Mark Klimek Lectures 2023

 Mark Klimek Lectures 2023

LECTURE 1

ACID BASES

• learn how to convert lab values to words

• the rule of the B’s

= if the pH and the BiCarb are both in the same

 direction -> metabolic

 Hint: draw arrows beside each to see directions

 * down = acidosis

 * up = alkalosis

- respiratory -> has no b in it; if in other directions

 (or if bicarb is normal value)

- KNOW NORMAL pH, BiCarb, CO2

• Hint: DON’T MEMORIZE LISTS…know principles

(they test knowledge of principles by having you

generate lists..) - for “select all” questions

- ex. in general/principle what do opioids/pain

 meds do? = sedate you, CNS depressors

 * ex. what does dilaudid do? don’t memorize specifics

 or a list of dilaudid, know principles of opioids (such

 as sedation, CNS depression -> lethargy, flaccidity,

 reflex +1, hypo-reflexia, obtunded)

- boards don’t test by lists because all books/

 classes have different lists

• principles of S&S acid bases: as the pH goes so

goes my patient (except K+)

- pH up = PT up -> body system gets more

 irritable, hyper-excitable (EXCEPT K+)

 -> alkalosis - think of a body system and go

 high: hyper-reflexive (+3, +4 [2 is normal]),

 tachypnea, tachycardia, borborygmi, seizure

- pH down = PT down -> body systems shut

 down (EXCEPT K+)

 -> acidosis - think of a system and go low:

 hypo-reflexive (+1, 0), bradycardia, lethargy,

 obtunded, paralytic illeus, respiratory arrest

• ex. which acid-base disorders need an ambu-bag at

the bedside? = acidosis (resp. arrest)

• ex. which acid-base disorders need suction at the

bedside? = alkalosis (seize and aspirate)

• Mac Kussmaul - Kussmaul’s (compensatory

respiratory mechanism) is only present in only 1 of

the 4 metabolic (acid-base) disorders

* M = metabolic AC = acidosis

• most common mistake with select all questions = selecting

one more than you should (stop when you select the ones

you know! don’t get caught up on the “could be’s”)

• Hint: don’t select none or all on select all that apply

questions (never only one and never all)

• Causes of Acid-Base Imbalance:

- scenarios and what acid-base disorder would

 result (what would cause an imbalance)

 ** DON’T MIX UP S&S and CAUSATION

- often what causes something is the opposite of the S&S

- ex. diarrhea will cause a metabolic acidosis but once

 you are acidotic your bowel shuts down and you get a

 paralytic illeus

• when you get scenarios:

 -> if it’s a lung scenario = respiratory

 - then check if the client is over-ventilating

 (alkalosis) or under-ventilating (acidosis)

 - remember to look at the words (ex. over, under,

 ventilating) -> “as the pH goes so goes my PT”

 -> VENTILATING DOESN’T MEAN RESPIRATORY

 RATE; resp. rate is irrelevant w/ acid-base,

 ventilation has to do with gas exchange not resp.

 rate (look at the SaO2 -> if your resp. rate is fast

 but SaO2 is low you are under-ventilating)

 -> ex. PCA pump - What acid-base disorder

 indicates they need to come off of it? = respiratory

 acidosis (resp. depression -> resp. arrest)

—> if it’s not lung, it’s metabolic

• metabolic alkalosis - really only one scenario = if

the PT has prolonged gastric vomiting/suctioning

- because you are losing ACID

 * ex. GI surgery w/ NG tube with suctioning for

 3 days; hyperemesis graviderum

- otherwise everything else that isn’t lung you

 pick metabolic acidosis (DEFAULT)

 * ex. hyperemesis graviderum w/ dehydration

 acute renal failure, infantile diarrhea

• remember, you only have 4 to pick from:

- respiratory alkalosis - respiratory acidosis

- metabolic alkalosis - metabolic acidosis

• pay more attention to the modifying phrases than

the original noun

- ex. person w/ OCD who is now psychotic (psychotic

 trumps OCD); hyperemesis with dehydration (pay

 attention to dehydration)

VENTILATION

• ventilators -> know alarm systems (you set it up so

that the machine doesn’t use less than or more than

specific amounts of pressure)

 a) high pressure alarm = increased resistance

 to airflow (the machine has to push too hard to

 get air into lungs)

 - from obstructions:

 i. kinks in tubing (unkink it)

 ii. water condensation in tube (empty it!)

 iii. mucous secretions in the airway (change

 positions/turn, C&DB, and THEN suction)

*** suction is only PRN!!!

 -> priority questions = you would check

 kinks first, suction is not first

 b) low pressure alarm = decreased resistance

 to airflow (the machine had to work too little

 to push air into lungs)

 - from disconnections:

 i. main tubing (reconnect it duh!)

 ii. O2 sensor tubing (which senses FiO2 at

 the airway/trach area; black coated wire

 coming from machine right along the

 tubing - reconnect!)

• ventilators -> know blood gases

- resp. alkalosis = ventilation settings might be

 set too high (OVER-VENTILATING)

- resp. acidosis = ventilation settings might be set

 too low (UNDER-VENTILATING)

• ex. weaning a PT off ventilator -> should not be

under-ventilated, they need the ventilator; if they are

over-ventilating then they can be weaned

• never pick an answer where you don’t do something

and someone else has to do something

I 11 .

Iftube disconnects From pt

→

wrap with 3 Sided occublue

tape Lor petroleum dressing)

LECTURE 2

ABUSE (Psych and Med-Surge)

Psychological Aspect/Psycho-Dynamics

• # 1 psychological problem is the same in any/all

abusive situations = DENIAL

- abusers have an infinite capacity for denial so that

 they can continue the behavior w/o answering for it

• can use the alcoholism rules for any abuse

- ex. # 1 psych problem in child abuse, gambling or

 cocaine abuse is denial

• why is denial the problem? HOW CAN YOU TREAT

SOMEONE WHO DENIES/DOESN’T RECOGNIZE

THEY HAVE A PROBLEM

• denial = refusal to accept the reality of a problem

• treat denial by CONFRONTING the problem (it’s not

the same as aggression which attacks the person, not

the problem) = they DENY you CONFRONT

- pointing out to the person the difference between

 what they say and what they do

- Hint: never pick answers that attack the person

 -> ex. bad answers have bad pronouns - “you”

 -> ex. good answers have good pronouns - “I”, “we”

 -> ex. “you wrote the order wrong” vs. “I’m having

 difficulty interpreting what you want”

• loss and grief -> for this denial you must SUPPORT it

- DABDA = denial, anger, bargaining, depression, acceptance

• Hint: for questions about denial, you must look to see

if it is LOSS or ABUSE

- loss/grief = support

- abuse = confront

• #2 psychological problem in abuse = DEPENDENCY,

CO-DEPENDENCY

- dependency = when the abuser gets significant other

 to do things for them or make decisions for them

 -> the dependent = abuser

- co-dependency = when the significant other derives

 positive self-esteem from making decisions for or

 doing things for the abuser

 -> the abuser gets a life w/o responsibilities

 -> the sig. other gets positive self-esteem (which is

 why they can’t get out of the relationship)

• how do you treat it?

- set limits and enforce them

 -> start teaching sig. other to say NO (and they

 have to keep doing it)

- must also work on the self-esteem of the co-dependent

 (ex. I’m a good person because I’m saying “no”)

• manipulation = when the abuser gets the sig. other

to do things for them that are not in the best interest of

the sig. other

- the nature of the act is dangerous/harmful

- how is manipulation like dependency?

 -> in both the abuser is getting the other person to

 do something for them

- how do you tell the difference between manipulation

 & dependency?

 -> NEUTRAL vs. NEGATIVE (look at what they’re

 being asked to do)

 -> if the sig. other is being asked to do something

 neutral (no harm) its dependency/co-dependency

 -> if the sig. other is being asked to do something

 that will harm them or is dangerous to them they

 are manipulated

• how do you treat manipulation?

- set limits and enforce them -> “NO”

- easier to treat than dependency/co-dependency

 because no one likes to be manipulated (no positive

 self-esteem issue going on)

• ex. how many PT’s do you have w/ denial? = 1

ex. how many PT’s do you have w/ dependency/co-

 dependency = 2

ex. how many PT’s do you have w/ manipulation = 1

Alcoholism

Wernicke’s & Korsakoff’s

- typically separate BUT boards lumps them together

- wernicke’s = encephalopathy

- korsakoff’s = psychosis (lose touch with reality)

 -> tend to go together, find them in the same PT

• Wernicke Korsakoff’s syndrome:

a) psychosis induced by Vit. B1 (Thiamine) deficiency

 - lose touch w/ reality, go insane because of no B1

b) primary symptom -> amnesia w/ confabulation

 - significant memory loss w/ making up stories

 - they believe their stories

• How do you deal w/ these PT’s?

- bad way = confrontation (because they believe what

 they are saying and can’t see reality)

- good way = redirection (take what the PT can’t do

 and channel it into something they can do)

• Characteristics of Wenicke Korsakoff’s:

a) it’s preventable = take Vit. B1 (co-enzyme needed

 for the metabolism of alcohol which keeps alcohol

 from accumulating and destroying brain cells)

 * PT doesn’t have to stop drinking

b) it’s arrestable = can stop it from getting worse by

 taking Vit. B1

 * also not necessary to stop drinking

c) it’s irreversible (70% of cases) -> Hint: On boards,

 answer w/ the majority (ex. if something is majority

 of the time fatal, you say it’s fatal even if 5% of the

 time it’s not)

• Drugs for Alcoholism:

DISULFIRAM (Antabuse)

= aversion therapy -> want PT’s to develop a gut

 hatred for alcohol

 -> interacts w/ alcohol in the blood to make you very ill

 -> works in theory better than in reality

 -> onset & duration: 2 weeks (so if you want to

 drink again, wait 2 weeks)

or reunbum?

- PT teaching = avoid ALL forms of alcohol to avoid

 nausea, vomiting & possibly death

 -> including mouthwash, aftershaves/colognes/perfumes

 (topical stuff will make them nauseous), insect

 repellants, any OTC that ends with “-elixer”, alcohol-

 based hand sanitizers, uncooked (no-bake) icings

 which have vanilla extract, red wine vinaigrette

• Overdoses & Withdrawals:

- every abused drug is either an UPPER or DOWNER

 -> the other drugs don’t do anything

 -> #1 abused class of drug that is not an upper or

 downer = laxatives in the elderly

a) first establish if the drug is an upper or downer

 - uppers (5) = caffeine, cocaine, PCP/LSD (psychedelic

 hallucinogens), methamphetamines, adderol (ADD drug)

 * S&S -> make you go up; euphoria, tachycardia,

 restlessness, irritability, diarrhea, borborygmi,

 hyper-reflexia, spastic, seize (need suction)

 - downers = don’t memorize names -> anything that

 is not an upper is a downer! if you don’t know what

 the med is, you have a high chance that it’s a

 downer if it’s not part of the uppers list

 * S&S -> make you go down; lethargy, respiratory

 depression (& arrest)

 - ex. The PT is high on cocaine. What is critical to assess?

 -> NOT resps below 12 because they will be high

 -> maybe check reflexes

b) are they talking about overdose or withdrawal

 - overdose/intoxication = too much

 - withdrawal = not enough

 - ex. the PT has overdosed on an upper -> pick the

 S&S of too much upper

 - ex. the PT has overdosed on a downer -> pick the

 S&S of too much downer

 - ex. the PT is withdrawing from an upper -> not

 enough upper makes everything go down

 - ex. the PT is withdrawing from a downer -> not

 enough downer makes everything go up

• upper overdose looks like = downer withdrawal

• downer overdose looks like = upper withdrawal

• In what 2 situations would resp. depression & arrest

be your highest priority:

 - downer overdose

 - upper withdrawal

• In what 2 situations would seizure be the biggest risk:

 - upper overdose

 - downer withdrawal

• Drug Abuse in the Newborn:

- always assume intoxication, NOT withdrawal at birth

- after 24 hrs -> withdrawal

- ex. caring for infant of a Quaalude addicted mom 24

 hrs. after birth, select all that apply:

 -> downer withdrawal so everything is up = exaggerated

 startle, seizing, high pitched/shrill cry

• Alcohol Withdrawal Syndrome vs. Delirium Tremens

- they are both different! not the same

a) every alcoholic goes through withdrawal 24 hrs.

 after they stop drinking

 - only a minority get delirium tremens

 - timeframe -> 72 hrs. (alcohol withdrawal comes 1st)

 - alcohol withdrawal syndrome ALWAYS precedes

 delirium tremens, BUT delirium tremens does not

 always follow alcohol withdrawal syndrome

b) AWS is not life-threatening; DT’s can kill you

c) PT’s w/ AWS are not a danger to self/others; PT’s

 w/ DT’s are dangerous to self/others

 - they are withdrawing from a downer so they will

 be exhibiting upper S&S

 - DT’s are dangerous

• RN’s can accept but RPN’s can’t (because PT is unstable)

- on med-surge, the RN who takes them must decrease

 their workload (i.e. reduce PT load if they take a DT PT)

 -> Hint: on boards, the setting is always perfect

 (i.e. enough staff/time/resources on the unit etc.)

Differences

in Care

AWS DT

Diet Regular diet NPO/clear liquids

(because of risk for seizures which

can cause risk of aspiration)

Room Semi-private

anywhere on

the unit

Private near nurses station

(dangerous & unstable)

Ambulation Up ad lib Restricted bed rest -> no bathroom

privileges (use bedpans/urinals)

Restraints No restraints

(because not

dangerous)

Restraints (because dangerous)

- not soft wrist or 4 point soft

 because they’ll get out

- need to be in vest or 2-pt. locked

 leathers (opposite 1 arm & leg,

 rotate Q2hrs, lock the free

 limbs 1st before releasing the

 locked ones)

They both get ANTI-HYPERTENSIVES &

TRANQUILIZERS

- because everything is up (downer withdrawal)

They both get MULTIVITAMIN w/ B1

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DRUGS

AMINOGLYCOCIDES

• powerful class of antibiotics (when nothing else

works pull these outs, the big guns)

- don’t use unless anything else works

• boards love to test these drugs because they’re

dangerous and are a test of safety

• think: A MEAN OLD MYCIN

-> a mean old = they treat serious, life-threatening,

 resistant, Gram-neg bacteria infections (i.e. a mean

 old antibiotic for a mean old infection)

-> mycin = what they end with (all end w/ -mycin)

** not all -mycin’s are aminoglycosides BUT most

 are (the 3 that are not are erythromycin,

 azithromycin, clarithromycin = throw it off the list!)

• 2 toxic effects:

i) when you see ‘-mycin’, think mice

 - mice -> ears -> otto toxic

 - monitor hearing, tinnitus, vertigo/dizziness

ii) the human ear is shaped like a kidney so next

 effect is nephrotoxicity

 - monitor creatinine (not BUN, output, daily weight)

 * creatinine = the best indicator of kidney/renal

 function (pick 24 hr. creatinine clearance over

 serum creatinine if both available)

• #8 (fits nicely in the kidney) reminds you about 2

things about these drugs

- toxic to cranial nerve 8 = ear nerve

- administer Q8

• route:

- IM or IV

• do not give PO -> they are not absorbed

- if you give an oral ‘-mycin’ it will go into gut, dissolve,

 go through and come out as expensive stool (won’t

 have any systemic effect)

- EXCEPT in 2 cases = bowel sterilizers:

 * hepatic encephalopathy (hepatic coma) = to get

 ammonia down, oral ‘-mycin’s’ will sterilize the

 bowel by killing Gram-neg bacteria (E. coli) to help

 bring down ammonia and won’t harm the

 damaged liver because it doesn’t go through the

 liver (also gives diarrhea, more poop out is good)

 * pre-op bowel surgery = it sterilizes the gut by

 killing the E. coli bacteria

- if oral, no otto or nephro toxicity because not absorbed

- these are neomycin & kanamycin

 * Who can sterilize my bowels? NEO KAN

• Trough and Peak levels:

- trough = drug at lowest

- peak = drug at highest

** TAP levels - trough administer peak

 -> draw trough levels first

 -> administer your drug

 -> draw peak levels after drug administration

• Why draw levels? = narrow therapeutic window

- small difference between what works and what kills

- if the drug has a wide range then you wouldn’t

 need to draw TAP levels

 * ex. Lasix doses range from 5-80mg thus a wide

 range so you won’t need TAP levels

 * ex. Dig doses range from 0.125 - 0.25 so this

 narrow range needs TAPS levels

• A MEAN OLD MYCINS = major class that needs

TAPs drawn because of narrow window

• When do you draw TAPS?

-> depends on the route (don’t focus on the med)

a) Trough Levels

** doesn’t matter which route or med, always 30 mins.

- sublingual = 30 mins. before next dose

- IV = 30 mins. before next dose

- IM = 30 mins. before next dose

- Sub-Q = 30 mins. before next dose

- PO = 30 mins. before next dose

b) Peak Levels

** different but depends on the route (not the med)

- Sublingual = 5-10 mins after drug is dissolved

- IV = 15-30 mins after drugs is finished infusing

 * Hint: if you get two values that are correct (i.e. a

 15 min. answer and a 30 min. one) pick the highest

 without going over so 30 mins.

- IM = 30-60 mins. after administration

- Sub-Q = SEE (see diabetes lecture -> because the

 only Sub-Q peaks are Insulins)

- PO = forget about it, too variable so not tested

The BIG 10 Drugs to Know:

1. psych drugs

2. insulins

3. anti-coagulants

4. digitalis

5. aminoglycosides

6. steroids

7. calcium-channel blockers

8. beta-blockers

9. pain meds

10. OB drugs

LECTURE 3

Cardiac DRUGS

CALCIUM-CHANNEL BLOCKERS

Calcium-Channel Blockers are like Valium for your heart

• Valium -> calm’s you down; so CCB’s calm your heart

down (ex. if tachycardic, give CCB’s but not in shock)

- to REST YOUR HEART

- not stimulants

• calcium-channel blockers are negative inotropic,

chronotropic, & dromotropic drugs

- fancy way of saying that they calm the heart down

• When do you want to “depress” the heart? What do

CCB’s treat?

A: anti-hypertensives

 - relax heart & blood vessels to bring down BP

AA: anti-angina’s

 - relax heart to use less O2 to make angina go away

 - treats angina by addressing oxygen demand

AAA: anti-atrial arrhythmia

 - ex. atrial flutter, A-fib, premature atrial contractions

 - never ventricular

*** what about supra-ventricular tachycardia??

 -> because it means ‘above the ventricles’ (which

 are the atria)

• Side-Effects:

H & H = headache & hypotension

 -> hypoTN - from relaxed heart & vessels

 -> headache - vasodilation to brain

 ** Hint: headache is a good thing to select for

 ‘select all that apply’ questions (ex. low Na & high

 Na = headache, high & low glucose = headache, high &

 low BP = headache)

• Names of Calcium-Channel Blockers:

- anything ending in ‘-dipine’

- ex. amlodipine, nifedipine

- NOT just ‘-pine’

- also includes: VERAPAMIL & CARDIZEM

- which can be given as continuous IV drip??

 = Cardizem

• What VS needs to be assessed before giving a CCB?

- BP = because of risk of hypoTN

 -> parameters/guidelines - hold CCB if systolic is

 under 100

 -> so you need to monitor BP if PT is on a Cardizem

 continuous drip (if it’s under 100 then you may

 have to stop or change the drip rate)

CARDIAC-ARRYTHMIAS

• Interpreting Rhythm Strips (4 that need to be known

by sight):

a) Normal Sinus Rhythm

 = P wave before every QRS & followed by a T

 wave for every single complex

 -> all P wave peaks are equally distant from each

 other, QRS evenly spaced

b) V-Fib = chaotic squiggly line, no pattern

c) V-Tach = sharp peaks, has a pattern

d) A-Systole = flat-line

• Terminology:

- if QRS depolarization, it’s talking about ventricular

 (so rule out anything atrial)

- if it says P-wave then it’s talking about atrial

• 6 Rhythms most tested on N-CLEX:

1. “a lack of QRS’s” = A-systole

 - flat-line, no QRS

2. “P-wave” = Atrial

 - if it’s a sawtooth wave, always pick atrial flutter

3. “chaotic” - A-fib if w/ P-wave

4. “chaotic” - V-fib if w/ QRS

 - Hint: the word ‘chaos’ is used for fibrillation

5. “bizarre” = atrial tachycardia if w/ P-wave

6. “bizarre” = ventricular tachycardia if w/ QRS

 - Hint: the work ‘bizarre’ is used for tachycardias

• PVC’s (premature ventricular contractions)

= a.k.a. periodic wide bizarre QRS

- ventricular because QRS

- bizarre -> tachycardia

- you can call a group of PVC’s a short run of V-tach

- do Physician’s care about PT’s having PVC’s?

 -> NO, not a high priority = low priority

 -> 3 circumstances when you could elevate these

 PT’s to moderate priority (never reach high)

 i. if there are more than 6 PVC’s in a minute

 ii. if there are more than 6 PVC’s in a row

 iii. if the PVC fall on the T-wave of the previous

 beat (R on T phenomenon)

 -> most common order if you call the MD about a

 PT w/ PVC’s = D/C monitor (because then you

 can’t see the PVC’s and then you won’t call them)

• Lethal Arrhythmia’s:

- HIGH PRIORITY, 2 main ones (will kill you in 8 mins

 or less) -> these PT’s will probably be top priorities

a) A-Systole

b) V-Fib

** both have in common = no cardiac output

 -> no brain perfusion (and you’ll be dead in 8 mins)

• V-tach = potentially life-threatening (but not actually

life-threatening), but still makes it a fairly high priority

 - difference is that these PT’s have cardiac output

• in codes, even if the rhythm changes, if there is no

cardiac output it’s just as bad as the previous rhythm

POSITIVE NEGATIVE

Inotropes Cardiac Stimulants

- stimulate, speed

 up the heart

Cardiac Depressants

- calm the heart down, Chronotropes weaken & slow down

Dromotopes

• Treatment (more drugs):

a) PVC’s b) V-tach

= for ventricular use LIDOCAINE/AMIODARONE

 * in rural areas more Lidocaine use (cheaper &

 longer shelf-life)

c) Supra-Ventricular Arrhythmia’s

= atrial arrhythmia’s use ABCD’s

 • A -> ADENOCARD (Adenosine)

 - have to push in less than 8 seconds (FAST IV

 push) -> slam this drug, followed by a flush; use a

 big vein; BUT the problem w/ slamming it fast is

 the risk of PT going into A-Systole (for 30 seconds

 but they will come out of it so don’t worry [unless

 longer than 30 sec…])

** for IV pushes: when you don’t know you go slow

 • B -> BETA-BLOCKERS

 - all end in ‘-lol’

 - every ‘-lol’ is a BB & every BB is a ‘-lol’

 - are negative inotropes, chronotropes, &

 dromotropes like calcium-channel blockers (a.k.a.

 valium for your heart so they treat A, AA, AAA &

 have same side-effects)

 ** generally speaking, don’t make a big difference

 between Beta- & Calcium channel blockers;

 except that CCB are better for PT’s w/ asthma

 or COPD -> Beta-B’s bronchoconstrict

 • C -> CALCIUM-CHANNEL BLOCKERS

 - see Beta-Blockers & CCB’s earlier

 • D -> DIGITALIS (DIGOXIN, LANOXIN)

d) V-Fib

= for V-fib you D-fib (shock them!)

e) A-Systole

= use EPINEPHRINE & ATROPINE (in this order!)

 -> if epinephrine doesn’t work then use atropine

CHEST TUBES

• purpose is to re-establish negative pressure in the

pleural space (so that the lung expands when the

chest wall moves)

- pleural space -> negative is good (negative pressure

 makes things stick together)

- ex. gun shot to the lung add positive pressure

• Hint: when you get a chest tube question, look at the

reason for which it was placed (will tell you what to

expect & what not to expect)

- ex. pneumothorax = to remove air (because air

 created the positive pressure)

- ex. hemothorax = to remove blood

- ex. pneumohemothorax = to remove blood & air

• Hint: Also, pay attention to the location of the tubes:

a) Apical = the chest tube is way up high, thus it is

 removing air (because air rises)

- ex. it’s bad if you’re apical tube is draining 200 mL or

 it is not bubbling

b) Basilar = at the bottom of the lungs, thus it is

 removing blood/liquid (because of gravity)

- ex. it’s bad if your basilar tube is bubbling or not

 draining any mL

• ex. How many chest tubes & where would you place them

for a unilateral pneumohemothorax?

 - 2 chest tubes (apical for pneumo, basilar for hemo)

• ex. How many chest tubes & where would you place them

for a bi-lateral pneumothorax?

 - 2 tubes (apical on left, apical on right)

• ex. How many chest tubes & where would place them for

post-op chest surgery?

 - 2 tubes (apical & basilar on the side of the surgery)

 ** you are to assume that chest surgery/trauma is

 unilateral unless otherwise specified (they will

 say bilateral)

• Trick Question: How many chest tubes would you

need and where would you place them for a post-op

right pneumonectomy?

- NONE! because you are removing the lung so you

 don’t need to re-establish any pressure (there is not

 pleural space)!

Troubleshooting Chest Tubes:

• What do you do if you knock over the plastic

containers that certain tubes are attached to?

 -> set it back up & have PT take some deep breaths

 -> NOT a medical emergency! (don’t call MD)

• What do you do if the water seal breaks (the

actual device breaks?)

-> first = CLAMP it!!! because now positive pressure

 can get in! don’t let anything get in

-> 2nd = cut the tube away from the broken device

-> 3rd = stick that open end into sterile water

-> then unclamp it because you’ve re-established the

 water seal (doesn’t need clamp if it’s under water

 *** better for the tube to be under water than

 clamped! -> air can’t go in and stuff can still keep

 coming out (if clamped, nothing can come out

 which is what the tube is for)

• Ex. If they ask what the first thing is to do if the seal

breaks -> Clamp! BUT, if they ask what’s the best

thing to do -> put end of tube under water! (because it

actually solves the problem, clamping is a temp. fix)

• Hint: ‘BEST’ vs. ‘FIRST’ questions

- first questions = are about what order

- best questions = what’s the one thing you would do if

 you could only do 1 of the options

-> ex. You notice the PT has V-fib on the monitor. You

 run to the room and they are non-responsive with

 no pulse. What is the first thing you do?

 A) place a backboard?

 B) begin chest compressions?

 - “first” is about order so = pick A (because you

 wouldn’t start chest compressions first)

 - BUT, if the question ask “What’s the best thing to

 do?” -> you only get to do 1 thing not the other so

 you would pick B

• What do you do if the chest tube gets pulled out?

- first = take a gloved hand and cover the hole

- best = cover the hole with vaseline gauze

• Bubbling chest tubes: (ask yourself 2 questions)

a) Where is it bubbling?

b) When is it bubbling?

= the answer will depend on these 2 questions

 (sometimes bubbling is good, sometimes bad but

 depends on where & when)

- ex. Intermittent bubbling in the water seal -> GOOD

 (document it, never bad!)

- ex. Continuous bubbling in the water seal -> BAD

 (you don’t want this, means a leak in the system that

 you need to find and tape it until it stops leaking)

 ** in RPN scope

- ex. Intermittent in suction control chamber -> BAD

 (means suction is not high enough, turn it up on the

 wall until bubbling is continuous)

- ex. Continuous in suction control chamber -> GOOD

 (document it)

- Hint: both locations are opposites of each other

 (memorize one & deduce the others)

 —> if there is a seal it should not be continuous

 (ex. a sealed bottle of pop continuously

 bubbling means it’s leaking!)

• A straight catheter is to a foley catheter as a

thoracentesis is to a chest tube.

- in-&-out vs. continuous secured

- thoracentesis -> also helps re-establish neg.

 pressure (in-&-out chest tube)

- higher risk for infections are continuous

Rules for Clamping Tubes:

• a) Never clamp a tube for more than 15 seconds

 without a doctors order.

 - so if you break the water seal -> you have 15

 seconds to get that tube under water

• b) Use rubber-tipped doubled clamps.

 - the teeth of the clamp need to be covered w/

 rubber so that you don’t puncture the tube

CONGENITAL HEART DEFECTS

• every congenital heart defect is either TROUBLE or

NO TROUBLE (ALL BAD or NO BAD)

- either causes a lot of problems or it’s no big deal (no

 in-between defect)

• memorize one word: TRouBLe

• ex. You are teaching the parents about a heart defect:

- pick all the options that cause trouble

• Hint: Boards will not give pictures of defects and ask

you what they are.

- not our job, we don’t diagnose

- our role is teaching parents the implications

 -> so if it’s trouble = teach them things that it’s going

 to be a lot of trouble

 -> if it’s not trouble = pick the things saying it’s not

 going to be trouble

• There are 40+ congenital heart defects so just remember

TRouBLe (don’t memorize all of them!):

- Hint: all congenital heart defects that start w/ the

 letter T are Trouble Defects

- we don’t care about the defect, we care about what

 we’re teaching the parents

• All congenital heart defect kids (trouble or no trouble)

will have 2 things:

a) Murmur

- why? = because of the shunting of the blood

 (regardless of direction of shunt)

b) all have an Echocardiogram done (to find out

 what the defect is or why there’s a murmur)

• 4 Defects of Tetralogy of Fallout:

- VarieD PictureS Of A RancH (or Valentines Day Pick

 Someone Out A Red Heart)

1. VD = ventricular defect

2. PS = pulmonary stenosis

3. OA = overriding aorta

4. RH = right hypertrophy

• don’t have to recall these, RECOGNIZE them

- recall -> remember from nothing

- RECOGNIZE -> spot it when you see it (use the

 initials to recognize them in questions)

• ONLY DEFECT where they ask you what it is

Heart Defects TRouBLe (95% of

all heart defects)

No Trouble

Surgery NEED surgery now

to live - don’t need surgery

 right away; possibly

 need it years later if it

 causes a Trouble (but we don’t expect it to)

Growth & Dev. slow, delayed normal

Life Expectancy short normal

Parent’s

Experiencing grief, stress,

financial issues, lots

of caregiving issues

regular average person

issues

Going Home apnea monitor no apnea monitor

Hospital Stay at

Birth

weeks 24-48 hours

Who Follows

Your Care

Paediatric

Cardiologist Paediatrician,

paediatric NP

Shunting R to L

(TRouBLe)

L to R

Cyanosis Cyanotic -> Blue

(TRouBLe) Acyanotic

INFECTIOUS DISEASE and TRANSMISSION BASED

PRECAUTIONS (Isolations)

• Standard

• Universal

• Contact

- for anything enteric = can be caught from intestine

 -> fecal, oral

- C-Diff, Hep. A, Cholera, Dysentery

 * things with bugs in diarrhea

 * Hint for Hep A & B: Hep A -> think anus, Hep B ->

 think blood (anything from the bowel starts w/ a vowel)

- Staph infections

- RSV = respiratory syncytial virus (what babies, 1-2

 yr. old’s get that is not dangerous to adults but can

 be fatal for them)

 * transmitted by droplet BUT still put them on

 contact precautions because little kids catch it

 from touching things that other sick kids touched

- Herpes infections (includes Shingles -> Herpes

 Zoster virus even though caused by varicella)

- What’s involved in contact precautions?

 -> private room is preferred (but not required)

 * or 2 RSV kids in the same room

 * keep RSV kid & suspected RSV separate

 because you need positive cultures (not based

 on symptoms)

 -> NO: mask, eye/face shield (unless for universal),

 special filter mask, PT mask, neg. air flow

 -> YES: gloves, gown, hand-washing, special

 supplies & dedicated equipment (includes toys)

** disposable supply vs. dedicated equipment:

 - thermometer cover - BP cuff that stays in room

• Droplet

- for bugs that travel 3 feet on large particles due to

 sneezing/coughing

- all meningitis

 * cultured through lumbar puncture

- H Flu (haemophilus influenza B) -> commonly

 causes epiglotitis

 * never stick something down throat because it will

 cause obstruction

- What’s involved in droplet precautions?

 -> private room is preferred (but not required)

 * on boards select private

 * can also cohort based on positive cultures

 -> NO: gown, eye/face shield, special filter mask,

 neg. air flow

 -> YES: mask, gloves, hand-washing, PT worn

 mask (when leaving room), disposable supplies

 & dedicated equipment

• Airborne

- M-M-R; TB; varicella (chicken pox)

- What’s involved in airborne precautions?

 -> private room is required

 * unless co-horting

 -> NO: gown (mostly for contact), eye/face shields

 -> YES: mask, gloves, hand-washing, special-filter

 mask ONLY for TB, PT mask for leaving room

 (but really shouldn’t be leaving), neg. air flow

 ** disposable supplies & dedicated equipment is a

 good thing but not really as essential as in the

 other 2 (can let this one slide)

 -> TB: technically transmitted via droplet BUT put

 on airborne

• PPE = Personal Protective Equipment

- boards like to test how you put on or take off

- always take it off in alphabetical order

 -> ex. gloves, goggles, gown, mask

- putting on is reverse alphabetically for the ‘g’s’ &

 mask comes 2nd

 -> gown, mask, goggles, gloves

LECTURE 4

CRUTCHES, CANES, WALKERS

• major area of human function is locomotion so they test

these even though not a major emphasis in school

- area to test PT teaching & risk reduction

Crutches:

• How do you measure crutches?

** need to know for risk reduction -> so you don’t

 cause nerve damage

a) length of crutch = 2-3 finger-widths below anterior

 axillary fold to a point lateral to & slightly in front of the foot

 -> many questions ask where you measure from/to (so for

 crutches, if they ask anything measuring from axilla to

 foot -> rule out, they’re wrong instructions for length)

b) hand grip = can be adjusted up & down; when properly

 placed, should be apx. 30 degrees elbow flexion

• How to teach crutch gaits (4 kinds):

 ** names are pretty obvious w/ a few exceptions

a) 2-point

- move a crutch and opposite foot together followed

 by other crutch & opposite foot

- moving 2 things together

b) 3-point

- moving 2 crutches & the bad leg together

- moving 3 things together

c) 4-point

- moving everything separately

- move any crutch, then opposite foot, followed by

 next crutch then other foot

- very slow but very stable

d) Swing-through

- for non-weight bearing injuries (ex. amputations)

- plant crutches and swing the injured limb through

 (never touches down)

• When do they use them?

- ask yourself “how many legs are affected?”

- even for even, odd for odd

 * even point gaits when a weakness is evenly

 distributed (i.e. even # of legs messed up)

 - 2-point = mild problems (bilateral)

 - 4-point = severe problems (severe, bilateral

 weaknesses)

 - 3-point = only odd one, when only 1 leg is affected

• Ex. Early stages of rheumatoid arthritis = 2-point

Ex. Left, above the knee amputation = swing-through

Ex. First day post-op right knee replacement, partial weight-

 bearing allowed = 3-point

Ex. Advanced stages of ALS = 4-point

Ex. Left hip replacement, 2nd day post-op, non weight-bearing

 = swing-through

Ex. Bilateral total knee replacement, 1st day post-op, weight-

 bearing allowed = 4-point

Ex. Bilateral total knee replacement, 3 weeks post-op = 2 point

• Going up & down stairs:

- up with the good, down with bad

- crutches move with the bad leg

Cains:

• hold the cain on the strong side

- a lot of people use it the wrong way

Walkers:

• pick it up, set it down, walk to it

• if they must tie their belongings to the walker, tie it at

the sides, not the front

- boards doesn’t like things on the front (even tho most

 people do that anyways; they don’t like wheels or tennis

 ball on the bottom either)

DELUSIONS, HALLUCINATIONS, & ILLUSIONS (Psych)

Neurosis Non-Psychotic vs. Psychosis

• Hint: the first thing you have to do to get a psych

questions correct is decide: “Is my PT non-psychotic

or psychotic?”

= this will determine treatment, goals, prognosis,

 medication, length of stay, legalities…everything

Psychotic Symptoms:

• a) Delusions

= false, fixed, idea or belief; no sensory component

 (all in the brain, thinking it)

 i. Paranoid Delusions -> people are out to harm me

 - ex. the mafia are out to get me

 ii. Grandiose Delusions -> you are superior or you

 are the world’s smartest/greatest person

 - ex. thinking you are Christ, Genghis Khan

 iii. Somatic Delusions -> about a body part

 - ex. x-ray vision; there are worms in my body

• b) Hallucinations

= a false, fixed, sensory experience (purely sensory);

 5 senses so 5 for (1 for each sense)

 i. Auditory -> hearing things that aren’t there (primarily

 voices telling you to hurt yourself); most common

 ii. Visual -> seeing; 2nd most common

 iii. Tactile -> feeling things; 3rd most common

 iv. Gustatory -> tasting things that are not there

 v. Olfactory -> smelling things that are not there

 *** last 2 are relatively rare

• c) Illusions

= misinterpretation of reality; sensory experience

- difference from hallucination -> with an illusion there

 is a referent in reality

 -> referent = something in reality to which a person

 refers when they say something (they just

 misinterpret it)

• ex. PT says: “I hear demon voices” -> hallucination

ex. PT overhears nurses & MD’s laughing & talking at the nurse’s

 station & says: “Listen, I hear demon voices” -> illusion (there

 is a referent)

ex. person staring at a wall & says: “I see a bomb” -> hallucination

ex. person looks at fire extinguisher on the wall and says: “I see a

 bomb” -> illusion (referent)

• Hint: On the test, they will tell you that there is

something there thus, you can differentiate between a

hallucination & an illusion.

How do you deal with these Psychotic Symptoms?

• first thing you ask after determining if PT is psychotic:

What is their problem?

—> what kind of psychosis do they have?

• 3 Types of Psychosis:

1. Functional Psychosis

- can function in everyday life (i.e. have jobs, a

 marriage, etc.)

- 4 diseases: Schizo Schizo Major Manics

 i. Schizophrenia

 ii. Schizoaffective Disorder

 iii. Major Depression (if it’s major, test will say)

 iv. Manic (Acute)

 -> so bi-polar is functional, only psychotic

 during manic phase

- these PT’s have the potential to learn reality

 (because no damage)

 -> may need meds or set boundaries for structure

 -> nurse role = teach reality (4 steps)

 a) acknowledge feeling -> “I see you’re angry;

 “You seem upset”, “Tell me how you are feeling”,

 often uses the word feeling or shows a feeling

 b) PRESENT REALITY -> “I know that those voices

 are real to you but I don’t hear them” or telling

 them what is real (“I’m a nurse & this is a hospital”)

 c) set a limit -> “That topic/behavior is off-limits”,

 “We are not going to talk about that right now”,

 “Stop talking about that”

 d) enforce the limit -> “I see you’re too ill to stay

 reality based so our convo is over” (ending the

 conversation NOT taking away a privilege [i.e.

 punishment]; continuing to talk may enforce the

 non-reality)

 *** on the test, they won’t ask these specific steps but

 instead, will ask “how should the nurse respond…”

 *** try to pick the more positive statements (i.e. what

 they can have/do, not what they can’t); if between

 2 statements go w/ the positive one

• 2. Psychosis of Dementia

- psychosis because of actual damage to the brain

 * in Functional Dementia, there is no brain damage;

 it’s just messed up chemicals

- include PT’s w/ Alzeimer’s, psychosis after a stroke,

 organic brain syndrome; anything w/ “senile” or

 “dementia”

- cannot learn reality

 -> major difference from functional (which is why

 you have to determine type of psychosis)

NON-PSYCHOTIC PSYCHOTIC

Definition Has insight & is

reality-based

- even w/ emotional

 distress/illness,

 mental/behavioral

 disorder

- recognize what the

 problem is and how

 it affects their life

Has no insight & is not

reality-based

- don’t think/know their sick

- think everyone else has

 the problem but not them

 (blame anyone else)

- even if they say they’re

 sick but then they say the

 martians made them sick

 they don’t have insight

Treatment/

Techniques - good therapeutic

 communication (like any PT that displays

 good comm. skills)

** there’s nothing

special that you need

to do/know compared

to any med-surge,

paeds, or OB PT

- good therapeutic

 communication does not

 work because they are

 not rational

- need unique, specific

 strategies

Symptoms don’t have delusions,

hallucinations, or

illusions

DELUSIONS,

HALLUCINATION,

ILLUSIONS

- only in psychotic PT’s

- as soon as they get any

 of these they’ve crossed

 the line to being psychotic

 -> nurse role:

 a) acknowledge feeling

 b) REDIRECT them -> from something they can’t

 do to something they can do

 ** you don’t set-limits because it’s mean

 ** NOT APPROPRIATE to present reality to these

 PT’s when they are experiencing psychotic

 symptoms (BUT don’t confuse this w/ reality

 orientation)

 -> important to remember that forgetting things (like

 where they are or what room they’re in - PT’s w/

 dementia/Alzheimers) is NOT psychosis

 ** when they start having delusions, hallucinations or

 illusions, then they are psychotic

 -> reality orientation = telling them person, place,

 and time (ALWAYS APPROPRIATE w/

 DEMENTIA) - this deals w/ memory

3. Psychotic Delirium

 = a temporary, sudden, dramatic, episodic,

 secondary loss of reality; usually due to some

 chemical imbalance in the body

 * different because it’s temporary and very acute

 -> include PT’s that are short-term psychotic because

 of something else causing the psychosis

 - ex. a drug reaction, high on uppers or withdrawing

 from downers (delirium tremens), cocaine overdose,

 post-op psychosis (withdrawing from a downer), ICU

 psychosis (sensory deprivation), UTI (or any occult

 infection), thyroid storm, adrenal crisis

 - good thing is it’s temporary so focus is removing

 the underlying cause & keeping them safe

 -> nurse role:

 a) acknowledge feeling

 b) REASSURE them: it’s temp. & they’ll be safe

 ** don’t present reality -> they won’t get it

 ** don’t redirect -> not going to work

• Personality Disorders are different:

A = antisocial

B = borderline

N = narcissistic

** very sick personality disorders

** may be good to use Functional Psychosis

 techniques because you set limits

Other Psychotic Symptoms:

• Loosening of Association

= your thoughts aren’t wrapped too tight, all over the map

a) Flight of Ideas

 - coherent phrases but the phrases are not

 connected (not coherent together)

b) Word Salad

 - sicker, can’t even make a coherent phrase

 -> babble random words

c) Neologism

 - making up imaginary words

• Narrowed Self Concept

= when a psychotic refuses to leave their room or

 change their clothes

- functional psychotic

- #1 reason is because their definition of self is

 narrowed -> defined self based on 2 things:

 i. Where they are

 ii. What they are wearing

 *** so they don’t know who they are unless they are

 wearing those exact clothes in that exact room

- as the nurse, don’t make them change or leave the

 room (will cause escalating panic because they will

 lose their concept of self)

 * use the Functional Psychosis techniques

• Ideas of Reference

= think everyone is talking about you

- ex. see someone on the news and get upset

 because you think they are talking about you

- can have both paranoia & ideas of reference

 (paranoia if also think they are going to harm you)

LECTURE 5

DIABETES M.

• definition = an error of glucose metabolism

- causes issues because glucose is the primary fuel

 source and if your body can’t metabolize glucose,

 cells will die

• does not include diabetes insipidus = polyuria,

polydipsia leading to dehydration due to low ADH

 -> it’s just similar with the fluids, not the glucose part

 (similar symptoms)

- opposite syndromes of diabetes i. = SIADH

• relationship between amount of urine & specific

gravity of urine:

- they are opposites/inverse

- i.e. the less urine out, the higher the specific gravity;

 the more urine out, the lower the specific gravity

 * so diabetes = has more urine & low specific

 gravity (opposite with SIADH)

TYPE I vs. TYPE II:

Diet:

• primarily Type II

• a) It is a calorie restriction.

- tells you that calorie’s are important because the

 diet’s are named (ex. 1500 calorie…)

 *** this is the best strategy for them

• b) They need 6 small feedings a day.

- keeps blood sugar levels more normoglycemic

 throughout the day instead of 3 big peaks

Insulin:

• lowers blood glucose

• 4 main types you really need to know:

1. Regular Insulins -> the “R” is important

 - ex. Humulin R, Novalin R

 - onset = 1 hr.

 - peak = 2 hrs.

 - duration = 4 hrs.

 - is clear (solution) so it can be IV dripped (this is

 the one used if using IV’s)

 - short, rapid acting insulin (but Hesi will call it

 intermediate because we now have Lispro which

 acts faster)

2. N P H

 - true intermediate acting insulin

 - onset = 6 hrs.

 - peak = 8-10 hrs.

 - duration = 12 hrs.

 - is cloudy (suspension)

 * the issue w/ suspensions is that it precipitates

 -> the particles fall to the bottom over time so

 you CANNOT give via IV (or the PT will

 overdose & the brain will die)

 * Hint: general rule => never put anything

 cloudy in an IV bag

3. Lispro (Humalog)

 - fastest acting, rapid

 - onset = 15 mins.

 - peak = 30 mins.

 - duration = 3 hrs.

 - you give this as they being to eat so with meals

 (not ac) -> interrupt them while eating!

4. Lantus (Glargine)

 - long acting

 - peak = no essential peak because it’s so slowly

 absorbed -> thus, little to no risk for hypoglycemia

 - duration = 12-24 hrs.

 - only insulin you can safely & routinely give at

 bedtime because it will not cause them to go

 hypoglycemic during the night (YOU CANNOT

 ROUTINELY GIVE THE OTHERS AT BEDTIME)

** Hint: boards likes to test peaks & tend to test it by

 giving you a time when insulin was given & asking

 when they reach hypoglycemia (which is the peak).

• CHECK EXPIRY DATES ON INSULIN!!!

- What action by the nurse invalidates the

 manufacturer’s expiration date? = opening it

 -> the minute you open it the date is irrelevant

 because now you have 30 days from opening

 (have to write the date of opening & new expiry)

- refrigeration is optional in the hospital BUT you

 need to teach PT’s to refrigerate at home

 -> though at the hospital the ones that should be

 refrigerated should be the un-opened vials

- better to give warm, non-expired insulin than cold,

 expired insulin

Exercise:

• exercise potentiates insulin

= meaning, it does the same thing as insulin

—> think of exercise as another shot of insulin

- if you have more exercise during the day, you need

 less insulin shots (and bring easily metabolized

 carbs/snacks to sports games)

Differences TYPE 1 DM TYPE 2 DM

Names - Insulin dependent

- Juvenile onset

- Ketosis prone

- Non-insulin dependent

- Adult-onset

- Non-ketosis prone

S&S - polyuria

- polydipsia

- polyphagia (increased

 swallowing, but in

 context of DM it also

 relates to eating)

- same

Treatment D = diet —> least

 important (less

 restrictions than before)

I = insulin —> MOST IMPORTANT

E = exercise

D = diet —> MOST

 IMPORTANT

O = oral hypoglycemic (pills)

A = activity

→ if give N at 3- 5 pm then

when will

you check for

hypoglycemia?

writeEXP

in a

or day open in a

day

Sick Days:

• when a diabetic is sick -> GLUCOSE GOES UP

- need to take their insulin even if they’re not eating

• need to take sips of water because diabetics get

dehydrated

• any sick diabetic is going to have the 2 problems

of hyperglycemia & dehydration -> ALWAYS!

• stay as active as possible because it helps lower

glucose (even if they’re not eating when sick)

Complications of Diabetes:

 = 3 acute and a boatload of chronics

ACUTE

• 1. Low Blood Glucose (in both types)

- a.k.a. insulin shock, insulin reaction, hypoglycemia,

 hypoglycemic shock

- What causes this?

 -> not enough food

 -> too much insulin/medication (primary cause)

 -> too much exercise

- the danger is brain damage which becomes

 permanent (so be careful not overmedicate!)

- S & S:

 -> drunk in shock

 = think of how people look while drunk -> slurring,

 staggering, impaired judgement, delayed

 reaction time, labile (emotions all over)

 ** from cerebrocortical compromise

 = shock -> low BP, tachycardia, tachypnea, cold/

 pale/clammy skin, mottled extremities

 ** from vasomotor compromise

- Treatment:

 a) Administer rapidly metabolizable carbohydrate

 (i.e. sugars)

 -> ex. any juice, reg. pop, chewable candy, milk,

 honey, icing, jam

 b) BUT combine/follow w/ a starch or protein

 -> ex. cracker, slice of turkey

 *** skim milk is great because it gives both

 - bad combo is too much simple sugars (like pop & candy)

 - if unconscious give Glucagon (IM) or IV Dextrose

 (D10, D50) -> how do you determine which to give?

 = the setting (i.e. family calling from home, tell

 them to give IM but if in ER give IV)

 ** hard to get a vein because of vasoconstriction

• 2. High Blood Glucose in TYPE I = Diabetic Coma/

 DKA (Diabetic Keto-acidosis)

 -> Hint: Type I is also called “ketosis-prone”

- What causes this?

 -> too much food

 -> not enough medication

 -> not enough exercise

 *** none of these are the #1 cause because it is

 acute viral upper respiratory infections (w/in the

 last 2 weeks)

 - PT contracts upper resp. infection -> recovers

 w/in 3-5 days like everyone BUT after initial

 recovery, they start going downhill & getting

 more lethargic

 * so, if they come into the ER you should ask

 if they’ve had a viral upper resp. infection in

 the last 2 weeks

 -> what causes the high glucose is the stress of the

 illness that was not “shut off” and they start

 burning fats for fuel -> ketosis

- S & S:

 -> spell out D K A

 - D = dehydration

 - K = ketones (in blood), kussmaul’s, high K+

 * you can have ketones in your urine & not

 have DKA

 - A = acidotic (metabolic), acetone breath,

 anorexia (due to nausea)

 -> hot & flushed, dry = water is a coolant! if you

 lose water (as in dehydrate) you loose coolant

- Treatment:

 -> fast rate IV fluids (ex. 200/hr.), w/ reg. insulin in

 the bag

• 3. High Blood Glucose in TYPE II = HHNK/HHS

 (Hyperglycemic Hyperosmolar Non-Ketotic

 Syndrome)

= this is dehydration (for any HHNK/HHS question

 just call it DEHYDRATION)

- so think of the S&S of dehydration (low water, hot

 temp, flushed, dry)

- nursing diagnosis = fluid volume deficit

- #1 intervention -> giving fluids!

- outcomes you want to see = increased output, BP

 coming up, moist mucus membranes etc.

 ** so all the outcomes of a PT coming out of

 dehydration

- Why do these PT’s only get the D (& not the K & A)?

 -> they don’t burn fats (which make the ketones)

• Which one is insulin the most essential in treating?

= DKA

 -> you don’t have to use insulin w/ HHNK because

 you mostly need to re-hydrate them

• Which has a higher mortality rate?

= HHNK

 -> DKA’s tend to be a higher priority and symptoms

 are much more acute; HHNK’s tend to come in to

 ER later than they should because symptoms are

 not as visible & they end up getting worse (so by

 the time they come in it might be too far gone)

• Who would die first if didn’t treat them? (more lifethreatening)

= DKA

 -> but they tend to get treated in time

Long-term Complications:

• related to 2 problems:

a) poor tissue perfusion

b) peripheral neuropathy

• ex. Diabetics have renal failure. What would this be due to?

 -> poor tissue perfusion

ex. Diabetic PT has lost control of their bladder and are now

 incontinent. -> peripheral neuropathy

ex. PT can’t feel it when he injures himself. -> peripheral

 neuropathy.

ex. PT doesn’t heal well when he injures himself. -> poor

 tissue perfusion

Which lab test is the best indicator of long-term

blood glucose control?

• the hemoglobin A1C (HA1C), the glycosated/

glycosylated hemoglobin (all the same)

• numbers:

- 6 & lower is what you want to see

- 8 & above means you’re out of control

** what about 7? = border

 -> so they need to work done, evaluation, may

 have to go to hospital, may have an infection

 somewhere

• Hint: Boards doesn’t test units so just remember the

numbers!

LECTURE 6

DRUG TOXICITY

• 5 main ones to know

-> tests nurse safety

-> remember, they don’t test units

1. LITHIUM

• for the mania in bi-polar

• therapeutic level = 0.6 - 1.2

• toxic level = > 2

• What about between 1.2 - 2???

-> no books agree on what is going on in between

 those levels (grey area)

-> boards would not give you any values in the grey

 area (because item writers for the NCLEX need to

 test on what the books agree and books agree that

 over 2 is toxic)

2. DIGOXIN (LANOXIN)

• used to basically treat 2 things:

a) A-fib

 -> remember the ABCD’s of treating atrial arrythmias

b) congestive heart failure

• therapeutic level = 1 - 2

• toxic level = > 2

*** NOTE: both have 2! -> so if the question uses the

 value of 2, call it toxic (safer to call something

 toxic when it may not be than to say that it’s

 therapeutic when it might not be)

• take the apical heart rate before giving Dig

3. AMINOPHYLLINE

• airway antispasmodic

- technically not a bronchodilator -> it doesn’t

 stimulate beta-2 agonist cells to bronchodilate

- it just relaxes a muscle spasm

 -> in spasms = airway is narrow

 -> when you relax a spasm, airways widen (which

 is why it looks like a bronchodilator)

 * ex. epinephrine is a bronchodilator

• ex. sometimes PT’s come in w/ an acute asthamatic

attack & the bronchodilators aren’t working -> because

they are in an acute, lock-down spasm & the spasm is in

the way of the bronchodilator

 = give them aminophylline first to relieve the spasm

 = then you can give the bronchodilator after and it

 will work

• therapeutic level = 10 - 20

• toxic level = > 20

4. DILANTIN (PHENYTOIN)

• anticonvulsant; treat seizures

• therapeutic level = 10 - 20

• toxic level = > 20

5. BILIRUBIN

• waste product from the breakdown of RBC’s

• Hint: Boards will only test bili’s in newborns

- normal adult bili = 1-2 (low)

- newborns have higher levels from breaking down

 RBC’s from mom = 5 +

• therapeutic level -> elevated level = 10 - 20

- ex. if newborn has 9.9 it’s high but still “normal”

• bilirubin toxicity = > 20

- right around 14-15 is when MD’s start thinking about

 hospitalization because once you’re at 15, you’re

 halfway to toxic (don’t want it to get to 18 or 19, too

 close to toxic)

• pathologic jaundice = bili high & infant yellow at birth

- come out yellow

• physiologic jaundice = bili is normal at birth but over

the next 2-3 days it goes high

- becomes yellow

• HINT:

- for the two “L” drugs = 2 (pick the lower number)

- the other one’s = 20 (pick the higher #)

Kernicterus & Opisthotonos:

• kernicterus = bilirubin in the brain when it crosses

the BBB (condition) -> is in the brain, in the CSF, in

the meninges

- different from jaundice = yellow color from too much

 bilirubin in the skin

- usually occurs when you reach levels of 20

- bili in the brain causes aseptic meningitis & aseptic

 encephalitis; can be lethal

• opisthotonos = position the baby assumes when

they have bilirubin in the brain

= severe hyperextension due to the irritation of the

 meninges w/ the bilirubin

 -> newborns have high flexibility so when they

 hyperextend they’re heels will touch their ears &

 they will be rigid

 -> if you see a kid w/ levels of 15 extending the

 neck they need follow-up immediately (medical

 emergency)

• ex. In what position do you place an opisthotonic

child? = on their side

ABDOMINAL

DUMPING SYNDROME vs. HIATAL HERNIA

• both gastric emptying issues & are kind of opposites

 -> memorize one & you have the other

Hiatal Hernia:

• regurgitation of acid into the esophagus because the

upper part of your stomach herniates upward through

the diaphragm

- your stomach should stay in the abdominal cavity

• w/ this, you have a 2-chamber stomach (like having

 2 stomachs) -> band around the midd