LECTURE 1 ** DONÕT MIX UP S&S and CAUSATION

- often what causes something is the opposite of the S&S

- ex. diarrhea will cause a metabolic acidosis but once
ACID BASES
you are acidotic your bowel shuts down and you get a
¥ learn how to convert lab values to words paralytic illeus
¥ the rule of the BÕs
= if the pH and the BiCarb are both in the same
¥ when you get scenarios:
direction -> metabolic -> if itÕs a lung scenario = respiratory
Hint: draw arrows beside each to see directions - then check if the client is over-ventilating
* down = acidosis (alkalosis) or under-ventilating (acidosis)
* up = alkalosis - remember to look at the words (ex. over, under,
- respiratory -> has no b in it; if in other directions ventilating) -> Òas the pH goes so goes my PTÓ
(or if bicarb is normal value) -> VENTILATING DOESNÕT MEAN RESPIRATORY
- KNOW NORMAL pH, BiCarb, CO2 RATE; resp. rate is irrelevant w/ acid-base,
ventilation has to do with gas exchange not resp.
¥ Hint: DONÕT MEMORIZE LISTSÉknow principles rate (look at the SaO2 -> if your resp. rate is fast
(they test knowledge of principles by having you but SaO2 is low you are under-ventilating)
generate lists..) - for Òselect allÓ questions -> ex. PCA pump - What acid-base disorder
- ex. in general/principle what do opioids/pain indicates they need to come off of it? = respiratory
meds do? = sedate you, CNS depressors acidosis (resp. depression -> resp. arrest)
* ex. what does dilaudid do? donÕt memorize speciÞcs Ñ> if itÕs not lung, itÕs metabolic
or a list of dilaudid, know principles of opioids (such ¥ metabolic alkalosis - really only one scenario = if
as sedation, CNS depression -> lethargy, ßaccidity, the PT has prolonged gastric vomiting/suctioning
reßex +1, hypo-reßexia, obtunded) - because you are losing ACID
- boards donÕt test by lists because all books/ * ex. GI surgery w/ NG tube with suctioning for
classes have different lists 3 days; hyperemesis graviderum
- otherwise everything else that isnÕt lung you
¥ principles of S&S acid bases: as the pH goes so pick metabolic acidosis (DEFAULT)
goes my patient (except K+) * ex. hyperemesis graviderum w/ dehydration
- pH up = PT up -> body system gets more acute renal failure, infantile diarrhea
irritable, hyper-excitable (EXCEPT K+)
-> alkalosis - think of a body system and go ¥ remember, you only have 4 to pick from:
high: hyper-reßexive (+3, +4 [2 is normal]), - respiratory alkalosis - respiratory acidosis
tachypnea, tachycardia, borborygmi, seizure - metabolic alkalosis - metabolic acidosis
- pH down = PT down -> body systems shut
down (EXCEPT K+) ¥ pay more attention to the modifying phrases than
-> acidosis - think of a system and go low: the original noun
hypo-reßexive (+1, 0), bradycardia, lethargy, - ex. person w/ OCD who is now psychotic (psychotic
obtunded, paralytic illeus, respiratory arrest trumps OCD); hyperemesis with dehydration (pay
¥ ex. which acid-base disorders need an ambu-bag at attention to dehydration)
the bedside? = acidosis (resp. arrest)
¥ ex. which acid-base disorders need suction at the VENTILATION
bedside? = alkalosis (seize and aspirate) ¥ ventilators -> know alarm systems (you set it up so
¥ Mac Kussmaul - KussmaulÕs (compensatory that the machine doesnÕt use less than or more than
respiratory mechanism) is only present in only 1 of speciÞc amounts of pressure)
the 4 metabolic (acid-base) disorders a) high pressure alarm = increased resistance
* M = metabolic AC = acidosis to airßow (the machine has to push too hard to
get air into lungs)
¥ most common mistake with select all questions = selecting - from obstructions:
one more than you should (stop when you select the ones
i. kinks in tubing (unkink it)
you know! donÕt get caught up on the Òcould beÕsÓ)
ii. water condensation in tube (empty it!)
¥ Hint: donÕt select none or all on select all that apply iii. mucous secretions in the airway (change
questions (never only one and never all)
positions/turn, C&DB, and THEN suction)
*** suction is only PRN!!!
¥ Causes of Acid-Base Imbalance: -> priority questions = you would check
- scenarios and what acid-base disorder would
kinks Þrst, suction is not Þrst
result (what would cause an imbalance)
 b) low pressure alarm = decreased resistance
to airßow (the machine had to work too little
to push air into lungs)
- from disconnections: If tube disconnects From pt
I 11
i. main tubing (reconnect it duh!)
.

ii. O2 sensor tubing (which senses FiO2 at →

wrap with 3 Sided occu blue
the airway/trach area; black coated wire
coming from machine right along the tape Lor petroleum dressing )
tubing - reconnect!)

¥ ventilators -> know blood gases

- resp. alkalosis = ventilation settings might be
set too high (OVER-VENTILATING)
- resp. acidosis = ventilation settings might be set
too low (UNDER-VENTILATING)
¥ ex. weaning a PT off ventilator -> should not be
under-ventilated, they need the ventilator; if they are
over-ventilating then they can be weaned

¥ never pick an answer where you donÕt do something

and someone else has to do something
LECTURE 2 - how do you tell the difference between manipulation
& dependency?
ABUSE (Psych and Med-Surge) -> NEUTRAL vs. NEGATIVE (look at what theyÕre
Psychological Aspect/Psycho-Dynamics being asked to do)
-> if the sig. other is being asked to do something
¥ # 1 psychological problem is the same in any/all
abusive situations = DENIAL neutral (no harm) its dependency/co-dependency
- abusers have an inÞnite capacity for denial so that -> if the sig. other is being asked to do something
they can continue the behavior w/o answering for it that will harm them or is dangerous to them they
are manipulated
¥ can use the alcoholism rules for any abuse
- ex. # 1 psych problem in child abuse, gambling or ¥ how do you treat manipulation?
cocaine abuse is denial - set limits and enforce them -> ÒNOÓ
¥ why is denial the problem? HOW CAN YOU TREAT - easier to treat than dependency/co-dependency
SOMEONE WHO DENIES/DOESNÕT RECOGNIZE because no one likes to be manipulated (no positive
THEY HAVE A PROBLEM self-esteem issue going on)
¥ denial = refusal to accept the reality of a problem ¥ ex. how many PTÕs do you have w/ denial? = 1
¥ treat denial by CONFRONTING the problem (itÕs not ex. how many PTÕs do you have w/ dependency/co-
the same as aggression which attacks the person, not dependency = 2
the problem) = they DENY you CONFRONT ex. how many PTÕs do you have w/ manipulation = 1
- pointing out to the person the difference between
what they say and what they do Alcoholism
- Hint: never pick answers that attack the person WernickeÕs & KorsakoffÕs
-> ex. bad answers have bad pronouns - ÒyouÓ - typically separate BUT boards lumps them together
-> ex. good answers have good pronouns - ÒIÓ, ÒweÓ - wernickeÕs = encephalopathy
-> ex. Òyou wrote the order wrongÓ vs. ÒIÕm having - korsakoffÕs = psychosis (lose touch with reality)
difÞculty interpreting what you wantÓ -> tend to go together, Þnd them in the same PT
¥ loss and grief -> for this denial you must SUPPORT it ¥ Wernicke KorsakoffÕs syndrome:
- DABDA = denial, anger, bargaining, depression, acceptance a) psychosis induced by Vit. B1 (Thiamine) deÞciency
¥ Hint: for questions about denial, you must look to see - lose touch w/ reality, go insane because of no B1
if it is LOSS or ABUSE b) primary symptom -> amnesia w/ confabulation
- loss/grief = support - signiÞcant memory loss w/ making up stories
- abuse = confront - they believe their stories
¥ How do you deal w/ these PTÕs?
¥ #2 psychological problem in abuse = DEPENDENCY, - bad way = confrontation (because they believe what
CO-DEPENDENCY they are saying and canÕt see reality)
- dependency = when the abuser gets signiÞcant other - good way = redirection (take what the PT canÕt do
to do things for them or make decisions for them and channel it into something they can do)
-> the dependent = abuser ¥ Characteristics of Wenicke KorsakoffÕs:
- co-dependency = when the signiÞcant other derives a) itÕs preventable = take Vit. B1 (co-enzyme needed
positive self-esteem from making decisions for or for the metabolism of alcohol which keeps alcohol
doing things for the abuser from accumulating and destroying brain cells)
-> the abuser gets a life w/o responsibilities * PT doesnÕt have to stop drinking
-> the sig. other gets positive self-esteem (which is b) itÕs arrestable = can stop it from getting worse by
why they canÕt get out of the relationship) taking Vit. B1
¥ how do you treat it? * also not necessary to stop drinking
- set limits and enforce them c) itÕs irreversible (70% of cases) -> Hint: On boards,
-> start teaching sig. other to say NO (and they answer w/ the majority (ex. if something is majority
have to keep doing it) of the time fatal, you say itÕs fatal even if 5% of the
- must also work on the self-esteem of the co-dependent time itÕs not)
(ex. IÕm a good person because IÕm saying ÒnoÓ) ¥ Drugs for Alcoholism:
¥ manipulation = when the abuser gets the sig. other DISULFIRAM (Antabuse) or reunbum?
to do things for them that are not in the best interest of = aversion therapy -> want PTÕs to develop a gut
the sig. other hatred for alcohol
- the nature of the act is dangerous/harmful -> interacts w/ alcohol in the blood to make you very ill
- how is manipulation like dependency? -> works in theory better than in reality
-> in both the abuser is getting the other person to -> onset & duration: 2 weeks (so if you want to
do something for them drink again, wait 2 weeks)
 - PT teaching = avoid ALL forms of alcohol to avoid ¥ Alcohol Withdrawal Syndrome vs. Delirium Tremens
nausea, vomiting & possibly death - they are both different! not the same
-> including mouthwash, aftershaves/colognes/perfumes a) every alcoholic goes through withdrawal 24 hrs.
(topical stuff will make them nauseous), insect ell Her after they stop drinking
→
repellants, any OTC that ends with Ò-elixerÓ, alcohol- - only a minority get delirium tremens
based hand sanitizers, uncooked (no-bake) icings - timeframe -> 72 hrs. (alcohol withdrawal comes 1st)
which have vanilla extract,[red wine vinaigrette
] - alcohol withdrawal syndrome ALWAYS precedes
do not delirium tremens, BUT delirium tremens does not
pick
¥ Overdoses & Withdrawals: always follow alcohol withdrawal syndrome
- every abused drug is either an UPPER or DOWNER b) AWS is not life-threatening; DTÕs can kill you
-> the other drugs donÕt do anything c) PTÕs w/ AWS are not a danger to self/others; PTÕs
-> #1 abused class of drug that is not an upper or w/ DTÕs are dangerous to self/others
downer = laxatives in the elderly - they are withdrawing from a downer so they will
a) Þrst establish if the drug is an upper or downer be exhibiting upper S&S
- uppers (5) = caffeine, cocaine, PCP/LSD (psychedelic
all - DTÕs are dangerous
hallucinogens), methamphetamines,Mackler adderol (ADD drug) Differences AWS DT
* S&S -> make you go up; euphoria, tachycardia, in Care
restlessness, irritability, diarrhea, borborygmi, Diet Regular diet NPO/clear liquids
3+144
hyper-reßexia, spastic, seize (need suction) (because of risk for seizures which
can cause risk of aspiration)
- downers = donÕt memorize names -> anything that
Room Semi-private Private near nurses station
is not an upper is a downer! if you donÕt know what anywhere on (dangerous & unstable)
the med is, you have a high chance that itÕs a the unit
downer if itÕs not part of the uppers list Ambulation Up ad lib Restricted bed rest -> no bathroom
* S&S -> make you go down; lethargy, respiratory privileges (use bedpans/urinals)
depression (& arrest) constipation Restraints No restraints Restraints (because dangerous)
,
(because not - not soft wrist or 4 point soft
- ex. The PT is high on cocaine. What is critical to assess? dangerous) because theyÕll get out
-> NOT resps below 12 because they will be high - need to be in vest or 2-pt. locked
leathers (opposite 1 arm & leg,
-> maybe check reßexes rotate Q2hrs, lock the free
b) are they talking about overdose or withdrawal limbs 1st before releasing the
locked ones)
- overdose/intoxication = too much
They both get ANTI-HYPERTENSIVES &
- withdrawal = not enough TRANQUILIZERS
- ex. the PT has overdosed on an upper -> pick the - because everything is up (downer withdrawal)
S&S of too much upper They both get MULTIVITAMIN w/ B1
- ex. the PT has overdosed on a downer -> pick the
S&S of too much downer ¥ RNÕs can accept but RPNÕs canÕt (because PT is unstable)
- ex. the PT is withdrawing from an upper -> not
- on med-surge, the RN who takes them must decrease
enough upper makes everything go down
their workload (i.e. reduce PT load if they take a DT PT)
- ex. the PT is withdrawing from a downer -> not -> Hint: on boards, the setting is always perfect
enough downer makes everything go up (i.e. enough staff/time/resources on the unit etc.)
¥ upper overdose looks like = downer withdrawal
¥ downer overdose looks like = upper withdrawal
¥ In what 2 situations would resp. depression & arrest
be your highest priority:
- downer overdose
- upper withdrawal
¥ In what 2 situations would seizure be the biggest risk:
- upper overdose
- downer withdrawal

¥ Drug Abuse in the Newborn:

- always assume intoxication, NOT withdrawal at birth
- after 24 hrs -> withdrawal
- ex. caring for infant of a Quaalude addicted mom 24
hrs. after birth, select all that apply:
-> downer withdrawal so everything is up = exaggerated
startle, seizing, high pitched/shrill cry
DRUGS ¥ Why draw levels? = narrow therapeutic window
AMINOGLYCOCIDES - small difference between what works and what kills
¥ powerful class of antibiotics (when nothing else - if the drug has a wide range then you wouldnÕt
works pull these outs, the big guns) need to draw TAP levels
- donÕt use unless anything else works * ex. Lasix doses range from 5-80mg thus a wide
¥ boards love to test these drugs because theyÕre range so you wonÕt need TAP levels
dangerous and are a test of safety * ex. Dig doses range from 0.125 - 0.25 so this
¥ think: A MEAN OLD MYCIN narrow range needs TAPS levels
-> a mean old = they treat serious, life-threatening, ¥ A MEAN OLD MYCINS = major class that needs
resistant, Gram-neg bacteria infections (i.e. a mean TAPs drawn because of narrow window
old antibiotic for a mean old infection) ¥ When do you draw TAPS?
-> mycin = what they end with (all end w/ -mycin) -> depends on the route (donÕt focus on the med)
** not all -mycinÕs are aminoglycosides BUT most a) Trough Levels
are (the 3 that are not are erythromycin, ** doesnÕt matter which route or med, always 30 mins.
azithromycin, clarithromycin = throw it off the list!) - sublingual = 30 mins. before next dose
- IV = 30 mins. before next dose
¥ 2 toxic effects: - IM = 30 mins. before next dose
i) when you see Ô-mycinÕ, think mice - Sub-Q = 30 mins. before next dose
- mice -> ears -> otto toxic - PO = 30 mins. before next dose
- monitor hearing, tinnitus, vertigo/dizziness b) Peak Levels
ii) the human ear is shaped like a kidney so next ** different but depends on the route (not the med)
effect is nephrotoxicity - Sublingual = 5-10 mins after drug is dissolved
- monitor creatinine (not BUN, output, daily weight) - IV = 15-30 mins after drugs is Þnished infusing
* creatinine = the best indicator of kidney/renal * Hint: if you get two values that are correct (i.e. a
function (pick 24 hr. creatinine clearance over 15 min. answer and a 30 min. one) pick the highest
serum creatinine if both available) without going over so 30 mins.
¥ #8 (Þts nicely in the kidney) reminds you about 2 - IM = 30-60 mins. after administration
things about these drugs - Sub-Q = SEE (see diabetes lecture -> because the
- toxic to cranial nerve 8 = ear nerve only Sub-Q peaks are Insulins)
- administer Q8 - PO = forget about it, too variable so not tested
¥ route:
- IM or IV
¥ do not give PO -> they are not absorbed
- if you give an oral Ô-mycinÕ it will go into gut, dissolve,
go through and come out as expensive stool (wonÕt
have any systemic effect)
- EXCEPT in 2 cases = bowel sterilizers:
* hepatic encephalopathy (hepatic coma) = to get The BIG 10 Drugs to Know:
ammonia down, oral Ô-mycinÕsÕ will sterilize the 1. psych drugs
bowel by killing Gram-neg bacteria (E. coli) to help 2. insulins
bring down ammonia and wonÕt harm the 3. anti-coagulants
damaged liver because it doesnÕt go through the 4. digitalis
liver (also gives diarrhea, more poop out is good) 5. aminoglycosides
* pre-op bowel surgery = it sterilizes the gut by 6. steroids
killing the E. coli bacteria 7. calcium-channel blockers
- if oral, no otto or nephro toxicity because not absorbed 8. beta-blockers
- these are neomycin & kanamycin 9. pain meds
* Who can sterilize my bowels? NEO KAN 10. OB drugs

¥ Trough and Peak levels:

- trough = drug at lowest
- peak = drug at highest
** TAP levels - trough administer peak
-> draw trough levels Þrst
-> administer your drug
-> draw peak levels after drug administration
LECTURE 3 CARDIAC-ARRYTHMIAS
¥ Interpreting Rhythm Strips (4 that need to be known
Cardiac DRUGS by sight):
CALCIUM-CHANNEL BLOCKERS a) Normal Sinus Rhythm
Calcium-Channel Blockers are like Valium for your heart = P wave before every QRS & followed by a T
wave for every single complex
¥ Valium -> calmÕs you down; so CCBÕs calm your heart
down (ex. if tachycardic, give CCBÕs but not in shock) -> all P wave peaks are equally distant from each
- to REST YOUR HEART other, QRS evenly spaced
- not stimulants b) V-Fib = chaotic squiggly line, no pattern
c) V-Tach = sharp peaks, has a pattern
¥ calcium-channel blockers are negative inotropic,
chronotropic, & dromotropic drugs d) A-Systole = ßat-line
- fancy way of saying that they calm the heart down
POSITIVE NEGATIVE
¥ Terminology:
- if QRS depolarization, itÕs talking about ventricular
Inotropes Cardiac Stimulants Cardiac Depressants
- stimulate, speed - calm the heart down, (so rule out anything atrial)
Chronotropes up the heart weaken & slow down - if it says P-wave then itÕs talking about atrial
Dromotopes
¥ 6 Rhythms most tested on N-CLEX:
¥ When do you want to ÒdepressÓ the heart? What do 1. Òa lack of QRSÕsÓ = A-systole
CCBÕs treat? - ßat-line, no QRS
A: anti-hypertensives 2. ÒP-waveÓ = Atrial
- relax heart & blood vessels to bring down BP - if itÕs a sawtooth wave, always pick atrial ßutter
AA: anti-anginaÕs 3. ÒchaoticÓ - A-Þb if w/ P-wave
- relax heart to use less O2 to make angina go away 4. ÒchaoticÓ - V-Þb if w/ QRS
- treats angina by addressing oxygen demand - Hint: the word ÔchaosÕ is used for Þbrillation
AAA: anti-atrial arrhythmia 5. ÒbizarreÓ = atrial tachycardia if w/ P-wave
- ex. atrial ßutter, A-Þb, premature atrial contractions 6. ÒbizarreÓ = ventricular tachycardia if w/ QRS
- never ventricular - Hint: the work ÔbizarreÕ is used for tachycardias
*** what about supra-ventricular tachycardia?? ¥ PVCÕs (premature ventricular contractions)
-> because it means Ôabove the ventriclesÕ (which = a.k.a. periodic wide bizarre QRS
are the atria) - ventricular because QRS
¥ Side-Effects: - bizarre -> tachycardia
H & H = headache & hypotension - you can call a group of PVCÕs a short run of V-tach
-> hypoTN - from relaxed heart & vessels - do PhysicianÕs care about PTÕs having PVCÕs?
-> headache - vasodilation to brain -> NO, not a high priority = low priority
** Hint: headache is a good thing to select for -> 3 circumstances when you could elevate these
Ôselect all that applyÕ questions (ex. low Na & high PTÕs to moderate priority (never reach high)
Na = headache, high & low glucose = headache, high & i. if there are more than 6 PVCÕs in a minute
low BP = headache) ii. if there are more than 6 PVCÕs in a row
iii. if the PVC fall on the T-wave of the previous
¥ Names of Calcium-Channel Blockers: beat (R on T phenomenon)
- anything ending in Ô-dipineÕ -> most common order if you call the MD about a
- ex. amlodipine, nifedipine PT w/ PVCÕs = D/C monitor (because then you
- NOT just Ô-pineÕ canÕt see the PVCÕs and then you wonÕt call them)
- also includes: VERAPAMIL & CARDIZEM ¥ Lethal ArrhythmiaÕs:
- which can be given as continuous IV drip?? - HIGH PRIORITY, 2 main ones (will kill you in 8 mins
= Cardizem or less) -> these PTÕs will probably be top priorities
¥ What VS needs to be assessed before giving a CCB? a) A-Systole
- BP = because of risk of hypoTN b) V-Fib
-> parameters/guidelines - hold CCB if systolic is ** both have in common = no cardiac output
under 100 -> no brain perfusion (and youÕll be dead in 8 mins)
-> so you need to monitor BP if PT is on a Cardizem ¥ V-tach = potentially life-threatening (but not actually
continuous drip (if itÕs under 100 then you may life-threatening), but still makes it a fairly high priority
have to stop or change the drip rate) - difference is that these PTÕs have cardiac output
¥ in codes, even if the rhythm changes, if there is no
cardiac output itÕs just as bad as the previous rhythm
¥ Treatment (more drugs): b) Basilar = at the bottom of the lungs, thus it is
a) PVCÕs b) V-tach removing blood/liquid (because of gravity)
= for ventricular use LIDOCAINE/AMIODARONE - ex. itÕs bad if your basilar tube is bubbling or not
* in rural areas more Lidocaine use (cheaper & draining any mL
longer shelf-life) ¥ ex. How many chest tubes & where would you place them
c) Supra-Ventricular ArrhythmiaÕs for a unilateral pneumohemothorax?
= atrial arrhythmiaÕs use ABCDÕs - 2 chest tubes (apical for pneumo, basilar for hemo)
¥ A -> ADENOCARD (Adenosine) ¥ ex. How many chest tubes & where would you place them
- have to push in less than 8 seconds (FAST IV for a bi-lateral pneumothorax?
push) -> slam this drug, followed by a ßush; use a - 2 tubes (apical on left, apical on right)
big vein; BUT the problem w/ slamming it fast is ¥ ex. How many chest tubes & where would place them for
the risk of PT going into A-Systole (for 30 seconds post-op chest surgery?
but they will come out of it so donÕt worry [unless - 2 tubes (apical & basilar on the side of the surgery)
longer than 30 secÉ]) ** you are to assume that chest surgery/trauma is
** for IV pushes: when you donÕt know you go slow unilateral unless otherwise speciÞed (they will
¥ B -> BETA-BLOCKERS say bilateral)
- all end in Ô-lolÕ ¥ Trick Question: How many chest tubes would you
- every Ô-lolÕ is a BB & every BB is a Ô-lolÕ need and where would you place them for a post-op
- are negative inotropes, chronotropes, & right pneumonectomy?
dromotropes like calcium-channel blockers (a.k.a. - NONE! because you are removing the lung so you
valium for your heart so they treat A, AA, AAA & donÕt need to re-establish any pressure (there is not
have same side-effects) pleural space)!
** generally speaking, donÕt make a big difference
between Beta- & Calcium channel blockers; Troubleshooting Chest Tubes:
except that CCB are better for PTÕs w/ asthma ¥ What do you do if you knock over the plastic
or COPD -> Beta-BÕs bronchoconstrict containers that certain tubes are attached to?
¥ C -> CALCIUM-CHANNEL BLOCKERS -> set it back up & have PT take some deep breaths
- see Beta-Blockers & CCBÕs earlier -> NOT a medical emergency! (donÕt call MD)
¥ D -> DIGITALIS (DIGOXIN, LANOXIN) ¥ What do you do if the water seal breaks (the
d) V-Fib actual device breaks?)
= for V-Þb you D-Þb (shock them!) -> Þrst = CLAMP it!!! because now positive pressure
e) A-Systole can get in! donÕt let anything get in
= use EPINEPHRINE & ATROPINE (in this order!) -> 2nd = cut the tube away from the broken device
-> 3rd = stick that open end into sterile water
-> if epinephrine doesnÕt work then use atropine
-> then unclamp it because youÕve re-established the
water seal (doesnÕt need clamp if itÕs under water
*** better for the tube to be under water than
CHEST TUBES clamped! -> air canÕt go in and stuff can still keep
¥ purpose is to re-establish negative pressure in the coming out (if clamped, nothing can come out
pleural space (so that the lung expands when the which is what the tube is for)
chest wall moves) ¥ Ex. If they ask what the Þrst thing is to do if the seal
- pleural space -> negative is good (negative pressure breaks -> Clamp! BUT, if they ask whatÕs the best
makes things stick together) thing to do -> put end of tube under water! (because it
- ex. gun shot to the lung add positive pressure actually solves the problem, clamping is a temp. Þx)
¥ Hint: when you get a chest tube question, look at the ¥ Hint: ÔBESTÕ vs. ÔFIRSTÕ questions
reason for which it was placed (will tell you what to - Þrst questions = are about what order
expect & what not to expect) - best questions = whatÕs the one thing you would do if
- ex. pneumothorax = to remove air (because air you could only do 1 of the options
created the positive pressure) -> ex. You notice the PT has V-Þb on the monitor. You
- ex. hemothorax = to remove blood run to the room and they are non-responsive with
- ex. pneumohemothorax = to remove blood & air no pulse. What is the Þrst thing you do?
A) place a backboard?
¥ Hint: Also, pay attention to the location of the tubes: B) begin chest compressions?
a) Apical = the chest tube is way up high, thus it is - ÒÞrstÓ is about order so = pick A (because you
removing air (because air rises) wouldnÕt start chest compressions Þrst)
- ex. itÕs bad if youÕre apical tube is draining 200 mL or - BUT, if the question ask ÒWhatÕs the best thing to
it is not bubbling do?Ó -> you only get to do 1 thing not the other so
you would pick B
¥ What do you do if the chest tube gets pulled out? CONGENITAL HEART DEFECTS
- Þrst = take a gloved hand and cover the hole ¥ every congenital heart defect is either TROUBLE or
- best = cover the hole with vaseline gauze NO TROUBLE (ALL BAD or NO BAD)
¥ Bubbling chest tubes: (ask yourself 2 questions) - either causes a lot of problems or itÕs no big deal (no
a) Where is it bubbling? in-between defect)
b) When is it bubbling? ¥ memorize one word: TRouBLe
= the answer will depend on these 2 questions Heart Defects TRouBLe (95% of No Trouble
all heart defects)
(sometimes bubbling is good, sometimes bad but Surgery NEED surgery now - donÕt need surgery
depends on where & when) to live right away; possibly
need it years later if it
- ex. Intermittent bubbling in the water seal -> GOOD causes a Trouble (but
(document it, never bad!) we donÕt expect it to)
- ex. Continuous bubbling in the water seal -> BAD Growth & Dev. slow, delayed normal
(you donÕt want this, means a leak in the system that Life Expectancy short normal
you need to Þnd and tape it until it stops leaking) ParentÕs grief, stress, regular average person
Experiencing Þnancial issues, lots issues
** in RPN scope of caregiving issues
- ex. Intermittent in suction control chamber -> BAD Going Home apnea monitor no apnea monitor
(means suction is not high enough, turn it up on the Hospital Stay at weeks 24-48 hours
Birth
wall until bubbling is continuous)
Who Follows Paediatric Paediatrician,
- ex. Continuous in suction control chamber -> GOOD Your Care Cardiologist paediatric NP
(document it) Shunting R to L L to R
- Hint: both locations are opposites of each other (TRouBLe)
(memorize one & deduce the others) Cyanosis Cyanotic -> Blue Acyanotic
(TRouBLe)
Ñ> if there is a seal it should not be continuous
(ex. a sealed bottle of pop continuously ¥ ex. You are teaching the parents about a heart defect:
bubbling means itÕs leaking!) - pick all the options that cause trouble
¥ Hint: Boards will not give pictures of defects and ask
you what they are.
¥ A straight catheter is to a foley catheter as a
thoracentesis is to a chest tube. - not our job, we donÕt diagnose
- in-&-out vs. continuous secured - our role is teaching parents the implications
-> so if itÕs trouble = teach them things that itÕs going
- thoracentesis -> also helps re-establish neg.
to be a lot of trouble
pressure (in-&-out chest tube) -> if itÕs not trouble = pick the things saying itÕs not
- higher risk for infections are continuous going to be trouble
¥ There are 40+ congenital heart defects so just remember
Rules for Clamping Tubes: TRouBLe (donÕt memorize all of them!):
¥ a) Never clamp a tube for more than 15 seconds - Hint: all congenital heart defects that start w/ the
without a doctors order. letter T are Trouble Defects
- so if you break the water seal -> you have 15 - we donÕt care about the defect, we care about what
seconds to get that tube under water weÕre teaching the parents
¥ b) Use rubber-tipped doubled clamps. ¥ All congenital heart defect kids (trouble or no trouble)
- the teeth of the clamp need to be covered w/ will have 2 things:
rubber so that you donÕt puncture the tube a) Murmur
- why? = because of the shunting of the blood
(regardless of direction of shunt)
b) all have an Echocardiogram done (to Þnd out
what the defect is or why thereÕs a murmur)
¥ 4 Defects of Tetralogy of Fallout:
- VarieD PictureS Of A RancH (or Valentines Day Pick
Someone Out A Red Heart)
1. VD = ventricular defect
2. PS = pulmonary stenosis
3. OA = overriding aorta
4. RH = right hypertrophy
¥ donÕt have to recall these, RECOGNIZE them
- recall -> remember from nothing
- RECOGNIZE -> spot it when you see it (use the
initials to recognize them in questions)
¥ ONLY DEFECT where they ask you what it is
INFECTIOUS DISEASE and TRANSMISSION BASED -> YES: mask, gloves, hand-washing, special-Þlter
PRECAUTIONS (Isolations) mask ONLY for TB, PT mask for leaving room
¥ Standard (but really shouldnÕt be leaving), neg. air ßow
¥ Universal ** disposable supplies & dedicated equipment is a
¥ Contact good thing but not really as essential as in the
- for anything enteric = can be caught from intestine other 2 (can let this one slide)
-> fecal, oral -> TB: technically transmitted via droplet BUT put
- C-Diff, Hep. A, Cholera, Dysentery on airborne
* things with bugs in diarrhea
* Hint for Hep A & B: Hep A -> think anus, Hep B -> ¥ PPE = Personal Protective Equipment
think blood (anything from the bowel starts w/ a vowel) - boards like to test how you put on or take off
- Staph infections - always take it off in alphabetical order
- RSV = respiratory syncytial virus (what babies, 1-2 -> ex. gloves, goggles, gown, mask
yr. oldÕs get that is not dangerous to adults but can - putting on is reverse alphabetically for the ÔgÕsÕ &
be fatal for them) mask comes 2nd
* transmitted by droplet BUT still put them on -> gown, mask, goggles, gloves
contact precautions because little kids catch it
from touching things that other sick kids touched
- Herpes infections (includes Shingles -> Herpes
Zoster virus even though caused by varicella)
- WhatÕs involved in contact precautions?
-> private room is preferred (but not required)
* or 2 RSV kids in the same room
* keep RSV kid & suspected RSV separate
because you need positive cultures (not based
on symptoms)
-> NO: mask, eye/face shield (unless for universal),
special Þlter mask, PT mask, neg. air ßow
-> YES: gloves, gown, hand-washing, special
supplies & dedicated equipment (includes toys)
** disposable supply vs. dedicated equipment:
- thermometer cover - BP cuff that stays in room
¥ Droplet
- for bugs that travel 3 feet on large particles due to
sneezing/coughing
- all meningitis
* cultured through lumbar puncture
- H Flu (haemophilus inßuenza B) -> commonly
causes epiglotitis
* never stick something down throat because it will
cause obstruction
- WhatÕs involved in droplet precautions?
-> private room is preferred (but not required)
* on boards select private
* can also cohort based on positive cultures
-> NO: gown, eye/face shield, special Þlter mask,
neg. air ßow
-> YES: mask, gloves, hand-washing, PT worn
mask (when leaving room), disposable supplies
& dedicated equipment
¥ Airborne
- M-M-R; TB; varicella (chicken pox)
- WhatÕs involved in airborne precautions?
-> private room is required
* unless co-horting
-> NO: gown (mostly for contact), eye/face shields
LECTURE 4 Cains:
¥ hold the cain on the strong side
CRUTCHES, CANES, WALKERS - a lot of people use it the wrong way
¥ major area of human function is locomotion so they test
these even though not a major emphasis in school Walkers:
- area to test PT teaching & risk reduction ¥ pick it up, set it down, walk to it
Crutches: ¥ if they must tie their belongings to the walker, tie it at
¥ How do you measure crutches? the sides, not the front
- boards doesnÕt like things on the front (even tho most
** need to know for risk reduction -> so you donÕt
people do that anyways; they donÕt like wheels or tennis
cause nerve damage
ball on the bottom either)
a) length of crutch = 2-3 Þnger-widths below anterior
axillary fold to a point lateral to & slightly in front of the foot
-> many questions ask where you measure from/to (so for
crutches, if they ask anything measuring from axilla to
foot -> rule out, theyÕre wrong instructions for length)
b) hand grip = can be adjusted up & down; when properly
placed, should be apx. 30 degrees elbow ßexion
¥ How to teach crutch gaits (4 kinds):
** names are pretty obvious w/ a few exceptions
a) 2-point
- move a crutch and opposite foot together followed
by other crutch & opposite foot
- moving 2 things together
b) 3-point
- moving 2 crutches & the bad leg together
- moving 3 things together
c) 4-point
- moving everything separately
- move any crutch, then opposite foot, followed by
next crutch then other foot
- very slow but very stable
d) Swing-through
- for non-weight bearing injuries (ex. amputations)
- plant crutches and swing the injured limb through
(never touches down)
¥ When do they use them?
- ask yourself Òhow many legs are affected?Ó
- even for even, odd for odd
* even point gaits when a weakness is evenly
distributed (i.e. even # of legs messed up)
- 2-point = mild problems (bilateral)
- 4-point = severe problems (severe, bilateral
weaknesses)
- 3-point = only odd one, when only 1 leg is affected
¥ Ex. Early stages of rheumatoid arthritis = 2-point
Ex. Left, above the knee amputation = swing-through
Ex. First day post-op right knee replacement, partial weight-
bearing allowed = 3-point
Ex. Advanced stages of ALS = 4-point
Ex. Left hip replacement, 2nd day post-op, non weight-bearing
= swing-through
Ex. Bilateral total knee replacement, 1st day post-op, weight-
bearing allowed = 4-point
Ex. Bilateral total knee replacement, 3 weeks post-op = 2 point
¥ Going up & down stairs:
- up with the good, down with bad
- crutches move with the bad leg
DELUSIONS, HALLUCINATIONS, & ILLUSIONS (Psych) ex. person staring at a wall & says: ÒI see a bombÓ -> hallucination
Neurosis Non-Psychotic vs. Psychosis ex. person looks at Þre extinguisher on the wall and says: ÒI see a
bombÓ -> illusion (referent)
¥ Hint: the Þrst thing you have to do to get a psych
Hint: On the test, they will tell you that there is
questions correct is decide: ÒIs my PT non-psychotic ¥
something there thus, you can differentiate between a
or psychotic?Ó
hallucination & an illusion.
= this will determine treatment, goals, prognosis,
medication, length of stay, legalitiesÉeverything
NON-PSYCHOTIC PSYCHOTIC
How do you deal with these Psychotic Symptoms?
DeÞnition Has insight & is Has no insight & is not ¥ Þrst thing you ask after determining if PT is psychotic:
reality-based reality-based What is their problem?
- even w/ emotional - donÕt think/know their sick
distress/illness, - think everyone else has Ñ> what kind of psychosis do they have?
mental/behavioral the problem but not them
disorder (blame anyone else)
- recognize what the - even if they say theyÕre ¥ 3 Types of Psychosis:
problem is and how sick but then they say the
it affects their life martians made them sick 1. Functional Psychosis
they donÕt have insight
- can function in everyday life (i.e. have jobs, a
Treatment/ - good therapeutic - good therapeutic
Techniques communication (like communication does not marriage, etc.)
any PT that displays work because they are - 4 diseases: Schizo Schizo Major Manics
good comm. skills) not rational
** thereÕs nothing - need unique, speciÞc i. Schizophrenia
special that you need strategies
to do/know compared ii. Schizoaffective Disorder
to any med-surge,
paeds, or OB PT iii. Major Depression (if itÕs major, test will say)
Symptoms donÕt have delusions, DELUSIONS, iv. Manic (Acute)
hallucinations, or HALLUCINATION, -> so bi-polar is functional, only psychotic
illusions ILLUSIONS
- only in psychotic PTÕs during manic phase
- as soon as they get any
of these theyÕve crossed - these PTÕs have the potential to learn reality
the line to being psychotic (because no damage)
-> may need meds or set boundaries for structure
Psychotic Symptoms: -> nurse role = teach reality (4 steps)
¥ a) Delusions a) acknowledge feeling -> ÒI see youÕre angry;
= false, Þxed, idea or belief; no sensory component ÒYou seem upsetÓ, ÒTell me how you are feelingÓ,
(all in the brain, thinking it) often uses the word feeling or shows a feeling
i. Paranoid Delusions -> people are out to harm me b) PRESENT REALITY -> ÒI know that those voices
- ex. the maÞa are out to get me are real to you but I donÕt hear themÓ or telling
ii. Grandiose Delusions -> you are superior or you them what is real (ÒIÕm a nurse & this is a hospitalÓ)
are the worldÕs smartest/greatest person c) set a limit -> ÒThat topic/behavior is off-limitsÓ,
- ex. thinking you are Christ, Genghis Khan ÒWe are not going to talk about that right nowÓ,
iii. Somatic Delusions -> about a body part ÒStop talking about thatÓ
- ex. x-ray vision; there are worms in my body d) enforce the limit -> ÒI see youÕre too ill to stay
¥ b) Hallucinations reality based so our convo is overÓ (ending the
= a false, Þxed, sensory experience (purely sensory); conversation NOT taking away a privilege [i.e.
5 senses so 5 for (1 for each sense) punishment]; continuing to talk may enforce the
i. Auditory -> hearing things that arenÕt there (primarily non-reality)
voices telling you to hurt yourself); most common *** on the test, they wonÕt ask these speciÞc steps but
ii. Visual -> seeing; 2nd most common instead, will ask Òhow should the nurse respondÉÓ
iii. Tactile -> feeling things; 3rd most common *** try to pick the more positive statements (i.e. what
iv. Gustatory -> tasting things that are not there they can have/do, not what they canÕt); if between
v. Olfactory -> smelling things that are not there
2 statements go w/ the positive one
*** last 2 are relatively rare
¥ c) Illusions
= misinterpretation of reality; sensory experience ¥ 2. Psychosis of Dementia
- psychosis because of actual damage to the brain
- difference from hallucination -> with an illusion there
* in Functional Dementia, there is no brain damage;
is a referent in reality
itÕs just messed up chemicals
-> referent = something in reality to which a person
- include PTÕs w/ AlzeimerÕs, psychosis after a stroke,
refers when they say something (they just
organic brain syndrome; anything w/ ÒsenileÓ or
misinterpret it)
ÒdementiaÓ
¥ ex. PT says: ÒI hear demon voicesÓ -> hallucination
ex. PT overhears nurses & MDÕs laughing & talking at the nurseÕs - cannot learn reality
station & says: ÒListen, I hear demon voicesÓ -> illusion (there -> major difference from functional (which is why
is a referent) you have to determine type of psychosis)
 -> nurse role: ¥ Narrowed Self Concept
a) acknowledge feeling = when a psychotic refuses to leave their room or
b) REDIRECT them -> from something they canÕt change their clothes
do to something they can do - functional psychotic
** you donÕt set-limits because itÕs mean - #1 reason is because their deÞnition of self is
** NOT APPROPRIATE to present reality to these narrowed -> deÞned self based on 2 things:
PTÕs when they are experiencing psychotic i. Where they are
symptoms (BUT donÕt confuse this w/ reality ii. What they are wearing
orientation) *** so they donÕt know who they are unless they are
-> important to remember that forgetting things (like wearing those exact clothes in that exact room
where they are or what room theyÕre in - PTÕs w/ - as the nurse, donÕt make them change or leave the
dementia/Alzheimers) is NOT psychosis room (will cause escalating panic because they will
** when they start having delusions, hallucinations or lose their concept of self)
illusions, then they are psychotic * use the Functional Psychosis techniques
-> reality orientation = telling them person, place, ¥ Ideas of Reference
and time (ALWAYS APPROPRIATE w/ = think everyone is talking about you
DEMENTIA) - this deals w/ memory - ex. see someone on the news and get upset
because you think they are talking about you
3. Psychotic Delirium - can have both paranoia & ideas of reference
= a temporary, sudden, dramatic, episodic, (paranoia if also think they are going to harm you)
secondary loss of reality; usually due to some
chemical imbalance in the body
* different because itÕs temporary and very acute
-> include PTÕs that are short-term psychotic because
of something else causing the psychosis
- ex. a drug reaction, high on uppers or withdrawing
from downers (delirium tremens), cocaine overdose,
post-op psychosis (withdrawing from a downer), ICU
psychosis (sensory deprivation), UTI (or any occult
infection), thyroid storm, adrenal crisis
- good thing is itÕs temporary so focus is removing
the underlying cause & keeping them safe
-> nurse role:
a) acknowledge feeling
b) REASSURE them: itÕs temp. & theyÕll be safe
** donÕt present reality -> they wonÕt get it
** donÕt redirect -> not going to work

¥ Personality Disorders are different:

A = antisocial
B = borderline
N = narcissistic
** very sick personality disorders
** may be good to use Functional Psychosis
techniques because you set limits

Other Psychotic Symptoms:

¥ Loosening of Association
= your thoughts arenÕt wrapped too tight, all over the map
a) Flight of Ideas
- coherent phrases but the phrases are not
connected (not coherent together)
b) Word Salad
- sicker, canÕt even make a coherent phrase
-> babble random words
c) Neologism
- making up imaginary words
LECTURE 5 2. N P H
- true intermediate acting insulin
DIABETES M. - onset = 6 hrs.
- peak = 8-10 hrs. if N at 3- 5 then
pm
give
→
¥ deÞnition = an error of glucose metabolism
- causes issues because glucose is the primary fuel - duration = 12 hrs. when will
you
check for

?
- is cloudy (suspension) hypoglycemia
source and if your body canÕt metabolize glucose,
cells will die * the issue w/ suspensions is that it precipitates
-> the particles fall to the bottom over time so
¥ does not include diabetes insipidus = polyuria,
polydipsia leading to dehydration due to low ADH you CANNOT give via IV (or the PT will
-> itÕs just similar with the ßuids, not the glucose part overdose & the brain will die)
(similar symptoms) * Hint: general rule => never put anything
- opposite syndromes of diabetes i. = SIADH cloudy in an IV bag
3. Lispro (Humalog)
¥ relationship between amount of urine & speciÞc
gravity of urine: - fastest acting, rapid
- they are opposites/inverse - onset = 15 mins.
- i.e. the less urine out, the higher the speciÞc gravity; - peak = 30 mins.
the more urine out, the lower the speciÞc gravity - duration = 3 hrs.
* so diabetes = has more urine & low speciÞc - you give this as they being to eat so with meals
gravity (opposite with SIADH) (not ac) -> interrupt them while eating!
4. Lantus (Glargine)
TYPE I vs. TYPE II: - long acting
Differences TYPE 1 DM TYPE 2 DM
- peak = no essential peak because itÕs so slowly
absorbed -> thus, little to no risk for hypoglycemia
Names - Insulin dependent - Non-insulin dependent
- Juvenile onset - Adult-onset - duration = 12-24 hrs.
- Ketosis prone - Non-ketosis prone
- only insulin you can safely & routinely give at
S&S - polyuria - same bedtime because it will not cause them to go
- polydipsia
- polyphagia (increased hypoglycemic during the night (YOU CANNOT
swallowing, but in
context of DM it also ROUTINELY GIVE THE OTHERS AT BEDTIME)
relates to eating)
** Hint: boards likes to test peaks & tend to test it by
Treatment D = diet Ñ> least D = diet Ñ> MOST
important (less IMPORTANT giving you a time when insulin was given & asking
restrictions than before) O = oral hypoglycemic when they reach hypoglycemia (which is the peak).
I = insulin Ñ> MOST (pills)
IMPORTANT A = activity ¥ CHECK EXPIRY DATES ON INSULIN!!!
E = exercise
- What action by the nurse invalidates the
Diet: manufacturerÕs expiration date? = opening it
¥ primarily Type II -> the minute you open it the date is irrelevant write EXP
¥ a) It is a calorie restriction. because now you have 30 days from opening day
in a

- tells you that calorieÕs are important because the or

(have to write the date of opening & new expiry) open

day
in a

dietÕs are named (ex. 1500 calorieÉ) - refrigeration is optional in the hospital BUT you
*** this is the best strategy for them need to teach PTÕs to refrigerate at home
¥ b) They need 6 small feedings a day. -> though at the hospital the ones that should be
- keeps blood sugar levels more normoglycemic refrigerated should be the un-opened vials
throughout the day instead of 3 big peaks - better to give warm, non-expired insulin than cold,
expired insulin
Insulin:
¥ lowers blood glucose Exercise:
¥ 4 main types you really need to know: ¥ exercise potentiates insulin
1. Regular Insulins -> the ÒRÓ is important = meaning, it does the same thing as insulin
- ex. Humulin R, Novalin R Ñ> think of exercise as another shot of insulin
- onset = 1 hr. - if you have more exercise during the day, you need
- peak = 2 hrs. less insulin shots (and bring easily metabolized
- duration = 4 hrs. carbs/snacks to sports games)
- is clear (solution) so it can be IV dripped (this is
the one used if using IVÕs)
- short, rapid acting insulin (but Hesi will call it
intermediate because we now have Lispro which
acts faster)
Sick Days: - PT contracts upper resp. infection -> recovers
¥ when a diabetic is sick -> GLUCOSE GOES UP w/in 3-5 days like everyone BUT after initial
- need to take their insulin even if theyÕre not eating recovery, they start going downhill & getting
¥ need to take sips of water because diabetics get more lethargic
dehydrated * so, if they come into the ER you should ask
¥ any sick diabetic is going to have the 2 problems if theyÕve had a viral upper resp. infection in
of hyperglycemia & dehydration -> ALWAYS! the last 2 weeks
¥ stay as active as possible because it helps lower -> what causes the high glucose is the stress of the
glucose (even if theyÕre not eating when sick) illness that was not Òshut offÓ and they start
burning fats for fuel -> ketosis
Complications of Diabetes: - S & S:
= 3 acute and a boatload of chronics -> spell out D K A
ACUTE - D = dehydration
¥ 1. Low Blood Glucose (in both types) - K = ketones (in blood), kussmaulÕs, high K+
- a.k.a. insulin shock, insulin reaction, hypoglycemia, * you can have ketones in your urine & not
hypoglycemic shock have DKA
- What causes this? - A = acidotic (metabolic), acetone breath,
-> not enough food anorexia (due to nausea)
-> too much insulin/medication (primary cause) -> hot & ßushed, dry = water is a coolant! if you
-> too much exercise lose water (as in dehydrate) you loose coolant
- the danger is brain damage which becomes - Treatment:
permanent (so be careful not overmedicate!) -> fast rate IV ßuids (ex. 200/hr.), w/ reg. insulin in
- S & S: the bag
-> drunk in shock
= think of how people look while drunk -> slurring, ¥ 3. High Blood Glucose in TYPE II = HHNK/HHS
staggering, impaired judgement, delayed (Hyperglycemic Hyperosmolar Non-Ketotic
reaction time, labile (emotions all over) Syndrome)
** from cerebrocortical compromise = this is dehydration (for any HHNK/HHS question
= shock -> low BP, tachycardia, tachypnea, cold/ just call it DEHYDRATION)
pale/clammy skin, mottled extremities - so think of the S&S of dehydration (low water, hot
** from vasomotor compromise temp, ßushed, dry)
- Treatment: - nursing diagnosis = ßuid volume deÞcit
a) Administer rapidly metabolizable carbohydrate - #1 intervention -> giving ßuids!
(i.e. sugars) - outcomes you want to see = increased output, BP
-> ex. any juice, reg. pop, chewable candy, milk, coming up, moist mucus membranes etc.
honey, icing, jam ** so all the outcomes of a PT coming out of
b) BUT combine/follow w/ a starch or protein dehydration
-> ex. cracker, slice of turkey - Why do these PTÕs only get the D (& not the K & A)?
*** skim milk is great because it gives both -> they donÕt burn fats (which make the ketones)
- bad combo is too much simple sugars (like pop & candy)
- if unconscious give Glucagon (IM) or IV Dextrose ¥ Which one is insulin the most essential in treating?
(D10, D50) -> how do you determine which to give? = DKA
= the setting (i.e. family calling from home, tell -> you donÕt have to use insulin w/ HHNK because
them to give IM but if in ER give IV) you mostly need to re-hydrate them
** hard to get a vein because of vasoconstriction ¥ Which has a higher mortality rate?
= HHNK
¥ 2. High Blood Glucose in TYPE I = Diabetic Coma/ -> DKAÕs tend to be a higher priority and symptoms
DKA (Diabetic Keto-acidosis) are much more acute; HHNKÕs tend to come in to
-> Hint: Type I is also called Òketosis-proneÓ ER later than they should because symptoms are
- What causes this? not as visible & they end up getting worse (so by
-> too much food the time they come in it might be too far gone)
-> not enough medication ¥ Who would die Þrst if didnÕt treat them? (more life-
-> not enough exercise threatening)
*** none of these are the #1 cause because it is = DKA
acute viral upper respiratory infections (w/in the -> but they tend to get treated in time
last 2 weeks)
Long-term Complications:
¥ related to 2 problems:
a) poor tissue perfusion
b) peripheral neuropathy
¥ ex. Diabetics have renal failure. What would this be due to?
-> poor tissue perfusion
ex. Diabetic PT has lost control of their bladder and are now
incontinent. -> peripheral neuropathy
ex. PT canÕt feel it when he injures himself. -> peripheral
neuropathy.
ex. PT doesnÕt heal well when he injures himself. -> poor
tissue perfusion

Which lab test is the best indicator of long-term

blood glucose control?
¥ the hemoglobin A1C (HA1C), the glycosated/
glycosylated hemoglobin (all the same)
¥ numbers:
- 6 & lower is what you want to see
- 8 & above means youÕre out of control
** what about 7? = border
-> so they need to work done, evaluation, may
have to go to hospital, may have an infection
somewhere
¥ Hint: Boards doesnÕt test units so just remember the
numbers!
LECTURE 6 5. BILIRUBIN
¥ waste product from the breakdown of RBCÕs
DRUG TOXICITY ¥ Hint: Boards will only test biliÕs in newborns
- normal adult bili = 1-2 (low)
¥ 5 main ones to know
-> tests nurse safety - newborns have higher levels from breaking down
-> remember, they donÕt test units RBCÕs from mom = 5 +
¥ therapeutic level -> elevated level = 10 - 20
1. LITHIUM - ex. if newborn has 9.9 itÕs high but still ÒnormalÓ
¥ for the mania in bi-polar ¥ bilirubin toxicity = > 20
- right around 14-15 is when MDÕs start thinking about
¥ therapeutic level = 0.6 - 1.2
hospitalization because once youÕre at 15, youÕre
¥ toxic level = > 2
halfway to toxic (donÕt want it to get to 18 or 19, too
¥ What about between 1.2 - 2???
-> no books agree on what is going on in between close to toxic)
those levels (grey area) ¥ pathologic jaundice = bili high & infant yellow at birth
-> boards would not give you any values in the grey - come out yellow
area (because item writers for the NCLEX need to ¥ physiologic jaundice = bili is normal at birth but over
test on what the books agree and books agree that the next 2-3 days it goes high
over 2 is toxic) - becomes yellow

2. DIGOXIN (LANOXIN) ¥ HINT:

- for the two ÒLÓ drugs = 2 (pick the lower number)
¥ used to basically treat 2 things:
a) A-Þb - the other oneÕs = 20 (pick the higher #)
-> remember the ABCDÕs of treating atrial arrythmias
b) congestive heart failure Kernicterus & Opisthotonos:
¥ therapeutic level = 1 - 2 ¥ kernicterus = bilirubin in the brain when it crosses
the BBB (condition) -> is in the brain, in the CSF, in
¥ toxic level = > 2
*** NOTE: both have 2! -> so if the question uses the the meninges
value of 2, call it toxic (safer to call something - different from jaundice = yellow color from too much
toxic when it may not be than to say that itÕs bilirubin in the skin
therapeutic when it might not be) - usually occurs when you reach levels of 20
- bili in the brain causes aseptic meningitis & aseptic
¥ take the apical heart rate before giving Dig
encephalitis; can be lethal
3. AMINOPHYLLINE ¥ opisthotonos = position the baby assumes when
they have bilirubin in the brain
¥ airway antispasmodic
- technically not a bronchodilator -> it doesnÕt = severe hyperextension due to the irritation of the
stimulate beta-2 agonist cells to bronchodilate meninges w/ the bilirubin
- it just relaxes a muscle spasm -> newborns have high ßexibility so when they
-> in spasms = airway is narrow hyperextend theyÕre heels will touch their ears &
-> when you relax a spasm, airways widen (which they will be rigid
is why it looks like a bronchodilator) -> if you see a kid w/ levels of 15 extending the
* ex. epinephrine is a bronchodilator neck they need follow-up immediately (medical
emergency)
¥ ex. sometimes PTÕs come in w/ an acute asthamatic
attack & the bronchodilators arenÕt working -> because ¥ ex. In what position do you place an opisthotonic
they are in an acute, lock-down spasm & the spasm is in child? = on their side
the way of the bronchodilator
= give them aminophylline Þrst to relieve the spasm
= then you can give the bronchodilator after and it
will work
¥ therapeutic level = 10 - 20
¥ toxic level = > 20

4. DILANTIN (PHENYTOIN)
¥ anticonvulsant; treat seizures
¥ therapeutic level = 10 - 20
¥ toxic level = > 20
ABDOMINAL ¥ Three things to play around w/ to effect stomach
DUMPING SYNDROME vs. HIATAL HERNIA emptying time:
¥ both gastric emptying issues & are kind of opposites a) change the head of the bed
-> memorize one & you have the other b) change the water content of the meal
c) change the carbohydrate content of the meal
Hiatal Hernia: Gastric Emptying HIATAL HERNIA DUMPING
¥ regurgitation of acid into the esophagus because the Issue Treatments SYNDROME
upper part of your stomach herniates upward through Head of Bed - HIGH position - LOW position (lie
during & after ßat and turn to
the diaphragm meals (gravity side to eat)
- your stomach should stay in the abdominal cavity helps empty faster)
¥ w/ this, you have a 2-chamber stomach (like having Water Content - high ßuids - low ßuids (donÕt
give ßuid w/ the
2 stomachs) -> band around the middle meals -> an hour
¥ gastric contents move in the wrong direction at before or after)
the correct rate Carb Content - high carbs - low carbs to help
because they go stomach empty
-> rate is not the problem, itÕs the direction through faster slow
-> going the wrong way on a one way street Protein? - low protein - high protein
¥ S & S:
¥ Hint: Whatever carbs is, protein is the opposite.
- just plain GERD (gastro-esophageal reßux disease)
-> heartburn & indigestion
*** but just because you have GERD doesnÕt
mean you have hiatal hernia
- hiatal hernia is GERD when you lie down after
you eat (the GERD only occurs after lying down)
- you cannot have hiatal hernia if your symptoms
occur before lying down because hiatal hernia is
dependent on position & meal time
¥ Treatment:
Ñ> goal = want the stomach to empty faster
* because if itÕs empty, it wonÕt reßux
** see table

Dumping Syndrome:
¥ gastric contents dump too quickly into the duodenum
- usually follows gastric surgery
¥ gastric contents move in the right direction at the
wrong rate
-> the rate is the problem
-> speeding
¥ S & S:
** long list of issues so take what you know &
combine them to equal dumping syndrome
- drunk person -> staggering, slurring, impaired
judgment, delayed reactions, labile emotions
-> from decreased blood ßow to the brain because
all the blood is going to the gut (because it
dumped into the duodenum)
- shock -> classic sigs such as hypotension,
tachycardia, tachypnea, pale, cold & clammy
- acute abdominal distress -> cramping pain,
doubling over, guarding, borborygmi, diarrhea,
bloating, distention, tenderness
- so, think drunk + shock + acute abdominal distress
¥ Treatment:
Ñ> goal = want the stomach to empty slower
** see table
ELECTROLYTES ¥ If it is skeletal muscle or nerve, blame it on Ca
¥ to know the S & S of electrolyte disorders, memorize -> for everything else blame it on K+
3 sentences: - ex. Your PT has diarrhea. What caused it?
a) KalemiaÕs (K+ imbalances) do the same as the a) hyperK+ -> same as preÞx so could be this
preÞx except for heart rate & urine output. (write b) hypoK+ -> things go down so not this one
arrows to help) c) hypoCa -> opposites of preÞx so could be this
b) Calcemias (Ca) do the opposite of the preÞx. d) hypoMg -> opposites of preÞx so could be this
c) Magnesemias do the opposite of the preÞx. ** in a tie, donÕt pick Mg; if itÕs not skeletal or
nerve you rule out calcium
¥ KalemiaÕs do the same as the preÞx except for ** Hint: when answering these kinds of questions,
heart rate & urine output: draw arrows! (i.e. diarrhea is an ÒupÓ symptom)
- look at the preÞx: hyperK+ & hypoK+ (high & low) Ñ> if the question had asked about tetany use the
- symptoms will go HIGH w/ HYPER, LOW w/ HYPO sentences (preÞxes), arrows & tie breakers to
-> except for the heart rate & urine which goes help rule out options & because itÕs muscle &
opposite the preÞx nerve related, itÕs hypoCa
S&S HYPER K+ HYPO K+ ¥ Common mistake in electrolytes:
Brain irritability, aggitation, lethargy, ex. Your PT has tetany. What caused it? (tetany is the
restlessness, agressions, obtunded, stupor body going up)
obnoxiousness, decreased
inhibitions, loud/boistrous a) a high K+ -> makes body go up
Lungs tachypnea bradypnea b) a high Ca -> makes body go down! (opposites)
Heart LOW heart rate HIGH heart rate c) a low Mg -> makes body go up (but itÕs a tie)
- T waves = peaked (tall) (tachycardia) Ñ> 90% of students would pick Ca without properly
- ST wave = elevated
*** everything else about the looking at the question because the question is
heart aside from the rate go up going the other way (use the sentences & arrows)
Bowel diarrhea, borborygmi illeus, constipation
Muscle spasticity, increased tone, hyper- ßaccidity, low
** donÕt do the tie breaker Þrst
reßexive reßexes ¥ preÞxes -> arrows -> tie breakers
Urine LOW urine output HIGH urine output
¥ ex. Your PT has hyperK+. Select all that apply: Sodiums:
a) dynamic illeus e) U wave (goes down) -> sign of cardiac depression ¥ d e hydration
b) obtunded f) depressed ST wave
c) +1 reßex g) polyuria - hypernatremia
d) clonus h) bradycardia o
¥ verload
¥ Hint: donÕt forget, if you donÕt know something donÕt - hyponatremia
pick it (donÕt over select) ¥ dehydration & overload are opposites
-> think of the signs & symptoms of both situations
¥ Calcemias do the opposite of the preÞx.
- hyperCalcemia = body goes low ¥ ex. In addition to a high K+, what other electrolyte
-> ex. bradycardia, bradypnea, ßaccidity, lethargy, constipation imbalance is possible in DKA?
- hypoCalcemia = body goes high - hyperNatremia
-> ex. agitation, clonus, hyper-reßexive, seizure, tachycardia -> because of dehydration
¥ TrousseauÕs sign = put BP cuff on the arm and watch
to see if the hand spasms when itÕs pumped up ¥ Earliest (Þrst) sign of any electrolyte disorder:
¥ ChvostekÕs sign = tap the cheek -> watch for face = numbness & tingling -> paresthesia
spasms (hypocalcemia) ** circum-oral paresthesia (numb & tingling lips) is a
- sign of neuromuscular irritability associated w/ low Ca very early sign
-> Hint: in hypoCa it does the opposite of the preÞx ¥ UNIVERSAL SIGN of electrolyte imbalance is
so irritability would have to be hypoCa muscle weakness = ALL of them cause this
= paresis
¥ Magnesemias do the opposite of the preÞx.
- some review books say that hypomagnesemia is not Treating Electrolyte Imbalances:
associated w/ hypertension BUT it is ¥ the only one that really gets tested is K+
-> remember, high K+ is the most dangerous because
¥ Could it be possible that certain symptoms could be it can stop your heart
caused by either a K+, Mg, or Ca imbalance? YES ¥ Rules:
(How do you break the tie?) a) Never push K+ IV
- in a tie, donÕt pick Mg because itÕs not a major player b) Not more than 40 of K+ per L of IV ßuid
-> call and clarify if there is an order for more
(question the order if itÕs over 40)
 c) Give D5W w/ regular insulin (K enters early)
- fastest way to lower K+
-> this will drive the K+ into the cells out of the
blood (itÕs the K+ in the blood that kills you, not
the ones in the cells)
-> this doesnÕt get rid of the extra K+ but it hides it
well (doesnÕt really solve the problem BUT it
saves their the PTÕs life)
*** buys time to solve the underlying problem
(but if you donÕt Þx it the K+ will eventually
leak back into the blood) - temporary Þx
d) Kayexalate (K exits late)
- full of sodium; sits in the gut
- route: oral ingestion or rectal enema
- trades sodiums for K+ so you can poop out K+
-> PT ends up w/ high sodium (hypernatremia)
*** which is then dehydration which is easier to
treat (trading a life-threatening imbalance w/
a non life-threatening one BUT the PT will
still have an electrolyte imbalance)
-> pro's of kayexalate = getÕs rid of excess K+
permanently as it leaves the body
-> conÕs of kayexalate = takes a long time (HOURS)
& the PT may not live that long

¥ best way to get rid of K+ to Þx the imbalance by using

both D5W w/ reg. insulin + Kayexalate
LECTURE 7 -> Þrst way - ice packs
-> best way - cooling blanket
ENDOCRINE -> O2 per mask at 10L (BUT, remember they are
psychotic so good luck keeping that mask on)
¥ focus on the thyroid & adrenal glands -> what you
need to know most for the test ** maybe pick this Þrst if picking between O2 &
ice packs
¥ Hint: change the word ÔthyroidÕ to ÔmetabolismÕ (the
thyroid regulates metabolism) - will come out of it themselves or die -> self-limiting
- donÕt medicate
THYROID - 2 on 1 (need 2 people to care for these PTÕs)
Hyperthyroidism:
Post-Op Risks:
¥ a.k.a. hypermetabolism
Ñ> depends on type of surgery & timeframe (HAVE
¥ think of all the S & S that you would see in a high
metabolism such as: TO KNOW THIS)
- weight loss, high BP & heart rate, anxious & irritable, ¥ 1st 12 hours:
hyper, heat intolerance (cold tolerance), exophthalmus a) does not matter if total or partial; priority is airway
-> think Don Knotts - thyroid is in the neck
- called GraveÕs disease (run yourself into the grave) - any edema can cause constriction of airway
¥ 3 treatment options for too much hormone: b) hemorrhage
a) radioactive iodine - endocrine gland -> has a lot of blood vessels
i. PT should be in a room by themselves for 24 hrs. ¥ 12-48 hours:
-> no visits for the Þrst 24 hrs. - need to pay attention to the type of thyroidectomy
a) Total = tetany due to the low Ca
ii. after that, PT needs to be extra careful with their
urine (i.e. ßush 3 times after voiding, if urine spills - can cause constriction of dangerous
airway
bk

on the ßoor the hazmat team must be called) b) Sub-total/Partial = thyroid storm phyranax airway
¥ after 48 hrs: shuts off
-> radioactive material is excreted via urine
-> biggest risk to nurse is the urine - big risk is infection
b) PTU -> Propylthiouracil *** but never pick infection in the Þrst 72 hours
- Òputs thyroid underÓ = slows thyroid down
- primary use as a cancer drug BUT is used Hypothyroidism:
specially for hyperT ¥ a.k.a. hypometabolism
- nursing role: ¥ think of all the S & S seen in low metabolism:
-> be aware that it is an immunosuppresent so - obese (weight gain), ßat/boring personality, cold
WBC count needs to be monitored intolerance (heat tolerance), low BP & heart rate
c) Thyroidectomy (most common way) - called Myxedema
- partial or total removal -> PAY ATTENTION TO ¥ treatment option for not enough hormone:
THIS IN THE TEST (most important) - give thyroid hormones -> Synthroid (levothyroxine)
- total = need lifelong hormone replacement ¥ DO NOT SEDATE THESE PTÕS - because theyÕre
-> at risk for hypocalcemia (because of body is already super slow & you could put them into
parathyroid, hard to save it in a total) a coma = myxedema coma
-> check TrousseauÕs & ChvostekÕs - question any pre-op orders that have sedation (i.e.
- sub-total = donÕt need lifelong replacement Ambien before surgery)
because but may need it for a bit before the - if PT is NPO before surgery you need to call the MD
leftover thyroid starts Òkicking inÓ because they need to be able to take their morning
-> less risk for hypocalcemia thyroid hormone PO (never hold thyroid pills pre-
-> at risk for thyroid storm/crisis; op without express order to do so)
thyrotoxicosis (totalÕs never get this) -> if no hormone replacement they will be
hypothyroid & that will cause issues when being
¥ Thyroid Storm: given sedative agents (anesthetics) for surgery
1. super high temps. (105 & up)
2. extremely high BPÕs (stroke category; ex. 210/180)
3. severe tachycardia (ex. could be in the 180Õs)
4. have psychotic delirium
Ñ> MEDICAL EMERGENCY!!! can cause brain
damage (can fry the brain to death)
- immediate treatment = get the temperature down &
get the O2 up
ADRENAL CORTEX ¥ ex. PT w/ acute COPD exacerbation on Solu-Medrol
¥ coincidentally, these diseases start with the letter A or (a steroid) IV push Q8 to reduce inßammation in the
C (like the initials of adrenal cortex) airway. What nursing action needs to be taken on this
- ex. GraveÕs would not be one, CushingÕs would PT? = Accu-ChekÕs Q6 because of the high glucose!
-> steroids make glucose go up EVEN IF youÕre not
AddisonÕs Disease: a diabetic
¥ under-secretion of the adrenal cortex ¥ Treatment:
- one of the rarest endocrine disorders - adrenalectomy (classic treatment for hyper-
¥ S & S: secretory glands is to cut it out)
a) hyper-pigmented -> bilateral adrenalectomy (remove all)
- very tanned (look healthy) -> but then this causes you to have AddisonÕs which
b) do not adapt to stress (donÕt have regulation of means you have to have steroid treatment
stress response) (which makes you look like ÒCushmanÓ all over
- when stressed, BP will go down & glucose will again which is the reason you got the adrenals
down which will put them into shock removed in the Þrst place)
** the purpose of the stress response is perfuse -> takes about 1-2 yrs. just to get equilibrated back
the brain w/ blood (raise BP) & give the brain to feeling normal
glucose (raise glucose)
¥ Treatment: ¥ endocrine surgery creates the opposite problem
- steroids (because theyÕre low in steroids)
-> glucocorticoids
** all steroids end in Ô-soneÕ

C„?´´i´
-> in AddisonÕs you Òadd a -soneÓ

CushingÕs Syndrome:
¥ over-secretion of the adrenal cortex
- ÒcushyÓ sounds like you have more of something
¥ S & S:
** HAVE TO KNOW THIS
** gives you 2 things: the S&S of CushingÕs & the
side-effects of steroids ¥ H2O
** draw a picture of a little man (a.k.a. Cushman)
- moon face with a beard
- big big body w/ a bump on the front & the back +

- skinny arms & legs Na ←

- Þll him full of water & write ÔNaÕ inside (put K+ H2O ¥

outside of the body)

- draw striae on his abdomen (stretch marks)
- write Ôhigh glucoseÕ (MOST IMPORTANT)
- draw bruises
- word bubble = ÒIÕm mad. I have an infection.Ó
a) moon face
b) hirsutism (lots of excess hair)
reaotontmeryk obesity
c) central obesity cat

⑥
d) bumps = gynecomastia & kyphosis (buffalo hump)
e) atrophy of extremity muscles
f) retains Na & water (thus, losing K+)
g) stretch marks
h) hyperglycemia (look like diabetics)
i) easily bruised
j) easily irritable
k) immunosuppressed
¥ ex. If youÕre on a steroid and youÕre a diabetic,
what do you do?
- need a lot more insulin (because steroids increase
the blood glucose)
CHILDHOOD DEVELOPMENT ¥ 9 - 12 months:
¥ childrenÕs toys -> how to select the appropriate play - working on vocalization
activity/toy given the age of the child - best toy = speaking/talking toys
¥ 3 things to consider: -> ex. tickle me Elmo, talking books
- Is it safe? - purposeful activity w/ objects (at least 9 months)
- Is it age appropriate? -> ex. building w/ blocks
- Is it feasible? -> Hint: Never pick an answer w/ the following
words if the kid is under 9 months = build, sort,
Safety Considerations: stack, make, construct (because they are
¥ a) no small toys for children under 4 Òpurpose wordsÓ)
- no small parts that can be aspirated for under 4 ¥ Toddlers -> 1 - 3 years:
¥ b) no metal toys if oxygen is in use - working on gross-motor skills
- because of sparks -> running, jumping
- might use the word Òdye-castÓ instead of metal (ex. - best toy = push-pull toys
hot wheels car) -> ex. wagons, lawnmowers, little strollers
¥ c) beware of fomites - if it takes Þnger dexterity, then DO NOT choose it for
- fomite = non-living object that harbours microorganisms the toddler
** vector/host is the name for living -> ex. no colored pencils, no blunt scissors
- toys are notorious fomites on a pediatric unit (kids - Þnger-painting is appropriate (should be called
stick them in their mouths) ÒhandÓ painting) -> is not a dextrous activity, it is
- worst fomite = stuffed animals gross motor
- best kinds of toys -> hard plastic toys (because you - parallel play = play alongside others but not with
can terminally disinfect them) ¥ Preschoolers:
- ex. If you have a child who is immunosuppressed, a) working on Þne-motor skills
what would be the best toy for them? -> a hard -> things that use Þnger dexterity
plastic action Þgure b) working on balance
-> ex. tricycles, tumbling, skating, dance class
Feasibility: -> swimming is more of a gross motor skill because it
¥ Òcould you do itÓ in a certain situation doesnÕt take balance (can start this w/ infants)
¥ ex. Is swimming a good/safe activity for a 13 yr. old? YES
ex. Is swimming an age appropriate activity for a 13 yr. old? YES
- co-operative play = play w/ others
ex. Is swimming feasible for a 13 yr. old in a body cast? NO - pretend play = highly imaginative at this stage
¥ use common sense ¥ School-aged:
- characterized by the 3 CÕs
Age Appropriateness: a) creative = let them make it (donÕt make it & give it
¥ this is what mostly gets tested to them)
-> if the test gives you a certain age, you need to -> better to give them blank paper & crayons
know what toy/activity to give them instead of coloring book so that they can create
¥ 0 - 6 months: their own pictures
- children at this age are sensory-motor -> LEGO age! (let them create the trucks and cars
- best toy = musical mobile instead of giving them toy cars)
-> something that stimulates BOTH sensory & motor b) collective = they like collecting things
- if they donÕt have mobile as a choice, look for -> etc. beanie babies, pokemon, barbies
something that is large & soft c) competitive = like to play games where there is a
¥ 6 - 9 months: winner & a loser
- working on skills of object permanence (the idea -> preschoolers want games where everyone is the
that something is still there even if you canÕt see it) winner & everyone gets the same prize
-> play at this age should be teaching them this ¥ Adolescents:
- best toy = Òcover-uncover toyÓ - peer-group association = they want to hang out
-> choose something easy to cover & uncover (i.e. with their friends and Þt in
jack-in-a-box, pop up toys, books with movable - if you have a question stating that there are a group
parts that cover/uncover) of teenagers hanging out in one teenagerÕs room you
- peek-a-boo, putting blanket on head & pulling off let them unless 1 of 3 things is happening:
- 2nd-best toy = something large & hard a) if anyone is fresh post-op (under 12 hrs.)
- worst toy for this age is the musical mobile (because b) if anyone is immunosuppressed
they can pull themselves up, pull the mobile and c) if anyone has a contagious disease
strangle themselves)
NEURO b) Do not let PT sit for longer than 30 mins
LAMINECTOMY - question this typical post-op order: up in chair for
¥ lamina = the vertebral spinous processes 1 hr TID
-> the bumpy bones you feel on the spine -> in chair for meals is ok because usually meals
ectomy = removal only last for 30 mins
¥ removing posterior processes of the vertebral bones c) PT may walk, stand & lie down w/o restrictions
¥ reason -> to relieve nerve root compression - restrictions only on sitting
- cut away some of the bone to relieve the pressure -> jobs w/ sitting all day (i.e. admitting clerk) has
on nerves (give nerves more room to exit) shown to have the most occurrence of back
¥ a.k.a. decompression surgery issues/pain

S & S of Nerve Root Compression (3 PÕs): Post-Op Complications:

¥ Pain ¥ they depend on location!
¥ Paresthesia = numbness & tingling ¥ cervical:
¥ Paresis = muscle weakness - # 1 complication is pneumonia (because breathing
is affected)
¥ For Laminectomy questions, the most important ¥ thoracic:
thing to pay attention to in any neuro question is - pneumonia -> canÕt cough properly
LOCATION, LOCATION, LOCATION!! - ileus -> affected bowel function
- will determine symptoms, prognosis, & treatment ¥ lumbar:
- LOCATION IS EVERYTHING IN NEURO - urinary retention -> affected bladder function
¥ 3 locations in Laminectomies: - issues w/ the legs
- cervical = neck ¥ ex. You are caring for a PT w/ a lumbar oligodendrogliocytoma.
-> innervates the diaphragm (breathing) & arms WhatÕs the #1 problem?
a) airway c) cardiac arrhythmia
- thoracic = upper back b) ileus d) urinary retention -> itÕs lumbar
-> innervates abdominal muscles (cough *** LOCATION LOCATION LOCATION
mechanism) & gut muscles (bowels)
- lumbar = lower back ¥ typically, donÕt have chest tubes w/ laminectomies
-> innervates the bladder & the legs BUT the anterior thoracic will have chest tubes
- means the surgery goes through the front of the
Pre-Op Laminectomy: thorax to get to the spine so you need tubes in order
¥ when you change the location, you change the to address pneumo/hemathorax
answer
¥ ex. What is the most important pre-op assessment for Laminectomy WITH FUSION:
a cervical laminectomy? ¥ Òwith fusionÓ -> key word; means that a bone graft is
= breathing & if itÕs not one of the choices, pick the taken from the iliac crest
one that checks the function of the arms & hands - take some bone from your hip to fuse in between the
¥ ex. What is the most important pre-op assessment for bones from where the disc was taken out (to keep
a thoracic laminectomy? from grinding)
= coughing & bowel sounds ¥ most laminectomies donÕt have fusion
-> if abdominal muscle function is affected, PT wonÕt - because usually itÕs just the Òwing thingÓ being taken
be able to contract enough to cough properly out BUT if the disc is also removed, you need fusion
¥ ex. What is the most important pre-op assessment for ¥ PT will have 2 incisions:
a lumbar laminectomy? a) hip
= bladder function (voiding, distention), or function -> has the most pain, most bleeding & drainage (will
of legs and feet have the JP/Hemovac drain)
-> post-op, this one causes the most problems
Post-Op Laminectomy: ** surgeons want to get rid of this incision because it
¥ #1 post-op laminectomy answer on N-CLEX is log-roll costs more, has more risks, want to cut recovery
-> for any spinal injury time/hospital stay in half, less drainage if gone ->
¥ 3 other things to know about mobilizing PTÕs after surgeons are using cadaver bones from bone banks
surgery: (no more 2nd incision; risk for rejection is low)
a) Do not dangle these PTÕs b) spine
- go from lying to immediate standing/walking -> highest risk for rejection
- they can sit on the edge of the bed long enough to ** both have equal risk for infections
avoid orthostatic hypoTN but not more than that
Discharge Teaching for Laminectomies:
¥ very important!
¥ 4 Temporary Restrictions:
a) Do not sit for longer than 30 mins
- applies for 6 weeks
- Hint: if you have to guess long a restriction
applies for something, you should pick 6 weeks
(otherwise if you know what it is pick the it)
b) Lie ßat & log roll for 6 weeks
c) No driving for 6 weeks
d) Do not lift more than 5 pounds for 6 weeks
- ex. gallon on milk
¥ 3 Permanent Restrictions:
a) Will never be allowed to lift objects by bending
at the waist
- should lift with the knees (everyone should)
b) Cervical lamÕs are not allowed to lift anything
over their head
- for the rest of their life
- get step stools
c) No jerky amusement rides, off-roading, horse-
back riding etc.

¥ the Laminectomy info can be used to get any

spinal cord questions right
- pay attention to the locations
 Name and Normal Priority Level if Abnormal
LECTURE 8 Info Range
pH 7.35 - D = in the 6Õs (ex. 6.58)
7.45 i. nothing to hold
LAB VALUES ii. assess vitals (body goes down w/ the
¥ you have to know the main ones but also know pH) to make sure theyÕre alive
iii. nothing to prepare BUT treat the
which ones are more dangerous than others underlying cause (which only the MD
can do)
-> need to know how to prioritize PTÕs according to iv. call MD faster than in any other case
lab values (not good enough to just know basics) BUN 8 - 25 A = if elevated itÕs not a big deal
(blood -> assess PT for dehydration
¥ scheme (priority levels): urea
-> the value is abnormal BUT what priority is it? nitrogen) Hint: if they give an elevated blood value &
you have no clue whatÕs going on & they
A = not a priority/low priority; donÕt do anything nitrogen ask Òfor what would you assess themÓ
waste -> dehydration is a great guess (because all
about, not a big deal (donÕt really need to report it) products in blood values go up from concentration)
B = need to be concerned but nothing you need to do; the blood
HgB 12 - 18 B = 8 - 11
just needs closer monitoring ** boards - assess for low HgB (bleeding, malnutrition)
C = crossed a line from low to high priority; it is tend to
not go into C = below 8
critical, you have to do something about it genders i. nothing to hold
(this is the ii. assess for bleeding
i. always hold (if thereÕs something to hold) normal
adult iii. prepare to give blood
ii. assess (focused) HgB) iv. call MD
iii. prepare to give Bicarb 22 - 26 A
CO2 35 - 45 C = high but in the 50Õs
iv. call whomever is appropriate * not for -> PT will be dyspneic
D = highest priority that you can possibly have w/ a COPD i. nothing to hold
PTÕs, reg. ii. assess resp. status
lab value; do something STAT! PTÕs iii. prepare to get PT to do pursed-lipped
breathing (prolongs exhalation to get
-> you cannot leave their bedside (you can leave from rid of CO2)
the bedside of a ÒCÓ level if needed); get other arterial iv. breathing usually Þxes it so you donÕt
blood gas have to call
people to help
D = in the 60Õs -> one of the criteria for
resp. failure (MEDICAL EMERGENCY)
i. nothing to hold
¥ Hint: Assess before you do unless delaying doing ii. assess resp. status
puts your PT at higher risk! (ex. blood transfusion reaction) iii. prepare to intubate & ventilate
iv. call resp. therapy Þrst then MD
- ex. you should put the HOB up Þrst before doing resp.
assessment because keeping a dyspneic PT ßat on bed Hematocrit 36 - 54 B = elevated
-> assess for dehydration
longer puts them at higher risk * 3X the
- DONÕT FORGET TO SEE IF ITÕS A FIRST vs. BEST question HgB (so
memorize
the HgB
& multiply
Name and Normal Priority Level if Abnormal by 3)
Info Range
PO2 78 - 100 C = low but still in 70Õs
Serum 0.6 - 1.2 A i. nothing to hold
Creatinine - never make a PT w/ high creatinine as from ii. assess resp. status
(same as highest priority arterial iii. prepare to give O2
best Lithium) - probably have kidney disease BUT they blood gas iv. most times the O2 administration
indicator of are not going to die in the next 4 hours (not from works and you donÕt have to call the
kidney - only time you might call MD is if theyÕre pulse MD because the dyspnea goes away
function going for a test that has a dye in it (but still oximetry) * hypoxic -> heart rate speeds up Þrst and
wait to call in the morning, not right away) when the heart canÕt work hard anymore,
INR (inter- 2 - 3Õs C = anything that is 4 & above is the resp. rate goes up
national i. hold Coumadin
normalized ii. assess bleeding D = if in the 60Õs -> the other criteria for
ratio) iii. prepare to give Vit. K resp. failure (MEDICAL EMERGENCY)
(variation of iv. call MD i. nothing to hold
PT) ii. assess resp. status
iii. prepare to intubate & ventilate
monitors iv. call resp. therapy Þrst then MD
Coumadin * you can still put O2 during this time
K+ 3.5 - 5.3 C = if lower than 3.5 -> wonÕt solve the problem but will help
i. nothing to hold keep them calm
not a good ii. assess the heart O2 Sat 93 - 100 C = anything less than 93
indicator of iii. prepare to give K+ i. nothing to hold
something iv. call MD ii. assess them
speciÞc, iii. prepare to give O2 if really low
just that C = between 5.4 - 5.9 iv. donÕt need to call MD if O2 goes up
something i. hold all K+ * you better freak out though if in paeds it
is wrong ii. assess the heart goes below 95
iii. prepare to give D5W + reg. insulin + * anemia falsely elevates it (you should look
Kayexelate for other indicators); dye procedures in
the last few hours also invalidates it w/
iv. call MD false elevation
D = if > 6 (this PT could die soon; do all the
same as C but do it stat! & need more
than 1 person)

the doctor !
calling
→ hold assess before
i ,
prepare
Name and Normal Priority Level if Abnormal
Info Range
BNP should B = elevated BNP
(brain be under - you know they have CHF/watch them for
natriuretic 100 CHF
peptide) - itÕs not high priority because it indicates a
chronic condition
best
indicator of
congestive
heart failure
Sodium 135 - 145 B = if abnormal then assess
- if high -> assess for dehydration
- if low -> assess for overload
LOW
means C = if Na is abnormal and there is a
^"
* "infectionchange in LOC (because it becomes a

[ fight safety issue)

WBCÕs Total C = all of them -> if they go below their
* 3 counts WBC thresholds
that you 5,000 - i. nothing to hold
must 11,000 ii. assess for signs of infection

/
know
ANC
(absolute
Neutrophil
iii. instead of preparing, place them on
neutropenic precautions

increased bk count)
body 's fighting needs to
be above
a current
Infection
500
-> if it falls below you go from HIV to AIDS
CD4
needs to
above
200
Platelets C = below 90,000
-> bleeding precautions
D = below 40,000
RBCÕs 4-6 B
million
¥ memorize the 5 DÕs => highest priorities!
- pH in the 6Õs
- K+ in the 6Õs
- CO2 in the 60Õs
- O2 in the 60Õs
- platelet below 40,000
Ñ> boards doesnÕt really put these kind of PTÕs
against each other because itÕs not fair
¥ learn the CÕs
LECTURE 9 BENZODIAZEPINEs:
¥ anti-anxiety meds
PSYCHOTROPIC DRUGS ¥ considered to be minor tranquilizers (primary use)
¥ even though there are several classes, info tends to overlap ¥ they always have Ò-zepÓ in the name
¥ ALL psych drugs cause low BP & weight changes -> both major & minor tranquilizers have ÒZÕsÓ
-> usually weight gain (but a few cause weight loss) ¥ ex. Diazepam (Valium), Xanax, Clonazepam, Lorazepam
¥ for most of these meds, you need to take take them ¥ indications: are more than just minor tranquilizers
for 2-4 weeks before you get beneÞcial effect a) pre-op to induce anesthesia
- many PTÕs say that they donÕt work after only taking b) muscle relaxant
them for 1 week (nurse teaching) c) good for alcohol withdrawal
d) seizures
PHENOTHIAZINEs: e) help people when they are Þghting the ventilator
(relax & calm down)
¥ old class of drugs -> 1st gen/typical anti-psychotics
¥ ALL end in Ò-zineÓ ¥ work quickly but technically, you shouldnÕt take them
for more than 2-4 weeks
¥ actions:
- do not cure psych diseases -> reduce the symptoms ¥ relationship between an anti-depressant & a minor
- in large doses they are anti-psychotics tranquilizer?
-> Ò-zines for the zanyÓ - one takes 2-4 weeks and you can be on it for the
- in small doses they are anti-emetics rest of your life (anti-depressant)
- considered major tranquilizers - the other works quickly but you should only be on it
-> Aminoglycosides are to antibiotics as for 2-4 weeks (minor tranquilizer)
Phenothiazines are to tranquilizers = THE BIG Ñ> a lot of PTÕs get put on both when Þrst admitted as the
minor tranq. will work right away & then when the anti-
GUNS (when nothing else is going to work)
depressant kicks in, they are taken off the minor tranq.
¥ major side effects (not toxic effects):
A = anti-cholinergic (primarily dry mouth) * heparin is to warfarin as a tranquilizer is to
B = blurred vision an anti-depressant
C = constipation ¥ side effects:
D = drowsiness A = anti-cholinergic (primarily dry mouth)
E = EPS -> extrapyramidal syndrome (looks like B = blurred vision
ParkinsonÕs) C = constipation
F = photosensitivity D = drowsiness
aG = agranulocytosis (low WBC count, ¥ # 1 nursing diagnosis is risk for injury (safety issues)
immunosuppressed)
** side effect vs. toxic effect nursing actions: MAOIs - MONOMINE OXIDASE INHIBITORS:
- side effect = teach PT, inform MD, keep giving ¥ anti-depressants (one of the Þrst types developed)
med (& give drugs that can help alleviate) - donÕt really use them much anymore because of the
- toxic effect = hold drug, call MD immediately restrictions & side effects
¥ the nursing care is treating the side effects - dirt cheap compared to other anti-depressants
- #1 nursing diagnosis for a client on a tranquilizer is ¥ you need to spot an MAOI when you see it on the test
risk for injury (safety issues) from the beginning of the name
¥ decanoate = long-acting IM form given to non- Ñ> the beginnings of the name rhyme: Marplan,
compliant clients Nardil, Parnate (all brand names)
- is something that may be court ordered ¥ side effects:
A = anti-cholinergic (primarily dry mouth)
TRICYCLIC ANTI-DEPRESSANTS: B = blurred vision
C = constipation
¥ old class of anti-depressants & most have been
D = drowsiness
grandfathered into a newer class:
- NSSRI = non-selective serotonin re-uptake inhibitor ¥ the important thing is patient teaching:
a) to prevent severe, acute, sometimes life-
¥ are mood elevators used to treat depression
threatening hypertensive crisis (high BP)
= Òhappy pillsÓ
- PT must avoid all foods containing tyramine (an
- include Elavil, Tofranil, Aventyl, Desyrel
amino acid that regulates BP)
¥ side effects: -> NO aged cheese (can have mozzarella & cottage
A = anti-cholinergic (primarily dry mouth)
cheese), yogurt, cured/preserved/organ meats,
B = blurred vision
alcohol, caffeine, chocolate, fermented foods,
C = constipation
bananas, avocadoÕs (guacamole!), any dried fruit
D = drowsiness
E = euphoria b) do not take OTC meds when on an MAOI
LITHIUM: Ñ> EPS = side effect (no big deal)
¥ used to treat bi-polar disorder Ñ> NMS = medical emergency!!! (PT can die!)
-> it decreases mania (does not treat the depression) ¥ How do you tell the difference between EPS &
¥ of all psych drugs, itÕs the most unique (diff. side effects) NMS?? take a temperature
because all the other ones mess w/ neuro-transmitters -> no excuse for the nurse to miss NMS
-> Lithium does not = stabilizes nerve cell membranes -> Þrst action when faced w/ a PT that has anxiety &
¥ unique side effects that act more like an electrolyte: tremors = take their temp.
P = peeing P = pooping ** if over 102 call emergency response team coz itÕll
P = paresthesia -> earliest sign of all electrolyte imbalances be a bad situation (even if itÕs not 105 degrees yet)
¥ TOXIC effects: ¥ safety concerns related to the side effects:
Ñ> hold & call the MD - as soon as they get hit by Haldol, they go down
- tremors - metallic taste - severe diarrhea
¥ Interventions for PTÕs on Lithium: CLOZAPINE (CLOZARIL):
a) #1 = increase ßuids ¥ prototype 2nd gen/atypical anti-psychotic
-> because they are peeing & pooping a lot so at - new class for the ÒzanyÓ
higher risk for dehydration ¥ used to treat severe schizophrenia
b) watch Na levels ¥ was meant to replace the Ò-zinesÓ & Haldol
c) if they are sweating like crazy donÕt give free water, - advantage is that it does not have the side effects
give Gatorade or some other electrolyte solution A B C D E or F
-> PT has to have a normal Na for Lithium to work - has slight effects but minor compared to Ò-zinesÓ
d) NOTE: Lithium is closely linked to sodium. - BUT does have side effect aG (agranulocytosis)
- low Na = makes Lithium more toxic -> horrendous in trashing bone marrow
- high Na = makes Lithium ineffective -> causes unbelievably low WBC counts causing
*** need normal Sodium levels you to get horrible infections
¥ other variations created that have less aG effects but still
PROZAC -> SSRI - SELECTIVE SEROTONIN RE- have to monitor them
UPTAKE INHIBITOR: ¥ not everyone gets the low WBC so some people can
¥ similar to Elavil (NSSRI) take it but some people canÕt
¥ side effects: ¥ nursing priority = monitor WBC counts
A = anti-cholinergic (primarily dry mouth) ¥ Note: Geodon (Ziprasidone)
B = blurred vision
- has a black box warning -> prolongs the QT interval
C = constipation
D = drowsiness & can cause sudden cardiac arrest
E = euphoria Ñ> shouldnÕt really use in PTÕs w/ heart problems
¥ Prozac causes insomnia ¥ in general, these drugs end w/ Ò-zapineÓ
-> give it before noon (bad idea to give at bed time) - another tranquilizer class that has a ÒzÓ
¥ When changing the dosage for a young adult/
adolescent, watch for increased suicidal risk SERTRALINE (ZOLOFT):
-> only this age group & only when there is recent ¥ another SSRI like Prozac
dosage change ¥ also causes insomnia BUT you can give it at bedtime
¥ the big thing these days is testing the interactions:
HALDOL: a) cytochrome P450 system in the liver = major pathway
¥ has a decanoate form (long acting IM) in which drugs are metabolized & deactivated in the liver
¥ basically the same as Thorazine so side effects are: -> Zoloft is notorious for interfering w/ this system
- A B C D E F aG (causes toxicities of other drugs because they
are not getting metabolized)
¥ is also an old 1st gen/typical anti-psychotic like the -> whenever you add Sertraline to a PTÕs drug
Ò-zineÕsÓ (major tranquilizer) regimen, you will probably have to lower the
¥ the big thing they test for Haldol is NMS! dosages of the other drugs
- elderly PTÕs & young, white schizophrenics may
b) watch for interactions w/ St. JohnÕs Wort
develop NMS w/ Haldol overdose
- you will get serotonin syndrome
¥ NMS = neuroleptic malignant syndrome
-> potentially life-threatening
- potentially fatal hyper-pyrexia
-> looks like the MAO PTÕs that eat the tyramine
- could reach 106-108 degrees (deÞnitely over 105)
** SAD Head = sweaty, apprehensive, dizzy, headache
- dosage for elderly PTÕs should be half the adult dose
c) interactions w/ Warfarin (Coumadin)
¥ has anxiety & tremors (like EPS) & get both w/ it:
- if PT on both, they might bleed out (MUST reduce
** boards will want to know if you know the
Coumadin) -> watch for increased bleeding if on
difference between them
both because Zoloft makes Coumadin go toxic
LECTURE 10 ¥ 4 Positive Signs:
a) fetal skeleton on x-ray
MATERNAL NEWBORN b) fetal presence on ultrasound
PREGNANCY: c) auscultation of a fetal heart rate
-> starts beating at 5 weeks but you hear it
¥ you must be able to calculate a due date
- take the 1st day of the last menstrual period between 8-12 weeks
- add 7 days, subtract 3 months d) when examiner palpates fetal movement/outline
-> not a positive sign when mom feels it (i.e. quickening)
- ex. PTÕs last menstrual period was from June 10-15
** none of them have false positives
= due date is apx. March 17
¥ you need to know how much weight should/
¥ most OB information has a range where/when it
shouldnÕt be gained:
occurs (because every woman is different)
** donÕt worry about multiples or about women who
-> because of this it is critically important that you
are underweight/over-weight to begin w/
read OB questions carefully & properly
- Total weight gain = should be 28 lbs, +/- 3
¥ there can be 3 different questions for every fact in OB:
-> 1st T = 1 lb/month (3 lbs; too much is bad)
a) when would you ÞrstÉ
-> 2nd & 3rd T = 1 lb/week
-> pick the earliest part of the range
** on the test, if they give you a particular week of
b) when is it most likelyÉ
gestation, you have to be able to predict what the
-> pick the mid part of the range
weight should be
c) when should you ___ byÉ
- ex. Woman in 28th week who has gained 22 lbs.
-> pick the end of the range
What is your impression? ex. When should you Þrst auscultate a fetal heart? = at 8 weeks
-> Week 12 (end of 1st T) = 3 lbs., after that, each ex. When would you most likely auscultate fetal heart? = 10 weeks
week is 1 lb. ex. When should you auscultate a fetal heart by? = by 12 weeks
-> she should have gained 19 lbs, she gained 3 *** PAY ATTENTION TO WHICH ONE THEY ASK!
more than supposed to ¥ quickening = when the baby kicks -> 16 to 20 weeks
-> HINT: if you take the week & subtract 9, that is - Þrst feel = 16 weeks
the weight that should be gained - when is it most likely to feel = 18 weeks
* 12 - 9 = 3; 13 - 9 = 4, 20 - 9 = 11 - when should you feel it by = 20 weeks
- being over 1-2 lbs. is ok but if sheÕs 3 lbs. off she
needs further assessment ¥ The MAYBE Signs: (probableÕs & presumptiveÕs)
-> 4 lbs. or more off = could be trouble a) all urine & blood pregnancy tests
* ex. if PT is 6 lbs. underweight, she needs a biophysical -> a positive pregnancy test is NOT a positive sign
proÞle to make sure the baby is still alive of pregnancy (because it only means you have
- ideal weight gain = week - 9 the hormones that go w/ pregnancy, but doesnÕt
¥ Fundal Height: mean you always have a fetus)
- fundus = the top part of the uterus ** which is why you can have false positives
-> not palpable until week 12 (after 1st T) b) ChadwickÕs sign = cervical color change to
- When is the fundus at the umbilicus? cyanosis (bluish; includes vagina & labia)
= 20-22 weeks of gestation GoodellÕs sign = cervical softening
- it is important to know fundal location to recognize HegarÕs sign = uterine softening
date of viability and know what trimester the PT is in: *** all occur in alphabetical order (boards tends to the
= 20-22 weeks (24 is the end of the 2nd) order instead of the weeks they occur because
** ex. if a PT is brought into ER and w/ history about the weeks vary, order doesnÕt)
pregnancy (or she canÕt tell you), you need to know what
trimester sheÕs in to know whatÕs going on with the baby Patient Teaching in Pregnancy:
-> fastest way to know the trimester = palpate the ¥ teaching PTÕs the pattern of ofÞce visits
fundus (if you donÕt feel it at all, sheÕs in the *** good prenatal care is a major factor in infant
1st T & she is the priority, not the baby) mortality so teach women how often to come in for
-> if you feel the fundus at/below the good prenatal care
bellybutton sheÕs in 2nd T (she is still priority) a) once a month until week 28
-> if the fundus is above the umbilicus she is in - for all of 1st & 2nd T
the 3rd T and baby is the priority! - for the early part of 3rd T
b) once every 2 weeks until week 36
Signs & Symptoms of Pregnancy: c) once every week until delivery or week 42
¥ probable, presumptive, positive -> BUT on the test - by then, schedule for induction/c-section
there is only POSITIVE & everything else (maybeÕs)
¥ ex. If a woman comes in for her 12th week checkup, -> ischial spines = the smallest diameter through
when does she come in next? which the baby has to Þt for a vaginal birth (the
= week 16 tight squeeze, the narrowest part of the pelvis)
ex. If she comes in for her 28th week checkup? ** if the baby cannot Þt through there, the baby
= week 30 (& then 32, 34, 36) cannot be born vaginally
ex. If she comes in for her 36th week checkup?
-> negative stations = the head/presenting part is
= week 37, 38, 39, 40, 41, 42, take the baby
above the Òtight squeezeÓ
* negative news
¥ teach her that her hemoglobin will fall:
-> positive stations = the presenting part is below
- we donÕt worry about low HgB unless it gets really low
the ischial spines and has already made it through
- normal HgB for females = 12 - 16
the Òtight squeeze
-> 1st T - can fall to 11 & be perfectly normal (not
* positive news
considered low)
** ex. if the babyÕs head stays at -1 & -2 for 17
-> 2nd T - can fall to 10.5 & be normal hours after fully dilated & 100% effaced, the
-> 3rd T - can drop to 10 & still be called normal head is too big and PT needs a C-section
** acceptably low can be as low as 9 ** ex. if the babyÕs head stays at +3 for 17 hours,
- tolerate lower HgBÕs in pregnant women the further the baby can still be born vaginally but needs a
along they are than you would w/ non-pregnant PTÕs vacuum extractor, forceps, or an episiotomy
- engagement = station 0
¥ teaching about the discomforts of pregnancy: -> the presenting part is at the ischial spines
a) morning sickness = 1st T problem - lie = relationship of the spine of the mother & the
- treat by eating dry carbohydrates (ex. crackers) spine of baby
BEFORE you get out of bed -> longitudinal lie = parallel to momÕs spine (good!)
b) urinary incontinence = 1st & 3rd T problem -> transverse lie = perpendicular, sideways (spines
- why not the 2nd? the baby is an abdominal at a right angle); looks like a T; bad, trouble
pregnancy at this point and off the bladder -> oblique lie = baby is diagonal into momÕs hip
- treat by voiding every 2 hrs (should do this from instead of straight into the pelvis
the start of pregnancy until 6 weeks after delivery) - presentation = the part of the baby that enters the
c) difÞculty breathing = 2nd & 3rd T problem births canal Þrst
- teach tripod position (like COPD clients) -> ROA, LOA etc.
d) back pain = usually 2nd & 3rd T -> donÕt spend a ton of time memorizing the
- tends to get worse and worse the further along you presentations (this is a hard OB question; know
get in the pregnancy the stuff that everyone needs to know!)
- treat w/ pelvic tilt exercises (tilt pelvis forward) ** you cannot miss the easy ones!
* ex. put foot on stool -> the most common ones are ROA & LOA (right &
left occiput anterior)
¥ pregnancy questions are a good place for using ** you have much better chances guessing by
common sense because it is not a disease, itÕs a picking one of these (R before L)
healthy state
-> using good health patterns Stages of Labour & Delivery:
-> if you get a question you donÕt know, ask yourself ¥ 1 = Labour (all of it)
Òwhat would be good for anybody?Ó & pick that answer - 3 Phases of Labour:
a) Latent b) Active c) Transition
LABOUR & BIRTH Phases LATENT ACTIVE TRANSITION
¥ what is the truest, most valid sign that a woman is Dilation 0 - 4 cm 5 - 7 cm 8 - 10 cm
in labour??? Contraction every 5 - 30 every 3 - 5 every 2 - 3
FREQUENCY mins. mins. mins.
= onset of regular, progressive contractions Contraction 15 - 30 30 - 60 60 - 90
Ñ> not bloody show or water breaking (you can have DURATION seconds seconds seconds
these and not be in labour) Contraction ÒmildÓ ÒmoderateÓ ÒstrongÓ
INTENSITY
¥ Terminology: Hint: memorize the middle column (active
- dilation = the opening of the cervix labour) because everything is sequential
-> goes from 0 - 10 cm NOTE: contractions should not be longer
-> 0 = closed; 10 = fully dilated than 90 seconds or closer than every 2
mins. Ñ> means trouble in labour!
- effacement = thinning of the cervix - signs of uterine tetany, uterine hyper-
stimulation; parameters to stop Pitocin
-> goes from thick to 100% effaced
¥ ex. A woman comes into L & D. She is 5 cm dilated,
- station = relationship of the fetal presenting part to contractions 5 mins. apart lasting for 45 seconds. What phase
momÕs ischial spines is she in? = active
¥ 2 = Delivery of the Baby Interventions for ALL Other Complications in
¥ 3 = Delivery of the Placenta Labour & Birth:
¥ 4 = Recovery ¥ ex. include uterine atony, uterine hypoTN, vena cava
- 2 hours syndrom, uterine tetanyÉetc.
¥ What is the purpose of uterine contractions in: ¥ all treated the same, treated with LION:
- 1st stage = dilate & efface the surface L = 1st, turn them on their left side
- 2nd stage = push the baby out I = increase IV
- 3rd stage = push the placenta out O = oxygenate them
- 4th stage = stop bleeding by contracting the uterus N = notify MD
¥ When does postpartum technically begin? ** RPNÕs can do all except increase IV
= 2 hrs after delivery of the placenta - left side position is Þrst but also probably best
¥ DONÕT MIX UP PHASE & STAGE! pay attention! because it addresses uterine perfusion which
- ex. What is the #1 priority in the 2nd phase? protects/saves baby
= pain management ¥ PIT: in an OB crisis, if Pitocin is running, STOP IT!
- ex. What is the #1 priority in the 2nd stage? = this would become the Þrst thing then before turning
= clearing the babyÕs airway them onto their left side
- ex. What are major nursing actions to take in the 3rd
phase? = check dilation, help w/ pain & breathing
Pain Meds in Labour:
- ex. What are major nursing actions to take in the 3rd
stage? = assessing blood loss, making sure there ¥ do not administer a pain med to a woman in
are 3 vessels in the cord, making sure the whole labour if the baby is likely to be born when the
placenta comes out med peaks (review peaks lecture)
¥ Teaching PTÕs how to time contractions: - ex. You have a primigravida at 5 cm who wants her
- frequency = beginning of one contraction to IV push pain med. Will you give it or not?
beginning of the next (A to C) -> is it likely that a primigravida at 5 cm will deliver
- duration = beginning to end of 1 contraction (A to B) in the next 15-30 mins? NO, so give her the med
- intensity = strength of contraction -> subjective - ex. A multigravida at 8 cm wants her IM pain med.
- teach her to palpate w/ one hand over the fundus Do you give it?
with the pads of the Þngers (Þngertips) -> is it likely that she could deliver in the next 30-60
* use other hand to time it mins? YES, so no IM med for her

COMPLICATIONS OF LABOUR
¥ there are 18 that can occur in L & D that you need to
know BUT there are only 3 protocols you need to
know for all of them
¥ a) Painful Back Labour
- usually for OP positions (occiput posterior)
Ñ> think Òoh pain!Ó
- low priority
- do 2 things:
i. position = place her in knee chest position (face
down on hands & knees, bum up in air)
-> to have baby come off the coccyx
ii. push = take your Þst and push it into her sacrum
(applies counter pressure to relieve pain)
¥ b) Prolapsed Cord
- OB MEDICAL EMERGENCY!!! high priority!
- when the cord is the presenting part (comes out Þrst)
& so when the head comes down it presses on the
cord and cuts of the supply causing baby to Òkill itselfÓ
- do 2 things:
i. push = babyÕs head off cord (DONÕT touch the cord)
ii. position = knee chest position to take
compression off of the cord
** delivery is then usually emergency C-section (take
mom to OR in knee-chest position while holding head)
LECTURE 11 STAGE 3 of LABOUR = Delivery of the Placenta:
¥ a) make sure itÕs all there
MATERNAL NEWBORN continued ¥ b) check for 3 vessel cord
FETAL MONITORING PATTERNS: - 2 arteries
- 1 vein
¥ 7 that you should know but easy to remember
¥ a) Low Fetal Heart Rate
= under 110 STAGE 4 of LABOUR = Recovery:
- BAD! do L I O N & if Pit was running, stop it ¥ is the Þrst 2 hours after delivery of the placenta
¥ b) High Fetal Heart Rate ¥ 4 Things you do 4 Times an hour in the 4th Stage:
= over 160 *** Q15
- not a big deal, not a high priority a) vitals signs
- document & take momÕs temperature - assessing for S&S of shock (pressures down,
-> could be up because mom has a fever (so rates up, pale, cold & clammy)
nothing wrong with baby) b) check the fundus
- if boggy -> massage
¥ c) Low Baseline Variability
= when the fetal heart rate stays the same & does - if displaced -> catheterize
not change (whether high, low, or in the middle) c) check the perineal pads
- BAD! do L I O N - to see how much she is bleeding
- if excessive -> will 100% saturate in 15 mins. or
¥ d) High Baseline Variability
= fetal heart rate is always changing less (so if 98% saturated, sheÕs still ok)
- good! document it d) roll her over
- check for bleeding underneath her
¥ once a person is born, if their vital signs stay the
same they are called stable BUT before youÕre born, if Ñ> also lets you assess the perinanal area
your vital signs stay the same itÕs bad
-> we donÕt want to see the opposites happen POSTPARTUM:
¥ assessments -> usually 4-8 hrs. depending on PT stability
¥ e) Late Decelerations
= heart rate slows down near the end or after a ¥ B = breasts
U = uterine fundus (want it Þrm, midline, height r/t
contraction
to the bellybutton)
- BAD! do L I O N
-> should be going down 1 cm per postpartum day
¥ f) Early Decelerations
B = bladder
= heart rate slows down before or at the
B = bowel
beginning of a contraction
L = lochia (rubra, serosa, alba)
- normal, no big deal; document it
-> rubra = red; serosa = pink; alba = whitish yellowish
¥ g) Variable Decelerations
E = episiotomy
- VERY BAD!!! this is what happens when you have
H = hemoglobin & hematocrit
prolapsed cord -> push, position
E = extremity check
- this is the most unique one
-> check for thrombophlebitis (via bilateral calf
¥ 3 good
circumference measuring)
3 bad = all start w/ an L -> L I O N
-> HomanÕs sign is not the best answer because you
1 variable = push, position can have it w/o having thrombophlebitis & vice
¥ What causes the different heart rates? versa (not as reliable or valid)
V = variable C = cord compression A = affect (emotions)
E = early dec. H = head compression D = discomforts
A = acceleration O = itÕs ok ** 3 big things tested in postpartum are the uterine
L = late dec. P = placental insufÞciency fundus, lochia, & extremities
¥ What answer always wins in a tie??
- in OB = check fetal heart rate Variations in the NEWBORN:
¥ review all the normalÕs
STAGE 2 of LABOUR = Delivery of the Baby:
¥ know difference between:
¥ all about order: - caput succedaneum = c.s. -> crosses sutures
1 = deliver head -> symmetrical
2 = suction the mouth Þrst, then nose - cephalohematoma = bleeding
3 = check for nuchal cord (around the neck) ¥ normal physiologic jaundice -> appears after 24 hrs.
4 = deliver the shoulders & the body ¥ pathologic jaundice -> baby comes out yellow
¥ the baby MUST have an ID band on before it
leaves the delivery area
OB MEDS:
¥ donÕt have to be an expert; just know general info
what they are & a few main things about them
Ñ> 6 main meds
¥ Tocolytics = stops labour (threatening prematurity)
a) Terbutaline
- causes maternal tachycardia
b) Magnesium Sulphate
- watch for TOXICITY
- watch for hypermagnesemia (everything down)
-> heart rate down
-> BP down
-> hypo-reßexive (want to keep it +2)
-> resp. rate down (want at least 12 resps.)
-> LOC goes down
*** boards likes to test reßexes & resp rate most
- closely monitor the PTÕs reßexes & resp. rate
¥ Oxytocics = stimulate/start & strengthen labour
c) Pitocin
- can cause uterine hyper-stimulation (i.e.
contractions longer than 90 seconds, closer than 2
mins. apart -> BAD!)
d) Methergine
- causes high BP (contracting -> vasoconstriction
raises BP)
¥ Fetal Lung Maturing meds:
e) Betamethasone - a steroid
i. mom gets it
ii. given IM
iii. given before baby is born
- can be repeated as long as baby is in utero
f) Survanta (Surfactant)
i. baby gets it
ii. given transtracheal (blown in through trachea)
iii. given after baby is born
MEDICATION HELPS & HINTS PEDIATRIC TEACHING
¥ to help get basic facts down ¥ review of PiagetÕs theory of cognitive development
¥ What is Humulin 70/30? -> wonÕt actually name Piaget but will ask questions
= mix of N & R insulins on how you would teach children in order to test
- 70 & 30 are percentages knowledge of the theory
-> 70 % is N 4 Stages of Piaget (Cognition):
-> 30% is R ¥ a) 0 - 2 years = SENSORY-MOTOR
¥ Can you mix insulins in the same syringe? - these kids are totally present oriented
= YES -> donÕt think about past or future
- when you draw it up go clear to cloudy, R to N -> only sense what they are doing right now
(ÒRNÕs draw up RNÓ) - teaching: while/as you do it & teach them what you
- when talking about pressurizing the vials you inject are doing (think present tense)
air into N Þrst, then R & draw up R, then draw up N - teach verbally -> just tell them (donÕt understand
¥ Injections: ÒplayÓ yet)
Ñ> will ask what needle to use for a particular injection - ex. when teaching a PT about a procedure, teach
- IM = ÒIÓ looks like 1, pick the answer that has the 1Õs while doing it (wonÕt work to teach them ahead of
in them (21 gaugeÉ) time) -> no pre-op/post-op (except for the parents)
- SubQ = ÒSÓ looks like 5 ¥ b) 3 - 6 years = PRE-OPERATIONS (think preschool)
- these kids are fantasy oriented
HEPARIN vs. COUMADIN: -> imaginative, illogical, thinking obeys no rules
¥ in the top 3 most commonly tested drugs! -> Òyou canÕt reason w/ a preschoolerÓ
HEPARIN COUMADIN - understand past & future so you can teach them
Route IV or SubQ only PO before & after
Onset works immediately takes a few days -> BUT has to be shortly before or after (ex. the
to a week to work
morning of, the day of, 2 hrs. beforeÉ)
Length cannot be given for longer can be given for
of Use than 3 weeks (except the rest of your life -> donÕt give them too much time to get
Lovenox) imaginations going on something
- body starts making heparin
antibodies after 3 weeks - teaching: what you are going to do (future tense)
which can be life-threatening - teaching through play
Antidote Protamine sulphate Vit. K -> ex. the day of, teaching PT about lumbar puncture
Lab Test PTT (partial thromboplastin PT -> INR by playing w/ equipment/dolls
that time)
monitors ¥ c) 7 - 11 years = CONCRETE OPERATIONAL
can be given to pregnant cannot be given to - these kids are rule oriented
women pregnant women -> canÕt think abstractly yet, rigid
¥ only major anti-psychotic that can be given to -> only one way of doing something
pregnant women = HALDOL -> Òmy teacher saidÓ, or Òmy parents saidÓ
- will tell you youÕre doing something wrong if it was
K+ Wasting & K+ Sparing Diuretics: different from the way a previous person did it (ex.
¥ probably the only questions youÕll get about diuretics wound dressings by different nurses)
is whether if wastes or spares K+ - teaching: days ahead; what youÕre going to do + skills
¥ any diuretic drug ending in ÒXÓ it wasteÕs K+ - teach via age appropriate reading & demonstration
-> also Diuril ¥ d) 12 - 15 years = FORMAL OPERATIONAL
*** otherwise, it spares K+ - can abstract think & think cause & effect
-> Hint: as soon as a kid hits 12 and they ask
Baclofen: about teaching, itÕs no longer a pediatric question
¥ boards test muscle relaxants as a class and is an adult med-surge question (you teach
¥ sore ÒbackÓ -> if youÕre on Baclofen, youÕre on your them like an adult)
back loaÞnÕ - ex. WhenÕs the Þrst age that a child can manage
¥ 2 side effects: their own care? = 12
a) fatigue/drowsiness -> a 7 yr. old can do the skills related to their care
b) muscle weakness but canÕt manage; managing requires making
¥ Patient teaching: decisions which require abstract thinking
a) donÕt drink -> itÕs not the severity of the illness that determines
b) donÕt drive who can manage it, itÕs the age (ex. a 10 yr old w/
c) donÕt operate heavy machinery scraped knee vs. 13 yr old w/ renal dysfunction)
¥ Flexeril -> the other muscle relaxant they test *** key word is manage (13 yr. old); skills = 7-11
7 PRINCIPLES of PSYCH
¥ 1. Make sure you know which phase of the
relationship youÕre in
- pre-interaction, introduction/orientation, working, termination
¥ 2. Gift giving
- NO GIFTS IN PSYCH (giving or receiving)
- ex. donÕt accept ßowers from a PT w/ schizophrenia
because to you they might just be ßowers but to
them that might be a marriage proposal
¥ 3. DonÕt give advice
- ex. If the PT asks ÒWhat do you think I should do?Ó
you reply w/ ÒWhat do you think you should do?Ó
- you can give advice in med-surge or paeds
¥ 4. DonÕt give guarantees
¥ 5. Immediacy
- if a PT says something, the best answer is the
one that keeps them talking
-> donÕt pick answers that say Òrefer to social workÓ
because that shuts off communication right then
and there
-> Hint: itÕs never wrong to get your PT to talk
¥ f) Concreteness
- donÕt use slang
-> psych PTÕs tend to take things literally
- if PTÕs use made up words (neologism), those are
not concrete so donÕt use them
¥ g) Empathy
- you have to know empathy!!! -> all about feelings
- the best psych answers are the answers that
communicate to the PT that the nurse accepts the
PTÕs feelings as being valid, real, & worthy of action
- bad answers:
-> ÒdonÕt worryÓ (because it tells them not to feel)
-> ÒdonÕt feelÓ, Òyou shouldnÕt feelÉÓ, ÒI would feelÓ,
Òanybody would feelÓ, Ònobody would feelÓ, Òmost
people feelÓ

Empathy Questions:
¥ recognize that itÕs an Empathy question
- always have a quote in the question & each of the
answers is a quote (i.e. PT says; what would you say?)
¥ put yourself in the clientÕs place
- you often have to read the feeling into the questions
¥ ask yourself: If I say those words (in an answer)
and I meant them, how would I be feeling after?
¥ go and choose the answer that reßects that
feeling (or anything close)
- DONÕT choose the feeling that reßects the PTÕs
words
- empathy questions usually have a Òsucker
answerÓ (to sucker you into picking that one) & one
of them is one that reßects/over-emphasizes what
the PT said but ignores what the PT felt
-> youÕre supposed to pick the answer that
reßects what they felt (& ignores what is said)
* donÕt mix this up
LECTURE 12 ¥ 3 things that result in a black tag in an unwitnessed
accident: (tag them black & ship them last)
PRIORITIZATION, DELEGATION, STAFF MANAGEMENT - pulselessness
PRIORITIZATION: - breathlessness
¥ testing to see how you prioritize 4 different PTÕs - Þxed & dilated pupils -> brain death
¥ you are deciding which PT is sickest or healthiest ¥ d) the more vital the organ, the higher the priority
- pay attention to which one youÕre being asked for Ñ> only use as a tie breaker
- ex. if question is asking ÒWho do you discharge?Ó - talking about the organ of the modifying phrase (not
-> asking for your lowest priority/healthiest client the diagnosis)
- ex. ÒWho would you assess/check Þrst after report?Ó - Order of Organ Vitality:
-> the highest priority/sickest client i. brain
¥ Priority answers always have 4 parts: ii. lungs
a) age iii. heart
b) gender iv. liver
c) a diagnosis v. kidney
d) a modifying phrase vi. pancreas
- ex. a 10 yr. old male with hypospadias who is throwing up *** after that no one agrees
bile stained emesis
- 2 of these are irrelevant & you donÕt need them in DELEGATION:
your answer = age & gender ¥ DO NOT delegate the following to RPNÕs:
*** pay attention to age in paediatric teaching but in a) starting an IV
prioritization questions, you donÕt -> donÕt assume they have IV certiÞcation
- the modifying phrase is the most important b) hanging or mixing IV meds
** donÕt get stuck doing ABCÕs c) pushing IV push meds
** they can maintain & document IV ßow
4 Rules for Prioritization: d) administer blood or mess w/ central lines
¥ a) acute beats chronic -> no ßushing
- an acutely ill person is a higher priority -> if only option is Òchange central line dressingÓ, then
¥ b) fresh post-op (12 hrs.) beats medical/other surgical pick that otherwise, they shouldnÕt do that either
¥ c) unstable beats stable e) cannot plan care
- know the words in a modifying phrase that mean -> they implement, RNÕs plan
stable & unstable f) canÕt perform or develop teaching
STABLE UNSTABLE -> they can reinforce teaching
stable unstable g) canÕt take care of unstable PTÕs
chronic illness acute illness h) not allowed to do the Þrst of anything
post-op greater than 12 hours post-op less than 12 hours -> should be the RN (because they can plan)
local or regional anesthesia general anesthesia i) cannot do the following assessments:
lab abnormalities of an A or B lab abnormalities of a C or D - admission
level level
Òready for dischargeÓ, Òto be Ònot ready for dischargeÓ, Ònewly - discharge
dischargedÓ, Òadmitted longer admittedÓ, Ònewly diagnosedÓ, - transfer
than 24 hours agoÓ Òadmitted less than 24 hrs. agoÓ
unchanged assessments changing/changed assessments
- the Þrst assessment after there has been a change
PT is experiencing the typical PT is experiencing unexpected ¥ DO NOT delegate the following to a nursing aid:
expected S&S of the disease S&S Ñ> they are unlicensed personnel
with which they were
diagnosed - no charting
- donÕt mix up symptom severity w/ unexpected symptoms -> though, they can chart what they did but not
(ex. PT w/ kidney stones having severe pain is lower about the PT
priority than PT w/ mild chest pains when having an x-ray - canÕt give meds
- 4 things that always make you unstable -> except for topical, OTC barrier creams
(regardless of whether itÕs expected or not): - no assessments (except for vitals & accu-checks)
i. hemorrhage (donÕt confuse w/ bleeding) -> for cost reasons
ii. high fevers (over 105) -> risk for seizure -> watch for words like ÒevaluatingÓ
iii. hypoglycemia -> even if itÕs a normal value (if - no treatments (except for enemaÕs)
they say it, it is it) - be cautious about allowing them to catheterize (if
iv. pulselessness & breathlessness thatÕs the only option, pick that)
-> itÕs lowest priority only at the scene of a ¥ Aids can do ADLÕs (i.e. bed baths etc.) but
unwitnessed accident shouldnÕt do the Þrst of anything
¥ In extended care facilities, RPNÕs can many of the LOCATIONS
things listed that they canÕt do because in that setting, ¥ point & click questions
the PT population is a generally stable one. ¥ abdomen quadrants:
¥ DO NOT DELEGATE TO THE FAMILY SAFETY - i.e. what quadrant an organ is located etc.
RESPONSIBILITIES ¥ locations for auscultating the heart valves:
- the nurse is responsible for that -> you have to know exact spots
- you cannot delegate safety to a non-hospital - aortic = 2nd intercostal at R sternal border
caregiver - pulmonic = 2nd intercostal at L sternal border
-> you can to a sitter but they can only do what you - tricuspid = 4th intercostal at L sternal border
teach them to do and document that you taught - mitral = 5th intercostal at mid-clavicular line (where
them (& their competency) the apical pulse is)
- ex. If a PTÕs family member asks that you remove ¥ pulses:
restraints while they are there because they are - carotid - femoral - posterior tibial
watching them and that you can put them back on - radial - popliteal - dorsalis pedis
once they leave -> NO - brachial

STAFF MANAGEMENT:
¥ How do you intervene w/ inappropriate behavior of
staff? (handling your staff when they do stupid things) TEST TAKING TIPS
¥ There are always 4 answers: ¥ expect to do guessing on the test
*** the same answers show up all the time -> thatÕs the nature of computer adaptive testing
a) tell supervisor ¥ How do you guess???
b) confront them and/or take over immediately a) use your knowledge Þrst!
c) at a later date just talk to them b) common sense
c) a guessing strategy
d) ignore it Ñ> NEVER the answer (you never ignore
inappropriate behavior by staff)
- the Þrst 3 could be right or wrong depending on the GUESSING Strategies: (ONLY when you donÕt know
situation so you need to learn how to choose whatÕs going on; use knowledge & common sense Þrst!)
between them ¥ Psych Questions:
- the best answer (if youÕre totally clueless) is Òthe
¥ When you get a staff question ask yourself:
a) Þrst -> ÒIs what they are doing illegal?Ó nurse will examine their own feelings aboutÉÓ
YES = always choose Òtell supervisorÓ -> that way you donÕt counter-transfer (ex. the PT
NO = go to the next question reminds you of your dad & you didnÕt like your
b) ÒIs anyone (PT or staff) in immediate danger of dad so you treat him badly)
physical or psychological harm?Ó - Òestablish a trust relationshipÓ
YES = Òconfront immediately &/or take overÓ (so no -> if you pick something else youÕre saying itÕs not
one gets hurt; Òtelling supervisorÓ delays you that important to establish trust
doing something putting others at risk) -> BUT use common sense Þrst! (ex. if a PT is
NO = go to next question coming at you w/ a knife, safety Þrst duh!)
c) ÒIs this behavior legal, not harmful, but simply ¥ Nutrition/Food Questions:
inappropriate?Ó - in a tie, pick chicken (obvs. not fried)
YES = Òapproach laterÓ, no rush - if chicken is not there, pick Þsh
*** if a situation is both illegal & harmful you need to -> not shellÞsh
confront/do something Þrst & then call supervisor - never pick casseroles for children (wonÕt eat it)
(because you donÕt want to add more risk for harm - never mix medication in childrenÕs food
by delaying) BUT if itÕs just illegal, tell supervisor -> if doing it for an adult, ask permission Þrst
- toddlers = Þnger-food
-> might not be very healthy but they need stuff that
they can eat on the run
- preschoolers = leave them alone (one meal a day
is ok -> they eat when their hungry & usually picky)
¥ Pharmacology:
- the most common area tested is side effects
-> donÕt memorize dosages! routes! frequencies!
-> FOCUS ON SIDE EFFECTS = we assess side
effects, see if things are working (donÕt prescribe)
 - if you know what a drug does but you donÕt ¥ Sesame Street rule:
know the side effects: - you can use the rule when (& ONLY when) your only
-> pick a side effect in the same body system where remaining option is to give up -> WHEN NOTHING
the drug is working ELSE WORKS
- if you have no clue what the drug is: - Ò 3 of these things is not like the otherÓ
-> see if itÕs PO & if it is pick a GI side effect - the right answer tends to be different than the others
- never tell a child that medicine is candy -> because it is the only one which is correct
¥ OB Questions: -> usually the more unique & different option
- Òcheck fetal heart rateÓ - the wrong answers are similar because they share
¥ Med-Surge Questions: something in common
- Þrst thing you assess = LOC (not airway) -> they are all wrong
-> before you do compressions you call out the PTÕs
name/try to wake them up which is LOC ¥ donÕt be tempted to answer a question based on
- Þrst thing you do = establish an airway your ignorance instead of your knowledge:
¥ Pediatric Questions: - base answers on what you know, not what you donÕt know
- growth & development questions are all based on - if you donÕt know something in a question, pull that
the principle Òalways give the child more timeÓ (to out and focus on the things you do know
grow & develop, donÕt rush it) - USE COMMON SENSE! boards test obscure things
-> 3 Rules: to test your common sense
i. when in doubt, call it normal (in med-surge, ¥ if something really seems right, it probably is
when in doubt, call it abnormal so you donÕt - go w/ your gut!
make safety mistakes) -> unless you can prove that a different answer is
ii. when in doubt, pick the older age (the older superior (not Òjust as goodÓ)
age of the 2 that it could be, not the oldest; gives
more time) 3 Expectations YouÕre NOT Allowed to Have:
iii. when in doubt, pick the easier task (gives ¥ expectations that are not met breed negativity which
more time for the child to learn it) badly affects your test taking
¥ a) donÕt expect 75 questions
¥ General guessing skills: - prepare yourself for 250 questions
- rule out absolutes - if you get to 200 it doesnÕt mean youÕre failing (it
-> generally not good answers because they donÕt would have shut off earlier if you were)
apply to many situations ¥ b) donÕt expect to know everything
-> donÕt forget your knowledge & common sense (i.e. - because itÕs computer adaptive -> it will give you
certain things are absolute like Ònever push IV K+Ó stuff you donÕt know
or doing checks for med. administration) - know what everyone else needs to know
- if 2 answers say the same thing, neither is right ¥ c) donÕt expect everything to go right
- if 2 answers are opposite, one of them is - donÕt expect a perfect day
probably right
- the umbrella strategy:
-> Òwhich answer is more globalÓ
* ex. certain questions where you want to say Òall
of the aboveÓ but thatÕs not an option -> look for
an answer that is broad enough that covers all
the things you need (covers all the other answers)
- if the question gives you 4 right answers & asks
you to pick the one that is highest priority:
-> different from picking between 4 PTÕs; usually the
question is about 1 PT & youÕre picking between
4 different needs
-> think Òworst consequencesÓ for each option &
pick the answer that has the worst outcome if you
donÕt pick it
- when youÕre stuck between 2 answers, read the
question (it will have the clue!!)