Mark Klimek Lectures 1 To 12 Nursing Notes And Audios

Mark Klimek Lectures 1 To 12 Nursing Notes And Audios

Page 1 of 92

Lecture 1— Acid-Base Balance

Ventilators

Lecture 2— Alcohol

Wernicke

Overdose and Withdrawal

S/Sx

Aminoglycosides

Peak and Trough

Lecture 3— Drug Toxicities (Lithium,

Lanoxin, Dilantin, Bilirubin,

Aminophylline)

Kernicterus

Dumping/HH

Electrolytes: K+, CA, MG,

and NA

TX for HyperKalemia

Lecture 4— Crutches

Canes

Walkers

Delusions

Hallucinations

Psychosis

Psychotic and Non-Psychotic

Hallucination

Illusion

Delusion

Lecture 5— Diabetes Mellitus

Diabetes Insipidus

SIADH

Insulin

DKA

HHNK

Lecture 6— Drug Toxicities (Lithium,

Lanoxin, Dilantin, Bilirubin,

Aminophylline)

Kernicterus

Dumping/HH

Electrolytes: K+, CA, MG,

and NA

TX for HyperKalemia

Lecture 7— Thyroid (Hyper-, Hypo-)

Adrenal Cortex (Addison

Disease, Cushing)

Toys

Laminectomy

Lecture 8— Lab Values

Five Deadly Ds

Neutropenic Precaution

Lecture 9— Psych Drugs

Tri

Benzo

MAOI

Lithium

Prozac

Haldol

Clozaril

Zoloft

Lecture 10— Maternity and Neonatology

Lecture 11— Fetal Complications

Stages of Labor

Assessments

Variations for NB

Maternity Meds

Medication Hints

Psych Tips

Operational Stages

Lecture 12— Prioritization

Delegation

Staff Management

Guessing Strategies

GUIDE • Mark Klimek’s Lecture

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Acid/Base Balance (Start times: 30:00)

In order to solve acid-base disorders, it is

important to know the normal values for

pH, CO2 and HCO3 (bicarbonate), which

are shown below

• pH 7.35 to 7.45

• CO2 35 to 45

• HCO3 22 to 26

The first value to look at in an acid-base

disorder is the pH

• If pH is <7>

is acidotic

• If pH is <7>

is alkalotic

Now, to determine if the imbalance is metabolic or respiratory, determine whether HCO3 goes

in the same or opposite direction with pH

• Rule of the Bs: If pH and Bicarb move both in the same direction, then the acid-base

imbalance is metabolic … Otherwise, it is respiratory

Example #1

• pH 7.3 Acidotic

• HCO3 20 Metabolic

• This is an example of metabolic acidosis

Example #2

• pH 7.58 Alkalotic

• HCO3 32 Metabolic

• This is an example of metabolic alkalosis

Example #3

• pH 7.22 Acidosis

• HCO3 35 Respiratory

• This is an example of respiratory acidosis

As the pH goes, so goes my patient, except for Potassium … That means

• If pH is low, everything is low, except potassium

• If pH is high, everything is high, except potassium

Lecture 1 • Mark Klimek • 92:21

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If pH goes over 7.45, this is alkalosis

• Therefore everything is up: tachycardia, tachypnea, HTN, seizures, irritability, spastic,

diarrhea, borborygmi (increase bowel sounds), hyperreflexia (3+, 4+)

• However, potassium is opposite. Therefore, hypokalemia

• What is the nursing intervention?

o Pt need suctioning because of seizures

If pH goes below 7.35, this is acidosis

• Therefore, everything is down: bradycardia, constipation, absent bowel sounds, flaccid,

obtunded, lethargy, coma hyporeflexia (0, 1+), bradypnea, low BP

• However, potassium is high (hyperkalemia)

• What is the nursing intervention?

o Pt needs to be ventilated with an Ambu bag—respiratory arrest

So, remember that “MAC Kussmaul” is the only acid-base imbalance to cause Metabolic

ACidosis with Kussmaul respirations

Causes of Acid/Base imbalance

First ask yourself, “Is it LUNG? … If yes, then it is respiratory

• Then ask yourself, “Are they overventilating or underventilating?

o If UNDERventilating, then pick acidosis—pH is under 7.35

o If OVERventilating, then it is alkalosis, pH is over 7.45

What type of acid-base derangement is present in the following condition?

• In labor?

o Respiratory alkalosis … Overventilating—pH increases … Alkalosis)

• Drowning?

o Respiratory acidosis … Underventilating—pH decreases … Acidosis

• Pt is on PCA (patient-controlled anesthesia) pump?

o Ventilation is down … Respiratory acidosis

If it is not LUNG, then it is metabolic. If the patient has prolonged

gastric vomiting or suction (sucking out acid), pick alkalosis

• For everything else that isn’t lung, pick metabolic acidosis

• So, when you don’t know what to pick, pick metabolic

acidosis

Tip

• Set your default setting to Metabolic Acidosis

• Always pay attention to modifying phrase rather than original

noun

Figure 1. Patientcontrolled anesthesia

(PCA) pump.

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Ventilator

A ventilator is a machine designed to move breathable air into and out of the lungs, aids patients

who are physically unable to breathe, or breathing insufficiently to breathe … A ventilators is

equipped with a high and a low-pressure alarm

High pressures alarms are

always triggered by increased

resistance to air flow. Look

for obstructions, i.e.,

• Kinks in tubing …

Solution: unkink the tube

• Condensed water in the

dependent tube …

Solution: empty it

• Mucus plugs … Solution:

Ask pt to turn, cough, deep

breathe; or suction the

tubing PRN

What is the appropriate order

to address high pressure alarm

in a mechanical ventilator?

• (1) Unkink. (2) Empty

water out of tubing. (3) turn pt, ask pt to cough or deeply breathe, and (4) suction

Low pressures alarms are always triggered by decrease in resistance. This can be caused by

• Main tubing disconnection

• O2 sensor tube disconnection

• In both cases, reconnect the disconnected tubing unless tube is on floor … Bag pt and call

Respiratory Therapist

The ventilator may be set too high or too low

• Setting is too high … Pt is overventilated

o Respiratory Alkalosis … Panting

• Setting is too low … Pt is underventilated

o Respiratory Acidosis … Pt is retaining CO2

Question

The physician wants to wean pt off vent in the morning. At 6 am, the ABGs say respiratory

acidosis. What would you do next?

• Notify the physician that the pt is not ready to be weaned off the respirator

o Pt is is respiratory acidosis, which means that he is underventilated … Therefore not ready

to be weaned off the ventilator

o If pt were in respiratory alkalosis (overventilated), he should be ready to be weaned off

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Alcoholism

• The #1 psychological problem is DENIAL

• How do you respond/treat to pts in denial?

o Confront them by pointing out the difference b/w

what they say and what they do

o For instance, say something like: “Ok, you say

you’re not an alcoholic but it is 10 a.m. and you’ve

already had a 6 pack” … It is not the same as

aggression. Don’t attack the person

o Good answer has “I” … Bad answer has “YOU”

o One place where denial is ok—loss and grief

Stages of grief are “DABDA”—Denial, anger,

bargaining, depression, acceptance

o So when the question is about pt in denial, pay attention to whether you are dealing with

loss or abusive situation

Support = Loss

Confront = Abuse

Dependency vs. Co-dependency

• The #2 psychological problem is Dependency or Co-Dependency

• Dependency: when the get the significant other to do things or make decisions for them

o The abuser is dependent

• Co-dependency: when the significant other derive self-esteem for doing things or making

decisions for the abuser

o The significant other is the co-dependent

• Dependency and co-dependency has a symbiotic, yet a pathological relationship

o The dependent pt get a free ride on the co-dependent

o The co-defendant pt feels good from “doing stuff” for the abuser

• How do you treat dependency/codependency?

o Dependent pts are “abusers” … Confront them

o Co-dependent pts have self-esteem issues … Teach pts how to set limits and enforce them

o Agree in advance on what requests are allowed then enforce

o Teach significant other to say no

o Work on self-esteem on the co-dependent person

Manipulation

• Manipulation is when the abuser gets the significant other to do things or make decisions

that are not in the best interests of the significant other

o The nature of the act is dangerous and harmful to the significant other

Lecture 2 • Mark Klimek • 101:54

The title of this section is

alcoholism. However, this rule

can be used for any abuse

situation

1. So, what it the number 1

psychological problem in

child abuse? … In gambling?

… In cocaine abuse? … In

spousal abuse? … In elder

abuse?

a. The answer is denial

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• How is manipulation like dependency?

o In both situations the dependent person gets the co-dependent person to do things or make

decisions

o If what the significant other is being asked to do is not inherently dangerous and

harmful, then this is dependency/co-dependency

o However, if the significant other is being asked to do something inherently dangerous

and harmful, then this is manipulation

• Manipulation? Set LIMITS and Enforce them

Examples

Determine if either one of these situations is dependent/co-dependent problem or a manipulation

problem

• A 49-year-old alcoholic gets her 17-year-old son to go to the store and buy alcohol for her.

o The mother is manipulating the son

o This is an illegal act = Harmful

o Dependency … There are 2 patients

o The dependent has a denial issue

o The co-dependent has a self-esteem issue

• A 49-year-old alcoholic asks her 50-year-old husband to go to the store and buy alcohol for

her.

o This is not illegal for the husband to buy alcohol

o This a dependency/co-dependency situation

o Manipulation … There is 1 patient—no self-esteem issues

o Easier to treat because no one like to be manipulated

Wernicke (Korsakoff) Syndrome

Typically, Wernicke and Korsafoff are 2 separate disorders. The NCLEX however bundles the 2

as 1 condition

• Wernicke is an encephalopathy

• Korsakoff is a psychosis

• Wernicke and Korsafoff tend to go together

Wernicke and Korsafoff

• Psychosis induced by Vitamin B1, thiamine deficiency

• This is a situation the pt looses touch with reality due to vit B1 deficiency

• The primary S/Sx are amnesia (memory loss) and confabulation (making up stories)

o Confabulation—The lies for this pts are just as real as reality

How do deal with a pt with Wernicke and Korsafoff who is confabulating about going to a

meeting with Barack Obama this morning?

• Redirect the pt to something he can do

o For instance, tell pt something along that line: “Why can we go watch TV to see what is

on the news today”

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Characteristics of Wernicke and Korsafoff syndrome

1.Preventable … Take B1

2.Arrestable (stop it from getting worse) … Take B1

3.Irreversible (70%) … Will kill brain cells

Antabuse and Revia (Disulfiram)

• Antabuse—Alcohol deterrent

• Revia—Antidote

• Aversion (strong hatred) Therapy—a type of behavior therapy designed to make a patient

give up an undesirable habit by causing them to associate it with an unpleasant effect

o Works in theory better than in reality

• Onset (how long it takes to start working) and duration (how long it lasts) of effectiveness

of Antabuse/Revia is 2 weeks

o For instance, if pt will be at a function and would like to drink, the pt must be on

Antabuse/Revia at least 2 weeks prior to the event

• Patient teaching

o Teach pt to avoid all forms of EtOH. Not doing so may lead to symptoms of n/v, even

death

o Teach them to avoid the followings items as they contain alcohol … Mouth wash,

cologne, perfume, aftershave, elixir, most OTC liquid medicine, insect repellant, hand

sanitizer, vanilla extract (can’t have cupcake with unbaked icing)

o On the exam, do not pick the Red Wine vinaigrettes … It does not have alcohol in it

Overdose and Withdrawal

First thing you ask in an overdose question is: Is it an Upper or a Downer?

• This is because every abuse drug is either an Upper or a Downer

• However, laxative abuse in the elderly is neither an Upper nor a Downer

Upper Downer

• Caffeine

• Cocaine

• PCP/LSD (psychedelics/hallucinogens)

• Methamphetamines

• Adderall

• Memorize these five for the NCLEX

• There are over 135 drugs that are downers

• If it is not an upper, it is a downer

Signs and Symptoms

• Things go UP!

• Euphoria, seizures, restlessness,

irritability, hyperreflexia (3+, 4+),

tachycardia, increased bowels

(borborygmi), diarrhea

Signs and Symptoms

• Things go DOWN!

• Lethargic, respiratory depression/arrest,

constipated, etc.

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What are the highest nursing priority to anticipate in an Upper or Downer?

• Upper: The highest priority to anticipate in an Upper is suctioning due to seizures

• Downer: The highest priority to anticipate in a Downer is intubation/ventilation due to

respiratory arrest

Example

One of your pt is “high on cocaine.” What is critically important to assess?

• Having a RR of 12 is not a critical measurement to assess for that pt

• However, assessing for reflexes (3+ or 4+), irritability, borborygmi (increased bowel sounds), or

increased temperature would be more appropriate

o The “ABC rule” does not apply here … In fact, the pt’s ABC in cocaine toxicity is

unremarkable

After you know that the drug in question is an Upper or a Downer, the second question you

should ask yourself is whether it is an Overdose or a Withdrawal

• Overdose and withdrawal have the opposite effects

Overdose

Overdose on an Upper Overdose on a Downer

• Too much • Too little

Withdrawal

Withdrawal on an Upper Withdrawal on a Downer

• Too little • Too much

Question

The driver of a squad car calls the ER and says he is bringing a pt who in ODed on cocaine. What

do you expect to see? … Select all that apply

• Pt ODed on Upper OD … Expect to se Too much

o First question: Upper or a Downer?

o Second question: Overdose or Withdrawal?

o S/Sx would be: Irritability, 4+ reflexes, borborygmi, increased temperature, etc.

Question

The same pt is withdrawing from cocaine … Same question

• This pt is an Upper in Withdrawal = Too little

• Therefore, respiratory is under 12, pt is difficult to arouse, give them Narcan

Drug Abuse in the Newborn

Always assume intoxication, not withdrawal at birth, in a newborn less than 24 hours after birth.

24 hours or more after birth, you can assume the newborn isin withdrawal

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Question

You are caring for an infant born to Quaalude addicted mother 24 hours after birth. Select all that

apply

• Overdose/withdrawal condition … Ask the following 2 questions

o Is it an Upper or a Downer? … We don’t what it is because it is a “Quaalude” (it is likely

a Downer)

o Is it Overdose or Withdrawal? … 24 hours after birth (Withdrawal)

o A Downer in Withdrawal = Too much

o S/Sx = Difficult to console, seizure risk, shrill, high-pitched cry, exaggerated startle reflex

Alcohol Withdrawal Syndrome vs. Delirium Tremens

Alcohol Withdrawal Syndrome and Delirium Tremens are not the same

• Every alcoholic goes through alcohol withdrawal approximately 24 hours after the person

stops drinking

• However, less than 20% of alcoholics in alcohol withdrawal syndrome progress to delirium

tremens … Delirium tremens occurs about 72 hours after the person stop drinking

• Alcohol withdrawal syndrome always precedes delirium tremens; however, delirium tremens

does not always follow alcohol withdrawal syndrome

Alcohol Withdrawal Syndrome Delirium Tremens

• Occurs after 24 hours after drinking

• Non-life threatening to self and others

• Occurs after 72 hours after drinking

• Life threatening to self and others

Nursing Care Plan

• Regular diet

• Semiprivate room, anywhere on the unit

• Pt is up ad lib (Pt is free to move around

as desired)

• No restraints

Nursing Care Plan

• NPO (seizures) or clear liquid diet

• Private room, near nursing station

• Restricted bed rest (Pt is not free to move

around as desired—no bathroom)

• Restraints (vest or 2-point lock letters)

Note

• “Up ad lib” or “up ad liberum” means pt may have activity or free to move around as desired

any time

• 2-point lock letters restraints: Restraints in 1 upper and the contralateral lower extremities.

Release and secure upper arm first, and then release and secure the foot. Switch extremities

every 2 hours

• Give both anti-HTN medication, tranquilizer, multivitamin containing vit B1

Question

So what two situations would respiratory arrest be a priority?

• Overdose of a Downer

• Withdrawal of an Upper

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Question

Which pts would seizure be a risk for?

• Overdose of an Upper

• Withdrawal of a Downers

Aminoglycosides (Top 5 most tested drugs)

Aminoglycosides are the big

guns of ABXs (antibiotics)—

use them when nothing else

works. Aminoglycosides are

unsafe at toxic levels and

safety then becomes an issue.

They are the 5th most tested

drugs on the NCLEX

The most tested drugs on the

NCLEX are:

• Top 5

o Psychiatric

o Insulin

o Anticoagulant

o Digitalis

o Aminoglycosides

• Others

o Steroids

o Beta-blockers

o Calcium channel

blockers

o Pain medications

o Obstetrics medications

“A Mean Old Mysin” = Aminoglycosides

Would be used to treat serious, resistant, life-threatening, Gram negatives infections

• So, treat a mean old infection with a “Mean Old Mycin”

o Examples are: TB, septic peritonitis, fulminating pyelonephritis, septic shock, infection

from third degree wound covering >80% of the body

o However, sinusitis, otitis media, bladder infection, viral pharyngitis, and strep throat are

not old mean infections and are not treated with a mean old mycin

All aminoglycosides end in Mycin

• Gentamycin, Vancomycin, and Clindamycin, Streptomycin, Cleomycin, Tobramycin

• Not all drugs ending in mycin are aminoglycosides

o Azithromycin, Clarithromycin, Erythromycin … All have THRO in the middle … So,

THRO them off the “Mean Old Mycin” list

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What are toxic effects?

• Mycin—Sounds like Mice (Think ears) … Monitor hearing (#1), balance, tinnitus

(ringing of the ear, CN8 toxicity)

• The human ears are shaped like a kidney so another toxic effect of aminoglycosides

is nephrotoxicity (Toxic to the kidneys)

o Therefore, monitor Creatinine

What would be your answer if in a

question, you have to choose which is

the best between 24-hour creatinine

and serum creatinine?

The figure 8 drawn inside the ear should remind you of of 2 things

They are toxic to CN8

Administer them q8 hour

Do not give Mean Old Mycins PO because they are not absorbed, and therefore would not have

any systemic effects

There are 2 cases where Mean Old Mycins are given PO

• Hepatic encephalopathy (or hepatic coma) where ammonia level gets too high

• Pre-op bowel surgery: to sterilize the bowel before surgery

• In both cases, the ABX stays in the gut (not absorbed), sterilizes the bowel, and would not be

toxic

• The #1 action of an “oral mycin” … Sterilize the bowel

o Who can sterilize my bowel?

Neo Kan

o Neomycin and Kanamycin

Note

E. coli in the gut is the #1 producer of ammonia, which at toxic

levels, leads to encephalopathy

Troughs and Peaks

• Troughs is when drugs is at their lowest concentration in the

pt’s blood

• Peaks is when drugs is at their highest concentration in a pt’s

blood

“A Mean Old Mycin” is given IM or IV because it is excreted in feces and not absorbed in

the GI tract. It is used in hepatic encephalopathy to kill E. coli, and bowel surgery (to sterilize

the bowel).

1. Creatinine = Best indicator of kidney function

2. 24-hour creatinine clearance is better than Serum

creatinine

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“TAP” Levels

• A method to remember what is done before or after, when dealing with a medication with

troughs and peaks

• “TAP”—Trough, Administer, Peak

o Trough before drug administration

o Peak after drug administration

o Trough and Peak levels are drawn because of a drug’s narrow therapeutic window or

index

o Narrow therapeutic window or index means that there is a small difference in what works

and what kills

Which one of the following medications would “trough and peak”

important?

• Lasix (furosemide)

o Smaller dose: 5 or 10

o Larger dose: 80 or 120

• Digitalis (digoxin)

o Smaller dose: 0.125

o Larger dose: 0.25

o Would draw “TAP” (Trough, Administer, Peak) on digitalis

When to Draw a Through and a Peak

• Both Trough and Peak are not medication-dependent

• The trough, it is always drawn 30 minutes before next dose

• For the peak, it depends on the route

o Peak SubL 5 to 10 minutes after drug is dissolved

o Peak IV 15 to 30 minutes after drug is finished (bag empty)

o Peak IM 30 to 60 minutes

o Peak SubQ Depends on insulin (See diabetes lecture)

o Peak for PO Not necessary, not tested

Question

You give 100 mL of a drug at 200 mL per hour (the

drug takes 30 minutes to run). If you hang the drug at

10 a.m., it will finish running at 10:30 a.m. When will

the drug peak?

1. 10:15 a.m.

2. 10:30 a.m.

3. 10:45 a.m.

4. 11:00 a.m.

Answer: Two right answers—pick 11:00 a.m.

In this case, play the “Price Is Right”—go with the

highest time w/o going over

Note

1.Draw TAP on

Mean Old Mycins

because of their

narrow therapeutic

index

Note

• The same drug given by 2

different routes at the same time

will have different peaks

o Morphine

• However, 2 different drugs given

at the same time and route (IV)

will peak together

o Morphine and amphetamine

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Calcium Channel Blockers

CCBs (Calcium channel blockers) are like Valium for the heart

• They relax and slows down the heart

• In other words, CCBs have negative inotropic, chronotropic, dromotropic effects on the heart

(+) Inotropy, Chronotropy, Dromotropy (–) Inotropy, Chronotropy, Dromotropy

Positive inotropy

• Increase cardiac contractile force !

Ventricles empty more completely !

Cardiac output improved

Negative inotropy

• Weaken/decrease the force of myocardial

contraction

Positive chronotropy

• Increase rate of impulse formation at SA

node ! Accelerate heart rate

Negative chronotropy

• Decrease rate of impulse formation at the

SA node ! decelerate heart rate

Positive dromotropy

• Increase speed that impulses from SA

node travel to AV node (increase

conduction velocity)

Negative dromotropy

• Decrease speed that impulses from SA node

travel to AV node (decrease conduction

velocity)

When do you want to relax and slows down the heart? … To treat “A, AA, AAA”

• Antihypertensive

• AntiAnginal drugs (decreasing oxygen demand)

• AntiAtrialArrhythmia

Side Effects

Headache and hypotension

Name: ends in “dipine” … Not “pine”

• Also, verapimil, Cardizem (diltiazem)

• Cardizem (diltiazem) is given continuous IV drip

What are the parameters to assess before putting a pt on CCBs?

• Assess for BP

• Hold if SBP <100>

Cardiac arrhythmias

• Knowing how to interpret rhythm

• Must know the following 4 cardiac rhythms by sight

Lecture 3 • Mark Klimek • 111:11

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Normal Sinus Rhythm

• There is a P wave, followed by a QRS, followed be a T wave for every complex

• Peaks of the P wave is equally distant to the QRS, and fall within 5 small boxes

Ventricular Fibrillation

• No pattern

Ventricular Tachycardia

• Sharp peaks with a pattern

Asystole

• A flat line

If the question mentions

• QRS depolarization = Ventricular

• P wave = Atrial

The 6 rhythms most tested on the NCLEX

1. A lack of QRS complexes is asystole—a flat line

2. P waves (atrial) in the form of saw tooth wave = atrial

flutter

3. Chaotic P wave patterns = atrial fibrillation (a-fib)

(Chaotic: word used to describe fibrillation)

4. Chaotic QRS complexes = ventricular fibrillation (v-fib)

5.Bizarre QRS complexes = ventricular tachycardia (v-tach)

(Bizarre: word used to describe tachycardia)

6.Periodic wide bizarre QRS complexes = PVCs (Salvos of PVCs = A short runs of v-tach)

There are 3 levels of nursing

knowledge

1. Stuff you need to know

2. Stuff that is nice to know

3. Stuff that is nuts to know

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PVCs (premature ventricular contractions) are usually low priority

• However, elevate them to moderate priority if under the following 3 circumstances

o There are 6 or more PVCs in a minute

o More than 6 PVCs in a row

o R on T phenomenon (a PVC falls on a T wave)

• PVCs after an MI is common and is a low priority

Lethal arrhythmias are high priority and will kill a pt in 8 minutes or less. They are:

• Asystole and V-fib (ventricular fibrillation)

• Both rhythms produce low or no cardiac output (CO), without which there is inadequate or

no brain perfusion. This may lead to confusion and death

Potentially Lethal Cardiac Arrhythmia

• V-tach (ventricular tachycardia) is a potentially lethal cardiac rhythm but it has a CO

How would a pt with or without CO presents?

• CO is absent = there is no pulse

• CO is present = there is a pulse

Treatment of PVCs and V-tach

• Ventricular = Lidocaine

• Both are ventricular rhythms

• Treat with Lidocaine

• Amiodarone is eventually the NCLEX board will want as answer

Supraventricular arrhythmias are Atrial arrhythmias (supra = above)

Treatments are “ABCDs”

• Adenocard (Adenosine) … Fast IV push (push in less than 8 seconds and 20 mL NS flush

right after) … These pts will go into asystole for about 30 seconds and out of it

• Beta-blockers (end in -olol)

• CCBs

• Digitalis (digoxin), Lanoxin (another digitalis analog)

Beta-blockers have negative inotropic, chronotropic, dromotropic effects on the heart.

They treat “A, AA, AAA”

• Antihypertensive

• AntiAnginal drugs (decreasing oxygen demand)

• AntiAtrialArythmia

• Side Effects = Headache and hypotension

Treatment of V-fib and Asystole

• Defib for V-fib (Defib = defibrillate = Shock em!)

• Epinephrine and Atropine for Asystole

Tx: Atrial arrhythmias

• Adena

• Beta

• Calcium

• Dig

Tx: Ventricular arrhythmias

• Lidocaine

• Amiodarone

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Chest Tubes

Purpose: to reestablish

negative pressure in the

pleural space … Negative

pressure in the pleural

space makes thing stick so

that the lung expands

when the chest wall

expands

• Pleural space is the

space between the lung

(visceral pleura) and

the chest wall (parietal

pleura)

• In a pneumothorax,

chest tube removes air

• In a hemothorax,

chest tube removes

blood

• In a hemopneumothorax, chest tube

removes air and blood

Question

A chest tube is placed in a pt for a hemothorax (blood). What would you (the LPN) report to the

nurse? Or, what would you (the RN) report physician?

a. Chest tube is not bubbling

b.Chest tube drains 800 mL in the first 10 hours

c. Chest tube is not draining

d.Chest tube is intermittently bubbling

What is the chest tube not supposed to do? The chest tube is supposed to drain instead of

bubbling

• Therefore answer (c) is the right answer.

Question

A chest tube is placed in a pt for a pneumothorax (air). What would you (the LPN) report to the

nurse? Or, what would you (the RN) report physician?

a. Chest tube is not bubbling

b.Chest tube drains 800 mL in the first 10 hours

c. Chest tube is not draining

d.Chest tube is intermittently bubbling

With a pneumothorax, bubbling is expected

• Therefore, (a) is a good answer choice

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• Since this is a pneumothorax, not too much blood is expected

• Consequently, 800 mL of blood over 10 hours (80 mL per hour) is too much blood and needs

to be reported to the nurse or the physician

Also, pay attention to the location

the tube is placed

• Apical (top) or Basilar (base)

• Apical chest tube removes Air

• Basilar chest tube removes

Blood or fluid (due to gravity)

Examples

• An apical chest tube is

draining 300 mL the first hour

is bad … Bubbling (air) is

expected

• A basilar chest tube is draining

200 mL the first hour is

expected

• An apical chest tube is not

bubbling … This is a bad sign

because bubbling (air) is

expected

• A basilar chest tube is not

bubbling … This is a good

sign because bubbling (air) is

not expected

Example

Pt presents with a unilateral

hemopneumothorax. How to care

for this pt?

• Place an apical chest tube for

the pneumothorax and a

basilar for the hemothorax

Bilateral pneumothorax needs apical chest tube one on the right and one on the left

• Air tube = Apical = Top, on both sides

Posttrauma or postsurgical pt needs

• Pt presents with a unilateral hemopneumothorax. How to care for this pt? … Place an apical

and a basilar chest tube on the side of the problem … Always assume trauma and surgery is

unilateral unless otherwise specified

Trick question

Were would you place a chest tube for a postop right pneumonectomy?

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• Postop right pneumonectomy does not need a chest tube … Since the right lung was

removed, there is no need for a chest tube

• Chest tube will however be used for lobectomy (removal of a lobe of the lung), or wedge

resection

Closed chest drainage devices

• Types: Jackson-Pratt, Emisson, pneumovac, hemovac, etc.

• What happens if one of those drainage devices is knocked

over?

o Ask pt to take a deep breath and set the device back up

o Not a medical emergency … No need to call the physician

If the water seal of the chest tube breaks

• Clamp

o Clamping, unclamping, and placing the tube under water must be done in 15 seconds or

less

• Cut the tube away

• Submerge (stick) the end of the tube under sterile water

o The most important step

• Unclamp the tube if it was initially clamped, (clamping the tube prevent air to get into the

chest but does not allow anything from the chest to get out)

Question

The water seal chamber of the chest tube in a pt with a pneumothorax/hemothorax breaks. What

is the first course of action for the nurse?

a. Clamp the tube

b.Cut the tube away

c. Submerge (or stick) the end of the tube under sterile water

d. Unclamp the tube if it was initially clamped

In this case, the first course of action is the clamp the tube

Question

The water seal chamber of the chest tube in a pt with a pneumothorax/hemothorax breaks. What

is the priority (best) action of the nurse?

a. Clamp the tube

b.Cut the tube away

c. Submerge (or stick) the end of the tube under sterile water

d. Unclamp the tube if it was initially clamped

Knock someone or

something over: to

push or strike someone

or something, causing

the person or the thing

to fall

Note

If for whatever reason the chest tube breaks, clamp, unclamping to placing the tube under

water must be done in 15 seconds or less

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In this question, the priory action for the nurse is to submerge the end of the tube under sterile

water because doing so prevents air from getting into the chest. At the same time, this allows air

or blood from the chest to get out

• This solves the problem by reestablishing the water seal

Note

Clamping, unclamping, and placing the tube under water must be done in 15 seconds or less

Question

You notice on the monitor that a pt has v-fib. Pt is unresponsive and there is no pulse. What is

the first step in the management of this pt?

a. Place a backboard under pt’s back while pt is supine

b. Start chest compression

The first step is to place the backboard under pt’s back. “First” is about order.

Question

You notice on the monitor that a pt has v-fib. Pt is unresponsive and there is no pulse. What is

the best step in the management of this pt?

a. Place a backboard under pt’s back while pt is supine

b. Start chest compression

“Best” is about what is the priority. Chest compression is the priority action.

If a chest tube gets pulled out …

1.Take a gloved hand and cover the opening (first step)

2.Take a sterile Vaseline gauze and tape 3 sides (best step)

Chest tube is bubbling … Ask (1) where it is bubbling, and (2) when it is bubbling?

Ask the following 2 questions

• Bubbling … Where? In the water seal chamber

o If it is intermittent, it is good (document it)

o If it is continuous, it is bad and indicates a break/leak in the system (find it and tape it)

• Bubbling … Where? In the suction control chamber

o If it is intermittent, suction pressure is too low (increase it at the wall until it is

continuous)

o If it is continuous, it is good (document it)

Analogies

• A straight catheter is to a Foley catheter, as a thoracentesis is to a chest tube

o A straight catheter goes in and out … A Foley goes in, secure it, and continuous

drainage

o Thoracocentesis = go in and out … Chest tubes = go in, secure it, and leave it in place

• A Foley has a higher risk of infection than a straight cath

• A chest tube has a higher risk of infection than thoracocentesis

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Rules for clamping tubes

• Do not clamp a tube for more than 15 seconds without a physician’s order

• Use rubber tooth (will not puncture tubing), double clamps

• Therefore, when the water seal breaks, the nurse has no more than 15 seconds to clamp, cut

the tube, submerge it under sterile water, and then unclamp it

Congenital Heart Defects

• It’s either they cause a lot of trouble or no trouble

o But nothing in between

• Memorize one word: “TRouBLe” with the lower case vowels because congenital heart

defects are either:

o “TRouBLe”

or

o Nothing to worry about

A pediatric pt with “TRouBLe” as congenital heart defect

• Needs surgery now/soon to live

• Has slowed/delayed growth and development (failure to thrive)

• Has a shortened life expectancy

• Parents will experience a lot of grief, financial and emotional stress

• Pt is likely to be discharge home on a cardiac monitor

• After, birth, pt will be in the hospital for weeks

• Pediatrician or pediatric nurse will likely refer pt to a pediatric cardiologist

Question

The nurse is teaching the parent of an infant born with Tetralogy of Fallot. Which of the

following should the nurse talked to the parents about in the teaching session?

• The nurse should teach the newborn’s parents all of the choices listed above

A “TRouBLe” congenital heart defect

• “TRouBLe” shunts blood Right to Left

• “TRouBLe” is Blue (cyanotic)

• All “TRouBLe” start with the letter “T”

o Tetralogy of Fallot

o Truncus arteriosus

o Transposition of the great vessels

o Tricuspid atresia

o Totally anomalous of pulmonary vasculature (TAPV)

o Except, Left ventricular hypoplastic syndrome

These are examples if No TRouBLe congenital heart defects

• Ventricular septal defect (VSD)

• Patent ductust arteriosus (PDA)

• Patent foramen ovale

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• Atrial septal defect

• Pulmonic stenosis

All children with a congenital heart defect, whether TRouBle defect or No TRouBle defect,

have

• A Murmur

• An echocardiogram need to be done to find out the cause of the murmur

4 defects of Tetralogy of Fallot — “PROVe”

• Pulmonary artery stenosis

• RVH (right ventricular hypertrophy)

• Overriding aorta

• VSD (ventricular septal defect)

• No need to know what they are … Just need to spot them as answer choices on the board

Infectious Disease and Transmission-Based Precautions

There are 4 transmission-based precautions

• Standard or universal

• Contact

• Droplet

• Airborne precaution

Contact precautions

• Anything enteric (GI, or fecal/oral)

o C. diff., Hepatitis A, E. coli, cholera, dysentery

• Staph

• RSV (droplets fall onto object then pt touches object or put it in mouth)

Do not cohort 2 RSV pts unless culture and symptoms say that have the same disease

• Herpes

PPE (personal protective equipment) for contact precaution

• Private room is preferred

• Can be in the same room if cohort based on culture and not symptoms

• Hand washing ! Gown ! Gloves

• Disposable supply (gloves, paper plates, plastic utensils)

• Dedicated equipment (stethoscope, BP cuff) and toys stay in the room

Droplet precautions

• For bugs travelling on large particles through Coughing, Sneezing to less than 3 feet

• Meningitis

• H. influenza b

o Example: epiglottitis (nothing in the throat)

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PPE (Personal Protective Equipment)

• Private room is preferred

• Can be in the same room if cohort based on culture and symptoms

• Hand washing ! Mask ! Goggle or Face shield ! Gloves

• Disposable supply

• Dedicated equipment

Airborne precautions “Air MTV”

• MMR

• TB

• Varicella (chickenpox)

PPE

• Private room is preferred

• Can be in the same room if cohort based on culture and symptoms

• Hand washing ! Goggle or Face shield ! Gloves

• Wear mask when living the room

• Keep door closed

• Disposable supply (not essential)

• Dedicated equipment (not essential)

• Negative airflow

PPE (Personal Protective Equipment)

• Order to put in on … The “Gs” are in reverse alphabetical order and “Mask” comes 2nd

o Gown

o Mask

o Goggle

o Gloves

• Order to take it off … Do so in alphabetical order

o Gloves

o Goggle

o Gown

o Mask

Math Problems

Dosage calculation

IV drip rates = Volume × Drop factor / Time

• Micro/Mini drip = 60 drops per mL

• Macro drip = 10 drops per mL

Pediatric dose (2.2 lbs = 1 kg)

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Crutches, Canes, Walkers

One of the major human functions is

locomotion. Therefore, crutches,

canes and walkers are tested on the

NCLEX exam even though they are

not really emphasized in school. Also,

such knowledge is good for patient

teaching. With that said, crutches,

canes and walkers are devices used to

help pts with an unstable gait, whose

muscles are weak or who require a

reduction in the load on weightbearing structures

How do you measure the length of

crutches?

• Measuring crutches is important for risk reduction when ambulating and to avoid nerve

problems

• The length of a crutch is measured by

o Holding it vertically and placing the tip on the ground

o Having 2 to 3 finger widths between the pad and the

anterior axillary fold

o The tip is located to a point lateral (6 inches) and slightly in

front of foot (6 inches)

• Rule out landmarks on foot or say axilla!

• Handgrip measurement

o The angle of elbow flexion is 30 degrees

o The wrists should be at the level of the handgrip

How to Teach Crutch Gaits?

2-point gait—move a crutch and

opposite foot together, then the other

crutch with other foot together

• Together (Right leg & Left crutch)

! Together (Left leg & Right

crutch)

• For mild bilateral leg weaknesses

Lecture 4 • Mark Klimek • 96:58

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3-point gait—move (2 crutches & bad leg)

together ! Followed by unaffected leg

• The gait goes 3-1, 3-1, 3-1

• The affected (bad) leg is not on the

ground

• The unaffected (good) leg is on the

ground

4-point gait—move everything separately

• Move crutch ! Move opposite foot ! Followed by other crutch ! Followed by opposite

foot

• Right crutch ! Left foot ! Left crutch ! Right foot

• 4-point gait is very slow but very stable

Swing-through is for non-weight bearing (amputees)

• Similar to 3-point gait

• The unaffected foot get pass the tip of both crutches

• The person may be an amputee or does not bear weight on the leg at all

• Can move really fast

When do you use these gaits?

• Use Even-point gait for even, odd-point gait for odd

• Use the even numbered gaits when weakness in the feet is evenly distributed

o 2-point for mild problems

o 4-point for severe

• Use the odd numbered gait when one leg is affected

o 3-point for one leg

• If pt cannot bear weight or amputation

o Swing-through

Example

A pt affected with early stages of rheumatoid arthritis. What gait should the pt use?

• Both legs affected (because it is a systemic disease)

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• Early stage—mild

• 2-point gait

Example

A pt has left ATK (above the knee) amputation 2 days ago. What gait should the pt use?

• Non-weight bearing

• Swing-through

Example

Pt is first day postop, right knee, partial weight bearing allowed. What gait should the pt use?

• One leg affected

• Odd-numbered gait

• 3-point gait

Example

Pt is in advanced stages of ALS. What gait should the pt use?

• Bilateral leg weakness (because it is a systemic disease)

• Even-numbered gait

• Advanced stages = Severe

• 4-point gait

Example

Pt with left hip replacement, 2nd day postop on non-weight bearing instruction. What gait should

the pt use?

• Non-weight bearing of 1 leg

• Swing-through gait

Example

Pt with bilateral (B/L) total knee replacement first day postop. Weight bearing is allowed. What

gait should the pt use?

• Even-numbered gait = Bilateral

• Weight bearing

• First day postop = Severe

• 4-point gait

Example

Pt with bilateral total knee replacement 3 weeks postop. What gait should the pt use?

• Even-numbered gait = Bilateral

• Weight bearing

• 3 weeks postop = mild

• 2-point

Going Up and Down the Stairs With Crutches

• Remember this phrase

o “Up with the Good, and Down with the Bad”

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o When you go up the stairs, the good foot move up first

o When you go down the stairs, the bad foot move down last

• But, no matter what

o Both crutches always move with the bad leg

Figure 2. Crutcher.

Figure 3. Cane. Figure 4. Walker.

Cane

• Hold cane on the unaffected (strong) side

• Advance cane with the opposite side for a wide base of support

• Handgrip should be at the level the wrist

Walker

• Correct way to use a walker

o The walker is on the side of the pt, the pt “Picks it up … Sets it down … Walks to it”

o Once the walker is in front of the pt, the pt “Holds on to chair, Stands up, Then grabs

walker”

• Don’t tie belongings to the front of the walker—Tie them to either side so it won’t tip over

• The NCLEX board does not like tennis balls or wheels on walker can create problem

Psychiatry

First thing to ask in a psych question is: “Is the pt psychotic or non-psychotic?”

• The answer to this question will determine care plan, treatment, length of stay, legality, etc.

A Non-psychotic person has insight and is reality

based. What kinds of answers do you pick for these

people? What techniques do you use?

• Good therapeutic communication … Looks

like a Med/Surge pt

• Examples of therapeutic communications

o That must be very difficult/overwhelming for

you

o How are you feeling?

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o Tell me more about your …

o The exam is looking for “reflection, clarification, amplification, restatement, etc.”

The Psychotic person has no insight and is not reality based

• They don’t think they’re sick—everyone else has the problem

o Examples are: delusions, hallucinations, illusions

Delusions, hallucination and illusion are

psychotic symptoms

• Delusions—a false, fixed belief or idea or

thought. There is no sensory component. It is

all in your head. It is just a thought … 3

types of delusion

o Paranoid—People are out to get/kill me

o Grandiose—“I’m Christ” … “I am the

President” … “I am the world’s smartest

person”

o Somatic—Body part (I have x-ray vision,

there are worms inside my arm)

• Hallucination—a sensory experience

o Auditory (1st m c)—voices telling you to

harm yourself

o Visual (2nd m c)—I see bugs on the wall

o Tactile (3rd m c)—I feel bugs on my arm

(Most common = m c)

o Gustatory (taste)

o Olfactory (smell)

• Illusion—a misinterpretation of reality. It is

sensory

Differentiation between hallucination and illusion

• With illusion there is a referent in reality

o A referent is something that both the clinician and the pt can refer to … There is actually

something there

o The cord is a snake

• With hallucination, there is nothing there

Example

The pt staring at the empty wall says, “Listen, I hear demon voices.” Is that statement from the pt

a hallucination and an illusion?

• There is no referent there

• This is a hallucination

Example

The same pt overhears nurses and doctors laughing and talking at the nursing station, and says, “I

hear demon voices.” Is that statement from the pt a hallucination and an illusion?

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• There is actually a referent (real people) there

• This is an illusion

Other examples

• A pt looks with a blank stare and says, “I see a bomb.”

o This is a hallucination

• A pt looking at the fire extinguisher on the wall and says look, “I see a bomb.”

o This is an illusion

How do you deal with these psychotic patients?

• To deal with these psychotic pt, the first thing to ask is what type of psychosis the pt has?

There are 3 types of psychosis

1. Functional psychosis

2. Psychosis of dementia

3. Psychosis of delirium

A. Functional psychosis—they can function in everyday life

• 90% of the followings make up this category

• Chemical imbalance in the brain

• They are “Skeezo, Skeezo, Major, Manics”

o Schizophrenia, Schizoaffective disorder, Major depression (not depression), Mania

Example

• Bipolar = Depression and Mania

• Bipolar pts are psychotic in acute mania

B. Psychosis of dementia—what is their problem?

• Actual Brain destruction/damage

o Due to Alzheimer, stroke, organic brain syndrome

o Anything that says Senile/Dementia falls in the category

C. Psychotic Delirium—temporary, sudden, dramatic, episodic secondary to something else

• Loss of reality

o Due to UTI, thyroid imbalance, adrenal crisis, electrolytes, medications/drugs

Recap

Approach to Answering Psychiatric Questions

• First thing to ask is

o Is the pt non-psychotic? Or, is the pt psychotic?

• Pt is non-psychotic

o Address pt as you would address any Med/Surg pts

Use therapeutic communication

• Pt is psychotic

o Next, ask if they are functional, demented, or delirious?

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Functional = (1) Acknowledge feeling, (2) Present reality, (3) Set limits, and (4) Enforce

these limits

Demented = (1) Acknowledge their feeling, and (2) Redirect them—give them something

they can do

Delirious = (1) Acknowledge feeling, (2) Reassurance about safety and temporariness of

their condition

Functional Psychosis

• Schizo, mood disorders thought process, and mania (chemicals out of whack)

• This pt has the potential to learn reality (no brain damage)

• Your role as a nurse—teach reality

• Use the 4 step process to teach reality

o (1) Acknowledge feeling, (2) Present reality, (3) Set limits, and (4) Enforce these limits

What does this look like in a question?

1.The answer acknowledges pt’s feeling (look for the word “feel”)

You seem upset … That is so sad … It’s been so difficult … Tell me more about how you’re

feeling

2. Now, present reality ... “I know you see that demon, but I don’t see a demon” … Or, “I am a

nurse, this is hospital, this is your breakfast”

3. Set limit. ”We are not going to address that. Stop talking about…”

4.Enforce limit. “I see you’re too ill, so our conversation is over.” Ends the conversation.

You’re not punishing the client by taking away privileges

Psychosis of dementia

• They cannot learn reality … Don’t present it! They can’t learn it! Thus frustrates them, and

may discourage you!

• Deal with their problems in 2 steps

o (1) Acknowledge their feeling, and (2) Redirect them—give them something they can do

Do not confuse not presenting reality with reality orientation (Person, place, and time)

• Reality orientation = Pt is oriented to person, place, and time

Example

• Alzheimer lady is the lobby of waiting area of her nursing home. It is Sunday and she is all

dressed up. You day to her, “Mrs. Smith, you are all dressed up.” She said, “Yeah! My

husband is going to pick me up. We are going to church.” The problem is that the husband

has been dead for 10 years.

o She has a false, fixed belief

o She is delusional (or she is psychotic)

o What do you say to her?

o First, acknowledge her … You say, “That sounds nice.” (acknowledging)

o Second, redirect her … You say, “Why don’t we sit down here and talk about church? …

What church do you go to?” (redirecting)

o Don’t tell her husband is dead!, which is presenting reality

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Psychosis of delirium

• This is temporary, sudden, dramatic, episodic, secondary loss to reality

• Usually due to some chemical imbalance in the body

• Causes—UTI, thyroid imbalance, adrenal crisis, electrolytes, medications/drugs

• To manage these pts, treat the underlying cause

o Acknowledge feeling

o Reassure them of safety and temporariness of their condition

• They lost touch with of reality—Redirect them is futile

Example

A pt with schizoaffective disorder who points to 2 people talking across the room. The pt says,

“Those people are plotting to kill me.” What would you say? What is the most important word in

the vignette?

• Schizoaffective—psychosis

• I can see that would be frightening. They are not plotting.

• We are not going to talk about that. I can see you are too ill. We are ending the conversation

Example

A pt with Alzheimer disease who during your conversation points to 2 people talking across the

room and says, “You see these people, they are plotting to kill me”

• Alzheimer Disease—category is dementia

• Acknowledge feeling—“I understand you seem to be scared”

• Redirect—Let’s go somewhere you feel safe

Example

A pt with delirium tremens who during your conversation points to 2 people talking across the

room and says, “You see these people, they are plotting to kill me”

• Delirium tremens …

• “That must be scary”

• But you are safe. Your fear will go away when you get better

Psychotic symptoms

Loose associations

• Flight of Ideas: Rapid flow of though

• Word Salad: Throw words together and toss

out … (Sicker than flight of ideas)

• Neologisms: Make it up

• Narrowed self-concept: When a psychotic

refuse to change their clothes or leave the

room. Leave them alone

o This is a functional psychosis

o “Don’t make a psychotic do something they don’t want to do”

• Idea of reference: You think everyone is talking about you

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Dementia hallmark: Memory loss, inability to learn

• Always acknowledge feeling

• 2nd step always begins with “Re” … Reassure, Redirect, Reality

Recap

Approach to Answering Psychiatric Questions

• First thing to ask is

o Is the pt non-psychotic? Or, is the pt psychotic?

• Pt is non-psychotic

o Address pt as you would address any Med/Surg pts

Use therapeutic communication

• Pt is psychotic

o Next, ask if they are functional, demented, or delirious?

Functional = (1) Acknowledge feeling, (2) Present reality, (3) Set limits, and (4)

Enforce these limits

Demented = (1) Acknowledge their feeling, and (2) Redirect them—give them

something they can do

Delirious = (1) Acknowledge feeling, (2) Reassurance about safety and temporariness

of their condition

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Diabetes Mellitus (DM), Diabetes Insipidus (DI), Insulin

Diabetes mellitus = An error in glucose metabolism … Glucose is the body’s primary fuel

source

• Can be a lack of insulin DM1

• Can be insulin resistance DM2

DIABETES INSIPIDUS = Not a type of DM! … It is insidious, diabetes w/out the glucose

element

• It is Polyuria, Polydipsia leading to dehydration, due to low ADH.

• It is just the fluid part

So question is about low urine output or high urine output? …

• Similar to DM, DI has a high urine output

What is the opposite of Diabetes Insipidus?

• It is SIADH = Syndrome of inappropriate ADH (antidiuretic hormone)

So, DM has polyuria, polydipsia

Therefore, DI also has polyuria, polydipsia

However, SIADH is the opposite of the above 2 conditions …

• It presents w/ oliguria and no thirst

• Decrease urine output

• And then, decrease serum specific gravity (due to retention of water)

• Increase urine specific gravity (due to decrease urine volume)

Lots of urine retained, specific gravity is low = SIADH

Fluid Volume Deficit = DM, DI

Fluid Volume Excess = SIADH

Diabetes

• Type I—Insulin dependent, Juvenile onset, Ketosis prone

• Type II—Non-insulin dependent, Adult onset, Non-ketosis prone

• S/Sx of DM

o Polyuria—pee a lot

o Polydipsia—thirsty

o Polyphagia—(eat/swallow a lot)

Treatment for DM Type I (if you don’t treat)

• They will “DIE”

• Diet (calories from carbs, least important)

Lecture 5 • Mark Klimek • 71:46

Nursing

Diagnosis?

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• Insulin (most important)

• Exercise

Treatment for Type II DM

• They are “DOA”

• Diet (most important)

• Oral hypoglycemic

• Activity

Diet for DM2

• Primary treatment modality is Calorie restriction

• 1200 Cal, 1400 Cal, 1600 Cal

• These pts need to eat 6 small feeding per day—smaller more frequent meals—keeps blood

sugar more stable

Question

What is the best dietary action a DM2 should take?

a. Restrict calories

b. Divide meal into 6 feedings a day

Answer: (a) because pt can eat 6 meals but does not limit the Cal with each meal

Insulin acts to lower blood sugar

4 types of Insulin are covered here

1. R-Regular insulin—clear solution, IV drip (HESI-intermediate, Rapid, Run IV)

• Onset: 1 hour

• Peak: 2 hours

• Duration: 4 hours … (Audio says 3 hours, but it is 4 hours)

• Pattern: 1-2-4 (Pay attention to peak)

2. N-NPH, Intermediate insulin—it is cloudy, N = Not So Clear, Fast (Cloudy =

Suspension—it precipitates—can’t give IV drip), N = not so fast, not in the bag

• Onset: 6 hours

• Peak: 8 to 10 hours

• Duration: 12 hours

• Pattern: 6-8-10-12 (Hear the even #s and pay attention to peak)

Clear = Solution

Cloudy = Suspension ! Will precipitate (Not given over IV drip or put in an IV bag)

Question

How would the board ask question about peak of insulin?

For instance, you give 30 units of insulin to a pt at 7 a.m. When do you check for hypoglycemia?

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• Answer = Add the insulin peak time to the time of insulin administration

• For instance, if the pt was given NPH at 7 a.m., add 8 to 10 hours to the time

• Answer = Check for hypoglycemia between 3 and 5 p.m.

3.Lispro: (Humalog)

• Don’t give it AC (before meal) … Give it with the meal

• Onset: 15 min

• Peak: 30 min

• Duration: 3 hrs

• Pattern: 15-30-3

4.Glargine (Lantus)

• Long-acting insulin

• No Peak

• Duration 12 to 24 hrs

• Little to no risk for hypoglycemia (only one you can safely give at bedtime)

Note: Always check insulin expiration date

What action invalidates the manufacturers date?

• Opening the package

• Once the package is open, the new expiration date is 30 days after that

• Open package without an opening or expiration date should be thrown out

• Label the package either with

o “OPEN” and date package is open

or

o “EXP” and expiration date

• Once the package is open, refrigeration is optional

o However, unopened