Lecture Notes NCLEX

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LECTURE 1ACIDBASES- learn how to convert lab values to words- the rule of theB s= if the p H a n d the BiCarb are bothinthe samedirection - > m e t a b o l i cH i n t : draw arrows beside each to see directions* down =acidosis* up = afka/osis- respiratory - > has nobinit; ifin other directions(orifbicarb is normal value)- K N O W N O R M A L p H ,B i C a r b , C O 2. Hint:DON'T MEMORIZE LISTS...knowprinciples(they test knowledge of principles b y having yougenerate lists..) _fo r"select all" queBtiona- ex. in general/prindple what d o opioids/painmeds do? = sedate you, C N S depressors" ex. what coea dilaudid do? dorff memorize specificsor a list of dilaudid, know principles of opioids(suchas sedation, CNS depression -> lethargy, flacc dity,reflex +1, hypo-reflexia, obtundedj- boards dorit test b y lists because all books/classes have different lists* principles of S & Sa c i d b a s e s : a s thep H goes s ogoes m y patient (except K+)- p H u p = P T up - > body system gets moreirritable, hyper-excitable (EXCEPT K + )- > alkalosis -thrnk o fa body system and g ohigh:hyper-reflexive (+3, + 4 [2 i s normal]),tachypnea, tachycardia, borborygmi, seizure- p H down = P T down - > body systemsshutdown (EXCEPT K+)- > acidosis -ffi/nAcof a system and g o iow.hypo-reflexive (+1, 0). bradycardia, lethargy,obtunded, paralytic illeus, respiratory arrest. ex. which acid-base disorders need an ambu-bag atthe bedside? = acidosis(resp. arrest)- ex.which acid-base disorders need suction at thebedside? = alkalosis(seize and aspirate)- M a c Kussmaul -Kussmaul's (compensatoryrespiratory mechanism) is only present inonly 1ofthe 4 metabolic (add-base) disordersFM = metabolicA C = acidosis■most common mistake with se ect all questions =selectingone more than you should(stop when you select tne onesyou know! don't get caught up on the "could be's')■Hint:don't select rroneorail onselect all that applyquestions (never only one a n d never all).C a u s e s o f Acid-Base I m b a l a n c e :- scenarios and what acid-base disorder wouldrestrif {what would cause a n imbalance)** DON'T MIX U P S 4 S and CAUSATION- often what cajses aemelh ng is the opposite of the S&S- ex. diarrhea willcausea metabol c ac idosis but onceyou are ac dotic yourbowel shuts down and you get aparalytic illeus- when you get scenarios:- > if it's a l u n g scenario = respiratory- thencheck if the clientisover-venWatrng(atfcafosrs) o runder-ventilating (acidosis)- remember to look at the words (ex. over, under,ventilating) - > "as the p H goes s o gees m y PT"-> VENTILATING DOESNT MEAN RESPIRATORYRATE; resp. rate isirrelevsnfwlacid-base,ventilation has to co with gas excharge not resp.rate ( oak at t i e SaO2 -> il your resp. rate is fastbut SaO2 is low you are under-ventilating)-> ex. PCA pump - What acid-base disorderindicates they r e e d to come off of it? = respiratoryacidosis (resp. depression ->resp. arrest)—> if itsnot iung, i t s metabolic■metabolic alkalosis -really only one scenario = ifthe P T h a s prolonged gastric vomiting/suctio nin g- because you arelosing ACID1ex. G l surgery w f N G tube with suctioning for3 days; hyperemesis graviderum- o t h e r w i s eeverythinge l s ethat isn't lung youp i c kmetabolic acidosis (DEFAULT)* ex. hyperemesis graviderum w fdehydrationacute renal failure, infantile diarrhea- remember, you only have 4 to pick from:- respiratory alkalosis- respiratory acidosis- metabolic alkalosis- metabolic acidosis- pay more attention to the m o d i f y i n g p h r a s e s thanthe original noun- e x . person w / O C D who is now psychotic (psychotictrumps O C D ) ; hyperemesis with dehydration (payattention to dehydration)VENTILATION- ventilators - > ki'idvsysfe.ms(you set it up sothat the machine doesn t use /ess than ormore thanspecific amounts of pressure)a) h i g h p r e s s u r e a l a r m =increased resistanceto airflow (the machine has to push too hard toget air into lungs)- fromobstructions:i.kinksi n tubing (unkink it)ii.water condensation in tube (empty it!)iii. mucous secretions i n the airway (changepositions/turn C&DB,and THENsuction)suction is only PRNJI1- > priority questions = you would checkkinks first, suction is not first

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b) low pressure alarm =decreased resistanceto airflow (the machine had to work too littleto push air into lungs)- fromdisconnections:i. main tubing (reconnect it duh!)ii. 0 2 sensor tubing (which senses FiO2 atthe airway/trach area; black coated wirecoming from machine right along thetubing - reconnect!)- ventilators-> know blood gases- resp. alkalosis = ventilation settings might beset too high (OVER-VENTILATING)- resp. acidosis = ventilation settings might b e settoo low {UNDER-VENTILATING)■ex. weaning a PT off ventilator -> should not beunder-ventilated, they need the ventilator; if they areover-ventilating then they can be weaned- never pick an answer where you dent de somethingand someone else has to do something

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LECTURE 2ABUSE(Psych and Med- Surge)Psychological Aspect/Psycho-Dynamics■# 1psychological problem isthesame in any/allabusive situations= DENI AL- abusers have an infinite capacity for denial so thatthey can continue the behavior w/o answering for it- can use the alcoholism rules for any abuse- ex. # 1 psych problem i n child abuse, gambl ng□'cocaine abuse a de™aJ- whyis denial the problem? HOW CAN YOU TREATSOMEONE WHO DEN1ES/DOESN T RECOGNIZETHE Y HAVE A PROBLEM- denial = refusal to accept the reality of a problem■treat denialbyCONFRONTINGtheproblem(itsnotthe same as agression which attacks the person, notthe problem) =they DENY you CONFRONT- pointing out to the person the difference betweenwhat they say and what they do- Hintnever pick answers that attack the person-> ex. bad answers have bad pronouns - "you"-> ex. good answers have good pronouns - ' I " , "we"-> ex. "you wrote the order wrong" vs. "I’m havingdifficulty interpreting what you want'- loss and grief - > for this denial you mustSUPPORTit- DABDA = den al, anger, ba'gaining, depreasion, acceptance- Hint:for questions about denial you must look to seeif itis LOSS or ABUSE- loss/grief = support- abuse = confront- #2 psychological problem in abuse =DEPENDENCY,CO-DEPENDENCY- dependency=when the abuser gets significant otherto do things for them or make decisions lor them-> thedependent = abuser- co-dependency =when the significant otherderivespositive self-esteem from making decisions for ordoingthings for the abuser-> the abuser gets a life w/o responsibilities-> the sig. other gets positive self-esteem (which iswhy they can't get out of the relationship)- how do you treat it?- set limits and enforce them-> start teaching sig. other to say N O (and theyhave to keep doing it)- must also work on the self-esteem of the co-dependent(ex. I'm a good person becauseI’msaying"no’)- manipulation= when the abuser gets the sig. otherto do things for them that are not in the best interest ofthe sig. other- the nature of the act isdangerous/harmful- how is manipulation like dependency?-> in both the abuser is getting the other person todo something for them-how do you tell the difference between manipulation& dependency?- > NEJ-RAL vs\ E3 ATI7 E (look at what they'rebeing asked to do)- > if the sig. other is being asked to do somethingneutral (no harm} its dependency/co-dependency- > if the sig. other is being asked to do somethingthat will harm them or is dangerous to them theyare manipulated- how do you treat manipulation?- set limits and enforce them-> 'NO"- easier to treat than dependency/co-dependencybecause n o one likes to be manipulated (no positiveself-esteem issue going on)■ex. how many P Ts do you have w / denial? =1ex. how many P Ts do you have w / dependency/co-dependency = 2ex. how many P Ts do you have w / manipulation = 1AlcoholismWernicke s & Korsakoff's- typically separate BUT boards lumps them together- wemicke s = encephalopathy- korsakoffs = psychosis (lose touch with reality)-> tend to go together,findthem in the same PT• WernickeKorsakoff s syndrome:a} psychosis induced by Wf. B7 [Th/am/nej deficiency- lose touch w / reality, go insane because of no B1b) primary symptom ->amnesia w f confabulation- significant memory loss w / making up stories- they believe their stories• How do you deal w / these PT's?- bad way = confrontation (because they believe whatthey are saying and can't see reality)- good way= redirection(take what the PT can't doand channel it into something they can do)■Characteristics ofWenicke Korsakoff's:a}its preventable =take Vit. B i (co-enzyme neededfor the metabolism of alcohol which keeps alcoholfrom accumulating and destroying brain cells)FPT doesn't have to stop drinkingb)it s arrestable=can stop it from getting worse bytaking Vit. B1ralso not necessary to stop drinkingc)its irreversible(70% of cases) - > Hint: On boardsanswer w / the majority (ex. if something is majorityof the time fatal, you say it’s fatal even if 5 % of thetime its not)■Drugs for Alcoholism:DISULFIRAM (Antabuse)= aversion therapy-> want P Ts to develop aguthatred for alcohol-> interacts w/ alcohol in the blood to make you very ill- > worksin theory better than in reality- > onset &duration:2weeks(soifyou want todrink again, wait 2 weeks)

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- P T teaching= avoid A L L forms of alcohol to avoidnausea, vomiting & possibly death-> including mouthwash, aftershaves'cologne&''perfumes(topical stuff will make them nauseous), insectrepellanls. any OTC that ends with "-elixer, alcohol-based hard sanitizers, uncooked (no-bakei icingswhich have vsmWsextract,red wine vinaig-ette- Overdoses & Withdrawals:- every abusetf drug is either an UPPER orDOWNER- > the other drugs don't d o anything- > #1 abused class of drug that is not a n upper ordowner = laxativesinthe elderlya) first establishif thedrug is anupperor downer- uppers (5) =caffeine, cocaine, PCP/LSD (psychedelichallucinogens], metharr pfiafarranes, adderol {ADD drug)" S&S -> make you go up; euphoria, tachycardia.restlessness, irritability, diarrhea, oorbo-ygmi.hyoer-refexia. spastic, seize (need suction)- d o w n e r s = don't memorize names - > anything thatis not an upper is a downer! if you don't know whatthe med is, you have a high chance that i t s adowner if i t s not part of the uppers listTS&S - > make you go cown; lethargy, resp ratorydepression (fi. arrest)■ex. The PT is high on cocaine. What is critical to assess?- > N O T resps below1 2because they will b e high- > maybe check reflexesb) are they talking aboutoverdoseo rwithdrawsI- overdose/into xication =too much- withdrawal =not enough- ex. the P T has overdosed on an upper -> pick theS&S of too much upper- ex. the P T has overdosed on a downer -> pick theS&S of too much dowrer- ex. the P T is withdrawing from an uppep-> notenough uppe- makes everything go down- ex. the P T is withdrawing from a cowner -> notenough downer makes eveyth ng go up- upper overdose looks tike = downer withdrawal■downer overdose looks like = upper withdrawal- I n what 2 situations would resp. depression & arrestbe your highest priority:- downer overdose- upper withdrawal- I n what 2 situations would seizure be the biggest risk:- upper overdose- downer withdrawal■Alcohol Withdrawal Syndrome vs. Delirium Tremens- they are both different! not the samea)everyalcoholic goes through withdrawal 24hrs.after they stop drinking- only a m/norifyget delirium tremens- timeframe - > 72 hrs. (alcohol withdrawal comes 1st)- alcohol withdrawal syndrome ALWAYS precedesdelirium tremens, B U T delirium tremens does notalways follow alcohol withdrawal syndromeb) A W S is not life-threatening: D T s can kill youc) PT's w.' A W S are not a danger to self/others; PT'sw / D T s are dangerous to self/others- they are withdrawing from a downer s o they willbe exhibiting upper S & S- D T s are dangerousDifferencesAWSDTinCareDietRegular c etNPO/clear lieuica(because oi risk for seizures whichcan cauae risk c i asp ration)RoomSe"- -prvatePrivate nea- nurses staticinanywhere on (dangerous A unstab e i1he unitAmbulation Up ad libRestricted bed rest - > no ba1hroc<nprivileges (use bedpans- urinals)RestraintsNo restra nts Rest-aims (because dange-ous)(because not - not aofl wrist or 4 point softdangeroua)because tnev'll gel c ut- need to be id vSat or Z-pt. lockedleathers (opposite 1 arm i. leg,rotate {J2nra,lock the f-eelinribs 1st before releasing 1helocked ones)They both get ANTI-HYPERTENSIVES &TRANOUIDZERS- because everything ia up (downer withdrawal)They both get MULTIVITAMIN w/ B l■RN's can accent but RPN's can't (because PT is unstable)- on med-surge, the RN who takes them must decreasetheir workload (i.e. reduceP Tload if they take a D TPT)- > Hint:on boards, the setting is always perfect(i.e.enough staff/time/resourcesonthe unit etc.)• Drug Abuse i n the Newborn:- always assume intoxication N O T withdrawal at birth- after 24hrs- > withdrawal- ex. caring for infant of a Quaalude addicted m o m 2 4hrs. after birth, select all that apply:-> dowrer withdrawal so everything is up = exaggeratedstartle, seizing, high ptched'shrill cry

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DRUGSAMINOGLYCOCIDES■powerful class ofantibiotics(when nothing elseworks pull these outs, the bigguns)- don't use unless anything else works■boards iove to test these drugs because they redangerous and are a test of safety■thiik: A MEAN OLD MYCIN- > a mean oid =they treat serious, life-threatening,resistant, Gram-neg bacteria infections (i.e.a meanoi'dandbiotic for amean oidinfectionJ- > mycin =what they end with(allendw/-mycin)"notall-rnycin'sare aminoglycosides BUT mostare (the 3 that are not are erythromycin.azthromydn, clarithro mycin = throw rfoff the list!)• 2 toxic effects:i) when you see '-mycin , thinkmice- mice ->ears -> otto toxic-monitor hearing, tinnitus, vertgo/dizzinessii) the human ear i s shaped like akidney sonexteffect is nephrotoxicity- monitorcreatinine(notBUN, output, daily weight)'creatinine =the best indicator of kidney/renalfunction (pick 24 hrcreatinine clearance overserum creatinine if both available)- #8 (fits nicely in the kidney) reminds you about 2things about these drugs- toxic to cranial ner.'e 8 = ear nerve■administer Q8- route:- IM or IV. do not give PO -> they are not absorbed■if you give an oral -mycin' it will go into gut. dissolve,go through and come out as expensive stool {won'thave any systemic effect)- EXCEPTin2 cases =bowel sterilizers:rhepatic encephaicpathy (hepatic coma) =to getammonia down, oral '-rnycin's' will sterilize thebowel by killing Gram-neg bacteria (E. coli) to helpbringdownammonia andwont harm thedamaged liver because it doesn't go through theliver (also gives diarrhea, more poopout isgood)’ pre-op bowei surgery =it sterilizes the gut bykilling the E. coli bacteria- if oral, no otto or nephro toxicity because not absorbed- these areneomycin & kanamycin* Who can sterilize my bowels? NEO KAN■Trough and Peak levels:- trough = drug atlowest■peak = drug athighest*' TAP Jevefc- troughadminister peak-> draw trough levels first- > administer your drug- > draw peak levels after drug administration- Why draw levels? =narrow therapeutic window- small difference between what works and what kills- if the drug has a wide range then you wouldn'tneed to draw TAP levels' ex. Lasix doses range from 5-80mg thus a widerange so you won t need TAP levelsTex. Dig doses range from 0.125 - 0.25 so thisnarrow range needs TAPS levels- A MEAN OLD MYCINS = major class that needsTAPs drawn because of narrow window- When do you draw TAPS?-> depends on the route (don't focus o n the med)a)TroughLevels”doesn't matter which route or med. always 30 mins.- sublingual = 3 0 mins, before next dose- IV = 3 0 mins, before next dose- IM = 3 0 mins, before next dose- Sub-Q = 30 mins, before next dose- PO = 3 0 mins, before next doseb)Peak Levels"" different but depends on theroute(not the med)- Sublingual = 5-10 mins after drug is dissolved- IV = 15-30 mins after drugs isfinished infusingrHint:if you get two values that are correct (i.e. a15 min. answer and a 30 min. one)pick the highestwithout going overso 3 0 mins.- IM = 30-60 mins, after administration- Sub-Q = SEE (see diabetes lecture -> because theonly Sub-Q peaks are Insulins)- PO = forget about it, too variable so not testedThe BIG 1 0 Drugs to Know:1. psych drugs2. insulins3. anti-coagulants4. digitalis5 aminoglycosides6. steroids7. calcium-channel blockers8. beta-blockers9. pain meds10.OB drugs

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LECTURE 3C A R DI AC- AR R Y T HM l A S- Interpreting R h y t h m Strips( 4 that need t o b e k n o w nb y sight):a) N o r m a l Sinus Rhythm= P wave before every Q R S & followed b y a Twave for every single c o m p l e x- > all P wave peaks are equally distant from e a c hother, Q R S evenly spacedb )-Fib = chaotic squiggly line, n o patternc) V-Tach = sharp peaks, h a s a patternd) A-Systole = flat-line* Terminology:- i f Q R S d e p o l a r i z a t i o n ,itstalking aboutventricular(so r u l e o u t anything atrial)- ifitsays P-wavethenits talking aboutatrial-6 Rhythms m o s t tested o n N - C L E X :1 - ' a lack of Q R S s" = A-systole- flat-line, n o Q R S2. " P - w a v e " = Atrial- if i t s a 5.vrooth wave, alwayspickatrial flutter3 . "chaotic' - A-fib if w / P-wave4. "chaotic" - V - f i b if w / Q R S- H i n t : the word chaos' i s u s e d forfibrillation5 . 'bizarre" = atrial tachycardia if w / P-wave6 . 'bizarre" = ventricular tachycardia if w / Q R S- Hint:the work 'bizarre' i s used fortachycardias- P V C s(premature ventricular contractions)= a.k.a. periodic w i d e bizarre Q R S- ventricular because Q R S- bizarre - > tachycardia-you c a n call a group o f P V C s a short run o f V-tach- d oPhysician's care about P T ' s having P V C s ?- > N O , n o t a h i g h priority = l o w priority- > 3 circumstances when you could elevate theseP T stomoderatepriority (never reach high)i.ifthere are more than 6 P V C s i n a minuteii. if there are more than 6 PVC's i n a rowiii. if the P V C fall o n the T-wave of t h e previousbeat ( R o n T phenomenon)- > most common order if you call the N D about aP T w / P V C s = D/C monitor (because then youcan t see t h e P V C s a n d then you won t call them)• Lethal A r r h y t h m i a s :- H I G H P R I O R I T Y , 2 main o n e s (will kill you i n 8 m i n so r less) - > t h e s e P T s will probably b e top prioritiesa )A-Systoleb )V-Fib”both have i n common =n oc a r d i a co u t p u t- > n o brain perfusion ( a n d yourll b e d e a d i n8 mins)-V-tach =potentiallylife-threatening (but not actuallylife-threatening), b u t still m a k e s it a fairly high priority- difference i s that these P T ' s have cardiac output- i n c o d e s , even if the rhythm changes, if there i s n ocardiac output it's just a s b a d a s the previous rhythmCardiacD R U G SC A L C I U M - C H A N N E L B L O C K E R SCalcium-Channel Blockers are like Vaiium for your head■Valium - > c a l m ' s you down; s o C C B s c a l m your heartdown(ex.iftachycardic, g i v e C C B sbutnotinshock)- t o R E S T Y O U RH E A R T- not stimulants■calcium-channel blockers a r enegative i n o t r o p i cchronotropic, S. d r o m o t r o p i c drugs- fancy w a y of saying that t h e y c a l m t h e heart downPOSITIVENEGATIVEInotr o p e sChronotropesDromotopesCardiac StimjlartsCardiac Depressants- stimu ate. speed- earn the heart down,up the heartweaken & slow cowh- W h e n d o youwant to' d e p r e s s " theheart? W h a t d oCCB's treat?A: anti- hypertensives- relax heart & blood vessels t o bring down B PA A : anti-angina s- relax heart t o u s e less 0 2 t o m a k e a n g i n a g o away- treats a n g i n a by addressing oxygen d e m a n dAAA: anti-atrial a r r h y t h m i a- e x . atrial flutter, A-fib, premature atrial contractions- never ventricularmwhat aboutsupra-ventricular tachycardia??- > because it m e a n s ' a b o v e the ventricles' (whichare the atria)- Side-Effects:H & H = h e a d a c h e & h y p o t e n s i o n- > hypoTN - from relaxed heart Si vessels- > headache - vasodilation t o brain”H i n t : h e a d a c h e i s a g o o d thing t c s e ect for'select all that apply' questions (ex.low N a & highNa = headache, high fi. law glucose = headache, hign &low BP = headache).N a m e s o f C a l c i u m - C h a n n e l Blockers:- anything endingTiT - d ip i n e '- e x . amlodipine, nifedipine- N O T just '-pind- a l s o includes:V E R A P A M I L &C A R D I Z E M- which can b e g i v e n a s c o n t i n u o u s I V drip??= Cardizem■l/Vhaf V Sneeds to b e assessed before giving a C C B ?- B P = because of risk ofhypoTN- > parameters/guidelines - hold C C B ifsystoiici su n d e r 1 0 0- > s o you n e e d t o monitor B PifP T i s o n a C a r d i z e mcontinuous drip (if its u n d e r 1 0 0 then you m a yhave t o stop or c h a n g e the drip rate)

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- Treatment (more drugs):alPVCsb)V-tach= forventricularuse LIDOCAINE/AMIODARONE* i n rural areas mare Lidocaine use (cheaper &anger ahelf-lrte)c) Supra-Ventricular Arrhythmia s= atrial arrhythmia's use ABCDs■A->ADENOCARD (Adenosine)- have to push in less than 8 seconds (FAST IVpush}-> slam this drug, followed by a flush; use ab g vein: BUT the problem w/ slamming it last isthe risk of PT going nto A-Systole (for 30 secordsbut they wiff come out of it so don't worry [unlesslonger than 30 sec...])”for IV pushes: wften you oon't know you go slow■B-> BETA-BLOCKERS- afl end /n'-lot- every-lol’is a BB & every BBisa-lol'- are negative inotropes, chronotropes, &dromotropes like calciumchannel blockers (a_k.a.valium for your heart so they treat A, AA, AAA &have same side-effects)" g e n e r a ly spea<irg don’: Take a big differencebetween Beta- & Calcium channel blockers;except that CCB are better for P T s w/ asthmaor COPD -> Beta-B's bronchoconstrict■C ->CALCIUM-CHANNEL BLOCKERS- see Beta-Blockers & CCB's earlier■D -> DIGITALIS (DIGOXIN, LANOXIN)d) V-Fib= for V-fib you D-fib(shock them!)e)A-Systole= use EPINEPHRINE &ATROPINE (inthis order!)-> if epinephrine doesn't work then use atropineCHEST TUBES- purpose is tore-establish negative pressure inthepleuralspace(so that the lung expands when thechest wall moves)- pleural space ->negative is good(negative pressuremakes things stick together)- ex. gun shot to the lung add positive pressure■Hint:when you get a chest tube question, look at thereason for which it was placed(will tell you what toexpect & what not to expect)- ex. pneumothorax = to remove air (because aircreated the positive pressure!- ex. hemothorax = to remove blood- ex. pneumohemothorax = to remove blcod & air* Hint:Alsc, pay attention to the tocaf/onof the tubes:alApical =the chest tube is way u p high, thus itisremoving axr(because air rises)- ex. its bad if you re apical tube is draining 200 m L oritis not bubblingb)BasiIar =at the bottom of the Iungs. thus it isremoving b loodAiquid (because of gravity)- ex. i t s bad if your basilar tube is bubbling or notdraining any m L-ax. Hoivmany chest tubes3where would you place themfor a unilateral pneumohemothorax?- 2 chest tubes (apical for pneumo, basilar for nemo)- ax. H o w manychest tubes & where would you place themfor a bi-lateral pneumothorax?- 2 tubes (apical oneft.apical on right)■ax. H o w manychest tubes & where would place them farpost-op chest surgery?- 2 tubes (apical & basilar on the side of the surgery)"you are to assume that chest surgery/trauma isunilateral untess otherwise specified (theywillsay bilateral)* Trick Question:How many chest tubes would youneed and where would you place them for a post-opright pneumonectomy?- NONE! because you are removing the lung so youdon't need to re-establish any pressure (there is notpleural space)!Troubleshooting Chest Tubes:- What do you do if you knock over the plasticcontainers that certain tubes are attached to?- > set it back up & have PT take some deep breaths-> NOT a medical emergency!(don t callND)■What do you do if the water seal breaks (theactual device breaks?)-> first =CLAMPit!!!because now positive pressurecan get in! don't le: anything get in-> 2nd = cut the tube away from the broken device-> 3rd = stick that open end into sterile water-> then unclamp it because you've re-established thewater seal (doesn't need clamo if its under waterbetter for the tube to be under water thanclamped! -> air can t go in and stuff can still keepcoming out (if clamped, nothing can come outwhich is what the tube is for)■Ex.Ifthey ask what thefirstthing is to do if the sealbreaks -> Clamp! BUT, if they ask what's thebestthing to do -> put end of tube under water! (because itactually solves the problem, clamping is a temp, fix)- Hint:'BEST vs. FIRST questions- first questions =are about what order- best questions = what's the one thing you would doifyou couldonly do 1of the options-> ex.You notice the PT has V-fib on the monitor. Yourunto the room and they are non-responsive withno oulse. What is thefirstthing you do?A) place a backboard?B) begin chest compressions?- "first1is about order so = pick A (because youwouldn't start chest compressions first)- BUT,ifthe questionask"What s thebestthing todo?" -> you only get to do1thing not the other soyou would pick B

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- What do you do if the chest tube gets pulled out?- first= take a gloved hand and cover the hole- test= cover the hole with vaseline gauze- Bubbling chest tubes:(ask yourself 2 questions)a) Where i s it bubbling?b) When is it bubbling?= the answer will depend on these 2 questions(sometimes bubbling is good, sometimes bad butdepends o n where & when)■ex.intermittent bubbling in the water sea! -> GOOD(document it,never bad!\■ex.Continuous bubbling in the water seal -> BAD(you don't want this. means a leak in the system thatyou need to find and tapeituntil it stops leaking)"in RPN scope- ex. Infermiftenf insuction control chamber -> BAD(means suction is not high enough, turnitu p on thewall until bubbling is continuous)- ex. Continuousin suction control chamber -> GOOD(document it)- Hint: bothlocations are opposites of each other(memorize one & deduce the others)—> if there is a seal it should not b e continuous(ex. a sealed bottle of pop continuouslybubbling means its leaking!)- A straight catheter is to a foley catheter as athoracentesis is to a chest tube.- in-i-outvs. continuous secured- thoracentesis -> also helps re-establish neg.pressure (in-&-out chest tube)- higher risk for infections are continuousRules for Clamping Tubes:- al Never clamp a tube for more than15 secondswithout a doctors order.- so if you break the water seal -> you have 15seconds to get that tube under water- b) Userubber-tippeddoubled clamps.- the teeth of thedampneedtobe coveredw/rubber so that you don't puncture the tubeCONGENITAL HEART DEFECTS- every congenital heart defect is either TROUBLE orNO TROUBLE (ALL BAD or NO BAD)- either causes a lot of problems or its no nig deal (noin-between defect)- memorize one word:TRouBLeHeart DelectsTRouBLe (S5% o fall heart def seta)N o Tro ubleSurgeryNEED surgery nowto live- don'1 need su-ge-vnght away; pose Divneed it years later ir itcauses'a T'mubj'e(butwe don't expect it to)Growth & Dev.alow, delayednormalLife Expectancy shortnormalEarent'sExperiencinggrief, stress,tfnanc al issues, lotsregular average personissuesof caregiving issuesGoing Homeapnea monitornc apnea monitort pafjil a i Stay at weeks24-48 hoursWho FollowsYour CarePaediat-icCare olcgistPaediaticiaiLpaediat-ic NPShuntingR to L(TRouBLe)L t o RCyanosisCyanotic <= Blue(THou BLe)Acyanotic- ex. You are teaching the parents about a heart defect:- pick all the options that causetroubie• Hint:Boards will not give pictures of defects and askyou what they are.- not our job, we don't diagnose-our role is teaching parents the implications-> so f its trouble = teach them things that its goingto be a lot of trouble-> il it's not rouble = Dick the things say ng it's notgoing to be troube• There are 40+ congenital heart defects so just rememberTRouBLe (don't memorze all of them!):- Hint:all congenital heart defects thatstart w/theletter TareTroubie Defects- we don'tcare about the detect, we care about whatwere teaching the parents■All congenital heart defect kids (trouble orno trouble)will have 2 things:a)Murmur- why? = because of the shunting of the blood(regardless of direction of shunt)bj all have anEchocardiogramdone (to find outwhat the defect is or why there's a murmur)• 4 Defects of Tetralogy of Fallout:-VarieD Pictures Of ARancH (or Valentines Day=lc<Someone Out A Red Heart)1. VD= ventricular defect2. PS = pulmonany stenosis3.OA =overriding aorta4.RH =right hypertrophy• don't have torecailthese. RECOGNIZE them- recall > remember from nothing- RECOGNIZE -> spot it when you see it (use theinitials to recognize them in questions)- ONLY DEFECT where they ask you what it is

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INFECTIOUS DISEASE a n d TRANSMISSION B A S E DPRECAUTIONS(Isolations)- Standard- Universal- Contact- for anything e n t e r i c = can be caught from /nfesiwTe- > fecal, oral- C-Diff. Hep. A, Cholera, Dysenteryrthings with b u g s in diarrheaTHint for Hep A & B : Hep A - > think anus. Hep B - >think blood (anything from the bowsf starts w/ a vowel!- Staph infections- RSV =respiratory syncytia! virus(what babies, 1-2yr. old's get that is not dangeroustoadultsbutcanbe fatal for them)Ttransmitted b y dropletB U T stilt put them oncontact precautions because iittie kids catch itfrom touching thingsthat other sick kids touched- Herpes infections(includes Shingles - >HerpesZoster virus even though caused b y varicella)■What's involved in contact precautions?- > private room ispreferred(but not required)Tor 2 R S V kids in the same roomTkeep R S V kid &suspectedR S V separatebecause you need ocsit v e cultures (not basedon symptoms}- > N O :mask, eye/face shield (unless for universal},special filter mask, P T mask, neg. airflow->YES: gloves, gown, hand-washing, specialsupplies & dedicated equipment (includes toys)"disposable supply vs. dedicated equipment:- thermometer cover- BP cuff that stays in room• Droplet- forb u g s that travel 3 feetonlarge particles duetosneezing/coughing- allmeningitis" cultured through lumbar puncture- H Flu (haemophilus influenzaB ) - > commonlycausesepigiotitis’ never stick something down throat becauseit willcause obstruction■What's involved in droplet precautions?- > private room ispreferred(but not required)Ton boards select privateTcan also cohort based onpositive cultures- > N O :gown, eye/face shield, special filter mask.neg. air flow- > Y E S : mask, gloves, hand-washing, P T wornmask (when leaving room), disposable supplies& dedicated equipment- Airborne- M-M-R; T B : varicella (chicken pox)- W h a t s involved in airborne precautions?- > private room isrequiredrunless co-horting- > N O :gown (mostly for contact}, eye/face shields- > YES: mask, gloves, hand-washing, special-filtermask ONLY for TB, P T mask for leaving room(but really shouldn't be leaving), neg. air flow”disposable supplies & dedicated equipment i s agood thing but not really a s essential a s i n theother 2 (can let this one slide)- > TB: technically transmitted via dropletB U Tputo n airborne- P P E = Personal Protective Equipment- boards like to test how you put o n or take off-always t a k e i t off in alphabetical order- > ex. gloves, goggles, gown, mask- p u t t i n g o n is reverse alphabetically for the 'g s' &mask comes 2nd- > gown., mask, goggles, gloves

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LECTURE 4CRUTCHES. CANES, WALKERS■major area of human function islocomotions o they testthese even though not a major emshasis i n school- area to test P T teaching & risk reductionCrutches:- Howd o youmeasure crutches?”need to know for risk reduction - > so you don'tcause nerve damagea)lengtho fcrutch =2-3 finger-w dths belowanterioraxillary fold to a point lateral to & si ghtly in front of the foot-> many questions ask where you measure fromfto (so forcrutches, if they ask anything measuring Tarn ax Ila tofoot -> rule out. they're wrong instructions for length)b)hand grip =can be adjusted up & down; when properlyplaced,shouldoeapx. 3 0 degrees elbow hexion• How to teachcrutchg a i t s (4 kinds}T" names are pretty obvious w / a few exceptionsa) 2-point- move acrutch and opposite foottogether followedby other crutch & opposite foot- moving 2 things togetherb) 3-point- moving2 crutches &fhebad legtogether- moving 3 things togetherc) 4-point- movingeverything separately- move any crutch, then opposite foot, followed b ynext crutch then other foot- very slow but very stabled) Swing-through- fornon-weight bearinginjuries (ex. amputations)- plant crutches and swing the injured limb through(never touches down)- W h e n d o they use them?■ask yourself "how m a n y legs are affected?- even for even, odd for oddTeven point gaits when a weakness is evenlydistributed (i.e. even # of legs messed up)- 2-point =mildproblems (bilateral)- 4-point = severe problems (severe, bilateralweaknesses)- 3-point = onjy odd one, when only 1 leg i s affected.Ex.Eady stages of rheumatoid arthritis =2-pointEx. Left, atovB the fcnea amjMJtatrcvj = swing-throughEx. Frrafday post-op right knee replacement, partial weight-bearing allowed=3-pointEx. Adyancsd stages of ALS = 4-pointEx. Left L.'p replacement,2nd day post-op, non weight-hearing= swing-throughEx. BWsieraf totai' fcnae repfac&mefft,1st day post-op. weight-bearing allowed=4-poinlEx. ®/aHera/ totai' knee replacement, 3 weeks post-op = 2 point• Going up & down stairs:- up with the good, down with bad- crutches move with the bad legCains:* hold the cain o n thestrong side- a lot of people use it the wrong wayWalkers:- pick it up, set it down, walk to it• if they must tie their belongings to the walker, tie it atthe sides, not the front- boards doesn't li<e things on the front (even tno mostpeop e do that anyways: they dont like wheels or tennisball on the bottom either)

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ex- person storingstawall &says:see abomtf ->hallucination0 X- personlooksstfire extinguisher on the wall and says:" Isee sbornff -> illusion (referent)■Hint:O n the test, they will tell you that there issomething there thus, you can differentiate between ahallucination & an illusion.How do you deal with these Psychotic Symptoms?- first thing you ask after determining if PT is psychotic:What is their problem?—> what kind of psychosis do they have?- 3 Types of Psychosis:1. Functional Psychosis- c a n .ricf/c,'! i/t everyday v e (i e. have obs amarriage, etc.}- 4 diseases:SchizoSchizoMajor Manicsi.Schizophreniaii.Schizoaffective Disorderiii. Major Depression (if i t s major, test will say)iv. Manic (Acute)-> so bi-polar is functional, only psychoticduring manic phase-these PTs have the potential to learn reality(because no damage)-> may need medsorset boundariesforstructure- > nurse role = teach reality {4 steps}a)acknowledge feeling-> -|s e eyou're angry;'You seem upset', "Tell me how you are feeling',often uses the wcrd feeling or shows a feelingb)PRESENT REALITY ->"I know that those voicesare real to youbut Idon't hear them" or tellingthem what is real ("I'm a nurse & this is a hospital")c)seta limit-> "That topic/behaviorisoff-limits’,"Weare not going to talk about that right now",' Stop talking about that"d)enforce the limit-> "I see you're too ill to stayreality based s o our convo is over"(endingtheconversationNOTtaking away a privilege [Te.punishment]; continuing to talk may enforce thenon-reality)" " on the test, they won't ask these specific steps butinstead, will ask "how should the nurse respond...”" "try to pick the morepositive statements (i.e.whatthey can have,'do, not what they cant); if between2 statements go w/ the positive one- 2. Psychosisof Dementia-psychosis because of acfua/ damage to f/?e bra.'inTin Functional Dementia, there is no brain damage:its just messed up chemicals- include P Ts w / Alzeimer's, psychosis after a stroke,organic brain syndrome; anything w / " senile" or"dementia"-cannot learn reality-> major difference from functional (which is whyyou have to determine type of psychosis)DELUSIONS, HALLUCINATIONS, & ILLUSIONS (Psych)Neurosis Non-Psychotic vs. Psychosis* Hint:thefirst thingyou have to do to get a psychquestions correct is decide: 'Is m y PT non-psychoticor psychotic?"= this will determine treatment, goals, prognosis,medication, length of stay, legalities., everythingNON-PSYCHOTICPSYCHOTICDefinitionHas n o insight & isnotrealit y-basea- qon't think.'know their aick- th nk everyone e ae naathe problem bjt not them(bla™"e anyone eee)- even if they Bay they re,sick but tnen trrey aay themartiana made them sickthey oont nave insightood therapeutic□Himun caton coea notwork beca jee they are- RMRfifle,specificstrategies- good therapeutic- qCommunication Hikecany P T that displaysocod comm, skilieithere s n d h ngspec al tnat youTieecto do,'know,compareato any med-su'de.paetfe, or OB PTDELUSIONS,HALLUCINATION,ILLUS ONS- cnlv in Dsvchotc PTs- as scon sra they get anyof these they’ve crossed,the line to Be ng peycnoticHasinsight1. isneality-bpeed- eventt!emotonaldistreas/illness,mentabbenavio'aldisorder- reaogn ze what theproblem a and howit afiecls their lifeTreatment/TechniquesSymptomsdon't have delusions,hallucinations, o-illusionsPsychotic Symptoms:. a} Delusions= false, fixed, idea or belief; n osensory component(all in the brain,, thinking it)i.Paranoid Delusions-> people are outtoharm m e- ex. the mafia are our to get meii.Grandiose Delusions - >you are superior or youare the world s smartest jreatest person- ex. thinking you are Christ, Genghis Khaniii.Somatic Delusions-> about a body part- ex. x-ray vision; there are worms in my body■b)Hallucinations= a false, ’ xeo, sensory experience (pure y sensory):5 senses so 5 for (1 for each sense}i. Auditory _>heaping things that aren’t thepe (primarilyvoices telling you to hurt yourself); most commonii. Visual -> seeing; 2nd most commoniii. Tactile -> feeling things; 3rd most commoniv.Gustatory ->tasting things that are not thepev. Olfactory -> smelling things that are not there”Tast 2 are relatively rape- c) Illusions= misinterpretation of reality,sensory experience- difference from hallucination ->with an illusion thereis areferent in reality-> referent= something in reality towhicha personrefers when they say something (theyjustmisinterpretit)■ex.FT says:*! heardemon i/rwcss -> halluc nationex. P T ovrerfiearera/rses■£MUs laughing & talking st the nursd sstation & says:*1Listen,i hear oemor. voices' ->ill- s o r (thereta a referent)

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-> nurse role:al ac/mowJ'ecfgefeelingblREDIRECT them-> from something they can tdo to something they can do”you dont set-limits because i t s mean”NOT APPROPRIATE to present reality to thesePT's when they are experiencing psychoticsymptoms (BUT don't confuse this w/ realityorientation)-> important to remember that forgetting things (likewhere they are or what room they're i n - P T s w /dementia/Alzheimers) is NOT psychosis”when they start having delusions, halucirations orillusions, then they are psychotic-> reality orientation = telling them person, place,and time (ALWAYS APPROPRIATE w/DEMENTIA) - this deals w / memory3. Psychotic Delirium= atemporary,sudden, oramatic, episodic,secondary loss of reality; usually due to somechem/cai' irnbaiance in the bodyFdifferent because it's temporary and very acute- > include PT's that are short-term psychotic becauseof something else causing the psychosis- ex. a crug reaction, high on uppers or withdmwingfrom cowners (delirium tremens), cocaine overdose,post-oppsychosis (withdrawing from a dowrer). ICUpsychosis (sensory deprivation), UTl (or any occultinfection), tnyro d storm, adrenal crisis- good thing is it's temporary s o focus is removingthe underlying cause & keeping t h e m safe-> nurse role:al acknowledgefeelingbl REASSUREthem:it s temp. & they'll be safe"" don't present reality -> they won t get it"don't redirect -> not going to work* Personality Disorders are differentA = artsocialB = bopcerlineN = narcissistic”very sick personality disorders" may be gooc to use Functional Psychosistechniques because you set limits- Narrowed Self Concept=when a psycnofc refuses >:■leave the i roari orchange their clothes-functional psychotic- #1 reason is because their definition of self isnarrowed - > defined self based o n 2 things:i. Where they areii. What they are wearingso they dbrf fknow who they are unless they arewearing those exact clothes in that exact room- as the nurse, don't make them change or leave theroom (will cause escalating panic because they willlose their concept of self)Tuse the Functional Psychosis techniques- Ideas of Reference= think everyone is ta k ng abcut you- ex. see someone on the news and get upsetbecause you think they are talking about you- can have both paranoia & ideas of reference(paranoia if also think they are going to harm you)Other Psychotic Symptoms:- Loosening of Association= your thoughts aren't wrapped too tight, all over the mapal Flight of Ideas- coherent phrases but the phrases are notconnected (not coherent together)b) Word Salad- sicker, can t even make a coherent phrase-> babble random wordsc) Neologism- making up imaginary words

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