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NURSING REFERENCE CLIPBOARD

C L I P B OA R D P R I C E S :WITH CALCULATOR: $21.9525+ ..................$18.95 per clipboard50+ ..................$16.95 per clipboard

WITHOUT CALCULATOR: $18.9525+ ..................$15.95 per clipboard50+ ..................$13.95 per clipboard

STORAGE TRAY: $8.00FREE laminated sheet included with every clipboardoutlining common healthcare abbreviations,documentation tips, unsafe abbreviations andpatient care planning, a $9.00 value.

SHIPPING CHARGES: Please add the followingamounts to your order for shipping charges:1 - 5 ..................$2.50 per clipboard6 - 24 ................$1.25 per clipboard25+ ....................$0.75 per clipboardFor trays in any quantity, add $0.75

Q U ES T ION S ? Contact us at:Clipboards by Kwik KlipPhone: 800-653-7017 Fax: 954-212-2411 E-mail: clipboards@earthlink.net Website: www.clipboards.org

C O M P R E H E N S I V E N U R S I N GC L I P B O A R D I N C L U D E S :• Calculator with calendar and clock including second hand function.

• Cardiovascular assessment information including EKG intervals, heartsounds, hemodynamic norms and calculations, pulse scale, edemascale, murmur scale.

• Integumentary assessment information including skin breakdown areas, skinintegrity scale and descriptors for skin temperature, moisture and color.

• Elimination assessment information including urinalysis values anddescriptors 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, glasgowcoma scale, descriptors for pupil reaction, motor response, behaviorand level of consciousness.

• Respiration assessment information including common respiratory patterns,breath sound assessment, descriptors for breath quality, rate, sputumand cough.

• IV infusion information including IV infusion rate calculation, hourlydosage IV flow chart, multiple hour IV dosage flow chart.

• Injection information for needle length, gauge, maximum volume andinsertion degree.

• Normals for serum electrolytes, arterial blood gases, complete bloodcount, 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.

Copyright © 2006Kwik Klip Enterprises, all rights reserved.2901 Ellsworth Road, Nortonville, KS 66060Phone 800-653-7017 ● FAX 954-212-2411email clipboards@earthlink.netORDER ONLINE AT www.clipboards.org

PAIN INTENSITY SCALE

No Pain Worst Pain Possible

01

23

45

67

89

1011

12

01

23

45

67

89

1011

1213

1516

1718

2021

2224

2526

2728

2930

3114

1923

CARDIOVASCULAR HEART SOUNDS■ Distinct ■ Murmur ■ Rub■ Distant ■ Extra Sounds■ Muffled ■ Gallop PULSES 0 Absent+1 Weak, Thready+2 Normal+3 Strong+4 Bounding MUMUR SCALEI/VI Barely audibleII/VI Audible, low intensityIII/VI Immediately audible, mod intensityIV/VI Loud intensity without thrillV/VI Loud intensity with thrillVI/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

INTEGUMENTARY SKIN TEMP.■ Warm ■ Hot■ Cool ■ Cold

SKIN MOISTURE■ Clammy ■ Dry■ Diaphoretic ■ Moist

TURGOR■ Elastic ■ Firm■ Fragile ■ Edema

SKIN COLOR■ Ashen ■ Ruddy■ Dusky ■ Mottled■ Pale ■ Cyanotic■ Pink ■ Flushed■ Jaundiced

SKIN INTEGRITY

I ReddenedII Broken skin, superficialIII Crater, involves fat layerIV Crater, involves muscle & bone

BREAKDOWN AREAS■ Hip bones, tailbone, ischium■ Knees, heels, ankles, toes■ Spine, shoulder blades, elbows■ Ears, side/back of head

ELIMINATION URINE COLOR■ Yellow ■ Amber■ Milky ■ Tea■ Straw ■ Pink■ Red

URINARY FUNCTION■ Frequency ■ Urgency■ Polyuria ■ Dysuria■ Hematuria ■ Nocturia■ Calculi ■ Retention■ Incontinence

BOWEL SOUNDS

+ Present0 Absent� Hyperactive� Hypoactive

BOWEL PATTERNS■ Regular■ Constipation■ Diarrhea■ Impaction

ABDOMEN■ Firm ■ Soft■ Rigid ■ Tender■ Flat ■ Distended

NEUROLOGICAL PUPIL SCALE (mm)

PUPIL REACTION± Sluggish+ Reactive– Non-Reactive(PERRLA) pupils equal, round,reactive to light, accomodation normal

MOTOR RESPONSE■ Obeys commands■ Localizes pain■ Withdraws to pain■ No motor response LEVEL OF CONSCIOUSNESS (LOC)

A AlertV Voice ResponseP Pain ResponseU Unresponsive BEHAVIOR■ Agitated ■ Calm ■ Restless■ Anxious ■ Withdrawn

51 2 3 4

876

RESPIRATION QUALITY■ WNL■ Deep■ Shallow■ Labored■ Unlabored SOUNDS■ Clear■ Cough■ Moist RATE■ WNL■ Slow■ Rapid SPUTUM■ Clear■ White■ Yellow■ Green■ Frothy■ Brown■ Blood - tinged COUGH QUALITYP ProductiveN NonproductiveW WeakS Strong

EYESOPEN

None

To Pain

To Command

Spontaneously

None

Unintelligible

Inappropriate

Disoriented

Oriented

None

Extension Posture

Flexion Posture

Flexion & Withdrawl

Localizes Pain

Obeys Commands

VERBALRESPONSE

MOTORRESPONSE+ +

1

2

3

4

5

6

GLASGOW COMA SCALE

LOCATION

BREATH SOUNDS

DESCRIPTION

Bronchial

Vesicular

Broncho-vesicular

[Trachea] Loud, high pitched & harsh;expiration > inspiration

[Lung periphery] Soft, swishing, breezy, lowpitched; inspiration > expiration

[Main stem-bronchi] Soft, blowing, mediumpitched; inspiration = expiration

[Anywhere] High pitched musical squeaks

[Central airways] Bubbling, rumbling sound

[Lateral lung field; client in upright position]Grating, creaking or squeaking sound

[Anywhere; usually during inspiration]Soft crackling, popping, or bubbling sound

Wheezes

Rhonchi

Pleuralfriction rub

Rales

NO

RM

AL

AB

NO

RM

AL

DAILY PATIENT ASSESSMENT INFORMATION

EupneaNormal rate and rhythm

TachypneaRapid respirations; Rate rises 4 bpm for every degree > thannormal body temp.

BradypneaSlow regular respirations [< 12 bpm]

HyperpneaDeep respirations at normal rate

Kussmaul’sFast [> 20 bpm], deep [sigh like], labored respirationswithout pause

ApneusticProlonged gasping inspiration followed by very short & ineffecientexpiration

Cheyne-StokesFast deep respirations [30-170 secs] with periods of apnea[20-60 secs]

ApneaAbsence of breathing

COMMON RESPIRATORY PATTERNS#1

2

3

4

5

6

7

8

9

10

11

12

FUNCTIONSmell

Vision

Eye Movement,Pupil Dilation

Eye Movement

Chewing, sensation in faceand head

Eye Movement

Taste, facial movement

Hearing, balance

Taste, gag, swallow,saliva secretion

Sensory, motor, autonomiccontrol of viscera

Head and shoulder movement

Tongue movement

NAMEOlfactory

Optic

Oculomotor

Trochlear

Trigeminal

Abducens

Facial

Vestibulocochlear

Glossopharyngeal

Vagus

Spinal Accessory

Hypoglossal

CRANIAL NERVES

This Clipboard serves as a reference guide only andshould not be relied on in providing medical care. KwikKlip Enterprises is not responsible for the use of thisinformation in the provision of medical care.

AMOUNT TO ADMINISTER

MD order: Digoxin 0.25 mgDrug available: Digoxin0.125 mg per tabletD=0.25 H=0.125X=2 tablets

MD order: Dilantin 50 mgDrug available: Dilantin125 mg/5mlD=50 H=125Q=5 X=2 ml

D = MD order H= Dose on handQ = Amt of liquidX = Amt of medication to administer

PILLS

LIQUID

D____H

= X

D____H

x Q = X

IV INFUSION RATE CALCULATIONTotal Volume (ml) x IV Drip Factor = Drip Rate (gtts/min)

Time (mins)

Below 18.5 Underweight18.5 - 24.9 Normal25.0 - 29.9 OverweightAbove 30 Obese

BMI WEIGHT MANAGEMENT

BMI = Weight (kg) / (Height (m) x Height (m))

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Mail order form to Clipboards by Kwik Klip, 2901 Ellsworth Road, Nortonville KS, 66060, or FAX to 954-212-2411

ORDER FORM

2006EDITION

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 thestandard clip as well as the calculator clipboards, at$8.00 plus $0.75 shipping for each tray in any quantity.