NUR 490 Mark Klimek Lecture Notes new -Long Island University, Brooklyn

Mark Klimek Lecture Notes LECTURE 1: Acid Base Balance & Ventilator Interpreting blood gases (remember the rules of the B’s) • If the pH and the bicarb are both in the same direction then it ’s metaBolic (Bicarb Both Bolic), if they are in different directions then it is respiratory • If bicarb is normal and the pH is low or high then its respiratory • You will be given 8 values for arterial blood gas, always first look at the pH and the bicarb first • You get acidosis and alkalosis from the pH LABS: ABG’s The normal pH is 7.35-7.45 The normal bicarb is 22-26 (the bicarb years where you make all the decisions [22-26 years old], or 2+2+2=6) The normal CO2 is 35-45 (same as pH) Signs and Symptoms with ABG’s • As the pH goes up so does my patient o If the pH goes up, every system in your body gets more irritable/hyperexcitable • As the pH goes down so does my patient o If the pH goes down, systems in your body shut down • Except for potassium- When pH goes down, potassium goes up • If the pH goes up (alkalosis): you will find irritability, hyperreflexia (3&4), tachypnea, tachycardia, borborygmi (increased bowel sounds), seizure (need suctioning at the bed side because they can seize and aspirate) • If pH goes down (acidosis): hyporeflexia, bradycardia, lethargy, obtunded, paralytic ileus, coma, respiratory arrest (need bag-mask ventilation bag at bedside for respiratory arrest), +1 reflexes • MACkussmal- compensatory and respiratory pattern for only acid base disorder: MAC- Metabolic ACidosis Respiratory Acidosis multiple choice example: What would you see with a patient who is in respiratory acidosis? a. +1 reflex, b. diarrhea, c. adynamic ileus (no movement), d. spasm, e. urinary retention, f. paraxysmol atrial tachycardia, g. second degree lovitz, type 2 heart block (impulse is being slowed), h. hypokalemia LAB: REFLEXES 0&1-hyporeflexia 2-normal 3&4- hyperreflexia EXAMPLE: (In general what do pain meds do? ANSWER: They sedate you, they are CNS depressants: lethargy, lucidity, reflexes at +1, hyporeflexia, obtundent Causes of Acid Base Imbalance • Don’t get signs and symptoms mixed up with causation!!! • What causes something is the opposite of what the signs and symptoms are o EXAMPLE: diarrhea will cause a metabolic acidosis but once you get acidotic, it will shut your bowels down and you will get a paralytic ileus. • The first question you should ask yourself if the scenario involves a lung problem. o Is it a respiratory problem? BUT remember it can still be respiratory acidosis/alkalosis… • Next question you ask yourself… o is the client overventilating or underventilating? o If the patient is overventilating pick alkalosis o If they are underventilating pick acidosis • If the client is overventilating.. it has an attachment to the word- alkalosis (because they are both OVER)… ventilating OVER becomes respiratory ALKALOSIS • If the client is undeventilating.. it has an attachment to the word- acidosis (because they are both UNDER)- ventilating UNDER becomes respiratory ACIDOSIS Examples: 1) A woman is overzealously using her breathing techniques during labor, what acid base disorder will she exhibit? Overventilation o Respiratory Alkalosis 2) A child is near drowning, what acid base disorder would it be? Underventilating o Respiratory Acidosis 3) Your patient has emphysema, what acid base disorder would it be? Underventilating o Respiratory Acidosis Ventilating does not mean respiratory rate.. respiratory rate is irrelevant- ventilation has to do with gas exchange!! Examples: 1) Patient has pneumonia in 4 lobes of the lung, breathing at 50/min and their SO2 is at 78 on 8 liters per max o Explanation: Breathing really fast while still having a low O2 level means that the patient is still underventilating because respiratory rate has nothing to do with it. Everyone pays so much attention to rate when they should be paying closer attention to the SO2. o If your SO2 is good and you are breathing slow, you are fine but if your SO2 is low and you’re breathing fast, you are actually underventilating. A lot of times the respiratory rate compensates- pay attention to SO2!!! 2) Patient is on a PCA pump, what acid base imbalance would tell you they need to come off that thing? o A PCA pump depresses respirations. So, patients need to come off of it as soon as possible because if they were getting too much it would make their respiratory rate go really down which would make the patient underventilate so the answer would be respiratory acidosis. o So respiratory acidosis would tell you that you need to come off the PCA pump. What if its not lung? It would be Metabolic. Only one scenario that you will answer metabolic alkalosis: if the patient has prolonged gastric vomiting or suctioning pick metabolic alkalosis.. Why? o Pt is losing acid... pt will become basic Otherwise everything else that is not lung or the above, pick metabolic acidosis Ex. 1) Patient had GI surgery and has had an NG tube to low intermittent gone post suctioning for 3 days, what acid base disorder would he most likely exhibit? o Metabolic alkalosis 2) Patient has hyper emesis gravidarum , what acid base disorder are they going to exhibit o Metabolic alkalosis 3) Continuation: Pt is going to be dehydrated- what acid base disorder would they have? o Metabolic acidosis 4) Pt has acute renal failure, what acid base disorder would this be? o Metabolic acidosis- its not lung or vomiting or suctioning so it has to be metabolic acidosis 5) A pt with infantile diarrhea would have what acid base disorder? o Metabolic acidosis 6) A pt with third degree burns over 60 percent of the body? o First phase- metabolic acidosis If you don’t know what it is, just choose metabolic acidosis!! RECAP What do you have to know for Acid Base? • If the pH and the Bicarb are both in the same direction, its metabolic • The direction my pH goes, so does my patient, except for potassium • MACkussmal- compensatory and respiratory pattern for only acid base disorder: MAC- Metabolic Acidosis • Overventilate: (alkalosis) - translate the word • Underventalate: (acidosis) - (translate the word) • Vomiting or suctioning=metabolic alkalosis • Everything else is metabolic acidosis if I don’t know what it is *always pay attention to the modifying phrase than the original noun example* • Person with OCD who is now psychotic… what is more important? Obpsychotic and not OCD VENTILATION Alarms and how blood gases articulate with ventilates • High pressure alarm is set off by increased resistance to air flow (machine is having to push too hard to get the air into the lungs) – machine will set off a high pressure alarm ( set alarms for appropriate pressures) • What would cause the high pressure alarm? OBSTRUCTIONS 1) Kinks in the tubing (unkink the tube) 2) Water condensing within the tube/dependent loops (empty water out of tubing) 3) Mucus secretions in the airway (change position, turn, cough, deep breath and if that doesn’t work… THEN you suction) • Nurses must only suction patients as necessary and only when you have already turned, cough and helped patient deep breath ***good example for drag and drop question*** Low pressure alarms- decreased resistance- (too easy to push breath in) two disconnections. DISCONNECTION 1) main tubing (reconnect) 2) oxygen sensor tubing (senses the FIO2 right at the trache area- wire black coated.. goes right alone the tubing and comes right to the trache and hooks into the hole into the tubing) Acid Base disorders Respiratory alkalosis : Overventilating means ventilator settings may be too high Respiratory acidosis: Underventilating means the settings are too low Example 1) Dr. says to wean pt off vent in AM- 6 am ABGs show respiratory acidosis, what would you do? A. Follow the order B. Call respiratory therapy (**never pick answer where you don’t do something and someone else has to do something**) C. Hold the order and call the doctor D. Begin to decrease the settings ANSWER: C. Hold the order and call the doctor: because pt underventilating on the ventilator and without it he’d be even worse. If he has respiratory alkalosis it could mean he’s being overventalated, which means he doesn’t need the machine. Lecture 2: Alcoholism, Delirium Tremors & Peak and Trough Alcoholism: Psych + Med surg Psychodynamics- The number one problem of psychological in alcoholism is the same exact problem for any abuse: DENIAL • Abusers have an infinite capacity to deny • Denying allows the abuser to keep doing it without having to answer for it • It is number 1 because how can you treat someone who denies they have a problem and until they admit they have a problem. • Definition of denial: refusal to accept the reality of a problem How do you treat denial? • Confronting it by pointing out the difference to the person of what they say and what they do o “okay, you say you are not an alcoholic but its 10 am and you already drank a 6 pack” o “You say you’re not a child abuser but protective services has your children” • confrontation (attacks the problem) is not the same as aggression (attacks the person) • Don’t ever choose answer that uses the word YOU with confrontations only the letter I Deny -- confront • Not with loss and grieving (DABDA- denial, anger, bargaining, depression, acceptance) What do you do for the denial of loss and grief? • Support it because it serves a function Dependency and Codependency • Dependency- when the abuser gets the significant other to do things for them or make decisions for them (the abuser is dependent) • Codependency- when the significant other derives positive self-esteem from making decisions for or doing things for the abuser o Pathologic and yet symbiotic relationship o Abuser gets a life without responsibility and a SO gets positive self- esteem Treatment? • Set limits and enforce it- teach SO to start saying NO and to keep doing it • Must work on self-esteem of codependent person first or it will never work- the dependent abuser is going to make them feel bad when they start saying NO and emotionally manipulate them • Codependent person has to say.. I AM saying NO because I’m a good person- (usually the relationship will break up in the end) Manipulation • abuser gets SO to do things for him or her that is not in the best interest of the significant other. • Nature of the act is interest and harmful • This is like dependency because in both situations the abuser is getting the SO to do things for them and you can tell the difference by Neutral vs. Negative • If what the significant other is being asked to do is inherently harmful or dangerous to the SO it is manipulation • If what the significant other is being asked to do is neutral, NO HARM NO FOUL- it is dependency and codependency Examples 1) A 49 yr old alcoholic gets her 17 yr old daughter to go to the store and buy alcohol for her • manipulation because minor buying alcohol is illegal 2) A 49 yr old alcoholic asks her 50 yr old husband to go to the store and buy alcohol for her. • Dependency because there is no harm Treatment for manipulation- • Set limits and enforce them- start saying NO • It is easier to treat than dependency and codependency because nobody likes being manipulated and there is no positive self-esteem issue How many pts do you have with denial if bob is in denial? 1 If bob is dependent how many patients do you have? 2 ( dependent + codependent) If Bob is the manipulator how many patients do you have? 1 ALCOHOLISM • Wernicke’s-Korsakoff syndrome o Wernicke’s encephalopathy o Korsakoff psychosis But they tend to go together because you find them in the same patient Wernicke’s korsakoff is 1) Psychosis induced by vitamin B1 or thiamine deficiency – you lose touch with reality and go insane (loss of touch with reality) because you don’t have B1 2) Amnesia (memory loss) with confabulation (making up stories)- make up stories because they forget. They are psychotic because they believe it. Lie is just as real as reality and their memory loss is “what happened to the 90’s and they’ll lose entire decades of their memories”. Will often have an entire psychotic reality- real as anything else that is happening How would a nurse deal with this? Bad: confronting is wrong because it’s due to brain damage and most likely permanent Good: redirect the patient- take what the patient can/cant do and channel it to something that he can do “well why don’t you go shower so we can watch what the news of the day Washington D.C. TV” if he’s insisting he’s part of government. DO NOT present reality because they cannot learn it. Characteristics: ▪ Preventable: take Vitamin B1- coenzyme necessary for the metabolism of alcohol so if you don’t have B1 you will not metabolize alcohol and you will not go into KREB cycle where it would get used up for energy so it will instead accumulate and go into the brain and destroy brain cells ▪ Arrestable: which means you can stop it from getting worse by giving B1, stopping drinking is not necessary ▪ Irreversible: 70 % irreversible (go with the majority, 2 good news one bad news) DRUGS that have to do with alcohol Antabuse (revia)- DISULFURAM 1) What is it used for? • Aversion therapy - want alcoholics to develop a gut hatred for alcohol- when you take this drug it will interact with the alcohol level in your blood and make you horribly ill – to the point you couldn’t even pay them to drink- works in theory better than it works in reality – doesn’t work as well as it says it does 2) What is the onset and duration of its effectiveness- • 2 weeks. 2 weeks before they can drink safely on and off the drug. Usually Dr. will prescribe pill, then pt is taken to a transition home for 2 weeks to assure that they take the drug and then let out to the community where every time they drink they will get deathly ill but if they decide they want to want to drink at a (lets say) high school reunion, pt will need to stop taking it two weeks before. Teach these patients to avoid all forms of alcohol to avoid nausea, vomiting and possibly death 3) What do they need to avoid? • need to avoid mouthwash and aftershaves because they will get sick- nauseated • perfumes and colognes, insect repellents, any over the counter that ends in the word ELIXIR (all have alcohol), alcohol based hand sanitizers, no unbaked icings (all have vanilla extract which will make them sick) • DO NOT pick the red wine vinaigrette if it’s on a multiple choice question because it has no alcohol and they can have it OVERDOSES AND WITHDRAWS Every abused drug is either an UPPER or a DOWNER- because they are the only drugs that do anything Most abused type of drug that’s not an upper or a downer is laxatives in the elderly When you get an overdose question the first question you should ask yourself is… 1) is the drug an upper or a downer? UPPERS • Caffeine • Cocaine • PCP/LSD (psychedelic hallucinogens) • Methamphetamines (crystal meth) • Adderall- ADD drug Signs and symptoms: • Things go UP- • Examples: euphoria, tachycardia, restlessness, irritability, borborgimi, diarrhea, 3&4, spastic, seizure (suction bag needed) DOWNERS Everything that is not an upper is a downer Patients looking for an in between effect people will take both together 135 all together Examples: • Dilaudid • Morphine sulfate • Codeine • Demerol • Fentanyl • Ambien • Ativan • Xanax • Valium • Librium • Phenobarbital Downers make you go down because they are downers • lethargic- big danger is respiratory depression leading to respiratory arrest Example question: 1) PT is high on cocaine, what is most important to assess? • check reflexes – because it is an UPPER After you know whether the drug is an upper or a downer what is the second thing you ask yourself? 2) Are they talking about overdose (too much) or withdrawal (not enough)- because they are opposites RECAP QUESTIONS TO ASK YOURSELF 1) is the drug an upper or downer 2) is it overdose or withdrawal Overdose or intoxication- too much RECAP: • Overdose on an upper- everything goes up • Downer and intoxication- makes everything go down • Withdrawal- not enough/too little- too little upper makes everything go down and too little downer makes everything go up • Upper overdose looks like what other situation: downer withdrawal • Downer overdose looks like - upper withdrawal What two situations would respiratory arrest and depression be the highest priority? • Downer overdose and upper withdrawal Which two would seizure be your biggest risk? • Upper overdose and downer withdrawal Example 1) Squad calls you about pt who has overdosed on cocaine what would you expect to see? • upper • overdose-too much upper • CNS drug not autonomic drug • Seizure • 3-4 reflexes • irritability • increased temp 2) You are caring for a client withdrawing from cocaine, what is expected? • respirations less than 12 and difficult to arouse • need narcan DRUGs in the Newborn • Always assume intoxication not withdrawal at birth • After 24 hours assume baby is in withdrawal Example: You are caring for an infant who has qualine (downer) in system because of drug addict mom. What symptoms would you expect 24 hours after birth? SATA a. difficult to console b. ow core temp c. exaggerated startle reflex d. respiratory depression e. seizure risks Alcohol withdrawal syndrome vs. delirium tremors a) every alcoholic goes through withdrawal 24 hours after they stop drinking b) only a minority get delirium tremors after 72 hours c) alcohol withdrawal syndrome always precedes delirium tremors, but delirium tremors do always follow alcohol withdrawal syndrome d) AWS is not life threatening while DTS can kill e) AWS are not a danger to self and others f) DTS are a danger to self and others- unstable you can die g) AWS- loud and obnoxious- because they are withdrawing from a downer which makes everything go up h) Need to keep an eye on DTs because they are a danger to themselves and others Differences between AWS and DT’s AWS • Follow a regular diet • Semi private anywhere on the unit • Up ad lib- can go around anywhere they want to go • NO restraints because they are not a danger to self or others • Alcohol withdrawal patient can even be on overflow in Peds DTs • NPO or clear liquids because pt will be at risk for seizures (withdrawing from a downer makes everything go up) pt will get aspirations • Private room near nurses station- dangerous and unstable • Probably should be in ICU but not good for the rest of clients • Nurse needs to decrease workload to take on DT’s patient • Restricted bed rest • Must be restrained because they are dangerous, no bathroom, just bed pans • Need to be in a vest or 2 point locked leather restraints (arm and a leg, opposite) and rotate it every two hours. Lock left arm and then right leg and then opposite Both • both get antihypertensive (both withdrawing from downers so everything is going up) • Need a tranquilizer (both withdrawing from downers so everything is going up) • Both get B1- (to prevent wernicke’s and korsakoffs ) “no b1, or you’ll be 1” DRUGS • psych most common tested drug • Insulin is 2nd most common • Anticoagulants are 3rd most common • digitalis 4th most common • aminoglycosides 5th most common • steroids 6th most common • calcium channel blockers 7th most common • Beta blockers 8th most common • pain meds 9th most common • OB 10th most common AMNIOGLYCOSIDES- powerful class of antibiotics • When nothing else works pull out the aminoglycosides • Dangerous • Considered the gun for infections AMINOGLYCOSIDES • Think: “a mean old mycin” – that tells you they are antibiotics used to treat serious, life threatening, resistant, gram negative infections • Treat a mean old infection with a mean old mycin • Not for sinusitis or otitis media, or strep throat (not considered a mean old infection) • But yes for tuberculosis, septic peritonitis, pulmonary pyelonephritis, septic shock, burn wounds 80% of body (SERIOUS INFECTIONS) ***Mycins- all end in mycin but not all drugs that end in mycin are aminoglycosides 3 mycins that are not mean old mycins are: THRO! • Erythromycin • Zipthromycin • Claripthromycin Ends in mycin- it’s a mean old mycin. If it has thro, throw it off the list and only use for infections that are not that bad What are the toxic effects? 1) MICE- MYCIN- Mickey Mouse Ears – Ototoxic (ear), monitor hearing, ringing in the ears (tinnitus), and vertigo or dizziness (ear has equilibrium) 2) Human ear- connect the dots and its’ shaped like the kidney- nephrotoxicity- MUST monitor CREATININE- the best indicator of kidney or renal function- 24 hour creatnine clearance is better than serum creatnine. 3) HAVE A VISUAL OF THE NUMBER 8- the number 8 drawn inside the ear reminds you of the fact that they are.. Toxic to cranial nerve number 8 which is the EAR Nerve and you… 4) Administer them every 8 hours What is the route? IM or IV, do not give PO because they will not be absorbed Oral mycin= goes into gut, dissolves and go right through you has no systemic effect *** EXCEPT in two cases for oral! 1) Hepatic encephalopathy or hepatic coma- when ammonia levels get too high and you go into a coma… you can die. Treatment is to get the ammonia down and oral mycins do that because it will kill gram negative bacteria in your gut, sterilize your bowel, kill ecoli in your gut which is the number 1 producer of ammonia in your gut, and decreases it. Because these people have liver damage we do not want it going to the liver and its perfect because it goes in and right out the gut. *Makes you have diarrhea that makes you get rid of stuff. 2) Give during preop bowel surgery- to sterilize the bowel, ****will not have otoxicity because it is not absorbed, Both: sterilized bowel without causing ototoxicity because it is not absorbed What mycins are used for bowel sterilizers? Neomycin and Kanamycin are typically used as bowel sterilizers ***Sargent asks “who can sterilize my bowel?” “Neo Kan!” Trough and Peak Trough- when the drug is at its lowest Peak- when the drug is at is highest TAP levels T-draw your trough A- administer P-Draw your peak ***Narrow therapeutic window- small window between what works and what kills TAPS is important for this! Example: • Furosemide (Lasix)- wide range- TAPs not necessary • Dig- .125-.25??- narrow therapeutic window- TAPS necessary When do you draw trough? Route matters- Sublingual- 30 minutes before the next dose IV- 30 minutes before the next dose IM- 30 minutes before the next dose Subq- 30 minutes before the next dose PO- 30 minutes before the next dose When do you draw the peak? Depends on the route ***The same drug given in two different routes at the same time will have different peaks however two different drugs given at the same time and at the same route will peak together Sublingual- 5-10 minutes after the drug is dissolved IV-15-30 minutes after the drug is finished (when the bag is empty) IM- 30-60 minutes after you give it SUbq- SEE- See diabetes lecture (insulins) PO- never test PO’s because they’re all too variable Example: 1) 100 ml of a drug at 200 ml per hour- 30 min. hang it at 10, it’ll finish at 1030 and you will draw the peak at 11. WHENEVR YOU GET TWO IN THE CORRECT RANGE PLAY THE PRICE IS RIGHT-THE HIGHEST WITHOUT GOING OVER ( given 1045 as a choice also) Lecture 3: Calcium Channel Blockers, Arrhythmias, Chest tubes, Congenital heart defects Calcium Channel Blockers • calcium channel blockers are like valium for your heart • calms your heart • given when heart is tachycardic, pt is having tacharrhythmias, had a heart attack and need to rest heart • never give to stimulate heart • negative inotropic, chronotropic and dromotropic- its like valium for your heart- relax your heart and calm it down Positive Chrontropes: • strengthen • speed up and stimulate the heart • they are stimulants Negatives • cardiac depressant • weaken • slow down and depress the heart What do Calcium channel Blockers they treat? A) Antihypertensives- relax your heart blood vessels and blood pressure goes down AA) Antiangina- relax your heart, uses less oxygen, and decreases oxygen demand because it relaxes the heart- worst thing that can happen to person with angina is if their heart speeds up so we want to slow it down AAA) Anti Atrial Arrhythmias- (will not treat ventricular tachycardia) treats atrial flutter, atrial fibrillation, premature atrial contractions TRICK: supraventricular tachycardia- supra means above, and the atria is above the ventricle. Side effects? **think H&H H) headache – vessels dilate in the brain causing migraine H) hypotension- relaxes heart and blood vessels *headache is great choice for SATA most times NAMES of Calcium Channel Blockers: • Anything ending in dipine Example: Amlodipine • Think “Dipin in the calcium channel” (NOT PINE BECAUSE MANY DRUGS END IN PINE BUT CALCIUM CHANNEL BLOCKERS ALWAYS HAVE DIPIN in the word) Calcium channels you MUST KNOW BY NAME VERAPAMIL CARDIZEM - Continuous IV Drip ***Vital signs needed to measured before giving a calcium channel blocker, ex. Blood pressure because pt will be at risk for hypotension Parameters for Calcium Channel Blockers: • hold the calcium channel blocker if the systolic is under 100, must monitor the blood pressure continuously while on cardizem drip and if it was 98/52- slow down the drip and measure BP again to keep the systolic over 100 Cardiac Arrhythmias • Know how to interpret rhythm strips • Know 4 by site: o Normal sinus rhythm – p wave, qrs and t wave for every single complex, and peaks of QRS complex are evenly spaced o V fib- chaotic squiggly line, no pattern o Ventricular tachycardia – sharp peaks and jaggers with pattern o Asystole -down and out, crash and burn time, flat line Important terminology o QRS depolarization- ventricular, rule out anything that says atrial o P wave- refers to anything atrial and rule out ventricular o 6 rhythms most tested on NCLEX • Lack of QRS’s- no QRS- asystole (flat line) • Form of atrial- set P wave • Saw tooth- flutter- “I saw the teeth and my heart fluttered” • Chaotic- fibrillation • Bizzare always applies to tachycardia • Periodic bizzare wide QRS- pvc- SALVO of PVC’s =short run of Vtach, dr.’s don’t care as much for these, low priority PVC’s are low priority but if there are more than 6 PVC’s in a minute or in a row, OR if PVC’s fall on the t wave of the previous beat (R on T phenomena) they become moderate but are never high- PVC’s are good after an MI or a heart attack because that means they are reprofusing. Lethal arrhythmias • High priority Lethal and kill you in 8 minutes or less and are super high priority 1) Asystole 2) V-fib Both have no cardiac output which means no brain perfusion=dead in 8 minutes Potentially life threatening... but not life threatening… making it high priority 1) ventricular tachycardia What is the difference between Vtach and asystole? • Vtachers have a cardiac output (Dr. will ask… is there a pulse with that?) Treatment 1) PVC’s and Vtach-both ventricular • For ventricular use LIDOCAINE (lidocaine is not used in a lot of squads now in the bigger cities and they are using Amiodarone instead)- lidocaine is cheaper and has longer shelf life. 2) Supraventricular arrhythmias – atrials – use the ABCD’s- a. Adenocarb (adenosine)- need to push in less than seconds, fast IV push- usually when you don’t know you go slow, but this drug must be slammed in less than 8 seconds with a 20 ml of IV fluid flush right after- but risk going into asystole for about 30 seconds but they can come out of it- b. Beta blockers- LOL- best class of drugs ever, negative chromo, negative drono, negative, valium for your heart, so they will treat A, AA, AAA- anti atrial arrhythmia- headache and hypertension as a side effect like calcium channel blockers (better for people with asthma because beta blockers vasoconstrict), c. Calcium Channel blockers- like valium for the heart, negative chromo, dromo & inotropic, treat A, AA, AAA with the side effect of H&H, d. Digitalis (digoxin)- LAMOXIN, 3) VFIB- U D FIB- shock them 4) Asystole- epinephrine and atropine CHEST TUBES Purpose: to reestablish negative pressure in the pleural space so that the lung expands when the chest wall moves Pleural space- where negative is good Negative space- makes things stick together Inside of the chest wall is a lining called the parietal pleura Outside of the chest wall is a lining called the visceral pleura and it lines the outside of the lung between the parietal pleural and the pleural space Good air exchange happens because there is negative pressure in the pleural space Air and blood create positive pressure that pulls apart the lung and the chest wall- creating no air exchange Chest tubes reestablish negative pressure in the pleural space so that the lung expands when the chest wall moves In a pneumothorax the chest tube removes air to reestablish negative pressure -air caused the positive pressure so a chest tube needs to go into remove the air and reestablish negative space in the pleural space In a Hemothorax, the chest tube removes blood to reestablish negative pressure -blood is causing the positive pressure and it needs to be removed to reestablish negative pressure in the pleural space In a pneumohemothroax, the chest tube removes blood and air to reestablish negative pressure- blood and air is causing the positive pressure it needs to be removed to reestablish negative pressure in the pleural space If boards gives you a question that says you have a client in with chest tubes for a hemothorax- what would you report to nurse, lpns, dr or rn? 1) chest tube is not bubbling 2) the chest tube drained 800 ml in first 10 hours 3) the chest tube is not draining 4) the chest tube is intermittently bubbling What does a hemo chest tube do? • Drain blood so number 3 would need to be reported What would you report in a pneumothorax,? • The chest tube is not bubbling (needs bubbling) • The chest tube drained 800 ml in the first 10 hours (doing something its not supposed to do) ***must pay attention to the disease for which it was placed to know what to expect Location of the tubes 1) Apical- chest tube is way up high, which means you are removing air because air rises 2) Basilar- bottom of lungs and remove blood because blood is subject to gravity Example: Your apical chest tube is draining 300 ml per hour- BAD Your basilar is draining 200 ml per hour – Good Your apical tube is bubbling- GOOD Your basilar tube is not bubbling – GOOD A hemo would neeed a basilar tube A pneumo would need an apical tube And a hemo pneumo would need one of each Example: How many chest tubes, and where would you place a unilateral pneumo- hemothorax? -2 chest tubes on apical for pneumo and basilar for the hemo How many chest tubes and where would you place a bilateral pneumothorax? -2, on apical How many chest tubes and where would you place them for post op chest surgery? -2, an apical and a basilar on the side of the surgery because you are to assume that chest surgery or trauma is unilateral unless otherwise specified Trick question: How many chest tubes would you need and where would you place them for a post op, right pneumonectomy -none because it’s the removal of the lung and no pleural space USED for -lobectomy -wedge resections -etc. TROUBLESHOOTING What do you do if you knock over chest tube drainage water seal apparatus? -set it back up and have patient take deep breaths- NOT A MEDICAL EMERGENCY What do you do if water seal breaks? -different because positive pressure can get into the pleural space so you 1) CLAMPIT first so nothing gets in , 2) Cut it away from broken device 3) Stick end of tube in sterile water 4) Unclamp it because you reestablished water seal *CLAMP, CUT, SUBMERGE, UNCLAMP **its better to be under water than to be clamped because air cant go in but stuff can come out – water seal solves the problem What is the first thing your going to do when the water seal breaks? -Clamp (ORDER) What is the best thing to do when the water seal breaks? -Submerge tube under sterile water BEST QUESTION IS DIFFERENENT THAN A FIRST QUESTION Example: 1) You notice a pt has ventricular fibrillation on the monitor (no cardiac output + no pulse) what is the first thing you are going to do? a) Place a backboard b) Begin chest compressions This question is about order so you need to PLACE A BACKBOARD FIRST because it doesn’t make sense the other way around If you get the same question with the word best you would pick BEGIN CHEST COMPRESSIONS-because its technically the only thing you can do 2) What do you do if the chest tube gets pulled out? a) First thing- take a gloved hand and cover the hole b) Best thing- cover with vaseline gauze Where is it bubbling and when is it bubbling- ask yourself this question when you get bubbling questions a. Water seal- intermittent bubbling in the water seal is GOOD (DOCUMENT IT) b. Water seal- continuous bubbling in the water seal BAD- there is a leak the system and you need to find it and put tape over it until it stops leaking (LPNs can do this also) c. Suction control chamber- intermittent- BAD, suction is not high enough in that case- need to go to the wall and turn up the dial in the wall so that it become continuous d. Suction control chamber – continuous- GOOD- document it If something is sealed, should you have a continuous bubbling? NO because its leaking so intermittent is good and suction control is opposite of that *** A straight catheter (in and out) is to a foley catheter (in, secure it, leave it) as a thoracentesis (in and out to reestablish negative pressure) is to a chest tube (stick it in, secure it, leave it) RULES FOR CLAMPING TUBES 1) Never clamp a tube for longer than 15 seconds without a dr. order -ex: if you break the water seal, you have 15 seconds to cut it off and put tube under sterile water 2) Use rubber tipped double clamps- teeth need to be covered so that tube doesn’t get punctured and double because it’s best CONGENITAL HEART DEFECTS -Trouble or no trouble -Either it causes a lot of problems or its no big deal at all- no in between at all -GOOD or BAD TRouBLe – 7 letters – vowels lower case Trouble defect- need surgery in order to live No trouble defect- don’t need surgery but might have it years later when it causes any trouble but we wont expect it to have any trouble because its not trouble Trouble defect- • Growth and development- DELAYED • Life expectancy- SHORT • Apnea monitor because you are in trouble • In hospital for weeks at a time • Pediatric cardiologist follows your face **Nurses job is teaching parents the implications not the diagnosis based on whether or not its trouble** -TRouBLe- blood shunts right to left because R comes before L in the word trouble -TRouBLe-blood shunts left to right in defects with no trouble because that’s not how the word trouble is spelt ex. If a kid has a right to left shunt, what do you tell the parents about surgery? - right to left blood = TROUBLE If a kid has a left to right shunt, what do you tell the parents about surgery? - Left to right blood- NOT trouble Cyanotic- BLUE (letter B in trouble)- Right to left means BLUE!- TROUBLE Left to Right means Acyanotic –Not TROUBLE RECAP TROUBLE congenital heart defect -shunts blood right to left -cyanotic (blue) -needs surgery -delayed growth and development -decreased life span -needs cardiac pediatrician -exercise intolerance -needs meds -apnea monitor is going to stay longer -financial guilt -caregiver stress NO trouble congenital heart defect -left to right -not blue -no big deal TRouBle congential heart defect (T)- first letter – it just so happens that all congenital heart defects that start with the letter T are trouble and if it does not it is not trouble Examples: Ventricular Septal defect… trouble or no trouble? -no trouble because it starts with a V -shunts blood from the left -it is acyanotic -tell parents no big deal Tetralogy of Fallot… trouble or no trouble? T- trouble -Shunts blood right to left -Cyanotic -Short life expectancy -Financial stress -Growth and development delay Patent Ductus Arteriosis… trouble or no trouble? -No trouble -Shunts blood left to right -Kid is pink Patent Foramen Ovale… trouble or no trouble? -no trouble -shunts blood left to right -kid is pink Truncus Arteriosus -TROUBLE -shunts blood right to left -cyanotic -etc ….Transposition of the great vessels, triscuspid atresia, anything with a T means TROUBLE!! …Atrial septal defect, pulmonic stenosis-no trouble ONE EXCEPTION-left ventricular hypoplastic syndrome- won’t be brought up on nclex because its so rare ALL congenital heart defect kids will all have these things whether its trouble or not: 1) a murmur because the shunt of the blood 2) echocardiogram done to find out why 4 defects of tetralogy of Fallot mnemonic Varried pictures of a ranch VerrieD PictureS O A RancH VerrieD - Ventricular Defect PictureS - Pulmonary Stenosis Of A - Overiding Aorta RancH - Right Hypertrophy Ex. Your patient has tetralogy of fallot, select all the defects that apply VD, PS, OA, RH ANOTHER MNEMONIC: Valentines Day Pick Someone Out A Red Heart Infectious Diseases and Transmission Based Precautions Standard, universal, contact, droplet, airborne Contact- anything enteric- can be caught from intestine, fecal/oral CDIff, hep A (Anus), cholera, disenteri, staph infections, RSV (transmitted droplet but classified under contact precautions because little kids catch it by touching other things that little kids put in their mouth), herpes infections (shingles) (respiratory syncytial virus- fatal to little kids) **HEP B = (blood) **HEP A = (anus) Contact isolations- private room preferred- YES to private room, cohort- two RSV kids can be put in the same room (must be cultured and positive before putting them in the same room, NO mask, gown yes, gloves yes, handwashing, no eyeshields needed unless universal, NO special filter past, NO to patient wearing mask, YES to disposable supplies (plastic utensils, etc.) and dedicated equipment (stethoscope, toys, blood pressure cuff), NO negative airflow Droplet- for bugs that travel three feet on large particles- all meningitis and H flu- homofluous influenza B can cause epiglottitis Droplet Isolations- Private room preferred, YES to private room unless you are cohorting based on culture, if they have meningitis they all need lumbar puncture because that’s where you culture the meningitis, yes mask, yes gloves, no gown needed, handwashing yes, special eye face shields, no filter mask, pt need to wear mask when leaving room, disposable supplies and dedicated equipment, yes, No to negative airflow Airborne- measles, mumps, rubella, tuberculosis, and varicella chicken pox Airborne isolations: private room REQUIRED unless cohorting, mask yes, gloves yes, gown more for contact, hand washing, no eye face shields, filter mask only for TB, patient leave mask when leaving the room YES, disposable supplied and dedicated equipment not necessary, negative airflow YES. ****TB is spread by droplet but it is on airborne precautions Protect personal equipment- PPE - take it off in alphabetical order 1) gloves 2) goggles 3) gown 4) mask OFF is alphabetical ON is reverse alphabetical for the G’s but mask comes second 1) gown 2) mask 3) goggles 4) gloves Important things to know for math problems: Dosage calculations- when dr. orders what is not in the bottle and no conversion involved • Desired/have * available IV drip rate- volume * drop factor/ time in minutes **mini/micro drip= 60 drops per mil **macro- 10 drops per mil Pediatric dose using child’s weight- 2.2 lbs per kg **pay close attention to amount per day or amount to be given at 1 time Lecture 4 Crutches, Canes and walkers One of the major functions of humans is locomotion: testing frequently for casts, traction, crutches, and walkers Patient teaching is also important- risk reduction How do you measure crutches- important so that risk reduction is cut down on nerve damage How do you measure the length of the crutch- 2-3 finger widths below the anterior axillary fold to a point lateral to and slightly in front of the foot *** if any question says to measure from the axilla or from any landmark on the foot, they are wrong Hand grip- can be adjusted up and down and when the hand grips are properly placed the angle of proper flexion will be about 30 degrees How do you teach crutch gaits? 1) 2-point- move a crutch and the opposite foot together followed by the other crutch and the other foot together (2,2,2,2,2,….) 2) 3 point- moving two crutches and the bad leg together (3,1,3,1,3,1..) 3) 4 point – move everything separately ( 2 crutches + 2 legs = 4) 4) Swing through – for none weight bearing- ex. Amputations- or cant bear weight on a leg) – pretty fast- swing themselves **Amputation with a prosthetic device can bear weight When do they use these? **Even for even odd for odd** Use the even number gaits (2&4) when weakness is evenly distributed Use 2 point for a mild problem (mild bilateral weaknesses and 4 point for severe bilateral weaknesses) HOW many legs are affected (2) then pick 2 or 4 Use the odd number gait (3) when one leg is odd Examples: 1) early stages of rheumatoid arthritis (2 point-systemic disease so both legs should be assumed- early) 2) Left above the knee amputation (swing through) 3) First day post op right knee replacement partial weight baring allowed (3 point) 4) Advanced stages of advanced ALS (4 point- advanced) 5) Left hip replacement second day post op non weight bearing (swing through) 6) Bilateral total knee replacement first day post op weight baring allowed (4 point) 7) Bilateral total knee replacement 3 weeks post op (2 point) Going up and down stairs with crutches Up with good, down with the bad - go up with your good, lead with your good, crutches always move with the bad leg, - down with the bad, crutches always move with the bad leg Canes - Hold the cane on the good side - Advance it with the bad leg - When you put the crutch down you have a nice wide stance for support Walkers -Pick them up, set them down, walk to them- its slow but this is the right way -If they must tie their belongings to the walkers, have them tie to the sides, not the front -No wheels or tennis balls on walkers Delusions, Hallucinations and Illusions Nonpsychotic vs. Psychosis -Very first thing you need to do is decide whether pt is nonpsychotic or psychotic -Determines treatments, goals, length of stay, medications Nonpsychotic -person has insight and is reality based -emotionally ill -know they have a problem -know how its messing up their life -mentally distressed but not psychotic Techniques/approaches: -Good therapeutic communication- right answer for anybody -Nothing special that you are supposed to know (common sense things) Example: Pt Alice says she’s depressed and says to you, “I hate this depression and its ruining my life because I have no energy to do anything”- nonpsychotic Answer: “well how are you feeling now, what is currently making you stressed” Psychotics- No insight and is not reality based- don’t believe their sick and blame everyone else -no insight -treated differently because good communication does not work for them -unique specific strategies needed Symptoms -delusions, hallucinations and illusions are only psychotic -non psychotics do not have any -delusion- crossed the line and are not in the camp of psychotic Psychotic Symptoms Delusion- false fixed idea or belief, no sensory component 1) Paranoid delusion- false fixed belief that people are out to harm you (police, mafia, wife, kids, neighbors, etc.) 2) Grandiose delusion- false belief that you are superior (think your Christ, Mohammed, Genghis Kahn, worlds smartest or greatest person) 3) Somatic delusion- false fixed belief about a body part – I have x ray vision, I can melt stones with my eyes, there are worms inside my arms, you believe your pregnant as an 83 year old male. Hallucination- False fixed sensory idea – hear, taste, smell, see, touch 1) auditory- hear things- voices telling you to hurt yourself (most common reported) 2) visual- seeing things that are not there 3) tactile –feeling things that are not there 4) gustatory-tasting things that are not there (rare) 5) olfactory- smelling things that are not there (rare) Illusion- misinterpretation of reality -Misinterpreting what’s going on through a sensory experience -Differentiation between illusions and hallucinations- with an illusion there is a referent in realty- something to which a person refers when they same something -Actually something there but they misinterpret what’s there but with hallucination there is nothing there Examples: A pt says “I hear demon voices”- example of hallucination because it is sensory and nothing there A pt overhears a dr. and nurse laughing at the nursing station- and says “I hear demon voices”- example of illusion because they misinterpreted the real sound During an interview a client says “ look I see a bomb” example of hallucination because there is nothing actually there During an interview a client is looking at the fire extinguisher and says “look I see a bomb” this Is an example of an illusion because they are misinterpreting for a bomb How do you deal with psychotic symptoms in psychotic patient- Ask yourself what kind of psychosis do they have? 1) A functional psychosis- they can function in every day life ex. Have a family, children and a job and live alone and take care of themselves but they are psychotic Example of diseases: schizophrenics & major manics, Schizoaffective disorder, Major Depression (psychotic while depression is not), Manic (acutely)- bipolars are functional but they are not always psychotic 2) Psychosis of dementia – actual damage to the brain and brain is actually damage (in the functional they just haven’t learned adaptive behaviors well) but in this care there is actual brain damage ex. Alzheimers, post stroke, organic brain syndrome, senile or dementia falls in this category 3) Psychotic delirium- Functional psychotic- this person does not have brain damage- so they have the potential to learn reality because they don’t have any damage, might need medication to balance some chemicals and set structure but they can improve Role as a nurse: teach reality ( 4 step process) 1) acknowledge feeling 2) present reality 3) set a limit 4) enforce the limit ex. What’s the first thing you’ll say to a patient whom your going to acknowledge feeling- word feeling is used or specification of a feeling “you seem upset, that’s so sad, tell me more about how you’re feeling right now” Presenting reality “I know that is real to you but I do not see it”, “I understand those voices are real to you but I do not hear it” or tell them what is real “I am a nurse, this is a hospital and here is your breakfast” either one is good- second thing you do Setting a limit- “that topic is off limits in our conversation, stop talking about those aliens, we’re not going to talk about those voices” Enforcing the limit “I see you’re too ill to stay reality based so I am ending this conversation” stay away from answers like punishment- “since you cant follow the rules you lose your phone privilege” only enforcement is ending the conversation and wont stay reality based Ex. Schizophrenic (functional) patient says to you, “I’m going to kill you all by morning and I’m starting with you” 1) “I see you are upset” acknowledge feeling 2) “We’re going to be kept safe while we’re here” present reality 3) “We’re not going to talk about that kind of stuff” set limits 4) “ I see you are too ill for reality based conversations, so we are going to end this conversation, but we have medication to help your symptom” However if they have psychosis of dementia- can’t learn reality (2 steps) 1) Acknowledge their feeling 2) Redirect them – channel them from something they cannot do to something that they can do – DO 3) Do not present reality because they can’t learn it and it’ll just frustrate them 4) DO NOT set limits- unfair 5) Problem they usually have: where they are, where their room is, what day it is (NOT PSYCHOSIS , JUST FORGETTING) 6) What technique is not appropriate: do not present reality but DO NOT confuse with reality orientation (tell them person, place and time!!) EX. Patient with Alzheimer (dementia category)- waiting room of a nursing home on a Sunday, and you say “Mrs. Smith you’re all dressed up and she says, “yes my husband is coming to pick me up so that we can go to church” – PROBLEM: husband has been dead for 10 years so she is a FALSED FIXED BELIEF=DELUSIONAL 1) Acknowledge feeling “that sounds like an exciting thing to do” (recognize the feeling if it fits, exploring feeling means asking to try to find out what it is) 2) Redirect “why don’t we sit down here and talk about what’s going to happen at church today” … ask questions – reinforcement of intact memory –ask to see pictures of grandkids in her room to get her to go back to her room WRONG ANSWER: that sounds exciting but your husband is dead (only appropriate for schizo’s or major manics) 7) Structural brain problem and cannot learn reality 8) Functional can learn reality Psychotic Delirium- temporary sudden dramatic secondary loss of reality usually due to some chemical imbalance in the body- different than functional- sudden- different than dementia- temporary & secondary 1) People that are crazy for the short term because of something that is causing it ex taking a drug, or high on uppers, or withdrawing from downers, delirium tremors, cocaine overdose, methamphetamine overdose 2) Post op psychosis- withdrawing from a downer, everything goes up, particularly in the elderly- wacky for about 48 hours, looney 3) ICU psychosis- sensory deprivation 4) Cult hidden UTI in the elderly 5) Thyroid storm 6) Adrenal crisis 7) Roid rage (sometimes) *** TEMPORARY**** Focus: 2 STEPS 1) Acknowledging feeling 2) Reassure that its temporary and they will be kept safe Removing the underlying cause and keeping them safe DO NOT present reality because they are not going to get it EXAMPLE Functional: Patient with schizoaffective disorder who points to two people talking across the room, and they says, “those people are plotting to kill me”- 1) Say “I see you are frightened” … acknowledge feeling 2) “those people are not plotting to kill you, we’re all safe” … present reality 3) “furthermore we are not going to discuss this” … set limits 4) “I see you are to ill to have a reality based conversation so I’ll be back in a half hour to try again later” … enforce limits Dementia: Patient with alzeimers disease who points to two people talking across the room and says, “those people are plotting to kill me” 1) “you seem scared” acknowledge feeling 2) “Let’s go somewhere you can feel safer” redirecting Delirium: Patient with delirum tremons says to you the two people are plotting to kill me 1) “I see youre scared” acknowledge feeling 2) “You are safe and that feeling will go away when you get better” reassure they are safe and will get better Personality disorders are not considered psychosis they are baseline factors that come along – use good therapeutic communication skills- not classically psychotic 3 clusters for personality disorders: ABN –Abnormal Antisocial, Borderlines and Narcissistic, real sick personality disorders Treat them more like a functional but use more good communication skills- however functional allows you to set LIMITS Psych Axis Axis 1- primary psych disease diagnosis Axis 2- mental retardation and personality disorders Axis 3- medical conditions not psych Axis 4- psychosocial factors like unemployed, recently divorced, newly married, new baby Axis 5- score- estimation of how high your function ability is RECAP Psych questions to ask yourself: psychotic or nonpsychotic? Nonpsychotic- good therapeutic communication skills Psychotic- divide into three 1) acknowledge feeling (always first) 2) reality, redirect, or reassure 3 more psychotic symptoms Your thoughts are all over the place (loosely associated) 1) Flight of ideas- going from thought to though to thought Phrases are coherent but they are not tightly connected 2) Word salad- sicker- babble random words 3) Neologism- making up imaginary words 4) Narrowed self concept – when a functional PSYCHOTIC refuses to leave their room or change their clothes because its how they define who they are- WHERE they are and what they are WEARING- don’t know who they are unless they are wearing those things in that room- do not force because they will have a panic escalation, instead tell them 1) I see you are uncomfortable or upset, you don not have to leave the room or change your clothes until you are ready 5) Ideas of reference- think everyone is talking about you **For non-psychotic – ex. Depression, use good therapeutic communication skills “I see you are depressed and feeling down, its time for you to shower come with me and we will do it” just like you would a post op who just wants to lay in bed **Only time you’re allowed to make choices for patients is for depressed psychomotor patients Lecture 5 DIABETES Error of glucose metabolism-cannot metabolize glucose for whatever reason Glucose- primary fuel source and without that cells die=bad ***Diabetes Insipidus- totally different. Polyuria, polydipsia, leading to dehydration due to low ADH which looks a lot like diabetes mellitus which is why they share the same first name Best way to remember- like diabetes mellitus only just with the fluids- due to a low ADH- ask do you have a low urine output or low urine output? Both have high urine output Opposite syndrome of diabetes Insipidus= SIADH=syndrome of inappropriate ADH Diabetes mellitus has polyuria and polydipsia SIADH is the opposite so pt would have oliguria and not be thirsty because they are retaining water (gain weight suddenly) Urine output of 200 ml per hr for 3 hours and a normal blood glucose? Diabetes Insipidus Urine output of 200 ml per hour for 3 hours and a blood glucose of 280? Diabetes mellitus 10 cc of urine out in 3 hours and a normal blood glucose? SIADH Insulin lowers the blood glucose What is the relationship between amount of urine and specific gravity? - inverse - the less the urine out the higher the specific gravity - urine value goes up the specific gravity is low Which would have fluid volume deficit? - low fluid in the body and high output= DM & DI Who would have fluid volume excess? -SIADH Diabetes type 1 & 2 Type 1 Insulin dependent K-ketosis prone Type 2- -Not insulin dependent -Not ketosis prone Signs and Symptoms Polyuria- high urine output Polydipsia thirsty Polyphagia- increase swallowing- eating a lot – increased bleeding after a tonsillectomy Treatment 1) Type 1 without treatment can DIE D-diet (least important, count carbs, do checks and give insulin accordingly, just lay off refined sugars) I-Insulin (most important) E- exercise 2) Type 2 without treatment end up DOA D-diet (most important, some dr. like for it to be controlled with diet alone) O-oral hypoglycemic A-activity DIET INSULN AND EXERCISE A) calorie restriction (type two- restrict calorie) b) Need 6 small feedings a day (split 1800 calories into 6 meals to keep glucose levels and avoid peaks- blood glucose will stay more normal Example. Type 2 diabetic best diet to follow a) Restrict calories b) Divide food into 6 feedings a day Answer: restrict calories is most important Best: narrow it down to 2 and think it through- “I will do this one and not do that one and flip it around”- pick the answer you like better Insulin *Insulin lowers the blood glucose 4 types of Insulin you need to know: 1) Regular 2) NPH 3) Lispro 4) Humulog 5) Lantis Regular (stands for RAPID and RUN- Fast acting and ran in IV) -onset is in 1 hour -peak is in 2 hours -duration is 4 hours -clear (solution) so it can be IV dripped -Intermediate acting insulin- because 5-10 years ago we didn’t have Lispro and Regular was the fastest at the time -Still considered as a rapid short acting Insulin NPH (Not so fast (intermediate), and not in the bag) insulin -true intermediate acting insulin -onset is 6 hours -peak is 8-10 hours -duration is 12 hours -cloudy (suspension)- precipitates, particles falls to the bottom over time so it cannot be given IV drip or you will overdose patient and they will die Example of question for peak: You gave 30 units of N at 7 am, when would you check for hypoglycemia (when med is at its peak) Answer: N-3-5pm Humolog (Lispro) fastest acting insulin -Onset is 15 minutes -Peaks at 30 minutes -Duration is 3 hours -Given as they begin to eat (with meals) LANTIS (glargine)-long acting -long acting insulin -so slowly absorbed that it has no essential peak -little to no risk for hypoglycemia -only insulin you can safely give at bed time -will not go hypoglycemic at bed time so can be given routinely -duration is 12-24 hours **check expirations on Insulins- only good as long as its still closed -Once opened, the manufacturers date is irrelevant, the new expiration date will be 30 days after that (need to right EXP and then the date -Refrigeration is optional- don’t have to refrigerate in the institution -In the hospital the ones that should be refrigerated are the unopen vials however once a nurse opens two things happen 1) needs new exp date 2) does not need to be refrigerated BEST answer is-expiration date **exercise potentiates insulin (does the same thing as insulin) -think of insulin as another shot of insulin (and he got another shot of insulin— replace with any form of activity in a question) IF you have more exercise- need less insulin IF you have less exercise- need more insulin If a diabetic is going to be active – he better eat rapidly metaboliable carbohydrates SICK DAYS- flu, diarrhea, etc. -need to take their insulin even though they’re not eating because they are under the stress of insulin -need to take sips of water because they will get dehydrated -must stay as active as possible to lower their glucose because even if they don’t eat their blood glucose will go up 2 main problems with diabetics 1) Hyperglycemia 2) Dehydration Complications of Diabetes Never go to boards not knowing signs and symptoms of the three acute complications of diabetes 1) LOW BLOOD GLUCOSE in a Type 1 or Type 2 – called insulin shock, insulin reaction or hypoglycemic shock or hypoglycemia- means glucose is low a. What causes this: not enough food, too much insulin or medication (primary) and too much exercise- b. What is the danger? – Permanent brain damage-vegetative state with one mistake c. Signs and symptoms? – DRUNK + SHOCK- staggering, slurred speech, poor judgment, slow reaction time, labile(all over the place, laugh cry laugh cry), loud, obnoxious and belligerent, hypoglycemic – cerebral cortical compromise …. SHOCK- vasomotor part of the syndrome- low BP, tachycardia, tachypnea, cold, pale, clammy, mottle, patchy d. Treatment: administer rapidly metabolizable carbohydrates – SUGARS-ex. Any juice, candy, milk (lactose), honey, icing, jam, jelly. + ideal combination of food.. sugar+starch or protein = orange juice + crackers- apple juice + slice of turkey, milk (sugar + protein) but use skim milk because you don’t want them burning fats for ketones. HARD to find vein because they are in shock. If they are unconscious give glucagon, dextrose per IV D10 or D50 (D5 wont cut it) 2) DKA- Diabetic Ketone Acidosis- only TYPE 1(cause another name for Type 1 I ketosis pro and another name for type 2 is ketosis pro) a. Causes: too much food, not enough medication, not enough exercise will make glucose go high. But primary cause is acute viral upper respiratory infections within the last two weeks- after they recover they start going downhill and getting more lethargic-diabetic ketone acidosis coma i. Example: if a child comes in with a blood glucose of 250 and type 1- what’s the first question you would ask the parents=”have they had a viral respiratory infection in the last two weeks? “ Because what caused the glucose to get that high was the stress of that illness that was not cut off and they started to burn fats for fuel and got into a negative situation. b. Signs and symptoms: DKA- Dehydrated look (poor skin tugor, warm temperature, hot flushed dry skin), Ketones in their blood (you can have ketones in your urine and not have DKA but is for sure when its in your blood), kussmaul- deep and rapid (hyperventilate), high k+ (potassium), Acidotic (metabolic), acetone breath (fruit odor), Anorexia due to nausea because they don’t want to eat, c. Treatments: IV fluids at a fast rate, around 200 an hour, use regular insulin and run it at about 100 an hour, use D5 (only getting 60 calories an hour) will not cause hyperglycemia situation. 3) Low blood glucose is the type 1 is the same as type 2 4) High blood glucose aka HHNK, HHS HHNS, HHNC- TYPE 2 (non ketotic) – any time you see the prefix NON you know it’s a type 2- have the nons- type 1 never has anything that has NON in it – this is dehydration!-wherever you see the phrase, hyperosmolar, hyperglycemic nonketotic coma you can pull it out and replace for dehydration, (low water hot flushed dry, Nursing dx. Fluid volume deficit, nursing intervention: giving fluids, goals/outcomes: increased output, moist mucus membranes) DKA without the K or the A-, HHNK is just the D in DKA Which one is the use of insulin most essential in treatment, HHNK or DKA?- answer: DKA- don’t have use insulin with HHNK because they are just dehydrated and you need to just give fluids Highest mortality rate? HHNK Higher priority? DKA- because HHNK they come in a lot later because they don’t have the ketosis or acidosis that makes people see symptoms and don’t see symptoms until they are very bad and get worse--- DKA is acutely ill that can be simply treated wit insulin rehydration while HHNK is not Who would die first? DKA – lower mortality rate even though its more life threatening as they are treated first LONG TERM COMPLICATIONS of diabetes are related to 1) Poor tissue perfusion 2) Peripheral neuropathy Long-term complications 1) renal failure – poor tissue perfusion- losing control of bladder (peripheral neuropathy) 2) ganggreen 3) stasis ulcers 4) blindness 5) heart disease 6) brain disease Which lab test is the best indicator of long term glucose control? - Hemoglobin A1C- glycostat hemoglobin- glycosolated hemoglobin- same tests - Numbers: HA1C- 6 and lower (in control) - Number that means out of control? 8 and above - 7? they are on the border so they need a work up and evaluation for some type of infection somewhere- maybe - A1C- 0.9 change is HUGE Lecture 6 Drug Toxicities 1) Lithium- antimania- bipolar mania- therapeutic level is -0.6-1.2- toxic level is greater than or equal to 2, gray area in between where no books agree on- and is not tested on 2) Lanoxin (digoxin)- treats Atrial fibrillation (adena beta calcium dig) and congestive heart failure- 1-2 is therapeutic, toxic Is greater than or equal to 2- value of 2 is toxic because its safer to call something toxic when it may not be- 3) Aminofilin- relieves spasms in your airway- (technically not a bronchodilator- doesn’t stimulate your beta 2 agonist cell just relaxes a spasm,.. epinephrine is a bronchodilator)- inflammation- theyre in a spasm, acute lock down spasm, need to relieve spasm before giving bronchodilator so that it works better, 10-20 is the therapeutic level, under 10 is not enough, 21=toxic, 20=either way so call it toxic 4) Dilatin (phenytoin)- seizure, therapeutic level is 10-20 toxicity is greater than or equal to 20. 5) Billirubin- waste product from the break down of the red blood cells, when boards test bilirubin they only test it in newborns not in adult- babies are breaking down moms red blood cells so they are usually high- 8 = no big deal… elevated level= 10-20.. 9.9 and less= normal for newborn but high for an adult, toxicity= greater than or equal to 20- a child with what bilirubin and above needs to come to the hospital? 14-15 doctors start thinking about hospitalization because 15 means you are half way to toxic which will lead to death **Toxic levels: 2’s and 20’s 2’s -lithium and lanoxin- pick lower number for L’s 20’s- bilirubin, phenytoin, and aminofilin– go high Kernicterus- bilirubin in the brain – when your bilirubin crosses your blood brain barrier and crosses your spinal fluid- bilirubin in the brain – usually occurs when you get up around 20- and causes aspetic (no germs) meningitis/encephalitis (baby can die) Jaundice- bilirubin in the skin Opisthotonos- position baby ass