LECTURE 1

ACID BASES
• learn how to convert lab values to words • the rule of the B’s
= if the pH and the BiCarb are both in the same direction -> metabolic
Hint: draw arrows beside each to see directions * down = acidosis
* up = alkalosis
- respiratory -> has no b in it; if in other directions (or if bicarb is normal value)
- KNOW NORMAL pH, BiCarb, CO2

• Hint: DON’T MEMORIZE LISTS…know principles (they test knowledge of

principles by having you generate lists..) - for “select all” questions
- ex. in general/principle what do opioids/pain meds do? = sedate you, CNS
depressors * ex. what does dilaudid do? don’t memorize specifics or a list of dilaudid, know principles of
opioids (such as sedation, CNS depression -> lethargy, flaccidity, reflex +1, hypo-reflexia, obtunded)
- boards don’t test by lists because all books/ classes have different lists

• principles of S&S acid bases: as the pH goes so goes my patient (except K+)
- pH up = PT up -> body system gets more irritable, hyper-excitable
(EXCEPT K+)
-> alkalosis - think of a body system and go high: hyper-reflexive (+3, +4 [2 is
normal]), tachypnea, tachycardia, borborygmi, seizure –

pH down = PT down -> body systems shut down (EXCEPT K+)

-> acidosis - think of a system and go low: hypo-reflexive (+1, 0), bradycardia,
lethargy, obtunded, paralytic illeus, respiratory arrest
• ex. which acid-base disorders need an ambu-bag at the bedside? = acidosis (resp.
arrest)
• ex. which acid-base disorders need suction at the bedside? = alkalosis (seize and
aspirate)
• Mac Kussmaul - Kussmaul’s (compensatory respiratory mechanism) is only
present in only 1 of the 4 metabolic (acid-base) disorders
* M = metabolic AC = acidosis
• most common mistake with select all questions = selecting one more than you should (stop when you select
the ones you know! don’t get caught up on the “could be’s”)
• Hint: don’t select none or all on select all that apply questions (never only one and
never all)

• Causes of Acid-Base Imbalance:

- scenarios and what acid-base disorder would result (what would cause an
imbalance)
** DON’T 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 you are acidotic your bowel shuts down and
you get a paralytic illeus

• when you get scenarios:

-> if it’s a lung scenario = respiratory
 - then check if the client is over-ventilating (alkalosis) or under-ventilating (acidosis)
- remember to look at the words (ex. over, under, ventilating) -> “as the pH goes so
goes my PT” -> VENTILATING DOESN’T MEAN RESPIRATORY RATE; resp. rate is irrelevant w/ acid-
base, ventilation has to do with gas exchange not resp. rate (look at the SaO2 -> if your resp. rate is fast
but SaO2 is low you are under-ventilating) -> ex. PCA pump - What acid-base disorder indicates they need
to come off of it? = respiratory acidosis (resp. depression -> resp. arrest) —> if it’s not lung, it’s
metabolic
• metabolic alkalosis - really only one scenario = if the PT has prolonged gastric
vomiting/suctioning - because you are losing ACID
* ex. GI surgery w/ NG tube with suctioning for 3 days; hyperemesis graviderum
- otherwise everything else that isn’t lung you pick metabolic acidosis
(DEFAULT)
* ex. hyperemesis graviderum w/ dehydration acute renal failure, infantile
diarrhea

• remember, you only have 4 to pick from: - respiratory alkalosis - respiratory

acidosis - metabolic alkalosis - metabolic acidosis

• pay more attention to the modifying phrases than the original noun
- ex. person w/ OCD who is now psychotic (psychotic trumps OCD); hyperemesis
with dehydration (pay attention to dehydration)

VENTILATION
• ventilators -> know alarm systems (you set it up so that the machine doesn’t use
less than or more than specific amounts of pressure)
a) high pressure alarm = increased resistance to airflow (the machine has to
push too hard to get air into lungs)
- from obstructions:
i. kinks in tubing (unkink it)
ii. water condensation in tube (empty it!) iii. mucous secretions in the airway
(change positions/turn, C&DB, and THEN suction) *** suction is only PRN!!!
-> priority questions = you would check kinks first, suction is not first
b) low pressure alarm =
decreased resistance to airflow (the
machine had to work too little to
push air into lungs)
- from disconnections:
i. main tubing (reconnect it duh!)
ii. O2 sensor tubing (which senses
FiO2 at the airway/trach area;
black coated wire coming from
machine right along the 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 don’t

do something and someone else has to
do something

LECTURE 2
ABUSE (Psych and Med-Surge)
Psychological Aspect/Psycho-Dynamics • # 1 psychological problem is the
same in any/all abusive situations = DENIAL
- abusers have an infinite capacity for denial so that they can continue the behavior
w/o answering for it • can use the alcoholism rules for any abuse - ex. # 1 psych problem in
child abuse, gambling or cocaine abuse is denial
• why is denial the problem? HOW CAN YOU TREAT SOMEONE WHO
DENIES/DOESN’T RECOGNIZE THEY HAVE A PROBLEM
• denial = refusal to accept the reality of a problem • treat denial by CONFRONTING
the problem (it’s not the same as aggression which attacks the person, not the
problem) = they DENY you CONFRONT - pointing out to the person the difference
between what they say and what they do
- Hint: never pick answers that attack the person -> ex. bad answers have bad
pronouns - “you” -> ex. good answers have good pronouns - “I”, “we” -> ex. “you
wrote the order wrong” vs. “I’m having difficulty interpreting what you want”
• loss and grief -> for this denial you must SUPPORT it - DABDA = denial, anger, bargaining,
depression, acceptance • Hint: for questions about denial, you must look to see if it is LOSS
or ABUSE
- loss/grief = support
- abuse = confront
• #2 psychological problem in abuse = DEPENDENCY, CO-DEPENDENCY
- dependency = when the abuser gets significant other to do things for them or make decisions
for them -> the dependent = abuser
- co-dependency = when the significant other derives positive self-esteem from
making decisions for or doing things for the abuser
-> the abuser gets a life w/o responsibilities -> the sig. other gets positive self-esteem
(which is why they can’t get out of the relationship) • how do you treat it?
- set limits and enforce them
-> start teaching sig. other to say NO (and they have to keep doing it)
 - must also work on the self-esteem of the co-dependent (ex. I’m a good person because I’m saying
“no”) • manipulation = when the abuser gets the sig. other to do things for them that are
not in the best interest of the sig. other
- the nature of the act is dangerous/harmful - how is manipulation like
dependency?
-> in both the abuser is getting the other person to do something for them
- how do you tell the difference between manipulation & dependency?
-> NEUTRAL vs. NEGATIVE (look at what they’re being asked to do)
-> if the sig. other is being asked to do something neutral (no harm) its
dependency/co-dependency -> if the sig. other is being asked to do something that
will harm them or is dangerous to them they are manipulated
• how do you treat manipulation?
- set limits and enforce them -> “NO”
- easier to treat than dependency/co-dependency because no one likes to be
manipulated (no positive self-esteem issue going on)
• ex. how many PT’s do you have w/ denial? = 1 ex. how many PT’s do you have w/
dependency/co- dependency = 2
ex. how many PT’s do you have w/ manipulation = 1

Alcoholism
Wernicke’s & Korsakoff’s
- typically separate BUT boards lumps them together - wernicke’s =
encephalopathy
- korsakoff’s = psychosis (lose touch with reality) -> tend to go together, find
them in the same PT • Wernicke Korsakoff’s syndrome:
a) psychosis induced by Vit. B1 (Thiamine) deficiency - lose touch w/ reality, go
insane because of no B1 b) primary symptom -> amnesia w/ confabulation -
significant memory loss w/ making up stories - they believe their stories
• How do you deal w/ these PT’s?
- bad way = confrontation (because they believe what they are saying and can’t see
reality)
- good way = redirection (take what the PT can’t do and channel it into something
they can do) • Characteristics of Wenicke Korsakoff’s: a) it’s preventable = take Vit.
B1 (co-enzyme needed for the metabolism of alcohol which keeps alcohol from
accumulating and destroying brain cells) * PT doesn’t have to stop drinking
b) it’s arrestable = can stop it from getting worse by taking Vit. B1
* also not necessary to stop drinking
c) it’s irreversible (70% of cases) -> Hint: On boards, answer w/ the majority (ex. if
something is majority of the time fatal, you say it’s fatal even if 5% of the time it’s
not)
• Drugs for Alcoholism:
DISULFIRAM (Antabuse)
= aversion therapy -> want PT’s to develop a gut hatred for alcohol
-> interacts w/ alcohol in the blood to make you very ill -> works in theory better than in
reality
-> onset & duration: 2 weeks (so if you want to drink again, wait 2 weeks)
 - PT teaching = avoid ALL forms of alcohol to avoid nausea, vomiting & possibly
death
-> including mouthwash, aftershaves/colognes/perfumes (topical stuff will make them nauseous), insect
repellants, any OTC that ends with “-elixer”, alcohol- based hand sanitizers, uncooked (no-bake) icings
which have vanilla extract, red wine vinaigrette

• Overdoses & Withdrawals:

- every abused drug is either an UPPER or DOWNER -> the other drugs don’t do
anything
-> #1 abused class of drug that is not an upper or downer = laxatives in the elderly
a) first establish if the drug is an upper or downer - uppers (5) = caffeine, cocaine,
PCP/LSD (psychedelic hallucinogens), methamphetamines, adderol (ADD drug) * S&S -> make you go up;
euphoria, tachycardia, restlessness, irritability, diarrhea, borborygmi, hyper-reflexia, spastic, seize (need
suction) - downers = don’t memorize names -> anything that is not an upper is a
downer! if you don’t know what the med is, you have a high chance that it’s a
downer if it’s not part of the uppers list
* S&S -> make you go down; lethargy, respiratory depression (& arrest)
- ex. The PT is high on cocaine. What is critical to assess? -> NOT resps below 12 because they
will be high -> maybe check reflexes
b) are they talking about overdose or withdrawal - overdose/intoxication = too
much
- withdrawal = not enough
- ex. the PT has overdosed on an upper -> pick the S&S of too much upper
- ex. the PT has overdosed on a downer -> pick the S&S of too much downer
- ex. the PT is withdrawing from an upper -> not enough upper makes everything go down
- ex. the PT is withdrawing from a downer -> not enough downer makes everything go up
• 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
• Alcohol Withdrawal Syndrome vs. Delirium Tremens - they are both different! not the same
a) every alcoholic goes through withdrawal 24 hrs. after they stop drinking
- only a minority get delirium tremens
- timeframe -> 72 hrs. (alcohol withdrawal comes 1st) - alcohol withdrawal syndrome
ALWAYS precedes delirium tremens, BUT delirium tremens does not always follow
alcohol withdrawal syndrome b) AWS is not life-threatening; DT’s can kill you c) PT’s
w/ AWS are not a danger to self/others; PT’s w/ DT’s are dangerous to self/others
- they are withdrawing from a downer so they will be exhibiting upper S&S
- DT’s are dangerous
 Differen AWS DT
ces in
Care

Diet Regular NPO/clear liquids

diet (because of risk for seizures
which can cause risk of
aspiration)

Room Semi- Private near nurses station

private (dangerous & unstable)
anywhere
on the
unit

Ambulati Up ad lib Restricted bed rest -> no

on bathroom privileges (use
bedpans/urinals)

Restrain No Restraints (because

ts restraints dangerous) - not soft wrist
(because or 4 point soft because
not they’ll get out
dangerou - need to be in vest or 2-pt.
s) locked leathers (opposite 1
arm & leg, rotate Q2hrs,
lock the free limbs 1st
before releasing the locked
ones)

They both get ANTI-

HYPERTENSIVES &
TRANQUILIZERS
- because everything is up (downer
withdrawal) They both get
MULTIVITAMIN w/ B1

• RN’s can accept but RPN’s can’t (because PT is unstable) - on med-surge, the RN who takes them must
decrease their workload (i.e. reduce PT load if they take a DT PT) -> Hint: on boards, the
setting is always perfect
(i.e. enough staff/time/resources on the unit etc.)
DRUGS
AMINOGLYCOCIDES
• powerful class of antibiotics (when nothing else works pull these outs, the big
guns)
- don’t use unless anything else works
• boards love to test these drugs because they’re dangerous and are a test of
safety
• think: A MEAN OLD MYCIN
-> a mean old = they treat serious, life-threatening, resistant, Gram-neg bacteria
infections (i.e. a mean old antibiotic for a mean old infection)
-> mycin = what they end with (all end w/ -mycin) ** not all -mycin’s are
aminoglycosides BUT most are (the 3 that are not are erythromycin, azithromycin,
clarithromycin = throw it off the list!)
• 2 toxic effects:
i) when you see ‘-mycin’, think mice
- mice -> ears -> otto toxic
- monitor hearing, tinnitus, vertigo/dizziness ii) the human ear is shaped like a
kidney so next effect is nephrotoxicity
- monitor creatinine (not BUN, output, daily weight) * creatinine = the best indicator
of kidney/renal function (pick 24 hr. creatinine clearance over serum creatinine if
both available)
• #8 (fits nicely in the kidney) reminds you about 2 things about these drugs
- toxic to cranial nerve 8 = ear nerve
- administer Q8
• route:
- IM or IV
• do not give PO -> they are not absorbed - if you give an oral ‘-mycin’ it will go into
gut, dissolve, go through and come out as expensive stool (won’t have any systemic
effect)
- EXCEPT in 2 cases = bowel sterilizers:
* hepatic encephalopathy (hepatic coma) = to get ammonia down, oral ‘-mycin’s’ will
sterilize the bowel by killing Gram-neg bacteria (E. coli) to help bring down ammonia
and won’t harm the damaged liver because it doesn’t go through the liver (also gives
diarrhea, more poop out is good) * pre-op bowel surgery = it sterilizes the gut by
killing the E. coli bacteria
- if oral, no otto or nephro toxicity because not absorbed - these are neomycin & kanamycin
* Who can sterilize my bowels? NEO KAN

• Trough and Peak levels:

- trough = drug at lowest
- peak = drug at highest
** TAP levels - trough administer peak
-> draw trough levels first
-> administer your drug
-> draw peak levels after drug administration
• Why draw levels? = narrow therapeutic window - small difference between what
works and what kills - if the drug has a wide range then you wouldn’t need to draw
TAP levels
* ex. Lasix doses range from 5-80mg thus a wide range so you won’t need TAP
levels
* ex. Dig doses range from 0.125 - 0.25 so this narrow range needs TAPS levels
• A MEAN OLD MYCINS = major class that needs TAPs drawn because of narrow
window
• When do you draw TAPS?
-> depends on the route (don’t focus on the med) a) Trough Levels
** doesn’t matter which route or med, always 30 mins. - sublingual = 30 mins. before
next dose
- IV = 30 mins. before next dose
- IM = 30 mins. before next dose
 - Sub-Q = 30 mins. before next dose
- PO = 30 mins. before next dose
b) Peak Levels
** different but depends on the route (not the med) - Sublingual = 5-10 mins after drug
is dissolved - IV = 15-30 mins after drugs is finished infusing * Hint: if you get two
values that are correct (i.e. a 15 min. answer and a 30 min. one) pick the highest
without going over so 30 mins.
- IM = 30-60 mins. after administration
- Sub-Q = SEE (see diabetes lecture -> because the only Sub-Q peaks are
Insulins)
- PO = forget about it, too variable so not tested

The BIG 10 Drugs to Know:

1. psych drugs
2. insulins
3. anti-coagulants
4. digitalis
5. aminoglycosides
6. steroids
7. calcium-channel blockers
8. beta-blockers
9. pain meds
10. OB drugs
LECTURE 3
Cardiac DRUGS
CALCIUM-CHANNEL BLOCKERS
Calcium-Channel Blockers are like Valium for your heart • Valium -> calm’s you down;
so CCB’s calm your heart down (ex. if tachycardic, give CCB’s but not in shock) - to
REST YOUR HEART
- not stimulants
• calcium-channel blockers are negative inotropic, chronotropic, & dromotropic
drugs
- fancy way of saying that they calm the heart down
POSITIVE NEGATIVE

Inotropes Cardiac Cardiac

Stimulants - -
Chronotrop stimulate, Depressants
es speed up the
 Dromotope heart calm the heart
s
down,
weaken &
slow down

• When do you want to “depress” the heart? What do CCB’s treat?

A: anti-hypertensives
- relax heart & blood vessels to bring down BP AA: anti-angina’s
- relax heart to use less O2 to make angina go away - treats angina by addressing
oxygen demand AAA: anti-atrial arrhythmia
- ex. atrial flutter, A-fib, premature atrial contractions - never ventricular
*** what about supra-ventricular tachycardia?? -> because it means ‘above the
ventricles’ (which are the atria)
• Side-Effects:
H & H = headache & hypotension
-> hypoTN - from relaxed heart & vessels -> headache - vasodilation to brain
** Hint: headache is a good thing to select for ‘select all that apply’ questions (ex. low
Na & high Na = headache, high & low glucose = headache, high & low BP = headache)

• Names of Calcium-Channel Blockers:

- anything ending in ‘-dipine’
- ex. amlodipine, nifedipine
- NOT just ‘-pine’
- also includes: VERAPAMIL & CARDIZEM - which can be given as
continuous IV drip?? = Cardizem
• What VS needs to be assessed before giving a CCB? - BP = because of risk of
hypoTN
-> parameters/guidelines - hold CCB if systolic is under 100
-> so you need to monitor BP if PT is on a Cardizem continuous drip (if it’s under
100 then you may have to stop or change the drip rate)
CARDIAC-ARRYTHMIAS
• Interpreting Rhythm Strips (4 that need to be known by sight):
a) Normal Sinus Rhythm
= P wave before every QRS & followed by a T wave for every single complex
-> all P wave peaks are equally distant from each other, QRS evenly spaced
b) V-Fib = chaotic squiggly line, no pattern
c) V-Tach = sharp peaks, has a pattern
d) A-Systole = flat-line

• Terminology:
- if QRS depolarization, it’s talking about ventricular (so rule out anything atrial)
- if it says P-wave then it’s talking about atrial

• 6 Rhythms most tested on N-CLEX:

1. “a lack of QRS’s” = A-systole
 - flat-line, no QRS
2. “P-wave” = Atrial
- if it’s a sawtooth wave, always pick atrial flutter 3. “chaotic” - A-fib if w/ P-wave
4. “chaotic” - V-fib if w/ QRS
- Hint: the word ‘chaos’ is used for fibrillation 5. “bizarre” = atrial tachycardia if w/ P-
wave 6. “bizarre” = ventricular tachycardia if w/ QRS - Hint: the work ‘bizarre’ is
used for tachycardias
• PVC’s (premature ventricular contractions) = a.k.a. periodic wide bizarre
QRS
- ventricular because QRS
- bizarre -> tachycardia
- you can call a group of PVC’s a short run of V-tach - do Physician’s care about
PT’s having PVC’s? -> NO, not a high priority = low priority -> 3 circumstances
when you could elevate these PT’s to moderate priority (never reach high) i. if there are more
than 6 PVC’s in a minute ii. if there are more than 6 PVC’s in a row iii. if the PVC fall on the T-
wave of the previous beat (R on T phenomenon)
-> most common order if you call the MD about a PT w/ PVC’s = D/C monitor (because then you
can’t see the PVC’s and then you won’t call them) • Lethal Arrhythmia’s:
- HIGH PRIORITY, 2 main ones (will kill you in 8 mins or less) -> these PT’s will
probably be top priorities a) A-Systole
b) V-Fib
** both have in common = no cardiac output -> no brain perfusion (and you’ll be
dead in 8 mins) • V-tach = potentially life-threatening (but not actually life-threatening),
but still makes it a fairly high priority - difference is that these PT’s have cardiac output
• in codes, even if the rhythm changes, if there is no cardiac output it’s just as bad as
the previous rhythm
• Treatment (more drugs):
a) PVC’s b) V-tach
= for ventricular use LIDOCAINE/AMIODARONE * in rural areas more Lidocaine use
(cheaper & longer shelf-life)
c) Supra-Ventricular Arrhythmia’s
= atrial arrhythmia’s use ABCD’s
• A -> ADENOCARD (Adenosine)
- have to push in less than 8 seconds (FAST IV push) -> slam this drug, followed by a
flush; use a big vein; BUT the problem w/ slamming it fast is the risk of PT going into A-Systole (for 30
seconds but they will come out of it so don’t worry [unless longer than 30 sec…])
** for IV pushes: when you don’t know you go slow • B -> BETA-BLOCKERS
- all end in ‘-lol’
- every ‘-lol’ is a BB & every BB is a ‘-lol’
- are negative inotropes, chronotropes, & dromotropes like calcium-channel
blockers (a.k.a. valium for your heart so they treat A, AA, AAA & have same side-
effects)
** generally speaking, don’t make a big difference between Beta- & Calcium channel
blockers; except that CCB are better for PT’s w/ asthma or COPD -> Beta-B’s
bronchoconstrict • C -> CALCIUM-CHANNEL BLOCKERS - see Beta-Blockers &
CCB’s earlier
• D -> DIGITALIS (DIGOXIN, LANOXIN)
 d) V-Fib
= for V-fib you D-fib (shock them!)
e) A-Systole
= use EPINEPHRINE & ATROPINE (in this order!) -> if epinephrine doesn’t work
then use atropine

CHEST TUBES
• purpose is to re-establish negative pressure in the pleural space (so that the lung
expands when the chest wall moves)
- pleural space -> negative is good (negative pressure makes things stick together)
- ex. gun shot to the lung add positive pressure • Hint: when you get a chest tube
question, look at the reason for which it was placed (will tell you what to expect &
what not to expect)
- ex. pneumothorax = to remove air (because air created the positive pressure)
- ex. hemothorax = to remove blood
- ex. pneumohemothorax = to remove blood & air

• Hint: Also, pay attention to the location of the tubes: a) Apical = the chest tube is
way up high, thus it is removing air (because air rises)
- ex. it’s bad if you’re apical tube is draining 200 mL or it is not bubbling
b) Basilar = at the bottom of the lungs, thus it is removing blood/liquid (because
of gravity) - ex. it’s bad if your basilar tube is bubbling or not draining any mL
• ex. How many chest tubes & where would you place them for a unilateral pneumohemothorax?
- 2 chest tubes (apical for pneumo, basilar for hemo) • ex. How many chest tubes & where would you place
them for a bi-lateral pneumothorax?
- 2 tubes (apical on left, apical on right)
• ex. How many chest tubes & where would place them for post-op chest surgery?
- 2 tubes (apical & basilar on the side of the surgery) ** you are to assume that chest
surgery/trauma is unilateral unless otherwise specified (they will say bilateral)
• Trick Question: How many chest tubes would you need and where would you place
them for a post-op right pneumonectomy?
- NONE! because you are removing the lung so you don’t need to re-establish any
pressure (there is not pleural space)!

Troubleshooting Chest Tubes:

• What do you do if you knock over the plastic containers that certain tubes are
attached to? -> set it back up & have PT take some deep breaths -> NOT a medical
emergency! (don’t call MD)
• What do you do if the water seal breaks (the actual device breaks?)
-> first = CLAMP it!!! because now positive pressure can get in! don’t let anything get in
-> 2nd = cut the tube away from the broken device -> 3rd = stick that open end into sterile
water
-> then unclamp it because you’ve re-established the water seal (doesn’t need clamp if it’s under
water *** better for the tube to be under water than clamped! -> air can’t go in and stuff can still
keep coming out (if clamped, nothing can come out which is what the tube is for)
• Ex. If they ask what the first thing is to do if the seal breaks -> Clamp! BUT, if they ask
what’s the best thing to do -> put end of tube under water! (because it actually solves
the problem, clamping is a temp. fix) • Hint: ‘BEST’ vs. ‘FIRST’ questions
 - first questions = are about what order
- best questions = what’s the one thing you would do if you could only do 1 of the
options
-> ex. You notice the PT has V-fib on the monitor. You run to the room and they are non-
responsive with no pulse. What is the first thing you do?
A) place a backboard?
B) begin chest compressions?
- “first” is about order so = pick A (because you wouldn’t start chest
compressions first)
- BUT, if the question ask “What’s the best thing to do?” -> 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? - first = take a gloved hand and
cover the hole - best = cover the hole with vaseline gauze
• Bubbling chest tubes: (ask yourself 2 questions) a) Where is it bubbling?
b) When is it bubbling?
= the answer will depend on these 2 questions (sometimes bubbling is good,
sometimes bad but depends on where & when)
- ex. Intermittent bubbling in the water seal -> GOOD (document it, never bad!)
- ex. Continuous bubbling in the water seal -> BAD (you don’t want this, means a leak
in the system that you need to find and tape it until it stops leaking) ** in RPN scope
- ex. Intermittent in suction control chamber -> BAD (means suction is not high
enough, turn it up on the wall until bubbling is continuous)
- ex. Continuous in suction control chamber -> GOOD (document it)
- Hint: both locations are opposites of each other (memorize one & deduce the
others)
—> if there is a seal it should not be continuous (ex. a sealed bottle of pop
continuously bubbling means it’s leaking!)

• A straight catheter is to a foley catheter as a thoracentesis is to a chest

tube.
- in-&-out vs. continuous secured
- thoracentesis -> also helps re-establish neg. pressure (in-&-out chest tube)
- higher risk for infections are continuous

Rules for Clamping Tubes:

• a) Never clamp a tube for more than 15 seconds without a doctors order.
- so if you break the water seal -> you have 15 seconds to get that tube under
water
• b) Use rubber-tipped doubled clamps.
- the teeth of the clamp need to be covered w/ rubber so that you don’t puncture
the tube
CONGENITAL HEART DEFECTS
• every congenital heart defect is either TROUBLE or NO TROUBLE (ALL BAD or NO BAD)
- either causes a lot of problems or it’s no big deal (no in-between defect)
• memorize one word: TRouBLe
Heart TRouBLe No Trouble
Defects (95% of all
 heart defects)

Surgery NEED surgery - don’t need

now to live surgery right
away; possibly
need it years later
causes a
if it
Trouble (but
we
don’t expect it to)

Growth & slow, delayed normal

Dev.

Life short normal

Expectancy

Parent’s grief, stress, regular average

Experiencin financial issues, person issues
g lots of
caregiving
issues

Going Home apnea monitor no apnea monitor

Hospital weeks 24-48 hours

Stay at
Birth

Who Paediatric Paediatrician,

Follows Cardiologist paediatric NP
Your Care

Shunting R to L L to R
(TRouBLe)

Cyanosis Cyanotic -> Acyanotic

Blue
(TRouBLe)

• ex. You are teaching the parents about a heart defect: - pick all the options that cause
trouble
• Hint: Boards will not give pictures of defects and ask you what they are.
- not our job, we don’t diagnose
- our role is teaching parents the implications -> so if it’s trouble = teach them things that it’s
going to be a lot of trouble
-> if it’s not trouble = pick the things saying it’s not going to be trouble
• There are 40+ congenital heart defects so just remember TRouBLe (don’t memorize all of them!):
- Hint: all congenital heart defects that start w/ the letter T are Trouble Defects
- we don’t care about the defect, we care about what we’re teaching the parents
• All congenital heart defect kids (trouble or no trouble) will have 2 things:
a) Murmur
- why? = because of the shunting of the blood (regardless of direction of shunt)
b) all have an Echocardiogram done (to find out what the defect is or why there’s 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
• don’t 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 PRECAUTIONS (Isolations)
• Standard
• Universal
• Contact
- for anything enteric = can be caught from intestine -> fecal, oral
- C-Diff, Hep. A, Cholera, Dysentery
* things with bugs in diarrhea
* Hint for Hep A & B: Hep A -> think anus, Hep B -> think blood (anything from the bowel
starts w/ a vowel) - Staph infections
- RSV = respiratory syncytial virus (what babies, 1-2 yr. old’s get that is not
dangerous to adults but can be fatal for them)
* transmitted by droplet BUT still put them on 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) - What’s
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 filter mask, PT mask,
neg. air flow -> 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 influenza B) -> commonly causes epiglotitis
* never stick something down throat because it will cause obstruction
- What’s 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
filter mask, neg. air flow
-> YES: mask, gloves, hand-washing, PT worn mask (when leaving room),
disposable supplies & dedicated equipment
• Airborne
- M-M-R; TB; varicella (chicken pox)
- What’s involved in airborne precautions?
-> private room is required
* unless co-horting
 -> NO: gown (mostly for contact), eye/face shields
-> YES: mask, gloves, hand-washing, special-filter mask ONLY for TB, PT mask for
leaving room (but really shouldn’t be leaving), neg. air flow ** disposable supplies &
dedicated equipment is a good thing but not really as essential as in the other 2 (can
let this one slide)
-> TB: technically transmitted via droplet BUT put on airborne

• PPE = Personal Protective Equipment - boards like to test how you put on or
take off - always take it off in alphabetical order
-> ex. gloves, goggles, gown, mask
- putting on is reverse alphabetically for the ‘g’s’ & mask comes 2nd
-> gown, mask, goggles, gloves
LECTURE 4
CRUTCHES, CANES, WALKERS
• major area of human function is locomotion so they test these even though not a major emphasis in
school - area to test PT teaching & risk reduction
Crutches:
• How do you measure crutches?
** need to know for risk reduction -> so you don’t cause nerve damage
a) length of crutch = 2-3 finger-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, they’re wrong instructions for length) b) hand grip = can be adjusted up & down;
when properly placed, should be apx. 30 degrees elbow flexion • 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 “how many legs are affected?” - 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
Cains:
• hold the cain on the strong side
- a lot of people use it the wrong way

Walkers:
• pick it up, set it down, walk to it
• if they must tie their belongings to the walker, tie it at the sides, not the front
- boards doesn’t like things on the front (even tho most people do that anyways; they don’t like wheels or
tennis ball on the bottom either)
DELUSIONS, HALLUCINATIONS, & ILLUSIONS (Psych) Neurosis Non-Psychotic vs.
Psychosis
• Hint: the first thing you have to do to get a psych questions correct is decide: “Is my
PT non-psychotic or psychotic?”
= this will determine treatment, goals, prognosis, medication, length of stay,
legalities…everything
NON- PSYCHOTIC
PSYCHOTIC

Definitio Has insight & is Has no insight & is

n reality-based not reality-based
- even w/ - don’t think/know
emotional their sick - think
distress/illness, everyone else has
the problem but not
mental/behavio them (blame anyone
ral disorder else) - even if they say
- recognize what they’re sick but then
the problem is they say the
and how it martians made them
affects their life sick they don’t have
insight

Treatme - good - good therapeutic

nt/ communication does
Techniq therapeutic not work because
ues communication they are not rational
(like - need unique,
any PT that specific
displays good strategies
comm. skills) **
there’s nothing
special that you
need to do/know
compared to any
med-surge,
paeds, or OB PT

Sympto don’t have DELUSIONS,

ms delusions, HALLUCINATION,
hallucinations, or ILLUSIONS
 illusions - only in psychotic
PT’s - as soon as they
get any of these
they’ve crossed the
line to being psychotic

Psychotic Symptoms:
• a) Delusions
= false, fixed, idea or belief; no sensory component (all in the brain, thinking it)
i. Paranoid Delusions -> people are out to harm me - ex. the mafia are out to get
me
ii. Grandiose Delusions -> you are superior or you are the world’s
smartest/greatest person - ex. thinking you are Christ, Genghis Khan iii. Somatic
Delusions -> about a body part - ex. x-ray vision; there are worms in my body • b)
Hallucinations
= a false, fixed, sensory experience (purely sensory); 5 senses so 5 for (1 for each
sense)
i. Auditory -> hearing things that aren’t there (primarily voices telling you to hurt yourself); most common
ii. Visual -> seeing; 2nd most common
iii. Tactile -> feeling things; 3rd most common iv. Gustatory -> tasting things that are not there v.
Olfactory -> smelling things that are not there *** last 2 are relatively rare

• c) Illusions
= misinterpretation of reality; sensory experience - difference from hallucination ->
with an illusion there is a referent in reality
-> referent = something in reality to which a person refers when they say something
(they just misinterpret it)
• ex. PT says: “I hear demon voices” -> hallucination ex. PT overhears nurses & MD’s laughing & talking at the
nurse’s station & says: “Listen, I hear demon voices” -> illusion (there is a referent)
ex. person staring at a wall & says: “I see a bomb” -> hallucination ex. person looks at fire extinguisher on the wall
and says: “I see a bomb” -> illusion (referent)
• Hint: On the test, they will tell you that there is something there thus, you can
differentiate between a hallucination & an illusion.

How do you deal with these Psychotic Symptoms? • first thing you ask after
determining if PT is psychotic: What is their problem?
—> what kind of psychosis do they have?

• 3 Types of Psychosis:
1. Functional Psychosis
- can function in everyday life (i.e. have jobs, a marriage, etc.)
- 4 diseases: Schizo Schizo Major Manics i. Schizophrenia
ii. Schizoaffective Disorder
iii. Major Depression (if it’s major, test will say) iv. Manic (Acute)
-> so bi-polar is functional, only psychotic during manic phase
- these PT’s have the potential to learn reality (because no damage)
 -> may need meds or set boundaries for structure -> nurse role = teach reality (4
steps)
a) acknowledge feeling -> “I see you’re angry; “You seem upset”, “Tell me how you
are feeling”, often uses the word feeling or shows a feeling b) PRESENT REALITY -
> “I know that those voices are real to you but I don’t hear them” or telling them what
is real (“I’m a nurse & this is a hospital”) c) set a limit -> “That topic/behavior is off-
limits”, “We are not going to talk about that right now”, “Stop talking about that”
d) enforce the limit -> “I see you’re too ill to stay reality based so our convo is
over” (ending the conversation NOT taking away a privilege [i.e. punishment];
continuing to talk may enforce the non-reality)
*** on the test, they won’t ask these specific steps but instead, will ask “how should the nurse
respond…” *** try to pick the more positive statements (i.e. what
they can have/do, not what they can’t); if between 2 statements go w/ the positive one

• 2. Psychosis of Dementia
- psychosis because of actual damage to the brain * in Functional Dementia, there is
no brain damage; it’s just messed up chemicals
- include PT’s w/ Alzeimer’s, psychosis after a stroke, organic brain syndrome;
anything w/ “senile” or “dementia”
- cannot learn reality
-> major difference from functional (which is why you have to determine type of
psychosis)
-> nurse role:
a) acknowledge feeling
b) REDIRECT them -> from something they can’t do to something they can do
** you don’t set-limits because it’s mean ** NOT APPROPRIATE to present reality to
these PT’s when they are experiencing psychotic symptoms (BUT don’t confuse
this w/ reality orientation)
-> important to remember that forgetting things (like where they are or what room
they’re in - PT’s w/ dementia/Alzheimers) is NOT psychosis ** when they start having
delusions, hallucinations or illusions, then they are psychotic
-> reality orientation = telling them person, place, and time (ALWAYS
APPROPRIATE w/ DEMENTIA) - this deals w/ memory

3. Psychotic Delirium
= a temporary, sudden, dramatic, episodic, secondary loss of reality; usually
due to some chemical imbalance in the body
* different because it’s temporary and very acute -> include PT’s 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 it’s temporary so focus is removing the underlying cause &
keeping them safe -> nurse role:
a) acknowledge feeling
b) REASSURE them: it’s temp. & they’ll be safe ** don’t present reality -> they
won’t get it ** don’t 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 aren’t 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, can’t even make a coherent phrase -> babble random words
c) Neologism
- making up imaginary words
• Narrowed Self Concept
= when a psychotic refuses to leave their room or change their clothes
- functional psychotic
- #1 reason is because their definition of self is narrowed -> defined self based
on 2 things: i. Where they are
ii. What they are wearing
*** so they don’t know who they are unless they are wearing those exact clothes in
that exact room - as the nurse, don’t make them change or leave the room (will cause
escalating panic because they will lose their concept of self)
* use the Functional Psychosis techniques • Ideas of Reference
= think everyone is talking about you
- ex. see someone on the news and get upset because you think they are talking
about you - can have both paranoia & ideas of reference (paranoia if also think
they are going to harm you)
LECTURE 5
DIABETES M.
• definition = an error of glucose metabolism - causes issues because glucose is
the primary fuel source and if your body can’t metabolize glucose, cells will die
• does not include diabetes insipidus = polyuria, polydipsia leading to dehydration due
to low ADH -> it’s just similar with the fluids, not the glucose part (similar symptoms)
- opposite syndromes of diabetes i. = SIADH • relationship between amount of
urine & specific gravity of urine:
- they are opposites/inverse
- i.e. the less urine out, the higher the specific gravity; the more urine out, the lower
the specific gravity * so diabetes = has more urine & low specific gravity (opposite
with SIADH)

TYPE I vs. TYPE II:

Differences TYPE 2 DM
 Names - Insulin dependent - Non-insulin
- Juvenile onset dependent - Adult-
- Ketosis prone onset
- Non-ketosis prone

S&S - polyuria - same

- polydipsia
- polyphagia
(increased
swallowing, but in
context of DM it
also relates to
eating)

Treatme D = diet —> least D = diet —>

nt important (less MOST
restrictions than O=
I = insulin — IMPORTANT
before) oral hypoglycemic
> MOST
(pills) A = activity
IMPORTANT E =
exercise

Diet:
• primarily Type II
• a) It is a calorie restriction.
- tells you that calorie’s are important because the diet’s are named (ex. 1500
calorie…)
*** this is the best strategy for them
• b) They need 6 small feedings a day.
- keeps blood sugar levels more normoglycemic throughout the day instead of 3
big peaks

Insulin:
• lowers blood glucose
• 4 main types you really need to know:
1. Regular Insulins -> the “R” is important - ex. Humulin R, Novalin R
- onset = 1 hr.
- peak = 2 hrs.
- duration = 4 hrs.
- is clear (solution) so it can be IV dripped (this is the one used if using IV’s)
- short, rapid acting insulin (but Hesi will call it intermediate because we now have
Lispro which acts faster)
2. N P H
- true intermediate acting insulin
- onset = 6 hrs.
- peak = 8-10 hrs.
- duration = 12 hrs.
- is cloudy (suspension)
 * the issue w/ suspensions is that it precipitates -> the particles fall to the bottom
over time so you CANNOT give via IV (or the PT will overdose & the brain will die)
* Hint: general rule => never put anything cloudy in an IV bag
3. Lispro (Humalog)
- fastest acting, rapid
- onset = 15 mins.
- peak = 30 mins.
- duration = 3 hrs.
- you give this as they being to eat so with meals (not ac) -> interrupt them while
eating!
4. Lantus (Glargine)
- long acting
- peak = no essential peak because it’s so slowly absorbed -> thus, little to no
risk for hypoglycemia - duration = 12-24 hrs.
- only insulin you can safely & routinely give at bedtime because it will not cause
them to go hypoglycemic during the night (YOU CANNOT ROUTINELY GIVE THE
OTHERS AT BEDTIME) ** Hint: boards likes to test peaks & tend to test it by giving
you a time when insulin was given & asking when they reach hypoglycemia (which is
the peak). • CHECK EXPIRY DATES ON INSULIN!!!
- What action by the nurse invalidates the
manufacturer’s expiration date? = opening it -> the minute you open it the date is
irrelevant because now you have 30 days from opening (have to write the date of
opening & new expiry) - refrigeration is optional in the hospital BUT you need to
teach PT’s to refrigerate at home
-> though at the hospital the ones that should be refrigerated should be the un-
opened vials - better to give warm, non-expired insulin than cold, expired insulin

Exercise:
• exercise potentiates insulin
= meaning, it does the same thing as insulin —> think of exercise as another shot of
insulin - if you have more exercise during the day, you need less insulin shots (and
bring easily metabolized carbs/snacks to sports games)
Sick Days:
• when a diabetic is sick -> GLUCOSE GOES UP - need to take their insulin even if
they’re not eating • need to take sips of water because diabetics get dehydrated
• any sick diabetic is going to have the 2 problems of hyperglycemia &
dehydration -> ALWAYS! • stay as active as possible because it helps lower glucose
(even if they’re not eating when sick)

Complications of Diabetes:
= 3 acute and a boatload of chronics
ACUTE
• 1. Low Blood Glucose (in both types)
- a.k.a. insulin shock, insulin reaction, hypoglycemia, hypoglycemic shock
- What causes this?
-> not enough food
 -> too much insulin/medication (primary cause) -> too much exercise
- the danger is brain damage which becomes permanent (so be careful not
overmedicate!) - S & S:
-> drunk in shock
= think of how people look while drunk -> slurring, staggering, impaired judgement,
delayed reaction time, labile (emotions all over) ** from cerebrocortical compromise
= shock -> low BP, tachycardia, tachypnea, cold/ pale/clammy skin, mottled
extremities ** from vasomotor compromise
- Treatment:
a) Administer rapidly metabolizable carbohydrate (i.e. sugars)
-> ex. any juice, reg. pop, chewable candy, milk, honey, icing, jam
b) BUT combine/follow w/ a starch or protein -> ex. cracker, slice of turkey
*** skim milk is great because it gives both - bad combo is too much simple sugars (like pop &
candy) - if unconscious give Glucagon (IM) or IV Dextrose (D10, D50) -> how do you
determine which to give? = the setting (i.e. family calling from home, tell them to give
IM but if in ER give IV)
** hard to get a vein because of vasoconstriction
• 2. High Blood Glucose in TYPE I = Diabetic Coma/ DKA (Diabetic Keto-acidosis)
-> Hint: Type I is also called “ketosis-prone” - What causes this?
-> too much food
-> not enough medication
-> not enough exercise
*** none of these are the #1 cause because it is acute viral upper respiratory
infections (w/in the last 2 weeks)
- PT contracts upper resp. infection -> recovers w/in 3-5 days like everyone BUT
after initial recovery, they start going downhill & getting more lethargic
* so, if they come into the ER you should ask if they’ve had a viral upper resp.
infection in the last 2 weeks
-> what causes the high glucose is the stress of the illness that was not “shut off”
and they start burning fats for fuel -> ketosis
- S & S:
-> spell out D K A
- D = dehydration
- K = ketones (in blood), kussmaul’s, high K+ * you can have ketones in your urine
& not have DKA
- A = acidotic (metabolic), acetone breath, anorexia (due to nausea)
-> hot & flushed, dry = water is a coolant! if you lose water (as in dehydrate) you
loose coolant - Treatment:
-> fast rate IV fluids (ex. 200/hr.), w/ reg. insulin in the bag

• 3. High Blood Glucose in TYPE II = HHNK/HHS (Hyperglycemic

Hyperosmolar Non-Ketotic Syndrome)
= this is dehydration (for any HHNK/HHS question just call it DEHYDRATION)
- so think of the S&S of dehydration (low water, hot temp, flushed, dry)
- nursing diagnosis = fluid volume deficit
 - #1 intervention -> giving fluids!
- outcomes you want to see = increased output, BP coming up, moist mucus
membranes etc. ** so all the outcomes of a PT coming out of dehydration
- Why do these PT’s only get the D (& not the K & A)? -> they don’t burn fats (which
make the ketones)

• Which one is insulin the most essential in treating? = DKA

-> you don’t have to use insulin w/ HHNK because you mostly need to re-hydrate
them
• Which has a higher mortality rate?
= HHNK
-> DKA’s tend to be a higher priority and symptoms are much more acute; HHNK’s
tend to come in to ER later than they should because symptoms are not as visible &
they end up getting worse (so by
the time they come in it might be too far gone) • Who would die first if didn’t treat
them? (more life threatening)
= DKA
-> but they tend to get treated in time
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 can’t feel it when he injures himself. ->
peripheral neuropathy.
ex. PT doesn’t 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 you’re 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 doesn’t test units so just
remember the numbers!
LECTURE 6
DRUG TOXICITY
• 5 main ones to know
-> tests nurse safety
-> remember, they don’t test units

1. LITHIUM
• for the mania in bi-polar
• therapeutic level = 0.6 - 1.2
• toxic level = > 2
• What about between 1.2 - 2???
-> no books agree on what is going on in between those levels (grey area)
-> boards would not give you any values in the grey area (because item writers for
the NCLEX need to test on what the books agree and books agree that over 2 is
toxic)

2. DIGOXIN (LANOXIN)
• used to basically treat 2 things:
a) A-fib
-> remember the ABCD’s of treating atrial arrythmias b) congestive heart failure
• therapeutic level = 1 - 2
• toxic level = > 2
*** NOTE: both have 2! -> so if the question uses the value of 2, call it toxic (safer to
call something toxic when it may not be than to say that it’s therapeutic when it
might not be)
• take the apical heart rate before giving Dig

3. AMINOPHYLLINE
• airway antispasmodic
- technically not a bronchodilator -> it doesn’t stimulate beta-2 agonist cells to
bronchodilate - it just relaxes a muscle spasm
-> in spasms = airway is narrow
-> when you relax a spasm, airways widen (which is why it looks like a
bronchodilator)
* ex. epinephrine is a bronchodilator
• ex. sometimes PT’s come in w/ an acute asthamatic attack & the bronchodilators aren’t working ->
because they are in an acute, lock-down spasm & the spasm is in the way of the bronchodilator
= give them aminophylline first 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
5. BILIRUBIN
• waste product from the breakdown of RBC’s • Hint: Boards will only test bili’s
in newborns - normal adult bili = 1-2 (low)
- newborns have higher levels from breaking down RBC’s from mom = 5 +
• therapeutic level -> elevated level = 10 - 20 - ex. if newborn has 9.9 it’s high but
still “normal” • bilirubin toxicity = > 20
- right around 14-15 is when MD’s start thinking about hospitalization because once
you’re at 15, you’re halfway to toxic (don’t want it to get to 18 or 19, too close to
toxic)
• pathologic jaundice = bili high & infant yellow at birth - come out yellow
• physiologic jaundice = bili is normal at birth but over the next 2-3 days it goes high
- becomes yellow

• HINT:
- for the two “L” drugs = 2 (pick the lower number) - the other one’s = 20 (pick the
higher #)

Kernicterus & Opisthotonos:

• kernicterus = bilirubin in the brain when it crosses the BBB (condition) -> is in the
brain, in the CSF, in the meninges
- different from jaundice = yellow color from too much bilirubin in the skin
- usually occurs when you reach levels of 20 - bili in the brain causes aseptic
meningitis & aseptic encephalitis; can be lethal
• opisthotonos = position the baby assumes when they have bilirubin in the brain
= severe hyperextension due to the irritation of the meninges w/ the bilirubin
-> newborns have high flexibility so when they hyperextend they’re heels will touch
their ears & they will be rigid
-> if you see a kid w/ levels of 15 extending the neck they need follow-up
immediately (medical emergency)
• ex. In what position do you place an opisthotonic child? = on their side
ABDOMINAL
DUMPING SYNDROME vs. HIATAL HERNIA • both gastric emptying issues & are
kind of opposites -> memorize one & you have the other

Hiatal Hernia:
• regurgitation of acid into the esophagus because the upper part of your stomach
herniates upward through the diaphragm
- your stomach should stay in the abdominal cavity • w/ this, you have a 2-chamber
stomach (like having 2 stomachs) -> band around the middle
• gastric contents move in the wrong direction at the correct rate
-> rate is not the problem, it’s the direction
-> going the wrong way on a one way street • S & S:
- just plain GERD (gastro-esophageal reflux disease) -> heartburn & indigestion
*** but just because you have GERD doesn’t 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:
—> goal = want the stomach to empty faster * because if it’s empty, it won’t
reflux
** 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 flow 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:
—> goal = want the stomach to empty slower ** see table
• Three things to play around w/ to effect stomach emptying time:
a) change the head of the bed
b) change the water content of the meal
c) change the carbohydrate content of the meal
Gastric HIATAL DUMPING
Emptying HERNIA SYNDROME
Issue
Treatments

Head of Bed - HIGH position - LOW position

during & after (lie flat and
meals (gravity turn to side to
helps empty eat)
faster)

Water Content - high fluids - low fluids

(don’t give
fluid w/ the
meals -> an
hour before or
after)

Carb Content - high carbs - low carbs to

because they help stomach
go through empty slow
faster

Protein? - low protein - high protein

• Hint: Whatever carbs is, protein is the opposite.

ELECTROLYTES
• to know the S & S of electrolyte disorders, memorize 3 sentences:
a) Kalemia’s (K+ imbalances) do the same as the prefix except for heart rate &
urine output. (write arrows to help)
b) Calcemias (Ca) do the opposite of the prefix. c) Magnesemias do the
opposite of the prefix.
• Kalemia’s do the same as the prefix except for heart rate & urine output:
- look at the prefix: hyperK+ & hypoK+ (high & low) - symptoms will go HIGH w/
HYPER, LOW w/ HYPO -> except for the heart rate & urine which goes opposite
the prefix
S& HYPER K+ HYPO K+
S

Brai irritability, aggitation, lethargy,

n restlessness, agressions, obtunded,
obnoxiousness, stupor
decreased inhibitions,
loud/boistrous

Lung tachypnea bradypnea

s

Hear LOW heart rate HIGH heart

t - T waves = peaked (tall) rate
- ST wave = elevated (tachycardia
*** everything else about the )
heart aside from the rate go
up

Bow diarrhea, borborygmi illeus,

el constipation

Musc spasticity, increased tone, flaccidity, low

le reflexes
hyper
reflexive

Urin LOW urine output HIGH urine

e output

• ex. Your PT has hyperK+. Select all that apply:

a) dynamic illeus e) U wave (goes down) -> sign of cardiac depression b) obtunded f) depressed ST wave
c) +1 reflex g) polyuria
d) clonus h) bradycardia

• Hint: don’t forget, if you don’t know something don’t pick it (don’t over select)

• Calcemias do the opposite of the prefix. - hyperCalcemia = body goes low

-> ex. bradycardia, bradypnea, flaccidity, lethargy, constipation - hypoCalcemia = body goes high
-> ex. agitation, clonus, hyper-reflexive, seizure, tachycardia • Trousseau’s sign = put BP cuff on
the arm and watch to see if the hand spasms when it’s pumped up • Chvostek’s sign
= tap the cheek -> watch for face spasms (hypocalcemia)
- sign of neuromuscular irritability associated w/ low Ca -> Hint: in hypoCa it does the
opposite of the prefix so irritability would have to be hypoCa

• Magnesemias do the opposite of the prefix. - some review books say that
hypomagnesemia is not associated w/ hypertension BUT it is

• Could it be possible that certain symptoms could be caused by either a K+, Mg, or
Ca imbalance? YES (How do you break the tie?)
- in a tie, don’t pick Mg because it’s not a major player
• If it is skeletal muscle or nerve, blame it on Ca -> for everything else blame it
on K+
- ex. Your PT has diarrhea. What caused it? a) hyperK+ -> same as prefix so could be
this b) hypoK+ -> things go down so not this one
c) hypoCa -> opposites of prefix so could be this d) hypoMg -> opposites of prefix so could be this ** in
a tie, don’t pick Mg; if it’s not skeletal or nerve you rule out calcium
** Hint: when answering these kinds of questions, draw arrows! (i.e. diarrhea is an
“up” symptom) —> if the question had asked about tetany use the sentences
(prefixes), arrows & tie breakers to help rule out options & because it’s muscle &
nerve related, it’s hypoCa
• Common mistake in electrolytes:
ex. Your PT has tetany. What caused it? (tetany is the body going up)
a) a high K+ -> makes body go up
—>
b) a high Ca -> makes body go down! (opposites) c) a low Mg -> makes body go up (but it’s a tie)
90% of students would pick Ca without properly looking at the question because the
question is going the other way (use the sentences & arrows) ** don’t do the tie
breaker first
• prefixes -> arrows -> tie breakers

Sodiums:
• d e hydration
- hypernatremia
• o verload
- hyponatremia
• dehydration & overload are opposites
-> think of the signs & symptoms of both situations
• ex. In addition to a high K+, what other electrolyte imbalance is possible in DKA?
- hyperNatremia
-> because of dehydration

• Earliest (first) sign of any electrolyte disorder: = numbness & tingling ->
paresthesia
** circum-oral paresthesia (numb & tingling lips) is a very early sign
• UNIVERSAL SIGN of electrolyte imbalance is muscle weakness = ALL of
 them cause this = paresis

Treating Electrolyte Imbalances:

• the only one that really gets tested is K+
-> remember, high K+ is the most dangerous because it can stop your heart
• Rules:
a) Never push K+ IV
b) Not more than 40 of K+ per L of IV fluid -> call and clarify if there is an order
for more (question the order if it’s 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 (it’s the K+ in the
blood that kills you, not the ones in the
cells)
-> this doesn’t get rid of the extra K+
but it hides it well (doesn’t really solve
the problem BUT it saves their the
PT’s life)
*** buys time to solve the underlying
problem (but if you don’t fix it the K+
will eventually leak back into the blood)
- temporary fix 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 =
get’s rid of excess K+ permanently as
it leaves the body
-> con’s of kayexalate = takes a long
time (HOURS) & the PT may not live
that long
• best way to get rid of K+ to fix the
imbalance by using both D5W w/ reg.
insulin + Kayexalate
LECTURE 7
ENDOCRINE
• focus on the thyroid & adrenal glands -> what you need to know most for the test
• Hint: change the word ‘thyroid’ to ‘metabolism’ (the thyroid regulates metabolism)

THYROID
Hyperthyroidism:
• a.k.a. hypermetabolism
• think of all the S & S that you would see in a high metabolism such as:
- weight loss, high BP & heart rate, anxious & irritable, hyper, heat intolerance (cold tolerance),
exophthalmus -> think Don Knotts
- called Grave’s disease (run yourself into the grave) • 3 treatment options for too
much hormone: a) radioactive iodine
i. PT should be in a room by themselves for 24 hrs. -> no visits for the first 24 hrs.
ii. after that, PT needs to be extra careful with their urine (i.e. flush 3 times after
voiding, if urine spills on the floor the hazmat team must be called) -> radioactive
material is excreted via urine -> biggest risk to nurse is the urine
b) PTU -> Propylthiouracil
- “puts thyroid under” = slows thyroid down - primary use as a cancer drug BUT
is used specially for hyperT
- nursing role:
-> be aware that it is an immunosuppresent so WBC count needs to be monitored
c) Thyroidectomy (most common way)
- partial or total removal -> PAY ATTENTION TO THIS IN THE TEST (most
important)
- total = need lifelong hormone replacement -> at risk for hypocalcemia
(because of parathyroid, hard to save it in a total) -> check Trousseau’s &
Chvostek’s
- sub-total = don’t need lifelong replacement because but may need it for a bit
before the leftover thyroid starts “kicking in”
-> less risk for hypocalcemia
-> at risk for thyroid storm/crisis;
thyrotoxicosis (total’s never get this)

• Thyroid Storm:
1. super high temps. (105 & up)
2. extremely high BP’s (stroke category; ex. 210/180) 3. severe tachycardia (ex. could
be in the 180’s) 4. have psychotic delirium
—> MEDICAL EMERGENCY!!! can cause brain damage (can fry the brain to
death)
- immediate treatment = get the temperature down & get the O2 up
-> first way - ice packs
-> best way - cooling blanket
-> O2 per mask at 10L (BUT, remember they are psychotic so good luck keeping
that mask on) ** maybe pick this first if picking between O2 & ice packs
- will come out of it themselves or die -> self-limiting - don’t medicate
- 2 on 1 (need 2 people to care for these PT’s)
Post-Op Risks:
—> depends on type of surgery & timeframe (HAVE TO KNOW THIS)
• 1st 12 hours:
a) does not matter if total or partial; priority is airway - thyroid is in the neck
- any edema can cause constriction of airway b) hemorrhage
- endocrine gland -> has a lot of blood vessels • 12-48 hours:
- need to pay attention to the type of thyroidectomy a) Total = tetany due to the low
Ca
- can cause constriction of airway
b) Sub-total/Partial = thyroid storm
• after 48 hrs:
- big risk is infection
*** but never pick infection in the first 72 hours

Hypothyroidism:
• a.k.a. hypometabolism
• think of all the S & S seen in low metabolism: - obese (weight gain), flat/boring
personality, cold intolerance (heat tolerance), low BP & heart rate - called
Myxedema
• treatment option for not enough hormone: - give thyroid hormones -> Synthroid
(levothyroxine) • DO NOT SEDATE THESE PT’S - because they’re body is already
super slow & you could put them into a coma = myxedema coma
- question any pre-op orders that have sedation (i.e. Ambien before surgery)
- if PT is NPO before surgery you need to call the MD because they need to be able
to take their morning thyroid hormone PO (never hold thyroid pills pre- op without
express order to do so)
-> if no hormone replacement they will be hypothyroid & that will cause issues when
being given sedative agents (anesthetics) for surgery
ADRENAL CORTEX
• coincidentally, these diseases start with the letter A or C (like the initials of adrenal
cortex)
- ex. Grave’s would not be one, Cushing’s would

Addison’s Disease:
• under-secretion of the adrenal cortex
- one of the rarest endocrine disorders
• S & S:
a) hyper-pigmented
- very tanned (look healthy)
b) do not adapt to stress (don’t have regulation of stress response)
- when stressed, BP will go down & glucose will down which will put them into
shock
** the purpose of the stress response is perfuse the brain w/ blood (raise BP) &
give the brain glucose (raise glucose)
• Treatment:
- steroids (because they’re low in steroids) -> glucocorticoids
 ** all steroids end in ‘-sone’
-> in Addison’s you “add a -sone”

Cushing’s Syndrome:
• over-secretion of the adrenal cortex
- “cushy” sounds like you have more of something • S & S:
** HAVE TO KNOW THIS
** gives you 2 things: the S&S of Cushing’s & the side-effects of steroids
** 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
- fill him full of water & write ‘Na’ inside (put K+ outside of the body)
- draw striae on his abdomen (stretch marks) - write ‘high glucose’ (MOST IMPORTANT)
- draw bruises
- word bubble = “I’m mad. I have an infection.” a) moon face
b) hirsutism (lots of excess hair)
c) central obesity
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 you’re on a steroid and you’re a diabetic, what do you do?
- need a lot more insulin (because steroids increase the blood glucose)
• ex. PT w/ acute COPD exacerbation on Solu-Medrol (a steroid) IV push Q8 to reduce
inflammation in the airway. What nursing action needs to be taken on this PT? =
Accu-Chek’s Q6 because of the high glucose! -> steroids make glucose go up EVEN
IF you’re not a diabetic
• Treatment:
- adrenalectomy (classic treatment for hyper- secretory glands is to cut it out)
-> bilateral adrenalectomy (remove all)
-> but then this causes you to have Addison’s which means you have to have steroid
treatment (which makes you look like “Cushman” all over again which is the reason
you got the adrenals removed in the first place)
-> takes about 1-2 yrs. just to get equilibrated back to feeling normal

• endocrine surgery creates the opposite problem

CHILDHOOD DEVELOPMENT
• children’s toys -> how to select the appropriate play activity/toy given the age of the
child
• 3 things to consider:
- Is it safe?
- Is it age appropriate?
- Is it feasible?

Safety Considerations:
• a) no small toys for children under 4
- no small parts that can be aspirated for under 4 • b) no metal toys if oxygen is
in use
- because of sparks
- might use the word “dye-cast” instead of metal (ex. hot wheels car)
• c) beware of fomites
- fomite = non-living object that harbours microorganisms ** vector/host is the name for living
- toys are notorious fomites on a pediatric unit (kids stick them in their mouths)
- worst fomite = stuffed animals
- best kinds of toys -> hard plastic toys (because you can terminally disinfect them)
- ex. If you have a child who is immunosuppressed, what would be the best toy for
them? -> a hard plastic action figure

Feasibility:
• “could you do it” in a certain situation • 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 ex. Is swimming feasible for a 13 yr. old in a
body cast? NO • use common sense

Age Appropriateness:
• this is what mostly gets tested
-> if the test gives you a certain age, you need to know what toy/activity to give
them
• 0 - 6 months:
- children at this age are sensory-motor
- best toy = musical mobile
-> something that stimulates BOTH sensory & motor - if they don’t have mobile as a
choice, look for something that is large & soft
• 6 - 9 months:
- working on skills of object permanence (the idea that something is still there
even if you can’t see it) -> play at this age should be teaching them this - best toy =
“cover-uncover toy”
-> choose something easy to cover & uncover (i.e. jack-in-a-box, pop up toys,
books with movable parts that cover/uncover)
- peek-a-boo, putting blanket on head & pulling off - 2nd-best toy = something
large & hard
- worst toy for this age is the musical mobile (because they can pull themselves up,
pull the mobile and strangle themselves)
• 9 - 12 months:
- working on vocalization
- best toy = speaking/talking toys
-> ex. tickle me Elmo, talking books
- purposeful activity w/ objects (at least 9 months) -> ex. building w/ blocks
-> Hint: Never pick an answer w/ the following words if the kid is under 9 months =
build, sort, stack, make, construct (because they are “purpose words”)
• Toddlers -> 1 - 3 years:
- working on gross-motor skills
 -> running, jumping
- best toy = push-pull toys
-> ex. wagons, lawnmowers, little strollers - if it takes finger dexterity, then DO NOT
choose it for the toddler
-> ex. no colored pencils, no blunt scissors - finger-painting is appropriate (should
be called “hand” painting) -> is not a dextrous activity, it is gross motor
- parallel play = play alongside others but not with • Preschoolers:
a) working on fine-motor skills
-> things that use finger dexterity
b) working on balance
-> ex. tricycles, tumbling, skating, dance class -> swimming is more of a gross motor
skill because it doesn’t take balance (can start this w/ infants) - co-operative play =
play w/ others
- pretend play = highly imaginative at this stage • School-aged:
- characterized by the 3 C’s
a) creative = let them make it (don’t make it & give it to them)
-> better to give them blank paper & crayons instead of coloring book so that they
can create their own pictures
-> LEGO age! (let them create the trucks and cars instead of giving them toy cars)
b) collective = they like collecting things
-> etc. beanie babies, pokemon, barbies
c) competitive = like to play games where there is a winner & a loser
-> preschoolers want games where everyone is the winner & everyone gets the
same prize • Adolescents:
- peer-group association = they want to hang out with their friends and fit in
- if you have a question stating that there are a group of teenagers hanging out in one
teenager’s room you let them unless 1 of 3 things is happening: a) if anyone is fresh
post-op (under 12 hrs.) b) if anyone is immunosuppressed
c) if anyone has a contagious disease
NEURO
LAMINECTOMY
• lamina = the vertebral spinous processes -> the bumpy bones you feel on
the spine ectomy = removal
• removing posterior processes of the vertebral bones • reason -> to relieve nerve
root compression - cut away some of the bone to relieve the pressure on nerves
(give nerves more room to exit) • a.k.a. decompression surgery

S & S of Nerve Root Compression (3 P’s): • Pain

• Paresthesia = numbness & tingling
• Paresis = muscle weakness
• For Laminectomy questions, the most important thing to pay attention to in
any neuro question is LOCATION, LOCATION, LOCATION!!
- will determine symptoms, prognosis, & treatment - LOCATION IS EVERYTHING
IN NEURO • 3 locations in Laminectomies:
- cervical = neck
 -> innervates the diaphragm (breathing) & arms - thoracic = upper back
-> innervates abdominal muscles (cough mechanism) & gut muscles
(bowels)
- lumbar = lower back
-> innervates the bladder & the legs

Pre-Op Laminectomy:
• when you change the location, you change the answer
• ex. What is the most important pre-op assessment for a cervical laminectomy?
= breathing & if it’s not one of the choices, pick the one that checks the function of
the arms & hands • ex. What is the most important pre-op assessment for a thoracic
laminectomy?
= coughing & bowel sounds
-> if abdominal muscle function is affected, PT won’t be able to contract enough to cough properly
• ex. What is the most important pre-op assessment for a lumbar laminectomy?
= bladder function (voiding, distention), or function of legs and feet

Post-Op Laminectomy:
• #1 post-op laminectomy answer on N-CLEX is log-roll -> for any spinal injury
• 3 other things to know about mobilizing PT’s after surgery:
a) Do not dangle these PT’s
- go from lying to immediate standing/walking - they can sit on the edge of the bed
long enough to avoid orthostatic hypoTN but not more than that
b) Do not let PT sit for longer than 30 mins - question this typical post-op order:
up in chair for 1 hr TID
-> in chair for meals is ok because usually meals only last for 30 mins
c) PT may walk, stand & lie down w/o restrictions - restrictions only on sitting
-> jobs w/ sitting all day (i.e. admitting clerk) has shown to have the most
occurrence of back issues/pain

Post-Op Complications:
• they depend on location!
• cervical:
- # 1 complication is pneumonia (because breathing is affected)
• thoracic:
- pneumonia -> can’t cough properly
- ileus -> affected bowel function
• lumbar:
- urinary retention -> affected bladder function - issues w/ the legs
• ex. You are caring for a PT w/ a lumbar oligodendrogliocytoma. What’s the #1 problem?
a) airway c) cardiac arrhythmia
b) ileus d) urinary retention -> it’s lumbar *** LOCATION LOCATION LOCATION

• typically, don’t have chest tubes w/ laminectomies BUT the anterior thoracic will
have chest tubes - means the surgery goes through the front of the thorax to get to
the spine so you need tubes in order to address pneumo/hemathorax
Laminectomy WITH FUSION:
• “with fusion” -> key word; means that a bone graft is taken from the iliac crest
- take some bone from your hip to fuse in between the bones from where the disc
was taken out (to keep from grinding)
• most laminectomies don’t have fusion
- because usually it’s just the “wing thing” being taken out BUT if the disc is also
removed, you need fusion • PT will have 2 incisions:
a) hip
-> has the most pain, most bleeding & drainage (will have the JP/Hemovac drain)
-> post-op, this one causes the most problems ** surgeons want to get rid of this incision
because it costs more, has more risks, want to cut recovery time/hospital stay in half, less drainage if gone -
> surgeons are using cadaver bones from bone banks (no more 2nd incision; risk for rejection is low) b)
spine
-> highest risk for rejection
** both have equal risk for infections
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 flat &
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 lam’s 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
LECTURE 8
LAB VALUES
• you have to know the main ones but also know which ones are more
dangerous than others -> need to know how to prioritize PT’s according to lab
values (not good enough to just know basics) • scheme (priority levels):
-> the value is abnormal BUT what priority is it? A = not a priority/low priority; don’t
do anything about, not a big deal (don’t really need to report it) B = need to be
concerned but nothing you need to do; just needs closer monitoring
C = crossed a line from low to high priority; it is critical, you have to do
something about it i. always hold (if there’s something to hold) ii. assess
(focused)
iii. prepare to give
iv. call whomever is appropriate
D = highest priority that you can possibly have w/ a lab value; do something STAT!
-> you cannot leave their bedside (you can leave the bedside of a “C” level if
needed); get other people to help

• Hint: Assess before you do unless delaying doing puts your PT at higher risk! (ex. blood
transfusion reaction) - ex. you should put the HOB up first before doing resp. assessment because keeping a
dyspneic PT flat on bed longer puts them at higher risk
- DON’T FORGET TO SEE IF IT’S A FIRST vs. BEST question
Name Nor Priority Level if Abnormal
and mal
Name Ran
and ge
Info
Info

Serum 0.6 - A
- never make a PT w/ high
Creatini 1.2 creatinine as highest priority
ne (sam - probably have kidney disease
best e as BUT they are not going to die in
Lithiu the next 4 hours - only time you
indicat
m) might call MD is if they’re going
or of
kidney for a test that has a dye in it (but
still wait to call in the morning, not
function
right away)
INR 2 - 3’s C = anything that is 4 &
above is i. hold Coumadin
(inter
ii. assess bleeding
nationa iii. prepare to give Vit. K
l iv. call MD
normali
zed
ratio)
(variati
on of
PT)
monitor
s
Couma
din

K+ 3.5 - C = if lower than 3.5

not a 5.3 i. nothing to hold
good ii. assess the heart
indicato iii. prepare to give K+
r of iv. call MD
someth C = between 5.4 - 5.9
ing i. hold all K+
specific ii. assess the heart
, iii. prepare to give D5W + reg.
just that insulin + Kayexelate
somet
hing is iv. call MD
wrong D = if > 6 (this PT could die soon;
do all the
same as C but do it stat!
& need more than 1 person)

Name Nor Priority Level if Abnormal

mal
and Ran
Info ge

pH 7.35 - D = in the 6’s (ex. 6.58)

7.45 i. nothing
to hold
ii. assess vitals (body goes down
w/ the pH) to make sure they’re
alive iii. nothing to prepare BUT
treat the underlying cause (which
only the MD can do)
iv. call MD faster than in any other
case

BUN 8 - 25 A = if elevated it’s not a big deal

(blood -> assess PT for dehydration
urea Hint: if they give an elevated blood
nitroge
n) value &
you have no clue what’s
nitroge going on & they ask “for what
n ->
waste would you assess them”
product dehydration is a great guess
s in (because all
the blood values go up
blood from concentration)

HgB 12 - B = 8 - 11
18 - assess for low HgB (bleeding,
** malnutrition)
boar
ds C = below 8
tend i. nothing to hold ii. assess for
to
not go bleeding iii. prepare to give blood
iv.
into
gende call MD
rs
(this
is the
 norm
al
adult
HgB)

Bicarb 22 - A
26

CO2 35 - C = high but in the 50’s

* not 45 -> PT will be dyspneic
for i. nothing to
COPD hold
PT’s, ii. assess resp. status
reg. iii. prepare to get PT to do pursed-
PT’s lipped breathing (prolongs
from
exhalation to get
arterial rid of CO2) iv.
blood breathing usually fixes it so you
gas don’t have to call
D = in the 60’s -> one of the
criteria for resp. failure
(MEDICAL EMERGENCY) i.
nothing to hold
ii. assess resp. status
iii. prepare to intubate &
ventilate iv. call resp.
therapy first then MD

Hemato 36 - B = elevated
crit 54 -> assess for dehydration
* 3X
the
HgB
(so
memo
rize
the
HgB
&
multipl
y by
3)

PO2 78 - C = low but still in 70’s

from 100 i. nothing to hold
arterial ii. assess resp. status
blood iii. prepare to give O2
gas iv. most times the O2
(not administration works and you
from don’t have to call the MD
pulse because the dyspnea goes away *
oximetr hypoxic -> heart rate speeds up
first and when the heart can’t
y)
work hard anymore, the resp.
rate goes up
D = if in the 60’s -> the other
criteria for resp. failure
(MEDICAL EMERGENCY) i.
nothing to hold
ii. assess resp. status
iii. prepare to intubate &
 ventilate iv. call resp. therapy
first then MD * you can still put
O2 during this time -> won’t
solve the problem but will help
keep them calm

O2 Sat 93 - C = anything less than 93

100 i.
nothing to hold
ii. assess them
iii. prepare to give O2 if really
low iv. don’t need to call MD if
O2 goes up * you better freak out
though if in paeds it goes below
95
* anemia falsely elevates it (you
should look for other indicators);
dye procedures in the last few
hours also invalidates it w/ false
elevation

Name Nor Priority Level if Abnormal

mal
and Ran
Info ge

BNP shoul B = elevated BNP

(brain d - you know they have CHF/watch
natriur be them for CHF
etic under - it’s not high priority because it
peptid 100 indicates a chronic condition
e)
best
indicat
or of
conges
tive
heart
failure

Sodiu 135 - B = if abnormal then assess

m 145 - if high -> assess for dehydration
- if low -> assess for overload
C = if Na is abnormal and
change in LOC
there is a
(because it becomes a
safety
issue)

WBC’s Total C = all of them -> if they go

*3 WBC below their thresholds
counts 5,000 i. nothing to hold
that - ii. assess for signs of infection
you 11,00 iii. instead of preparing, place
must 0 them on neutropenic
know precautions
ANC
(abso
 lute
Neutr
ophil
count
) -> if it falls below you go from HIV
needs to AIDS
to be
above
500
CD4
need
s to
abov
e
200

Platele C = below 90,000

ts -> bleeding precautions
D = below 40,000

RBC’s 4-6 B
millio
n

• memorize the 5 D’s => highest

priorities! - pH in the 6’s
- K+ in the 6’s
- CO2 in the 60’s
- O2 in the 60’s
- platelet below 40,000
—> boards doesn’t really put these
kind of PT’s against each other
because it’s not fair • learn the C’s
LECTURE 9
PSYCHOTROPIC DRUGS
• ALL psych drugs cause low BP &
• even though there are several classes, info tends to overlap
weight changes -> usually weight gain (but a few cause weight loss)
• for most of these meds, you need to take take them for 2-4 weeks before you get
beneficial effect - many PT’s say that they don’t work after only taking them for 1
week (nurse teaching)

PHENOTHIAZINEs:
• old class of drugs -> 1st gen/typical anti-psychotics • ALL end in “-zine”
• actions:
- do not cure psych diseases -> reduce the symptoms - in large doses they are anti-
psychotics -> “-zines for the zany”
- in small doses they are anti-emetics
- considered major tranquilizers
-> Aminoglycosides are to antibiotics as
 Phenothiazines are to tranquilizers = THE BIG GUNS (when nothing else is going
to work) • major side effects (not toxic effects):
A = anti-cholinergic (primarily dry mouth)
B = blurred vision
C = constipation
D = drowsiness
E = EPS -> extrapyramidal syndrome (looks like Parkinson’s)
F = photosensitivity
aG = agranulocytosis (low WBC count,
immunosuppressed)
** side effect vs. toxic effect nursing actions: - side effect = teach PT, inform MD,
keep giving med (& give drugs that can help alleviate) - toxic effect = hold drug,
call MD immediately
• the nursing care is treating the side effects - #1 nursing diagnosis for a client on a
tranquilizer is risk for injury (safety issues)
• decanoate = long-acting IM form given to non compliant clients
- is something that may be court ordered

TRICYCLIC ANTI-DEPRESSANTS:
• old class of anti-depressants & most have been grandfathered into a newer
class:
- NSSRI = non-selective serotonin re-uptake inhibitor • are mood elevators used to
treat depression = “happy pills”
- include Elavil, Tofranil, Aventyl, Desyrel • side effects:
A = anti-cholinergic (primarily dry mouth)
B = blurred vision
C = constipation
D = drowsiness
E = euphoria
BENZODIAZEPINEs:
• anti-anxiety meds
• considered to be minor tranquilizers (primary use) • they always have “-zep” in
the name
-> both major & minor tranquilizers have “Z’s” • ex. Diazepam (Valium), Xanax, Clonazepam,
Lorazepam • indications: are more than just minor tranquilizers a) pre-op to induce
anesthesia
b) muscle relaxant
c) good for alcohol withdrawal
d) seizures
e) help people when they are fighting the ventilator (relax & calm down)
• work quickly but technically, you shouldn’t take them for more than 2-4 weeks
• relationship between an anti-depressant & a minor tranquilizer?
- one takes 2-4 weeks and you can be on it for the rest of your life (anti-
depressant)
- the other works quickly but you should only be on it for 2-4 weeks (minor
tranquilizer)
—> a lot of PT’s get put on both when first admitted as the minor tranq. will work right away & then when
the anti- depressant kicks in, they are taken off the minor tranq. * heparin is to warfarin as a
 tranquilizer is to an anti-depressant
• side effects:
A = anti-cholinergic (primarily dry mouth)
B = blurred vision
C = constipation
D = drowsiness
• # 1 nursing diagnosis is risk for injury (safety issues)
MAOIs - MONOMINE OXIDASE INHIBITORS: • anti-depressants (one of the first
types developed) - don’t really use them much anymore because of the restrictions &
side effects
- dirt cheap compared to other anti-depressants • you need to spot an MAOI when you
see it on the test from the beginning of the name
—> the beginnings of the name rhyme: Marplan, Nardil, Parnate (all brand
names)
• side effects:
A = anti-cholinergic (primarily dry mouth)
B = blurred vision
C = constipation
D = drowsiness
• the important thing is patient teaching:
a) to prevent severe, acute, sometimes life- threatening hypertensive crisis (high
BP) - PT must avoid all foods containing tyramine (an amino acid that regulates
BP)
-> NO aged cheese (can have mozzarella & cottage cheese), yogurt, cured/preserved/organ meats,
alcohol, caffeine, chocolate, fermented foods, bananas, avocado’s (guacamole!), any dried fruit b) do
not take OTC meds when on an MAOI
LITHIUM:
• used to treat bi-polar disorder
-> it decreases mania (does not treat the depression) • of all psych drugs, it’s the most unique
(diff. side effects) because all the other ones mess w/ neuro-transmitters
-> Lithium does not = stabilizes nerve cell membranes • unique side effects that act more
like an electrolyte: P = peeing P = pooping
P = paresthesia -> earliest sign of all electrolyte imbalances • TOXIC effects:
—> hold & call the MD
- tremors - metallic taste - severe diarrhea • Interventions for PT’s on Lithium:
a) #1 = increase fluids
-> because they are peeing & pooping a lot so at higher risk for dehydration
b) watch Na levels
c) if they are sweating like crazy don’t give free water, give Gatorade or some other
electrolyte solution -> PT has to have a normal Na for Lithium to work d) NOTE:
Lithium is closely linked to sodium. - low Na = makes Lithium more toxic
- high Na = makes Lithium ineffective
*** need normal Sodium levels

PROZAC -> SSRI - SELECTIVE SEROTONIN RE UPTAKE INHIBITOR:

• similar to Elavil (NSSRI)
• side effects:
 A = anti-cholinergic (primarily dry mouth)
B = blurred vision
C = constipation
D = drowsiness
E = euphoria
• Prozac causes insomnia
-> give it before noon (bad idea to give at bed time) • When changing the dosage
for a young adult/ adolescent, watch for increased suicidal risk -> only this age group
& only when there is recent dosage change

HALDOL:
• has a decanoate form (long acting IM)
• basically the same as Thorazine so side effects are: - A B C D E F aG
• is also an old 1st gen/typical anti-psychotic like the “-zine’s” (major tranquilizer)
• the big thing they test for Haldol is NMS!
- elderly PT’s & young, white schizophrenics may develop NMS w/ Haldol overdose
• NMS = neuroleptic malignant syndrome - potentially fatal hyper-pyrexia
- could reach 106-108 degrees (definitely over 105) - dosage for elderly PT’s should
be half the adult dose • has anxiety & tremors (like EPS) & get both w/ it: ** boards will
want to know if you know the difference between them
—> EPS = side effect (no big deal)
—> NMS = medical emergency!!! (PT can die!) • How do you tell the difference
between EPS & NMS?? take a temperature
-> no excuse for the nurse to miss NMS
-> first action when faced w/ a PT that has anxiety & tremors = take their temp.
** if over 102 call emergency response team coz it’ll be a bad situation (even if it’s not 105 degrees yet) •
safety concerns related to the side effects: - as soon as they get hit by Haldol, they
go down

CLOZAPINE (CLOZARIL):
• prototype 2nd gen/atypical anti-psychotic - new class for the “zany”
• used to treat severe schizophrenia
• was meant to replace the “-zines” & Haldol - advantage is that it does not have the
side effects A B C D E or F
- has slight effects but minor compared to “-zines” - BUT does have side effect aG
(agranulocytosis) -> horrendous in trashing bone marrow
-> causes unbelievably low WBC counts causing you to get horrible infections
• other variations created that have less aG effects but still have to monitor them
• not everyone gets the low WBC so some people can take it but some people can’t
• nursing priority = monitor WBC counts • Note: Geodon (Ziprasidone)
- has a black box warning -> prolongs the QT interval & can cause sudden cardiac
arrest
—> shouldn’t really use in PT’s w/ heart problems • in general, these drugs end
w/ “-zapine” - another tranquilizer class that has a “z”

SERTRALINE (ZOLOFT):
• another SSRI like Prozac
• also causes insomnia BUT you can give it at bedtime • the big thing these days is testing the
interactions: a) cytochrome P450 system in the liver = major pathway in which drugs are
metabolized & deactivated in the liver -> Zoloft is notorious for interfering w/ this system (causes
toxicities of other drugs because they are not getting metabolized)
-> whenever you add Sertraline to a PT’s drug regimen, you will probably have to lower the
dosages of the other drugs
b) watch for interactions w/ St. John’s Wort - you will get serotonin
syndrome
-> potentially life-threatening
-> looks like the MAO PT’s that eat the tyramine ** SAD Head = sweaty, apprehensive, dizzy,
headache c) interactions w/ Warfarin (Coumadin)
- if PT on both, they might bleed out (MUST reduce Coumadin) -> watch for
increased bleeding if on both because Zoloft makes Coumadin go toxic
LECTURE 10
MATERNAL NEWBORN
PREGNANCY:
• you must be able to calculate a due date - take the 1st day of the last
menstrual period - add 7 days, subtract 3 months
- ex. PT’s last menstrual period was from June 10-15 = due date is apx. March 17
• you need to know how much weight should/ shouldn’t be gained:
** don’t worry about multiples or about women who are underweight/over-weight to
begin w/ - Total weight gain = should be 28 lbs, +/- 3 -> 1st T = 1 lb/month (3 lbs;
too much is bad) -> 2nd & 3rd T = 1 lb/week
** on the test, if they give you a particular week of gestation, you have to be able to
predict what the weight should be
- ex. Woman in 28th week who has gained 22 lbs. What is your impression?
-> Week 12 (end of 1st T) = 3 lbs., after that, each week is 1 lb.
-> she should have gained 19 lbs, she gained 3 more than supposed to
-> HINT: if you take the week & subtract 9, that is the weight that should be
gained
* 12 - 9 = 3; 13 - 9 = 4, 20 - 9 = 11
- being over 1-2 lbs. is ok but if she’s 3 lbs. off she needs further assessment
-> 4 lbs. or more off = could be trouble
* ex. if PT is 6 lbs. underweight, she needs a biophysical profile to make sure the baby is still alive
- ideal weight gain = week - 9
• Fundal Height:
- fundus = the top part of the uterus
-> not palpable until week 12 (after 1st T) - When is the fundus at the
umbilicus?
= 20-22 weeks of gestation
- it is important to know fundal location to recognize date of viability and know what
trimester the PT is in: = 20-22 weeks (24 is the end of the 2nd)
** ex. if a PT is brought into ER and w/ history about the pregnancy (or she can’t tell you), you need to know
what trimester she’s in to know what’s going on with the baby -> fastest way to know the trimester
= palpate the fundus (if you don’t feel it at all, she’s in the 1st T & she is the
priority, not the baby) -> if you feel the fundus at/below the bellybutton she’s in
 2nd T (she is still priority) -> if the fundus is above the umbilicus she is in the 3rd T
and baby is the priority!

Signs & Symptoms of Pregnancy:

• probable, presumptive, positive -> BUT on the test there is only POSITIVE &
everything else (maybe’s)
• 4 Positive Signs:
a) fetal skeleton on x-ray
b) fetal presence on ultrasound
c) auscultation of a fetal heart rate
-> starts beating at 5 weeks but you hear it between 8-12 weeks
d) when examiner palpates fetal movement/outline -> not a positive sign when mom feels it
(i.e. quickening) ** none of them have false positives

• most OB information has a range where/when it occurs (because every

woman is different) -> because of this it is critically important that you read OB
questions carefully & properly
• there can be 3 different questions for every fact in OB: a) when would you first…
-> pick the earliest part of the range
b) when is it most likely…
-> pick the mid part of the range
c) when should you ___ by…
-> pick the end of the range
ex. When should you first auscultate a fetal heart? = at 8 weeks ex. When would you most likely auscultate fetal
heart? = 10 weeks ex. When should you auscultate a fetal heart by? = by 12 weeks *** PAY ATTENTION
TO WHICH ONE THEY ASK! • quickening = when the baby kicks -> 16 to 20 weeks -
first feel = 16 weeks
- when is it most likely to feel = 18 weeks
- when should you feel it by = 20 weeks

• The MAYBE Signs: (probable’s & presumptive’s) a) all urine & blood pregnancy
tests
-> a positive pregnancy test is NOT a positive sign of pregnancy (because it only
means you have the hormones that go w/ pregnancy, but doesn’t mean you always
have a fetus)
** which is why you can have false positives b) Chadwick’s sign = cervical color
change to cyanosis (bluish; includes vagina & labia) Goodell’s sign = cervical
softening
Hegar’s sign = uterine softening
*** all occur in alphabetical order (boards tends to the order instead of the weeks
they occur because weeks vary, order doesn’t)

Patient Teaching in Pregnancy:

• teaching PT’s the pattern of office visits *** good prenatal care is a major factor in
infant mortality so teach women how often to come in for good prenatal care
a) once a month until week 28
- for all of 1st & 2nd T
 - for the early part of 3rd T
b) once every 2 weeks until week 36
c) once every week until delivery or week 42 - by then, schedule for
induction/c-section
• ex. If a woman comes in for her 12th week checkup, when does she come in next?
= week 16
ex. If she comes in for her 28th week checkup? = week 30 (& then 32, 34, 36)
ex. If she comes in for her 36th week checkup? = week 37, 38, 39, 40, 41, 42, take the baby

• teach her that her hemoglobin will fall: - we don’t worry about low HgB unless it gets really
low - normal HgB for females = 12 - 16
-> 1st T - can fall to 11 & be perfectly normal (not considered low)
-> 2nd T - can fall to 10.5 & be normal
-> 3rd T - can drop to 10 & still be called normal ** acceptably low can be as low
as 9
- tolerate lower HgB’s in pregnant women the further along they are than you would
w/ non-pregnant PT’s

• teaching about the discomforts of pregnancy: a) morning sickness = 1st T

problem
- treat by eating dry carbohydrates (ex. crackers) BEFORE you get out of bed
b) urinary incontinence = 1st & 3rd T problem - why not the 2nd? the baby is an
abdominal pregnancy at this point and off the bladder - treat by voiding every 2 hrs
(should do this from the start of pregnancy until 6 weeks after delivery) c) difficulty
breathing = 2nd & 3rd T problem - teach tripod position (like COPD clients) d) back
pain = usually 2nd & 3rd T
- tends to get worse and worse the further along you get in the pregnancy
- treat w/ pelvic tilt exercises (tilt pelvis forward) * ex. put foot on stool

• pregnancy questions are a good place for using common sense because it is not
a disease, it’s a healthy state
-> using good health patterns
-> if you get a question you don’t know, ask yourself “what would be good for anybody?” & pick that answer

LABOUR & BIRTH

• what is the truest, most valid sign that a woman is in labour???
= onset of regular, progressive contractions —> not bloody show or water
breaking (you can have these and not be in labour)
• Terminology:
- dilation = the opening of the cervix
-> goes from 0 - 10 cm
-> 0 = closed; 10 = fully dilated
- effacement = thinning of the cervix
-> goes from thick to 100% effaced
- station = relationship of the fetal presenting part to mom’s ischial spines
-> ischial spines = the smallest diameter through which the baby has to fit for a
vaginal birth (the tight squeeze, the narrowest part of the pelvis) ** if the baby
 cannot fit through there, the baby cannot be born vaginally
-> negative stations = the head/presenting part is above the “tight squeeze”
* negative news
-> positive stations = the presenting part is below the ischial spines and has already
made it through the “tight squeeze
* positive news
** ex. if the baby’s head stays at -1 & -2 for 17 hours after fully dilated & 100% effaced, the
head is too big and PT needs a C-section ** ex. if the baby’s head stays at +3 for 17 hours, the
baby can still be born vaginally but needs a vacuum extractor, forceps, or an episiotomy -
engagement = station 0
-> the presenting part is at the ischial spines - lie = relationship of the spine of the
mother & the spine of baby
-> longitudinal lie = parallel to mom’s spine (good!) -> transverse lie =
perpendicular, sideways (spines at a right angle); looks like a T; bad, trouble ->
oblique lie = baby is diagonal into mom’s hip instead of straight into the pelvis
- presentation = the part of the baby that enters the births canal first
-> ROA, LOA etc.
-> don’t spend a ton of time memorizing the presentations (this is a hard OB
question; know the stuff that everyone needs to know!) ** you cannot miss the
easy ones!
-> the most common ones are ROA & LOA (right & left occiput anterior)
** you have much better chances guessing by picking one of these (R before L)

Stages of Labour & Delivery:

• 1 = Labour (all of it)
- 3 Phases of Labour:
a) Latent b) Active c) Transition
Phases LATENT ACTIVE TRANSITIO
N

Dilation 0 - 4 cm 5 - 7 cm 8 - 10 cm

Contracti every 5 - every 3 - 5 every 2 - 3

on 30 mins. mins.
FREQUE mins.
NCY

Contract 15 - 30 30 - 60 60 - 90
ion seconds seconds seconds
DURATI
ON

Contract “mild” “moderate” “strong”

ion
INTENSI
TY

Hint: memorize the middle column

(active
labour) because everything is
NOTE: contractions
sequential
 should not be longer
than 90
seconds or closer than every 2
mins. —> means trouble in labour!
- signs of uterine tetany, uterine
hyper- stimulation; parameters to
stop Pitocin

• ex. A woman comes into L & D. She is 5 cm dilated, contractions 5 mins. apart lasting for 45 seconds. What phase
is she in? = active
• 2 = Delivery of the Baby
• 3 = Delivery of the Placenta
• 4 = Recovery
- 2 hours
• What is the purpose of uterine contractions in: - 1st stage = dilate & efface the
surface
- 2nd stage = push the baby out
- 3rd stage = push the placenta out
- 4th stage = stop bleeding by contracting the uterus • When does postpartum
technically begin? = 2 hrs after delivery of the placenta • DON’T MIX UP PHASE &
STAGE! pay attention! - ex. What is the #1 priority in the 2nd phase? = pain management
- ex. What is the #1 priority in the 2nd stage?
= clearing the baby’s airway
- ex. What are major nursing actions to take in the 3rd phase? = check dilation, help w/ pain & breathing
- ex. What are major nursing actions to take in the 3rd stage? = assessing blood loss, making sure there
are 3 vessels in the cord, making sure the whole placenta comes out
• Teaching PT’s how to time contractions: - frequency = beginning of one
contraction to beginning of the next (A to C)
- duration = beginning to end of 1 contraction (A to B) - intensity = strength of
contraction -> subjective - teach her to palpate w/ one hand over the fundus with the
pads of the fingers (fingertips)
* use other hand to time it

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) —> think “oh pain!”
- 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 fist 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 first) & so when the head comes down it presses on the cord and cuts of the supply
causing baby to “kill itself” - do 2 things:
 i. push = baby’s head off cord (DON’T 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)
Interventions for ALL Other Complications in Labour & Birth:
• ex. include uterine atony, uterine hypoTN, vena cava syndrom, uterine tetany…etc.
• all treated the same, treated with LION:
L = 1st, turn them on their left side
I = increase IV
O = oxygenate them
N = notify MD
** RPN’s can do all except increase IV
- left side position is first but also probably best because it addresses uterine
perfusion which protects/saves baby
• PIT: in an OB crisis, if Pitocin is running, STOP IT! = this would become the first
thing then before turning them onto their left side

Pain Meds in Labour:

• do not administer a pain med to a woman in labour if the baby is likely to be
born when the med peaks (review peaks lecture)
- ex. You have a primigravida at 5 cm who wants her IV push pain med. Will you
give it or not? -> is it likely that a primigravida at 5 cm will deliver in the next 15-30
mins? NO, so give her the med - ex. A multigravida at 8 cm wants her IM pain med.
Do you give it?
-> is it likely that she could deliver in the next 30-60 mins? YES, so no IM med for
her
LECTURE 11
MATERNAL NEWBORN continued
FETAL MONITORING PATTERNS:
• 7 that you should know but easy to remember • a) Low Fetal Heart Rate
= under 110
- BAD! do L I O N & if Pit was running, stop it • b) High Fetal Heart Rate
= over 160
- not a big deal, not a high priority
- document & take mom’s temperature
-> could be up because mom has a fever (so nothing wrong with baby)
• c) Low Baseline Variability
= when the fetal heart rate stays the same & does not change (whether high, low,
or in the middle) - BAD! do L I O N
• d) High Baseline Variability
= fetal heart rate is always changing
- good! document it
• once a person is born, if their vital signs stay the same they are called stable BUT
before you’re born, if your vital signs stay the same it’s bad
-> we don’t want to see the opposites happen • e) Late Decelerations
 = heart rate slows down near the end or after a contraction
- BAD! do L I O N
• f) Early Decelerations
= heart rate slows down before or at the beginning of a contraction
- normal, no big deal; document it
• g) Variable Decelerations
- VERY BAD!!! this is what happens when you have prolapsed cord -> push,
position
- this is the most unique one
• 3 good
3 bad = all start w/ an L -> L I O N
1 variable = push, position
• What causes the different heart rates? V = variable C = cord compression
E = early dec. H = head compression A = acceleration O = it’s ok
L = late dec. P = placental insufficiency • What answer always wins in a tie??
- in OB = check fetal heart rate

STAGE 2 of LABOUR = Delivery of the Baby: • all about order:

1 = deliver head
2 = suction the mouth first, then nose
3 = check for nuchal cord (around the neck) 4 = deliver the shoulders & the
body
• the baby MUST have an ID band on before it leaves the delivery area
STAGE 3 of LABOUR = Delivery of the Placenta: • a) make sure it’s all there
• b) check for 3 vessel cord
- 2 arteries
- 1 vein

STAGE 4 of LABOUR = Recovery:

• is the first 2 hours after delivery of the placenta • 4 Things you do 4 Times an
hour in the 4th Stage: *** Q15
a) vitals signs
- assessing for S&S of shock (pressures down, rates up, pale, cold & clammy)
b) check the fundus
- if boggy -> massage
- if displaced -> catheterize
c) check the perineal pads
- to see how much she is bleeding
- if excessive -> will 100% saturate in 15 mins. or less (so if 98% saturated, she’s
still ok)
d) roll her over
- check for bleeding underneath her
—> also lets you assess the perinanal area

POSTPARTUM:
• assessments -> usually 4-8 hrs. depending on PT stability • B = breasts
 U = uterine fundus (want it firm, midline, height r/t to the bellybutton)
-> should be going down 1 cm per postpartum day B = bladder
B = bowel
L = lochia (rubra, serosa, alba)
-> rubra = red; serosa = pink; alba = whitish yellowish E = episiotomy
H = hemoglobin & hematocrit
E = extremity check
-> check for thrombophlebitis (via bilateral calf circumference measuring)
-> Homan’s sign is not the best answer because you can have it w/o having thrombophlebitis & vice
versa (not as reliable or valid)
A = affect (emotions)
D = discomforts
** 3 big things tested in postpartum are the uterine fundus, lochia, & extremities

Variations in the NEWBORN:

• review all the normal’s
• know difference between:
- caput succedaneum = c.s. -> crosses sutures -> symmetrical
- cephalohematoma = bleeding
• normal physiologic jaundice -> appears after 24 hrs. • pathologic jaundice -> baby comes
out yellow
OB MEDS:
• don’t have to be an expert; just know
general info what they are & a few
main things about them —> 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-reflexive (want to keep it +2)
-> resp. rate down (want at least 12
resps.) -> LOC goes down
*** boards likes to test reflexes & resp
rate most - closely monitor the PT’s
reflexes & 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
• to help get basic facts down
• What is Humulin 70/30?
= mix of N & R insulins
- 70 & 30 are percentages
-> 70 % is N
-> 30% is R
• Can you mix insulins in the same syringe? = YES
- when you draw it up go clear to cloudy, R to N (“RN’s draw up RN”)
- when talking about pressurizing the vials you inject air into N first, then R & draw
up R, then draw up N • Injections:
—> will ask what needle to use for a particular injection - IM = “I” looks like 1, pick the answer
that has the 1’s in them (21 gauge…)
- SubQ = “S” looks like 5

HEPARIN vs. COUMADIN:

• in the top 3 most commonly tested drugs!
HEPARIN COUMADIN

Route IV or SubQ only PO

Onset works immediately takes a few

days to a
week to work

Lengt cannot be given for can be given

h for the rest of
longer than 3 weeks
of Use your life
(except Lovenox)
-
body starts making
heparin antibodies after
3 weeks which can be
life-threatening
 Antido Protamine sulphate Vit. K
te

Lab PTT (partial PT -> INR

Test thromboplastin time)
that
monito
rs

can be given to cannot be

pregnant women given to
pregnant
women

• only major anti-psychotic that can be given to pregnant women = HALDOL

K+ Wasting & K+ Sparing Diuretics:

• probably the only questions you’ll get about diuretics is whether if wastes or spares
K+
• any diuretic drug ending in “X” it waste’s K+ -> also Diuril
*** otherwise, it spares K+

Baclofen:
• boards test muscle relaxants as a class • sore “back” -> if you’re on Baclofen,
you’re on your back loafin’
• 2 side effects:
a) fatigue/drowsiness
b) muscle weakness
• Patient teaching:
a) don’t drink
b) don’t drive
c) don’t operate heavy machinery
• Flexeril -> the other muscle relaxant they test
PEDIATRIC TEACHING
• review of Piaget’s theory of cognitive development -> won’t actually name Piaget
but will ask questions on how you would teach children in order to test knowledge
of the theory
4 Stages of Piaget (Cognition):
• a) 0 - 2 years = SENSORY-MOTOR
- these kids are totally present oriented
-> don’t think about past or future
-> only sense what they are doing right now - teaching: while/as you do it & teach
them what you are doing (think present tense)
- teach verbally -> just tell them (don’t understand “play” yet)
- ex. when teaching a PT about a procedure, teach while doing it (won’t work to teach them
ahead of time) -> no pre-op/post-op (except for the parents )
• b) 3 - 6 years = PRE-OPERATIONS (think preschool) - these kids are fantasy
 oriented
-> imaginative, illogical, thinking obeys no rules -> “you can’t reason w/ a
preschooler”
- understand past & future so you can teach them before & after
-> BUT has to be shortly before or after (ex. the morning of, the day of, 2 hrs.
before…) -> don’t give them too much time to get imaginations going on
something
- teaching: what you are going to do (future tense) - teaching through play
-> ex. the day of, teaching PT about lumbar puncture by playing w/ equipment/dolls
• c) 7 - 11 years = CONCRETE OPERATIONAL - these kids are rule oriented
-> can’t think abstractly yet, rigid
-> only one way of doing something
-> “my teacher said”, or “my parents said”
- will tell you you’re doing something wrong if it was different from the way a
previous person did it (ex. wound dressings by different nurses)
- teaching: days ahead; what you’re going to do + skills - teach via age appropriate reading &
demonstration • d) 12 - 15 years = FORMAL OPERATIONAL - can abstract think &
think cause & effect -> Hint: as soon as a kid hits 12 and they ask about teaching,
it’s no longer a pediatric question and is an adult med-surge question (you teach
them like an adult)
- ex. When’s the first age that a child can manage their own care? = 12
-> a 7 yr. old can do the skills related to their care but can’t manage; managing
requires making decisions which require abstract thinking -> it’s not the severity of
the illness that determines who can manage it, it’s the age (ex. a 10 yr old w/
scraped knee vs. 13 yr old w/ renal dysfunction) *** key word is manage (13 yr. old);
skills = 7-11
7 PRINCIPLES of PSYCH
• 1. Make sure you know which
phase of the relationship you’re
in
- pre-interaction, introduction/orientation, working,
termination • 2. Gift giving
- NO GIFTS IN PSYCH (giving or
receiving) - ex. don’t accept flowers from
a PT w/ schizophrenia because to you
they might just be flowers but to them
that might be a marriage proposal
• 3. Don’t give advice
- ex. If the PT asks “What do you think I
should do?” you reply w/ “What do you
think you should do?” - you can give
advice in med-surge or paeds • 4. Don’t
give guarantees
• 5. Immediacy
- if a PT says something, the best
answer is the one that keeps them
 talking
-> don’t pick answers that say “refer to
social work” because that shuts off
communication right then and there
-> Hint: it’s never wrong to get your
PT to talk • f) Concreteness
- don’t use slang
-> psych PT’s tend to take things
literally - if PT’s use made up words
(neologism), those are not concrete so
don’t 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 PT’s
feelings as being valid, real, & worthy of
action - bad answers:
-> “don’t worry” (because it tells them not
to feel) -> “don’t feel”, “you shouldn’t
feel…”, “I would feel”, “anybody would
feel”, “nobody would feel”, “most people
feel”

Empathy Questions:
• recognize that it’s 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
client’s 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
reflects that feeling (or anything
close)
- DON’T choose the feeling that
reflects the PT’s words
- empathy questions usually have a
“sucker answer” (to sucker you into
picking that one) & one of them is one
that reflects/over-emphasizes what the
PT said but ignores what the PT felt
-> you’re supposed to pick the
answer that reflects what they felt (&
ignores what is said) * don’t mix this
 up
LECTURE 12
PRIORITIZATION, DELEGATION, STAFF MANAGEMENT PRIORITIZATION:
• testing to see how you prioritize 4 different PT’s • you are deciding which PT is
sickest or healthiest - pay attention to which one you’re being asked for - ex. if
question is asking “Who do you discharge?” -> asking for your lowest priority/healthiest
client - ex. “Who would you assess/check first after report?” -> the highest
priority/sickest client
• Priority answers always have 4 parts:
a) age
b) gender
c) a diagnosis
d) a modifying phrase
- ex. a 10 yr. old male with hypospadias who is throwing up bile stained emesis
- 2 of these are irrelevant & you don’t need them in your answer = age & gender
*** pay attention to age in paediatric teaching but in prioritization questions, you
don’t
- the modifying phrase is the most important ** don’t get stuck doing ABC’s

4 Rules for Prioritization:

• a) acute beats chronic
- an acutely ill person is a higher priority
• b) fresh post-op (12 hrs.) beats medical/other surgical • c) unstable beats stable
- know the words in a modifying phrase that mean stable & unstable
STABLE UNSTABLE

stable unstable

chronic illness acute illness

post-op greater than 12 post-op less than 12 hours

hours

local or regional general anesthesia

anesthesia

lab abnormalities of an A lab abnormalities of a C

or B level or D level

“ready for discharge”, “to “not ready for discharge”,

be discharged”, “newly admitted”, “newly
“admitted longer than diagnosed”, “admitted less
24 hours ago” than 24 hrs. ago”

unchanged assessments changing/changed

assessments

PT is experiencing the PT is experiencing

typical unexpected
expected S&S of S&S
the disease with which
they were
diagnosed

- don’t mix up symptom severity w/ unexpected symptoms (ex. PT w/ kidney stones having severe pain is
lower priority than PT w/ mild chest pains when having an x-ray - 4 things that always make you
unstable (regardless of whether it’s expected or not): i. hemorrhage (don’t confuse
w/ bleeding) ii. high fevers (over 105) -> risk for seizure iii. hypoglycemia -> even if
it’s a normal value (if they say it, it is it)
iv. pulselessness & breathlessness
-> it’s lowest priority only at the scene of a unwitnessed accident
• 3 things that result in a black tag in an unwitnessed accident: (tag them black & ship
them last) - pulselessness
- breathlessness
- fixed & dilated pupils -> brain death
• d) the more vital the organ, the higher the priority —> only use as a tie breaker
- talking about the organ of the modifying phrase (not the diagnosis)
- Order of Organ Vitality:
i. brain
ii. lungs
iii. heart
iv. liver
v. kidney
vi. pancreas
*** after that no one agrees

DELEGATION:
• DO NOT delegate the following to RPN’s: a) starting an IV
-> don’t assume they have IV certification b) hanging or mixing IV meds
c) pushing IV push meds
** they can maintain & document IV flow
d) administer blood or mess w/ central lines -> no flushing
-> if only option is “change central line dressing”, then pick that otherwise, they shouldn’t do that either e)
cannot plan care
-> they implement, RN’s plan
f) can’t perform or develop teaching
-> they can reinforce teaching
g) can’t take care of unstable PT’s
h) not allowed to do the first of anything -> should be the RN (because they
can plan) i) cannot do the following assessments: - admission
- discharge
- transfer
- the first assessment after there has been a change • DO NOT delegate the
following to a nursing aid: —> they are unlicensed personnel
- no charting
-> though, they can chart what they did but not about the PT
 - can’t give meds
-> except for topical, OTC barrier creams - no assessments (except for vitals &
accu-checks) -> for cost reasons
-> watch for words like “evaluating”
- no treatments (except for enema’s)
- be cautious about allowing them to catheterize (if that’s the only option, pick that)
• Aids can do ADL’s (i.e. bed baths etc.) but shouldn’t do the first of
anything
• In extended care facilities, RPN’s can many of the things listed that they can’t do
because in that setting, the PT population is a generally stable one.
• DO NOT DELEGATE TO THE FAMILY SAFETY RESPONSIBILITIES
- the nurse is responsible for that
- you cannot delegate safety to a non-hospital caregiver
-> you can to a sitter but they can only do what you teach them to do and document
that you taught them (& their competency)
- ex. If a PT’s family member asks that you remove restraints while they are there
because they are watching them and that you can put them back on once they
leave -> NO

STAFF MANAGEMENT:
• How do you intervene w/ inappropriate behavior of staff? (handling your staff when
they do stupid things) • There are always 4 answers:
*** the same answers show up all the time
a) tell supervisor
b) confront them and/or take over immediately c) at a later date just talk to
them
d) ignore it —> NEVER the answer (you never ignore inappropriate behavior by
staff)
- the first 3 could be right or wrong depending on the situation so you need to learn
how to choose between them
• When you get a staff question ask yourself: a) first -> “Is what they are
doing illegal?” YES = always choose “tell supervisor”
NO = go to the next question
b) “Is anyone (PT or staff) in immediate danger of physical or psychological
harm?”
YES = “confront immediately &/or take over” (so no one gets hurt; “telling supervisor”
delays you doing something putting others at risk) NO = go to next question
c) “Is this behavior legal, not harmful, but simply inappropriate?”
YES = “approach later”, no rush
*** if a situation is both illegal & harmful you need to confront/do something first &
then call supervisor (because you don’t want to add more risk for harm by delaying)
BUT if it’s just illegal, tell supervisor
LOCATIONS
• point & click questions
• abdomen quadrants:
- i.e. what quadrant an organ is located etc. • locations for auscultating the
heart valves: -> you have to know exact spots
- aortic = 2nd intercostal at R sternal border - pulmonic = 2nd intercostal at L sternal
border - tricuspid = 4th intercostal at L sternal border - mitral = 5th intercostal at
mid-clavicular line (where the apical pulse is)
• pulses:
- carotid - femoral - posterior tibial - radial - popliteal - dorsalis pedis -
brachial

TEST TAKING TIPS

• expect to do guessing on the test
-> that’s the nature of computer adaptive testing • How do you guess???
a) use your knowledge first!
b) common sense
c) a guessing strategy

GUESSING Strategies: (ONLY when you don’t know what’s going on; use knowledge
& common sense first!) • Psych Questions:
- the best answer (if you’re totally clueless) is “the nurse will examine their own
feelings about…” -> that way you don’t counter-transfer (ex. the PT reminds you
of your dad & you didn’t like your dad so you treat him badly)
- “establish a trust relationship”
-> if you pick something else you’re saying it’s not that important to establish trust
-> BUT use common sense first! (ex. if a PT is coming at you w/ a knife, safety
first duh!) • Nutrition/Food Questions:
- in a tie, pick chicken (obvs. not fried)
- if chicken is not there, pick fish
-> not shellfish
- never pick casseroles for children (won’t eat it) - never mix medication in
children’s food -> if doing it for an adult, ask permission first - toddlers = finger-
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 -> don’t memorize dosages! routes!
frequencies! -> FOCUS ON SIDE EFFECTS = we assess side effects, see if things
are working (don’t prescribe)
- if you know what a drug does but you don’t know the side effects:
-> pick a side effect in the same body system where the drug is working
- if you have no clue what the drug is:
-> see if it’s PO & if it is pick a GI side effect - never tell a child that medicine
is candy • OB Questions:
- “check fetal heart rate”
• Med-Surge Questions:
- first thing you assess = LOC (not airway) -> before you do compressions you call
out the PT’s name/try to wake them up which is LOC - first thing you do = establish
 an airway
• Pediatric Questions:
- growth & development questions are all based on the principle “always give the
child more time” (to grow & develop, don’t rush it)
-> 3 Rules:
i. when in doubt, call it normal (in med-surge, when in doubt, call it abnormal so
you don’t make safety mistakes)
ii. when in doubt, pick the older age (the older age of the 2 that it could be, not the
oldest; gives more time)
iii. when in doubt, pick the easier task (gives more time for the child to learn it)

• General guessing skills:

- rule out absolutes
-> generally not good answers because they don’t apply to many situations
-> don’t forget your knowledge & common sense (i.e. certain things are absolute like
“never push IV K+” or doing checks for med. administration) - if 2 answers say the
same thing, neither is right - if 2 answers are opposite, one of them is probably
right
- the umbrella strategy:
-> “which answer is more global”
* ex. certain questions where you want to say “all of the above” but that’s 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 PT’s; usually
the question is about 1 PT & you’re picking between 4 different needs
-> think “worst consequences” for each option & pick the answer that has the worst
outcome if you don’t pick it
- when you’re stuck between 2 answers, read the question (it will have the
clue!!)
• Sesame Street rule:
- you can use the rule when (& ONLY when) your only remaining option is to give up -
> WHEN NOTHING ELSE WORKS
- “ 3 of these things is not like the other” - the right answer tends to be different
than the others -> because it is the only one which is correct -> usually the more
unique & different option - the wrong answers are similar because they share
something in common
-> they are all wrong

• don’t be tempted to answer a question based on your ignorance instead of your

knowledge: - base answers on what you know, not what you don’t know - if you don’t know
something in a question, pull that out and focus on the things you do know
- USE COMMON SENSE! boards test obscure things to test your common sense
• if something really seems right, it probably is - go w/ your gut!
-> unless you can prove that a different answer is superior (not “just as good”)

3 Expectations You’re NOT Allowed to Have: • expectations that are not met breed
negativity which badly affects your test taking
• a) don’t expect 75 questions
- prepare yourself for 250 questions
- if you get to 200 it doesn’t mean you’re failing (it would have shut off earlier if you
were) • b) don’t expect to know everything
- because it’s computer adaptive -> it will give you stuff you don’t know
- know what everyone else needs to know • c) don’t expect everything to go
right
- don’t expect a perfect day