ANTICHOLINERGIC vs.

CHOLINERGIC EFFECTS

ANTICHOLINERGIC

Mucus
Bronchodilation
Drymouth
Dryeyes
Urinaryretention
Dryskin
Constipation
ShutdownGI
PreventsVwhentryingtointubate

CHOLINERGIC
Bronchorrhea (large amounts of
mucus in airway)
Bronchoconstriction
Salivation
Lacrimating
Urination
Diaphoresis/Diarrhea
GI Upset
Emesis

ACID BASE GASES

A. ABG Interpretation
a. Rule of the Bs
i. Ifthe
pH
andthe
BICARB (HCO3)
ii. Are
BOTH
inthesamedirection,
iii. Thenitis
METABOLIC
b.
pH=acidosis

c.
pH=alkaline
B. Values
a. NormalpH=7.357.45
b. NormalBicarb=2226
c. PaO2=80100mmHg
d. PaCO2=3545mmHg
e. SaO2=95100%
C. Signs & Symptoms of Acid-Base Imbalance
a. As the
pH
goes, so goes
the patient
exceptfor
Potassium
(bc it
willtrytocompensate)
pH UP

[ALKALOSIS]

Tachycardia
Tachypnea
Diarrhea
Tremors
Seizure
Hyperreflexia
Agitated
Borborygmi(

bowelsounds)
Hypertension
Palpitations
Tetany
Anxiety/Panic
Poly

pH DOWN

[ACIDOSIS]

Bradycardia
Bradypnea
Hypotension

lucidity
anorexia
coma
lethargy
cardiaarrest
suppressed,decreased,falling

D. Causes of Acid-Base Imbalance

a. Firstask,Isit
Lung?

i. IfYES

thenitis
Respiratory
b. Thenaskyourself:
i. Arethey
Overventilating
or
Underventilating?
1. If
Overventilating

pick
Alkalosis
2. If
Underventilating

pick
Acidosis
c. Ifnotlung,thenits
Metabolic
i. If the patient has
prolonged gastric
vomiting or suction,
pick
Metabolic Alkalosis
ii. Foreverythingelsethatisntlung,pick
Metabolic Acidosis
1. Also,ifyoudontknowwhattopickchoose
Metabolic
Acidosis

VENTILATOR ALARMS
1. High Pressure Alarms
aretriggeredby

resistancetoairflowandcan
becausedby
obstructions
ofthreetypes:
a. Kinked Tube
i. NRSACTION:

Unkink it
b. Water in tubing (caused by condensation)
i. NRSACTION
: Empty it/Remove H2O
c. Mucus in airway
i. NRSACTION:
Turn, C&DB; only use suction if C&DB
fails, as a last resort

2. LowPressureAlarms
aretriggeredby
resistancetoairflowandcanbe
causedbydisconnectionsofthe:
a. Tubing
i. NRSACTION:
Pay attention to where tubing

is(contamination)
ii. Ifonfloor,changeout
iii. Ifonchest,cleanwithalcoholthenputbackon
3. Respiratory Alkalosis (Overventilation)
meansventilatorsettingsmay
betoo
HIGH.
4. Respiratory Acidosis (Underventilation)
meansventilatorsettingsmay
betoo
LOW.
5. To Wean

Tograduallyandincrementallydecreasewiththegoalof

riddingalltogether

ALCOHOLISM
Note:
Remember in a psych question if you are asked to prioritize DO NOT
forget Maslow! Use the following priorities:
1. Physiological
2. Safety
3. Comfort
4. Psychological
5. Social
6. Spiritual
Also, ALL PSYCH PATIENTS START AS MED SURG PATIENTSRULE OUT
ALL FEASIBLE MED ANSWERS BEFORE PICKING PSYCH ANSWERS
1. Psychodynamics of Alcoholism
a. The#1psychologicalprobleminabuseis
DENIAL.
i. Definition:
1. Refusaltoaccepttherealityoftheirproblem.
ii. Treatment:
1. Confrontitbypointingouttothepersonthedifference
betweenwhattheysayandwhattheydo.
2. Incontrast,supportthedenialoflossandgrief(BC
theuseofdenialisservingafunctioningperson)

b. DEPENDENCY/CODEPENDENCY
i. Dependency:
Whenthe
abuser
getsthesignificantotherto
dothingsforthemormakedecisionsforthem.
ii. Codependency:
Whenthesignificant
other
derivespositive
self-esteem
fromdoingotherthingsforormakingdecisions
forthe
abuser
.
iii. Treatment:
1. Set
boundary (limits)
and
enforce
them.Agreein
advanceonwhatrequestsareallowedthenenforce
theagreement
2. Workonthe
self-esteem
ofthecodependentperson.

c. MANIPULATION
i. Definition:
Whentheabusergetsthesignificantothertodo
thingsforhim/herthatarenotinthebest
interest
ofthe
SignificantOther.Thenatureoftheactisdangerousor
harmful
tothesignificantother
ii. Treatment:
1. Set
limits
and
enforce
2. Itseasiertotreatthandependency/codependency
because
nobody
likestobemanipulated

2.
Wernickes (Korsakoffs) Syndrome
a. Psychosis
inducedby
Vitamin B1
(Thiamine)deficiency.
b. Primarysymptom:

amnesia
with
confabulation
(makingupstories
tofillinmemorylossbelieveastrue)
c. Characteristics:
i. Preventable
1. BygivingB1vitamins
ii. Arrestable
1. Canstopfromgettingworsenotimplybetter
iii. Irreversible
1. Dementiasymptomsdontgetbetteronlyworse

3. Antabuse/Revia
a. Disulfiram(drugsusedforalcoholism
b. AversionTherapy
c. Onsetanddurationofeffectiveness:
2 weeks
i. Takedrugs2weeksandbuildsupinbloodtoalevelthat
whendrinkingalchwillbecomehorriblysickifofffortwo
weeks,willbeabletodrinkwithoutsicknessagain
d. Patientteaching:
AvoidALLformsof
alcohol
toavoid
nausea,
vomiting, and possibly death
,including:
i. Mouthwash,aftershave,perfumes/cologne,insectrepellant,
vinigarettes(saladdressings),vanillaextract,elixirs
(containsalchOTCmed),alcoholpreppad,alchsanitizer

OVERDOSE VS. WITHDRAWAL

Firstaskyourself,isthe
drugan

upper
ora
downer?
UPPERS

Names:

Caffeine
Cocaine
PCP/LSD (Psychedelic
hallucinogens)
Methamphetamines-speed
ADHD- adderrall/Ritalin
Bath Salts (Cath-Kath)

DOWNERS
Names
:
Everything else

Signs/Symptoms:

Signs/Symptoms:

Tachycardia
Hypertension
Diarrhea
Agitation
Tremors
Clonus
Belligerence
Seizures
Exaggerated, shrill, high pitched
cry
Difficult to console

Bradycardia
Hypotension
Constipation
Constricted pupils
Flaccidity
Respiratory arrest
Decreased core body temp


Thenaskyourself,Aretheytalkingabout
overdose
or
withdrawal?

Overdose/Intoxication

Withdrawal

I have too much

I dont have enough..

Too much upper:

Everything is UP

Too little upper:

Everything is DOWN

Too much downer

Everything is DOWN

Too little downer:

Everything is UP

Drug Addiction in the Newborn

Alwaysassume
intoxication (first 24 hours after birth),
thenafterthistime,
assume
withdrawal
Alcohol Withdrawal Syndrome vs. Delirium Tremens
1. Differences:
a. Everyalcoholicgoesthrough
alcohol withdrawal syndrome
(AWS)
(after24hours)
b. Onlyaminorityget
delirium tremors (DT)
c. AWS
isnotlifethreatening.
DTs
cankillyou.
AWS
Semi-private-anywhere
Regular diet
Up Ad Lib (no activity
restriction)
Do not restrain

DTs
Private-near nurses station
Clear liquids or NPO
Restricted bedrest (no
bathroom privileges)
Should be restrained (2 pt
leather restraints)
2 extremity restrictedarm
on one side and leg on one,
one upper extremity and one
opposite lower extremity

BOTH
Anti-hypertensives
Tranquilizer
B1 multi-vitamin (to prevent
dementia)

d. Patientswith
AWS
are not

dangerous
tothemselvesorothers.
Patientswith
DTs
are

dangerous
toselfandothers.

AMINOGLYCOSIDES
1. Think
A mean old mycin
2. Powerful antibioticsto treat
severe, life-threatening, resistant
infections
3. All aminoglycosides end in
mycin, but not all drugs that end in
mycin
areaminoglycosides.Forexample..
a. Azithromycin,clarithromycin,erythromycin
thromycin

NOT
4. Examples of aminoglycosides
: Streptomycin, Cleomycin, Tobramycin,
Gentamicin,Vancomycin,Clindamycin
5. Toxic Effects
:
a. Themostfamousfeatureoftheworldsmostfamousmouse(ears)
i. Toxiceffect:
ototoxicity
ii. Mustmonitor
hearing, balance, tinnitus
b. Thehumanearisshapedlikea
kidney
i. Toxiceffect:
nephrotoxicity
ii. Monitor:
creatinine
1. Bestindicatorofkidneyfunction
2. 0.61.2mg/dL
c. Thenumber
8
drawninsidetheearremindsyouof:
i. Cranialnerve
8
(Drugtoxicto)
ii. Frequencyofadministration:
Every 8 hours
6. Route of Administration
a. Give
IM
or
IV
b. DonotgivePO
(not absorbed)
exceptinthesetwocases:
i. Hepaticencephalopathy
1. Also called Liver Coma, AmmoniaInduced
Encephalopathy
2. Whenwantasterilebowel
3. Duetoahigh
ammonia
level
ii. PreopBowelsurgery
1. REMEMBERthismilitarysoundoff:
a. NEOmycin
b. KANmycin
c. WHO CAN STERILIZE MY BOWEL? NEO
KAN
d. ^PO,2bowelsterilizers

7. Trough and Peak Levels

a. ReasonfordrawingTAPlevels:
narrow therapeutic range
b. Timetable:
ROUTE
Sublingual

TROUGH (lowest)
30 min before next dose

PEAK (highest)
5-10 mins after drug dissolve

IV

30 min before next dose

15-30 min after drug finished

IM

30 min before next dose

30-60 min after drug given

SQ

30 min before next dose

See diabetes lecture

PO

30 min before next dose

Forget about it.

BIOTERRORISM
1. Categories of Biological Agents
a. Category A (Most serious)
i. S
mallpox
ii. T
ularemia
iii. A
nthrax
iv. P
lague
v. H
emorrhagicfever[Ebola]
vi. B
otolism
b. Category B
i. Allothers.Alonglist.
c. Category C
i. Hanta
virus
ii. Nipeh
virus
2. Category A Biological Agents
a. Smallpox
i. Inhaledtransmission/onAirbornePrecautions
ii. Diesfromsepticemia.Bloodinfection.*onlyclassAthatdies
fromthis.
iii. Rashstartsaroundmouthfirst(earlyID&isolationiscrucial
tocontain)
b. Tularemia
i. Inhaled
ii. Chestsymptoms(coughing,chestpain,sputum)
iii. Diesfromrespiratoryfailure
iv. TreatwithStreptomycin(watchhearingandcreatinine)
c. Anthrax
i. Spreadbyinhalation
ii. Lookslikeflu(chestsymptomsandachymuscles)
iii. Diesfromrespiratoryfailure
iv. TreatwithCipro,PCN,andstreptoycin
d. Plague
i. Spreadbyinhalation
ii. Hasthe3Hs:
1. Hemoptysis(coughingupblood)
2. Hematemesis(vomitingblood)
3. Hematochezia(bloodydiarrhea)
iii. DiesfromrespiratoryfailureandDIC
iv. TreatwithDoxycyclineandMycins
v. Nolongercommunicableafter24hoursoftreatment
e. Hemorrhagic Fever [Ebola]
i. 21daytimeframe
ii. Primarysymptomsarepetechairandecchymosis
iii. High%fatal

iv. DieofDIC
f. Botolism
i. Ingested(drink/eat)
ii. Has3majorsymptoms:
1. Descending
paralysis(startsatheadgoesdownto
diaphragm)
2. Fever
3. Butisalert
iii. Diesfromrespiratoryfailure
3. Chemical Agents
a. MustardGas

Blisters(Vesicant,eventuallycoverairway)
b. Cyanide

Respiratoryarrest.TreatwithSodiumThiosulfateIV
c. Phosginechloride

Choking
d. Sarin

Nerveagent.
i. Symptoms(CholinergicEffects)
1. B
ronchorrhea
2. B
ronchoconstriction
3. S
alivation
4. L
acrimating
5. U
rination
6. D
iaphoresis/diarrhea
7. G
Iupset
8. E
mesis
4. Allchemicalagentsrequireonlysoapandwatercleansingexceptfor
Sarin,whichrequiresableach
a. NursingActions:BioterrorismIsolation,Antibiotics
b. Chemical:Decontamination
i. Sendallsuspectedcasestodecontaminationcenter
ii. Removeallclothing
iii. Chemicalhazarddoublebag
iv. Incinerated
v. Showerinsoapandwater(bleachsarin)
vi. Dischargedingovernmentclothes

CALCIUM CHANNEL BLOCKERS

Note: They are like Valium for your heart

1. CalciumChannelBlockers:
Negative
[ino,chrono,dromo]
Digisonlydrugthatmixes+&effectsother99%eitherhave+or
ACTION
DEFINITION
POSITIVE

NEGATIVE

Inotropic
Strengthof
Strong
Weak
heartbeat
Chronotropic
Rateofheartbeat Fast
Slow
Dromotropic
Conductivity
Excitable
Blocks/Slows
conduction
2. WhatdoCalciumChannelBlockerstreat?(Indications)
a. A
ntihypertensives(BPwayUPrelaxesbloodvessels)
b. A
ntianginal(relaxesreducesO2demand)
c. A
nti
A
trial
A
rrthymia(doesnottxventriculararrthymias)
3. SideEffects(

):
a. H
eadache
b. H
ypotension
c. B
radycardia
4. NamesofCalciumChannelBlockers
a. soptin(Verapeunil)
b. zem
c. dipine
5. NursingActions:beforeadministratingBPsystoliclowerthan100..if<
100holdandcallDr

CARDIAC ARRYTHMIAS
1. Terminology
a. QRS depolarization
alwaysreferto
ventricular
(notatrial,
junctional,ornodal)
b. P wave
refersto
atrial
2. Six rhythms tested on NCLEX
a. Asystole
i. AlackofQRSdepolarizations(astraightline)
b. Atrial flutter
i. RapidPwavedepolarizationsinasawtooth(flutter)
c. Atrial fibrillation
i. Chaotic
Pwavedepolarizations(lacksanydiscernable
pattern)
d. Ventricular fibrillation
i. Chaotic
QRSdepolarizations
e. Ventricular tachycardia
i. Wide,
bizarre
QRSs
ii. Tachyisalwaysdiscernablerepeatingpattern
f. Premature ventricular contractions (PVC)
i. Periodic
wide,bizarreQRSs
ii. Generallylowtomoderatepriority.unlesseveryoneelsehas
anormalrhythm
iii. Be concerned, if:
1. Morethan
6
perminute
2. 6
inarow
3. PVCfallsof
T-wave
ofpreviousbeat
3. Lethalarrhythmias
a. Asystole
b. Vfib
4. Potentiallylifethreateningarrhythmia:
V-tach
a. Pulselessvtachsameasasystoleandv.fibandwoulddependon
howlongdown
b. After8minsconsiderdead
5. Treatment
a. PVCs
i. Lidocaine
(Ventricular,lastslonger)
, Amiodorone
b. VTach
i.
Lidocaine
c. Supraventriculararrhythmias
i. Adenosine
(pushfastIVpushusually8sorfaster)
ii. Beta-Blockers
(lol)
iii. Calcium Channel Blockers
iv. Digoxin (Digitalis) Lanocin
d. VFib
i. Besttreatmentelectrically

ii. Shock=200Defibrillate
e. Asystole
i. Epinephrine
ii. Atropine
iii. S/Eanticholinergics

CHEST TUBES
Thepurposeforchesttubesistoreestablish
negative
pressureinthepleural
space
1. Ina
pneumothorax,
thebesttuberemoves
air
2. Ina
hemothorax,
thechesttuberemoves
blood
3. Ina
pnemohemothorax,
thechesttuberemoves
air
and
blood

Locationofchesttubes:
1. Apicals
(HIGH)forAir
a. LabelAuphigh
2. Basilar
(LOW)forBlood
a. LabelBplacedatbasebottomoflung

Examples
1. Howmanychesttubes(andwhere)forunilateralpneumohemothorax?
a. 2; apical and basilar all on same side
2. Howmanychesttubes(andwhere)forbilateralpneumothorax?
a. 2; apical right and left
3. Howmanychesttubes(andwhere)forpostopchestsurgery?
a. 2; apical and basilar unilateral
b. Exception:Ifsurgerytotalpneymonectomythen

nochesttube
bcnopleuralspace
c. Alwaysassumechesttraumaandsurgeryisunilateral

ProblemSolving

1. Whatdoyoudoifyoukickoverthecollectionbottle?
a. Notabigdealcanjustsititrightbackuphavetakeacoupledeep
breaths
2. Whatdoyoudoifthewatersealbreaks?
a. Thisismoreserious,becauseitisallowingairincreatinga2way
b. First:
Clampchesttube(Betternowaythan2wayforbriefperiodof
time)**inroutinecareneverclampchesttube!!
c. Best:
Submerge
i. Cuttubeaway(down)bydevicesubmergeunderwater
preferablysterilethenunclamp
3. Whatdoyoudoifthechesttubecomesout?
a. First:
coverholewithglovedhandVaselinegauzedressing4
sidedsteriledressingtape
b. Best:
Vaselinegauze
4. Bubbling
a. Askyourselftwoquestions:
i. WHEN
isitbubbling

ii. WHERE
isitbubbling

5. Rulesforclampingthetube:

a. Neverclampforlongerthan
15 seconds
withoutaDr.sorder
b. Use
rubber tipped double clamp

CONGENITAL HEART DEFECTS

Everycongenitalheartdefectiseither
TROUBLE
or
NO TROUBLE
TRouBLe
R-L

Blood shunts

Cyanotic

All CHDs beginning with T are trouble

Exception

Left ventricular hyperplasic syndrome

Examples of Trouble

Tricuspid
Tricuspid arterioles
Tetralogy of Fallot

Examples of No Trouble

Ventricular septal defect

Patent foramen ovale
Patent ductus arterioles
Pulomary

AllCHDkidshavetwothingswhethertroubleornot:
1. Murmur
2. Allgetechocardiogramdone(@least1)

FourdefectspresentinTetralogyofFallot:
1. V
arie
D

Ventricular Defect
2. P
icture
S

Pulmonic Stenosis
3. O
f
A

Overriding Aorta
4. R
anc
H

Right Hypertrophy

CRUTCHES, CANES, & WALKERS

1. Howtomeasure:
2-3 finger widths
belowanterioranxillaryfoldtoapoint
lateral to
andslightlyinfrontoffoot
2. Whenthehandgripisproperlyplaced,theangleofelbowflexionwillbe
30
degrees
3. Typesofgaits:
a. 2-Point Gait
i. StepOne:
Moveonecrutchandoppositefoot
together
ii. StepTwo:
Moveothercrutchandotherfoottogether
iii. Remember
:2pointstogetherfora2pointgait
iv. Examples
:onekneereplacement
b. 3-Point Gait
i. StepOne:
Movetwocrutchesandbadlegtogether
ii. StepTwo:
movegoodfootbyself
iii. Remember:
3pointiscalled3pointbecausethreepoints
touchdownatonce
iv. Examples:
Stairs
c. 4-Point Gait
i. StepOne:
Onecrutch
ii. StepTwo:
Oppositefoot
iii. StepThree:
OtherCrutch
iv. StepFour:
Otherfood
v. Examples:
totalbothkneerightaftersurgery
d. Swing-through:
fortwobracedextremities
i. Examples
:
arthritisbracedlegs
4. Whentouseeachgait
a. Usethe
even
numberedgaits(2&4point)whenweaknessis
evenly
distributed(bilateral).Twopointformildproblemfourpoint
forsevereproblem
b. Usethe
odd
numberedgait(3point)whenonelegis
odd
(unilateralproblem)
5. Stairs:whichfoot
leads
whengoingupanddownstairsoncrutches?
a. Remember:
UP
withthegood
DOWN
withthebad
b. Thecrutchesalwaysmovewiththe
bad
leg
6. Cane
a. Holdcanonthe
strong (unaffected)
side
b. Advancecanewiththe
weak
sideforawidebaseofsupport
7. Walkers
a. Pickitup,setitdown,
walk
toit
b. Tie belongings to side of walker, not front
c. Gettingoutofchairtowalkeralwayspush,neverpull(samefor
cane,crutches)


1.
2.

3.

4.

5.

6.

7.

DELUSIONS, HALLUCINATIONS, & ILLUSIONS

PsychoticvsNonPsychotic
a. A
non-psychotic
personhas
insight
&is
reality based
b. A
psychotic
personhas
NO
insightandis
NOT
realitybased
Delusions
a. Definition:
adelusionisa
false, fixed
belieforideaorthought.
Thereisno
sensory
component.
b. Threetypesofdelusions:
i. Paranoid or Persecutory
:
false,fixedbeliefthatpeopleare
outto
harm
you.
ii. Grandiose:
False,fixedbeliefthatyouare
superior
iii. Somatic:
False,fixedbeliefabout
parts of your body
Hallucinations
a. Definition:
ahallucinationisafalse,fixed
sensory
experience
b. Fivetypesofhallucinations:
i. Auditory(mostcommon*hearing)
ii. Visual
iii. Tactile
iv. Olfactory
v. Gustatory
Illusions
a. Definition:
Anillusionisa
misinterpretation
of
reality.
Itisa
sensory
experience.
b. Differentiationbetweenillusions&hallucinations:
with illusions
there is a
referent
inreality
Whendealingwithapatientexperiencingdelusions,hallucinationsor
illusions,firstaskyourself,Whatistheirproblem?
a. Functional
Psychosis
b. Psychosisof
Dementia
c. Psychotic
Delirium
Functional Psychosis
a. Theseare:
i. Schizophrenia
ii. SchizoaffectiveDisorder
iii. MajorDepression
iv. Mania
b. Patienthasthepotentialtolearn
reality
c. Foursteps:
i. Acknowledge
how they feel
ii. Present
reality
iii. Set
alimit
iv. Enforce
the limit
Psychosis of dementia
a. Theseare:

i. Alzheimers
ii. Senility
iii. OrganicBrainSyndrome
iv. PostStroke
v. Wernickes
b. Thispatienthasa
destructive
problemand
cannot
learnreality.
c. Twosteps:
i. Acknowledge
their feelings
ii. Redirect
8. Psychotic delirium
a. Description:
Episodic,temporary,suddenonset,dramatic,lossof
reality,secondarytoachemicalimbalance
b. Twosteps:
i. Acknowledgetheirfeeling
ii. Reassure(itwillgetbetter,Iwillkeepthemsafe)
9. Loosening of association
a. Flight of Ideas:
stringingphrasestogether
b. Word salad:

stringwordstogether
c. Neologisms:
makingupnewwords
10. Narrowed self-concept:
a. whena
PSYCHOTIC
refusesto:
i. Leavetheroomandrefusestochangetheirclothing
ii. Actiondonotmakethem!Tellthemtheycanwaituntilthey
areready
11. Ideas of reference
a. Whenyouthinkeveryoneistalkingaboutyou

DIABETES MELLITUS
1. Definition:
DMisaerrorof
glucose
metabolism
a. (vsDiabetesInsipidus
polyuria, polydipsia leading to
dehydration)
2. Types:
a. Type I
i. I
nsulindependent
ii. J
uvenileOnset
iii. K
etosisprone(tendtomakeketones)
b. Type II
i. Nonalltheabove
ii. Noninsulindependent
iii. Nonjuvenileonset
iv. Nonketosisprone
3. SignsandSymptoms
a. P
olyuria
b. P
olydipsia
c. P
olyphagia
4. Treatment
a. Type I
i. Diet(3)
ii. Insulin(1)
iii. Exercise(2
)
b. Type II
i. Diet(1)
ii. Oralhypoglycemics(3)
iii. Activity(2)
c. Diet (type II)
i. Calorierestriction
ii. Needtoeat6xaday
d. Insulinactsto
lower
bloodsugar
i. Typesofinsulin

Type of Insulin
REGULAR
(clear,
short acting, rapid;
IV)
NPH
(cloudy,
intermediate acting)
HUMALOG (Insulin
Lispro)
(Worlds
fastest acting; give
with meals)
Lantus (Glargine)
(long acting insulin)

Onset
1 hour

Peak
2 hours

Duration
4 hours

6 hours

8-10 hours

12 hours

15 minutes

30 minutes

3 hours

Slow absorption

No peak, therefore no
risk of hypoglycemia

12-24 hours

ii. Check
expiration date
1. Afteropennewexpirationdate2030daysafter
opening
iii. Refrigeration:
optional for opened; necessary for
unopened
e. Exercise
Potentiates (decreases)
insulin:
i. Ifmoreexercise,need
decrease
insulin
ii. Iflessexercise,need
increase
insulin
f. Sickdays
i. Take
insulin
(evenifnoteating!)
ii. Take
sips of H20 to prevent dehydration
iii. Stayasactiveaspossible
5. ComplicationsofDM
a. Low Blood Sugar in Type I DM (=insulin shock) [Hypoglycemia]
i. Causes:
1. Notenough
food
2. Toomuch
exercise
3. Toomuch
insulin
ii. Danger:
1. Permanentbraindamage
iii. SignsandSymptoms
1. Cerebralimpairment&vasomotorcollapse(blood
vesselwallmusclesdonthaveenoughEtomaintain
tone)

slurredspeech,staggeredgait,abnormal
reactiontime,uncontrolledemotions,loweredBP,
increasedpulse,skinpale,cold,clammy,inattentive
tosocialboundaries
iv. Treatment
1. Administerrapidlymetabolizable
Carbohydrates
(sugar)

b.

c.
d.

e.
f.

2. Idealcombination:
food with sugar and protein (&
maybe starch)
3. Ifunconsciousness:
Nothing! Glucagon IM,
Dextrose IV, never anything in mouth!
High Blood Sugar in Type I DM- DKA Diabetic Coma
[Hyperglycemia]
i. Causes:
1. Toomuch
food
2. Notenough
insulin
3. Notenough
exercise
4. #1 cause is acute viral upper respiratory infection
within the last week or two
ii. SignsandSymptoms
1. D
ehydration(appeardry,hot,flush,HA,pulseweak,
thready,increaseintemp)
2. K
etones(inurine&blood)increaseinK+Kussmaul
respirations
3. A
cidodicacetone(fruity)breathanorexiawith
nausea
iii. Treatment
1. IVwithregularinsulin@200/hrathighflowrate
Low Blood Sugar in Type II DM (Hypoglycemia)
i. TreatmentisthesameasforlowBGMinTypeIDiabetes
High Blood Sugar in Type II DM (Hyperglycemia)
i. CalledHHNK(orHHNC):
1. Hyperosmolar,hyperglycemic,nonketoticcoma
ii. Thisis
dehydration
iii. Signs&symptomsarelikeS&Sof
dehydration
1. Including: increased temp
iv. Treatment:

rehydrate (glucose will usually turn to normal

on own)
Longtermcomplicationsarerelatedtotwoproblems:
i. Problemswithtissueperfusion
ii. Peripheralneuropathy(nervedamage)
WhichlabtestisthebestindicatorofLTBGMcontrol
(compliance/effectiveness)?
Hemoglobin A1C
i. HA1C for dx

>6.5

DM/pre DM
ii. Monitoring tx

>7.0 out of control

DRUG TOXICITIES

DRUG
Lithium (antimania)
Lanoxin (uses #1 CHD #2
atrial arrhythmias)
Aminophylline (airway
antispasmodic)
Dilantin (seizures)
Bilirubin (not a drug)

THERAPEUTIC LEVEL
0.6-1.2
1-2

TOXIC LEVEL
>
2.0
>
2

10-20

>
20

10-20
Elevated hyperemibilirubin
10-20
Toxic >20

>
20
Kernicterus
Bilirubin >20; crosses

BBB in CSF- invaded

brain causes
encephalitis meningitis
Opisthotonos

Position of extension
seen with kernicterus
Arching d/t bili
irritation in brain
Place this child on
his/her side

Totalbilirubin:01.0mg/dl
Direct(conjugated)bilirubin:00.3mg/dL
Indirect(unconjugated)bilirubin:00.3mg/dL

DUMPING SYNDROME VERSUS HIATAL HERNIA

DEFINITION

HIATAL HERNIA (2
chambered stomach)

DUMPING SYNDROME

Regurgitation of acid into

Post op gastric surgery

esophagus, because
upper stomach herniates
upward through the
diaphragm
Gastric contents move in
the wrong direction (UP
instead of DOWN)
direction at the
correct
rate
SIGNS & SYMPTOMS

Treatment
1. HOB during & 1 hour

after meals
2. Amount of fluids with

meals
3. Carbohydrate content of

meals

Upper GI S/S:
Indigestion
Heart burn
GERD
Chest pain

1. Raise HOB (High

Fowlers)
2. High Fluids
3. High Carbs (Decrease
Protein)

complication in which
gastric contents dump
too quickly into the
duodenum
Gastric contents move in

the correct (DOWN)

direction at the wrong
(too fast) rate
Lower GI S/S
A
cute lower abdominal

distress: diarrhea,
cramping, gas, abdominal
pain, cramping, guarding,
splinting, rigidity,
distension
D
runk (look), all blood
going to gut not brain (
cerebrally impaired;
confused
S
hock: blood in
parasympathetic system;
pale, cold, clammy,
decreased BP, rapid pulse
D&S hypoglycemis
1. Low HOB
2. Low/Restricted
fluids- in between
meals
3. Low Carbs (Increase
Protein)


ELECTROLYTES
KALEMIAS
do the
same
the prefix except for
heart rate
and
urine output

HYPERKALEMIA

HR

UO

HYPOKALEMIA

HR

UO

CALCEMIAS
do the
opposite
the prefix. No exceptions. [& anything to BP]

HYPERCALCEMIA

HYPOCALCEMIA

Two signs of neuromuscular irritability

associated with
low calcium:
1. Chovosteks sign

Tapcheek

spasm
2. Trousseaus sign

Put on BP cuff and arm goes into carpal

spasm( arm looks like swan neck)


MAGNESEMIAS
do the
opposite
the prefix
Note: In a tie, never pick Mg. If symptom involves nerve or skeletal muscle, pick
Calcium
. For
any other symptom, pick
Potassium
HYPERMAGNESEMIA

HYPOMAGNESEMIA

NATREMIAS

HYPERNATREMIA
E

dehydration
Poor skin turgor
Dark urine
Hot flushed skin
Increase urine specific gravity
Weak, thready pulse

HYPONATREMIA
O

overload
Increased weight
edema


The
earliest
signofanyelectrolytedisorderis
numbness (paresthesia) &
tingling
The
universal
sign/symptomofelectrolyteimbalanceis
muscle (paresis)
weakness

ELECTROLYTE TREATMENT
1. Never
push
Potassium IV
[Fatal]
2. Notmorethan
40 mEq
ofK+perliterofIVfluid[clarifyifover40]
3. Give
D5W with regular insulin
todecreaseK+[carriermediated
transport]
4. Kayexalate
[Kexitlate]
a. Putsdrugingut,fullofsodiumNapickedupbybloodstream
Doesntneedthatmuch+charge,sobodyexchangesforK,
diarrhea)
b. B/Cisslow

dothiswithD5W+insulin

ENDOCRINE OVERVIEW
Thyroid

1. Hyperthyroidism
(HyperMetabolism)
i. Signs & Symptoms
1.
weight

tachycardia

BP

Agitation

Restlessness

nervousness

diarrhea

energy

bulgingeyes

warm

<3organmosteffective

ii. Graves
Disease[literallyrunselfintograve]
iii. Theproblemishyperthyroidism.Treatmentoptions:
1. Radioactive Iodine
a. Watchoutforurine[DANERGOUS]
i. Useprivatebathroom
ii. Flush23times
2. PTU (Protothyroidircil) *sp
a. Cancerdrugknocksoutcellsmetastizing
problemagranulocytosis(

WBC)
b. Educationisolation,wearmask,nokids
3. Surgical removal
a. Thyroidectomy(removethyroid)
i. Total thyroidectomy
1. Needlifelong
T3, T4 hormone
replacement
2. Atriskfor
hypocalcemia
(bcat
riskforloosingparathyroidgland)
3. S/Shypocalcemia:
tetany
a. Earliestsign:
paresthesia
ii. Subtotal thyroidectomy
1. Atriskfor
thyroid storm
2. S/Sthyroidstorm:
a. Veryhighfever>104F
b. VeryhighV/S
c. PsychoticDelirium*life
threateningpriority
3. Treatment
a. Waitout:eitherdie,come
out,giveO2andlower
bodytemp
b. Txfocusesonsavingthe
brainuntiltheycomeout
ofit

c. Loweringbodytemp:
i. Icepacks:onaxilla,
axilla,groin,groin,
back,neck
ii. Coolingblanket

iii. Postoprisks
1st

12 hours
airway&hemorrhage
**afterfirst12oursitisassumed
thatthepatientisstable
Postoprisks

12-48 hours for

TOTAL:

calcium (tetany)
Postoprisks

12-48 for
SUB-TOTAL:
Thyroid storm
2. Hypothyroidism
(HypoMetabolism)
a. Signs & Symptoms
i.
weight

cold

sluggish

slow

decreasedBP

bradycardia

hairandnailsbrittle

decreasedE

b.
c.
d.
e.

Nameofdisease:
mxyedema
Treatment:
thyroid pills
Caution: DO NOT
sedatethesepatients!(already

)
Surgical Implication:
callanesthesiologistandaskifthyroidpills
shouldbeheld.Donotdowellwithanesthesia

Adrenal Cortex Diseases

(startwithlettersAorC)
1. AddisonsDisease
a. Under secretion
(toolittle)ofadrenalcortex
b. Signs & Symptoms
Hyperpigmented(3or4shadesdarkerthanbefore)
Inabilitytoadaptnormallytostresssendsoff
limitshock

c. Treatment
i. Givesteroids[glucocorticoidsandmineralcorticoids]
1. Steroidsallendinsone
2. CushingsSyndrome
a. Over secretion
ofadrenalcortex
b. Signs & Symptoms
[alsoreflexS/Sofsteroids]
c. Treatment:
adrenoectomy

INFECTIOUS DISEASE & TRANSMISSIONN-BASED PRECAUTIONS

Select all that apply
Private Room
Mask

Eye/Face Shields
Special Filter Respirator Masks

Gloves

Pt wear mask when leaving room

Gown
Handwashing

Disposable supplies
Negative air flow

Contact:
For:
1. Herpes,
2. anything Staph (MRSA),
3. Enteric (intestinal) [cholera, shigellosis, rotovirus],
4. RSV (Respiratory Synctial Virus)
a. [spreaddropletbutresearchfoundthisisbestfor
precautions]

Droplet:
For
1. ALLViruses
2. ALLInfluenzas[DTaP,Pertussis,Mumps]
Select all that apply
Private Room
Mask

Eye/Face Shields
Special Filter Respirator Masks

Gloves

Pt wear mask when leaving room

Gown
Handwashing

Disposable supplies
Negative air flow

Select all that apply

Private Room
Mask
most important

Eye/Face Shields
Special Filter Respirator Masks

Gloves

Pt wear mask when leaving room

Gown

Disposable supplies

Handwashing

Negative air flow

Airborne:
For:
1. TB*spreaddrolet
2. ChickenPox(varicella)
3. Measles
4. SARS(Severeacuterespiratorysystem)
Select all that apply
Private Room
Mask

Eye/Face Shields
Special Filter Respirator Masks
w/TB only N95

Gloves

Pt wear mask when leaving room

Gown
Handwashing

Disposable supplies
Negative air flow

PERSONAL PROTECTIVE EQUIPMENT (PPE)

Unlessotherwisespecified,assumethatPPEincludes:
Gowns, Goggles, Mask,
Gloves
Theproper
place
fordonning(puttingon)PPEis
outside of the room
TheproperorderfordonningPPEis:
1. Putongown
2. Putonmask
3. Putongoggles
4. Putongloves

Theproper
place
forremoving(doffing)PPEis
inside room
TheproperorderforremovingPPEis:
1. Gloves
2. Goggles
3. Gown
4. Mask

needtotakemaskoffoutsidesoyoudontbreathein
contaminatedair
Inairborneprecautions
ONLY
,themaskisremoved
outside of the room

HANDWASHING AND GLOVING

Handwashing
HandwashingversusScrubbing
Position
Length
Handles
When

Use

Handwashing
Hands below
elbows
Seconds
Yes; sink with handles
Upon entry or leaving room
before and after gloving,
when soil hands

Scrubbing
Elbows below
hands
Minutes
No sink with handles
When patient is
immunosuppressed for any
reason

Soap and water

Something with chloro in it

Use an Alcohol-Based Solution

1. Onenteringorleavingaroom
2. Beforeputtingongloves,aftertakingoffgloves
3. Cannot

aftersoilhands!!
What about after using the rest room?

mustusesoapandwater

Dryfrom
cleanest (hand)
to
dirtiest (elbow)
Turnwateroffwith
new
papertowel

Sterile Gloving
Glove
dominant
handfirst.
Grasp
outside
ofcuff.
Touchonlythe
inside
ofglovesurface.
Donot
roll
cuff.
Fingers
inside of
secondglovecuff.
Keepthumb
abducted back
.
Onlytouch
outside
surfaceofglove
Sk
in
touches
in
sideofglove
Out
sideofgloveonlytouches
out
sideofglove
Remove
glove
to
glove

Skin
to
skin

INTERDISCIPLINARY CARE
Identifyingwhichpatientsneedinterdisciplinarycare
different than
prioritizing

who would most benefit from a team working together on

their care
Patientswhodonotneedinterdisciplinarycare:
Patients who need or have
multiple doctors
PatientwhoDOneedinterdisciplinarycare:
1. MajorCriteria
a. Patientswith
multi-dimensional
needs
i. Forexample:
1. Physical
2. Psychological
3. Social
4. Spiritual
5. Intellectualneeds
b. Patientswhoneed
rehabilitation
2. MinorCriteria[choosingbetweenpatients]
a. Apatientwhosecurrent
treatment
isineffective
b. Apatientwhoispreparingfor
discharge

LAB VALUES
A=ABNORMAL

Do Nothing
B= BE CONCERNED

Assess/Monitor
C=CRITICAL

Do Something
D = DEADLY DANGEROUS

Do Something NOW
Creatinine
Best indicator of Kidney Function
0.6-1.2
Elevated = A
INR (International Normalized Ratio)
Monitors Coumadin (Warfarin) Therapy [Anticoagulant]
Therapeutic 2-3
>
4=C
o Patient could bleed to death
o Hold all warfarin
o Assess for bleeding
o Prepare to administer Vitamin K
o Call Physician
Potassium (K+)
3.5-5.3
Low=C [Hypokalemia]
o Assess the heart (may include EKG which aid can do)
o Prepare to give K+
o Call physician
5.4-5.9 = C [Hyperkalemia]
High but still in the 5s
o Hold K+
o Assess heart (may include EKG which aid can do)
o Prepare Kayexelate and d5W with regular insulin
o Call physician
>
6 = D Cardiac Danger Zone
o Do steps simultaneously
o Need help once levels hit 6; if cardiac symptomatic call rapid
response team
pH
7.35-7.45 (as pH drops so does the patient)
K+ can increase which can stop the heart
Low pH in the 6s = D [severe acidosis]
Immediately assess vital signs

 Call dr if v/s bad, also call rapid response team

BUN [Blood Urea Nitrogen]
8-30
Elevated =B
Check for dehydration
HgB [Hemoglobin]
12-18
8-11 = B
<8 = C
Assess for bleeding (may transfuse <8)
Call Dr
HCO3 (Bicarb)
22-26
Abnormal =A
CO2
35-45
In 50s = C
o Assess respiratory status
o Do have patient do pursed lip breathing (like blowing out
candle)
In 60s = D Respiratory failure
o Assess respiratory status; if symptomatic call rapid response
o Do pursed lip breathing
o Prepare ventilate and intubate
o Call DR
o Cal respiratory therapist
Hct (Hematocrit)
36-54
Abnormal = B; Assess for bleeding
PO2 (Oxygen level in blood; obtained from ABG)
78-100
Low 70-77 =C Respiratory insufficiency
o Assess respiratory status
o Give oxygen
Low
<
60s =D Respiratory failure
o Assess respiratory status
o Give oxygen
o Prepare intubate and ventilate
o Call Dr

o Call respiratory therapist

O2 Sat
93-100
<93=C
o Assess RR
o Give O2
BNP
Good indicator of CHF
Normal <100
Elevated=B
Sodium
135-145
Abnormal =B (Hypo-Overload) (Hyoer-dehydration)
If change in LOC=C
o Fall risk * Implement precautions and call dr
WBCs
WBCs 5,000-10,000
o WBC < 5000 = C
Absolute Neutrophil Count (ANC) >500
o ANC <500 =C
CD4 Count (T Cells)
o Should be greater than 200
o <200= AIDS
o CD4 < 200 =C
For top three implement (NP) reverse isolation precautions:
o Neutropenic Precautions:
Stricthandwashing
ShowerBIDwithantimicrobialsoap
Avoidcrowds
Privateroom
Limitnumberofstaffenteringtheroom
Limitvisitorstohealthyadults
Nofreshflowersorpottedplants
Lowbacteriadiet
Norawfruits,veggies,salads
Noundercookedmeat
Donotdrinkwaterthathasbeenstandinglongerthan15
minutes
Vitalsigns(temp)every4hours
CheckWBC(ANC)daily
Avoiduseofindwellingcatheter

Donotreusecups..mustwashinbetweenuse
Usedisposableplates,cups,straws,plasticknife,fork,
spoon
Dedicateditemsinroom:stethoscope,BPcuff,
Thermometer,Gloves

Terminology
:
o High WBC Count
Leukocytosis
o Low WBC Count
Leukopenia
Neutropenia
Agranulocytosis
Immunosuppression
BoneMarrowSuppression
Platelets (Thrombocyte Clotting Cell)
Wide range 150,000-400,000
o <90,000 = C
Assess for bleeding
Bleeding precautions
Call Dr
o <40,000 = D
could spontaneously hemorrhage to death
Assess for bleeding
Bleeding precautions
Prepare for transfusion
Call DR
o Bleeding Precautions(Thrombocytopenic Protocol):
NounnecessaryvenipunctureinjectionorIV.Usesmall
gauge
Handlepatientgentlyusedrawsheet
Useelectricrazor
Notoothbrushorflossing
Nohardfoods
Wellfittingdentures(norub)
Blownosegently
Norectaltemp,enema,suppository
Noaspirin
Nocontactsports
Nowalkinginbarefeet
Notightclothesorshoes
Usestoolsoftener.Nostraining
NotifyMDofbloodinurine,stool
RBCs

 4-6
Abnormal =B (check for bleeding)
Summary/Analysis
Knowthe5Dswhicharethemostdangerous
K+
>6
pH6&<6
CO260sandup
pO260sanddown
Plt<40,000
KnowwhattodofortheCs
DontspendtimememorizingtheA&Bs
WhenshouldyoucallaRapidResponseTeam?
When symptomatic! ASAP!
Dont call before assessing

LACINECTOMY AND SPINAL CORD

1. Definition
:
a. Ectomy=removalof
b. Lamina=Vertebralspinousprocesses
2. Reasonforlaminectomy:totreatnerveroot
compression
3. Signs&Symptomsofnerverootcompression
a. P
ain[usuallydistalextremities]
b. P
aresthesia[numbnessandtingling]
c. P
aresis[muscleweakness]
4. Locations:
a. Cervical(neck)
b. Thoracic(upperback)
c. Lumbar(lowerback)
5. Pre-op Cervical Laminectomy
a. cervicalspineinnervatesdiaphragmandarms!
b. Mostimportantassessment:
i. Breathing
ii. 2nd

:
howarearmsfunctioning
6. Pre-op Thoracic Laminectomy
a. Thoracicinnervatesabdomenandbowelfunctions
b. Mostimportantassessment:
i. Cough mechanism and bowel function
7. Pre-op Lumbar Laminectomy
a. Innervatesbladderandlegs
b. Mostimportantassessment:
i. Bladder retention and leg function
8. Post-Op Care
a. #1 post op answer on NCLEX with spinal cord:

log roll (move

spine in ONE piece)
b. Specificactivity/mobilizationstrategypostop
i. DoNOTdangle(sittingworstpositionforspine/back)
ii. Limitsittingfor30minutesatatime
iii. Maywalk,stand,orlaywithoutrestrictions
c. Post-Op Complications
i. Cervical:
Watchfor
pneumonia (diaphragm and arm probs)
ii. Thoracic:
Watchfor
asirational pnemonia
(abdominal-paralytic ileus [bowel])
iii. Lumbar:
Watchfor
urinary retention (bladder retention and
lower extremity probs)
d. Laminectomywithfusioninvolvestakinga
bone graft
fromthe
iliac
crest
(mostcommonsite).(andfusethem)
i. Ofthetwositeswhichsitehasthemost:
1. Pain?
Hip
2. Bleeding/drainage?
Hip
3. Riskforinfection?
50/50 equal spine and hip

4. Riskforinjection?
Spine site
Surgeonsareusingcadaverbonefrombonebanks.Why?
So dont have to do grafts, reducing rejection and infection rate. Bone has
decreased protein with antigens and wont be as easily rejected. Decrease
pain in patients post op as well.
9. Discharge Teaching
a. Temporaryrestrictions[normallyalways6weeks]
i. Dont
sit
forlongerthan
30 minutes
ii. Lie flat & Log roll
for6weeks
iii. No
driving
for6weeks
iv. Liftingrestrictions:donotlifemorethan
5lbs for 6 weeks
b. Permanentrestrictions[forever]
i. Laminectomypatientswillneverbeallowedtoliftby
bending at waist [must use knees]
ii. Cervicallaminectomypatientswillneverbeallowedtolife
objects
above head
iii. Nohorsebackriding,offtrailbiking,jerkyamusementpark
rides,etc

PEDIATRIC TEACHING
Piagets Stages of Intellectual Development
Age/Stage

Characteristics

Teaching Guidelines

Age: 0-2 years old

Stage: Sensorimotor

Totally present-oriented.
Only think about when they
SENSE or are DOING right
now. Dont understand past
or future
Fantasy oriented
Illogical
No rules

When
As you do it
What
You are currently
doing
How
Verbally explained

Age: 3-6 years old

Stage: Pre-Operational

Age: 7-11 years old

Stage: Concrete Operations

Rule-oriented
Live & Die by the rules!
Cannot abstract
Only 1 way to do things
*Perfect age to teach skills

Age: 12-15 years old

Stage: Formal Operations

Able to think abstractly

Understand cause-effect
Adult when it comes to
thinking

When
teach ahead of time
(not too far, a hour or two;
day of or morning before)
What
you are going to do
How
using play [doll,
story..]
When
can teach days
ahead
What
you are going to do
+ skills
How
dont use toys and
play!
Internet
Use age appropriate reading
and audio visual material
When
like adult
What
like adult
How
like adult
Like any other med surg pt

KIDS TOYS
Threeprinciplestoconsiderwhenchoosingappropriatetoys..
1. Isit
safe
2. Isit
age appropriate
3. Isit
feasible
Safety considerations:
1.Nosmalltoysforchildren4andunder
2.Nometalboyswhereoxygenisinuse
3.Bewareoffomites[soifimmunocompromised

nostuffedanimals!]
AgeAppropriateness:
1.First year of life
a.
0-6 months (sensorimotor)
1)
Besttoy:
musicalmobile
nd
2)

2Besttoy:
Somethinglarge,soft(cantbeswallowed,nofomites)

b. 6-9 months (object permanence)

1)
Besttoy:
cover/uncovertoys[peakaboo]jackinthebox
2)
2nd
Besttoy:
large,hard,plasticmetal

c. 9-12 months
1)
Besttoy:
verbaltoy[toywhichtalks]
2)
Purposefulactivitywith
objects[@9mosfirststartdoingpurposeful
things]
Avoidanswerswiththefollowingwordsinthemforchildren9monthsand
younger:
Build
Sort
Stack
Make
Construct

2. Toddler (1-3 years)

a. Besttoy
push/pulltoy[wagon]
b. Workon
Grossmotor
c. Characterizedby
parallelplay[nexttoeachotherbutnotwith]

3. Preschoolers (3-6 years)

a. Workon
finemotor[puzzles,chalk,crayons]
b. Workon
balance[dance,skate]
c. Characterizedby
cooperativeplay
d. TheyLiketopretend

4. School age (7-11 years)

Characterizedbythe3Cs
1. C
ollective[liketocollectex.Beaniebabies]
2. C
reative[blankpaper,coloringpencils,legosneedtomakethings
intootherthings]
3. C
ompetitive[winners&losers]

5. Adolescents (12-18 years)

Theirplayis
peer group association
(hangoutinlargegroups,doingnothing)

Allowadolescentstobeineachothersroomsunlessoneofthemis:
1. Immunosuppressed
2. Contagious
3. Freshpostop(12hours)

MEDICATION HELPS & HINTS

1. Humulin 70/30

2. Drawing up Insulin

1)
2)
3)
4)

PressurizeNormal
PressurizeRegular
DrawupRegular[clearbeforecloudy]
DrawupNormal

3. Injections

IM

SQ

4.
Heparin & Coumadin
HEPARIN

Works right away (so start right

away)
IV & SQ
21 days [ after that body makes own
enzymes-dangerous]
o therefore, notify MD if at
it 2 weeks and ask if time
to switch to Warfarin
o when start may be on bed
rest 5-10 days until
bodies enzymes adapt
Antidote: protamine sulfate
PTT
Can be given in pregnancy
o Not safe however
o Class C: use with caution

K+ sparing vs K+ wasting Diuretics

COUMADIN(WARFARIN)
Takes days (therefore start heparin

too at same time)

Kicked in when INR 2-3
PO
Antidote:
Vitamin K
PT (INR)
Cannot give in pregnancy
o Can cross placenta
o Class X

Baclofen (Lioresal)
Musclerelaxants
CantakewithOxycodone&cutdose
1)Causesdrowsiness
2)Relaxesmuscles(muscleweakness)
3)Noalcohol
4)Nodriving
5)Cannotsupervisekidsunder12alone

PSYCHIATRIC NURSE TEST-TAKING

PRINCIPLES
PhaseSpecificity
Thebestpsychanswersarethoseanswersthataremostappropriatetothe
phaseofthenursepatienttherapeuticrelationshipthatyouarein

Ifthequestiontellsyouthephaseoftherelationship,thephasewillbethe
determinantofwhichansweriscorrect
The phases of the nurse-patient relationship:
The Pre-Interaction Phase
Purpose:
Forthenursetoexplorehis/herownfeelings.Topreventjudgmental,
intolerantreactions.
Length:
Beginswhenyoulearnyouaregoingtobecaringforsomeoneandends
whenyoumeetthem.
CorrectAnswer(s):
Thenursewillexploreher/hisownfeelingsabout
The Introductory Phase
Purpose:
Toestablishtrustandexplore/assess
Length:
Beginswhenyoufirstmeetthepatientandendswhenamutually
agreeduponcareplanisinplace
KeyWords:
Thesephrasesaredesignedtohinttoyouthatyouareintheintroductory
phase:
o 1.
During the initial interview
o 2.
Upon admitting the patient..
o 3.
On admission
o 4.
At your first few meeting with..
o 5.
While assessing
o 6.
On the day of admission
o 7.
While formulating nursing diagnoses
Correctanswers:
Shouldbeverytolerant,accepting,explorative,probing,nosy.
Bewarmandfuzzy

The Working Phase (Therapeutic Phase)

Purpose:
Toimplementtheplanofcare
Length:
Fromthefinishedcareplanuntildischarge
KeyWords:
1.Duringthetherapeuticinterview

 2.Whileimplementingthecareplan..
3.Whileworkingonthecareplangoals
4.Duringtreatmentsessions..
5.Duringtherapy..
6.Inyourweeklysession..
7.Threedaysafteradmission
8.Afterimproving..
CorrectAnswers:
Shouldbeveryfocused,directive,tough.Insomewaystheseanswerswill
seemsternandslightlyunfriendly.Setlimits.Enforcepropercommunication.

The Termination Phase

Theonlyquestionaskedherehasbeen,Whendoestheterminationphase
begin?
TheanswerOnadmission

GIFT GIVING
Inpsych,donotgivesomethingofvaluetothepatient.Conversely,donot
acceptsomethingofvaluefromthepatient

Agiftissomethingoftangibleorintangiblevaluegivenfromonepersonto
another.

Giftsinclude:hugs,kisses,compliments,opinions,holdinghands,placinganarm
around,etc

DO NOT
dothesebehaviorsinpsych.(Maybeappropriateinmedsurg)
Differencebetweencomplimentingandobservingprogress

ADVICE-GIVING
DONOTGIVEADVICE.Letthepatientformulateownsolutionsandalternatives.

Remember,givingadviceandsettinglimitsarenotthesame.Theformerisbad,
thelatterisgood.

KEY WORDS TO AVOID:

1.
Suggestthat..
2.
Advisethepatientto..
3.
Tellthepatientto..
4.
IfIwereyou,Iwould
5.Youshoulddo..
6.Yououghtto..
7.YoushouldNOTdo..
8.Dontdo
9.Recommendthat

AnywordswiththesephrasesviolatethisprincipleandareWRONG.
RULE
THEM OUT!
Alwayssay,Andwhatdo
you
thinkyoushoulddo,Mr.Smith?

GUARANTEE GIVING
DONOTGIVEGUARANTEESINPSYCH.Youcannotpredictthehumanmind
ofknowanothersexperience

GivingguaranteesisokayinMed/Surgiftrue

KEY WORDS:
1.
Ifyouthen
2.Youwillimproveifyou..
3.Wecan

Aguaranteeviolatestrustwhenthepromisedresultsdonotappear

Onlythingscanguarantee:1)medswillwork2)youaresafe

IMMEDIACY
Thebestpsychanswerscommunicatetothepatientthatthenurseiswillingto
dealwiththepatientsproblemrightthenandrightthere

Key Phrases:
AVOID
answerslikethese
1.Referpatientto
2.Haveyouspokentoyouraboutthis?
3.Whydontyoutalktoyouraboutthis?

Avoidchangingthesubjectunlessyouarerefocusingapatientwhoisavoiding
thesubjectoftherapeuticsession

CONCRETENESS
Thebestpsychanswersarethoseanswersthatsayexactlywhattheymeanina
literalsensewordforword

KEY PHRASES:
Avoidslang,figurativespeech,sayings,proverbs,verses,
poetry,stories,parables,allegories,neologisms.

Tie-Breakers
1.Whyquestionsarenotasgood
2.Reflectionisgood.
3.Openendedisbetterthanclosedended.
4.Answerswith
I, me, we, us
inthesubjectarenotgood.
5.Shortestanswersarethebest

PSYCH TREATMENT PROTOCOLS

CATEGORY
DEPRESSION

PROTOCOL
Most cases not psychotic
Suicide rates high
o If even slightest indication

must bluntly ask, have you

ever thought of..
Psychomotor retardation: sit around
and dont do anything, slow, inactive
o Must push these patients to
do things and be very
directive
Activities: in a group, but does not
require interaction ex. Movie, craft

SCHIZOPHRENIA

High suicide rate

Activities: group, requiring

interaction-this brings pt to reality

BIPOLAR

Hypomania:
minor; preceding; admit

at this phase to prevent full mania. Pt

hyperexaggerated but still functioning

Mania:
full blown; when stops ADLs

and other responsibilities

o Major problems:
dehydration, malnutrition,
lack of sleep
o Actions: high cal finger
foods, allow sleep/naps

whenever they want, gross

motor activities alone

ANXIETY DISORDER
most common psych
prob in U.S.

Phobias: treatment: desensitization

SUBSTANCE ABUSE

Denial

(gradual exposure)
4 levels:
o 1. Talk about it
o 2. See pics of it
o 3. Be in environment with
is
o 4. Actually experience it
Patient has to be calm and ready to
experience each next level

Dependency

Manipulation

VIOLENT CLIENTS

Deal with violence as a team (of 5-1

person for each extremity)

In de-escalation process- only one

person talks
Always give patient a chance to gain

control of self before taking action

EMPATHY
Thebestpsychanswersarethoseanswersthatcommunicatetothepatientthat
thenurseacceptsthatpatientsfeelingsasbeingvalid,real,andworthyofaction.

Key Phrases:
Alowempathyanswerisalwayswrong

AvoidSaying:
1.Dontworry
2.Dontfeel
3.Youshouldntfeel
4.Iwouldfeel
5.Anybodywouldfeel
6.Nobodywouldfeel
7.Mostpeoplewouldfeel

Four Steps to Answering Empathy Questions

1.Recognizethatitisanempathyquestion
Empathy questions have a
quote
in the question, and each of the answers
contains a
quote.
2.Putyourselfintheclientsshoes.Saytheirwordsasifyoureallymeantthem.

3.Askyourself,IfIsaidthosewordsandreallymeantthem,howwouldIbe
feeling
rightnow?

4.Choosetheanswerthatreflectsthe
feelings
...nottheanswerthatreflectstheir
words.

PSYCHOTROPIC DRUGS
Note: All psych drugs cause a decrease in BP and weight change
1. Phenothiazines
a. Allendin
zine
b. Verypotent
c. Immediateonset
d. Ex.Thorazine,Compazine
e. Actions
:
i. Doesnotcuredisease.Reducessymptoms
ii. Large doses:
Psychoticsymptoms(Hallucinations
iii. Small doses:
Nausea/Vomiting
iv. Major:
Tranquilizers

f. SideEffects:
(rememberABCDEFG)
i. A
nticholinergicEffects
ii. B
lurredvisionand
B
ladderretention
iii. C
onstipation
iv. D
rowsiness
v. E
xtraPyramidalSyndrome(EPS)
vi. F
Photosensitivity
vii. A
G
ranulocytosis(lowWBCcountimmunosuppression)
viii. Teach patient to report sore throat and any S/S of infection
toDR
g. Nursing Care: treat side effects. Number one nursing diagnosisis
safety.
h. Deconate after name of drug means it is
long acting (at least 2
weekstomonth)IMformgivento
non-compliant
patients
2. Tricyclic Antidepressants
a. Antidepressant
b. mood elevators
totreatdepression
c. Ex.Elavil,Tofranil,Aventyl,Desyrel
d. pram,trip
e. SideEffects:
(ElavilstartswithEsothisgroupgoesthroughE)
i. A
nticholinergicEffects
ii. B
lurredvisionand
B
ladderretention
iii. C
onstipation
iv. D
rowsiness
v. E
uphoria
f. Musttakemedsfor
2-4 weeks
beforebeneficialeffects
3. Benzodiazepines
a. Antianxietymeds(considered
minor tranquilizers)
b. Alwayshave
pam, -lam
inthename
c. Prototype:Diazepam(Valium)
d. Indications:

i. Inductionofanesthetic
ii. Musclerelaxant
iii. Alcoholwithdrawal
iv. Seizuresespeciallystatusepilepticus
v. Facilitatesmechanicalventilation
e. Tranquilizersworkquickly
i. Mustnottakeformorethan
90 days/3 weeks-3 mos
ii. KeeponValiumuntilElavilkicksin
f. SideEffects:
i. A
nticholinergicEffects
ii. B
lurredvisionand
B
ladderretention
iii. C
onstipation
iv. D
rowsiness
g. #1NursingDX:
Safety
4. Monoamine Oxidase (MAO) Inhibitors
a. Antidepressants
b. Depression is thought to be caused by a deficiency of
norepinephrine, dopamine, and serotonin in the brain. Monoamine
oxidase is the enzyme responsible for breaking down
norepinephrine, dopamine, and serotonin. MAO inhibitors prevent
the breakdown of these neurotransmitters and thus restore more
normallevelsanddecreasedepression.
c. 24weeks
d. DrugNames:
i. Mar
plan
ii. Nar
dil
iii. Par
nate
e. SideEffects
i. A
nticholinergicEffects
ii. B
lurredvisionand
B
ladderretention
iii. C
onstipation
iv. D
rowsiness
f. Interactions:
(PatientTeaching)
i. To prevent severe, acute, sometimes fatal
hypertensive
(stroke) crisis
, the patient MUSTavoidallfoods containing
TYRAMINE.
1. Foods containing TYRAMINE:
a. Fruits and veggies
(remembersaladBAR)
i. AVOID:
1. B
ananas
2. A
vocados
3. R
aisins(anydriedfruits)

b. Grains: all okay except things made from

activeyeast
c. Meats
i. No organ meats: liver, kidney, tripe,
heart,etc
ii. No preserved meats: smoked, dried,
cured,pickled,hotdogs
d. Dairy
i. Noagedcheese
ii. Noyogurt
iii. Cannoteatbrickcheese
e. Other
i. No alcohol, elixirs, tinctures, caffeine,
chocolate,licorice,soysauce
ii. DrugInteractions:
1. Teach patient not to take OTC meds unless theyare
prescribed

5. Lithium
a. Anelectrolytenotice
ium
endingasinpotassium,etc
b. UsedfortreatingBPD(manicdepression)itdecreases
mania
c. SideEffects:
(The3Ps)
i. P
eeing(Polyuria)
ii. P
ooping(Diarrhea)
iii. P
aresthesia(Firstsignofelectrolyteimbalance)
d. Toxic:
i. Tremors, metallic taste, severe diarrhea or any otherneuro
signsbesidesparesthesia
ii. #1intervention:
keep hydrated
iii. Ifsweating,give
electrolyte drink
aswellasfluids
e. Note:
Closelylinked tosodium.Monitor sodiumlevels.
Low sodium
levelsprolonglithiums halflife,causinglithiumtoxicity.
Highsodium
levelsdecreasetheeffectivenessofLithium.
i. WillonlyworkasprescribedifSodiumnormal!!

6. Prozac (Fluoxetine)
a. ProzacisaSSRI(Antidepressant)
b. SimilartoElavil(Atricyclicantidepressant)sameinfo
c. SideEffects:
i. A
nticholinergicEffects
ii. B
lurredvisionand
B
ladderretention
iii. C
onstipation
iv. D
rowsiness
v. E
uphoria
d. Prozaccauses
insomnia
,sogivebefore12noon
i. IfBIDgiveat6A&12N
e. Whenchangingthe doseof Prozacforaadolescentoryoungadult
watchfor
suicidal ideation

7. Haldol (Haloperidol)
a. Also hasdeconateform[IM,longacting,giventoptswhowonttake
pills
b. SameinfoasThorazine
c. Verypotent
d. Immediateonset
e. Actions
:
i. Doesnotcuredisease.Reducessymptoms
ii. Large doses:
Psychoticsymptoms(Hallucinations
iii. Small doses:
Nausea/Vomiting
iv. Major:
Tranquilizers

f. SideEffects:
(rememberABCDEFG)
i. A
nticholinergicEffects
ii. B
lurredvisionand
B
ladderretention
iii. C
onstipation
iv. D
rowsiness
v. E
xtraPyramidalSyndrome(EPS)
vi. F
Photosensitivity
vii. A
G
ranulocytosis(lowWBCcountimmunosuppression)
viii. Teach patient to report sore throat and any S/S of infection
toDR
g. Nursing Care: treat side effects. Number one nursing diagnosisis
safety.
h. **Elderly patients may develop Neuroleptic Malignant
Syndrome (NMS), a potentially fatal hyperpyrexia (fever) with a
temp of >104 F from overdose. Dose for elderly patient should
be HALF of usual adult dose.

8. Clozaril (Clozapine)
a. Secondgenerationatypicalantipsychotic
b. Usedtotreatsevereschizophrenia
c. Advantage
: it does
nothaveside effects A, B, C, D, E, orF (much
less)
d. Disadvantage: it DOES have side effect:
Agranulocytosis(worse
thancancerdruginsusceptiblepatients)
e. ForfirstmonthneedWBCcountsweekly.IfWBCLOWSTOP!
f. DonotconfusewithKlonopin(Clona
zep
am)

9. Zoloft (Sertraline)
a. AnotherSSRIlikeProzac
b. S/EABCDE
c. 24weekstowork
d. AlsocausesinsomniabutCANbegiveninevenings
e. Watchforinteractionwith:
i. St. Johns wort-
serotonin syndrome *deadly
1. S
weating
2. A
pprehension

impendingsenseofdoom
3. D
izziness
4. HEAD-
ache
ii. Warfarin (Coumadin)- watch for
bleeding (may need to
lowerwarfarindose)
1. WhentakeZoloftwarfarinandINRstaysUP