LECTURE 1
ACID BASES
- learn how to convert lab values to words
- the rule of the B s
= if the p H a n d the BiCarb are both in the same
direction - > m e t a b o l i c
H i n t : draw arrows beside each to see directions
* down = acidosis
* up = afka/osis
- respiratory - > has no b in it; if in other directions
(or if bicarb 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...know principles
(they test knowledge of principles b y having you
generate lists..) _fo r "select all" queBtiona
- ex. in general/prindple what d o opioids/pain
meds do? = sedate you, C N S depressors
" ex. what coea dilaudid do? dorff memorize specifics
or a list of dilaudid, know principles of opioids (such
as sedation, CNS depression -> lethargy, flacc dity,
reflex +1, hypo-reflex ia, obtundedj
- boards dorit test b y lists because all books/
classes have different lists
* principles of S & S a c i d b a s e s : a s the p H goes s o
goes m y patient (except K+)
- p H u p = P T up - > body system gets more
irritable, hyper-excitable (EXCEPT K + )
- > alkalosis - thrnk o f a body system and g o
high: hyper-reflexive (+3, + 4 [2 i s normal]),
tachypnea, tachycardia, borborygmi, seizure
- p H down = P T down - > body systems shut
down (EXCEPT K+)
- > acidosis - ffi/nAc of 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 at
the bedside? = acidosis (resp. arrest)
- ex. which acid-base disorders need suction at the
bedside? = alkalosis (seize and aspirate)
- M a c Kussmaul - Kussmaul's (compensatory
respiratory mechanism) is only present in only 1 of
the 4 metabolic (add-base) disorders
F M = metabolic A C = acidosis
■ most common mistake with se ect all questions = selecting
one more than you should (stop when you select tne ones
you know! don't get caught up on the "could be's')
■ Hint: don't select rroneor ail on select all that apply
questions (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 would
restrif {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 will cause a metabol c ac idosis but once
you are ac dotic your bowel shuts down and you get a
paralytic illeus
- when you get scenarios:
- > if it's a l u n g scenario = respiratory
- then check if the client is over-venWatrng
(atfcafosrs) o r under-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 RESPIRATORY
RATE; resp. rate is irrelevsnfwl acid-base,
ventilation has to co with gas excharge not resp.
rate ( oak at t i e SaO2 -> il your resp. rate is fast
but SaO2 is low you are under-ventilating)
-> ex. PCA pump - What acid-base disorder
indicates they r e e d to come off of it? = respiratory
acidosis (resp. depression -> r esp. arrest)
—> if its not iung, i t s metabolic
■ metabolic alkalosis - really only one scenario = if
the P T h a s prolonged gastric vomiting/sucti o nin g
- because you are losing ACID
1 ex. G l surgery w f N G tube with suctioning for
3 days; hyperemesis graviderum
- o t h e r w i s e everything e l s e that isn't lung you
p i c k metabolic acidosis (DEFAULT)
* ex. hyperemesis graviderum w f dehydration
acute 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 than
the original noun
- e x . person w / O C D who is now psychotic (psychotic
trumps O C D ) ; hyperemesis with dehydration (pay
attention to dehydration)
VENTILATION
- ventilators - > ki'idv sysfe.ms (you set it up so
that the machine doesn t use /ess than or more than
specific amounts of pressure)
a) h i g h p r e s s u r e a l a r m = increased resistance
to airflow (the machine has to push too hard to
get air into lungs)
- from obstructions:
i. kinks i n tubing (unkink it)
ii. water condensation in tube (empty it!)
iii. mucous secretions i n the airway (change
positions/turn C&DB, and THEN suction)
suction is only PRNJI1
- > priority questions = you would check
kinks first, suction is not first

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

LECTURE 2
ABUSE (Psych and Med- Surge)
Psychological Aspect/Psycho-Dynamics
■ # 1 psychological problem is the same in any/all
abusive situations = DENI AL
- abusers have an infinite capacity for denial so that
they 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
- why is denial the problem? HOW CAN YOU TREAT
SOMEONE WHO DEN1ES/DOESN T RECOGNIZE
THE Y HAVE A PROBLEM
- denial = refusal to accept the reality of a problem
■ treat denial by CONFRONTING the problem (its not
the same as agression which attacks the person, not
the problem) = they DENY you CONFRONT
- pointing out to the person the difference between
what they say and what they do
- Hint never 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 having
difficulty interpreting what you want'
- loss and grief - > for this denial you must SUPPORT it
- DABDA = den al, anger, ba'gaining, depreasion, acceptance
- Hint: for questions about denial you must look to see
if it is LOSS or ABUSE
- loss/grief = support
- abuse = confront
- #2 psychological problem in abuse = DEPENDENCY,
CO- DEPENDENCY
- dependency= when the abuser gets significant other
to do things for them or make decisions lor them
-> the dependent = abuser
- co-dependency = when the significant other derives
positive self-esteem from making decisions for or
doing things for the abuser
-> the abuser gets a life w/o responsibilities
-> the sig. other gets positive self-esteem (which is
why 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 they
have to keep doing it)
- must also work on the self-esteem of the co-dependent
(ex. I'm a good person because I’m saying "no’)
- manipulation = when the abuser gets the sig. other
to do things for them that are not in the best interest of
the sig. other
- the nature of the act is dangerous/harmful
- how is manipulation like dependency?
-> in both the abuser is getting the other person to
do something for them
-how do you tell the difference between manipulation
& dependency?
- > NE J - RA L vs \ E 3 AT I 7 E (look at what they're
being asked to do)
- > if the sig. other is being asked to do something
neutral (no harm} its dependency/co-dependency
- > if the sig. other is being asked to do something
that will harm them or is dangerous to them they
are manipulated
- how do you treat manipulation?
- set limits and enforce them -> 'NO"
- easier to treat than dependency/co-dependency
because n o one likes to be manipulated (no positive
self-esteem issue going on)
■ ex. how many P Ts do you have w / denial? = 1
ex. how many P Ts do you have w / dependency/co-
dependency = 2
ex. how many P Ts do you have w / manipulation = 1
Alcoholism
Wernicke s & Korsakoff's
- typically separate BUT boards lumps them together
- wemicke s = encephalopathy
- korsakoff s = psychosis (lose touch with reality)
-> tend to go together, find them in the same PT
• Wernicke Korsakoff s syndrome:
a} psychosis induced by Wf. B7 [Th/am/nej deficiency
- lose touch w / reality, go insane because of no B1
b) 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 what
they are saying and can't see reality)
- good way = redirection (take what the PT can't do
and channel it into something they can do)
■ Characteristics of Wenicke Korsakoff's:
a} its preventable = take Vit. B i (co-enzyme needed
for the metabolism of alcohol which keeps alcohol
from accumulating and destroying brain cells)
F PT doesn't have to stop drinking
b) it s arrestable = can stop it from getting worse by
taking Vit. B1
r also not necessary to stop drinking
c) its irreversible (70% of cases) - > Hint: On boards
answer w / the majority (ex. if something is majority
of the time fatal, you say it’s fatal even if 5 % of the
time its not)
■ Drugs for Alcoholism:
DISULFIRAM (Antabuse)
= aversion therapy -> want P Ts to develop a gut
hatred for alcohol
-> interacts w/ alcohol in the blood to make you very ill
- > works in theory better than in reality
- > onset & duration: 2 weeks (so if you want to
drink again, wait 2 weeks)

- P T teaching = avoid A L L forms of alcohol to avoid
nausea, vomiting & possibly death
-> including mouthwash, aftershaves'cologne&''perfumes
(topical stuff will make them nauseous), insect
repellanls. any OTC that ends with "-elixer, alcohol-
based hard sanitizers, uncooked (no-bakei icings
which have vsmWs extract, red wine vinaig-ette
- Overdoses & Withdrawals:
- every abusetf drug is either an UPPER or DOWNER
- > the other drugs don't d o anything
- > #1 abused class of drug that is not a n upper or
downer = laxatives in the elderly
a) first establish if the drug is an upperor downer
- uppers (5) = caffeine, cocaine, PCP/LSD (psychedelic
hallucinogens], 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 that
is not an upper is a downer! if you don't know what
the med is, you have a high chance that i t s a
downer if i t s not part of the uppers list
T S&S - > make you go cown; lethargy, resp ratory
depression (fi. arrest)
■ ex. The PT is high on cocaine. What is critical to assess?
- > N O T resps below 1 2 because they will b e high
- > maybe check reflexes
b) are they talking about overdose o r withdrawsI
- overdose/into xi cation = too much
- withdrawal = not enough
- ex. the P T has overdosed on an upper -> pick the
S&S of too much upper
- ex. the P T has overdosed on a downer -> pick the
S&S of too much dowre r
- ex. the P T is withdrawing from an uppe p -> not
enough uppe- makes everything go down
- ex. the P T is withdrawing from a cowner -> not
enough 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 & arrest
be 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 same
a) every alcoholic goes through withdrawal 24 hrs.
after they stop drinking
- only a m/norifyget delirium tremens
- timeframe - > 72 hrs. (alcohol withdrawal comes 1st)
- alcohol withdrawal syndrome ALWAYS precedes
delirium tremens, B U T delirium tremens does not
always follow alcohol withdrawal syndrome
b) A W S is not life-threatening: D T s can kill you
c) PT's w.' A W S are not a danger to self/others; PT's
w / D T s are dangerous to self/others
- they are withdrawing from a downer s o they will
be exhibiting upper S & S
- D T s are dangerous
Differences AWS DT
in Care
Diet Regu lar c et NPO/clear lie uica
(because oi risk for seizures which
can cauae risk c i asp ration)
Room Se"- -prvate Private nea- nurses staticin
anywhere on (dangerous A unstab e i
1he unit
Ambulation Up ad lib Restricted bed rest - > no ba1h roc<n
privileges (use bedpans- urinals)
Restraints No restra nts Rest-aims (because dange-ous)
(because not - not aofl wrist or 4 point soft
dangeroua) because tnev'll gel c ut
- need to be id vSat or Z-pt. locked
leathers (opposite 1 arm i. leg,
rotate {J2nra,lock the f-ee
linribs 1st before releasing 1he
locked 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 decrease
their workload (i.e. reduce P T load if they take a D T PT)
- > Hint: on boards, the setting is always perfect
(i.e. enough staff/time/resources on the unit etc.)
• Drug Abuse i n the Newborn:
- always assume intoxication N O T withdrawal at birth
- after 24 hrs - > withdrawal
- ex. caring for infant of a Quaalude addicted m o m 2 4
hrs. after birth, select all that apply:
-> dowrer withdrawal so everything is up = exaggerated
startle, seizing, high ptched'shrill cry

DRUGS
AMINOGLYCOCIDES
■ powerful class of antibiotics (when nothing else
works pull these outs, the big guns)
- don't use unless anything else works
■ boards iove to test these drugs because they re
dangerous 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 mean
oi'd andbiotic for a mean oid infectionJ
- > mycin = what they end with (all end w/ -mycin)
" not all -rnycin's are aminoglycosides BUT most
are (the 3 that are not are erythromycin.
azthromydn, clarithro mycin = throw rf off the list!)
• 2 toxic effects :
i) when you see '-mycin , think mice
- mice ->ears -> otto toxic
-monitor hearing, tinnitus, vertgo/dizziness
ii) the human ear i s shaped like a kidney so next
effect is nephrotoxicity
- monitor creatinine (not BUN, output, daily weight)
'creatinine = the best indicator of kidney/renal
function (pick 24 hr creatinine clearance over
serum creatinine if both available)
- #8 (fits nicely in the kidney) reminds you about 2
things 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't
have any systemic effect)
- EXCEPT in 2 cases = bowel sterilizers:
r hepatic encephaicpathy (hepatic coma) = to get
ammonia down, oral '-rnycin's' will sterilize the
bowel by killing Gram-neg bacteria (E. coli) to help
bring down ammonia and won t harm the
damaged liver because it doesn't go through the
liver (also gives diarrhea, more poop out is good)
’ pre-op bowei surgery = it sterilizes the gut by
killing the E. coli bacteria
- if oral, no otto or nephro toxicity because not absorbed
- these are neomycin & kanamycin
* Who can sterilize my bowels? NEO KAN
■ Trough and Peak levels:
- trough = drug at lowest
■ peak = drug at highest
*' TAP Jevefc - trough administer 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't
need to draw TAP levels
' ex. Lasix doses range from 5-80mg thus a wide
range so you won t need TAP levels
T ex. Dig doses range from 0.125 - 0.25 so this
narrow range needs TAPS levels
- A MEAN OLD MYCINS = major class that needs
TAPs drawn because of narrow window
- When do you draw TAPS?
-> depends on the route (don't focus o n the med)
a) Trough Levels
” 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 dose
b) Peak Levels
"" different but depends on the route (not the med)
- Sublingual = 5-10 mins after drug is dissolved
- IV = 15-30 mins after drugs is finished infusing
r Hint: if you get two values that are correct (i.e. a
15 min. answer and a 30 min. one) pick the highest
without going over so 3 0 mins.
- IM = 30-60 mins, after administration
- Sub-Q = SEE (see diabetes lecture -> because the
only Sub-Q peaks are Insulins)
- PO = forget about it, too variable so not tested
The BIG 1 0 Drugs to Know:
1 . psych drugs
2. insulins
3. anti-coagulants
4. digitalis
5 aminoglycosides
6. steroids
7. calcium -channel blockers
8. beta-blockers
9. pain meds
10. OB drugs

LECTURE 3 C 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 n
b y sight):
a) N o r m a l Sinus Rhythm
= P wave before every Q R S & followed b y a T
wave for every single c o m p l e x
- > all P wave peaks are equally distant from e a c h
other, Q R S evenly spaced
b ) -Fib = chaotic squiggly line, n o pattern
c) V-Tach = sharp peaks, h a s a pattern
d) A-Systole = flat-line
* Terminology:
- i f Q R S d e p o l a r i z a t i o n , its talking about ventricular
(so r u l e o u t anything atrial)
- if it says P-wave then its talking about atrial
- 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 S
2. " P - w a v e " = Atrial
- if i t s a 5 .vrooth wave, always pick atrial flutter
3 . "chaotic' - A-fib if w / P-wave
4. "chaotic" - V - f i b if w / Q R S
- H i n t : the word chaos' i s u s e d for fibrillation
5 . 'bizarre" = atrial tachycardia if w / P-wave
6 . 'bizarre" = ventricular tachycardia if w / Q R S
- Hint: the work 'bizarre' i s used for tachycardias
- 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 o Physician'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 these
P T s to moderate priority (never reach high)
i. if there are more than 6 P V C s i n a minute
ii. if there are more than 6 PVC's i n a row
iii. if the P V C fall o n the T-wave of t h e previous
beat ( R o n T phenomenon)
- > most common order if you call the N D about a
P T w / P V C s = D/C monitor (because then you
can 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 s
o r less) - > t h e s e P T s will probably b e top priorities
a ) A-Systole
b ) V-Fib
” both have i n common = n o c a r d i a c o u t p u t
- > n o brain perfusion ( a n d yourll b e d e a d i n 8 mins)
- V-tach = potentially life-threatening (but not actually
life-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 o
cardiac output it's just a s b a d a s the previous rhythm
Cardiac D R U G S
C A L C I U M - C H A N N E L B L O C K E R S
Calcium-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 heart
down (ex. if tachycardic, g i v e C C B s but not in shock)
- t o R E S T Y O U R H E A R T
- not stimulants
■ calcium-channel blockers a r e negative i n o t r o p i c
chronotropic, 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 down
POSITIVE NEGATIVE
Inotr o p e s
Chronotropes
Dromotopes
Cardiac Stimjlarts Cardiac Depressants
- stimu ate. speed - earn the heart down,
up the heart weaken & slow cowh
- W h e n d o you want to ' d e p r e s s " the heart? W h a t d o
CCB's treat?
A: anti- hypertensives
- relax heart & blood vessels t o bring down B P
A 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 d
AAA: anti-atrial a r r h y t h m i a
- e x . atrial flutter, A-fib, premature atrial contractions
- never ventricular
m what about supra-ventricular tachycardia??
- > because it m e a n s ' a b o v e the ventricles' (which
are 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 & high
Na = 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 i p 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 S needs to b e assessed before giving a C C B ?
- B P = because of risk of hypoTN
- > parameters/guide lines - hold C C B if systoiic i s
u n d e r 1 0 0
- > s o you n e e d t o monitor B P if P T i s o n a C a r d i z e m
continuous drip (if its u n d e r 1 0 0 then you m a y
have t o stop or c h a n g e the drip rate)

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- Treatment (more drugs):
al PVC s b) V-tach
= for ventricular use LIDOCAINE/ AMIODARONE
* i n rural areas mare Lidocaine use (cheaper &
anger ahelf-lrte)
c) Supra-Ventricular Arrhythmia s
= atrial arrhythmia's use ABCD s
■ A->ADENOCARD (Adenosine)
- have to push in less than 8 seconds (FAST IV
push}-> slam this drug, followed by a flush; use a
b g vein: BUT the problem w/ slamming it last is
the risk of PT going nto A-Systole (for 30 secords
but they wiff come out of it so don't worry [unless
longer than 30 sec...])
” for IV pu shes: wften you oon' t know you go slow
■ B -> BET A- BLOCKERS
- afl end /n '-lot
- every -lol’ is a BB & every BB is a -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 difference
between Beta- & Calcium channel blockers;
except that CCB are better for P T s w/ asthma
or 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 (in this order!)
-> if epinephrine doesn't work then use atropine
CHEST TUBES
- purpose is to re-establish negative pressure in the
pleural space (so that the lung expands when the
chest wall moves)
- pleural space -> negative is good (negative pressure
makes things stick together)
- ex. gun shot to the lung add positive pressure
■ Hint: when you get a chest tube question, look at the
reason for which it was placed (will tell you what to
expect & what not to expect)
- ex. pneumothorax = to remove air (because air
created the positive pressure!
- ex. hemothorax = to remove blood
- ex. pneumohemothorax = to remove blcod & air
* Hint: Alsc, pay attention to the tocaf/on of the tubes:
al Apical = the chest tube is way u p high, thus it is
removing a xr(because air rises)
- ex. its bad if you re apical tube is draining 200 m L or
it is not bubbling
b) BasiI ar = at the bottom of the Iungs. thu s it i s
removing b loodA iqu id (because of gravity)
- ex. i t s bad if your basilar tube is bubbling or not
draining any m L
- ax. Hoiv many chest tubes 3 where would you place them
for a unilateral pneumohemothorax?
- 2 chest tubes (apical for pneumo, basilar for nemo)
- ax. H o w many chest tubes & where would you place them
for a bi-lateral pneumothorax?
- 2 tubes (apical on eft. apical on right)
■ ax. H o w many chest tubes & where would place them far
post-op chest surgery?
- 2 tubes (apical & basilar on the side of the surgery)
" you are to assume that chest surgery /trauma is
unilateral untess otherwise specified (they will
say bilateral)
* Trick Question: How many chest tubes would you
need and where would you place them for a post-op
right pneumonectomy?
- NONE! because you are removing the lung so you
don't need to re-establish any pressure (there is not
pleural space)!
Troubleshooting Chest Tubes:
- What do you do if you knock over the plastic
containers that certain tubes are attached to?
- > set it back up & have PT take some deep breaths
-> NOT a medical emergency! (don t call ND)
■ What do you do if the water seal breaks (the
actual device breaks?)
-> first = CLAMP it!!! because now positive pressure
can 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 the
water seal (doesn't need clamo if its under water
better for the tube to be under water than
clamped! -> air can t go in and stuff can still keep
coming out (if clamped, nothing can come out
which is what the tube is for)
■ Ex. If they ask what the first thing is to do if the seal
breaks -> Clamp! BUT, if they ask what's the best
thing to do -> put end of tube under water! (because it
actually 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 do if
you could only do 1 of the options
-> ex. You notice the PT has V-fib on the monitor. You
run to the room and they are non-responsive with
no oulse. What is the first thing you do?
A) place a backboard?
B) begin chest compressions?
- "first1is about order so = pick A (because you
wouldn't start chest compressions first)
- BUT, if the question ask "What s the best thing to
do?" -> you only get to do 1 thing not the other so
you 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 but
depends 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 th is. means a leak in the system that
you need to find and tape it until it stops leaking)
" in RPN scope
- ex. Infermiftenf in suction control chamber -> BAD
(means suction is not high enough, turn it u p on the
wall until bubbling is continuous)
- ex. Continuous in suction control chamber -> GOOD
(document it)
- Hint: both locations 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 continuously
bubbling means its leaking!)
- A straight catheter is to a foley catheter as a
thoracentesis 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 continuous
Rules for Clamping Tubes:
- al Never clamp a tube for more than 15 seconds
without a doctors order.
- so if you break the water seal -> you have 15
seconds to get that tube under water
- b) Use rubber-tipped doubled clamps.
- the teeth of the damp need to be covered w/
rubber so that you don't puncture the tube
CONGENITAL HEART DEFECTS
- every congenital heart defect is either TROUBLE or
NO TROUBLE (ALL BAD or NO BAD)
- either causes a lot of problems or its no nig deal (no
in-between defect)
- memorize one word: TRouBLe
Heart Delects TRouBLe (S5% o f
all heart def seta) N o Tro ub le
Surgery NEED surgery now
to live - don'1 need su-ge-v
nght away; pose Div
need it years later ir it
causes 'a T'mubj'e (but
we don't expect it to)
Growth & Dev. alow, delayed normal
Life Expectancy short normal
Earent's
Experiencing grief, stress,
tfnanc al issues, lots regular average person
issues
of caregiving issues
Going Home apnea monitor nc apnea monitor
t pafjil a i Stay at weeks 24-48 hours
Who Follows
Your Care Paediat-ic
Care olcgist PaediaticiaiL
paediat-ic NP
Shunting R to L
(TRouBLe) L t o R
Cyanosis Cyanotic <= Blue
(THou BLe) Acyanotic
- ex. You are teaching the parents about a heart defect:
- pick all the options that cause troubie
• Hint: Boards will not give pictures of defects and ask
you what they are.
- not our job, we don't diagnose
-our role is teaching parents the implications
-> so f its trouble = teach them thing s that its going
to be a lot of trouble
-> il it's not rouble = Dick the things say ng it's not
going to be troube
• There are 40+ congenital heart defects so just remember
TRouBLe (don't memorze all of them!):
- Hint: all congenital heart defects that start w/ the
letter T are Troubie Defects
- we don't care about the detect, we care about what
were teaching the parents
■ All congenital heart defect kids (trouble or no trouble)
will have 2 things:
a) Murmur
- why? = because of the shunting of the blood
(regardless of direction of shunt)
bj all have an Echocardiogram done (to find out
what the defect is or why there's a murmur)
• 4 Defects of Tetralogy of Fallout:
-VarieD Pictures Of ARancH (or Valentines Day =l c<
Someone Out A Red Heart)
1. VD= ventricular defect
2. PS = pulmonany stenosis
3. OA = overriding aorta
4. RH = right hypertrophy
• don't have to recail these. RECOGNIZE them
- recall > remember from nothing
- RECOGNIZE -> spot it when you see it (use the
initials 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 D
PRECAUTIONS (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, Dysentery
r things with b u g s in diarrhea
T Hint 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 -2
yr. old's get that is not dangerous to adults but can
be fatal for them)
T transmitted b y droplet B U T stilt put them on
contact precautions because iittie kids catch it
from touching things that other sick kids touched
- Herpes infections (includes Shingles - > Herpes
Zoster virus even though caused b y varicella)
■ What's involved in contact precautions?
- > private room is preferred (but not required)
T or 2 R S V kids in the same room
T keep R S V kid & suspected R S V separate
because you need ocsit v e cultures (not based
on symptoms}
- > N O : mask, eye/face shield (unless for universal},
special filter mask, P T mask, neg. air flow
->YES: gloves, gown, hand-washing, special
supplies & dedicated equipment (includes toys)
" disposable supply vs. dedicated equipment:
- thermometer cover - BP cuff that stays in room
• Droplet
- for b u g s that travel 3 feet on large particles due to
sneezing/coughing
- all meningitis
" cultured through lumbar puncture
- H Flu (haemophilus influenza B ) - > commonly
causes epigiotitis
’ never stick something down throat because it will
cause obstruction
■ What's involved in droplet precautions?
- > private room is preferred (but not required)
T on boards select private
T can also cohort based on positive cultures
- > N O : gown, eye/face shield, special filter mask.
neg. air flow
- > Y E S : mask, gloves, hand-washing, P T worn
mask (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 is required
r unless co-horting
- > N O : gown (mostly for contact}, eye/face shields
- > YES: mask, gloves, hand-washing, special-filter
mask ONLY for TB, P T mask for leaving room
(but really shouldn't be leaving), neg. air flow
” disposable supplies & dedicated equipment i s a
good thing but not really a s essential a s i n the
other 2 (can let this one slide)
- > TB: technically transmitted via droplet B U T put
o 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 4
CRUTCHES. CANES, WALKERS
■ major area of human function is locomotion s o they test
these even though not a major emshasis i n school
- area to test P T teaching & risk reduction
Crutches:
- How d o you measure crutches?
” need to know for risk reduction - > so you don't
cause nerve damage
a) length o f crutch = 2-3 finger-w dths below anterior
axillary fold to a point lateral to & si ghtly in front of the foot
-> many questions ask where you measure fromfto (so for
crutches, if they ask anything measuring Tarn ax Ila to
foot -> rule out. they're wrong instructions for length)
b) hand grip = can be adjusted up & down; when properly
placed, should oe apx. 3 0 degrees elbow hexion
• How to teach crutch g a i t s (4 kinds}
T" names are pretty obvious w / a few exceptions
a) 2-point
- move a crutch and opposite foot together followed
by other crutch & opposite foot
- moving 2 things together
b) 3-point
- moving 2 crutches & fhe bad leg together
- moving 3 things together
c) 4-point
- moving everything separately
- move any crutch, then opposite foot, followed b y
next crutch then other foot
- very slow but very stable
d) Swing-thro ugh
- for non-weight bearing injuries (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 odd
T even point gaits when a weakness is evenly
distributed (i.e. even # of legs messed up)
- 2-point = mild problems (bilateral)
- 4-point = severe problems (severe, bilateral
weaknesses)
- 3-point = onjy odd one, when only 1 leg i s affected
. Ex. Eady stages of rheumatoid arthritis = 2-point
Ex. Left, atovB the fcnea amjMJtatrcvj = swing-through
Ex. Frraf day post-op right knee replacement, partial weight-
bearing allowed= 3-point
Ex. Adyancsd stages of ALS = 4-point
Ex. Left L.'p replacement, 2nd day post-op, non weight-hearing
= swing-through
Ex. BWsieraf totai' fcnae repfac&mefft, 1st day post-op. weight-
bearing allowed= 4-poinl
Ex. ®/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 leg
Cains:
* hold the cain o n the strong side
- a lot of people use it the wrong way
Walkers:
- pick it up, set it down, walk to it
• if they must tie their belongings to the walker, tie it at
the sides, not the front
- boards doesn't li <e things on the front (even tno most
peop e do that anyways: they dont like wheels or tennis
ball on the botto m either)

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ex- person storing st a wall & says: see a bomtf -> hallucination
0 X- person looks st fire extinguisher on the wall and says: " I see s
bornff -> illusion (referent)
■ Hint: O n the test, they will tell you that there is
something there thus, you can differentiate between a
hallucination & 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 .ri cf/c,'! i/t everyday v e (i e. have obs a
marriage, etc.}
- 4 diseases: Schizo Schizo Major Manics
i. Schizophrenia
ii. Schizoaffective Disorder
iii. Major Depression (if i t s major, test will say)
iv. Manic (Acute)
-> so bi-polar is functional, only psychotic
during manic phase
-these PTs have the potential to learn reality
(because no damage)
-> may need meds or set boundaries for structure
- > nurse role = teach reality {4 steps}
a) acknowledge feeling -> -| s e e you're angry;
'You seem upset', "Tell me how you are feeling',
often uses the wcrd feeling or shows a feeling
b) PRESENT REALITY -> "I know that those voices
are real to you but I don't hear them" or telling
them what is real ("I'm a nurse & this is a hospital")
c) set a limit -> "That topic/behavior is off-limits’,
"We are not going to talk about that right now",
' Stop talking about that"
d) enforce the limit -> "I see you're too ill to stay
reality based s o our convo is over" (ending the
conversation NOT taking away a privilege [Te.
punishment]; continuing to talk may enforce the
non-reality)
" " on the test, they won't ask these specific steps but
instead, will ask "how should the nurse respond...”
" " try to pick the more positive statements (i.e. what
they can have,'do, not what they cant); if between
2 statements go w/ the positive one
- 2. Psychosis of Dementia
-psychosis because of acfua/ damage to f/?e bra.'in
T in 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 why
you have to determine type of psychosis)
DELUSIONS, HALLUCINATIONS, & ILLUSIONS (Psych)
Neurosis Non- Psychotic vs. Psychosis
* Hint: the first thing you have to do to get a psych
questions correct is decide: 'Is m y PT non-psychotic
or psychotic?"
= this will determine treatment, goals, prognosis,
medication, length of stay, legalities., everything
NON-PSYCHOTIC PSYCHOTIC
Definition Has n o insight & is not
realit y-basea
- qon't think.'know their aick
- th nk everyone e ae naa
the problem bjt not them
(bla™"e anyone eee)
- even if they Bay they re,
sick but tnen trrey aay the
martiana made them sick
they oont nave insight
ood therapeutic
□Himun caton coea not
work beca jee they are
- RMRfifle, specific
strategies
- good therapeutic - q
Communication Hike c
any P T that displays
ocod comm, ski lie i
there s n d h ng
spec al tnat youTieec
to do,'know, comparea
to any med-su'de.
paetfe, or OB PT
DELUSIONS,
HALLUCINATION,
ILLUS ONS
- cnlv in Dsvchotc PTs
- as scon sra they get any
of these they’ve crossed,
the line to Be ng peycnotic
Has insight 1. is
neali t y-bpeed
- even tt! emotonal
distreas/illness,
mentabbe navio'al
disorder
- reaogn ze what the
problem a and how
it afiecls their life
Treatment/
Techniques
Symptoms don't have delusions,
hallucinations, o-
illusions
Psychotic Symptoms:
. a} Delusions
= false, fixed, idea or belief; n o sensory component
(all in the brain,, thinking it)
i. Paranoid Delusions -> people are out to harm m e
- ex. the mafia are our to get me
ii. Grandiose Delusions - > you are superior or you
are the world s smartest jreatest person
- ex. thinking you are Christ, Genghis Khan
iii. 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 the pe (primarily
voices telling you to hurt yourself); most common
ii. Visual -> seeing; 2nd most common
iii. Tactile -> feeling things; 3rd most common
iv. Gustatory -> tasting things that are not the p
e
v. Olfactory -> smelling things that are not there
” T ast 2 are relatively rap
e
- c) Illusions
= misinterpretation of reality, sensory experience
- difference from hallucination ->with an illusion there
is a referent in reality
-> referent = something in reality to which a person
refers when they say something (they just
misinterpret it)
■ ex. FT says:*! hear demon i/rwcss -> halluc nation
ex. P T ovrerfieare ra/rses ■£ MUs laughing & talking st the nursd s
station & says:* 1Listen, i hear oemor. voices' -> ill- s o r (there
ta a referent)

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-> nurse role:
al ac/mowJ'ecfge feeling
bl REDIRECT them -> from something they can t
do to something they can do
” you dont set-limits because i t s mean
” NOT APPROPRIATE to present reality to these
PT's when they are experiencing psychotic
symptoms (BUT don't confuse this w/ reality
orientation)
-> important to remember that forgetting things (like
where they are or what room they're i n - P T s w /
dementi a/Alzheimers) is NOT psychosis
” when they start having delusions, halucirations or
illusions, then they are psychotic
-> reality orientation = telling them person, place,
and time (ALWAYS APPROPRIATE w/
DEMENTIA) - this deals w / memory
3. Psychotic Delirium
= a temporary, sudden, oramatic, episodic,
secondary loss of reality; usually due to some
chem/cai' irnbaiance in the body
F different because it's temporary and very acute
- > include PT's that are short-term psychotic because
of something else causing the psychosis
- ex. a crug reaction, high on uppers or withdmwing
from cowners (delirium tremens), cocaine overdose,
post-op psychosis (withdrawing from a dowrer). ICU
psychosis (sensory deprivation), UTl (or any occult
infection), tnyro d storm, adrenal crisis
- good thing is it's temporary s o focus is removing
the underlying cause & keeping t h e m safe
-> nurse role:
al acknowledge feeling
bl REASSURE them: 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 different
A = art social
B = bopcerline
N = narcissistic
” very sick personality disorders
" may be gooc to use Functional Psychosis
techniques because you set limits
- Narrowed Self Concept
=when a psycnofc refuses >:■ leave the i roari or
change their clothes
-functional psychotic
- #1 reason is because their definition of self is
narrowed - > defined self based o n 2 things:
i. Where they are
ii. What they are wearing
so they dbrf f know who they are unless they are
wearing those exact clothes in that exact room
- as the nurse, don't make them change or leave the
room (will cause escalating panic because they will
lose their concept of self)
T use the Functional Psychosis techniques
- Ideas of Reference
= think everyone is ta k ng abcut you
- ex. see someone on the news and get upset
because 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 map
al Flight of Ideas
- coherent phrases but the phrases are not
connected (not coherent together)
b) Word Salad
- sicker, can t even make a coherent phrase
-> babble random words
c) Neologism
- making up imaginary words

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