Mark Klimek Yellow Book

If the pH and the BiCarb are both in the same direction then it is?
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If my patient has prolonged gastric vomiting or suction I choose?Metabolic AlkalosisIf it is not lung or prolonged vomiting or suctioning I choose?Metabolic AcidosisKussmal RespirationsMetabolic Acidosis ( Remember MacKussmalBefore measuing ABGs you should check what?Allen's test. Should be positive. Pt makes a fist and pressure is applied to the ulnar and the radial arteries Ulnar pressure is released and color should return in 7 seconds (means it's positive and OK to take ABG's).Definition of CompensationPH is normal! It is never compensated if it is abnormal.If PH normallook in the direction it is going. Closer to Acidic? (7.35) acidosis. Then look at Bicarb & figure out which is abnormal. If Bicarb is out of range, it's metabolic acidosis. If C02 is abnormal, it's Respiratory Acidosis :)If your pt is acidotic and you need to pick a symptomPick the symptom where everything is DOWN. ( And vice Versa) Ex: 2 degree Morbitz Type 2 BLOCK. <---- Down directionIf you don't know what causes an acid base balance, pickMetabolic AcidosisIf in doubt in ABGs, always pickHeadache, nausea, weakness & numbness+ tingling. It can be either up or down.High pressure alarms are triggered when?They cannot push air inHigh pressure alarms are caused by what three types of obstructions?Kinking, Water in dependant loops and mucus in the airway.If kinking in the tube is present you?UnkinkIf water is present in the dependant loops you?Open system and empty water.If mucus is present you?Turn them, cough and have them deeo breath first. If ineffective you then suction.Don't suction unlessCoughing & deep breathing is deemed inappropriate.In order to suction, you must be able to hearMucus in the lungLow pressure alarms are triggered when?It is to easy to push air in.Low pressure alarms are normally caused by?DisconnectionIf the tubing is disconnected you?ReconnectIf O2 sensor line is disconnected you?ReconnectIn a vented client respiratory alkalosis means the vent setting may be too?HighIn a vented client respiratory acidosis means the vent may be too?LowWhat do you do if the patients disconnected tube is on the floor?Bag them, (call for help) get new tube and then reconnect.First question to ask if the low pressure alarm soundsWhere is the tubing?!HOLDH- High Pressure O- Obstruction L- Low D- DisconnectionsNever put anything in YOUR scope of practiceOn anyone elseMake sure your answer isPATIENT FOCUSED. TAKE CARE OF YOUR PATIENT! Don't answer based on staff, building, machine, etc. PATIENT FIRST.What does wean mean?Decrease GraduallyWhat do you do if the patients disconnected tube is on the chest?Reconnect ... if its above the waist its ok.Remember is PSYCH if you are asked to Prioritize, Don't forgetMASLOW! 1. Physiological 2. Safety 3. Comfort - Includes pain 4. Psychological 5. Social 6. SpiritualWhen prioritizing, always use Maslow + ABCsFor one patient. Don't if you have more than one patient.What is the biggest problem in abuse?DenialTo treat denial you need to?Confront them.Definition of DenialRefusal to accept reality of their problemHow do you confront?Point out the difference between what they say and what they do.What is the one circumstance that you as a nurse would support denial?Loss and GriefAlways goMed surg first. Then PsychWhat is dependency?When the abuser gets a significant other so make decisions for them or do thing for them.What is codependency?When the significant other gets positive self esteem from doing things or making decisions for an abuser.To treat dependency/codependency you ?Set limits and enforce them. Say NO and follow through. Agree in advance on what requests are allowed, then enforce the agreement. Work on self esteem of the codependent.What is manipulation?When the abuser gets the significant other fo do things for them that is not in the best interest of the significant other. This can be dangerous and harmful to the significant other.How do you treat manipulation?Set limits and enforce.Why is manipulation easier to treat then dependency/codependency?Because no one likes being manipulated.DABDAD- Denial A- Anger B- Bargaining D- Depression A- AcceptancePsych Needs, In orderDenial Depend ManipulationTo address a patient's psychological needs, they must be:STABLE, safe, comfortable.PainNever killed anyone. NOT the top priority, especially if there are physiological needs in the question that make the patient unstable.What is Wernickes (Korsakoffs) Syndrome?Psychosis induced by vitamin B1 (Thiamine) deficiency.Symptom of Wernickes Korsakoffs syndrome?Amnesia with confabulation. = Loss of memory with making up stories to fill in the gaps.Vitamin B1 helps breakdown?AlcoholSo without B1 what happens?Alcohol isn't metabolized correctly goes to the brain and causes WernickesPrimary symptom of Wernickes?Amnesia with confabulation (making up stories).Is Wernickes preventable?Yes- Take Vitamin B1Is Wernickes arrestable?Yes- Take Vitamin B1Is Wernickes reversible?NoWhat is the goal of patients dementia/organic brain syndrome?Maintain function, Never Improve.What is aversion therapy?When you try and make the patient hate something.Antabuse onset and duration is?2 weeksTeach a patient taking Antabuse to avoid what?AlocholOn top of alcohol a patient taking Antabuse should also avoid what other 7 things?Alcohol Aftershave, Cologne, Perfumes Insect Repellent Elixirs Vanilla Extract Vinaigrettes Handsanitizer Alcohol Prep Pads Vanilla IcingHow long does it take for Antabuse to get out of the system so they can drink Alcohol again?2 weeksWhat are Elixirs?95% of liquids. If it is not an antibiotic, assume it is an elixir, so the patient can't have it if on antabuse. This rule applies for diabetics too (elixers also have sugar).What happens if a person on Antabuse ingests alcohol?Nausea, Vomiting, & Possibly DeathIn Overdose VS Withdrawal, Ask yourself?Is this drug an upper or a downer?What are the five uppers?Caffeine, Cocaine, Methamphetamines, PCP/LSD and ADHD Meds, Bath SaltsDowners are?Everything other then the five uppers. Heroin Ativan Valiumn FetanylS/S of upper use?Everything goes up Tachycardia Increased BP Irritability Fever Diarrhea +4 Reflexes Pupil Dilation Excitability Seizures Borborygmi ETC.S/S of downer use?Everything goes down Bradycardia Lethargy Constricted Pupils Hyporeflexia Flaccidity Respiratory DepressionThen ask yourself:Are they talking about Overdose or Withdrawal?Overdose/Intoxication:I have too much....Withdrawal:I don't have enough...Overdose of a downer causes everything to go?DownOverdose of an upper causes everything to go?UpWithdrawal of an upper causes everything to go?DownWithdrawal of a downer causes everything to go?UpUpper withdrawal looks likeDowner OverdoseDowner Withdrawal looks likeUpper overdoseAt birth if the mother was addicted to a substance always assume the newborn is?OverdosedIf 24 hours after birth assume the baby is in?WithdrawalEvery alcoholic goes through what withing 24 hours after cessation?Alcohol Withdrawal syndromeWhat is Alcohol Withdrawal Syndrome?Hyper irritability state less than 24 hours after the first drinkAfter 72 hours of alochol withdrawal a small minority may get?Delirium TremensCan Delirium Tremens kill you?YesCan Alcohol Withdrawal Syndrome kill you?NoAre patients with Alcohol Withdrawal Syndrome a danger to themselves or others?NoAre patients with Delirium Tremens a danger to themselves or others?YesN/I for Delirium Tremens?Private room near nurses station NPO/Clear liquids Restricted bed rest Restraints, tranquilizer, multivitamin (B1 Vitamin/Thiamine) Antihypertensive.N/I for Alcohol Withdrawal Syndrome?Semi-private room anywhere Regular diet Up and ad-lib, no restraint Tranquilizer Multivitamin (B1/Thiamine) Antihypertensive.A two point restraint is?One arm and the opposite leg.N/I for restraints?Check Q15min Rotate sites Q2HAll aminoglycosides end in?"mycin" VancomycinFor Aminoglycosides, think:A Mean Old MycinAminoglycosides treat?Big gun antibiotics. Treat serious, life threatening, resistant infectionsIf it has "thro" in it you?Throw it out...Zithromycin. It treats a minor infectionToxic effects of aminoglycosides?Ototoxicity Nephrotoxicity Cranial nerve 8 (vestibulocochlear nerve) which senses sound.The one Aminoglycoside that doesn't end in Mycin?AmikacinWhat is another word for aminoglycoside?GlycopeptideMonitor what with aminoglycoside use?Hearing, balance, tinnitus & creatinine (best indicator of renal function)Best indicator of aminoglycoside toxicity?Ototoxicity (Ears)Frequency of administration for aminoglycosides?Q8HAminoglycoside route of administration?Im or IVAminoglycosides are given PO for what two reasons?Hepatic Encephalopathy and Pre-op bowel surgery.What is Hepatic Encephalopathy also called?Liver Coma, Ammonia-Induced EncephalopathyIf fluid resuscitation is used in shock, there will beIncreased Urine OutputNeomycin and Kanmycin are used for what?Bowel sterilzation? Can also be given for C.DiffWho can sterilize my bowel?"Neo" "Kan"If you give aminoglycosides PO, do you have to worry about side effects?NoHepatic Encephalopathy is caused by?High ammonia levelsWhat raises ammonia levels the most?Ecoli in the gutWhy do you draw TAP levels?Narrow therapeutic WindowWhen do you draw a trough level?30 minutes before the next scheduled dose.When do you draw a sublingual peak level?5-10 minutes after it is dissolved.When do you draw a IV peak level?15-30 minutes after dose is finished.When do you draw a IM peak level?30-60 minutes after givenIf you must pick a time to draw the peak, pick the highest amount of time without going over the limitsSo for IV, Pick 30 Minutes, not 15.Category A Bio terrorism AgentsMost LethalWhat are the Category A Bio terrorism Agents?Smallpox Tularemia Anthrax Plague Hemorrhagic Fever, Such as Ebola BotulismCategory BA big, long list.Category C. Not very LethalHanta Virus Nipeh VirusSmall Pox Early Detection SymptomRash that starts around the mouthSmall poxInhalation. Pt on AIRBORNE Precautions Dies from Septicemia. No treatmentTularemiaInhalation Chest Symptoms Dies from RESPIRATORY FAILURE Treat with StreptomycinAnthrax spreads byInhalation (AIRBORNE PRECAUTIONS)Anthrax looks likeRespiratory FLUAnthrax death occurs from?Respiratory FailureTreat Anthrax withCipro, Penicillin, StreptomycinPlague spreads byInhalation3 H's of PlagueBlood Everywhere. H- emoptysis - Coughing up blood H-ematemesis - Blood in Vomitus H-ematochezia - Bright red blood in the diarrheaPlague patients die byDIC and respiratory DistressHemorrhagic Illnesses (Like Ebola)Petechiae and ecchymoses = Pinpoint Hemorrhage, especially on Chest & BruisingBotulism isIngested - Most Lethal Dies from Respiratory Arrest3 Major Symptoms of BotulismDescending Paralysis (Starts in face and goes down) Fever But is AlertGullian BarreAscending ParalysisChemical AgentsMustard Gas, Cyanide, and Phosgine ChlorineMustard Gas The Chemical Agent causesBlistersCyanide The Chemical Agent CausesRespiratory Arrest.What do you use to treat Cyanide Poisoning?Sodium Thiosulfate IVWhat does Phosgine Chloride CauseChokingSarin, the Nerve Agent, CausesMassive Cholinergic parasympathic responseCholinergic, Parasympathetic effects cause?B-ronchorrhea B-ronchospasm S-Salivation L-acrimating U-rinating Constantly D-iaphoretic + Diarrhea G-I distress E-mesisEbola (Hemorrhagic Fever) PrecautionsStandard, Contact, and DropletAll chemical agents require only soap and water except for Sarin, which requiresA WEAK BleachWhat do you do in a Chemical Attack?Decontaminate + TreatWhat is the Nurse's role in Chemical Decontamination?Put clothes in Biohazard bag that gets burned Put them in a Government Issued suit They may need to be housed for a whileBiochemical Attack, what do you do?QuarrentineCalcium Channel Blockers are like what for the heart?ValiumCalcium Channel BlockersNegative Ino, Chrono, DromoCalcium Channel Blockers treat what? (the 6 A's)Antihypertensive, Anti-Anginal, Anti Atrial Arrythmia and SVTSCalcium Channel Blocker side effects? (the 2 H's)Headache and Hypotension Also BradycardiaCalcium Channel Blockers treat what Arrhythmias starting with?A, as well as SVTWhat causes angina?Chest pain due to decreased O2 supply and demand issues.What do Anti-Anginal Medications do?Decrease O2 demand on the Heart, allowing more O2 to chest (dilate)90% of Calcium Channel Blockers end in?"dipine" and "zem"When giving a Calcium Channel Blocker you hold and notify if?Systolic is 100 or lower."QRS" refers to?Ventricular"P" refers to?AtrailAsystole is?A lack of QRS repolarizationsAsystoleTX: Epinephrine (Think Heart Stimulant)Atrail Flutter is?Rapid P-wave repolarizations in a saw tooth pattern.Atrial FlutterPharmacological therapy, such as beta blockers, antiarrhythmics, or calcium-channel blockers, need frequent monitoring of EKG rhythm strips, heart sounds, and apical pulse rate. (Unlikely to ask this)Atrial- Fib is?Chaotic QRS depolarizationsAtrial FibrillationChaotic Between QRS, but QRS is still PRESENT. HR Has to be Irregular. Treatment: Heparin. IMMEDIATELY.What do you do if the A-fib is unwitnessed?1. Heparin First 2. Cardioversion 3. ADENOsine 8 second Push- Watch for the pt to go into Asystole BETA Blocker CALCIum Channel Blockers DIGitalis (Lanoxin)V-fib is?Chaotic QRS depolarizationsVentricular FibrillationTX: Shock therapy. you DE-FIB.V-tach is?Wide bizarre QRS'sVentricular TachycardiaTreatment: Lidocaine & amniodaroneSVT - Subventricular TachycardiaNarrow QRS. Treatment: A-denosine 8 second Push- Watch for the pt to go into Asystole B-eta Blocker C- Calcium Channel Blockers D- igitalis (Lanoxin)PVC is?Periodic wide, bizarre QRS'sPVCPVC is the deviation in the picture from the normal QRS. Treatment is Lidocaine & AminodoroneBe concerned about PVC's if? ( rule of 6's)More then 6 per minute, 6 in a rowWhat are the 2 lethal arrythmias?A-systole and V-Fib (Pic if V-Fib, Asystole is Flat Lining)What are the 4 potentially life threatening arrythmias?V-tach, A-fib, A-flutter and PVCWhat are the 6 arrythmias you are tested over on the NCLEX?V-fib, A-fib, A-flutter, PVC, A-systole and V-tachWhat are the 6 arrythmias for NCLEX in order for prioritization?A-systole, V-fib, V-tach, A-fib, A-flutter and PVCWhen talking about arrythmias the word "chaotic" means?FibrillationWhen talking about arrythmias the word 'bizarre" means?TachyPVC's fall on what wave of the previous beat?T waveWhen prioritizing lethal arrhythmias, if one happened 6 minutes ago and the other happened 15 minutes ago, which do you choose?Always choose the closest to the 8 minute mark. After 8 minutes the survival rate is LOW.To treat PVC's you give?Lidocaine/AmnioderoneTo treat V-tach you give? (If it starts with V you use..)Lidocaine/AmnioderoneTo treat supraventricular arrythmias you give?Adeno Beta Calci Dig (Lonoxin)Supra means?AboveTo treat V-fib you ?Defibrillate ... For V-fib you D-fibTo treat AsystolE you give?CPR Epinephrine (atropine no longer given) OxygenIf asked how to treat A-fib first you?Give Heparin then ABCD.... Heparin is instant Warfarin and Plavix take time.What is the purpose of Chest Tubes?To re-establish negative pressure in the pleural spacePneumothorax removesAirHemothorax removesBloodPneumohemothoraxAir and BloodAn Apical chest tube is placed?High (for air) A for airA Basilar chest tube is placed?Low (for blood) B for bloodChest tubes after a surgery or trauma assumes it's a?Unilateral PneumohemothoraxDoes a pneumonectomy get a chest tube?No..removes the pleural spacePatient Positioning after Chest SurgeryChest Tube Up, good side downPatient Positioning after Chest SurgeryOperative side (Good lung up) Or Back (Supine)What 4 things do you do if the water seal breaks on a chest tube?Clamp it 1st!! Cut broken device off of tube Put the tube in water (NS) Unclamp.What do you do if you kick over the collection bottle?Set it back up Tell the patient to take some deep breathsWhat is the BEST thing to do if the water seal breaks?Put it in water (NS). (the first= clamp it)What 4 things do you do if a chest tube comes out?Cover hole with a gloved hand Put on a vaseline gauze dressing, Put on sterile dressing and then tape on 3 sides.How many chest tubes (and where) for a Unilateral Pneumohemothorax ?2 chest tubes, One side (Unilateral) one apical (for air/pneumo) and one basal (for blood-hemo)How many chest tubes (and where) for bilateral Pneumothorax?Bilateral- chest tubes on both sides Pneumo- (air) Apical = 2 apical chest tubes (one on each side)How many chest tubes (And Where) for post-op chest surgery?Unilateral, pneumohemo (2 chest tubes, one side, apical and basal) Assume Chest trauma is a gunshot wound.Straight Catheter is to a foley catheterLike a Thoracentesis is to a Chest Tube :) (meaning less invasive, less infection risk)How long can you clamp a chest tube?No longer then 15 seconds without a doctors order.What do you use to clamp a chest tube and why?Rubber tipped double clamps. Rubber because it won't pierce the tube and double because were nurses and if one is good two is better.Is bubbling in the water seal continuously good?No it is bad. You need to find the air leak, tape it, report it and then record it.Is bubbling in the water seal intermittently good?Yes it should tidal on inhalationIs bubbling in the suction control chamber intermittently good?No it is bad. You need to dial up the suction, report and record.Is bubbling in the suction control chanber continuously good?YesWhen picking answers, narrow it down to two, then ask yourselfIf i did this, but not this, what would be the outcome? Is it better?In routine care, do you ever clamp a chest tube?No. In an emergency, you can.When picking answers ask yourself ?Which one is MOST important to leave undone. More so than the others.All congenital heart defects that are trouble start with a ?"T"Which exception to the rule of congenital heart defects doesn't start with a T?Left Ventricular Hypoplastic SyndromeWhat defects have right to left shunts and are cyanotic?Trouble defectsWhat defects have left to right shunts and are acyanotic?Not trouble defectsAll congenital heart defects have what?Murmur and an echocardiogram doneWhat are the four defects of Tetrology of Fellot?Ventricular Defect, Pulmonic Stenosis, Overriding Aorta and Right HypertrophyWhat is the saying to help remember the four defects of Tetrology of Fellot?VarieD PictureS Of A RancH1 fingerwidth is how many cm's?1How to measure crutches2-3 cm/fingerwidths below anterior AXILLARY FOLD to a point lateral and slightly in front of the footWhen measuring crutches, don't pickany foot landmark like a "toe" or "heel"When the handgrip of a crutch is properly in place the elbow felxion should be?30*If crutch is not 30*, what will happen?Nerve DamageCrutches should be how many fingerwidths below the armpit?2-3Describe a 2 point gait?1. one crutch and opposite foot together 2. Other crutch and other foor together. 2 points 2gether and the same time.Describe a 3 point gait?1. Move two crutches and bad leg together. 2. Move good foot. Move all three together and then the good leg.Describe a 4 point gait?NOTHING moves together 1. Right crutch 2. Left foot. 3. Left crutch. 4. Right foot. It moves one at a time so 1,2,3,4 and 1,2,3,4, and 1,2,3,4Describe swing through?Traditional crutchingWho uses Swing Through?Amputees, non weight bearing (sprain/break)Use the even numbered gaits when weakness is?Evenly distributed (bilateral) Remember, Even for Even, Odd for OddWhen using the even gaits what one is for severe and what one for mild problems?2 point gait for mild 4 point gait for severe.4 point gait for what?Fresh Post OpIf the question says "systemic disease" when it comes to crutchesAssume it impacts both legsUse the odd numbered gait when?The problem is affecting one leg (unilateral)When going up the stairs or down the stairs with crutched remember?UP with the GOOD and DOWN with the BADCrutches always move with what leg?The bad leg.What side do you hold the cane?Strong side.What side do you advance the cane with?The weak side for a wide base support. *Step with opposites*For walkers remember you?Pick it up, set it down and walk to it.Remember for walkers that youAlways push, never pull NO tennis balls on legs If you put something on the walker, make it the side not frontA non psychotic person hasinsight and is reality basedA psychotic person hasNo Insight and is Not reality basedNot all psych patients arePsychotic. Show this in your answers!7 Hallucinatory WordsLook See Listen Hear Feel Taste SmellIf the question has "appear" in psych, it isA delusion ( a belief)What is a delusion?A false fixed belief, idea or thought. This has no sensory component.What are the three types of delusions?Paranoid or Persecutory, Grandiose and SomaticWhat is a paranoid delusion?False fixed belief that people are out to harm you (CIA, FBI).What is a grandiose delusion?False fixed belief that you are superior (God, the Pope).What is a somatic delusion?False fixed belief about a body part (X-ray vision).What is a hallucination?False, fixed sensory experience.Five types of hallucinations?Auditory, visual, tactile (feel) olfactory gustatory (taste)Most common type of hallucination?Auditory (Especially Command)What is an illusion?Misinterpretation of reality. It is a sensory experience.How can you diffirentiate between illusions and hallucinations?Illusion: Sensory response to something in reality [the news (reality) is talking TO them (illusion)] Hallucination: Sensory response but nothing in reality pertainsDon't treat all Psych patientsThe same/like they are psychoticExample of an illusion?The clock on the wall is a bomb (the clock is real, but the belief isn't)What are the four types of functional psychosis?Schizophrenia Schizoaffective disorder, Major depression/mania (bipolar). (SCHIZO SCHIZO MAJOR MANIC)Functional Psychotics have WHATThe potential to learn realityIf a functional psychotic is having a delusion or illusion you?Acknowledge the feeling ( I see you are upset), Present reality (but we have no spiders in the room) Set a limit ( we're not going to talk about that lets talk about something else) Enforce the limit ( I see you're to ill to talk about reality). Follow with : We have medication to treat those symptomsNEVER set limits onFeelingsPresent realityPositivelyExample of presenting reality positively:Tell them what they CAN do instead of what they CAN'T do.5 examples of psychosis of dementia?Alzheimers, dementia, organic brain syndrome, wernickes seniality.When deciding whether to redirect or reassureFunctional Psychotic (Schizophrenia) or Non Functional (Dementia)Re directing is NOTOrders Distraction Doing a physical actionRe-direction ISTaking what a patient is fixating on and that they are expressing inappropriately, and you get them to express it appropriatelyFor patients with OCD, youNegotiate a balanceIf a patient has psychotic depressionNo reality. Won't get dressed because they believe they are a prisoner in Iran.What do you do if a patient with psychosis of dementia is having a hallucination or illusion?Acknowledge their feelings Redirect them. DON'T Challenge them.Examples of Psychosis of dementia:Alzheimer's Disease, Senility, Organic Brain Syndrome/Post Stroke Dementia, Lewy Body Disease, Parkinson's, Wereneke'sPatients with Psychosis of DementiaCannot learn reality because they have brain damageWhat causes Psychotic Delirium?Chemical Imbalance (electrolyte Imbalance), Sepsis, UTI.Is Psychotic Delirium permanent?No. Assure them its temporary. A dramatic, episodic onset of skewed reality d/t acute illness.What is flight of ideas?Jump from word to word. (This room is big, I liked the movie BIG when they were on the piano, Elvis could play the piano).What is word salad?Jump from word to word. Bob, Car, Sleep, Foot etc..What is neologisms?Make up new words.If a patient is psychotic, should you force them to do things?NO. They will become violent.What is a narrowed self concept?When they refuse to leave the room or get dressed. (DON'T force them to do it) Respond by saying " I see you are uncomfortable, when you are ready, you can do it"What is ideas of reference?When they think everything is about them. (Everyone is talking about me)Type I diabetes (IJK)?Insulin dependant Juvenile onset Ketosis prone ( makes ketones)Type II diabetes?Non insulin dependant Adult onset Non ketosis proneDiabetes S/S?Polyuria, Polydypsia and polyphagia (hunger)What is diabetes mellitus ?An error in glucose metabolismWhat is diabetes Insipidus?Not enough ADH, pituitary glandHow do you treat type I diabetes? (DIE)Diet 3 Insulin 1 Exercise 2How do you treat type II diabetes? (DOA)Diet 1 Oral hypoglycemic 3 Activity 2 (Obesity Reduction)In a tonsellectomy, what days are most important post op?Days 6-8, biggest risk for bleeding.Diabetes is also what?DehydrationACBefore MealsTID3 times a dayQDEvery day/dailyODOnce a dayQODEvery other dayQID/QDS4 times dailySIADH isfluid overload. (crackles, Edema, etc.) DO: Fluid restrictions + sodium supplementsType II diabetics need how many calories a day?1,200-1,800#1 Priority in Type 1 diabetesMedication (insulin)#1 Priority in type 2 =Diet + Exercise (NEED TO LOSE WEIGHT)Type II diabetics need how many feedings a day?6 small mealsType 2 diabetes will do what when in acute illness?Go to type 1 and need insulinThe peak in insulin is a risk for what?Biggest risk for HYPOGLYCEMIAWhich Insulins and peaks for hypoglycemia?Humalog: 30 minutes after dose Regular: 2 hours after dose NPH: 6 hours after doseFreezing insulin does what?De natures itWhat two drugs can increase blood sugar?Glucagon and EpinephrineIf client exercises more they need?Less insulin and a snackReplace the word exercise with?Another shot of insulinBest answer for a type 2 diabetic?Calorie RestrictionIf client exercises less they need?More insulinAs a rule in shockAnything that is a pressure goes down Anything that is a RATE goes upWhen a client is sick what does it do to there blood sugar?It increases d/t stressTeach diabetics who are sick to?Take insulin, Stay hydrated Stay as active as possible.What are the 4 types of insulin?Humalog (log rolls down hill FAST) Regular, (RN, R then N) NPH (iNNNtermediate) Lantus/Levemir (glargine) L for LOONGRegular insulins all have what in them?RRegular insulin onset?1 hourRegular insulin peak?2 hoursRegular insulin duration?4 hoursNPH insulin all have a what in them?NNPH onset?6 hoursNPH peak?8-10 hoursNPH duration?12 hoursNPH is not so fast and...not in the bag (IV)Regular insulin is...rapid and runs IVWith humalog when do you give it?With mealsHumalog onset?15 minutesHumalog peak?30 minutesHumalog duration?3 hoursWhat is the only insulin safe to give at bedtime?Lantus/Glargine Duration 12-24hrs No peakWhich insulin works the fastest?HumalogWhat are the three reasons that cause low blood sugar in type I diabetes?too much insulin (#1) too much exercise not enough foodWhat is the biggest danger with low blood sugar?Brain damageS/S of low blood sugar are?S/S of shock and being drunk... clammy, weak, slurred speech, poor gait etc.For Hypoglycemia, Pick signs and symptoms of1. Cerebral impairment (drunk) - slurred speech, judgement changes, staggering gait If it makes you look drunk, pick it. 2. Shock symptom = pale, cold, rapid + thready pulses, etc.If ICP is increasedPressure goes UP Rate goes DOWN (Opposite of hypoglycemia)Treatment for low blood sugar in type I diabetes?Rapidly metabolizable carb (Juice, Pop, chewed candy) or carb and protein/carb and starch. (MILK, or jam + crackers)If a diabetic is unconsciousNPO give Glucagon IM or Dextrose IV.Examples of rapidly metabolizing carbs?Juice, hard candy, icing, honey, syrupDiabetic Ketoacidosis (AKA high blood sugar in Type I diabetes) is caused by what 3 things?Too much food Not enough insulin Not enough exerciseWhat is the #1 cause of DKA?Viral upper respiratory infection within last 2 weeks.So if you suspect DKA, what should you ask?Have you had a cold lately?DKA S/S?D-ehydration K-etones in urine/blood, Kussmauls and K+ A-cidosis, Acetone breath, Anorexia d/t nauseaDKA treatment?High IV flow rate (150-200hr) with insulin R in prescribed mixture (Rehydrate and push K back into cell, Oxygenate)Treatment for low blood sugar in Type II is the same as Type I low blood sugar treatment....High blood sugar in type II aka hyperosmolar, hyperglycemic, non-ketotic coma (HHNK) is the same as?DehydrationHHNK S/S?Same as dehydrationTreatment for HHNK is?Rehydrate but no insulin in the bag (type II has insulin still) Insulin in the bag with type I diabetes d/t burned fat = ketones=acidicDiabetes complications, in order of priority:1.Hypoglycemia 2.DKA 3.HHNCIf you don't know if a blood glucose is high or low, pickLow If you give candy to a hyperglycaemic they're condition won't change If you give candy to hypoglycaemic you'll save their lifeWhat are the two long term problems from diabetes?Peripheral neuropathy Poor tissue perfusion.What lab is the best indicator for long term blood sugar maintenance?HGBA1C (glycosated hemoglobin) <7 is an ideal sign of CONTROLLED diabetesWhat is the H1AC diagnosis level?Greater to or equal to 6.5Lithium therapeutic level?0.6-1.2Lithium toxic level?over 2.0Lanoxin (digoxin) therapeutic level?1-2Lanoxin (digoxin) toxic level?Over 2.0Aminophylline therapeutic level? (Antispasmotic)10-20Aminophylline toxic level?Over 20Dilantin therapeutic level?10-20Dilantin toxic level?Over 20Elevated bilirubin level?10-20 neonate onlyToxic bilirubin level?Over 20 neonate onlyDilantin is an?AnticonvulsantAminophylline is an?Airway antispasmoticLanoxin(digoxin) is for?CHF, Atrial arrhythmiaLithium decreases?ManiaWhat is Kernicterus?When bilirubin is over 20 and in the CSF(cerebrospinal fluid) and brain Assessment: hyperextension d/t menigial irritationWhat is Opisthotonos?POSITION of hyperextension seen with kernicterus. ANY EXTENSION, Even slight extension of the neck! DO: Place on there side if present.If kernicterus and opisthotonos are occuring you?Turn baby on their side Call doctor Draw bilirubin level Increase the IV rate and start billirubin lights.Hiatal hernia is?Stomach herniates into esophagus Gastric contents move in WRONG DIRECTION at the CORRECT RATE.Definition of Hiatal Hernia?Reguritation of acid into the esophagus, because upper stomach herniates upward through the diaphragmDefinition of dumping syndrome?Post-op gastric surgery complication in which gastric contents dump too quickly into the duodenumDumping syndrome is?Gastric contents moving in the RIGHT DIRECTION and the INCORRECT RATE.S/S of hiatal hernia are?GERD upon lying after mealsS/S of dumping syndrome are?DRUNK + SHOCK + ABD DISTRESS Acute abdominal distress= gas, ^bs, cramping, bloat Drunk=staggered gait, slurred speech Shock= cold, pale, hypotension, tachy3 treatments for hiatal hernia is?High fowlers during and 1hr after meals Increase fluids with meals Increased carbs3 treatments for dumping syndrome?Lay flat on side during and 1hr after meals Decrease fluids during meals(drink between meals) Decrease carbs (aka ^ protein diet)Kalemias do the same as the prefix except for the what?The HR and urine output. (opposite) eg HyperK= BRADY, tachypnea, diarrhea HypoK= TACHY, lethargy, POLYurea, iliusCalcemias do the opposite of the prefix plus all what?BP changes eg: Hypocalcemia FAST everything (Low bp) Hypercalcemia: SLOW everything (high BP)So hypocalemia.. pick symptoms consistent with what?UP... Plus BP changesSo hypokalemia... pick symptoms consistent with what?Down... and UP HR and UP Urine OutputWhat is Chvosteks sign?Push the cheek and it spasms (low calcium)What is Trousseaus sign?BP cuff inflated and causes a carpal spasm. (Low calcium)Magnesemias do the opposite of the prefix plus all what?BP changes Calcium and Mag have inverse relationshipCalcium below what is a medical emergency?6.0 N=8.2-10.3?In a tie never pick ___________ If the symptom involves nerve or skeletal pick__________ For any other symptom pick___________...magnesium ....calcemia. ....potassium.What is the rule for Natremias?The one with the E =dehydration HypErnatremia has s/s of dehydration the one with the O = overload HypOnatremia has s/s of fluid overload.Earliest sign of an electrolyte overload is?Numbnesss and tingling (AKA parasthesia)Universal s/s of an electrolyte imbalance is?Muscle weakness (AKA paresis)Nere push what electrolyte?K+To decrease K+ you give?D5W with Insulin R (insulin pulls the K+ from the blood and pulls it in the cell with glucose. this buys time but doesnt solve the problem)Kayexelate does what?Gets rid of K+ slow and late= K-exits-lateHow much K+ can you have per liter of IV fluid?40 mEq If higher, clarify order.In electrolyte questions, pay attention to:Cause & effect questions. WHICH one are they asking?What two words mean the same thing as immunosuppresion?Agranulocytosis and neutropenia.Hyperthyroidism (AKA graves disease) is the same as saying?HypermetabolismAnesthesia (total loss) is to paresthesia (partial loss) asParalysis (total loss) is to paresis (partial loss)S/S of Hyperthyroidism?Same as hypermetabolism... agitated, nervous, diarrhea, heat Intolerant, ^HR, ^BP, thin, hyperactive etc.Remember RUN yourself in the GRAVE...Graves disease treatment options are? (3)1.Radiation with I131 (radioactive iodine) (1st 24hrs be alone and flush the toilet alot. Urine is very dangerous/radioactive) 2. PTU(drug- Puts Thyroid Under) worry about immunosuppresion. 3. Surgical removal.What are the two types of Thyroidectomys?Total and Sub-total.With a Total Thyroidectomy what do they need for life?Hormone replacement (Synthroid)What are you at risk for following a Total Thyroidectomy?Hypocalcemia- taking parathyroid with sx (parathyroid regulates calcium)For a Sub-total Thyroidectomy you are at risk for what?Thyroid stormS/S of a Thyroid storm are?The same as graves disease but incredibly higher. Exp: HR 180, Temp 108*, psychotic delirium.Thyroid storm treatment?High flow O2, 5 ice packs= 2 under each arm, 2 groin, 1 back of neck. OR cooling blanketFirst thing to do in thyroid storm is?Ice pack Then cooling blanketPost Op Thyroidectomy risks 1st 12 hrs?Hemorrhage and airway. After 1st 12hrs assume they are stable.Never pick infection within48 hours after surgeryGet cooling blankets to shut offOne degree higher than what the doctor wantsPost Op thyroidectomy risks 12-48 hrs for Total Thyroidectomy?Tetany ( they are stable at this point so don't pick airway or hemorrhage)Post Op thyroidectomy risks 12-48 hrs for Sub-total Thyroidectomy?Thyroid storm (this can cause brain damage ..too febrile)Hypothyroidism is the same as saying?HypometabolismHypothyroidism S/S?Same as hypometabolism ie, tired, sluggish Cold intolerant obese decreased hr, p, rrWhat is the name of the disease for hypothyroidism?MyexedemaTreatment for hypothyroidism?Hormone supplementIf asked a question and your patient is critical remember to always STAY with the patient!!...Do you sedate a patient with hypothyroidism?No you could put them into a coma.If a patient with hypothyroidism is NPO for surgery you still give them what?Hormone replacement medication.What is Addison's Disease?Under secretion of the adrenal hormones ( Normal- Stress= ^glucose, ^BP= perfusion Addison's-No adrenaline + stress= v glucose, v bp=shock)S/S of Addison's Disease?Hyperpigmentation Do not adapt to stress. Also becomes dehydrated easilyAddisons Disease treatment?glucocorticoids - think blood sugar monitoring and immunosuppressionWith Addison's Disease you ADD what?ADD-A-SONECushing Syndrome is the oversecretion of?The adrenal cortex.S/S of Cushing's Syndrome?Think of the Cush Man... Moon face-steroids buffalo hump thin legs and bones striae (stretch marks), male breasts, hirstusism high glucose Immunosuppressed/infection bruisingCUSHMAN! draw him!Gaining h20 Infection Irritability Weak bones Wasting, thin extremities Bruises Easily Moon Face Acne Losing K Buffalo Hump Striae/Stretch Marks Breasts in Men Trunkal Obesity Hair on faceCushings Syndrome treatment?Adrenalectomy Biliateral Adrenectomy is always worseHep AAnus to mouthHep BBloodPts with Adrenal cortex diseases must haveMed alert braceletSymptoms of cushings are side effects of what?SONES.Contact precautions are used for what 4 types of diseases?RSV (babies) Herpies zoster, Staph infections and Enteric (bowel) infections (cdiff, collera)RSVSpread by droplet, but they are on contact precautions (Only affect infants)Contact precautions have what 5 things?Private room - door can be open Gloves Gown- if giving direct care Handwashing Disposable supplies Dedicated equipmentDroplet precautions are for what 2 diseases?All meningitis and all influenza Pertusis, Diptheria, Mumps, All MeningitisDroplet precations have what 6 things?Private room- door can be open Gloves Mask- #1 in this group Handwashing Pt wears mask when leaving room Disposable/dedicated equipmentAirborne precautions are for what 4 diseases?SARS (Severe Acute Respiratory Syndrome), TB, Measles and VaricellaAirborne precautions have what 9 things?Private room-door closed Mask Gloves Gown Handwashing Special filter respirator masks Pt wears a mask when leaving room Disposable/dedicated supplies Negative airflow roomPPE contains?Gloves, gown, gogles and mask unless told otherwise.Proper order for donning PPE?1. gown 2. mask 3. goggles 4. glovesWhere do you remove PPE?In the room.Where do you put on PPE?Outside the room.Proper order for removing PPE?1. gloves 2. goggles 3. gown 4. maskIn airborne precautions it is ok to remove what piece of PPE outside of the room?MaskWhat position are your hands for handwashing?Hands below elbowHow long do you wash for handwashing?15 secondsCan the faucet have handles for handwashing?YesWhat do you use in handwashing?Soap and waterWhen do you wash your hands?Before and after gloves, entering and exiting a room and after you soil your hands.What position are your hands in for scrubbing?Elbows below hands.What is the length for hand scrubbing?3-7 minutesWhat do you use for hand scrubbing?Cleaning agent must have the prefix "chlor"Can the sink have handles for scrubbing?NoWhen do you use scrubbing?Immunosuppresion, surgery, transplant, chemo, HIVDry yours hands from...?Cleanest to least cleanYou can use alcohol based solution when?Before and after gloves, entering and leaving a roomhow to sterile gloveGlove Dominant Hand First Grasp Outside of the cuff Touch only the inside of the glove surface Do not roll the cuff Fingers inside of the second glove cuff Only touch the outside of the glove with your first gloved handRemember with sterile glovingOnly touch the OUTSIDE of the surface glove Glove to Glove Skin to SkinOn nclex, when drying handsSwipe ONE swipe per paper towel then throw it away and get another oneWhat can't children under four have?Small toysIf a child has O2 is use what type of toys can't be used?MetalBeware of FoamitesNonliving object that harbors microorganismsWhat is the best toy for a 0-6 month old?Musical mobile (get rid of this at 6 months or when the child is sitting up)What toy is good for an immunosuppressed patient?Action figure. Can't harbor microorganismsWhat three things should you ask yourself when choosing appropriate toys for kids?Is it safe Is it appropriate Is it feasibleRemember: 9 Months in the womb9 months until purposeful activityWhat is the 2nd best toy for a 0-6 month old?Anything soft and largeWhat is the best toy for a 6-9 month old?Cover/uncover toy eg. jack in boxWhat is the second best toy for a 6-9 month old?Anything large that they can't swallow.What is the best toy for a 9-12 month old?Talking toy.What is the second best toy for a 9-12 month old?Anything that is purposeful (play with blocks)What 5 words should you avoid when answering a question about toys for a child under 9 months old?Build Make Construct Sort StackWhat is the best toy for a toddler (1-3 yr.)?Push/pull toy wagon, strollerWhat should you work on with a toddler (1-3 yr.) ?Gross motor eg. run, jump NOT finger dexterity <- fine motorWhat is toddler (1-3 yr.) play characterized by?Parallel play (with another child but alone)What two things should you work on with a preschooler (3-6 yr.) ?Fine motor (fingers) Balance (dance, gymnastics)What sort of play do preschoolers (3-6 yr.) prefer?Pretend playWhat is preschooler (3-6 yr.) play characterized by?Co-operative play (together) Everybody winsSchool age (7-11 yr.) is characterized by the 3 C's, what are they?Creative (no coloring book, use blank paper) Collecting CompetitiveAdolescents (12-18 yr.) "play" is?Peer associatedAllow adolescents to be in each others rooms unless?Contagious Immunosupressed Fresh post-op <12 hrIf you're being questioned over a drag and drop and you're given an option that would require a doctors order assume that you have that order. But if an option is to call the doctor, you call first then give....Best indicator of kidney function?CreatnineCreatinine norm?0.6-1.2INR monitors?Coumadin/Warafin therapyINR therapeutic level?2-3If the INR is over 4 you?Hold all Coumadin/Warafin Assess bleeding Prepare to give K+ Call doctorPotassium norm?3.5-5.3If the potassium is below 3.5 you?Assess the heart Prepare to give potassium Call the doctorIf the potassium is high (5.4-5.9 high but still within the 5's) you?Hold potassium if in the IV Assess the heart Prepare to give D5W with insulin Call the doctorIf the potassium is over 6 you?Stop what you're doing and assess If negative effects present you call rapid response. If no negative effects you do the same as "high but within the 5's)pH norm?7.35-7.45If the pH is under 6 you?Assess vital signs Call the doctor ASAPBUN norm?8-30If the BUN is elevated check for?DehydrationHow should you prioritize labs?Which level will do the most harm to the body and NOT the disease it's associated with.If you have a lab thats high and you don't know why pick?DehydrationHgb norm?12-18Hgb under 8 you?Assess bleeding Prepare blood Call doctorElevated Hemoglobin?DehydrationBicarb (HCO3) norm?22-26CO2 norm?35-45CO2 is the 50's you?Assess respiratory status Do pursed lip breathing ^ exhale time DON't give O2 if the above isn't working call the doctor!Severe Acidosis means what?Hyperkalemia! Biggest priorityCO2 in the 60's (respiratory failure) you?Assess respiratory status Do pursed lip breathing Prepare for intubation Call respiratory therapy Call the doctorHct norm?36-54PO2 norm?78-100PO2 70-77 you?Assess respiratory status Give O2PO2 below 60 you?Assess respiratory status Give O2 Prepare for intubation Call respiratory therapy Call the doctorO2 sat norm?93-100O2 sat below 93 you?Assess respiratory status Give O2BNP norm?<100BNP is a good indicator of what?CHFWhat is the best indicator of CHF?ANFANF and BNP=CHFSodium norm?135-145Sodium is ok if abnormal unless what occurs?Change in LOCWBC norm?5,000-11,000Absolute neutrophil count (ANC) norm?500CD4 norm?>200 (below that=aids)If the WBC count is high this is called?LeukocytosisIf the WBC is low it is called?Leukopenia Neutropenia Agranulocytosis Immunosupression Bone marrow supressionIf the WBC is low you should?Follow strict handwashing Shower BID with antimicrobial soap Avoid crowds Private room No fresh flowers or potted plants Low bacteria diet- no raw fruits/veggies, no undercooked meat. No water drinking if its been sitting for longer then 15 minutes. Vitals Q4H Check WBC daily Avoid reusable plates/silverware etc,Platelets norm?150,000-400,000If platelets are below 90,000 you?Check for bleeding Place on bleeding precautions (thrombolytic precautions)If platelets are below 40,000 you?Prepare platelet transfusion Call the doctorRBC norm?4-6What is a lamina? Reason for laminectomy?Vertebral spins process (bumpy bones at back of neck) To treat nerve root compression.3 P's of nerve root compression (S/S) ?Pain Paresis= muscle weakness ParasthesiaKnowing the location of a laminectomy is key to getting the ? right....Cervical =NeckThoracic =Upper backLumbar =Lower backPre-op cervical laminectomy's most important assessment is?1st breathing (rate and rhythm) 2nd arm and motor sensoryPre-op thoracic laminectomy's most important assessment is?1st cough (uses abdominal muscles) 2nd bowel sounds (If you can't contract these muscles, you can't cough)Pre-op lumbar laminectomy's most important assessment is?1st voiding ( when was last time, can they) 2nd leg motor and sensory.The rule of ABC"s doesnt work in what area of health?NeuroWhat is the #1 post-op answer for the NCLEX?Log roll the patientActivity requirements/restrictions Q8H after laminectomy surgery?Do NOT dangle (AKA sit on the side of bed) May stand, walk and lay without restrictions Don't sit longer than 30 minutesWhat post-op complication do you watch for with a cervical laminectomy?Pneumonia/Atelectesis (breathing issues)What post-op complication do you watch for with a thoracic laminectomy?Decreased cough= Aspiration > pneumonia Decreased GI= iliusWhat post-op complication do you watch for with a lumbar laminectomy?Urinary retentionFor a laminectomy what incision site is more painful?Hip siteFor a laminectomy what incision has the most drainage/bleeding?Hip siteFor a laminectomy what incision site has the highest risk for infection?50/50 equalIf being asked about a surgery and the length of time for restrictions your default answer should be?6 weeksSurgeons are using cadaver from bone banks. Why?Because they only do one incision Quicker heel timeDischarge teaching for a laminectomy?Don't sit for longer then 30 minutes for 6 weeks Ly flat and log roll for 6 weeks No driving for 6 weeks Do not lift more then 5 lb. for 6 weeksPermanent restrictions for a laminectomy?Do not lift by bending at the waist No crazy activities... jerky rides, horseback ridingFor a cervical laminectomy they can never?Lift objects above the head.Nageles rule for calculating a due date is?1st day of the last menstrual period Add 7 days Subtract 3 monthsNormal weight gain for pregnancy?28 + or - 3 lb1st trimester weight gain?1 lb a month x 3 months2nd/3rd trimester weight gain?1 lb a week x 6 monthsAfter week 12 you can subtract 9 to get appropriate weight gain. (Think 9months)Week 12 = 3 lbs 13 = 4 lbs 14 = 5 lbs 15 = 6 lbs 16 = 7 lbs 17 = 8 lbs eg. week 14-9= 5lbs 28-9= 23 lbsFundal height is not palpable until week?12The fundus is palpable at the naval at week?20-22If the fundus is not above the naval the baby is not?ViablePositive signs of pregnancy?Fetal skeleton on X-ray Fetal presence on ultrasound Auscultation of FHR (heart at week 8, most likely at 10 and should be heard by 12) Examiner palpates fetal movementProbable/presumptive signs of pregnancy are?All urine and blood testsWhat is Chadwicks sign?Cervical change to cyanosis (blue hue)What is Goodells sign?Cervical softeningWhat is Hegars sign?Softening moves from the cervix to the uterus.Good prenatal care = dr apt _______ times a month until week 28once a monthGood prenatal care= dr apt ________ a month weeks 28-36Twice a monthGood prenatal care= dr apt ______ times a month weeks 36 to birth4 times a monthIs it normal to be slightly anemic during pregnancy?YesNormal Hgb level in women is?12-16Hgb level in first trimester?Can fall to 11 and it is normal.Hgb level in second trimester?Can fall to 10.5 and is normal.Hgb level in the third trimester?Can fall to 10 and is normal.How do you treat morning sickness? (1st trimester)Dry carbHow do you treat urninary incontinence during pregnancy? (1st and 3rd trimester)Void Q2HHow do you treat dyspnea during pregnancy? (2nd and 3rd trimester)Tri-pod position (sit, lean forward, elbows on knees)How do you treat back pain in pregnancy? (2nd and 3rd trimester)Pelvic tilt exerciseAlways teach a pregnant women to pee how often from day of pregnancy to 6 weeks post partum?Q2HTruest most valid sign of labor is?Regular contractionsDilation is?Opening of the cervix (0-10)Effacement is?Thinning of the cervix (0-100%)Station is?This refers to the baby's presenting part (normally the head) to the mothers ischeal spine. So if the baby is above the ischeal spine they are given a - number, if they are below they are given a + number. + numbers are positive news - numbers are negative news.Engagement is?Station 0Lie is?Relationship between the spine of the baby and the spine of the mom. Vertical (parallel) is ok, Tranverse (perpindicular) is bad.Transverse Lie?C- Section!Presentation is?The part of the body that enters the birth canal first.The first stage of labor is?The labor part.The second stage of labor is?Delivery of the baby.The third stage of labor is?Delivery of the placenta.The fourth stage of labor is?Recovery (1st 2 hours after the placenta is delivered)How often do you monitor during labor?Q15min until the 2hr mark after placental delivery. Then Q1H.The first stage of labor has how many phases?3What are the three phases of labor?Latent, Active and TransitionLatent phase is?0-4 cm dilated Contractions are 5-30min apart Lasting 15-30 sec. They are mildActive phase is? ONLY MEMORIZE THIS (The other phases can be figured out)5-7 cm dilated Contractions are 3-5 min apart Lasting 30-60 sec. They are moderateTransition phase is?8-10 cm dilated Contractions are 2-3 min apart Lasting 60-90 seconds They are strongContractions should be no longer then ____ and no closer then_____.90 sec and 2 minutes > = uterine tetany & hyperstimulation =decreased 02 to babyHow do you assess frequency of contractions?Beginning of one contraction to the beginning of another.How do you assess duration of a contraction?Beginning to end of contractionHow do you assess the intensity of a contraction?Palpate with one hand over fundus and with the fingertips.How do you treat painful back labor?Knee to chest position You use your fist and press on the patients sacrum.How do you treat prolapsed cord? 911!! OB emergencyPush head back in knee-chest (hands and knees) or Trendelenburg Or elevate hips on pillows Don't put the patient on their left side. Cover the cord in moist salineWhat interventions do you do for all other OB complications? (LION)If Pitosin is running stop this first then LION L-eft side position I-ncrease IV O-2 N-otify doctorVEAL CHOPV- Variable C- Cord Comphression E- Early Decels H- Head Compression A- Accelerations O - OK L-Late Decels P - PlacentaDo not give what type of pain medication to a women in labor if the medication is likely to peak when the baby is born?Systemic- AKA IV, IM and oralLow fetal heart rate is ?Bad LION if hr under 110High fetal heart rate?160 This is ok Take mom's tempLow baseline variability? (aka heart rate not changing)Bad LIONHigh baseline variability?HR changing a lot. This is ok.Late decelerations?Bad (placental insufficiency) LIONEarly decelerations?Head pressed on. This is ok.Variable decelerations?HR up or down, cord compression = VERY BAD Prolapsed cord= push head up, change mom positionACE of spades answer for OB?Check fetal HRIf in OB its low or late you?LIONIf variable its?Very bad and you push and position.The second stage of labor and delivery is all about?OrderSo what do you do and in what order for the second stage?Deliver the head Suction 1st the mouth then the nose Check for nuchle cord (cord around neck) Deliver shoulders and body ID bandDuring the third stage of labor and delivery (placental delivery) you do what two things?Make sure it's intact( can 1)hemorrhage 2) infection) Check for three vessels (2 arteries, 1 vein)AVAWhat are the 4 things you do 4 times an hour for the 4th stage of labor?VS- check for S/S of shock Fundus- if boggy, massage. If displaced,void/cath Perineal pad- excessive lochia= pad saturated Q15min 911 Roll on side and check the pad for bleeding.The uterus should be like what after delivery?Firm not boggy Fundal height= days postpartum (3days= 3cm below naval) Midline- if not catheterizeLochia color rubra?Red- rub it redLochia color serosa?pink- rose pinkLochia color alba?White- albino whiteModerate lochia is?4-6 inches on pad in one hourExcessive lochia is?Saturated pad in 15 minutesExtremity assessment post partum should check?Pulses Edema S/S of thrombophlebitis- bilateral calf circumference is the best way to check. If they are equal its ok if not its positive for whichever calf is bigger)Post partum assessment should include what?Uterus Lochia ExtremitiesMilia is?Distended sebacious glands which appear as tiny white spots on babys face.Epsteins pearls are?Small,white epithelial cysts on babys gums.Mongolian spots are?Bluish/black macules appearing over the buttocks and or thighs of darker skinned neonates.Erythema toxicum neonatorum is?Red papular rash on babys torso which is benign and disappears after a few days.Hemangiomas is?Benign tumor of the capillaries.Cephalohematoma is?Swelling caused by bleeding between the osteum and periosteum of the skull. This swelling does not cross suture lines.Caput Succedaneum is?Edematous swelling on the scalp caused by pressure during birth. This swelling may cross suture line. It usually disappears in a few day.Hyperbilirubinemia is?Normal, physiologic jaundice appears after 24 hours of age and disappears at about one week.Vernix caseosa is?Whitish, cheese like substance which covers the skin on an unborn baby.Acrocyanosis is?Normal cyanosis of the babys hands and feet which appears intermittently over the 1st 7-10 days.Nevus/Nevi is?The generic term for a birthmark.What 2 newborn variations are you most likely to be tested on for the NCLEX?Cephalohematoma and Caput SuccedaneumTocolytics do what to labor?Stop itWhat are the two tocolytics?Trobutaline= increases moms hr Nifediopine= ccb= decreases hr bp Magsulfate= decreases hr, bp, refleces, rr, loc (watch RR and watch Reflexes)SE for Terbutaline?Maternal tachycardia This drug is not good if a heart issue is already present.SE of Nifedipine?Headache and Hypotension (H&H)Oxytocics do what to labor?Start itWhat are the two oxytocic's?Pitocin=Oxytocin Cervidil= Prostaglandin MethergineOxytocics used for PP Hemorrhage:Pitocin, MethergineSE of Pitocin?Can cause hyperstimulation (contractions longer than 90 sec. and closer then 2 min.)If FHR is less then 110 stop it, if FHR is normal you slow it. Used also for PP Hemorrhage.With an Epidural, give what after delivery?Fluid Bolus to combat hypotension because they are a FALL RISKLiquid meds in math calculationsRoundSE of Cervidil?Effacement which leads to contractions.What are the two neonatal lung medications?Betamethasone SurvantaHow do you give Betamethasone?To the mom Before delivery IMSE of Betamethasone?^ in glucose so monitor blood sugarHow do you give Survanta?To the baby After delivery By inhalationHumulin 70/30 is what?70% N insulin (intermediate) 30% R insulin (short rapid)When drawing up insulins its?RN (regular then N) draw what you are RN)If your are pressurizing for drawing up insulin you?Draw what you are backwards. NR----> RNFor injections an IM needle must be?A 1 in both gauge and length. If not, pick the CLOSEST.For injections SUBQ needles must have?A 5 in both gauge and length.What routes can you give Heparin?IV or SUBQHow quickly does Heparin work?ASAPHeparin does notThin blood/dissolve clots. It prevents clots from happeningWhat do you monitor if on Heparin?PTTAntidote for Heparin is?Protamine SulfateHeparin is what pregnancy class?CHow can Coumadin be given?Oral onlyFor Heparin, Ask:How long have they been on it?How long does it take for Coumadin to work?3-5 daysWhat do you monitor in Coumadin?Pt-INR(this is only for Coumadin)qWhat is the antidote for Coumadin?Vitamin KWhat pregnancy class is Coumadin?XSwitching from Heparin to Coumadin must?Be 14 days after heparin (5 days before coumadin) or there is a risk for DIC.Clot busters end in what?AseAll K+ wasting diuretics end in?X... If it ends in X its X's out K+ everything else it K+ sparing diuretics.Generic for Baclofen(this will be on the NCLEX)Lioresil or Flexeril -muscle relaxant/antispasmoticWhat is Baclofen(Lioresil, Flexeril)?Muscle relaxerBaclofen(Lioresil, Flexeril) SE?Muscle weakness and drowsinessWhat should you teach a patient taking Baclofen(Lioresil, Flexeril)?Don't drive/ operate machinery Don't drink alcohol Don't care for children under 12 Causes muscle weakness Causes DrowsinessWhat is the saying that can be used to help remember Baclofen(Lioresil,Flexiril)?When you're on Baclofen you're on your back loafin.Pregnancy CategoriesA- Safe B- Problems in Animals, Not Humans C- Caution, if benefits outweigh the risks you can use it X- NEVER.A 0-2 yr old is in what Paiget stage?Sensory motor total present thinking Only teach what you do, while you do it Tell them directlyA 3-6 yr old is in what Piaget stage?Pre-operational Fantasy based teach just before (morning of) Teach what you are going to do Learn through playA 7-11 yr old is in what Piaget stage?Concrete operation (think of a 7-11 with concrete around it) Rule oriented (can't abstract) teach days ahead Teach what to do +skills Be age appropriate, use demonstrationsA 12-15 yr old is in what Piaget stage?Formal operations Can abstract Can be taught like adults can manage their own carePiagets sensory motor stage is characterized by?Present oriented Only think about what they SENSE or are DOING now.As a nurse when, what and how do you teach a child in sensorimotor stage?Teach when you're doing it What you're doing to them Do it verballyPiagets pre-operational stage is characterized by?Fantasy oriented Illogical No rulesTeaching 0-2 years old?Teach them as it happens, verbally tell them what you're doing as you do itTeaching 3-6 year olds?Teach them the day of, Don't let them sleep on it. Tell them what you're going to do - future tense. USE PLAY. Picture book, dolls, play with equipmentTeaching, 7-11 year olds?Teach days before. Teach them what you're going to plus skills (they can draw up insulin) Don't use play. Use Age Appropriate audio + visual materialsTeaching 12-15 year olds?Teach them like an adult! They can think abstractly.As a nurse when, what and how do you teach a child in the pre-operational stage?Teach the day of- to avoid nightmares What you're going to do Do this through playPiagets concrete operations stage is characterized by?Rule oriented Live and die by the rules Cannot abstractAs a nurse when, what and how do you teach a child in the concrete operations stage?Teach them ahead of time What you're going to do Use visual and audio and use age appropriate readingAt what Piaget stage can you teach a skill like how to draw up insulin?Concrete operationsPiagets formal operations stage can be taught like?An adultStage 1 Pressure UlcerNon Blanching RednessStage 2 Pressure UlcerSkin no longer intact, fleshy pink base with a break in skin integrity This is where Blistering isStage 3 Pressure UlcerYellow fatty tissue seen at the baseStage 4 Pressure UlcerBright Red Muscle or Bone is seenMiliaDistended sebaceous glands which appear as tiny white spots on the baby's face. NORMAL.Epstein's PearlsSmall, white epithelial cysts on the baby's spotsMongolian SpotsBlue-ish black macules appearing over the buttocks and/or thighs of darker skinned neonatesErhythema Toxicum NeonatorumRed papular rash on the baby's torso which is benign and disappears after a few daysHemangiomasBenign tumor of the capillariesCephalohematomaSwelling caused by bleeding between the osteum and the periosteum of the skull. This swelling does not cross the suture lines.Caput SuccedaneumCrosses the suture linesHyperbilirubinemiaNormal, Physiologic JaundiceVernix CaseosaWhite wax like substance that covers the skin of an unborn babyAcrocyanosisnormal cyanosis of the baby's hands and feet. Appears intermittently over the first 7-10 daysNevus/NeviNormal BirthmarkPulse PointsIf S1 is louder in a heart soundIt's in the tricuspidIf S2 is louder is the heart soundIt's AorticFor prioritization the question will give what 4 pieces of information?Age Gender Disease Modifying phraseFor a prioritization question the most important information is?The modifying phraseFor a prioritization question what 2 pieces of information do not matter?Age and genderWhat are the four rules of prioritization?Acute < chronic Fresh post-op(12hr.) < medical or other surgical. Unstable < stable The more vital the organ the higher the priority(use only as a tie breaker)What is the best rule out of all 4 for prioritization?#4What makes a patient stable? (7)Chronic illness Over 12 hr post op Local or regional anesthesia Unchanged assessment Phrase "to be discharged" Lab values A or B Typical S/S for the disease they have or what they are receiving treatment for.What makes a patient unstable? (7)Acute illness Post-op less than 12 hr General anesthesia Changed assessment Phrase "newly admitted" or "newly diagnosed" Labs C & D Unexpected S/SWhat 4 things are always considered unstable?Hemorrhage Hypoglycemia Fevers over 104* Pulselessness and breathlessnessThe more VITAL the ORGANThe HIGHER the priorityWhat are the main 6 organs in prioritized order?1. Brain 2. Lung 3. Heart 4. Liver 5. Kidney 6. PancreasWhat do you not delegate to a family member?Safety responsibilities-" can you watch your dad really fast while I grab something."Family can only do what you ____ them for the patient?TeachONLY RN SCOPE (Don't delegate to LPN)Starting an IV Hanging of mixing IV Meds Evaluating IV Site or anything Giving IV Push Meds Giving an Blood Transfusion Preforming Admission, discharge, transfer assessment, or any UNSTABLE patient Plan of Care Developing or Preforming Teaching Taking Verbal Orders from MDDo not Delegate to an UAPChart about a Patient (They may document what they DID) Assessment Meds/IV. They MAY apply topical lotions/creams Treatments, except for Soap Suds Enema You MAY delegate ADLs.Perfect Glasgow Coma Score?15If another staff member is doing something illegal you?Tell the supervisor.What do you do if another staff member is placing the patient in physical or psychological harm?Intervene and take over.What do you do if a staff members behavior is legal, not harmful but just inappropriate?Counsel them later at a better time.PSYCH do not receive______ do not give _______ keep the pt ________ about it Use _______ when communicating Put self in client's _______ choose answer that reflectsgifts advise talking the feelings of the client shoes Don't fucus on words said, but feelings (empathy questions have a quote in them)All psych medications cause what?Weight changes and low BP.What group of drugs is the most commonly tested on the NCLEX?PsychotropicWhat are phenothiazines?Psychotropic drugsPhenothiazines end in?"zine"Large doses of phenothiazines are ?Anti-psychoticSmall doses of phenothiazines are?AntiemeticsMajor doses of phenothiazines are?Tranquilizers..... BIG GUNS.The SE for phenothiazines are? (ABCDEFG)A-nticholinergic SE B-lurred vision C-onstipation D-rowsiness E-xtra paramital syndrome F-otosensitivity aG-granulocytosisWhat do you teach patients taking phenothiazines?Report sore throat and any signs of infection. Keep medicating, tell dr of SE If toxic effect hold drug, tell drWhat is the #1 nursing diagnosis for a patient taking phenothiazines?Risk for injury --- Keep pt SafeIf a drug has the word _____ behind it, it means long IM form for noncompliance?DeconoateDeconoate means?Long IM form given to noncompliant patients.Tranquilizers work?ASAPAntidepressants work?In 2-4 weeksTranquilizers shouldn't be taken?LongAntidepressants can be taken?LongWhat are the four Tricyclic antidepressants you need to know?Elavil Tofranil Aventyl DesyrelTricyclic SE? (Elavil starts with E so they go through E ABCDE)A-nticholinergic effects B-lured vision C-onstipation D-rowsiness E-uphoria (happy)Tricyclic's do what to the mood?Elevates it elavil- elevatesBenzodiazepines are ?Antianxiety meds.Benzodiazepines are considered minor __________?TranquilizersBenzo's have what in the name?"zep"Must not take Benzo's for longer than?6 weeksBenzo's can also be used for what 5 other reasons?1. Anesthesia induction 2. Muscle relaxant 3. Alcohol withdrawal 4. Seizures 5. Facilitates mechanical ventilationBenzo SE? (ABCD)A-nticholinergic effects B-lured vision C-onstipation D-rowsinessWhat is the #1 nursing diagnosis for Benzo's?SafetyMAOI's treat?DepressionMAOI's are the?Mar-plan Nar-dil Par-nateMAOI SE?A-nticholinergic effects B-lured vision C-onstipation DrowsinessTo avoid a severe hypertensive crisis patients taking MAOI's must avoid all foods with?Tyraminea list of Tyramine foodsAGED & FERMENTED Cheese Sour cream Yogart Soy sause cured meats beer/wine smoked fishLithium SE? (The 3 P's)Peeing Pooping ParasthesiaLithium toxic SE?Metallic taste Severe diarrheaNumber 1 intervention for Lithium toxicity?Keep them hydrated If sweating give sodium as well as fluidsWhile on Lithium you must monitor the level as well as what?SodiumProzac is?An SSRIProzac has the same side effects as Elavil?ABCDEProzac causes what?InsomniaWhen should you give Prozac?Before 12 noon.If Prozac is BID give at what times?6A and 12NWhen changing the dose of Prozac for a young adult you must monitor for?SuicideIf you don't know what a drug is and you are being asked which lab is important.... you need to remember?ALT A L-iver T-estWhat is the average dose of Haldol?5 mgHaldol has the SE?ABCDEFGElderly patients need to take what amount of Haldol?Half the regular amount.If an elderly patient OD's on Haldol what are they at risk for?NMS -Neuroleptic Malignant SyndromeHyperprexia is?Fever- really bad feverNMS has what associated with it?HyperprexiaClozaril(Clozapine) is what?A second generation tranquilizerMost second generation tranquilizers have what in them?"zap"How often do you have to draw a WBC for a patient taking a second generation tranquilizer?1 a week for 1 month 1 a month for 6 months 1Q6 months for lifeClozaril(Clozapine) is used to treat?Severe schizophreniaIf a question has a drug with "zap " in it, the answer is probably?Infection relatedClozaril(Clozapine) has what SE?AgranulocytosisZoloft(Sertraline) is a?SSRICan Zoloft be taken in the evening?YesDoes Zoloft cause insomnia?YesZoloft decreases metabolism and can cause?Toxic drug levelsWhat should you monitor with Zoloft use?Other drugs levelsPatients taking Zoloft should NOT take what?St. John's wortSt. John's wort and Zoloft use can cause?Serotonin SyndromeWhat are the S/S of serotonin syndrome?S-weating A-pprehension (sense of doom) D-izziness H-eadacheIf a patient is on drug A for 10 yrs. and the doctor adds drug B which drug dose needs to be lowered?Drug ATx Protocol for DepressionHigh Calorie, FIBER FOODS. Activities that are with others, but not interactive. Like Parallel Play. Dangers: Suicide. If They suggest it, be direct and ask them if they have a planTx Protocol for SchizophreniaObvious Foods. They are suspicious. If they are on antipsychotics, think FIBER. Activity- With people to reinforce reality Huge homicide/suicide risk. They are the biggest risk for other-direct violenceTx Protocol for BipolarMania - Very high calorie, Finger Foods (on the go) Needs Gross Motor Activity Let them sleep whenever they can Not usually self destructiveTx Protocol for Anxiety DisorderNo special diet, more anxious = more allergies Activity absorbs anxiety Self destructive behavior is not an issue.HypomaniaManic but can functionManicCan't function in societyStages of desensitizationTalk about it Look At Pictures Be Environment with it Interact/Experience itFor a phobia, the first thing you do isLet them avoid it for now.Violent ClientsGoal is to de-escalate. Walk with a pacing patient. Say "I see you are upset" Need 5 people to control a person. 1 person charge.For Empathy QuestionsAlways pick the answer that reflects the patient's FEELINGS, *Not* Actions, or the nurses feelings.Abdomen Organ LandmarksHeart Ausculation LandmarksThe ACE of spades answer for nutrition is to either pick ____ or _____.Chicken FishNever choose _______ as a food for children.CasserolFor a toddler pick ______ food.FingerFor a preschooler ____ meal a day is ok!!!1 (they aren't growing as fast)If you know what a particular drug does pick a SE in the ______ body system.SameIf you have no idea what a drug is check to see if it is ___. If it is, pick a _______ SE.PO GIAce of Spades answer for OB?Check the FHR.What is the first thing you assess in a Med-Surg situation?L.O.C. = Bob, Bob, Bob are you ok????What is the first thing you do in a Med-Surg situation?AirwayFor Peds when in doubt call it?NormalFor Peds when in doubt pick?The older age.For Peds when in doubt pick the?Easier task for the child.In Peds always give?More timeEmpathy question have?A quote in the question and a quote in the answer.In psych choose the answer that reflects the _______ and not the _______ they said.Feelings WordsWarfarin, watch for?BleedingWhen you get a select all that apply question, do NOT askWhat list do I remember?When you get a select all that apply question, ask yourself:What principle do I know that could guide me to make my selection?When you get a select-all that apply question, ask yourself:What does this disease/drug/procedure do to the BODY? For example, hypocalcemia makes the body responses go UP.Do not use the following words in your thought process:Maybe, If, Possibly, Might, Could. They lead to OVERSELECTION!Boards love to make an answerRight, but in the wrong direction. For example, Hyperkalemia when it should be HypOkalemiaNever select an answer on a SATABased on another answer you chose. Base it on the QUESTION.Watch for opposite answers...The list will often contain a __ concept going in the ___direction.Correct Concept in the Wrong Direction. READ CAREFULLY!Make sure to decide if the question is asking what ___ the phenomenon OR what ___ from it.Causes the phenomenon or results from it. These are often the totally opposite answer.Rule outAbsolutes. Like "Always" or "Never"If two answers say the same thingNeither is right "tachycardia", "racing heart"If two answers are oppositeOne of them is probably rightPick the answer that is moreGlobal. (Umbrella Answer) For example, "Initiate suicide precautions" instead of "Remove belt", "medicate", "supervision", ect.Don't be tempted to answer a question based on your ___ instead of your____Ignorance instead Knowledge (if you've never heard of it, DON'T PICK IT)If you don't know a drug in the question...Cross it out, ignore it. Look at the route or other info about it. Like "IVPB" and base your answer on what you DO know about THAT!If you don't know an answerYou do know the answer. Use your common sense!If an answer seems rightIt probably is. Right answers are different from wrong answers just because they are right!Only change an answerIf you have a rationale and can answer as to why THAT answer is superior to one you originally choseEvery psych patient is aMed-surg patient firstIn order to pick a psych answer, the patient must beStable, Safe, and comfortablePriorities, in OrderPhysiological, Safety, Comfort(Includes Pain), Psychological, Social, Spiritual (Maslow's)Boards try to trick you with the words"bile stained " and "vomitus" in acid base. It is NOT from the stomach, it is from the intestine, so it means metabolic acidosis.Patients that do NOT need interdisciplinary carePt with multiple med surg diagnoses. Not the sickest or the most unstable people!Patients that do need interdisciplinary carePatients with multidimensional needs. For example, physical, intellectual, psychological, emotional, spiritual.Patients who need rehabilitationNeeds interdisciplinary Care AutomaticallyTie breakers when deciding which patient needs interdisciplinary care morePatient who's current treatment is ineffective, or the patient who is preparing for dischargeBest indicator of CHFANF (ANF+BNP=CHF)Plague is not longer commutable when?After 48 hours of treatmentStop beta blockers & calcium channel blockers ifPatient had MI or suspected MIIf a diabetic is unconsciousIf in hospital, give dextrose IV If at home, give GlucagonPt just had gastric surgery...acting drunk and in shock with ABDOMINAL distress... Think?Dumping syndrome! Low everything!Pt has chest pain when lying down and indigestionHiatal HerniaCushing's patients with an adrenalectomy need what?A "SONE" because they are more like an addison's pt nowAll adrenal cortex disorders start with?A or CProlapsed cord / Variable decelerations, do you turn them on their left side?NO! Knee to chest position, tredelenburg, or elevate hips on pillows. Also cover chord in moist salinePressurizing insulinDraw up whole dose of air Put air into N (equal to liquid amount ordered) Put air into R Draw up R Draw up NWheezes are heard, what would you give?BronchodilatorTheophyllineLong acting bronchodilatorShould you massage a pressure sore if it won't blanch?NOLithium toxicityTremors, Metallic taste, neuro symptoms besides parenthesiaHigh sodium levels in lithiumDecrease the effectivenessLow sodium levels in lithiumProlong lithiums half lifeIf you don't know the drug, monitorLiver Enzymes Then Creatinine Then WBCElderly patients on HaldolShould be 2.5 mg (half of the regular dose of 5)In a patient with suspected shock, how should you position them?Legs elevatedNursing diagnoses mustSupport the assessment data in the questionWhen intervening in daycare, look for task that isUnsuitable for age groupLow bowel surgeryLow residue dietRuptured membranesCheck for prolapsed cordAntacids should not be given?With meals. They interfere with absorption With other meds. They stop other med absorptionAfter an amputation, for the first 24 hours, don'tPut the leg under s pillow, might cause contracturesWhenever a time is mentioned after a medication is given, like "a pt received morphine. One half hour later, the patient wants to ambulate"Think about the peak times of the medication and if there are any safety risks involved! Don't ambulate if a medication is likely to peak!In the pre interaction phase the nurse will?Explore his/own feelings about...If you see the words "During the initial interview" "Upon admitting the patient" "On admission" "At your first few meetings with" "While assessing" "On the day of admission" "While FORMULATING nursing diagnoses"Correct answers should be: Tolerant Accepting Explorative Probing "Nosy" Be warm and fuzzy This is the introductory phase. You would not set limitsIf you see the words "During the therapeutic interview" "While implementing the care plan" "While working on the care plan goals" "During treatment sessions" "During therapy" "In your weekly session" "Three days after admission"You are in the working phase, also known as the "therapeutic phase" Do: Be very focused, directive, "tough" In some ways these answers will seem stern and slightly unfriendly. Enforce proper communication.Gift giving in psychDo not gift give in psychWhat shouldn't you give in psych?Hugs, kisses, compliments, opinions, holding hands, placing arm around, etc. NO ADVICE/recommendationsDo you give advice in psych?NO.Rule out these words in psych"Suggest that" "Advise the patient to" "Tell the patient to" "If I were you, I would..." "You should do" "You ought to" "You should NOT do" "Don't do" "Recommend that"In psych should you give guarantees?NODon't pass the buckDon't tell a patient "refer patient to" or "have you spoken to your doctor about this?"The best psych answersReflect the feelings the patient feels and not the words they said Reflect Are open ended (not yes/no questions ) Don't have "I, me, we, us" Shortest answers are better Why questions are not as goodThis test is not about you.It's about the PATIENT.Take care of yourPATIENT Not the machine