I.
Acid-Base Balance:
A. If they give you ABG, convert it to words: metabolic/respiratory
acidosis/alkalosis
B. Ways to evaluate: look at the pH and the bicarb and then look at which direction
they are going (same direction or opposite direction)
C. Rules of the B’s: this is used to determine metabolic versus respiratory
1. If the ph and the Bicarb are Both in the same direction, it is metaBolic
2. If the ph and the Bicard are in opposite directions than we only have one
other option and that is respiratory
D. pH:
1. Normal value: 7.35-7.45
2. Acidosis: <7.35
3. Alkalosis: >7.45
E. Bicarbonate: normal value is 22-26
F. Principle: As the pH goes so goes my patient except for my potassium
1. Acidosis: when the pH goes down your body shuts down
a) Hyporeflexia: 0 and 1 DTR
b) Bradycardia
c) Lethargy
d) Bradypnea
e) Obtunded: one level past fatigue
f) Paralytic ileus
g) Coma
h) Respiratory arrest
2. Alkalosis: when the pH goes up everything in your body get hyper
excitable and irritable
a) Irritability
b) Hyperreflexia: 3 and 4 DTR
c) Tachypnea
d) Tachycardia
e) Borborygmi: increased bowel sounds
f) Seizure
G. MAC Kussmaul: only seen in one acid base imbalance and that is MAC
(Metabolic ACidosis)
H. Is it a LUNG scenario? If it is, it is a respiratory. Then ask is the patient over
ventilating or under ventilating?
1. Over ventilating: alkalosis
2. Under ventilating: acidosis
I. If it is not a lung scenario, then it has to be a metabolic cause.
II.
III.
J. If the patient has prolonged gastric vomiting or suctioning, pick metabolic
alkalosis.
1. This is because you are losing acid, if you lose acid you become basic
K. For everything else that is not LUNG, pick metabolic acidosis. Set this answer as
the default answer for any unknown diseases or conditions.
Ventilators:
A. High pressure alarm:
1. Triggered by increased resistance to air flow
2. Machine is having to push too hard to get airflow into the patient, there is
resistance
3. Causes: due to obstructions usually
a) Kinks in tubing (Solution: fix the tube)
b) Water is collecting in dependent loops of the tubing (Solution: fix
the tube or empty the water)
c) Mucus secretions are in the airway (Solution: first change position,
cough, deep breathing and suction as needed)
d) Patient is biting the tube
B. Low pressure alarm:
1. Triggered by a decreased resistance to air flow
2. Causes:
a) Main tube is disconnected (Solution: reconnect tubing)
b) Oxygen sensor is disconnected (Solution: reconnect the sensor to
the ventilator)
C. Respiratory alkalosis: the patient is being over ventilated, the ventilator setting are
too high
D. Respiratory acidosis: the patient is being under ventilated, the ventilator setting
are too low
Alcoholism and Substance/Physical Abuse:
A. Psychological problems associated with abuse:
1. Denial: this is present in every single type of abuse, this is because how
can you treat someone that denies they have a problem?
a) Definition of denial: refusal to accept the reality of a problem
b) How to treat denial: confrontation - point out the difference
between what they say and what they do
c) Confrontation vs. aggression: never attack the person, attack the
problem
d) You have 1 patient
2. Dependency/Codependency:
a) Dependendency:when the abuser gets the significant other to do
things for them or make decisions for them
(1) Example: abuser asks significant other to call boss to call
out sick for him
(2) Gain: abuser gets a responsibility free life
b) Codependency: when the significant other derives positive selfesteem when doing things for or making decisions for the abuser
(1) Example: significant other gains positive self-esteem from
doing tasks assigned
(2) Gain: positive self-esteem
c) Treatment: hard to treat cause they’re both gaining from it
(1) Set limits and enforce them: teach significant other to say
no and to keep doing it
d) You have 2 patients the dependent and codependent person
3. Manipulation:
a) Definition: when the abuser gets the significant other to do things
for him or her that are not in the best interest of the significant
other; the nature of the act is dangerous or harmful
b) Manipulation is like dependency because the abuser gets the
significant other to do things for them
c) The difference between manipulation and dependency is in the
nature of the act: if the action being requested is neutral then the
definition is dependency; whereas, if the action being requested is
inherently dangerous or harmful then it is manipulation.
d) Treatment:
(1) Set limits and enforce them
(2) Easier to treat than dependency/codependency because
nobody likes to be manipulated, and there is no positive
self-esteem issue going on
e) You have 1 patient
B. Alcoholism:
1. Wernicke’s and Korsakoff’s: typically separate but boards lump them
together because you will typically find them in the same patient;
Wernicke’s is a type of encephalopathy and Korsakoff’s is a type of
psychosis
a) Manifestations:
(1) Psychosis induced by vitamin B1 or thiamine deficiency,
where you go insane and become psychotic
(2) Amnesia with confabulation (memory loss with making up
stories, they make up stories because they forgot), they are
labeled as psychotic as opposed to normal people who fill
in fake details because the lie that they create is reality to
them, they truly believe that they are ronald reagan's
secretary
b) Characteristics:
(1) Preventable: they just need to take vitamin B1 (thiamine)
(2) Arrestable: can stop it from getting worse just have the
client take vitamin B1
(3) Irreversible (about 70% of the cases)
c) Treatment:
(1) When someone is talking crazy, we do not present reality,
we redirect them
2. Medications: Antabuse, Disulfiram
a) It is a form of aversion therapy
b) Onset and Duration: 2 weeks
(1) A patient stays at a rehab therapy to ensure they take it for
2 weeks
(2) After, they are let out into the community and if they drink
they will get deathly ill, works by making them want to
avoid that deathly ill feeling of after they drink
(3) If they want to drink without feeling deathly ill, they have
to wait 2 weeks after their last dose before it is safe to drink
again
c) Patient teaching:
(1) Avoid all forms of alcohol to avoid nausea, vomiting and
possibly death
(a) Examples: mouthwash, aftershave, perfumes and
colognes, insect repellants, any OTC that ends in
elixir (robitussin), alcohol based hand sanitizer, no
bake icings
3. Overdose and Withdrawal: only need to know the answer to 2 questions
a) Question #1: Is the drug an upper or a downer?
(1) Uppers: makes things go up
(a) Drugs:
(i) Caffeine
(ii) Cocaine
(iii)
PCP/LSD (psychedelics hallucinogens)
(iv) Methamphetamines
(v)
Adderall
(b) Manifestations:
(i) Euphoria
(ii) Tachycardia
(iii)
Restlessness
(iv) Irritability
(v)
Borborygmi
(vi) Diarrhea
(vii) Spastic
(viii)
Hyperreflexia (3 and 4)
(ix) Seizures
(2) Downers:
(a) Drugs: everything that isn’t an upper, just remember
the uppers and know every other drug is a downer
(i) Opioids
(ii) Benzos
(iii)
Ativan
(iv) Xanax
(v)
Valium
(vi) Alcohol
(b) Manifestations: opposite of the uppers
(i) Lethargy
(ii) Respiratory arrest
b) Question #2: Is the question talking about overdose or withdrawal?
(1) Overdose/Intoxication:
(a) Upper: everything is going to just keep going up
(b) Downer: everything is just going to keep going
down
(2) Withdrawal:
(a) Upper: if you don’t have enough upper everything
goes down
(b) Downer: if you don’t have enough downer
everything goes up
C. Drug addiction in the newborn:
1. Always assume intoxication not withdrawal at birth
2. After 24 hours, then the baby would be in withdrawal.
D. Alcohol Withdrawal Syndrome vs. Delirium Tremens: alcohol withdrawal
syndrome always precedes delirium tremens, however delirium tremens does not
always follow alcohol withdrawal syndrome
1. Alcohol Withdrawal:
a) Every alcoholic goes through alcohol withdrawal
b) Onset: 24 hours after the last drink
c) Not life threatening
d) Not a danger to self or others
e) Nursing care:
(1) Regular diet
(2) Semi private room anywhere on the unit
(3) Up ad lib
(4) No restraints
(5) Administered antihypertensive
(6) Administered tranquilizer
(7) Administered multivitamin (containing vitamin B1 to
prevent Wernicke’s and Korsakoff’s)
2. Delirium tremens:
a) Only a minority will get delirium tremens
b) Onset: 72 hours after the last drink
c) Life threatening
d) These patients are a danger to themself and others
e) Nursing care:
(1) NPO or clear liquids
(2) Private room near nurses station
(3) Restricted bed rest
(4) Must be restrained:
(a) Good:
(i) Two point locked leather restraints:
(a) One arm and one leg use opposite
sides and rotate the sides every 2
hours
(ii) Vest restraint
(b) No good:
(i) 2 point soft restraints
(5) Administered antihypertensive
(6) Administered tranquilizer
(7) Administered multivitamin (containing vitamin B1 to
prevent Wernicke’s and Korsakoff’s)
IV.
Drugs:
A. Aminoglycosides: very powerful class of antibiotics, when nothing else works
bring out the aminoglycosides
1. THINK THE FOLLOWING: “a mean old mycin”
a) Treat a mean old infection with the mean old micin
b) All aminoglycosides end in “-mycin” (but not all drugs that end in
“-mycin”)
2.
3.
4.
5.
6.
c) Examples of drugs that ARE NOT aminoglycosides: all these
drugs include “thro”, if it has “thro”, throw it off the list of
aminoglycosides
(1) Erythromycin
(2) Azithromycin
(3) Clarithromycin
Aminoglycosides are used to treat infections that are:
a) Serious
b) Life threatening
c) Resistant
d) Gram negative
e) Examples:
(1) Tuberculosis
(2) Septic shock
(3) Septic peritonitis
Toxic effects: when we think “-mycins” think mice then think mice “ears”
then think about how ears look like a kidney
a) Ototoxicity:
(1) Monitor for:
(a) Hearing (PRIORITY)
(b) Tinnitus (ringing in the ears)
(c) Vertigo/equilibrium
b) Nephrotoxicity:
(1) Monitor:
(a) Creatinine: this is the BEST indicator of kidney
function
(i) Order of best lab test:
(a) 24 hour creatinine is best indicator of
kidney function
(b) Serum creatinine is 2nd best
indicator of kidney function and
would beat everything else
c) Toxic to Cranial Nerve VIII (Vestibulocochlear)
Administered every 8 hours
Route of administration:
a) IM
b) IV
Do not give these drugs PO because they are not absorbed and produce not
effect, except for 2 cases:
a) Hepatic encephalopathy:
V.
(1) Goal of treatment: get rid of the build up of ammonia
(2) Purpose:
(a) oral “-mycins” will go through the gut and kill gram
negative bacteria
(b) Primary source of ammonia comes from E. coli in
the gut, these medications kills of the E.coli in the
gut and it doesn’t even touch the liver because it is
not absorbed
b) Preoperative bowel surgery:
(1) Goal: sterilize the bowel
c) Oral “-mycins” are known as the bowel sterilizers, any can be used
but the following are most commonly used:
(1) Neomycin
(2) Kanamycin
B. Calcium Channel Blockers: “calcium channel blockers are like valium for your
heart” makes it easy to remember what this drug does, valium calms people down,
this drug is gonna calm the heart down.
1. Calcium channel blockers are negative inotropic, negative chronotropic
and negative dromotropic: all its saying is that its like valium for the heart,
it’s calming down the heart
2. What do they treat:
a) A: Antihypertensive - it works by relaxes the heart and blood
vessels which causes the blood pressure to go down
b) AA: AntiAnginal - works by slowing the heart rate and decreasing
the oxygen demand from the heart
c) AAA: Anti Atrial Arrhythmia - everything that starts with atrial
and also supra ventricular because it's above the ventricle like SVT
3. Side effects: H&H
a) Headache: vasodilation in the brain and can cause migraine like
symptoms
b) Hypotension: relaxes heart and blood vessels
4. Names: anything ending in “-dipine” + 2 but think you’re “dipine” in the
calcium channel
a) Amlodipine
b) Nifedipine
c) Verapamil
d) Cardizem: can be given continuous IV drip
5. Before administering we need to: check the client’s blood pressure
a) Guideline for holding medication: systolic blood pressure: <100
Trough and Peak Drug Levels:
VI.
A. Trough levels: lowest serum level of the drug
B. Peak levels: highest serum level of the drug
C. “TAP” levels: when to draw the labs
a) Trough:
(1) Sublingual: 30 minutes before the next dose
(2) IV: 30 minutes before the next dose
(3) IM: 30 minutes before the next dose
(4) Subcutaneous: 30 minutes before the next dose
(5) PO: 30 minutes before the next dose
b) Administer
c) Peak:
(1) Sublingual: 5-10 minutes after the drug is dissolved
(2) IV: 15-30 minutes after the drug is finished
(3) IM: 30-60 minutes after the drug is administered
(4) Subcutaneous: refer to diabetes/insulin section
(5) PO: forget about it, too variable
Cardiac Arrhythmias:
A. Know the following by sight:
1. Normal sinus rhythm:
a) There is a p wave before every QRS
b) Every QRS is followed by a t wave
c) Notice that each peak of the p wave is equally distant from one
another
2. Ventricular fibrillation:
a) Chaotic squiggly line
b) There is no pattern
3. Ventricular tachycardia:
a) There is a pattern
4. Asystole
5. Atrial flutter
a) Whenever “saw tooth” formation is included pick atrial flutter
b) Think: Jaws movie, I saw the teeth and my heart did flutter
B. Whenever the question that includes “QRS” wave or complex then we can rule
out anything that does not include ventricular
C. Whenever the question includes “P” wave we can rule out anything that does not
include atrial
D. The word “chaotic” in a question is always the word used to describe fibrillation,
can be in relation to ventricular or atrial
E. The word “bizarre” used in a question is always the word used to describe
tachycardia, can be in relation to atrial or ventricular
VII.
F. If “periodic wide bizarre qrs” was included in a question, this would be premature
ventricular contraction (PVC)
1. More than 6 PVCs in a minute or more than 6 in a row, or if the PVC falls
on the T wave would be listed as a moderate priority
G. Lethal Arrhythmias: will kill you in 8 minutes or less
1. Asystole
a) No cardiac output
2. Ventricular fibrillation
a) No cardiac output
H. Potentially life threatening arrhythmias:
1. Ventricular tachycardia:
a) This rhythm produces cardiac output
I. Treatment:
1. PVC and Ventricular tachycardia: Lidocaine
2. Supraventricular (Atrial) arrhythmias:
a) A - adenocard/adenosine: push this in less than 8 seconds, super
fast IV push medication
b) B - beta blockers: “lol”
(1) They are negative chronotropic, dromotropic, inotropic
(2) They are like valium for the heart
(3) Treat: A, AA, AAA
(4) Side effects:
(a) Headache
(b) Hypotension
c) C - calcium channel blockers
(1) Better than beta blockers for people with asthma because
beta blockers can cause bronchoconstriction
d) D - digitalis (digoxin, lanoxin)
3. Ventricular fibrillation: for V-Fib we Defib
a) Treatment: defibrillation
4. Asystole: in the following
a) Epinephrine
b) Atropine
Chest Tubes:
A. Purpose: to reestablish negative pressure in the pleural space
1. Negative pressure in the pleural space is good
2. It makes things stick together
3. Negative pressure should be present in the pleural cavity which is found in
between the parietal pleura and the visceral pleura
B. When an injury occurs that punctures the pleural cavity, we lose the negative
pressure and it becomes positive pressure. The chest wall continues to move in
regular fashion trying to cause air exchange but with the loss of the negative
pressure the lungs do not stick to the chest wall therefore no air exchange occurs.
C. When a chest tube is inserted with suction, it provides the pleural cavity with
manual negative pressure until the patient is healed.
D. When you get a chest tube question: assess why the chest tube was placed
1. Pneumothorax: chest tube needs to remove air that created the pressure
change
2. Hemothorax: chest tube needs to remove blood that caused pressure
change
3. Pneumohemothorax: both blood and air
E. Location of the chest tubes:
1. Apical: a for a (apial for air)
a) Means that the tube is way up high
b) This is to remove air because air rises to the top
2. Basilar: b for b (basilar for blood)
a) Means that the tube is at the bottom of the lung
b) This is to remove blood because blood is subject to gravity
F. You must assume chest trauma and surgery is unilateral until stated otherwise,
NEVER assume bilateral
G. Trick question: no chest tubes are used for pneumonectomies
VIII.
H. Troubleshooting chest tubes:
1. If the chest tube device falls over:
a) Pick up and have the patient take a couple deep breaths everything
is okay
2. If the water seal breaks:
a) Clamp it
b) Cut the tube off from the broken device
c) submerge open tube under sterile water
d) Unclamp the tube
3. The chest tube gets pulled out:
a) First thing to do: cover the hole with a gloved hand
b) Best thing to do: cover it with a vaseline gauze
4. Bubbling chest tubes: ask yourself 2 questions
a) Where is it bubbling?
b) When is it bubbling?
c) Good times:
(1) Intermittent in the water seal chamber: document this
(2) Continuous in the suction control chamber
d) Bad times:
(1) Continuous in the water seal chamber: there is a leak in the
system
(a) Nursing care: find the leak and place tape over it to
reseal the system
(2) Intermittent in the suction control chamber: this means that
the suction is too low
(a) Nursing care: go to the wall and turn up the suction
until it bubbles continuously
I. A thoracentesis to a chest tube is a straight catheter to a foley catheter: think of a
thoracentesis as an in and out chest tube
1. Less risk of infection
J. Do not clamp a chest tube for longer than 15 seconds without a doctor's order
1. Use rubber tip clamps and double clamp: we want to use rubber tips so we
don’t puncture the tube
Congenital Heart Defects: every congenital heart defect is either TRouBLe or no
TRouBLe
A. TRouBLe: causes a lot of problems
1. All trouble congenital heart defects start with the letter T:
a) TAPV
b) Tetralogy of Fallot
c) Tricuspid Atresia
IX.
d) Transposition of the great vessels
2. All of these defects right to left shunting: think R before L
3. B stands for blue or cyanotic which we will see in the newborn
4. Implications: troubled lifestyle
a) Delayed growth
b) Need surgery
c) Parental grief and stress
d) Decreased life expectancy
B. No trouble: doesn’t cause any problems
C. All congenital heart defects, both trouble and no trouble, will have a murmur
D. All congenital heart defects, both trouble and no trouble, will have an
echocardiogram done
E. Know the 4 defects of Tetralogy of Fallot: VarieD PictureS Of A RancH
1. Ventricular Defect
2. Pulmonary Stenosis
3. Overriding Aorta
4. Right Hypertrophy
Infectious disease and transmission based precautions:
A. Standard (Universal):
B. Contact: for anything enteric, can be cause from intestine (fecal or oral)
1. Examples:
a) C. diff
b) Hep A
c) Cholera
d) Dientary
e) E. coli
f) Hep E
g) Staph
h) RSV: transmitted by droplet but kids get it from touching
everything
i) Herpes zoster (shingles)
2. Implementations:
a) Private room is preferred: say yes to private room
b) No mask, eye glasses or face shield
c) Gloves
d) Gown
e) Hand hygiene
f) Disposal supplies and dedicated equipment
C. Droplet: bugs
1. Examples:
X.
XI.
a) Meningitis
b) H. influenza: known to cause epiglottitis
2. Implementations:
a) Private room is preferred
b) Mask
c) Gloves
d) No gown
e) Hand hygiene
f) Patient must wear mask when they leave the room
g) No negative airflow
h) Disposable supplies and dedicated equipment
D. Airborne
1. Examples:
a) Measles
b) Mumps
c) Rubella
d) Tuberculosis
e) Varicella (chicken pox)
2. Implementations
a) Private room
b) Mask
c) Gloves
d) Gown is not necessary
e) Hand hygiene
f) Special filter mask only for TB
g) Patient needs to wear a mask if they leave the room
h) Disposable supplies and dedicated equipment
i) Need negative airflow
PPE Order:
A. Donning: reverse alphabetical for the G’s however mask goes second
1. Gown
2. Mask
3. Goggles
4. Gloves
B. Doofing: take it off in alphabetical order
1. Gloves
2. Goggles
3. Gown
4. Mask
Crutches, Canes and Walkers:
A. How to measure crutches:
1. Length of the crutch: 2-3 finger widths below the anterior axillary fold to a
point lateral to and slightly in front of the foot
a) Any instructions including axilla or landmarks on the foot it is
wrong and we should rule that answer from the question out
2. Measurement of the hand grip: when the handgrip is properly placed, the
angle of elbow flexion will be at a 30 degrees
B. How to walk with crutches: “even for even, odd for odd” - use the even numbered
gaits when the weakness is evenly distributed
1. 2-point: yove a crutch and the opposite foot at the same time
a) When is it used:
(1) Mild injury
(2) Bilateral weakness
2. 3-point: you move 2 crutches and the bad leg all at the same time
a) When is it used:
(1) Unilateral weakness
3. 4-point: you move everything separately, slow but effective
a) The cycle goes:
(1) Right crutch
(2) Left leg
(3) Left crutch
(4) Right leg
b) When is it used:
(1) Severe injury
(2) Bilateral weakness
4. Swing through:
a) When is it used:
(1) For non weight bearing
(2) Amputee
C. Up and down star with crutches: remember “Up with the Good, Down with the
Bad”
1. Going up stairs:
a) Good leg first
b) Then crutches follow with the bad leg
2. Down stairs:
a) Down with the crutches and the bad leg
b) Good leg follows
D. Walking with a cane:
1. Cane goes on the strong side
2. Cane moves with the weak leg
XII.
3. Helps provide a nice wide base when stepping with the weak leg
E. How to use a walker:
1. Pick up the walker
2. Set it down
3. Walk to it
4. If they must tie their belongings to the walker, have them tie it to the side
of the walker not tied to the front of the walker
5. No wheels or tennis balls on walkers
Delusions, Hallucinations and Illusions:
A. The very first thing you have to do for psych questions is ask myself “is my
patient psychotic or not psychotic (neurotic)?”
1. Neurotic or not psychotic person: they have insight and and is reality
based, yes they are emotionally ill however they know they have a
problem and they now how it is messing up they’re life
a) Treatment:
(1) Good therapeutic communication: we use this with every
type of patient because they’re not psychotic, just like we
would in med surg or OB
b) Symptoms: they DO NOT have delusions, hallucinations, illusions
2. Psychotic person: no insight and not reality, they think everybody else has
the problem and not them
a) Treatment: good therapeutic communication does not work with
these people
b) Symptoms:
(1) Delusions: a false, fixed idea or belief and there is no
sensory component, there is no feeling to it just a thought
(a) Paranoid delusion: a false, fixed belief that people
are out to harm you
(b) Grandiose: a false, fixed belief that you are superior
(c) Somatic: a false, fixed belief about your body parts
(i) Example: “i have worms inside my arm” or
a male states that he is pregnant
(2) Hallucinations: a false, fixed sensory experience (based on
hearing, taste, touch, sight and smell)
(a) Auditory: this is the most common
(i) hearing things
(ii) Most common auditory hallucination:
hearing voices telling you to hurt yourself
(b) Visual: this is the second most common
hallucination, this is seeing things that are not there
(c) Tactile: this is the third most common, this is
feeling things that are not there
(d) Gustatory: tasting things that are not there
(relatively rare)
(e) Olfactory: smelling things that are not there
(relatively rare)
(3) Illusions: a misinterpretation of reality, this is a sensory
experience
(a) There is a referent to reality: this is something that
is actually there but the person just misinterprets
(b) Example:
(i) Client states: “I hear demon voices, listen”
(ii) But in the background, nurses at the nurses
station are talking
(4) Loosening of association: your thoughts are all over the
map
(a) Flight of ideas: go from thought to thought to
thought
(i) Make coherent phrases however they are not
tightly connected
(ii) Each phrase by itself is coherent however
the phrase as a whole is not coherent
(b) Word salad: they cant even make a phrase that is
coherent, they just babble random words
(i) These people are sicker than those that have
flight of ideas because they make no sense
(c) Neologisms: making up imaginary words
(d) Narrowed self-concept: when a (typically)
functional psychotic refuses to leave their room or
change their clothes
(i) How they define them self is based on very
few things:
(a) Where they are
(b) What they are wearing
(ii) The reason they refuse to leave is because if
they leave the room or change their clothes
they will not know who they are, doing
either of those things terrifies them
(iii)
Do not make them leave the room or change
their clothes
State: “I see you are scared you do not have
to change your clothes or leave the room
until you feel comfortable”
(e) Ideas of reference: when the patient thinks that
everybody is talking about them
(i) Two people in the hallway talking, they
would think they are talking about them
c) If the answer to the first question is that they are psychotic:
(1) Next thing to ask yourself: “what is their problem?” or
“What type of psychosis are they experiencing?”
(a) Functional: they can still function in everyday life
(i) Schizo-schizo major manics [schizophrenic,
schizoaffective, major depression, bipolars
in their manic phases]
(ii) How to handle: they don’t have brain
damage, so they have the potential to learn
reality
(iii)
Nursing care:
(a) Teach reality:
(i) Acknowledge feeling
(ii) Present reality
(iii)
Set a limit
(iv) Enforce the limit not
punishing, the only proper
enforcement is ending the
conversation
(b) Dementia: actual damage or structural damage to
the brain causes the memory loss
(i) Examples:
(a) Alzhiemers
(b) Psychotic post stroke
(c) Organic brain syndromes
(d) Senile or dementia
(ii) How to handle: they do have brain damage
so they are unable to and do not have the
potential to learn reality
(iii)
Nursing care:
(a) Acknowledge feeling
(iv)
(b) Redirect them: Channel them from
something they cannot do to
something that they can do
(c) DO NOT present reality: presenting
reality occurs during psychosis
periods in which these clients are
unable to learn reality
(d) Reorient clients: tell them where
they are and what is going on, this
occurs during memory loss periods
(e) DO NOT set limits
(c) Delirium: this is a temporary sudden dramatic
secondary loss of reality, this is usually due to some
chemical imbalance in the body. (underlined
characteristics make it different from functional and
dementia)
(i) Who are these people: they would be people
that are crazy for the short term because of
something else causing them to be crazy
(a) Drug reaction: tagamet could do it,
people that are high on uppers or
withdrawing from downers
(b) Delirium tremens
(c) Meth or cocaine overdose
(d) Post operative psychosis
(e) ICU psychosis
(f) UTI in the elderly
(g) Thyroid storm
(h) Adrenal crisis
(i) “Roid rage” if it’s really wild
(ii) Treatment:it is only temporary as long as we
(a) Acknowledge their feelings
(b) Reassure them of 2 things:
(i) That is temporary
(ii) That we will keep them safe
(c) Remove the underlying cause
(d) Keep them safe
(e) DO NOT present reality: they will
not get it
XIII.
(f) DO NOT redirect them: they will not
get it
Diabetes Mellitus (DM): an error of glucose metabolism, you don't metabolise your
glucose well; this is a problem because glucose is our primary fuel source and without
metabolism of our primary fuel source cells will die
A. Type 1: insulin dependent, juvenile onset, ketosis prone
1. Treatment: if untreated they can DIE
a) D: diet (the least important)
b) I: insulin
c) E: exercise
B. Type 2: non-insulin dependent, non ketosis prone, adult onset
1. Treatment: if untreated they end DOA
a) D: diet (the most important)
b) O: oral hypoglycemic
c) A: activity
C. Symptoms:
1. Polyuria:increased urine
2. Polydipsia: increased thirst
3. Polyphagia: increased eating
D. Diet: when talking about diet, we’re mostly considering adn referring to type 2
diabetics
1. Calorie restriction
2. Need 6 small feedings a day
E. Insulin: acts to lower the blood glucose level
1. 4 types of insulin to know:
a) Regular (R): humulin R, novolin R
(1) Onset: 1 hour
(2) Peak: 2 hours
(3) Duration: 4 hours
(4) Characteristics:
(a) Clear
(b) Solution: can be used for IV drip insulin
(c) Short-Rapid acting insulin
b) NPH insulin
(1) Onset: 6 hour
(2) Peak: 8-10 hours
(3) Duration: 12 hours
(4) Characteristics:
(a) Cloudy
(b) Suspension: cannot be given IV
(c) Intermediate acting insulin
c) Humalog or Lispro insulin:
(1) Onset: 15 minutes
(2) Peak: 30 minutes
(3) Duration: 3 hours
(4) This drug is given WITH meals, not before the meals
d) Lantus or glargine: it is so slowly absorbed that it has no essential
peak, it has little to no risk of hypoglycemia, this is the only drug
that you can safely give at bedtime because they will not go
hypoglycemic in the middle of the night
(1) Duration: 12-24 hours
2. Check the expiration date on insulin vials
a) Expiration date listed from manufacturer is only good as long as its
sealed
b) After opened, expiration date is 30 days post opening the insulin
3. Refrigeration is optional in the hospital but we must teach the patients to
refrigerate their insulin at home
a) Unopened vials of insulin should be refrigerated
4. Exercise:
a) potentiates insulin
b) When a client exercises, think of it as another shot of insulin
c) More exercise requires less insulin
d) Less exercise requires more insulin
F. Sick days:
1. Glucose is going to go up in diabetics on sick days
2. Take insulin even though they are not eating
3. Take sips of water
4. Deal with 2 problems:
a) Hyperglycemia
b) Dehydration
5. Stay as active as possible
G. Complications of Diabetes:
1. Acute:
a) Hypoglycemia:
(1) Causes:
(a) Not enough food
(b) Too much insulin or medication: this is the primary
cause
(c) Too much exercise
(2) Danger: brain damage
(3) Signs and symptoms: Drunk + Shock
(a) Staggering gait
(b) Slurred speech
(c) Imparied judgement
(d) Delayed reactions
(e) Labile emotions
(f) Obnoxious
(g) Decreased social inhibition
(h) Low blood pressure
(i) Tachycardia
(j) Tachypnea
(k) Cool clammy and pale skin
(l) Mottled skin
(4) Treatment:
(a) Administer sugar or rapidly metabolised
carbohydrate:
(i) examples include juice, soda, candy, milk,
honey, icing, jam, jelly
(ii) Ideal include sugar and starch or protein:
juice and crackers
(iii)
Glucagon IM if unconscious
(iv) D10 or D50 IV
b) Diabetic Ketoacidosis (DKA): only a type 1 diabetic can get DKA
(1) Cause of hyperglycemia:
(a) Too much food
(b) Not enough medication
(c) Not enough exercise
(2) Cause of DKA:
(a) Acute viral upper respiratory infections within the
last 2 weeks
(3) Signs and symptoms: DKA
(a) Dehydration
(b) Ketones in the blood
(c) Kussmaul respirations
(d) K: they have a high potassium
(e) Acidotic
(f) Acetone breathe: fruity odor to the breath
(g) Anorexia due to nausea
(4) Treatment: focus is on dehydration and high sugar
(a) Rehydrate: 200 mL/hr
XIV.
XV.
XVI.
(i) Can add regular insulin
c) Hyperosmolar Hyperglycemic Nonketotic (HHNK) is the exact
same thing as dehydrated, replace HHNK with dehydration: for
signs, symptoms, treatment and nursing care look at it like
dehydration
2. Chronic: all issues are related to two problems - poor tissue perfusion or
peripheral neuropathy
a) Renal failure
b) Gangrene stasis ulcers
c) Impotence
d) Brain disease
H. Which lab test is the best determination of long term blood glucose control:
1. Hemoglobin A1C (HgbA1C)
2. Also called: glycosylated hemoglobin
3. Results that we want to see: <6%
4. Results that resemble out of control: >8%
Diabetes Insipidus:
A. polyuria and polydipsia leading to dehydration due to low antidiuretic hormone
(ADH)
B. Just the fluid part of DM no involvement of glucose
Syndrome of Inappropriate AntiDiuretic Hormone (SIADH): this is the opposite of
diabetes insipidus
A. Symptoms:
1. Oliguria
2. No thirsty
3. Insidious weight gain
4. Elevated urine specific gravity
Drug Toxicities:
A. Lithium: antimanic drug
1. Function: used for bipolar, to control the mania not depression
2. Therapeutic level: 0.6-1.2
3. Toxic level: greater than or equal to 2.0
B. Lanoxin/Digoxin/Digitalis:
1. Function: used for atrial fibrillation and heart failure
2. Therapeutic level: 1-2
3. Toxic level: greater than or equal to 2.0
C. Aminophylline:
1. Function: used as an airway antispasmodic, relieves airways spasms
2. Therapeutic level: 10-20
3. Toxic level: greater than or equal to 20
XVII.
D. Dilantin:
1. Function: it is used for controlling seizures
2. Therapeutic level: 10-20
3. Toxic level: greater than or equal to 20
E. Bilirubin: boards will only test the bilirubin level of newborns
1. Normal value for newborns: 1-10
2. Elevated level: 10-20
a) We don’t even get worried until their value is 10-20
3. Toxicity level: greater than or equal to 20
4. Vocabulary:
a) Kernicterus: when bilirubin crosses you blood brain barrier and it
is in your brain, cerebrospinal fluid and meninges
(1) This happens when bilirubin is around 20 and you can die
b) Apistatonis: a position the baby assumes when they have bilirubin
in the brain
(1) The baby will hyperextend due to the irritation, due to
babies extreme flexibility their heels could maybe touch
their ears
(2) “In what position do you place a child in this position?”
place them on their side
Dumping syndrome vs. Hiatal hernia: gastric emptying problems
A. Dumping syndrome: usually follow gastric surgery in which the gastric contents
dump too quickly into the duodenum
1. Gastric contents move in the right direction at the wrong rate
2. Speed issue
3. Manifestations: drunk, shock and acute abdominal distress
a) Staggering gait
b) Slurred speech
c) Delayed reaction time
d) Labile emotions
e) Hypotension
f) Tachycardia
g) Tachypnea
h) pale, cool and clammy skin
i) Guarding
j) Cramping
k) Borborygmi
l) Diarrhea
m) Bloating
n) Tenderness
XVIII.
4. Treatment: want the stomach to enter slower
a) Head of bed: have head of bed flat, eating on their side
b) Fluids: decrease fluids with meals, no fluid with meals
c) Carbohydrates: low carbohydrate based meals
B. Hiatal hernia: regurgitation of acid back into the esophagus because the upper part
of the stomach herniates upward through the diaphragm
1. Gastric contents move in the wrong direction at the correct rate
2. Direction issue
3. Manifestations: symptoms of GERD only if you eat and then lay down
a) Heartburn
b) Indigestion
4. Treatment: want the stomach to empty faster
a) Head of the bed: have it in high position, gravity makes it empty
faster
b) Fluids: encourage high fluid intake
c) Carbohydrates: encourage high carbohydrate meal
Electrolytes:
A. Memorize the following sentences:
1. Kalemias (K+) do the same as prefixes except for heart rate and urine
output
2. Calcemias (Ca+) do the opposite of the prefix
a) Hypocalcemia:
(1) Chvosteks: touch the cheek to elicit a spasm
(2) Trousseau: hand spasm when using a blood pressure cuff
3. Magnesemia’s do the opposite of the prefix
B. Sodium:
1. Hypernatremia: think dehydration
2. Hyponatremia: think fluid overload
C. Keynote signs of electrolytes imbalances:
1. The earliest sign of any electrolyte imbalance is:
a) Paresthesia: numbness and tingling
b) Circumoral paresthesia is a very early electrolyte imbalance and
boards loves to bring this up
2. Muscle weakness is another sign of every type of electrolyte imbalance:
a) Paresis: muscle weakness
D. Treatment:
1. Hypokalemia:
a) Never PUSH potassium IV
b) Not more than 40 of K per 1 L of NS
XIX.
2. Hyperkalemia: most dangerous electrolyte balance of them all can literally
stop your heart
a) The fastest way to lower potassium: administer IV D5W with
regular insulin
(1) Works fast and quick
(2) However, only a temporary solution and it only hides the
potassium
b) Kayexalate (sodium polystyrene sulfonate): enema or drinkable
solution
(1) Swaps sodium for potassium and they poop out potassium
(2) Permanent solution it gets rid of the potassium
(3) Takes a long time to have the effect, can take hours
Endocrine: we only need to know thyroid and adrenal
A. Thyroid: change this word to metabolism, because that is what the thyroid does
1. Hyperthyroidism (Grave’s disease): hyper metabolism
a) Signs and symptoms:
(1) Weight loss
(2) Skinny
(3) Tachycardia
(4) Elevated blood pressure
(5) Irritable
(6) Obnoxious
(7) Heat intolerance
(8) Cold tolerance
(9) Exophthalmos: bulging eyeballs
b) Treatment:
(1) Radioactive iodine:
(a) Patient should be by themself for 24 hours
(b) After they have to be really careful with their urine:
(i) Flush 3 times
(ii) If they spill urine outside of toilet bowl, call
hazmat team
(c) No family visitation for the first 24 hours
(2) PTU (propothyo uracil): used for hyperthyroidism
(a) Patient will be immunosuppressed, watch the WBC
count
(3) Surgical removal: thyroidectomy
(a) Total or Complete:
(i) Lifelong hormone replacement
(ii) At risk for hypocalcemia
(b) Subtotal or Partial:
(i) Do not need lifelong hormone replacement
(ii) Not much risk for hypocalcemia
(iii)
Risk for THYROID STORM
(thyrotoxicosis): classified as medical
emergency
(a) Self limiting condition
(b) Manifestations:
(i) Super high temperatures
>105F
(ii) Extremely high blood
pressure (stroke category)
(iii)
Severe tachycardia
(iv) Psychotic delirium
(c) Treatment:
(i) Get temperature down:
cooling blankets, ice packs,
cooled IV fluids
(ii) Get oxygen up: face mask
with 10L
(c) Post-operative risks:
(i) Priority for the first 12 hours is the same for
both surgeries:
(a) keeping the airway open
(b) Monitoring for hemorrhage
(ii) 12-48 hours post-op:
(a) Total:
(i) Tetany due to low calcium
(b) Sub-total:
(i) Thyroid storm
(iii)
Greater than 48 hours: never pick infection
in the first 72 hours on a question
(a) Infection
2. Hypothyroidism (Myxedema): low metabolism
a) Manifestations:
(1) Obese
(2) Flat
(3) Boring
(4) Dull
(5) Heat tolerance
(6) Cold intolerance
(7) Bradycardia
(8) Decreased blood pressure
(9) Decreased temperature
b) Treatment:
(1) Provide more thyroid hormone:
(a) Synthroid
(b) Levothyroxine
c) Caution:
(1) Do not sedate these people: can cause myxedemic coma
(2) Question the pre-op order of ambien which would not be
needed for them
(3) NEVER hold your thyroid pills before surgery
B. Adrenal Cortex: both disorders start with A or C
1. Addison’s disease: under secretion from the adrenal cortex, addisons you
just “add a -sone”
a) Signs and symptoms:
(1) Hyperpigmented: very tan
(2) Do not adapt to stress
(a) Stress response:
(i) Purpose:
(a) Raise the blood pressure to perfuse
the brain
(b) Raise the glucose available
(ii) Addison’s disease:
(a) Blood pressure goes down
(b) Glucose goes down
(c) Will send them directly into shock in
a very short amount of time
b) Treatment: administer steroids or glucocorticoids: end with “sone”
2. Cushing’s syndrome: over secretion from the adrenal cortex
a) Signs and symptoms: (also can be used as the side effects of
steroids or “-sone”)
(1) Moon face
(2) Hirsutism: excess hairiness on the body
(3) Gynecomastia: female type breasts on a man
(4) Central obesity: weight gain in the body with arms and legs
that are skinny
(5) Buffalo hump
(6) Atrophy of muscles
(7) Retaining sodium and water
(8) Losing potassium
(9) Striae: stretch marks on abdomen
(10)
Hyperglycemia: diabetics need to monitor more
frequently and administer more insulin
(11)
Bruises easily
(12)
Immunocompromised
(13)
Irritable
b) Treatment:
(1) Adrenalectomy: surgical removal
(a) Bilateral adrenalectomy:
(i) Risk: Addison's disease - this would cause
the patient to have to supplement and take
steroids which side effects are the signs and
symptoms of the original problem
XX.
Children’s Toys:
A. 3 things to consider:
1. Is it safe?
a) No small toys for children under 4 years of age: choking hazard
b) No metal (die-cast) toys if oxygen is in use
c) Beware of fomites: a non-living object that harbors
microorganisms
(1) Hard plastic toys can be disinfected
(2) Stuffed animals cannot be
2. Is it feasible?
3. Is it age appropriate?
a) Infancy: 0-6 months, sensorimotor based
(1) Musical mobile
(2) Something soft and large
b) 6-9 months: object permanence based
(1) Cover-uncover toy
(2) Something hard and large
(3) Worst toy: musical mobile
c) 9-12 months: working on vocalization
(1) Verbal toys:
(a) See and say
(b) Talking books
(2) Begin to do tasks with purpose:
(a) Build a 3 block tower
XXI.
d) Toddlers: 1-3 years old
(1) Push-pull toy: helps work on the gross motor skills
(2) Finger painting
(3) Parallel play: play alongside but not with
e) Pre-schoolers: fine motor skills
(1) Anything with finger dexterity
(2) Work on their balance
(3) Cooperative play: play with each other in groups
(4) Imaginary play: big on pretend play
f) School age child:
(1) Creative:
(a) blank paper and colored pencils
(b) legos
(2) Collective: always collecting something (baseball cards,
pokemon)
(3) Competitive: like to play games with winners and losers
g) Adolescents:
(1) peer group association: want to hang out with their friends
doing nothing but just hanging out
(2) 3 conditions to break up teenages hanging out in one
patients room:
(a) If anyone is less than 12 hours post-operative
(b) If anyone is immunosuppressed
(c) If anyone is contagious
Laminectomy: removal of the lamina (vertebral spinous processes), the posterior wings of
the spinal bones
A. Purpose: to relieve nerve root compression
B. Signs and symptoms of nerve compression:
1. Pain
2. Paresthesia: numbness and tingling
3. Paresis: muscle weakness
C. Most important thing to pay attention to in any neuro questions: Location
1. Cervical: neck
a) Function: assess during pre-op
(1) Innervates the diaphragm: breathing
(2) Mobility of arms and hands
2. Thoracic: upper back
a) Function: assess during the pre-op
(1) Cough mechanism: how well the patient coughs
(2) Bowels: elimination
D.
E.
F.
G.
3. Lumbar: lower back
a) Function: assess during the pre-op
(1) Innervates the bladder: when was the last time they voided
(2) Mobility of the legs
Post operative laminectomy:
1. Log rolling is the top answer for laminectomy and spinal surgery
2. Do not dangle these people, or sit on the edge of the bed
3. Do not sit for longer than 30 minutes
4. They may walk, stand, and lie down without restrictions
5. Complications:
a) Cervical:
(1) Pneumonia because they won’t breathe so well after
surgery
b) Thoracic:
(1) Pneumonia because of a bad cough reflex
(2) Ileus because of impaired bowel innervation
c) Lumbar:
(1) Urinary retention
(2) Weakness and impaired mobility of the legs
Chest tubes: not typical used in laminectomies
1. Exception: an anterior thoracic laminectomy will require a chest tube
Laminectomy with fusion: involves a bone graft from the iliac crest
1. Prevents grinding between vertebrae
2. Remove the disc
3. Fuse the iliac crest in between the vertebrae
4. Nursing considerations:
a) Hip:
(1) More painful
(2) More likely to hemorrhage
(3) Possibility of infection
b) Spine:
(1) More likely for rejection
(2) Possibility of infection
Discharge teaching:
1. Temporary restrictions:
a) Do not sit for longer than 30 minutes: 6 week restriction
b) Lie flat and log roll: 6 week restriction
c) No driving: 6 week restriction
d) Do not lift more than 5 lbs (gallon of milk): 6 week restriction
2. Permanent restrictions:
XXII.
a) Never allowed to lift objects by bending at the waist: lift with the
knees
b) Cervical laminectomies are not allowed to ever lift anything over
their head for the rest of their life
c) No off trail biking, jerky amusement park rides or horseback riding
Lab Values: have to know numerical value as well as the priority of out of range values
A. Priority Rating Key:
1. A: yes the value is abnormal, could mean presence of disease but in the
scheme of things, it is not really a big deal
2. B: the value is abnormal and there is a need to be concerned but there is
nothing that needs to be done, just closer observation
3. C: this is now considered high priority, must do something about this
4. D: this is the highest priority
B. Serum Creatinine:
1. The best indicator of kidney and renal function
2. Normal range: 0.6 - 1.2
3. Priority level A
C. INR:
1. Monitors coumadin or warfarin efficacy
2. Normal range: want it to be within the 2s and 3s
3. Priority level: anything in the 4 range is a priority level C
D. Potassium:
1. Good indicator that something is wrong, but of nothing specific
2. Normal value: 3.5 - 5.0
3. Priority level:
a) Low potassium is a level C
b) Potassium of 5.1 - 5.9 is a level C
c) Potassium of >6.0 is a level D
E. pH:
1. Normal value: 7.35 - 7.45
2. Priority level: a pH that is in the 6’s is a level D
F. BUN:
1. Has to do with waste products in the blood
2. Normal value: 10-20
3. Priority level: when elevated, no big deal (level A) just assess them for
dehydration
G. Hemoglobin (hgb):
1. Oxygen carrying component
2. Normal adult range: 12-18
3. Priority level:
H.
I.
J.
K.
L.
M.
N.
O.
a) 8-11 would be a level B, assess them for bleeding or malnutrition
b) <8 would be a level C,
Bicarbonate:
1. Normal level: 22-26
2. Abnormal bicarbonate is level A
Carbon Dioxide:
1. Normal range: 35-45
2. Priority level:
a) Elevated but in the 50’s is a level C
b) Elevated but in the 60’s is a level D
Hematocrit:
1. Normal range: 36-54
2. Priority level: elevated hematocrit is a level B, assess for dehydration
PaO2 (oxygen from ABG):
1. Normal range: 80 - 100
2. Priority level:
a) Low but still in the 70’s is a level C
b) Low and now in the 60’s is a level D
Oxygen saturation:
1. Normal value: 95-100
2. Priority level: anything less than 93 is a level C
3. Falsely elevated their oxygen saturation (thinking the patients better than
they actually are):
a) Patient is anemic
b) Any procedure that included dye
BNP:
1. Best indicator of congestive heart failure
2. Normal range: should be <100
3. Priority level: elevated BNP is a level B
Sodium:
1. Normal: 135 - 145
2. Priority level:
a) Elevated sodium is a level B and assess for dehydration
b) If the question states that there is a change in LOC and an
abnormal sodium level it is a higher priority due to a safety issue
WBC:
1. Total WBC:
a) Normal range: 5,000 - 11,000
b) Priority level:
(1) Low level is a level C and place on neutropenic precautions
XXIII.
XXIV.
2. ANC:
a) Normal range: must be > 500
b) Priority level: low level is a level C and place on neutropenic
precautions
3. CD4 count:
a) Normal range: must be >200
b) Priority level: low level is a level C and place on neutropenic
precautions
P. Platelet:
1. Normal range: 150,000 - 400,000
2. Priority level:
a) < 90,000 is a level C for bleeding precautions
b) <40,000 is a level D for bleeding precautions
Q. RBC:
1. Normal range: 4 - 6 million
2. Priority level: abnormal RBC is a level B
R. Memorize the 5 values that are level D:
1. pH in the 6’s
2. Potassium in the 6’s
3. PaCO2 in the 60’s
4. PaO2 in the 60’s
5. Platelet <40,000
S. Memorize the values that are level C:
1.
Order of taking action on a high priority lab value:
A. Hold: whether it be hold the medication or stop the infusion
B. Assess: assess the patient, focused assessment on the area that the lab value is
pointing out
C. Prepare: prepare the antidote if there is one
D. Call: physician, RT or surgeon or whomever
Psychotropic Drugs: all psych drugs cause low blood pressure and weight changes
A. Phenothiazines (first generation antipsychotics, typical antipsychotics): old class
of drug
1. All end in “-zine”
2. Actions: do not cure psych diseases just reduce the symptoms
a) In large doses they are antipsychotics
b) In small doses they are antiemetics
c) Considered major tranquilizers: aminoglycosides are to antibiotics
like phenothiazines are to tranquilizers
3. Side effects: ABCDEFG
a) Anticholinergic: primarily dry mouth
b) Blurred vision
c) Constipation
d) Drowsiness
e) EPS: extrapyramidal syndrome (looks like parkinsons)
f) f(ph)otosensitivity
g) aGranulocytosis: low WBC count (immunosuppressed)
4. Nursing care: safety issues and patient is at a large risk for injury
5. Nursing actions:
a) Patient experiences a side effect: inform the patient, call the doctor
and still give the drug
b) Patient experiences a toxic effect: hold the drug and call the doctor
immediately
B. Tricyclic Antidepressants:
1. Tofranil, Avantil, Desaril and Elavil
2. Action: they are mood elevators used to treat depression
3. Side effects: ABCDE
a) Anticholinergic: primarily dry mouth
b) Blurred vision
c) Constipation
d) Drowsiness
e) Euphoria
4. Must take them for 2-4 weeks before they have a therapeutic effect
C. Benzodiazepines:
1. Action: anti-anxiety medication
a) Considered to be a minor tranquilizer
b) Muscle relaxant
c) Can be used for pre-op to decrease anxiety and anesthesia
d) Used for alcohol withdrawal
e) Help people who are fighting the ventilator
f) Good for seizures
2. All drugs of this class include “zep”
3. Work quickly but must not take them for more than 2-4 weeks because
they can become dependent
4. Side effects: ABCD
a) Anticholinergic: primarily dry mouth
b) Blurred vision
c) Constipation
d) Drowsiness
5. Nursing diagnosis: safety risk due to tranquilizer
D. Monoamine Oxidase Inhibitors (MAOI):
1. Action:
2. The beginnings of the names all rhyme: mar, nar, par
a) Marplan
b) Nardil
c) Parnate
3. Side effects:
a) Anticholinergic: primarily dry mouth
b) Blurred vision
c) Constipation
d) Drowsiness
4. Patient teaching:
a) Prevent severe acute hypertensive crisis: the patient must avoid
ALL foods containing tyramine
(1) Know what foods include tyramine:
(a) Banana
(b) Avocado
(c) Raisins: any dried fruit
(d) No organ meats
(e) No preserved meats: smoked, dried, pickled
(i) Hot dog
(ii) Salami
(iii)
Pepperoni
(f) No cheeses except cottage and mozzarella
(g) Yogurt
(h) Alcohol
(i) Chocolate
b) Do not take OTC medications
E. Lithium:
1. Action: used for bipolar disorder because it depresses mania
2. Does not influence neurotransmitters it just stabilized the cell membrane
3. Side effects: PPP
a) Peeing
b) Pooping
c) Paresthesia: because we are purposely causing an increase in
lithium (electrolyte)
4. Toxic effects:
a) Coarse tremors
b) Metallic taste
c) Severe diarrhea
5. Nursing intervention:
a) Ensure the patient is getting a lot of fluids
b) Monitor sodium values to monitor for dehydration
c) If the patient is sweating a lot, give the patient gatorade and not
just regular water because they need electrolytes: you need sodium
for lithium to have an effect
6. Lithium is closely linked to sodium:
a) Low sodium: makes lithium more toxic
b) High sodium: makes lithium ineffective
F. Prozac:
1. Action: selective serotonin reuptake inhibitor, increases the patient's mood
2. Side effects: ABCDE
a) Anticholinergic: primarily dry mouth
b) Blurred vision
c) Constipation
d) Drowsiness
e) Euphoria
3. Can cause insomnia, give this medication before noon: DO NOT give at
bedtime
4. When changing the dose of this medication for adolescents and young
adults watch the patient for increased suicidal ideation
G. Haldol (First generation antipsychotic or typical antipsychotic):
1. Action:
2. Has a long acting IM form
3. Only antipsychotic that can be given to pregnant women
4. Side effects: ABCDEFG
a) Anticholinergic: primarily dry mouth
b) Blurred vision
c) Constipation
d) Drowsiness
e) EPS
f) Photosensitivity
g) agranulocytosis
5. Neuromalignant syndrome (NMS):
a) elderly patients and young white schizophrenics
b) May be developed from an overdose of haldol
c) Potentially fatal hyperpyrexia:
(1) Temperatures above 105: ranging from 106-108
(2) Anxiety
(3) Tremors
H.
I.
J.
K.
d) Difference between NMS vs EPS: take a temperature, call if it is
above 102
(1) NMS:
(a) Toxic effect
(b) Medical emergency
(c) Dangerous high fever
(2) EPS:
(a) Side effect
(b) Can be expected
6. There are safety concerns related to side effects
Clozapine or Clozaril: prototype of the second generation or atypical
antipsychotic
1. Action: used to treat severe schizophrenia
2. Meant to replace haldol and the “-zines”
3. Does not have the side effects: ABCDEF, very minor of those if any
4. Side effects:
a) Agranulocytosis: will absolutely trash you bone marrow and will
be severely immunocompromised
2nd generation antipsychotics:
1. Drugs typically end in “-zapine”
2. Still a tranquilizer
Geodon: has a black box warning and can cause a prolonged QT interval and can
cause sudden cardiac arrest
1. Should not be sued in patients with heart problems
Zoloft or Sertraline:
1. Action: increases mood
2. Causes insomnia but can give it at bedtime
3. This drug is notorious for interfering with the pathway in the liver that
breaks down drugs
a) Increases toxicities of other drugs
b) Drug interactions:
(1) St. John’s Wort: if taken together it can cause serotonin
syndrome (potentially life threatening)
(a) Symptoms: remember SAD Head
(i) Sweating
(ii) Apprehension: an impending sense of doom
(iii)
Dizziness
(iv) Headache
(2) Warfarin or coumadin: when taken together the patient will
bleed out, they really have to decrease the coumadin
XXV.
Pregnancy:
A. Calculate a due date:
1. Take the first day of the last menstrual period
2. Add 7 days
3. Subtract 3 months
B. Weight gain: total gain is 28 pounds + or - 3 pounds
1. Ideal weight gain = gestation week # subtract 9
2. First trimester:
a) Gain 1 pound each month
b) 3 months = 3 pound gain
3. Second trimester:
a) Gain 1 pound per week
4. Key of priority:
a) Within 1-2 pounds is okay
b) 3 pounds off calls to assess her
c) 4 pounds off something is wrong
C. Fundus: top part of the uterus
1. Not palpable until week 12 (end of first trimester)
2. The fundus is at the belly button at 20-22 weeks of gestation (end of 2nd
trimester)
3. The boards uses this to evaluate our knowledge of assessing what
trimester the woman is in
D. Priority of patient depending on trimester:
1. First trimester: mom
2. Second trimester: mom
3. Third trimester: newborn
E. Signs of pregnancy:
1. Positive:
a) Fetal skeleton on X-ray
b) Fetal presence on ultrasound
c) Auscultation of fetal heart rate (happens between 8-12 weeks)
d) When the examiner palpates fetal movement
2. Maybe’s:
a) Urine and blood tests: may have hormone imbalances that provide
positive result but not newborn
b) Chadwicks: cervical color change to cyanosis (happens first)
c) Goodell’s: cervical softening (happens second)
d) Hegar’s: uterine softening (happens third)
F. Patient teaching of pregnancy:
1. Pattern of office visits:
XXVI.
a) Once a month until week 28
b) Once every 2 weeks from week 28-36
c) Once a week from week 36 until delivery or week 42
2. Teach the patient that their hemoglobin will fall: normal Hgb is 12-16
a) First trimester: may fall to 11 but it is not low
b) Second trimester: may drop to 10.5 but it is not low
c) Third trimester: may drop to 10 but it is not low
3. Discomforts of pregnancy:
a) First trimester:
(1) Nausea: treat with dry carbohydrates before you get out of
bed
(2) Urinary incontinence: treat with voiding every 2 hours
b) Second trimester:
(1) Difficulty breathing: treat with teaching the patient tripod
positioning (feet flat, hands on the table or on the knees
leaning forward)
(2) Back pain: treat with pelvic tilt exercises
c) Third trimester:
(1) Urinary incontinence: treat with voiding every 2 hours
(2) Difficulty breathing: treat with teaching the patient tripod
positioning (feet flat, hands on the table or on the knees
leaning forward)
(3) Back pain: treat with pelvic tilt exercises
Labor and Birth:
A. Valid sign a woman is in labor: onset of regular progressive contractions
B. Terms:
1. Dilation: the opening of the cervix, goes from 0-10 cm
2. Effacement: thinning of the cervix, it goes from thick to 100%
3. Station: the relationship between the fetal presenting part to the mom’s
ischial spine (the most narrow part of the birth canal)
a) Negative station: the presenting part is above the ischial spine
b) Positive station: the presenting part is below the ischial spine
4. Engagement: station 0, the presenting part is right at
5. Lie: relationship between the spine of the mother and the spine of the baby
a) Vertical lie: good and allows vaginal birth
b) Transverse lie: trouble
6. Presentation: the part of the baby that enters the birth canal first
a) Most common: is ROA or LOA pick these when they come up on
questions, pick R before L
C. 4 stages of Labor and Delivery:
1. Labor:
a) Phases of Labor: have to know these
(1) Latent
(a) Dilate from 0-4 cm
(b) Contractions:
(i) Frequency: every 5-30 min
(ii) Length: 15- 30 seconds
(iii)
Intensity: mild
(2) Active:
(a) Dilate from 5-7 cm
(b) Contractions:
(i) Frequency: every 3-5 min
(ii) Length: 30-60 seconds
(iii)
Intensity: moderate
(3) Transition:
(a) Dilate from 8-10
(b) Contractions:
(i) Frequency: every 2-3 min
(ii) Length: 60-90 seconds
(iii)
Intensity: strong
b) Note**: contractions cannot be longer than 90 seconds or more
frequent than every 2 minutes
c) Patient teaching:
(1) How to time contraction frequency: the beginning of one
contraction until the beginning of the next
(2) How to time contraction length: the beginning of one
contraction until the end of the same contraction
(3) Intensity is the strength of contraction: purely subjective
(4) How to palpate contraction: use only one hand, place hand
over the fundus with the pads of the fingers (finger tips)
d) Purpose of uterine contractions during this stage: dilation and
effacement
2. Delivery of the baby
a) Purpose of uterine contractions during this stage: push out the baby
b) First you deliver the head
c) Suction the mouth and then the nose, it goes alphabetical
d) Check for a nuchal cord (around the neck)
e) Deliver the shoulders and the body
f) The baby must have an ID band on before it leaves the delivery
area
3. Delivery of the placenta
a) Purpose of uterine contractions during this stage: push out the
placenta
b) Ensure that the whole placenta has been delivered
c) Check for a 3 vessel cord: think AVA
(1) 2 arteries
(2) 1 vein
4. Recovery: this stage lasts for 2 hours after delivery of the placenta
a) Purpose of uterine contractions during this stage: stop bleeding
b) So postpartum begins 2 hours after the delivery of the placenta:
right after the recovery
c) 4 things you do, 4 times per hour in the 4th stage: every 15 minutes
(1) Vital signs: assessing for signs and symptoms of shock
(a) Pressures go down
(b) Rates go up
(c) Pale, cold and clammy
(2) Check the fundus:
(a) Boggy: massage it
(b) Displaced: catheterize the patient
(3) Check the perineal pads: look to see how much the patient
is bleeding
(a) It is troublesome when she 100% saturates 1 pad
every 1hour
(4) Roll the patient over: check the underneath of her to see if
blood has missed the pad and is excessively bleeding
D. Complications of Labor:
1. Painful back labor: occurs when the newborn is presenting either LOP or
ROP, low priority
a) Treatment:
(1) Position: get on hands and knees (knee chest position, like
downward dog), helps relieve pressure off the spine
(2) Push: push in to the sacrum
2. Prolapsed Cord: when the cord is the presenting part, the baby can kill
itself, high priority
a) Treatment:
(1) Push: push the baby's head off the cord into the uterus
(2) Position: place the mother in knee chest position
3. Interventions for all other complications:
a) Treatment: LION
(1) Turn them on their Left side
XXVII.
(2) Increase IV
(3) Oxygenate them
(4) Notify physician
4. In an OB crisis if pitocin is running, stop the pitocin: this becomes priority
before LION if it is running
E. Pain medication for labor: do not administer a pain medication to a woman in
labor if the baby is likely to be born when the medication peaks
Fetal Monitoring Patterns:
A. Low fetal heart: <110 bpm
1. This is bad
2. Nursing actions: LION
a) Turn them on their Left side
b) Increase IV
c) Oxygenate them
d) Notify physician
e) And if pitocin was running stop the pitocin
B. High fetal heart rate: >160 bpm
1. This is no big deal, this is okay
2. Nursing actions:
a) Document it
b) Take mom’s temperature
C. Low baseline variability:
1. This is bad
2. When the fetal heart rate stays the same and does not change
3. Nursing actions: LION
a) Turn them on their Left side
b) Increase IV
c) Oxygenate them
d) Notify physician
e) And if pitocin was running stop the pitocin
D. High baseline variability:
1. This is good
2. This means that the baby’s heart rate is always changing
3. Nursing actions:
a) Document this
E. Late decelerations:
1. This is bad
2. When the heart rate slows down near the end or after a contraction, this is
caused by placental insufficiency
3. Nursing actions:LION
XXVIII.
XXIX.
a) Turn them on their Left side
b) Increase IV
c) Oxygenate them
d) Notify physician
F. Early decelerations:
1. This is good
2. When the fetal heart rate slows down at the beginning or before a
contraction, this is caused by head compression
3. Nursing actions:
a) Document this
G. Variable decelerations:
1. This is very bad
2. Occurs when there is a prolapsed cord, cord compression
3. Nursing actions:
a) Push
b) Position
ACE of spades for OB answers: “check the fetal heart rate”
Postpartum:
A. What do you assess: done every 4-8 hours depending on if she is stable or not, use
the acronym BUBBLE HEAD
1. Breasts
2. Uterine fundus*:
a) Want it to be firm and and midline alignment
b) Boggy uterus: massage it
c) Displaced: catheterize them
d) Height of the fundus: fundal height = day postpartum
3. Bladder
4. Bowel
5. Lochia*: vaginal drainage that occurs in the following order
a) Rubra: bright red
b) Serosa: pink
c) Alba: white
d) Drainage amount:
(1) 4-6 inches on a pad an hour is alright
(2) Saturating a pad every 15 minutes is bad
6. Episiotomy
7. Hemoglobin and hematocrit
8. Extremity check*:
a) Looking for thrombophlebitis: do bilateral calf circumference
measurements
XXX.
XXXI.
9. Affect: mothers emotion
10. Discomfort
Caput succedaneum vs cephalohematoma: look at the initials
A. Caput succedaneum: C.S.
1. Crosses Sutures
2. Caputs symmetrical
B. Cephalohematoma: C.
1. Does not cross sutures
2. Is not symmetrical
OB Medications:
A. Tocolytics: these stop labor, they are threatening premature birth and we want to
stop it
1. Terbutaline:
a) It causes maternal tachycardia
2. Magnesium sulfate:
a) It stops uterine contractions
b) Side effects:
(1) Bradycardia
(2) Hypotension
(3) Decreased reflexes*
(4) Depressed respirations*
(5) Decreased LOC
c) Parameters for titrating:
(1) Respirations need to stay greater than 12
(2) Reflexes need to be +2
B. Oxytocics: these stimulate and strengthen labor
1. Pitocin:
a) Can cause uterine hyperstimulation, causing contractions that are
longer than 90 seconds and closer together than every 2 minutes
b) Methergine:
(1) Causes high blood pressure
C. Fetal lung maturing medications:
1. Betamethasone: steroid
a) It is given to the mother
b) It is administered IM injection
c) It is given before the baby is born
2. Survanta: this is surfactant
a) It is given to the neonate
b) It is administered via transtracheal, like a nebulizer type thing
c) It is given after the baby is born
XXXII.
Medications helps and hints:
A. Humulin 70/30: a mix of insulin
1. 70 is insulin N
2. 30 is insulin R
B. Drawing up insulin: we want to become an RN, do it that way
1. Draw up Regular insulin first
2. Then drawn up N insulin
C. Injection: they ask what needle to use
1. IM injection: I looks like a 1, pick the answer in which both the gauge and
the length have a 1 in them
2. Subcutaneous: S looks like a 5, pick the answer in which both the gause
and the length have a 5 in them
D. Heparin vs. Coumadin:
1. Heparin:
a) Administered:
(1) IV
(2) Subq
b) Effective: immediately
c) Cannot be given for longer than 3 weeks, except for lovenox
d) Antidote: protamine sulfate
e) Lab test used to monitor therapeutic effect: PTT
f) Can be given to pregnant women
2. Coumadin (warfarin):
a) Administered:
(1) PO
b) Effective: from a few days to a week to work
c) Can be given for the rest of your life
d) Antidote: vitamin K
e) Lab test used to monitor therapeutic effect: PT or INR
f) Cannot be given to pregnant women
E. Potassium wasting or potassium sparing diuretics: any diuretic that ends in the
letter x, x’s out K plus diuril
a) Wasting drugs: most generic names will end in “-semides”
(1) Lasix
(2) Bumex
(3) Clotrex
(4) Esidrex
(5) Demodex
(6) Diuril
F. Baclofen and flexeril:
XXXIII.
1. Side effects:
a) Fatigue
b) Muscle weakness
2. Patient teaching:
a) Don't drink
b) Don't drive
c) Don't operate heavy machinery
Patient teaching to pediatrics: boards will not bring up piaget, but if we get a patient
teaching question for peds it is asking us about piaget
A. 4 stages for kids thinking:
1. 0-2 years old: sensorimotor thinking
a) Piaget says they are totally present oriented, they don't think about
the past or future they are only focused on what they are seeing or
doing right now
b) When do you teach: teach them while you are doing it
c) What do you teach them: you teach them what you are doing,
present tense
d) How: verbally, just tell them
e) No such thing is pre-op or pre test teaching for the child
2. 3-6 years old: pre-operational stage
a) Piaget says that they are fantasy oriented, imaginative, illogical,
their logic obeys no rules, if they can think it it can happen; they
understand the future and the past
b) When do you teach: teach them shortly before, like the morning of,
the day of or 2 hours before
c) What do you teach: what you are going to do, future tense
d) How: play, using a story, a book, dolls
3. 7-11 years old: concrete operational
a) Piaget says that they live and die by the rules, there is only one
way to do things and every other way is wrong
b) 7 years old is the youngest age when they can accomplish skills
c) When do you teach: teach them days ahead, a day before
d) What do you teach: what you are going to do plus we can teach
them skills because they follow it by the rules and are rigid
e) How: use age appropriate reading and demonstration
4. 12-15 years old: formal operations
a) Piaget says that they can abstract and think cause and effect, when
the child becomes 12 it now becomes like teaching an adult in
regular med-surg
XXXIV.
XXXV.
XXXVI.
b) 12 years old is the youngest age at which an individual can manage
their own care
7 principles to obey when taking psych tests:
A. Know what phase of the nurse-patient relationship you are in:
1. Pre interaction
2. Introduction
3. Orientation
4. Working
5. Termination
B. Don't give or accept gifts in psych
C. Don't give advice in psych
D. Don't give guarantees in psych
E. If a patient says something, the best answer is the one that keeps them talking: it’s
never wrong to get a patient to talk
F. Don’t use slang
G. You got to know empathy: the best psych answers are those answers that
communicate to the patient that the nurse accepts that patients feelings as being
valid real and worthy of action
4 step process for answering empathy questions: empathy ignores what is said, and goes
with what is felt
A. Recognize that it is an empathy question:
1. they always have a quote in the question
2. All four responses will be a quote
B. Put yourself in the clients place, and say their words like you really mean them
C. Then ask yourself if I said those words and really meant them how would I be
feeling right now
D. Go and choose the answer that reflects that feeling or anything close, do not
choose the answer that reflect their words
Prioritization:
A. Prioritization: testing to see how you prioritize 4 different patients
1. Deciding which patient is sickest and healthiest
B. Question Format:
1. Answers will contain:
a) Age: irrelevant
b) Gender: irrelevant
c) Diagnosis: important
d) Modifying phrase: more important
C. Rules for prioritization:
1. Acute beats chronic
2. Fresh post op (12 hours) beats medical or other surgical greater than 12
hours post op
3. Unstable beats stable
a) Things that make a patient Unstable:
(1) Unstable
(2) Acute illness
(3) Post-op less than 12 hours
(4) General anesthesia only in the first 12 hours
(5) Lab abnormalities of a C or D level
(6) Newly admitted, newly diagnosed or admitted less than 24
hours ago
(7) Changing or changed assessments
(8) Experiencing unexpected signs and symptoms
b) Things that make a patient Stable:
(1) Stable
(2) Chronic illness
(3) Post-op greater than 12 hours
(4) Local or regional anesthesia
(5) Lab abnormalities of an A or B level
(6) Ready for discharge, to be discharged or admitted longer
than 24 hours ago
(7) Unchanged assessments
(8) Experiencing the typical expected signs and symptoms of
the disease with which they were diagnosed
4. Used as a tiebreaker: only use as a tiebreaker
a) The more vital the organ, the higher the priority
b) Do the tiebreaker based on the organ that is addressed in the
modifying phrase
c) Order:
(1) Brain
(2) Lungs
(3) Heart
(4) Liver
(5) Kidney
(6) Pancreas
D. 4 things that are always unstable: even if it is expected, it is unstable
1. Hemorrhage
2. High fever: over 105F
3. Hypoglycemia
4. Pulselessness and breathlessness
XXXVII.
XXXVIII.
E. 3 things that result in a black tag:
1. Pulselessness
2. Breathlessness
3. Fixed and dilated pupils, even if they are still breathing
Delegation:
A. Do not delegate the following to a LPN:
1. Start an IV
2. Hanging or mixing IV medications
3. Pushing IV push meds
4. Administer blood products
5. Mess with central lines
6. Create a care plan
7. Perform or develop patient teaching
8. Take care of unstable patients
9. Not allowed to do the first of anything
10. Not allowed to do the following assessments:
a) Admission
b) Discharge
c) Transfer
d) The first assessment after there has been a change
B. Do not designate the following to a UAP:
1. Cannot chart: they can chart what they did, but cannot chart about the
patient
2. Cannot give medications except for topical over the counter barrier creams
3. Cannot do assessments except for vitals and accuchecks
4. Cannot do treatments except enemas
5. Should never do the first of anything
C. Delegating to the family
1. Do not delegate safety responsibilities
2. Only what you teach them, it must be documented that you provided
education to properly do the task
Staff management:
A. How to intervene when there is inappropriate behavior of staff:
1. There is always 4 answers and they go like:
a) Tell supervisor
b) Confront them and take over immediately
c) At a later date, just talk to them
d) Ignore it: this is never the answer
2. When you get a staff question, the first question you should ask yourself
is: “is what they are doing illegal?”
XXXIX.
a) If yes, the answer for this question is: tell the supervisor
b) If no, the next question you ask yourself is “Is anyone, the patient
or the staff member, in immediate danger of physical or
psychological harm?”
(1) If yes, the answer for this question is: confront and take
over
(2) If no to both of the 2 questions, ask yourself “Is the act
legal, not harmful but simply inappropriate?”
(a) If yes, the answer to this question is: approach the
later and talk to them
How you guess: first use knowledge, then use common sense and if neither of those work
guess
A. Psych questions:
1. The best answer is usually “the nurse examines their own feelings about
it”
2. “Establish a trust relationship”
B. Nutrition questions:
1. In a tie pick chicken
2. If chicken isn’t there, pick fish (not shellfish)
3. Never pick casseroles for children
4. Never mix medication in children’s food
5. Toddler’s its finger food
6. Hot dogs and popcorn are the top things that toddlers choke on
7. Leave preschoolers alone, they eat when they're hungry and can survive
off one meal only
C. Pharmacology questions: most commonly tested area is side effects
1. If you know what a drug does but don’t know the side effects: pick a side
effect in the same body system where the drug is working
2. If you have absolutely no clue what the drug is:
a) If it is PO: pick a GI side effect
3. Never tell a child medicine is candy
D. OB questions: check the fetal heart rate
E. Med-surg questions:
1. First thing you assess: LOC
2. First thing you do: establish an airway
F. Pediatric questions:
1. Growth and development rules: always give the child more time to grow
and develop
a) When in doubt call it normal
b) When in doubt pick the older age when you have it narrowed down
XL.
c) When in doubt pick the easier task
G. General guessing skills:
1. Rule out absolute answers
2. If 2 answers say the same thing, neither one of them is right
3. If two answers are opposite one of the is probably right
4. Umbrella strategy: when you want an option that would say “select all that
apply” but it is not there, use an umbrella answer that incorporates as
many right answers in it
5. When a question provides four right answer and asks for a priority need:
a) Play the worst consequences
b) Take each answer and ask what is the worst thing that could
happen
c) The one with the worst consequences is the highest priority
6. When you're stuck between 2 answers: read the question again, don’t just
keep rereading the answers
H. Sesame street rule: only use this rule when LITERALLY NOTHING else works
1. The right answer tends to be different than all the others
I. If you don’t know what is included in the question, take that part out and focus on
what you do know!
J. If something seems right, it probably is: never go against your gut unless you can
prove it is superior and not just as good
Three expectations you are not allowed to have: it wasn’t what they expected, wanted or
was looking for: causes negativity and then that influences their performance
A. Do not expect 75 questions: psychologically prepare for 265 questions
B. Do not expect to know everything
C. Do not expect everything to go right