EKG *a = awake VITAL SIGNS *s = sleeping

QRS COMPLEX Age Resp Rate Heart Rate Systolic BP Diastolic BP

Neonate a 100-205
P Wave: 0.08-0.1 sec 30-50 60-80 35-55
1-28 days s 90-160
PR Interval: 0.12-0.2 sec
Infant a 100-190
QRS: 0.06-01 sec 1-12 mos
25-40 80-160 50-70
PR SEGMENT ST SEGMENT s 90-160
QTC Interval: 0.33-0.47 sec
P Toddler a 98-140
T 20-30 90-105 55-70
0.04 sec 1-3 yrs s 80-120
Preschooler a 80-120
0.2 sec 20-30 95-110 60-75
PR INTERVAL Q 3-5 yrs s 65-100
S
School Age a 75-118
QT INTERVAL 20-24 100-120 60-75
*QT: Varies with HR, <1/2 of the R-R interval 6-12 yrs s 58-90
Adolescent/ a 60-100 110-120 65-80
EKG INTERPRETATION 12-20
Adult >13 yrs s 50-90 Elevated: 120-129

Normal rhythm Stage I HTN 130-139 80-89

Stage II HTN >140 >90
Premature ventricular beat Gauge
Color Recommended Uses
Size
Paroxysmal supraventricular tachycardia (PSVT) 14G Trauma, rapid blood trasfusion, surgery
Orange

Atrial fibrillation Rapid fluid replacement, trauma,

16G
Gray rapid blood transfusion
Atrial flutter Rapid fluid replacement, trauma,
18G
Green rapid blood transfusion
Atrial flutter with 1:1 AV conduction Most infusions, rapid fluid replacement,
20G
Pink trauma, routine blood transfusion
Atrial flutter with variable AV conduction Most infusions neonate, pediatric,
22G
Blue elderly, routine blood transfusion
Most infusions neonate, pediatric,
Torsades de pointes Yellow 24G routine blood transfusion,
neonate or pediatric blood transfusion

Premature atrial contraction 26G Neonate

Purple

Sinus bradycardia NORMAL LIVER FUNCTION TEST (LFT’s) LAB NORMAL

ALT 7 to 55 U/L
Sinus tachycardia CHEMISTRY
AST 8 to 48 U/L
ALP 45 to 115 U/L Na 135 - 145 meq/L
Monomorphic ventricular tachycardia Albumin 3.5 to 5.0 g/dL K 3.5 - 5 meq/L
Total protein 6.3 to 7.9 g/dL
Cl 96 - 108 meq/L
Ventricular fibrillation Bilirubin 0.1 to 1.2 mg/dL
GGT 9 to 48 U/L CO2 22-29 meq/L

LD 122 to 222 U/L BUN 7 - 20 mg/dL

Ventricular tachycardia
PT 9.5 to 13.8 seconds Cr 0.7 - 1.4 mg/dL
HEIGHT Glu 70 - 115 mg/dL
Inches 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 CBC
Feet/Inches 4’10” 4’11” 5’0” 5’1” 5’2” 5’3” 5’4” 5’5” 5’6” 5’7” 5’8” 5’9” 5’10” 5’11” 6’0” 6’1” 6’2” 6’3” 6’4” 6’5” 6’6” 6’7” 6’8”
WBC 4,500 - 11,000
WEIGHT PLT 140,000 - 450,000
Lb 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 190 200 210 225 250 275 300
RCB Male: 4.5 - 5.5
kg 18.2 22.7 27.3 31.8 36.4 40.9 45.5 50.0 54.5 59.1 63.6 68.2 72.7 77.3 81.8 86.4 90.9 95.5 102.3 113.6 125.0 136.4 Female: 4 - 4.9

TEMPERATURE Male: 13.5 - 16.5

Hgb
Female: 12 - 15
F 32 90 91 92 93 94 95 96 97 98 98.6 99 100 101 102 103 104 105 106 107 108 212
Male: 41 - 50
HCT
C 0 32.1 32.8 33.3 34 34.4 35 35.6 36.1 36.7 37 37.2 37.8 38.3 38.9 39.4 40.0 40.6 41.1 41.6 42.2 100 Female: 36 - 44

CONVERSIONS PAIN ASSESSMENT TOOL

C* 9/5+32=F 1 kg = 1000 g 0 1 2 3 4 5 6 7 8 9 10
(F-32)*5/9=C 1 kg = 2.2 lb
No Pain Mild pain Moderate Pain Serious Pain Severe Pain Worst Pain Possible
lb/2.2=kg 1 mg = 1,000 mcg
kg*2.2=lb 1 oz = 30 ml
www.Tribe-RN.com These charts are for reference only.
Tribe RN is not responsible for any decisions made based
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2 mm 3 mm 4 mm 5 mm 6 mm 8 mm 10 mm 12 mm
 NORMAL BLOOD GAS VALUES INTERPRETING ABNORMAL BLOOD GAS RESULTS
Arterial Venous pH HCO3 CO2 Possible Causes
Diabetes/DKA, Addison’s, Liver/Renal Failure, Diarrhea,
pH 7.35-7.45 7.31-7.41 Metabolic Acidosis Toxins/Drugs, Ethylene Glycol
PaCO2/PCO2 35-45 mmHg 41-51 mmHg Vomiting, Diuretics, Antacids Use, Cushing’s, Administering
Metabolic Alkalosis Alkaline Solutions, Continuous Suctioning of Gastric Contents
HCO3 22-28 meq/L 23-29 meq/L
Obstruction, Pneumonia, Over Sedation, Paralysis, Increased
Respiratory Acidosis
pO2 80-100 mmHg 30-40 mmHg Metabolism, CNS Depression

Respiratory Alkalosis Anemia, CHF, Over Mechanical Ventilation, Increased

O2 Sat >95% 60-80%
Respiratory Rate/Depth, Fever
SHOCK
BP HR CO Pulse Pressure SVR CAP Refill CVP UOP Assessment

Hypovolemia Narrow Poor Weak thready pulse, cool, pale

Nml/
Cardiogenic Narrow Poor Weak thready pulse, cool, pale, tachypnea, crackles
Nml/
Neurogenic Nml to Wide Nml Warm dry skin, vasodilation, loss of sympathetic tone
Skin reactions, throat swelling, Dyspnea, pruritus, urticarial, restlessness,
Anaphylactic Narrow Nml
decreased LOC, bounding pulses
Nml/ Nml/
Early Sepsis Nml to Wide Nml Varies Nml Bounding pluses, tachypnea, flushed skin, fever, alkalosis
Late Sepsis Narrow Poor Weak pulse, cool, difficulty breathing, acidosis, decreased LOC

BLOOD PRODUCT TRANSFUSIONS - ADULTS

Product Suggested flow rate Considerations
1st 15 min: 60-120 ml/hr After 15 min: 240 ml/hr Infusions must not exceed 4hrs
PRBC’s Active hemorrhage: infuse as rapidly as possible For pt’s at risk for fluid overload, 1ml/kg/hr Use filter in line – 170-260 microns
1st 5 min: 120-300 ml/hr Generally given over 1 hr. Do not exceed 4 hrs.
Platelets Active hemorrhage: infuse as rapidly as possible After 1st 5 min: 300 ml/hr Use filter in line – 170-260 microns
1st 5 min: 120-300 ml/hr
Plasma Active hemorrhage: infuse as rapidly as possible After 1st 5 min: 300 ml/hr Use filter in line – 170-260 microns

Cryoprecipitate As rapidly as tolerated Use filter in line – 170-260 microns BASIC ASSESSMENT
If reaction is suspected: Neuro: Pupils, Orientation, Speech,
Monitor closely for VS/assessment changes
in the first 5-15 minutes of infusion. Stop the transfusion Cardiac: Vein distention, auscultate heart,
Normal Vital sign changes Keep line open with saline assess pulses and perfusion.
All products Temp +/- 0.5 C Call the physician and blood bank Respiratory: Ears, Nose, Throat, auscultate
RR +/- 5 bpm lung sounds, inspect chest rise/rate.
Document pt’s symptoms
HR +/- 10 bpm Inspect, auscultate, palpate 4 quadrants.
BP +/- 20 mmHg Send patient's labs and return blood Palpate/percuss liver. Palpate stomach/
product to the lab
GI/GU:
bladder. Assess bowel/bladder elimination.
Nutritional status.
MEDICATION MATH MADE SIMPLE
Skin/ Color/appearance, intact w/o wounds, rashes,
Desired Dose Musculoskeletal: lesions, erythema. ROM. Turn and reposition.
Quantity or Concentration = Dose
Available Dose GLASGOW COMA SCALE
PRESSURE ULCER CLASSIFICATION Behavior Response Score
Staging Description Spontaneously 4
1 Non-blanchable erythema/purple hue of skin changes in temperature and sensation Eye opening To speech 3
response To pain 2
2 Partial-thickness skin loss (i.e. blister or shallow crater) No response 1
3 Full-thickness skin loss involving necrosis of subcutaneous tissue Oriented to time, place, and person 5
4 Full-thickness skin loss with extensive necrosis to tendon, muscle, bone, or joint Confused 4
Best verbal
Inappropriate words 3
Unstageable Ulcer with eschar. Wound base cannot be assessed response
Incomprehensible sounds 2
Purple non-blanchable area of intact skin that demarcates between 24-48 hours due to deep No response 1
DTI
tissue destruction Obeys commands 6
Stages 1 2 3 4 Moves to localized pain 5
Best motor Flexion withdrawal from pain 4
Skin response Abnormal flexion (decorticate) 3
Abnormal extension (decerebrate) 2
Fat No response 1
________
Muscle Best response 15
Total score: Comatose patient 8 or less
Bones Totally unresponsive 3

Time HR RR BP Temp Sat I Tubes

O2 O