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Google Doc Mark K NCLEX Study Guide

This lecture covers acid-base balance principles, focusing on interpreting lab values, recognizing metabolic vs. respiratory causes, understanding pH effects on the body, and applying knowledge to clinical scenarios like alarms and drug effects.

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    ** DON'T MIX UP S&S and CAUSATION - D f t e n what causes something is the opposite of the S&S - ex. diarrhea will cause a metabolic acidosis but once you are acidotic your bowel shuts down ano you get a paralytic illleus • when you get seenan os: - > if : s a lung scenario = respiratory - then check if the client is over-ventilating (alkalosis) or under-ventila ting (acidosis) - remember to look at the words (ex. over, under, ventilating) -> "as the pH goes so goes my PT" -> VENTILATING DOESN'T MEAN RESPIRATORY RATE: resp. rate is irrelevant w/ acid-base, ventilation has to do with gas exchange not resp. rate (look at the SaO2-> if your resp. rate is fast but SaO2 is low you are under- ventilating) -> ex. RCA pump - What acic-base disorder indicates they need to come off of it? = respiratory acidosis {resp. depression -> resp. arrest} — > if its not iung, its metabolic • metabolic alkalosis - really only one scenario = i f the P T has prolonged gastric vomiting/suctioning - because you are losing ACID * ex. G l surgery w/ N G tube with suctioning for 3 days; hyperemesis graviderum - otherwise everything else that isn't lung you pick metabo/ic acidosis (DEFAULT) * ex. hyperemesis graviderum w/ cfenj/drafrop acute renal failure, infantile diarrhea ■ remember, you only have 4 to pick from: - respiratory alkalosis - respiratory acidosis - metabolic alkalosis - metabolic acidosis • pay more attention to the modifying phrases than the original noun - ex. person w/ OCD who is now psychotic (psychotic trumps OCD); hyperemesis with dehydration (pay attention to dehydration) VENTILATION • ventilators -> know alarm systems (you set it up so that the machine doesn't use less than or more than specific amounts of pressure) a) high pressure alarm = increased resistance to airflow (the machine has to push too hard to get air into lungs) - from obstructions: i. kinks in tubing (unkink it) ii. water condensation in tube (empty it!) iii. mucous secretions in the airway (change positions/turn, C&DB,and THEN suction) *** suction i s only PRNII! - > priority questions = you would check kinks first, suction is not first LECTURE 1 ACID 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 same direction -> metabolic Hint: draw arrows beside each to see directions * down = acidosis * up = alkalosis - respiratory -> has no b in it; if in other directions (or if bicarb is normal value) - KNOW NORMAL pH, BiCarb, CO2 • Hint: DON'T MEMORIZE LISTS...know principles (they test knowledge of principles by having you generate lists..) - for "select all" questions - ex. in general/principle what d o opioids/pain meds do? = sedate you, CNS depressors * ex. what does dilaudid do? don't memorize specifics or a fei of dilaudid, know principles of opioids {such as secation. CNS depression -> lethargy, flaccidity. reflex +1, hypo-reflexia. obtundeo) - boards don't test b y lists because all books/ classes have different lists • principles of S&S acid bases: a s the pH goes so goes m y patient (except K+) - p H up = P T up -> body system gets more irritable, hyper-excitable (EXCEPT K+) -> alkalosis - think of a body system and g o high ', hyper-reflexive (+3, + 4 [2 is normal]), tachypnea, tachycardia, borborygmi, seizure - p H down = P ~ down -> body systems shut down (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 at the bedside? = acidosis (resp. arrest) • ex. which acid-base disorders need suction at the bedside? = alkalosis (seize and aspirate) • M a c Kussmaul - Kussmaul's (compensatory respiratory mechanism) is only present in only 1 of the 4 metabolic (acid-base) disorders * M = metabolic A C = acidosis • most common mistake with select all questions = selecting one more than you should (stop when you select the ones you know! don't get caught up on the "could be's") • Hint: don't select none or all on select all that apply questions (never only one and never all) • Causes of Acid-Base Imbalance: - scenarios and what acid-base disorder would resu/t (what would cause an imbalance) b) l o w pressure a l a r m = decreased resistance to airflow (the machine had to work too little to push air into lungs)

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    - from disconnections: i. main tubing (reconnect it duh!) ii. 0 2 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 b e under-ventilated, they need the ventilator; if they are over-ventilating m e n they can be weaned « never pick an answer where you don't do something and someone else has to do something LECTURE 2 ABUSE (Psych and Med-Surge) Psychological Aspect/Psycho-Dynamics • # 1 psychological problem is the same in any/all abusive situations = DENIAL - abusers have an infinite capacity for denial so that they can continue the behavior w/o answering for it ■ can use the alcoholism rules for any abuse - ex. # 1 psych problem in child abuse, gambling or cocaine abuse is denial ■ why is denial the problem? HOW CAN YOU TREAT SOMEONE W H O DENIES/DOESNT RECOGNIZE THEY HAVE A PROBLEM • denial = refusal to accept the reality of a problem • treat denial by CONFRONTING the problem (it's not the same as aggression which attacks the person, not the problem) = they DENY you CONFRONT - pointing out to the person the difference between what they say and what they do - Hint never pick answers that attack 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 having difficulty interpreting what you want" • loss and grief - > for this denial you must SUPPORT it - DAB DA = denial, anger, bargaining, depression, acceptance * Hint: for questions about denial, you must look to see if it is LOSS or ABUSE - loss/grief = support - a b u s e = confront • #2 psychological problem in abuse = DEPENDENCY, CO-DEPENDENCY - dependency = when the abuser gets significant other to do things for them or make decisions for them -> the dependent - abuser - co-dependency = when the significant other derives positive self-esteem from making decisions for or doing things for the abuser -> the abuser gets a life w/o responsibilities -> the sig. other gets positive self-esteem (which is why they can't get out of the relationship) • how do you treat it? - set limits and enforce them -> start teaching sig. other to say N O (and they have to keep doing it) - must also work on the self-esteem of the co-dependent (ex. I'nn a good person because I'm saying "no”)* manipulation = when the abuser gets the sig. other to do things for them that are not in the best interest of the sig. other - the nature of the act is dangerous/harmful - how is manipulation like dependency? -> i n 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 d o you have w / denial? = 1 ex. h o w many P T s do you have w / dependency/co- dependency = 2 ex. how many PT's do you have w/ manipulation = 1 Alcoholism Wernicke's & Korsakoff's - typically separate BUT boards lumps them together - w e r n i c k e s = encephalopathy - korsakoffs - psychosis (lose touch with reality) -> tend to go together, find them in the same P T ■ Wernicke Korsakoff s syndrome:

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    a) psychosis induced b y Vit. B l (Thiamine) deficiency - lose touch w / reality, g o insane because of n o B l b) primary symptom - > amnesia w / confabulation - significant memory loss w / making u 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 what they are saying a n d can't see reality) - good way = redirection (take what the P T can't d o and channel it into something they can do) ■ Characteristics o f Wenicke Korsakoff s : a) ifs preventable = take Vit. B l (co-enzyme needed for the metabolism of alcohol which keeps alcohol from accumulating and destroying brain cells) * * P T doesn't have to stop drinking b) tfs arrestab/e = can stop it from getting worse b y taking Vit. B l * also not necessary to stop drinking c) ifs irreversible (70% of cases) - > Hint: O n boards, answer w l the majority (ex. if something is majority - ex. the PT has overdosed on a downer -> pick the S&S of too much downer - ex. the PT is withdrawing from an upper -> not enough upper makes everything go down - ex. the PT is withdrawing from a downer -> not enough downer makes everything go up • upper overdose looks like = downer withdrawal • downer overdose looks like - upper withdrawal « In what 2 situations would resp. depression & arrest b e your highest priority: - downer overdose - upper withdrawal * In what 2 situations would seizure b e t h e biggest risk: - upper overdose - downer withdrawal of the t i m e fatal, y o u say it's fatal e v e n if 5 % of t h e time it's not) • D r u g s for Alcoholism: DI SULFIRAM (Antabuse) = aversion therapy - > want PT's to develop a gut hatred for alcohol -> interacts w/ alcohol in the blood to make you very ill - > works in theory better than in reality - > onset & duration: 2 weeks (so if you want to drink again, wait 2 weeks) - P T teaching - avoid A L L forms of alcohol to avoid nausea, vomiting & possibly death -> including mouthwash, aftershaves/colognesfperfumes (topical stuff will make them nauseous), insect repellants, any OTC that ends with ’-elixer". alcohol- based hand sanitizers, uncooked (no -bake) icings which have vanrlta extract, red wine vinaigrette Overdoses & Withdrawals: - every abused drug is either an UPPER or D O W N E R - > the other drugs don't d o anything - > ?fl abused class o f drug that i s not an upper or downer - laxatives in the elderly a) first establish if t h e drug i s an upper or downer - uppers (5) = caffeine, cocane. PCP/LSD {psycheceic hallucinogens) m etha.mp.n efamfnes , adderci (ADD drug) * S£S -> make you go up; euphoria, tachycardia, restlessness, irritability, diarrhea, borborygmi, hyper- reflexia, spastic, seize (neeo suction) - downers = don't memorize names - > anything that i s not a n upper i s a downer! if you don't know what t h e m e d is, you have a high chance that it's a downer if its not part of the uppers list * S £ S - > make you go down; lethargy, respiratory depression {& arrest) - ex. The PT is high on cocaine. What is critical to assess? - > N O T resps b e l o w 1 2 b e c a u s e they will b e high - > maybe check reflexes b) are they talking about overdose or withdrawal - overdose/intoxication = too much - withdrawal = not enough - ex. the PT has overdosed on an upper -> pick the S&S of too much upper Drug Abuse in the Newborn: - always assume intoxication, N O T withdrawal at birth - after 2 4 hrs - > withdrawal - ex. caring for infant of a Quaalude addicted m o m 2 4 hrs. after birth, select all that apply: -> downer withdrawal so everything is up = exaggerated startle, seizing, high pitchedfshrill cry ■ Alcohol Withdrawal Syndrome vs, Delirium Tremens - they are both different! not the same a) every alcoholic goes through withdrawal 2 4 hrs. after they stop drinking - only a minority get delirium tremens - timeframe - > 7 2 hrs. (alcohol withdrawal comes 1st) - alcohol withdrawal syndrome ALWAYS precedes delirium tremens, B U T delirium tremens does not always follow alcohol withdrawal syndrome b)AWS is not life-threatening; D T s can kill you c) PT's w/ A W S are not a danger to self/others; PT's w l DT's are dangerous to self/others - they are withdrawing from a downer s o they will b e exhibiting upper S & S - D T r s are dangerous Differenc es in Care AWS DT Diet Regular diet NPO.i'clear liquids {because of risk for seizures which can cause risk of aspiration) Room Semi- private anywhere o n the unit Private near nurses station (dangerous & unstable) Ambulatio n Up ad lib Restricted beo rest -> no bathroom privileges (use bedpar s,'urinals)

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    * hepatic encephalopathy (hepatic coma) = to get ammonia down, oral -mycin's' will sterilize the bowel b y killing Gram-neg bacteria (E. coli) to help bring down ammonia and won't harm the damaged liver because it doesn't go through the liver (also gives diarrhea, more poop out is good) * pre-op bowel surgery = it sterilizes the gut by killing the E. coli bacteria - if oral, no otto or nephro toxicity because not absorbed - these are neomycin & kanamycin * Who can sterilize m y bowels? NEO KAN > Trough and Peak levels: - trough = drug at fewest - peak = drug at highest ** 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't need to draw TAP levels * 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 MYCINS = major class that needs TAPs drawn because of narrow window ■ When do you draw TAPS? -> depends on the route (don't focus on the med) a) Trough Levels ** doesn't matter which route or med, always 30 mins. - sublingual = 30 mins, before next dose - IV = 30 mins, before next dose - IM = 30 mins, before next dose - Sub-Q = 30 mins, before next dose - P O = 3 0 mins, before next dose b) Peak Levels ** different but depends on the route (not the med) - Sublingual = 5-10 mins after drug is dissolved - IV = 15-30 m n s after drugs is finished infusing * Hint: if you get two values that are correct (i.e. a 15 min. answer and a 30 min. one) pick the highest without going over s o 30 mins. - IM = 30-60 mins, after administration - Sub-Q = SEE (see diabetes lecture -> because the only Sub-Q peaks are Insulins) - P O = forget about it, too variable so not tested Restraint s No restraints (because not dangerous ) Restraints (because dangerous) - not soft wrist or 4 point soft because they'll get out - need to be i n vest or 2-pt. locked leathers (opposite 1 arm & leg. rotate Q2hrs, lock the free limbs 1st before releasing the locked ones) They both get ANTI-HYPERTENSI VES & TRANQUILIZERS - because everything is up (downer withdrawal) They both ger MULTIVITAMIN w/Bl • R N s can accept but RPN's can't [because PT is unstable) - on med-surge, the RN who takes them must decrease their workload (i.e. reduce PT load if they take a DT PT) - > Hint: on boards, the setting is always perfect (i.e. enough staff/time/resources on the unit etc.) DRUGS AMINOGLYCOCIDES ■ powerful class of antibiotics (when nothing else works pull these outs, the big guns) - don't use unless anything else works • boards fove to test these drugs because the/ re dangerous and are a test of safety • think: A MEAN OLD MYCIN -> a mean old - they treat serious, life-threatening, resistant, Gram-neg bacteria infections (i.e. a mean old antibiotic for a mean old infection) -> mycin = what they end with (all end w/ -mycin) ** nor all -mycin's are aminoglycosides BUT most are (the 3 that are not are erythromycin, azithromycin, clarithromycin = fhrcw ff off ffie fet.Q • 2 toxic effects: i) when you see ’-mycin 1 , think m i c e - mice-> ears -> otto toxic - monitor hearing, tinnitus, vertigo/dizziness i) the human ear is shaped like a kidney so next effect is nephrotoxicity - monitor creatinine (not BUN, output, daily weight) * creatinine = the best indicator of kidney/renal function (pick 2 4 hr. creatinine clearance over serum creatinine if both available) • f+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 • d o not give PO - > they are not absorbed - if you give an oral '-mycin' it wi11 go into gut, dissolve, go through and come out as expensive stool (wont have any systemic effect) - EXCEPT in 2 cases = bowel sterilizers The BIG 10 Drugs to Know: 1. psych drugs

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    2 . insulins 3. anti-coagulants 4 . digitalis 5 . aminoglycosides 6. steroids 7. calcium-channel blockers 8. beta-blockers 9. pain m e d s 10. O B drugs LECTURE 3 Cardiac D R U G S C A L C I U M - C H A N N E L BLOCKERS Ca/cfum-Channef Blockers are like Valium for your heart ■ V a l i u m - > calm r s y o u down; s o CCB's calm your heart down (ex. if tachycardic, give CCB's but not in shock) - to R E S T Y O U R HEART - not stimulants « calcium-channel blockers are negative inotropic, chronotropic, & dromotroprc drugs - 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 V drip?? = Cardizem ■ What V S needs to b e assessed before giving a C C B ? - B P = because of risk of hypoTN - > parameters/guidelines - hold C C B if systolic is under 1 0 0 - > s o you n e e d to monitor B P if P T i s o n a Cardizem continuous d r i p (if it's under 100 then you m a y have to stop o r c h a n g e t h e drip rate) CARDI AC- ARRYTHMI A S • Interpreting Rhythm Strips ( 4 that need to b e known b y sight): a) Normal S i n u s Rhythm = P wave before every Q R S & followed b y a T wave for every single complex - > all P wave peaks are equally distant from each other, Q R S evenly spaced b) V-Fib = chaotic squiggly line, n o pattern c) V-Tach = s h a r p peaks, has a pattern d) A-Systole = flat-line ■ Terminology: - if Q R S depolarization, it’s talking about ventricular (so rule out anything atrial) - if it says P-wavethen it's talking about atrial • 6 Rhythms most tested o n N-CLEX: 1 . " a lack of Q R S s' = A-systole - flat-line, n o Q R S 2. "P-wave" = Atrial - if it’s a sawtooth wave, always pick atriaj flutter 3 . "chaotic” - A-fib if w / P-wave 4. "chaotic" - V-fib if w / Q R S - Hint: t h e word 'chaos' i s used for fibrillation 5. "bizarre" = atrial tachycardia if w / P-wave 6 . ''bizarre" = ventricular tachycardia if w / Q R S - Hint: the work 'bizarre' is used for tachycardias • P V C s (premature ventricular contractions) = a.k.a. periodic wide bizarre Q R S - ventricular because Q R S - bizarre - > tachycardia - y o u can call a group of P V C s a short run o f V - tach - d o Physician 's care about PT's having P V C s ? - > NO, not a h i g h priority = low priority -> 3 circumstances when you could elevate these PT's to moderate priority (never reach high) i. if there are more than 6 P V C s in a minute ii. if there are more than 6 PVCs in a row iii. if the PVC fall on the T-wave of the previous beat ( R o n T phenomenon) -> most common order if you call the M D about a P T w / P V C s = D/C monitor (because then you can't see the PVCs and then you won't call them) • Lethal Arrhythmia's: - H I G H PRIORITY, 2 m a i n ones (will kill you i n 8 mins or less) - > these PT's will probably b e top priorities a) A-Systole b) V-Fib POSITIVE NEGATIVE Inotropes Cardiac Stimulants stimulate, speed up the heart Cardiac - calm Depressants the heart down, weaken i slow down Chronotrope s Dromotopes • When d o y o u want to "depress" the heart? What d o CCB's treat? A: anti-hypertensives - relax heart & blood vessels to bring down B P A A : anti - a n g i n a s - relax heart to u s e less 0 2 t o make a n g i n a g o away - treats angina b y addressing oxygen demand AAA: anti-atrial arrhythmia - ex. atrial flutter, A-fib, premature atrial contractions - never ventricular *** what about supra-venfncufar tachycardia?? - > because it means 'above the ventricles' (which are the atria) ■ Side-Effects: H & H = headache & hypotension - > hypoTN - from relaxed heart & vessels - > headache - vasodilation to brain ** Hint: headache is a g o o d thing t o select for select all that apply questions (ex. low N a & high Na = heaoache, high &. low glucose = headache, high i low 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 -> no brain perfusion (and you'll be dead in 8 mins) ■ V-tach - potentially life-threatening (but not actually life- threatening), but still makes it a fairly high priority - difference is that these P T s have cardiac output • in codes, even if the rhythm changes, if there is no cardiac output it's just as bad as the previous rhythm * Treatment (more drugs): a) PVC's b) V-tach = for ventricular use LIDOCAINE?AMIODARONE * in rural areas more Li o ocair e use (cheaper & Ior ger shelf-1ife) c) Supra-Ventricular Arrhythmia's = atrial arrhythmia's use ABCD's • A -> ADENOCARD (Adenosine) - have to push in less than 8 seconds (FAST IV push) -> slam this drug, followed by a flush; use a big vein; BUT the problem wf slamming it fast is the risk of PT going into A-Systole {for 30 seconds but they wfficame out of it so don't worry [unless longer than 30 sec...]) ** for IV pushes: when you don't know you go slow • B -> BETA-BLOCKERS - all end in '-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 difference between Beta- & Calcium channel blockers; except that CCB are better for PT's w/ asthma or COPD -> Beta-B's bronchoconstrict • C -> CALCIUM- CHANNEL BLOCKERS - see Beta-Blockers & CCB's earlier . D -> DIGITALIS (DIGOXIN, LANOXIN) d) V-Fib = for V-fib you D-fib (shock them!) e) A-Systole = use EPINEPHRINE & ATROPINE (in this order!) -> if epinephrine doesn't work then use atropine * Hint: Also, pay attention to the location of the tubes a) Apical - the chest tube is way up high, thus it is removing air (because air rises) - ex. ifs bad if you're apical tube is draining 200 m L or it is not bubbling b) Basilar = at the oottom of the lungs, thus it is removing blood, 1 liquid (because of gravity) - ex. ifs bad if your basilar tube is bubbling or not draining any m L * ex. How many chest tubes & where would you place them for a unilateral pneumohemothorax? - 2 chest tubes (apical for pneumo, basilar for hemo} ■ ex. Hoiv m any chest tubes & where would you place them for a bi-lateral pneumothorax? - 2 tubes (apical on left, apical on right) * ex. How many chest tubes & where would place them for post-op chest surgery? - 2 tubes (apical & basilar on the side of the surgery) ** you are to assume that chest surgeryrtraum a is uni Iateral unless otherwise specified (they will say bilateral) ■ Trick Question: How many chest cubes would you need and where would you place them for a post- op right pneumonectomy? - NONE! because you are removing the lung s o you don't need to re-establish any pressure (there is not pleural space)! Troubleshooting Chest Tubes: ■ What do you do if you knock over the plastic containers that certain tubes are attached to? - > set it back up & have PT take some deep breaths -> NOT a medical emergency! (don't call MD) ■ What do you do if the water seal breaks (the actual device breaks?) -> first = CLAMP it!!! because now positive pressure can get in! don t let anything get in -> 2nd = cut the tube away from the broken device -> 3rd = stick that open end into sterile water -> then unclamp it because you've re-established the water seal (doesn't need clamp if it's under water *** better for the tube to be under water than clamped! - > air can't go in and stuff can still keep coming out (if clamped. nothing can come out which is what the tube is for) ■ Ex. If they ask what the first thing is to do if the seal breaks -> Clamp! BUT, if they ask what's the best thing to do -> put end of tube under water! (because it actually solves the problem, clamping is a temp, fix) • Hint: BEST vs. FIRST questions - first questions = are about what order - best questions = what's the one thing you would do if you could only d o 1 of the options -> ex. You notice the PT has V-fib on the monitor. You run to the room and they are non-responsive with no pulse. What is the first thing you do? A) place a backboard? B) begin chest compressions? - "firsd'is about order so = pick A (because you wouldn't start chest compressions first) CHEST TUBES * purpose is to re-establish negative pressure in the pleural space (so that the lung expands when the chest wall moves) - pleural space -> negative is good (negative pressure makes things stick together) - ex. gun shot to the lung add positive pressure • Hint: when you get a chest tube question, look at the reason for which it was placed (will tell you what to expect & what not to expect) - ex. pneumothorax - to remove air (because air created the positive pressure) - ex. hemothorax = to remove blood - ex. pneumohemothorax = to remove blood & air

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    - BUT, if the question ask "What's the best thing to do?" -> you only get to do 1 thing not the other so you would pick B * What d o you d o if the chest tube gets pulled out? - first = take a gloved hand and cover the hole - best = cover the hole with vaseline gauze ♦ Bubbling chest tubes: (ask yourself 2 questions) a) Where i s it bubbling? b) When i s it bubbling? = the answer will depend on these 2 questions (sometimes bubbling is good, sometimes bad but depends on where & when) - ex. Intermittent bubbling in the water seal -> GOOD (document it, never bad!) - ex. Continuous bubbling in the water seal -> BAD (you don't want this, means a leak in the system that you need to find and tape it until it stops leaking) ** in RPN scope - ex. Intermittent in suction control chamber -> BAD (means suction i s not high enough, tum it up on the wall until bubbling is continuous) - ex. Continuous in sucfion 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!) w e don't expect it to) Growth &. Dev. slow, delayed normal Life Expectancy short normal Parent's Experiencing grief, stress, firarcial issues, lots of caregiving issues regular average person issues Going Home apnea monitor no apnea monitor Hospital Stay at Birth weeks 24-48 hours Who Follows Your Care Paediatric Carciologist Paediatrician, paediatric NP Shunting R t o L (T RouBLe) L t o R Cyanosis Cyanotic -> Blue (TRouBLe) 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 our job, we don't diagnose - our role is teaching parents the implications -> so if its trouble = teach them things that i t s going to be a lot of trouble - > if it's not trouble = pick the things saying i t s not going to b e trouble • There ate 40+ congenital heart defects so just remember TRouBLe (don't memorize all of them’): - Hint: all congenital heart defects that start wl the letter T are Trouble Defects - we don't care about the defect, we care about what w're teaching the parents • All congenital heart defect kids (trouble or no trouble) will have 2 things: a) Murmur - why? = because of the shunting of the blood (regardless of direction of shunt) b) all have an Echocardiogram done (to find out what the defect is or why there's a murmur) * 4 Defects of Tetralogy of Fallout: - VarieD Pictures Of A RancH (or Valentines Day Pick Someone Out A Red Heart) 1 . VD = ventricular defect 2. P S = pulmonary stenosis 3. O A = overriding aorta 4. R H = right hypertrophy • don't have to recall these, RECOGNIZE ♦ A straight catheter i s to a foley catheter a s a thoracentesis is to a chest tube. - in-&-outvs. continuous secured - thoracentesis -> also helps re-establish neg. pressure (in-&-out chest tube) - higher risk for infections are continuous Rules for Clamping Tubes: * a) Never clamp a tube for more than 1 5 seconds without a doctors order. - so if you break the water seal -> you have 1 5 seconds to get that tube under water * b) Use rubber-tipped doubled clamps. - the teeth of the clamp need to be covered w / rubber so that you don't puncture the tube CONGENITAL HEART DEFECTS ♦ every congenital heart detect is either TROUBLE or NO TROUBLE (ALL BAD or NO BAD) - either causes a lot of problems or i t s no big deal (no in-between defect) * memorize one word: TRouBLe Heart Defects TRouBLe (95% of all heart defects) N o Trouble Surgery NEED surgery now to live - don't reeo surgery right away; possibly r e e d it years later if causes a Trouble It

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    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 INFECTIOUS DISEASE and TRANSMISSION BASED PRECAUTIONS (Isolations) • Standard • Universal • Contact - for anything enteric = can b e caught from intestine -> fecal, oral - C-Diff, Hep. A , Cholera, Dysentery * things 'tvith bugs in diarrhea * Hint for 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, 1-2 yr. old's get that is not dangerous to adults but can b e fatal for them) * transmitted b y droplet BUT still put them on contact precautions because little kids catch it from touching things that other sick kids touched - Herpes infections (includes Shingles -> Herpes Zoster virus even though caused b y varicella) - What's involved in contact precautions? -> private room is preferred (but not required) * or 2 RSV kids in the same room * keep R S V kid & suspected RSV separate because you need positive cultures (nor based o 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, special supplies & dedicated equipment (includes toys) ** disposable supply vs. dedicated equipment: - thermometer cover - BP cuff that stays in l oom • Droplet - for bugs that travel 3 feet o n large particles due to sneezing/coughing - all meningitis * cultured through lumbar puncture - H Flu (haemophikis influenza B) -> commonly causes epiglotitis * never stick something down throat because it will cause obstruction - What's involved in droplet precautions? -> private room is preferred (but not required) * on boards select private * can also cohort based o n positive cultures -> NO: gown, eye/face shield, special filter mask, neg. air flow -> YES: mask, gloves, hand-washing, P T worn mask (when leaving room), disposable supplies & dedicated equipment • Airborne - M-M-R; TB; varicella (chicken pox) - What's involved in airborne precautions? -> private room is required * unless co-horting - > N O : gown (mostly for contact), eye/face shields - > YES: mask, gloves, hand-washing, special-filter mask ONLY for TB, PT mask for leaving room (but really shouldn't b e 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 o n airborne • PPE = Personal Protective Equipment - boards like to test how you put o n or take off - always take it off in alphabetical order - > ex. gloves, goggles, gown, mask - putting o n is reverse alphabetically for the 'g r s' & mask comes 2nd -> gown, mask, goggles, gloves LECTURE 4 CRUTCHES, CANES, WALKERS * major area of human function is tocomotion so they test these even though not a major emphasis in school - area to test P T teaching & risk reduction Crutches: * H o w do you measure crutches? M need to know for risk reduction -> s o you don't cause nerve damage a) length of crutch = 2 - 3 finger-widths below anterior axillary folo to a point lateral to & slightly in front of the foot -> many questions ask where you measure fromrto (so for crutches, if they ask anything measuring from axilla to foot -: rule out, they're wrong instructions for length; b) hand grip = can be adjusted up &. down; when properly placed, should be apx. 30 degrees elbow flexion • How to teach crutch gaits (4 kinds): ** names are pretty obvious w/ a few exceptions a) 2-point - move a crutch and opposite foot together followed by other crutch & opposite foot - moving 2 things together b) 3-point - moving 2 crutches & the bad leg together - moving 3 things together c) 4-point - moving everything separately - move any crutch, then opposite foot, followed b y next crutch then other foot - very slow but very stable d) Swing-through - for non -weight bearing injuries (ex. amputations) - plant crutches and swing the injured limb through (never touches down) * When d o they use them? - ask yourself "how many legs are affected? - even for even, odd for odd * even point gaits when a weakness is evenly distributed (i.e. even # of legs messed up) - 2- point = 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 stages o f rheumatoid arthritis = 2-point Ex. Left, above the knee amputation = swi ng-through Ex. First day post- o p right knee replacement. partial weight- bearing allowed = 3- point Ex. Advanced stages ofALS = 4-point Ex. Left hip replacement, 2nd day post-op, non weight-bearing = swing-through Ex. Brtatera/ total knee replacement, 1 s t day post-op, weight- bearing allowed = 4-point Ex. Brtatera/ tota/ Knee rep/acement, 5 wteeks post-op = 2 point • Going up & down stairs: - up with the good, down with bad - crutches move with the bad leg Cains: • hold the cain on the strong side - a lot of people use it the wrong way Walkers : • pick it up, set it down, walk to it • rf they must tie their belongings to the walker, tie it at the sides, not the front - b o a r d s doesn't like things o n the f r o i t [even t h o m o s t p e o p l e o o t h a t a n y w a y s : they don't like w h e e l s or tennis ball 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: the first thing you have to do co get a psych questions correct is decide: "Is my P T non- psychotic or psychotic?" = this will determine treatment, goals, prognosis, medication, length of stay, legalities...everything hallucinations, o r illusions ILLUSIONS - only in psychotic PT's - a s soon as they get any of these they've crossed the line t o being psychotic Psychotic Symptoms: • a) Delusions = false *ixed. idea cr belief; no sensory component (all in the brain, thinking it) i Paranoid Delusions -> people are out to harm m e - ex. the mafia are out to get m e 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, se.nsoiy experience (purely sensory); 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 (primarily v o i c e s telling y o u to h u r t yourself): m o s t c o m m o n ii. Visual - > seeing; 2 n d most c o m m o n iii. T a c t i l e - > feeling things: 3 r d m o s t c o m m o n iv. 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 e v . 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, 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. P T says.' "J hear demon voices" -> hallucination ex. P T overhears nurses & MD's laughing & talking ar ifte .nurse's station £ says; "Lister?, i hear demon voices’ -> illusion (there is a referent) e x . p e r s o n starting a t a w a i l & says; " / s e e a b o m b " - > hallucinat on ex. person looks ar fire exti'ngu.'sfter o n the waW and says: " / s e e a bomb' 1 -> illusion (referent) • Hint: O n the test, they will tell you that there is something there thus, you can differentiate between a hallucination & an illusion. How do you deal with these Psychotic Symptoms? • first thing you ask after determining if PT is psychotic: What is their problem? —> what kind of psychosis do they have? ■ 3 Types of Psychosis: 1. Functional Psychosis - can function in everyday life (i.e. have jobs, a marriage, etc.) - 4 diseases: Schizo Schizo Major Manics i. Schizophrenia ii Schizoaffective Disorder NON-PSYCHOTIC PSYCHOTIC Definitio n H a s i n s i g h t s i s reality-based - even wf emodoral distress/illness. mentab'behaviora 1 disorder - recognize what the problem is and how it affects their life Has n o i n s i g h t s is not reality-based - don't think/krcw their sick - think everyone else has t h e problem but not t h e m (blame anyone else) - even if they say they're sick but then they say the martians made them sick they don't have insight Treatme nt/ Techniq u e s - g o o o therapeutic comnAim-cat-on (1 k e any P T that displays good comm, skills} ** there's nothing special that you need t o oo/know compared to any med-surge, paeds, or 0 6 PT - good therapeutic commurication does not work because they are not rational - r e e d unique, specific strategies Symptom s don't have delusions. 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 psychotic during manic phase - these P Ts have the potential to learn reality (because no damage) -> may need meds or set boundaries for structure -> nurse role = teach reality (4 steps) a) acknoi/v/edge feeling -> "I see you're angry; "You seem upset", ’Tell m e how you are feeling", often uses the word feeling or shows a feelinc b) PRESENT REALITY -> "I know that those voices are real to you but I don't hear them" or telling them what is real ('Tm a nurse & t h i s is a hospital") c ) s e t a limit -> "That topic/behavior is off-limits", "We are not going to talk about that right now'', "Stop talking about that" d) enforce the limit -> " I see you're too ill to stay reality based so our convo is over" (ending the conversation NOT taking away a privilege [i.e. punishment]; continuing to talk may enforce the non -reality) *** on the test, they won't ask these specific steps but instead, will ask "how should the nurse respond..." *** try to pick the more positive statements (i.e. what they can have/do, not what they can't); if between 2 statements go w/ the positive one > 2 Psychosis of Dementia - psychosis because of actual damage to the brain * in Functional Dementia, there is no brain damage; it's just messed u p chemicals - include PT's w/ Alzeimer's, psychosis after a stroke, organic brain syndrome; anything w / "senile" or "dementia" - cannot leam reality -> major difference from functional (which is why you have to determine type of psychosis) -> nurse role: a) acknowledge feeling b) REDIRECT them -> from something they can't do to something they can do ** you don't set-limits because its mean ** N O T APPROPRIATE to present reality to these PT's when they are experiencing psychotic symptoms (BUT don't confuse this w/ reality orientation) -> important to remember that forgetting things (like where they are or what room they're in - PT's w/ dementia/Alzheimers) is NOT psychosis ** when they start having Delusions, hallucinations or illusions, then they are psychotic - > reality orientation = telling them person, place, and time (ALWAYS APPROPRIATE w / DEMENTIA) - this deals w l memory 3. Psychotic Delirium = a temporary, sudden, dramatic, episodic, secondary loss of reality; usually d u e to some chemical imbalance in the body * different because it's temporary and very acute -> include PT's that are short-term psychotic because of something else causing the psychosis - ex. a drug reaction, high on uppers or withdrawing from downers {delirium tremens), cocaine overcose, post-op psychosis {withdrawing from a o owner), ICU psychosis {sensory deprivation), UTI [or any occult infection}, thyroid storm, adrenal crisis - good thing is it's temporary s o focus is removing the underlying cause & keeping them safe - > nurse role: a) acknowledge feeling b) REASSURE them: it's temp. & they'll be safe ** don't present reality -> they won't get it ** don't redirect -> not going to work ■ Personality Disorders are different: A = antisocial B = borderline N = narcissistic ** very sick personality disorders ** may be good to use Functional Psychosis techniques because you set limits Other Psychotic Symptoms: ■ Loosening of Association = your thou gms a r en't wrapped too tight, a I over t i e map a) Flight of Ideas - coherent phrases but the phrases are not connected (not coherent together) b) Word Salad - sicker, can't even make a coherent phrase -> babble random words c) Neologism - making up imaginary words • Nat rowed 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 *** s o they don't know who they are unless they are wearing those exact clothes in that exact room - as the nurse, don't make them change or leave the room (will cause escalating panic because they will lose their concept of self) * use the Functional Psychosis techniques* Ideas of Reference = think everyone is talking about you - ex. see someone on the news and get upset because you think they are talking about you - can have both paranoia & ideas of reference (paranoia if also think they are going to harm you) LECTURE 5 DIABETES M.

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    ■ definition = an error of glucose metabolism - causes issues because glucose is the primary fuel source and if your body can't metabolize glucose, cells will die • does not include diabetes insipidus = polyuria polydipsia leading to dehydration due to l o w ADH - > it's just similar with the fluids, not the glucose part (similar symptoms) - opposite syndromes of diabetes i. = SIADH • relationship between amount of urine & specific gravity of urine: - they are opposites/inverse - i.e. the less urine out, the higher the specific gravity; the more urine out, the lower the specific gravity * so diabetes = has more urine & low specific gravity (opposite with SIADH) - peak = 2 hrs. - duration = 4 hrs. - is clear (solution' so it can be IV dripped (this is the one used if using IVs) - short, rapid acting, insulin (but Hesi will call it intermediate because w e now have Lispro which acts faster) 2. N P H - true intermediate acting insulin - onset = 6 hrs. - peak - 8-10 hrs. - duration = 1 2 hrs. - is cloudy (suspension) * the issue w/ suspensions is that it precipitates -> the particles fall to the bottom over time so you CANNOT give via IV (or the PT will overdose & the brain will die) * Hint: general rule => never put anything cloudy in an IV bag 3. Lispro (Humalog) - fastest act/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! 4 Lantus (Glargine) - long acting - peak - no essential peak because it s so slowly absorbed -> thus, little to no risk for hypoglycemia - duration = 12-24 hrs. - only insulin you can safely &. routinely give at bedtime because it will not cause themjto go hypoglycemic during the night (YOU CANNOT ROUTINELY GIVE THE OTHERS AT BEDTIME) ** Hint: boards likes to test peaks & tend to test it by giving you a time when insulin was given & asking when they reach hypoglycemia f which is the peak). • CHECK EXPIRY DATES O N INSULIN!!! - What action by the nurse invalidates the manufacturer's expiration date? = opening it -> the minute you open it the date is irrelevant because now you have 30 days from opening (have to write the date of opening & new expiry] - refrigeration is optional in the hospital BUT you need to teach PT's to refrigerate at home - > though at the hospital the ones that should be refrigerated should be the un-opened vials - better to give warm, non-expired insulin than cold, expired insulin TYPE I vs. TYPE II: Differeric — es TYPE 2 DM Names - Insulin dependent -Juvenile onset - Ketosis prone - Non-insulin dependent - Adult- onset - Non-ketosis prone S£S - polyuria - polydipsia - polyphagia (increased swallowing, but i n context of D M it also relates to eating) - same Treatmen t D = diet —> least importart (less restrictions than before) 1= insulin —> MOST IMPORTANT E = exercise D = diet —> MOST IMPORTANT 0 = oral hypoglycem c (pills) A = activity Diet: ■ primarily Type II • a) It is a calorie restriction. - tells you that calorie's are important because the diet's are named (ex. 1500 calorie...) *** this is the best strategy for them ■ b) They need 6 small feedings a day. - keeps blood sugar levels more normoglycemic throughout the day instead of 3 big peaks Insulin: ■ lowers blood glucose ■ 4 main types you real y need to know 1 Regular 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 —> think of exercise as another shot of insulin - if you have more exercise during the day, you need less insulin shots (and bring easily metabolized carba'snacks to sports games)

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