Mark Klimek's Lecture 4-12

Lecture 4 • Mark Klimek • 96:58 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 weightbearing 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 Page 24 of 92 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) Page 25 of 92 • 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” Page 26 of 92 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? Page 27 of 92 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? Page 28 of 92 • 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? Page 29 of 92 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 Page 30 of 92 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 Page 31 of 92 Dementia hallmark: Memory loss, inability to learn • Always acknowledge feeling • 2nd step always begins with “Re” … Reassure, Redirect, Reality 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 Page 32 of 92 Lecture 5 • Mark Klimek • 71:46 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) Nursing Diagnosis? 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) Page 33 of 92 • 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? Page 34 of 92 • 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 Page 35 of 92 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 Page 36 of 92 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 Page 37 of 92 Lecture 6 • Mark Klimek • 87:50 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 Page 38 of 92 • 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 Page 39 of 92 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 Page 40 of 92 • “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 Page 41 of 92 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) Page 42 of 92 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 Page 43 of 92 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 imbalance, high potassium is the most problematic • High potassium can stop the heart • The fastest way to lower potassium level is to o Give D5W and regular insulin to decrease potassium o This will drive the potassium into the cell and out of the blood o Temporary solution but quick • Kayexalate is long-term solution o Through enema or ingestion, Kayexalate exchanges potassium for sodium Page 44 of 92 o Potassium is eliminated through feces and pt becomes hypernatremic o Hypernatremia is managed with IV fluid administration o The downside is it takes hours to work • To solve this problem o Give D5W, Regular insulin, and Kayexalate and the same time D5W and Regular insulin work instantly Kayexalate works in a few hours—K Exits Late Page 45 of 92 Lecture 7 • Mark Klimek • 115:33 Thyroid and Adrenals Since the thyroid gland regulate metabolism, whenever you see the word “thyroid,” change it to “metabolism” Hyperthyroidism • Hypermetabolism • So, what are the S/Sx of hypermetabolism? o Weight loss o HR up, BP up o Hyperpersonality o They have heat intolerance … Can tolerate cold because body is like a furnace o Exophthalmos (bulging eyes) … Think Susan Sarandon, or Don Knotts Exophthalmos is seen in Graves disease Run yourself into the Graves disease Figure 5. Don Knotts with Exophthalmos or bulging eyes. Hyperthyroidism—3 Treatment Modalities 1. Nuke it with radioactive iodine o Pt must flush three times after urinating o Call hazmat team if urine is spilled on the floor o Pt needs a private room in the first 24 hours o Visitors restriction and in hospital and at home in first 24 hours 2. PTU (Propylthiouracil) o PTU “Puts Thyroid Under” o PTU’s primary use is for cancer—Monitor WBC b/c pt is immunosuppress 3. Thyroidectomy o Surgical removal of the thyroid is the most common treatment o To answer questions on the Board correctly, pay attention whether it is a Total, Sub (a.k.a. Partial) thyroidectomy o Total thyroidectomy needs lifelong hormone replacement, and pt is risk for hypocalcemia due to difficulty to spare the parathyroid glands Page 46 of 92 Question What are the symptoms of hypocalcemia? • Paresthesia, tetany, twitching, spasm, clonus, seizure, jitteriness, tremor (all UP!). also, Chvostek and Trousseau signs Treatment of Subthyroidectomy • Do not need lifelong hormone replacement • May need to supplement at first • HOWEVER, they are at risk for thyroid storm S/Sx of thyroid storm — A medical emergency • Temps of 105 or above o Get temp down, bring oxygen up o Bring body temperature down using ice packs/cooling blankets o Oxygen per mask at 10L o Stay with patient • High BP, stroke level — about 210/180 • Severe tachycardia 180 as high as 200 • Psychotically delirious Lowering body temperature in thyroid storm • First step is ice pack • Best step is cooling blanket Postop Risks in total thyroidectomy and subtotal thyroidectomy • First 12 hours—risks are the same for both total and subtotal 1. Top priority is airway, due to edema 2. Next is hemorrhage because it is an endocrine gland—very vascular • Next 12 to 48 hours—It matters what kind of surgery you’ve had now 1. Total: big danger is tetany due to low calcium TOTAL = TETANY … Can close off airway with an irreversible spasm 2. Subtotal: big danger is thyroid storm SUBTOTAL = STORM (Severe) • After 48 hours—risk is infection Note: For any type of procedure, the risk of infection significantly increases after 72 hours Hypothyroidism • Hypometabolism • So, what are the S/Sx of hypomatabolism? o Obesity o HR down, BP down o Personality: Flat, boring, dull o They have cold intolerance … Can tolerate heat o Academically challenged Page 47 of 92 Myxedema • This is when a pt with severe hypothyroidism presents with skin involvement Myxedema coma • Severe hypothyroidism leading to decreased mental status, hypothermia, and other symptoms related to slowing of function in multiple organs • Medical emergency Treatment of hypothyroidism • Levothyroxine (Synthroid) • Taken in the morning 30 minutes to 1 hour before breakfast • Taken alone on an empty stomach with water Do not sedate these pts • They’re already super slow. They can go into a coma Question What pre-op order from the physician would you question? • Ambien (zolpidem) at hs • (at hs = at bedtime) Question A pt dx with hypothyroidism will be undergoing surgery the next morning. The physician ordered the pt NPO at 12:00 am. Pt is on Synthroid and multivitamin pills. What should the nurse question? • Clarify the NPO order for the Synthroid … Why? o The pt needs the Syntroid medication to get through surgery. Otherwise, the condition may potentiate the suppressing effects of the anesthesia during surgery o Therefore, don’t hold thyroid pills unless explicitly orders Adrenal Cortex Disease Interestingly, all adrenal cortex diseases either start with an “A” or a “C” • Addison Disease (a.k.a. hypoadrenalism or adrenal insufficiency), Cushing Addison disease • Under secretion of steroids (they are a time bomb!) • S/Sx: pts are Hyperpigmented (very tan) • They do NOT adapt to stress Question What is the purpose of the stress response in an individual? • To maintain o A normal blood pressure to perfuse the brain and other organs Page 48 of 92 o An adequate level of glucose to feed the body Question What could happen if these pts can’t adapt to stress? • Under stress, pts with Addisson disease will go into shock and have an hypoglycemic episode (Addisonian crisis) Treatment • Give steroids • Glucocorticoids drugs that end in -SONE o Prednisone o Methylprednisone • “In Addison, you ADD-a-SONE” Cushings Syndrome • If you have a cushy touchie … You got more • Oversecretion of adrenal cortex (steroids) Figure 6. Cushings disease. All the S/Sx of Cushings are the S/E of Steroid medications Important! … Draw this picture over and • Draw picture of a little man over, while repeating the list on the left such • Give man a MOON FACE that to commit to memory the S/Sx of • Give him a beard—hirsutism Cushings and the S/E of steroid medications • Draw a big body—truncal or central obesity • Arms and legs are skinny—muscle atrophy • Bump on front—gynecomastia (big breast) • Bump on back—buffalo hump • Fill him full of water (he is retaining Na+ and water) He is losing K+ out the back • Give him some striae—stretch marks • Most important one of all—high serum glucose o Do Accu-Checks q6h. They look like diabetics • Easy bruising—put bruises all over him • Make him say something in a speech balloon … “I’M MAD, BECAUSE I HAVE AN INFECTION” o Grouchy (“Roid rage”) o Immunosuppressed Question A pt comes in with an acute exacerbation of COPD. The pt is being treated with Solu-Medrol (methylprednilosone) IV push q8 hours to reduce the inflammation in the airway. What nursing action needs to be taken while the pt is on the medication? • Do an Accu-Checks q6 hours • Since pt is on steroid, his condition is similar to diabetes even though he is not diabetics Page 49 of 92 • The complications are worse if pt is diabetic Treatment for Cushings • Adrenalectomy • What happens with a bilateral adrenalectomy? o Now pt has Addison disease o Now give steroids (ending in SONE) to treat. o Pt will start looking like Cushman (Cushinoid-like) o It takes about a year or so—after a lot of titration—for the pt to start looking normal Kids Toys (50:16) When you select toys and play activities for children, there are three things to consider 1. Is it safe? 2. Is it age appropriate? 3. Is it feasible? o Is it possible to do easily or conveniently? o For instance, swimming in hospital with body cast Safety • Size (no small toys for kids under 4) • Over 4 small pieces are fine • NO Metal (or dye-cast) if oxygen is in use o Think of a flint-sparks! • Beware of fomites o A fomite is a non-living object that harbors microorganisms, such as stuffed animals—the worst type of fomites o Hard plastic toys are fine … They can easily be disinfected Note If you have a child who is immunosuppressed … Give them a hard plastic action figure. It can easily be disinfected Age appropriate toys (See Piaget’s Theory of Cognitive Development on page 79) Infants • 0 to 6 months— • 6 to 9 months— Sensorimotor. Best toy is a musical mobile (Best choice) Toy should be large but soft (2nd best choice) Object permanence. Best toy teach them to Cover/Uncover This is to teach them that the object is still there even if they can’t see it Examples are: Jack-in-the-Box and Peek-a-Boo Toy should be large but firm Worse toy after 6 months is the Musical Mobile because of the risk of strangulation Page 50 of 92 • 9 to 12 months— Vocalization. Best toys are speaking or verbal toys Good list of toys are: Tickle me Elmo, Woody Cowboy, See and SayBarnyard Friends, Talking books For purposeful play, the infant should be at least 9 months or older • These words mean purposeful play: build, sort, stack, make, and construct • Baby in womb for 9 months, another 9 months for purposeful play Toddlers • 1 to 3 years— Preschoolers • 3 to 6 years— School age • 7 to 11 years— Adolescents • 12 to 18 years— Work on Gross Motor skills, which is running, jumping Best toys for this age group are Push/Pull toys Examples are: Lawn mowers, Wagon, dog with floppy feet They can paint (They use the hand to paint) They are characterized Parallel Play (think terrible two) Work on fine motor skills Therefore, preschoolers have finger dexterity; hence, can write, draw, use colored pencils, scissors Work on balance—Dance, ice skates, tricycles, tumbling They are characterized by Cooperative Play • Need to cooperate in Preschool (= Pretend) • You’d be the sheriff, I’ll be robber … Highly imaginative Concrete Characterized by the “3 Cs” 1. Creative—Give them blank paper to draw, they like to get involved … Toys: Legos, Transformers 2. Collective—Baseball cards, Webkinz, Barbies, Beanie Babies 3. Competitive—Winner/losers Peer group association Allow adolescents to be in each other’s rooms unless one of them has been/is 1. Recently post-op for <12 hrs 2. Immunosuppressed 3. Contagious Note: When given a variety of ages to choose from, always go younger because children regress, when sick you want to give them time to grow Page 51 of 92 Laminectomy (78:32) Lamina: the vertebral spinous process (bumpy bones along backbone) Ectomy: removal Laminectomy is the removal of the vertebral spinous process Question Why perform a laminectomy? • To relieve nerve root compression … In other words, cutting away the bony prominence gives the nerve more room Question What the S/Sx of nerve root compression? • The 3 “Ps” 1. Pain 2. Paresthesia (tingly) 3. Paresis (muscle weakness) When you get a laminectomy question, pay attention to location, location, location • There are 3 different locations where laminectomy is performed 1. Cervical 2. Thoracic 3. Lumbar 1. Cervical—neck • What is the most important pre-op assessment for cervical? o Cervical innervates the diaphragm and the arms o First, assess for breathing o Next, check functions of arms/hands • Post-op complication o Watch for pneumonia 2. Thoracic—upper back • What is most important pre-op for thoracic? o Thoracic innervates gut/abdominal muscles … Assess cough and bowels (cannot cough when you cannot contract abs) • Post-op complication o Pneumonia and paralytic ileus 3. Lumbar—lower back • What is most important pre-op for lumbar? o Lumbar innervates Bladder and legs … Assess for urinary retention or last time pt voided or is the bladder empty o Next best answer is to evaluate leg functions • Post-op complication Page 52 of 92 o Urinary retention and Leg problems • Lumbar = Legs, Urinary retention Postop Laminectomy • Number 1 answer for postop laminectomy, including spinal surgery, is log roll • Better pick log roll Mobilizing pt after laminectomy or spinal surgery • Do not dangle these pts—have them seat at the edge of the bed • They should go from supine to walking as soon as possible • Can they sit on bed long enough to overcome orthostatic hypotension? o Yes, but not for 10 to 15 minutes • Do not allow pt to sit for more than 30 minutes • So, what post-op order would you question for a laminectomy? o Up in chair for 1 hour TID • These pts may o Walk, stand, lie down without restriction o Sitting is bad Question You are caring for a pt with a lumbar oligodendrogliocytoma. What is the #1 problem? a. Airway b. Ileus c. Cardiac arrhythmia d. Urinary retention Answer Who cares what oligodendrogliocytoma is. The lesion is in the lumbar spine. Therefore, we should assess for urinary retention, then for leg problems • If the question instead mentions lumbar abscess or lumbar surgery, lumbar ependymoma, the answer would be the same Note Typically there are no chest tubes with Laminectomy. However, the anterior thoracic will have chest tubes • What does anterior thoracic means? o From the front through the chest to the spine Recap—Laminectomy • Cervical = Neck and Arms • Thoracic = Lungs and GI • Lumbar = Bladder and Legs Laminectomy with fusion • This involves taking a bone graft from (1) the iliac crest and (2) the spine • Bone from your hip is taken and put it in place so no bone-to-bone Questions Of the two incisions, which site has the most Pain? • THE HIP Of the 2, which one will have/need the most Bleeding/Drainage? Page 53 of 92 • THE HIP • This is where the HEMOVAC, JP will be Of the 2, which one has the higher risk of infection? • They are equal Of the 2, which one has the higher risk for rejection? • The spine Since the hip gives more problems, surgeons want to get rid of hip incision. Why? • Because, it is shorter recovery … It cuts the infection in half … It decreases the drainage by 80% … Decreases the pain by 80% • That is why surgeons are using cadaver bone from banks because the risk of rejection is very low o Bone are not protein and protein is what triggers the antigen-antibody response Discharge Teaching? There are 4 temporary restrictions and 3 permanent • Temporary restrictions … (6 weeks) 1. Do not sit for >30 minutes 2. Lie flat, log roll for 6 weeks 3. Don’t drive for 6 weeks 4. Don’t lift more than 5 lbs for 6 weeks (gallon of milk) Permanent restrictions • Permanent restrictions 1. Laminectomy patients will never be allowed to lift by bending at waist (use knees) 2. Cervical laminectomy should never be allowed to lift anything over the head 3. No horseback riding, off trail biking, jerky amusement park rides, etc. … Note This lecture on laminectomy can be used to get any spinal cord question correct … Pay attention to location Page 54 of 92 Lecture 8 • Mark Klimek • 53:53 You will be asked to prioritize different pts based on lab values Therefore, it is not good enough to simply know the normal/abnormal lab values You would have to rank or prioritize pts based on abnormally critical lab values Use the “ABCD” scheme to prioritize pt based on lab values • Low priority o A is low priority … This lab result can be ignored for a few hours or, if late at night, until very early morning o B is concerning … This lab result needs to be closely monitored • High priority o C is critical … You need to do something The RN does the first set of assessments for this lab for Levels C or D … Example: V/S, lung o D is highest priority … Stay at the bedside and heart auscultations, abdominal exam, etc. Lab Values (05:11) Lab Creatinine (Cr) Best indicator of kidney or renal function Range 0.6 to 1.2 INR “ABCD” Scheme Level A Level B if dye procedure (such as a catheterization) is involved Level C when 4 and above Monitors coumadin … Also 2 to 3 reflects PT (or Prothrombin time) • Action to take in following order … Hold Coumadin ! Focus Assessment for bleeding ! Prepare to give vit K ! Call HCP Potassium (K+) Blood chemistry 3.5 to 5.3 Level C if Low Level C if High Level D if over 6 • LOW potassium … Action to take in the following order … Nothing to hold ! Assess heart (EKG) ! Prepare to give K+ ! Call HCP • HIGH potassium (bet 5.4 and 5.9) … Action to take in the following order … Hold K+ ! Assess heart (EKG) ! Prepare to give Insulin/Kayexelate ! Call HCP • HIGH potassium (6 or more) … Action to take in the following order … Hold K+ ! Assess heart (EKG) ! Prepare to give Insulin/Kayexelate STAT ! Call HCP, stay with pt pH Blood chemistry 7.35 to 7.45 Level D if pH in the 6s • Action to take … Nothing to hold ! Assess V/S ! Nothing to prepare ! Call HCP Page 55 of 92 BUN Waste product in blood 8 to 25 Level A (Blood urea nitrogen) • Action to take … Nothing to hold ! Assess for dehydration ! Prepare IV fluid ! Call HCP Hemoglobin (Hb) Blood 12 to 18 Level B if 8 to 11 Level C if <8 • Action to take for a Level C … Nothing to hold ! Assess for bleeding/anemia/malnutrition ! Prepare blood ! Call HCP Bicarbonate 22 to 26 Level A CO2 Level C if in the 50s Level D if in the 60s or higher • Action to take for a Level C … Nothing to hold ! Assess for breathing ! Ask pt to perform purse-lipped breathing ! Call HCP o This is not a COPD pt • Action to take for a Level D … Nothing to hold ! Prepare to intubate/ventilate ! Call (Respiratory therapy ! HCP), do not leave pt o This is respiratory failure Hematocrit (Hct) Assess for dehydration 36 to 54 Level B O2 or PaO2 Blood chemistry 78 to 100 Level C if 70 to 77 Level D if in the 60s or lower, respiratory failure • Action to take for a Level C … Nothing to hold ! Assess for respiration difficulty and dyspnea, prepare to give oxygen ! Call HCP o In a pt with hypoxia, the heart rate increases first, then the respiratory rate increases afterwards due to compensation o In a coronary care unit, the 2 most common episodic causes of tachycardia in heart pt are hypoxia and dehydration Treatment: Give the O2 to pt and increase the rate of fluid administration usually solve the problem • Action to take for a Level D … Prepare to intubate/ventilate pt ! (Call Respiratory therapist ! HCP), stay with pt O2 Saturation 93 to 100 Level C if <93 • Action to take for a Level C … Nothing to hold ! Give pt O2 • What invalidates your reading? o Anemia o Or a Dye procedure—It colors the blood o Both falsely elevated BNP B >100 indicates CHF. Monitor <100 Level B if >100 (Brain natriuretic pt for sign of CHF peptide) Page 56 of 92 Sodium (Na) Electrolyte 135 to 145 Level B if abnormal Level C if abnormal and there is change in pt’s LOC • Action to take for a Level B … Nothing to hold ! Assess for fluid overload (hypOnatremia) or dehydration (hypERnatremia) ! Prepare for furosemide (hypOnatremia) or IV fluid (hypERnatremia) ! Call HCP • If there is a change in LOC, pt becomes level C and a safety issue WBC Total 4,000 Level C <4,000 to 11,000 ANC (Absolute >500 Level C <500 neutrophil count) CD4 >200 Level C <200 • CD4 >200 but <500 is HIV • CD4 <200 is AIDS • Action for WBC, ANC and CD4 … Assess and put on pt neutropenic precautions o Refer to neutropenic precautions below Platelet (PLT) 150,000 to Level C if <90,000 450,000 Level D if <40,000 RBC 4 to 6 million Level B if abnormal (Red blood cell) Platelet and RBC (Continued onto Lecture 9) Neutropenic Precautions • Strict hand washing • Vital q4 hrs • Dedicated stethoscope, BP cuff • Reverse/protective isolation • Shower BID with microbial soap • Avoid crowds • Private room • Limit staff/visitors • No fresh flowers/potted plants • No raw fruits/veggies/undercooked meat • No water pitcher standing for over 15 minutes • Check WBC daily • No indwelling catheters • Do not reuse cups or disposable plates Page 57 of 92 Five Deadly “Ds” • The following are 5 priority pts based on their lab values • The NCLEX exam will not put one of the followings against another o K+ >6 o pH in the 6s o CO2 in the 60s o pO2 <60 o Platelets <40,000 Lecture 9 • Mark Klimek • 56:14 Platelet and RBC (Continued from Lecture 8) Lab Platelet (PLT) Range 150,000 to 450,000 4 to 6 million RBC (Red blood cell) Neutropenic Precautions • Strict hand washing • Vital q4 hrs • Dedicated stethoscope, BP cuff • Reverse/protective isolation • Shower BID with microbial soap • Avoid crowds • Private room • Limit staff/visitors • No fresh flowers/potted plants • No raw fruits/veggies/undercooked meat • No water pitcher standing for over 15 minutes • Check WBC daily • No indwelling catheters • Do not reuse cups or disposable plates “ABCD” Scheme Level C if <90,000 Level D if <40,000 Level B if abnormal Five Deadly “Ds” • The following are 5 priority pts based on their lab values • The NCLEX exam will not put one of the followings against another o K+ >6 o pH in the 6s o CO2 in the 60s o pO2 <60 o Platelets <40,000 Psychiatric Drugs ALL psychiatric drugs cause low BP and weight changes—usually weight gain Major Classes Phenothiazines • First generation or typical antipsychotics • All end in “ZINE” o Example: Thorazine, Compazine • They don’t cure … They just reduce symptoms • We use ZINEs for the ZANY (Cuckoos) … Antipsychotics • In small doses, they are antiemetics (to treat vomiting) Page 58 of 92 Phenothiozines are major tranquilizers • Major tranquilizers—big guns psych meds—are Antipsychotics • Analogy o Aminoglysoside are to Antibiotics what Phenothiazines are to Antipsychotics • Antipsychotics S/Es = “ABCDEFG” o Anticholinergic (dry mouth, urinary retention) o Blurred vision o Constipation o Drowsiness o EPS (tremors, Parkinson) o Foto sensitivity o aGranulocytosis (low WBC count, immunosuppressed) Teach patient how to recognize and report sore throat and symptoms of infection Question • What is the nursing action when someone presents with a S/E? o Educate Question • What is the nursing action when someone presents with a Toxic effect? o HOLD the drug ! Notify HCP Note • The #1 nursing diagnosis for “ABCDF” S/Es is to teach pt about SAFETY • The #1 nursing diagnosis for “G” S/Es is to teach pt to report signs of infections to HCP Decanoate or “Caprate” form of a medication • The long-acting form of a drug • Sometimes denoted with the letter “D” • IM form given for non-compliance • Often Court-ordered Tricyclic Antidepressants • Grandfathered into the NSSRI (Non-selective serotonin reuptake inhibitor) group • Mood elevators (Happy pills) • Elavil (elevates), Trofranil, Aventyl, Desyrel o Elevates the mood o Side effects of TCA are Anticholinergic (especially, dry mouth) Blurred Vision Constipation Drowsiness Euphoria (happy) • Must take meds for 2 to 4 weeks for beneficial effects • So, after the first week of antidepressant therapy, pt will complain the drug is not working Page 59 of 92 • Teach pt that the medication takes about 2 to 4 weeks to reach therapeutic effects Benzodiazepines Naming of antipsychotics • Anti-anxiety, minor tranquilizers • If you want to put someone asleep, give • Always have ZEP in the name him the ZZzzs • Remember ZZzzs for falling/going to • Zines for the Zany (major antipsychotics) sleep • Zeps for the minor antipsychotics • Many benzodiazepines end in “Pam” or o If you are old enough, you may “Lam” answer that question … What do you • Prototype: Valium, induction of find at a Zeppelin concert? anesthetic, muscle relaxant, alcohol Minors on tranquilizers • Can be used as o Seizures medications o Preop induction of anesthesia o Muscle relaxants o EtOH withdrawal medications o Ventilation—medication to relax and calm down pts on a ventilator • Benzos work quickly … But do not take them for more than 2 to 4 weeks Administer major and minor tranquilizers at the same time. Why? • The major antipsychotics take a long time to start working • The minor antipsychotics start working right away • Both are administered at the same time • Example: pt is usually put on Valium and Elavil at the same time o Valium is discontinued in 2 to 4 weeks once Elavil kicks in Note A similar example for giving major and minor tranquilizers together is the concurrent use of Heparin and Coumadin (warfarin) • Heparin works right away but a pt should not be on it for a long time • Coumadin takes a few days to start working but a pt can be on it for the rest of his life S/Es of Benzodiazepines are “ABCD” • Anticholinergic • Blurred Vision • Constipation • Drowsiness Monamine Oxidase (MAO) Inhibitors • Antidepressant • Depression is thought to be caused by norepinephrine, dopamine, and serotonin in brain • Name of MAOIs starts with • MARplan, NARdil, PARnate the beginnings—all rhyme • S/E of MAOIs o Anticholinergic Page 60 of 92 o Blurred Vision o Constipation o Drowsiness Teaching Points • Avoid tyramine-containing food … May cause Hypertensive Crisis • Food with tyramine o Fruits/Veggies—Avoid salad “BAR”: Bananas, Avocados (guacamole), Raisins (dried fruit) o Grains—Ok to have, except Yeast o Meats—No organs liver, kidney, tripe, heart, no preserved meats (smoked, dried, cured, pickled, hot dogs) o Dairy—No chees except for mozzarella, cottage cheese (no aged cheese) o No EtOH, elixirs, tinctures (iodine/betadine) caffeine, chocolate, licorice, soy sauce Lithium • Used for treating Bipolar disorder—it decreases the mania LI = BI • S/E: Very Unique—acts more like an electrolyte—think: Potassium/Lithium • The 3 Ps as S/Es o Peeing (Polyuria) o Pooping (diarrhea) o Paresthesia (earliest sign of electrolyte imbalance) The earliest sign of electrolyte imbalance is Paresthesias = Numbness and Tingling Toxic effects of lithium • Tremors • Metallic taste • Severe diarrhea Question What is the #1 nursing intervention in a pt on lithium presenting with peeing/pooping all the time? • #1 intervention o Give pt fluids • The above S/Sx are S/Es—expected • Monitor sodium • Low sodium makes lithium toxic • High makes lithium ineffective • Sodium needs to be normal Question What is the #1 nursing intervention in a pt on lithium presenting with metallic taste and severe diarrhea? • #1 intervention o Give pt fluids Page 61 of 92 • Notify the HCP—this is a toxic effect Prozac (fluoxetine) • SSRI, mood elevator • Side effects of Prozac are o Anticholinergic o Blurred Vision o Constipation o Drowsiness o Euphoria (happy) • Causes insomnia so give before noon. If bid, give at 6 a.m. and noon • When changing doses, watch for suicidal risk in adolescents o Must recently change the dose and be an adolescent of young adult HALDOL (haloperidol) • Tranquilizers (basically same as Thorazine) • S/E of Haldol o Anticholinergic (dry mouth, urinary retention) o Blurred vision o Constipation o Drowsiness o EPS (tremors, Parkinson) o Foto sensitivity o aGranulocytosis (low WBC count, immunosuppressed) Teach patient how to recognize and report sore throat and symptoms of infection • First generation antipsychotics • Pts may develop NMS (neuroleptic malignant syndrome) from overdose o Seen in elderly and young white schizophrenic pts o High fever over 105 o Their doses should be about ½ usual adult dose Question A pt is being treated with an antipsychotic medication. Pt becomes anxious and presents with tremors. What is the nurse intervention to differentiate NMS (neuroleptic malignant syndrome) from EPS (extrapyramidal syndrome)? • Measure the pts’ temperature o If temperature is WNL, this is EPS o If temperature is 102 and rising, call the emergency response team and notify HCP … NMS is lifethreatening • NMS presents with anxiety and tremors, and so does EPS Note: With Haltol, there are safety concerns related to the S/Es Clozaril (clozapine) • Atypical antipsychotic Page 62 of 92 • Advantage it does not have A-F side effects • Don’t confuse it with Klonopin/Clonazepam! • S/Es of clozapine o aGranulocytosis! It is worse than cancer drugs and can trash the pt’s bone marrow Note • Geodon (ziprasidone) has a black box warning • Prolong the QT interval, which can cause sudden cardiac arrest • Do not use in pts with cardiac condition Note: Second generation antipsychotics end in “Zapine” Question What is the #1 nursing intervention in a pt taking Clozaril (clozapine) • Monitor the WBC Zoloft (Sertraline) • Antidepressant • Can cause insomnia • Interact with the followings because they are not metabolized in the liver o St. John’s Wort and cause serotonin syndrome o Warfarin and cause bleeding • S/E of serotonin syndrome is “SAD Head” o Sweating o Apprehensive (impending sense of doom) o Dizzyness o Headache Note: The nurse should anticipate lowering the dose of sertraline (Zolof) of a pt on St. John’s Wort and Warfarin Page 63 of 92 Lecture 10 • Mark Klimek • 87:50 Maternity and Neonatology Determining the estimated date of delivery • Use the Naegele rule—take first day of last menstrual period (LMP), add 7 days and subtract 3 months from it o For instance, if the last menstrual period of a pt was between June 10 and 15 o The estimated date of delivery = March 17 Weight gained during pregnancy • 1st trimester (12 weeks) o 1 lb per month = Total of 3 lbs • 2nd and 3rd trimesters o Add 1 lb every week • The ideal weight gained during pregnancy o 28 lbs, plus or minus 3 o Between 25 to 31 lbs If weight gained during pregnancy is within • +/–1 to 2 lbs of the ideal weight for the gestational week … Pt is WNL If weight gained is within • +/–3 lbs … Assess her • +/–4 lbs or more… There is trouble o perform a BPP on the fetus Alternative method A quick and dirty way to come up with the ideal weight gained during pregnancy is to • Take the number of weeks gestation minus 9 Question A woman is in her 28th week gestation. She gained 22 lbs, what is your impression? • Using the long method o First trimester (12 weeks) … She gained 3 lbs o 28 weeks minus 12 weeks = 16 weeks o Therefore, she would add an extra 16 lbs on her weight o 3 + 16 = 19 lbs … She has 3 lbs extra than her ideal weight o Therefore, assess the pt • Alternatively, subtract 9 from the number of weeks gestation o 28 – 9 = 19 lbs Question A pregnant woman at 31 weeks gestation gained 15 lbs. what is your impression? • Using the short method, this pt ideal weight should be o 31 – 9 = 22 lbs o However, 22 – 15 = 7 lbs less than the ideal o Therefore, the nurse needs to assess the biophysical profile (BPP) on the fetus Page 64 of 92 Fundal Height • Fundal height cannot be palpated until week 12 o That when the fundus is midway between the umbilicus and the pubic symphysis • The fundus can be palpated at the umbilicus between 20 and 22 weeks What is the significance of being able to palpable fundal height? • The examiner should be able to determine in what trimester the pregnancy is o In case pt is unconscious, for instance o It has diagnostic significance as well … A much bigger than normal fundus may indicate molar pregnancy Positive Signs of Pregnancy The Boards test positive signs and everything else 1. Fetal skeleton on x-ray 2. Presence of fetus on ultrasound 3. Auscultation of fetal heart (Doppler) 4. Examiner palpates fetal movement (outline) • Not the mother but the examiner Ranges of Values In OB, there are 3 types of questions regarding range of values For instance, the fetal HR can be heard first between 8 to 12 weeks gestation Quickening (baby Qicks) may be first felt between 16 to 20 weeks gestation Therefore, if the question ask • When would you first? o Fetal Heart: 8 weeks o Quickening: 16 weeks o This is the earliest date • When would you most likely? o Fetal Heart: 10 weeks o Quickening: 18 weeks o This is the date midway in the range • When should you __________ by? o Fetal Heart: 12 weeks o Quickening: 20 weeks o This is the latest date Maybe Signs of Pregnancy 1. Positive urine/blood hCG tests • A positive pregnancy test may result from other conditions • For instance, cancer 2. Chadwick sign—cervical color change to cyanosis (Cs) • Bluish discoloration of the vulva, vagina and cervix Goodell sign—good and soft • Softening of the cervix Hegar sign—uterine softening Page 65 of 92 • Softening of lower uterine segment Chadwich ! Goodells ! Hegar • All 3 signs are in alphabetical order and • Move up from the vulva, vagina, cervix to the uterus Patient Teaching for Prenatal Visit During pregnancy, pt is advised to go for prenatal visits as follows • Once a Month until week 28 • Every other week between 28 and 36 • Once a week after week 36 until delivery or week 42, whichever comes first o At week 42, delivery can be induced or by C-section Question If a woman comes in for her 12th week prenatal checkup, when is her next prenatal visit? • Her next visit is at 16 weeks Lab Values Hemoglobin (Hb) level will fall during pregnancy • Normally Hb in female = 12 – 16 • A pregnant woman can tolerate lower levels of Hb • First Trimester: Hb can fall to 11 and be perfectly normal • Second Trimester: Hb can fall to 10.5 and be perfectly normal • Third Trimester: Hb can fall to 10 and be perfectly normal UWorld Hemoglobin (Hb) • 1st & 3rd trimester o 11 g/dL • 2nd trimester o 10.5 g/dL • If Hb <9, anemia evaluation Question How do you treat morning sickness? • Morning sickness is usually seen during the 1st trimester • Treatment: Dry carbohydrates—not before breakfast but—before pt gets out of bed Question How do you deal with urinary incontinence? • Urinary incontinence is seen in the 1st and 3rd trimesters • Pt needs to void every 2 hours from the day she gets pregnant until 6 weeks postpartum Question A pregnant pt complains of difficulty breathing. What should you advise her to do? • Difficulty breathing is a problem during the 2nd and 3rd trimesters Figure 7. • Advise pt to assume to tripod position Tripoding. o Tripod position is a physical stance often assumed by people experiencing respiratory distress o The pt will be leaning forward with hands on knees or the surface of a desk or table Page 66 of 92 Question A pregnant pt complains of back pain. What should you advise her to do? • Back Pain is seen during the 2nd and 3rd trimester • Advise pelvic tilt exercises to pt Labor and Birth What is the truest most valid sign that she is in labor? • The truest most valid sign of labor is the onset of regular/progressive contractions To Know • Dilation is opening cervix from 0 to 10 cm • Effacement is thinning of the cervix. It goes from thick to 100% efface (thin like paper) • Station is the relation between fetal presenting part and the mother’s ischial spines (know this)—the narrowest part of the pelvis o Positive numbers mean the baby has made it through this tight squeeze—good to go o Positive numbers = Positive news o If a baby stays at a –3, –2, –1, it can’t get through vaginally. It needs C-section for delivery • Engagement is station zero—this means the presenting part is at the ischial spines Page 67 of 92 Lie is relationship between the spine of the mother and spine of the baby • You want a vertical lie—compatible with vaginal birth o If the mother’s spine and the baby’s spine is parallel—we got a baby • If lie is perpendicular—tranverse lie = Trouble … C-section o If we got them perpendicular, we’ve got trouble—T Most common presentation is ROA or LOA—that’s the guess—don’t bother memorizing • ROA (right occiput anterior) • LOA (left occiput anterior) Note • Pick ROA before LOA Before giving digitalis, always take an apical HR Delivery of the Fetus and the Placenta (heart rate) • There are 4 stages of labor Stage 1 Onset of Labor—It has 3 phases • Latent—cervical dilation from 0 to 4 cm o Phase 1 o Contractions are 5 to 30 minutes apart, lasting 15 to 30 seconds o Mild intensity • Active—cervical dilation from 5 to 7 cm o Phase 2 o Contractions are 3 to 5 minutes apart, lasting 30 to 60 seconds o Moderate intensity • Transition—cervical dilation from 8 to 10 cm o Phase 3 o Contractions are 2 to 3 minutes apart, lasting 60 to 90 seconds o Strong intensity Question A pregnant woman comes in to L&D (labor and delivery). She is 5 cm dilated, with contraction 5 minutes apart, lasting 45 seconds. What phase of labor is the pt in? • The pt is in ACTIVE phase One good studying strategy to use for memorizing the 3 phases of Stage 1 labor is to know everything about the Active (or Phase 2) of Stage 1 • Once you know the upper and lower limit values, you can deduce the values of Phase 1 and Phase 3 o Phase 2 — Contractions: 3 to 5 minutes and last 30 to 60 seconds Stages and Phases of Labor • Stage 1—Onset of Labor ! Cervical Dilation and Effacement o Phase 1—Latent o Phase 2—Active o Phase 3—Transition • Stage 2—Delivery of Baby • Stage 3—Delivery of Placenta Page 68 of 92 • Stage 4—Recovery: 2 hours until bleeding stops HESI Questions What is purpose of uterine contraction in first stage? • Dilation and effacement of the cervix What is the purpose in 2nd stage? • Delivery of baby What is the purpose 3rd stage? • Delivery of placenta What is the purpose of 4th stage? • Stop bleeding When does postpartum technically begin? • 2 hours after delivery of placenta Pay attention to whether the question is asking about stages or phases • There are 4 stages • There are 3 phases, which are part of Stage 1 Questions What is the #1 priority of second phase? • Pain management What is the #1 priority of second stage? • Clearing baby’s airway Questions What is the #1 priority of third phase? • Checking cervical dilation, Helping pregnant mother with breathing and pain management What is the #1 priority of third stage? • Assess the placenta for smoothness and intactness, and for 3-vessel (not 2) umbilical cord present Stages and Phases of Labor • Stage 1—Onset of Labor o Phase 1—Latent … Dilation from 0 to 4 cm Contractions are 5 to 30 minutes apart, lasting 15 to 30 seconds Mild intensity o Phase 2—Active … dilation from 5 to 7 cm Contractions are 3 to 5 minutes apart, lasting 30 to 60 seconds Moderate intensity o Phase 3—Transition … dilation from 8 to 10 cm Contractions are 2 to 3 minutes apart, lasting 60 to 90 seconds Strong intensity • Stage 2—Delivery of Baby • Stage 3—Delivery of Placenta • Stage 4—Recovery: 2 hours until bleeding stops Page 69 of 92 Memorize for the following 3 quetions Uterine contraction should be no longer than 90 seconds and no closer than 2 minutes Questions What is a sign of uterine tetany? • No longer than 90 seconds and no closer than 2 minutes What parameters regarding uterine contraction would make you stop Pitocin? • No longer than 90 seconds and no closer than 2 minutes What is uterine hyperstimulation? • No longer than 90 seconds and no closer than 2 minutes Know that phrase • No longer than 90 seconds and no closer than 2 minutes Assessment of frequency of contraction • Frequency is from the beginning of one contraction and beginning of the next Assessment of duration of contraction • Duration of contraction is from the beginning to end of one contraction Intensity of labor • Assessment of intensity of labor is purely subjective • Teach her how to palpate with one hand over the fundus with the pads of the fingers Complications of labor • There are 18 complications • Know them all • But only 3 protocols—focus on the 3 protocols Painful Back pain—“OP” = Oh Pain. What do you do? • Position—Push • What position? o KNEE-CHEST position then o PUSH with fist into sacrum to use counter pressure Page 70 of 92 “OP” … Anything (right or left) occiput posterior Prolapsed Cord • Push head in off cord and position knee-chest or Trendelenburg • Prep for C-section • Think PUSH/POSTION o Push head off the cord of fetus and position mother to knee-chest Interventions for all other complications • Tetany • Maternal hypertension • Vena cava syndrome • Toxemia • Uterine rupture • All treated the same—with “LION” o Left side (place mother on the left side) o IV o Oxygen o Notify HCP • Stop Pitocin (pit) if it was running—the first thing to do Figure 8. Knee-chest position. Implement before “LION” • In an OB crisis, if pitocin is running, stop it first. Then, implement “LION” When to administer systemic pain medication • Do not administer a systemic pain medication to a woman in labor if the baby is likely to be born when the med is at its peak … For example Questions • You have a primagravida at 5-cm dilated who wants her IV push pain med. What is the nursing intervention? o Hold the pain medication o This is because the pt is primagravida and will deliver in about 15 to 30 minutes when the medication peaks • You have a multigravida at 8-cm wants her IM pain med. What is the nursing intervention? o Do not administer the pain medication Labor and Delivery (Continued onto next lecture) Page 71 of 92 Lecture 11 • Mark Klimek • 78:29 Labor and Delivery (Continued from previous lecture) Fetal Monitoring Patterns There are 7 fetal monitoring patterns to learn … The ones that start with the letter “L” are bad heart tracings. Use the mnemonic “LION” as the nursing intervention Normal fetal heart rate = 120 to 160 beats per minutes 1. Low Fetal HR (heart rate)—HR <110 • This is BAD • You do “LION” o Left side (place mother on the left side) o IV o Oxygen o Notify HCP • Stop Pitocin (pit) if it was running o Implement before “LION” 2. High Fetal HR—HR >160 • Document acceleration of fetal HR • Take the mother’s temp • Not a high priority … Baby is WNL Figure 9. Remember “VEAL CHOP” for the causes of 4 HR patterns. 3. Low Baseline Variability • This is BAD • Fetal HR stays the same—it doesn’t change • You do “LION” o Left side o IV o Oxygen o Notify HCP • Stop pit if it is running (first) 4. High Baseline Variability • Fetal heart rate is always changing—This is GOOD • Document finding Note In utero, low variability of V/S is a bad sign but highly variable V/S is a good sign Page 72 of 92 5. Early Deceleration • This is normal … No big deal • Document finding 6. Variable (VERY) Decelerations • This is very BAD • This indicates prolapsed cord • What is the nursing intervention? o PUSH and POSITION 7. Late Decelerations • This is BAD • You do “LION” o Left side o IV o Oxygen o Notify HCP • Stop pit if it is running Recap • Look at the first letter of a fetal heart rate tracing, it is a bad heart tracing if it starts with an “L” o Therefore, do “LION” which also starts with the letter “L” • Variable deceleration is very bad o PUSH and POSITION) • Ace of spades means that this answer works every time o Check the FHR Second stage of L&D (labor and delivery) • Delivery of the fetus … This is about order. 1. Deliver head … The mother needs to stop pushing 2. Suction the mouth then the nose … ABC order 3. Check for nuchal (around the neck) cord 4. Deliver the shoulders, next, the body 5. Make sure baby has ID band on before it leaves the delivery area Third stage of L&D • Delivery of the placenta • What do you check for with the delivery of the placenta? o Make sure the placenta is complete and intact o Check for 3-vessel cord—2 arteries and 1 vein, AVA Fourth Stage of L&D • Recovery • There are 4 things you do in the 4th stage, 4 times an hour (every 15 minutes) Page 73 of 92 1. Vital signs: Assessing for shock … Blood pressure goes down, HR goes up … Pt looks pale, cold, and clammy 2. Fundus: If it is boggy, massage it … If displaced, catheterize it 3. Check perineal pads … If there is excessive bleeding, the pad will saturate in 15 minutes or less 4. Roll pt over and check for bleeding underneath her Recap • 4 things to do every 15 minutes in the 4th stage of labor o V/S ! Fundus ! Peri pads ! Roll Post partum Assessment • Assess every 4 to 8 hours • Assess for “BUBBLE HEAD” • Make sure you focus on the 3 designated steps stated as important from BUBBLE HEAD “BUBBLE HEAD” stands for • Breasts • Uterine fundus should be firm … Important o Massage if fundus is boggy and midline o Catheterize pt if fundus is boggy and not midline Question What should the postpartum uterine tone, height, and location normally be? • The tone of the fundus should be firm, not boggy • The height of the fundus after delivery should be at the umbilicus (or navel) o Fundus involutes about 2 cm every day PP (postpartum) • The location of the uterus should be midline o If not midline, the bladder is distended • Bladder • Bowel • Lochia is vaginal drainage postpartum (Know the order) … Important o Rubra—red o Serosa (if your cheeks are rosy)—pink o Alba (albino)—white o Moderate amount: 4 to 6 inches on pad in an hour o Excessive: saturate a pad in 15 minutes • Episiotomy • Hemoglobin/hematocrit Page 74 of 92 Figure 10. Fundal height postpartum. • Extremities—Looking for thrombophlebitis … Important o What is the best way to determine if a pt has thrombophlebitis? The best way is to measure Bilateral calf circumference (Best answer) Homan sign is not the best answer • Affect—emotional • Discomforts Recap The 3 big things about postpartum on the exam are • Fundus • Lochia • Thrombophlebitis Variations in the newborn All of the following skin conditions are normal • Milia—White, pinhead-size, distended sebaceous glands on the nose, cheek, chin, and occasionally on the trunk. Usually disappear after a few week of bathing • Epstein pearls—Palatal cysts of the newborn, which are small white or yellow cystic vesicles • Mongolian spot—Bluish discoloration in the sacral region of newborn usually seen in African Americans … Carefully document its presence as such action may prevent child abuse charges against parents or caregiver • Erythema toxicum neoratorum—Described as flee-bitten lesion … pink rash with firm, yellow-white papules or pustule on the face, chest, abdomen, back and buttocks of some newborns. Usually appears 24 to 48 hours after birth and disappear in a few days • Hemangioma—An abnormal accumulation of blood vessels in the skin of the newborn. It is one of the most common birthmarks associated with childhood and affect 10% of all children Milia Epstein pearls Mongolian spot Erythema toxicum neonatorum Hemangioma Cephalohematoma vs. Caput succedaneum … Make sure you know these 2 • Cephalohematoma—A collection of blood between the periosteum of a skull bone and the bone itself o Occurs in one or both sides of the head o Occasionally forms over the occipital bone o Develops within the first 24 to 48 hours after birth Page 75 of 92 • Caput succedaneum—An edema of the scalp of the neonate during birth from mechanical trauma of the initial portion of scalp pushing through a narrowed cervix o The edema crosses the suture lines o May involve wide areas of the head or it may just be a size of a large egg o Caput Succedaneum (CS)—Crosses Suture line, and Caput Symmetrical Cephalohematoma Caput succedaneum Caput Succedaneum (CS)—Crosses Suture line, and Caput Symmetrical Hyperbilirubinemia in the Newborn • Physiologic jaundice is normal and appears after 24 hours after birth … Disappears in about one week • Pathologic jaundice is seen in the 1st 24 hours after birth Vernix caseosa Acrocyanosis Fatty, whitish secretion of the fetal sebaceous gland to protect the skin from amniotic fluid exposure Blue discoloration of the hands and feet in the newborns during the first few days after birth • Normal finding and not indicative of poor oxygenation, respiratory distress, or cold stress Nevi (Telangiectatic nevi) Nevi or telangiectatic nevi, a.k.a. “stork bites,” are pink and easily blanched skin lesion that appear on upper eyelid, nose, upper lip, lower occipital area, and nape of the neck • No clinical significance • Disappears by 2 years of age Page 76 of 92 Port wine stain Port-wine stain or nevus flammeus is seen at birth and is composed of a plexus of newly formed capillaries in the papillary layer of the corium • Commonly found on the face and neck • Red to purple, varies in size, shape and location • Does not blanch on pressure OB Medications—6 • Terbutaline (Brethine) • Mag sulfate • Pitocin • Methergine • Bexamethasone • Surfactant 1. Tocolytics (Stop contractions, stop labor) • Tocolytics are given to women in premature labor that must be stopped • Terbutaline (Brethine) o S/E: maternal tachycardia (don’t give with cardiac disease) • Mag sulfate o Treatment with Mag sulfate will induce hypermagnesemia, which will cause everything to go down o HR will go down, BP go down, Reflexes go down, RR go down, LOC go down Question So, what is the nursing intervention for hypermagnesemia due to mag sulfate treatment? • Monitor respiration o If RR <12, decrease dose of Mag sulfate • Assess for reflexes o Normal reflex is 2+ o If reflexes are 0 or 1+ … Decrease dose of mag sulfate o If reflexes are 3+ or 4+ … Increase dose of mag sulfate 2. Oxytocics (Stimulate and strengthen labor) • Pitocin (Oxytocin) o S/Es: Uterine hyperstimulation (defined as longer than 90 seconds, closer than 2 minutes) The nursing intervention is to lower the dose of pitocin in case of uterine hyperstimulation • Methergine o Causes HTN—if it contracts blood vessels it makes sense that this increases BP 3. Fetal/Neonatal Lung Meds • Betamethasone (steroid) o Given to mother IM Page 77 of 92 o Can repeat as long baby is in utero o S/E: increase glucose (steroid) • Surfactant (Survanta) o Given to baby via transtracheal route o Given After birth Medication Helps and Hints 1. What is Humalin 70/30? • Mix of insulin N and R … 70% = N … 30% = R o So, if 100 units of 70/30 is given to a pt … the pt gets 70 units of N and 30 units of R o Or, for 50 units—35 units of N and 15 units of R o To remember the bigger number, think of a fraction … The numerator N is on top; therefore, Insulin N is the bigger number Question Can you mix insulin in same syringe and how? • Yes, insulin can be mixed in the same syringe • How do you mix insulin? o (1) Pressurize vial and (2) Draw up insulin (1) To pressurize the vial … Inject air into N, the into R, Draw up R (2) To draw up insulin … Think of RN Needle for Insulin Injections • Know what needle to use for insulin injection? Figure 11. Pressurizing vials with air and drawing • Giving an IM injection up insulin. o Pick answer in which both answers have a “1” in them o “I” in IM looks like the “#1” o Use a 21-gauge, 1-inch long needle • Giving a SubQ injection o 5 looks like an “S” in “SubQ” o Pick the answer that has “5s” in it o Use a 25-gauge, 0.5 inch needle 2. Heparin • Given IV or SubQ • Works immediately • Cannot be given for more than 3 weeks (21 days) Page 78 of 92 After 21 days the body start making antibodies against heparin. Therefore, it is not given for more than 21 days o Except for Lovenox (enoxaparin) • Antidote: Protamine sulfate • Labs: PTT • Can be used during pregnancy— Class C medication 3. Coumadin • Given only PO • Takes few days to a week to work (likely 4 to 5 days) • Pts can be on Coumadin for their entire life • Antidote: Vitamin K • Labs: PT/INR • Can’t be used during pregnancy— Class X medication Note: The only antipsychotic that can be given to pregnant women is Haldol 4. Diuretics • K-wasting and K-sparing diuretics • Any diuretic ending in “X,” “Xes” out K o So, it wastes “K” like Lasix o PLUS Diuril • If it does not end in “X,” it is a sparer • Examples Brand Generic Aldactone Spinorolactone o Spinorolacone-Hydrochlorothiazide o Adactazide Amiloride-Hydrochlorothiazide o Modurectic o Lasix Furosemide o Bumex Bumetanide o Clotrix Clotrimazole o Esidrex Hydrochlorothiazide o Demadex Torsemide o Diuril Chlorothiazide 5. Baclofen and Cyclobenzaprine • 2 muscle relaxants to know for the NCLEX o Brand Generic o Lioresal Baclofen o Flexeril Cyclobenzaprine • The 2 things being tested on the board are o The 2 S/Es (1) Fatigue/Drowsiness Page 79 of 92 (2) Muscle weakness (paresis) o The 3 things to teach (1) Don’t drink (2) Don’t drive (3) Don’t operate heavy machinery Note: The following phrase help you remember baclofen as a muscle relaxant … “When you are on baclofen, you are on your back loafing” Pediatric Teaching Piaget’s Theory of Cognitive Development—4 Stages • There is some overlap with Piaget’s Theory of Cognitive Development and toy appropriateness based on age on page 50 • Make sure not to confused between the two 1. Sensorimotor—0 to 2 years • They only think about what they are sensing right now • You can teach only in the present (while you are doing it) o Think Present Tense o Just tell them o Children at this age don’t understand play o Tell them as it is happening Question A 19-month-old infant is about to have a lumbar puncture (LP) for csf analysis and culture. How would the nurse teach the child? • Tell the child how the LP is done while it is being done. • There is no such thing as preop teaching for this age group • Preop teaching are only for the parents—mom and dad—or guardian 2. Preoperational (Preschooler)—3 to 6 years • They are fantasy-oriented, imaginative, and illogical, there thinking obeys no rules • However, they understand the future and they understand the past Question A 3-year-old child is schedule for a lumbar puncture (LP) for csf analysis and culture. What is the nurse’s best action to teach the child about the procedure? Page 80 of 92 • Teach 2 hours before …, the morning of …, or the day of the procedure how it will be performed • They are in the “imaginative” stage … Don’t give them a whole lot of time to imagine the worst • Teach them what will be done … Future Tense • They can learn by playing 3. Concrete Operations—7 to 11 years • “7/11 Grocery Stores are surrounded by concrete”—no trees, no flowers • Children in this age group are rule-oriented o Live and Die by the Rules and Cannot Abstract o There is one way to do things … Everything else is wrong • Teach them a day or two ahead of time • Teach them what you’re going to do and how to do skills • Use age-appropriate reading and demonstration (skill) Question An 8-year-old child is schedule for a lumbar puncture (LP) for csf analysis and culture. What is the nurse’s best action to teach the child about the procedure? • Use age-appropriate demonstration 1 or 2 days before the procedure 4. Formal Operations—12 to 15 years • They can abstract and think Cause and Effect • As soon as children become twelve, teach them like an adult o This is now a regular Med-Surge question • When is the first age a child can manage his care? o 12 years old o Manage means making decisions which require the person to abstract Question Which of the following 4 children will be able to manage his own care? a. A 7-year-old with Cystic Fibrosis b. An 8-year-old with Diabetes Mellitus c. A 10-year-old with a scraped knee d. A 13-year-old with Chronic Renal Failure Answer: (d) • A 10-year-old with a scraped knee as one of the answer choices is a diversion to fool the exam taker. Answer to these questions is not about the severity of the condition but about the ageappropriateness to make decision o The 10-year-old will Wash, Dry, apply Neosporin and Bandaid the wound as thought … He will continue to do the same thing if the wound becomes is exudating pus and swollen the 4th day … A 12-year-old will likely stop and seek help • A 13-year-old with chronic renal failure will get help if they are thought to auscultate for a bruit over a shunt and heard nothing on day 3 o This is managing Page 81 of 92 o This means that knowing what you can do when you can, and seek help when you cannot Note: Manage = 13-year-lod … Skill = 8-year-old Seven Principles to Obey When Taking Psychiatric Tests 1. Make sure you know what phase of the nurse-patient relationship you are in 2. Don’t give/accept gifts in psych • If a schizophrenic pt gives you flowers, to you the HCP it may be flowers; to him, it may be a marriage proposal 3. Don’t give advice! • If the pt says, “What do you think I should do?” Reply by asking them the same question” “What do you think you should do?” • The pt won’t be able to blame you in the future even if things work in his favor • Avoid giving advise in psych 4. Never give guarantees • For instance, “If you cry, you will feel better.” • There are chances that crying may not help the pt 5. Immediacy • If you are between 2 answer choices and you don’t know which one to pick, pick the one that keep him talking • Don’t refer to someone 6. Concreteness • Psych pts take you literally. Therefore … • Never use slang • If a pt says “I feel rotten.” Don’t reply by saying, “You feel rotten?” • Don’t ever say to an upset pt to “Chill out!” • Don’t use figurative speech such as: “What goes around, comes around” 7. Empathy • Empathy is about the nurse accepting the patient’s feelings • Don’t ever pick an answer that says, “Don’t you worry …” … “You shouldn’t feel …” … “Anybody would feel …” … “I know how you feel …” … 4 steps to answering empathy questions • Empathy questions will always have a quote • Role play the feelings (Put yourself in their place) and say the words as you really meant them • Ask yourself if I said these words, how would I be feeling right now? • Choose the answer that reflects the pt’s feeling, and ignore what the pt said Page 82 of 92 Lecture 12 • Mark Klimek • 124:17 Prioritization, Delegation and Staff Management • • • • This is the most important lecture in the whole review There will be at least 15 questions on this section alone Most exam takers dead guess in the section Learn the material and do not guess Prioritization Prioritize—you are deciding which pt is sickest or healthiest… Make sure you know what you’re looking for Question For instance, if the question states that there was a disaster in town and you are making room for the wounded, who would you discharge? • In that case, would you be looking for the highest or lowest priority pt? • Answer: the lowest priority pt Question However, if the question states that you receive handoff end-of-shift reports on 4 pts. Which pt will you check first? • Answer: the highest priority pt Answers will usually have 4 parts • (1) Age, (2) Gender, (3) Dx, and (4) a modifying phrase • For example: A 10-year-old male with hypospadias is throwing up bile stained emesis o Age: 10-year-old o Gender: male o Diagnosis (Dx): hypospadias o Modifying phrase: throwing up bile stained emesis • 2 of which are irrelevant for answering the question o Age and gender are not important in prioritization • Age is important in pediatrics • Of all 4 parts, the modifying phrase is more important Remember The modifying phrase is always the most important Example Two pts: one has angina pectoris and the other myocardial infarction. Who has the higher Page 83 of 92 priority pt? • Answer: The MI pt • Go by the patient’s condition since there is no modifying phrase Example Now modifying phrases are added to each of the diagnosis, which pt becomes the higher priority? a. Pt with unstable BP and Angina b. Pt with stable vital sigh and MI • Answer: Pt with angina and unstable BP becomes the priority pt 4 rules for prioritization 1. Acute beats Chronic • Meaning that an Acutely ill pt has higher priority than Chronically ill pts • For instance, among the following pts, a pt with COPD, CHF, or appendicitis, which one has the highest priority? o Pt with appendicitis (acute condition). Both COPD and CHF are chronic conditions 2. Fresh Post-op (12 hours) beats medical or other surgical • For instance, among the following pts, a pt 2-hour postcholecystectomy, a pt with COPD, and a pt with acute appendicitis, which pt has the highest priority? o The 2-hour postcholecystectomy is the highest priority pt … (Fresh post-op, <12 hours) • Pt with “radical neck dissection” is added to the above scenario? o The 2-hour postcholecystectomy is the highest priority pt • Pt with “bilateral above the knee amputation” is added to the above scenario? o The 2-hour postcholecystectomy is the highest priority pt • Pt with “right frontal craniotomy” is added to the above scenario? o The 2-hour postcholecystectomy is the highest priority pt The point here is that surgery less than 12 hours takes precedence over medical and other surgical conditions 3. Unstable beats Stable • This means that an Unstable pt has a higher priority over Stable pts How to determine that a pt is stable or unstable? Word description that makes a pt stable • Stable • Chronic illness • Post-op greater than 12 hours • Local or regional anesthesia • Lab abnormalities in the A or B level o Creatinine, BUN, Hemoglobin 8 to 11, Bicarb, elevated Hematocrit, elevated BNP, elevated Na level, RBCs off Word description that makes a pt unstable • Unstable • Acute illness • Post-op less than 12 hours • General anesthesia in the first 12 hours • Lab abnormalities in the C or D level o INR in the 4s, K in the 6s, pH in 6s, CO2 in the 50s, low O2 sat, high WBC, low ANC, low CD4, low Platelets Page 84 of 92 Word description that makes a pt stable • Ready for discharge, To be discharged, Admitted longer than 24 hours • Unchanged assessment • Experiencing the typical expected S/Sx of the disease with which they were diagnosed Word description that makes a pt unstable • Newly diagnosed, Newly admitted, Not ready for discharge, Admitted less than 24 hours • Changing or changed assessment • Experiencing unexpected S/Sx Example Which of the following pt is the highest priority? a. A 16-year-old female with meningococcal meningitis who has had a temp of 103.8 ºF since she was admitted 3 days ago b. 67-year-old male with IBS (irritable bowel syndrome) who spiked a temp of 103.4 ºF this afternoon Answer: the 67-year-old pt has the highest priority • 16-year-old: Dx: meningococcal (acute)—high o Who has had (constant)—low o Temp of 103.8 (expected)—low o Admitted 3 days ago (>24 hours)—low • 67-year-old: Dx: Irritable bowel syndrome (chronic)—low o Temp spiked (changed)—high o This afternoon (acute)—high Four things that always make you unstable, even if they are expected • Hemorrhage—(but not bleeding) • High fevers over 105 ºF—can lead to seizure • Hypoglycemia—can lead to brain damage • Pulseless or Breathless o Example, V-fib or asystole o Exception: At the scene of an unwitnessed accident pulseless and breathless pts are low priority because they are likely dead. Therefore, low priority In a mass casualty incident, these 3 things result in a BLACK TAG 1. Pulseless 2. Breathless 3. Fixed and dilated pupils (even they are still breathing) • Therefore, “Tag them black and ship them last” 4. Tie Breaker Rule • If the above 3 rules result in a tie breaker, use the following as a guide Page 85 of 92 • The more vital the organ, the higher the priority • Use this rule with the organ of the modifying phrase and not the diagnosis 1. Brain 2. Lung 3. Heart 4. Liver 5. Kidney 6. Pancreas Example a. You have a 23-year-old male with CHF (chronic—low) with K (6.6—high), and no EKG changes (constant—low) • Organ: Heart (potassium) b. Chronic Renal failure (chronic low) with a creatinine of 24.7 (expected—low), and pink, frothy sputum (unexpected—high) • Organ: Lung (frothy) c. Acute Hepatitis (acute—high) with jaundice (expected—low), increased ammonia (expected—low) who you cannot arouse (unexpected—high) • Organ: Brain (He Wins!) Example Determine whether the following are stable or unstable • Angina pectoris—stable • Angina pectoris with crushing sternal pain—stable, (expected) • Angina pectoris not relieved by rest—not stable Delegation of Responsibility Do not delegate the following responsibilities to an LPN. An LPN is not allowed to assume the following responsibilities … The LPN 1. Cannot start an IV 2. Cannot hang or mix IV meds 3. Cannot push IV Push meds LPN can only maintain an IV and document the flow 4. Cannot administer blood or deal with Central lines … Including flush, change dressings 5. Cannot make the care plan … They can however implement the care plan 6. Cannot perform or develop teaching … They can reinforce teaching 7. Cannot take care of unstable pts 8. Cannot perform the “first” of anything … The first of anything is either making the care plan or assessment For instance, the LPN • Can perform tube feeding only after the nurse did the first tube feeding • Can change post-op dressing only after the nurse change the first dressing • Should they change the first post-op dressing the day of surgery? No • Can feed stroke pt only after the nurse did the first feeding • Can ambulate post-op pt only after the nurse had first done so Page 86 of 92 • Can take pt out of bed post-op only after the nurse had first done so • Can take a set of V/S post-op only after the nurse had first done so 9. Is not allowed to assess: admission, d/c, transfer, or first assessment after a change. Example • I think I heard new crackles on that guy in Room 52. Who should go assess this pt? ... The RN or the LPN? o The RN must assess the pt since this is a new onset or change of a symptoms Example • So who sould the RN check? And who should the LPN check? a. Angina with crushing substernal chest pain, 3 days ago, on nitro b. Subtotal thyroidectomy done 2 days ago and now states “why are they watching elephants?” o The RN should check the pt with subtotal thyroidectomy (onset of a new and worsening symptom, which may be thyroid storm) o The LPN should check pt with angina with crushing chest pain (expected) Do not delegate the following responsibilities to a UAP 1. Charting—UAP can chart what they did but they cannot chart about the pt. For example, • They can chart, “side rail is up, bed is lowered, etc.” • They cannot chart, “patient less anxious, tolerated ambulating well” 2. Medication administration—They cannot administer medications unless medication is • Topical medications, over the counter (OTC) medications, and barrier creams • Cannot give Nitroglycerin or Neosporin ointments because nitroglycerin and Neosporin are not OTC • Can they give hydrocortisone cream? No • Can they give A&D ointment? Yes 3. Assessments—Except vitals or Accu-Chek for diabetes 4. Treatments—Except for enemas The RN may delegate ADL (activity of daily living) tasks to a UAP … However, the UAP should never do any ADL task first What to and not to delegate to the family members and friends of pts • Never delegate to the family safety responsibilities. For example, if a family member or friend of pt tells the RN o “Would you leave the restraints on my dad off and I’ll call you before I leave?” The answer is: Do NOT delegate safety responsibility to family members or friends of pts o RN cannot delegate safety to a non-hospital caregiver unless the person is trained (seater) on how to do the tasks. The RN must document in the pt’s record what exactly was taught o Can the mother give insulin shot to her 3-year-old child? Yes, if you teach her and document teaching o What if a new mother asks the RN to “leave the railing of my baby’s crib down and I will put it back up after finish bathing my baby. You can go about what your business” The RN’s answer should be something similar to that. “Don’t worry about me leaving, I Page 87 of 92 will stay with you to make until you are done.” The point is to make sure the rail is put back up before you leave the room Staff Management How do you intervene with inappropriate behavior from staff? This is not prioritizing, this is not delegating … this is handling staff members who did stupid things There are always 4 answers 1. Tell Supervisor 2. Confront them and take over the task the staff is implementing immediately 3. Talk to them later 4. Ignore it Never ignore inappropriate behaviors … So, “ignore it” is the wrong answer • Use the incident as an opportunity to teach and change behavior Choosing among the remaining 3 options depends on the nature of the incident … Therefore, ask yourself one of the following? • Is the staff doing something Illegal? o If answer is YES … Then, Tell Supervisor • If what the staff is doing is not illegal? o Then ask yourself if anyone (patient, the co-worker, or other staff member) is in immediate of physical or psychological harm? o If answer is YES … Confront immediately and take over • If no one is in harm’s way, ask yourself if this behavior is simply inappropriate o If so, talk to that particular staff at a later time about the incident Examples 1. You suspect the RN is diverting narcotics. Tell Supervisor 2. The Aide is giving perineal care to pt, not wearing gloves? Confront and take over the task 3. The RN is going home with bulging pockets? Tell Supervisor 4. You notice surgeon contaminates her gloves? Confront 5. The RN always gives report, always says exasperation instead of exacerbation … Talk to them later If an illegal act can be harmful to the pt … first, takeover the task and then report the incident to supervisor Questions What if you find 2 pts involving in sexual intercourse? What is best thing to do? • Shut the door and give then privacy • As a staff, you do the same if you stumble upon a pt masturbating in his or her room Page 88 of 92 Organ Location If a question is asking you to identify a named organ on a picture on the screen, it is a simple point-and-click on the organ on the screen … To do so, move the mouse over the area and click • An “X” identifies the organ you want to select as your answer • As long as you are in the general vicinity, you will identify the organ, given you are correct Note • Not present on both pictures are the brain, lungs and kidneys • Questions regarding the brain will be more on identifying the lobes with relation to their functions Auscultation Over Heart Valves When answering questions to identify heart valves, you must click exactly over a narrow area as to mimic stethoscope placement. The areas auscultated for murmurs (or sounds) are remembered by “A PET M” • The Aortic valve is located in the 2nd intercostal space, right of the sternal border • The Pulmonic valve is located in the 2nd intercostal space, left of the sternal border • The Erb point is rarely asked on the exam o It is located in the 3rd intercostal space, left of the sternal border o Erb point is between the pulmonic and the tricuspid valve • The Tricuspid valve is located in the 4th intercostal space, left of the sternal border Page 89 of 92 • The Mitral valve is located in the 5th intercostal space at the midclavicular line o The apical pulse is in the same location as the mitral valve auscultation Palpating for Pulses Know where on the body these pulses are located • For instance, anticipate questions about identifying the popliteal pulse on a picture on the human body Guessing Strategies Everybody taking this exam will guess at some point. Instead of guessing blindly, here are some strategies that can help you answer questions correctly Use these approaches when all the answers do not make sense … 1. In psych nursing • Pick, “I will examine my feelings” o This is to prevent countertransference o Countertransference: A pt reminds a nurse of her dad, who she a bad relation with, so she interacts in a hostile manner with the pt • Or pick, “Establish a trust relationship” 2. Nutrition • When all else fails, go with “baked”—not fried—but “backed chicken” o If there is no chicken, pick fish—not shellfish (lobsters, crabs, or shrimp). Shellfish is high in cholesterol • Never pick casseroles for children—they won’t eat it o A casserole is any kind of stew or side dish that is cooked slowly in an oven • Don’t mix meds in kids food o Always ask pts for permission before you mix their food and medication together • For toddlers, pick “finger food” o Examples are: Hot dogs, tofu, French fries o Your answer should focus on what can they eat on the run • For preschoolers, “leave them alone” o One meal a day is ok Page 90 of 92 o Growth curve around preschool year plateaus … Toddlers growth curve goes up 3. Pharmacology • Memorize S/E • Don’t memorize dosage, route • If you know what a drug does but don’t know the S/E, how do you proceed? … Pick the “S/E in the same body system the drug is working” o For instance, if you have a GI drug, and drowsiness, tachycardia, and diarrhea are part of the answer choices. What S/E will you pick? Pick “diarrhea” o From the same above list … For cardiac drug, pick “tachycardia” o For CNS drug, pick “drowsiness” o If you have no idea what the drug is … and the drug is PO, pick a GI side-effect • Never tell a child a “medication is candy” o The child may give grandma’s valium to other children thinking the pill is candy 4. OB: check “fetal heart rate” 5. Med/Surge • What is the first thing to assess? “Check for LOC (level of consciousness)”—not airway o Think about a code or you find a pt on the floor … LOC is always checked first o “Sir, Sir, Sir! Are you ok? Can you hear me?” If there is no response, A-B-C is then done next • What is the first thing to do? “Establish an airway” 6. Pediatrics • For growth and development, you can always narrow down your answer to three rules, which goes along “giving the child more time” o Rule #1: When in doubt, “call it normal” … Example: Some six year olds can read. Some can and some can’t. Pick the answer that says, “Give the child more time” … There is no doubt that a 13-year-old who not potty-trained is normal o Rule #2: When in doubt, pick the “older age” in the 2 that it could be … In what age can the child walk? Both 12 months and 14 months are right … Pick 14 months. In that case, you give the child more time o Rule #3: When in doubt, pick the “easier task” … At 6 months, a baby can roll over or sit with support … Pick “roll over” as your answer because it is the easier task. • In growth and development, there are always two correct answers. The mantra is to give the child more time … Chant in your head: “NORMAL, OLDER, EASIER” 7. General guessing skills • “Rule out absolutes” … That is if you are guessing. However, it is commonly known to never push potassium • Avoid answer choices that say the same thing … Neither one is correct. For instance, the following 2 answer choices are the same. Answer choice #1: Increased bowel sounds … Answer choice #2: borborygmi. Pick a different one • If two answers are opposite, one is probably correct • Umbrella strategy … Find more than one correct answer? Find the global answer. Ex: Use safety and good body mechanics if possible 8. Prioritization of pt needs • Pt is need with the worst outcome has the highest priority—in other words, pick the Worst Consequences Game o For example: Which is highest priority for suicidal patient? (a) Don’t give tranquilizer. (b) Page 91 of 92 Don’t orient to unit? (c) Don’t put him on suicide precautions? And (d) Don’t introduce him to staff? To answer this question, ask yourself is: “What would happen if I did not implement the task?” Answers: (a) Agitated, (b) Lost, (c) DEAD, (d) Doesn’t know anyone. The worse case scenario is (c). The pt would be DEAD. Answer choice (c) is the answer. 9. When you’re stuck between two answers … Go back and read question. You probably missed something 10. The Sesame Street Rule • When nothing else works, look at all the answer choices to see which one looks different from the others o Looking at the picture below, one is not like the others … If that happens on the exam, the answer choice that looks different is likely the right answer o The wrong answers look the same 11. Don’t be tempted to answer based on ignorance rather than knowledge • If you don’t know drug, pull it out of the question and try to answer based on fundamental knowledge or common sense o For example: The Piggyback question about Amikacin … You don’t know the medication Amikacin, but you do know that piggybacks need a pump. Don’t analyze those first 10 questions on the NCLEX. USE COMMON SENSE 12. The are 3 expectations you are not allowed to have • Expectation #1: Remember—the test will not be what you expect o Don’t expect 75 (RN) or 85 (LPN) questions … Go to the exam center and expect 265 or 285 questions o Prepare yourself to go for the maximum o If you freak OUT when you get to 76 (RN) or 86 (LPN) and on, it might impact your performance on the exam … Negativity will kill you o This is a computer-adapted test—if you get to 200 you’re not failing … You’re still in the game! • Expectation #2: Don’t expect to know everything. It ain’t happening • Expectation #3: Don’t expect a perfect day o Perfect parking spot o Perfect Seat Partner o You stuck it out through nursing school this far … You have perseverance and strength of character o Get through one question at a time Page 92 of 92