspace at around left midclavicular line: mitral valve area
-ERBs point is left of the sternum at the third intercostal space
(APE to man)
capillary refill and normal
a simple test that measures how long it takes for color to return to the skin after pressure is applied, < 3 seconds
minimum urine output to perfuse for organs:
30 ml/hr
abbreviations:
PRN – as needed
AC = before meals
HS = at bedtime (hours of sleep)
LPM = liters per minute
ROM = range of motion
OOB = out of bed
t or tsp = teaspoon
T or tbsp = tablespoon
nasogastric tube used for:
to decompress (drain) the stomach, to administer tube feedings (enteral feedings)
urinary catheter:
to monitor fluid status (primary reason in acute care), to treat urinary retention, to manage urinary incontinence when affecting the integumentary
system
JP drain:
to drain excess fluid from a wound bed, to prevent hematoma or seroma
chest tube:
To drain air and fluid from the pleural cavity secondary to
pneumo/hemothorax or lung surgery
tracheostomy tube:
to create an artificial airway secondary to upper airway obstruction or weak respiratory drive requiring assistive
ventilation
intake and output:
-abbreviated as I&O
-used to monitor fluids consumed, injected, and excreted
-includes intake of “pseudo” solids that become liquid at
room temperature—Jell-O, popsicles
-includes liquids that exit the body—diarrhea, urine, vomitus, gastric suction, chest drainage, etc.
-preferred method is milliliters (mL) NOT cc
-may require conversion—household to metric
-recorded during the hour within which the fluid is consumed, injected, or excreted
-totaled for each shift, then totaled for 24 hour period
calculating intake and output:
-I&O record usually has key for conversions (e.g., 6 oz coffee cup = 180 mL)
-after conversions, items are added for totals:
1/3 glass apple juice (1 glass = 6 oz) = 60 mL
1/2 cup coffee (1 cup = 8 oz) = 120 mL
1/2 pint milk (1 pint = 500 mL) = 250 mL
blood count normal levels:
-red blood cell: Male: 4.5-5.5
Female: 4.1-5.1
-hemoglobin: Male: 14-18
Female: 12-16
-hematrocrat: Male: 42%-52%
Female: 36%-46%
-platelet: 150,000-450,000
-white blood count: 4,500-11,000
other normal lab results:
-potassium: 3.5-5
-sodium: 135-145
-glucose (blood sugar): 70-100
(fasting for non-diabetic adult)
-calcium (Ca) 8.2-10.2
-ionized calcium 4.5-5.5
-blood urea nitrogen (BUN): 8-21
-creatinine Female: 0.5-1.1
Male: 0.6-1.2
-albumin (Alb) 3.4-4.8 (decreased malnutrition)
-BNP <100 (often associated with heart failure)
-carbon dioxide (CO2): 22-26 Note: a venous sample is used mainly to evaluate acid-base balance. It is not the same as an arterial sample for an ABG
coagulation levels:
-PTT – partial thromboplastin
time (used to monitor heparin therapy): 25-35 seconds
-PT - prothrombin time: 10-13 seconds
-INR – international normalized ratio: < 2
minimum output for adult should be over:
30 mL or more, find average, add up total urine and divide by number of hours being recorded
order of health assessment:
inspection, palpation, percussion, auscultation
cardiac marker for MI:
Troponin I Normal: < 0.3
urine:
-Urine Specific Gravity: 1.005-1.030
-pale yellow color
-ph: 5-9
REVIEW HEALTH ASSESSMENT:
You have to know how to correctly do a health assessment on a patient (stethoscope placement for lungs, heart, abdomen, order of assessment, lung sounds, etc.) If you do not remember these, you need to review from health assessment. There will be MULTPILE
assessment questions on the clinical readiness test
