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Mark Klemik Lecture 1: Acid Base Principles
As the ph goes, so goes my pt (except for k+) When ph goes up, systems in the body get irritable/hyper-excitable, borborygmi* When ph goes down, systems in the body shut down MacKussmauls. You see Kussmauls with metabolic acidosis There’s a difference between s/s of acid base imbalances vs. causes of acid base imbalances Cause: Ask yourself is it lung? Then it's respiratory Is the pt over ventilating or under ventilating? For Over- pick alkalosis Under- pick acidosis Ventilation means gas exchange. Resp. rate doesn't matter. Sao2 matters. It's not lung? Then it's metabolic. ** Only 1 scenario for Metabolic alkalosis : If pt has prolonged vomiting or suctioning For everything else that isn't lung, pick metabolic acidosis Idk what to pick- Metabolic acidosis Modifying phrase trumps original noun. “An ocd pt who is now psychotic” (look @ psychotic). “A vomiting pt who is now dehydrated” (look @ dehydrated).
Vent Alarms High pressure alarm goes off : working too hard (obstruction)
- Check for kinks, unkink
- Water condensation in the tube, empty it
- Mucus in the airway: turn/cough/deep breathe,
- If that doesn't work then suction (last resort)
Low pressure alarm goes off : that was too easy (disconnection) a. Main tubing: reconnect b. O2 sensor tubing (senses fio2 @ trachea area): reconnect
Translate respiratory alkalosis to ventilating over (settings are too high) Respiratory acidosis to ventilating under (settings are too low)
Mark Klemik Lecture 2: Alcohol/Drugs
Denial is the #1 problem in all abusive situations Alcoholism: #1 problem psychologically is denial. Treat it by confronting it. Point out the difference from what they say and what they do. With abuse you confront, with loss you support. Dependency: the abuser gets to keep using Codependency: the significant other feels positive self esteem from supporting the habit Set limits & enforce them, teach them to say no. “I'm saying no because I'm a good person.” Manipulation: Abuser gets significant other to do things for him/her that's not in the best interest for the significant other. The nature of the act is dangerous or harmful. Set limits & enforce them, teach them to say no. Manipulation is easier to treat than dependency because there's no positive self esteem issue with manipulation. Neutral: dependency/codependency has 2 pts. Negative: manipulation has 1 pt.
Wernicke Korsakoff- Psychosis induced by Vitamin B1 or Thiamine S/s: Amnesia with confabulation (memory loss with making up stories) Don't confront them or present reality. Redirect them. To prevent/stop it from getting worse: Take vitamin B1. They don't have to stop drinking, and it’s irreversible.
Aversion Therapy: Antabuse (disufiram) & ReVia (naltrexone) Makes you hate alcohol and if you drink it you’ll get deathly ill Takes 2 weeks to get into the system Need 2 weeks to get out of system to safely drink again Teach pt to avoid all alcohol products:
- Mouthwash
- Aftershave
- Perfumes/Cologne
- Insect repellent
- Anything that ends in elixir
- Alcohol based hand sanitizer
- Unbaked icing (vanilla extract) ****They can have red wine vinegarette!** Every abused drug is either an upper or downer.
NPO/clear liquids (seizure risk), private room, near nurses station, strict best rest / need bed pans & urinals, must be restrained appropriately: vest or 2 point locked leathers (opposite arm & leg) rotate every 2 hours. Meds: antihypertensive pill, tranquilizer, b1 vitamin
Aminoglycocides- A Powerful Class of Antibiotics A mean old mycin for a mean old infection Life threatening, resistant, serious, and gram negative infections All end in mycin, but not all that end in mycin are mean old mycins NOT MeanOldMycins : Arithromycin, Zythromycin, and Clarithromycin. If it has thro, throw it off the list!! They are ototoxic (ear toxic) mycin (mice- ears) Monitor for hearing, tinnitus, vertigo/dizziness The human ear is shaped like the kidney, so watch for nephrotoxicity Best indicator of liver funct: 24hr creatinine clearance ****** #2 serum creatinine Administer them q8hr. Route: IM or IV. Don’t give PO for infection! Only 2 cases to give orally: sterilize the bowel
- Hepatic encephalopathy/hepatic coma/liver coma (when ammonia level gets too high & gets to your brain) Kills the E. coli in the gut & lower the ammonia level
- Pre-op bowel surgery to sterilize the bowel Oral mycins will kill gram-negative bacteria in your gut (sterilize bowel) Sargent asks: Who can sterilize my bowel? Neo can! NEOMYCIN and CANOMYCIN!
TAP Levels: Trough- When drug is at its lowest (Draw before drug admin) Peak- When drug is at its highest (Draw after drug admin) TAP (trough, administer drug, peak) for narrow therapeutic windows THE DRUG DOESN’T MATTER, THE ROUTE MATTERS ;) Sublingual/IV/IM/SQ/PO Trough : Draw 30 mins before the next dose Sublingual Peak : 5-10 mins after drug is dissolved IV Peak : 15-30 mins after drug is finished IM Peak : 30-60 mins SQ- See diabetes lecture PO- They don’t test PO peaks When there’s 2 right answers, pick the highest without going over
Mark Klemik Lecture 3- Cardiac/Chest Tubes/Infection Precautions CCB’s are like Valium for your heart (calms your heart down)
CCB’s are negative inotropics, negative dromotropics, and negative chromotropics. Weaken, slow down, and depress the heart. Cardiac depressant.
They treat: A, A-A, and A-A-A Anti-hypertensive Anti-angina Anti-atrial-arrhythmia= it treats everything atrial related , EXCEPT supra ventricular tachycardia (supra means above, above the ventricle is the atrial). Side effects: Headache & hypotension
Names of CCB’s: Names ending in “dipine” (You're dipping in the calcium channel) Verapamil Cardizem = Continuous IV drip Monitor BP intermittently. If systolic is below 100, hold. For drip, if systolic was 98 titrate it down.
Cardiac Arrhythmias: Normal sinus rhythm- Peaks of p waves are evenly spaced V-fib- Chaotic squiggly line. No pattern V-tach- Sharp peak & jags. There's a pattern Asystole- Flat line QRS depolarization- Answer will always be ventricular P wave- Answer will always be atrial Lack of a P wave- Answer will always be ventricular A lack of QRS- Asystole A-flutter- Saw tooth Chaotic is always the word used to describe fibrillation Bizarre is always the word used for tachycardia
Low Priority: Premature ventricular contraction (PVC) A bunch of PVC’s is like a short run of V-Tach Moderate Priority: If more than 6 PVC’s in a minute or row and/or if PVC falls on the T wave of the previous beat. They never are high priority!
Potentially Life Threatening: V-Tach- Pt has a pulse Lethal Priority: Kills you in 8 mins or less
- Submerge in sterilized water
- Unclamp because we reestablished the water seal. In a best/priority question you only get to pick one. In a first question you get to do the rest of the options , but you have to pick which one is first
What do you do when chest tube gets dislodged? **First**** Cover hole with gloved hand **Best**** Cover with Vaseline gauze
If there’s bubbling in chest tube: Ask yourself where/when? Water Seal Intermittent bubbling: Always good, document* Continuous bubbling: Always BAD, tape it* If it’s sealed should it be continuously bubbling? No , it’s leaking! Suction Control Chamber Intermittent bubbling: Always bad, suction isn’t high enough* Continuous bubbling: Always good, document*
A straight-cath (in and out foley) is to a foley (continuous drainage) as a thoracentisis (in and out chest tube) is to a chest tube (continuous drainage) Higher risk for infection- Foley & chest tube
Rules for clamping tubes Never clamp a tube for longer than 15 secs w/o a Dr order Use rubber tip double clamps
Congenital Heart Defects Every CHD is either trouble or no trouble TR ou BL e - need surgery to live, everything is bad, short life expectancy, delayed growth & development, exercise intolerance, financial difficulties, pediatric cardiologist.
A trouble defect is right to left, because R comes before L. A no-trouble defect is left to right. Right to left means blue (cyanotic), left to right means acyanotic. All trouble heart defects that are trouble start with T. All heart defects (trouble or not) have a murmur and they all have an echocardiogram done. Tetralogy of Fallot: V arie D P icture S O f A R anc H Ventricular Defect Pulmonary Stenosis Overriding Aorta Right Hypertrophy
Infectious Disease & Transmission Based Precautions Contact: Anything enteric (fecal/oral) C-diff, Hep A (stands for anus), Herpes, Staph infections, and RSV (Respiratory Syncytial Virus, babies get it) transmitted by droplet but works best still on contact precautions Private room, but can be in the same room if in cohort PPE- Gloves, Gown, Disposable supplies/dedicated supplies
Droplet (sneezing/coughing) : Meningitis, H-flu (causes epiglottis) Private room, unless cohort They need a lumbar puncture for cultures PPE- Gloves, Mask, Pt wears mask when leaving room, Disposable supplies/dedicated supplies, No gown
Airborne: Measles, Mumps, Rubella, TB, and Varicella. Private room required unless cohort. Mask, Gloves, Special filter mask (ONLY FOR TB), Pt wear mask when leaving room, Negative airflow room. TB is spread by droplet but airborne precaution. PPE Always take off in alphabetical order Gloves, goggles, gown, mask Put on in the reverse alphabetical in the G’s, but mask comes second Gown, mask, goggles, gloves Mark Klemik Lecture 4: Crutches/Canes/Walkers/Psych
How To Measure Length of Crutches: 2-3 finger widths below the anterior axillary fold to a point lateral to and slightly in front of the foot ***No landmarks on the foot or axilla****
S/s: Delusions, Hallucinations, Illusions *
Delusion : A false, fixed idea or belief. Thinking, not sensing Paranoid Delusion- False, fixed belief that people are out to harm you Grandiose Delusion- False, fixed belief that you are superior Somatic Delusion- False belief about your body (X-ray vision) Erotomanic Delusion- False, fixed belief another person (usually famous or powerful) is in love with them. Jealous Delusion- False, fixed belief that their partner is unfaithful Persecutory Delusion- False, fixed of being treated in a malicious way
Hallucination: False, fixed sensory experience (5 senses) Most common in order- Auditory, Visual, Tactile. Rare ones -Gustatory (tasting) & Olfactory (smelling)
Illusion: Misinterpretation of reality (sensory experience) ***The difference between hallucination & illusion is, with an illusion there’s a referent in reality. There’s actually something there , but they just misinterpreted it. With a hallucination there’s actually NOTHING there ***
3 Types of Psychotics Functional psychotics: Can be married, have a family, job, live alone, pay bills… 90% of functionals are Schizo Schizo Major Manic Schizo- Schizophrenia Schizo- Schizo-affective Disorder Major- Major Depression Manic- Bipolar
- Dementia : Brain damage
- Delirium : Temporary, sudden dramatic secondary loss of reality usually due to a chemical imbalance in the body. (Ex- Ppl high on uppers, withdrawal from downers, drugs like Tegamet, post op pt, occult UTI in elderly, thyroid storm, adrenal crisis, etc)
How to answer these questions: Ask yourself, are they psychotic or non-psychotic? If non-psychotic, pick best good therapeutic communication response. If they’re psychotic, decide which 3 categories that person falls in.
For Functional - This pt has the potential to learn reality
- Acknowledge their feelings “You seem angry” “That must be distressing”
“Tell me how you’re feeling”
- Present reality “I know that___ is real to you, but I don’t see ___” “I am a nurse & this is a hospital”
- Set a limit “That topic is off limits in our conversation” “That topic we talk together we’re not going to talk about that” “Stop talking about those aliens/voices”
- Enforce the limit End the conversation Don’t punish/restrict them “I see you’re too ill to stay reality based, so our conversation is over”
For Dementia- This pt has a brain damage and can’t learn reality
- Acknowledge their feelings “That seems exciting” “I see that you’re happy” “I see that you’re sad”
- Redirect them DON’T present reality You can reality orient them (person, place, time) “Ok, let’s sit here and you can tell me about church while we wait for your dead husband” DON’T change the subject
For Delirium- Remove the underline cause & keep them safe
- Acknowledge their feelings “That seems exciting” “I see that you’re happy” “I see that you’re sad”
- Reassure them “You are safe and that will go away when you get better”
Abnormal (Abn)- Antisocial, Borderline, Narcissistic Treat them like a functional. Set limits!
Loose associations: Flight of Ideas- Thought to thought to thought to thought Word Salad- Random words Neologism- Making up imaginary words Narrow Self-concept- When a functional psychotic refuses to leave their room or change their clothes. (They define who they are based on where they are and what they’re wearing. They don’t know who they are if they get undressed/ it terrifies them) Ideas of Reference- Pt thinks everyone is talking about them
Acute abdominal distress : Pain, guarding, borborygmi, diarrhea, bloating, distention, tenderness Tx: Low position (HOB flat) Turn to side with head down Low fluids ( 1-2hrs before or after meals , not with the meals), Low carbs. If you want the stomach to empty slow, everything is low. Except protein
Electrolytes:
Kalemias - Do the same as the prefix except for heart rate * and urine output. S/s Hyperkalemia - Agitation, irritability, tachypnea, bradycardia, tall p waves, elevated ST waves, diarrhea, borborygmi, spastic muscles, hyperreflexia, oliguria
S/s Hypokalemia - Lethargy, tachycardia, bradypnea, dynamic ileum, constipation, flaccid muscles, hyporeflexia, polyuria
Calcemias- Do the opposite. Muscles & nerves* S/s Hypercalcemia- bradycardia, bradypnea, flaccid muscles, hypoactive reflexes, lethargy, constipation
S/s hypocalcemia- Tachycardia, agitation, irritability, tachypnea, diarrhea, borborygmi, spastic muscles, hyperreflexia, seizure, chvostek (cheek, face spasm) sign & trousseau sign (BP hand spasm), gay french man* lol
Magnesemias- Do the opposite. In a tie between Calcemia & Magnesium, don’t pick Magnesium* S/s Hypermagnesima - Bradycardia, bradypnea, flaccid muscles, hypoactive reflexes, lethargy, constipation S/s Hypomagnesima - Tachycardia, agitation, irritability, tachypnea, diarrhea, borborygmi, spastic muscles, hyperreflexia, seizure
Sodium- Dehydration Vs. Fluid Overload The one with the E is dehydration, the one with the O is overload Dehydration- HypErnatremia, hot flushed skin give lots of fluids, hot/flushed skin Overload- HypOnatremia, fluid restriction & give Lasix
Earliest sign of any electrolyte imbalance is numbness/tingling aka Paresthesia Nclex Vocab Word: Circumoral Parasthesia - Numb/tingling lips All electrolyte imbalances cause muscle weakness AKA paresis
Tx for Potassium: Never IV push K+ Never give more than 40 of K+ per liter of IV fluid
Fastest way to lower K+ Give D5W with regular insulin K+ enters early K+ in blood will kill you, not K+ in cells D5W with insulin will push the K+ into the cell **Temporary but works fast *****
Kayexalate: Full of sodium, given via enema or orally K+ exits late Trades sodium for K+ so u shit it out. It results in hypernatremia (dehydration) so give them fluids to correct it **Takes hours but it’s permanent *****
Mark Klimek Lecture 7- Endocrine Glands/Toys/Laminectomy (Don’t have to know thymus, pineal, parathyroid)
Hyperthyroidism: Graves Disease Turn thyroid into metabolism (hyper metabolism) “You’re going to run yourself into the grave”. Missy Elliot is a closet Elsa, the cold never bothered her anyway, and she hates the beach. S/s: Weight loss, high HR, low BP, irritable/hyper, heat intolerance, cold tolerance, exophatalmos (bulging eyes)
Tx:
S/s: Hyper pigmented (very tan), does not adapt to stress If they undergo any stress they might go into shock Glucose goes down & BP goes down Tx: Steroids (-sones) ADD i SONe LOL :)
Cushing’s Syndrome: Over Secretions of Adrenal Cortex If you have a cushy bank account you have more $
S/s of Cushing’s & side effects of steroids: High glucose** (hyperglycemic)(insulin resistant) Moon face Hirsutism Big body / buffalo hump Gynecomastia Central obesity (apple body) Skinny extremities due to muscle atrophy Retains sodium & water Loses potassium Bruises and striae Irritable Immunosuppressed “I’m mad. I have an infection” Tx:
Adrenalectomy- Bilateral: You get Addison’s Toys: Is it safe? Is it age appropriate? Is it feasible?
Safety No small toys for kids under 4. No metal/die-cast toys if o2 is in use (sparks) Beware of fomites (teddy)(nonliving object that harbors microorganisms)
Age appropriate 0-6 months : Musical mobile, Soft & large, Teething soft books
6-9 months: Teach object permanence (looks for the toy when you hide it) Best option is a “cover/uncover toy” (Ex: Jack in the box, pop up pals, books with windows, peek a boo) Second best: large plastic/wood/metal
Worst toy is a musical mobile NEVER pick answers with the words: build, sort, stack, make, construct, for a child under 9 months
9-12 months: Learning to speak Speaking toys Talking books
Toddlers (1-3 years): Push/pull toy (Ex: Popper, stroller, doggie, wagon, etc) Work on gross motor skills: running/jumping DO NOT choose answers with finger dexterity (Ex: Cut, use pencils, color) NOT INCLUDING FINGER PAINTING! Parallel play-play alongside other kids, but not together
Preschoolers: Finger dexterity/work on balance Tricycles Tumbling Class/Dance Class Coloring Play together They like to pretend (Imaginative thinkers)
School Aged Kids: Characterized by Triple C’s Create: Let them make it (Blank paper & colored pencils, Legos) Collective (Pokemon cards, digimon, beanie babies) Competitive: Play games that they can win
Adolescence: Peer group association Hang out with friends Let this happen unless pt is fresh out of post op (<12 hrs), contagious disease, or immunosuppressed
Laminectomy : Removal of vertebral spinal processes (winged ends of vertebrae) Relieves nerve root compression
S/S: 3 P’s: Pain, Paresthesia, Paresis
The most important thing to pay attention to is location b/c it will determine prognosis, treatment, symptoms
Locations:
B- (Be concerned)- Assess/monitor C- (Critical)- Do something, you can leave the bed side D- (Deadly/Dangerous)- Do something now, NEVER LEAVE BED SIDE OF D**
Serum Creatinine: 0.6-1. unless question says they have a dye procedure in the morning
INR: 2- Anything 4+ is (C)
Potassium: 3.5-5. Low or high is (C) unless it reaches 6+ then it is a (D)
pH: 7.35- 7. Anything in the 6’s is a (D)
BUN: 8- (A) Assess for dehydration
Hemoglobin: 12- If 8-11 it’s a (B) Assess for anemia/bleeding/malnutrition If below 8 (C) Assess for bleeding, prepare to give blood, call doctor Bicarbonate: 22- (A)
Co2: 35- 46-59 is a (C) Assess respirations, prepare to do pursed lip breathing 60+ is a (D) Assess respirations, prepare for intubation/ventilation, call respiratory therapy then the doctor
Hematocrit: 36-54 (3x’s the hemoglobin) 54+ is a (B) Assess for dehydration
P02: 78- Low 70s it’s a (C) Assess respiratory, prepare to give 02 Hypoxia 60s and lower is a (D) Give 02, assess respirations, prepare for intubation/ventilation, call respiratory therapy then doctor
O2: 93-
If less than 93 it’s a (C) Assess respirations, raise head of bed, give 02, unless “best” question then just give 02 BNP: < 100 100+ (B) Look for signs of CHF Sodium: 135- (B) Unless change in LOC, then it’s a (C) Platelets: Below 90,000 is a (C) Below 40,000 is a D RBCs: 4-6 mil (B) WBC: therapeutic 5,000-11, ANC: 500+ CD4: 200+ Less than normal value for WBC, ANC, CD4 are all (C) Low CD4=AIDs Place on Neutropenic Precautions**
Neutropenic Precautions: Strict Hand washing Shower BID with antimicrobial soap Avoid Crowds Private Room Limit numbers of staff entering room Limit Visitors for Healthy Adults No fresh flowers or potted plants Low Bacteria Diet: No Raw Fruits, Veggies, Salads No Undercooked meat. Do not drink water than has been standing longer than 15 minutes Vital signs (Especially Temperature) every 4 hours Check WBC (ANC) Daily Avoid the use of an indwelling catheter Do not re-use cups.. must wash between uses Use disposable plates, cups, straws, plastic knife, fork, spoon Dedicated Items in Room: Stethoscope BP Cuff Thermometer Gloves
