Mark Klimek Lecture Notes Guide Latest Update 2025 / 2026 (Graded A+) Guaranteed Pass, Exams of Nursing

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LECTURE 1 * learn how to convert lab values to words * the rule of the B’s = if the pH and the _BiCarb are _b othin the same direction -> metabolic Hint: draw arrows beside each to see directions * down = acidosis * up = alkalosis - respiratory -> has no b in it; if in other directions (or if bicarb is normal value) - KNOW NORMAL pH, BiCarb, COZ © Hint: DON’T MEMORIZE LISTS...know principles (they test knowledge of principles by having you generate lists.) - for “select all” questions - ex. in general/principle what do opioids/pain meds do? = sedate you, CNS depressors * ex. what does dilaudid do? don’t memorize specifics or a list of dilaudid, know principles of opioids (such as sedation, CNS depression -> lethargy, flaccidity, reflex +1, hypo-reflexia, obtunded) - boards don’t test by lists because all books/ classes have different lists * principles of S&S acid bases: as the pH goes so goes my patient (except K+) - pH up = PT up -> body system gets more irritable, hyper-excitable (EXCEPT K+) -> alkalosis - think of a body system and go high: hyper-reflexive (+3, +4 [2 is normal]), tachypnea, tachycardia, borborygmi, seizure - pH down = PT down -> body systems shut down (EXCEPT K+) -> acidosis - think of a system and go low: 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) » Mac Kussmaul - Kussmaul’s (compensatory respiratory mechanism) is only present in only 1 of the 4 metabolic (acid-base) disorders * M= metabolic AC = acidosis * most common mistake with select all questions = selecting ‘one more than you should (stop when you select the ones you know! don’t get caught up on the “could be’s”) » Hint: don’t select none or ail on select all that apply questions (never only one and never all) * Causes of Acid-Base Imbalance: - scenarios and what acid-base disorder would result (what would cause an imbalance) b) low pressure alarm = decreased resistance to airflow (the machine had to work too little to push air into lungs) ** DON’T MIX UP S&S and CAUSATION - often what causes something is the opposite of the S&S - ex. diarrhea will cause a metabolic acidosis but once you are acidotic your bowel shuts down and you get a_ paralytic illeus * when you get scenarios: -> if it’s a lung scenario = respiratory - then check if the client is over-ventilating (alkalosis) or under-ventilating (acidosis) - remember to look at the words (ex. over, under, ventilating) -> “as the pH goes so goes my PT” -> VENTILATING DOESN'T MEAN RESPIRATORY RATE; resp. rate is irrelevant w/ acid-base, ventilation has to do with gas exchange not resp. rate (look at the $aO2 -> if your resp. rate is fast but Sa02 is low you are underventilating) -> ex. PCA pump - What acid-base disorder indicates they need to come off of it? = respiratory acidosis (resp. depression -> resp. arrest) —> if it’s - from disconnections: nat lung, it’s metabolic i. main tubing (reconnect it duh!) ii. O2 sensor ¢ metabolic alkalosis - really only one scenario = if the PT tubing (which senses FiO2 at the airway/trach has prolonged gastric vomiting/suctioning - because area; black coated wire coming from machine you are lasing ACID right along the tubing - reconnect!) * ex. GI surgery w/ NG tube with suctioning for «ventilators -> know blood gases - resp. alkalosis = 3 days; hyperemesis graviderum - otherwise ventilation settings might be set too high (OVER- everything else that isn’t lung you pick metabolic VENTILATING) acidosis (DEFAULT) * ex. hyperemesis graviderum w/ dehydration acute renal failure, infantile diarrhea - resp. acidosis = ventilation settings might be set too low (UNDER-VENTILATING) * remember, you only have 4 to pick from: - respiratory = ex. weaning a PT off ventilator -> should not be alkalosis - respiratory acidosis - metabolic alkalosis - under-ventilated, they need the ventilator; if they are metabolic acidosis over-ventilating then they can be weaned * pay more attention to the modifying phrases than the never pick an answer where you don’t do something original noun and someone else has to do something - ex. person w/ OCD who is now psychotic (psychotic trumps OCD); hyperemesis with dehydration (pay attention to dehydration) . E VENTILATION «ventilators -> know alarm systems (you set it up so 7 that the machine doesn’t use fess than or more than T specific amounts of pressure) U a) high pressure alarm = increased resistance to airflow (the machine has to push too hard to R get air into lungs) - from E obstructions: 2 i. kinks in tubing (unkink it) ii. water condensation in tube (empty it!) iii. mucous secretions in the airway (change _positions/turn, _ABUSE (Psych and Med-Surge) Psychological C&DB, and THEN suction) *** suction is only Aspect/Psycho-Dynamics © # 1 psychological PRNIII problem is the same in any/all abusive situations = -> priority questions = you would check kinks first, DENIAL suction is not first touch with reality) -> tend to go together, find them in the same PT = Wernicke Korsakoff’s syndrome: a) psychosis induced by Vit. B1 (Thiamine) deficiency - lose touch w/ reality, go insane because of no B1 b) primary symptom -> amnesia w/ 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 do and channel it into something they can do) « Characteristics of Wenicke Korsakoff's: a) it’s preventable = take Vit. B1 (co-enzyme needed for the metabolism of alcohol which keeps alcohol from accumulating and destroying brain cells) * PT doesn’t have to stop drinking b) it’s arrestable = can stop it from getting worse by taking Vit. B1 * also not necessary to stop drinking c) it’s 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 it’s not) Drugs for Alcoholism: DISULFIRAM (Antabuse) = aversion therapy -> want PT’s to develop a gut hatred for alcohol -> interacts w/ alcohol in the blood to make you very ill - > onset & duration: 2 weeks (so if you want to drink again, wait 2 weeks) - PT teaching = avoid ALL forms of alcohol to avoid nausea, vomiting & possibly death -> including mouthwash, aftershaves/colognes/perfumes (topical stuff will make them nauseous), insect repellants, any OTC that ends with “-elixir”, alcohol- based hand sanitizers, uncooked (na-bake) icings_ which have vanilla extract, red wine vinaigrette * Overdoses & Withdrawals: - every abused drug is either an UPPER or DOWNER 1) first establish if the drug isan upper or downer - uppers (5) = caffeine, cocaine, PCP/LSD (psychedelic hallucinogens), methamphetamines, add_er_al | (ADD drug) * S&S - make you go up; euphoria, tachycardia, restlessness, irritability, diarrhea, borborygmi, hyperreflexia, spastic, seize (need suction) - downers = 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 it’s a downer if it’s not part of the uppers list * 5&5 -> make you go down; lethargy, respiratory depression (& arrest) - ex. The PT is high on cocaine. What is critical to assess? > NOT resps below 12 because they will be high -> maybe check reflexes b) are they talking about overdose or withdrawal - overdose/intoxication = too much - withdrawal = not enough - ex. the PT has overdosed on an upper -> pick the S&S of too much upper - ex. the PT has overdosed on a downer -> pick the S&S of too much downer - ex. the PT is withdrawing from an upper -> not enough upper makes everything go down - ex. the PT is withdrawing froma downer -> not enough downer makes everything go up * upper overdose looks like = downer withdrawal « downer overdose looks like = upper withdrawal * In what 2 situations would resp. depression & arrest be your highest priority: - downer overdose - upper withdrawal ¢ In what 2 situations would seizure be the biggest risk: - upper overdose - downer withdrawal « Drug Abuse in the Newborn: - at birth, always assume intoxication, - after 24 hrs -> withdrawal - ex. caring for infant of a Quaalude (not upper) addicted mom 24 hrs. after birth, select all that apply: -> downer withdrawal so everything is up = exaggerated startle, seizing, high pitched/shrill cry ¢ Alcohol Withdrawal Syndrome vs. Delirium Tremens a) every alcoholic goes through alcohol withdrawal 24 hrs. after they stop drinking - only a minority get delirium tremens - timeframe -> 72 hrs. (alcohol withdrawal comes 1st) - alcohol withdrawal syndrome ALWAYS precedes delirium tremens, BUT delirium tremens does not always follow alcohol withdrawal syndrome b) AWS is not life- threatening; DT’s can kill you c) PT’s w/ AWS are nota danger to self/others; PT’s w/ DT’s are dangerous to self/others = they are withdrawing from a downer so they will be exhibiting upper S&S - DT’s are dangerous surge, the RN who takes them must decrease their © When do you draw TAPS? -> depends on the route (don’t workload (i.e. reduce PT load if they take a DT PT) focus on the med) a) Trough Levels -> Hint: on boards, the setting is always perfect ** doesn’t matter which route or med, always 30 mins. - {i.e. enough staff/time/resources on the unit etc.) sublingual = 30 mins. before next dose DRUGS - IV = 30 mins. before next dose AMINOGLYCOCIDES - IM = 30 mins. before next dose * powerful class of antibiotics (when nothing else works 7 SubGie B0lnins. clone weitdiden pull these outs, the big guns) - PO=30 mins. before next dose b) Peak Levels aaonit useiupless/anvailbe.else Wonks ** different but depends on the route (not the med) - * boards love to test these drugs because they‘re Sublingual = 5-10 mins after drug is dissolved - IV = 15- dangerous and are a test of safety 30 mins after drugs is finished infusing * Hint: if you «think: A MEAN OLD MYCIN get two values that are correct (i.e. a 15 min. answer -> a mean ald = they treat serious, life-threatening, and a 30 min. one) pick the highest without going resistant, Gram-neg bacteria infections (i.e. a mean overs 30 mitns:-IM =30-60 mitisvafter old antibiotic for a mean old infection) -> mycin = administration - Sub-Q = SEE (see diabetes lecture -> what they end with (all end w/ -mycin) ** not all - because the only Sub-Q peaks are Insulins) mycin’s are aminoglycosides BUT most are (the 3 - PO = forget about it, too variable so not tested that are not are erythromycin, azithromycin, clarithromycin = throw it off the list!) - peak = drug at highest ** TAP levels - trough administer peak -> draw trough levels first oa The BIG 10 Drugs to Know: -> administer your drug 1. psych drugs -> draw peak levels after drug administration 2. insulins * Why draw levels? = narrow therapeutic window - small . . 3. anti-coagulants difference between what works and what kills - if the drug . , 4. digitalis has a wide range then you wouldn’t need to draw TAP levels 5. aminoglycosides * ex, Lasix doses range from 5-80mg thus a wide 6. steroids range so you won’t need TAP levels * ex. Dig doses 7. calcium-channel blockers range from 0.125 - 0.25 so this narrow range needs 8. beta-blockers TAPS levels 9. pain meds 10. OB drugs eA MEAN OLD MYCINS = major class that needsTAPs drawn ) LECTURE 3 because of narrow window CALCIUM-CHANNEL BLOCKERS ‘select all that apply’ questions (ex. low Na & high Na = Calcium-Channel Blockers are like Valium for your heart © headache, high & low glucose = headache, high & low BP = Valium -> calm’s you down; so CCB’s calm your headache) heart down (ex. if tachycardic, give CCB’s but not in Names of Calcium-Channel Blockers: shock) - to REST YOUR HEART = —— ae a anything ending in ‘-dipine’ - not stimulants = ex. amlodipine, nifedipine *calcium-channel blockers are negative inotropic, P = NOT just ‘pine’ chronotropic, & dromotropic drugs - fancy way of = also includes: VERAPAMIL & CARDIZEM - which can saying that they calm the heart down be given as continuous IV drip?? = Cardizem POSITIVE NEGATIVE L What VS needs to be assessed before giving a CCB? - BP = because of risk of hypoTN Inotropes Cardiac - Cardiac Depressants -> parameters/guidelines - hold CCB if systolic_is under Stimulants -calm the heart down, Chronotropes stimulate, 100 speediiap weaken & slow -> so you need to monitor BP if PT is on a Cardizem down Drometapes the heart continuous drip (if it’s under 100 then you may have to © When do you want to “depress” the heart? What do stop or change the drip rate) CCB’s treat? * Interpreting Rhythm Strips (4 that need to be known by sight): A: anti-hypertensives - relax heart & blood vessels to bring down BP AA: anti-angina’s a) Normal Sinus Rhythm - relax heart to use less O2 to make angina =P wave before every QRS & followed by aT wave for gO away - treats angina by addressing oxygen every single complex demand -> all P wave peaks are equally distant from each other, AAA: anti-atrial arrhythmia QRS evenly spaced - ex. atrial flutter, A-fib, premature atrial b) V-Fib = chaotic squiggly line, no pattern contractions - never ventricular c) V-Tach = sharp peaks, has a pattern *** what about supra-ventricular tachycardia?? -> . . . d) A-Systole = flat-line because it means ‘above the ventricles’ (which are the atria) * Terminology: © Side-Effects: - if QRS depolarization, it’s talking about HGH headache Shypatension ventricular (so rule out anything atrial) - if it says BihYRGTIN" frokmtelaxes hesrk& vessels ~ P-wave then it’s talking about atrial > headache - vasodilation to brain ** Hint: headache is a good thing to select for * 6 Rhythms most tested on N-CLEX: #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) Asystole = use EPINEPHRINE & ATROPINE (in this order!) -> if epinephrine doesn’t work then use atropine 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 geta 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), air is in pleural space, chest tube will re-establish negative pressure - ex. hemothorax = to remove blood - ex. pneumohemothorax = to remove blood & air Hint: Also, pay attention to the location of the tubes: a) Apical = the chest tube is way up high, thus it is removing _a_ir (because air rises) - ex. it’s bad if you're apical tube is draining 200 mL or it is not bubbling b) Basilar = at the bottom of the lungs, thus it is removing _b load fliquid (because of gravity) - ex. it’s bad if your basilar tube is bubbling or not draining any mL * ex. How many chest tubes & where would you place them for a unilateral pneumohemothorax? - 2 chest tubes (apical for pneumo, basilar for hemo) ® ex. How many chest tubes & where would you place them for a bi-lateral pneumothorax? - 2 tubes (apical on left, apical on right) ex. How many chest tubes & where would place them for post-op chest surgery? - 2 tubes (apical & basilar on the side of the surgery) ** you are to assume that chest surgery/trauma is unilateral unless otherwise specified (they will say bilateral) ¢ Trick Question: How many chest tubes would you need and where would you place them for a postop 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 MD) © What do you do if the water seal breaks (the actual device breaks?) -> first = CLAMP ! because now positive pressure can get in! don’t let 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 clamp if it’s 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 pulse. What is the first thing you do? A) place a backboard? B) begin chest compressions? - “first” is about order so = pick A (because you wouldn’t start chest compressions first) - BUT, if the question ask “What's the best thing to da?” -> you only get to do 1 thing not the other so you would pick B What do you do if the chest tube gets pulled out? - first = take a gloved hand and cover the hole - best = cover the hole with vaseline gauze e Bubbling chest tubes: (ask yourself 2 questions) a) Where is it bubbling? b) When is it bubbling? = the answer will depend on these 2 questions (sometimes bubbling is good, sometimes bad but depends on where & when) = ex. Intermittent bubbling in the water seal -> GOOD (document it, never bad!) - ex. Continuous bubbling in the water seal -> BAD (you don’t want this, means a leak in the system that you need to find and tape it until it stops leaking) ** in RPN scope - ex. Intermittent in suction control chamber -> BAD (means suction is not high enough, turn it up 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 be continuous (ex. a sealed bottle of pop continuously bubbling means it’s leaking!) © Astraight catheter is to a foley catheter as a thoracentesis is to a chest tube. - in-&-out vs. continuous secured - thoracentesis -> also helps re-establish neg. pressure (in-&-out chest tube) - higher risk for infections are continuous Rules for Clamping Tubes: a) 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 clamp need to be covered w/ rubber so that you don’t puncture the tube © every congenital heart defect is either TROUBLE or NO TROUBLE (ALL BAD or NO BAD) - either causes a lot of problems or it’s no big deal (no in-between defect) ® memorize one word: TRouBLe Heart Defects TRouBLe (95% of No Trouble all heart defects) Pick Someone Out A Red Heart) 1. VD = ventricular defect 2. PS = pulmonary stenosis 3. OA = overriding aorta 4. RH = right hypertrophy * don’t have to recall 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 ¢ Standard © Universal Zoster virus even though caused by varicella) — What's involved in contact precautions? -> private room is preferred (but not required) * or 2 RSV kids in the same room (cohort) * keep RSV kid & suspected RSV separate because you need positive cultures (not based on symptoms) -> NO: mask, eye/face shield (unless for universal), special filter mask, PT 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 bugs that travel 3 feet on large particles due to sneezing/coughing 1. all meningitis * cultured through lumbar puncture 2. H Flu (haemophilus influenza B) -> commonly causes epiglotitis * never stick something down throat because it will cause obstruction What’s involved in droplet precautions? -> private room is preferred (but not required) 7 can also cohort based on positive cultures -> NO: gown, eye/face shield, special filter mask, neg. air flow -> YES: mask, gloves, hand-washing, PT worn mask (when leaving room), disposable supplies & dedicated equipment Airborne - M-M-R; TB; varicella (chicken pox) - What's invalved in airborne precautions? -> private room is required * unless co-horting -> NO: gown (mostly for contact), eye/face shields -> YES: mask, gloves, hand-washing, special-filter mask ONLY for TB, PT mask for leaving room (but really shouldn’t be leaving), neg. air flow ** disposable supplies & dedicated equipment isa good thing but not really as essential as in the other 2 (can let this one slide) -> TB: technically transmitted via droplet BUT put on airborne PPE = Personal Protective Equipment - boards like to test how you put on or take off - always take it off in alphabetical order -> ex. gloves, goggles, gown, mask - putting on is reverse alphabetically for the ‘g’s’ & mask comes 2nd -> gown, mask, goggles, gloves LECTURE 4 * major area of human function is locomotion so they test these even though not a major emphasis in school - area to test PT teaching & risk reduction Crutches: e How do you measure crutches? ** need to know for risk reduction -> so you don’t cause nerve damage a) length of crutch = 2-3 finger-widths below anterior axillary fald to a point lateral to & slightly in front of the foot -> many questions ask where you measure from/to (so for crutches, if they ask anything measuring from axilla to foot > rule out, they’re wrong instructions for length) b) hand grip = can be adjusted up & down; when properly placed, should be gpx. 30 degrees elbow flexion How to teach crutch gaits (4 kinds): ** 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 & the bad leg tagether - moving 3 things together c) 4-point - moving everything separately - move any crutch, then opposite foot, followed by next crutch then other foot - very slow but very stable d) Swing-through - for non-weight bearing injuries (ex. amputations) plant crutches and swing the injured limb through (never touches down) @When do they use them? - ask yourself “how many legs are affected?” - even for even, odd for odd * even point gaits when a weakness is evenly distributed (i.e. even # of legs messed up) - 2point = mild problems (bilateral) - 4-point = severe problems (severe, bilateral weaknesses) - 3-point = only odd one, when only 1 leg is affected * Ex. Early stages of rheumatoid arthritis = 2-point Ex. Left, above the knee amputation = swing-through Ex. First day postop right knee replacement, partial weight- bearing allowed = 3point Ex. Advanced stages of ALS = 4-point Ex. Left hip replacement, 2nd day post-op, non weightbearing = swing- through Ex. Bilateral total knee replacement, 1st day post-op, weight- bearing allowed = 4-point Ex. Bilateral total 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 Ca nes: - hold the cane on the strong side - advance with bad leg 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 -Neurosis- Non-Psychotic vs. Psychosis © Hint: the first thing you have to do to get a psych questions correct is decide: “Is my PT nonpsychotic or psychotic? ” = this will determine treatment, goals, prognosis, medication, length of stay, legalities...everything NON-PSYCHOTIC PSYCHOTIC - 4diseases: Schizo Schizo Major Manics i. Schizophrenia ii. Schizoaffective Disorder iii. Major Depression (if it’s major, test will say) iv. Manic (Acute) - so bi-polar is functional, only psychotic during manic phase - these PT’s 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 -> “| see you're angry; “You seem upset”, “Tell me how you are feeling”, often uses the word feeling or shows a feeling b) PRESENT REALITY -> “| know that those voices are real to you but | 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 -> “| see you're tao ill to stay reality based so our convo is over” (ending the conversation NOT taking away a privilege [i.e. 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 pasitive statements (i.e. what they can have/do, not what they can’t); if between 2 statements go w/ the positive one 2. Psychosis of Dementia - psychosis because of actual damage to the brain - 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) -> nurse role: a) acknowledge feeling b) REDIRECT them -> from something they can’t do to something they can do ** you don’t set-limits because it’s mean -> important to remember that forgetting things (like where they are or what room they’re in - PT’s w/ dementia/Alzheimers) is NOT psychosis ** when they start having delusions, hallucinations or illusions, then they are psychotic -> reality orientation = telling them person, place, and time (ALWAYS APPROPRIATE w/ DEMENTIA) - this deals w/ memory ** NOT APPROPRIATE to present reality to these PT’s when they are experiencing psychotic symptoms (BUT don’t confuse this w/ reality orientation) 3. Psychotic Delirium =a temporary, sudden, dramatic, episodic, secondary loss of reality; usually due to some chemical imbalance in the body * 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 drug reaction, high on uppers or withdrawing from downers (delirium tremens), cocaine overdose, post-op psychosis (withdrawing from a downer), ICU psychosis (sensory deprivation), UTI (or any occult infection), thyroid storm, adrenal crisis - good thing is it’s temporary so focus is removing the underlying cause & keeping them safe -> nurse role: a) acknowledge feeling b) REASSURE them: it’s temp. & they'll be kept safe ** don’t present reality -> they won’t get it ** don’t redirect -> not going to work * Personality Disorders are different: A= antisocial B= borderline N= narcissistic ** very sick personality disorders - use Functional Psychosis techniques because you set limits Other Psychotic Symptoms: * Loosening of Association = your thoughts aren’t wrapped too tight, all over the map a) 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 © Narrowed Self Concept = when a psychotic refuses to leave their room or change their clothes - functional psychotic - #1 reason is because their definition of self isnarrowed -> defined self based on 2 things: i. Where they are ii. What they are wearing *** so they don’t 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) * use the Functional Psychosis techniques ¢ Ideas of Reference = think everyone is talking about 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) LECTURE 5 DIABETES M. definition = an error of glucose metabolism - causes issues because glucose is the primary fuel source and if your body can’t metabolize glucose, cells will die * does not include diabetes insipidus = polyuria, polydipsia leading to dehydration due to low ADH -> it’s just similar with the fluids, not the glucose part (similar symptoms) - opposite syndromes of diabetes i. = SIADH (decreased urine output, normal blood glucose, oliguria) * relationship between amount of urine & specific gravity of urine: - they are opposites/inverse -peak = no essential peak because it’s so slowly absorbed -> thus, little to no risk for hypoglycemia - duration = 12-24 hrs. -only insulin you can safely & routinely give at bedtime because it will not cause them to go hypoglycemic during the night (YOU CANNOT ROUTINELY GIVE THE OTHERS AT BEDTIME) ** Hint: boards likes to test peaks & tend to test it by giving you a time when insulin was given & asking when they reach hypoglycemia (which is the peak). « CHECK EXPIRY DATES ON INSULIN!!! - What action by the nurse invalidates the manufacturer's expiration date? = opening it -> the minute you open it the date is irrelevant because now you have 30 days from opening (have to write the date of opening & new expiry) - refrigeration is optional in the hospital BUT you need to teach PT’s to refrigerate at home -> though at the hospital the ones that should be refrigerated should be the un-opened vials - better to give warm, non-expired insulin than cold, expired insulin Exercise: e exercise potentiates insulin = meaning, it does the same thing as insulin —> think of exercise as another shot of insulin - if you have more exercise during the day, you need _ less insulin shots (and bring easily metabolized carbs/snacks to sports games) Sick Days: ewhen a diabetic is sick -> GLUCOSE GOES UP - need to take their insulin even if they’re not eating © need to take sips of water because diabetics get dehydrated any sick diabetic is going to have the 2 problems of hyperglycemia & dehydration -> ALWAYS! « stay as active as possible because it helps lower glucose (even if they’re not eating when sick) Complications of Diabetes: = 3 acute and a boatload of chronics ACUTE ® 1, Low Blood Glucose (in both types) - a.k.a. insulin shock, insulin reaction, hypoglycemia, hypoglycemic shock - What causes this? -> not enough food -> too much insulin/medication (primary cause) -> too much exercise - the danger is brain damage which becomes permanent (so be careful not overmedicate!) - S & Ss: -> drunk in shock = think of how people look while drunk -> slurring speech, staggering gait, impaired judgement, delayed reaction time, labile (emotions all over), loud ** from cerebracortical compromise = shock -> low BP, tachycardia, tachypnea, cold/ pale/clammy skin, mottled extremities ** from vasomotor compromise - Treatment: a) Administer rapidly metabolizable carbohydrate (ie. sugars) -> ex. any juice, reg. pop, chewable candy, milk, honey, icing, jam b) BUT combine/follow w/ a starch or protein -> ex. cracker, slice of turkey *** skim milk is great because it gives both - bad combo is too much simple sugars (like pop & candy) - if unconscious give Glucagon (IM) or IV Dextrose (D10, D50) -> how do you determine which to give? = the setting (i.e. family calling from home, tell them to give IM but ifin ER give IV) ** hard to get a vein because of vasoconstriction ¢ 2. High Blood Glucose in TYPE | = Diabetic Coma/ DKA (Diabetic Ketoacidosis) -> Hint: Type | is also called “ketosis-prone” - What causes this? -> too much food -> not enough medication -> not enough exercise *“** none of these are the #1 cause because itis acute viral upper respiratory infections (w/in the last 2 weeks) - PT contracts upper resp. infection -> recovers w/in 3-5 days like everyone BUT after initial recovery, they start going downhill & getting more lethargic * so, if they come into the ER you should ask if they’ve had a viral upper resp. infection in the last 2 weeks -> what causes the high glucose is the stress of the illness that was not “shut off” and they start burning fats for fuel -> ketosis - A= _a cidotic (metabolic), a_cetone breath, _a norexia (due to nausea) -> hot & flushed, dry = water is a coolant! if you lose water (as in dehydrate) you loose coolant - Treatment: Long-term Complications: # related to 2 problems: a) poor tissue perfusion b) peripheral neuropathy * ex. Diabetics have renal failure. What would this be due to? - > poor tissue perfusion ex. Diabetic PT has lost control of their bladder and are now incontinent. -> peripheral neuropathy ex. PT can’t feel it when he injures himself. -> peripheral neuropathy. ex. PT doesn’t heal weil when he injures himself. -> poor tissue perfusion Which lab test is the best indicator of longterm blood glucose control? « the hemoglobin A1C (HA1C), the glycosated/ glycosylated hemoglobin (all the same) * numbers: - 6 & lower is what you want to see - 8 & above means you're out of control ** what about 7? = border -> fast rate IV fluids (ex. 200/hr.), w/ reg. insulin in the bag S&S: -> spell out DKA ¢ 3. High Blood Glucose in TYPE Il = - D=dehydration HHNK/HHNS (Hyperglycemic Hyperosmolar - K=_k etones (in blood), kausmaul’s, Non-Ketotic Syndrome) high_K + = this is dehydration (for any HHNK/HHS question just call * you can have ketones in your urine & not have it DEHYDRATION) DKA = so think of the S&S of dehydration (low water, hot temp, flushed, dry)