Mark Klimek Notes PDF

Key: -​ bold (titles) -​ red (important letters or mnemonics) -​ yellow (highlighted info) Lecture 1 Acid Base Balance -​ Convert lab values to words & interpret -​ Rule of the B’s -​ If the pH & the Bicarbonate are Both in the same...

Key: -​ bold (titles) -​ red (important letters or mnemonics) -​ yellow (highlighted info) Lecture 1 Acid Base Balance -​ Convert lab values to words & interpret -​ Rule of the B’s -​ If the pH & the Bicarbonate are Both in the same direction then it’s metaBolic — otherwise it’s respiratory (since it has no B in it) -​ Values -​ pH = 7.35-7.45 -​ HCO3 = 22-26 -​ CO2 = 35-45 -​ Principles -​ As the pH goes, so goes my patient — except for K+ -​ pH goes up — alkalotic — hyper & irritable -​ Pt needs suctioning cause they could seize & aspirate -​ pH goes down — acidosis — low & slow -​ Pt needs Ambu bag cause they could go into respiratory arrest -​ MAC Kussmaul — only acid base balance to cause Metabolic ACidosis with Kussmaul respirations -​ Example: Pt has respiratory acidosis. SATA -​ +1 reflexes !! -​ Diarrhea – high X -​ Adynamic ileus !! (Without movement) -​ Spasm – high X -​ Urinary retention !! -​ Paroxysmal atrial tachycardia – high X -​ Second degree Mobitz Type II Heart Block !! -​ Hypokalemia – would be hyperkalemia due to exclusion of K+ -​ Causes -​ First ask “is it LUNG?” → respiratory problem -​ Second ask “are they over ventilating or under ventilating?” -​ OVERventilating = alkalosis (OVER 7.45) -​ UNDERventilating = acidosis (UNDER 7.35) -​ Ventilation is about gas exchange not respiratory rate — not about RR, it’s about the SAO2  -​ Important to look at SAO2 instead cause RR could end up compensating & lead you to wrong answer -​ If it is not LUNG → metabolic problem -​ If patient has prolonged gastric vomiting or suctioning (losing acid)— pick alkalosis -​ Everything else that isn't lung — pick acidosis Ventilators -​ Alarms -​ High pressure alarms — always triggered by increased resistance to air flow -​ Machine is having to push too hard to get the air into the lungs -​ Caused by obstructions! -​ Kinks = unkink it -​ Water condensing in the tube = empty it -​ Mucus secretions in airway = change position, turn, cough, deep breathe, & then suction -​ More suction = more secretions problems -​ Only suction when necessary — when they cannot mobilize secretions after they turn, cough, & deep breathe -​ Low pressure alarms — always triggered by decreased resistance -​ Machine works too little/too easy to get air into lungs -​ Caused by disconnections! -​ Main tubing = reconnect -​ O2 sensor tubing (measures FIO2; oxygen delivered) = plug it back in -​ Only reconnect unless tube is on floor — bag pt & call RT -​ Settings -​ Overventilated = setting too high = respiratory alkalosis — panting -​ Underventilated = setting too low = respiratory acidosis — retaining CO2  Lecture 2 Alcohol -​ Number one problem in all abusive situations = Denial -​ Abusers have an infinite capacity to deny -​ Deny in order to continue the behavior — allows them to keep doing it without having to answer for it/deny that they have a problem -​ Why is this a problem? → can’t treat someone who denies they have problem -​ Definition — refusal to accept the reality of a problem -​ How to treat? -​ Confront them with what they do & say -​ Confrontation attacks problem while aggression attacks person -​ When dealing with psychodynamic issues with staff, use the “I” statements not “You” -​ Denial is okay in loss & grief situations — support not confront! -​ Stages of grief — DABDA -​ Number two problem that abusers have = dependency/codependency -​ Dependency — abuser asks partner to do things for them -​ Codependency — partner gets positive self esteem from doing things for abuser -​ How to treat? Set limits & enforce them -​ Teach partner to say no -​ Work on self esteem of codependent person -​ Because when they say no, the abuser will attack their self esteem Manipulation -​ When abuser gets partner to do things that are not in the best interest of partner — dangerous & harmful -​ Like dependency — getting partner to do things -​ Manipulation = dangerous & harmful -​ Dependency = not inherently dangerous & harmful -​ How to treat? Set limits & enforce them Wernicke (Korsakoff) Syndrome -​ Go together -​ Wernicke — encephalopathy -​ Korsakoff — psychosis -​ Psychosis induced by Vit B1, thiamine deficiency (lose touch with reality d/t deficiency) -​ Primary S/Sx  -​ Amnesia (memory loss) -​ Confabulation (making up stories) -​ They believe their lies — just as real as reality -​ How to deal with pt with this: -​ Do not present reality because they can’t learn it -​ Do not get in fight about what is real — pointless -​ Redirect instead to something that they can do -​ Characteristics: -​ Preventable —> take Vit B1 (needed to metabolize alcohol — if not it will accumulate & destroy brain cells) -​ Arrestable (stop from getting worse) —> take Vit B1 -​ Irreversible (70%) Antabuse & Revia (Disulfiram) -​ Aversion therapy — develop a gut hatred for habit -​ When you take in the alcohol, you will get super sick -​ Doesn’t work as well as they say it does — just in theory -​ Onset & duration = 2 weeks -​ Patient teaching: -​ Teach to avoid all forms of alcohol — to avoid N/V, death -​ Items that contain alcohol: mouth wash, cologne, perfume, aftershave, any OTC that ends in elixir, insect repellant, alcohol based hand sanitizer, uncooked icing since it has vanilla extract -​ Do not pick Red Wine vinaigrette! — it does not have alcohol! Overdose & Withdrawal -​ Every abused drug is either an Upper or Downer -​ Laxatives are abused by the elderly -​ Upper -​ Types: -​ Caffeine -​ Cocaine -​ PCP/LSD (psychedelics/hallucinogens) -​ Methamphetamines -​ Adderall -​ Signs & Symptoms: -​ Things go UP! -​ Euphoria, tachycardia, restlessness, irritability, hyper reflexes (3+, 4+) increased bowels (borborygmi), diarrhea, spastic, seizures  -​ Priority: check reflexes -​ Anticipate suctioning d/t seizures -​ Downer -​ If it’s not an upper, then it’s a downer -​ Signs & Symptoms: -​ Things go DOWN! -​ Lethargic, respiratory depression/arrest, constipated -​ Priority: check respirations -​ Anticipate intubation/ventilation d/t respiratory arrest -​ After knowing that the drug is an Upper or Downer, ask yourself if it’s an Overdose or Withdrawal -​ Too little upper — makes everything go down -​ Too little downer — makes everything go up -​ Upper overdose = downer withdrawal -​ Biggest risk — seizures -​ Downer overdose = upper withdrawal -​ Biggest risk — respiratory arrest Drug Abuse in Newborn -​ Always assume intoxication not withdrawal at birth -​ After 24 hours or more after birth — withdrawal Alcohol Withdrawal Syndrome vs Delirium Tremens -​ Not the same -​ Every alcoholic goes through alcoholic withdrawal approx. 24 hrs after they stop drinking -​ Less than 20% alcoholics in alcoholic withdrawal syndrome progress to delirium tremens — about 72 hrs after they stop drinking -​ AWS — not life threatening to self to others -​ Regular diet -​ Semi private; anywhere -​ Up ad lib (free to move around anywhere) -​ No restraints -​ DT — can kill you; life threatening to self or others -​ NPO (seizures) or clear liquids -​ Private; near nursing station -​ Restricted bed rest (no bathroom privileges; not free to move around) -​ Restraints (vest or 2 point (extremities; opposite arm & leg) lock leathers) -​ Switch extremities every 2 hours -​ Both get anti-HTN med, tranquilizer, multivitamin containing Vit B1  -​ Anti-HTN since everything is going up due to downer withdrawal -​ Tranquilizer since they’re up -​ Multivitamin to prevent Wernicke Aminoglycosides -​ Dangerous; powerful class of abx — use it when nothing else works -​ Common tested drugs: -​ Top 5 -​ Psychiatric, Insulin, Anticoagulant, Digitalis, Aminoglycosides -​ Others -​ Steroids, Beta blockers, CCB, Pain, OB meds -​ Aminoglycosides = A Mean Old Mycin -​ Abx used to treat serious, resistant, life-threatening, gram negative infections -​ Treat a mean old infection with mean old mycin -​ Yes — TB, septic peritonitis, fulminating pyelonephritis, septic shock, infection from third degree wound covering >80% of body -​ No — sinusitis, otitis media, bladder infections, viral pharyngitis, strep throat -​ All aminoglycosides end in Mycin -​ Not all drugs ending in Mycin are aminoglycosides -​ Azithromycin, Erythromycin, Clarithromycin have THRO in middle = THRO them off the list! -​ Toxic effects: -​ Mycin — sounds like mice (think ears of Mickey Mouse) = Ototoxic -​ Monitor hearing, balance, tinnitus -​ Human ears are shaped like kidneys = Nephrotoxic -​ Monitor Creatinine (best indicator of kidney function) -​ If they ask 24 hr creatinine or serum creatinine, 24 hr is better -​ Number 8 drawn inside the ear reminds you of: -​ Toxic to CN8 (ear nerve) -​ Administer every 8 hours -​ Route: IM or IV -​ Do not give PO — they are not absorbed -​ Except in: -​ Hepatic encephalopathy (hepatic coma) when ammonia gets too high — kills E. coli (#1 producer of ammonia) in the gut & decreases ammonia level -​ Pre-op bowel surgery to sterilize the bowel  -​ Will not have ototoxicity or nephrotoxicity because they are not absorbed -​ Oral Mycin = sterilizes bowel -​ Neomycin & Kanamycin -​ ”Who can sterilize my bowel?” — Neo Kan! Peak & Trough -​ Trough — when drug is at its lowest -​ Peak — when drug is at its highest -​ TAP levels — trough, administer, peak -​ Trough before drug admin -​ Peak after drug admin -​ Drawn due to narrow therapeutic window — small difference in what works & what kills (such as digoxin) -​ Mean Old Mycins have TAPs drawn on them due to their narrow therapeutic windows — not the only drugs that have TAPs drawn but they a major class in which you draw TAPs -​ When to draw Trough & Peak:​ -​ Don’t have to know what the drug is — not medication dependent but route dependent -​ Troughs — always drawn 30 mins before next dose -​ Peaks — depend on route -​ SubL — 5-10 min after drug dissolves -​ IV — 15-30 mins after drug is finished (start clock when bag is empty) -​ IM — 30-60 mins -​ SubQ — depends on insulin (diabetes lecture) -​ PO — not necessary, not tested (forget about it) -​ If there are two right answers with peak questions, choose the answer with the highest time without going over time range  Lecture 3 Calcium Channel Blockers -​ CCB are like Valium for the heart — calm heart down -​ CCBs are negative inotropic, chronotropic, dromotropic = fancy words to say that they relax & calm heart — cardiac depressant -​ When would you want to relax, slow, calm heart down? -​ To treat A, AA, AAA -​ Antihypertensive — relax heart & blood vessels = BP goes down -​ AntiAnginal — relaxes heart & uses less oxygen; decreases oxygen demand -​ Angina will speed up heart & cause issues -​ AntiAtrialArrhythmia — treats atrial arrhythmias -​ Also treats SVT since Supraventricular means above the ventricles & atrium is above -​ Side effects: H&H — headache & hypotension -​ Headache = d/t vasodilation in brain & gives you a migraine (HA pertains to a lot of situations) -​ Hypotension = relaxes heart & blood vessels -​ Names: ends in “dipine” NOT “pine” — -​ “Dipine in the calcium channel’ -​ Others that are in this category: -​ Verapamil -​ Cardizem — can be given continuous IV drip -​ Assess BP & hold if SBP where? In water seal chamber -​ Intermittent = good (document it) -​ Continuous = bad (there is a leak; find it & tape it until it stops leaking) -​ Bubbling —> where? In suction control chamber -​ Intermittent = bad (suction is too low; go to wall & increase until continuous) -​ Continuous = good (document it) -​ If something is sealed — you should NOT have continuous bubbling cause that would mean it’s leaking (intermittent is good) Analogies -​ A straight catheter is to a Foley catheter as a thoracentesis is to a chest tube -​ The one staying in has a higher risk of infection Rules for clamping tubes -​ Do not clamp for more than 15 secs without order -​ Use rubber tipped double clamps (cover teeth of clamp with rubber so it won’t puncture tubing) Congenital Heart Defects -​ Every defect is either trouble or no trouble — nothing in between -​ Memorize: TRouBLe (lowercase vowels) -​ If a congenital heart defect is TRouBLe: -​ Need surgery now/soon to live -​ Has slowed/delayed growth & development (failure to thrive) -​ Has a shortened life expectancy -​ Parents will experience a lot of grief, financial & emotional stress -​ Pt is likely to be discharged home on a cardiac monitor -​ After birth, pt will be in hospital for weeks -​ Pediatrician or pediatric nurse will likely refer pt to a pediatric cardiologist -​ TRouBLe —> shunts blood Right to Left -​ TRouBLe —> Blue (cyanotic) -​ All TRouBLe starts with letter T -​ Tetralogy of Fallot -​ Truncus arteriosus -​ Transposition of the great vessels -​ Tricuspid atresia -​ Totally anomalous of pulmonary vasculature (TAPV) -​ Except, Left ventricular hypoplastic syndrome -​ No TRouBLe congenital heart defects -​ Ventricular septal defect (VSD) -​ Patent ductus arteriosus (PDA) -​ Patent foramen ovale -​ Atrial septal defect -​ Pulmonic stenosis -​ All children with a congenital heart defect (whether TRouBLe or not TRouBLe) will have murmur & echocardiogram done to find out cause of murmur -​ 4 defects of Tetralogy of Fallot -​ VarieD PictureS Of A RancH -​ VD = ventricular defect -​ PS = pulmonary stenosis -​ OA = overriding aorta -​ RH = right hypertrophy Infectious Disease & Transmission-Based Precautions -​ 4 types: standard/universal, contact, droplet, airborne -​ Contact precautions: -​ Types: -​ Anything enteric (can be caught by intestine; fecal/oral) -​ C diff, Hep A, E. coli, cholera, dysentery -​ Staph -​ RSV (droplets fall onto object then pt touches object or put it in mouth — kids get it from touching things that other kids touched) -​ Herpes -​ PPE: -​ Private room is preferred -​ Can be placed in same room as long as you cohort — same disease based on culture & NOT symptoms -​ Hand washing, Gown, Gloves -​ Disposable supplies (gloves, paper plates, plastic utensils) -​ Dedicated equipment (stethoscope, BP cuff) & toys stay in room -​ Droplet precautions: -​ For bugs traveling 3 feet on large particles due to coughing or sneezing -​ Types: -​ Meningitis -​ H. Influenzae b -​ Causes epiglottitis (nothing in throat) -​ PPE: -​ Private room is preferred -​ Can be in same room if cohort based on culture -​ Meningitis culture from spinal taps/lumbar punctures -​ Hand washing, Mask, Gloves -​ Pt wears mask when leaving room -​ Disposable supply -​ Dedicated equipment -​ Airborne precautions: -​ Types — “MTV” -​ MMR (measles, mumps, rubella) -​ TB (spread by droplet but airborne precaution since particles stays in air) -​ Varicella (chickenpox) -​ PPE: -​ Private room required unless cohorting -​ Hand washing, Mask, Gloves  -​ Pt wears mask when leaving room -​ Special filtered mask for TB -​ Keep door closed -​ Disposable supply (not essential) -​ Dedicated equipment (not essential) -​ Negative airflow PPE -​ Order to put it on — reverse alphabetical for G’s but mask comes second -​ Gown -​ Mask -​ Goggles/Face Shield -​ Gloves -​ Order to take it off — in alphabetical order -​ Gloves -​ Goggles/Face Shield -​ Gown -​ Mask Math Problems -​ Dosage calculation -​ IV drip rates = Volume x Drop factor/Time -​ Micro/Mini drip = 60 drops per mL -​ Macro drip = 10 drops per mL -​ Pediatric dose (2.2 lbs = 1 kg) -​ Always be dividing by 2.2 -​ Leading zeros as long as they maintain place — NO trailing zeros -​ Boards will tell you what to round to -​ You do not have to put units in answer  Lecture 4 Crutches, Canes, Walkers -​ Measuring Crutches -​ Important for risk reduction & avoiding nerve problems -​ Length of crutch — 2-3 finger widths below anterior axillary fold to a point & lateral to slightly in front of foot -​ Wrong — landmarks on foot or say axilla! -​ Hand Grip measurement -​ Can be adjusted up & down -​ When hand grips are properly placed, the angle of elbow flexion will be about 30 degrees -​ How to Teach Crutch Gaits -​ 2 point gait — move a crutch & opposite foot together followed by the other crutch & other foot together — always moving 2 things 2gether 2,2,2… -​ 3 point gait — moving two crutches & bad leg together followed by good leg — 3,1,3,1… -​ 4 point gait — move everything separately -​ Move crutch, opposite leg, other crutch, other leg, etc. — very slow but stable -​ Swing through — for non-weight bearing such as amputation — bad leg never touches down -​ Can move really fast -​ When to Use Gaits -​ Even for even, Odd for odd -​ Even numbered gaits when the weakness is evenly distributed — even number of legs messed up -​ 2 point for mild problem -​ Mild bilateral weaknesses -​ 4 point for severe problem -​ Severe bilateral weaknesses -​ Odd numbered gait when affected leg is odd -​ 3 point -​ If pt cannot bear weight or have amputation -​ Swing through -​ Going Up & Down Stairs with Crutches -​ Up with the Good, Down with the Bad -​ Up stairs — lead with good leg -​ Down stairs — lead with bad leg -​ Crutches always move with bad leg  -​ Canes -​ Hold cane on strong side -​ Advance with bad leg for wide base of support which keeps you upright -​ Walker -​ Pick them up, Set them down, Walk to them -​ Don’t tie belongings to front of walker, tie on side so it won’t tip over -​ Wheels & tennis balls can create problems Psych -​ Non-psychotic vs psychosis -​ First decide if pt is non-psychotic or psychotic -​ Matters since it’ll determine treatment, goals, prognosis, medications, length of stay, legalities, etc. -​ Non-psychotic person -​ Has insight & reality based -​ They know they have a problem, they know what the problem is, they know how it’s messing up their life & what they sense is what you can sense -​ Good therapeutic communication -​ Tell me more about… -​ That must be very difficult.. -​ How are you feeling… -​ Reflection, clarification, amplification, restatement, etc. -​ Psychotic person -​ Has no insight & not reality based -​ They don’t know they’re sick & think everyone else has the problem & not them — blames everyone but themselves -​ They may be able to state the disease but doesn’t mean they have the insight -​ Delusions, hallucinations, & illusions — psychotic symptoms -​ Delusions — false, fixed belief or idea or thought -​ Fixed — they don’t change it -​ No sensory component — all in head -​ 3 types of delusions: -​ Paranoid: people are out to harm you -​ Grandiose: you are superior (I am the world’s smartest man; I am the President) -​ Somatic: body part (I have X-ray vision; there are worms inside my arm; my body is hollow) -​ Hallucinations — false, fixed sensory experience  -​ Auditory (1st most common) -​ Hearing things that aren’t there -​ Voices telling you to harm yourself -​ Visual (2nd most common) -​ Seeing things that aren’t there -​ Tactile (3rd most common) -​ Feeling things that aren’t there -​ Gustatory -​ Tasting things that aren’t there -​ Olfactory -​ Smelling things that aren’t there -​ Illusions — misinterpretation of reality/what’s going on -​ Sensory experience Differentiation between hallucinations & illusions -​ Illusion — there is a referent in reality -​ Something in reality to which a person refers when they say something — something's there but they just misinterpret what it is -​ Hallucination — there is absolutely nothing there How to Deal with Psychotic Patients -​ First ask what type of psychosis does pt have -​ 3 types of psychosis: -​ Functional psychotic -​ Can function in everyday life (have a job, married, take care of themselves, pay taxes, etc.) -​ No brain damage but chemicals are out of balance — have potential to learn reality -​ Role as nurse — teach reality -​ 4 step process: -​ Step 1: Acknowledge feeling -​ Usually word “feel” is in answer/or word specifies feeling -​ I see you’re upset…that must be distressing…that’s so sad…tell me more about what you’re feeling… -​ Step 2: Present reality -​ You can tell them what reality is or compare their views with yours  -​ I know…is real to you..but I don’t…I understand those voices are real to you but I don’t hear them….I am a nurse, this is a hospital and this is your breakfast -​ Step 3: Set limits -​ That topic is off limits in our conversation…When we talk together, we’re not going to talk about that…Stop talking about… -​ Step 4: Enforce limits -​ Ending the conversation — not taking away privilege like a punishment -​ Good because you won’t accomplish anything & by continuing you’re just reinforcing non-reality -​ I see you’re too ill to stay reality based so our conversation is over… -​ 4 diseases that make up 90% of this category: -​ “Skeezo, Skeezo, Major, Manics” -​ Schizophrenia, Schizoaffective disorder, Major depression (not depression), Mania -​ Bipolars are only psychotic in mania phase -​ Example: ”I can see that would be frightening. They are not plotting. We are not going to talk about that. I can see you are too ill. We are ending the conversation.” -​ Psychosis of dementia -​ Actual damage to brain -​ Due to Alzheimer’s, stroke, organic brain syndrome -​ Anything that says Senile/Dementia falls in this category -​ Cannot learn reality — do not present it -​ Will only frustrate & anger them & discourage you -​ Presenting reality is not the same as reality orientation (person, place, time) — appropriate with dementia -​ 2 steps: -​ Step 1: Acknowledge feeling -​ Step 2: Redirect them -​ Channel them from something they can’t do to something they can do  -​ Example: “I understand you seem to be scared. Let’s go somewhere you feel safe” -​ Psychotic Delirium -​ Temporary, sudden, dramatic, episodic, secondary loss of reality -​ Usually due to some chemical imbalance in body -​ Crazy for the short term because of something else causing them to be crazy — due to drugs/medications (withdrawal, overdose, post op, UTI, thyroid storm, adrenal crisis, electrolytes) -​ Manage by treating underlying cause -​ 2 steps:​ -​ Step 1: Acknowledge feeling -​ Step 2: Reassure them of safety & temporariness of condition -​ Do not present reality since they lost touch with reality — won’t do anything -​ Example: “That must be scary. But you are safe. Your fear will go away when you get better.” How to Approach Questions -​ 1st step: Is pt non-psychotic or psychotic? -​ 2nd step: If non-psychotic → good therapeutic communication -​ 3rd step: If psychotic → figure out which of the 3 categories -​ All three start with acknowledge feeling -​ Next step always begins with Re — Reality, Redirect, Reassure Psychotic Symptoms -​ Loose associations — thoughts are wrapped too tight/all over the map -​ Flight of Ideas — go from thought to thought -​ Say phrases that are coherent but phrases aren’t connected/coherent together -​ Word Salad -​ Sicker than flight of ideas -​ Can’t make phrase that is coherent — just babble random words -​ Neologisms — making up imaginary words -​ Narrowed self-concept — when a psychotic refuses to leave their room or change their clothes -​ Functional psychotic -​ Self-concept — how you define who you are -​ They define themselves very narrow — based on two things: where they are & what they’re wearing  -​ Reason for doing so — they don’t know who they are unless they are wearing those things in that room — terrifies them to change & leave -​ Don’t make them do it — they will cease to know who they are & they will panic = someone will get hurt -​ “I see you are uncomfortable/upset. You do not have to leave your room or change your clothes until you are ready.” -​ Idea of reference – You think everyone is talking about you  Lecture 5 Diabetes Mellitus — error of glucose metabolism (glucose is body’s primary fuel source — w/o it, cells die) -​ Lack of insulin -​ Insulin resistance Diabetes Insipidus — not a type of DM -​ Polyuria & polydipsia leading to dehydration d/t low ADH -​ Just the fluid part of DM — high UOP -​ Opposite of DI — SIADH DM has polyuria & polydipsia — DI has polyuria & polydipsia -​ SIADH is the opposite of those conditions so… -​ Low UOP (oliguria) & not thirsty (retaining water) Amount of urine & specific gravity relationship — inverse -​ Less urine out = higher specific gravity -​ SIADH -​ More urine out = lower specific gravity -​ DM, DI Fluid volume deficit = DM, DI Fluid volume excess = SIADH Diabetes -​ Type I — Insulin dependent, Ketosis prone -​ Type II — Non-insulin dependent, Non-ketosis prone -​ S/S: Polyuria (pee a lot), polydipsia (drink a lot), polyphagia (eat a lot/inc swallowing) -​ Treatment: -​ Type I — don’t treat, they will DIE -​ Diet (least important) -​ Insulin (most important) -​ Exercise -​ Type II — don’t treat, they are DOA -​ Diet (most important) -​ Oral hypoglycemic (pill) -​ Activity -​ Least important for type I = most important for type II  -​ Diet for DM2 -​ Calorie restriction — primary dietary modification -​ They need 6 small feedings a day -​ Smaller more frequent meals keeps blood sugar more stable -​ Best – Restrict calories or divide meals? -​ Restrict calories is best bc eating 6 meals doesn’t limit calories with each meal Insulin — acts to lower blood glucose -​ 4 types: -​ R - Regular -​ Onset: 1 hr -​ Peak: 2 hrs -​ Duration: 4 hrs -​ Clear, solution — can be IV drip -​ HESI: Intermediate acting insulin -​ FDA: Rapid short acting insulin -​ R: regular, rapid, run IV -​ Pattern: 1-2-4 — remember peak! (2) -​ N - NPH -​ Onset: 6 hrs -​ Peak: 8-10 hrs -​ Duration: 12 hrs -​ Intermediate acting insulin -​ Cloudy, suspension = precipitates (particles fall to bottom over time) — cannot be given IV drip -​ N: NPH, not so fast (intermediate), not in bag (no IV) -​ Pattern: 6-8-10-12 — remember peak! (8-10) -​ Lispro/Humalog -​ Fast acting insulin -​ Give as pt begins to eat — with meal not AC (before meals) -​ Onset: 15 mins -​ Peak: 30 mins -​ Duration: 3 hrs -​ Pattern: 15-30-3 -​ Glargine/Lantus -​ Long acting insulin -​ No peak — slowly absorbed -​ Little to no risk for hypoglycemia -​ Only one you can safely give at bedtime  -​ Duration: 12-24 hrs -​ Always check insulin expiration dates! -​ What action invalidates the manufacturer's expiration date? -​ Opening the package/vial -​ Expiration date is only good if still closed -​ Once the package is open, manufacturer's expiration date is irrelevant — new expiration date is 30 days after that -​ Make sure to write: -​ ”OPEN” and the date when it was opened or ”EXP” and expiration date -​ Refrigeration is optional in the hospital but you should teach patients to refrigerate insulin at home -​ Unopened vials of insulin should be refrigerated in the hospital -​ When vial is opened: you must write new expiration date & it does not need to be refrigerated any longer — in the hospital -​ Exercise potentiates (does the same thing as) insulin -​ Exercise is like having another shot of insulin -​ More exercise = more shots of insulin = need less insulin -​ Less exercise = need more insulin Sick days -​ When a diabetic gets sick = glucose will go up (due to stress of illness) -​ Have to take insulin even if they aren’t eating -​ Take sips of water because they will get dehydrated -​ Any sick diabetic has 2 problems: -​ Hyperglycemia & Dehydration -​ Stay active as possible — helps lower glucose Acute complications -​ Low blood glucose (in DMT1 or 2) called hypoglycemia, hypoglycemic shock, or insulin shock/reaction -​ Causes: -​ Not enough food -​ Too much insulin/medication -​ #1 cause of hypoglycemia in diabetics — danger: permanent brain damage -​ Too much exercise -​ Signs & Symptoms: Drunk in Shock -​ Drunk -​ Staggering gait  -​ Slurred speech -​ Poor judgment -​ Cerebral impairment (labile: all over the place; laugh, cry, laugh, cry) -​ Slow/delayed reaction time -​ Decreased social inhibition -​ Shock — vasomotor collapse -​ Low BP -​ Tachycardia -​ Tachypnea -​ Cold/clammy -​ Pale -​ Mottled skin Treatment -​ Administer sugars (rapidly metabolizable carbohydrates) -​ Juice (any), candy, regular soda, milk (lactose), honey, icing, jam, jelly -​ Boards wants combo: sugar + starch or protein -​ Orange juice + crackers -​ Apple juice + slice of turkey -​ Milk is sugar + protein — use ½ skim milk to they don’t burn fats for ketones -​ Bad answer: -​ Candy + soda — too much sugar -​ 5 packs of sugar emptied into a glass of orange juice -​ Unconscious patients: -​ Setting will determine what you give -​ Give Glucagon IM -​ Instruct mom over phone -​ Give Dextrose (D10, D50) IV -​ In ER DKA — high blood glucose in type I (keto is the clue!) -​ Type I — ketosis prone -​ Causes: -​ Too much food -​ Not enough insulin/med -​ Not enough exercise -​ None of these three are the #1 cause of DKA — the #1 cause is acute viral upper respiratory infection within last 2 weeks (stress of illness caused it to go up — started burning fat for fuel) -​ Signs & Symptoms: DKA  -​ Dehydration (dry mucous membranes, weak, threads pulses, poor skin elasticity + turgor, headache, dry skin, hot, flushed, dry) -​ Running out of coolant/water in car — it overheats -​ So when you’re dehydrated, you overheat & your skin is flushed -​ Ketones in serum, Kussmauls, high K+ -​ Not everyone with ketones in urine has DKA -​ Kussmaul's — hyperventilate -​ Acidosis, Acetone breath (fruity odor), Anorexia (due to nausea) -​ Treatment: -​ Insulin IV (Regular) -​ IV fluids (fast rate — around 200 ml/hr) HHNK or HHS or HHNS — high blood glucose in type II -​ These pt don’t burn ketones = no acid -​ Whenever you think of HHNK, think of dehydration! -​ Skin is dry, warm, flushed, decreased turgor, increased HR -​ #1 Nursing Diagnosis — Fluid volume deficit -​ #1 Nursing Intervention — Rehydrate with fluids -​ Outcomes — Increased UOP, moist mucous membranes, etc. Between DKA & HHNK -​ Which is more dependent on insulin? DKA -​ Which one has a higher mortality rate? HHNK -​ Which has higher priority? -​ HHNK pts come later since they don’t have the symptoms — they come in when they’re already bad & may not make it -​ DKA pts are acutely ill that come in with all these symptoms that we can treat with rehydration with insulin Long term complications of diabetes: -​ Related to 2 things: poor tissue perfusion or peripheral neuropathy -​ Examples: Renal failure, gangrene, stasis ulcers, blindness, heart disease, brain disease, etc. -​ If they say, diabetics have renal failure = d/t poor tissue perfusion -​ If they say, diabetics lost control of bladder & are now incontinent = d/t peripheral neuropathy -​ Can’t feel when they injure themselves — peripheral neuropathy -​ Can’t heal well once they injure themselves — poor tissue perfusion Hb A1C — lab test that is the best indicator of long-term blood glucose level -​ Aka Glycosylated Hb — avg blood sugar over last 90 days -​ Want it to be 6 or lower — normal -​ Hb >8 — out of normal -​ Hb 7 — borderline; have pt come in for evaluation/work up  Lecture 6 Drug Toxicities -​ Lithium (anti-mania drug) -​ Used for bipolar — not used for the depression just the mania -​ Therapeutic level — 0.6-1.2 -​ Toxic level — greater than or equal to 2 -​ Notice gray area — higher than 1.2 but under 2 -​ Lanoxin/Digoxin -​ Used to treat Afib & CHF -​ Therapeutic level — 1-2 -​ Toxic level — greater than or equal to 2 -​ If given 2, it’s safer to call something toxic when it may not be than to say it’s therapeutic when it might not be — err on safe side -​ Aminophylline -​ Airway antispasmodic — relieves spasms in airway -​ Therapeutic level — 10-20 -​ Toxic level — greater than or equal to 20 -​ Non-therapeutic level — lower than 10 -​ They need to take more or question if they’re even taking it -​ Dilantin/Phenytoin -​ Used for seizures -​ Therapeutic level — 10-20 -​ Toxic level — greater than or equal to 20 -​ Bilirubin -​ Waste product of the breakdown of RBCs -​ Normal adult level — 0.2-1.2 -​ Always tested on Newborns -​ Newborns have higher bilirubin than adults since they are breaking down the mother’s RBCs -​ Elevated level — 10-20 -​ Toxic level — greater than or equal to 20 -​ Physicians want to hospitalize newborns with bilirubin of about 14-15 -​ Once you hit 15, you’re halfway to toxic Patterns for toxic levels -​ 2s & 20s -​ 2s: Lithium & Lanoxin — start with L = Low number -​ 20s: Aminophylline, Dilantin, Bilirubin = go High Jaundice — yellow color of skin due to bilirubin in blood  -​ Yellow skin & sclera Kernicterus — excess bilirubin in brain -​ Occurs when level in blood gets to around 20 -​ In the brain — causes aseptic (sterile) meningitis & encephalopathy due to irritation of bilirubin -​ Can be deadly -​ Causes Opisthotonos -​ Position that the newborn assumes when they have bilirubin in brain due to irritation of meninges -​ Hyperextended posture -​ Medical emergency -​ Place newborn on side Pathological vs. Physiological Jaundice -​ If newborn comes out yellow at birth = pathological -​ Something is wrong -​ If newborn turns yellow 2-3 days postpartum = physiological -​ That’s okay; typical & expected Dumping Syndrome vs. Hiatal Hernia -​ Both gastric emptying problems & are opposites -​ Hiatal Hernia -​ Regurgitation of gastric acid upward into esophagus -​ Gastric contents move in the wrong direction at the correct rate — stomach empties at a normal rate but the direction is the problem -​ S/S: Similar to GERD (heartburn & indigestion) -​ Hiatal hernia is GERD if you lie down after you eat -​ Treatment: want the stomach to empty faster so it doesn’t reflux/go back up -​ Elevate HOB during & after meals -​ Causes gravity to empty it faster -​ Increase amount of fluids with meals -​ Liquidity meal will go through stomach faster -​ Increase amount of Carb content -​ Carbs go through stomach fast -​ High-atal Hernia = everything High for tx -​ Dumping Syndrome -​ Usually follows gastric surgery -​ Gastric contents are dumped too quickly into duodenum -​ Gastric contents move in the correct direction at the wrong rate  -​ S/S: -​ Drunk: staggering gait, slurred speech, impaired judgment, delayed reaction time, emotional/labile -​ d/t cerebral impairment from decreased blood flow to brain since all blood is going to the gut -​ Shock: hypotension, tachycardia, tachypnea, pale, cold, clammy -​ Acute Abdominal Distress: N/V, diarrhea, cramping, pain, guarding, borborygmi, bloating, distension, tenderness -​ Treatment: want stomach to empty slower -​ Lower HOB (flat) during meals & turning to side to eat -​ Decrease amount of fluids — 1-2 hrs before or after meals -​ Decrease the amount of Carb content -​ Everything Low = stomach empties Slow Protein in diet? -​ Protein does opposite of carbs -​ Protein bulks gastric content, takes longer to digest, & moves slower through gut -​ Low protein in HH -​ High protein in DS Electrolytes -​ Kalemias do the same as the prefix (hypo/hyper) except for HR & UOP -​ Calcemias do the opposite as the prefix -​ Magnesemias do the opposite as the prefix Kalemias S/S -​ Hyperkalemia: -​ Brain: seizures, agitation, restlessness, aggression, irritability, obnoxiousness, decreased inhibitions -​ Lungs: tachypnea -​ Heart: bradycardia, tall T waves, elevated ST -​ Bowel: diarrhea, borborygmi -​ Muscle: spasticity, increased tone, hyperreflexia (+3 +4) -​ UOP: decreased UOP/oliguria -​ Hypokalemia: -​ Lethargy, bradypnea, tachycardia, polyuria, constipation, paralytic ileus, muscle flaccidity, hyporeflexia (+1) Calcemias S/S -​ Hypercalcemia:  -​ Bradycardia, bradypnea, flaccid muscles, hypoactive reflexes, lethargy, constipation -​ Hypocalcemia: -​ Agitation, Irritability (clonus), +3 +4 reflexes, spasm, seizure, tachycardia, Chvostek sign (tap cheek — cheek spasms (sign of neuromuscular irritability associated with low calcium)), Trousseau (inflate BP cuff — hand spasm) Choosing answers -​ For potassium — pick answers related to heart -​ Any other symptom not related to nerve or skeletal involvement -​ Generally anything affecting BP -​ For calcium — pick answers related to muscle & nerves/skeletal muscle & nerve involvement Common mistake -​ Tetany is caused by hyperkalemia not hypercalcemia even if it’s muscles! -​ Pay attention to the prefix! Natremias — Sodium -​ HypErnatremia = DEhydration -​ Hot, flushed, dry skin, thready pulse, rapid HR -​ Give fluid -​ HypOnatremia = Overload -​ Crackles, distended neck veins -​ Fluid restriction, Lasix -​ Nursing Diagnosis: Fluid volume excess Besides high potassium, what other electrolyte imbalance is possible in DKA? -​ Hypernatremia d/t dehydration SIADH — overload = hyponatremia DI — dehydration = hypernatremia HHNK — dehydration = hypernatremia Earliest sign of any electrolyte disorder -​ Paresthesia = numbness & tingling -​ Circumoral paresthesia = numb & tingling around lips Universal sign of all electrolyte imbalance -​ Paresis = Muscle weakness Treatment -​ Potassium is the only one boards will test -​ NEVER push potassium IV -​ Not more than 40 of K per L of IV fluid -​ If you receive an order of more than 40 — question, call, & verify with HCP How To Lower Potassium -​ High potassium is bad — can stop the heart -​ High potassium is the worst electrolyte imbalance -​ Fastest way to lower potassium: -​ Give D5W with regular insulin — drives potassium into cells & out of blood to decrease potassium (potassium in blood will kill you — not the potassium in the cells) -​ Doesn’t get rid of excess potassium but hides it in the cell -​ Good side: Quick -​ Bad side: Temporary solution — potassium will just leak back out -​ Long-term solution: Kayexalate/Sodium polystyrene sulfonate -​ Through enema or ingestion -​ Full of sodium — trades potassium for sodium -​ Potassium is eliminated through feces & pt becomes hypernatremic -​ Hypernatremic = dehydration -​ Managed with IV fluid administration -​ Good side: Permanent — gets rid of potassium outside of body never to reoccur -​ Bad side: Takes hours to work -​ To solve problem: -​ Give them both — D5W & regular insulin & Kayexalate at the same time -​ D5W & regular insulin work instantly — K Enters Early -​ Potassium — K -​ Makes K enter cell -​ Does it quick/early -​ Kayexalate works in a few hours — K Exits Late -​ Potassium — K -​ Makes K exit out body -​ Does it slow/late  Lecture 7 Thyroid & Adrenals -​ Thyroidism = Metabolism -​ Hyperthyroidism — Hypermetabolism — Graves Disease -​ S/S: Weight loss, HR up, BP up, Hyperpersonality (irritable, hyper, obnoxious, excited), heat intolerance (they’re already burning up), cold tolerance (they’re like a furnace; cold doesn’t affect them), exophthalmos (bulging eyes) -​ “You’re going to run yourself into the grave-s disease” — running all the time = hyper -​ Treatment -​ Radioactive iodine -​ Pt should be in a private room by themselves for 24 hrs — after that, they have to be really careful with their urine (flush 3x, call hazmat team if they spill on the floor) -​ No family visitation in first 24 hrs — if at home, they need to stay in room & no one can go in for 24 hrs -​ PTU (Propylthioruracil) — Puts Thyroid Under -​ Primary use: Cancer — monitor WBC d/t immunosuppression -​ Thyroidectomy -​ Surgical removal — most common tx -​ Pay attention if question is asking about total or sub (partial) -​ Total thyroidectomy: lifelong hormone replacement -​ Thyroid is gone & pt is at risk for hypocalcemia (almost impossible to spare the parathyroids) -​ Hypocalcemia S/S: -​ Paraesthesia, tetany, spasms, clonus, seizures, tachycardia, hypertension, irritability, jitteriness, tremor, Chvostek & Trousseau signs -​ Sub Thyroidectomy: do not need lifelong hormone replacement -​ Still have some thyroid left; may need to be on replacement/supplement for a little while -​ Risk for thyroid storm/crisis/thyrotoxicosis: medical emergency! (Can cause brain damage — permanent) -​ S/S: -​ Super high temp 105 or above -​ Extremely high BP — stroke category (about 210/180) -​ Severe tachycardia (180s & high as 200s)  -​ Psychotically delirious -​ Treatment: get temp down & oxygen up! -​ First step: Ice packs -​ Best step: Cooling blanket -​ Oxygen per mask at 10L -​ Stay with patient -​ Self-limiting condition — not really medicating; all we’re doing is sparing their brain until pt comes out of it -​ Post-op Risks: -​ First 12 hrs (doesn’t matter what type) -​ Top priority — airway (d/t edema) -​ Next problem — hemorrhage (since it is an endocrine gland which has lots of blood vessels) -​ Next 12-48 hrs (type matters) -​ Total: big danger = tetany (d/t low calcium) -​ Dangerous since it could close vocal cords in irreversible spasm = airway gets cut off -​ Total = Tetany -​ Subtotal: big danger = thyroid storm -​ Sub = Storm -​ After 72 hrs, big risk = infection -​ Hypothyroidism — Hypometabolism — Myxedema -​ S/S: Weight gain (obese), Hypopersonality (flat, boring, dull), cold intolerance, heat tolerance (can’t tolerate what you are), HR down, BP down, academically challenged (slow test takers, lower grades = can’t process fast enough) -​ Treatment: -​ Give hormones d/t not enough hormones — Levothyroxine (Synthroid) -​ Caution: -​ DO NOT sedate​ -​ They’re already super slow— could go into coma = myxedema coma -​ DO NOT hold thyroid pills unless explicitly ordered — especially before surgery (d/t suppressing effects of anesthesia) Adrenal Cortex -​ All adrenal cortex diseases start with A or C (Addison Disease, Cushing) -​ Addison Disease  -​ Under secretion of adrenal cortex -​ S/S: -​ Hyperpigmented (very tan) -​ Do not adapt to stress -​ Purpose of stress response: to perfuse brain with blood & give brain glucose (raise glucose & BP) -​ With Addison Disease, when they undergo stress — glucose & BP will go down = shock -​ Treatment: -​ Steroids -​ Glucocorticoids — end in -sone -​ “In Addison, you ADD a SONE” -​ Cushing’s Syndrome -​ Oversecretion of adrenal cortex -​ “Cushy bank account = more money” -​ S/S: (of both Cushing’s & Steroid medications) -​ Moon face -​ Hirsutism (beard) -​ Truncal/Central obesity (big body) -​ Muscle atrophy (arms & legs are skinny) -​ Gynecomastia (big breasts/bump on front) -​ Buffalo hump (bump on back) -​ Retaining sodium & water (full of water) -​ Loss of K+ (out the back) -​ Striae (stretch marks) -​ High serum glucose -​ Most important — hyperglycemics; look like diabetics -​ Need more insulin d/t steroid use -​ Accu-checks Q6H -​ Easy bruising (bruises) -​ “Roid rage” (grouchy/irritable) -​ Immunosuppressed -​ Treatment: -​ Adrenalectomy -​ Bilateral adrenalectomy = Addison’s -​ Give steroids (sone) to treat -​ Steroids can have side effects that cause pt to look like Cushman  -​ Takes about a year or two to get pt to start looking/feeling normal Kids Toys -​ Things to consider when choosing toys & play activities: -​ Is it safe? -​ Is it age appropriate? -​ Is it feasible? (Possible to do easily/conveniently) -​ Safety: -​ No small toys for children under 4 -​ Over 4 — small parts are fine -​ No metal (dye-cast) toys if oxygen is in use -​ Due to flint-sparks -​ Beware of fomites -​ Non-living object that harbors microorganisms (stuffed animals — worst fomites) -​ Hard plastic toys are fine — easily disinfected -​ Age Appropriate: -​ Infants: -​ 0-6 months -​ Sensorimotor (something that stimulates both motor & sensory) -​ Best: Musical mobile -​ 2nd best: Toy that should be large but soft (so they don’t hurt themselves or choke) -​ 6-9 months -​ Object permanence (concept that the object is still there even if they can’t see it) -​ Best: Cover/Uncover toys -​ Teaching them that concept -​ Examples: Jack in the Box, Peek a Boo, books that have windows -​ 2nd best: Toy that should be large but firm/hard (wood, metal, plastic) -​ Worst toy after 6 months — musical mobile d/t risk of strangulation -​ 9-12 months -​ Vocalization (learning to speak) -​ Best: Speaking/Verbal toys  -​ Examples: Woody Cowboy, Tickle me Elmo, See and say barnyard friends, Talking books -​ Purposeful play — should be at least 9 months -​ Purpose words: build, sort, stack, make, & construct -​ Toddlers: -​ 1-3 years -​ Gross motor skills (run, jump) -​ Best: Push/Pull toys -​ Examples: Lawn mower, wagon, strollers, dogs with floppy feet -​ DO NOT choose activities that take finger dexterity — colored pencils, scissors, etc. -​ They CAN paint (use hands) -​ Characterized by Parallel Play (play alongside others but not with others) -​ Preschoolers: -​ 3-6 years -​ Fine motor skills (finger dexterity — write, draw, use colored pencils, scissors -​ Balance (dance, ice skates, tricycles, tumbling) -​ Characterized by Cooperative Play (play with others) -​ Like to pretend — highly imaginative -​ School age: -​ 7-11 years -​ Concrete -​ Characterized by 3 C’s: -​ Creative -​ Give them blank paper to draw, they make whatever they’re playing -​ Toys: Legos, Transformers -​ Collective -​ Beanie bears, Pokémon, Baseball cards, Barbies -​ Competitive -​ Winner/losers (don’t like being the loser but like playing games where there is a winner & losers) -​ Adolescents: -​ 12-18 years -​ Peer group association (want to hang out with friends) -​ Allow adolescents to be in each other’s room unless one of them has been/is:  -​ Recently post-op for 30 mins -​ Lie flat, log roll for 6 weeks -​ DO NOT drive for 6 weeks -​ DO NOT lift more than 5 lbs for 6 weeks (gallon of milk) -​ Permanent restrictions: -​ Laminectomy patients will never be allowed to lift objects by bending at waist (use knees) -​ Cervical laminectomy should never be allowed to lift anything over the head -​ No horseback riding, off trail biking, jerky amusement park rides, etc.  Lecture 8 Lab Values -​ Need to know lab values & which one is low, middle, high priority when compared to others — prioritize patients -​ Not enough to just know normal/abnormal values -​ ABCD scheme -​ A — low priority (abnormal but no big deal; don’t have to do anything about it — can be ignored for a few hours, all night long, & have doctor discover it in the morning) -​ B — concerning (abnormal & need to be concerned but there’s nothing to be done — just watch closely) -​ C — critical (you must do something about it) -​ D — highest priority (stay at bedside — can’t leave) -​ Creatinine — best indicator of kidney or renal function -​ Range: 0.6-1.2 -​ Level A (never prioritize a pt with high creatinine as high priority; they do have kidney disease but won’t die in the next few hours) -​ If pt will have dye procedure like catheterization — can be moved to Level B -​ INR — monitors Coumadin therapy; variation of PT -​ Range: 2-3 -​ Level C (if 4 & above) -​ Actions: Hold Coumadin —> Focus Assessment for bleeding —> Prepare to give Vit K —> Call HCP -​ Potassium -​ Range: 3.5-5.3 -​ Level C (if lower than 3.5) -​ Actions: Nothing to hold —> Focus Assessment of heart —> Prepare to give K+ —> Call HCP -​ Level C (if higher than 5.3) -​ Actions: Hold K+ —> Focus Assessment of heart —> Prepare to give Regular Insulin/Kayexalate & D5W—> Call HCP -​ Level D (if over 6) -​ Actions: Hold K+ —> Focus Assessment of heart —> Prepare to give Regular Insulin/Kayexalate & D5W STAT —> Call HCP & stay with pt -​ pH -​ Range: 7.35-7.45 -​ Level D (if pH is in the 6s) -​ Actions: Nothing to hold —> Focus Assessment of V/S —> Nothing to prepare —> Call HCP & stay with pt -​ BUN (Blood Urea Nitrogen) — waste product in blood -​ Range: 8-25 -​ Level A -​ Actions if elevated (no big deal): Nothing to hold —> Focus Assessment for dehydration —> Prepare IV fluid —> Call HCP -​ Hemoglobin — blood -​ Range: 12-18 -​ Level B (if 8-11) -​ Assess them for bleeding/anemia/malnutrition -​ Level C (if less than 8) -​ Actions: Nothing to hold —> Focus Assessment for bleeding/anemia/malnutrition —> Prepare blood —> Call HCP -​ Bicarbonate -​ Range: 22-26 -​ Level A -​ CO2 -​ Range: 35-45 -​ Level C (if in 50s) -​ Actions: Nothing to hold —> Focus Assessment of breathing/respiratory status —> Ask pt to perform pursed-lip breathing (prolonging exhaling to get rid of CO2) —> Call HCP -​ Not a COPD pt -​ Most of the time the pursed lip breathing will fix so you don't’ have to call — they breathe easier instead of being dyspneic -​ Level D (if in 60s or higher) — one of the criteria to make it respiratory failure -​ Actions: Nothing to hold —> Focus Assessment of breathing/respiratory status —> Prepare to intubate/ventilate —> Call (RT first & then HCP) & stay with pt -​ Hematocrit -​ Range: 36-54 (remember by mult 3 to Hgb) -​ Level B -​ Actions if elevated: Assess for dehydration -​ O2/PaO2 (from arterial blood gas NOT pulse ox) -​ Range: 78-100 -​ Level C (if 70-77) -​ Actions: Nothing to hold —> Focus Assessment for respiratory difficulty & dyspnea —> Prepare to give oxygen —> Call HCP -​ If pt with hypoxia — HR increases first & then RR increases after d/t compensation  -​ In a coronary care unit, the two most common causes of episodic tachycardia in heart pt = hypoxia & dehydration -​ Treatment: giving O2 to pt & increasing rate of fluid administration usually solves the problem -​ Know it worked when dyspnea, restlessness, tachycardia, & anxiety goes away -​ Level D (if in the 60s or lower) — other criteria to make it respiratory failure -​ Actions: Nothing to hold —> Assessment for respiratory difficulty & dyspnea —> Prepare to intubate/ventilate —> Call (RT first then HCP) & stay with pt -​ Can put oxygen on pt — won’t solve problem but will make them more calm -​ *Resp failure — CO2 & O2 both in 60s = intubate/ventilate! -​ COPD pts have various ranges (usually high on CO2 & low on O2) -​ *Assess before you do — unless delaying doing put pt at higher risk (in that case, do before you assess) -​ *Other example: -​ Best: Oxygen -​ First: Elevate HOB -​ O2 Saturation -​ Range: 93-100 -​ Level C (if less than 93) -​ Action: Nothing to hold —> Assess —> Give pt O2 —> Call HCP -​ Less than 95 is bad in peds cause they don’t desaturate like adults -​ What could invalidate reading? -​ Anemia & dye procedure in last 48 hrs (colors blood) -​ Both are falsely elevated — seems like pt is better off than they actually are -​ BNP (brain natriuretic peptide) — best indicator for CHF -​ Range: Assess for fluid overload (hyponatremia)/Assess for dehydration (hypernatremia) —> Prepare for furosemide (hyponatremia)/IV fluid (hypernatremia) —> Call HCP -​ Level C (if abnormal & there is a change in pt LOC)  -​ Safety issue -​ WBC -​ Total WBC: 5k-11k -​ Level C (if less than 5k) -​ ANC (absolute neutrophil count): >500​ -​ Level C (if less than 500) -​ CD4: >200 -​ HIV = CD4 >200 but Place pt on neutropenic precautions -​ Platelet -​ Range: 150k-450k -​ Level C (if less than 90k) -​ Level D (if less than 40k) -​ Place pt on bleeding precautions -​ RBC -​ Range: 4-6 million -​ Level B (if abnormal) Five Deadly D’s -​ K+ in the 6s -​ pH in the 6s -​ CO2 in the 60s -​ O2 in the 60s -​ Plt