Rule of B's for ABGs

if the pH and the Bicarb are Both in the same direction it is metaBolic

normal pH
normal Bicarb
pH: 7.35-7.45
Bicarb: 22-26

Kussmul respirations
MACkussmul= metabolic acidosis

S&S of acid-base imbalance

as the pH goes, so goes my patient except for potassium
UP: (alkolosis):decreased K+, highest risk for seizures
DOWN: (acidosis): increased K+, highest risk for respiratory arrest

causes of respiratory acid-base imbalance

lung=respiratory
overvent or undervent
overvent= alkolosis
undervent=acidosis

causes of metabolic acid-base imbalance

not lung=metabolic
prolonged gastric vomiting or suction=metabolic alkolosis (losing acid)
everything else=metabolic acidosis

high pressured ventilator alarms

triggered by increase resistance to air flow and can be caused by obstruction of
three types:
kinked tube: unkink it
water in tube: empty it
mucus in airway: turn, cough, deep breathe

low pressured ventilator alarams

triggered by decreased resistance to air flow and can be caused by disconnections:
tubing: reconnect if not contaminate
if contaminated (below bed level): call first, then bag, reconnect

respiratory alkalosis vs acidosis

alkalosis: ventilator setting may be too high (overvent)
acidosis: ventilator setting may too low (undervent)

HOLD
high pressured alarms
obstruction
low pressured alarms
disconnection

Maslow
1. physiological
2. safety
3. comfort
4. psychological
5. social
6. spiritual

#1 problem in substance abuse

denial: refusal to accept the reality of their problem
treatment: confront it by pointing out to the person the difference between what
they say and what they do.
however, in grief and loss support denial

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dependency/codependency
dependency: when abuser gets SO to do things for them or make decisions for them
codependency: when the SO derives positive self-esteem from doing things for or
making decisions for the abuser

treating dependency/codenpendency
set limits and enforce them. agree in advance what requests are allowed then
enforce the agreement
work on the self-esteem of the codependent person

manipulation
when abuser gets the SO to do things for him/her that are no in the best interest of
the SO. nature of the act is dangerous or harmful to SO

treatment of manipulation
set limits and enforce them
easier to treat than dependency/codependency because no body likes being
manipulated

wenicke's korsakoff syndrome

psychosis caused by a lack of B1 (thiamine) deficiency
primary symptom: amnesia with confabulation
-preventable
-arrestable
-irreversible

antabuse/revia (disulfiram)
aversion therapy
onset/duration of effectiveness: 2 weeks
pt teaching: avoid all forms of alcohol to avoid nausea, vomiting, death

uppers
cocaine, caffeine, PCP/LSD, methamphedimines, ADHD meds (amphetimines), bath
salts
S&S: increase everything, pupils dilate (mydriasis), seizures

downers
codeine, heroin, alcohol, marijuana
S&S: decrease everything, pupils constrict (miosis), respiratory arrest

overdose vs withdrawal
upper overdose: everything is high
upper withdrawal: everything is low

downer overdose: everything is low

downer withdrawal: everything is high

alcohol withdrawal syndrome vs delirium tremens

every alcoholic go through AWS (24 hrs) only a minority get DT (usually 72 hrs)
AWS is not life-threatening. DT can kill you
PT with AWS are not dangerous to themselves or others. PTs with DT's are
dangerous to self and others

pg 8

aminoglycosides (a mean old mycin)

antibiotics to treat serious, life-threatening, resistant
all end in -mycin/micin, but not all drugs that end in -mycin/micin are "a mean old
mycin" (all have thro in them and are opposites of aminoglycosides)

toxic effects of "a mean old mycin"

think of mice (ears)
ototoxicity
must monitor balance, tinitus, hearing (most important)

ear is shaped like a kidney

nephrotoxicity
monitor creatinine (best indicator of kidney fx)

#8 drawn inside the ear reminds you

cranial nerve 8
frequency of administration: q8h

route of administration for "a mean old mycin"

give IV or IM
do not give PO (not absorbed) except in tow cases: sterilize the bowel ->
neonmycin/canmycin

hepatic encephalopathy
also called liver coma, ammonia-induced encephalopathy, due to a high ammonia
level

pre-op bowel surgery

remember this military sound-off
Q: who can sterile my bowel?
A: Neo-can

through and peak levels for amonoglycin

reasons for drawing TAP levels: narrow therapuetic range
pg 10

category A bioterrorism
can hurt people worst
S: small pox
T: tularemia
A: anthrax
P: plague
H: hemorrhagic fever
B: botulism

category C bioterrorism
nipen virus
harita virus

small pox
person to person
inhaled transmission/on airborne precautions
dies from septicemia. no treatment
rash starts around mouth first-> early finding then quarentine

tularemia
inhaled, not passed person to person
chest symptoms
dies from respiratory failure
treat with streptomycin
anthrax
spread by inhalation, not person to person
looks like respiratory flu=chest symptoms
dies from respiratory failure
treat with cipro, pcn and streptomycin

plague
spread by inhalation, not person to person
has the 3 H's
-hemoplysis: coughing blood
-hematemesis: puking blood
-hematochezia: bloody diarrhea
dies from respiratory failure and DIC (treat with heparin)
treat with doxycycline and mycins
no longer communicable after 48 hours of treatment

hemorrhagic illnesses
inhalation
primary symptoms are petechiae (red spots) and ecchymoses
high % fatal

botulism
ingested
3 major symptoms:
-descending paralysis
-fever
-but is alert
dies from respiratory failure
kids: trach, intabate, coma

chemical agents
mustard gas: blister
cynaide: resp arrest, treat with sodium thiosulfate IV
phosgine chlorine: choking
sarin: nerve agent. symptoms (cholenergenic crisis):
-Bronchorrhea: huge resp mucus
-Bronchoconstriction
-Salavation (excessive)
-Lacarmating (tears)
-Urinating (polyuria)
-Diarrhea/diaphoresis
-GI upset
-Emesis

pg 13
calcium channel blockers
negative ino, chorno, dromo
weak, slow, blocks/slow conduction

Ca+ channel blockers treat

antihypertensives: decrease BP
Anti Anginals: treat angina- decrease O2 demand
Anti Atrial Arrhythemias: "supraventricular"

side effects:
headache, hypotension, bradycardia

names of Ca+ channel blockers

isoptin, -zem, -dipine (i saw them dippin the calcium channel"

cardiac arrhythmias terminology

QRS depolarization always refers to ventricular
P waves refers to atrial

a-sytole
a lack of QRS depolarization (flat line)

atrial flutter
rapid P-wave depolarizations in a saw-tooth pattern (flutter)

ventricular fibrillation
chaotic QRS depolarizations

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ventricular tachycardia
wide, bizarre QRS's (repeating pattern of tachycardia)

premature ventricular contraction

periodic wide, bizarre QRS's (usually low priority, one spot)
be concerned about PVC's if:
more than 6 per minute
6+ in a row (short run of v-tachy)
PVC falls on T-wave of previous beat

lethal arrhythmias
brain dies in 8 minutes
asystole
v-fib
(no cardiac output)
time is most important who has been down longest w/o going over 8 minutes

potentially life-threatening arrhythmia

v-tachy
then a-fib: d/t clots
then PVC
then heart blocks

treatment for arrhythmias

PVC's: lidocaine, amiodarone

V-tach: lidociane, amiodarone

supraventricular arrhythmias
-adenosine
-beta blaockers
-calcium channel blockers
-digitalis- directly on heart

V-fib: shock, defib as much until you get sinus

asystole: positive agent -> epinephrine (slow HR give atropine), headache,

tachycardia

pg 16

apical vs basilar chest tubes

apical (high) for air-bubbling
basilar (low) for blood

what do you do if the water seals break

first: clamp tube, cut tube off device, submerge under water, unclamp
best: submerge

what do you do if the chest tube comes out

first: cover with gloved hand, replace w/ vasoline gauze, dry sterile dressing, tape
on 3 sides
best: replace with vasoline guaze

bubbling in chest tube....

water seal: intermittently (good), continuously (bad) means leak in system

suction control chamber: intermittently (bad) suction not enough, continuously

(good)

rules for clamping tube

never clamp for longer than 15 seconds w/o dr's order
use rubber tipped clamps- don't want to cut tube clamp when water seal breaks

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congenital heart defects
every congenital heart defect is either TRouBLe or no trouble

R-L = all trouble shunt right to left

B = blue (cyanotic)
T = all defects that start with t are trouble

2 things congenital heart defects have in common

murmur
ECG done: have to figure out what is which it is

4 defects in TOF
VarieD = ventricular defect
PictureS = pulmonic stenosus
Of A = overriding aorta
RancH = right hypertrophy

measuring crutches, canes walkers

2-3 cms fingerwidths below anterior axillary fold, to a point lateral to and slight in
front of foot

when hand grip is properly placed, the angle of elbow flexion will be 30 degrees

2-point gait
1: move on crutch and opposite food together
2: move other crutch and other foot together

3 point gait
1: move two crutches and bad leg together
2: move good foot

4 point gait
1: 1 crutch
2: opposite foot
3: other crutch
4: other foot

nothing moves together

swing through
two braced extremities

when to use each gait

even numbers when weakness is evenly distributed. 2 point for mild, 4 point for
severe

odd numbers when one leg is odd

stairs and crutches

up with the good and down with the bad
crutches always move with the bad leg

canes
hold cane on the strong side
advance cane with weak side for a wide base of support

walkers
pick it up, set it down, walk to it
chair to walker: push don't pull. push off chair to standing then walk to walker

psychotic vs nonpsychotic
nonpsychotic person has insight and is reality-based
a psychotic person has no insight and not reality-based

delusions
is a false fixed belief or idea or thought. there is no sensory component.

3 types of delusions
paranoid/persecutory:
-false, fixed belief that people are out to harm you

grandiose
-false, fixed belief that you are superior

somatic:
-false, fixed belief about a body part

hallucinations
is a false fixed sensory experience

five types of hallucinations

1-auditory (most common: command)
2-visual
3-tactile/sensory
4-guastatory
5-olfactory
illusions
is a misinterpretation of reality. it is a sensory experience
with illusions there is a referral in reality

functional psychosis
schizophrenia, schizo affective, major depression, mania

pt has potential to learn reality

4 steps for functional psychosis

acknowledge feelings
present reality: tell them "what is"
set a limit: "were not going to talk about..."
enforce the limit

psychosis of dementia
alzheimer's, organic brain syndrome, post stroke, Wierneke's, dementia
pt has a brain destruction problem and cannot learn reality

2 steps of psychosis of dementia

acknowledge the feelings
redirect them: take what they're fixated on and turn it into something appropriate

psychotic delirium
temporary episodic sudden onset dramatic loss of reality d/t chemical imbalance

2 steps of psychotic delirium

acknowledge the feeling
reassure: safety and it will go away

loosening of association
flight of ideas
word salad
neologisms
flight of ideas: tangentiality- string of words
word salad: words together loosely
neologism: make up new words

narrowed self-concept when psychotic refuses to:

leave the room and refuses to change clothes, they only know who they are if they're
in the room and in their clothes

ideas of reference
the think everything is about them, tv, radio, etc
diabetes mellitus
error of glucose metabolism

diabetes insipidus
polyuria, polydipsia, leading to dehydration

type I diabetes
insulin dependent
juevenille onset
ketosis prone

type II diabetes
non-insulin dependent
adult onset
non-ketosis prone

S&S of diabetes
polyuria >200 mL/hr
polydipsia
polyphagia- increased appetite (usually means frequent swallowing)

treatment: type I vs type II

type I:
1-insulin
2-exercise
3-diet

type 2:
1-diet: calorie restriction, need to eat 6 times a day
2-exercise
3- oral hypoglycemics

regular insulin
can be run as IV (rapid and run)

onset: 1 hr
peak: 2 hr
duration: 4 hr

N= NPH
cloudy, no IV

onset: 6 hrs
peak: 8-10 hrs
duration: 12 hrs
humalog/insluin lispro
fastest; give with meals or 15 minutes before

onset: 15 min
peak: 30 min
duration: 3 hrs

glargine
(large), no risk for hypoglycemia; safe to give at bed

slow absorption
duration: 12 hrs

insulin rules
check expiration date (most important)
refrigeration: optional for open insulin, must for closed

more exercise, need less insulin

less exercise, need more insulin

Low blood sugar in type I/II

causes:
not enough food, too much insulin, too much exercise

danger: brain damage-always permanent

S&S: cerebral impairment (drunk like), vasomotor collapse, BP decrease, RR

increase, pulse thready, weak, cold, clammy

treatment for low blood sugar in type I/II

administer rapidly metabolize carbs (juice, candy, icing, jelly syrup)
ideal combination: 1 sugar and 1 protein
if unconscious: nothing by mouth, glucagon IM

high blood sugar in type I: DKA- diabetic coma

causes:
too much food, not enough insulin, not enough exercise

#1 cause is acute viral upper respiratory infection within the last week- 10 days

S&S:
dehydration
ketones, kussmal, high K+ = metabolic acidosis
acidosis, acitone breathe, anorexia d/t nausea

treatment for hyperglycemia

fluids (D5W, D545), 200+ ml/hr, regular insulin

high blood sugar in type II

called HHNK(c): hyperosmolar, hyperglycemic, non-ketotic coma
this is dehydration
S&S of dehydration
treatment: rehydrate

lab test is best indicator of long-term blood glucose control

hemoglobin HA1C
below 7 = diabetes
for screening below 6.5

long-term complications for diabetes

poor tissue perfusion and peripheral neuropathy

lithium (antimania) drug tox

therapeutic: 0.6-1.2
toxic: > 2

lanoxin/digitalis (CHF, a fib) drug tox

therapeutic: 1-2
toxic: >2

aminophylline (airway antispasm) drug tox

therapeutic: 10-20
toxic: >20

dilatin/phenytoin (antiseizure) drug tox

therapeutic 10-20
toxic: >20

bilirubin levels (waste product from breakdown of RBC)

neonate therapeutic >10
elevated level: hyperbilirubinemia: 10-20
---hospitalized around 15
toxic: >20

kernicterus: when bilirubin gets in cerebral spinal fluid-massive encephalitis

opisthotonos: position of extension seen w/ Kernictreus, decerabration, REALLY

BAD, ominous sign: slight extension of wrist

hiatal hernia
regurgitation of acid into esophagus, because upper stomach herniates upward
through the diaphragm
gastric contents move in the wrong direction at the correct rate

S&S:
upper GI signs when you lie down after eating

dumping syndrome
post-op gastric surgery complication in which gastric contents dump too quickly
into the duodenum

gastric contents move in the correct direction at the wrong rate

S&S
lower GI (diarrhea, cramping, borboygme, when sit up) after eating

treatment for hiatal hernia & dumping syndrome

hiatal:
high fowlers
high liquid % w/ meals
high carbs (low protein)

dumping syndrome:
low fowlers
low liquid % w/ meals
low carbs (high protein)

kalemias hyper vs hypo

kalemias do the same as the prefix except for heart rate and urine output

hyper: increase everything, decrease HR, urine output

hypo: decrease everything, increase HR, urine output

calcemias hyper vs hypo

calcemias do the opposite as the prefix

hyper: decrease everything, BP increase/decrease

hypo: increase everything, BP increase/decrease

2 signs of neuromuscular irritability associated w/ a low calcemia:

1-Chvostek's sign: tap cheek then facial spasm
2-Trousseau's sign: BP on arm then go into carpospasm (hand spasm)

magnesemias hyper vs hypo

magnesemias do the opposite the prefix.
hyper: decrease everything, BP increase/decrease

hypo: increase everything, BP increase/decrease

in a tie of Mg, K, Ca...

never pick Mg. if symptoms involve nerve or skeletal muscle pick Ca, anything else
pick K

Natremias hyper vs hypo

hypEr: dEhydration
give fluids, dry skin, poor skin turgor, DKA, HHNK

hypO: Overload
give diuretics, crackles in lungs, weight gain

earliest/universal sign of electrolyte imbalance

earliest sign: numbness and tingling (parethesia)

universal sign: paresis (muscle weakness)

electrolyte treatment
hypokalemia:
never push K+ IV
not more than 40 of K+ per liter of IV fluid

hyperkalemia:
give D5W w/ regular insulin to decrease K+ buys time
Kayexalate/polystyrene (K+ exits late)

hyperthyrodism
S&S: bulging eyes, hyperactive, agitated, nervous, anxious,, heat intolerant,
increased HR, increased BP, increased temp/RR, increased bowel fx, thin

Graves Disease: RUN yourself into the GRAVE

treatment for hyperthyrodism

radioactive iodine-all the iodine is uptaken by thyroid which kills the thyroid,
problem with radioactive urine, flush toilet a lot

PTU-knocks out hyperactive thyroid by agranulocytosis and infection

total thyroidectomy
need lifelong hormone replacement
at risk for hypocalcemia
S&S: tetany, parthesia
subtotal thyroidectomy
at risk for thyroid storm/crisis/thyroidtoxicosis
stay with pt
S&S of thyroid storm:
1-hyperpyrexia (high fever 104+)
2-really high VS (HR 200, BP 210/190)
3-psychotic delirium

treatment: high flow rate O2, decrease temp with ice packs (5), spare the brain

hypothyroidism
S&S: lethargic, weight gain, bradycardia, depression, delay rx time, cold intolerance,
decreased temp and VS, brittle nails and hair

hasimotos

hypothyroidism treatment
thyroid hormone

DO NOT sedate them, they'll go into a coma

surgical implication: anesthesia (call anesthesiologist about NPO thyroid hormone)

addison's disease
under secretion of adrenal cortex
S&S: hyperpigmentation, do not respond to stress well
treatment: give steriods: corticoids, glucocorticoids, -sones

cushing's syndrome
over secretion of adrenal cortex
S&S: cush man
moon face
hirsutism-hairy
acne
gynecomastia (boobs)
buffalo hump
central obesity
skinny extremities
retaining water
losing potassium
stretch marks
osteoporosis
increased BS and BP
bruises easily
easily irritable
immunospressed

treatment: adrenalectomy

PPE
proper place for donning: outside room
order for donning:
gown, mask, goggles, gloves

proper place for removing: inside room except mask

order for removing:
gloves, goggles, gown, mask

handwashing vs scrubbing
handwashing:
hands below elbows, seconds, can use handles, when soiled/enter/exit, soap and
water

scrub:
hands above elbows, minutes, can't use handles, immunospressed pts,
chlorahexidine

sterile gloving
glove dominant hand
grasp outside of cuff
touch only inside of glove
do not roll cuff
fingers slide inside second glove
keep thumb abducted
only touch outside surface of glove
skin touches inside of glove
outside of glove only touch outside of glove
remove glove to glove
skin to skin

interdisciplinary care
DO NOT need: multiple dx

DO need: multidimensional needs:

physical, emotional, social, spiritual, vocational
and pts who need rehabilitation

tie breakers for interdisciplinary

pt whose current treatment is ineffective
pt who is preparing for discharge
safety considerations for kids toys
no small toys for kids under 4
no metal toys if oxygen is in use
beware of fomites (non-living objects that harbor microorganisms)(plush toys) (if
immunospressed give plastic toys)

0-6 month toys

sensorimotor
best: mobile (musical)
2nd best: large and soft

6-9 months toys

object permanence
best: something that teaches object permanence... cover/uncover (jack n box, etc)
2nd best: large and hard

9-12 months toys

best toy is verbal toy
purposeful activity with objects
9 plus months use:
build, stack, construct, make, sort

toddlers 1-3 years toys

best: push-pull
work on gross motor
characterized by parallel play

preschoolers 3-6 years toys

work on fine motor
work on balance (bikes, skating, etc)
characterized by cooperative play
they like to pretend

school age 7-11 years toys

creative
competitive
collective

adolescents 12-18 years toys

their play is peer group association
allow adolescents groups to be in each other rooms unless:
-fresh post-op of 12 hrs or unstable
-anyone is contagious
-immunospuressed pt

creatinine
best indicator of kidney/renal fx
0.6-1.2
elevated = A(bnormal)
kidney failure. dye procedure ->only exception

INR
monitors warfarin therapy
therapeutic 2-3
>4 = C(ritical)
hold all warfarin
assess for bleeding
prepare to give vit. K
call doctor

potassium
therapeutic: 3.5-5.3

low = C(ritical)
assess cardiac->ECG by UAP
prepare to give K+
call doctor

5.4-5.9= C(ritical)
hold K+
assess cardiac
prepare to give polystrene w/ D5W and regular insulin
call doctor

>6 = D(eadly)
do all above all at once

pH
7.35-7.45

pH in 6's = D(eadly)
assess VS
DR has to find cause

BUN
8-30

elevated = B(e concerned)

check for dehydration

HgB
12-18
8-11= B(e concerned)-> check for bleeding
<8 = C(ritical) -> assess bleeding, prepare blood transfusion, call doc

HCO3
22-26

abnormal= A(bnormal)

CO2
35-45

in 50's = C(ritical): resp. insufficiency

assess respiratory
do pursed lip breathing

in 60's = D(eadly): resp. failure

assess respiratory
do pursed lip breathing
prepare to intubate and ventilate
call resp. therapy
call doc

Hct
36-54

abnormal= B(e concerned)

PO2
78-100

low 70-77 = C(ritical)

assess respiratory
give 02

low 60's = D(eadly): resp. failure

assess respiratory
give O2
prepare to intubate and ventilate
call resp. therapy
call doc

O2sat
93-100
< 93 = C(ritical)
assess respiratory
give 02

BNP
good indicator of CHF
< 100
elevated = B(e concerned)

sodium
135-145
abnormal = B(e concerned)
if change in LOC = C(ritical) -> fall risk

WBC's
WBC: 5000-11000

ANC: 500

CD4 count: <200 = AIDS

any of these that are low mean critical

neutropenic precautions
strict handwashing
shower BID with antimicrobial soap
avoid crowds
private room
limit # of staff entering room
limit visitors to healthy adults
no fresh flowers or potted plants
low bacteria diet: no raw fruits, veggies, salads, no undercooked meat
do not drink water that has been standing longer than 15 minutes
VS (temp) q4h
check WBC (ANC) daily
avoid use of indwelling catheter
do not re-use cups
use disposable plates, cups, straws, etc
dedicate items in room

platelets
150000-400000

< 90000 = C(ritical)

< 40000 = D(eadly)
bleeding precautions
no unnecessary venipuncture- injection or IV. use small gauge
handle pt gently; use draw sheet
use electric razor
no toothbrush or flossing
no hard foods
well-fitting dentures
blow nose gently
no rectal temp, enema, suppository
no aspirin
no contact sports
no walking in bare feet
no tight clothes or shoes
use stool softener, no straining
notify MD of blood in urine or stool

RBC's
4-6
abnormal= B(e careful)

laminectomy:
treat nerve root compression
S&S of nerve root compression:
-pain
-paresthesia
-paresis

locations of laminectomy
cervical (neck)
thoracic (upper back)
lumbar (lower back)

Pre-op cervical laminectomy

diaphragm and arms
most important assessment: breathing, respiratory assessment, arm fx

Pre-op thoracic laminectomy

most important assessment: cough, bowel sounds, abdominal wall muscles and gut

pre-op lumbar laminectomy

most important assessment: bladder: when they last voided, bladder scanner, leg fx

post-op care for laminectomy

LOG ROLL
may walk/stand/lie down w/o restrictions
do not dangle these pts
sitting is worst position for your back, limit for 30 min at a time

post-op complications for laminectomy

cervical: pneumonia
thoracic: pneumonia, paralytic illeus
lumbar: urinary retention

laminectomy with fusion

taking bone graph from iliac crest
hip is most painful
hip has most drainage/bleeding
hip and back have same risk for infection
back has most risk for rejection

laminectomy temporary restrictions

don't sit for longer than 30 min for 6 weeks
lie flat and log roll for 6 weeks
no driving for 6 weeks
do not lift more than 5 lbs for 6 weeks

laminectomy permanent restrictions

laminectomy pts will never be allowed to lift by bending at waist-> bend at knees
cervical laminectomy pt will never be allowed to lift objects about their heads ->use
step stool
no horseback riding, off-trail biking, jerk amusement park rides, etc

Nagele's rule
take first day of last menstrual period
add 7 days
subtract 3 months

weight gain during pregnancy

total weight gain: 28 lbs plus/minus 3 lbs
1st trimester weight gain: 1 lb per month = 3 lbs
2nd/3rd trimester 1 lb per wk

after 12 weeks, week # - 9 = lbs

fundal height landmarks

fundus is not palpable until week 13

fundus typically reaches the umbilical level at week 20/22

positive signs of pregnancy

fetal skeletal on x ray
fetal presence on ultra sound
auscaltation of fetal heart ~10 weeks
examiner palpates fetal movement/outline

probable/presumptive signs of pregnancy:

all urine and blood pregnancy tests
Chadwick sign: Cervical Color Change to Cyanosis
Goodell's sign: cervical softening
Hegar's sign: uterine softening

pattern of office visits when pregnant

once a month until week 28
once every two weeks until 36
once a week until delivery/42 weeks

discomforts of pregnancy
morning sickness
urinary incontinence/frequency
dyspnea
back pain
morning sickness: 1st trimester, dry carbs before getting out of bed

urinary incontinence/frequency: 1st and 3rd, void q2h, do not do kegels

dysnpea: 2nd/3rd, tailor sitting/tripod position

back pain: 2nd/3rd, pelvic tilt exercise `

dilation
opening of cervix (0-10 cm)

effacement
thinning of cervix (thick-100%)

station
relationship of fetal presenting part to mom's ischial spine

negative station is bad, baby is above ischial sprine

positive station baby can be born vaginally

engagment
station 0

lie
relationship between spine of baby and spine of mom
parallel = vertical lie = good

perpendicular = transverse lie = bad

presentation
part of the baby that enters the birth canal fist

four stages of labor and delivery

stage 1: labor (Iatent, active, transitional)
stage 2: delivery of baby
stage 3: delivery of placenta
stage 4: recovery (2 hrs after placenta delivery)

assessment of contractions
frequency
duration
intensity
frequency: beginning of one contraction to the beginning of the next
duration: beginning to end of one contraction
intensity: strength of contraction. palpate with one hand over the fundus with
fingertips

painful back labor

1-position in knee-chest
2-push on sacrum

prolapsed cord
1- push head up
2- position: knee-chest/trendelenberg/elevate hips on pillow
3- immediate c-section

interventions for all other complication of labor and birth

Left side
Increase IV
Oxygenate 10l->mask
Notify physician
PITocin <- Stop usually before LION but only if they say its running

pain meds in labor

do not administer systemic pain meds to a woman in labor IF the baby is likely to be
born when the med is peaking

fetal monitor patterns

low fetal HR
FHR acceleration
low baseline variability
high baseline variability
late decelerations
early decelerations
variable decelerations
Low: under 110 -> LIONPIT
FHR: document
Low: LIONPIT
high: document
late decel: LIONPIT d/t placenta
early decel: head compression
variable: VERY BAD->prolasped cord, push->position

what do you always check

FETAL HEART RATE

second stage of labor and delivery order

deliver head
suction mouth and nose
check for cord around neck
deliver shoulders and body
make sure baby has an ID band on before leaves mothers side

delivery of placenta
make sure it's all there ->retained placenta = hemorrhage then infection
3 blood vessel 2 arteries and 1 vein

recovery stage
first 2 hrs after placenta delivery
4 things you do 4 times an hour in 4th stage:
1-VS assess for S&S of shock
2-fundus needs to be firm-> if boggy, massage. if displaced void/cath
3-pads-> excessive lochia=pads sat in <15 min
4- roll her over-> check for bleeding under pt

Postpartum uterus
tone: firm if boggy massage
height: fundal height = day PPD (3 PPD = 3 cm below navel)
location: midline uterus left or right means drain bladder

lochia PP
rubra = red
serosa = pink
alba = white

amount:
moderate = 4-6 inches on pad in one hour
excessive = saturate pad in <15 min

tocolytics: stop premature labor

terbutaline
nifedipine
terbutaline (breathine): causes maternal tachycardia

nifedipine: Ca+ channel blocker, causes maternal bradycardia

oxytocics: start labor and make more powerful

pitocin
cervidil
pitocin (oxytocin): causes uterine hyperstimulation -> contractions longer than 90
seconds and closer than 2 minutes. used for PP hemorrhage (pitocin and
methergine)

cervidil (prostaglandin): can start uterine contractions

fetal/neonate lung meds

bethamethasone/steriods
survanta
bethamethasone: increases BP and BS. don't give to DM or preeclampsia. give to
mother IM before baby is born

survanta: give to baby after birth through breathing treatment/ventilator

humulin 70/30 insulin

mix of R&N
70% N 30% R
ex.) 50 u of 70/30
= n: 35 r:15

drawing up insulin
N-1-put air = to dose into end of vial
R-2-put air into R
R-3-pull up R
N-4-pull up N

IM vs SQ
IM: 1 in gauge and 1 in inches
SQ: 5 in gauge and 5 in inches

heparin vs coumadin
heparin:
works immediately
IV&SQ
21 days only (max)
antidote; profamin sulfate
labs: PTT
can be give to pregnant woman "C"

coumadin
takes days
oral only
given over a long time
antidote is vit k
labs: only PT (INR)
cannot be given to pregnant woman "X"

K+ sparing vs wasting diuretics

dine, zide, mide = K+ wasters

tone= K+ sparing

baclofen (lioresal)
muscle relaxants
"back loafin"

1-cause drowsiness
2-cause fatigue
3-don't drink alcohol
4-don't drive car
5-don't be responsible for kids under 12

0-2 yr piaget
sensiormotor
totally present-oriented only think about what they SENSE or DOING right now

when: as you're doing

what: you're doing
how: verbal

3-6 yr piaget
pre-operational

fantasy-oriented, illogical, no rules

when: hour/2hr/morning/ same day

what: you're going to do
how: play

7-11 yr piaget
concrete operational

rule oriented, live and die by the rules, cannot abstract

when: days ahead

what: you're going to do
how: skills-reading/audio

12+ piaget
formal operational

able to think abstractly, understand cause-effect

teach like an adult

lung sounds
crackles: discontinuous d/t fluid in airway. give diuretic (zide)
wheezes: continuous d/t narrowing of airways. give albuterol or steriod (sone)

heart sounds
S1: d/t closure of mitral and tricuspid, blood hits them. "lub". louder when
stethoscope is by mitral valve

S2: when blood hits closed arotic/pulmonic valves. "dub" louder when stethoscope
is by aortic valve

sound 2 is loudest in space (ICS) 2

bruits: turbulent blood flow in artery. always bad unless AV fistula

stages of pressure sores

stage 1: no break in skin integrity-nonblanching erythemia
stage 2: skin broken; tissue in wound roughly same color as skin
stage 3: skin broken all way through dermis in SubQ; yellow fat
stage 4: skin broken down to muscle/bone; white/bright red

4 rules for prioritization

acute beat chronic
fresh postop (first 12 hrs) beats medical or other surgical
unstable beats stable

things that make a pt stable

use of "stable"
chronic illness
post op 12+ hrs
local/regional anesthesia
unchanged assessment
phrase: "to be discharge"
lab values "A&B"

STABLE PTS ARE EXPERIENCING THE TYPICAL S&S OF THE DISEASE WITH WHICH
THEY HAVE BEEN DX AND ARE RECEIVING TREATMENT

things that make pt unstable

use of "unstable"
acute illness
post-op < 12hrs
general anesthesia
changed assessment
use of "newly"
lab values "C&D"

UNSTABLE PTS ARE EXPERIENCING UNEXPECTED S&S, COMPLICATIONS

always unstable:
hemorrhage
hypoglycemia
hyperpyrexia
pulselessness and breathlessness

tie breakers for prioritization

more vital the organ the higher the priority
1-brain
2-lung
3-heart/CV
4-liver
5-kidney
6-pancreas

do not delegate to LPN

starting an IV
hanging/mixing IV meds
evaluating anything
giving IV push
giving blood transfusion
performing admission, discharge, transfer assessment
planning of care
developing or performing teaching (can reinforce and review)
taking verbal orders from MD or transcribing orders

do not delegate to UAP

charting-can document what they did
assessments-except for VS&Accucheck
pass meds-may apply OTC topical lotions/creams
treatments-except for SSE (soaps, suds, enemas)
you may delegate ADLs

do not delegate to family

safety responsibilities, they can only do what you teach them to do

staff management, 4 options

1-tell supervisor (if its illegal)
2-confront and take over (immediate danger/harm)
3-counsel later on (inappropriate)
4- NEVER IGNORE

depression
diet: high fiber, prepare everything
activity: group, no interaction required
safety: self destructive behavior

schizophrenia
diet: high fiber, do not prepare anything
activity: group w/ interaction
safety: other destructive behaviors

bipolar/mania
diet: high calorie finger foods
activity: gross motor, physical activity w/o competition
safety: accidents

anxiety disorders
diet: regular
activity: physical activity w/ competition
safety: not a problem

violent clients
calm down first
need 5 people to restrain them
only one person talks

psychotropic drugs cause...

low BP and weight gain

phenothiazines
end in -zine
actions: reduces symptoms
-large doses: psychotic
-small doses: antiemetics
-major doses: tranquelizers

side effects:
Anticholenergic ->dry mouth (xoerstomia)
Blurred vision and bladder retention
Constipation
Drowsiness
Extrapyramidal symptoms
Fotosensitivities
aGranulocytosis->immunosupressed

nursing care: treat side effects, safety

deconate
after the name of a drug means it is a long acting IM form given to non compliant pts

tricyclic antidepressants
"mood elevators"
have -trip- in them

side effects
Antichlonergic->dry mouth
Blurred vision and bladder retention
Constipation
Drowsiness
Euphoria

must take meds for 2-4 weeks before beneficial effects

benzodiazepines
antianxiety meds (minor tranquelizers)
always have -pam or -lam

indications:
induction of anesthetic
muscle relaxant
alcohol withdrawal
seizures--especially status epilepticus
facilitates mechanical ventilation

most not take for more than 3 months

stay on until other meds kick in

side effects:
Antichlonergic ->dry mouth
Blurred vision and bladder retention
Constipation
Drowsiness

nursing dx=safety

monoamine oxidase MAO inhibitors

anitdepressants
DIET
prevent breakdown of norepinephrine, dopamine, and serotonin

mar-plan
nar-dil
par-nate

side effects
Antichlonergic ->dry mouth
Blurred vision and bladder retention
Constipation
Drowsiness

Preventing hypertensive crisis with MAO inhibitors pts must avoid food containing...
tyramine:
avoid: fruits and veggies: salad "bar":
-Bananas
-Avacados
-Raisins (any dried fruit)

grains: all okay excepts things made from active yeast

Meats:
no organ meat: liver, kidney, etc
no preserved meats: smoked, dried, cured, pickled, hotdogs

dairy:
no cheese expect for mozzarella and cottage cheese
no yogurt or aged cheese

other:
no alcohol, elixirs, tinctures, caffeine, chocolate, licorice, soy sauce

lithium
an electrolyte
treats bipolar by decreasing mania

side effects
peeing
pooing
paresthia

toxic: tremors, metallic taste, sever diarrhea

-#1 intervention: increase fluids
-if sweating give sodium as well as fluids

prozac
SSRI-> -xep- -xet-
tricyclic antidepressant
Side effects: ABCDE

causes insomnia, give before noon.

if BID give at 0600 and 1200

changing dose watch for suicide

haldol
deconate form

elderly patients may develop NMS from overdose. Neuroleptic malignant

syndrome--potentially fatal hyperpyrexia with temp of 104 F

dose for elderly pt should be half of usual adult

clozaril
schizoprenia

agranulocytosis!!!!

zoloft
causes insomnia but CAN give in the evening

watch for interactions with St. John's wort- serotonin syndrome

S-sweating
A- apprehension
D- dizziness
Head-headache (splitting)

warfarin-watch for increased bleeding