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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 metabol c ac dosis but once you are ac dotic you r 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 Dver-i/enf'af p (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; rasp, rale is inetevsrrfw/ acid-base, ventilation has to co with gas excharge not resp. 'ate (look at tie SaO2 -> if your resp. rale is fast but EaO2 is low you are under-ventilating) -> ex. PC A pump - What acid-base diso r der ind cates they reed to come off of it? = respiratory ac cosis (resp. depression -> resp. arrest) —> if its not lung, its metabolic • metabolic alkalosis - really only one scenario = if the PT has prolonged gastric vomiting/suctioning - because you are losing ACID "ex. Gl 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 Rb6‘ s YJERt NOT ON UM *NCiexU * LECTURE 1 ACID BASES • learn how to convert lab values to words - the rule of the Bs = if the pH and the BiCarb are both in the same direction -> metabolic Hint: draw arrows beside each to see directions ’ down = ac/cfos/s * 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 opioid s/pain meds do? = sedate you, CNS depressors F ex. what does di audid do? dori I memorize specifics o. r a fef of dtlaudid, know principles of opioids (such as sedation, CHS dep p essian -> l&lhargy, flacc dity, reflex +1, hypo-reflex ia, -Dblunded) - boards don't test by lists because all books/ classes have different lists ■ principles of S4S 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 ot 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+l -> acidosis - thwik of 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 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 T M = metabolic AC = acidosis ■ pay more attention tc 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 does nt 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 PRNJII -> priority questions = you would check kinks first, suction is not first . most common mistake with se ect all questions = selecting one more than you should (stop when you select the ones you know! don't get caught up on the "could he's”) • Hint: don't select noneor aflon select all that apply questions (never only one and never all) - Causes of Acid- Base Imbalance: - scenarios and what acid-base disorder would resuttfwhat would cause an imbalance}

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    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. 02 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 dont de something and someone else has to do something

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    Etsy:lNURSINGNOTES101 LECTURE 2 ABUSE (Psych and Med-Surge) Psycfro/ogrcaMspect/Psycho-DynanNcs - # 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 peycn problem in child abuse, gambling or cocaine abuse ia aerae) - why is denial the problem? HOW CAN YOU TREAT SOMEONE WHO DEN1ES/DOESN T RECOGNIZE THE Y HAVE A PROBLEM - denial = refusal to accept the reality of a problem * treat denial by CONFRONTING the problem (it's not the same as agpress/on 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 rever 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 = cen al, arger, ba r gaining, 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 ■ c o - d e p e n d e n c y = 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 dancreroirs.'/Tarmfu/ - 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 P T 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 Wernickes & Korsakoff s - 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 PT ■ Wernicke K o r s a k o f f s s y n d r o m e : a} psychosis induced by Wf. Bl (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 Wen i eke Korsakoff's: a} rtsprevejifabfe= 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 r also not necessary to stop drinking c) rfs 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 if s not) - Drugs for Alcoholism: DISULFIRAM (Antabuse} = aversion therapy -> want PTs 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}

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    - PT teaching = avoid ALL forms of alcohol to avoid nausea, vomiting & possibly death -> including mouthwash, aftershaves/colognes/perfumes (topical stuff will make tnem nauseous), insect repel ants, any OTC that ends with "-elixer", alcohol- based hard sanitizers, uncooked (no-ba<el icings which have vanilla extract, 'ed 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 al first establish if the drug is an upperor downer - uppers (5) = caffeine, coca ne, PCP/LSD (psychedelic hallucinogens}, methsmphsfaiTwrws. adderoi {ADD drug? T 5&S -> make you go up: euphoria, tachycardia, restlessness, irritability, diarrhea, oorbo r ygmi. hyper-reflexia, spastic, seze (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 its a downer if its not part of the uppers list ’ S&S -> make you go cown; letnargy. resp ratory 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 bl are they talking about overdose or withdraws I - overdose/intoxi cation = 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 dowrer - ex. the PT is withdrawing from an uppe p -> not enough uope r makes everytning go down - ex. the PT is withdrawing from a cowner -> not enough downer makes eveyth ng go up ■ upper overdose looks tike - 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. ■ 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 mmor/tyget 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; DTs can kill you c) PT's w/ AWS are not a danger to sellf/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 - DTs are dangerous Diflsrsnces AWS DT in Cans Diet Regu lar c et NPCWclear lie uids (because a1 risk for seizures which can cause -isk ci asp ration) Room Semi-prvate Private near nurses station anywhere on (dangerous A unstable) the unit Ambulation Up ad lib Rest-kited bed rest -> no balh-oom privileges (use bedpans'urinals) Restraints Norestrants Restraints (because dangerous) (because not - not soft wrist or 4 point soft dangerous) because tney'll gel out - need to be in vest or 2-pt. locked leathers (opposite 1 arm 8. leg, rotate Q2hrs, lock 1he f-ee I mbs 1st before releasing the locked ones) Thev both get ANTI- HYPERTENSIVES & TRANQUILIZERS - becajse eve-ylhing is up (downer withdrawal) They both gel MULTIVITAMIN w,' Bl ■ RN's can accept but RPN's can't (because PT is unstable) - on med-surge, the RN who takes :hem 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.) • 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 ptched'Shrill cry

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    DRUGS AMINOGLYCOC1DES - powerful class of antibiotics (when nothing else works pull these outs, the big guns) - don't use unless anything else works ■ boards /oue fo test fhese drugs because theyre dangerous 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 mean o/d antibiotic for a mean oj'd intectionj -> mycto = what they end with (all end w/ -mycin} ” not all -mycin's are aminoglycosides BUT most are (the 3 that are not are erythromycin azihromycin, clarithromycin = torow if off toe tist.i) - 2 toxic effects i) when you see -mycin. think mice - mice ->ears -> otto toxic -monitor hearing, tinnitus, vertgo/dizziness ii) the human ear is shaped like a kidney so next effect is nephrotoxicity - monitor treat'.nine (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 i- 2 case . = bowel sterilizers: T hepatic encephalopathy (hepatic coma} = to get ammonia down, cral ’-mycin's' will sterilize the bowel by killing Gram-neg bacteria (E. coli) to help bring down ammonia and wont harm the damaged liver because it doesn't go through the liver (also gives diarrhea, more poop out is good.) r pre-op bowei 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 ■ 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 T ex. Lasix doses range from 5-80mg thus a wide range so you wont need TAP levels " ex. Dig doses range from 0.125 - 0.25 so this narrow range needs TAPS levels - A MEAN OLD MYCIN3 = major class that reeds 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 2 0 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 mot the med) - Sublingual = 5-10 mins after drug is dissolved - IV = 15-30 mins after drugs is finished tofesingr T Hint: if you get two values 'hat 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. caldum-channel blockers 8 beta-blockers 9. pain meds 10. OB drugs ■ Trough 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 E O CAR DI AC- AR R Y T H Ml AS - 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 c o m p l e x -> all P wave peaks are e q u a l l y distant from each other. QRS evenly spaced b) .'-jib = chaotic squiggly line, no pattern c) '.'-Tach = sharp peaks, has a pattern d} - -Systole = flat-fine - Terminology: - if QRS d e p o l a r i z a t on, it's talking about ventricular (so rule out anything atrial) - if it says P-wave then it s t a l k i n g about atrial Cardiac D R U G S C A L C E U M - C H A N N E L B L O C K E R S CS/c/um-C/ianne/ B/ocxe/s are M e Va/rum for your heart • Valium -> calm's you down; so C C 8 s calm your heart down (ex. if tachycardic, give CCB s but not in shock) - to R E S T YOUR HEART - not stimulants • calcium-channei b l o c k e r s are negative i n o t r o p i c c 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 down POSITIVE NEGATIVE inotropes Cardiac Stimulants Cardiac Depressants * - stimulate, speec - caTmtne near! cown. bnronotropes u o the heart weaken & slow cown Dromotopes - 6 Rhythms most tested on N - C L E X : 1 a lack of QRS's" = A-systole - flat-line, no QRS 2. " P - w a v e " = Atrial - if its a sawtooth wave, always pick afoa) flutter 3. " c h a o t i c ' - A-tib if w/ P-wave 4. "chaotic" - V-fib if w/ QRS L ! I - H i n t : the wore chaos is used tor >'t •-..'.aifor 5 bizarre" = atrial t a c h y c a r d i a if w/ P - w a v e 6. bizarre" = ventricular tachycardia if w/ Q R S - Hint, the work 'b zarre' is usee for foc.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 you want io ' d e p r e s s " the heart? What do CCS's treat? At anti- h y p e r t e n s i v e s - relax heart & blood vessels to bring down BP AA: anti-angina s 4 CUT Vt P ftlN - relax heart to use less 0 2 to make a n g i n a go away - treats a n g i n a by addressing oxygen d e m a n d AAA; anti-atrial arrhythmia - ex. atrial flutter, A-fib. premature atrial contractions - never ventricular m what about supra-ventricular tachycardia?? -> because it means 'above the ventricles' (which are the atria) - 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 brain ” Hint: h e a d a c h e is a good thing tc se set for 'select ail that apply' questions (®t. low Na & nign Na = 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 e 1 - ex. a m l o d i p i n e nifedipine ■ N 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/S needs to be assessed before giving a C C B ? - BP = because of risk of hypoTN -> parameters/guide lines - hold CCB if systolic is under 1 00 -> so you need to monitor BP if PT is on a Cardizem c o n t i n u o u s drip (if it's under 1 00 then you may have to stop or change the drip rate} - bizarre -> tachycardia -you can call a group of P V C s a short run of V-tach - d o Physician's care about PT's having P V C s ? -> NO, not a high priority = low priority -> 3 circumstances when you could elevate these P T s t o moderate priority (re -er eac- 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 tall on the T-wave of the previous beat ( R o n T phenomenon) -> most common order if you call the MO about a PT w/ P V C s = D/C monitor ( Decause then you can t see the PVCs and then you won t call them) - Lethal Arrhythmia s: - HIGH PRIORITY 2 main ones will - ill you in 8 m ns ji ess -> these P T s will p r o b a b l y be top priorities a} A - S y s t o l e b) V-Fifa ” both have in common = no cardiac output -> no brain perfusion (and you II be dead in 8 mins) - . -tach = potenf/a/jyHte-th reate ning (but not actually life-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 s if there is no cardiac 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 the bottom of the lungs, thus it is removing bfoodlliquid (because of gravity) -ex. its bad if your basilar tube is bubbling or not draining any mL ■ ax. How many chest tubes & where would you place them for s unilateral pneumohemothorax? - 2 chest tubes (apical for preumo. basilar for nemo) ■ ax. How many chest tubes S where would you place them for a bi-lateral pneumothorax? - 2 tubes (apical on left, apical on right) * ax. 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 uni'ess 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 it 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 ND) - 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 clams if its under water ™ better for the tube to be under water than clamped! -> alir 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, cfamping is a temp fix) - Hint: 'BEST vs. FIRST questions - first questions = are about what order - test questions = what's the one thing you would do if you could only do I cf the options -> ex. You notice the FT 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 - Treatment (more drugs): a) PVC s b) V-tach = for ventricular use LIDOC AINE/AMIODARONE ' in rural areas mare Liaocaine use (cheaper A lange- ahelf-He) c) Supra-Ventricular Arrhythmia's = atrial arrhythmia's use ABCUs ■ A->ADENOCARO (Adenosine) - have to push in less than 8 seconds {FAST IV push)-> Siam tnis drjg ; followed by a flush; use a bi g vein: BU T the prob e m w/ slamming it fast is the risk of PT going into A-Systo e (for 30 seconds but they will come out of it so don't worry [unless lorger than 30 sec...]) ” for IV pushes: when you don t know you go slow ■ B -> BETA- BLOCKERS - a ii 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-L't yco D-fib (shock them!) el A-Systo le = use EPINEPHRINE & ATROPINE {in this order!) -> if epinephrine doesn't work then use atropine CHEST TUBES • purpose is to re-estab/rs/r nerjafrVe pressure in the pleural space (so that the lung expands when the chest wall moves) - pleural space -> rregabve 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 tacatron ot the tubes. a) Apical = the chest tube is way up high, thus it is removing air(because air rises) - ex. its bad if you re apical tube is draining 200 mL or it is not bubbling

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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 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. /nfemfffenf bubbling in the water seal -> GOOD (document it, never badfl - 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. Infermjftent 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-S.-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 clam ps. - the teeth of the damp 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 its no Dig deal (no in-between defect) - memorize one word: TRouBLe Heart Delecta TRp uBLe (95% of all heart defects} No Trouble Su rgery N ED surgery now - don't need surgery -igrt away; possitn'j need it years late - if it causea 'a Trouble (but we do n'1 expect it to) Growth & Dev. alow, delayed no-mal Life Expectancy short normal Parents Experiencing grief, stress., ffnanc el seuea, lots of ca'egvng issues regular average person iBffjes Going Home apnea monitor no apnea monitor t c o i t a l Stoy at weeks 24-40 houra Who Follow® Your Care Paediatric Card ologist Paediatrician, oaediat-ic NP Shunting R_to L (TRouBLe) L t o R Cyanosis Cyanotic -> Blue (TTtou BLe) Acyanotic - 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 ou r job, we don't diag nose -our role is teaching parents the implications -> so f ts troube = leach them things that ts going to be a lot ol trousle -> il it's not rouble = pick the things saying it's not going to be troube ■ The p e 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 Troubte Defects - we con f care about the defect, we care about what were 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 R a n c H (cr Valentines Day =l c< Someone Out A Red Heart) 1. VD= ventricular defect 2. PS = pulmonary stenosis 3. O A = ove r riding aorta 4. RH = right hypertrophy • dont 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

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    INFECTIOUS DISEASE and TRANSMISSION BASED PRECAUTIONS (Isolations) - Standard - Universal - Contact - for anything enteric = can be caught from fnfestfne -> fecal oral - C-Diff, Hep. A, Cholera, Dysentery r things with bugs in diarrhea T Hint 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 -2 yr. old s get that is not dangerous to adults but can be fatal for them) r transmitted by droplet BUT still put them on contact precautions because little kids catch it from touching Wrings 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) T or 2 RSV kids in the same room r 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 tc sneezing/ccughing - all meningitis ’ cultured through lumbar puncture - H Flu (haemophilus influenza B)-> commonly causes epiglottis ’ never stick something down throat because it will cause obstruction - What’s involved in droplet precautions? -> private room is preferred (but not required) r on boards select pr vate r 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) - W h a t s involved in airborne precautions? -> private room is required r unless co-horting -> NO: gown (mostiyfor 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 Eke to test how you put on or take off -always take it off in alphabetical cider -> ex. gloves, goggles, gown, mask - p u t t i n g on is reverse alphabetically for the g s' & mask comes 2nd -> gown. mask, goggles, gloves I N FECUOhl , , CONSOL MRWRME PRECAUTION H>- s.j Miftues L<J MEZ HECTfS ZWCR -r C W f t U CONTACT PEKAUTi * MUSR T MRE R S E HeSWfHOfliJ INFECTION VIIUWO W C C T I O N ENTEKU. 'j tSft (< H i n n s s»Mpitx > I M P H I W ? PtOiCulOSVS & SCOPES t MOCCUS t STfiPH tlUTilPEMC PRC CtAVTlbNS ? 7 ’

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    LECTURE 4 y\J 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 t.a) length of crutch = 2-3 finger-widths below anted or axillary folc to a point lateral to & si ghtly in front of the foot -> many questions ask where you measure fromfto (so for crutches, if they ask anything measuring from ax Ila to foot -> rule out, they re wrong instructions for length) bl hand grip = can be adjusted up & down; when properly placed, should be apx. 30 dagraas elbow Haxion ■ 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 5 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-v,eight 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 r even point gaits when a weakness is evenly distributed (i.e. even # of legs messed up) - 2-point = mjfcf problems (bilateral j ■ 4-point = severe problems (severe, bilateral weaknesses) - 3-point = chmy odd one, when only 1 leg is affected . Ex. Eady stages of rheumatoid arthritis = 2-point Ex. LaS, atove- the knee ampufatio.? = ewing-througri 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. BWsierai total knee replacement, 1st day post-op. weight- bearing a'lcwed = 4-point Ex. BWsierai tatai knee reptacsmert', 3 weeks post-op = 2 point ■ Going up & down stairs: - up with the good, down with bad - crutches move with the bad leg Gains: * 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 ■ ever tic most peop e do that anyways; they don't like wheels or tennis ball on the bottom either)

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    DELUSIONS, HALLUCINATIONS, 4 ILLUSIONS (Psych) Neurosis Non- Psychotic vs. Psychosis - Hint: the first thing you have to do to get a psych ex. person sianng st a waH& says: "J see a bomtf -> hallucination BX - person .toks st fire extinguishes on the v/ai" snd says: '7 see s bomb' -> illusion {refereci) ■ Hint: On the test, they will tell you that there is something there thus, you can differentiate between a hallucination & an illusion. questions correct is decide: 'Is my PT non-psychotic or psychotic?" = this will determine treatment, goals, prognosis, medication, length of stay, legalities., .everything NON-PSYCHOTIC D e f i n i t i o n Has i n a i g h l & ie rsalrty-bSsed - eyen w/ emotional distreaa.'illTesB, mentabbenavioral disorder - racoon ize what tne problem a and how rt affectB their lite Treatment/ - good thejapputic Techniques fiommunicaucn (like any PT that d splays acbd comm, ski He j there e noth ng spec al that you Tieec to do/know compared to any med-surge, paeca , or C B PT Symptoms rjont have delusions, hallucinations, or illusions PSYCHOTIC Has no insight & i s n o l reality-based - cpnit th 'nk.'knovj the. r sck - think everyone e ae naa the problem but not them (bla e anyone else) - even if they say i h e y - e sick but then they aay the martiana made them sick they con * 1 ! have insight - good therapeutic com "'un caton coea net work because the? are - R M R B le. spec f c strategies How do you deal with these Psychotic Symptoms? - first thing you ask after determining i F 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 its 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 feef/og -> "| s e e 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 -> "| 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...' T ” try to pick the more positive statements (i.e. what thev can have/do. not what they cant); if between 2 statements go w/ the positive one DELUSIONS, - only in pavchotc p-'s - as scon as they get any of these they've crossed, the ne to Being psycnotic Psychotic Symptoms: - al Delusions = false, fixed, idea o< belief; no sensory component (all in the brainTthinking 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 _> heading things that aren't there (primarily voices teFing you to hurt yourself); most common ii. Visual -> seeing; 2nd most common iii. Tactile -> feeling tilings: 3rd most common iv. Gustatory -> tasting things that are not the r e v. Olfactory -> smel ing things that are not there ” T last 2 are relatively rare - c) Illusions = .nr/srnferpreLaf/on of reafffy; 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:"/ near detrain nc.ted -> haiku ci nation ex. pm ovemears rarses £ ,’,fi7s Aauphing £ raiVnnp ar the nurse's siatran £ says: 'Listen, I .hear demon voices' -> IILs-or (there a a referent) - 2. Psychosis of Dementia -psychosis because of actual damage to the brain r in 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 Learn reality -> major difference from functional (which is why you have to determine type of psychosis)

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    -> nurse role: al acknowledge feeling bl REDIRECT them -> from something they can t do to something they can do ” you dont set-limits because its 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 - PTs w/ dementi a/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 ■ 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 " T so they dodt 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} r use the Functional Psychosis techniques - Ideas of Reference = ■ ■ < e veryone is la k ng 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) 3. P s y c h o t i c D e l i r i u m = a temporary, sudden, dramatic, episodic, secondary loss of reality; usually due to some chemical imbalance in the body r different because its temporary and very acute -> include PT's that are short-term psychotic because of something else causing the psychosis - ex. a crug reaction, high on uppers or withdrawing from cowners (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 its temporary so focus is removing the u n d e r l y i n g cause & k e e p i n g them safe -> nurse role: al acknowledge feeling bl 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 = bo p cerline N = narcissistic ” very sick personality disorders ” may be good to use Functional Psychosis techniques because you set im its Other 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 map al 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

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