NCLEX MARK Lecture Notes and link

Master acid-base imbalances with simple rules, not memorized lists. Includes key concepts like Rule of the B’s, ventilation alarms, metabolic vs. respiratory clues, and real-world nursing examples.

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Etsy:1NURSING NOTES101** DON'T MIX UP S4S and CAUSATION- often what cajses someth ng is tne opposite of the SAS- ex. diarrhea will cause a metabolc ac dosis but onceyou are ac dotic yourbowel shuts down and you get aparalytic illeus- when you get scenarios:-> if it's a lung scenario = respiratory- then check if the client is Dver-i/enf'afp(alkalosis)orunder- ventilating (acidosis)- remember to look at the words (ex. over, under,ventilating) -> "as the pH goes so goes my PT"-> VENTILATING DOESN'T MEAN RESPIRATORYRATE; rasp, rale is inetevsrrfw/ acid-base,ventilationhas to co with gas excharge not resp.'ate (look at tie SaO2 -> if your resp. rale is fastbut EaO2 is low you are under-ventilating)-> ex. PCA pump - What acid-base disorderind cates they reed to come off of it? = respiratoryac cosis (resp. depression -> resp. arrest)—> if its not lung, its metabolic• metabolic alkalosis - really only one scenario = ifthe PT has prolonged gastric vomiting/suctioning- because you arelosing ACID"ex. Gl surgery w/ NG tube with suctioning for3 days; hyperemesis graviderum- otherwise everything else that isn't lung youpickmetabolic acidosis (DEFAULT)" ex. hyperemesis graviderum w/dehydrationacute renal failure, infantile diarrhea. remember, you only have 4 to pick from:- respiratory alkalosis- respiratory acidosis- metabolic alkalosis- metabolic acidosisRb6‘sYJERt NOTON UM *NCiexU*LECTURE 1ACID BASES• learn how to convert lab values to words- the rule of theBs= if the pH and the BiCarb are both in the samedirection -> metabolicHint:draw arrows beside each to see directions’ down = ac/cfos/s* up =alkalosis- respiratory -> hasnob init;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 yougenerate lists..) -for "select all" questions- ex. in general/principle what do opioids/painmeds do? = sedate you, CNS depressorsFex. what does di audid do?dori I memorizespecificso.ra fefof dtlaudid, know principles of opioids(suchas sedation, CHS deppessian -> l&lhargy, flacc dity,reflex +1, hypo-reflex ia, -Dblunded)- boards don't test by lists because all books/classes have different listsprinciples ofS4S acid bases:asthe pH goes sogoes my patient (except K+)- pH up = PT up -> body system gets moreirritable, hyper-excitable (EXCEPT K+)-> alkalosis -think ot a body system and gohigh,hyper-reflexive (+3, +4 [2 is normal]},tachypnea, tachycardia, borborygmi, seizure- pH down = PT down -> body systems shutdown (EXCEPT K+l-> acidosis -thwikof a system and go Sow.hypo-reflexive (+1, 0), bradycardia, lethargy,obtunded, paralytic illeus, respiratory arrest. ex. which acid-base disorders need an ambu-bag atthe bedside? = acidosis(resp. arrest)ex.which acid-base disorders need suction at thebedside? = alkalosis(seize and aspirate)- Mac Kussmaul -Kussmaul s (compensatoryrespiratory mechanism) is only present inonly1 ofthe 4 metabolic (acid-base) disordersTM = metabolicAC = acidosispay more attention tc themodifying phrasesthanthe original noun- ex. personw/OCD whoisnow psychotic (psychotictrumps OCD); hyperemesis with dehydration (payattention to dehydration}VENTILATION- ventilators -> knowalarm systems(you set it upsothat the machine does nt useless thanormore thanspecific amounts of pressure)a} high pressure alarm =increased resistanceto airflow (the machine has to push too hard toget air into lungs)- from obstructions:i. kinks in tubing (unkink it)ii.water condensation in tube (empty it!)iii. mucous secretionsinthe airway (changepositions/turn, C&DB, andTHENsuction)suction is only PRNJII-> priority questions = you would checkkinks first, suction is not first. most common mistake with se ect all questions=selectingone more than you should(stop when you select the onesyou know! don't get caught up on the "could he's”)• Hint:don't select noneoraflonselect all that applyquestions (never only one and never all)- Causes of Acid- Base Imbalance:- scenarios and what acid-base disorder wouldresuttfwhat would cause an imbalance}

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b) low pressure alarm =decreased resistanceto airflow (the machine had to work too littleto push air into lungs)- from disconnections:i. main tubing (reconnect it duh!)ii. 02 sensor tubing (which senses FiO2 atthe airway/trach area; black coated wirecoming from machine right along thetubing - reconnect!)ventilators -> knowblood gases- resp. alkalosis = ventilation settings might beset too high (OVER-VENTILATING)- resp. acidosis = ventilation settings might be settoo low {UNDER-VENTILATING)ex. weaning a PT off ventilator -> should not beunder-ventilated, they need the ventilator; if they areover-ventilating then they can be weanednever pick an answer where you dont de somethingand someone else has to do something

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Etsy:lNURSINGNOTES101LECTURE 2ABUSE(Psych and Med-Surge)Psycfro/ogrcaMspect/Psycho-DynanNcs- # 1 psychological problem isthesameinany/allabusive situations =DENIAL- abusers have an infinite capacity for denial so thatthey can continue the behavior w/o answering for it- can use the alcoholism rules for any abuse- ex. # 1 peycn problem in child abuse, gambling orcocaine abuse ia aerae)- whyis denial the problem? HOW CAN YOU TREATSOMEONE WHO DEN1ES/DOESN T RECOGNIZETHE Y HAVE A PROBLEM- denial = refusal to accept the reality of a problem* treat denial by CONFRONTING the problem (it's notthe same as agpress/onwhichattacks the person, notthe problem) =they DENY you CONFRONT- pointing out to the person the difference betweenwhatthey say and what they do- Hintrever pick answers that attack the person-> ex. bad answers have bad pronouns - "you"-> ex. good answers have good pronouns - 'I", "we"-> ex. "youwrotethe order wrong" vs.'I'mhavingdifficulty interpreting what you want"- loss and grief -> for this denial you mustSUPPORTit- DABDA = cen al, arger, bargaining, depression, acceptance* Hint:for questions about denialyou must look to seeif itis LOSS or ABUSE- loss/grief = support- abuse = confront- #2 psychological problem in abuse =DEPENDENCY,CO-DEPENDENCY- dependency= whenthe abuser gets significant otherto do things for them or make decisions for them-> the dependent -abuserc o - d e p e n d e n c y = when the significant other derivespositive self-esteem from making decisions for ordoingthings for the abuser-> the abuser gets a life w/o responsibilities->the sig. other gets positive self-esteem {which iswhy 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 theyhave 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 = whenthe abuser gets the sig. otherto do things for them that are not in the best interest ofthe sig. other- the nature of the act is dancreroirs.'/Tarmfu/- how is manipulation like dependency?-> inboth the abuser is getting the other persontodo something for them-howdo you tellthe difference between manipulation& dependency?-> NEUTRAL vs. NEGATIVE (look at what they'rebeing asked to do)-> if the sig. other is being asked to do somethingneutral {no harm} its dependency/co-dependency-> if the sig. other is being asked to do somethingthat will harm them or is dangerous to them theyare manipulated- how do you treat manipulation?- set limits and enforce them ->'NO"-easier to treat than dependency/co-dependencybecause no one likes to be manipulated (no positiveself-esteem issue going on)ex. how many P T s do you have w/ denial? =1ex. how many PT s do you have w/ dependency/co-dependency = 2ex. how many PT s do you have w/ manipulation = 1AlcoholismWernickes & Korsakoffs- typically separate BUT boards lumps them together- wemicke s = encephalopathy-korsakoff's = psychosis (lose touch with reality)-> tend to go together, find them in the same PTWernickeK o r s a k o f f s s y n d r o m e :a} psychosis induced by Wf.Bl(Thiamine) deficiencylose touch w/ reality, go insane because of no B1b} primary symptom ->amnesia w/ confabulation- significant memory loss w/ making up stories- they believe their storiesHow do you deal w/ these PT's?- bad way = confrontation (because they believe whatthey are saying and can't see reality)- good way =redirection(take what the PT can't doand channel it into something they can do}Characteristics of Wen ieke Korsakoff's:a} rtsprevejifabfe= take Vit. B1 (co-enzyme neededfor the metabolism of alcohol which keeps alcoholfrom accumulating and destroying brain cells)' PT doesn't have to stop drinkingb)it s arrestable =can stop it from getting worse bytaking Vit. B1ralso not necessary to stop drinkingc) rfsirreversible(70% of cases) -> Hint: On boards,answerw/ themajority (ex. if something is majorityof the time fatal, you say it’s fatal even if 5% of thetime if s not)- DrugsforAlcoholism:DISULFIRAM (Antabuse}= aversion therapy-> want PTs to develop a guthatred for alcohol-> interacts w/ alcohol in the blood to make you very ill-> works in theory better than in reality-> onset & duration: 2 weeks(soifyou want todrink again, wait 2 weeks}

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- PT teaching = avoid ALL formsofalcohol to avoidnausea, vomiting & possibly death-> including mouthwash, aftershaves/colognes/perfumes(topical stuff will make tnem nauseous), insectrepel ants, any OTC that ends with "-elixer", alcohol-based hard sanitizers, uncooked (no-ba<el icingswhich havevanillaextract, 'ed wine vinaigrette- Overdoses & Withdrawals:- everyabuseddrug is either anUPPERorDOWNER-> the other drugs don't do anything-> £1 abused class of drug that is not an upper ordowner = laxatives in the elderlyal first establishif thedrug is anupperor downer- uppers(5) = caffeine, coca ne, PCP/LSD (psychedelichallucinogens}, methsmphsfaiTwrws. adderoi {ADD drug?T5&S -> make you go up: euphoria, tachycardia,restlessness, irritability, diarrhea, oorborygmi.hyper-reflexia, spastic, seze (need suction)- downers= don't memorize names -> anything thatis not an upper is a downer! if you don't know whatthe med is, you have a high chance that its adowner if its not part of the uppers list’ S&S -> make you go cown; letnargy. resp ratorydepression (&.arrest)- ex. The PT is high on cocaine. What is critical to assess?-> NOT resps below 12 because they will be high-> maybe check reflexesbl are they talking aboutoverdoseorwithdrawsI- overdose/intoxication =toomuch- withdrawal =not enough- ex. the PT has overdosed on an upper -> pick theS&S of too much upper- ex. the PT has overdosed on a downer -> pick theS&S of too much dowrer- ex. the PT is withdrawing from an uppep-> notenough uopermakes everytning go down- ex. the PT is withdrawing from a cowner -> notenough downer makes eveyth ng go upupper overdose looks tike - downer withdrawal• downer overdose looks like = upper withdrawal- In what 2 situations would resp. depression & arrestbe your highest priority:- downer overdose- upper withdrawal• In what 2 situations would seizure be the biggest risk:- upper overdose- downer withdrawal.AlcoholWithdrawal Syndromevs.Delirium Tremens- they are both different! not the samea)everyalcoholic goes through withdrawal 24hrs.after they stop drinking- only a mmor/tyget delirium tremens- timeframe -> 72 hrs. (alcohol withdrawal comes 1st)- alcohol withdrawal syndrome ALWAYS precedesdelirium tremens, BUT delirium tremens does notalways follow alcohol withdrawal syndromeb) AWS is not life-threatening; DTs can kill youc) PT's w/ AWS are not a danger to sellf/others; PT'sw/ DT's are dangerous to self/others- they are withdrawing from a downer so they willbe exhibiting upper S&S- DTs are dangerousDiflsrsncesAWSDTin CansDietRegu lar c etNPCWclear lieuids(because a1 risk for seizures whichcan cause -isk ci asp ration)RoomSemi-prvatePrivatenearnurses stationanywhere on (dangerous A unstable)the unitAmbulation Up ad libRest-kited bed rest -> no balh-oomprivileges (use bedpans'urinals)RestraintsNorestrants Restraints (because dangerous)(because not - not soft wrist or 4 point softdangerous)because tney'll gel out- need to be in vest or 2-pt. lockedleathers (opposite 1 arm 8. leg,rotate Q2hrs, lock 1he f-eeI mbs 1st before releasing thelocked ones)Thevboth get ANTI-HYPERTENSIVES &TRANQUILIZERS- becajse eve-ylhing is up (downer withdrawal)They both gel MULTIVITAMIN w,' BlRN's can accept but RPN's can't (because PT is unstable)- on med-surge, the RN who takes :hem must decreasetheir 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.)• Drug Abuse in the Newborn:- always assume intoxication. NOT withdrawal at birth- after24 hrs-> withdrawal- ex. caring for infant of a Quaalude addicted mom 24hrs. after birth, select all that apply:-> downer withdrawal so everything is up = exaggeratedstartle, seizing, high ptched'Shrill cry

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DRUGSAMINOGLYCOC1DES- powerful class ofantibiotics(when nothing elseworks pull these outs, the big guns)- don't use unless anything else worksboards /oue fo test fhese drugs because theyredangerous and are a test of safety- think: A MEAN OLD MYCIN-> a mean o.'d= they treat serious, life-threatening,resistant, Gram-neg bacteria infections (i.e. a meano/d antibiotic for a mean oj'd intectionj-> mycto = what they end with(allendw/-mycin}not all -mycin's are aminoglycosides BUT mostare (the 3 that are not are erythromycinazihromycin, clarithromycin = torow if off toe tist.i)- 2 toxic effectsi) when you see -mycin. thinkmice- mice ->ears -> otto toxic-monitor hearing, tinnitus, vertgo/dizzinessii) the humanear is shapedlike akidneyso nexteffect isnephrotoxicity- monitortreat'.nine(not BUN output, daily weight)'creatinine= the best indicator of kidney/renalfunction(pick 24 hrcreatinine clearance overserum creatinine if both available)#8 (fits nicely in the kidney) reminds you about 2things about these drugs- toxic to cranial nerve 8 = ear nerve- administer Q8- route:- IM or IV- do notgive PO-> theyarenot absorbed- if you give an oral -mycin' it will go into gut, dissolve,go through and come out as expensive stool (won thave any systemic effect)- EXCEPT i- 2 case .= bowel sterilizers:Thepatic encephalopathy (hepatic coma} =to getammonia down, cral ’-mycin's' will sterilize thebowel by killing Gram-neg bacteria (E. coli) to helpbring down ammonia and wont harm thedamaged liver because it doesn't go through theliver (also gives diarrhea, more poop out is good.)rpre-op bowei surgery =it sterilizes the gut bykilling the E coli bacteriaif oral, no otto or nephro toxicity because not absorbed- these are neomycin & kanamycin’ Who can sterilize my bowels? NEO KANWhy draw levels? =narrow therapeutic window- small difference between what works and what kills- if the drug has a wide range then you wouldn'tneed to draw TAP levelsTex. Lasix doses range from 5-80mg thus a widerange so you wont need TAP levels" ex. Dig doses range from 0.125 - 0.25 so thisnarrow range needs TAPS levels- A MEAN OLD MYCIN3 = major class that reedsTAPs drawn because of narrow window- When do you draw TAPS?-> depends on theroute(don't focus on the med)a} Trough Levelsdoesn’t matter which route or medalways20 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 doseb)Peak Levelsdifferent but depends on the route mot the med)- Sublingual = 5-10 mins after drug is dissolved- IV = 15-30 mins after drugs is finished tofesingrTHint:if you get two values 'hat are correct (i.e. a15 minanswer and a 30 min. one)pick the highestwithout going overso 30 mins.- IM = 30-60 mins, after administration- Sub-Q = SEE (see diabetes lecture -> because theonly Sub-Q peaks are Insulins)- PO = forget about it, too variable so not testedThe BIG 10 Drugs to Know:1.psych drugs2. insulins3 anti -coagulants4. digitalis5. aminoglycosides6. steroids7. caldum-channel blockers8beta-blockers9. pain meds10. OB drugsTrough and Peak levels:- trough = drug at /owesf- peak = drug at highest*' MP.'evefc -trough administer peak-> draw trough levels first-> administer your drug-> draw peak levels after drug administration

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LECTURE 3£ ) O N EOCAR DI AC- AR R Y T H Ml AS- Interpreting Rhythm Strips(4 that need to be knownby sight):a} Normal Sinus Rhythm= P wave before every QRS & followed by a Twave for every single c o m p l e x-> all P wave peaks are e q u a l l y distant from eachother. QRS evenly spacedb).'-jib = chaotic squiggly line, no patternc) '.'-Tach = sharp peaks, has a patternd} - -Systole = flat-fine-Terminology:- if QRS d e p o l a r i z a t on, it's talking aboutventricular(so rule out anything atrial)- if it says P-wave then it s t a l k i n g aboutatrialCardiacD R U G SC A L C E U M - C H A N N E L B L O C K E R SCS/c/um-C/ianne/ B/ocxe/s are M eVa/rum for your heartValium -> calm's you down; so C C 8 s calm your heartdown(ex. if tachycardic, give CCB s but not in shock)- to R E S TYOUR HEART- not stimulants• calcium-channei b l o c k e r s arenegative i n o t r o p i cc h r o n o t r o p i c , S. d r o m o t r o p i c o r u g s- fancy way of saying that they calm the heart downPOSITIVENEGATIVEinotropesCardiac StimulantsCardiac Depressants*- stimulate, speec- caTmtne near! cown.bnronotropesu othe heartweaken & slow cownDromotopes-6 Rhythms most tested on N - C L E X :1a lack of QRS's" = A-systole- flat-line, no QRS2. " P - w a v e " = Atrial- if its asawtooth wave, always pickafoa)flutter3. " c h a o t i c ' - A-tib if w/ P-wave4. "chaotic" - V-fib if w/ QRSL !I- H i n t :the worechaosis used tor>'t •-..'.aifor5bizarre" = atrial t a c h y c a r d i a if w/ P - w a v e6.bizarre" = ventricular tachycardia if w/ Q R S- Hint,the work 'b zarre' is usee forfoc.iyca/'oras-P V C s(premature ventricular contractions)= a.k.a. periodic wide bizarre Q R S- ventricular because Q P S'W h e n do youwant io ' d e p r e s s " theheart?WhatdoCCS's treat?At anti- h y p e r t e n s i v e s- relax heart & blood vessels to bring down BPAA: anti-anginas4CUT VtP ftlN- relax heart to use less 0 2to makea n g i n a go away- treats a n g i n a by addressing oxygen d e m a n dAAA; anti-atrial arrhythmia- ex. atrial flutter, A-fib. premature atrial contractions- never ventricularmwhat aboutsupra-ventricular tachycardia??-> because it means 'above the ventricles' (whichare theatria)- Side-Effects:H & H = headache & h y p o t e n s i o n-> hypoTN - from relaxed heart & v e s s e l s> h e a d a c h e - vasodilation to brainHint:h e a d a c h e is a good thing tc se set for'select ail that apply' questions(®t.low Na & nignNa = headache, hign & low g ucoae = headache, high &low BP = headache)- N a m e s of C a l c i u m - C h a n n e l B l o c k e r s :- anything e n d i n g in- d i p i n e1- ex. a m l o d i p i n enifedipineN O T just '-pine'- also i n c l u d e s ' VERAPAMIL & C ARD1ZEM- which can be given as continuous IV drip??= Cardizem*bVhaf 1/Sneeds to be assessed before giving a C C B ?- BP = because of risk ofhypoTN-> parameters/guidelines - hold CCB ifsystolicisunder 1 00-> so you need to monitor BPif PTis on a Cardizemc o n t i n u o u s drip (if it's under 1 00 then you mayhave to stop or changethedrip rate}- bizarre -> tachycardia-you can call a group of P V C sa short run of V-tach- d oPhysician's care about PT's having P V C s ?->NO, not a high priority = low priority-> 3 circumstances when you could elevate theseP T s t omoderatepriority (re -ereac- high)i. if there are more than 6 PVC's in a minuteii. if there are more than 6 PVC's in a rowiii. if the PVC tall on the T-wave of the previousbeat ( R o n T phenomenon)-> most common order if you call the MO about aPT w/ P V C s = D/C monitor (Decause then youcan t see the PVCs and then you won t call them)-LethalArrhythmia s:- HIGH PRIORITY 2 main oneswill - ill you in 8 m nsjiess-> these P T swill p r o b a b l y be top prioritiesa} A - S y s t o l eb) V-Fifaboth have in common = no cardiac output-> no brain perfusion (and you II be dead in8 mins)-. -tach = potenf/a/jyHte-th reate ning (but not actuallylife-threatening), but still m a k e s it a fairly high priority- difference is that these PT's have c a r d i a c output- in c o d e s , even rf the rhythm c h a n g e sif there is nocardiac output it's ju st as cad as the p r e v i o u s rhythm

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b) Basilar= at thebottomof the lungs, thusitisremovingbfoodlliquid (because of gravity)-ex. its bad if your basilar tube is bubbling or notdraining any mLax. Howmany chest tubes & where would you place themfor s unilateral pneumohemothorax?- 2 chest tubes (apical for preumo. basilar for nemo)ax. Howmany chest tubes S where would you place themfor a bi-lateral pneumothorax?- 2 tubes (apicalonleft,apical on right)* ax. Howmany chest tubes & where would place them forpost-op chest surgery?- 2 tubes (apical & basilar on the side of the surgery)"you are to assume that chest surgery/trauma isunilateral uni'ess otherwise specified(they willsay bilateral)- Trick Question:How many chest tubes would youneed and where would you place them for a post-opright pneumonectomy?- NONE! because you are removing the lung so youdon't need to re-establish any pressure (there is notpleural space)!Troubleshooting Chest Tubes:- What do you do it you knock over the plasticcontainers that certain tubes are attached to?-> set it back up & have PT take some deep breaths-> NOT a medical emergency!(don't call ND)- What do you do if the water seal breaks (theactual device breaks?)-> first =CLAMP it!!!because now positive pressurecan get in! don't let anything get in-> 2nd= cutthe tube away from the broken device-> 3rd = stick that open end into sterile water->then unclamp it because you've re-established thewater seal (doesn't need clams if its under water™ better for the tube to be under water thanclamped! -> alir can t goinand stuff can still keepcoming out (if clamped nothing can come outwhich is what the tube is for)- Ex.Ifthey ask what thefirstthing is to do if the sealbreaks -> Clamp! BUT, if they ask what's the bestthing to do -> put end of tube under water! (because itactually solves the problem, cfamping is a tempfix)- Hint: 'BESTvs. FIRST questions- first questions = areabout what order- testquestions =what's the one thing you would doifyou couldonly doI cf the options-> ex. You notice the FT has V-fib on the monitor. Yourunto the room and they are non-responsive withnopulse. What is thefirstthing you do?A) place a backboard?B) begin chest compressions?- "first”is about order so = pick A (because youwouldn't start chest compressions first)- BUT. if the question ask "What s thebestthing todo?" -> you only get to do 1 thing not the other soyou would pick B- Treatment (more drugs):a) PVC sb) V-tach= forventricularuse LIDOCAINE/AMIODARONE' in rural areas mare Liaocaine use (cheaper Alange- ahelf-He)c) Supra-Ventricular Arrhythmia's= atrial arrhythmia's use ABCUsA->ADENOCARO (Adenosine)- have to push in less than 8 seconds {FAST IVpush)-> Siam tnis drjg;followed by a flush; use abig vein: BUT the prob em w/ slamming it fast isthe risk of PT going into A-Systo e (for 30 secondsbut theywillcome out of it so don't worry [unlesslorger than 30 sec...])for IV pushes: whenyou don t know you go slowB -> BETA- BLOCKERS- aiiend .in '-lol- every-lol'is a BB & every BBisa '-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 differencebetween Beta- & Calcium channel blockers;except that CCB are better for PT's w/ asthmaor COPD -> Beta-B's bronchoconstrictC ->CALCIUM-CHANNEL BLOCKERS- see Beta-Blockers & CCB's earlierD -> DIGITALIS (DIGOXIN, LANOXIN)d) V-Fib= forV-L't ycoD-fib(shock them!)elA-Systole= use EPINEPHRINE & ATROPINE {in this order!)-> if epinephrine doesn't work then use atropineCHEST TUBES• purpose is to re-estab/rs/r nerjafrVepressurein thepleural space (so that the lung expands when thechest wall moves)- pleural space -> rregabveis good(negative pressuremakes things stick together)- ex. gun shot to the lung add positive pressure- Hint:when you get a chest tube question look at thereason for which it was placed(will tell you what toexpect & what not to expect)- ex. pneumothorax = to remove air (because aircreated the positive pressure)- ex. hemothorax = to remove blood- ex. pneumohemothorax = to remove blood & air- Hint:Also, payattention tothe tacatronot the tubes.a)Apical =the chest tube is wayuphigh, thusit isremovingair(because air rises)- ex. its bad if you re apical tube is draining 200 mL oritisnotbubbling

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-What do you do if the chest tube gets pulled out?- firef = take a gloved hand and cover the hole- best=cover the hole with vaseline gauze- B u b b l i n g chesttubes:(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 butdepends on where & when)- ex. /nfemfffenfbubbling in the water seal -> GOOD(document it, neverbadfl- ex.Continuous bubbling in the water seal -> BAD(you don't want this, means a leak in the system thatyou need to find and tapeituntil it stops leaking)in RPN scope- ex. Infermjftent insuction control chamber -> BAD(means suction is not high enough, turn it up on thewall until bubblingiscontinuous)- 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 continuouslybubbling means it's leaking!)- A straight catheter is to a foley catheter as athoracentesis is to a chest tube.- in-&-out vs. continuous secured-thoracentesis -> also helps re-establish neg.pressure (in-S.-out chest tube)- higher risk for infections are continuousRules for Clamping Tubes:- a) Never clamp a tube for more than15 secondswithout a doctors order.- so if you break the water seal -> you have 15seconds to get that tube under water- b) Userubber-tippeddoubledclamps.- the teeth of the damp need to be covered w/rubber so that you don't puncture the tubeCONGENITAL HEART DEFECTSevery congenital heart defect is either TROUBLE orNO TROUBLE (ALL BAD or NO BAD)- either causes a lot of problems or its no Dig deal (noin-between defect)- memorizeone word: TRouBLeHeart DelectaTRp uBLe (95% ofall heart defects}No TroubleSu rgeryNED surgery now- don't need surgery-igrt away; possitn'jneed it years late- if itcausea 'aTrouble(butwe do n'1 expect it to)Growth & Dev.alow, delayedno-malLife Expectancy shortnormalParentsExperiencinggrief, stress.,ffnanc el seuea, lotsof ca'egvng issuesregular average personiBffjesGoing Homeapnea monitorno apnea monitort c o i t a l Stoy at weeks24-40 houraWho Follow®Your CarePaediatricCard ologistPaediatrician,oaediat-ic NPShuntingR_to L(TRouBLe)L t o RCyanosisCyanotic -> Blue(TTtouBLe)Acyanotic- ex. You are teaching the parents about a heart defect:- pick alltheoptionsthatcausetrouble• Hint:Boards will not give pictures of defects and askyou what they are.- not ou r job, we don't diag nose-our role is teaching parents the implications-> so f ts troube = leach them things that ts goingto be a lot ol trousle-> il it's not rouble = pick the things saying it's notgoing to be troubeThepe are 40+ congenital heart defects so just rememberTRouBLe (don't memorize all of them!):- Hint: all congenitalheartdefects that startw/theletter T are Troubte Defects- we con fcare about the defect, we care about whatwere 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 anEchocardiogramdone (to find outwhat the defect is or why there's amurmur)- 4 Defects of Tetralogy of Fallout:-VarieD Pictures Of A R a n c H (cr Valentines Day=lc<Someone Out A Red Heart)1. VD= ventricular defect2. PS = pulmonary stenosis3. O A = overriding aorta4. RH = right hypertrophy• dont have torecallthese. RECOGNIZE them- recall -> remember from nothing- RECOGNIZE -> spot it when you see it (use theinitials to recognize them in questions)- ONLY DEFECT where they ask youwhatit is

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INFECTIOUS DISEASE and TRANSMISSION BASEDPRECAUTIONS (Isolations)- Standard- Universal- Contact- for anythingenteric =can be caught from fnfestfne-> fecaloral- C-Diff, Hep. A, Cholera, Dysenteryrthings with bugs in diarrheaTHint for Hep A & B: Hep A -> think anus. Hep B ->think blood (anything from the iwn'&|starts w? a vowel)- Staph infections- RSV = respiratory syncytia/ virus (what babies, 1 -2yr. old s get that is not dangerous to adults but canbe fatal for them)rtransmitted by droplet BUTstill putthem oncontactprecautions because little kids catchitfrom touching Wringsthat other sick kids touched- Herpes infections(includes Shingles-> HerpesZoster virus even though caused by varicella)- What's involved in contact precautions?-> private room ispreferred(but not required)Tor 2 RSV kids in the same roomrkeep RSV kid & suspected RSV separatebecause you need positive cultures (not basedon symptoms)->NO:maskeye/face shield (unless for universal),special filter mask, PT mask, neg. air flow->YES: gloves. gown, hand-washing, specialsupplies & 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 tcsneezing/ccughing- allmeningitis’ cultured through lumbar puncture- H Flu (haemophilus influenzaB)-> commonlycausesepiglottis’ never stick something down throat because it willcause obstruction- What’s involved in droplet precautions?-> private room is preferred (but not required)ron boards select pr vatercan also cohort based on positive cultures->NO:gowneye/face shield, special filter mask,neg. air flow->YES: mask, gloves, hand-washing, PT wornmask (when leaving room), disposable supplies& dedicated equipment-Airborne- M-M-R;TB: varicella (chicken pox)- W h a t s involved in airborne precautions?-> private room isrequiredrunless co-horting-> NO: gown (mostiyfor contact), eye/face shields-> YES: mask, gloveshand-washingspecial-filtermask ONLY for TB. PT mask for leaving room(but really shouldn't be leaving), neg. air flow"disposable supplies & dedicated equipment is agood thing but not really as essential as in theother 2 (can let this one slide)-> TB: technically transmitted via droplet BUT puton airbornePPE = Personal Protective Equipment- boards Eke to test how you put on or take off-alwaystake it offin alphabetical cider-> ex. gloves, goggles, gown, mask- p u t t i n g on is reverse alphabetically for theg s' &mask comes 2nd-> gown. mask, goggles, glovesI N FECUOhl , ,CONSOLMRWRMEPRECAUTIONH>-s.jMiftuesL<JMEZHECTfS ZWCR -r C W f t UCONTACT PEKAUTi*MUSR T MRERSEHeSWfHOfliJ INFECTIONVIIUWOW C C T I O NENTEKU.'j tSft(<H i n n ss»Mpitx>I M P H I W?PtOiCulOSVS&SCOPES tMOCCUStSTfiPHtlUTilPEMC PRCCtAVTlbNS?7 ’

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LECTURE 4y\JCRUTCHES, CANES, WALKERSmajor area of human function islocomotionso they testthese even though not a major emphasis in school- area to test PT teaching & risk reductionCrutches:* How do you measure crutches?need to know for risk reduction -> so you don'tcause nerve damaget.a)lengthofcrutch =2-3 finger-widths below antedoraxillary folc to a point lateral to & si ghtly in front of the foot-> many questions ask where you measure fromfto (so forcrutches, if they ask anything measuring from ax Ila tofoot -> rule out, they re wrong instructions for length)blhand grip =can be adjusted up & down; when properlyplaced,shouldbeapx. 30 dagraas elbow HaxionHowto teachcrutch gaits(4 kinds}:names are pretty obvious w/ a few exceptionsa) 2-point- move acrutch and opposite foottogether followedby other crutch & opposite foot- moving 2 things togetherb) 3-point- moving2 crutches5the bad legtogether- moving 3 things togetherc) 4-point- movingeverything separatelymove any crutch, then opposite foot, followed bynext crutch then other foot- very slow but very stabled) Swing-through- fornon-v,eight bearinginjuries (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 oddreven point gaits when a weakness is evenlydistributed (i.e. even # of legs messed up)- 2-point = mjfcf problems (bilateralj4-point = severe problems (severe, bilateralweaknesses)- 3-point = chmy odd one, when only 1 leg is affected.Ex.Eady stages of rheumatoid arthritis =2-pointEx. LaS, atove- the knee ampufatio.? = ewing-througriEx. Firstday post-op right knee replacement. partial weight-bearing allowed =3-pointEx.Advanced stages of ALS =4-pointEx.Left hip replacement, 2nd day post-op, non weight-bearing= swing-throughEx. BWsieraitotalkneereplacement, 1st day post-op. weight-bearing a'lcwed =4-pointEx. BWsierai tatai knee reptacsmert', 3 weekspost-op =2 pointGoing up & down stairs:- up with the good, down with bad- crutches move with the bad legGains:* hold the cain onthestrong side- a lot of people use it the wrong wayWalkers:- pick it up, set it down, walk to it- if they must tie their belongings tothewalker,tieit atthe sides, not the frontever tic mostpeop e do that anyways; they don't like wheels or tennisball on the bottom either)

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DELUSIONS, HALLUCINATIONS, 4 ILLUSIONS (Psych)Neurosis Non- Psychotic vs. Psychosis- Hint:thefirst thingyou have to do to get a psychex. person sianngst a waH&says: "J see abomtf ->hallucinationBX- person .toks st fireextinguishes on thev/ai"sndsays: '7 seesbomb' ->illusion {refereci)Hint:On the test, they will tell you that there issomething there thus, you can differentiate between ahallucination & an illusion.questions correct is decide: 'Ismy PT non-psychoticor psychotic?"= this will determine treatment, goals, prognosis,medication, length of stay, legalities., .everythingNON-PSYCHOTICD e f i n i t i o nHas i n a i g h l & iersalrty-bSsed- eyen w/ emotionaldistreaa.'illTesB,mentabbenavioraldisorder- racoon ize what tneproblem a and howrt affectB their liteTreatment/- good thejapputicTechniquesfiommunicaucn (likeany PT that d splaysacbd comm, ski He jthere e noth ngspec al that you Tieecto do/know comparedto any med-surge,paeca , or C B PTSymptomsrjont have delusions,hallucinations, orillusionsPSYCHOTICHas noinsight &i s n o lreality-based- cpnit th 'nk.'knovj the.rsck- think everyone e ae naathe problem but not them(blae anyone else)- even if they say i h e y - esick but then they aay themartiana made them sickthey con*1! have insight- good therapeuticcom "'un caton coea network because the? are- R M R Ble. spec f cstrategiesHow do you deal with these Psychotic Symptoms?- first thing you ask after determining iFPT is psychotic:What is their problem?—>what kind of psychosis do they have?- 3TypesofPsychosis:1. Functional Psychosis- can function in everyday life(i.e. have jobs, amarriage, etc.)-4 diseases:Schizo Schizo Major Manicsi.Schizophreniaii.Schizoaffective Disorderiii. Major Depression (if its majortest will say)iv. Manic (Acute)-> so bi-polar is functional, only psychoticduring manic phase-these PT s have the potential tolearnreality(because no damage)-> may need meds or set boundaries for structure-> nurse role = teach reality {4 steps}a) acknowledge feef/og -> "|s e eyou're angry;'You seem upset', "Tell me how you are feeling',often uses the word feeling or shows a feelingb)PRESENT REALITY-> "I know that those voicesare real to you but I don’t hear them" or tellingthem what is real ("I’m a nurse & this is a hospital")c)setalimit"That topic/behavior is off-limits',’Weare not going to talk about that right now",'Stop talking about that"d)enforce the limit-> "| see you're too ill to stayreality based so our convo is over" (ending theconversation NOT taking away a privilege [i.e.punishment]: continuing to talk may enforce thenon-reality)™ on the test, they won't ask these specific stepsbutinstead, will ask "how should the nurse respond...'Ttry to pick the morepositive statements(i.e. whatthev can have/do. not what they cant); if between2 statements go w/ the positive oneDELUSIONS,- only in pavchotc p-'s- as scon as they get anyof these they've crossed,thene to Being psycnoticPsychotic Symptoms:- alDelusions= false, fixed, idea o<belief;no sensory component(all in the brainTthinking it)i. ParanoidDelusions-> people are out to harm meex. the mafia are out to get meii. GrandioseDelusions-> you are superior or youare the world s smartest/greatest person- ex. thinking you are Christ, Genghis Khaniii.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 _>heading things that aren't there (primarilyvoices teFing you to hurt yourself); most commonii. Visual -> seeing; 2nd most commoniii. Tactile -> feeling tilings: 3rd most commoniv.Gustatory ->tasting things that are not therev. Olfactory -> smel ing things that are not thereTlast 2 are relatively rare- c)Illusions= .nr/srnferpreLaf/on of reafffy; sensory experience- difference from hallucination ->with an illusion thereis areferentinreality-> referent= something in reality to which a personrefers when they say something (theyjustmisinterpret it}ex. PT says:"/ near detrain nc.ted -> haikucinationex. pm ovemears rarses £ ,’,fi7s Aauphing £ raiVnnp ar the nurse'ssiatran £ says: 'Listen,I.hear demon voices' ->IILs-or(therea a referent)- 2. Psychosis of Dementia-psychosis because ofactual damage to the brainrin Functional Dementia, there is no brain damage;its just messed up chemicals- include PT s w/ Alzeimer's, psychosis after a stroke,organic brain syndrome; anything w/ "senile" or"dementia"-cannot Learnreality-> major difference from functional (which is whyyou have to determine type of psychosis)

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-> nurse role:alacknowledge feelingblREDIRECT them ->from something they can tdo to something they can doyou dont set-limits because its meanNOT APPROPRIATE to present reality to thesePT's when they are experiencing psychoticsymptoms (BUT don't confuse thisw/ realityorientation}-> important to remember that forgetting things (likewhere they are or what room they're in - PTs w/dementia/Alzheimers) is NOT psychosis"when they start having delusions, hallucinations orillusions, then they are psychotic-> realityorientation= telling them person, place,and time (ALWAYS APPROPRIATE w/DEMENTIA) - this deals w/ memoryNarrowedSelf Concept= when apsychoticrefuses to leave their room orchange their clothes-functional psychotic- #1 reason is because their definition of self isnarrowed -> defined self based on 2 things:i.Where they areii. What they are wearing"Tsothey dodt know who they are unless they arewearing those exact clothes in that exact room- as the nurse, don't make them change or leave theroom (will cause escalating panic because they willlose their concept of self}ruse the Functional Psychosis techniques- IdeasofReference=<e veryone is la k ng about you- ex. see someone on the news and get upsetbecause you think they are talking about you- can have bothparanoia& ideas of reference(paranoia if also think they are going to harm you)3. P s y c h o t i c D e l i r i u m= atemporary,sudden, dramatic, episodic,secondary loss of reality; usually due to somechemical imbalance in the bodyrdifferent because its temporary and very acute-> include PT's that are short-term psychotic becauseof something else causing the psychosis- ex. a crug reaction, high on uppers or withdrawingfromcowners (delirium tremens), cocaine overdose.,post-op psychosis (withdrawing from a downer). ICUpsychosis (sensory deprivation), UTi (or any occultinfection), thyroid storm, adrenal crisis- good thing is its temporary so focus isremovingthe u n d e r l y i n g cause & k e e p i n g them safe-> nurse role:alacknowledge feelingblREASSURE them:it's temp. & they'll be safe"don't present reality -> they won't get itdon't redirect -> not going to work- Personality Disorders are differentA = antisocialB = bopcerlineN = narcissisticvery sick personality disordersmay be good to use Functional Psychosistechniques because you set imitsOther Psychotic Symptoms:L o o s e n i n g of A s s o c i a t i o n= your thoughts aren't wrapped too tight, all over tine mapalFlightof Ideas- coherent phrases but the phrases are notconnected (not coherent together)b} Word Salad- sicker, can t even make a coherent phrase-> babble random wordsc)Neologism- making up imaginary words
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