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RNotes®: Nurse's Clinical Pocket Guide
Mental Status Assessment
Table of Contents
Free Topics
Airway-Nasal and Oral
Apical-Radial Pulse
Blood Specimen-Finger Stick Blood Glucose (FSBG)
Calculator - APGAR Score - Calculator
Calculator - Body Surface Area (BSA) - Calculator
Ostomy Care
Post-Procedure Guidelines
Pre-Procedure Guidelines
Pulse Oximetry
Assess
Normal Range Vital Signs
Pain Assessment
Characteristics of Acute and Chronic Pain
Focused Assessment-OPQRST
Pain Assessment
Pain Scales-Faces Pain Rating Scale
Pain Scales-Faces Pain Rating Scale - Pain Scales-Flacc Pain Scale for Pediatric Patients
Pain Scales-Faces Pain Rating Scale - Spanish Numerical Pain Scale
Referred Pain
Physical Assessment
Abdominal Organs and Quadrants
Abdominal Organs and Quadrants - Cranial Nerves: Assessment
Abdominal Organs and Quadrants - Genitourinary Assessment
Abdominal Organs and Quadrants - Integumentary Assessment
Abdominal Organs and Quadrants - Musculoskeletal Assessment
Abdominal Organs and Quadrants - Neurological Assessment
Cardiac Auscultation Sites
Deep Venous Thrombosis (DVT)
Dermatomes
Dermatomes - Determining Responsiveness: Avpu Scale
Dermatomes - Glasgow Coma Scale
Different Approaches to Physical Assessment
Different Approaches to Physical Assessment - Cardiovascular Assessment
Different Approaches to Physical Assessment - Focused Symptom Analysis (OPQRST)
Edema Grading Scale
Edema Grading Scale - Gastrointestinal Assessment
Physical Assessment
Pupil Scale (mm)
Pupil Scale (mm) - Dehydration
Pupil Scale (mm) - Electrolyte Imbalance
Pupil Scale (mm) - Fluid and Electrolytes
Pupil Scale (mm) - Nutritional Assessment
Psychiatric-Mental Health Assessment
Areas Susceptible to Pressure Ulcers
Areas Susceptible to Pressure Ulcers - Pressure Ulcers
Auscultation of Lung Sounds
General Safety Guidelines
General Safety Guidelines - Mental Status Assessment
Pressure Ulcer Prevention Strategies
Psychiatric-Mental Health Assessment
Respiratory Patterns
Respiratory Patterns - Lung Sounds-Differential Diagnosis
Respiratory Patterns - Wound Assessment
Risk Factors for Development of Pressure Ulcers
Suicidal Patient
Suicidal Patient - Respiratory Assessment
Temperature
Assessment Overview
Factors that Affect Vital Signs
Health History
Temperature
Vital Sign Assessment
Life Span
Advanced Pediatric Life Support (PALS 2010)
Advanced Pediatric Life Support (PALS 2010)
Assessment of the Pediatric Patient
Bradycardia (HR less than 60 bpm)-Poor Perfusion
Cardiac Arrest
Cardiac Arrest - Pediatric Formulas (>1 Year)
Tachycardia-Poor Perfusion
Be Alert! Pain Assessment and Intervention
Be Alert! Pain Assessment and Intervention
Nonpharmacological Interventions for Pain
Signs and Symptoms by Developmental Stage
Be Alert! Respiratory Distress in Pediatrics
Be Alert! Respiratory Distress in Pediatrics
Developmental Milestones
Complications of Pregnancy
Bleeding: Placenta Abruptio
Bleeding: Placenta Abruptio Versus Placenta Previa
Bleeding: Placenta Previa
Blood Pressure (Elevated): Pre-eclampsia
Blood Pressure (Low): Supine Hypotensive Syndrome
Complications of Pregnancy
Gestational Diabetes
Hyperemesis Gravidarum
Dehydration in the Elderly
Dehydration in the Elderly
Delirium and Dementia in the Elderly
High Risk Factors for Dehydration
Nursing Interventions
Risk Factors
Signs and Symptoms
Delivery-Uncomplicated
Assisting During Delivery
Clinical Findings (Imminent Delivery)
Delivery-Uncomplicated
Delivery-with Complications
Breech Presentation
Cord Presentation (Prolapsed Cord)
Delivery-with Complications
Limb Presentation
Meconium-Stained Amniotic Fluid
Vaginal Bleeding
Depression and Suicide in the Elderly
Depression and Suicide in the Elderly
Fall Prevention
Fall Prevention - Pharmacokinetics in the Elderly
Nursing Interventions
Nursing Interventions - Eating Problems in the Elderly
Nursing Interventions - Fall Risk Assessment and Prevention
Signs of Suicidal Intent
Electronic Fetal Monitoring
Electronic Fetal Monitoring
Fetal Heart Rate (FHR)
Fetal Heart Rate Patterns
Variability (Cardiac Rhythm Irregularities)
Variability (Cardiac Rhythm Irregularities) - Early Deceleration
Variability (Cardiac Rhythm Irregularities) - Late Deceleration
Variability (Cardiac Rhythm Irregularities) - Variable Deceleration
Geriatric Patients
Age-Related Changes and Implications
Geriatric Patients
Health History
Health History
Immunization History
Immunization History - Injections (IM) for Pediatric Patients
Recurrent Childhood Illnesses
Mother: Postpartum Care and Assessment
Abdomen and Uterus
Breasts and Breastfeeding
Emotional Status
Lower Extremities
Mother: Postpartum Care and Assessment
Perineum
Perineum - Pediatric Quick Reference (Vitals-Equipment-Electricity)
Newborn: Initial Care and Assessment
ABCs, Temperature, and Vital Signs
APGAR Score
Identification and Infant Safety
Measurements
Newborn: Initial Care and Assessment
Physical Assessment
Physical Assessment - Routine Infant Reflexes
Routine Newborn Medication and Labs
Newborn-Emergency Drug Reference
Newborn-Emergency Drug Reference
Newborn-Equipment Size and Insertion Depth
OB Patients: Pregnancy-Newborn-Postpartum
Basic Terms Associated with Pregnancy
Due Date Prediction (nägeles Rule)
Fetal Development Timetable
Fundal Height Assessment
Hormones Associated with Pregnancy
Immunization During Pregnancy: 2013
Normal Changes Throughout Pregnancy
OB Patients: Pregnancy-Newborn-Postpartum
Weight Gain and Nutritional Requirements
Polypharmacy in the Elderly
Assessment and Prevention
Polypharmacy in the Elderly
Progression of Labor
Factors Affecting Progression of Labor (Four Ps)
Factors Affecting Progression of Labor (Four Ps) - Comparison of True and False Labor
Factors Affecting Progression of Labor (Four Ps) - Stages of Labor
Progression of Labor
Emerg Trauma
Cardiopulmonary Resuscitation (CPR) Maneuvers
Cardiopulmonary Resuscitation: 2010 Guidelines
Cardiopulmonary Resuscitation: 2010 Guidelines
Choking: 2010 Guidelines
Code Responses and Responsibilities
Defibrillation and Pacing
Automatic External Defibrillator (AED)
Automatic External Defibrillator (AED) - Electrode Size
Defibrillation and Pacing
Manual Defibrillation
Synchronized Electrical Cardioversion
Transcutaneous Pacing
Hazmat/Weapons of Mass Destruction (WMD)
Biological Agents
Chemical and Nerve Agents
General Hazmat Decontamination Guidelines
Hazmat/Weapons of Mass Destruction (WMD)
Medical Emergencies
Abdominal Pain
Allergic Reaction: Anaphylaxis
Altered Mental Status (AMS)
Bradycardia (ACLS)
Cardiac Arrest (ACLS)
Chest Pain
Diabetic Emergencies
Dizziness, Vasovagal Response, Syncope
Hypertension
Hypotension
Increasing Intracranial Pressure
Infection: Fever/Sirs/Sepsis
Initial Assessment and Intervention for All Pts
Medical Emergencies
Overdose (OD)
Postoperative Hemorrhage
Respiratory Distress
Seizure
Suicidal/Combative Patient
Tachycardia (ACLS)
Transfusion Reaction
Trauma-Assessment
Assessment-Primary Trauma Survey
Assessment-Secondary Trauma Survey
Indications for Spinal Immobilization
Special Considerations
Trauma-Assessment
Trauma-Basic Management
Abdominal Trauma
Chest Trauma
Chest Trauma - Chest Trauma-Comparing Different Types
Extremity Trauma
Extremity Trauma - Amputations
Head Trauma
Trauma-Basic Management
Traumatic Emergencies
Abuse
Bites and Stings
Burn Injury
Cold Injury-Frostbite
Drowning-Near Drowning-Submersion
High-Altitude Illness
Hyperthermia
Hypothermia
Traumatic Emergencies
Meds/IV/Fluids
Abbreviation Alert!
Abbreviation Alert!
Additional Abbreviations, Acronyms, and Symbols
Ampule
Formulas: Medication and Infusion Rates
Joint Commission Official âdo Not Useâ List: 2009
Administration Alerts!
Administration Alerts!
Always Remember! Assessment and Documentation
Always Remember! Critical General Points
Always Remember! Medication Right
Always Remember! Triple Check
IV Fluid Drip Rate Table (Drops/Min)*
Administration Routes
Administration Routes
Buccal-Transmucosal
Ears-Drops
Eyes-Drops or Ointment
Inhalation-Handheld Nebulizer
Inhalation-Metered Dose Inhaler
Injection
IV
Nasogastric-Gastric Tubes
Oral (PO)
Rectal (PR)
Sublingual
Topical
Transdermal Patch
Vaginal (PV)
Administration-Preparation
Administration-Preparation
Ampule
Vial
Vial - Formulas: Medication and Infusion Rates
Vial - IV Fluid Drip Rate Table (Drops/Min)*
High-Alert Medication Classes
Angle of Injection
High-Alert Medication Classes
Injections-Intradermal (ID)
Injections-Intramuscular (IM)
Injections-Intramuscular Landmarks
Injections-Intramuscular Z-Track Method
Injections-Subcutaneous (SC)
Injections-Subcutaneous (SC) - Anticoagulant Alert!
Injections-Subcutaneous (SC) - Insulin Alert!
Injections-Subcutaneous and Intradermal Sites
Specific High-Alert Medications
Specific High-Alert Medications - Injections
Insulin-Mixing Technique
Insulin-Mixing Technique
Insulin-Types
Intravenous (IV)-Access, Infusion, Maintenance
Access-Inserting A Peripheral IV or Saline Lock
Infusion-Continuous
Infusion-Intermittent IV Piggyback (IVPB)
Infusion-IV Push Medications
Intravenous (IV)-Access, Infusion, Maintenance
Maintenance-Flushing Peripheral and Central Lines
Routine Care of Peripheral and Central Lines
Supplies
Troubleshooting IV Complications
Intravenous Solution Types
Crystalloids
Intravenous Solution Types
Volume Expanders (Colloids)
Medication Errors
Medication Errors
Pregnancy Risk Categories
Prevention
Response
Vial
Formulas: Medication and Infusion Rates
IV Fluid Drip Rate Table (Drops/Min)*
Vial
LABS/ECG
12-Lead ECG
12-Lead ECG
12-Lead Placement-Chest and Limb Leads
Localizing Ischemiaon12-Lead
Sample ECG Rhythms
Basic Chemistry and Electrolytes
Basic ECG Interpretation
Basic ECG Interpretation
Cardiac Anatomy and Conduction
ECG Components
Lead Placement-Standard Three- and Five-Wire
Blood Gas Analysis
Diseases & Patient ED
Diseases and Disorders
Alzheimers Disease (AD)
Asthma
Cancer: General Overview
Chronic Obstructive Pulmonary Disease (COPD)
Common Types of Cancers
Congestive Heart Failure (CHF)
Coronary Artery Disease (CAD)
Crohns Disease
Diabetes Mellitus (DM)
Diseases and Disorders
Food and Dietary Considerations
Hypertension (HTN)
Irritable Bowel Syndrome (IBS)
Multiple Sclerosis (MS)
Pancreatitis
Peripheral Vascular Disease (PVD)
Renal Failure: Chronic (CRF)
Testicular Self-Examination (TSE)
Urinary Incontinence
Tools/Index
Common Formulas and Equivalents
Body Surface Area (BSA) Formula
Common Equivalents
Common Formulas and Equivalents
Common Standard-to-Metric Formulas
Conversions: Standard-to-Metric
Waist-to-Hip Ratio
Cultural Diversity in Health Care
American Indian
Arab Heritage
Asian Heritage
Bosnian Heritage
Cuban Heritage
Cultural Diversity in Health Care
English-to-Spanish Translation
Filipino Heritage
Haitian Heritage
Mexican Heritage
Puerto Rican Heritage
Russian Heritage
Select References
Symbols and Abbreviations
Web Resources
Procedure
Airway-Maneuvers for Opening
Airway-Maneuvers for Opening
Head-Tilt, Chin-Lift
Jaw-Thrust
Airway-Nasal and Oral
Airway-Nasal and Oral
Nasopharyngeal Airway (NPA)
Oropharyngeal Airway (OPA)
Antiembolic Devices
Antiembolic Devices
Elastic Stockings (TED Hose)
Procedure
Apical-Radial Pulse
Apical-Radial Pulse
Apical-Radial Pulse Deficit (If Present)
Aspiration Precautions
Aspiration Precautions
General Guidelines
Signs of Dysphagia
Assistive Devices
Assistive Devices
Canes
Crutches
Walkers-Avoid UsingonStairs
Bladder Irrigation, Continuous (CBI)
Bladder Irrigation, Continuous (CBI)
Procedure
Setup
Bladder Scanner
Bladder Scanner
Indications
Procedure
Blood Administration
Blood Administration
Procedure
Procedure - Blood Products
Supplies
Blood Specimen-Arterial Blood Gas
Blood Specimen-Arterial Blood Gas
Procedure
Supplies
Blood Specimen-Finger Stick Blood Glucose (FSBG)
Blood Specimen-Finger Stick Blood Glucose (FSBG)
Procedure
Supplies
Blood Specimen-Venous Sample
Blood Specimen-Venous Sample
Procedure
Procedure - Order of Lab Draw
Supplies
Chest Tubes
Chest Tubes
Insertion
Removal
Setup of Closed Chest Drainage System
Troubleshooting
Cold Therapy
Cold Therapy
Electric Pump Cooling Device
Ice Bag or Pack
Supplies
Dressing Change-Sterile
Dressing Change-Sterile
Procedure
Supplies
Dressings
Application Techniques
Dressing Types
Dressings
Nasogastric (NG) Tube
Confirming Proper Placement of NG Tube
Insertion of NG Tube
Nasogastric (NG) Tube
Oral Care-Unconscious or Debilitated Patient
Removal of NG Tube
Ostomy Care
Applying or Changing An Ostomy Bag
Ostomy Care
Oxygen Administration
Types of Ostomies
Post-Procedure Guidelines
Pre-Procedure Guidelines
Pulse Oximetry
Conditions that May Produce False Readings
Pulse Oximetry
Restraints
Alternatives to Restraints
Common Reasons for Using Restraints
Laws Pertaining to Restraints
Restraints
Safety Guidelines
SBAR-Communication Technique
Types of Restraints
Sputum/Throat Culture
Expectorated Specimens
General Guidelines
Sputum/Throat Culture
Suctioned Specimens (Sputum Trap)
Throat Culture
Standard Precautions
Hand Hygiene
Personal Protective Equipment (PPE)
Removing Soiled Gloves
Sharps-Linen-Refuse-Equipment
Standard Precautions
Transmission-Based Precautions
Stool-Specimen Collection
Cysts and Spores-Ova and Parasites
Occult Blood (Hemoccult, Guaiac)
Stool-Specimen Collection
Suctioning
Closed System-Ventilated Patient
Nasopharyngeal/Oropharyngeal
Suctioning
Tracheostomy Care
Cleaning
Dislodgement
Supplies
Tracheostomy Care
Tube Feedings
Administering Feedings
Checking Residuals
Checking Residuals - Nclex Tube Feeding-Complications
Tube Feedings
Urinary Catheter-Insertion
Condom Catheter Application
Indwelling and Straight Catheters
Urinary Catheter-Insertion
Urinary Catheter-Removal
Urine-Specimen Collection
Catheterized Patients
Clean-Catch (Midstream)
First Morning
Random
Second Void
Timed (24-Hour Urine)
Urine-Specimen Collection
Ventilators-Patient in Distress
Ventilated Patient in Respiratory Distress
Ventilators-Patient in Distress
Wound Culture
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