Google Doc Mark K NCLEX Study Guide

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** DON'T MIX UP S&S and CAUSATION -Dft e nwhat causes something is the opposite of the S&S - ex.diarrhea will cause a metabolic acidosis but onceyouare acidotic your bowel shuts down ano you get aparalytic illleus• when you get seenanos:- > if : s alungscenario = respiratory- then check if the client isover-ventilating(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:resp. rate isirrelevantw/ acid-base,ventilation has to dowith gas exchange not resp.rate (look at the SaO2-> ifyour resp. rate is fastbut SaO2 is low you are under-ventilating) -> ex. RCA pump - What acic-base disorderindicates they need to come off of it? = respiratoryacidosis {resp. depression -> resp. arrest} —> if its notiung, its metabolic• metabolic alkalosis- really only one scenario= i fthe P T has prolonged gastricvomiting/suctioning - because you arelosingACID* ex. G l surgery w/ N G tube with suctioning for3 days; hyperemesis graviderum- otherwise everything else that isn't lung youpick metabo/icacidosis (DEFAULT)* ex. hyperemesis graviderum w/ cfenj/drafropacute renal failure, infantile diarrhea■remember, you only have 4 to pick from: -respiratory alkalosis - respiratory acidosis -metabolic alkalosis - metabolic acidosis• pay more attention to themodifying phrasesthanthe originalnoun- ex. person w/ OCD who is now psychotic (psychotictrumps OCD); hyperemesis with dehydration (payattention to dehydration)VENTILATION• ventilators -> knowalarm systems(you setit upsothat the machine doesn't useless than or more thanspecific amounts of pressure)a)high pressure alarm =increased resistanceto airflow (the machine has to push too hard toget air intolungs)- fromobstructions:i. kinks in tubing (unkink it)ii. water condensation in tube (empty it!) iii.mucous secretions in the airway (changepositions/turn, C&DB,andTHENsuction) ***suction i s only PRNII!- > priority questions = you would checkkinks first, suction is not firstLECTURE 1ACID BASES• learn how to convert lab values to words• the rule of the B's= if the p H and the BiCarb are both in the samedirection -> metabolicHint:draw arrows beside each to see directions* down =acidosis* up =alkalosis- respiratory -> has nobin 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 yougenerate lists..) -for "select all" questions- ex.ingeneral/principle what d o opioids/painmeds do? = sedateyou,CNS depressors*ex.what does dilaudid do? don'tmemorize specificsorafeiof dilaudid, know principles of opioids{suchassecation. CNS depression -> lethargy, flaccidity.reflex+1, hypo-reflexia. obtundeo)- boards don't test b y lists because allbooks/ classes have different lists• principles of S&S acid bases: a sthe pH goes sogoes m ypatient (except K+)- p H up = P T up -> body system gets moreirritable, hyper-excitable (EXCEPT K+)-> alkalosis -think of a body system and g ohigh',hyper-reflexive (+3, + 4 [2isnormal]),tachypnea, tachycardia, borborygmi, seizure -p H down = P ~ down -> body systems shutdown (EXCEPT K+)-> acidosis -think of a system and go low.hypo-reflexive (+1, 0),bradycardia,lethargy,obtunded, paralytic iIleus, 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)• M a cKussmaul -Kussmaul's (compensatoryrespiratory mechanism) is only present inonly 1ofthe 4 metabolic (acid-base) disorders* M = metabolic A C = acidosis• most common mistake with select all questions= selectingone more than you should(stop when you select the onesyou know! don't get caught up on the "could be's")• Hint:don't select none orallon select all that applyquestions (never only one and never all)• Causes of Acid-Base Imbalance:- scenarios and what acid-base disorder wouldresu/t (what would cause an imbalance)b)l o wpressurea l a r m=decreasedresistanceto airflow (the machine had to worktoo littleto push air into lungs)

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- fromdisconnections:i.main tubing(reconnect itduh!)ii. 0 2 sensor tubing(whichsenses FiO2 atthe airway/trach area: black coated wirecoming from machine right along thetubing -reconnect!)« ventilators - >know blood gases- resp. alkalosis - ventilation settings mightbeset too high ( OVER-VENTILATING)- resp. acidosis = ventilation settings might besettoo low (UNDER-VENTILATING)• ex. weaning a PT off ventilator -> should not b eunder-ventilated, they need the ventilator; if theyare over-ventilating m e n they can be weaned« never pick an answer where you don't dosomething and someone else has to do somethingLECTURE2ABUSE (Psych and Med-Surge)Psychological Aspect/Psycho-Dynamics• # 1psychological problemisthesame inany/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. # 1psych problem in child abuse, gambling orcocaine abuse isdenial■why is denial the problem? HOW CAN YOU TREATSOMEONE W H O DENIES/DOESNT RECOGNIZETHEY HAVE A PROBLEM• denial = refusal to accept the reality of a problem •treat denial by CONFRONTING the problem(it'snotthe same asaggressionwhich attacks the person, notthe problem)= they DENY youCONFRONT -pointingout to the person the difference betweenwhat theysay and what they do- Hintnever pick answers that attack die person ->ex. bad answers have bad pronouns - "you" - > ex.good answers have good pronouns - "I", "we" -> ex."you wrote the order wrong" vs. T m havingdifficultyinterpreting what you want"• lossandgrief - > for this denial you mustSUPPORTit- DABDA = denial, anger, bargaining, depression, acceptance *Hint:for questionsaboutdenial,youmustlook toseeif itis LOSS or ABUSE- loss/grief = support- a b u s e =confront• #2 psychologicalproblem inabuse= DEPENDENCY,CO-DEPENDENCY- dependency =when the abuser gets significant otherto do things for them or make decisions for them -> thedependent - abuser- co-dependency =when the significant other derivespositive self-esteem from making decisions for ordoing things for the abuser-> the abuser gets a life w/o responsibilities-> thesig. other gets positive self-esteem (which iswhy theycan't get out of the relationship) • how do you treat it?- set limits and enforce them-> start teaching sig. other to say N O (and theyhave to keep doingit)- must also work on the self-esteemofthe co-dependent(ex. I'nn a good person because I'm saying "no”)*manipulation =when the abuser gets the sig. othertodo things for them that are not in the best interest ofthesig. other- the nature of the act isdangerous/harmful- how is manipulationlike dependency?-> i n both the abuser is getting the other person todo something for them- how do you tell the 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 somethingthatwill harm them or is dangerous to them theyaremanipulated* 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 d o you have w / denial? = 1 ex.h o w many P T s do you have w / dependency/co-dependency = 2ex. how many PT's do you have w/ manipulation = 1AlcoholismWernicke's & Korsakoff's- typically separate BUT boards lumps themtogether- w e r n i c k e s = encephalopathy- korsakoffs - psychosis (lose touch withreality)-> tend to go together, find them inthesameP T■Wernicke Korsakoff s syndrome:

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a) psychosis induced b yVit. B l (Thiamine)deficiency -lose touch w / reality, g o insane becauseof n o B l b) primary symptom - > amnesiaw /confabulation- significant memory loss w / makingu p stories- they believe their stories• H o w d o you deal w/ these PT's?- bad w a y = confrontation (because they believe whatthey are saying a n d can't see reality)- good way =redirection(take what the P T can't d oand channel it into something they can do)■Characteristics o f Wenicke Korsakoff s : a) ifspreventable =takeVit.B l(co-enzyme neededforthe metabolism ofalcoholwhich keeps alcoholfromaccumulating and destroying brain cells)** P T doesn'thave to stop drinkingb) tfs arrestab/e = can stopitfrom getting worse b ytakingVit.B l* also not necessary to stop drinkingc) ifsirreversible(70% of cases) - >Hint:O n boards,answerw lthe majority (ex. if something ismajority- ex. the PT has overdosed on a downer -> pick theS&S of too much downer- ex. the PT is withdrawing from an upper -> notenough upper makes everything go down- ex. the PT is withdrawing from a downer -> notenough downer makes everything go up• upper overdose looks like = downer withdrawal •downer overdose looks like -upper withdrawal« Inwhat 2 situations would resp. depression & arrestb eyour highest priority:- downer overdose- upper withdrawal* In what 2 situations would seizure b e t h e biggestrisk: - upper overdose- downer withdrawalof the t i m e fatal, y o u say it's fatal e v e n if 5 % of t h etime it's not)• D r u g s for Alcoholism:DISULFIRAM (Antabuse)= aversiontherapy - >want PT's 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(so if you want todrink again, wait 2 weeks)- P T teaching -avoid A L L forms of alcoholtoavoidnausea, vomiting & possibly death-> including mouthwash, aftershaves/colognesfperfumes(topical stuff will make them nauseous), insectrepellants,any OTC that ends with ’-elixer". alcohol- based handsanitizers, uncooked (no-bake) icingswhich havevanrltaextract, red wine vinaigretteOverdoses & Withdrawals:- everyabuseddrug iseitheran UPPERorD O W N E R- > the other drugs don't d o anything- > ?flabused class o f drugthati s not anupperordowner - laxatives in the elderlya) first establish if t h e drug i s anupperordowner -uppers (5) =caffeine, cocane. PCP/LSD {psycheceichallucinogens)metha.mp.nefamfnes , adderci (ADD drug) *S£S -> make you go up; euphoria, tachycardia,restlessness, irritability, diarrhea, borborygmi,hyper-reflexia, spastic, seize (neeo suction)- downers = don'tmemorizenames- > anything thati s not a nupperi sa downer! if you don't know whatt h e m e d is, youhave a high chance that it's adowner ifitsnot partof theuppers list* S £ S - > make you go down; lethargy, respiratorydepression {& arrest)- ex. The PT is high on cocaine. What is critical to assess? -> N O T resps b e l o w1 2b e c a u s e theywillb ehigh- >maybe check reflexesb)are they talking aboutoverdoseorwithdrawal- overdose/intoxication = toomuch- withdrawal =not enough- ex. the PT has overdosed on an upper -> pick theS&S of too much upperDrug Abuse in the Newborn:- always assume intoxication, N O T withdrawal atbirth - after2 4 hrs - >withdrawal- ex. caring for infant of a Quaalude addicted m o m 2 4hrs. after birth, select all that apply:-> downer withdrawal so everything is up = exaggeratedstartle, seizing, high pitchedfshrill cry■Alcohol Withdrawal Syndrome vs, Delirium Tremens- they are both different! not the samea)every alcoholic goes through withdrawal2 4 hrs.after they stop drinking- only a minority get delirium tremens- timeframe - > 7 2 hrs. (alcohol withdrawal comes 1st)- alcohol withdrawal syndrome ALWAYS precedesdelirium tremens, B U T delirium tremens does notalways follow alcohol withdrawal syndrome b)AWS isnotlife-threatening;D T scan kill you c) PT's w/ A W Sare not a dangertoself/others; PT'sw lDT's aredangeroustoself/others- they are withdrawing from a downer s o they willb e exhibitingupperS & S- D Trs are dangerousDifferencesinCareAWSDTDietRegulardietNPO.i'clear liquids{because of risk for seizureswhich can cause risk ofaspiration)RoomSemi-privateanywhereo ntheunitPrivate near nurses station(dangerous & unstable)AmbulationUp ad libRestricted beo rest -> nobathroom privileges (usebedpar s,'urinals)

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* hepatic encephalopathy (hepatic coma) =to getammonia down, oral -mycin's' will sterilize thebowelb y killing Gram-neg bacteria (E. coli) to helpbringdown ammonia and won't harm thedamaged liverbecauseitdoesn't go through theliver (also givesdiarrhea, more poop out is good) * pre-opbowelsurgery =itsterilizes the gut bykilling the E.colibacteria- if oral, no otto or nephro toxicity because notabsorbed - these areneomycin & kanamycin* Who cansterilizem ybowels?NEO KAN> Trough and Peak levels:- trough =drug at fewest- peak =drug athighest** TAP levels -trough administer peak-> draw trough levels first-> administer your drug-> draw peak levels after drug administration■Why draw eve s? =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 levels* ex. 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 MYCINS = major class that needsTAPs drawn because of narrow window■When do you draw TAPS?-> dependsontheroute(don't focusonthemed) a)TroughLevels** doesn't matter which route or med, always 30mins. - 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- P O = 3 0 mins, before next doseb) Peak Levels** different but depends on the route (not the med) -Sublingual = 5-10 mins after drug is dissolved - IV =15-30 m n s after drugs is finishedinfusing* Hint:ifyou get two values that are correct (i.e. a15 min.answer and a 30 min. one)pick the highestwithoutgoing overs o 30 mins.- IM = 30-60 mins, after administration- Sub-Q = SEE (see diabetes lecture -> becausetheonly Sub-Qpeaksare Insulins)- P O = forget about it, too variable so not testedRestraintsNorestraints(becausenotdangerous)Restraints (becausedangerous) - not soft wrist or4 point softbecause they'llget out- need to be i n vest or 2-pt.lockedleathers (opposite 1arm & leg.rotate Q2hrs, lockthe freelimbs 1st beforereleasing thelocked ones)They both get ANTI-HYPERTENSI VES& TRANQUILIZERS- because everything is up (downerwithdrawal) They both ger MULTIVITAMINw/Bl• R N s can accept but RPN's can't [because PT is unstable)- on med-surge, the RN who takes them 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.)DRUGSAMINOGLYCOCIDES■powerful class ofantibiotics(when nothing elseworkspullthese outs, the bigguns)- don't use unless anything else works• boards fove to test these drugs because the/ redangerous and are a test of safety• think:A MEAN OLD MYCIN-> a meanold -they treat serious, life-threatening,resistant, Gram-neg bacteria infections (i.e. a meanoldantibiotic for a meanoldinfection)-> mycin=what they end with (all end w/ -mycin)** nor all -mycin's are aminoglycosides BUT mostare (the 3 that are not are erythromycin,azithromycin, clarithromycin = fhrcw ff off ffie fet.Q• 2 toxic effects:i) when you see ’-mycin1, think m i c e- mice-> ears -> otto toxic- monitor hearing, tinnitus, vertigo/dizziness i)the human ear is shaped like akidneyso nexteffect is nephrotoxicity- monitorcreatinine(not BUN,output, dailyweight)* creatinine= the best indicator ofkidney/renalfunction (pick 2 4 hr. creatinineclearance overserum creatinine if both available)• f+8 (fits nicely in the kidney) reminds you about 2things about these drugs- toxic to cranial nerve 8- earnerve- administer Q8• route:- IM or IV• d o not give PO - > they are not absorbed -if yougive an oral '-mycin' it wi11go into gut, dissolve,gothrough and come out as expensive stool (wonthave any systemic effect)- EXCEPTin2 cases =bowel sterilizersThe BIG 10 Drugs to Know:1.psych drugs

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2 . insulins3. anti-coagulants4 . digitalis5 . aminoglycosides6. steroids7. calcium-channel blockers8. beta-blockers9. pain m e d s10. O B drugsLECTURE 3CardiacD R U G SC A L C I U M - C H A N N E L BLOCKERSCa/cfum-ChannefBlockers are like Valium for yourheart■V a l i u m - > calmrs y o u down; s o CCB's calm yourheartdown (ex. if tachycardic, give CCB's but not inshock) - to R E S T Y O U R HEART- not stimulants« calcium-channel blockers arenegative inotropic,chronotropic, & dromotroprcdrugs- fancy w a y of saying that they c a l m the heart down- also includes:V E R A P A M I L & C A R D I Z E M- which can b e given a s continuous I Vdrip?? = Cardizem■What V Sneeds to b e assessed before giving aC C B ?- B P = because of risk ofhypoTN- > parameters/guidelines - hold C C B ifsystolicisunder 1 0 0- > s o you n e e d to monitor B P if P T i s o n a Cardizemcontinuous d r i p (ifit'sunder100then you m a yhavetostop o r c h a n g e t h e drip rate)CARDIAC-ARRYTHMIA S• Interpreting Rhythm Strips ( 4that need tob eknownb y sight):a) Normal S i n u s Rhythm= P wave before every Q R S & followed b y a Twave for every single complex- > all P wave peaks are equally distant from eachother, Q R S evenly spacedb) V-Fib = chaotic squiggly line, n o patternc) V-Tach = s h a r p peaks, has a patternd) A-Systole = flat-line■Terminology:- ifQ R S depolarization,it’s talking aboutventricular(so rule out anything atrial)- if it saysP-wavethenit's talking aboutatrial• 6 Rhythms most tested o n N-CLEX:1 ." a lack of Q R S s' = A-systole- flat-line, n o Q R S2. "P-wave" = Atrial- if it’s a sawtooth wave, always pick atriajflutter3 . "chaotic” - A-fibif w /P-wave4. "chaotic" - V-fibif w /Q R S- Hint:t h e word 'chaos' i s used forfibrillation5."bizarre" = atrial tachycardia if w / P-wave 6 .''bizarre" = ventricular tachycardia if w / Q R S -Hint:the work 'bizarre' is used fortachycardias• P V C s(premature ventricularcontractions) = a.k.a. periodic widebizarre Q R S- ventricular because Q R S- bizarre - > tachycardia- y o u cancalla groupof P V C s a short run o f V -tach -d o Physician's care about PT's havingP V C s ?- > NO, notah i g h priority = low priority-> 3 circumstances when you could elevate thesePT's tomoderatepriority (never reach high)i. if thereare more than 6 P V C s in a minuteii. if there aremore than 6 PVCs in a rowiii.ifthe PVC fallontheT-wave of the previousbeat ( R o n T phenomenon)-> most common order if you call the M D about aP T w / P V C s = D/C monitor (because thenyoucan'tsee the PVCs and then you won't call them)• LethalArrhythmia's:- H I G H PRIORITY, 2 m a i n ones (will kill you i n 8minsor less) - > these PT'swillprobably b etoppriorities a)A-Systoleb)V-FibPOSITIVENEGATIVEInotropesCardiacStimulantsstimulate, speedup the heartCardiac- calmDepressantsthe heart down,weaken islowdownChronotropesDromotopes• Whend o y o u want to "depress" the heart?What d oCCB's treat?A: anti-hypertensives- relax heart & blood vessels to bring downB P A A : anti- a n g i n a s- relax heart to u s e less 0 2t omake a n g i n a g oaway- treats angina b y addressing oxygen demandAAA: anti-atrial arrhythmia- ex. atrial flutter, A-fib, premature atrialcontractions - never ventricular*** what about supra-venfncufartachycardia??- >because it means 'above the ventricles'(whichare the atria)■Side-Effects:H & H = headache & hypotension- > hypoTN - from relaxed heart & vessels-> headache - vasodilation to brain** Hint:headache is a g o o d thing t o select forselect all that apply questions (ex. low N a & highNa =heaoache, high &.low glucose = headache, high ilow BP =headache)• Names of Calcium-Channel Blockers:- anything ending in'-dipine'- ex. amlodipine, nifedipine- N O T just '-pine'

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** both have in common =no cardiac output->nobrain perfusion (and you'll be dead in8 mins)■V-tach-potentiallylife-threatening (but not actually life-threatening), but still makes it a fairly high priority -difference is that these P T s have cardiac output • incodes, even if the rhythm changes, if there is nocardiac output it's just as bad as the previous rhythm* Treatment (more drugs):a)PVC's b) V-tach= forventricularuseLIDOCAINE?AMIODARONE* in rural areas moreLioocair e use (cheaper &Ior ger shelf-1ife)c)Supra-Ventricular Arrhythmia's= atrialarrhythmia's use ABCD's• A ->ADENOCARD (Adenosine)- have to push in less than 8 seconds (FAST IVpush) ->slam this drug, followed by a flush; use abig vein; BUT the problem wf slamming it fast istherisk of PT going into A-Systole {for 30 secondsbutthey wfficame out of it so don't worry [unlesslongerthan 30 sec...])** forIV pushes: when youdon't know you goslow• B -> BETA-BLOCKERS- allend in '-lot- every '-lol' is a B B & 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 differencebetween Beta- & Calcium channel blockers;exceptthat CCB are better for PT's w/ asthmaor COPD ->Beta-B's bronchoconstrict• C -> CALCIUM-CHANNEL BLOCKERS- see Beta-Blockers &CCB's earlier. D -> DIGITALIS (DIGOXIN, LANOXIN)d)V-Fib= for V-fib you D-fib(shock them!)e) A-Systole= useEPINEPHRINE & ATROPINE(in thisorder!)-> if epinephrine doesn't work then useatropine* Hint:Also, pay attention to thelocationof thetubesa)Apical -the chest tube is way up high,thus it isremovingair(because air rises)- ex.ifsbadifyou're apical tube is draining200m Lorit is not bubblingb) Basilar = at the oottom of the lungs, thus it isremovingblood,1liquid (because of gravity) - ex.ifs bad if your basilar tube is bubbling or notdraining any m L* ex. How many chest tubes & where would you place themforaunilateral pneumohemothorax?- 2 chest tubes (apical for pneumo, basilar for hemo}■ex. Hoiv many chest tubes & where would you place themfor a bi-lateral pneumothorax?- 2 tubes (apical on left, apical on right)* ex.How many chest tubes & where would place them forpost-op chest surgery?- 2 tubes (apical & basilar on the side of thesurgery)** you are to assume that chestsurgeryrtraum a isuniIateralunlessotherwisespecified(they willsay bilateral)■Trick Question:How many chest cubes would youneed and where would you place them for a post-op right pneumonectomy?- NONE! because you are removing the lung s o youdon't need to re-establish any pressure (there is notpleural space)!Troubleshooting Chest Tubes:■What do you do if 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 MD)■What do you do if the water seal breaks (theactual device breaks?)-> first = CLAMPit!!!because now positivepressurecan get in! don t let anything get in-> 2nd = cut the tube away from the brokendevice-> 3rd = stick that open end into sterilewater-> then unclamp it because you've re-established thewater seal (doesn't need clamp if it's under water***better for the tube to be under water thanclamped! -> air can't go in and stuff can still keepcoming out (ifclamped. nothing can come outwhich is whatthetube is for)■Ex.If they ask what thefirstthingis to doif the sealbreaks -> Clamp! BUT,ifthey ask what's the best thingto do -> put end of tube under water! (becauseitactually solves the problem, clamping is a temp, fix) •Hint:BEST vs. FIRST questions- first questions =are about what order- best questions = what's the one thing you would doifyou could onlyd o 1of the options-> ex. You notice the PT has V-fib on the monitor.Yourun to the room and they are non-responsivewithno pulse. What is the first thing you do?A) place a backboard?B) begin chest compressions?- "firsd'is about order so = pick A (because youwouldn't start chest compressions first)CHEST TUBES* purpose is tore-establish negative pressurein thepleural space (so that the lung expands when thechest wall moves)- pleural space ->negative is good(negativepressuremakes things stick together)- ex. gun shot to the lung add positive pressure •Hint: whenyou get a chest tube question, look at thereasonfor which itwasplaced(will tell you what toexpect & what not to expect)- ex. pneumothorax - to remove air (becauseaircreated the positive pressure)- ex. hemothorax =toremove blood- ex. pneumohemothorax = to remove blood & air

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- BUT, if the question ask "What's the best thing todo?" -> you only get to do 1 thing not the other soyou would pick B* What d o you d o if the chest tube gets pulledout?- first = take a gloved hand and cover the hole- best = cover the hole with vaseline gauze♦Bubbling chest tubes:(ask yourself 2questions) a)Where i s it bubbling?b) Wheni s itbubbling?= the answer will depend on these 2 questions(sometimes bubbling is good, sometimes bad butdepends on where & when)- ex.Intermittent bubbling in the water seal ->GOOD(documentit,never bad!)- ex.Continuous bubbling in the water seal -> BAD(you don't want this, means a leak in the system thatyou need to find and tape it until it stops leaking)**in RPN scope- ex. Intermittentin suction control chamber -> BAD(means suction i s not high enough, tum it up on thewall until bubbling is continuous)- ex. Continuous in sucfioncontrol chamber ->GOOD(document it)- Hint:both locations are opposites of eachother(memorize one & deduce the others)—•> if there is a seal it should not be continuous(ex. a sealed bottle of pop continuouslybubblingmeans it's leaking!)w e don't expectit to)Growth &.Dev.slow, delayednormalLifeExpectancyshortnormalParent'sExperiencinggrief, stress,firarcial issues,lots of caregivingissuesregular averageperson issuesGoing Homeapnea monitorno apnea monitorHospital StayatBirthweeks24-48 hoursWhoFollowsYour CarePaediatricCarciologistPaediatrician,paediatric NPShuntingR t o L(T RouBLe)L t o RCyanosisCyanotic ->Blue(TRouBLe)Acyanotic• ex. You are teaching the parents about a heartdefect: - pick all the options that causetrouble• Hint:Boards will not give pictures of defects and askyou what they are.- not our job, we don't diagnose- our role is teaching parents the implications->so if its trouble = teach them things that i t s goingtobe a lot of trouble- > if it's not trouble = pick the things saying i t s notgoing to b e trouble• There ate 40+ congenital heart defects so just rememberTRouBLe (don't memorize all of them’):- Hint:all congenital heart defects that startwltheletter Tare Trouble Defects- wedon't care about the defect,we care aboutwhatw'reteaching the parents• All congenital heart defect kids (trouble or no trouble)will have 2 things:a)Murmur- why? = because of the shunting of theblood(regardless of direction of shunt)b) all have an Echocardiogram done (to findoutwhat the defect is or why there's a murmur) *4 Defects of Tetralogy of Fallout:- VarieD Pictures Of A RancH(or ValentinesDayPickSomeone Out A Red Heart)1 . VD = ventricular defect2.P S = pulmonary stenosis3. O A = overriding aorta4. R H = right hypertrophy• don't haveto recallthese, RECOGNIZE♦A straight catheter i s to a foley catheter a s athoracentesis is to a chest tube.- in-&-outvs. continuous secured- thoracentesis -> also helps re-establishneg.pressure (in-&-out chest tube)- higher risk for infections are continuousRules for Clamping Tubes:* a)Never clamp a tube formorethan1 5secondswithout a doctors order.- so if you break the water seal -> you have 1 5seconds to get that tube under water* b) Userubber-tippeddoubled clamps.- the teeth of the clamp need to be covered w /rubber so that you don't puncture the tubeCONGENITAL HEART DEFECTS♦every congenital heart detect is either TROUBLE orNO TROUBLE (ALL BAD or NO BAD)- either causes a lot of problems or i t s no big deal(noin-between defect)* memorize one word:TRouBLeHeart DefectsTRouBLe (95%of all heartdefects)N o TroubleSurgeryNEED surgerynow to live- don't reeo surgeryright away; possiblyr e e d it years later ifcauses aTroubleIt

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them - recall -> remember from nothing- RECOGNIZE -> spot it when you see it (usetheinitials to recognize them in questions)• ONLY DEFECT where they ask you what it isINFECTIOUS DISEASE and TRANSMISSION BASEDPRECAUTIONS (Isolations)• Standard• Universal• Contact- foranythingenteric =can b e caughtfromintestine-> fecal, oral- C-Diff, Hep. A , Cholera, Dysentery* things 'tvith bugs in diarrhea* Hintfor H e p A &. B: Hep A -> think anus, Hep B ->think blood (anything from the boivef starts wf a vowel) -Staph infections- RSV =respiratory syncytial vims(what babies, 1-2yr. old's get that is not dangerous to adults but canb e fatal for them)* transmitted b y dropletBUT still put them oncontact precautions because little kids catch itfrom touching thingsthat other sick kids touched -Herpes infections(includes Shingles -> HerpesZoster virus even though caused b y varicella) -What's involved in contact precautions?-> private roomispreferred(butnot required)* or 2 RSV kids in the same room* keep R S V kid &suspectedRSV separatebecauseyou need positive cultures (nor basedo n symptoms)- > N O :mask, eye/face shield (unless for universal),special filter mask, P T mask, neg. air flow- > YES:gloves, gown, hand-washing, specialsupplies &dedicated equipment (includes toys) ** disposablesupply vs. dedicated equipment:- thermometer cover -BP cuff that staysinl oom• Droplet- for bugs that travel 3 feet o n large particles due tosneezing/coughing- all meningitis* cultured through lumbar puncture- H Flu (haemophikis influenza B) ->commonlycausesepiglotitis* never stick something down throat because it willcause obstruction- What's involved in droplet precautions?-> private roomispreferred(butnot required)* on boards select private* can also cohort based o n positive cultures->NO:gown, eye/face shield, special filter mask,neg.airflow-> YES:mask, gloves, hand-washing, P T wornmask (when leaving room), disposable supplies&dedicated equipment• Airborne- M-M-R; TB; varicella (chicken pox)- What's involved in airborne precautions?-> private room isrequired* unless co-horting- > N O : gown (mostly for contact), eye/face shields- > YES: mask, gloves, hand-washing, special-filtermask ONLY for TB, PT mask for leaving room(butreally shouldn't b e leaving), neg. air flow**disposable supplies & dedicated equipment is agood thing but not really as essential as in theother2 (can let this one slide)-> TB: technically transmitted via dropletBUTputo n airborne• PPE = Personal Protective Equipment -boards like to test how youputo n or take off- always take it offin alphabetical order- > ex. gloves, goggles, gown, mask- putting o nis reverse alphabeticallyforthe 'grs' &mask comes 2nd-> gown, mask, goggles, glovesLECTURE 4CRUTCHES, CANES, WALKERS* major area of human function is tocomotion so they testthese even though not a major emphasis in school -area to test P T teaching & risk reductionCrutches:* H o w do youmeasure crutches?Mneed to know for risk reduction -> s o you don'tcause nerve damagea)length of crutch= 2 - 3 finger-widths below anterioraxillary folo to a point lateral to & slightly in front of the foot ->many questions ask where you measure fromrto (so forcrutches, if they ask anything measuring from axilla tofoot -:rule out, they're wrong instructions for length;b)hand grip =can be adjusted up &. down; when properlyplaced, shouldbe apx. 30 degreeselbow flexion •How to teachcrutchgaits(4kinds):** names are pretty obvious w/ a few exceptionsa)2-point- movea crutch and opposite foottogether followedby other crutch & opposite foot- moving 2 things togetherb)3-point- moving2 crutches & the bad legtogether- moving 3 things togetherc)4-point- movingeverything separately- move any crutch, then opposite foot, followed b ynext crutch then other foot- very slow but very stabled)Swing-through- for non-weightbearinginjuries (ex. amputations) -plant crutches and swing the injured limb through(never touches down)* When d o they use them?- ask yourself "how many legs areaffected? -even for even, odd for odd* even point gaits when a weakness is evenlydistributed (i.e. even # of legs messed up)- 2-point = mi/d problems (bilateral)- 4-point = severe problems (severe, bilateral

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weaknesses)- 3-point =only odd one,when only 1 leg is affected• Ex. Barty stageso f rheumatoid arthritis =2-point Ex.Left,above the knee amputation= swing-through Ex.First day post-o p right knee replacement. partial weight-bearing allowed =3-pointEx.Advanced stages ofALS =4-pointEx. Lefthip replacement, 2nd day post-op, non weight-bearing= swing-throughEx. Brtatera/total knee replacement,1 s tday post-op, weight-bearing allowed =4-pointEx. Brtatera/ tota/ Knee rep/acement, 5 wteeks post-op = 2point •Going up & down stairs:- up with the good, down with bad- crutches move with the bad legCains:• hold the cain on thestrong side- a lot of people use it the wrong wayWalkers:• pick it up, set it down, walk to it• rf theymusttie their belongings to the walker, tie it atthe sides, not the front- b o a r d s doesn't like things o n the fro i t[event h o m o s tp e o p l e o o t h a t a n y w a y s : theydon'tlike w h e e l s or tennisball o n t h e bottom either)□E L U S I O N S ,H A L L U C I N A T I O N S , &I L L U S I O N S( P s y c h )Neurosis Non-Psychotic vs. Psychosis• Hint:thefirst thingyou have to do co get a psychquestions correct is decide:"Is my P T non-psychoticor psychotic?"= this will determine treatment, goals, prognosis,medication, length of stay, legalities...everythinghallucinations, o rillusionsILLUSIONS- only in psychotic PT's -a s soon as they get anyof these they've crossedthe line t o beingpsychoticPsychotic Symptoms:• a) Delusions= false*ixed. idea cr belief;no sensorycomponent(all in the brain, thinking it)i Paranoid Delusions-> peopleareout toharmm e - ex. the mafia are out to get m eii.Grandiose Delusions-> you are superior or youare the world's smartest/greatest person- ex.thinking you are Christ, Genghis Khaniii. SomaticDelusions -> abouta body part - ex. x-ray vision;there are worms in my body . b)Hallucinations= a false, fixed, se.nsoiy experience (purelysensory);5 senses so 5 for [1 for each sense)i.Auditory-> hearing t h i n g s that aren't t h e r e (primarilyv o i c e s telling y o u to h u r t yourself): m o s t c o m m o nii.Visual- > seeing; 2 n d most c o m m o niii.T a c t i l e - > feeling things: 3 r d m o s t c o m m o niv.G u s t a t o r y - >tasting things t h a t a r e n o t t h e r ev . O l f a c t o r y - > smelling t h i n g s that a r e n o t there*** last 2 are relatively rare. c)Illusions= misinterpretation of reality, sensoryexperience -difference from hallucination -> with an illusion thereis areferent in reality-> referent =something in reality to which a personrefers when they say something (they justmisinterpret it)• ex. P T says.' "J hear demon voices" -> hallucination ex. P Toverhears nurses & MD's laughing & talkingar ifte .nurse'sstation £ says; "Lister?,i hear demon voices’-> illusion (thereis a referent)e x . p e r s o nstartinga t aw a i l &says; " /s e eab o m b " - >hallucinat on ex. personlooksar fire exti'ngu.'sfter o n the waWandsays:" / s e e abomb'1-> illusion (referent)• Hint:O n the test, they will tell you that there issomething there thus, you can differentiate betweenahallucination & an illusion.How do you deal with these Psychotic Symptoms?• first thing you ask after determining if PT is psychotic:What is their problem?—> what kind of psychosis do they have?■3 Typesof Psychosis:1. Functional Psychosis- canfunction in everyday life(i.e. have jobs,amarriage, etc.)- 4 diseases:Schizo Schizo MajorManics i. SchizophreniaiiSchizoaffective DisorderNON-PSYCHOTICPSYCHOTICDefinitionH a si n s i g h t si sreality-based- evenwfemodoraldistress/illness.mentab'behaviora1disorder- recognize whattheproblem isand howit affectstheir lifeHasn o i n s i g h t sisnotreality-based- don't think/krcw theirsick - think everyoneelse hast h e problembut not t h e m(blameanyone else) - even ifthey say they'resickbut then they say themartians made themsickthey don't haveinsightTreatment/Techniqu e s- g o o o therapeuticcomnAim-cat-on (1k eany P T thatdisplaysgoodcomm, skills} **there's nothingspecial that youneedt o oo/knowcomparedto anymed-surge,paeds,or 0 6 PT- good therapeuticcommurication doesnotwork because theyarenot rational- r e e d unique,specificstrategiesSymptomsdon't havedelusions.DELUSIONS,HALLUCINATION,

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iii.Major Depression(if its major, test will say)iv.Manic (Acute)-> s o bi-polar is functional, only psychoticduring manic phase- these P Ts have the potential to learnreality(because no damage)-> may need meds or set boundaries forstructure ->nurse role= teach reality (4 steps)a)acknoi/v/edgefeeling-> "I see you're angry;"You seem upset", ’Tell m e how you are feeling",often uses the word feeling or shows a feelincb)PRESENT REALITY ->"Iknow that those voicesare real to you but I don't hear them" or tellingthemwhat is real ('Tm a nurse & t h i s is a hospital") c ) s e t alimit ->"That topic/behavior is off-limits","We arenot going to talk about that right now'',"Stop talkingabout that"d)enforce the limit ->" I 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 steps butinstead, will ask "how should the nurse respond..."*** try to pick the more positive statements (i.e. whatthey can have/do, not what they can't); if between2 statements gow/the positive one>2Psychosis of Dementia- psychosis because of actualdamage to the brain*in Functional Dementia, there is no brain damage;it's just messed u p chemicals- include PT's w/ Alzeimer's, psychosis after astroke,organic brain syndrome; anything w /"senile" or"dementia"- cannot leam reality-> major difference from functional (which is whyyou have to determine type of psychosis)-> nurserole:a)acknowledge feelingb)REDIRECT them ->from something they can'tdo to something they can do** you don't set-limits because its mean** N O TAPPROPRIATE to present reality to thesePT'swhen 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 - PT's w/dementia/Alzheimers) is NOT psychosis** when theystart having Delusions, hallucinations orillusions, then theyare psychotic- > reality orientation= telling them person, place,and time (ALWAYS APPROPRIATE w /DEMENTIA) - this dealsw lmemory3.Psychotic Delirium= a temporary,sudden,dramatic,episodic,secondary loss of reality; usually d u e to somechemical imbalancein the body* different because it's temporary and very acute->include PT's that are short-term psychotic becauseof something else causing the psychosis- ex. a drugreaction, high on uppers or withdrawingfrom downers{delirium tremens), cocaine overcose,post-op psychosis{withdrawing from a oowner), ICUpsychosis {sensorydeprivation), UTI [or any occultinfection}, thyroid storm,adrenal crisis- good thing is it's temporary s o focus isremovingthe underlying cause & keeping them safe - >nurse role:a)acknowledge feelingb)REASSURE them:it's temp. & they'll be safe** don't present reality -> they won't get it** don'tredirect -> not going to work■Personality Disorders are different:A = antisocialB = borderlineN = narcissistic** very sick personality disorders** may be good to use Functional Psychosistechniques because you set limitsOther Psychotic Symptoms:■Loosening of Association= your thougms aren't wrapped too tight, a I over t i e mapa) Flight of 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• Nat rowed Self Concept= when apsychoticrefuses to leave their room orchange their clothes- functional psychotic- # 1reason is because their definition of self isnarrowed -> defined self based on 2 things:i.Wherethey areii. What they are wearing*** s o they don't know who they are unless they arewearing those exact clothes in that exact room -asthe nurse, don't make them change or leave theroom (will cause escalating panic because they willlose their concept of self)* use the Functional Psychosis techniques*Ideasof Reference= think everyone is talking about you- ex. see someone on the news and get upsetbecause you think they are talking about you - canhave both paranoia & ideas of reference(paranoia if also think they are going to harm you)LECTURE 5DIABETES M.

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■definition =an error ofglucosemetabolism -causes issues becauseglucoseis the primary fuelsource and if your body can't metabolize glucose,cellswilldie• doesnotincludediabetes insipidus =polyuriapolydipsia leadingtodehydrationdue to l o w ADH - >it's just similar with the fluids, not the glucose part(similar symptoms)- opposite syndromes of diabetes i. = SIADH •relationship betweenamount of urine & specificgravity of urine:- they are opposites/inverse- i.e.the less urine out, thehigherthe specificgravity;the moreurine out,the lower the specificgravity * so diabetes = has more urine & lowspecificgravity (opposite withSIADH)- peak = 2 hrs.- duration = 4 hrs.- is clear (solution' so it can beIV dripped(this isthe one used if using IVs)- short,rapidacting,insulin (but Hesi will call itintermediate because w e now haveLisprowhichacts faster)2.NP H- trueintermediateactinginsulin- onset = 6 hrs.- peak - 8-10 hrs.- duration = 1 2 hrs.- is cloudy (suspension)* the issue w/ suspensionsisthatitprecipitates->the particles fall to the bottom over time soyouCANNOT give via IV (or the PT willoverdose & thebrain will die)* Hint:general rule =>never put anythingcloudy in an IV bag3. Lispro(Humalog)- fastestact/bg,rapid- onset = 15 mins.- p e a k = 3 0 mins.- duration = 3 hrs.- you give this as they being to eat so with meals(notac) -> interrupt them while eating!4Lantus (Glargine)- longacting- peak - no essential peak because it s so slowlyabsorbed ->thus, littletono risk for hypoglycemia -duration = 12-24 hrs.- onlyinsulin youcan safely &.routinely give atbedtime because it will not cause themjto gohypoglycemic during the night (YOU CANNOTROUTINELY GIVE THE OTHERS AT BEDTIME) **Hint:boards likes to test peaks & tend to test it bygiving you a time when insulin was given & askingwhen they reach hypoglycemia fwhich is the peak). •CHECK EXPIRY DATESO N INSULIN!!!- What action by the nurse invalidates themanufacturer's expiration date? =opening it ->the minute you open it the date is irrelevantbecause now you have30 days from opening(have to write the date of opening & new expiry]-refrigeration is optionalinthe hospital BUT youneed to teach PT's to refrigerate at home- > though at the hospital the ones that should berefrigerated should be theun-opened vials - betterto give warm, non-expired insulin than cold,expired insulinTYPE I vs. TYPE II:Differeric—esTYPE 2 DMNames- Insulin dependent-Juvenile onset- Ketosis prone- Non-insulindependent - Adult-onset- Non-ketosis proneS£S- polyuria- polydipsia- polyphagia(increasedswallowing, but i ncontext of D M italsorelates toeating)- sameTreatmentD =diet —> leastimportart (lessrestrictions than before)1= insulin —> MOSTIMPORTANTE =exerciseD =diet —> MOSTIMPORTANT0=oral hypoglycem c(pills)A = activityDiet:■primarily Type II• a) It is a calorie restriction.- tells you that calorie's are important becausethediet's are named (ex. 1500 calorie...)*** this is the best strategy for them■b) They need 6 small feedings a day.- keeps blood sugar levels morenormoglycemicthroughout the day instead of3bigpeaksInsulin:■lowersblood glucose■4 main types you real y need to know1Regular Insulins ->the"R''is important- ex. Humulin R, Novalin R- onset = 1 hr.Exercise:* exercise potentiates insulin= meaning, it does the same thing as insulin —>thinkof exercise as another shot of insulin - if youhave more exercise during the day, you needlessinsulin shots (and bring easily metabolizedcarba'snacks to sports games)

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