Anticholinergic vs Cholinergic effects

ANTICHOLINERGIC	CHOLINERGIC
· ¯ Mucus · Bronchodilation · Dry mouth · Dry eyes · Urinary retention · Dry skin · Constipation · Shut down GI · Prevents V when trying to intubate	· Bronchorrhea (large amounts of mucus in airway) · Bronchoconstriction · Salivation · Lacrimating · Urination · Diaphoresis/Diarrhea · GI Upset · Emesis

pH UP ­ K¯ [ALKALOSIS]	pH DOWN ¯ K­ [ACIDOSIS]
· Tachycardia · Tachypnea · Diarrhea · Tremors · Seizure (need suction) · Hyperreflexia · Agitated · Borborygmi (­ bowel sounds) · Hypertension · Palpitations · Tetany · Anxiety/Panic · Poly	· Bradycardia · Bradypnea · Hypotension · ¯ lucidity · anorexia · coma · lethargy · cardia arrest · suppressed, decreased, falling · hyporeflexia · obtunded · paralytic ileus · respiratory arrest (need ambu bag)

UPPERS ­	DOWNERS¯
Names: · Caffeine · Cocaine · PCP/LSD (Psychedelic hallucinogens) · Methamphetamines-speed · ADHD- adderrall/Ritalin · Bath Salts (Cath-Kath)	Names: · Everything else
Signs/Symptoms: · Tachycardia · Hypertension · Diarrhea, borborygmi · Agitation · Tremors · Clonus · Belligerence · Seizures, need suction · Exaggerated, shrill, high pitched cry · Difficult to console	Signs/Symptoms: · Bradycardia · Hypotension · Constipation · Constricted pupils · Flaccidity · Respiratory arrest, need ambu bag · Decreased core body temp

Overdose/Intoxication	Withdrawal
“I have too much…”	“I don’t have enough..”
Too much upper: à Everything is UP ­	Too little upper: à Everything is DOWN ¯
Too much downer à Everything is DOWN ¯	Too little downer: à Everything is UP­

AWS	DT’s	BOTH
Semi-private-anywhere	Private-near nurses station	Anti-hypertensives
Regular diet	Clear liquids or NPO	Tranquilizer
Up Ad Lib (no activity restriction)	Restricted bedrest (no bathroom privileges)	B1 multi-vitamin (to prevent Wenicke Korsakoff)
Do not restrain	Should be restrained (2 pt leather restraints) 2 extremity restricted—arm on one side and leg on one, one upper extremity and one opposite lower extremity

ROUTE	TROUGH (lowest)	PEAK (highest)
Sublingual	30 min before next dose	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.

• Dies from respiratory failure

3. Chemical Agents
   1. Mustard Gas à Blisters (Vesicant, eventually cover airway)
   2. Cyanide à Respiratory arrest. Treat with Sodium Thiosulfate IV
   3. Phosgine chloride à Choking
   4. Sarin à Nerve agent.
      1. Symptoms (Cholinergic Effects)
         1. Bronchorrhea
         2. Bronchoconstriction
         3. Salivation
         4. Lacrimating
         5. Urination
         6. Diaphoresis/diarrhea
         7. GI upset
         8. Emesis
      2. All chemical agents require only soap and water cleansing except for Sarin, which requires a bleach
         1. Nursing Actions: Bioterrorism- Isolation, Antibiotics
         2. Chemical: Decontamination
            1. Send all suspected cases to decontamination center
            2. Remove all clothing

• Chemical hazard double bag

1. Incinerated
2. Shower in soap and water (bleach- sarin)
3. Discharged in government clothes

CALCIUM CHANNEL BLOCKERS

Note: They are like Valium for your heart. When you want to rest your heart

1. Calcium Channel Blockers: Negative [ ino, chrono, dromo ] cardiac depressant

Dig is only drug that mixes + & - effects; other 99% either have + or -

2. What do Calcium Channel Blockers treat? (Indications)
   1. Antihypertensives (BP way UP-relaxes blood vessels)
   2. Antianginal (relaxes- reduces O2 demand) decreasing oxygen demand, relaxes heart
   3. Anti Atrial Arrhythmia (does not tx ventricular arrhythmias) supraventricular arrhythmia
3. Side Effects(­):
   1. Headache (vasodilation in brain=migraine)
   2. Hypotension (relaxes heart
   3. Bradycardia
4. Names of Calcium Channel Blockers
   1. –soptin (Verapamil)
   2. –zem (Cardizem – continuous IV drip)
   3. –dipine
5. Nursing Actions: before administrating – BP systolic lower than 100..if < 100 hold and call Dr. Slow it down (titrate down), and measure again

CARDIAC ARRYTHMIAS

1. Terminology
   1. “QRS depolarization” always refer to ventricular (not atrial, junctional, or nodal)
   2. “P wave” refers to atrial
   3. Know normal sinus rhythms (P wave evenly spaced)
2. Six rhythms tested on NCLEX
   1. Asystole (flat line)
      1. A lack of QRS depolarization’s (a straight line)
   2. Atrial flutter
      1. Rapid P-wave depolarization’s in a saw-tooth (flutter)
   3. Atrial fibrillation
      1. Chaotic P-wave depolarization’s (lacks any discernable pattern)
   4. Ventricular fibrillation (squiggly line, no pattern)
      1. Chaotic QRS depolarization’s (squiggly line)
   5. Ventricular tachycardia (sharp peaks and jagged, pattern)
      1. Wide, bizarre QRS’s
      2. Tachy is always discernable repeating pattern
   6. Premature ventricular contractions (PVC)
      1. Periodic wide, bizarre QRS’s
      2. Generally low to moderate priority. unless everyone else has a normal rhythm

• Be concerned, if:
  1. More than 6 per minute
  2. 6 in a row
  3. PVC falls of T-wave of previous beat

3. Lethal arrhythmias
   1. Asystole
   2. V-fib
4. Potentially life threatening arrhythmia: V-tach
   1. Pulseless v-tach; same as asystole and v. fib and would depend on how long down
   2. After 8 mins consider dead
5. Treatment
   1. PVC’s
      1. Lidocaine (Ventricular, lasts longer), Amiodorone
   2. V Tach
      1. Lidocaine
   3. Supraventricular arrhythmias
      1. Adenosine (push fast IV push; usually 8s or faster)
      2. Beta-Blockers (-lol)

• Calcium Channel Blockers

1. Digoxin (Digitalis) Lanocin

1. V-Fib
   1. Best treatment electrically
   2. Shock = 200 Defibrillate
2. Asystole
   1. Epinephrine
   2. Atropine

• S/E anticholinergics

CHEST TUBES

The purpose for chest tubes is to re-establish negative pressure in the pleural space

1. In a pneumothorax, the best tube removes air
2. In a hemothorax, the chest tube removes blood
3. In a pnemohemothorax, the chest tube removes air and blood

Location of chest tubes:

1. Apicals (HIGH) for Air
   1. Label “A”- up high
2. Basilar (LOW) for Blood
   1. Label “B”- placed at base; bottom of lung

Examples

1. How many chest tubes (and where) for unilateral pneumohemothorax?
   1. 2; apical and basilar all on same side
2. How many chest tubes (and where) for bilateral pneumothorax?
   1. 2; apical right and left
3. How many chest tubes (and where) for post-op chest surgery?
   1. 2; apical and basilar unilateral
   2. Exception: If surgery total pneymonectomy then à no chest tube bc no pleural space
   3. Always assume chest trauma and surgery is unilateral

Problem Solving

1. What do you do if you kick over the collection bottle?
   1. Not a big deal; can just sit it right back up; have take a couple deep breaths
2. What do you do if the water seal breaks?
   1. This is more serious, because it is allowing air in creating a 2 way
   2. First: Clamp chest tube (Better no way than 2 way for brief period of time) **in routine care never clamp chest tube!!
   3. Best: Submerge
      1. Cut tube away (down) by device; submerge under water preferably sterile-then unclamp
   4. What do you do if the chest tube comes out?
      1. First: cover hole with gloved hand; Vaseline gauze dressing; 4 sided sterile dressing; tape
      2. Best: Vaseline gauze
   5. Bubbling
      1. Ask yourself two questions:
         1. WHEN is it bubbling
         2. WHERE is it bubbling

5. Rules for clamping the tube:
   1. Never clamp for longer than 15 seconds without a Dr.’s order
   2. Use rubber tipped double clamp

CONGENITAL HEART DEFECTS

Every congenital heart defect is either TROUBLE or NO TROUBLE

T R o u B L e

R-L àBlood shunts,

B àCyanotic,

T àAll CHD’s beginning with “T” are trouble

Exception à Left ventricular hyperplasic syndrome

All CHD kids have two things whether trouble or not:

1. Murmur, because of shunt of blood
2. All get echocardiogram done (@ least 1)

Four defects present in Tetralogy of Fallot:

1. VarieD à Ventricular Defect
2. PictureS à Pulmonic Stenosis
3. Of A à Overriding Aorta
4. RancH à Right Hypertrophy

CRUTCHES, CANES, & WALKERS

1. How to measure: 2-3 finger widths below anterior anxillary fold to a point lateral to and slightly in front of foot
2. When the handgrip is properly placed, the angle of elbow flexion will be 30 degrees
3. Types of gaits:
   1. 2-Point Gait
      1. Step One: Move one crutch and opposite foot together
      2. Step Two: Move other crutch and other foot together

• Remember: 2 points together for a 2 point gait

1. Examples: one knee replacement

1. 3-Point Gait
   1. Step One: Move two crutches and bad leg together
   2. Step Two: move good foot by self

• Remember: 3 point is called 3 point because three points touch down at once

1. Examples: Stairs

1. 4-Point Gait
   1. Step One: One crutch
   2. Step Two: Opposite foot

• Step Three: Other Crutch

1. Step Four: Other food
2. Examples: total both knee right after surgery

1. Swing-through: for two braced extremities
   1. Examples: arthritis braced legs
2. When to use each gait
   1. Use the even numbered gaits (2&4 point) when weakness is evenly distributed (bilateral). Two point for mild problem; four-point for severe problem
   2. Use the odd numbered gait (3 point) when one leg is odd (unilateral problem)
3. Stairs: which foot leads when going up and down stairs on crutches?
   1. Remember: UP with the good; DOWN with the bad
   2. The crutches always move with the bad leg
4. Cane
   1. Hold can on the strong (unaffected) side
   2. Advance cane with the weak side for a wide base of support
5. Walkers
   1. Pick it up, set it down, walk to it
   2. Tie belongings to side of walker, not front
   3. Getting out of chair to walker- always push, never pull (same for cane, crutches)

DELUSIONS, HALLUCINATIONS, & ILLUSIONS

1. Psychotic vs Non-Psychotic
   1. A non-psychotic person has insight & is reality based
   2. A psychotic person has NO insight and is NOT reality based
2. Delusions
   1. Definition: a delusion is a false, fixed belief or idea or thought. There is no sensory
   2. Three types of delusions:
      1. Paranoid or Persecutory: false, fixed belief that people are out to harm you.
      2. Grandiose: False, fixed belief that you are superior

• Somatic: False, fixed belief about parts of your body

3. Hallucinations
   1. Definition: a hallucination is a false, fixed sensory experience
   2. Five types of hallucinations:
      1. Auditory (most common* hearing)
      2. Visual

• Tactile

1. Olfactory
2. Gustatory

4. Illusions
   1. Definition: An illusion is a misinterpretation of It is a sensory experience.
   2. Differentiation between illusions & hallucinations: with illusions there is a referent in reality
5. When dealing with a patient experiencing delusions, hallucinations or illusions, first ask yourself, “What is their problem?”
   1. Functional Psychosis
   2. Psychosis of Dementia
   3. Psychotic Delirium
6. Functional Psychosis
   1. These are:
      1. Schizophrenia
      2. Schizoaffective Disorder

• Major Depression

1. Mania

1. Patient has the potential to learn reality
2. Four steps:
   1. Acknowledge how they feel
   2. Present reality

• Set a limit

1. Enforce the limit

7. Psychosis of dementia
   1. These are:
      1. Alzheimers
      2. Senility

• Organic Brain Syndrome

1. Post Stroke
2. Wernickes

1. This patient has a destructive problem and cannot learn reality.
2. Two steps:
   1. Acknowledge their feelings
   2. Redirect
3. Psychotic delirium
   1. Description: Episodic, temporary, sudden onset, dramatic, loss of reality, secondary to a chemical imbalance
   2. Two steps:
      1. Acknowledge their feeling
      2. Reassure (it will get better, I will keep them safe)
   3. Loosening of association
      1. Flight of Ideas: stringing phrases together
      2. Word salad: string words together
      3. Neologisms: making up new words
   4. Narrowed self-concept:
      1. when a PSYCHOTIC refuses to:
         1. Leave the room and refuses to change their clothing
         2. Action- do not make them! Tell them they can wait until they are ready
      2. Ideas of reference
         1. When you think everyone is talking about you

DIABETES MELLITUS

1. Definition: DM is a error of glucose metabolism
   1. (vs Diabetes Insipidus polyuria, polydipsia leading to dehydration)
2. Types:
   1. Type I
      1. Insulin dependent
      2. Juvenile Onset

• Ketosis prone (tend to make ketones)

1. Type II
   1. “Non” all the above
   2. “Non” insulin dependent

• “Non” juvenile onset

1. “Non” ketosis prone

3. Signs and Symptoms
   1. Polyuria
   2. Polydipsia
   3. Polyphagia
4. Treatment
   1. Type I
      1. Diet (3)
      2. Insulin (1)

• Exercise(2)

1. Type II
   1. Diet (1)
   2. Oral hypoglycemics (3)

• Activity (2)

1. Diet (type II)
   1. Calorie restriction
   2. Need to eat 6x a day
2. Insulin acts to lower blood sugar
   1. Types of insulin

Never put anything cloudy in IV bag

AC before meal

PC after meals

1. Check expiration date
   1. After open new expiration date 20-30 days after opening

• Refrigeration (unopened): optional for opened; necessary for unopened

1. Exercise Potentiates (decreases) (exercise is like getting another shot of insulin) insulin:
   1. If more exercise, need decrease insulin and more fast carbohydrates
   2. If less exercise, need increase insulin
2. Sick days
   1. Take insulin (even if not eating!)
   2. Take sips of H20 to prevent dehydration

• Stay as active as possible

1. 2 problems – hyperglycemia & dehydration

5. Complications of DM
   1. Low Blood Sugar in Type I DM (=insulin shock) [Hypoglycemia]
      1. Causes:
         1. Not enough food
         2. Too much exercise
         3. Too much insulin (overmedicated)
      2. Danger:
         1. Permanent brain damage

• Signs and Symptoms
  1. Drunk, In Shock = hypoglycemia

Cerebral impairment & vasomotor collapse (blood vessel wall muscles don’t have enough E to maintain tone) à slurred speech, staggered gait, slow reaction time, uncontrolled emotions (labile), lowered BP, increased pulse, tachypnea, skin pale, mottled, patchy, cold, clammy, inattentive to social boundaries

1. Treatment
   1. Administer rapidly metabolizable Carbohydrates (sugar)
   2. Ideal combination: food with sugar and protein (& maybe starch) crackers and orange juice, apple juice and slice of turkey (1/2 cup skim milk)
   3. If unconsciousness: Nothing! Glucagon IM, Dextrose (D10, D50) IV, never anything in mouth!
2. High Blood Sugar in Type I DM- DKA Diabetic Coma [Hyperglycemia]
   1. Causes:
      1. Too much food
      2. Not enough insulin
      3. Not enough exercise
      4. #1 cause is acute viral upper respiratory infection within the last week or two – have they had a viral infection w/in last 2 weeks?
   2. Signs and Symptoms
      1. Dehydration (appear dry, hot, flush, HA, pulse weak, thready, increase in temp, headache)
      2. Ketones (in blood); increase in K+; Kussmaul respirations (deep, rapid breathing, hyperventilate)
      3. Acidodic (metabolic); acetone (fruity) breath; anorexia with nausea

• Treatment
  1. D5 IV with regular insulin @ 200/hr at high flow rate

1. Low Blood Sugar in Type II DM (Hypoglycemia)
   1. Treatment is the same as for low BGM in Type I Diabetes
2. High Blood Sugar in Type II DM (Hyperglycemia)
   1. Called HHNK (or HHNC):
      1. Hyperosmolar, hyperglycemic, non-ketotic coma
   2. This is dehydration

• Signs & symptoms are like S&S of dehydration
  1. Including: increased temp

1. Treatment:rehydrate (glucose will usually turn to normal on own)

1. Long term complications are related to two problems:
   1. Poor tissue perfusion, renal failure, don’t heal as well
   2. Peripheral neuropathy (nerve damage) loss control of bladder, can’t feel when injure
2. Which lab test is the best indicator of LT BGM control (compliance/effectiveness) ? Hemoglobin A1C (glycosolated hemoglobin)
   6. HA1C for dx à >6.5 à DM/pre DM (want to see <6)
   7. Monitoring tx à >8.0 out of control, 7 is maybe

DRUG TOXICITIES

• Total bilirubin: 0-1.0 mg/dl
• Direct (conjugated) bilirubin: 0-0.3 mg/dL
• Indirect (unconjugated) bilirubin: 0-0.3 mg/dL
• Pathologic jaundice: high at birth, baby yellow at birth - dangerous
• Physiologic jaundice: normal at birth, next 2-3 days, high in bilirubin

DUMPING SYNDROME VERSUS HIATAL HERNIA

ELECTROLYTES

Patient has diarrhea, what caused it?

Hypokalemia X

Hyperkalemia

Hypocalcemia X

Hypomagnesemia X

Tetany (low)

Hypokalemia

Hyperkalemia

Hypocalcemia

The earliest sign of any electrolyte disorder is numbness (paresthesia) & tingling

The universal sign/symptom of electrolyte imbalance is muscle (paresis) weakness

ELECTROLYTE TREATMENT

1. Never push Potassium IV [Fatal]
2. Not more than 40 mEq of K+ per liter of IV fluid [clarify if over 40]
3. Give D5W with regular insulin to decrease K+ [carrier mediated transport]
4. Kayexalate [K-exit-late]
   1. Puts drug in gut, full of sodium; Na picked up by bloodstream; Doesn’t need that much + charge, so body exchanges for K, diarrhea)
   2. B/C is slow à do this with D5W + insulin

Potassium (K+) imbalance, give Kayexalate with D5W and insulin

ENDOCRINE OVERVIEW

Thyroid (thyroidism=metabolism)

1. Hyperthyroidism (Hyper-Metabolism)
   1. Signs & Symptoms
      1. ¯ weight ¨ tachycardia ¨­ BP¨ Agitation¨ Restlessness¨ nervousness ¨ diarrhea¨ ­ energy¨ bulging eyes (exophthalmos)¨ warm¨ <3 organ most effective, heat intolerance (already burning)

1. Graves Disease [literally run self into grave]

• The problem is hyperthyroidism. Treatment options:
  1. Radioactive Iodine (should be by themselves for 24hrs)
     1. Watch out for urine [DANERGOUS]
        1. Use private bathroom
        2. Flush 3 times
     2. PTU (Propothyroiduricil) puts thyroid under
        1. Cancer drug-knocks out cells metastizing problem- agranulocytosis (¯ WBC)
        2. Education- isolation, wear mask, no kids
     3. Surgical removal
        1. Thyroidectomy (remove thyroid)
           1. Total thyroidectomy
              1. Need lifelong T3, T4 hormone replacement
              2. At risk for hypocalcemia (bc at risk for losing parathyroid gland)
              3. S/S hypocalcemia: tetany, spasm, clonus, seizure, tachycardia, Chvostek, Trousseau
                 1. Earliest sign: paresthesia
              4. Subtotal (partial) thyroidectomy
                 1. At risk for thyroid storm (thyroid crisis)
                 2. S/S thyroid storm:
                    1. Very high fever >105 F
                    2. Very high BP
                    3. Severe tachycardia
                    4. Psychotic Delirium *life threatening priority (causes brain damage)
                 3. Treatment
                    1. Wait out: either die, come out, give O2 (per mask at 10L) and lower body temp
                    2. Tx focuses on saving the brain until they come out of it
                    3. Lowering body temp:
                       1. Ice packs (first way): on axilla, axilla, groin, groin, back, neck
                       2. Cooling blanket (best way)

• Post-op risks1^st 12 hours airway & hemorrhage
  • **after first 12 ours it is assumed that the patient is stable
  • Post-op risks12-48 hours for TOTAL: ¯ calcium (tetany, langyeal tetany closes airway)
  • Post-op risks12-48 for SUB-TOTAL: Thyroid storm
  • Total= tetany, Sub=storm

2. Hypothyroidism (Hypo-Metabolism) MYXEDEMA
   1. Signs & Symptoms
      1. ­ weight¨ cold¨ sluggish¨slow¨ decreased BP¨bradycardia¨ hair and nails brittle¨decreased E

1. Name of disease: myxedema
2. Treatment: thyroid pills – levothyroxine, synthoid
3. Caution: DO NOT sedate these patients! (already ¯ )
4. Surgical Implication: call anesthesiologist and ask if thyroid pills should be held. Do not do well with anesthesia. NEVER HOLD THYROID PILLS

Adrenal Cortex Diseases (start with letters A or C)

1. Addison’s Disease (time bombs – decompensate rapidly)
   1. Under secretion (too little) of adrenal cortex
   2. Signs & Symptoms

• Hyperpigmented (3 or 4 shades darker than before)
• Inability to adapt normally to stress—sends off limit—shock (dec glucose, dec BP), adrenal gland is undersecreted

1. Treatment
   1. Give steroids [glucocorticoids and mineralcorticoids]
      1. Steroids all end in –sone (betamethasone, prednisone, hydrocortisone)
      2. Addison’s you Add a -sone (undersecretion)
   2. Cushing’s Syndrome
      1. Over secretion of adrenal cortex (cushy=more)
      2. Signs & Symptoms [also side effects of steroids -sone]
         1. Moon face, puffy
         2. Excess hair (hirsutism)

• Trunkal or central obesity (arms and legs skinny – muscle atrophy)

1. Gynecomastia (female breasts on men)
2. Buffalo hump
3. Retaining sodium and water, losing potassium

• Striae (stretch marks) on abdomen
• High glucose (hyperglycemic – look like diabetics)

1. Bruises easily
2. I’m mad, I have an infection – irritable, immunosuppressed

With steroids, need accuchecks since increase in glucose

1. Treatment: adrenalectomy (will create opposite disease)
   1. If bilateral adrenalectomy, will have Addison’s, will then give steroids, and then look like Cushman

INFECTIOUS DISEASE & TRANSMISSIONN-BASED PRECAUTIONS

Contact:

For :

1. Herpes,
2. anything Staph (MRSA),
3. Enteric (intestinal) [cholera, shigellosis, rotovirus], C. diff, Hep A
4. RSV (Respiratory Synctial Virus)
   1. [spread droplet; but research found this is best for precautions]

Droplet: For

1. ALL Viruses
2. ALL Influenzas [DTaP, Pertussis, Mumps]

Airborne:

For:

1. TB *spread drolet
2. Chicken Pox (varicella)
3. Measles
4. SARS (Severe acute respiratory system)

PERSONAL PROTECTIVE EQUIPMENT (PPE)

Unless otherwise specified, assume that PPE includes: Gowns, Goggles, Mask, Gloves

The proper place for donning (putting on) PPE is outside of the room

The proper order for donning PPE is:

1. Put on gown
2. Put on mask
3. Put on goggles
4. Put on gloves

The proper place  for removing (doffing) PPE is inside room, except mask

The proper order for removing PPE is:

1. Gloves
2. Goggles
3. Gown
4. Mask à need to take mask off outside so you don’t breathe in contaminated air

In airborne precautions ONLY, the mask is removed outside of the room

HANDWASHING AND GLOVING

Handwashing

Handwashing versus Scrubbing

Use an Alcohol-Based Solution

1. On entering or leaving a room
2. Before putting on gloves, after taking off gloves
3. Cannot à after soil hands!!

What about after using the rest room? à must use soap and water

Dry from cleanest (hand) to dirtiest (elbow)

Turn water off with new paper towel

Sterile Gloving

Glove dominant hand first.

Grasp outside of cuff.

Touch only the inside of glove surface.

Do not roll cuff.

Fingers inside of second glove cuff.

Keep thumb abducted back.

Only touch outside surface of glove

Skin touches inside of glove

Outside of glove only touches outside of glove

Remove glove to glove

Skin to skin

INTERDISCIPLINARY CARE

Identifying which patients need interdisciplinary care…different than prioritizingà who would most benefit from a team working together on their care

Patients who do not need interdisciplinary care: Patients who need or have multiple doctors

Patient who DO need interdisciplinary care:

1. Major Criteria
   1. Patients with multi-dimensional needs
      1. For example:
         1. Physical
         2. Psychological
         3. Social
         4. Spiritual
         5. Intellectual needs
      2. Patients who need rehabilitation
   2. Minor Criteria [choosing between patients]
      1. A patient whose current treatment is ineffective
      2. A patient who is preparing for discharge

LAB VALUES

A=ABNORMAL à Do Nothing

B= BE CONCERNED à Assess/Monitor

C=CRITICAL à Do Something

D = DEADLY DANGEROUS à Do Something NOW

Creatinine

• Best indicator of Kidney Function
• 6-1.2
• Elevated = A

INR (International Normalized Ratio)

• Monitors Coumadin (Warfarin) Therapy [Anticoagulant]
• Therapeutic 2-3
• > 4=C
  • Patient could bleed to death
  • Hold all warfarin
  • Assess for bleeding
  • Prepare to administer Vitamin K
  • Call Physician

Potassium (K+)

• 5-5.3
• Low=C [Hypokalemia]
  • Assess the heart (may include EKG which aid can do)
  • Prepare to give K+
  • Call physician
• 4-5.9 = C [Hyperkalemia]
• High but still in the 5’s
  • Hold K+
  • Assess heart (may include EKG which aid can do)
  • Prepare Kayexelate and d5W with regular insulin
  • Call physician
• > 6 = D Cardiac Danger Zone
  • Do steps simultaneously
  • Need help once levels hit 6; if cardiac symptomatic call rapid response team

pH

• 35-7.45 (as pH drops so does the patient)
• K+ can increase which can stop the heart
• Low pH in the 6’s = D [severe acidosis]
• Immediately assess vital signs
• Call dr if v/s bad, also call rapid response team

BUN [Blood Urea Nitrogen]

• 8-25
• 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 50’s = C
  • Assess respiratory status
  • Do have patient do pursed lip breathing (like blowing out candle)
• In 60’s = D Respiratory failure
  • Assess respiratory status; if symptomatic call rapid response
  • Do pursed lip breathing
  • Prepare ventilate and intubate
  • Call DR
  • 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
  • Assess respiratory status
  • Give oxygen
• Low < 60s =D Respiratory failure
  • Assess respiratory status
  • Give oxygen
  • Prepare intubate and ventilate
  • Call Dr
  • Call respiratory therapist
  • When someone is hypoxic, which rate increases first? – heart rate
  • 2 most common causes of episodic tachycardia in heart pts – hypoxia, dehydration

O2 Sat

• 93-100
• <93=C
  • Assess RR
  • Give O2

BNP

• Good indicator of CHF
• Normal <100
• Elevated=B

Sodium

• 135-145
• Abnormal =B (Hypo-Overload) (Hyper-dehydration)
• If change in LOC=C
  • Fall risk * Implement precautions and call dr

WBCs

• WBCs 5,000-10,000
  • WBC < 5000 = C
• Absolute Neutrophil Count (ANC) >500
  • ANC <500 =C
• CD4 Count (T Cells)
  • Should be greater than 200
  • <200= AIDS
  • CD4 < 200 =C
• For top three implement (NP) reverse isolation precautions:
  • Neutropenic Precautions:
    • Strict handwashing
    • Shower BID with antimicrobial soap
    • Avoid crowds
    • Private room
    • Limit number of staff entering the 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
    • Vital signs (temp) every 4 hours
    • Check WBC (ANC) daily
    • Avoid use of indwelling catheter
    • Do not re-use cups..must wash in between use
    • Use disposable plates, cups, straws, plastic knife, fork, spoon
    • Dedicated items in room: stethoscope, BP cuff, Thermometer, Gloves
  • Terminology:
    • High WBC Count
      • Leukocytosis
    • Low WBC Count
      • Leukopenia
      • Neutropenia
      • Agranulocytosis
      • Immunosuppression
      • Bone Marrow Suppression

Platelets (Thrombocyte Clotting Cell)

• Wide range 150,000-400,000
  • <90,000 = C
    • Assess for bleeding
    • Bleeding precautions
    • Call Dr
  • <40,000 = D
    • could spontaneously hemorrhage to death
    • Assess for bleeding
    • Bleeding precautions
    • Prepare for transfusion
    • Call DR
  • Bleeding Precautions(Thrombocytopenic Protocol):
    • No unnecessary venipuncture-injection or IV. Use small gauge
    • Handle patient gently; use drawsheet
    • Use electric razor
    • No toothbrush or flossing
    • No hard foods
    • Well fitting dentures (no rub)
    • 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, stool

RBCs

• 4-6 million
• Abnormal =B (check for bleeding)

Summary/Analysis

Know the 5 D’s which are the most dangerous

• K+ >6
• pH 6 & <6
• CO2 60’s and up
• pO2 60’s and down
• Plt <40,000

Know what to do for the C’s

Don’t spend time memorizing the A&B’s

When should you call a Rapid Response Team? When symptomatic! ASAP! Don’t call before assessing

LACINECTOMY AND SPINAL CORD

1. Definition:
   1. ‘Ectomy’ = ‘removal of’
   2. ‘Lamina’ = Vertebral spinous processes
2. Reason for laminectomy: to relieve nerve root compression
3. Signs & Symptoms of nerve root compression
   1. Pain [usually distal extremities]
   2. Paresthesia [numbness and tingling]
   3. Paresis [muscle weakness]
4. Locations :
   1. Cervical (neck)
   2. Thoracic (upper back)
   3. Lumbar (lower back)
5. Pre-op Assessment Cervical Laminectomy
   1. cervical spine innervates diaphragm and arms!
   2. Most important assessment:
      1. Breathing
      2. 2^nd: how are arms and hands functioning
   3. Pre-op Thoracic Laminectomy
      1. Thoracic innervates abdomen and bowel functions
      2. Most important assessment:
         1. Cough mechanism and bowel function
      3. Pre-op Lumbar Laminectomy
         1. Innervates bladder and legs
         2. Most important assessment:
            1. Bladder retention and leg function
         3. Post-Op Care
            1. #1 post op answer on NCLEX with spinal cord:log roll (move spine in ONE piece)
            2. Specific “activity”/mobilization strategy post-op
               1. Do NOT dangle (sitting-worst position for spine/back)
               2. Limit sitting for 30 minutes at a time

• May walk, stand, or lay without restrictions

1. Post-Op Complications
   1. Cervical: Watch for pneumonia (diaphragm and arm probs)
   2. Thoracic: Watch for asirational pnemonia (abdominal-paralytic ileus [bowel])

• Lumbar: Watch for urinary retention (bladder retention and lower extremity probs)

1. Laminectomy with fusion involves taking a bone graft from the iliac crest (most common site). (and fuse them)
   1. Of the two sites which site has the most:
      1. Pain? Hip
      2. Bleeding/drainage? Hip
      3. Risk for infection? 50/50 equal spine and hip
      4. Risk for injection? Spine site

Surgeons are using cadaver bone from bone banks. Why?

So don’t 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
   1. Temporary restrictions [normally always 6 weeks]
      1. Don’t sit for longer than 30 minutes
      2. Lie flat & Log roll for 6 weeks

• No driving for 6 weeks

1. Lifting restrictions: do not lift more than 5lbs for 6 weeks

1. Permanent restrictions [forever]
   1. Laminectomy patients will never be allowed to lift by bending at waist [must use knees]
   2. Cervical laminectomy patients will never be allowed to life objects above head

• No horseback riding, off-trail biking, jerky amusement park rides, etc

PEDIATRIC TEACHING

Piaget’s Stages of Intellectual Development

KIDS TOYS & Play activities

Three principles to consider when choosing appropriate toys..

1. Is it safe
2. Is it age appropriate
3. Is it feasible

Safety considerations:

1. No small toys for children 4 and under
2. No metal toys (diecast) where oxygen is in use
3. Beware of fomites (nonliving that harbors microorganisms [so if immunocompromised à no stuffed animals!]

Age Appropriateness:

1.First year of life

1. 0-6 months (sensorimotor)

 1)Best toy: musical mobile

2) 2^nd Best toy: Something large, soft (can’t be swallowed, no fomites)

1. 6-9 months (object permanence)

1)Best toy: cover/uncover toys [peak a boo]; jack in the box

2)2^nd Best toy: large, hard, plastic metal

1. 9-12 months

1)Best toy: verbal toy [toy which talks]

2)Purposeful activity with objects [@ 9 mos first start doing purposeful things]

Avoid answers with the following words in them for children 9 months and younger:

• Build
• Sort
• Stack
• Make
• Construct

2. Toddler (1-3 years)
3. Best toy push/pull toy [wagon]
4. Work on Gross motor
5. Characterized by parallel play [next to each other but not with]

3. Preschoolers (3-6 years)
4. Work on fine motor [puzzles, chalk, crayons]
5. Work on balance [dance, skate]
6. Characterized by cooperative play
7. They Like to pretend

4. School age (7-11 years)

Characterized by the 3 C’s

1. Collective [like to collect- ex. Beanie babies]
2. Creative [blank paper, coloring pencils, legos—need to make things into other things]
3. Competitive [winners & losers]

5. Adolescents (12-18 years)

Their “play” is peer group association (hang out in large groups, doing nothing)

Allow adolescents to be in each others’ rooms unless one of them is:

1. Immunosuppressed
2. Contagious
3. Fresh post-op (12 hours)

MEDICATION HELPS & HINTS

1. Humulin 70/30

2. Drawing up Insulin

• Pressurize Normal
• Pressurize Regular
• Draw up Regular [clear before cloudy]
• Draw up Normal

3. Injections

4. Heparin & Coumadin

K+ sparing vs K+ wasting Diuretics

Baclofen (Lioresal)

• Muscle relaxants
• Can take with Oxycodone & cut dose ½

1) Causes drowsiness

2) Relaxes muscles (muscle weakness)

3) No alcohol

4) No driving

5) Cannot supervise kids under 12 alone

PSYCHIATRIC NURSE TEST-TAKING

PRINCIPLES

Phase Specificity

The best psych answers are those answers that are most appropriate to the phase of the nurse-patient therapeutic relationship that you are in

If the question tells you the phase of the relationship, the phase will be the determinant of which answer is correct

The phases of the nurse-patient relationship:

The Pre-Interaction Phase

Purpose: For the nurse to explore his/her own feelings. To prevent judgmental, intolerant reactions.

Length: Begins when you learn you are going to be caring for someone and ends when you meet them.

Correct Answer(s): “The nurse will explore her/his own feelings about…”

The Introductory Phase

Purpose: To establish trust and explore/assess

Length: Begins when you first meet the patient and ends when a mutually agreed-upon care plan is in place

Key Words:

• These phrases are designed to hint to you that you are in the introductory phase:
  • “During the initial interview…”
  • “Upon admitting the patient..”
  • “On admission…”
  • “At your first few meeting with..”
  • “While assessing…”
  • “On the day of admission…”
  • “ While formulating nursing diagnoses…”

Correct answers: Should be very tolerant, accepting, explorative, probing, “nosy.” Be warm and fuzzy

The Working Phase (Therapeutic Phase)

Purpose: To implement the plan of care

Length: From the finished care plan until discharge

Key Words:

• “During the therapeutic interview…”
• “While implementing the care plan..”
• “While working on the care plan goals…”
• “During treatment sessions..”
• “During therapy..”
• “In your weekly session..”
• “Three days after admission…”
• “After improving..”

Correct Answers:

Should be very focused, directive, “tough.” In some ways these answers will seem stern and slightly unfriendly. Set limits. Enforce proper communication.

The Termination Phase

The only question asked here has been, “When does the termination phase begin?

The answer “On admission”

GIFT GIVING

In psych, do not give something of value to the patient. Conversely, do not accept something of value from the patient

A gift is something of tangible or intangible value given from one person to another.

Gifts include: hugs, kisses, compliments, opinions, holding hands, placing an arm around, etc

DO NOT do these behaviors in psych. (May be appropriate in med-surg)

Difference between complimenting and observing progress

ADVICE-GIVING

DO NOT GIVE ADVICE. Let the patient formulate own solutions and alternatives.

Remember, giving advice and setting limits are not the same. The former is bad, the latter is good.

KEY WORDS TO AVOID:

1. “Suggest that..”

2.”Advise the patient to..”

3. “Tell the patient to..”
4. “If I were you, I would…”
5. “You should do..”
6. “You ought to..”
7. “You should NOT do..”
8. “Don’t do…”
9. “Recommend that…”

Any words with these phrases violate this principle and are WRONG. RULE THEM OUT!

Always say, “And what do you think you should do, Mr. Smith?”

GUARANTEE GIVING

DO NOT GIVE GUARANTEES IN PSYCH. You cannot predict the human mind of know another’s experience

Giving guarantees is okay in Med/Surg—if true

KEY WORDS:

1. If you…then…”
2. “You will improve if you..”
3. “We can…”

A guarantee violates trust when the promised results do not appear

Only things can guarantee: 1) meds will work 2) you are safe

IMMEDIACY

The best psych answers communicate to the patient that the nurse is willing to deal with the patient’s problem right then and right there

Key Phrases:

AVOID answers like these

1. “Refer patient to…”

2.” Have you spoken to your…about this?”

3. “Why don’t you talk to your…about this?

Avoid changing the subject—unless you are refocusing a patient who is avoiding the subject of therapeutic session

CONCRETENESS

The best psych answers are those answers that say exactly what they mean in a literal sense—word for word

KEY PHRASES: Avoid slang, figurative speech, sayings, proverbs, verses, poetry, stories, parables, allegories, neologisms.

Tie-Breakers

1. “Why” questions are not as good
2. Reflection is good.
3. Open-ended is better than closed-ended.
4. Answers with I, me, we, us in the subject are not good.
5. Shortest answers are the best

PSYCH TREATMENT PROTOCOLS

EMPATHY

The best psych answers are those answers that communicate to the patient that the nurse accepts that patients feelings as being valid, real, and worthy of action.

Key Phrases: A low-empathy answer is always wrong

Avoid Saying:

1. “Don’t worry…”
2. “Don’t feel…”
3. “You shouldn’t feel…”
4. “I would feel…”
5. “Anybody would feel…”
6. “Nobody would feel…”
7. “Most people would feel…”

Four Steps to Answering Empathy Questions

1. Recognize that it is an empathy question

Empathy questions have a quote in the question, and each of the answers contains a quote.

2. Put yourself in the clients shoes. Say their words as if you really meant them.

3. Ask yourself, “If I said those words and really meant them, how would I be feeling right now?”

4. Choose the answer that reflects the feelings...not the answer that reflects their words.

PSYCHOTROPIC DRUGS

Note: All psych drugs cause a decrease in BP and weight change

1. Phenothiazines
   1. All end in –zine
   2. Very potent
   3. Immediate onset
   4. Thorazine, Compazine
   5. Actions:
      1. Does not cure disease. Reduces symptoms
      2. Large doses: Psychotic symptoms (Hallucinations…

• Small doses: Nausea/Vomiting

1. Major Tranquilizers

1. Side Effects: (remember ABCDEFG…)
   1. Anticholinergic Effects
   2. Blurred vision and Bladder retention

• Constipation

1. Drowsiness
2. Extra Pyramidal Syndrome (EPS)
3. FPhotosensitivity

• AGranulocytosis (low WBC count-immunosuppression)
• Teach patient to report sore throat and any S/S of infection to DR

1. Nursing Care: treat side effects. Number one nursing diagnosis is
2. “Deconate” after name of drug means it is long acting (at least 2 weeks to month) IM form given to non-compliant patients

2. Tricyclic Antidepressants
   1. Antidepressant
   2. “mood elevators” to treat depression
   3. Elavil, Tofranil, Aventyl, Desyrel
   4. –pram, -trip
   5. Side Effects: (Elavil starts with E so this group goes through E)
      1. Anticholinergic Effects
      2. Blurred vision and Bladder retention

• Constipation

1. Drowsiness
2. Euphoria

1. Must take meds for 2-4 weeks before beneficial effects

3. Benzodiazepines
   1. Antianxiety meds (considered minor tranquilizers)
   2. Always have –pam, -lam in the name
   3. Prototype: Diazepam (Valium)
      1. Zep – minors tranquilized in Led Zeplin concerts
   4. Indications:
      1. Induction of anesthetic
      2. Muscle relaxant

• Alcohol withdrawal

1. Seizures—especially status epilepticus
2. Facilitates mechanical ventilation

1. Tranquilizers work quickly
   1. Must not take for more than 90 days/3 weeks-3 mos
   2. Keep on Valium until Elavil kicks in
2. Side Effects:
   1. Anticholinergic Effects
   2. Blurred vision and Bladder retention

• Constipation

1. Drowsiness

1. #1 Nursing DX: Safety

4. Monoamine Oxidase (MAO) Inhibitors
   1. Antidepressants
   2. 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 normal levels and decrease depression.
   3. 2-4 weeks
   4. Drug Names:
      1. Mar-plan
      2. Nar-dil

• Par-nate

1. Side Effects
   1. Anticholinergic Effects
   2. Blurred vision and Bladder retention

• Constipation

1. Drowsiness

1. Interactions: (Patient Teaching)
   1. To prevent severe, acute, sometimes fatal hypertensive (stroke) crisis, the patient MUST avoid all foods containing TYRAMINE.
      1. Foods containing TYRAMINE:
         1. Fruits and veggies(remember salad “BAR”)
            1. AVOID:
               1. Bananas
               2. Avocados
               3. Raisins (any dried fruits)
            2. Grains: all okay except things made from active yeast
            3. Meats
               1. No organ meats: liver, kidney, tripe, heart, etc
               2. No preserved meats: smoked, dried, cured, pickled, hot dogs, lunch meats
            4. Dairy
               1. No aged cheese
               2. No yogurt

• Cannot eat brick cheese

1. CAN eat cottage and mozzarella

1. Other
   1. No alcohol, elixirs, tinctures, caffeine, chocolate, licorice, soy sauce
2. Drug Interactions:
   1. Teach patient not to take OTC meds unless they are prescribed

5. Lithium
   1. An electrolyte—notice –ium ending as in potassium, etc
   2. Used for treating BPD (manic depression)—it decreases mania
   3. Side Effects: (The 3 P’s)
      1. Peeing (Polyuria)
      2. Pooping (Diarrhea)

• Paresthesia (First sign of electrolyte imbalance)

1. Toxic:
   1. Tremors, metallic taste, severe diarrhea or any other neuro signs besides paresthesia
   2. #1 intervention: increase fluids

• If sweating, give electrolyte drink as well as fluids

1. Note: Closely linked to sodium. Monitor sodium levels. Low sodium levels prolong lithiums half-life, causing lithium toxicity. High sodium levels decrease the effectiveness of Lithium.
   1. Will only work as prescribed if Sodium normal!!

6. Prozac (Fluoxetine)
   1. Prozac is a SSRI (Antidepressant)
   2. Similar to Elavil (A tri-cyclic antidepressant)—same info
   3. Side Effects:
      1. Anticholinergic Effects
      2. Blurred vision and Bladder retention

• Constipation

1. Drowsiness
2. Euphoria

1. Prozac causes insomnia, so give before 12 noon
   1. If BID give at 6A & 12 N
2. When changing the dose of Prozac for an adolescent or young adult watch for suicidal ideation

7. Haldol (Haloperidol)
   1. Also has deconate form [IM, long acting, given to pts who wont take pills
   2. Same info as Thorazine
   3. Very potent
   4. Immediate onset
   5. Actions:
      1. Does not cure disease. Reduces symptoms
      2. Large doses: Psychotic symptoms (Hallucinations…

• Small doses: Nausea/Vomiting

1. Major: Tranquilizers

1. Side Effects: (remember ABCDEFG…)
   1. Anticholinergic Effects
   2. Blurred vision and Bladder retention

• Constipation

1. Drowsiness
2. Extra Pyramidal Syndrome (EPS)
3. FPhotosensitivity

• AGranulocytosis (low WBC count-immunosuppression)
• Teach patient to report sore throat and any S/S of infection to DR

1. Nursing Care: treat side effects. Number one nursing diagnosis is
2. **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)
   1. Second generation atypical antipsychotic
   2. Used to treat severe schizophrenia
   3. Advantage: it does not have side effects A, B, C, D, E, or F (much less)
   4. Disadvantage: it DOES have side effect: Agranulocytosis (worse than cancer drug in susceptible patients)
   5. For first month need WBC counts weekly. If WBC LOW STOP!
   6. Do not confuse with Klonopin (Clonazepam)

9. Zoloft (Sertraline)
   1. Another SSRI like Prozac
   2. S/E ABCDE
   3. 2-4 weeks to work
   4. Also causes insomnia but CAN be given in evenings
   5. Watch for interaction with:
      1. St. John’s wort- serotonin syndrome *deadly
         1. Sweating
         2. Apprehension àimpending sense of doom
         3. Dizziness
         4. HEAD-ache
      2. Warfarin (Coumadin)- watch for bleeding (may need to lower warfarin dose)
         1. When take Zoloft- warfarin and INR stays UP