Summary NURSING 4530 (NURSING4530) Mark Klimek Lectures 1 to 12 Complete Study Guide. A+ Guide.

Lecture 1— Acid-Base Balance Dumping/HH Ventilators Electrolytes: K+, CA, MG, and NA Lecture 2— Alcohol TX for HyperKalemia Wernicke Overdose and Withdrawal Lecture 7— Thyroid (Hyper-, Hypo-) S/Sx Adrenal Cortex (Addison Aminoglycosides Disease, Cushing) Peak and Trough Toys Laminectomy Lecture 3— Drug Toxicities (Lithium, Lanoxin, Dilantin, Bilirubin, Lecture 8— Lab Values Aminophylline) Five Deadly Ds Kernicterus Neutropenic Precaution Dumping/HH Electrolytes: K+, CA, MG, Lecture 9— Psych Drugs and NA Tri TX for HyperKalemia Benzo MAOI Lecture 4— Crutches Lithium Canes Prozac Walkers Haldol Delusions Clozaril Hallucinations Zoloft Psychosis Psychotic and Non-Psychotic Lecture 10— Maternity and Neonatology Hallucination Illusion Lecture 11— Fetal Complications Delusion Stages of Labor Assessments Lecture 5— Diabetes Mellitus Variations for NB Diabetes Insipidus Maternity Meds SIADH Medication Hints Insulin Psych Tips DKA Operational Stages HHNK Lecture 12— Prioritization Lecture 6— Drug Toxicities (Lithium, Delegation Lanoxin, Dilantin, Bilirubin, Staff Management Aminophylline) Guessing Strategies Kernicterus Acid/Base Balance (Start times: 30:00) In order to solve acid-base disorders, it is important to know the normal values for pH, CO2 and HCO3 (bicarbonate), which are shown below • pH 7.35 to 7.45 • CO2 35 to 45 • HCO3 22 to 26 The first value to look at in an acid-base disorder is the pH • If pH is <7.35, the acid-base imbalance is acidotic • If pH is <7.45, the acid-base imbalance is alkalotic Now, to determine if the imbalance is metabolic or respiratory, determine whether HCO3 goes in the same or opposite direction with pH • Rule of the Bs: If pH and Bicarb move both in the same direction, then the acid-base imbalance is metabolic … Otherwise, it is respiratory Example #1 • pH 7.3 Acidotic • HCO3 20 Metabolic • This is an example of metabolic acidosis Example #2 • pH 7.58 Alkalotic • HCO3 32 Metabolic • This is an example of metabolic alkalosis Example #3 • pH 7.22 Acidosis • HCO3 35 Respiratory • This is an example of respiratory acidosis As the pH goes, so goes my patient, except for Potassium … That means • If pH is low, everything is low, except potassium • If pH is high, everything is high, except potassium If pH goes over 7.45, this is alkalosis • Therefore everything is up: tachycardia, tachypnea, HTN, seizures, irritability, spastic, diarrhea, borborygmi (increase bowel sounds), hyperreflexia (3+, 4+) • However, potassium is opposite. Therefore, hypokalemia • What is the nursing intervention? o Pt need suctioning because of seizures If pH goes below 7.35, this is acidosis • Therefore, everything is down: bradycardia, constipation, absent bowel sounds, flaccid, obtunded, lethargy, coma hyporeflexia (0, 1+), bradypnea, low BP • However, potassium is high (hyperkalemia) • What is the nursing intervention? o Pt needs to be ventilated with an Ambu bag—respiratory arrest So, remember that “MAC Kussmaul” is the only acid-base imbalance to cause Metabolic ACidosis with Kussmaul respirations Causes of Acid/Base imbalance First ask yourself, “Is it LUNG? … If yes, then it is respiratory • Then ask yourself, “Are they overventilating or underventilating? o If UNDERventilating, then pick acidosis—pH is under 7.35 o If OVERventilating, then it is alkalosis, pH is over 7.45 What type of acid-base derangement is present in the following condition? • In labor? o Respiratory alkalosis … Overventilating—pH increases … Alkalosis) • Drowning? o Respiratory acidosis … Underventilating—pH decreases … Acidosis • Pt is on PCA (patient-controlled anesthesia) pump? o Ventilation is down … Respiratory acidosis If it is not LUNG, then it is metabolic. If the patient has prolonged gastric vomiting or suction (sucking out acid), pick alkalosis • For everything else that isn’t lung, pick metabolic acidosis • So, when you don’t know what to pick, pick metabolic acidosis Tip • Set your default setting to Metabolic Acidosis • Always pay attention to modifying phrase rather than original noun Figure 1. Patient- controlled anesthesia (PCA) pump. Ventilator A ventilator is a machine designed to move breathable air into and out of the lungs, aids patients who are physically unable to breathe, or breathing insufficiently to breathe … A ventilators is equipped with a high and a low-pressure alarm High pressures alarms are always triggered by increased resistance to air flow. Look for obstructions, i.e., • Kinks in tubing … Solution: unkink the tube • Condensed water in the dependent tube … Solution: empty it • Mucus plugs … Solution: Ask pt to turn, cough, deep breathe; or suction the tubing PRN What is the appropriate order to address high pressure alarm in a mechanical ventilator? • (1) Unkink. (2) Empty water out of tubing. (3) turn pt, ask pt to cough or deeply breathe, and (4) suction Low pressures alarms are always triggered by decrease in resistance. This can be caused by • Main tubing disconnection • O2 sensor tube disconnection • In both cases, reconnect the disconnected tubing unless tube is on floor … Bag pt and call Respiratory Therapist The ventilator may be set too high or too low • Setting is too high … Pt is overventilated o Respiratory Alkalosis … Panting • Setting is too low … Pt is underventilated o Respiratory Acidosis … Pt is retaining CO2 Question The physician wants to wean pt off vent in the morning. At 6 am, the ABGs say respiratory acidosis. What would you do next? • Notify the physician that the pt is not ready to be weaned off the respirator o Pt is is respiratory acidosis, which means that he is underventilated … Therefore not ready to be weaned off the ventilator o If pt were in respiratory alkalosis (overventilated), he should be ready to be weaned off Alcoholism • The #1 psychological problem is DENIAL • How do you respond/treat to pts in denial? o Confront them by pointing out the difference b/w what they say and what they do o For instance, say something like: “Ok, you say you’re not an alcoholic but it is 10 a.m. and you’ve already had a 6 pack” … It is not the same as aggression. Don’t attack the person o Good answer has “I” … Bad answer has “YOU” o One place where denial is ok—loss and grief Stages of grief are “DABDA”—Denial, anger, bargaining, depression, acceptance o So when the question is about pt in denial, pay attention to whether you are dealing with loss or abusive situation Support = Loss Confront = Abuse Dependency vs. Co-dependency • The #2 psychological problem is Dependency or Co-Dependency • Dependency: when the get the significant other to do things or make decisions for them o The abuser is dependent • Co-dependency: when the significant other derive self-esteem for doing things or making decisions for the abuser o The significant other is the co-dependent • Dependency and co-dependency has a symbiotic, yet a pathological relationship o The dependent pt get a free ride on the co-dependent o The co-defendant pt feels good from “doing stuff” for the abuser • How do you treat dependency/codependency? o Dependent pts are “abusers” … Confront them o Co-dependent pts have self-esteem issues … Teach pts how to set limits and enforce them o Agree in advance on what requests are allowed then enforce o Teach significant other to say no o Work on self-esteem on the co-dependent person Manipulation • Manipulation is when the abuser gets the significant other to do things or make decisions that are not in the best interests of the significant other o The nature of the act is dangerous and harmful to the significant other • How is manipulation like dependency? o In both situations the dependent person gets the co-dependent person to do things or make decisions o If what the significant other is being asked to do is not inherently dangerous and harmful, then this is dependency/co-dependency o However, if the significant other is being asked to do something inherently dangerous and harmful, then this is manipulation • Manipulation? Set LIMITS and Enforce them Examples Determine if either one of these situations is dependent/co-dependent problem or a manipulation problem • A 49-year-old alcoholic gets her 17-year-old son to go to the store and buy alcohol for her. o The mother is manipulating the son o This is an illegal act = Harmful o Dependency … There are 2 patients o The dependent has a denial issue o The co-dependent has a self-esteem issue • A 49-year-old alcoholic asks her 50-year-old husband to go to the store and buy alcohol for her. o This is not illegal for the husband to buy alcohol o This a dependency/co-dependency situation o Manipulation … There is 1 patient—no self-esteem issues o Easier to treat because no one like to be manipulated Wernicke (Korsakoff) Syndrome Typically, Wernicke and Korsafoff are 2 separate disorders. The NCLEX however bundles the 2 as 1 condition • Wernicke is an encephalopathy • Korsakoff is a psychosis • Wernicke and Korsafoff tend to go together Wernicke and Korsafoff • Psychosis induced by Vitamin B1, thiamine deficiency • This is a situation the pt looses touch with reality due to vit B1 deficiency • The primary S/Sx are amnesia (memory loss) and confabulation (making up stories) o Confabulation—The lies for this pts are just as real as reality How do deal with a pt with Wernicke and Korsafoff who is confabulating about going to a meeting with Barack Obama this morning? • Redirect the pt to something he can do o For instance, tell pt something along that line: “Why can we go watch TV to see what is on the news today” Characteristics of Wernicke and Korsafoff syndrome 1. Preventable … Take B1 2. Arrestable (stop it from getting worse) … Take B1 3. Irreversible (70%) … Will kill brain cells Antabuse and Revia (Disulfiram) • Antabuse—Alcohol deterrent • Revia—Antidote • Aversion (strong hatred) Therapy—a type of behavior therapy designed to make a patient give up an undesirable habit by causing them to associate it with an unpleasant effect o Works in theory better than in reality • Onset (how long it takes to start working) and duration (how long it lasts) of effectiveness of Antabuse/Revia is 2 weeks o For instance, if pt will be at a function and would like to drink, the pt must be on Antabuse/Revia at least 2 weeks prior to the event • Patient teaching o Teach pt to avoid all forms of EtOH. Not doing so may lead to symptoms of n/v, even death o Teach them to avoid the followings items as they contain alcohol … Mouth wash, cologne, perfume, aftershave, elixir, most OTC liquid medicine, insect repellant, hand sanitizer, vanilla extract (can’t have cupcake with unbaked icing) o On the exam, do not pick the Red Wine vinaigrettes … It does not have alcohol in it Overdose and Withdrawal First thing you ask in an overdose question is: Is it an Upper or a Downer? • This is because every abuse drug is either an Upper or a Downer • However, laxative abuse in the elderly is neither an Upper nor a Downer Upper Downer • Caffeine • Cocaine • PCP/LSD (psychedelics/hallucinogens) • Methamphetamines • Adderall • Memorize these five for the NCLEX Signs and Symptoms • Things go UP! • Euphoria, seizures, restlessness, irritability, hyperreflexia (3+, 4+), tachycardia, increased bowels • There are over 135 drugs that are downers • If it is not an upper, it is a downer Signs and Symptoms • Things go DOWN! • Lethargic, respiratory depression/arrest, constipated, etc. (borborygmi), diarrhea What are the highest nursing priority to anticipate in an Upper or Downer? • Upper: The highest priority to anticipate in an Upper is suctioning due to seizures • Downer: The highest priority to anticipate in a Downer is intubation/ventilation due to respiratory arrest Example One of your pt is “high on cocaine.” What is critically important to assess? • Having a RR of 12 is not a critical measurement to assess for that pt • However, assessing for reflexes (3+ or 4+), irritability, borborygmi (increased bowel sounds), or increased temperature would be more appropriate o The “ABC rule” does not apply here … In fact, the pt’s ABC in cocaine toxicity is unremarkable After you know that the drug in question is an Upper or a Downer, the second question you should ask yourself is whether it is an Overdose or a Withdrawal • Overdose and withdrawal have the opposite effects Overdose Overdose on an Upper Overdose on a Downer • Too much • Too little Withdrawal Withdrawal on an Upper Withdrawal on a Downer • Too little • Too much Question The driver of a squad car calls the ER and says he is bringing a pt who in ODed on cocaine. What do you expect to see? … Select all that apply • Pt ODed on Upper OD … Expect to se Too much o First question: Upper or a Downer? o Second question: Overdose or Withdrawal? o S/Sx would be: Irritability, 4+ reflexes, borborygmi, increased temperature, etc. Question The same pt is withdrawing from cocaine … Same question • This pt is an Upper in Withdrawal = Too little • Therefore, respiratory is under 12, pt is difficult to arouse, give them Narcan Drug Abuse in the Newborn Always assume intoxication, not withdrawal at birth, in a newborn less than 24 hours after birth. 24 hours or more after birth, you can assume the newborn is in withdrawal Question You are caring for an infant born to Quaalude addicted mother 24 hours after birth. Select all that apply • Overdose/withdrawal condition … Ask the following 2 questions o Is it an Upper or a Downer? … We don’t what it is because it is a “Quaalude” (it is likely a Downer) o Is it Overdose or Withdrawal? … 24 hours after birth (Withdrawal) o A Downer in Withdrawal = Too much o S/Sx = Difficult to console, seizure risk, shrill, high-pitched cry, exaggerated startle reflex Alcohol Withdrawal Syndrome vs. Delirium Tremens Alcohol Withdrawal Syndrome and Delirium Tremens are not the same • Every alcoholic goes through alcohol withdrawal approximately 24 hours after the person stops drinking • However, less than 20% of alcoholics in alcohol withdrawal syndrome progress to delirium tremens … Delirium tremens occurs about 72 hours after the person stop drinking • Alcohol withdrawal syndrome always precedes delirium tremens; however, delirium tremens does not always follow alcohol withdrawal syndrome Alcohol Withdrawal Syndrome Delirium Tremens • Occurs after 24 hours after drinking • Non-life threatening to self and others Nursing Care Plan • Regular diet • Semiprivate room, anywhere on the unit • Pt is up ad lib (Pt is free to move around as desired) • No restraints • Occurs after 72 hours after drinking • Life threatening to self and others Nursing Care Plan • NPO (seizures) or clear liquid diet • Private room, near nursing station • Restricted bed rest (Pt is not free to move around as desired—no bathroom) • Restraints (vest or 2-point lock letters) Note • “Up ad lib” or “up ad liberum” means pt may have activity or free to move around as desired any time • 2-point lock letters restraints: Restraints in 1 upper and the contralateral lower extremities. Release and secure upper arm first, and then release and secure the foot. Switch extremities every 2 hours • Give both anti-HTN medication, tranquilizer, multivitamin containing vit B1 Question So what two situations would respiratory arrest be a priority? • Overdose of a Downer • Withdrawal of an Upper Question Which pts would seizure be a risk for? • Overdose of an Upper • Withdrawal of a Downers Aminoglycosides (Top 5 most tested drugs) Aminoglycosides are the big guns of ABXs (antibiotics)— use them when nothing else works. Aminoglycosides are unsafe at toxic levels and safety then becomes an issue. They are the 5th most tested drugs on the NCLEX The most tested drugs on the NCLEX are: • Top 5 o Psychiatric o Insulin o Anticoagulant o Digitalis o Aminoglycosides • Others o Steroids o Beta-blockers o Calcium channel blockers o Pain medications o Obstetrics medications “A Mean Old Mysin” = Aminoglycosides Would be used to treat serious, resistant, life-threatening, Gram negatives infections • So, treat a mean old infection with a “Mean Old Mycin” o Examples are: TB, septic peritonitis, fulminating pyelonephritis, septic shock, infection from third degree wound covering >80% of the body o However, sinusitis, otitis media, bladder infection, viral pharyngitis, and strep throat are not old mean infections and are not treated with a mean old mycin All aminoglycosides end in Mycin • Gentamycin, Vancomycin, and Clindamycin, Streptomycin, Cleomycin, Tobramycin • Not all drugs ending in mycin are aminoglycosides o Azithromycin, Clarithromycin, Erythromycin … All have THRO in the middle … So, THRO them off the “Mean Old Mycin” list What are toxic effects? • Mycin—Sounds like Mice (Think ears) … Monitor hearing (#1), balance, tinnitus (ringing of the ear, CN8 toxicity) • The human ears are shaped like a kidney so another toxic effect of aminoglycosides is nephrotoxicity (Toxic to the kidneys) o Therefore, monitor Creatinine What would be your answer if in a question, you have to choose which is the best between 24-hour creatinine and serum creatinine? The figure 8 drawn inside the ear should remind you of of 2 things They are toxic to CN8 Administer them q8 hour Do not give Mean Old Mycins PO because they are not absorbed, and therefore would not have any systemic effects There are 2 cases where Mean Old Mycins are given PO • Hepatic encephalopathy (or hepatic coma) where ammonia level gets too high • Pre-op bowel surgery: to sterilize the bowel before surgery • In both cases, the ABX stays in the gut (not absorbed), sterilizes the bowel, and would not be toxic • The #1 action of an “oral mycin” … Sterilize the bowel o Who can sterilize my bowel? Neo Kan o Neomycin and Kanamycin Note E. coli in the gut is the #1 producer of ammonia, which at toxic levels, leads to encephalopathy Troughs and Peaks • Troughs is when drugs is at their lowest concentration in the pt’s blood • Peaks is when drugs is at their highest concentration in a pt’s blood “TAP” Levels • A method to remember what is done before or after, when dealing with a medication with troughs and peaks • “TAP”—Trough, Administer, Peak o Trough before drug administration o Peak after drug administration o Trough and Peak levels are drawn because of a drug’s narrow therapeutic window or index o Narrow therapeutic window or index means that there is a small difference in what works and what kills Which one of the following medications would “trough and peak” important? • Lasix (furosemide) o Smaller dose: 5 or 10 o Larger dose: 80 or 120 • Digitalis (digoxin) o Smaller dose: 0.125 o Larger dose: 0.25 o Would draw “TAP” (Trough, Administer, Peak) on digitalis When to Draw a Through and a Peak • Both Trough and Peak are not medication-dependent • The trough, it is always drawn 30 minutes before next dose • For the peak, it depends on the route o Peak SubL 5 to 10 minutes after drug is dissolved o Peak IV 15 to 30 minutes after drug is finished (bag empty) o Peak IM 30 to 60 minutes o Peak SubQ Depends on insulin (See diabetes lecture) o Peak for PO Not necessary, not tested Question You give 100 mL of a drug at 200 mL per hour (the drug takes 30 minutes to run). If you hang the drug at 10 a.m., it will finish running at 10:30 a.m. When will the drug peak? 1. 10:15 a.m. 2. 10:30 a.m. 3. 10:45 a.m. 4. 11:00 a.m. Answer: Two right answers—pick 11:00 a.m. In this case, play the “Price Is Right”—go with the highest time w/o going over Calcium Channel Blockers CCBs (Calcium channel blockers) are like Valium for the heart • They relax and slows down the heart • In other words, CCBs have negative inotropic, chronotropic, dromotropic effects on the heart (+) Inotropy, Chronotropy, Dromotropy (–) Inotropy, Chronotropy, Dromotropy Positive inotropy • Increase cardiac contractile force  Ventricles empty more completely  Cardiac output improved Positive chronotropy • Increase rate of impulse formation at SA node  Accelerate heart rate Positive dromotropy • Increase speed that impulses from SA node travel to AV node (increase conduction velocity) Negative inotropy • Weaken/decrease the force of myocardial contraction Negative chronotropy • Decrease rate of impulse formation at the SA node  decelerate heart rate Negative dromotropy • Decrease speed that impulses from SA node travel to AV node (decrease conduction velocity) When do you want to relax and slows down the heart? … To treat “A, AA, AAA” • Antihypertensive • AntiAnginal drugs (decreasing oxygen demand) • AntiAtrialArrhythmia Side Effects Headache and hypotension Name: ends in “dipine” … Not “pine” • Also, verapimil, Cardizem (diltiazem) • Cardizem (diltiazem) is given continuous IV drip What are the parameters to assess before putting a pt on CCBs? • Assess for BP • Hold if SBP <100 Cardiac arrhythmias • Knowing how to interpret rhythm • Must know the following 4 cardiac rhythms by sight Normal Sinus Rhythm • There is a P wave, followed by a QRS, followed be a T wave for every complex • Peaks of the P wave is equally distant to the QRS, and fall within 5 small boxes Ventricular Fibrillation • No pattern Ventricular Tachycardia • Sharp peaks with a pattern Asystole • A flat line If the question mentions • QRS depolarization = Ventricular • P wave = Atrial The 6 rhythms most tested on the NCLEX 1. A lack of QRS complexes is asystole—a flat line 2. P waves (atrial) in the form of saw tooth wave = atrial flutter 3. Chaotic P wave patterns = atrial fibrillation (a-fib) (Chaotic: word used to describe fibrillation) 4. Chaotic QRS complexes = ventricular fibrillation (v-fib) 5. Bizarre QRS complexes = ventricular tachycardia (v-tach) (Bizarre: word used to describe tachycardia) 6. Periodic wide bizarre QRS complexes = PVCs (Salvos of PVCs = A short runs of v-tach) PVCs (premature ventricular contractions) are usually low priority • However, elevate them to moderate priority if under the following 3 circumstances o There are 6 or more PVCs in a minute o More than 6 PVCs in a row o R on T phenomenon (a PVC falls on a T wave) • PVCs after an MI is common and is a low priority Lethal arrhythmias are high priority and will kill a pt in 8 minutes or less. They are: • Asystole and V-fib (ventricular fibrillation) • Both rhythms produce low or no cardiac output (CO), without which there is inadequate or no brain perfusion. This may lead to confusion and death Potentially Lethal Cardiac Arrhythmia • V-tach (ventricular tachycardia) is a potentially lethal cardiac rhythm but it has a CO How would a pt with or without CO presents? • CO is absent = there is no pulse • CO is present = there is a pulse Treatment of PVCs and V-tach • Ventricular = Lidocaine • Both are ventricular rhythms • Treat with Lidocaine • Amiodarone is eventually the NCLEX board will want as answer Supraventricular arrhythmias are Atrial arrhythmias (supra = above) Treatments are “ABCDs” • Adenocard (Adenosine) … Fast IV push (push in less than 8 seconds and 20 mL NS flush right after) … These pts will go into asystole for about 30 seconds and out of it • Beta-blockers (end in -olol) • CCBs • Digitalis (digoxin), Lanoxin (another digitalis analog) Beta-blockers have negative inotropic, chronotropic, dromotropic effects on the heart. They treat “A, AA, AAA” • Antihypertensive • AntiAnginal drugs (decreasing oxygen demand) • AntiAtrialArythmia • Side Effects = Headache and hypotension Treatment of V-fib and Asystole • Defib for V-fib (Defib = defibrillate = Shock em!) • Epinephrine and Atropine for Asystole Chest Tubes Purpose: to reestablish negative pressure in the pleural space … Negative pressure in the pleural space makes thing stick so that the lung expands when the chest wall expands • Pleural space is the space between the lung (visceral pleura) and the chest wall (parietal pleura) • In a pneumothorax, chest tube removes air • In a hemothorax, chest tube removes blood • In a hemopneumo- thorax, chest tube removes air and blood Question A chest tube is placed in a pt for a hemothorax (blood). What would you (the LPN) report to the nurse? Or, what would you (the RN) report physician? a. Chest tube is not bubbling b. Chest tube drains 800 mL in the first 10 hours c. Chest tube is not draining d. Chest tube is intermittently bubbling What is the chest tube not supposed to do? The chest tube is supposed to drain instead of bubbling • Therefore answer (c) is the right answer. Question A chest tube is placed in a pt for a pneumothorax (air). What would you (the LPN) report to the nurse? Or, what would you (the RN) report physician? a. Chest tube is not bubbling b. Chest tube drains 800 mL in the first 10 hours c. Chest tube is not draining d. Chest tube is intermittently bubbling With a pneumothorax, bubbling is expected • Therefore, (a) is a good answer choice • Since this is a pneumothorax, not too much blood is expected • Consequently, 800 mL of blood over 10 hours (80 mL per hour) is too much blood and needs to be reported to the nurse or the physician Also, pay attention to the location the tube is placed • Apical (top) or Basilar (base) • Apical chest tube removes Air • Basilar chest tube removes Blood or fluid (due to gravity) Examples • An apical chest tube is draining 300 mL the first hour is bad … Bubbling (air) is expected • A basilar chest tube is draining 200 mL the first hour is expected • An apical chest tube is not bubbling … This is a bad sign because bubbling (air) is expected • A basilar chest tube is not bubbling … This is a good sign because bubbling (air) is not expected Example Pt presents with a unilateral hemopneumothorax. How to care for this pt? • Place an apical chest tube for the pneumothorax and a basilar for the hemothorax Bilateral pneumothorax needs apical chest tube one on the right and one on the left • Air tube = Apical = Top, on both sides Posttrauma or postsurgical pt needs • Pt presents with a unilateral hemopneumothorax. How to care for this pt? … Place an apical and a basilar chest tube on the side of the problem … Always assume trauma and surgery is unilateral unless otherwise specified Trick question Were would you place a chest tube for a postop right pneumonectomy? • Postop right pneumonectomy does not need a chest tube … Since the right lung was removed, there is no need for a chest tube • Chest tube will however be used for lobectomy (removal of a lobe of the lung), or wedge resection Closed chest drainage devices • Types: Jackson-Pratt, Emisson, pneumovac, hemovac, etc. • What happens if one of those drainage devices is knocked over? o Ask pt to take a deep breath and set the device back up o Not a medical emergency … No need to call the physician If the water seal of the chest tube breaks • Clamp o Clamping, unclamping, and placing the tube under water must be done in 15 seconds or less • Cut the tube away • Submerge (stick) the end of the tube under sterile water o The most important step • Unclamp the tube if it was initially clamped, (clamping the tube prevent air to get into the chest but does not allow anything from the chest to get out) Question The water seal chamber of the chest tube in a pt with a pneumothorax/hemothorax breaks. What is the first course of action for the nurse? a. Clamp the tube b. Cut the tube away c. Submerge (or stick) the end of the tube under sterile water d. Unclamp the tube if it was initially clamped In this case, the first course of action is the clamp the tube Question The water seal chamber of the chest tube in a pt with a pneumothorax/hemothorax breaks. What is the priority (best) action of the nurse? a. Clamp the tube b. Cut the tube away c. Submerge (or stick) the end of the tube under sterile water d. Unclamp the tube if it was initially clamped In this question, the priory action for the nurse is to submerge the end of the tube under sterile water because doing so prevents air from getting into the chest. At the same time, this allows air or blood from the chest to get out • This solves the problem by reestablishing the water seal Note Clamping, unclamping, and placing the tube under water must be done in 15 seconds or less Question You notice on the monitor that a pt has v-fib. Pt is unresponsive and there is no pulse. What is the first step in the management of this pt? a. Place a backboard under pt’s back while pt is supine b. Start chest compression The first step is to place the backboard under pt’s back. “First” is about order. Question You notice on the monitor that a pt has v-fib. Pt is unresponsive and there is no pulse. What is the best step in the management of this pt? a. Place a backboard under pt’s back while pt is supine b. Start chest compression “Best” is about what is the priority. Chest compression is the priority action. If a chest tube gets pulled out … 1. Take a gloved hand and cover the opening (first step) 2. Take a sterile Vaseline gauze and tape 3 sides (best step) Chest tube is bubbling … Ask (1) where it is bubbling, and (2) when it is bubbling? Ask the following 2 questions • Bubbling … Where? In the water seal chamber o If it is intermittent, it is good (document it) o If it is continuous, it is bad and indicates a break/leak in the system (find it and tape it) • Bubbling … Where? In the suction control chamber o If it is intermittent, suction pressure is too low (increase it at the wall until it is continuous) o If it is continuous, it is good (document it) Analogies • A straight catheter is to a Foley catheter, as a thoracentesis is to a chest tube o A straight catheter goes in and out … A Foley goes in, secure it, and continuous drainage o Thoracocentesis = go in and out … Chest tubes = go in, secure it, and leave it in place • A Foley has a higher risk of infection than a straight cath • A chest tube has a higher risk of infection than thoracocentesis Rules for clamping tubes • Do not clamp a tube for more than 15 seconds without a physician’s order • Use rubber tooth (will not puncture tubing), double clamps • Therefore, when the water seal breaks, the nurse has no more than 15 seconds to clamp, cut the tube, submerge it under sterile water, and then unclamp it Congenital Heart Defects • It’s either they cause a lot of trouble or no trouble o But nothing in between • Memorize one word: “TRouBLe” with the lower case vowels because congenital heart defects are either: o “TRouBLe” or o Nothing to worry about A pediatric pt with “TRouBLe” as congenital heart defect • Needs surgery now/soon to live • Has slowed/delayed growth and development (failure to thrive) • Has a shortened life expectancy • Parents will experience a lot of grief, financial and emotional stress • Pt is likely to be discharge home on a cardiac monitor • After, birth, pt will be in the hospital for weeks • Pediatrician or pediatric nurse will likely refer pt to a pediatric cardiologist Question The nurse is teaching the parent of an infant born with Tetralogy of Fallot. Which of the following should the nurse talked to the parents about in the teaching session? • The nurse should teach the newborn’s parents all of the choices listed above A “TRouBLe” congenital heart defect • “TRouBLe” shunts blood Right to Left • “TRouBLe” is Blue (cyanotic) • All “TRouBLe” start with the letter “T” o Tetralogy of Fallot o Truncus arteriosus o Transposition of the great vessels o Tricuspid atresia o Totally anomalous of pulmonary vasculature (TAPV) o Except, Left ventricular hypoplastic syndrome These are examples if No TRouBLe congenital heart defects • Ventricular septal defect (VSD) • Patent ductust arteriosus (PDA) • Patent foramen ovale • Atrial septal defect • Pulmonic stenosis All children with a congenital heart defect, whether TRouBle defect or No TRouBle defect, have • A Murmur • An echocardiogram need to be done to find out the cause of the murmur 4 defects of Tetralogy of Fallot — “PROVe” • Pulmonary artery stenosis • RVH (right ventricular hypertrophy) • Overriding aorta • VSD (ventricular septal defect) • No need to know what they are … Just need to spot them as answer choices on the board Infectious Disease and Transmission-Based Precautions There are 4 transmission-based precautions • Standard or universal • Contact • Droplet • Airborne precaution Contact precautions • Anything enteric (GI, or fecal/oral) o C. diff., Hepatitis A, E. coli, cholera, dysentery • Staph • RSV (droplets fall onto object then pt touches object or put it in mouth) Do not cohort 2 RSV pts unless culture and symptoms say that have the same disease • Herpes PPE (personal protective equipment) for contact precaution • Private room is preferred • Can be in the same room if cohort based on culture and not symptoms • Hand washing  Gown  Gloves • Disposable supply (gloves, paper plates, plastic utensils) • Dedicated equipment (stethoscope, BP cuff) and toys stay in the room Droplet precautions • For bugs travelling on large particles through Coughing, Sneezing to less than 3 feet • Meningitis • H. influenza b o Example: epiglottitis (nothing in the throat) PPE (Personal Protective Equipment) • Private room is preferred • Can be in the same room if cohort based on culture and symptoms • Hand washing  Mask  Goggle or Face shield  Gloves • Disposable supply • Dedicated equipment Airborne precautions “Air MTV” • MMR • TB • Varicella (chickenpox) PPE • Private room is preferred • Can be in the same room if cohort based on culture and symptoms • Hand washing  Goggle or Face shield  Gloves • Wear mask when living the room • Keep door closed • Disposable supply (not essential) • Dedicated equipment (not essential) • Negative airflow PPE (Personal Protective Equipment) • Order to put in on … The “Gs” are in reverse alphabetical order and “Mask” comes 2nd o Gown o Mask o Goggle o Gloves • Order to take it off … Do so in alphabetical order o Gloves o Goggle o Gown o Mask Math Problems Dosage calculation IV drip rates = Volume × Drop factor / Time • Micro/Mini drip = 60 drops per mL • Macro drip = 10 drops per mL Pediatric dose (2.2 lbs = 1 kg) Crutches, Canes, Walkers One of the major human functions is locomotion. Therefore, crutches, canes and walkers are tested on the NCLEX exam even though they are not really emphasized in school. Also, such knowledge is good for patient teaching. With that said, crutches, canes and walkers are devices used to help pts with an unstable gait, whose muscles are weak or who require a reduction in the load on weight- bearing structures How do you measure the length of crutches? • Measuring crutches is important for risk reduction when ambulating and to avoid nerve problems • The length of a crutch is measured by o Holding it vertically and placing the tip on the ground o Having 2 to 3 finger widths between the pad and the anterior axillary fold o The tip is located to a point lateral (6 inches) and slightly in front of foot (6 inches) • Rule out landmarks on foot or say axilla! • Handgrip measurement o The angle of elbow flexion is 30 degrees o The wrists should be at the level of the handgrip How to Teach Crutch Gaits? 2- point gait—move a crutch and opposite foot together, then the other crutch with other foot together • Together (Right leg & Left crutch)  Together (Left leg & Right crutch) • For mild bilateral leg weaknesses 3- point gait—move (2 crutches & bad leg) together  Followed by unaffected leg • The gait goes 3-1, 3-1, 3-1 • The affected (bad) leg is not on the ground • The unaffected (good) leg is on the ground 4- point gait—move everything separately • Move crutch  Move opposite foot  Followed by other crutch  Followed by opposite foot • Right crutch  Left foot  Left crutch  Right foot • 4-point gait is very slow but very stable Swing-through is for non-weight bearing (amputees) • Similar to 3-point gait • The unaffected foot get pass the tip of both crutches • The person may be an amputee or does not bear weight on the leg at all • Can move really fast When do you use these gaits? • Use Even-point gait for even, odd-point gait for odd • Use the even numbered gaits when weakness in the feet is evenly distributed o 2-point for mild problems o 4-point for severe • Use the odd numbered gait when one leg is affected o 3-point for one leg • If pt cannot bear weight or amputation o Swing-through Example A pt affected with early stages of rheumatoid arthritis. What gait should the pt use? • Both legs affected (because it is a systemic disease) • Early stage—mild • 2-point gait Example A pt has left ATK (above the knee) amputation 2 days ago. What gait should the pt use? • Non-weight bearing • Swing-through Example Pt is first day postop, right knee, partial weight bearing allowed. What gait should the pt use? • One leg affected • Odd-numbered gait • 3-point gait Example Pt is in advanced stages of ALS. What gait should the pt use? • Bilateral leg weakness (because it is a systemic disease) • Even-numbered gait • Advanced stages = Severe • 4-point gait Example Pt with left hip replacement, 2nd day postop on non-weight bearing instruction. What gait should the pt use? • Non-weight bearing of 1 leg • Swing-through gait Example Pt with bilateral (B/L) total knee replacement first day postop. Weight bearing is allowed. What gait should the pt use? • Even-numbered gait = Bilateral • Weight bearing • First day postop = Severe • 4-point gait Example Pt with bilateral total knee replacement 3 weeks postop. What gait should the pt use? • Even-numbered gait = Bilateral • Weight bearing • 3 weeks postop = mild • 2-point Going Up and Down the Stairs With Crutches • Remember this phrase o “Up with the Good, and Down with the Bad” o When you go up the stairs, the good foot move up first o When you go down the stairs, the bad foot move down last • But, no matter what o Both crutches always move with the bad leg Figure 2. Crutcher. Figure 3. Cane. Figure 4. Walker. Cane • Hold cane on the unaffected (strong) side • Advance cane with the opposite side for a wide base of support • Handgrip should be at the level the wrist Walker • Correct way to use a walker o The walker is on the side of the pt, the pt “Picks it up … Sets it down … Walks to it” o Once the walker is in front of the pt, the pt “Holds on to chair, Stands up, Then grabs walker” • Don’t tie belongings to the front of the walker—Tie them to either side so it won’t tip over • The NCLEX board does not like tennis balls or wheels on walker can create problem Psychiatry First thing to ask in a psych question is: “Is the pt psychotic or non-psychotic?” • The answer to this question will determine care plan, treatment, length of stay, legality, etc. A Non-psychotic person has insight and is reality based. What kinds of answers do you pick for these people? What techniques do you use? • Good therapeutic communication … Looks like a Med/Surge pt • Examples of therapeutic communications o That must be very difficult/overwhelming for you o How are you feeling? o Tell me more about your … o The exam is looking for “reflection, clarification, amplification, restatement, etc.” The Psychotic person has no insight and is not reality based • They don’t think they’re sick—everyone else has the problem o Examples are: delusions, hallucinations, illusions Delusions, hallucination and illusion are psychotic symptoms • Delusions—a false, fixed belief or idea or thought. There is no sensory component. It is all in your head. It is just a thought … 3 types of delusion o Paranoid—People are out to get/kill me o Grandiose—“I’m Christ” … “I am the President” … “I am the world’s smartest person” o Somatic—Body part (I have x-ray vision, there are worms inside my arm) • Hallucination—a sensory experience o Auditory (1st m c)—voices telling you to harm yourself o Visual (2nd m c)—I see bugs on the wall o Tactile (3rd m c)—I feel bugs on my arm (Most common = m c) o Gustatory (taste) o Olfactory (smell) • Illusion—a misinterpretation of reality. It is sensory Differentiation between hallucination and illusion • With illusion there is a referent in reality o A referent is something that both the clinician and the pt can refer to … There is actually something there o The cord is a snake • With hallucination, there is nothing there Example The pt staring at the empty wall says, “Listen, I hear demon voices.” Is that statement from the pt a hallucination and an illusion? • There is no referent there • This is a hallucination Example The same pt overhears nurses and doctors laughing and talking at the nursing station, and says, “I hear demon voices.” Is that statement from the pt a hallucination and an illusion? • There is actually a referent (real people) there • This is an illusion Other examples • A pt looks with a blank stare and says, “I see a bomb.” o This is a hallucination • A pt looking at the fire extinguisher on the wall and says look, “I see a bomb.” o This is an illusion How do you deal with these psychotic patients? • To deal with these psychotic pt, the first thing to ask is what type of psychosis the pt has? There are 3 types of psychosis 1. Functional psychosis 2. Psychosis of dementia 3. Psychosis of delirium A. Functional psychosis—they can function in everyday life • 90% of the followings make up this category • Chemical imbalance in the brain • They are “Skeezo, Skeezo, Major, Manics” o Schizophrenia, Schizoaffective disorder, Major depression (not depression), Mania Example • Bipolar = Depression and Mania • Bipolar pts are psychotic in acute mania B. Psychosis of dementia—what is their problem? • Actual Brain destruction/damage o Due to Alzheimer, stroke, organic brain syndrome o Anything that says Senile/Dementia falls in the category C. Psychotic Delirium—temporary, sudden, dramatic, episodic secondary to something else • Loss of reality o Due to UTI, thyroid imbalance, adrenal crisis, electrolytes, medications/drugs Recap Approach to Answering Psychiatric Questions • First thing to ask is o Is the pt non-psychotic? Or, is the pt psychotic? • Pt is non-psychotic o Address pt as you would address any Med/Surg pts Use therapeutic communication • Pt is psychotic o Next, ask if they are functional, demented, or delirious? Functional = (1) Acknowledge feeling, (2) Present reality, (3) Set limits, and (4) Enforce these limits Demented = (1) Acknowledge their feeling, and (2) Redirect them—give them something they can do Delirious = (1) Acknowledge feeling, (2) Reassurance about safety and temporariness of their condition Functional Psychosis • Schizo, mood disorders thought process, and mania (chemicals out of whack) • This pt has the potential to learn reality (no brain damage) • Your role as a nurse—teach reality • Use the 4 step process to teach reality o (1) Acknowledge feeling, (2) Present reality, (3) Set limits, and (4) Enforce these limits What does this look like in a question? 1. The answer acknowledges pt’s feeling (look for the word “feel”) You seem upset … That is so sad … It’s been so difficult … Tell me more about how you’re feeling 2. Now, present reality ... “I know you see that demon, but I don’t see a demon” … Or, “I am a nurse, this is hospital, this is your breakfast” 3. Set limit. ”We are not going to address that. Stop talking about…” 4. Enforce limit. “I see you’re too ill, so our conversation is over.” Ends the conversation. You’re not punishing the client by taking away privileges Psychosis of dementia • They cannot learn reality … Don’t present it! They can’t learn it! Thus frustrates them, and may discourage you! • Deal with their problems in 2 steps o (1) Acknowledge their feeling, and (2) Redirect them—give them something they can do Do not confuse not presenting reality with reality orientation (Person, place, and time) • Reality orientation = Pt is oriented to person, place, and time Example • Alzheimer lady is the lobby of waiting area of her nursing home. It is Sunday and she is all dressed up. You day to her, “Mrs. Smith, you are all dressed up.” She said, “Yeah! My husband is going to pick me up. We are going to church.” The problem is that the husband has been dead for 10 years. o She has a false, fixed belief o She is delusional (or she is psychotic) o What do you say to her? o First, acknowledge her … You say, “That sounds nice.” (acknowledging) o Second, redirect her … You say, “Why don’t we sit down here and talk about church? … What church do you go to?” (redirecting) o Don’t tell her husband is dead!, which is presenting reality Psychosis of delirium • This is temporary, sudden, dramatic, episodic, secondary loss to reality • Usually due to some chemical imbalance in the body • Causes—UTI, thyroid imbalance, adrenal crisis, electrolytes, medications/drugs • To manage these pts, treat the underlying cause o Acknowledge feeling o Reassure them of safety and temporariness of their condition • They lost touch with of reality—Redirect them is futile Example A pt with schizoaffective disorder who points to 2 people talking across the room. The pt says, “Those people are plotting to kill me.” What would you say? What is the most important word in the vignette? • Schizoaffective—psychosis • I can see that would be frightening. They are not plotting. • We are not going to talk about that. I can see you are too ill. We are ending the conversation Example A pt with Alzheimer disease who during your conversation points to 2 people talking across the room and says, “You see these people, they are plotting to kill me” • Alzheimer Disease—category is dementia • Acknowledge feeling—“I understand you seem to be scared” • Redirect—Let’s go somewhere you feel safe Example A pt with delirium tremens who during your conversation points to 2 people talking across the room and says, “You see these people, they are plotting to kill me” • Delirium tremens … • “That must be scary” • But you are safe. Your fear will go away when you get better Psychotic symptoms Loose associations • Flight of Ideas: Rapid flow of though • Word Salad: Throw words together and toss out … (Sicker than flight of ideas) • Neologisms: Make it up • Narrowed self-concept: When a psychotic refuse to change their clothes or leave the room. Leave them alone o This is a functional psychosis o “Don’t make a psychotic do something they don’t want to do” • Idea of reference: You think everyone is talking about you Dementia hallmark: Memory loss, inability to learn • Always acknowledge feeling • 2nd step always begins with “Re” … Reassure, Redirect, Reality Diabetes Mellitus (DM), Diabetes Insipidus (DI), Insulin Diabetes mellitus = An error in glucose metabolism … Glucose is the body’s primary fuel source • Can be a lack of insulin DM1 • Can be insulin resistance DM2 DIABETES INSIPIDUS = Not a type of DM! … It is insidious, diabetes w/out the glucose element • It is Polyuria, Polydipsia leading to dehydration, due to low ADH. • It is just the fluid part So question is about low urine output or high urine output? … • Similar to DM, DI has a high urine output What is the opposite of Diabetes Insipidus? • It is SIADH = Syndrome of inappropriate ADH (antidiuretic hormone) So, DM has polyuria, polydipsia Therefore, DI also has polyuria, polydipsia However, SIADH is the opposite of the above 2 conditions … • It presents w/ oliguria and no thirst • Decrease urine output • And then, decrease serum specific gravity (due to retention of water) • Increase urine specific gravity (due to decrease urine volume) Lots of urine retained, specific gravity is low = SIADH Fluid Volume Deficit = DM, DI Fluid Volume Excess = SIADH Diabetes • Type I—Insulin dependent, Juvenile onset, Ketosis prone • Type II—Non-insulin dependent, Adult onset, Non-ketosis prone • S/Sx of DM o Polyuria—pee a lot o Polydipsia—thirsty o Polyphagia—(eat/swallow a lot) Treatment for DM Type I (if you don’t treat) • They will “DIE” • Diet (calories from carbs, least important) • Insulin (most important) • Exercise Treatment for Type II DM • They are “DOA” • Diet (most important) • Oral hypoglycemic • Activity Diet for DM2 • Primary treatment modality is Calorie restriction • 1200 Cal, 1400 Cal, 1600 Cal • These pts need to eat 6 small feeding per day—smaller more frequent meals—keeps blood sugar more stable Question What is the best dietary action a DM2 should take? a. Restrict calories b. Divide meal into 6 feedings a day Answer: (a) because pt can eat 6 meals but does not limit the Cal with each meal Insulin acts to lower blood sugar 4 types of Insulin are covered here 1. R-Regular insulin—clear solution, IV drip (HESI-intermediate, Rapid, Run IV) • Onset: 1 hour • Peak: 2 hours • Duration: 4 hours … (Audio says 3 hours, but it is 4 hours) • Pattern: 1-2-4 (Pay attention to peak) 2. N-NPH, Intermediate insulin—it is cloudy, N = Not So Clear, Fast (Cloudy = Suspension—it precipitates—can’t give IV drip), N = not so fast, not in the bag • Onset: 6 hours • Peak: 8 to 10 hours • Duration: 12 hours • Pattern: 6-8-10-12 (Hear the even #s and pay attention to peak) Clear = Solution Cloudy = Suspension  Will precipitate (Not given over IV drip or put in an IV bag) Question How would the board ask question about peak of insulin? For instance, you give 30 units of insulin to a pt at 7 a.m. When do you check for hypoglycemia? • Answer = Add the insulin peak time to the time of insulin administration • For instance, if the pt was given NPH at 7 a.m., add 8 to 10 hours to the time • Answer = Check for hypoglycemia between 3 and 5 p.m. 3. Lispro: (Humalog) • Don’t give it AC (before meal) … Give it with the meal • Onset: 15 min • Peak: 30 min • Duration: 3 hrs • Pattern: 15-30-3 4. Glargine (Lantus) • Long-acting insulin • No Peak • Duration 12 to 24 hrs • Little to no risk for hypoglycemia (only one you can safely give at bedtime) Note: Always check insulin expiration date What action invalidates the manufacturers date? • Opening the package • Once the package is open, the new expiration date is 30 days after that • Open package without an opening or expiration date should be thrown out • Label the package either with o “OPEN” and date package is open or o “EXP” and expiration date • Once the package is open, refrigeration is optional o However, unopened bottle must be kept refrigerated o Although it is good practice to teach pt to refrigerate insulin at home Exercise potentiates insulin action • Exercise is like another shot of insulin • Therefore, if a student is schedule to play soccer (exercise) this afternoon … It is necessary to decrease the dosage of insulin • In addition, the school nurse must give the student rapidly metabolized carbohydrates— snacks or juice Sick Days … Pt has a fever or the flu, and so on • Serum glucose levels go up • Need their insulin even though pt is eating • Take sips of water because they get dehydrated • Any sick diabetic pt has 2 problems o Hyperglycemia and Dehydration Acute complications of Diabetes • Low blood glucose—a.k.a. Hypoglycemia or Hypoglycemic shock or Insulin shock/reaction • Why are some of the causes o Not enough food o Too much insulin (#1 cause, can lead to permanent brain damage) o Too much exercise What does hypoglycemia look like? • Think of Drunk pt in Shock • Drunk o Staggering gait o Slurred speech o Cerebral impairment (labile) o Slow reaction time o Decrease social inhibition • Shock—Vasomotor collapse o Tachycardia, tachypnea, Low BP o Cold/clammy, mottled skin Treatment • Give pt sugars or Rapidly metabolizable carbohydrate such as o Juice (any), candy, regular soda, milk (lactose), honey, icing, jelly, jam • Boards want sugar + starch or protein o For example, apple juice + turkey, Milk is sugar/protein—1/2 cup Skim milk • Bad answer o Candy + Soda—1 sugar is good, 2 sugars are bad o 5 packs of sugar emptied into a glass of orange juice • Unconscious pts—pay attention to location • Glucagon IM if the mother is on the phone • Dextrose IV (D10, D50) if in the ER DKA—High Glucose in a Type I (keto is the clue!) Causes • Too much food • Not enough insulin • Not enough exercise • #1 cause acute viral Upper Respiratory Infection within last 2 weeks S/Sx of DKA is “DKA” • Dehydration (dry, poor skin elasticity and turgor, warm) … Water is a coolant (you overheat) • Ketones in serum, Kussmauls, High K+ • Acidosis, Acetone breath, Anorexia due to nausea Note: Ketone in urine does not necessarily means DKA Treatment • Insulin IV (Regular!) • IV fluid! 200 mL/hr (some of the fastest rate) HHNK or HHS or HHNS • High blood sugar in a Type 2 • These pts don’t burn ketones, no acid • Whenever you see HHNK, think dehydration • Severe Dehydration! o Skin is dry, flushed, decreased turgor, increased HR o #1 Nursing diagnosis: fluid volume deficit (same as dehydration) o #1 Nursing intervention: Rehydration! o Outcomes in successful treatment: Increase urine output, Moist mucous membrane, etc. o Long-term complications: Poor perfusion, Peripheral neuropathy Between DKA and HHNK • Which one is more dependent on insulin? o DKA pt is more dependent on insulin o HHNK pt needs to be rehydrated • Which one has a higher mortality rate? o More pts die HHNK • Which is a higher priority? o DKA is a more acute condition and responds very quickly to insulin o HHN pts show up late in the emergency room and do not readily respond to treatment Long-term complication of diabetes • Related to o Poor tissue perfusion or o Peripheral neuropathy • Examples of long-term complications: Renal failure, Gangrene, Heart failure, Urinary incontinence, Pt can’t feel a burn on the foot • For instance o Renal failure is a cause of poor perfusion o Urinary incontinence is a cause of peripheral neuropathy Which lab test is the best indicator of long-term blood glucose level? • Hb A1C, a.k.a. glycosated Hb or glycosylated Hb o Average blood sugar over last 90 days • (Hb = Hemoglobin) • Hb < 6 is normal • Hb > 8 is out of control • Hb 7 Borderline—have pt come in for evaluation Drug Toxicities, Hiatal hernia, Dumping syndrome Drug Toxicities—Know these FIVE medications 1. Lithium (antimania drug) • Used for Bipolar o Specifically, for the manic episodes but not for the depression • Therapeutic level: 0.6 to 1.2 • Toxic level: >2.0 • Notice gray area: 1.3 to 2 2. Lanoxin or Digoxin • Used to treat A-Fib and CHF • Therapeutic level: 1 to 2 • Toxic level: >2 3. Aminophylline—muscle spasm relaxer for the airway • Compound of the bronchodilator theophylline • Therapeutic level: 10 to 20 • Toxic level: >20 • Non-therapeutic level: <10 … if it is not therapeutic, increase dose of medication, and assess for compliance 4. Dilantin (phenytoin) • Seizure medication • Therapeutic level: 10-20 • Toxic level: >20 5. Bilirubin • Breakdown product of Red Blood Cells • Normal level in adults: 0.2 to 1.2 • Always tested in the Newborns on the NCLEX • In Newborns bilirubin is much higher than in adults o Elevated level: 10 to 20 o Toxicity: >20 • When do physicians want to hospitalize these newborns? o When bilirubin level is about 14 to 15 Patterns • 1s and 10s • 2s and 20s o 2s: Low # (Lithium and Lanoxin) o 20s: High # (Aminophylline, Dilantin and Bilirubin) Jaundice—Yellow skin from excess bilirubin in the blood • It appears as yellow skin and sclera Kernicterus—Excess bilirubin in the brain • Occurs when level in the blood gets >20 • In the brain, it may cause aseptic (sterile) meningitis or encephalopathy (don’t need to know) • It can be DEADLY Opisthotonos • Position the newborn assume due to irritation of the meninges from kernicterus • Presentation: hyperextended posture … (Is a medical emergency) Question In what position do you place an opisthotonic newborn? • Put newborn on the side Pathological vs. Physiological Jaundice • If the newborn comes out yellow, something is wrong = Pathologic jaundice • If the newborn turn yellow 2 to 3 days postpartum, that’s ok = Physiologic jaundice Dumping Syndrome vs. Hiatal Hernia • Both gastric emptying problems and are opposites Hiatal Hernia • Regurgitation of gastric acid upward or backward into esophagus • “Like a cow with 2 stomachs,” gastric contents go in wrong direction at the correct rate • S/Sx of hiatal hernia is similar to GERD (Heartburn and indigestion) • S/Sx of hiatal hernia = S/Sx of GERD when lying down after a meal o In other words, Heartburn, Indigestion on lying down after eating • Treatment o Can do 3 things, as shown below 1. Elevate HOB (head of bed) during and 1 hour after meals 2. Increase the amount of fluids with meals 3. Increase the amount of Carb content o These cause the stomach to empty quickly so its content doesn’t back up o High-atal Hernia … Everything high Dumping Syndrome • Gastric contents are dumped too quickly into duodenum o Right direction but at wrong rate • S/Sx of dumping syndrome o Drunk: Staggering gate, impaired judgment, labile—all blood gone to gut o Also get Shock: cold/clammy, tachycardia, pale o Now add Acute abdominal distress: n/v, diarrhea, cramping, guarding, borborygmi, bloating, distention • Dumping syndrome = Drunk, Shock, Acute Abdominal Distress Note • Drunk is what it is • Shock is what it is • Drunk + Shock = Hypoglycemia • Drunk + Shock + Acute abdominal distress = Dumping syndrome Treatment of Dumping Syndrome • Can do 3 things, as shown below 1. Lower HOB (head of bed) during meals and turn pt on the side 2. Decrease the amount of fluids 1 or 2 hours before or after meals 3. Decrease the amount of Carb content o These 3 things prevent the stomach to empty quickly or dump its content into the duodenum • Dumping syndrome … Everything low What is protein is added in the diet? • Protein does the opposite of carbohydrate • Protein bulks gastric content, takes longer to digest, and moves slower through the gut • Therefore, give o Low protein in hiatal hernia o High protein for dumping syndrome Electrolytes • Memorize these 3 sentences 1. Kalemias do the same as the prefix (hypo-, hyper-), except for HR and urine output which go opposite 2. Calcemias do the opposite as the prefix 3. Magnesemias do the opposite as the prefix • Natremias o HypoNatremia = Volume overload … HyperNatremia = Dehydration Kalemia(s) • Go in the same direction as the prefix, except for HR and urine output (UO), which go in the opposite direction • Hypo—Symptoms go low with hypo, except HR and UO • Hyper—Symptoms go high with hyper, except HR and UO Some S/Sx of Hyperkalemia • Brain: seizures, agitation, irritability, loud down • Heart: tented T waves, ST elevated, tachypnea • Bowel: diarrhea, borborygmi • Muscle: spasticity, increase tone, hyperreflexia (3+, 4+) • Heart rate: down (bradycardia) • UO: down (oligouria) Some S/Sx of Hypokalemia • Lethargy, bradypnea, paralytic ileus, constipation, muscle flaccidity, hyporeflexia (0, 1+) • Tachycardia (HR is up) • Polyuria (UO is up) Question Your patient has hyperkalemia, select all that apply a. Adynamic ileus b. Obtunded c. 1+ reflex d. Clonus (irritable) e. U wave f. Depressed ST g. Polyuria h. Bradycardia Answer • Kalemia goes in the same direction, except HR and urine output … therefore, • Clonus are bradycardia are right Calcemia(s) • Go in the opposite direction as the prefix • Hypo—Symptoms go high with hypo • Hyper—Symptoms go low with hyper Calcemias do the opposite of the prefix—it is a sedative • So Hypercalcemia is bradycardia, bradypnea, flaccid, hypoactive reflexes, lethargy, constipation, etc. • So Hypocalcemia is agitation, irritability, 3+ or 4+ reflexes, spasm, seizure, tachycardia, Chvostek sign (tap the cheek), Trousseau (inflate BP cuff), etc. Choosing answers for potassium and calcium • For potassium pick answers related to heart problems • For calcium pick answers related to muscle problems Magnesemia(s) • Magnesium goes in the opposite direction of the prefix—it is also a sedative It is possible that S/Sx are from several electrolytes imbalances. In that case, • Choose CALCIUM if nerve or skeletal involvement • Pick POTASSIUM for any other symptom o Generally anything effecting blood pressure Your patient has diarrhea … Which one of the following electrolyte imbalances causes diarrhea? Hyperkalemia, hypokalemia, hypocalcemia, or hypomagnesemia • Tetany? Hypocalcemia Test tip • Common mistake • Tetany = Hyperkalemia—prefix example. Pay attention Natremia(s)—Sodium • HypErnatrema = DEhydration o Hot, flushed, dry skin, thready pulse, rapid HR … Give fluid o Associate “E” in hypernatremia with DEhydration • HypOnatremia = Overload o Crackles, distended neck veins … Fluid restriction, Lasix o Associate “O” in hyponatremia with Overload o Nursing Dx: Fluid Volume Excess Question In addition to a high potassium, what other electrolyte abnormality can be seen in DKA? • Hypernatremia = Dehydration • DKA should make you think of DEhydration, which is also associates with hypErnatremia Question In addition to High Potassium what other electrolyte imbalance is possible in DKA? • Answer: Hypernatremia Review—Think dehydration or Fluid overload • SIADH: Hyponatremia • DI: Hypernatremia • HHNK: Hypernatremia How to spot early signs of electrolyte imbalance? • The earliest sign of any electrolyte disturbance is o Numbness and tingling = Paresthesia o Circumoral paresthesia = Numbness and tingling around the lips • The universal sign of all electrolyte imbalances is o Muscle weakness = Paresis Treatment • Potassium is the only one Boards will test • Never Push Potassium IV • Potassium <40 mEq/L of IV fluid o If >40 mEq/L, clarify dosage with physician How do you lower potassium? • Of all electrolyte imbala