Techytechy

This is the second set of the most important Nursing grades or scales that every medical practitioner and aspiring nurse should know in his or her studies. With this, your Nursing life will become a lot clearer, not to mention, a lot easier. By simply knowing these scales or grades by heart, these will place you way ahead of your colleagues. These grading system are not only used at school but also during the actual work experience in the hospitals and other related areas. So nurses and friends, hope you enjoy reading the material below: 

• APGAR Score

a. heart rate

    0      absent

    1      <100bpm

    2      >100bpm

b. respiratory effort

     0     absent

     1     slow, weak cry

     2     good, strong cry

c. muscle tone

     0     flaccid

     1     some flexion

     2     well flexed extremities

d. reflex irritability

     0     no response

     1     grimace

     2     cough/sneeze/cry

e. color

     0     blue/pale

     1     acrocyanotic

     2     completely pink

­Thus, if:

   0-4 grave condition

   5-7 needs intensive care

   7and above NB doing well

• Urinalysis  (albumin test using acetic acid)

            negative      – no albumin

            trace             - mildly clear to liquid opaque

            + to ++        – frankly cloudy

            +++              – white like an egg white

• Urinalysis (sugar test using Benedict’s solution)

              Negative   - no change in color

              Trace          - blue green

              1+ to 2+     - yellow green

              3+ to 4+     – orange yellow

• Pain Rating Scale

            1-3       - mild

            4-7       - moderate

            8-10     - severe

• Breast Cancer Staging

            Stage 1             less than 2cm, confined in the breast

            Stage 2             up to 5cm, axillary spread

            Stage 3             greater than 5cm, chest spread

            Stage 4             distant metastasis

• Placental Grading by Ultrasound (UTZ)

             0     =    12-24 weeks

             1     =     30-32 weeks

             2     =     36 weeks

             3     =     38 weeks

• Ankle clonus in eclampsia

     Mild             = 2 movements

     Moderate   = 3-5 movements

     Severe        = over 6 movements

• Age of Gestation (AOG) with fundal height monitoring

        -   Fundal height at symphysis pubis =12th week gestation

        -   Midway between symphysis pubis & umbilicus = 16^th wk. gestation

        -   At the umbilicus = 20^th wk.

        -   At the xyphoid process = 36^th wk.

• Stress test (Oxytocin Challenge Test)

             (+) / (+) window / late deceleration / Abnormal

             (-) / (-) window / no deceleration / Normal

• Kick Counts

            (+) / Normal / 3 or more movements in 1 hour

            (-) / AbN°/2 or more movements in 1 hour

• Classification of perineal laceration

           1^st degree      laceration at the perineal skin

           2^nd degree     at the muscle of perineum

           3^rd degree      rectal sphincter

           4^th degree      lumen of the rectum