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NCLEX Review: Acid-Base, Alcoholism, & Pharmacology Notes
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! ! ! ! ! ! ! Mark!Kilmek!NCLEX!Review! Audio!Recordings! !! ! ! It!takes!three!things!to!pass!the!NCLEX:!knowledge,!confidence,!and!skill!in!taking!exams.! ACID=BASE!BALANCE! Rule!of!the!B’s! ! If!the!pH!and!the!bicarbonate…!are!both!in!the!same!direction…!than!its!metabolic! ! If!they!are!the!opposite!it!must!be!respiratory.! ! pH!<!7.35!acidosis! pH!>!7.45!alkalosis! ! ALKALOSIS! ↑!in!pH!=!the!patients!body!systems!↑! HyperPreflexes!(3/4),!tachycardia,!tachypnea,! borborygmi!(++!bowel!sounds),!irritability! Risk!for!seizures!!!keep!suction!close! Bicarbonate!22=26! (2+2+2!=!6)! pH!7.35=7.45! (compensated!when!in!neutral!range)! ACIDOSIS! ↓!in!pH!=!the!patients!body!systems!↓! HypoPreflexes!(0/1),!bradycardia,!paralytic!ileus,! lethargic/obtunded,!coma! Risk!for!resp.!arrest!!!keep!ambu!bag!close! ! ! Note:!the!only!exception!is!potassium!(K)!as!it!will!move!in!the!opposite!direction!of!the!pH! ! ! Mac!Kussmaul!! Respiratory!pattern!for!only!one!acid!base! In!an!acidotic!environment!chemical!reactions! balance!disorder! stop,!where!in!a!basic!environment!chemical! (Metabolic!Acidosis)! reactions!increase!(acts!as!a!catalyst)! ! ! ! ! !!!!!!!!!The!cause!of!the!acid!base!imbalance!is!opposite!to!the!symptoms!that!the!imbalance!causes.! Lung!scenario!=!Respiratory! ! Over!(high!pH)Pventilation!(respiratory)!! ! !!alkalosis! Under!(low!pH)Pventilation!(respiratory)! ! !!acidosis! ↓↓! ! Note:!Respiration!rate!is!irrelevant.!Pay! attention!to!SaO2!saturation,!ventilation!has!to! do!with!gas!exchange!and!O2!sat!measures!that! ! ! Not!a!lung!scenario!=!Metabolic! ! A!scenario!involving!suction!or!vomiting!is! metabolic!alkalosis!(losing!acidic!gastric! secretions!=!more!basic,!making!it!alkalytic)! ! A!scenario!not!involving!the!lungs,!suction,!or! vomiting!is!metabolic!acidosis!(by!default)! ↓↓! Note:!the!modifying!phrase!of!the!old!original! situation!becomes!the!new!now!situation! ! VENTILATORS! High!Pressure!Alarm!! Triggered!by!an!increase!in!resistance!to!air!flow!(obstruction).!The!machine!needs!to!push!too!hard! to!get!the!air!into!the!lungs!and!usually!indicates!an!obstruction.! 1. Kink!in!the!tubing!(unkink!the!tube)! 2. Water!condensation!within!the!tube!(empty!water!from!tube)! 3. Mucus!secretions!in!the!airway!(change!position,!cough,!deep!breath)!!!only!suction!when! client!cannot!clear!secretions! Low!pressure!alarm! Triggered!by!a!decrease!in!resistance!to!air!flow!(disconnection).!!It!is!way!too!easy!to!move!air!and! usually!indicates!a!disconnection.! P Main!tube!disconnection!(reconnect!the!tubes)! P O2!sensor!tubing!disconnection!!!which!senses!the!FiO2!at!tracheostomy!(black!wire)! (reconnect!O2!sensor)! When!do!you!need!to!change!the!settings!on!the!ventilator?! ! Respiratory!alkalosis!=!ventilator!setting!is!too! high!(overPventilate)! ! Respiratory!acidosis!=!ventilator!setting!is!too! low!(underPventilate)! ! Note:!You!want!to!see!a!patient!over!ventilating!on!a!ventilator,!this!indicates!that!they!do!not!need! it!to!breathe!anymore.!A!client!underPventilating!on!a!ventilator!means!they!need!it!to!keep!them! breathing.! ! ! ! ALCOHOLISM! ! ! The!#1!psychological!problem!of!alcoholism!and!abuse!situations!=!denial! ! Abusers!have!an!infinite!capacity!to!deny!and!have!to!in!order!to!continue!the!behavior.!Allows! ! them!to!keep!abusing!without!having!an!answer!for!it!and!deny!they!even!have!a!problem.! ! !!Someone!can!only!be!treated!once!they!admit!to!having!a!problem! ! Denial!is!treated!by!confronting!it!(point!out!the! ! difference!between!what!they!say/!do.! Confrontation!attacks!a!problem!whereas! aggression!attacks!a!person!(use!‘I’!not!‘you’)! ! Denial!is!operative!in!grief!and!loss!(healthy! Note:!Is!their!denial!from!loss!or!abuse?!This!will! ! and!normal!first!reaction!should!be!supported)! determine!whether!to!support!or!confront.! ! ! The!#2!psychological!problem!of!abusers!=!dependency!and!co=dependency! ! Dependency!=!gets!significant!other!to!do!things!for!them!and!make!decisions!for!them! Co=dependency!=!significant!other!gets!positive!selfPesteem!from!making!decisions!and!doing!things! ! for!abuser!(pathological/symbiotic!relationship)!! ! Note:!treatment!focuses!on!setting!limits!and!enforcing!it,!work!with!the!significant!other!to!say! ! Note:!To!treat!coPdependency!set!limits!and!enforce!them.!(Teach!them!to!say!NO).! ! ! Manipulation!=!abuser!gets!significant!other!to! do!things!for!them!that’s!not!in!their!best! interest!(negative,!harmful,!and!dangerous)! Note:!There’s!only!1!person!to!treat!in! manipulation!and!denial!where!in!dependency! there’s!two!(manipulation!is!easier!to!treat).!! Wernicke’s!Encephalopathy!and!Korsakoff’s!Psychosis!Syndrome! Preventable!diseases!that!can!be!stopped!but!once!you!have!it,!it’s!irreversible!(separate!diseases! but!often!found!in!the!same!patient)! ! P Induced!by!Vitamin!B1!Thiamine!deficiency!!!this!breaks!down!ETOH!in!the!body,!without! ! it!alcohol!accumulates!and!becomes!toxic,!leading!to!brain!damage.!The!alcoholic!doesn’t! ! even!need!to!stop!drinking!they!just!need!to!take!the!vitamin!and!be!fine.! ! Symptoms! ! Insanity!and!amnesia!(memory!loss)!with! ! confabulation!(making!up!stories).! ! Need!redirection!!!! ! What!makes!them!different?! They!really!believe!the!lie!to!be!reality.!This!is! permanent!so!you!cannot!present!reality,!it!will! only!turn!into!a!fight!(they!can’t!learn!reality)! ! ! Revia/Antabuse!(Disulfiram)! ! ! ! A!form!of!aversion!therapy!that!wants!alcoholics!to!develop!a!hatred!for!alcohol!–!if!!!!!!! ! ! drinking!when!taking!the!drug,!it!will!interact!in!the!blood!and!make!the!person!SUPER!sick! ! to!the!stomach!making!them!associate!alcohol!with!the!negative!feeling.! ! ! Note:!Works!better!in!theory.!In!reality,!it!takes!up!to!2!weeks!to!become!effective!and!the!patient! ! ! ! will!need!to!stop!taking!the!drug!for!2!weeks!before!they!can!safely!drink!again.! ! Patient!Teaching! ! Teach!pts!to!avoid!all!forms!of!ETOH!to!avoid!nausea,!vomiting,!and!possible!death!(mouthwash,! ! aftershave,!perfume,!insect!repellants,!vanilla!extract,!OTC!medications!that!end!in!‘elixir’.! ! ! Overdose!and!Withdrawal! ! For!these!questions,!ask!yourself…! Every!abused!drug!is!an!‘upper’!or!a!‘downer’,! ! ! drugs!that!aren’t!abused!are!neither!because! ! 1. Is!the!drug!an!upper!or!a!downer?! they!have!no!effect.! 2. Are!they!talking!about!overdose!or! !P Exception:!most!abused!drug!that!is! withdrawal?! ! neither!is!laxatives!in!the!elderly.! ! UPPERS! DOWNERS! ! !!!!!1.!Caffeine! ! 2.!Cocaine! !!!!!1.!Fentanyl!!! 2.!Morphine!! ! ! !!!!!3.!PCP/LSD! ! 4.!Methamphetamines! !!!!!3.!Ativan!! ! 4.!Valium!! ! !!!!!5.!Adderall! !!!!!5.!Heroine!! ! 6.!Sedatives/Relaxants! ! Anything!that ↑!=!euphoria,!tachy,!restless,! Anything!that!↓!=!brady,!respiratory!depression,! irritable,!borborigmi,!diarrhea,!spastic,!seizure! ! and!respiratory!arrest! ! ! Note:!Upper!overdose!looks!like!a!downer!withdrawal!(associated!with!seizure!risk).! ! Downer!overdose!looks!like!an!upper!withdrawal!(associated!with!respiratory!and!CNS!depression).! ! Always!assume!intoxication!at!birth!to!24!hours!(not!withdrawal).!! ! After!24!hours!is!when!a!child!will!go!through!withdrawal.!Downer!withdrawal!!!! ! difficult!to!console,!exaggerated!startle!reflex,!seizure!risk,!shrill!highPpitched!cry! ! high!pitched!cry!and!risk!for!seizure!! Alcohol!Withdrawal!(stable)!vs.!Delirium!Tremens!(dangerous)! ! Every!alcoholic!goes!through!withdrawal!24!hours!after!they!stop!drinking.!Only!a!small!amount!of! ! them!will!go!into!delirium!tremens!a!couple!days!(72!hours)!after!withdrawal.! Note:!Alcohol!withdrawal!syndrome!always!precedes!delirium!tremens,!but!delirium!tremens!does! not!always!follow!alcohol!withdrawal!syndrome! Care!of!AWS!&!DT! ! ! ! Alcohol!Withdrawal! ! ! ! Delirium!Tremens! ! ! !!!!!!!Regular!diet! ! ! ! !!!!NPO/!clear!liquids!(seizure!risk)! ! !!!!!!!!SemiPprivate!room!anywhere!on!the!unit!!!!!!!!!!!!!!!!!!!!!!!!!!!Private!room!near!nursing!station!! ! !!!!!!!!!!!!!!!Free!to!ambulate!with!no!restrains! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!Restricted!bedrest!and!restrained! ! ! ! Care!of!both!AWS!&!DT!include:!anti=hypertensive,!tranquilizer,!and!multivitamin!with!vitamin!B1! ! Note:!a!vest!or!two!point!locked!leather!restraints!may!be!used!in!delirium!tremens!(opposite!arm! ! to!leg!that!rotates!every!2!hours)! ! ! ! AMINOGLYCOSIDES! ! ! ! Powerful!antibiotics!that!are!only!used!when!nothing!else!works!because!they!are!super!dangerous.! ! ! “A!mean!old!mycin!treats!a!mean!old!infection”! Most!aminoglycosides!end!in!“mycin”,!however,! rd ! ~!Peritonitis,!septic!shock,!infected!3 !degree! there!are!3!that!are!not!aminoglycosides! ! burn!wounds!on!80%!of!the!body!~! 1. Arthromycin! ! ! 2. Zithromycin! The!2!toxic!effects!of!aminoglycosides! ! 3. Clarithromycin! !1. Ototoxic!(ear)!—!hearing,!ringing,!and! “Thro”!it!off!the!list!(not!‘mean’,!only!a!little)! ! dizziness!! ! Note:!The!#8!can!fit!nicely!inside!a!kidney!so! !2. Nephrotoxic!—!serum!creatinine!is!the! best!indicator!of!kidney!function!or!a!24P think!it!is!toxic!to!cranial!nerve!8!and!it’s! ! hour!creatinine!clearance!! administered!every!8!hours!by!IM!or!IV! ! Note:!when!thinking!of!mycin!think!of!mice!ears! Don’t!give!mycins!PO!because!they!are!not! ! &!the!human!ear!is!shaped!like!a!kidney! absorbed!and!have!no!effects! ! ! ! ! Trough!and!peak!levels!(TAP)!! Only!give!orally!with…! ! in!antibiotic!therapy/treatment! Hepatic!encephalopathy!–!high!ammonia!levels! ! can!cause!brain!damage,!oral!mycins!kill!e.!coli! Trough!!!when!a!drug!is!at!its!lowest! ! in!the!gut!decreasing!ammonia!levels!and!not! Peak!!!when!a!drug!is!at!its!highest! ! harming!the!liver.! ! T!(draw!your!trough)!! Pre=op!bowel!surgery!–!used!to!sterilize!the! ! A!(administer!the!drug)! bowel!and!doesn’t!cause!kidney!damage!or!even! ! P!(draw!the!peak)! reach!the!liver!(Tip:!drill!sergeant!asks!who!can! ! sterilize!my!bowel!–!“neo!can!”! The!reason!for!drawing!TAP!levels!is!due!to!the! ! 1. Neomycin! narrow!therapeutic!window!–!the!difference! ! 2. Canomycin! between!what!works!and!what!kills.! ! ! ! The!route!doesn’t!matter!in!troughs!!!always!draw!30!minutes!before!the!next!dose.! ! BUT!the!route!determines!the!drugs!peak!levels! ! The!same!drug!that!is!given!by!2!different!route!will!have!2!different!peaks.!When!2!different!drugs! ! are!given!by!the!same!route!they!will!peak!together.! ! 1. SL!=!5=10!minutes!after!drug!dissolves! ! 2. IV!=!15=30!minutes!after!drug!is!finished! Note:!SC!peaks!are!only!in!insulin!and!no!peak!is! ! 3. IM!=!30=60!minutes!after!drug!is!finished! drawn!for!PO!medications!due!to!the!variability! ! ! ! Note:!When!selecting!the!time!for!drawing!the!peak!and!there!are!two!correct!answers!choose!the! highest!without!going!over.! ! ! ! ! ! ! CALCIUM!CHANNEL!BLOCKERS! ! Calcium!channel!blockers!are!like!valium!for!your!heart!!!they!calm!the!heart!down! ! ! Calcium!channel!blockers!that!are!negative! Calcium!channel!blockers!are!used!to!treat!A,! ! inotropic,!chronotropic,!and!dromotropic!are! AA,!and!AAA! cardiac!depressants!!!they!weaken,!slow! A!—!Antihypertensive!used!to!relax!the!heart! ! down,!and!depress!the!heart! and!blood!vessels!to!decrease!blood!pressure! ! AA!—!AntiPangina!used!to!relax!the!heart!so!it! Beta=blockers!are!also!heart!depressants!but! ! uses!less!oxygen,!decreasing!the!oxygen! calcium!channel!blockers!are!better!for!asthma! ! demand! (on!the!contrary,!positive!inotropic,! ! Note:!the!worst!thing!for!angina!is!speeding!up! chronotropic,!and!dromotropic!medications!are! ! the!heart!rate! ! ! heart!stimulants)! ! AAA!—!AntiParterial!arrhythmia!used!in!atrial! ! fibrillations!or!flutter,!premature!atrial! !Note:!Exception:!CCB’s!treat!supra!ventricular! ! contractions!(anything!atrial)! tachycardia!(SVT)!because!“supra”!means! ! Note:!Calcium!channel!blockers!don’t!treat! “above”!and!the!atria!are!above!the!ventricles! anything!to!do!with!the!ventricles! !! ! ! Remember:!H!and!H.! Note:!Measure!BP!before!giving!ca!channel! ! Headaches!due!to!vasodilation!in!the! blockers!and!hold!if!the!systolic!BP!is!under! ! brain!and!hypotension.! 100mmHg! ! ! ! Names!of!Calcium!Channel!Blockers! ! 1.!Anything!ending!in!depine!–!“dipping!in!the!calcium!channel”!(amlodipine,!nifedipine)! ! 2.!Verapamil! ! 3.!Cardizem!–!monitor!BP!if!on!a!drip!and!change!the!IV!rate!to!keep!the!systolic!BP!above! ! 100mmHG! !! ! ! CARDIAC!ARRHYTHMIAS! ! ! ! Ventricular!Fibrillation! Normal!Sinus!Rhythm! ! A!chaotic!squiggly!line!with!no!pattern! There’s!a!P,!QRS,!and!T!wave!for!every!beat!and! ! ! the!peaks!of!the!P!wave!is!equal!distance!! ! (Note:!if!P!waves!normal!and!QRS!are!inverted!that’s! ! okay)! ! ! ! ! ! ! ! Asystole!(flat!line)! Ventricular!Tachycardia! ! ! Has!sharp!peaks!with!a!pattern! ! ! ! ! ! ! ! ! ! ! ! ! When!asked!about!QRSd!polarization!they!are! When!asked!about!anything!P!wave!they!talking! ! !! talking!about!ventricular!(rule!out!anything! about!atrial!(unless!says!lack!of!p!wave!then!its! ! atrial)! not!talking!about!the!atria)! ! ! ! Ventricular!Arrhythmias!Treatment! Atrial!Arrhythmias!Treatment! !! ! PVC’s!or!Ventricular!tachycardia! Supra!ventricular!arrhythmia!(SVA)!is!treated! can!be!treated!with!amiodarone!or!lidocaine! ! with!the!use!of!ABCD’s!of!atrial!treatment! ! ! ! A!–!Adenocard/adenosine! ! ! B!–!Beta!Blockers!(ends!in!lol)! Note:!You!MUST!administer! ! ! C!–!Calcium!Channel!Blockers! adenocard/adenosine!within!8!seconds!–!need! ! ! D!–!Digitalis!(Digoxin/Lanoxin)! to!slam!it!into!the!body,!the!patient!will!go!into! ! ! asystole!for!30!seconds!and!then!come!out!of!it! ! Note:!try!to!remember!adenoPbetaPcalciumPdig! ! ! Ventricular!Fibrillation! Asystole! ! For!vPfib!you!defib!(shock!!)! Epinephrine!(if!that!doesn’t!work!give!atropine)! ! ! Note:!If!the!patient!has!a!pulse!they!have!cardiac!output!(CO)!but!if!they!don’t!then!they!have!no!CO! ! !! The!Top!6!Cardiac!Rhythms!on!the!NCLEX! ! ! ! 1. Ventricle!asystole! ! –! ! High!priority!(lethal)! ! ! ! ! ! ! ! ! No!cardiac!output!or!brain!perfusion! ! ! ! ! ! ! ! ! Lack!of!QRS!complex! ! ! ! –!! ! A!form!of!atrial!rhythm! ! 2. P!wave!! ! 3. Sawtooth!rhythm!! ! –!! ! Flutter! ! ! ! –!! ! Ventricular!tachycardia!! ! 4. Bizzar!!! !! ! ! ! ! ! ! Potentially!life!threatening! !! ! ! ! ! ! ! Have!a!cardiac!output! ! 5. Chaos!!! ! ! –!! ! Ventricular!fibrillation!! ! ! ! ! ! ! ! ! High!priority!(lethal)!! !! ! ! ! ! ! ! No!cardiac!output!or!brain!perfusion! ! ! (Ventricular!tachycardia)!! ! 6. Periodic!wide!QRS/!short!! –!! !! run!or!group!of!PVC’s!!! ! ! Not!a!priority!unless:! o There’s!>!6!PVC’s!in!one!minute! ! o There’s!>!6!PVC’s!in!a!row! ! o If!a!PVC!falls!on!the!T!wave!of!a!previous! ! beat! !! !! Note:!PVC’s!after!a!heart!attack!are!good,!meaning!the!heart!is!reperfusing!and!don’t!call!the!doctor! ! if!having!PVC’s! !! ! ! ! ! ! ! CHEST!TUBES! ! Chest!tubes!are!used!to!re=establish!negative!pressure!in!the!plural!space!by!sucking!fluid!or!air!out! ! so!the!lung!expands!when!the!chest!wall!moves,!negative!pressure!makes!things!stick!together.! !! Pay!attention!to!tube!location! ! Air!or!fluid!between!the!lungs!causes!positive! 1.!!Apical!P!chest!tube!is!up!high!(removes!air! pressure!which!doesn’t!allow!air!exchange.! ! because!air!rises)! ! !Pay!attention!to!placement!reason! 2.!!Basilar!P!chest!tube!is!down!low!(removes! ! 1. Hemothorax!=!blood!(drainage)! blood!because!it’s!subjected!to!gravity)! ! 2. Pneumothorax!=!air!(bubbles)! Note:!An!apical!and!basilar!chest!tube!is!placed! !! for!a!unilateral!pneumohemothorax! !! ! Note:!How!many!chest!tubes!should!be!placed! Note:!Chest!tube!trick!question…! ! for!postPop!chest!surgery?!Two.!(apical!and! How!many!chest!tubes!and!where!for!postPop! ! basilar)!on!the!side!of!the!surgery.!You!must! pneumonectomy?!None!because!the!lung!is! ! assume!that!chest!surgery/trauma!is!unilateral! removed!and!you!do!not!need!to!rePestablish! unless!otherwise!stated! pressure!in!something!that!doesn’t!exist! ! !! ! ! ! !!! If!a!closed!chest!tube!system!gets!knocked!over,!set!it!up!and!encourage!deep! Troubleshooting! !! ! !breaths!(no!big!deal).! !! ! If!water!seal!or!tube!system!breaks,!a!positive!pressure!can!enter!the!plural!space:! ! !!!!!!!1.!!!!!Clamp! ! ! ! ! 2.!!!!!Cut!tube!away!from!broken!system!! !!!!!!!3.!!!!!Submerge!tube!and!sterile!water! ! 4.!!!!!Unclamp!tube!(water!seal!is!established)! ! !! Note:!It’s!better!for!the!tube!to!be!submerged!then!clamped!up!because!air!cannot!get!in!but!stuff! ! can!come!out!(clamping!may!be!the!FIRST!thing!to!do!but!submerging!is!the!BEST!thing!to!do).! !! Bubbling!—!when!it’s!good!or!bad!(depends!where)! Chest!Tube!Dislodgment! ! ! ! ! ! P The!first!thing!to!do!is!cover!the!hole! ! with!a!gloved!hand! ! P The!best!thing!to!do!is!cover!the!hole! ! with!a!Vaseline!gauze! ! ! Thoracentesis!vs.!Chest!Tube! ! Thoracentesis!(in!and!out)! ! Chest!tube!(secure!and!higher!risk!of!infection)! !! ! ! ! ! ! ! ! ! ! ! 1. Bubbling!in!water!seal!!!intermittent!is! good,!continuous!means!leak!(use!tape)! 2. Bubbling!in!suction!control!chamber!!! continuous!is!good,!intermittent!means! suction!is!too!low! 1.!!!Don’t!clamp!the!tube!for!more!than! 15!seconds!without!a!doctor’s!order!(need! sterile!water!close!by!incase!prolonged!clamp)! 2.!!!Use!a!rubber!tip!double!clamp!so!it!doesn’t! puncture!the!tube! ! CONGENTIAL!HEART!DEFECTS! ! ! They!are!either!trouble!(lots!of!problems)!! Troubled!defects:!!need!surgery!to!live,!have! ! or!no!trouble!(no!big!deal)! poor!growth/development,!low!life!expectancy! !! and!lots!of!stress,!grief!and!financial!issues! ! ! Note:!!All!no!trouble!defects!are!no!big!deal!shunt!blood!left!to!right!and!are!acyanotic.!! ! !!!!!!!!!!!!All!troubled!defects!start!with!‘T’,!shunt!blood!right!to!left!and!are!cyanotic.! !! All!congenital!heart!defects! The!four!defects!of!TETRALOGY!OF!FALLOT:! ! 1. !Will!have!a!murmur!regardless!if!it’s!a! 1. VD!=!ventricular!defect! ! trouble!or!not!because!blood!is!being! 2. PS!=!pulmonary!stenosis! shunted! 3. OA!=!overriding!aorta! ! 4. RH!=!right!hyper!trophy! ! 2. !All!heart!defect!kids!will!have!an!EKG! done! ! ! ! ! ! INFECTIOUS!DISEASES! ! ! ! There!are!4!transmission!based!precautions:! Contact!Precautions! ! ! They!are!for!anything!enteric!(anything!that!can! !1. Standard/universal! be!cut!from!intestines!–!c.!diff,!hep!A,!colera),! 2. Contact! staph!infections,!respiratory!syncytial!virus! ! 3. Droplet! (RSV),!and!herpes! ! Note:!Hepatitis!A!comes!anus!(fecalPoral)! !4. Airborne! hepatitis!B!comes!from!blood! ! ! ! Contact!isolation!follows!the!following:! ! ! 1. Private!room!is!preferred!or!cohort! Note:!RSV!is!a!droplet!transmitted!but!it!goes! ! 2. Gloves!and!gown! under!contact!precautions!because!kids!catch!it! ! 3. HandPwashing! from!touching!things!other!kids!have!touched! ! 4. Disposable!supply!for!dedicated! and!putting!it!in!their!mouths.! equipment! ! ! ! Droplet!isolation!precautions!follow!the! Droplet!Precautions! ! following:! Bugs!that!travel!3!feet!on!large!particles!due!to! ! 1. Private!room!is!preferred!or!cohort! sneezing!and!coughing!!!meningitis!and!H.!flu! ! 2. Mask,!gloves!(no!gown)! which!causes!epiglottitis! 3. HandPwashing! ! Airborne!Precautions! 4. Patient!wears!mask!when!leaving!room! ! Are!for!measles,!mumps,!rubella,!TB!(spread'by' 5. Disposable!supply!for!dedicated! ! droplet)!and!varicella!(chickenpox)! equipment! ! ! ! Airborne!isolation!follows!the!following:! Personal!Protective!Equipment! ! ! Taking!Off! ! Putting!On! !1. Private!room!is!required!or!cohort! !!!!!!!!!!!!!!!(Alphabetical!order)!!!!!!!!!!(Reverse!alphabetical!order;!mask!#2)! 2. Mask,!gloves! !3. HandPwashing! 1. Gloves!! !!!!!!!!!!1.!!!Gown! ! !4. Special!filter!mask!for!TB!only! 5. Patient!wears!mask!when!leaving!room! 6. Negative!pressure!room! 2. Goggles! 3. Gown! ! 4. Mask! ! !!!!!!!!!!2.!!!Mask! !!!!!!!!!!3.!!!Goggles! !!!!!!!!!!4.!!!Gloves! CRUTCHES/CANES/WALKERS! ! ! Crutches!Measurements! ! Measure!crutches!for!risk!reduction!and!to!decrease!the!risk!of!causing!nerve!damage! ! P Length!is!2!to!3!finger!widths!below!the!axilla!to!lateral/slightly!in!front!of!the!foot! ! P Handgrips!can!be!adjusted!so!that!the!elbow!flexion!is!30°! ! ! Crutches!Gaits! ! ! Mild!! ! 1. Two!point!–!similar!to!walking!sticks!!!move!2!things!together! !2. Three!point!–!with!a!broken!leg!!!move!3!things!together! ! Severe!! !3. Four!point!–!slowly!walking!with!bilateral!weakness!!!move!4!things!together!(slow/sturdy)! !4. Swing!through!–!swing!between!crutches!!!patients!that!cannot!weight!bear!(amputations)! ! ! Note:!Use!the!even!numbered!gaits!when!the! Note:!Use!the!odd!number!gait!when!one!leg!is! ! weakness!is!evenly!distributed!(ask!yourself! odd!! what!number!of!legs!are!being!used)! ! ! ! Stairs!with!Crutches! Walking!with!Canes! !Up!with!the!good!and!down!with!the!bad! Hold!the!cane!on!the!strong!side!and!advance!it! ! When!going!↑!stairs!go!up!with!the!good!foot;! with!the!bad!leg!as!an!extra!support! ! then!when!going!↓!stairs!go!with!the!bad!foot!! ! ! ! Walkers! ! Pick!them!up,!set!them!down,!and!walk!to!them!P!!its!slow!but!It’s!safer! ! If!patients!want!to!tie!their!belongings!to!the!walker,!tie!them!to!the!sides!(not!the!front)!and!do!not! ! put!wheels!or!tennis!balls!on!walkers! ! ! ! DELUSIONS/!HALLUCINATIONS/!ILLUSIONS! ! ! ! The!very!first!thing!you!need!to!decide!with!a!psych!question!is!if!you’re!dealing!with!a!psychotic! ! patient!or!nonPpsychotic!patient!as!it!determines!the!course!of!treatment!or!care! ! ! Non=Psychotic!Person!and!Techniques! Psychotic!Person!and!Techniques! ! The!nonPpsychotic!person!has!insight!and!is! A!psychotic!person!doesn’t!have!insight!and!is! ! reality!based.!!They!may!be!distressed!or! not!reality!based.!They!don’t!know!they’re!sick! ! disturbed!but!they!know!they!have!a!problem.! and!believe!everyone!else!has!a!problem.! P Good!therapeutic!communication! !P Good!therapeutic!communication!is!the! strategies!do!not!work!(it’s!your!fault)! ! right!technique!for!any!nonPpsychotic! P Psychotic!persons!can!experience! ! client! delusions,!hallucinations,!and!illusions! ! ! ! Delusion:!A!false!fixed!idea!or!belief! Hallucination:!A!false!fixed!a!sensory!experience!! ! P! Paranoid!–!people!are!out!to!harm!you! P Auditory!(common!P!voices)!!!!=!!!!!!Visual! P Tactile!! ! !!!=!!!!!!Gustatory!!!!! !P Grandiose!–!think!you!are!superior! ! ! ! P Somatic!–!belief!about!body!part! P Olfactory! ! ! Illusion:!A!misinterpretation!of!reality!and!is!a!sensory!experience! Illusions!vs.!Hallucinations! With!an!illusion!there!is!a!referent!in!reality!(there’s!something!there!they!just!interpret!it!wrong).! ! With!hallucinations!there!is!absolutely!nothing!there.! ! ! Strategies!for!dealing!with!psychotic!persons!!!First!need!to!ask!yourself:!what!is!their!psychosis?! ! Functional,!dementia,!or!psychotic!delirium?! ! ! Functional! ! Teaching!reality!to!a!functional!psychotic! They!can!function!in!everyday!life!despite!being! ! ! psychotic.!A!chemical!dysfunction!that!has! 1. Acknowledge!feeling!–!!that!must!be! ! potential!to!learn!reality! stressful! ! 2. Present!reality!–!you!see!this!but!I!do!not! !P !Schizophrenia! 3. Set!limits!–!that!topic!is!off!limits! !P !Schizoaffective! 4. Enforce!the!limit!–!I!see!you!were!too!ill! P! !Major!depression! to!continue!the!conversation!so!we!will! P! !Manic!(bipolar!manic!stage)! stop!now! ! ! ! Dementia! Strategies!to!dealing!with!dementia!psychosis! ! ! Brain!is!damaged,!meaning!they!cannot!learn! ! 1. Acknowledge!their!feeling! reality! !P Alzheimer’s!or!organic!brain!syndrome! 2. Redirection! ! ! ! Note:!Do!not!confuse!present!reality!with!reality! Note:!Do!not!present!reality!because!they!can’t! ! orientation!which!is!appropriate!such!as! learn!it!!!it!will!only!make!them!worse!and!do! ! orientation!to!the!room,!place,!etc.! not!set!limits!because!that’s!mean! ! ! ! Strategies!to!dealing!with!delirium!psychosis! Delirium! ! ! A!temporary,!sudden,!dramatic,!secondary,!loss! 1. Acknowledge!the!feeling! of!reality!(due!to!a!chemical!imbalance!in!body)! ! 2. Reassure!them!that!it’s!temporary!and! !P !Overdose!or!withdrawal! they!are!safe! P !Infection,!thyroid!storm,!UTI! ! ! ! Note:!Personality!disorders!are!not!psychosis!so!you!should!use!good!communication!skills.!!! ! Only!use!the!presentation!of!reality!with!ABN’s!(antisocial,!borderline,!and!narcissistic)!!!these! ! patients!would!be!treated!like!a!functional!psychotic!so!you!must!set!limits!as!they!are!very!sick!and! ! often!have!big!problems.! ! ! ! Loosening!of!Association! Narrowed!Self=Concept! (Thoughts!are!all!over!the!place)! When!a!psychotic!patient!refuses!to!leave!their! ! room!or!change!their!clothes! ! Flight!of!ideas!–!the!phrase!make!sense!but!the! ! ! ! ! ! ! phrases!together!don’t! (Functional!psychotic)!They!base!who!they!are! Word!salad!–!cannot!even!make!a!phrase!just! as!a!person!on!their!location!and!what!they! ! random!words! wear!!!if!that!changes!that!terrifies!them! ! Neologism!–!making!up!imaginary!words! ! ! ! Note:!The!only!time!you’re!allowed!to!make!choices!and!direct!a!client!is!when!they!are!nonP ! psychotic!(depressed)!or!are!psychomotor!retarded.! ! DIABETES!MELLITUS! ! ! An!error!of!glucose!metabolism,!glucose!is!the!body’s!main!source!of!energy!and!it!can’t!break! down!due!to!a!lack!of!insulin!or!cells!become!resistant!to!insulin! ! ! ! Note:!Diabetes!insipidus!is!a!different!disease!P!polyuria!and!polydipsia!leading!to!dehydration!due! ! to!low!ADH!(this!looks!like!diabetes!mellitus!but!it!is!just!a!fluid!part!and!not!the!glucose!part)! ! !! Specific!Urine!Gravity!and!Amount!of!Urine! Note:!SIADH!is!the!opposite!of!diabetes!insipid! ! The!relationship!between!the!two!is!inverse…! having!oliguria!and!are!not!thirsty!due!to!water! ! the!less!urine!out,!the!higher!the!specific! retention!–!gain!weight!suddenly!!!fluid! gravity;!the!more!urine!out!the!lower!specific! ! volume!excess! gravity! ! ! ! ! ! ! !Insulin=dependent,!! Non=insulinPdependent!! ! ! ! ! !and!ketosis!prone!are!the! and!non=ketosis!prone!are!! ! ! ! ! !two!types!of!type!I!DM.! the!two!types!of!type!II!DM.! ! SIGNS!AND!SYMPTOMS!(Type!I!DM)! If!Type!II!diabetes!is!not!treated!they!can!end!up! ! The!3!P’s!!!polyuria!polydipsia!and!polyphagia! in!DOA!–!diet,!oral!hypoglycemic,!and!activity! (the!most!important!is!diet,!mostly!diet!alone)! ! If!Type!I!diabetes!are!not!treated!they!can!die!–! ! need!to!manage!diet,!insulin,!and!exercise! Diet:!calorie!restrictions!and!! (insulin!is!the!most!important!&!diet!is!the!least)! ! require!6!small!feedings!a!day! ! ! ! INSULIN! ! ! ! Insulin!acts!to!lower!the!glucose!in!the!blood!—!insulin!R,!N,!humulin,!and!glargine! ! ! Insulin!R!(regular)! Insulin!NPH!(intermediate)! ! Rapid!and!run!a!fast!acting!insulin!that’s!clear!! Not!so!fast!and!not!in!the!IV!bag!because!it’s! ! (Can!run!as!an!IV!drip)! cloudy! !P Onset!1!hour! P Onset!6!hours! !P Peak!2!hours! P Peak!8=10!hours! P Duration!12!hours! !P Duration!4!hours! ! Note:!Hypoglycemia!occurs!when!insulin!is!at!its! Note:!Cloudy!solutions!are!suspensions!and!not! ! peak! IV!because!they!precipitate!(particles!settle)! ! ! ! Humolog/!Lispro! Glargine/Lantus! ! Given!with!meals!(fastest!acting)! Long!acting!insulin!that’s!slowly!absorbed!and! !P Onset!15!minutes! has!no!peak!so!hypoglycemia!is!not!an!issue! !P Peak!30!minutes! P !Duration!12=24!hours! ! !P Duration!3!hours! ! ! Note:!Always!check!insulin!expiration!date!and!once!a!new!bottle!is!opened!it!expires!in!30!days!–! ! write!open!date!and!new!expiration!date!on!bottle.! ! Don’t!refrigerate!unopened!bottles!and!unless!it’s!opened!or!in!the!home.! ! ! ! ! ! ! Exercise! P Exercise!is!like!giving!another!shot!of!insulin;!it!does!the!same!thing.!! P If!you!exercise!you!need!less!insulin!–!always!have!a!snack!when!exercising! ! Diabetic!Sick!Day! When!diabetics!are!sick!their!glucose!goes!higher!and!need!to!take!more!insulin.! Sick!diabetics!have!two!problems,!dehydration!and!hyperglycemia.!They!also!need!to!stay!as!active! ! as!possible!to!keep!blood!sugar!down.! ! ! ! ! ! ! ! Hypoglycemia!! Note:!Low!blood!sugar!appears!as!drunk!and! ! ! ! Due!to!not!enough!food,!! signs!of!shock!–!low!BP,!tachycardia,!tachypnea,! ! ! ! ! too!much!insulin/meds,! &!cool/pale/mottled!skin!! ! ! ! or!too!much!exercise!(the!risk!is! ! Hypoglycemia!Treatment:! ! ! ! brain!damage).!!! Administer!a!rapidly!metabolized!carbohydrate! ! “Drunk!in!shock”! in!combo!with!a!starch!or!protein!(SKIM!MILK!)! ! ! Unconscious!Diabetic!Coma! ! Administer!IM!glucagon!or!hang!10=50%!dextrose!IV!drip! ! ! ! ! Note:!The!setting!determines!the!route!(home!=!glucagon,!hospital!=!IV!dextrose)!and!any! dexterous!solution!less!than!10%!will!not!have!an!effect!on!the!blood!glucose!level.! ! ! ! DKA!Signs!and!Symptoms:! Diabetic!Ketoacidosis!(DKA)! ! Only!type!I!diabetics!can!get!DKA.! D!–!Dehydration!(causes!body!to!overheat!=!hot,! flushed,!dry)! ! The!#1!cause!of!DKA!is!acute!viral!upper! K!–!Ketones!in!the!blood,!Kussmal!respirations! respiratory!infection!within!the!past!two!weeks.! ! (hyperventilate),!and!high!K!(potassium)! ! Normally,!they!recover!but!then!go!downhill! A!–!Acidotic,!acetone!breath,!and!anorexia!due! fast!(the!stress!of!the!illness!increases!the! ! to!nausea! glucose!and!continues!turning!into!DKA)! ! ! ! ! Note:!Ketones!in!the!urine!means!nothing,! DKA!Treatment:! when!it’s!in!the!blood!the!person!is!in!DKA!and! Fast!fluid!resuscitation!with!D5W!and!an!insulin! ! that’s!a!huge!concern! regular!drip!(200mL/hour)! ! ! ! ! ! Hyperglycemic!Non=Ketotic!(HHNK)! Note:!More!people!die!from!HHNK!than!DKA,! ! Only!type!II!diabetics!can!get!HHNK.! they!don’t!have!the!symptoms!like!DKA!and!it! ! Basically!means!dehydration!!having!fluid! goes!unnoticed!longer!!!but!acute!DKA!is!more! ! volume!deficit!where!the!priority!is!fluid! lifePthreatening!(they!just!get!treatment!faster)! ! resuscitation!(hot,!flushed,!dry)! ! ! ! ! ! ! ! ! ! ! The!complications!are!either!due!to!two!things:!poor!tissue!perfusion!(renal!! ! ! ! ! failure/poor!healing)!or!peripheral!neuropathy!(no!feeling!or!bladder!control)! ! ! HA1C!(Glycosylated!Hemoglobin!Test)!! ! Best!lab!test!of!long=term!blood!sugar!control.!!You!want!the!values!to!be!6!or!lower…!7!requires! ! some!work!up!and!8!or!higher!is!out!of!control.! ! ! ! ! ! ! ! ! ! DRUG!TOXICITY’S! ! Lithium! Lanoxin!(digoxin)! ! Anti=mania!drug!in!bipolar!disorder! For!atrial!fibrillation!and!CHF! !P Therapeutic!level!=!0.6=1.2! P Therapeutic!level!=!1=2! !P Toxic!level!≥!2! P Toxic!level!≥!2! ! ! ! ! Dilanton! ! Note:!It’s!safer!to!call!something!toxic!when! !Used!for!seizures! ! they!are!not!than!to!call!something!safe!when! P Therapeutic!level!=!10=20! ! they!are!actually!toxic.! P Toxic!level!≥!20! ! ! ! ! Aminofilin! !Anti=airway!spasmodic!in!the!muscles!(technically!not!a!bronchodilator!because!it!does!not! ! stimulate!the!B2!receptors).!!Sometimes!bronchodilators!do!not!work!in!asthma!attacks!because!the! ! muscles!are!spasming!!!give!Aminofilin!first!then!bronchodilator! ! P Therapeutic!level!=!10=20! !P Toxic!level!≥!20! ! ! Bilirubin! What!is!jaundice?!!Bilirubin!in!the!skin.! ! Waste!product!due!to!the!breakdown!of!RBC’s!! ! Kernicterus:!Bilirubin!in!the!brain!that!occurs! P Therapeutic!elevated!levels!in!newborns! when!the!child’s!bilirubin!reaches!20!and!can! ! 10=20!! cause!death! !P Toxic!level!≥!20! P Opisthotonus:!!Position!child!assumes! ! Can!manage!10!to!13!levels!at!home!with!fluids! when!they!have!Kernicterus! ! (peeing/pooping)!and!sunlight! (hyperextension!and!rigidity)!! ! !At!14!to!15!starting!to!become!toxic!and!need! ! !!put!the!child!on!their!side.! ! ! ! to!go!to!the!hospital! ! ! ! ! Physiological!Jaundice!(typical)!–!! ! Occurs!2=3!days!after!birth! ! ! ! ! ! ! Pathological!Jaundice!(not!good)!–!! Yellow!at!birth!and!something’s!wrong! GASTRO! ! ! ! Hiatal!hernia! Dumping!Syndrome! ! !Regurgitation!of!acid!because!upper!part!of!the! Dumping!syndrome!usually!follows!gastric! ! surgery!for!stomach!contents!dump!too!fast!into! stomach!herniated!the!diaphragm!–!contents! move!at!the!right!rate!but!in!the!wrong! the!duodenum!–!contents!move!in!the!right! ! direction!(2!chamber!stomach)! direction!at!the!wrong!rate!(speeding)! ! ! Symptoms!of!dumping!syndrome…! Symptoms!of!hiatal!hernia…! ! !1. Drunk!(dizziness,!vomiting)! 1. Gerd!(heartburn!and!indigestion)!when! !2. Shock!(flushed)! laying!down!after!eating! !3. Acute!abdominal!distress!(guarding)! (raise!HOB)!(high!fluids)!(high!carbs)! ! ! ! ! TREATMENT! ! The!head!of!bed!position,!amount!of!water!and!food,!and!calories!or!protein! Dumping!Syndrome:!Lower!HOB,!fluids!hours!before/after!meals,!low!carbs! Hiatal!Hernia:!Raise!HOB,!high!fluids,!high!carbs!! ! Note:!Protein!will!always!be!opposite!of!the! number!of!calories! ! Dumping!syndrome!!!you!want!the!stomach!to! ! empty!slower!“when!everything!is!low!the! ! stomach!empties!slow”! ! ! ! Hiatal!hernia!!!you!want!the!stomach!to!empty! faster!because!if!there’s!no!stuff!in!the!stomach! it!won’t!cause!reflux!“in!hiatal!hernia! everything!needs!to!be!high”! ! ! ELECTROLYTE!IMBALANCES! ! ! ! Kalemias! Signs!and!symptoms…! ! Potassium!imbalances!do!the!same!as!the!prefix! Hyperkalemia!–!agitation,!tachypnea,! ! except!for!heart!rate!and!urine!output! ! (Symptoms!will!go!high!with!hyperkalemia!and! ! low!with!hypokalemia)! !! bradycardia,!diarrhea,!+3/4!reflexes,! ↓!urine!OP!! Hypokalemia!–!lethargy,!tachycardia,! bradypnea,!constipation,!flaccidity,!+1!reflexes! ! ! 1. Never!push!K+!IV!and!no!more!than!40!of!K+!per!liter!of!fluid! ! TREATMENT!FOR! 2. D5W!with!regular!insulin!–!the!fastest!way!to!lower!potassium! POTASSIUM!IMBALANCE! ! ! ! ! ! !by!driving!the!K+!into!the!cells!and!out!of!the!blood!(quick!but!! ! ! ! ! ! ! temporary)! ! 3.!!!!!K=exalate!(PO/PR)!–!pill!full!of!sodium!that!when!gets!into!the!gut!it!trades!potassium!for! ! sodium!so!that!the!excess!sodium!is!excreted!from!the!body!(the!sodium!causes!dehydration)!–!just! ! need!to!treat!the!fluids!(slow!but!permanent)!“The!K+!exits!late”!! ! ! Give!D5W!with!regular!insulin!and!K=exalate!at!the!same!time.! ! ! ! Note:!a!‘U’!wave!indicates!heart!depression!due!to!a!low!potassium! ! ! ! Calcemias! Signs!and!symptoms…! ! ! Hypercalcemia!–!bradycardia,!hypoactive! ! reflexes,!bradypnea,!lethargy,!constipation! Calcium!imbalances!do!the!opposite!of!the! ! Hypocalcemia!–!tachycardia,!neuromuscular! prefix!–!if!Ca!goes!high,!everything!goes!low,!etc.! ! irritability!(Chevosteks!sign!P!tap!the!cheek),! ! Trussous!sign!(hand!spasm!with!BP!cuff)! ! ! Magnesemia! Note:!If!there’s!a!tie!don’t!pick!magnesium,!it’s! ! ! probably!not!causing!the!problem.!Skeletal! Magnesium!imbalances!do!the!opposite!of!the! ! muscles!and!nerves!=!Ca.!Anything!else!=!K.! prefix! ! ! Electrolyte!Imbalance!Signs! !! Natremia! P The!earliest!sign!of!any!electrolyte! ! ! imbalance!is!parastesia!(numbness!and! !1. Hypernatremia!—!dehydration! tingling)! !2. Hyponatremia!—!fluid!overload! P !The!universal!sign!of!electrolyte!imbalance! ! ! is!parisis!(muscle!weakness)! ! ! ! ! ! ! ! ! ! ENDOCRINE!GLAND! ! ! The!thyroid!gland!regulates!the!body’s!metabolism.! ! HYPERTHYROIDISM! ! ! ! ! !!!!!High!metabolism—!weight!loss,!irritable/hyper,!heat!intolerance/!cold! ! ! tolerance,!exophthalmos!(bulging!eyes),!hypertension,!tachycardia! ! ! Grave’s!Disease!!!“you!are!going!to!run!yourself!into!the!grave”! ! ! ! Hyperthyroidism!Treatment! ! 1.!!!Radioactive!Iodine!—!patients!should!be!in!a!room!alone!for!24!hours!then!after!it!is!just!their! ! urine!that’s!hazardous!(flush!three!times!and!call!hazmat!for!urine!spills)! ! 2.!!!Prophlyiouracil!(PTU)!—!primarily!a!cancer!drug!used!for!hyperthyroidism!“puts!thyroid!under”.! ! Causes!immunosuppression!so!watch!for!WBC!counts.! ! 3.!!!Thyroidectomy!(total!or!subtotal)!—!removal!of!the!thyroid! ! P Total!!!lifelong!hormone!replacement!and!risk!for!low!calcium!(Chvosteks!sign!and! ! Trousseaus!sign)! ! P Subtotal!!!short=term!hormone!replacement!and!risk!for!thyroid!storm/crisis!(super!high! ! temperature,!heart!rate,!and!blood!pressure,!psychotic!delirium,!medical!emergency!and! ! can!cause!brain!damage! ! Note:!Get!the!temperature!down!and!oxygen! Thyroid!Storm/Crisis! ! up!=!ice,!cooling!blanket,!and!oxygen!mask!(10L)! P! Super!high!temperature!(above!105)! Note:!They!will!come!out!of!it!on!their!own! !P High!heart!rate!(180s)! P High!blood!pressure!(210/180)! when!the!thyroid!levels!get!it!out!of!their!system! ! P Psychotic!delirium! and!do!not!medicate,!it!will!make!them!worse! ! This!is!a!medical!emergency!and!can!cause!brain! Note:!We!are!sparing!their!brain!until!they!come! ! damage! out!of!this! ! ! Thyroidectomy!Post=Op!Risks! ! The!priorities!for!the!first!24!hours!–!airway!and!bleeding.!Between!12!and!48!hours!need!to!pay! ! attention!to!the!type!of!thyroidectomy:! !1. Total!–!tetany!(spasm!due!to!low!calcium)!! ! 2.!!!Subtotal!–!thyroid!storm! ! ! ! !Note:!Infection!should!not!be!a!risk!before!72!hours!of!anything!–!it!takes!time!for!bugs!to!go! ! HYPOTHYROIDISM! ! ! ! Low!metabolism—!weight!gain,!flat/dull!personality,!heat!tolerance/! ! ! ! ! cold!intolerance,!slow!thinkers!(do!not!process!things!fast!enough),!hypotension,!bradycardia! ! ! Risks! ! Hypothyroidism!Treatment! Don’t!sedate!or!give!sleeping!pills!to!these! ! 1.!!!Hormone!replacement!–!they!do!not!have! people!!(could!result!in!coma=myxedema!coma)! ! enough!hormones!so!you!must!replace!them! Always!give!thyroid!hormone!on!the!morning!of! (synthroid,!levothyroxine)! ! surgery!even!if!NPO!(anesthesia!can!cause!a! Myxedema! ! coma!or!death)!!!wont!make!it!off!the!OR!table! ! ! ! ! ! ! ! ! ADRENAL!CORTEX! ! ! ! ! ! These!diseases!start!with!an!A!or!C! Addison’s!disease!and!Cushing!Syndrome! Addison’s!Disease! Under!secretion!of!the!adrenal!cortex.!Signs!and!symptoms!are:!hyperpigmentation!(very!tan)!and! do!not!adapt!to!stress.!Since!they!do!not!have!a!stress!response!they!will!not!raise!blood!glucose! ! and!blood!pressure!under!stress!(easily!causing!brain!damage/death)! !! ! Treatment! ! Note:!Addison’s!patients!are!time!bombs;!even! Give!them!glucocorticoid’s!(steroids)!because!it! ! having!a!tooth!filled!at!the!dentist!or!a!small!car! is!what!they!are!low!on.! ! accident!can!cause!death! “In!Addison’s!you!add!a!sone”! ! ! ! Cushing’s!Syndrome! ! Over!secretion!of!the!adrenal!cortex.!!!!!!!!“if!you!have!a!“cushy”!bank!account!you!have!‘more’”! ! P Moon!shape!face! ! ! ! P!!!!!Central!obesity/H2O!and!sodium!retention! ! P Stretch!marks!and!bruising! ! ! P!!!!!Gynocomastitis!(moobs)! ! P Muscle!atrophy! ! ! ! P!!!!!Irritable!! ! P Immunosuppressed! ! ! ! P!!!!!Hersuitism!(++!hair)! ! P High!blood!glucose! ! ! ! P!!!!!Losing!potassium! ! ! Note:!The!signs!and!symptoms!of!Cushing’s!are!the!same!as!the!side!effects!of!steroids! ! ! ! Note:!If!you’re!a!diabetic!on!a!steroid!the!blood! Treatment! ! sugar!increases!x2,!even!if!the!patient!is!not! Adrenalectomy!–!takes!1=2!years!to!feel!normal! ! diabetic!they!should!get!Q4H!blood!sugar! again!afterwards.! ! checks! P Will!cause!Addison’s!which!will!require! ! ! steroids!(will!look!like!Cushman!again)! ! ! Note:!An!endocrine!surgery!causes!the!opposite!problem!and!will!need!a!medication!to!fix!that! ! ! ! !! Symptoms!of!Cushing’s!! ! (Side!Effects!of!Steroids)! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! CHILDREN’S!TOYS! ! ! When!selecting!toys!or!activities!for!children!there’re!three!things!to!consider:! ! 1. Is!it!safe?!!! ! P No!small!toys!for!children!under!four!(due!to!aspiration)! ! P No!metal!toys!if!oxygen!is!in!use!(metal!may!be!worked!as!diePcast)! ! P Beware!of!fomites!!!non=living!object!that!harbors!microorganisms!(stuffed!animals)! 2. ! Is!it!age!appropriate?! 3. ! Is!it!feasible?!!Could!you!actually!play!in!the!situation!the!child!is!in?! ! 0=6!Months!(infancy)! 6=9!Months!(infancy)! ! Best!toys!are!musical!mobiles!because!this!age! Best!toys!are!cover/uncover!toys!like!window! ! is!learning!sensory=motor!skills.!!!Second!best! books/peek=a=boo!(or!jack!in!the!box)!because! ! option!is!something!that!is!soft!and!large!(so! this!age!is!learning!object!permanence.!!Second! ! they!cannot!hurt!themselves!or!choke)! best!option!is!something!that!is!large!and!hard.! ! Note:!Musical!mobiles!are!worse!at!6=9!months!due!to!strangulation.!!Never!pick!an!answer!with! ! building,!constructing,!stacking,!sorting,!making!if!the!child!is!under!9!months.!It!is!at!9!months!and! ! above!that!children!start!purposeful!activities.! ! ! 9=12!Months!(infancy)! 1=3!Years!(toddler)! ! ! Best!toys!are!push=pull!toys!because!this!age!is! ! Best!toys!are!verbal!toys!because!this!age!is! learning!gross!motor!skills!(running,!jumping,! ! learning!to!speak.! finger!painting)!and!parallel!play.! ! ! 3=4!Years!(preschooler)! 5=12!Years!(school=aged)! ! ! Best!activities!involve!the!3!C’s:!! P Creativity!(let!them!make!it!–!blank! Best!toys!use!finger!dexterity,!balance,!and! ! paper,!Legos)! imagination!because!this!age!is!learning!fine! ! P Collecting!(kids!collect!toys!P!Barbie’s)! motor!skills!and!cooperative!play.! ! P Competition!(school!fundraisers)! ! Note:!Let!teens!hang!out!with!their!friends! 12=18!Years!(adolescence)! ! ! unless!they!are!fresh!post=op!(less!than!12! ! Best!activities!involve!peer!group!association! hours!after!surgery),!immunosuppressed,!or!the! ! like!hanging!out!with!friends.! friend!has!a!contagious!disease.! ! ! ! ! PIAGET’S!STAGES!OF!DEVELOPMENT! ! ! ! ! ! ! LAMINECTOMY! ! ! A!laminectomy!is!the!removal!of!the!vertebrae’s!spinal!processes!—!the!bony!pointy!parts!(wings)! on!the!back!are!removed!to!relieve!nerve!root!compression.! ! ! Signs!of!Nerve!Root!Compression! ! ! The!3!P’s:! Note:!The!most!important!thing!is!to!pay! attention!to!the!location!—!this!determines!the! !1. Pain! 2. Paresthesia!(numbness/tingling)! symptoms,!prognosis,!and!treatment! ! !3. Paresis!(muscle!weakness)! Location!of!Compression! ! !1. Cervical!(neck)! ! ! P!!!!!Diaphragm!–!check!their!breathing! ! ! P!!!!!Arms!and!hands!–!assess!function! !2. Thoracic!(upper!back)! ! ! P!!!!!Cough!–!assess!cough!mechanism!! ! ! P!!!!!Abdomen!–!assess!abdominal!muscles!with!! ! !!!!!!cough!(contraction)!and!assess!bowel!sounds! ! !3. Lumbar!(lower!back)! ! ! P!!!!!Bladder!–!assess!voiding!(distended,!last!time)! ! ! ! ! ! P!!!!!Legs!–!assess!function! ! Postop!Laminectomy!Restrictions! ! 1.!!!Log!roll!for!transferring!in!and!out!of!bed! ! 2.!!!No!dangling!legs.!Sit!at!the!edge!of!bed!only!long!enough!to!overcome!orthostatic!hypotension! 3.!!!Do!not!sit!for!longer!than!30!minutes!–!meals!are!okay! ! ! ! Note:!The!only!restriction!is!sitting!because!it’s! Note:!An!anterior!thoracic!laminectomy!will! ! very!bad!for!the!back!–!they!may!walk,!stand,! have!a!chest!tube!(because!it!goes!through!the! ! and!lay!down!without!any!restriction! front!of!the!body)! ! ! ! Post=op!Complications! ! Cervical!laminectomy!!!trouble!breathing!deeply!causing!risk!for!pneumonia! ! Thoracic!laminectomy!!!trouble!coughing/no!bowel!sounds!causing!risk!for!pneumonia!and!ileus! ! Lumbar!laminectomy!!!urine!retention!and!problems!with!the!legs! ! ! Laminectomy!with!Fusion ! ! Involves!taking!a!bone!graft!from!the!iliac!crest!(hip)!to!use!for!fusion!–!so!there!is!no!grinding!of! ! the!vertebral!bone.!Most!laminectomies!do!not!need!this!because!most!do!not!remove!the!disc.! !P Patient!will!have!2!incisions!—!the!hip!will!have!more!pain,!bleeding,!and!drainage! !P The!risk!for!infection!is!the!same!for!both!incisions!(the!spine!has!↑!risk!for!rejection)! ! ! Laminectomy!Discharge!Teaching! ! The!temporary!restrictions!include:! ! ! The!permanent!restrictions!include:! !– No!sitting!for!longer!than!30!minutes! !!!!!!—!!!!!Bend!with!knees!not!the!waist! !– !Must!lay!flat!and!logroll!for!6!weeks!! !!!!!!—!!!!!Cannot!lift!anything!overhead!and!no! ! – !No!driving!or!lifting!more!than!5!pounds! ! !!jerky!movements!(cervical)! Always!pick!six=week!for!restriction!length.! LAB!VALUES! ! Abnormal!but!not!a!priority! Abnormal,!but!no!need!to!be!concerned!right!now!(monitor!patient)! ! Critical!value!–!hold,!assess,!and!call!the!doctor! ! ! High!priority!and!must!very!concerned!–!do!not!leave!the!bedside!and!require!help! ! ! Serum!Creatine!(0.6=1.2)! INR!(International!Normal!Ratio)!(2=3.5)! ! ! Monitors!Coumadin!(warfarin)!therapy!which!is! Best!indicator!of!kidney/renal!function.! ! blood!clotting.! If!abnormal!this!is!not!a!high!priority…!! !Any!number!above!a!4!is!a!critical!value! ! P Hold!next!dose,!do!a!focused! !P But,!call!doctor!in!morning!if!patient!is! going!for!a!dye!procedure!(nephrotoxic)! assessment,!prepare!to!give!vitamin!K,! ! call!the!doctor! ! !! Potassium!(3.5=5.3)! ! If!potassium!is!greater!or!equal!to!6!the!patient! !A!low!potassium!is!a!critical!value! !P Assess!heart,!prepare!to!give!potassium,! could!die!within!two!minutes!(stay!with!the! ! call!the!doctor!! patient!and!get!team!involved)! P Hold!all!potassium,!assess!heart,!prepare! ! A!high!potassium!is!a!critical!value! for!EKG,!prepare!to!give!Kxalate/insulin,! !P Hold!all!potassium,!assess!heart,!prepare! call!the!doctor! ! to!give!Kxalate/insulin,!call!the!doctor! ! ! ! pH!(from!arterial!line)!7.35=7.45! BUN!(Blood!Urea!Nitrogen)!(8=25)! ! ! !A!pH!of!6!or!less!is!extremely!high!priority! ! Nitrogen!waste!products!in!the!blood.!If!the! (essentially!means!they!are!dead)! value!is!high,!then!assess!the!patient!for! !P Assess!vitals!and!ensure!they!are!alive,! dehydration.! ! call!the!doctor!STAT!! ! ! ! Note:!If!you!are!given!a!question!where!the!blood!lab!tests!are!high!a!good!guess!is!dehydration! ! because!of!the!concentration.!If!the!value!is!low,!then!guess!fluid!volume!access.! ! ! Hemoglobin!(12=18)! ! Only!need!to!know!normal!adult!human!values!not!male!or!female! ! A!value!between!8!and!11!is!most!likely!due!to!bleeding!or!malnutrition! ! A!value!less!than!8!is!a!critical!value! !P Assess!for!bleeding,!prepare!to!give!blood,!call!the!doctor! ! ! Hematocrit!(36=54)! Bicarbonate!(HCO3)!(22=26)! ! Hematocrit!is!always!the!hemoglobin!range!x3.! An!abnormal!value!is!not!a!priority.! ! ! High!hematocrit!is!not!a!big!deal!(dehydration)! ! ! Carbon!Dioxide!(CO2)!(35=45)! ! !A!CO2!value!in!the!50s!is!a!critical!value! !P !Assess!respiratory!status,!prepare!pursed!lip!breathing! ! Note:!Pursed!lip!breathing!–!“blowing!out!a!candle”!prolongs!exhalation!and!rids!excess!CO2,! corrects!the!problem!so!no!need!to!call!dr.! ! A!CO2!value!in!the!60s!is!extremely!high!priority;!patient!is!in!respiratory!failure!(medical! ! emergency)!–!stay!with!the!patient! ! P Assess!respiratory!status,!prepare!for!intubation!and!ventilation,!call!respiratory!therapy! then!call!the!doctor! Note:!This!does!not!apply!to!COPD!patients;!they!have!a!high!CO2!for!respiratory!drive! ! PO2!(78=100)! Note:!Assess!before!you!act!unless!delaying! (oxygen!level!from!arterial!line)! doing!in!order!to!assess!puts!the!patient!at!risk! If!oxygen!is!in!the!low!70s!it!is!a!critical!value! ! ! Hypoxia! P Assess!respiratory!status,!prepare!to! The!HR!will!increase!first!before!the!respiratory! ! administer!oxygen,!do!not!call!doctor!if! rate!because!it’s!trying!to!compensate! ! dyspnea!and!tachycardia!goes!away! Causes!of!episodic!tachycardia!in!cardiac! ! If!oxygen!is!in!the!60s!the!patient!is!in!serious! patients:! ! respiratory!failure! 1. Hypoxia!(administer!O2)! !P Administer!O2,!assess!respiratory!status,! 2. Dehydration!(administer!fluids)! ! prepare!to!intubate!and!ventilate! ! !Note:!If!you!have!2!do!actions!and!position!is!one!of!them!do!that!first!but!if!it!is!a!best!question! ! then!what!would!benefit!them!more!–!O2!rather!than!position! ! ! ! SaO2!is!invalid!when!patient!has!anemia!or!has! SPO2!Saturation!(93=100)! had!a!dye!procedure!in!the!last!48!hours!(false! Anything!less!than!93!is!a!critical!value,!the! ! elevation)! patient!is!in!bad!shape!put!on!O2!then!assess! ! This!gives!an!invalid!O2!sat!reading!making!the! !P In!pediatrics,!kids!do!not!desaturate!!! patient!appeared!better!than!they!actually!are! anything!below!95!is!a!concern! ! ! Sodium!(135=145)! !BNP!(Brain!Neutropedic!Peptide)!(<!100)! Best!indicator!of!congestive!heart!failure.! If!value!is!high!monitor!for!dehydration;!if!low! ! An!elevated!BPN!is!abnormal!but!just!indicates!a! monitor!for!overload.! ! chronic!condition!(monitor)! However,!if!abnormal!value!with!a!change!in! ! ! LOC!it!is!a!critical!value!(safety!issue)! ! ! Total!White!Blood!Cells!(5000=11!000)! Absolute!Neutrophil!Count!(ANC)!(>!500)! ! !If!this!value!is!elevated!it!is!a!critical!value!! If!value!falls!below!500!it!is!a!critical!value!and! !P Assess!for!infection,!prepare! you!must!follow!the!same!steps!as!WBC! ! neutropenic!precautions,!call!the!doctor!! elevation.! ! ! ! Immunity!Cells!(CD4)!(>!200)! Note:!WBC,!ANC,!and!CD4!cells!credit!the!bodies! ! If!this!value!falls!below!200!it!is!a!critical!value;! immunity!system;!if!the!value!changes!they!are! ! indicates!advanced!HIV/AIDS!and!follow!the! all!critical!values!–!indicating!infection!and!a! ! same!steps!as!WBC!elevation.! low!defense!system!! ! ! ! ! Red!Blood!Cells!(4=6!million)! Platelets!>!90!000! ! An!abnormal!value!is!no!big!deal!but!you!must! A!low!value!is!a!critical!value!but!if!the!value!is! ! monitor!the!patient! less!than!40!000!then!establish!thrombopenic! ! ! precautions!!!risk!for!hemorrhage!! ! ! Note:!Organ!transplant!patients!are!also!immunosuppressed! ! ! ! Note:!Memorize!the!5!extremely!high!priorities!first:!! !P pH!in!the!6’s,!potassium!in!the!6’s,!CO2!in!the!60’s!and!O2!in!the!60’s,!and!platelet!count!of! ! less!than!40!000.! ! Then!memorize!all!of!the!critical!values.!If!you!come!across!something!you!did!not!memorize!then! ! it!must!not!be!a!big!deal.! ! PSYCHOTROPHIC!DRUGS! ! ! All!psych!drugs!cause!low!blood!pressure!and!weight!changes! ! ! Phenothiazine!(old!major)! ! The!first!generation!antipsychotics!—!all!drugs!in!this!class!end!in!“zine”;!they!decrease!the! ! symptoms!of!psychotic!diseases! P ! Small!doses!of!phenothiazine!can!be!used!as!antiemetic’s!where!large!doses!are!antipsychotics! ! (“use!zines!for!the!zany”)!—!considered!major!tranquilizers!and!are!used!when!nothing!else! ! works!(big!guns)! ! ! Major!Side!Effects!of!Phenothiazine! Note:!EPS!is!a!side!effect!that!looks!like! ! Parkinson’s!P!rigidity!and!shuffling!gait.!EPS!will! A!—!anticholinergic!(dry!mouth)! ! receive!Parkinson’s!drugs!to!treat!this!but!this! B!—!blurred!vision! ! increases!dry!mouth!and!constipation!further! C!—!constipation! ! ! D!—!drowsy! Note:!When!a!client!is!experiencing!EPS!teach! E!—!extra!pyramidal!syndrome!(EPS)! ! the!patient,!inform!the!doctor,!and!continue!to! F!—!photosensitivity!(skin!burns!to!light)! ! give!the!medication! aG!—!agranulocytosis!(low!WBC!count)! ! ! ! ! All!of!the!listed!side!effects!for!phenothiazine! Dacanate! ! put!the!patient!at!risk!for!injuries!so!safety!is! Usually!comes!at!the!end!of!many!drug!names! ! the!#1!nursing!diagnosis!for!this!and!other! (meaning!a!long!acting!IM!injection)!–!for!non= tranquilizers! compliant!client’s!(may!have!court!orders)! ! ! ! ! Tricyclic!Antidepressants!(NSSRI)! ! A!non=selective!serotonin!reuptake!inhibitor!that!is!used!to!treat!depression!by!elevating!mood! P ! These!drugs!take!2!to!4!weeks!before!they!start!to!work!but!the!patient!can!take!these!forever! ! Elavil!—!tofranil!—!adadil!—!desyrel! ! Side!Effects!of!Tricyclic!Antidepressants! A!—!anticholinergic!! ! B!—!blurred!vision! If!you!can!remember!that!Elavil!elevates!your! ! mood!and!link!the!3!others!with!it,!it!will!help! C!—!constipation! ! D!—!drowsy! ! you!to!remember!what!they!do!! E!—!euphoria! ! ! ! ! Benzodiazepines! Antianxiety!medications!considered!to!be!minor!tranquilizers!(always!has!‘zep’!in!the!name)! ! !P These!medications!work!right!away!but!can’t!be!taken!longer!than!2=4!weeks! P ! ! Benzodiazepine!Side!Effects! ‘Zeps’!can!also!be!used!for!pre=op!anesthesia,! A!—!anticholinergic!! ! muscle!relaxants,!alcohol!withdrawal,!seizures,! B!—!blurred!vision! and!patients!on!ventilator’s! ! C!—!constipation! P Also!used!with!antidepressants!as!a! ! D!—!drowsy! substitute!until!they!kick!into!effect! ! ! ! Monamine!Oxidase!Inhibitor!(MAOI)! ! Antidepressants,!still!given!but!not!common!!!these!meds!all!start!with!‘mar,!nar,!or!par’! ! ! To!prevent!a!hypertensive!crisis!patients!must!avoid!all!food!containing!tyramine! ! Remember!the!salad!BAR:! B!–!bananas!!!A!–!avocado!!!R!–!raisins!(dried!fruit)! ! More!tyramine!foods!to!avoid:! P No!organs,!preserved!or!processed!meats! P No!cheese!or!yogurt!(may!have!cottage!and!mozzarella!cheese)! !P No!alcohol,!chocolate,!caffeine,!soy!sauce,!or!OTC!elixers! ! ! Lithium! ! Used!to!treat!bipolar!disorder!by!decreasing!mania! ! P This!is!the!only!psych!drug!that!does!not!mess!with!neurotransmitters,!it!stabilizes!nerve! ! cell!membranes! !P Lithium!is!very!similar!to!an!electrolyte!and!only!works!well!with!normal!sodium!level! ! ! Lithium!Side!Effects! ! ! Lithium!is!a!unique!drug!and!has!unique!side! Note:!The!first!indicator!of!electrolyte! ! effects!(the!3!P’s)! imbalance!is!numbness/tingling! !!!!!P!!!!!Peeing!!!!!P!!!!!Pooping!!!!!P!!!!!Paresthesia! ! ! ! ! Toxic!effects!of!lithium! The!#1!nursing!intervention!when!someone!is! ! 1. Tremors! on!lithium!is!to!increase!fluids!(constant!peeing/! !2. Metallic!taste! pooping!making!them!at!risk!for!dehydration)!! !3. Severe!diarrhea! !!must!watch!Na!levels! ! P Low!Na!=!lithium!more!toxic! Note:!If!you!notice!any!signs!of!toxicity!hold!the! ! P High!Na!=!lithium!is!ineffective! med!and!call!the!doctor! ! ! Prozac!(SSRI)! ! A!selective!serotonin!reuptake!inhibitor!that!is!similar!to!Elavil!(NSSRI)!so!the!same!set!of!side! ! effects!belong.!However,!Prozac!can!cause!insomnia!so!you!must!give!the!medication!before!noon.!! ! ! ! Side!Effects!of!Prozac! ! A!—!anticholinergic!! ! B!—!blurred!vision! ! Note:!If!there’s!a!dose!change!watch!for!suicidal! C!—!constipation! ! D!—!drowsy! risk!in!adolescence!and!young!adults!only! ! E!—!euphoria! ! ! ! ! Haldol! ! First!generation!antipsychotic!that!has!a!decanate!form!(longPacting!IM)!—!hits!patients!hard! ! Neuroleptic!malignant!syndrome!(NMS)!—!elderly!patients!and!young!white!schizophrenics!may! ! develop!NMS!from!an!overdose!of!Haldol!(similar!to!EPS!but!hyperpyretic!(106P108°))! ! ! EPS!vs.!NMS! ! Note:!Taking!the!patients!temperature!will!tell! Both!will!have!anxiety!and!tremors! the!difference!between!the!two,!NMS!will! !P EPS!is!a!side!effect! always!have!a!high!temperature! !P NMS!is!a!toxic!effect!(emergency)! ! ! ! Clozapine/Clozaril!(new!major)! ! A!second!generation!antipsychotic!that!was!made!to!replace!phenothiazine’s!and!Haldol!with!less! ! side!effects!(used!to!treat!severe!schizophrenia)!! !P The!problem!with!this!drug!is!agranulocytosis!–!destroys!bone!marrow!making!patients!very! ! susceptible!to!infection! ! ! P P Not!everyone!will!have!the!side!effects!so!you!need!to!watch!white!blood!cell!counts! ! ! Note:!Geodon!is!a!type!of!clozapine!that!can! Typically,!all!clozapine’s!medications!! cause!QT!elevation!–!sudden!cardiac!arrest!(do! will!end!with!‘zapine’! not!use!with!heart!problem!patients)! ! ! ! Sertraline/Zoloft!Antidepressant!(SSRI)! ! Antidepressant!—!causes!insomnia!but!can!be!given!at!bedtime ! ! ! ! ! Sertraline!interferes!with!other!drugs!by!messing!with!the!metabolism!in!the! Interactions! ! ! ! liver!causing!other!drugs!to!accumulate!becoming!toxic!(must!lower!the!dose! ! ! ! ! ! of!most!other!drugs!patient!is!on)! ! ! !Avoid!St.!John’s!wort!with!this!drug!it!can!cause!serotonin!syndrome!–!signs!of!this!are!SADHead! ! !P S!—!sweating! P A!—!apprehension!(sense!of!doom)! !P D!—!dizzy! !P H!—!headache! ! ! Sertraline!must!not!be!given!with!Coumadin!because!it!will!cause!hemorrhage!–!you!need!to! ! decrease!warfarin!dose!so!it!does!not!become!toxic! ! ! ! MATERNAL/NEWBORN! ! ! ! ! ! ! ! ! !! Calculating!a!Due!Date! Take!the!first!day!of!the!last!period,!add!7!days,! !! and!subtract!three!months! ! ! ! Note:!Take!the!week!of!gestation!and!subtract! ! 9!pounds!(will!give!you!the!ideal!weight!gain)! ! !P If!the!mother!is!3=4!lbs!over!the!ideal! weight!gain!–!assess!(could!be!trouble)! ! ! ! ! FUNDAL! The!fundus!is!not!palpable!until!! HEIGHT! ! ! ! the!12th!week!in!at!20=22!weeks! ! ! ! the!fundus!height!is!at!the!belly!button! ! ! Four!Positive!Signs!of!Pregnancy! ! ! !1. Fetal!skeleton!present!on!xPray! ! First!trimester!—!will!gain!one!pound!per!month! (3!lbs!total)! Second!&!third!trimester!—!will!gain!1!pound! per!week!! Overall!the!mom!will!gain!28!±3!pounds! ! ! ! Note:!Fundal!height!helps!determine!what! trimester!the!mom!is!in! ! ! P P !2. Fetal!presence!on!ultrasound! !3. Auscultation!of!fetal!heart!rate! 4. Examiner!feels!fetal!movement! ! ! Quickening!(kicking)!(16=20!weeks)! ! First!able!to!auscultate!at!16!weeks! ! Most!likely!able!to!auscultate!at!18!weeks! ! Should!be!able!to!auscultate!by!20!weeks! ! ! Average!Pregnancy!Weight!Gain! ! P P Possible!Signs!of!Pregnancy! All!urine!and!blood!pregnancy!tests! Chadwick!sign!–!cervical!color!change!to! cyanosis!(1st)! Goodell’s!sign!–!cervical!softening!(2nd)! Hegar!sign!–!uterine!softening!(3rd)! Fetal!Heart!(8=12!weeks)! ! First!able!to!auscultate!at!8!weeks! Most!likely!able!to!auscultate!at!10!weeks! Should!be!able!to!auscultate!by!12!weeks! Patient!Teaching!—!Office!Visits! Check!up!visits!once!a!month!until!week!28!–!at!28!weeks’!visit!occur!every!two!weeks!until!36! weeks.!At!36!weeks’!visits!occur!once!a!week!until!delivery!or!42!weeks!(induction!or!CPsection)! Normal!Fall!of!Hemoglobin! ! First!trimester!=!11! ! Second!trimester!=!10.5! ! Third!trimester!=!10! ! The!normal!female!hemoglobin!range!is!12=16! ! ! ! ! ! Discomforts!of!Pregnancy! Morning!sickness!–!first!trimester!(need!dry! carbohydrates!before!rising!from!bed)! Urinary!incontinence!–!first!and!third!trimester,! not!second!because!baby!is!up!high!(abdominal! pregnancy).!Treat!by!voiding!every!two!hours.! Difficulty!breathing!–!second!and!third! trimester!(tripod!position)! Back!pain!–!second!and!third!trimester!(pelvic! tilts!exercises!P!push!hips!forward)! ! True!Sign!of!Labor! ! ! Onset!of!regular!progressive!contractions! ! ! ! Terms!to!Know! !P Dilation:!the!opening!of!the!cervix!from!0!to!10!cm! !P Effacement:!thinning!of!the!cervix!(from!thick!to!100%!effaced)! !P Station:!relationship!of!fetal!presenting!parts!to!mom’s!ischial!spines! o The!ischial!spines!are!the!smallest!diameter!of!which!the!baby!has!to!fit!to!be!born! ! vaginally!(narrowest!part)! !P Negative!station:!the!presenting!part!is!above!the!tight!squeeze!(ischial!spines)! !P Positive!station:!babies!presenting!part!is!below/made!it!through!the!tight!squeeze! !P !P ! !P Engagement:!is!station!zero!where!the!babies!presenting!part!is!at!the!tight!squeeze! Lie:!the!relation!between!the!spine!of!a!mom!and!the!spine!of!the!baby! o Vertical!lie!is!good!and!perpendicular!lie!is!bad!(transverse!‘t’)! Presentation:!the!part!of!the!baby!that!enters!the!canal!first!(most!common!is!ROA!or!LOA).! ! !!Mark!would!pick!ROA!before!LOA! ! !P Four!Stages!of!Labor!and!Delivery! LABOR!–!Has!three!phases…! 1! ! ! 1. Latent! ! !!!!!Stage!#1!—!LABOR! 2. Active! ! !!!!!Stage!#2!—!DELIVERY!OF!BABY! 3. Transition! ! !!!!!Stage!#3!—!DELIVERY!OF!PLACENTA! “LAT”!in!latent!gives!the!order!they!occur!in! ! !!!!!Stage!#4!—!RECOVERY! Purpose!of!uterine!contractions!is!to!dilate!and! ! efface!the!the!cervix! ! !DELIVERY!OF!PLACENTA!! DELIVERY!OF!BABY!! ! Purpose!of!uterine!contractions!is!to!! ! push!the!baby!out! ! ! RECOVERY!(two!hours)! ! Purpose!of!uterine!contractions!is!to!! ! stop!bleeding!! ! ! Phase!#1!=!LATENT! ! !P !!!!P!!!!Dilation!=!0=4!cm!! P Frequency!=!5=30!minutes! !P Duration!=!15=30!seconds! !P Intensity!=!mild! ! 2! ! 4! ! 3! Purpose!of!uterine!contractions!is!to!! ! push!the!placenta!out!! ! Note:!Postpartum!does!not!begin!until!2!hours! after!the!delivery!of!the!placenta!(after!the! recovery!time!has!passed)! ! P P P P Phase!#2!=!ACTIVE! Dilation!=!5=7!cm! Frequency!=!3=5!minutes! Duration!=!30=60!seconds! Intensity!=!moderate! P !P !P P Phase!#3!=!TRANSITION! Dilation!=!8=10!cm! Frequency!=!2=3!minutes! Duration!=!60=90!seconds! Intensity!=!strong! Note:!Contractions!should!be!no!longer!the!90! seconds!or!be!any!closer!than!every!two! minutes!! Uterine!tetany!or!uterine!hyperstimulation! !!!!!!!Must!stop!pitocin!infusion! ! ! ! ! Duration:!the!beginning!to!the!end!of!the! ! Note:!Teach!mom!to!palpate!contractions!with! contraction! ! Frequency:!the!beginning!of!one!contraction!to! one!hand!over!the!fundus!with!the!pads!of!the! ! fingers!pressing!gently! the!beginning!of!the!next! ! Intensity:!strength!of!the!contraction!! ! ! COMPLICATIONS!OF! ! LABOR! ! ! Protocols!for!complications!! ! !P Painful!back!labor!(OP)!–!position!on!hands!and!knees!(knee/chest)!then!push!on!sacrum! P Prolapsed!cord!–!emergency!where!the!cord!is!the!presenting!part!and!when!the!head!of! ! the!baby!pushes!on!it,!the!baby!dies.!Must!push!head!back!up!and!then!position!knee/chest! ! All!other!labor!complications!are!treated!the!same!way!(by!using!LION):! ! ! L!–!turn!them!on!their!left!side! ! ! I!–!increase!IV! ! ! O!–!oxygenate! ! ! N!–!notify!doctor! ! ! ! Note:!In!an!OB!crisis,!if!PIT!(pitocin!or!oxytocin)! Pain!Medications! is!running!than!the!first!thing!to!do!is!to!stop!it.!! Do!not!give!pain!meds!if!the!baby!is!likely!to!be! ! PIT!comes!before!LION! born!when!the!medication!peaks! ! ! ! ! ! ! ! Fetal!Heart!Tracing! ! ! ! ! ! ! 1.!!!!!Low!fetal!heart!rate!–!below!110!(bad!LION)! ! 2.!!!!!High!fetal!heart!rate!–!above!160!(not!bad!just!take!mom’s!temperature!P!probably!a!fever)! ! 3.!!!!!Low!variability!–!heart!rate!does!not!change!(bad!LION)! ! 4.!!!!!High!variability!–!heart!rate!always!changing!(good!–!document)! ! 5.!!!!!Late!decelerations!–!the!heart!rate!slows!at!the!end/after!contraction!(bad!LION)! ! 6.!!!!!Early!decelerations!–!the!heart!rate!slows!down!at!the!beginning/before!contraction!(good!–!! !!!!!!!!document)! ! 7.!!!!!Variable!decelerations!–!prolapse!cord!so!need!to!push!then!position!(very!bad!)! ! ! ! Note:!!The!answer!that!always!wins!in!maternity!nursing!is!check!fetal!heart!rate!no!matter!what! ! happens! ! ! Causes!of!Fetal!Heart!Rate!Changes! ! ! ! 1.!!!!!Variable!decelerations! ! !! Cord!compression! ! ! ! 2.!!!!!Early!decelerations! ! !!! Head!compression! ! ! ! 3.!!!!!Acceleration!! ! ! !!! Okay!! ! ! 4.!!!!!Late!decelerations!!!!!! ! !!! Placental!insufficiency! ! Delivery!of!the!Placenta! Delivery!of!the!Baby! ! 1. Deliver!the!head! This!is!the!third!stage!of!labor!and!delivery!–!you! !2. Section!mouth!then!nose! need!to!ensure!the!following:! !3. Check!for!a!nuchal!cord!(around!the! 1. Make!sure!it’s!all!there! neck)! !4. Deliver!the!shoulders/body! 2. Check!for!3!vessel!cord!(AVA)!–!2! !5. The!baby!must!have!an!ID!band!on! arteries!and!1!vein! ! ! before!it!leaves!the!delivery!room! ! ! Recovery! ! This!is!the!fourth!stage!of!labor!and!delivery!–!in!the!first!two!hours!after!the!delivery!of!the! ! placenta!–!There!are!4!for!things!to!do!x!4!in!the!fourth!stage! !1. Vitals!–!assess!for!shock! !2. Fundus!check!–!massage!if!boggy!&!catheterize!if!displaced! !3. Pad!check!–!100%!saturation!is!bad!but!if!not!100%!saturated!every!15!min!then!its!okay! !4. Roll!her!over!–!check!for!bleeding!underneath!! ! ! Postpartum!Assessment! ! Performed!every!4!to!8!hours!depending!on!how!stable!the!mom!is!–!BUBBLE!HEAD! ! !!!! ! ! ! P!!!Breasts! !!!! ! P!!!Uterine!fundus!!!!! ! =!!!Hemoglobin/hematocrit! ! ! !!!! ! ! P!!!Bladder! !!!!!!!!!!!!!! P!!!Extremities!! ! !!!! ! ! P!!!Bowel! !!!!!!!!!!!!!! P!!!Affect!(emotional)! ! !!!! ! ! P!!!Lochia! !!!!!!!!!!!!!! P!!!Discomfort! !!!! ! ! ! P!!!Episiotomy! ! ! Note:!Uterine!fundus!should!be!hard!and! Note:!When!checking!the!extremities!measure! ! midline.!Measure!in!centimeters!below!the!belly! calf!circumference!bilaterally!to!determine!if! ! button!the!number!of!days!postpartum! there!is!thrombophlebitis!(blood!clot)! ! ! ! ! Variations!in!the!Newborn! ! Note:!Lochia!is!vaginal!drainage!that!should! !All!are!normal!even!though!they!sound!bad:! ! cover!4!to!6!inches!of!the!pad!each!hour!and! P Erythemia!toxicum!–!rash! ! progresses!through!types:! P Cephalohematoma!! !P Rubra!–!red! P Caput!succedaneum!–!crosses!sutures! P Serosa!–!pink! ! and!is!symmetrical! P Alba!–!white! P Hyperbilirubinemia!! ! ! ! ! Maternity!Medications! ! !1. Tocolytics!!!to!stop!premature!labor:!! o Terbutaline!will!also!cause!maternal!tachycardia! ! ! ! ! o Magnesium!sulfate!will!decrease!HR,!BP,!respirations,!and!reflexes! ! 2. Oxytoxics!!!stimulate!and!strengthen!labor!contractions:! !! o Pictocin!will!cause!uterine!hyper=stimulation!(!>!90!seconds!or!closer!than!2!mins)! ! o Methergine!will!also!cause!maternal!hypertension! ! 3. Fetal!lung!maturing!medications:! o Betamethasone!–!given!to!the!mom!by!IM!before!the!birth! o Survanta!(surfactant)!–!given!to!the!baby!by!transtracheal!(neb)!after!birth!! HELPFUL!HINTS!AND!TRICKS! ! ! Humulin!70/30! ! Insulin!70/30!is!a!mix!of!R!and!N!insulins!having!70%!of!N!(longPacting)!and!30%!of!R! != 70/30!is!a!fraction,!you!can!remember!that!N!is!70!because!it!is!the!numerator!! ! !!Mixing!insulin!P!!use!RN,!but!if!injecting!air!and!then!drawing,!inject!air!into!NR!then!draw!RN! ! ! Heparin! Coumadin! Injection!needle!sizes! ! IM!–!21G!(1!in)!!!‘I’!looks!like!a!1!so!choose!the! ! IV!or!SQ! PO! answer!with!1!in!both!parts! Fast=acting! Slow=acting!! ! S/C!–!25G!(5/8!in)!!!‘S’!looks!like!a!5!so!choose! (immediately)! (takes!daysPweeks)! ! the!answer!with!5!in!both!parts! Cannot!be!given! Can!be!given!for!the! ! ! longer!than!3!weeks! rest!of!your!life! Diuretics! ! (except!for!Lovenox)! ! Probably!the!only!question!we!will!get!is!‘does!it! ! because!antibodies! waste!K+!or!spare!K+’?! !P Any!diuretic!ending!in!x,!x’s!out!the!K+! start!to!develop!! Antidote!is! Antidote!is!vitamin!K! ! (wastes!K+),!everything!else!are!K+! protamine!sulfate! ! sparing!diuretics!(except!ending!in! PTT!lab!test! PT!(INR)!lab!test! ! ‘diuril’)!! ! Can!give!to!pregnant! Can!not!give!to! ! ! moms! pregnant!women! ! ! Note:!Can!only! ! Muscle!Relaxants! give!the! Cause!fatigue!and!muscle!weakness.!!! ! antipsychotic! !!Teach!patient!not!to!drink,!drive!or!operate! ! Haldol!to!a! heavy!machinery!! ! pregnant!mom! How!to!remember!baclofen!and!flexeril:! ! ! !“On!your!back!lofen!or!flexing!your!muscles”! ! ! 0!to!2!years!–!sensorimotor! 3!to!6!years!–!preoperational! ! ! – Fantasy!oriented!not!logic/reason! !– Can!only!think!of!the!present! – Understand!past/future! !– !Use!voice!not!play! – Learn!through!play! ! “while!we!do!it!we!will!tell!them!what!we!are! “on!the!day!of!teach!what!you!are!going!to!do! doing”! ! through!play”! ! ! ! 7!to!11!years!–!concrete!operational! 12!years!and!up!–!formal!operational! ! ! – Rule!oriented!not!abstract! – Abstract!thinkers!–!can!think!of!cause! !– Rigid!and!only!1!way!to!do!things! and!effect! !– Learn!days!before! – Learn!as!adults,!so!you!must!teach!them! !– Teach!them!what!you!are!going!to!do! like!an!adult! ! and!skills!! – Can!manage!own!care!and!decisions! !– Use!agePappropriate!reading!and! ! demonstration! ! ! ! ! Note:!The!age!of!the!kid!determines!if!they!can!manage!their!care,!not!the!problem!they!have!–! Managing!is!knowing!when!to!seek!help! ! Seven!principles!to!obey!in!psych!questions:! 1. Know!what!phase!of!the!patient!relationship!you!are!in! !2. Do!not!give!or!accept!gifts! 3. Do!not!give!advice! ! 4. Always!keep!the!patient!talking;!do!not!end!the!conversation!! !5. Do!not!refer!to!someone!else! !6. Do!not!use!slang!or!figure!of!speech!they!take!everything!seriously! !7. Empathy!–!accepts!the!patient’s!feelings!as!being!valid!(do!not!choose!the!answer!that! ! restates!what!they!said)! ! ! Four!steps!for!empathy!questions:! !1. Notice!it’s!an!empathy!question!–!quotes!in!question!and!quotes!in!answers! !2. Put!yourself!in!the!client’s!shoes!and!say!what!they!said!and!mean!it! !3. If!you!said!those!words!and!really!meant!them,!think!how!would!feel!right!now! !4. Choose!the!answer!that!reflects!that!feeling!(not!what!reflects!their!words)!and!do!not!pick! ! repeating!what!already!said! ! ! ! ! ! ! Decide!what!patient!is! The!Rules!of!Prioritization! ! ! ! ! the!sickest!or!healthiest! !1. Age!–!not!important!in!prioritization!! 1. Acute!is!always!higher!than!chronic! 2. Gender!–!not!important!in!prioritization! 2. Less!than!12!hours!fresh!post=op!is!more! ! 3. Diagnosis!–!important! priority!than!medical!or!other!surgical! ! 4. Modifying!phrase!–!this!is!always!more! 3. Unstable!beats!stable! ! important!so!pay!attention!to!this! ! ! ! Three!things!that!are!always!unstable!even!if!it! ! Stable! Unstable! is!expected! ! Chronic!illness! Acute!illness! 1. Hemorrhage! ! PostPop!greater!than! PostPop!less!than!12! 2. High!fevers!(they!can!seize)! hours! ! 12!hours! 3. Hypoglycemia! Local/regional! General!anesthetic! 4. Pulseless!and!breathless!at!an! ! anesthetic! unwitnessed!accident!are!considered! ! A/B!lab!abnormal! C/D!lab!abnormal! dead!but!if!it’s!witnessed!they!are!a! ! values! values! priority! ! ! ! Not!ready!for! Black!tagging!people!(unwitnessed!event)! ! discharge,!newly! Ready!for!discharge! P Pulseless!! diagnosed,!newly! !or!admitted!more! P Breathless! admitted,!or!admit! ! than!24!hours!ago! P Fixed!and!dilated!pupils! less!than!24!hours! ! ! ago! ! The!breaking!rules!for!prioritization! Unchanged! Changing!or!changed! ! assessments! The!more!vital!the!organ!the!higher!the!priority! assessments! ! Experiencing!the! ! (organ!of!the!modifying!phrase!and!not!of!the! Experiencing!the! diagnosis!itself)! ! expected!signs!and! unexpected!signs!and! 1. !Brain! ! ! 2.!!!!!Lungs! !symptoms!of!the! symptoms! !!!!!!!3.!!!!Heart! ! ! 4.!!!!!Liver! disease!which!they! ! !!!!!!!5.!!!!Kidney! ! 6.!!!!!Pancreas! were!diagnosed!with! ! ! ! ! ! DELEGATION! Delegation!NOT!for!the!LPN! ! ! 1. Start,!hang,!mix,!or!push!IV!drugs!–!they!can!maintain!and!document!the!flow! ! ! 2. Administer!blood!products!or!mess!with!central!lines! ! 3. Create!care!plans!–!they!can!implement!the!care!plan! ! 4. Plan!or!develop!teaching!–!they!can!reinforce!it! 5. Care!for!unstable!patients! ! 6. Be!or!do!the!first!of!anything!! ! P Vitals,!dressing!change,!ambulation,!assessment,!etc.! ! 7. Can’t!admit,!discharge,!transfer!or!perform!the!first!assessment!after!a!change! ! ! Delegation!for!the!Aid!(UPA)! Note:!Be!cautious!about!letting!UPA’s! ! 1. Can!put!on!OTC!topical!barrier!creams! catheterize!–!pick!any!other!option!unless!it’s! ! and!do!enemas!(can’t!do!treatments)! the!only!one! ! 2. Can!do!vitals!and!blood!glucose!checks! ! Delegation!to!Families! ! (cannot!do!assessments)! Do!not!delegate!any!safety!responsibilities!to! 3. Can!help!with!ADL’s!(not!the!firsts)!and! ! document!about!what!was!done!but!not! the!family!–!the!nurse!is!responsible!for!the! ! safety!of!the!patient! about!the!patient!! ! ! ! Intervening!with!Inappropriate!Behaviors! ! ! ! Handling!staff!when!they!do!something!stupid! ! ! Never!ignore!it–!take!the!opportunity!to!teach!and!change!the!behavior! ! 1. If!what!they’re!doing!is!illegal!–!tell!the!supervisor! ! 2. Is!anyone!in!immediate!danger–!confront!immediately!and!takeover! ! 3. If!not!illegal!or!harmful!but!inappropriate!–!talk!to!them!at!a!later!date! !! ! ! ! ! ! ! Psychology! ! ! 1. Knowledge! 1. Best!answer!to!psych!questions!is!the! ! 2. !Common!sense! nurse!will!examine!their!own!feelings!so! 3. !Guessing!strategy! ! not!to!counter!transfer! ! ! 2. Establish!a!trusting!relationship! ! !! Nutrition! ! 1. In!a!tie!pick!chicken!(not!fried)!and!if!that’s!not!there!pick!scale!fish!(not!shell!fish)! ! 2. Don’t!choose!the!casserole!for!a!child!they!won’t!eat!it! ! 3. Don’t!mix!medications!in!children’s!food!and!must!ask!before!you!do!it!for!an!adult! ! 4. Give!toddlers!finger!foods! ! 5. Preschoolers!leave!them!alone!–!one!meal!a!day!is!okay;!they!eat!when!they’re!hungry! ! ! Medications! ! P If!you!know!the!drug!but!not!the!side!effects!–!pick!a!side!effect!in!the!same!body!system! where!the!drug!is!working! ! ! P If!you!have!no!clue!what!a!drug!is!but!it’s!given!PO!–!guess!the!GI!side!effects! P Do!not!tell!a!child!that!medication!is!candy! ! ! Child’s!Growth!and!Development! Medical!–!Surgical! ! Questions!are!always!based!on!giving!the!child! ! ! more!time!to!develop!–!when!in!doubt:! 1. The!first!thing!you!assess!is!LOC! ! P Call!it!normal! 2. The!first!thing!you!do!is!establish!an! ! P Pick!the!older!age! airway! ! P Pick!the!easier!task! ! !! ! General!Guessing!Skills!for!the!NCLEX! ! 1. Two!answers!say!the!same!thing!don’t!pick!them! ! 2. If!two!answers!are!opposite,!one!of!them!is!probably!right! ! 3. If!want!to!pick!all!of!the!above–!look!for!an!umbrella!answer! ! 4. If!have!one!patient!and!need!to!choose!their!priority!need–!think!about!the!worst! consequence!if!you!don’t!do!something! ! ! 5. Is!stuck!between!two!answers!reread!the!question!for!clues/if!you!missed!something! ! 6. When!nothing!else!works–!all!the!wrong!answers!are!all!the!same,!the!right!answer!is! different!than!all!others! ! 7. Don’t!answer!questions!based!on!ignorance,!base!it!on!knowledge! !! !
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