Mark K Lecture Notes Compiled

Lecture 1- Acid-Base Principles

Acid/Base Balance:
●​ Rule of the B’s => If pH & Bicarb (HC03) are BOTH in the same direction => MetaBolic
○​ Otherwise, if pH & Bicarb in opposite directions => Respiratory
○​ Acidotic if pH < 7.35 & Alkalotic if pH > 7.45
●​ As the pH goes ____, so does my patient; except for Potassium
○​ Low pH => all Low S/S & Hyperkalemia
○​ High pH => all High S/S & Hypokalemia
●​ MAC Kussmaul’s (our favorite Scottsman)
○​ Kussmaul’s respirations (fast, deep breathing) => Metabolic Acidosis

Causes of Acid/Base Imbalances:

●​ Is it a LUNG problem? => If yes, it is RESPIRATORY
○​ If Overventilating => Respiratory Alkalosis (pH > 7.45)
○​ If Underventilating => Respiratory Acidosis (pH < 7.35)
●​ If it is NOT a Lung problem => it is METABOLIC
○​ Prolonged Gastric Vomiting or Suctioning (↓ acid) => Metabolic Alkalosis
○​ Everything else (other than vomiting/suctioning) => Metabolic Acidosis
■​ NOTE: If you do not know what to pick => pick Metabolic Acidosis (Default Setting)

Ventilator Settings:
●​ High Pressure Alarms => triggered by Increased Resistance to Airflow => OBSTRUCTIONS
○​ Kinks in Tubing (NC: unkink tube)
○​ Condensed water in tube (NC: empty tube)
○​ Mucus plugs (NC: turn pt, cough, deep breathe, suction)
●​ Low Pressure Alarms => triggered by Decreased Resistance to Airflow => DISCONNECTIONS
○​ Main tube disconnection; O2 sensor tube disconnection
○​ NC: Reconnect tube
●​ Ventilator Settings Too High/Low:
○​ Vent Settings too HIGH => Overventilating => Respiratory Alkalosis
○​ Vent Setting too LOW => Underventilating => Respiratory Acidosis
Lecture 2- Alcohol

Alcoholism:
●​ #1 problem in Abuse (or any psychological problem) => DENIAL
○​ NC: Confront pt (for abuse)
●​ 5 Stages of Grief: DABDA
○​ Denial > Anger > Bargaining > Depression > Acceptance
●​ Dependency => getting another person to do things for them; abuser is Dependent
●​ Co-Dependency => other person derives self-esteem for doing things for the abuser
●​ Manipulation => when abuser gets other person to do things for them that are NOT in the best interest
for them => nature of act is dangerous/harmful to the other person
○​ NC/Tx: Set limits & enforce them

Wernicke/Korsakoff Syndrome:
●​ Wernicke => encephalopathy; Korsakoff => Psychosis
○​ NOTE: NCLEX bundles Wernicke & Korsakoff together
●​ Wernicke/Korsakoff => Psychosis induced by Vitamin B1, thiamine deficiency
○​ S/S: psychosis, amnesia (memory loss), confabulation (making up stories)
○​ NC: redirect pt (don’t present reality to pts who cannot learn it); take Vitamin B1

Antabuse & Revia/Disulfiram:

●​ Antabuse/Revia/Disulfiram => alcohol aversion therapy => unpleasant effect if alcohol is consumed
○​ Takes 2 weeks to come into effect
○​ Education: avoid ALL forms of EtOH eg mouthwash, cologne, perfume, aftershave, OTC
medicine, insect repellent, hand sanitizer, unbaked icing, vanilla extract

Overdose & Withdrawal:

●​ Upper or a Downer?
○​ Every Abused drug is an Upper or a Downer except Laxatives in the elderly
●​ Uppers: MEMORIZE 5 DRUGS​
○​ Caffeine, Cocaine, PCP/LSD (psychedelics/hallucinogens), Methamphetamines, Adderall
○​ S/S: Everything goes UP! (eg seizures, restlessness, irritability, hyperreflexia, tachycardia, etc)
●​ Downers:
○​ Everything Else! (~135 downer drugs)
○​ S/S: Everything goes DOWN! (eg lethargy, resp depression/arrest, constipation, etc)
●​ Overdose or Withdrawal:
○​ Overdose on Upper => Too much Upper => UP S/S
○​ Overdose on Downer => Too much Downer => DOWN S/S
○​ Withdraw on Upper => Too little/not enough Upper => DOWN S/S
○​ Withdraw on Downer => Too little/not enough Downer => UP S/S

Drug Abuse in Newborns:

●​ < 24 hours after birth => INTOXICATION (think: Intoxication comes Before Withdrawal!)
●​ ≥ 24 hours after birth => WITHDRAWAL

Alcohol Withdrawal Syndrome vs. Delirium Tremens:

●​ Alcohol Withdrawal Syndrome => occurs in EVERY alcoholic ~24 hours after stopping drinking
○​ NOT life-threatening
●​ Delirium Tremens => occurs in < 20% of alcoholics after 72 hours after stopping drinking
 ○​ Life-threatening; Danger to self & others
○​ NC: NPO (seizure precautions), private room near nursing station, restricted bed rest, restraints

Aminoglycosides:
●​ Aminoglycosides => Big guns of Antibiotics => use when nothing else works
○​ Aminoglycosides => “A Mean Old Mycin” => used to tx serious, resistant, life-threatening,
gram negative infections (eg TB, septic peritonitis, etc)
○​ ALL Aminoglycosides end in -Mycin; but not ALL drugs ending in mycin are aminoglycosides
■​ If it ends in -mycin it is a Mean Old Mycin (Aminoglycoside); but if it has -thro in it;
throw it off the list
●​ eg Gentamycin, Vancomycin, Clindamycin, Streptomycin => Aminoglycosides
●​ Azithromycin, Clarithromycin, & Erythromycin => NOT Aminoglycosides
○​ Toxic Effects:
■​ Mycin sounds like MICE => think EARS => Ototoxic (monitor hearing, tinnitus, vertigo)
■​ Ears look like Kidneys => Nephrotoxic (toxic to kidneys; monitor Creatinine) ​
●​ NOTE: Creatinine is BEST indicator of Kidney Function
○​ Route: IM or IV => NOT absorbed PO route
■​ Only given PO for hepatic encephalopathy or pre-op bowel surgery => to Sterilize Gut
■​ #1 action for Oral -Mycin => To Sterilize the Bowel
●​ Who can sterilize my bowel? ... Neo Kan (Neomycin & Kanamycin)

Trough & Peaks/TAP:

●​ Troughs => when drugs are at their LOWEST Concentration
●​ Peaks => when drugs are at their HIGHEST Concentration
●​ “TAP” => Trough, Administer, Peak
○​ Troughs taken Before Drug Administration
○​ Peaks taken After Drug Administration
●​ Both Troughs & Peaks are NOT medication-dependent => Route Dependent!
○​ Troughs => Always drawn 30 minutes before next dose (for ALL Routes)
○​ Peaks => Depends on Route:
■​ SubL Peak => 5-10 minutes After drug is dissolved
■​ IV Peak => 15-30 minutes after drug is finished
■​ IM Peak => 30-60 minutes after
■​ SubQ Peak => Depends on type of Insulin
■​ PO Peak => Not Tested
Lecture 3- Cardiac & Pharmacology

Calcium Channel Blockers- “-dipine”

●​ Calcium Channel Blockers => have negative inotropic, chronotropic, & dromotropic effects on the heart
=> Relaxes the Heart!​
○​ Negative ino/chrono/dromo => Relax Heart vs Positive ino/chrono/dromo => Stimulates Heart
●​ Calcium Channel Blockers Treat: A, AA, AAA
○​ Antihypertensives
○​ AntiAnginal drugs
○​ AntiAtrialArrhythmias (only Atrial; NOT Ventricular!)
●​ Side Effects: Headache & Hypotension (H&H from vasodilation)
●​ CCB Name => ends in “-dipine” (NOT -pine)
○​ Tip: You’re dipping (-dipine) in the Calcium Channel
○​ Outlier CCBs: Verapamil & Cardizem (Diltiazem) => given continuous IV drip
●​ CCB NC/Assessment:
○​ Assess for BP => Hold if Systolic BP <100

Cardiac Arrhythmias:

●​ Normal Sinus Rhythm:

○​ P wave, followed by QRS, followed by T wave
○​ Peaks of P waves are equally distant to QRS

●​ Ventricular Fibrillation:
○​ No pattern at all

●​ Ventricular Tachycardia:
○​ Sharp peaks w/ a pattern => Tombstone

●​ Asystole:
○​ Flat line
ECG KeyWords:
●​ QRS => Ventricular
●​ P wave => Atrial
●​ “Sawtooth” => Atrial Flutter
●​ “Chaotic” => Fibrillation
●​ “Bizarre” => Tachycardia

Rhythms Most Tested on NCLEX:

1.​ Lack of QRS Complex => Flatline => Asystole
2.​ P waves (atrial) that are sawtooth waves => Atrial Flutter
3.​ Chaotic P wave pattern => Atrial Fibrillation
4.​ Chaotic QRS complexes => Ventricular Fibrillation
5.​ Bizarre QRS complexes => Ventricular Tachycardia
6.​ Periodic wide bizarre QRS complexes => PVCs
●​ Note PVCs => short run of V-tach
●​ PVCs are LOW PRIORITY unless:
○​ ≥ 6 PVCs in 1 minute OR ≥ 6 PVCs in a row OR PVC falls on T wave

●​ Lethal Arrhythmias => Asystole & Ventricular Fibrillation (Vfib) => Low/No Cardiac Output => No
pulse => No brain perfusion => Death => #1 priority pt
●​ Ventricular Tachycardia (VTach) => potentially lethal => but has a Cardiac Output => Yes Pulse
○​ Lower priority than Asystole & Vfib

Treatment for Ventricular Dysrhythmias- Vtach/PVCs:

●​ Lidocaine or Amiodarone
●​ Tip: make letter “V” with 2 fingers (V for Ventricular) => turn to side => “L” for Lidocaine => turn again
=> “A” for Amiodarone

Treatment for Atrial Dysrhythmias (Afib, Aflutter, SVT, etc): ABCD’s

●​ A => Adenosine => Fast IV push => will go in & come out of asystole
●​ B => Beta-Blockers (-lol)
●​ C => Calcium Channel Blockers (-dipine)
●​ D => Digitalis (Digoxin/Lanoxin)

Beta-Blockers:“-lol”
●​ Beta Blockers => similar to CCB’s => Negative ino/chrono/dromo => Relaxes the Heart!
●​ Treat A, AA, AAA => Antihypertensive; AntiAnginal; AntiAtrialArythmias
●​ Side Effects => Headache & Hypotension (H&H due to vasodilation)

Treatment for V-fib & Asystole:

●​ “Defib for V-fib”
●​ Asystole => Epinephrine & Atropine => 1st & Last letter of AsystolE => Atropine & Epinephrine

Chest Tubes:
●​ Purpose => reestablish negative pressure in pleural space
●​ Reason for Chest Tube Placement:
○​ Pneumothorax => removes AIR => chest tube should Bubble ​
■​ Use Apical chest tube to remove AIR
○​ Hemothorax => removes BLOOD => chest tube should Drain
 ■​ Use Basilar chest tube to remove BLOOD
○​ Hemopneumothorax => removes AIR & BLOOD
■​ Use Apical & Basilar chest tubes to remove AIR & BLOOD
●​ Location of Chest Tube:
○​ Apical => Top of Chest => Removes AIR => chest tube should Bubble
○​ Basilar => Bottom of Chest => Removes BLOOD => chest tube should Drain

Troubleshooting Chest Tubes:

●​ Chest tube knocked over => ask pt to take a deep breath & set it back up => NOT an emergency
●​ Water Seal Breaks => Clamp chest tube (< 15 secs) => Cut Tube => Submerge in sterile water =>
Unclamp tube
●​ Chest Tube Pulled Out => Cover Opening w/ Gloved Hand => Tape 3-sided Vaseline gauze over hole
●​ Chest Tube Bubbling => Where & When ***
○​ Water Seal Chamber:
■​ Intermittent => Good
■​ Continuous => Bad (if something is completely sealed eg water seal chamber; it should
NOT be continuously bubbling => BAD)
○​ Suction Control Chamber:
■​ Intermittent => Bad => Suction too low => Increase Suction (on wall)
■​ Continuous => Good (continuous bubbling in Suction Control Chamber means suction is
working => GOOD)

Thoracentesis vs Chest Tube:

●​ Straight Cath is to Foley Cath as Thoracentesis is to Chest Tube
○​ Thoracentesis => goes in & out ; Chest Tubes => go in & leave it in place

Congenital Heart Defects:

●​ TRouBLe:
○​ tRoubLle => shunts blood Right to Left
○​ trouBle => Blue => Cyanotic
○​ All Trouble Defects start w/ letter “T”:
■​ Tetralogy of Fallot, Truncus arteriosus, Transposition of vessels, Tricuspid atresia, TAPV
●​ No “Trouble” Defects => do NOT start w/ “T” (eg Ventricular septal defect, patent ductus arteriosus, etc)
○​ Opposite of Trouble defects => shunts blood Left to Right, acyanotic
●​ ALL CHDs (trouble or no trouble) have murmurs & ECGs performed

4 Defects of Tetralogy of Fallot => “PROVe”

●​ P => Pulmonary artery stenosis
●​ R => Right Ventricular Hypertrophy (RVH)
●​ O => Overriding aorta
●​ V => Ventricular Septal Defect (VSD)

4 Transmission-Based Precautions:
●​ Standard/Universal
●​ Contact
●​ Droplet
●​ Airborne
Contact Precautions- SEWER:
●​ S => Skin infections (herpes); Staph Infections
●​ E => Enteric (GI, fecal/oral) => c.diff, hep A, e.coli, cholera, etc
●​ W => Wound Infections
●​ E => Eye infections
●​ R => Rotavirus/ RSV
●​ PPE: Gown & Gloves ; Private Room

Droplet Precautions- PIMP:

●​ P => Pertussis
●​ I => Influenza (h.influenza)
●​ M => Meningitis
●​ P => Pneumonia
●​ PPE: Mask, Goggles or Face Shield, Gloves ; Private Room preferred

Airborne Precautions- Air MTV:

●​ M => MMR; Measles/Mumps/Rubella
●​ T => Tuberculosis
●​ V => Varicella
●​ PPE: N95 Mask (Respirator for TB), Goggles or Face Shield, Gloves ; Private Negative Airflow
Room

Donning & Doffing PPE:

●​ Don PPE in REVERSE ALPHABETICAL Order w/ Mask as step #2
○​ Gown > Mask > Goggles > Gloves
●​ Doff PPE in ALPHABETICAL Order:
○​ Gloves > Goggles > Gown > Mask

Math Problems:
●​ IV Drip Rate Formula:
○​ (Volume mL x Drop Factor gtt/mL) /
Time in mins = gtt/min
■​ Micro/Mini Drip => 60 drops/mL
■​ Macro Drip => 10 drops/mL
●​ 2.2 lbs = 1 kg
Lecture 4- Canes/Crutches/Walkers & Psych

Crutches/Canes/Walkers:
●​ Measuring Length of Crutches:
○​ 2-3 finger widths between the pad of the crutch & the anterior axillary fold
○​ Tip of crutches => located at a point lateral (6 inches) & in front of the foot (6 inches)
○​ Handgrip => Angle of Elbow flexion is 30 degrees

Crutch Gaits:
●​ Even for Even; Odd for Odd => even # gait (2 or 4) for 2 legs affected; odd # gait for 1 leg affected
●​ 2 point gait => move crutch & opposite foot together, then the other crutch w/ opposite foot together
○​ Left crutch & Right foot; Right crutch & Left foot
○​ For Mild, Bilateral (2 legs affected) Leg Weakness
●​ 3 point gait => move 2 crutches & bad leg together, followed by unaffected leg
○​ Unaffected leg is on the ground vs Affected leg is not on the ground
○​ For 1 affected leg
●​ 4 point gait => move everything separately!!
○​ Crutch => Opposite foot => Other crutch => Opposite foot
○​ For Severe, Bilateral (2 legs affected) Leg Weakness
●​ Swing through => for non-weight bearing (Amputees)
○​ 3-point gait but non-weight bearing/amputated leg NEVER touches the ground!

●​ Up w/ the GOOD & Down w/ the BAD

○​ Go UP the stairs w/ good foot first; Go DOWN the stairs w/ bad foot first
○​ Both crutches Always go w/ the Bad leg!!

Canes:
●​ Hold Cane on the UNAFFECTED (Strong) Side
●​ But advance the cane w/ the Bad Leg

Walker:
●​ Pick it up ... Set it down ... Walk to it
●​ NOTE: don’t tie belongings to front of walker

Psych:
●​ 1st Question to Ask in Psych Question => is the pt Psychotic or non-psychotic?
●​ Non-Psychotic pt => pt has insight & is reality based
○​ NC: Use Good, therapeutic communication
●​ Psychotic pt => has NO insight & is NOT reality based
○​ Has delusions, hallucinations & illusions
○​ Delusions => false, fixed beliefs/ideas or thoughts
■​ Paranoid; Grandiose; Somatic
○​ Hallucinations => a sensory experience
■​ Auditory, Visual, Tactile, Gustatory, Olfactory
○​ Illusions => misinterpretation of reality; but has a referent to reality (eg cord is a snake)
●​ 3 Types of Psychosis:
1.​ Functional Psychosis => can function in everyday life
●​ “Skeezo, Schizo, Major, Manics” => Schizophrenia, Schizoaffective, Major depressions,
Mania
 2.​ Psychosis of Dementia
●​ Actual brain damage => eg Alzheimers, stroke, organic brain syndrome
3.​ Psychosis of Delirium
●​ Temporary delirium due to something else, eg UTI, thyroid storm, adrenal crisis,
electrolyte, medications, delirium tremens, etc

Steps to Answer Psych Questions:

1.​ Psychotic or Non-Psychotic?
2.​ Non-Psychotic => Therapeutic Communication
3.​ Psychotic => Function/Dementia/Delirium?
a.​ Functional Psychotic => 1. Acknowledge feeling 2. Present reality 3. Set limits 4. Enforce limit
b.​ Psychosis of Dementia => 1. Acknowledge feeling 2. Redirect them
c.​ Psychosis of Delirium => 1. Acknowledge feeling 2. Reassure about Safety & Temporariness
Lecture 5- Diabetes

●​ Diabetes Mellitus => error in glucose metabolism ; S/S: 3Ps: Polyuria, Polydipsia, Polyphagia
○​ DM Type 1 => lack of Insulin
■​ Insulin dependent, Ketosis prone
■​ Tx: DIE => Diet (least important), Insulin (most important), Exercise
○​ DM Type 2 => Insulin resistance
■​ Non-insulin dependent, Non-ketosis prone
■​ Tx: DOA => Diet (most important), Oral hypoglycemics, Activity/Exercise
●​ Diet => Calorie restriction & 6 small meals/day
●​ Diabetes Insipidus => Think: Diabetes w/OUT glucose element
○​ Polyuria & Polydipsia leading to Dehydration, due to low ADH! (fluid volume deficit)
●​ Syndrome of Inappropriate ADH (SIADH) => opposite of Diabetes Insipidus
○​ S/S: Oliguria, decreased thirst, due to high ADH! (fluid volume overload)

●​ Urine Specific Gravity => [Urine] ​

○​ High urine specific gravity => High [urine] & Low Urine Output
○​ Low urine specific gravity => Low [urine] & High Urine Output

Types of Insulin:
1.​ R- Regular Insulin
●​ Rapid/Short Acting; Clear solution, IV drip (only Insulin that can be given IV)
●​ Onset: 1 hour; Peak: 2 hours; Duration: 4 hours; Pattern: 1-2-4
2.​ N-NPH Insulin
●​ Intermediate Insulin; Cloudy- Suspension; N= Not so Clear, Not so Fast, Not in the (IV) Bag
●​ Onset: 6 hours; Peak: 8-10 hours; Duration: 12 hours; Pattern: 6-8-10-12
3.​ Lispro (Humalog)
●​ Short Acting; fastest acting insulin! Give w/ meal not before meal
●​ Onset: 15 mins; Peak: 30 mins; Duration: 3 hours; Pattern: 15-30-3
4.​ Glargine (Lantus)
●​ Long Acting; No Peak- slowly absorbed; Little/No risk for Hypoglycemia => can give at Bedtime!
●​ Duration: 12-24 hours

Insulin Rules:
●​ New Insulin expiration date is 30 days after opening package; Refrigeration is optional once opened
●​ Exercise is like another shot of Insulin => Decreases BG => give carbohydrates!
●​ Sick Days => pt’s Blood Glucose Increases (from stress)
○​ Need to take Insulin even if NOT eating
○​ Sick Diabetic pt’s 2 problems => Hyperglycemia & Dehydration

●​ Hypoglycemia => Low blood glucose; not enough food, too much insulin (#1 cause), too much exercise
○​ S/S: DRUNK IN SHOCK
■​ Drunk: staggering gait, slurred speech, cerebral impairment, labile, slow reaction, etc
■​ Shock: tachycardia, tachypnea, hypotension, cold/clammy, mottled/pale skin
○​ Tx: Give Sugars (rapidly metabolizable carbohydrates):
■​ Best Combo: Sugar + Starch or Protein => eg apple juice + turkey or skim milk
■​ Unconscious pts => Glucagon IM or Dextrose IV
●​ Diabetic Ketoacidosis (DKA) => High glucose in Type 1 DM (keto = type 1!)
 ○​ Causes: too much food, not enough insulin, not enough exercise, recent upper viral
respiratory infection (#1 cause)
○​ S/S: DKA
■​ D => Dehydration (dry skin, poor elasticity & turgor, warm => water is coolant)
■​ K => Ketones in blood/urine, Kussmaul’s respirations, High K+
■​ A => Acidosis (metabolic), Acetone breath, Anorexia
○​ Tx: Insulin IV (regular insulin), IV fluids for dehydration (200ml/hr)
●​ HHNK/HHNS => High Blood Sugar in Type 2 DM (non-ketotic => Type 2 DM!)
○​ DKA w/out K&A => just left w/ DEHYDRATION!
○​ S/S: Severe Dehydration: dry/flushed/hot skin, decreased turgor, increased HR
○​ Tx: Rehydration

●​ Long-Term Complications of DM => Poor Tissue Perfusion & Peripheral Neuropathy (eg renal
failure, gangrene, heart failure, foot problems, etc)
●​ HbA1C => best lab indicator of glucose control => average blood sugar over last 90 days
○​ HbA1c < 6 => normal; HbA1c > 8 => out of control; HbA1c of 7 => more Evaluation needed
Lecture 6- Psych Pharmacology; Hernias

Drug Toxicities:
1.​ Lithium => Antimania drug for Bipolar disease (specifically for manic episodes)
●​ Therapeutic Level: 0.6 -1.2
●​ Toxic Level: > 2
2.​ Lanoxin/Digoxin => Cardiac Glycoside to treat AFib (ABCDs of Atrial Dysrhythmia Tx) & Heart Failure
●​ Therapeutic Level: 1 - 2
●​ Toxic Level: > 2
3.​ Aminophylline => Muscle spasm relaxer for Airway; Bronchodilator
●​ Therapeutic Level: 10 - 20
●​ Toxic Level: > 20
4.​ Dilantin (phenytoin) => anti-seizure medication
●​ Therapeutic Level: 10 - 20
●​ Toxic Level: > 20
5.​ Bilirubin => breakdown product of Red Blood Cells
●​ Newborn Elevated Level: 10-20
●​ Toxic Level: > 20

●​ Jaundice => yellow skin/sclera from excess bilirubin in the blood

●​ Kernicterus => excess bilirubin in the BRAIN => when Bilirubin level > 20, can be DEADLY
●​ Opisthotonos => hyperextended position of newborns due to irritation in the meninges from kernicterus
○​ Note: Place newborns on their SIDE when they are in opisthotonic position
●​ Pathologic Jaundice => when newborns are yellow at birth => something is WRONG
●​ Physiologic Jaundice => when newborns turn yellow 2-3 days postpartum => OK!

Hiatal Hernia vs. Dumping Syndrome:

●​ Hiatal Hernia => regurgitation of gastric acid upward or backwards into the esophagus
○​ Gastric contents go in WRONG DIRECTION at CORRECT RATE => Direction Issue
○​ S/S: GERD => Heartburn & Indigestion upon lying down after a meal
○​ Tx: want stomach to empty FASTER:
■​ Elevate HOB, Increase fluid intake w/ meals, Increase Carb content (carbs digest
quickly) => High-atal Hernia => Everything is High for Tx
●​ Dumping Syndrome => gastric contents are dumped too quickly into duodenum
○​ Gastric contents go in RIGHT DIRECTION at WRONG RATE => Speed Issue
○​ S/S: Drunk + Shock + Acute Abdominal Distress (n/v, diarrhea, cramping, guarding, borborygmi)
○​ Tx: want stomach to empty SLOWER:
■​ Lower HOB during meals & turn to side (prevent aspiration), decrease fluid intake
during/before meals, decrease Carb content/ increase Protein content
■​ “When everything is Low, the stomach goes Slow”

Electrolyte Imbalances:
1.​ Kalemias do the SAME as the prefix, except HR & UO (opposite direction)
●​ Hyperkalemia => All ↑ S/S except ↓ HR & UO
○​ S/S: seizures, agitation, irritability, ST elevation, tachypnea, BRADYCARDIA, diarrhea,
borborygmi, OLIGURIA, etc
●​ Hypokalemia => All ↓ S/S, except ↑ HR & UO
○​ S/S: lethargy, bradypnea, constipation, hyporeflexia, TACHYPNEA, POLYURIA, etc
2.​ Calcemias & Magnesemias do the OPPOSITE of the prefix
 ●​ HYPOcalcemia & HYPOmagnesemia => All ↑ S/S
○​ Hypocalcemia S/S => Chvostek sign (face spasm when cheek is tapped), Trousseau
sign (hand spasms when BP cuff is inflated)
●​ HYPERcalcemia & HYPERmagnesemia => All ↓ S/S

●​ TIE in Electrolyte Imbalances:

○​ Calcium => choose nerve/skeletal S/S (eg tetany)
○​ Potassium => any other S/S (eg diarrhea)
○​ Magnesium => rule out in a tie

●​ Natremias:
○​ HypErnatremia => DEhydration
■​ S/S: hot, flushed, dry skin, rapid HR, etc
■​ Tx: Give fluids
■​ Diseases Associated w/ Dehydration: DKA, HHNK, Diabetes Insipidus
○​ HypOnatremia => Overload
■​ S/S: crackles, distended neck veins, edema, etc
■​ Tx: Fluid restriction, Lasix
■​ Diseases Associated w/ Fluid Overload: SIADH

●​ Earliest S/S of electrolyte disturbance => Numbness & Tingling => Paresthesia
○​ Circumoral paresthesia => Numbness & tingling around the lips
●​ Universal S/S of all electrolyte imbalance => Muscle Weakness => Paresis

Potassium Imbalance Tx:

●​ NEVER Push Potassium IV!!!
●​ NEVER give Potassium > 40 mEq/L IV fluid; if > 40 => clarify dosage w/ provider
●​ Lower Potassium:
○​ High Potassium can stop the Heart => most dangerous electrolyte imbalance!
○​ D5W & Regular Insulin => Temporary & quick solution to drive potassium into cell & out of blood
○​ Kayexalate => Long-term solution, takes hours to work
■​ exchanges K+ for Na+ (causes hypernatremia)
■​ K Exits Late => Kayexalate
○​ Administer D5W, Regular Insulin & Kayexalate at the SAME time for Hyperkalemia
Lecture 7- Endocrine/ Play/ Laminectomy

Thyroid Gland:
●​ Thyroid => Metabolism
●​ Hyperthyroidism/ Grave’s Disease => Hypermetabolism:
○​ “Run yourself into a Grave” => Run is Hypermetabolism => Hyperthyroidism
○​ S/S: weight loss, ↑ HR & BP, Heat Intolerance (cannot tolerate what they are- always hot),
Exophthalmos (bulging eyes)
○​ Tx:
1.​ Radioactive Iodine => pt must flush x3 after urinating, call hazmat team if urine is spilled,
private room & isolated for first 24 hours
2.​ PTU (“Puts Thyroid Under”) => tx for cancer => monitor WBC, pt is immunosuppressed
3.​ Thyroidectomy => surgical removal of thyroid => most common Tx
●​ Total Thyroidectomy => needs lifelong hormone replacement & pt at risk for
hypocalcemia
●​ Subtotal/Partial Thyroidectomy => do NOT need lifelong hormone replacement,
risk for Thyroid Storm
○​ Thyroid Storm S/S => temp >105, High BP, Severe Tachycardia, Delirium

●​ Post-op Risk for Total & Subtotal Thyroidectomy:

○​ 1st 12 hours for both Total & Subtotal => Airway & Hemorrhage
○​ 12 hours - 48 hours:
■​ Total => Tetany from low calcium => can close airway due to spasms
■​ Subtotal => Thyroid Storm
○​ > 48 hours => Risk for Infection
○​ TIP: never choose risk for infection as priority until after 72 hours post ANY surgery

●​ Hypothyroidism/ Myxedema => Hypometabolism

○​ S/S: obesity, ↓ HR, ↓BP, flat/dull/boring personality, cold intolerance (always cold from
hypometabolism), academically challenged, etc
○​ Tx: Levothyroxine (Synthroid) => thyroid hormone replacement => take in AM 30 mins before
breakfast alone on empty stomach
○​ NC: Do NOT sedate Hypothyroid pts & do NOT hold Levothyroxine pills (even before surgery)
=> already slow => can go into coma

Adrenal Cortex:
●​ All Adrenal Cortex diseases either start w/ an A or a C (eg Addison’s & Cushings)
●​ Addison’s Disease => under secretion of Adrenal hormones
○​ S/S: Hyperpigmented (tan skin), do NOT adapt well to Stress
○​ Tx: Steroids (-sone eg prednisone) => “In Addison, you Add-a-Sone”
●​ Cushing’s Syndrome => oversecretion of Adrenal hormones => “cushy touchie”
○​ S/S: moon face, beard (hirsutism), trucal/central obesity, skinny extremities, big breasted
(gynecomastia), buffalo hump, edema (retain Na+ & H20), Hypokalemia, striae, bruising,
HYPERGLYCEMIC, IMMUNOSUPPRESSED
■​ NC: must perform Accucheck q6hrs for hyperglycemia
○​ Tx: Adrenalectomy => removal of adrenal gland

Kids Toys:
 ●​ Safety => No small toys for kids under 4 y/o; No Metal or dye-cast) if O2 is in use; Beware of Fomites
(hard, plastic toys are best for older kids so they can be disinfected)
●​ Infants (0-6 months) => Sensorimotor:
○​ Musical Mobile is best; Toys that are Large & Soft
●​ Infants (6-9 months) => Object Permanence:
○​ Toys that Cover/Uncover => eg Jack in the Box, Peek a Boo; Large & Firm toys
●​ Infants (9-12 months) => Vocalization:
○​ Speaking or Verbal toys & Purposeful play starting 9 months (build, sort, stack, make, etc)
●​ Toddlers (1-3 years) => Gross Motor Skills; Parallel Play
○​ Push/Pull toys => eg lawn mowers, wagons, paint, etc
●​ Preschoolers (3-6 years) => Fine Motor Skills; Cooperative Play
○​ Finger dexterity => eg write, draw, color, balance, dance, ice skate, etc
○​ Highly Imaginative => Pretend Play
●​ School Age (7-11 years) => Concrete
○​ 3 C’s => Creative; Collective; Competitive
●​ Adolescents (12-18 years) => Peer Group Association

Laminectomy:
●​ Laminectomy => removal of the vertebral spinous processes (bumpy bones along spine) to relieve
nerve root compression (give nerves more room)
○​ Nerve Root Compression S/S: 3 “P’s” => Pain, Paresthesia (numbness & tingling), Paresis
(muscle weakness)
○​ Laminectomy Location: Cervical, Thoracic, Lumbar:
■​ Cervical => Neck
●​ Innervates Diaphragm & Arms => Assess Breathing & Arm/Hand function
●​ Postop complication => Pneumonia
■​ Thoracic => Upper Back
●​ Innervates Abdominal Muscles => Assess Cough & Bowels
●​ Postop complication => Pneumonia & paralytic ileus
■​ Lumbar => Lower Back
●​ Innervates Bladder & Legs => Assess Urinary Retention & Leg Function
●​ Postop complication => Urinary retention & Leg problems
○​ NC:
■​ LOG ROLL; do NOT Dangle pts on side of bed; do NOT allow pt to sit > 30 mins (Sitting
is BAD position for back); supine to walking
○​ Education:
■​ Temporary Restrictions (6 weeks):
●​ Do NOT sit for > 30 mins; Lie flat, Log roll, Don’t drive, Don’t lift > 5 lbs
■​ Permanent Restrictions
●​ Do NOT lift by bending at waist, lift anything over the head, horseback ride, etc

NOTE: Cervical/Thoracic/Lumbar => can be used for ANY Spinal Cord question! => pay attention to
Location!
Lecture 8- Lab Values

●​ A => Low Priority; B => Concerning; C => Critical; D => Deadly (highest priority)
●​ Creatinine (serum) => best indicator of kidney/renal function
○​ Level A
○​ Range: 0.6 - 1.2
●​ INR => monitors coumadin & reflects PT time
○​ Level C if > 4
○​ Range: 2 - 3
○​ NC: Hold Coumadin => Assessment for bleeding => prepare Vit K => call Provider
●​ Potassium => best indicator that something is wrong, but very general
○​ Level C if Low or High; Level D if > 6
○​ Range: 3.5 - 5.0
○​ NC: Hypokalemia => Assess heart => prepare K+ => Call provider
■​ Hyperkalemia => Hold K+ => Assess heart => prepare Insulin/D5W + Kayexalate
●​ pH => blood chemistry
○​ Level D if pH in the 6’s
○​ Range: 7.35 - 7.45
●​ BUN => waste product in blood
○​ Level A
○​ Range: 8 - 24
●​ Hemoglobin (Hbg) => reflects oxygenation in blood
○​ Level B if 8-11; Level C is < 8
○​ Range: 12 - 18
○​ NC: Assess for bleeding/anemia/malnutrition => prepare Blood Transfusion => call Provider
●​ Bicarbonate (HCO3) => refle↑cts CO2 in blood
○​ Level A
○​ Range: 22 - 26 (2+2+2 = 6)
●​ CO2
○​ Level C if in 50’s; Level D if in 60’s
○​ Range: 35 - 45 (same as pH w/out decimal point- 7.35-7.45)
○​ NC: Assess Breathing => Pursed-Lip Breathing => Prepare Intubate/Ventilate => Call RT & MD
●​ Hematocrit (Hct) => % of RBCs in blood => Assess Dehydration (dehydration ↑ ALL blood lab values)
○​ Level B
○​ Range: 35 - 55%
●​ O2/PaO2 => O2 in the Blood
○​ Level C if 70-77; Level D if in 60’s
○​ Range: 80 - 100
○​ NC: Level C: Assess respiration => give O2 => call provider
■​ Level D: prepare to Intubate/Ventilate => Call RT & MD => stay w/ pt
●​ O2 Saturation (SaO2)
○​ Level C if < 93
○​ Range: 93 - 100
○​ NC: Assess => give O2; NOTE: Anemia & recent dye procedure invalidates SaO2 reading
●​ BNP (Brain Natriuretic Peptide) => BNP > 100 indicates CHF => best indicator of CHF
○​ Level B if > 100
○​ Range: < 100
●​ Sodium
○​ Level B if abnormal; Level C if pt has change in LOC
 ○​ Range: 135 - 145
○​ NC: Assess fluid overload (hypOnatremia) & dehydration (hypErnatremia) => lasix or IV fluids
●​ WBC
○​ Level C if < 4,000
○​ Range: 5,000 - 10,000
●​ ANC (absolute neutrophil count) => tells you ability to fight infections; immune system
○​ Level C if < 500
○​ Range: > 500
●​ CD4
○​ Level C if < 200
○​ Range: > 200
○​ NOTE: 200 is the line between HIV & AIDS => CD4 > 200 is HIV vs. CD4 < 200 is AIDS
●​ Platelet => assess bleeding; thrombocytopenic precautions
○​ Level C if < 90,000; Level D if < 40,000
○​ Range: 200,000 - 400,000
●​ RBC
○​ Level B if abnormal
○​ Range: 4 - 6 million

5 Deadly D’s => Highest Priority Pts:

1.​ Potassium (K+) in the 6’s => normal is 3.5 - 5
2.​ pH in the 6’s => normal is 7.35 - 7.45
3.​ CO2 in the 60’s => normal is 35 - 45
4.​ pO2 in the 60’s => normal is 80 - 100
5.​ Platelets < 40,000 => normal is 200,000 - 400,000
Lecture 9- Psych Drugs

●​ ALL Psych Drugs cause Hypotension (↓ BP) & Weight changes (usually weight gain)

Major Classes of Psych Drugs:

●​ Phenothiazines: -ZINE
○​ 1st generation typical antipsychotics; Major Tranquilizers (big guns of psych meds)
○​ Side Effects: ABCDEFG:
■​ Anticholinergic (HA, dry mouth, insomnia, etc), Blurred vision, Constipation, Drowsiness,
Extrapyramidal symptoms (eg tremors), Foto sensitivity, aGranulocytosis (low WBC)
●​ Tricyclic Antidepressants: Elavil (elevates mood), Trafanil, Aventyl, Desyrel (rhymes)
○​ NSSRI => Non-selective Serotonin Reuptake Inhibitors; Mood Elevators => Happy Pills
○​ Side Effects: ABCDE
■​ Anticholinergic (HA, dry mouth, etc), Blurred Vision, Constipation, Drowsiness, EPS
○​ NOTE: Must take meds for 2-4 weeks to see beneficial effects
●​ Benzodiazepines: -ZEP-
○​ Anti-anxiety; Minor Tranquilizers => ZZZZ ... => Falling asleep => Tranquilizers
○​ Many end in -Pam or -Lam => LoraZEPAM, DiaZEPAM, etc
○​ Uses: seizures, preop, muscle relaxants, ETOH withdrawal, fighting the vent
○​ Side Effects: ABCDE
■​ Anticholinergic (HA, dry mouth, etc), Blurred Vision, Constipation, Drowsiness, EPS
○​ NOTE: Work Quickly but canNOT be taken for > 2-4 weeks (opposite of antidepressants)
●​ Monoamine Oxidase (MAO) Inhibitors: MARplan, NARdil, PARnate (MAR, NAR, PAR rhymes)
○​ Antidepressants
○​ Side Effects: ABCDE
■​ Anticholinergic (HA, dry mouth, etc), Blurred Vision, Constipation, Drowsiness, EPS
○​ Education => Avoid TYRAMINE containing foods:
■​ Avoid salad BAR => Bananas, Avocados, Raisins (any dried fruit), Organ meats/
Preserved meats, Dairy (cheese, yogurt), alcohol, caffeine, chocolate, etc
●​ Lithium:
○​ Tx Bipolar Disorder- Manic phase (think LI => tx BI)
○​ Side Effects: Unique => works like electrolyte: 3 P’s
■​ Peeing (Polyuria), Pooping (diarrhea), Paresthesia (numbness & tingling)
○​ Toxic Effects: Tremors, Metallic taste, Severe diarrhea/vomiting
○​ *** NC: Monitor Sodium => Sodium must be normal:
■​ Hyponatremia makes Lithium Toxic & Hypernatremia makes Lithium Ineffective
●​ Prozac (Fluoxetine):
○​ SSRI, Mood Elevator => Happy Pills
○​ Side Effects: ABCDE
■​ Anticholinergic (HA, dry mouth, etc), Blurred Vision, Constipation, Drowsiness, EPS
○​ NC: causes Insomnia => give before noon; ↑ Suicide Risk in adolescents after dose change
●​ Haldol (Haloperidol):
○​ Tranquilizer (similar to -zines); Typical 1st generation antipsychotics
○​ Side Effects: ABCDEFG:
■​ Anticholinergic (HA, dry mouth, insomnia, etc), Blurred vision, Constipation, Drowsiness,
Extrapyramidal symptoms (eg tremors), Foto sensitivity, aGranulocytosis (low WBC)
○​ Toxic Effect => Neuroleptic Malignant Syndrome (NMS) => s/s of EPS but w/ High Fever (>102)
■​ NOTE: EPS is side effect => OK; NMS is toxic effect => Medical Emergency!
●​ Clozaril (clozapine): -ZAPINE
 ○​ 2nd generation Atypical Antipsychotic
○​ Side Effect => Agranulocytosis => ↓ WBC => ↑ infection
●​ Zoloft (Sertraline):
○​ Antidepressant
○​ Side Effects of Serotonin Syndrome => SAD HEAD
■​ Sweating, Apprehensive (sense of doom), Dizzy, HEADache
○​ NC: Sertraline + St. John’s Wort = Serotonin Syndrome => Life-Threatening!
■​ Sertraline + Coumadin (warfarin) = Increased Bleeding!
■​ Sertraline interferes w/ other drug metabolism => ↑ drug toxicities (NC: ↓ dose of other
drugs when pt is on Sertraline)

Tranquilizers End in ZZZ...

●​ -Zines => 1st generation, Typical Antipsychotics; (old) Major Tranquilizers
●​ -Zapines => 2nd generation, Atypical Antipsychotics; (new) Major Tranquilizers
●​ -Zep- => Minor Tranquilizers
Lecture 10- Maternity OB Part 1

Naegle’s Rule- EDB:

●​ Naegle’s Rule => 1st day of Last Menstrual Period (LMP); Subtract 3 months & Add 7 days

Weight Gain during Pregnancy:

●​ 1st Trimester (12 weeks) => 1 lbs per MONTH => 3 lbs total
●​ 2nd & 3rd Trimesters (13-36 weeks) => 1 lbs per WEEK => 24 lbs total
●​ Ideal Weight Gain for ENTIRE pregnancy => ~28 lbs +/- 3 => 25 - 30 lbs
●​ Calculate Ideal Weight Gain:
○​ Ideal Weight Gain = # Weeks Gestation - 9
○​ Ideal weight gain +/- 1-2 lbs => OK; +/- 3 lbs => Assess; +/- 4 lbs or more => Trouble

Fundal Height:
●​ Fundus canNOT be palpated until week 12 (end of 1st Trimester) => fundus is midway between
umbilicus & pubic symphysis
●​ Fundus is palpated at Umbilicus between 20 - 22 weeks (~ date of viability => end of 2nd Trimester)

Positive S/S of Pregnancy:

1.​ Fetal Skeleton on X-ray
2.​ Fetal presence on Ultrasound
3.​ Auscultation of Fetal Heart on Doppler
4.​ Palpation of Fetal Movement by Examiner

●​ FHR can be 1st heard/auscultated between 8-12 weeks gestation

●​ Quickening (baby kicks) first felt between 16-20 weeks gestation

Maybe S/S of Pregnancy (Probable & Presumptive):

1.​ Positive urine/blood hCG Pregnancy test
2.​ Chadwick Sign => Cervical (& vulva/vagina) Color Change to Cyanosis (Chadwick => all C’s)
3.​ Goodell Sign => Cervical Softening (Goodell => Good & Soft)
4.​ Hegar’s Sign => Uterine Softening

Order: Chadwick => Goodell => Hegar (occurs in Alphabetical Order! C > G > H)

Pt Education/ Prenatal Visits:

●​ Once a month till week 28 => Every other week between week 28-36; Once a week till Delivery or w42
●​ Pregnant woman can tolerate lower Hgb levels => down to 10 (normal is 12-18)
●​ Urinary Incontinence (1st & 3rd trimesters) => Void q2 hours
●​ Difficulty Breathing (2nd & 3rd trimesters) => Tripod Positioning
●​ Back Pain (2nd & 3rd trimesters) => Pelvic Tilt exercises
●​ Palpate Contractions w/ One Hand over Fundus w/ Pads of Finger (fingertips)

*** Truest S/S that woman is in Labor => Onset or Regular/Progressive Contractions

●​ Lie => relationship between mom’s spine & baby’s spine

○​ Vertical => spines are parallel => Good; Transverse => spines are perpendicular => Trouble
●​ Presentation => most common is ROA (right occiput anterior) & LOA (left occiput anterior)
Stages & Phases of Labor: (4 Stages of Labor & 3 Stages of Labor => All in 1st Stage of Labor)
1.​ Stage 1 => Onset of Labor => Cervical Dilation & Effacement
a.​ Phase 1 => Latent
●​ Cervical dilation from 0-4 cm
●​ Contractions are 5-30 mins apart; lasting 15-30 seconds
●​ Mild Intensity Contractions
b.​ Phase 2 => Active NOTE: JUST MEMORIZE PHASE 2 & Deduce Phase 1 & 3!
●​ Cervical dilation from 5-7 cm
●​ Contractions are 3-5 mins apart; lasting 30-60 seconds
●​ Moderate Intensity Contractions
c.​ Phase 3 => Transition
●​ Cervical dilation from 8-10 cm
●​ Contractions are 2-3 mins apart; lasting 60-90 seconds
●​ Strong Intensity Contractions
2.​ Stage 2 => Delivery of Baby
3.​ Stage 3 => Delivery of Placenta
4.​ Stage 4 => Recovery (2 hours post delivery of placenta)

*** Uterine Contractions should NOT be Longer than 90 seconds or Closer than 2 minutes ***

Complications of Labor:
●​ Pain Back Pain => “OP” => Oh Pain
○​ Tx: 1. Position (Knee-Chest position) 2. Push (fist into sacrum- counterpressure)
●​ Prolapsed Cord => cord is presenting part & baby presses on it => Medical Emergency!
○​ Tx: 1. Push (push baby’s head off cord) 2. Position (Knee-Chest) 3. Prepare for C-section
●​ ALL OTHER COMPLICATIONS (eg tetany, maternal HTN, vena cava, toxemia, etc): LION
○​ L => Left Side (rescue position for mothers)
○​ I => IV fluids (increase rate)
○​ O => Oxygen
○​ N => Notify Provider
○​ STOP Pitocin/Oxytocin 1st if it is running, then Lion => Pit LION

●​ NOTE: only administer Pain meds for pt in Labor if baby is NOT likely to be born when the med is at its
peak => eg IV meds peak in 15-30 mins; IM meds peak in 30-60 mins
Lecture 11- Maternity OB Part 2

Fetal Monitoring Patterns:

1.​ Low Fetal HR (HR < 110) (normal FHR is 120-160)
●​ BAD => LION (left side, IV, O2, Notify) & Stop Pitocin/Oxytocin
2.​ High Fetal HR (HR > 160)
●​ OK => Document & Take mom’s temp; Not a high priority
3.​ Low Baseline Variability
●​ BAD => LION (left side, IV, O2, Notify) & Stop Pitocin/Oxytocin
4.​ High Baseline Variability
●​ GOOD => Document
5.​ Early Deceleration
●​ OK/Normal => Document
6.​ Variable Deceleration
●​ Very BAD => Cord Compression/Prolapsed Cord => Push (push baby’s head off of cord) &
Position (knee-chest position for mom)
7.​ Late Deceleration
●​ BAD => LION (left side, IV, O2, Notify) & Stop Pitocin/Oxytocin

●​ Best OB Answer => Check Fetal HR

2nd Stage of Labor => Deliver Baby:

1.​ Deliver Head
2.​ Suction mouth, then nose (M > N, alphabetical)
3.​ Check Nuchal cord (cord around neck)
4.​ Deliver shoulders, then body
5.​ Make sure baby has ID band BEFORE leaving delivery area

3rd Stage of Labor => Deliver Placenta:

●​ Deliver placenta
●​ Check that placenta is intact & complete & Check for a 3-vessel cord (AVA => 2 Arteries, 1 Vein)

4th Stage of Labor => Recovery:

●​ 4 Things you do 4 Times/hour (q15 mins) in the 4th Stage
○​ Vital Signs (assess for shock), Fundus, Perineal Pads (hemorrhage), Roll pt over (hemorrhage)

Postpartum Assessment:
●​ BUBBLE HEAD
●​ Breasts; Uterus; Bladder; Bowel; Lochia; Episiotomy; Hgb/Hct; Extremities; Affect/emotion; Discomforts
●​ Uterus => fundus should be FIRM, not boggy & MIDLINE => if not midline => Bladder is distended
○​ Fundus should be at level of umbilicus after delivery => Fundal Height = Day Postpartum
●​ Lochia => vaginal discharge postpartum
○​ Rubra = red; Serosa = pink; Alba = white; Excessive amount = Saturating pad in 15 mins
●​ Extremities => look for Thrombophlebitis => Assess by measuring Bilateral Calf Circumference

Cephalohematoma vs. Caput Succedaneum:

●​ Cephalohematoma => collection of blood in scalp
○​ Does NOT cross sutures; NOT symmetrical
●​ Caput Succedaneum => edema of the scalp
 ○​ C.S => Crosses Sutures; Caput Symmetrical

Physiologic vs. Pathologic Jaundice:

●​ Physiologic Jaundice => NORMAL => appears AFTER 24 hours after birth => disappears in a week
●​ Pathologic Jaundice => ABNORMAL (patho => problem) => appears in the 1st 24 hours after birth

OB Medications: 6 NEED TO KNOW MEDS:

●​ Terbutaline, Mag Sulfate, Pitocin/Oxytocin, Methergine, Dexamethasone, Surfactant
●​ Tocolytics => Stop contractions, Stop labor => for premature labor that needs to be stopped
○​ Terbutaline (Brethine):
■​ Side Effect => Maternal Tachycardia
○​ Mag Sulfate: => also used to prevent SEIZURES in Preeclampsia
■​ Side Effect => induce hypermagnesemia => ↓ S/S => ↓ BP, ↓ HR, ↓ RR, ↓ Reflexes
●​ Oxytocics => Stimulate & Strengthen labor
○​ Pitocin (Oxytocin):
■​ Side Effect => Uterine Hyperstimulation (contractions > 90sec, closer than 2 mins)
○​ Methergine:
■​ Side Effect => Maternal HTN (contracts blood vessels)
●​ Fetal Lung Meds => to mature fetal lungs:
○​ Betamethasone => steroid given to MOTHER IM, BEFORE baby is born
■​ Side Effect => Increased glucose (steroid)
○​ Surfactant (Survanta) => given to Baby via Transtracheal rout, AFTER birth

Insulin:
●​ Humalin 70/30 => mix of Insulin N & Insulin R => 70% N & 70% R (think N is in Numerator- 70%)
●​ Mixing N & R Insulins:
○​ N, R, R, N => Not Retired, Registered Nurse
○​ Draw R before N (RN’s do it this way); but Pressurize N before R
●​ Insulin Needles:
○​ IM Injections => I in IM looks like 1 => choose 21 gauge & 1-inch long needle
○​ SubQ Injections => S in SubQ looks like 5 => choose 25 gauge & 0.5 inch needle

Heparin vs. Coumadin/Warfarin:

●​ Heparin:
○​ given IV or SubQ; works IMMEDIATELY, canNOT take for > 3 weeks (21 days)
○​ Antidote: Protamine Sulfate (heParin = Protamine sulfate)
○​ Labs: PTT (Ptt => 2 t’s look like H); CAN be used during pregnancy
●​ Coumadin/Warfarin:
○​ Given PO only; works after a few days to a week; CAN take for entire life
○​ Antidote: Vitamin K (Coumadin = K)
○​ Labs: PT/INR; canNOT be used during pregnancy

Diuretics:
●​ K+ wasting & K+ sparing diuretics:
●​ Any Diuretic ending in -X => Xes out K (wastes K) + Diuril
○​ Eg Lasix, Bumex => Xes out K => K-wasting diuretics

Muscle Relaxants:
●​ Baclofen (on your back loafing) & Cyclobenzaprine & Flexeril (flex your muscles)
 ○​ Side Effects: Fatigue/Drowsiness & Muscle weakness (paresis)
○​ Pt Education: Don't drink/ drive/ operate heavy machinery

Piaget’s Theory of Cognitive Development- 4 Stages:

1.​ Sensorimotor => 0-2 years old
●​ Only thinks in PRESENT tense
●​ NO Pre-op teaching => just tell them what you are doing Right Now
2.​ Preoperational => 3-6 years old
●​ Fantasy oriented, imaginative, illogical, no rules; learn by playing
●​ Understand future & past tense => pre-op teaching the day/morning of the procedure
3.​ Concrete Operational => 7-11 years old (think 7/11 grocery stores are surrounded by Concrete)
●​ Rule oriented, cannot abstract, teach them 1-2 days ahead of time, teach them skills
4.​ Formal Operational => 12-15 years old
●​ Can think abstractly & cause/effect; Teach them LIKE AN ADULT; can manage their care

Psych Rules:
●​ Don’t give/accept gifts in psych, Don’t give advice, Don’t give guarantees, Immediacy (keep them
talking), Concreteness (don't use slang/figurative speech), Empathy
○​ Empathy questions have quotations => Ignore what the pt SAYS & choose what they FEEL
Lecture 12- Prioritization & Delegation

Prioritization:
●​ Prioritization answer choices usually have 4 parts:
○​ 1. Age 2. Gender 3. Diagnosis 4. Modifying phrase
○​ Age & Gender are Irrelevant => Ignore! Only look at Diagnosis & Modifying phrase
○​ Modifying Phrase is MOST important
●​ 4 Rules of Prioritization:
1.​ Acute Beats Chronic
2.​ Fresh Post-Op (12 hours or less) Beats Medical or other Surgical
3.​ Unstable pt beats Stable pt
●​ Stable => chronic illness, post-op > 12 hrs, local/regional anesthesia, lab abnormalities
A or B level, ready for discharge, admitted > 24 hrs, unchanged, typical/expected S/S
●​ Unstable => acute illness, post-op < 12 hrs, general anesthesia, lab abnormalities C or
D level, newly diagnosed/admitted, admitted < 24 hrs, changed, unexpected S/S
○​ Hemorrhage, Fever > 105 F, Hypoglycemia, & Pulselessness
/Breathlessness (Vfib or Asystole) => ALWAYS Unstable pt
4.​ Tie Breaker Rule => the more vital the organ, the higher the priority:
●​ Brain > Lung > Heart > Liver > Kidneys > Pancreas

Delegation:
●​ Do NOT delegate to LPN:
○​ Starting IV, hanging/pushing IV meds, administer blood, central lines, make care plan,
perform/develop teaching, take care of unstable pts, perform the “firsts” of anything
○​ Assess for Admission, Discharge, Transfer, 1st assessment after a change
●​ Do NOT delegate to UAP:
○​ Charting, Medication Administration, Assessments (except vitals/glucose), Treatments
●​ Do NOT delegate any Safety Responsibilities to Families

Staff Management:
●​ Always 4 Answer choices: Tell Supervisor, Confront them, Talk to them later, Ignore it
○​ Ignore is NEVER the right answer
○​ Is it ILLEGAL => Yes => Tell Supervisor
○​ Is it ILLEGAL => No => Is anyone in harm’s way => Yes => Confront Immediately
○​ Is it ILLEGAL => No => Is anyone in harm’s way => No => Talk to them later
Guessing Strategies:
●​ Psych:
○​ pick “I will examine my feelings” or “establish a trust relationship”
●​ Nutrition:
○​ Pick baked chicken or fish if chicken is not an answer choice
○​ Never pick casseroles for children => they won't eat them
○​ Don’t mix meds in kid’s food
○​ Toddlers => pick Finger foods
○​ Preschoolers => leave them alone => its ok if they don’t eat much => slowed growth
●​ Pharmacology:
○​ Memorize side effects
○​ Pick side effect in the same body system the drug is working
■​ For PO meds => pick GI side effect if you don’t know
○​ Never tell a child a medication is candy
●​ OB:
○​ Pick “check fetal heart rate”
●​ MedSurg:
○​ 1st thing to Assess => check LOC vs 1st thing to Do => Establish Airway
●​ Peds:
○​ When in doubt, call it Normal
○​ When in doubt, pick the Older Age
○​ When in doubt, pick the Easier Task
○​ Peds => NORMAL, OLDER, EASIER
●​ General: ​
○​ Rule out absolutes
○​ Avoid answer that say the same thing
○​ If 2 answer choices are opposites, one is probably correct
○​ Umbrella strategy => pick global/more general answer
○​ When nothing else works, pick the answer choice that looks different than the others
○​ If you don’t know the drug, pull it out of the question & answer it w/ fundamental knowledge