Mark Klimek Notes-Nclex Resources

1Mark Klimek notes

How to guess

1. Use knowledge

2. Common sense

3. Guessing strategy

Psych

 Nurse will examine own feeling about something-so do not counter transfer

 Establish trust relationship

Nutrition

 Pick chicken not fried chicken

 Fish but not shellfish

 Never pick casseroles for kids

 Never mix meds in food

 Toddlers-finger foods

 Preschool-one meal a day is OK. Leave them alone

3 expectations to have

 Do not expect 75 questions-think 265

 Do not expect to know everything

 Do not expect everything will go right

Pharm

 Most tested area is side effects

 Do not worry about route or dose

 If know what drug does but do not know side effect-pick a side effect in same body systemthedrugisworking

 No idea what the drug is-look to see if it is PO-pick GI side effect

 Never tell kids that med is candy

OB-check fetal HR

Med Surg

 1

st thing assess-LOC

 1

st thing do-establish airway

Peds

 All based on principle-give child more time to grow and develop

 When in doubt-call it normal

 When in doubt-pick the older age

 When in doubt-pick the easier task-more time to do the harder one

2General

 Rule out absolutes

 If 2 answers say same thing-neither is correct

 If 2 answers are opposite-one is probably right

 Umbrella strategy

 If questions has 4 right answers and ask for priority of needs of a patient-worse consequences game-worstoutcome

 When stuck between two answers-read the question

Sesame street rule-use only as last option

 Right answer tends to be different than the rest

 Wrong answers are usually all similar

 Right answer is most unique or different

Answer based on what you know, not what you don’t know

 If you dont know something in a question-pull it out of the equation-use common sense

 Nclex also testing on common sense-do not overanalyze-do not think like a nurse

 Go with gut answer-only if other answer is superior

3Prioritization

 Decide who is sickest or healthiest--->based on question

 ABC does no work with prioritization questions

 Answers will have 4 parts

 Age

 Gender

 Diagnosis

 Modifying phrase

 2 are irrelevant ---->age and gender

 In Peds pay attention to age but in prioritization age is not important

 Modifying phrase most important

 Ex: pt has angina pectoris vs MI ----> MI is high priority

 Pt has angina pectoris and unstable BP vs MI with stable VS ---->angina with unstable BPisnowthepriority

4 rules to prioritization

1. Acute beats (higher priority than) chronic

Example: COPD versus appendicitis--->appendicitis is the priority

2. Fresh postop (<12>

Example: 2 hr post op versus appendicitis--->2 hr post op is the priority

3. Unstable beats stable

Stable words Unstable words

 Stable

 Chronic illness

 Post op >12 hrs

 Local or regional anesthesia

 Lab abnormalities A or B level

 Unchanged assessments

 To be discharged

 Ready for discharge

 Admitted longer than 24 hrs ago

 Experiencing the typical expected S/S of

disease with which they were diagnoses

 Unstable

 Acute illness

 Post op <12>

 General anesthesia (1st 12 hrs)

 Lab abnormalities C or C level

 Changed/changing assessment

 Not ready for discharge

 Newly diagnosed

 Newly admitted

 Experiencing unexpected S/S

Example:

 16 yo w/ meningococcal meningitis who has had temp of 103.8 F since admission 3 days ago.

 61 yo male w/IBS who spiked temp of 103 F this afternoon.

 Who is higher priority and why?--->2 nd option is priority-->have more high priorities than1st

Always unstable no matter what-even if expected

4 Hemorrhaging (not bleeding)

 High fever over 105 F--->patient can have seizure

 Hypoglycemia

 Pulselessness (vfib or asystole) or breathlessness

Note: at scene of accident (unwitnessed)- they are death-low priority

3 things that causes blacktag

@ scene of accident

 Pulselessness

 Breathlessness

 Fixed and dilated pupils (even if still breathing)

4. Tiebreaker---> the more vital the organ, the higher the priority.

 Organ in which the modifying phrase is referring to

 Most vital organs

1. Brain

2. Lungs

3. Heart

4. Liver

5. Kidneys

6. Pancreas

5Psychotropic drugs

All have decrease BP and change in weight (mostly weight gain)

Phenothiazines-all end in zine

 Old class of drugs-1st gen antipsych

 Does not cure psych diseases-decrease

symptoms

 Large doses-antipsychotics

 Small doses-antiemetics

 Considered major tranquilizers

Side effects of tranquilizers

 Anticholinergic effects-Dry mouth

 Blurred vision

 Constipation

 Drowsiness

 Eps (extraparametal syndrome-like Parkinsons

 F I cheated-photosensitivity

 AGranulocytosis-low WBC

ABCDEFG

 Nursing actions when pt has S/E-teach pt to

inform doc and keep taking pill

 Adverse effects/toxic effects-hold drug and call

doc

 #1 dx for tranquilizer pts-risk for injury/safety

issues

 Know decanoate (added at end of drug

names)-long acting IM form given to

noncompliance clients. May be court order

Benzodiazepines-always have zep

in the name

 Antianxiety meds

 Minor tranquilizers

Prototypes-diazepam, lorazepam,

fluorezepam, clorazepam

More than minor tranquilizers

 Preop induce anethesia

 Alcohol withdrawal

 Seizures

 Help relax and calm down

when on ventilator

 Work quickly

 Do not take for more than

2-4 weeks

 S/E-same as psychotropic but

on ABCD (anticholinergic

effects)

 #1 dx-safety/injury

Clozapine (clozaril)-majorityendinginzapine

 Prototype(original)-2ndgenatypicalantipsychotics

 Treat schizophrenia

 Does not have S/EA-F Have S/E agranulocyte-lowWBC-Bad

 Monitor lowWBCTricyclic antidepressants (il)

 Old class of antidepressant

 Now into new NSSRI

 Mood elevator to treat depression

 Elavil (amitriptyline)

 Tofranil (imipramine)

 Anafranil (clomipranine)

 Desyrel (trazodone HCL)

Elavil S/E

 A-D

 Euphoria-upper

 Must take 2-4 weeks for full effect-teach pt it

will take a while

 Can be on it for life

Prozac (fluoxetine)-SSRI

 Depression, OCD, panic

disorder

 Similar to Elavil-same S/E

 A-D and euphoria

 Causes insomnia-give before

12pm NOT at bedtime

 When changing dose for

adolescent or young

adult-watch for suicide risk

 Suicidal risk

 Prozac not risk alone

 Recently changed dose

& adolescent/young adult

Zoloft (Sertraline)-SSRI

 Antidepressant

 Causes insomnia but cangiveatbedtime

 When taking-have tolowerdoseofother meds-high levels-doesnotmetabolize

 St Johns Wart cannot betaken-willcause serotonin syndrome(sweating, apprehension, dizzy,headache)

 Coumadin/warfarin-will bleed-needto reduce coumadinHaldol (haloperidol)

 Long acting IM-decanoate form

 S/E same as phenothiazine (A-G)

 Old antipsychotics

 NMS-neuroleptic malignant syndrome-elderly pts and young white schizophrenic due to overdose

NMS-neuroleptic malignant syndrome

 fatal hyperpyrexia-fever

 Anxiety and tremor

 105-108 temperature-medical emergency-even 102 F call for help

 Dose for elderly- 1/2 adult dose

6MAO Inhibitors

 1

st class antidepressants

 Beginning of names (Mar), (Nar), (Par)-trade

name not generic

 Marplan (Isocarboxazid)

 Nardil (Phenelzine)

 Parnate (Tranylcypromine)

Side effects

 Dry mouth

 Nausea

 Diarrhea or constipation

 Drowsiness

 Dizziness

 Headache

Foods

 Fruit/veggie-do not have thiamine so can

have

Except: banana, avocado, raisin (any dry fruit) - BAR

 Breads, cookies, pie-OK

 No organ meat

 No preserved meats

 No dairy (cottage and mozzarella cheese OK)

 No yogurt

 No alcohol or chocolate

 Teach patient not to take OTC when on

MAOI

Lithium

 Treat bipolar-decreases the mania

 Stabilizes nerve cell membrane

 Most unique-side effects different

 S/E-act like electrolytes

 Peeing

 Pooping

 Paresthesia (numbness &tingling)

 If give large dose lithium-paresthesia first sign If S/E (normal occurence to med)-give medanddonot need to call doc

 Toxic effects-overdose-tremors, metallictaste, severediarrhea

 Hold and call doc

Interventions on lithium Increase fluids-peeing and pooing side effect soreduces risk of dehydration

 Monitor sodium- so reduce risk of dehydration Pt sweating and working outdoors-give Gatoradenotwater-need normal sodiumLithium linked to sodium Monitor sodium

 Decrease sodium-lithiumbecomes toxic Increase sodium-lithiumineffective

 Sodium needs to be normal (competitie binders)

7Test knowledge of principles

As the pH goes---->so does my patient

 High pH--->irritability, excitable

 Low pH--->shut down

 Except for potassium

 High pH--->K low

 Low pH--->K high

pH and bicarb (HCO3) in same direction--->metabolic

Sign & Symptom of High pH (alkalosis) Sign & Symptom of Low pH(acidosis)

 Irritability

 Hyperflexia

 Hypoxia

 Tachypnea

 Borborygmus (increased bowel sounds)

 Seizure-suction machine @ bedside

 Hyporeflexia

 Bradycardia

 Lethargy

 Obtunded (one step further than lethargy)

 Paralytic ileus

 Coma

 Respiratory arrest-ambubag @bedside

 Kussmaul’s respiration-metabolic acidosis. Deeplaboredbreathing pattern. Form of hyperventilation.

If Lung---->respiratory issue

 If client over ventilating

(hyperventilating)---->losing CO2(alkalosis)

 If client is under ventilating

(hypoventilating)---->retaining CO2(acidosis)

 Near drowning is hypovent---->resp acidosis

 Emphysema is also hypovent--->resp acidosis

 RR different than ventilation--->pay attention to

SaO2

 Pt with PCA pump has depressed respiration and

so ventilation going down--->resp acidosis

If not Lung--->metabolic issue

 Pt has prolonged gastric vomiting OR suctioning--->pickmetabolic alkalosis--->losing acid and become basic If not lung, vomiting, or suctioning--->metabolicacidosisExamples:

 GI surgeryand NG tube low and suctionging 3

days--->metabolic alkalosis

 Hyperemesis gravida--->metabolic acidosis

 Dehydration, acute renal failure, 3

rd degree burn 60%, idopathicbolus xxx ---->metabolic acidosis

 Pay more attention to the modifying phrase over the original

noun--->pt with vomiting, who is not dehydrated

8Electrolytes

Potassium Calcium Magnesium SodiumKalemias-do the same as

the prefix except:

HR & UO

Calcemias do the

opposite of the prefix

Magnesemias do the

opposite of the prefix

Natremia thinkneurochanges

Hyperkalemia

 Everything high

 HR & UO low

Hypercalcemia

 Everything low

 “too much sedative” Hypermagnesemia

 Everything low

 “too much sedative” Hypernatremia Dehydration Hypokalemia DKA-b/c of dehydrationHypokalemia

 Everything low

 HR & UO high

Hypocalcemia

 Everything high

 “not enough sedative”  Choveseck sign and

Trousseau sign

-->neuromuscular

irritation-->seizure

Hypomagnesemia

 Everything high

 “not enough sedative” Hyponatremia Fluid overload hyperkalemiaOnly potassium treatment on NCLEX

 Never push potassium IV

 Not more than 40 mEq--->question and clarify

 Fastest way to lower potassium--> D5W w/Regular insulin

 Drive potassium into cells out of blood (preven from

killing)

 Does not rid of K but put in cell to save life

 Over next 8 hrs will leak back into blood

 Only temporary

 Kayexalate

 Goes into gut

 Full of sodium

 Trades Na for K

 Excrete kayexalate with K

 Blood ends up high in

sodium--->hypernatremia--->dehydration results

 Give IV fluids

 Takes hours but permanent solution to lower K

 Remember---> K exits late (kayexalate

Miscellaneous

 Earliest sign of electrolyte

imbalance--->numbness and tingling(paresthesis) Circumoralparesthesis--->numbness andtinglinglips

 Universal sign of electrolyte

imbalance--->muscle weakness (paresis)

Mg 1.2-2.1

Calcium 9-10.5

Potassium 3.5-5.3

Na 135-145

9Thyroid and Adrenal

Hypothyroidism Hyperthyroidism

 Hypometabolism

 Obese

 Boring, dull

 Cold intolerance-give blanket

 Heat tolerance

 Low BP

 Low HR

 Slow test takers

 Myxedema

 Not enough hormones

Treatment

 Thyroid hormones--->synthroid/levothyroxine

 Do not sedate them--already slow

 So question preop order of ambien (sleeping pill)

 Never hold thyroid pills without doctor confirming

 Hypermetabolism

 Weight loss

 Irritability

 Heat intolerance

 Cold tolerance

 Exopthalmus

 Sweating/diaphoresis

 Graves disease

3 ways to treat

1. Radioactive iodine

 Put in room alone for 24 hours

 Flush urine 3x-no spill on floor--->hazmat teamto clean2. PTU-puts thyroid under

 Cancer drug but helps to lower thyroid

 Immunosuppression-monitor WBC

3. Surgical removal-Thyroidectomy

 Total thyroidectomy

 Lifelong hormone replacement.

 At risk for hypoparathyroidism (lowcalcium)

 Partial (subtotal) thyroidectomy

 Do not need lifelong replacement.

 Risk for thyroid storm/toxicosis

Thyroid storm S/S

 High temp (105 F)

 High BP--->like stroke

 Severe tachycardia

 Psychotic delirium

 Medical emergency and can cause brain damage

Thyroid Storm treatment

 First--->ice pack

 Best---->cooling blanket

 Decrease temp

 Increase O2-oxygen mask 10L

 Either come out alive or die. Self limiting condition 2 staff for one patient

Post op

Priority 1

st 12 hours

1. Airway

2. Hemorrhage

12-48 hour window

 Total thyroidectomy-tetany due to low calcium

 Partial thyroidectomy-thyroid storm

After 48 hours

 Risk for infection

10Addison’s Disease Cushing’s Syndrome

 Undersecretion of adrenal cortex

S/S

 Hyperpigmented (very tan)

 Do not adapt to stress-->any

stress--->low glucose and low BP--->go

into shock

Purpose of stress response is to raise glucose

and BP

 Stress is bad

Treatment

 Give steroids(ending in

asone)--->glucocorticoids

In addisons--->add asone

Extra: need to increase sodium in diet

Addisonian crisis-due to decrease BP

 Oversecretion of adrenal cortex

S/S

 Puffy moon face

 Hursuitism-lots of hair

 Trunkal/central obesity

 Buffalo hump

 Gynecomastia (man boobs)

 Atrophy of the extremities (muscle wasting)

 Retain sodium and water

 Loosing potassium-fecal

 Striae on abdomen (stretch marks)

 High glucose (look like diabetes)

 Bruising

 Infection (immunosuppressed)

 Grouchy

Treatment

 Adrenalectomy-if done bilaterally-->get Addison’sdisease--->(asone) steroids

Laminectomy

 Removal of vertebral spinous processes--->wings of the vertebral bones

 To relieve nerve root compression

 S/S of nerve root compression---> 3Ps---->pain paresthesia (numbness/tingling), paresis (muscle weakness)

 Location of problem is most important

 3 locations--->cervical, thoracic, lumbar

Can apply to all spine issues b/c it is based on location

Preop

Cervical

 Innervate diaphragm and arms

 Assess breathing and function of arms/hands

Thoracic

 Innervate abdominal and ab muscles

 Assess cough mechanism and bowel sounds

Lumbar

 Innervate bladder and legs

 Assess bladder (last void) and function of legs

Postop complications

 Cervical--->trouble breathing, pneumonia

 Thoracic--->pneumonia, paralytic ileus

 Lumbar--->urinary retention, leg problems

Anterior thoracic-will have chest tube from front though chest tospine-->pneumothorax

Laminectomy with fusion-bone graft from iliac crest (hip). 2incision-hipand spine-hip most pain and bleeding-->hemovac and drainage.

Can use cadaver bone instead of hip graft

Postop

 Do not dangle at edge of

bed-for ortho hypotension it is

OK

 Do not sit for longer than 30

min

 May walk, stand, lie down w/o

restriction

 Logroll

Discharge teaching

 Do not sit longer than 30 min

lasting 6 weeks

 Lie flat and log roll for 6 weeks

 No driving for 6 weeks

 No lifting > 5 lbs for 6 weeks

Permanent restrictions

 Never allowed to lift objects bybendingatwaist-->use knees

 Cervical laminectomy-no liftingover

head-need step stool

 No biking, rollercoaster, horsebackriding

11Lab values

Heparin---> PTT

Coumadin---> INR and PT

A-->abnormal but do nothing

B-->abnormal need to be concerned but just monitor

C-->priority, must do something

D-->highest priority

 Remember the 5 D’s

 Remember the C’s

 Know the Neutropenic Precautions

 Hypoxia pt--->HR high first and then RRgoes up Hypoxia & dehydration-->causes episodic tachycardia Anemia patients have falsely elevated pulse oximetry Priority protocol--->hold, assess (focused), prepare..., callphysician

Serum creatinine-kidney function 0.6-1.2 A

INR-monitor coumadin 2-3

>4 C Prepare Vitamin K

Potassium 3.5-5.3

<3>

>5.4-5.9 C Prepare Kayexalate, D5WRinsulin>6 D STAT-prep Kayexalate, D5WRinsulinpH 7.35-7.45

6’s D Assess vitals, nothing to prep, call DocBUN-nitro waste in blood 8-25

>25 B Assess for dehydration

Hemoglobin 12-18

8-11 B Assess bleed, malnutrition

<8>

Hematocrit (3x Hgb) 36-54

>54 B Assess for dehydration

Bicarb 22-26 A

CO2 35-45

50’s C Assess respiration, prep...pursed lipbreathing,

may not need to call Doc

60’s D Respiratory failure, stay in room, prepintub/vent,call respiratory and Doc

PO2

ABG

78-100

Low 70’s C Assess respiration, prep to give O2, maynot needto call Doc

Low 60’s D Respiratory failure, intub/vent, put onOz, callDoc

SaO2 93-100

<93>

BNP <100>

>100 B Watch for CHF

Sodium (Na) 135-145

<135>145 B Assess for dehydration. With decreaseLOC->CTotal WBC 5000-11000

Immunosuppressed. Assess for infectionandplace on neutropenia precautions

<5000>

Absolute neutrophil count (ANC) >500

<500>

CD4 count >200

<199>

Platelets 140,000-200,000

<90>

< or> B

12Drug Toxicity

Lithium Digitalis (Lanoxin) Aminophyline Phenytoin BilirubinBipolar (mania) Treat afib and

congestive HF

Antidote:digibind

Relieves spasms in

airway. Muscle

spasm relaxer

seizures Tested innewborns-normallyhigh. WasteproductfrombreakdownofRBC0.6-1.2 therapeutic

level

1-2 therapeutic

level

10-20 therapeutic

level

10-20 therapeutic

level

10-20 elevatedlevel>2 toxic level >2 toxic level >20 toxic level >20 toxic level >20 toxic level

 Kernicterus-bilirubin in brain-->cross BBB

 Bilirubin at level 20-->asepsis (w/o infection), meningitis, and encephalitis-->can die

 Opisthotonos-position baby assumes when bilirubin in brain. Hyperextend due to irritationw/

meninges and bilirubin. Place child on side when this occurs.

 Jaundice-bilirubin in skin

Calcium channel blockers (CCB)

Are like calcium for your heart--->calms

heart down

 Heart tachycardic-->could use relaxant so

give CCB

 Shock--->body slowing down so NO

CCB

 Give when heart needs a break/rest

 Are (-) inotroped, dromotropes,

chromotropes-->weaken, slow down, and

depress heart

 Antihypertensive-relax heart & blood

vessels-->BP goes down

 Antiangina drug-relax heart-->uses less

O2 so decrease O2 demand

 Antiatrial arrhythmia-treat afib, aflutter,

supraventricular tach, and other atrials

Side Effects

 Headache--->vasodilation in brain gives migraine Hypotension

Note: better for asthma patients than beta blockers

Names

 Ending in (dipine)

 Also cardizem/diltiazem

 Also verapamil

Administration

 Measure BP prior to admin

Hold if systolic BP is <100>

13Notes on Arrhythmias

Atrial arrhythmias ABCD

Anticoag, Beta blockers, CCB, digitalis (digoxin/lanoxin)

Vfib defib

Asystole CPR

Epinephrine

Atropine

Vtach

PVC

Lidocaine

Amniodarone

Review cardiac rhythms

 Know by sight

 Normal sinus

 Vfib

 Vtach

 Asystole

 Know P wave (atrial), QRS complex (ventricular), sawtooth-atrial flutter

Signs & Symptoms Treatment

Hiatal Hernias

 Regurgitation of acid into

esophagus because the

upper stomach hernias

upward through the

diaphragm.

 When eat, food sits above

diaphragm then comes

back up

 Gastric contents go wrong

way but still empties

correct rate

 A direction issue

 GERD-heartburn indigestion

 Symptoms depend on position (lying down

after eat)

 GERD at random times is not hiatal hernia

Want stomachtoemptyfaster

High HOB-gravityemptystomachfasterHigh fluidHigh carbs

Dumping Syndrome

 Follows gastric surgery

 Contents dump quickly

into duodenum

 Contents move in right

direction but at wrong

rate

 A speed issue

 Think drunk person

 Staggering gait, slurred speech, labile

emotions, delayed reaction, cerebral

impairment (decrease flow to brain)

 Shock- decrease BP, increase HR, pale,

cold, clammy

 DRUNK +SHOCK = hypoglycemia

 Acute abdominal distress

 Borborygme (diarrhea)

 Crampy

 Guarding

 Distending

 Tenderness

Head flat toeat, turnedto side

Lowfluid--->1hrbefore andaftermealLowcarb

14Tip: Be aware of “first” versus “best” when choosing answer

Chest tubes-higher risk for infection than thoracentesis

 Purpose is to re-establish (-) pressure in pleural space. The (-) is good because it makes

things stick together.

 Pneumothorax (air)-chest tube removes air causing (+) pressure and re-establishes (-) pressure Hemothorax (blood)-chest tube remove blood causing (+) pressure and re-establishes (-)

pressure

 Pneumohemothorax-air and blood-->apical and basilar tubes

 Disease will tell what to expect

 Post op pneumonectomy (lung removal)-no chest tube

Location of tubes

 Apical-up high-->removes air (pneumothorax)-->because air rises

Air should be bubbling

 Basilar-bottom-->removes blood (hemothorax)

Blood should have drainage

Troubleshooting

 If closed drainage is knocked over-->set back up and have patient take deep breath-->not

emergency-do not need to call HCP

 If water seal breaks--> (+) pressure can get in the pleural space

FIRST--->clamp it, cut away from broken device, end of cut tube-stick in sterile water,

unclamp-re-establish water seal

If asked what is the BEST thing if water seal breaks-->submerge tube under sterile water

 Chest tube pulled out--> FIRST thing-->take gloves hand and cover hole

BEST thing---->vasoline gauze

 Bubbling

Water seal has intermittent bubbling--->good-->document

Water seal has continuous bubbling---->bad--->leak-find it and tape it until stops leaking

Suction control chamber has intermittent bubbling--->bad--->suction not high enough-go to water

and turn up until bubbling continues

Suction control chamber--->good--->document

Rules for clamping tube

1. Longer than 15 sec clamp tube-->need doctors order-->have sterile water nearby

2. Use 2 rubber tip double clamps

Thoracentesis- in and out to regain (-) pressure in lungs

15Crutches

 2-3 finger width below axilla fold

 Point lateral to and anterior to foot

 Hand grip-elbow flexion 30 degrees

 2 point - crutch and opposite foot together-mild bilateral weakness

 3 point - 2 crutches and bad leg together

 4 point - move a crutch then opposite leg and then the other crutch and opposite leg- severe bilateral

weakness

 Swing through - cannot bear weight. Leg does not tough the ground. Can be used for amputeeStairs

 Up with good foot then crutches

 Down with bad foot then crutches

Cane

 Cane on strong side

Walker

 Pick up-->set down--->walk to it

 Belonging to side of walker

 No tennis balls or wheels on water

Diabetes Insipidus SIADH

 Polyuria, polydypsia leading to dehydration due

to low ADH

 High urine output ---> low urine specific gravity

 Fluid volume deficit

 Oliguria, not thirsty

 Gain weight

 Retain water

 Decrease urine output --> high urinespecificgravity

 Fluid volume excess

Diabetes S/S Treatment

Type I

 Insulin

dependent

 Juvenile onset

 Ketosis prone

 Polyuria (increase

urine)

 Polyphasia (increase

swallowing)

 Polydypsia (increase

thirst)

DIE

 Diet

 Least important-count carbs/calories

 Insulin

 Most important-lower blood sugar

 Exercise

DM-Type 2

 Non insulin

dependent

 Non ketosis

prone

 Adult onset

DOA

 Diet

 Most important-restrict calories and6smallmeals

 Oral hyperglycemic

 Activity

163 acute Complications of Diabetes

Hypoglycemia Causes

 Not enough fluid

 Too much insulin/meds--->Primary cause

 Too much exercise

 Danger--->brain damage

S/S

 DRUNK-labile (all over the place)

 SHOCK

 Decrease BP

 Tachycardia

 Tachypnea

 Cold and clammy

 Pale

 Patchy

Treatment

 Rapid-metabolizecarb/sugar Juice, hardcandy, milk,honey, jam/jelly Give combo of food-sugarandprotein

 Milk (skim) withcrackerOR juice with cracker

 Unconscious--->giveglucagonIMor dextrose IV(D10orD50)

DKA

Only Type 1

Ketones in

blood-confirm

DKA

Ketones in

urine-no

confirmed DKA

Causes

 #1 cause---> acute viral upper respiratory

infection

 After recovery-getting lethargic

 Blood glucose 800 in ER- ask if there was a

respiratory infection in last 2 weeks.

S/S

 Dehydration

 Ketones, Kussmaul, increase K (potassium)

 Acidosis, acetone breath (fruity breath),

anorexia (due to nausea-do not want to eat)

Treatment

 Priority-acidosis, ketones Give insulin

 For dehydration-->IVfluids(Regular insulinfast rate)HHNC/HHNK

Type 2 DM

 Same as dehydration

 Skin same as dehydration--->dry, warm, poor

turgor

 Fluid volume deficit #1 Dx

 Do not burn fat or make ketones

 More die from this

Treatment

#1

 Give fluids

 Outcome same as rehydration Increased output

 Increased BP Moist mucous membraneLong term complications of diabetes Lab test glucose--->Ha1Cmonitoring1. Poor tissue perfusion

2. Peripheral neuropathy

Complications are due to type 1 and 2

 Normal -----> 6 and lower

 Out of control ----->8 and up

 Borderline ---> 7 ---> education, workup-mayhave infection

Insulin ----> lowers blood glucose

17Need to know 4

Rapid short acting Intermediate acting Fast acting LongactingRegular (Humulin

R, Novalin R)

 Onset 1 hr

 Peak 2 hr

 Duration 4 hr

 Clear solution

 IV drip insulin

R--->rapid run IV

NPH

 Onset 6 hrs

 Peak 8-10 hrs

 Duration 12 hrs

 Cloudy

 Suspension (not

solution)-particles

fall to bottom

 Cannot IV drip

N-->not so fast

(intermediate) not in the

bag (no IV)

Lispro

 Onset 15 min

 Peak 30 min

 Duration 3 hrs

 Give as begin to eat

(with meal)

Lantus/GlargineNo essential

peak-slowLowhypoglycemicrisk

Safelygivenat

bedtimeregardlessofglucoseDuration12-2hrs Diabetic is sick--->glucose goes up

 Even if do not eat-->need insulin

 Take sips of water--->avoid dehydration

 Stay as active as possible---->lowers glucose

 Check expiration dates

 Open it-->expiration date no longer valid--->new expiration is 30 days after open. Document oncontainer

 Refrigeration optional in hospital

 Teach to refrigerate at home

 Exercise increases insulin--->think of exercise as insulin

 When exercise/sports--->need less insulin

 Ac-before meal

 Hs- at bedtime

Medication help and hints

 What is humulin 70/30?

 Mix of R and N insulin 70% NPH ans 30% Regular

 Can you mix insulin in same syringe--->Regular first then NPH

N-air in

R-air in

R-draw Regular

N-draw NPH

 What needle to give particular injection

 IM ---> 21 gauge 1 inch

 Subcut ---> 25 gauge 5/8 inch

18Heparin and Coumadin

 Heparin

 IV or subcut

 Works immediately

 Cannot be given longer than 3 weeks (except Lovenox)-can create antibodies

 Lab to monitor--> PTT

 Can be given to pregnant women

 Antidote-->protamine sulfate

 Coumadin

 PO

 Takes few days to a week to work

 Can take forever

 Labs to monitor---> PT and INR

 Cannot be given to pregnant women

 Antidote--->vitamin K

 Diuretics ending in X, semide, plus diuril ----> wastes K (potassium)

 Muscle relaxants

 Flexeril

 Baclofen

 S/E ---> fatigue, muscle weakness

 Teach ----> do not drink, do not drive, do not operate machinery

Aminoglycosides-powerful class of antibiotics

 Think- a mean old mycin

 End in mycin

 Not aminoglycosides (thro) throw off

the list--->erythromycin,

azythromycin, clarithromycin

 Dangerous drugs

 Antiibiotics to treat serious, life

threatening, gram (-), resistant

infection.

 Tuberculosis

 Septic peritonitis

 Fulminating pyelonephritis

 Burns >80% of body

 Sepsis

**mean out infection**

Toxic effects

 End in mycin-->sound like

mice

 Mice-->think of ear

-->ototoxic-monitor hearing,

ringing (tinnitis),

vertigo/equilibrium, dizziness

 Ear shaped like

kidney--->second toxic

effect--->

nephrotoxicity--> monitor

creatinine-24 hr creatinine

clearance

 Admin every 8 hours-IM or

IV

 Do not give PO-not absorbed

Hepatic

enceph/coma-->reduceammonia--->oral mycinwill do that.

Sterilize bowel-->killecoli anddecreaseammonia

Who cansterilizebowel-->neocan-->neomycin,

canomcin--->specificfor sterilizingbowelbefore surgery--takenPO