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Lecture 1 — Acid-Base Balance Ventilators Lecture 2 — Alcohol Wernicke Overdose and Withdrawal S/Sx Aminoglycosides Peak and Trough Lecture 3 — Drug Toxicities (Lithium, Lanoxin, Dilantin, Bilirubin, Aminophylline) Kernicterus Dumping/HH Electrolytes: K+, CA, MG, and NA TX for HyperKalemia Lecture 4 — Crutches Canes Walkers Delusions Hallucinations Psychosis Psychotic and Non-Psychotic Hallucination Illusion Delusion Lecture 5 — Diabetes Mellitus Diabetes Insipidus SIADH Insulin DKA HHNK Lecture 6 — Drug Toxicities (Lithium, Lanoxin, Dilantin, Bilirubin, Aminophylline) Kernicterus Dumping/HH Electrolytes: K+, CA, MG, and NA TX for HyperKalemia Lecture 7 — Thyroid (Hyper-, Hypo-) Adrenal Cortex (Addison Disease, Cushing) Toys Laminectomy Lecture 8 — Lab Values Five Deadly Ds Neutropenic Precaution Lecture 9 — Psych Drugs Tri Benzo MAOI Lithium Prozac Haldol Clozaril Zoloft Lecture 10 — Maternity and Neonatology Lecture 11 — Fetal Complications Stages of Labor Assessments Variations for NB Maternity Meds Medication Hints Psych Tips Operational Stages Lecture 12 — Prioritization Delegation Staff Management Guessing Strategies GUIDE • Mark Klimek’s Lecture
If pH goes over 7.45, this is alkalosis
- Therefore everything is up: tachycardia, tachypnea, HTN, seizures, irritability, spastic, diarrhea, borborygmi (increase bowel sounds), hyperreflexia ( 3 +, 4 +)
- However, potassium is opposite. Therefore, hypokalemia
- What is the nursing intervention? o Pt need suctioning because of seizures If pH goes below 7.35, this is acidosis
- Therefore, everything is down: bradycardia, constipation, absent bowel sounds, flaccid, obtunded, lethargy, coma hyporeflexia (0, 1 +), bradypnea, low BP
- However, potassium is high (hyperkalemia)
- What is the nursing intervention? o Pt needs to be ventilated with an Ambu bag—respiratory arrest So, remember that “MAC Kussmaul” is the only acid-base imbalance to cause M etabolic AC idosis with Kussmaul respirations Causes of Acid/Base imbalance First ask yourself, “Is it LUNG? … If yes, then it is respiratory
- Then ask yourself, “Are they overventilating or underventilating? o If UNDERventilating, then pick acidosis—pH is under 7. o If OVERventilating, then it is alkalosis, pH is over 7. What type of acid-base derangement is present in the following condition?
- In labor? o Respiratory alkalosis … Overventilating —pH increases … Alkalosis)
- Drowning? o Respiratory acidosis … Underventilating —pH decreases … Acidosis
- Pt is on PCA (patient-controlled anesthesia) pump? o Ventilation is down … Respiratory acidosis If it is not LUNG, then it is metabolic. If the patient has prolonged gastric vomiting or suction (sucking out acid), pick alkalosis
- For everything else that isn’t lung, pick metabolic acidosis
- So, when you don’t know what to pick, pick metabolic acidosis Tip
- Set your default setting to Metabolic Acidosis
- Always pay attention to modifying phrase rather than original noun Figure 1. Patient- controlled anesthesia (PCA) pump.
Ventilator A ventilator is a machine designed to move breathable air into and out of the lungs, aids patients who are physically unable to breathe, or breathing insufficiently to breathe … A ventilators is equipped with a high and a low-pressure alarm High pressures alarms are always triggered by increased resistance to air flow. Look for obstructions, i.e.,
- Kinks^ in^ tubing^ … Solution: unkink the tube
- Condensed water in the dependent tube … Solution: empty it
- Mucus plugs … Solution: Ask pt to turn, cough, deep breathe; or (^) suction the tubing PRN What is the appropriate order to address high pressure alarm in a mechanical ventilator?
- (1) Unkink. (2) Empty water out of tubing. (3) turn pt, ask pt to cough or deeply breathe, and (4) (^) suction Low pressures alarms are always triggered by decrease in resistance. This can be caused by
- Main tubing disconnection
- O 2 sensor tube disconnection
- In both cases, reconnect the disconnected tubing unless tube is on floor … Bag pt and call Respiratory Therapist The ventilator may be set too high or too low
- Setting is too high … Pt is overventilated o Respiratory Alkalosis … Panting
- Setting is too low … Pt is underventilated o Respiratory Acidosis … Pt is retaining CO Question The physician wants to wean pt off vent in the morning. At 6 am, the ABGs say respiratory acidosis. What would you do next?
- Notify the physician that the pt is not ready to be weaned off the respirator o Pt is is respiratory acidosis, which means that he is underventilated … Therefore not ready to be weaned off the ventilator o If pt were in respiratory alkalosis (overventilated), he should be ready to be weaned off
- How is manipulation like dependency? o In both situations the dependent person gets the co-dependent person to do things or make decisions o If what the significant other is being asked to do is not inherently dangerous and harmful , then this is dependency/co-dependency o However, if the significant other is being asked to do something inherently dangerous and harmful , then this is manipulation
- Manipulation? Set LIMITS and Enforce them Examples Determine if either one of these situations is dependent/co-dependent problem or a manipulation problem
- A 49 - year-old alcoholic gets her 17 - year-old son to go to the store and buy alcohol for her. o The mother is manipulating the son o This is an illegal act = Harmful o Dependency … There are 2 patients o The dependent has a denial issue o The co-dependent has a self-esteem issue
- A 49 - year-old alcoholic asks her 50 - year-old husband to go to the store and buy alcohol for her. o This is not illegal for the husband to buy alcohol o This a dependency/co-dependency situation o Manipulation … There is 1 patient—no self-esteem issues o Easier to treat because no one like to be manipulated Wernicke (Korsakoff) Syndrome Typically, Wernicke and Korsafoff are 2 separate disorders. The NCLEX however bundles the 2 as 1 condition
- Wernicke is an encephalopathy
- Korsakoff is a psychosis
- Wernicke and Korsafoff tend to go together Wernicke and Korsafoff
- Psychosis induced by Vitamin B1, thiamine deficiency
- This is a situation the pt looses touch with reality due to vit B1 deficiency
- The primary S/Sx are amnesia (memory loss) and confabulation (making up stories) o Confabulation—The lies for this pts are just as real as reality How do deal with a pt with Wernicke and Korsafoff who is confabulating about going to a meeting with Barack Obama this morning?
- Redirect the pt to something he can do o For instance, tell pt something along that line: “Why can we go watch TV to see what is on the news today”
Characteristics of Wernicke and Korsafoff syndrome
1. Preventable … Take B
2. Arrestable (stop it from getting worse) … Take B
3. Irreversible (70%) … Will kill brain cells
Antabuse and Revia (Disulfiram)
- Antabuse— Alcohol deterrent
- Revia— Antidote
- Aversion (strong hatred) Therapy—a type of behavior therapy designed to make a patient give up an undesirable habit by causing them to associate it with an unpleasant effect o Works in theory better than in reality
- Onset (how long it takes to start working) and duration (how long it lasts) of effectiveness of Antabuse/Revia is 2 weeks o For instance, if pt will be at a function and would like to drink, the pt must be on Antabuse/Revia at least 2 weeks prior to the event
- Patient teaching o Teach pt to avoid all forms of EtOH. Not doing so may lead to symptoms of n/v, even death o Teach them to avoid the followings items as they contain alcohol … Mouth wash, cologne, perfume, aftershave, elixir, most OTC liquid medicine, insect repellant, hand sanitizer, vanilla extract (can’t have cupcake with unbaked icing) o On the exam, do not pick the Red Wine vinaigrettes … It does not have alcohol in it Overdose and Withdrawal First thing you ask in an overdose question is: Is it an Upper or a Downer?
- This is because every abuse drug is either an Upper or a Downer
- However, laxative abuse in the elderly is neither an Upper nor a Downer Upper Downer
- Caffeine
- Cocaine
- PCP/LSD (psychedelics/hallucinogens)
- Methamphetamines
- Adderall
- Memorize these five for the NCLEX
- There are over 135 drugs that are downers
- If it is not an upper, it is a downer Signs and Symptoms
- Things go UP!
- Euphoria, seizures, restlessness, irritability, hyperreflexia (3+, 4+), tachycardia, increased bowels (borborygmi), diarrhea Signs and Symptoms
- Things go DOWN!
- Lethargic, respiratory depression/arrest, constipated, etc.
Question You are caring for an infant born to Quaalude addicted mother 24 hours after birth. Select all that apply
- Overdose/withdrawal condition … Ask the following 2 questions o Is it an Upper or a Downer? … We don’t what it is because it is a “Quaalude” (it is likely a Downer) o Is it Overdose or Withdrawal? … 24 hours after birth (Withdrawal) o A Downer in Withdrawal = Too much o S/Sx = Difficult to console, seizure risk, shrill, high-pitched cry, exaggerated startle reflex Alcohol Withdrawal Syndrome vs. Delirium Tremens Alcohol Withdrawal Syndrome and Delirium Tremens are not the same
- Every alcoholic goes through alcohol withdrawal approximately 24 hours after the person stops drinking
- However, less than 20% of alcoholics in alcohol withdrawal syndrome progress to delirium tremens … Delirium tremens occurs about 72 hours after the person stop drinking
- Alcohol withdrawal syndrome always precedes delirium tremens; however, delirium tremens does not always follow alcohol withdrawal syndrome Alcohol Withdrawal Syndrome Delirium Tremens
- Occurs after 24 hours after drinking
- Non-life threatening to self and others
- Occurs after 72 hours after drinking
- Life threatening to self and others Nursing Care Plan
- Regular diet
- Semiprivate room, anywhere on the unit
- Pt is up ad lib (Pt is free to move around as desired)
- No restraints Nursing Care Plan
- NPO (seizures) or clear liquid diet
- Private room, near nursing station
- Restricted bed rest (Pt is not free to move around as desired—no bathroom)
- Restraints (vest or 2 - point lock letters) Note
- “Up ad lib” or “up ad liberum” means pt may have activity or free to move around as desired any time
- 2 - point lock letters restraints: Restraints in 1 upper and the contralateral lower extremities. Release and secure upper arm first, and then release and secure the foot. Switch extremities every 2 hours
- Give both anti-HTN medication, tranquilizer, multivitamin containing vit B Question So what two situations would respiratory arrest be a priority?
- Overdose of a Downer
- Withdrawal of an Upper
Question Which pts would seizure be a risk for?
- Overdose of an Upper
- Withdrawal of a Downers Aminoglycosides (Top 5 most tested drugs) Aminoglycosides are the big guns of ABXs (antibiotics)— use them when nothing else works. Aminoglycosides are unsafe at toxic levels and safety then becomes an issue. They are the 5th most tested drugs on the NCLEX The most tested drugs on the NCLEX are:
- Top 5 o Psychiatric o Insulin o Anticoagulant o Digitalis o Aminoglycosides
- Others o Steroids o Beta-blockers o Calcium channel blockers o Pain medications o Obstetrics medications “A Mean Old Mysin” = Aminoglycosides Would be used to treat serious, resistant, life-threatening, Gram negatives infections
- So, treat a mean old infection with a “Mean Old Mycin” o Examples are: TB, septic peritonitis, fulminating pyelonephritis, septic shock, infection from third degree wound covering >80% of the body o However, sinusitis, otitis media, bladder infection, viral pharyngitis, and strep throat are not old mean infections and are not treated with a mean old mycin All aminoglycosides end in Mycin
- Genta mycin , Vanco mycin , and Clinda mycin , Strepto mycin , Cleo mycin , Tobra mycin
- Not all drugs ending in mycin are aminoglycosides o Azi thro mycin, Clari thro mycin, Ery thro mycin … All have THRO in the middle … So, THRO them off the “Mean Old Mycin” list
“TAP” Levels
- A method to remember what is done before or after, when dealing with a medication with troughs and peaks
- “TAP” — T rough, A dminister, P eak o Trough before drug administration o Peak after drug administration o Trough and Peak levels are drawn because of a drug’s narrow therapeutic window or index o Narrow therapeutic window or index means that there is a small difference in what works and what kills Which one of the following medications would “trough and peak” important?
- Lasix (furosemide) o Smaller dose: 5 or 10 o Larger dose: 80 or 120
- Digitalis (digoxin) o Smaller dose: 0. o Larger dose: 0. o Would draw “TAP” ( T rough, A dminister, P eak) on digitalis When to Draw a Through and a Peak
- Both Trough and Peak are not medication-dependent
- The trough , it is always drawn 30 minutes before next dose
- For the peak , it depends on the route o Peak SubL 5 to 10 minutes after drug is dissolved o Peak IV 15 to 30 minutes after drug is finished (bag empty) o Peak IM 30 to 60 minutes o Peak SubQ Depends on insulin (See diabetes lecture) o Peak for PO Not necessary, not tested Question You give 100 mL of a drug at 200 mL per hour (the drug takes 30 minutes to run). If you hang the drug at 10 a.m., it will finish running at 10:30 a.m. When will the drug peak?
- 10:15 a.m.
- 10:30 a.m.
- 10:45 a.m.
- 11: 00 a.m. Answer: Two right answers—pick 11 :00 a.m. In this case, play the “Price Is Right”—go with the highest time w/o going over Note
- Draw TAP on Mean Old Mycins because of their narrow therapeutic index Note
- The same drug given by 2 different routes at the same time will have different peaks o Morphine
- However, 2 different drugs given at the same time and route (IV) will peak together o Morphine and amphetamine
Calcium Channel Blockers CCBs (Calcium channel blockers) are like Valium for the heart
- They relax and slows down the heart
- In other words, CCBs have negative inotropic, chronotropic, dromotropic effects on the heart (+) Inotropy, Chronotropy, Dromotropy (–) Inotropy, Chronotropy, Dromotropy Positive inotropy
- Increase cardiac contractile force! Ventricles empty more completely! Cardiac output improved Negative inotropy
- Weaken/decrease the force of myocardial contraction Positive chronotropy
- Increase rate of impulse formation at SA node! Accelerate heart rate Negative chronotropy
- Decrease rate of impulse formation at the SA node! decelerate heart rate Positive dromotropy
- Increase speed that impulses from SA node travel to AV node (increase conduction velocity) Negative dromotropy
- Decrease speed that impulses from SA node travel to AV node (decrease conduction velocity) When do you want to relax and slows down the heart? … To treat “A, AA, AAA”
- A ntihypertensive
- A nti A nginal drugs (decreasing oxygen demand)
- A nti A trial Ar rhythmia Side Effects Headache and hypotension Name: ends in “dipine” … Not “pine”
- Also, verapimil, Cardizem (diltiazem)
- Cardizem (diltiazem) is given continuous IV drip What are the parameters to assess before putting a pt on CCBs?
- Assess for BP
- Hold if SBP < Cardiac arrhythmias
- Knowing how to interpret rhythm
- Must know the following 4 cardiac rhythms by sight Lecture 3 • Mark Klimek • 111:1 1
PVCs (premature ventricular contractions) are usually low priority
- However, elevate them to moderate priority if under the following 3 circumstances o There are 6 or more PVCs in a minute o More than 6 PVCs in a row o R on T phenomenon (a PVC falls on a T wave)
- PVCs after an MI is common and is a low priority Lethal arrhythmias are high priority and will kill a pt in 8 minutes or less. They are:
- Asystole and V-fib (ventricular fibrillation)
- Both rhythms produce low or no cardiac output (CO) , without which there is inadequate or no brain perfusion. This may lead to confusion and death Potentially Lethal Cardiac Arrhythmia
- V-tach (ventricular tachycardia) is a potentially lethal cardiac rhythm but it has a CO How would a pt with or without CO presents?
- CO is absent = there is no pulse
- CO is present = there is a pulse Treatment of PVCs and V-tach
- Ventricular = Lidocaine
- Both are ventricular rhythms
- Treat with Lidocaine
- Amiodarone is eventually the NCLEX board will want as answer Supraventricular arrhythmias are Atrial arrhythmias (supra = above) Treatments are “ABCDs”
- A denocard (Adenosine) … Fast IV push (push in less than 8 seconds and 20 mL NS flush right after) … These pts will go into asystole for about 30 seconds and out of it
- B eta-blockers (end in - olol)
- C CBs
- D igitalis (digoxin), Lanoxin (another digitalis analog) Beta-blockers have negative inotropic, chronotropic, dromotropic effects on the heart. They treat “A, AA, AAA”
- A ntihypertensive
- A nti A nginal drugs (decreasing oxygen demand)
- A nti A trial A rythmia
- Side Effects = Headache and hypotension Treatment of V-fib and Asystole
- Defib for V-fib (Defib = defibrillate = Shock em!)
- Epinephrine and Atropine for Asystole Tx: Atrial arrhythmias
- Adena
- Beta
- Calcium
- Dig Tx: Ventricular arrhythmias
- Lidocaine
- Amiodarone
Chest Tubes Purpose: to reestablish negative pressure in the pleural space … Negative pressure in the pleural space makes thing stick so that the lung expands when the chest wall expands
- Pleural space is the space between the lung (visceral pleura) and the chest wall (parietal pleura)
- In a pneumothorax , chest tube removes air
- In a hemothorax , chest tube removes blood
- In a hemopneumo- thorax , chest tube removes air and blood Question A chest tube is placed in a pt for a hemothorax (blood). What would you (the LPN) report to the nurse? Or, what would you (the RN) report physician? a. Chest tube is not bubbling b. Chest tube drains 800 mL in the first 10 hours c. Chest tube is not draining d. Chest tube is intermittently bubbling What is the chest tube not supposed to do? The chest tube is supposed to drain instead of bubbling
- Therefore answer (c) is the right answer. Question A chest tube is placed in a pt for a pneumothorax (air). What would you (the LPN) report to the nurse? Or, what would you (the RN) report physician? a. Chest tube is not bubbling b. Chest tube drains 800 mL in the first 10 hours c. Chest tube is not draining d. Chest tube is intermittently bubbling With a pneumothorax, bubbling is expected
- Therefore, (a) is a good answer choice
- Postop right pneumonectomy does not need a chest tube … Since the right lung was removed, there is no need for a chest tube
- Chest tube will however be used for lobectomy (removal of a lobe of the lung), or wedge resection Closed chest drainage devices
- Types: Jackson-Pratt, Emisson, pneumovac, hemovac, etc.
- What happens if one of those drainage devices is knocked over? o Ask pt to take a deep breath and set the device back up o Not a medical emergency … No need to call the physician If the water seal of the chest tube breaks
- Clamp o Clamping, unclamping, and placing the tube under water must be done in 15 seconds or less
- Cut the tube away
- Submerge (stick) the end of the tube under sterile water o The most important step
- Unclamp the tube if it was initially clamped, (clamping the tube prevent air to get into the chest but does not allow anything from the chest to get out) Question The water seal chamber of the chest tube in a pt with a pneumothorax/hemothorax breaks. What is the first course of action for the nurse? a. Clamp the tube b. Cut the tube away c. Submerge (or stick) the end of the tube under sterile water d. Unclamp the tube if it was initially clamped In this case, the first course of action is the clamp the tube Question The water seal chamber of the chest tube in a pt with a pneumothorax/hemothorax breaks. What is the priority (best) action of the nurse? a. Clamp the tube b. Cut the tube away c. Submerge (or stick) the end of the tube under sterile water d. Unclamp the tube if it was initially clamped Knock someone or something over: to push or strike someone or something, causing the person or the thing to fall Note If for whatever reason the chest tube breaks, clamp, unclamping to placing the tube under water must be done in 15 seconds or less
In this question, the priory action for the nurse is to submerge the end of the tube under sterile water because doing so prevents air from getting into the chest. At the same time, this allows air or blood from the chest to get out
- This solves the problem by reestablishing the water seal Note Clamping, unclamping, and placing the tube under water must be done in 15 seconds or less Question You notice on the monitor that a pt has v-fib. Pt is unresponsive and there is no pulse. What is the first step in the management of this pt? a. Place a backboard under pt’s back while pt is supine b. Start chest compression The first step is to place the backboard under pt’s back. “First” is about order. Question You notice on the monitor that a pt has v-fib. Pt is unresponsive and there is no pulse. What is the best step in the management of this pt? a. Place a backboard under pt’s back while pt is supine b. Start chest compression “Best” is about what is the priority. Chest compression is the priority action. If a chest tube gets pulled out …
- Take a gloved hand and cover the opening (first step)
- Take a sterile Vaseline gauze and tape 3 sides (best step) Chest tube is bubbling … Ask (1) where it is bubbling, and (2) when it is bubbling? Ask the following 2 questions
- Bubbling … Where? In the water seal chamber o If it is intermittent , it is good (document it) o If it is continuous , it is bad and indicates a break/leak in the system (find it and tape it)
- Bubbling … Where? In the suction control chamber o If it is intermittent , suction pressure is too low (increase it at the wall until it is continuous) o If it is continuous , it is good (document it) Analogies
- A straight catheter is to a Foley catheter , as a thoracentesis is to a chest tube o A straight catheter goes in and out … A Foley goes in, secure it, and continuous drainage o Thoracocentesis = go in and out … Chest tubes = go in, secure it, and leave it in place
- A Foley has a higher risk of infection than a straight cath
- A chest tube has a higher risk of infection than thoracocentesis
