Lecture # 1

acid base/vents

ACID BASE

R – respiratory pH: 7.35 – 7.45

O – opposite pCO2: 35 – 45
M – metabolic HCO3: 22 – 26
E – equivalent pO2: 80 – 100 mmHg

 PH and bicarb (22-26): same directionmetabolic

 PH and bicarb: different directionresp
  pH = acidosis
o  K+ (hyperkalemia)
  pH = alkalosis
o  K+ (hypokalemia)
 Alkalosis: PH up, systems in body go  except Potassium
o ie: tachycardia, tachypnea, borborygmi ( bowel sounds), hyperreflexia (3, 4), irritability,
seizures/aspirate (should have suction at the bedside)
 2: normal reflex
 0, 1: hypo
 Acidosis: PH down, systems in body shut down except Potassium
o ie: lethargy, hyporeflexia (0, 1), obtunded, bradycardia, paralytic ileus, coma, urinary retention,
respiratory arrest (should have an ambo bag at the bedside)

 would see Kussmauls resps. w/ metabolic acidosis only.

o think MAC Kussmauls (MAC = Metabolic ACidosis)
 s+s of acid base imbalances are different then CAUSES of acid base imbalances
 cause:
o ask yourself:
 is it lung? If yes then = RESPIRATORY
 are they over ventilating? yes = alkalosis
 are they under ventilating? yes = acidosis
 RR does not matter:
o Gas change not relavant to RR rate
o Pneumonia in 4 lobes, RR 50/min, SaO2=50underventilation
 RR high but acidosis
o PCA pump: resp depression, RR lowunderventilationacidosis
o COPD, RR 35min, underventilation
 if not respiratory/lung then = metabolic
 only 1 scenario when metabolic alkalosis
 pt has prolonged suctioning/vomiting
 everything else that is not lung pick metabolic acidosis
o pt hyperemesismeta alkalosispt become dehydrationmeta acidosis
o pt renal failuremeta acidosis
o infant diarrheameta acidosis
o 3rd degree burns 60% of bodymeta acidosis

 don’t know what to pick?

o PICK METABOLIC ACIDOSIS IT’S THE MOST COMMON

VENT ALARMS
 High pressure alarmtrigger: ie: working too hard (obstruction)
o order of what to do
 check for kinks  unkink
 water condensation in tube  empty it
 mucus in pts airway  turn pt/cough/deep breath
 if this does not work then suction (suction as last resort)
 suction PRN, not scheduled.
 Low pressure alarm ie: that was too easy (connection)
 look @ main tubing  reconnect
 O2 sensor tubing (senses if fiO2 @ trachea area)  reconnect

 Resp alkalosis: over ventilatingsettings too high

 Resp acidosis: under ventilatingsetting too low
 Order to decrease the order
- 0600: resp. acidosis, what would you do
 follow the order
 call resp. therapy
 hold the order, call Dr
 begin to decrease the settings
- if pt resp alkalosis, good, pt did not need ventilator.
a.
Lecture # 2
alcohol/overdose/withdrawal/aminoglycosides/TAPS

ALCOHOL

 Denial is #1 problem in ALL abusive situations

o Refuse the reality.
 Alcoholism #1 problem psychologically is denial
o denial allows abuser to cont. w/o answering to it b/c you can’t tx something they won’t admit to
 tx denial by confronting it
o point out the difference between what they say and what they do
 ie: you say you’re not an alcoholic but you’ve had a 6 pack and its 10 am
 confrontation  aggression
o aggression attacks the person
 ie: you are an alcoholic you have to admit it
 denial also occurs w/ loss + grief
o 5 stages of grief (DABDA)
 D – denial
 Loss or abuse
o Abuse: confront
o Loss: support
 A – anger
 B – bargaining
 D – depression
 A – acceptance
 w/ abuse you confront
 w/ loss/grief you support
 dependency/codependency #2 problem that abusers have
 dependency = the abuser gets their significant other to do things for them or make decisions for them
 codependency = significant other feels positive self esteem from doing things/supporting the abuser
 when tx dependency/codependency set limits and enforce them
o teach significant others to say no
 “I’m sorry no b/c I’m a good person”
 Manipulation = abuser gets the 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 harmful/dangerous
o ie: an alcoholic mother sends her 16 y/o daughter to the LC to buy her booze
 manipulation is easier to tx than dependency b/c there's no positive self esteem issue w/ manipulation
 Neutral: dependency/codependency has 2 pts
 Negative: manipulation has 1 pt

Wernicke Korsakoff

 psychosis caused by Vitamin B1 or Thiamine insufficiency

 s+s: amnesia w/ confabulation (memory loss w/ making up stories)
 do not confront or present reality REDIRECT them
 to prevent/stop it from getting worse: take vitamin B1

Aversion Therapy

 aversion = a gut hatred for something (what we want alcoholics to develop is a gut hatred for alcohol)
o give pt a medication (disufiram/naltrexone) if pt drinks alcohol will make pt super sick
 pt must be on this med for @ least 2 weeks in order for this aversion therapy to work
 also needs to be off med for 2 weeks in order to get out of system in order to safely
drink again
 teach pt to avoid all alcohol products:
o mouthwash
o aftershave
o perfume/cologne
o insect repellent
o anything that ends in elixir
o alcohol based hand sanitizer
o uncooked icing (vanilla extract)
o most OTC liquid medications
 o they can have red wine vinaigrette

OVERDOSE/WITHDRAWALS

 every abused drug is either an upper or a downer

o the most abused drug that is neither = laxatives (esp. in elderly population)
 uppers (5)
o caffeine, cocaine, PCP/LSD (hallucinogens), methamphetamines, Adderall
 s+s: things go 
 euphoria, tachycardia, tachypnea, restlessness, irritability, reflexes (3, 4 ie spastic),
borborygmi, diarrhea, seizure
 downers (anything that is not an upper)
o heroin, alcohol, marijuana, benzos etc
 s+s: things go 
 lethargy, resp. depression, bradycardia, bradypnea

How to answer the question:

 ask yourself: is the drug an upper or downer?
 is the question asking about overdose or withdrawal?
 withdrawal in upper: everything goes 
 withdrawal in downer: everything goes 
 resp. depression biggest risk in:
o downer OD and upper withdrawal
 seizure biggest risk in:
o downer withdrawal and upper OD

Drug Addiction in Newborns

 always assume intoxication, not withdrawal at birth
o baby has to be @ least 24 hrs old to go through withdrawal
 withdrawal: difficult to console, exaggerated startle reflex, seizure risk, shrill high pitch cry

Alcohol Withdrawal Syndrome (AWS) vs Delirium Tremens (DT)

 every alcoholic goes through AWS within 24 hrs after their last drink
 only a minority get DT which happens within 72 hrs after their last drink

Alcohol Withdrawal
 not life threatening
 no danger to self or others
 regular diet, semi private room anywhere on the unit (can go anywhere they want), no restraints

Delirium Tremens
 can kill you
 dangerous to self and others
 NPO/clear liquids (aspiration/seizure risk), private room near nurse’s station, strict bed rest, no bathroom
privileges (need bed pans & urinals), must be restrained appropriately (vest or 2 point locked leathers  1 arm
+ 1 leg [opposite arm & leg] rotate restraints Q2H)

Meds for AWS + DT

 Anti HTN
o b/c everything is going up d/t withdrawal of a downer
 tranquilizer
o b/c withdrawal from a downer
 Vitamin B1
o to prevent Wernicke Korsakoff

AMINOGLYCOSIDES

 powerful abx
 remember: a mean old mycin for a mean old infection
o life threatening, resistant, serious and gram-negative infections
 all aminoglycosides end in mycin but not all meds that end in mycin are aminoglycosides
o not aminoglycosides = arithromycin, zythromycin and clarithromycin
  if it has a thro = throw it out
 they are ototoxic (ear toxic)
o monitor hearing, tinnitus, vertigo/dizziness
 ear is shaped like the kidney  watch for nephrotoxicity
o monitor Cr (best indicator for kidney function)
 do not select urine output, BUN or total daily weights
 if they say serum Cr vs 24 hr Cr clearance, 24 hr Cr clearance is the best choice
 administer Q8H IV or IM
o no PO admin for infection b/c not absorbed
 only 2 cases you can give PO
o hepatic encephalopathy/hepatic coma/liver coma (when ammonia level too high and gets to the brain)
 PO mycins will kill the Ecoli in the gut and lower the ammonia level
o pre op bowel sx to sterilize the bowel
 PO mycins will kill gram negative bacteria in the gut
Remember: who can sterilize my bowel?
NEO CAN! (neomycin and canomycin)
TAP Levels

 TAP = Trough Administer drug Peak

 trough = when drug is @ its lowest
o draw before drug admin
 peak = when drug is @ its highest
o draw after drug admin
 TAP levels are drawn for narrow therapeutic window (for what works and what kills)
o ie: Lasix dose is wide (10 mg – 120 mg) wide range no TAP necessary
o digoxin dose is narrow (0.125 mg – 0.25 mg) narrow range  TAP crucial
 all aminoglycosides have TAP s d/t narrow therapeutic windows
 DRUG DOES NOT MATTER ROUTE MATTERS
o for ALL routes trough is ALWAYS drawn 30 minutes before admin of next dose
o sublingual peak: 5 – 10 minutes after drug has dissolved
o IV peak: 15 – 30 minutes after drug is finished infusing
o IM peak: 30 – 60 minutes after injection
o SQ peak: depends on the type of insulin (see DM lecture – lecture #5)
o PO peak: do not test for PO peak
o If 2 different drugs are given at the same time via the same route will have the same peak time
 But if 1 drug is given via 2 different routes you will have 2 different peak times
 when there is 2 right answers pick the highest without going over
o ie: you give 100 mL IV of a drug at 200 mL/hr (will take 30 minutes to infuse) and you hang it at 1000,
when would you draw the peak?
A) 1015
B) 1030
C) 1045
D) 1100
Both C and D are correct (range for IV is 15 -30 minutes, so play the price is right, cause
whoever is the highest without going over the range is the winner)
Lecture # 3
cardiac/chest tubes/infection precaution

CARDIAC

Calcium Channel Blockers (CCB’s)

 like Valium for your heart (calms your heart down  HR)
 are negative inotropics, negative dromotropics, and negative chromotropics
o inotropic = strength of heart
 positive inotropic = strong heart beat
 negative inotropic = weak heart beat
o chronotropic = rate of heart
 positive chronotropic = fast HR
 negative chronotropic = slow HR
o dromotropic = conductivity of the heart
 positive dromotropic = excitable heart
 negative dromotropic = blocks/slow conduction
 weaken, slow down, and depress the heart
o ie Cardiac depressant
 what do CCB’s tx? (indications) 3 A’S
o antihypertensive
 relaxes the heart and blood vessels   BP
o antianginals
 relaxes heart so you can use less O2 by  O2 demand
o anti atrial arrhythmia
 tx’s everything atrial related - ie afib, aflutter
 will not tx VT, PVT, however will tx supra VT b/c supra means above and above the ventricle
is the atria
 side effects
o headache d/t vasodilation in the brain
o hypotension d/t the relaxation of the heart and blood vessels
 monitor BP intermittently
 if systolic is below 100, HOLD
o for IV drip if systolic was 98 titrate down
 names of CCB
o anything ending in “dipine”
 ie amlodipine
o 2 other CCB you need to know by name
 Verapamil
 Cardizem = continuous IV drip

Cardiac Arrhythmias

 Normal sinus rhythm (NSR)

o peaks of P waves are evenly spaced
o theres a P wave, QRS and T wave for every single complex
 Ventricular fibrillation (VFIB)
o chaotic squiggly line, no pattern
 Ventricular tachycardia (VT)
o sharp peaks + jags, there is a pattern
o wide bizarre QRS’s
 Premature Ventricular Contractions (PVC’s)
o Periodic wide, bizarre QRS’s
o A bunch of PVC’s is like a short run of VT
 Asystole
o flat line, lack of QRS depolarizations
 Aflutter
o Always described as saw tooth
 QRS depolarization – Answer will always be ventricular
 P wave – Answer will always be atrial
 Lack of a P wave – Answer will always be ventricular
 Chaotic is always the word used to describe fibrillation
 Bizarre is always the word used for tachycardia
Low Priority
 PVC’s

Moderate Priority
 more than 6 PVC’s/min
 6 PVC’s in a row
 PVC falls on the T wave of the previous beat

Potentially Life Threatening

 VT – still have a pulse

Lethal Priority (dead in less than 8 mins)

 Asystole – no pulse
 VFIB – no pulse

Treatment

 PVC’s + VT
o for ventricular: lidocaine and amiodarone
 Supraventricular (atrial) – ABCD’s
o Adenocard (Adenosine)
 Push in less than 8 seconds
 Don’t worry about asystole
 When it comes to IV push, when you don’t know go slow
o Beta blockers (ending in “lol”)
 Just like CBC’s, same tx, same side effects
o Calcium channel blockers
 Better for asthmatics as beta blockers bronchoconstrict
o Digoxin/Digitalis (Lanoxin)
 VFIB
o D-fib (shock them)
 Asystole
o Epinephrine and atropine (in that order if Epi doesn’t work)

CHEST TUBES

 purpose of a chest tube is to reestablish negative pressure in the pleural space

 pneumothorax
o chest tube removes air
 hemothorax
o chest tube removes blood
 pneumohemothorax
o chest tube removes air and blood
 Report in Hemothorax
o the chest tube isn't draining
 Report in Pneumothorax
o the chest tube isn't bubbling

2 locations:
 Apical (up high) removes air
 Basilar (bottom of lungs) removes blood
 Use both locations for Pneumohemothorax

how many chest tubes + where would you place them for post op chest sx?
 Always assume chest sx/trauma is unilateral unless otherwise specified
 Place 2 chest tubes (1 apical and 1 basilar) on same side of surgery
 The only time its bilateral is when they say it’s bilateral

What do you do if you knock over a closed chest drainage device? (ex: pneumovac, pleur-evac, etc)
 set it back up, not an emergency

What if the water seal breaks?

  emergency b/c positive pressure can get in plural space
1. Clamp the water seal so nothing can get in
2. Cut it away from the broken device
3. Submerge end of tube in sterilized water
4. Unclamp b/c water seal has been reestablished
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 w/ gloved hand
 Best: Cover w/ 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 = go to wall  suction
 Continuous bubbling: Always good = document

Rules for clamping tubes

 Never clamp a tube for longer than 15 secs w/o a MD order
 Use rubber tip double clamps

CONGENITAL HEART DEFECTS (CHD)

 Every CHD is either TRouBLe or no TRouBLe

 TRouBLe
o need sx to live, everything is bad, short life expectancy, delayed growth and development, exercise
intolerance, financial difficulties, pediatric cardiologist
 a tRoubLe defect is right to left because R comes before L in trouble
 A no-trouble defect is left to right.
 Right to left means blue (cyanotic), left to right means pink (acyanotic)
 All trouble heart defects that are trouble start with T
o Tetralogy of fallot, trunkus arteriosis, trans position of great vessels, tricuspid stenosis, tricuspid
atresia, totally anomalous pulmonary vasculature (TAPV)
 No trouble CHD
o Patent foramen ovale, ventricular septal defect, atrial septal defect, pulmonary stenosis, patent ductus
arteriosis
 All CHD pts will have 2 things (trouble or not)
o all will have a murmur (b/c of shunting of the blood)
o all will have an echocardiogram done
Four defects of Tetralogy of Fallot are: VarieD PictureS Of A RancH (pay attention to bold capitalized letters)
 VD – ventricular Defect
 PS – Pulmonary Stenosis
 OA – Overriding Aorta
 RH – Right Hypertrophy
o Or remember: Valentines Day Pick Someone Out A Red Heart

INFECTIOUS DISEASE + TRANSMISSION BASED PRECAUTIONS

Four transmission-based precautions:

 Standard/universal
 Droplet
 Contact
 Airborne

Contact Isolation
 Anything enteric (ie caught from intestine fecal/oral)
 C-diff, Hep A, herpes, staph infections and RSV (respiratory syncytial virus – babies get it, is transmitted via
droplet but works best on contact precautions)
 Private room, but can be in same room if cohort
 PPE- Gloves, Gown, Disposable supplies/dedicated supplies
Droplet Isolation
 For bugs that travel 3 feet on large particles – d/t sneezing/coughing
 All meningitis, H-flu (causes epiglottis)
 Private room, unless cohort
 Lumbar puncture (LP) for cultures
 PPE- Gloves, Mask, Pt wears mask when leaving room, Disposable supplies/dedicated supplies, No gown

Airborne Isolation
 Measles, mumps, rubella, TB (spread by droplet but airborne precaution) and varicella
 Private room unless cohort
 PPE- Mask, Gloves, Special filter mask (ONLY FOR TB), Pt wear mask when leaving room, Negative airflow
room

PPE
 Always take off in alphabetical order
o Gloves  goggles  gown  mask
 Put on in the reverse alphabetical order in the G’s but mask goes on second
o Gown  mask  goggles  gloves
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
 When the hand grip is properly placed the angle of elbow flexion will be 30 degrees

Crutch Gaits
 2 point
o Move a crutch + opposite foot together, then move other crutch and other foot together
o Called 2 point b/c 2 points touch down together (ie 1 crutch and 1 foot)
o Used for mild bilateral weakness
 3 point
o Move 2 crutches + bad leg together then move good foot
o Called 3 point b/c 3 points touch down at once
 4 point
o Left crutch followed by right foot, right crutch followed by left foot
o Nothing moves together b/c everything is ++ weak
o Used for severe bilateral weakness
 Swing through
o Non weight bearing (amputation)
o Place crutch down and swing leg/stump through
 Pay attention to question b/c an amputee w/ a prosthetic can weight bear
 Even for even, odd for odd
o Use the even # of gaits (2 point and 4 point) when the weakness is bilateral (ie. both legs are affected)
o If unilateral weakness (ie. only 1 leg affected) use odd # of gaits (3 point)

Stairs and Crutches

 Up w/ the good, down w/ the bad
 The crutches always move w/ the bad leg

Cane
 Hold cane on the strong side (unaffected side) and advance the cane w/ the opposite side for a wide base
support

Walkers
 Pick it up, set it down, walk to it
 do NOT tie belongings to the front of the walker, if they must tie something to the walker, tie it the sides
 No wheels, or tennis balls on walkers
 Correct way to get up from a chair using a walker
o Hold on to chair, stand up then grab walker

PSYCH – Non-Psychotic vs. Psychosis

Non-psychotic pt:
 Has insight (ie. knows that they’re sick and that it’s affecting their life)
 Use good therapeutic communication (like normal people)

Psychotic pt:
 Does not think they’re sick, has no insight and is not reality based
 s+s: Delusions, Illusions, Hallucinations

Delusion
 false fixed belief, idea or thought, there is no sensory component
 types of delusions
o paranoid/persecutory – false fixed belief that people are out to harm you
o grandiose – false fixed belief that you’re superior (ie. you’re Christ)
o somatic – false fixed beliefs about a body part (ie. x-ray vision)

Illusion
 misinterpretation of reality (a sensory experience)
Hallucination
 a false fixed sensory experience (5 senses)
  auditory (hear things) most common
 visual (see things) 2nd most common in adults but most common in children
 tactile (feeling things) 3rd most common
 gustatory (tasting things) rare
 olfactory (smelling things) rare

***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
1. Functional psychotics
 Can be married have a family a job etc
 90% of functionals are:
o Schizo- Schizophrenia
o Schizo- Schizo-affective Disorder
o Major- Major Depression
o Manic- Bipolar but only in the manic phase

2. Dementia
 Psychotic d/t brain damage (ie. Alzheimer’s)

3. Delirium
 Temporary, sudden, dramatic secondary loss of reality, usually d/t a chemical imbalance in the body
o ie. people high on uppers, withdrawal from downers, post op pts, occult UTI in elderly, thyroid storm,
adrenal crisis

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
1. Acknowledge their feelings
 “You seem angry”
 “That must be distressing”
 “Tell me how you’re feeling”
2. Present reality
 “I know that___ is real to you, but I don’t see ___”
 “I am a nurse & this is a hospital”
3. 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”
4. 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
1. Acknowledge their feelings
 “That seems exciting”
 “I see that you’re happy”
 “I see that you’re sad”
2. 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
 1. Acknowledge their feelings
 “That seems exciting”
 “I see that you’re happy”
 “I see that you’re sad”
2. 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
Lecture # 5
Diabetes

Diabetes Mellitus (DM)

 An error of glucose metabolism

Diabetes Insipidus
 Polyuria, polydipsia leading to dehydration d/t low ADH, low specific gravity, FVD
 Just the fluid part of diabetes (glucose is not effected)

SIADH
 Opposite of diabetes insipidus
 Low urine output (oliguria), not thirsty, high specific gravity, FVE

DM1
 Insulin dependent (not producing insulin)
 Juvenile onset
 Ketosis prone
 s+s: polyuria, polydipsia, polyphagia
 tx: diet (calories from carbs), insulin (most important), exercise

DM2
 Non-Insulin Dependent (body resisting insulin)
 Adult onset
 Non-ketosis prone
 s+s: polyuria, polydipsia, polyphagia
 tx: diet (most important), PO hypogylcemics, activity

Insulin
 acts to  blood sugar
 4 types MUST KNOW

Regular Insulin (short acting) - R

 Onset 1hr, peak 2hrs, duration 4hrs
 Clear solution
 Can be IV drip
 R = Rapid & run
 Taken before a meal

NPH (Intermediate acting) – N

 Onset 6hrs, Peak 8-10hrs, Duration 12hrs
 Cloudy, suspension (must mix)
 Never IV
 NPH = Not so fast & not in the bag
 Taken after a meal

Humalog/Lispro (Rapid acting)

 Onset 15 mins, Peak 30 mins, Duration 3 hrs
 Give insulin with meals

Lantis/Glargine (Long acting)

 Slow absorption, no peak, duration 12-24 hrs
 Low risk of hypoglycemia
 Safely given @ hs

Humulin 70/30 (N+R insulin)

 Percentages mixed of N + R insulin (N= 70 R= 30)
o Ie. if 10 units of Humulin 70/30 to be given, 7 units of N, 3 units of R
 Can mix in same syringe
 Cloudy (inject air), clear (inject air), clear (draw up insulin), cloudy (draw up insulin)

Key Points:
 Check expiration date: once opened good for 30 days, write day you opened it and “opened” or write the
expiration date and “exp”
  teach pts to refrigerate their insulin at home. Hospitals keep unopened bottles of insulin in the fridge, but they
can come out of the fridge once opened
 exercise does the same thing as insulin, if diabetic is going to exercise must bring something to eat first
(rapidly metabolized carbs)
 when diabetics are sick, glucose goes , must take insulin even when not eating, take sips of water or they
might get dehydrated and try to stay as active as possible

Best test for long term is HBA1C (Glycosated Hemoglobin):

 average blood sugar over last 90 days
 Good = 6 & lower
 Needs work up / evaluation = 7
 Out of control = 8 & up

Acute Complications of DM

Hypoglycemia (think drunk + shock)

 Caused by: too much insulin/meds, not enough food, too much exercise
 s+s (drunk): staggering gait, slurred speech, impaired judgment, delayed reaction times, labile (emotions all of
the place)
 s+s (shock):  BP, tachycardia, tachypnea, pallor, clammy, mottled skin
 tx:
o administer rapidly metabolized carbs (sugar)
o ie. juice, soda, candy, honey, jam, ½ skim milk, orange juice + crackers, apple juice + slice of turkey
o give 1 sugar + 1 starch/protein NOT 2 sugars
o if unconscious give glucagon IM, IV dextrose (D10W or D50W)
o if talking to parents over the phone tell them to give IM glucagon, if they’re in the ER say IV dextrose

Hyperglycemia in DM1: DKA  HIGH PRIORITY

 causes: acute viral upper resp. infection within last 2 weeks, too much food, not enough meds, exercise
 s+s: dehydrated (hot, flushed, dry skin), ketones in blood, Kussmauls resps (metabolic acidosis),  K+,
acetone breath (fruity breath), anorexia d/t nausea
 tx:
o IV insulin
o IV fluid bolus

Hyperglycemia in DM2: HHNK  MORE FATAL

 HHNK = hyperosmolar, hyperglycemic, non ketotic coma (severe dehydration)
 s+s: tachycardia,  skin turgor, pt will be dry
 tx:
o IV fluids to rehydrate

Chronic complications of DM
 Poor Tissue Perfusion
 Peripheral Neuropathy
Lecture # 5
toxic levels/dumping syndrome/electrolytes

Toxicity Levels (5)

 Lithium
o Therapeutic level: 0.6 – 1.2
o Toxic level:  2
 Digoxin (Lanoxin)
o Therapeutic level: 1 – 2
o Toxic level:  2
 Aminophylline
o Therapeutic level: 10 – 20
o Toxic level:  20
 Dilantin (Phenytoin)
o Therapeutic level: 10 – 20
o Toxic level:  20
 Bilirubin (only tested in newborns)
o Therapeutic level:  9.9
o Elevated range: 10 – 20
o Toxic level:  20
o Hospitalize when you get hallway in the elevated level

Kernicterus
 Bilirubin in the brain, CSF
 Occurs when bilirubin gets around 20

Opisthotonus
 Position of slight extension in neck seen in pts w/ kernicterus (bad sign)
 Hyperextend d/t irritation of the meninges
 Put pt on their side

DUMPING SYNDROME VS HIATAL HERNIA

Hiatal Hernia
 Regurgitation of acid into the esophagus b/c upper part of the stomach herniates upwards through the
diaphragm
 2 chambered stomach
 Moving in the wrong direction at the right rate
o ie. driving the right speed but going the wrong direction on a oneway street
 s+s:
o GERD aka heartburn + indigestion
o GERD is regular heart burn if you get it at a random time
o Its hiatal hernia if you lay down right after you eat
 tx:
o high position HOB
o high fluids, high carbs
o everything needs to be high except protein (low)

Dumping Syndrome
 usually a complication following gastric sx
 gastric contents dump too quickly into the duodenum
 moving in the right direction at the wrong rate
o ie. driving in the right direction down a one way but speeding
 s+s:
o drunk: staggering gait, slurred speech, delayed reaction time, emotional labile
o shock:  BP, tachycardia, pallor, cold clammy skin
o acute abdominal distress: pain, guarding, borborygmi, diarrhea, bloating, distension, tenderness
 tx:
o low position (HOB flat)
o turn to side w/ head down
o low fluids (1 – 2 hours before or after meals, not w/ meals), low carbs
o if you want the stomach to empty slow, everything is low (except protein)
ELECTROLYTES
Kalemias (potassium)
 do the same as the prefix (hyper/hypo), except for HR and urine output do the opposite
 s+s hyperkalemia
o agitation, irritability, tachypnea, oliguria, bradycardia, tall P waves, elevated ST waves, diarrhea,
borborygmi, spastic muscles, hyperreflexia
 s+s hypokalemia
o lethargy, tachycardia, bradypnea, polyuria, dynamic ileum, constipation, flaccid muscles, hyporeflexia
Calcemias (calcium)
 do the opposite of the prefix NO EXCEPTIONS
 hyper = 
 hypo = 
 s+s hypercalcemia
o bradycardia, bradypnea, flaccid muscles, hyporeflexia, lethargy, constipation
 s+s hypocalcemia
o tachycardia, agitation, irritability, tachypnea, diarrhea, borborygmi, spastic muscles, hyperreflexia,
seizure, chvostek sign (cheek/face spasm) and trousseau sign (BP cuff  hand spasm)

Magnesemias (magnesium)
 do the opposite of the prefix
 hyper = 
 hypo = 
 s+s hypermagnesima
o bradycardia, bradypnea, flaccid muscles, hypoactive reflexes, lethargy, constipation
 s+s hypomagnesima
o tachycardia, agitation, irritability, tachypnea, diarrhea, borborygmi, spastic muscles, hyperreflexia,
seizure

test tips for tie breaking

 if a tie do NOT pick magnesium
 if symptom involves nerve or skeletal muscle pick calcium
 for any other symptom pick potassium

Sodium- Dehydration Vs. Fluid Overload

 the one w/ the E (hypErnatremia) is dehydration
 the one w/ the O (hypOnatremia) is overload
 hypernatremia
o hot flushed skin, give lots of fluids
 hyponatremia
o fluid restriction and 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

Potassium
 NEVER IV push K+
 NEVER give more than 40 mEq/L of IV fluid
o If on NCLEX order is over 40 mEq, call and clarify order
Fastest way to lower K+
 Give D5W w/ regular insulin which drives K+ intracellularly and out of the blood
o Temporary but works fast

Kayexalate
 Full of sodium given via enema or PO
 Trades sodium for K+ so you shit it out
 Results in hypernatremia (dehydration) so give them fluids to correct it
 Takes hours but is permanent
Lecture # 7
endocrine glands/toys/laminectomy

ENDOCRINE

 Do not need to know thymus, pineal or parathyroid glands

 Focus on adrenal and thyroid

Hyperthyroidism = Graves Disease

 Turn thyroid into metabolism (hypermetabolism)
 “you’re going to run yourself into the grave”
 s+s: weight loss,  HR,  BP, irritable/hyper, heat intolerance, cold tolerance, exophatalmos (burning eyes)
 tx
o radioactive iodine
 pt should be isolated for 24 hrs
 have to be careful w/ their urine: flush 3 times, if they spill it need to call hospital hazmat team
NOT housekeeping
 no visitors for 24 hrs
o PTU (cancer drug)
 Puts thyroid under (brings it under)
 Monitor pts WBC’s
o Thyroidectomy – total vs sub
 Totals need lifelong hormone replacement and are at risk for hypocalcemia
 Subtotals do not need lifelong hormone replacement
 Subs are at risk for thyroid storm/crisis/thyrotoxicosis
 s+s of thyroid storm: Extremely high VS, extremely high temperature, psychotically
delirious MEDICAL EMERGENCY – CAUSES BRAIN DAMAGE
 tx for thyroid storm:
o ice pack (first), cooling blanket (best), O2 mask @10 L
o do not medicate them, they will either come out of it themselves or die
o 2 staff for 1 pt

Post Op Risks
 in the first 12 hrs top priority is airway, second priority is hemorrhage (regardless if total or sub thyroidectomy)
 12-48hrs for Total is Tetany r/t hypocalcemia.
 12-48hrs for Subtotal is Storm
 NEVER PICK INFECTION IN FIRST 72 HRS
o THIS APPLIES TO EVERYTHING

Hypothyroidism = Myxedema
 Hypometabolism
 s+s: obese, flat/boring/dull personality, heat tolerance, cold intolerance,  BP,  HR, slow people (ie. slow to
process things, slow test takers, slow learners), lethargic, constipation
 tx:
o thyroid hormone Synthroid
 ie levothyroxine
o do not sedate these people they will go into a myxedema coma
o never hold thyroid hormones the day of sx

Adrenal Cortex Diseases – all start w/ A or C

Addison’s Disease
 under secretions of adrenal cortex
 s+s:
o hyperpigmented (very tanned)
o do not adapt to stress (if they undergo any stress they might go into shock  glucose and BP goes 
 tx:
o steroids
 drugs that end in “sones”
 remember in Addison’s: ADD I SONE

Cushing’s Syndrome
 over secretion of adrenal cortex
  think “cushy” means more
o ie. a cushy chair has more stuffing, a cushy bank account has more $$
 s+s and side effects of steroids
o high glucose (hyperglycemic, insulin resistant) most important to remember
o moon face
o hirsutism ( body hair)
o central obesity (apple body)
o buffalo hump (hump on back)
o gynecomastia (man breasts)
o water retention (retains sodium)
o skinny extremities d/t muscle atrophy
o loses potassium
o bruises + striae (stretch marks)
o irritable
o immunosuppressed
o  bone density
o “I’m mad, I have an infection”
 tx:
o adrenalectomy (if you do a bilateral you will get Addison’s  replacement therapy  steroids ending
in “sones”)

CHILDRENS TOYS

3 principles to consider when choosing toys:

1. is it safe?
2. Is it age appropriate
3. Is it feasible (specific to child’s situation)

Safety
 No small toys for kids under 4
 No metal/die-cast toys if O2 is in use (can cause sparks)
 Beware of fomites (a non-living object that harbors microorganisms)
o Worst: plush toys/stuffed animals
o Least: hard plastic toys that can be disinfected

Age Appropriate

0 – 6 months
 best: musical mobile b/c these kids are sensory motors so best toy is something that stimulates both sensory
and motor
 2nd best: large and soft
o ie. teething soft books

6 – 9 months
 teaching object permanence (looks for the toy when you hide it)
 best: cover/uncover toy
o ie. jack in the box, pop up pals, books w/ windows, peak a boo
 2 best: firm but large (word, metal, hard plastic)
nd

 Worst: musical mobile (risk for strangulation)

 NEVER pick answers for a child under 9 months w/ the following words:
o build, sort, stack, make & construct

9 – 12 months
 learning to speak
 best: speaking toys
o ie. tickle me elmo, woody doll, speak and spell, talking books

Toddlers (1 – 3 years)
 push, pull toys (ie. wagon, stroller, dog, popper, etc)
 work on gross motor skills
 o running, jumping
 do no choose answers w/ finger dexterity
o ie. coloring, cutting
o this does not include finger painting
 parallel play
o play alongside other kids but not together

Preschoolers
 work on fine motor skills (finger dexterity) and balance
o dancing, gymnastics, skating
 characterized by co-operative play
o play together
 like to pretend play, highly imaginative

School Aged Kids (7 – 11 years)

 characterized by 3 C’s
o create
 let them make it (blank paper + crayons, legos)
o collective
 pokemon cards, beanie babies
o competitive
 play games where there is a winner and a loser (they don’t like to lose)
Adolescents (12 – 18 years)
 peer group association
 hang out w/ friends
 allow adolescents be in each others room unless one of them is
o fresh post op (<12 hrs)
o immunosuppressed
o contagious disease

TIP: when given a variety of ages to choose from always go younger b/c children regress when sick and you want to
give them as much time to grow

LAMINECTOMY

Ectomy = removal
Lamina = vertebral spinal processes
ie. the winged ends of vertebrae

What is the reason for a laminectomy?

 To relive nerve root compression

s+s of nerve root compression (3 P’s)

 pain
 paresthesia
 paresis

**The most important thing to pay attention to is location b/c it will determine prognosis, treatment, symptoms**
LOCATION = most important in NEURO Q’s

Locations
 Cervical (neck)
 Thoracic (upper back)
 Lumbar (lower back)

Pre-op Assessment
 Cervical
o Most important assessment is breathing and function of upper extremities
 Thoracic
o Most important assessment is cough (tests abdominal muscles) and bowel sounds
  Lumbar
o Most important assessment is bladder (urine output/when did they last void) and leg function

On NCLEX #1 answer post op spinal = log roll

Specific “activity”/mobilization strategy post op

 Do not dangle pts legs/sit on edge of bed
 Allowed to walk, stand and lie down w/o restrictions
 Do not sit for longer than 30 minutes

Post-op Complications
 Cervical
o Pneumonia
 Thoracic
o Pneumonia and Paralytic Ileus
 Lumbar
o Urinary retention followed by leg problems
Anterior Thoracic
 From the front through the chest to the spine
o Will have a chest tube b/c there will be a pneumohemothorax

Laminectomy w/ Fusion
 Bone graft from the iliac crest (hip)
 2 incisions: one from hip and one on the spine
o 1 incision if surgeon uses cadaver bone to  recovery time,  risk of post op complications etc
o Hip has most pain/bleeding/drainage
o Both hip/spine have = risk for infection
o Spine highest risk for rejection

Discharge Teaching
 4 temporary restrictions (6 weeks)
o Do not sit longer than 30 minutes
o Lie flat and log roll
o No driving
o No lifting more than 5 pounds
 ie. a gallon of milk
 3 permanent restrictions
o Never be allowed to lift by bending at the waist (bend at the knees)
o Cervical laminectomys will never be allowed to lift objects above their heads
o No horseback riding, off trail biking, jerky amusement park rides etc
Lecture # 8
lab values

Klimek code:
A (Abnormal): Do nothing
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 (Cr)

 Best indicator of kidney function
 0.6 – 1.2 (50 – 110)
 Abnormal Cr would be categorized as an A (Would never prioritize a pt w/ an  Cr as your highest priority)
 Only be concerned if the pt is going for a dye procedure and their Cr is , then you can notify MD (but still
wouldn’t be an urgent call)

INR
 Monitors warfarin therapy
 2 – 3’s
 Anything 4 is a C
  INR = bleed risk
 If INR 4 what do you do? (in order)
o Hold warfarin
o Assess bleeding (focus assessment)
o Prepare to give vitamin K
o Call the MD

Potassium (K+)
 3.5 – 5.3
 K low = C
o assess heart
o prepare to give K
o call the MD
 5.4 – 5.9 = C
o Hold all K+
o Assess heart
o Prepare kayexalate/D5W w/ regular insulin
o Call the MD
  6 = D (can die within 2 minutes)
o Hold K+
o assess heart Will need a team to achieve all of
o prepare kayexalate/D5W this as you can not leave the pt
o call the MD

pH
 7.35 – 7.45
 Anything in the 6’s = D
o Vitals (to make sure they’re still alive)
o Call the MD to determine the cause (getting MD is most important)

BUN
 8 – 25
 If elevated assess for dehydration = B

Hemoglobin (Hgb)
 12 – 18 (120 – 180)
 If 8 – 11 = B
o assess for anemia/bleeding
 If < 8 level C
o assess for bleeding
o prepare to give blood
o call the MD
Bicarbonate (HC03)
  22 – 26
 If out of range = A not worrisome

Carbon Dioxide (CO2)

 35 – 45
 If in 50’s = C
o Does not apply to COPD pts
o Assess resps.
o Pursed lip breathing
o Do not give O2, will worsen the problem
 If in 60’s = D
o Sign of resp. failure
o Assess resps.
o Pursed lip breathing (to  anxiety)
o Prepare to intubate and ventilate
o Call RT (resp. therapy)
o Call MD

Hematocrit (HCT)
 36 – 54 (3x the Hgb)
 Elevated = B
 Assess for dehydration

PO2 (from blood gas not monitor)

 78 – 100
 If 70 – 77 = C
o Sign of resp. insufficiency
o Assess resps
o Give O2
 If in 60’s = D (pt is hypoxic)
o Sign of resp. failure
o Give O2 (to  pt anxiety)
o Assess resps
o Prepare intubation/ventilation
o Call RT
o Call MD

O2 Saturation
 93 – 100
 Less than 93 = C
o Assess resps
o Give O2

BNP
 Best indicator of CHF
 < 100
 100 + = B
o Assess for signs of CHF

Sodium (Na)
 135 – 145
 If abnormal = B
o If high assess for dehydration
o If low assess for overload
 If change in LOC = C

RBC’s
 4 – 6 million
 Abnormal red count = B

WBC
 5,000 – 11,000
ANC (absolute neutrophil count)
 Needs to be above 500
CD4
 Above 200
o Below 200 = AIDS

Less than normal value for WBC, ANC, + CD4 = C

 Assess for infection
 Place on neutropenic precautions

Neutropenic Precautions
 Strict hand washing
 Shower BID w/ antimicrobial soap
 Avoid Crowds
 Private Room
 Limit numbers of staff entering room
 Limit visitors to healthy adults
 No fresh flowers or potted plants
 Low Bacteria Diet
o No raw fruits, veggies, salads, undercooked meats
 Do not drink water that has been standing for longer than 15 mins
 VS (Especially Temp) Q4H
 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
o Stethoscope, BP cuff, gloves, thermometer

Other names for low WBC count Other name for high WBC count
 Leukopenia  Leukocytosis
 Neutropenia
 Agranulocytosis
 Immunosuppression
 Bone marrow suppression

Platelets (PLT)
 150,000 – 400,000 (150 – 400 x 10 (to the 9th power)/L)
 Below 90,000 = C
o Thrombocytopenic precautions
o Assess for bleeding
 Below 40,000 = D
o Can spontaneously bleed to death
o Assess for bleeding
o Thrombocytopenic precautions

Bleeding Precautions
 No unnecessary venipuncture injection or IV (use small gauge)
 Handle pt gently (use draw sheets)
 Use electric razor
 No toothbrushing/flossing
 No hard foods
 Well fit dentures
 Blow nose gently
 No rectal temperature, enema or suppository (use stool softeners, no straining)
 No aspirin
 No walking in bare feet, no shoes, no tight clothes
 No contact sports
 Notify MD if blood in urine or stool
Memorize the 5 D’s
1. pH in 6’s
2. K+  6
3. CO2 in 60’s
4. pO2 in  60’s
 5. PLT’s < 40,000

When should you call a rapid response team?

 When lab values are critical or deadly dangerous or if bad symptoms during assessment

What do you do when something is critical? (drag and drop style question)
1. ALWAYS hold and stop first
2. Assess
3. Prepare to give _____
4. Call the MD
Lecture # 9
psychotropic drugs

all psych drugs cause:

 Hypotension
 Weight changes
o Most cause weight gain, few cause weight loss

Phenothiazines (1st gen/typical antipsychotics)

 all end in “zine”
 do not cure psych diseases only  symptoms
 zines for the zaney (crazy)
 zzzz zines (sedatives)
 small dose used as antiemetic
 large dose used as antipsychotic
 major tranquilizers
 #1 dx is risk for injury/safety issues
 nrsg care – tx side effects
 NEVER stop the ZINE
 teach pt to report sore throat and s+s of infection to MD

side effects – non toxic (remember ABCDEFG)

 A – anticholinergic (dry mouth)
 B – blurred vision
 C – constipation
 D – drowsiness
 E – EPS (extrapyramidal syndrome – Parkinson’s symptoms, ie pill rolling, cogwheel, rigidity, shuffling gait)
 F – “f”otosensitivity (skin burns)
 G – aGranulocytosis (low WBC – immunosuppressed)

Deconate or “D”
 Long acting IM form of phenothiazine given to non-compliant pts
 Comes after the name of the drug

Tricyclic Antidepressants – grandfathered into a new class known as NSSRI’s

 mood elevators to tx depression
 takes 2-4 weeks before you see effects
 examples: Elavil, Tofranil (love to test this drug), Avatil, Desyrel
o think Elavil elevates your mood

side effects
 A – anticholinergic (dry mouth)
 B – blurred vision
 C – constipation
 D – drowsiness
 E – euphoria (way too happy)

Benzodiazepines
 Antianxiety meds
 Considered to be minor tranquilizers
 Always have zep/pam/lam
 Indications
o pre op to induce anesthesia
o muscle relaxant
o alcohol withdrawal
o seizures (esp. status epilepticus)
o facilitates mechanical ventilation
 work quickly but should not be taken for more than 2-4 weeks
 #1 nursing dx is safety/injury

side effects
 A – anticholinergic (dry mouth)
 B – blurred vision
  C – constipation
 D – drowsiness

MAOI’s (monoamine oxidase inhibitors)

 antidepressants
 beginning of names all rhyme
o parnate, nardil, marplan (Par, Nar, Mar or PaNaMa)
 pt teaching
o to prevent hypertensive crisis, avoid all foods containing tyramine
o no salad BAR
 bananas
 avocados
 raisins (dried fruit)
o no organs, preserved foods (hot dogs, lunch meat), no smoked, dried, cured, pickled etc
o no dairy except mozzarella and cottage cheese
o no alcohol
o no chocolate
o no OTC meds
o no caffeine

side effects
 A – anticholinergic (dry mouth)
 B – blurred vision
 C – constipation
 D – drowsiness

Lithium
 used for bipolar disorder
o b/c it  mania, does not treat depression
 only psych drug that does not mess w/ neurotransmitters, stabilizes nerve cell membranes
#1 intervention while on Lithium
  fluids
 if sweating give Gatorade/poweraid – do not give water
o high in electrolytes
 monitor for dehydration and Na levels
o low Na = makes lithium toxic
o high Na = makes lithium not work

side effects (3 p’s)

 peeing (polyuria)
 pooping (diarrhea)
 paresthesia (tingling/numbness)
toxic effects (hold and call MD)
 tremors
 metallic taste
 severe diarrhea

Prozac
 SSRI antidepressant (similar to Elavil)
 Mood elevator
side effects
 A – anticholinergic (dry mouth)
 B – blurred vision
 C – constipation
 D – drowsiness
 E – euphoria
*insomnia is caused by Prozac  give dose before noon, do not give @ hs*
*when changing dose in teenagers/adolescents,  risk for suicide*
Haldol (haloperidol)
 typical 1st gen antipsychotic
 tranquilizer
 similar to thorazine
 also has a deconate form
side effects
 A – anticholinergic (dry mouth)
 B – blurred vision
 C – constipation
 D – drowsiness
 E – EPS (Parkinson’s symptoms)
 F – “f”otosensitivity (skin burns)
 G – aGranulocytosis (low WBC – immunosuppressed)

Haldol OD – Neuroleptic Malignant Syndrome (NMS) – BIG DEAL MEDICAL EMERGENCY

 Potentially fatal hyperplasia (fever) w/ temp above 39
 Includes anxiety and tremors
 Dose for elderly should be ½ adult dose
 Take the temp to differ from EPS

Clozaril/Clozapine (2nd gen atypical antipsychotic)

 used to tx severe schizophrenia
 created to replace the “zines” + Haldol
 does not have the side effects of A – F but has SEVERE aGranulocytosis (it destroys your marrow)
 monitor WBC’s (can go very low)

Geodon (Ziprasidone)
 BLACK BOX WARNING
o prolongs QT interval and can cause sudden cardiac arrest
o do not give to pts w/ heart conditions

Zoloft (Sertraline)
 SSRI: can cause insomnia but can be given @ hs
  dose of warfarin (can bleed out)
 St John Wart + Zoloft = serotonin syndrome

side effects of serotonin syndrome (SAD HEAD)

 Sweating
 Apprehension (impending sense of doom)
 Dizziness
 Headache
Lecture # 10 & 11
maternal/newborn overview and helpful hints

PREGNANCY

nageles rule (calculating due date)

 take first day of last menstrual period (LMP) add 7 days then subtract 3 months
o ex: LMP June 10 through June 15
June 10 + 7 days = June 17 – 3 months
due date = March 17

average total weight gain

 28 lbs +/- 3 lbs
ideal weight gain
 week of gestation – 9 (+/- couple lbs)
o if more than 3 lbs need to assess
o ex: week 28 – 9lbs = 19 lb weight gain

1st trimester (1 – 12 weeks)

 1 lb/month = 3 lbs total
 fundus not palpable, mother is priority
 if you can palpate the fundus or she
gains 10 lbs she might have
hydatidiform mole (growth of
abnormal fertilized egg) or she may
not be in 1st tri
 you can palpate fundus @ end of first
tri (week 12)

2nd trimester (13 - 27 weeks)

 1 lb/week
 fundus @ umbilicus or below it,
mother is priority
 @ 20 – 22 weeks the fundus is @
umbilicus

3rd trimester (28 - 40 weeks)

 1 lb/week
 fundus above umbilicus, baby is
priority

Signs of Pregnancy
4 Positive Signs
 fetal skeleton on an x ray
 fetal presence on ultrasound
 examiner palpates fetal movement
 auscultation of the fetal heart rate
(FHR) w/ doppler
o HR begins to beat @ 5 weeks, but can hear it @ 8 – 12 weeks
o 3 different Q’s for OB Q’s
 when should you FIRST auscultate a fetal heart: 8 weeks
 when should you MOST LIKELY auscultate a fetal heart: 10 weeks
 when SHOULD you first auscultate a fetal heart by: 12 weeks
 FIRST: pick earliest range
 MOST LIKELY: pick mid part of range
 SHOULD: pick end of range

Probable/Presumptive signs (the maybes)

 all urine and blood pregnancy tests
 chadwicks, goodells, hegars sign (in that order)
 Chadwick: Cervical color change to cyanosis
 Goodells: Cervical softening
 Hegar: Uterine softening
Pt teaching
 come once/month until week 28 (3rd tri)
  week 28 come once every 2 weeks until week 36
 week 36 come every week until delivery (up until week 42 – they would then be induced)
 hgb will fall, it can fall to 10 and still be normal
 tx morning sickness (hyperemesis gravidarum) w/ dry carbs BEFORE you get out of bed, not for breakfast
 dyspnea (2nd/3rd tri) teach tripod position
 back pain (2nd/3rd tri) pelvic tilt exercises

Labor and Birth

 truest most valid sign of labor
o onset of regular progressive contractions
 dilation: opening of the cervix (0 – 10 cm)
 effacement: thinning of cervix (thick – 100% effaced)
 station: relationship of fetal presenting part to moms ischial spine (tightest squeeze for baby head)
o negative station: presenting part is above the tight squeeze (-1, -2) = BAD
o positive station: presenting part is below the tight squeeze (+1, +2) GOOD
o 0 station: baby is at the ischial spine
 lie: relationship between spine of mom and spine of baby
o vertex lie (longitudinal): compatible for natural birth
o transverse lie (shoulder presentation): TROUBLE
o mom and baby’s spine are parallel: GOOD
 presentation: part of baby that enters the birth canal first
o most common is ROA or LOA (pick R before L)

4 Stages of Labor

Stage 1: labor (3 phases)

 phase 1: latent
o 0 – 4 cm dilated
o contraction frequency: 5 – 30 mins apart
o contraction strength: mild
o contraction length: 15 – 30 secs
 phase 2: active
o 5 – 7 cm dilated
o contraction frequency: 3 – 5 mins apart
o contraction strength: moderate
o contraction length: 30 – 60 secs
o priority is pain management
 phase 3: transition
o 8 – 10 cm dilated
o contraction frequency: 2 – 3 mins apart
o contraction strength: strong
o contraction length: 60 – 90 secs

only memorize active phase, if values are less than active phase values pick latent, if values are more than active
phase values then pick transition
contractions should not be longer than 90 secs and closer than 2 mins apart
  this is a sign of uterine tetany or uterine hyperstimulation
 STOP PITOCIN

How to Time Contractions

 frequency: the beginning of one contraction to the beginning of the next (mins)
 duration: beginning to end of one contraction (secs)
 intensity: purely subjective by mom
o palpate w/ 1 hand over fundus w/ pads of the fingers

Purpose of Contractions
 1st stage: dilate and efface cervix
 2nd stage: push baby out
 3rd stage: push placenta out
 4th stage: stop bleeding (contract uterus)

Stage 2: delivery of baby

 priority is clearing baby’s airway
 deliver head
o suction mouth  suction nose
o check for nuchal cord (cord around the neck)
 deliver shoulders then body
 baby must have ID band on before leaving the delivery room

Stage 3: delivery of placenta

 make sure placenta is in tact and is all there (placenta accreta)
 check for a 3 vessel cord (2 arteries 1 vein) – AVA (2 a’s 1 v)

Stage 4: Recovery
 post partum begins 2 hrs post delivery of placenta
 contract uterus to stop bleeding
 4 things you should do 4 times (Q15mins) in 4th stage
o VS: looking for s+s of shock
  BP,  HR,  RR, pale, cold and clammy
o fundus check
 If boggy massage
 If displaced may have full bladder = void or catheterize
o pads
 check pad saturation (should not soak a pad in less than 1 hr)
o roll her
 check perineum for bleeding

Complications
 painful back labor (low priority)
o usually in OP position (OP = oh pain)
o tx: position then push
 reposition (knee chest – ie face down ass up) then push (take fist and push into sacrum –
applies counter pressure)
 prolapsed cord (OB emergency)
o cord is presenting which wraps around baby’s neck
o tx: push then position
 push head off cord; position (knee chest)
 interventions for all other complications
o LION
 Left side
 Increase IV
 O2
 Notify physician

If Pitocin is running stop the Pitocin FIRST, then do LION

Pain Management
 do not administer a pain medication to a woman in labor if the baby is likely to be born when the med peaks
o ie you have a prim mom @ 5 cm who wants IV morphine, would you give it?
yes IV meds peak in 15 – 30 mins after administration
FETAL MONITORING PATTERNS

low fetal HR (under 110)

 bad! do LION, if Pitocin running stop Pitocin FIRST

high fetal HR (over 160)

 no big deal, document and take mom’s temperature (mom most likely has a fever)

low baseline variability

 bad! FHR stays the same, does not change (high, low or middle, doesn’t matter, does not change) do LION

high baseline variability

 good! baby’s HR is always changing, document

late decels
 bad! baby’s HR slows down near the end of a contraction, do LION

early decels
 good! baby’s HR slows before or at the beginning of a contraction, document

variable decels
 very bad! prolapsed cord (cord compression) put mom in push position

check FHR always a good choice to pick on NCLEX

Variable Cord compression

Early decels Head compression
Acceleration Ok
Late decels Placental insufficiency

Post Partum Assessment

 Q4H – Q8H (depends on stability)
 Assessing BUBBLE HEAD (but only focus on 3 of these)
Breast Hemoglobin/hematocrit
Uterine fundus** Extremity check**
Bladder Affect – emotional
Bowel Discomfort
Lochia**
Episiotomy

Uterine Fundus
 want it to be firm
o if boggy  massage
 want it to be midline
o if displaced (off to the side)  catheterize
 fundal height = day post partum
o right after delivery it is at the pubis, 24 hrs post delivery it is at the umbilicus
Lochia (vaginal drainage)
 rubra (red)  color of lochia for first few days
 serosa (pink)  color of lochia a week or so post partum
 alba (white)  last stage of lochia
 amount is key
o moderate: 4 – 6 inches on pad Q1H
o excessive: saturate pad Q15 mins
Extremity Check
 looking for thrombophlebitis via bilateral calf measurements

Variations in the Newborn (all are normal)

Milia
 distended sebaceous glands which appear as tiny white spots on baby’s face

Epstein’s Pearls
 small white epithelial cysts on baby’s gums
Mongolian Spots
 bluish-black macules appearing over the buttocks and/or thighs of darker skinned neonates (almost looks like
a bruise)

Erythema Toxicum Neonatorum

 red popular rash on baby’s torso (benign) and disappears after a few days

Hemangiomas
 benign tumor of capillaries

Cephalohematoma
 swelling caused by bleeding between the ostium and periosteum of the skull (does not cross the suture lines)

Caput Succedaneum
 edematous swelling caused by pressure during delivery (crosses suture lines)

Hyperbilirubinemia
 physiological jaundice: appears 24 hrs after birth and disappears in about 1 week

Vernix Caseosa
 whitish cheese like substance which appears intermittently over first 7 – 10 days

Acrocyanosis
 normal cyanosis of baby’s hands and feet which appears intermittently over the first 7 – 10 days

Nervus/Nevi (birthmarks)
 nervus flammeus
o non blanchable “port wine stain
 telangiectatic nevi
o blanchable pink “stork bites”

OB Meds – only antipsychotic pregnant woman can get is haldol

Tocolytics (stops labor)

 terbutaline
o causes maternal tachycardia
 mag sulfate
o causes hypermagnesemia which will cause all of the following to go  : uterine contractions, HR, BP,
RR, reflexes and LOC
o NCLEX will focus on RR and reflexes
 as long as RR is above 12 it’s ok, if under 12 titrate mag sulfate down
 2+ reflexes are good if 1+ bad need to titrate mag sulfate down

Oxytoxics (stimulate and strengthen labor)

 Pitocin (oxytocin)
o Causes uterine hyperstimulation (longer than 90 secs closer than 2 mins)
 Methergine
o Cause  BP

Fetal Lung Maturing Meds

 Betamethasone (steroid)
o given to mom via IM before baby is born
 Servanta (surfactant)
o given to neonate, given trans-tracheal (blown into trachea), given after baby is born
Pharmacology Help/Hints

Injections (what size needle)

 IM
o 21 gauge/ 1 inch (always pick the gauge/inch w/ a 1 in it – 1 looks like I)
 subcut
o 25 gauge/ 5/8th (always pick the gauge/inch w/ a 5 in it – 5 looks like S)

Heparin vs Coumadin
Heparin
 given IV or subcut
 works immediately
 can not be given longer than 3 weeks (except for Lovenox) b/c after 3 weeks start to make heparin antibodies
(can be life threatening)
 antidote: protamine sulfate
 lab: PTT
 can be given to pregnant women

Coumadin
 only given PO
 takes a few days to a week to work
 can be on forever
 antidote: vitamin K
 lab: PT/INR
 can not be given to pregnant women

Potassium Wasting/Sparing Diuretics

 any diuretic ending in X (semides – furosemide [ie. Lasix] as well as Diuril) wastes K+
 all others are sparing

Muscle Relaxants
 baclofen + flexeril
 2 side effects tested
o fatigue/drowsiness and muscle weakness
 3 teaching points tested
o do not drink, do not drive, do not operate heavy machinery
 baclofen = on your back loafin (relaxing)
 felxeril = flex your muscles

Piagets Theory of Cognitive Development

4 stages
 sensorimotor
o age 0 – 2 y/o
o present oriented
o do not think about past or future only senese what they’re doing right now
o teaching guidelines
 when: as you do it (pre teach parents)
 what: what you are doing
 how: verbally
 pre operational
o age 3 – 6 y/o (pre schoolars)
o fantasy oriented
o teaching guidelines
 when: slightly ahead of time
ie. the day/morning of, two hours before
 what: you will be doing (future tense)
 how: through play, toys, stories
 concrete operational
o age 7 – 11 y/o
o rule oriented (can not abstract)
o teaching guidelines
 when: days ahead
 what: what you’re going to do plus skills on how
 how: age appropriate reading and demonstration
 formal operations
o age 12 + y/o (adult med/surge)
o abstract thinking, understand cause-effect (thinking like adults emotionally but physically not there)
o teaching guidelines
 like an adult

7 principles in Psych Nurse/Pt relationships

 make sure you know what phase of the relationship you’re in
 gift giving: do not give/accept gifts from pts
 don’t give advice – “What do you think you should do”
 don’t guarantee anything – “If you talk to me I can help you/don’t cry you’ll feel better”
 best answer is the one that keeps them talking (open ended), it’s never wrong to get a pt to talk in any
instance
 concreteness – don’t use slang b/c psych pts take things literally; don’t ask them what their neologisms are
 empathy – acknowledge feeling, always be empathetic; never choose answers like this “don’t feel…” “don’t
worry” read the feeling in the question
1. recognize an empathy question: always have quote in the question and in the answers
2. put yourself in the clients shoes
3. ask yourself “If I said those words and meant them, how would I be feeling?”
4. Choose the answer that reflects that feeling, NOT their words. Empathy ignores what is said and
responds to what they feel
Lecture # 12
prioritization/delegation/staff management

prioritization
 determine which pt is the sickest or the healthiest depending on the Q
 answers have 4 parts
o age, gender, dx and modifying phrase
 ie. 10 y/o male w/ hypospadias who’s throwing up bile and emesis
o age and gender are irrelevant (in peds Q’s age is important, not in prioritization)
o dx and modifying phrase are whats most important
 modifying phrase is the MOST important

4 rules for prioritization

 acute beats chronic
o ie. a pt w/ COPD, a pt w/ CHF and a pt w/ appendicitis, who is the highest priority?
 the appendicitis pt
 fresh post op (1st 12 hrs) beats medical or other surgical no matter what
 unstable beats stable
o if it says stable in the Q its stable
 the more vital the organ, the higher the priority (tie breaker only)
o most vital: brain  lungs  heart  liver  kidney  pancreas
the organ we’re talking about is the organ in the modifying phrase no the dx itself

Stable vs Unstable

Stable Pts
 the word stable
 chronic illness makes you stable
 post op >12 hrs
 local or regional anesthesia
 lab abnormalities of an A or B level
 phrases “ready for d/c” “to be d/c” or admitted longer than 24 hrs
 unchanged assessment
 experiencing the typical expected s+s of the disease they were dx w/

Unstable Pts
 the word unstable
 acute illness
 post op <12 hrs
 general anesthesia only in first 12 hrs
 lab abnormalities of a C or D level
 phrases “not ready for d/c” “newly admitted” “newly dx” or “admitted less than 24 hrs ago”
 changing or changed assessment  something new or something different
 experiencing unexpected s+s of the disease they were dx w/

4 pts who’re always unstable regardless of whether it’s expected or not

 hemorrhage (different then bleeding)
 hypoglycemia
 fever  104 (they will seize)
 pulselessness or breathlessness (must be witnessed)

3 things that result in black tags in an unwitnessed accident

 pulselessness
 breathlessness
 fixed and dilated pupils (even if they’re breathing and have a pulse) low priority

Delegation: LPN
 do not delegate the following to an LPN
o starting an IV Can maintain and
o hanging/mixing IV meds document flow of IV
o pushing IV meds
o can’t administer blood
o can’t work w/ central lines
o can’t plan care (RN makes care plan, LPN can implement it)
 o can’t preform/develop teaching but they can reinforce it (RN must do initial teaching)
o can’t care for unstable pts
o can’t do the first of anything (ie. assess, first post op drsg change, first time ambulating a post op pt,
first set of VS’s after sx)
o can’t do the following assessments
 admission
 discharge
 transfer
 first assessment after there has been a change

Delegation: UAP (HCA)

 do not delegate the following to a UAP
o charting: can chart what they did but not about the pt (ie. side rails up, bed in lowest position, call bell
in reach, bed bath given = OK; pt less anxious today, tolerated ambulation well = not OK)
o can’t give meds
 EXCEPT can apply topical OTC barrier creams
o Assessments
 can do VS and accuchecks
o tx
 except for enemas…. catheterize as last resort
o can delegate ADL’s (bed, bath, morning care) but should never do the first
 can also not feed a stroke pt within first 24 hrs of stroke

do not delegate to the family, safety responsibilities (ie. taking off restraints for a family member in the room)
w/ sitters/care givers they can only do what you teach them to do and you must make sure you document that you
taught them

staff management
 how do you handle inappropriate behavior amongst staff? always 4 options
o tell supervisor
o confront them and intervene immediately
o approach them later on and talk to them
o ignore the behavior (NEVER the answer)
 ask yourself: is what they’re doing illegal?
o If yes: choose tell the supervisor
o If no, ask yourself: is anyone in immediate danger of physical/psychological harm?
 If yes choose: confront them immediately
 If no and is just inappropriate behavior choose approach later
o If its illegal and harmful: confront then tell supervisor
Lecture # 13

Valves of the heart (point and click) no leeway

 Aortic Valve: 2nd intercostal space (at the right sternal border)
 Pulmonic Valve: 2nd intercostal space (at the left sternal border)
 Tricuspid Valve: 4th intercostal space (at the left sternal border)
 Mitral Valve: 5th intercostal space (at the mid clavicular line) (**apical pulse**)

Pulses (point and click) Organs (Point and click)

How to Guess
Use knowledge first, then common sense, then educated guess

 Psych questions: best answer is “the nurse will examine their own feelings about…” to prevent
countertransference; another is “establish a trusting relationship”

 Nutrition questions: in a tie, pick chicken (unless it’s fried), if chicken’s not there pick fish (not shellfish b/c
high in cholesterol); also never pick casseroles for children (child won’t eat it); never mix meds in children’s
food; for toddlers choose finger foods; preschoolers leave them alone, one meal a day is okay

 Pharmacology questions: memorize side effects of drugs; if you know what a drug does but you don’t know
the side effects, pick a side effect in the same body system where the drug is working i.e: GI drug pick
diarrhea or a CNS drug pick drowsiness etc; if you don’t know what the drug is look to see if it’s PO pick a GI
side effect; never tell a child medicine is candy

 OB questions: check fetal heart rate.

 Med Surge questions: LOC over airway on assessments, but the first thing you do should be establish
airway

Pediatric Growth and Development questions (will always give you two right answers, but what’s the MOST
right)
3 Rules based on the principle: always give the child more time to grow and develop; don’t rush child’s growth and
development
Rule 1: When in doubt call it normal
Rule 2: When in doubt pick the older age
Rule 3: When in doubt pick the easier task

General Guessing
 rule out generalized absolutes if you’re guessing
 if two answers say the same thing, neither of them is right
 if two answers are opposite, one of them is probably right
 the “umbrella strategy”: look for an answer that covers all the others without saying it does (i.e: use safety and
good body mechanics when transferring a patient from bed to wheelchair)
 if the question gives you four right answers and the question is asking for prioritization, use the rules above,
however if they give you one patient in the question and it asks “which needs is highest priority” don’t use
it! Do the worst consequence game. Choose the answer with the most severe consequence.
 when you’re stuck between two answers, re-read the question
 the Sesame Street Rule: (use as a last resort) Right answers tend to be different than the others because
it is the only one which is right so the other “wrong” answers have something in common
 don’t be tempted to answer a question based on your ignorance instead of your knowledge. Pull the “thing”
you don’t know out of the question and answer it with the things you know. Boards will give you things you
never heard of to measure your common sense
o Which of the following is important to do in the case of Amicasin IV piggyback?
 Cover the bag with foil to protect from light – ignorant answer
 Use IV pump – based on knowledge
 If something really seems right, it probably is. DON’T go against your gut answer unless you can prove why
the other is superior
 Conflicts on the job: never say you. Always say “I”
 Headache good thing to check on SATA!
 NEVER PICK INFECTION IN FIRST 72 HRS of anything!

3 Expectations CAN’T HAVE because they cause negativity:

 Rule #1*: Don’t expect 75 questions, prepare to get all 265 questions. “I’m still in the game”.
 Rule #2: Don’t expect to know everything.
 Rule #3: Don’t expect everything to go right.