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Mark!Kilmek!NCLEX!Review!
Audio!Recordings!
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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!
!!
!