Mark Klimek Notes 2
Mark Klimek Notes 2
Mark Klimek Notes 2
Vent Alarms
High pressure alarm goes off: working too hard (obstruction)
1. Check for kinks, unkink
2. Water condensation in the tube, empty it
3. Mucus in the airway: turn/cough/deep breathe,
4. If that doesn't work then suction (last resort)
Low pressure alarm goes off: that was too easy (disconnection)
a. Main tubing: reconnect
b. O2 sensor tubing (senses fio2 @ trachea area): reconnect
Uppers (5):
Caffeine, Cocaine, PCP/LSD (hallucinogens), Methamphetamines, Adderral
S/s: (Things go up) euphoria, tachycardia, tachypnea, restlessness,
irritability, borborygmi/diarrhea, reflexes +3/+4 (spastic), seizure
Downers:
Heroin, Marijuana, Alcohol, Benzos (everything not an upper)
S/s: Lethargy, respiratory depression, bradycardia, bradypnea,
ALCOHOL WITHDRAWAL:
Regular diet, semi-private room anywhere on unit, up adlib (go anywhere
they want), no restraints.
Meds: Antihypertensive pill, Tranquilizer, Vitamin B1
DELIRIUM TREMENS:
NPO/clear liquids (seizure risk), private room, near nurses station, strict best
rest / need bed pans & urinals, must be restrained appropriately: vest or 2
point locked leathers (opposite arm & leg) rotate every 2 hours.
Meds: antihypertensive pill, tranquilizer, b1 vitamin
--
TAP Levels:
Trough- When drug is at its lowest (Draw before drug admin)
Peak- When drug is at its highest (Draw after drug admin)
TAP (trough, administer drug, peak) for narrow therapeutic windows
THE DRUG DOESN’T MATTER, THE ROUTE MATTERS ;)
Sublingual/IV/IM/SQ/PO Trough: Draw 30 mins before the next dose
Sublingual Peak: 5-10 mins after drug is dissolved
IV Peak: 15-30 mins after drug is finished
IM Peak: 30-60 mins
SQ- See diabetes lecture
PO- They don’t test PO peaks
When there’s 2 right answers, pick the highest without going over
Names of CCB’s:
Names ending in “dipine” (You're dipping in the calcium channel)
Verapamil
Cardizem = Continuous IV drip
Monitor BP intermittently. If systolic is below 100, hold.
For drip, if systolic was 98 titrate it down.
Cardiac Arrhythmias:
Normal sinus rhythm- Peaks of p waves are evenly spaced
V-fib- Chaotic squiggly line. No pattern
V-tach- Sharp peak & jags. There's a pattern
Asystole- Flat line
QRS depolarization- Answer will always be ventricular
P wave- Answer will always be atrial
Lack of a P wave- Answer will always be ventricular
A lack of QRS- Asystole
A-flutter- Saw tooth
Chaotic is always the word used to describe fibrillation
Bizarre is always the word used for tachycardia
Low Priority:
Premature ventricular contraction (PVC)
A bunch of PVC’s is like a short run of V-Tach
Moderate Priority:
If more than 6 PVC’s in a minute or row and/or if PVC falls on the T wave of
the previous beat. They never are high priority!
Treatment:
Supra Ventricular (Atrial) ABCD’s
Adenocard (Adenosine):
Push in less then 8 secs
Don't worry about Asystole
When it comes to IV push, when you don’t know go slow
Beta blockers (ending in “lol”)
Just like CCB’s, same treatment, same side effects
Calcium channel blockers
Better for asthmatics
Digoxin/Digitalis (Lanoxin)
V-fib D-fib
Asystole Epinephrine & Atropine (In that order if Epi doesn’t work)
PVC’s & V-Tach Use Amiodarone for Ventricular
Crutch Gaits
2 point: move a crutch and opposite foot together
3 point: two crutches and bad leg together
4 point: left crutch followed by right foot, right crutch followed by left foot
Swing through: non-weight bearing (amputation)
Amputation with a prosthetic: can bear weight
Even for even, odd for odd. Use the even # gaits when the weakness is
evenly distributed (you have an even # of legs messed up)
2 point for mild bilateral weakness
4 point for severe bilateral weakness
Ask yourself how many legs are affected? If even # of legs (2) pick either 2
or 4 point gait. If 1 leg is affected, pick odd number (3 point gait). Ask
yourself whether mild or severe.
Up with the good, down with the bad. Going upstairs, lead with good foot
(crutches move with bad legs)
Cane
Hold cane on strong side.
Walkers
Pick it up, set it down, walk to it
If they must tie something to the walker, tie it to side, not the front of it
No wheels, or tennis balls on walkers**
Psychotic pt:
Doesn’t think they’re sick & has no insight
S/s: Delusions, Hallucinations, Illusions *
3 Types of Psychotics
Functional psychotics: Can be married, have a family, job, live alone, pay bills…
90% of functionals are Schizo Schizo Major Manic
Schizo- Schizophrenia
Schizo- Schizo-affective Disorder
Major- Major Depression
Manic- Bipolar
For Dementia- This pt has a brain damage and can’t learn reality
1. Acknowledge their feelings “That seems exciting”
“I see that you’re happy”
“I see that you’re sad”
2. Redirect them **DON’T present reality**
You can reality orient them (person, place, time)
“Ok, let’s sit here and you can tell me about church while
we wait for your dead husband”
DON’T change the subject
For Delirium- Remove the underline cause & keep them safe
1. Acknowledge their feelings “That seems exciting”
“I see that you’re happy”
“I see that you’re sad”
2. Reassure them “You are safe and that will go away when you get better”
Loose associations:
Flight of Ideas- Thought to thought to thought to thought
Word Salad- Random words
Neologism- Making up imaginary words
Narrow Self-concept- When a functional psychotic refuses to leave their
room or change their clothes. (They define who they are based on where
they are and what they’re wearing. They don’t know who they are if they get
undressed/ it terrifies them)
Ideas of Reference- Pt thinks everyone is talking about them
Mark Klemik Lecture 6: Toxic Levels/Dumping Syndrome/Electrolytes
Hiatal Hernia:
Regurgitation of acid into your esophagus because the upper part of
stomach herniates upwards through the diaphragm
2 chambered stomach
Moving in the wrong direction at the right rate
Going the WRONG WAY on a ONEWAY street
S/s:
GERD aka heartburn / indigestion
GERD is regular heart burn if you get it at a random time
It’s hiatal hernia if you lay down right after you eat
Tx:
High position HOB
High fluids, high carbs.
Everything needs to be high, except protein (low)
Dumping Syndrome:
Usually following gastric sx.
The gastric contents dump too quickly into the duodenum.
Moving in the right direction at the wrong rate.
SPEEDING TICKET!
S/s:
Drunk: Staggering gait, slurred speech, delayed reaction time, emotional
labile
Shock: Hypotension, pail cold clammy skin, tachycardia
Acute abdominal distress: Pain, guarding, borborygmi, diarrhea, bloating,
distention, tenderness
Tx:
Low position (HOB flat)
Turn to side with head down
Low fluids (1-2hrs before or after meals, not with the meals), Low carbs.
If you want the stomach to empty slow, everything is low. Except protein
Electrolytes:
Kalemias- Do the same as the prefix except for heart rate* and urine output.
S/s Hyperkalemia- Agitation, irritability, tachypnea, bradycardia, tall p
waves, elevated ST waves, diarrhea, borborygmi, spastic muscles,
hyperreflexia, oliguria
Tx for Potassium:
Never IV push K+
Never give more than 40 of K+ per liter of IV fluid
Kayexalate:
Full of sodium, given via enema or orally
K+ exits late
Trades sodium for K+ so u shit it out.
It results in hypernatremia (dehydration) so give them fluids to correct it
Takes hours but it’s permanent ***
Tx:
1. Radioactive Iodine-
Pt should be isolated for 24 hrs,
They have to be careful with their urine
If they spill it you need to call hospital hazmat team
2. PTU (cancer drug) -
Puts Thyroid Under
Monitor WBC’s
3. Thyroidectomy- Total vs. Sub
Total’s need lifelong hormone replacement & at risk for hypocalcemia
Subtotal’s don’t need lifelong hormone replacement.
Subs are at risk for thyroid storm/crisis/thyrotoxicosis:
Very high temps of 105+, very high BP (stoke category), severe
tachycardia, psychotically delirious. VERY BAD! Causes brain damage
Tx:
Ice pack (First), Cooling blanket (Best), 02 per mask @ 10 L
Do not medicate. They will either come out on their own or die
2 staff to 1 pt
Post Op Risks:
In the first 12 hrs, top priority is airway
2nd is hemorrhage.
12-48hrs for Total is Tetany r/t hypocalcemia.
12-48hrs for Subtotal is Storm
NEVER PICK INFECTION IN FIRST 72 HRS!
S/s:
Obese, flat/boring/dull personality, heat tolerance, cold intolerance, pulse &
BP low, slow people, myxedema
Tx:
Thyroid hormone Synthroid (levothyroxine)
Do not sedate these people! They will get into a myxedema coma
NEVER HOLD THYROID HORMONES THE DAY OF SURGERY!
Safety
No small toys for kids under 4.
No metal/die-cast toys if o2 is in use (sparks)
Beware of fomites (teddy)(nonliving object that harbors microorganisms)
Age appropriate
0-6 months:
Musical mobile, Soft & large, Teething soft books
6-9 months: Teach object permanence (looks for the toy when you hide it)
Best option is a “cover/uncover toy”
(Ex: Jack in the box, pop up pals, books with windows, peek a boo)
Second best: large plastic/wood/metal
Worst toy is a musical mobile
NEVER pick answers with the words: build, sort, stack, make, construct, for
a child under 9 months
S/S:
3 P’s: Pain, Paresthesia, Paresis
**The most important thing to pay attention to is location b/c it will determine
prognosis, treatment, symptoms**
Locations:
Cervical
Thoracic
Lumbar
Pre-op assessment:
Cervical: Airway & function of arms/hands
Thoracic: Cough/Bowel mechanisms
Lumbar: Bladder- when was the last time they voided? & leg function
Post op spinal #1 answer: log roll**
DON’T DANGLE THE PTS LEGS!
DON’T SIT FOR LONGER THAN 30 MINS!
THEY MAY WALK, STAND, LAY DOWN W/O RESTRICTION
Complications:
Cervical: Pneumonia
Thoracic: Pneumonia & Paralytic Ileus
Lumbar: Urinary retention followed by leg problems
3 permanent restrictions:
Never lift objects by bending with the waist
Cervical lams not allowed to lift ANYTHING over their head
No jerking, horse back riding, 6 flags
Terms:
Anterior Thoracic: From the front thru the chest to the spine
INR: 2-3
Anything 4+ is (C)
Potassium: 3.5-5.3
Low or high is (C) unless it reaches 6+ then it is a (D)
BUN: 8-25
(A) Assess for dehydration
Hemoglobin: 12-18
If 8-11 it’s a (B) Assess for anemia/bleeding/malnutrition
If below 8 (C) Assess for bleeding, prepare to give blood, call doctor
Bicarbonate: 22-26
(A)
Co2: 35-45
46-59 is a (C)
Assess respirations, prepare to do pursed lip breathing
60+ is a (D)
Assess respirations, prepare for intubation/ventilation, call respiratory
therapy then the doctor
P02: 78-100
Low 70s it’s a (C)
Assess respiratory, prepare to give 02
Hypoxia 60s and lower is a (D)
Give 02, assess respirations, prepare for intubation/ventilation, call
respiratory therapy then doctor
O2: 93-100
If less than 93 it’s a (C)
Assess respirations, raise head of bed, give 02, unless “best” question then
just give 02
BNP: < 100
100+ (B)
Look for signs of CHF
Sodium: 135-145
(B) Unless change in LOC, then it’s a (C)
Platelets:
Below 90,000 is a (C)
Below 40,000 is a D
RBCs: 4-6 mil (B)
WBC: therapeutic 5,000-11,000
ANC: 500+
CD4: 200+
Less than normal value for WBC, ANC, CD4 are all (C)
Low CD4=AIDs
Place on Neutropenic Precautions**
Neutropenic Precautions:
Strict Hand washing
Shower BID with antimicrobial soap
Avoid Crowds
Private Room
Limit numbers of staff entering room
Limit Visitors for Healthy Adults
No fresh flowers or potted plants
Low Bacteria Diet: No Raw Fruits, Veggies, Salads
No Undercooked meat.
Do not drink water than has been standing longer than 15 minutes
Vital signs (Especially Temperature) every 4 hours
Check WBC (ANC) Daily
Avoid the use of an indwelling catheter
Do not re-use cups.. must wash between uses
Use disposable plates, cups, straws, plastic knife, fork, spoon
Dedicated Items in Room:
Stethoscope
BP Cuff
Thermometer
Gloves
ASSESS FOR INFECTION!!!
D.I:
Polyuria, polydipsia leading to dehydration due to low ADH, low specific
gravity, fluid volume deficit
SIADH:
Low urine output, oliguria, not thirsty, high specific gravity, fluid volume
excess
DM Type 1:
Insulin dependent
Ketosis Prone
S/s: Polyuria, polydipsia, polyphagia
Tx for type 1: Diet, Insulin (most important), Exercise (DIE)
DM Type 2:
Non-Insulin Dependent
Non-Ketosis Prone
S/s: Polyuria, polydipsia, polyphagia
Tx for type 2: Diet (most important), Oral hypoglycemic (pill), Activity (DOA)
A- Calorie restriction** (ex: 1600 calories / day)
B- 6 small feedings / day (ex: 1600/ 6)
Humalog/Lispro(Rapid acting)
Onset 15 min, Peak 30 min, Duration 3 hours.
Give insulin with meals*
Key Points:
Check expiration date. After you open a bottle, the new expiration date is 30
days after that. Write the date you opened it and “exp” or “opened”.
Teach pts to refrigerate their insulin at home. Hospitals keep unopened
bottles of insulin in the fridge, but they can come out of the fridge once
opened.
Exercise does the same thing as insulin. Exercise is like another shot of
insulin. If a diabetic is going to play soccer/exercise, they have to bring
something to eat first. (Rapidly metabolized carbs)**
When diabetics are sick their glucose goes up. They have to take their
insulin even when they’re not eating. Take sips of water or they might get
dehydrated. Stay as active as possible.
Pressurizing the vial: inject air into the N bottle, then inject the air into R,
then draw up the R, followed by the N= NRRN
Side effects:
Anticholinergic (dry mouth)
Blurred vision
Constipation
Drowsiness
#1 Dx is injury
Pt Teaching:
To prevent hypertensive crisis, avoid all foods containing tyramine
Salad BAR
Bananas
Avocados
Raisins (dried fruit)
Organ/preserved/hot dogs/lunch meats (smoked, dried, cured, pickled, etc.)
No dairy EXCEPT for mozzarella and cottage cheese
No yogurt
No alcohol
No chocolate
Don’t take OTC meds while on MAOi’s
Side Effects:
Anticholinergic (dry mouth)
Blurred vision
Constipation
Drowsiness
Euphoria (way too happy)
*Insomnia- Give BEFORE noon, NOT at bedtime*
Increased suicide risk when changing doses with young adults
Side Effects:
Anticholinergic (dry mouth)
Blurred vision
Constipation
Drowsiness
EPS- extrapyramidal syndrome (parkinson’s symptoms) no big deal
Fotosensitivity
aGranulocytosis (immunosuppressed) (destroys marrow)
Geodon (Ziprasidone):
Black box warning- Prolongs QT interval and can cause sudden cardiac arrest,
DON’T give to people with heart conditions.
Zoloft (Sertraline):
SSRI, can cause insomnia but you can give it at bedtime
⁃ **Zoloft interferes with this system increasing toxicity with other drugs**
Lower the dose of other drugs
Warfarin/Coumadin must be reduced because you can bleed out
**St. John Wort + Zoloft = Serotonin syndrome** DON’T TAKE St. John Wort
Sweating
Apprehension/impending sense of doom
Dizziness
HEADaches
Pregnancy:
Complications:
Painful back labor: Position Push: Reposition (knee chest:
FaceDownAssUp), then push (take fist & push into sacrum) Low priority
Prolapsed Cord: cord is presenting which wraps around baby’s neck, high
priority. Push position: push head off the cord, position her in knee chest
Pain MGMT:
Do not administer pain med to a woman if the baby is likely to be born when
the med peaks****
L- left side
I- increase IV
O- O2
N- notify
Breast
Uterine fundus**
Bladder
Bowel
Lochia**
Episotomy
Hemoglobin/hematocrit
Extremity check**
Affect
Discomfort
OB Meds:
Tocolytics: Stops labor
Terbutaline- (causes maternal tachy)
Mag Sulfate- (causes hypermagnasemia) making uterine contractions, HR,
BP, reflexes, respiratory rate, and LOC go down)
As long as the respirations are above 12, it’s ok. If under titrate down
2+ reflexes is good, 1+ is bad
Heparin VS Coumadin:
Heparin- given IV or SQ, works immediately, cannot be given for more then
3 weeks (except for Lovenox (LMWH), antidote: protamine sulfate, lab: PTT
(count on your fingers “heparin” you’re only left with 3 fingers), can be given
to pregnant women.
Coumadin- given only PO, takes a few days to a week to work, can take
forever, antidote: vitamin K, lab: PT/INR (count on your fingers “Coumadin”
you’re only left with 2 fingers), cannot be given to pregnant women.
Potassium Wasting/Sparing Diuretics:
Any diuretic ending in X X’s out K+ (wastes) + Direril
All others are sparing
Muscle Relaxers:
Fatigue/Drowsiness/Muscle weakness
Teach not to drink/drive/operate heavy machinery when taking these
Baclofen and Flexeril are most tested**
When you’re on your Baclofen you are your Back Loafin’
Priority/Delegation:
Determine which pt is the sickest or healthiest depending on the question.
Age, gender, dx, and modifying phrase, i.e.: "10 yr old male w/ hypospadias
who's throwing up bile & emesis." *Irrelevant are age and gender*
Dx & modifying phrase is important, but modifying phrase is always more
important.
Stable Pts:
The word “stable”
Chronic illness makes you stable
Post op greater than 12hrs
Local or regional Anesthesia
Lab abnormalities of an A or B level
Phrases “ready for discharge”, "to be discharged”, or "admitted longer than
24hrs ago"
Unchanged assessment
Experiencing the typical expected s/s of the disease with which they were
diagnosed
Unstable Pts:
Acute illness
The word “unstable”
Post op less than 12hrs
General Anesthesia
Lab abnormalities of C or D
Phrases "not ready for discharge”, "newly admitted”, "newly diagnosed”, or
"admitted less than 24 hrs ago"
Changing/changed assessment
Experiencing unexpected s/s of the disease with which they're diagnosed
Tie Breaker:
The more vital the organ, the higher the priority
The organ we're talking about is the organ of the modifying phrase is
happening, not the dx itself
Delegation: LPN
Do not delegate the following responsibilities to an LPN:
Starting an IV
Hanging/Mixing IV meds
Pushing IV Push meds, BUT they can maintain/document the flow
They can’t administer blood or mess with central lines (including flushing or
changing central line dressings unless thats the only option they can do)
They cannot plan the care, BUT they can implement but not create the
care plan
They can’t perform/develop teaching, BUT they can reinforce it
They can’t care for unstable patients
They can’t do the first of anything, RN must do the first of anything
They can’t do admission/discharge/transfer/first assessment after a change.
Delegation: UAP/Aid
Do not delegate the following responsibilities to an UAP/Nurses Aid:
Charting. They can chart what they did BUT not about the pt
Giving meds EXCEPT for topical OTC barrier creams
Assessments other than vital signs and accu-chek (finger stick)
Treatments EXCEPT enemas... catheterize last resort
You CAN delegate ADL’s but they should never do the first**
Do not delegate to the family of the pt safety responsibilities (i.e.: taking off
restraints for a family member in the room)
With sitters/care givers, they can only do what you teach them to do and you
must make sure you document that you taught them
Staff MGMT:
How do you handle inappropriate behavior amongst staff?
There are always four answers: “Tell supervisor”, “Confront them and take
over immediately”, “Approach them later on and talk to them about it”, and
“Ignore the behavior”
Ignore the behavior is NEVER the answer
Ask yourself “Is what they are doing illegal?”
If yes, choose “Tell the supervisor” (always the answer in this case)
If no, ask yourself “Is anyone in immediate danger of physical/psychological
harm?”
If yes, choose “Confront immediately and take over” (always the answer in
this case)
If no, and it’s just inappropriate, legal, and not harmful behavior, choose
“Approach them later on and talk to them about it” (always the answer in this
case)
If it’s harmful and illegal, confront first then tell supervisor
Nutrition questions: in a tie, pick chicken (unless it’s fried), if chicken’s not
there pick fish (not shellfish). Also never pick casseroles for children. Never
mix meds in children’s food. For toddlers choose finger foods. Preschoolers
leave them alone, one meal a day is okay.