Mark Klimek's Lecture Notes PDF

GUIDE Mark Klimek’s Lecture Lecture 1— Acid-Base Balance Dumping/HH Ventilators Electrolytes: K+, CA, MG, and NA Lecture 2— Alcohol...

GUIDE Mark Klimek’s Lecture Lecture 1— Acid-Base Balance Dumping/HH Ventilators Electrolytes: K+, CA, MG, and NA Lecture 2— Alcohol TX for HyperKalemia Wernicke Overdose and Withdrawal Lecture 7— Thyroid (Hyper-, Hypo-) S/Sx Adrenal Cortex (Addison Aminoglycosides Disease, Cushing) Peak and Trough Toys Laminectomy Lecture 3— Drug Toxicities (Lithium, Lanoxin, Dilantin, Bilirubin, Lecture 8— Lab Values Aminophylline) Five Deadly Ds Kernicterus Neutropenic Precaution Dumping/HH Electrolytes: K+, CA, MG, Lecture 9— Psych Drugs and NA Tri TX for HyperKalemia Benzo MAOI Lecture 4— Crutches Lithium Canes Prozac Walkers Haldol Delusions Clozaril Hallucinations Zoloft Psychosis Psychotic and Non-Psychotic Lecture 10— Maternity and Neonatology Hallucination Illusion Lecture 11— Fetal Complications Delusion Stages of Labor Assessments Lecture 5— Diabetes Mellitus Variations for NB Diabetes Insipidus Maternity Meds SIADH Medication Hints Insulin Psych Tips DKA Operational Stages HHNK Lecture 12— Prioritization Lecture 6— Drug Toxicities (Lithium, Delegation Lanoxin, Dilantin, Bilirubin, Staff Management Aminophylline) Guessing Strategies Kernicterus Page 1 of 92 Page 2 of 92  Lecture 1 Mark Klimek 92:21 Acid/Base Balance (Start times: 30:00) In order to solve acid-base disorders, it is important to know the normal values for pH, CO2 and HCO3 (bicarbonate), which are shown below pH 7.35 to 7.45 CO2 35 to 45 HCO3 22 to 26 The first value to look at in an acid-base disorder is the pH If pH is 2.0 Notice gray area: 1.3 to 2 2. Lanoxin or Digoxin Used to treat A-Fib and CHF Therapeutic level: 1 to 2 Toxic level: >2 3. Aminophylline—muscle spasm relaxer for the airway Compound of the bronchodilator theophylline Therapeutic level: 10 to 20 Page 38 of 92  Toxic level: >20 Non-therapeutic level: 20 5. Bilirubin Breakdown product of Red Blood Cells Normal level in adults: 0.2 to 1.2 Always tested in the Newborns on the NCLEX In Newborns bilirubin is much higher than in adults o Elevated level: 10 to 20 o Toxicity: >20 When do physicians want to hospitalize these newborns? o When bilirubin level is about 14 to 15 Page 39 of 92 Patterns 1s and 10s 2s and 20s o 2s: Low # (Lithium and Lanoxin) o 20s: High # (Aminophylline, Dilantin and Bilirubin) Jaundice—Yellow skin from excess bilirubin in the blood It appears as yellow skin and sclera Kernicterus—Excess bilirubin in the brain Occurs when level in the blood gets >20 In the brain, it may cause aseptic (sterile) meningitis or encephalopathy (don’t need to know) It can be DEADLY Opisthotonos Position the newborn assume due to irritation of the meninges from kernicterus Presentation: hyperextended posture … (Is a medical emergency) Question In what position do you place an opisthotonic newborn? Put newborn on the side Pathological vs. Physiological Jaundice If the newborn comes out yellow, something is wrong = Pathologic jaundice If the newborn turn yellow 2 to 3 days postpartum, that’s ok = Physiologic jaundice Dumping Syndrome vs. Hiatal Hernia Both gastric emptying problems and are opposites Hiatal Hernia Regurgitation of gastric acid upward or backward into esophagus Page 40 of 92  “Like a cow with 2 stomachs,” gastric contents go in wrong direction at the correct rate S/Sx of hiatal hernia is similar to GERD (Heartburn and indigestion) S/Sx of hiatal hernia = S/Sx of GERD when lying down after a meal o In other words, Heartburn, Indigestion on lying down after eating Treatment o Can do 3 things, as shown below 1. Elevate HOB (head of bed) during and 1 hour after meals 2. Increase the amount of fluids with meals 3. Increase the amount of Carb content o These cause the stomach to empty quickly so its content doesn’t back up o High-atal Hernia … Everything high Dumping Syndrome Gastric contents are dumped too quickly into duodenum o Right direction but at wrong rate S/Sx of dumping syndrome o Drunk: Staggering gate, impaired judgment, labile—all blood gone to gut o Also get Shock: cold/clammy, tachycardia, pale o Now add Acute abdominal distress: n/v, diarrhea, cramping, guarding, borborygmi, bloating, distention Dumping syndrome = Drunk, Shock, Acute Abdominal Distress Note Drunk is what it is Shock is what it is Drunk + Shock = Hypoglycemia Drunk + Shock + Acute abdominal distress = Dumping syndrome Page 41 of 92 Treatment of Dumping Syndrome Can do 3 things, as shown below 1. Lower HOB (head of bed) during meals and turn pt on the side 2. Decrease the amount of fluids 1 or 2 hours before or after meals 3. Decrease the amount of Carb content o These 3 things prevent the stomach to empty quickly or dump its content into the duodenum Dumping syndrome … Everything low What is protein is added in the diet? Protein does the opposite of carbohydrate Protein bulks gastric content, takes longer to digest, and moves slower through the gut Therefore, give o Low protein in hiatal hernia o High protein for dumping syndrome Electrolytes Memorize these 3 sentences 1. Kalemias do the same as the prefix (hypo-, hyper-), except for HR and urine output which go opposite 2. Calcemias do the opposite as the prefix 3. Magnesemias do the opposite as the prefix Natremias o HypoNatremia = Volume overload … HyperNatremia = Dehydration Kalemia(s) Go in the same direction as the prefix, except for HR and urine output (UO), which go in the opposite direction Hypo—Symptoms go low with hypo, except HR and UO Hyper—Symptoms go high with hyper, except HR and UO Some S/Sx of Hyperkalemia Brain: seizures, agitation, irritability, loud down Heart: tented T waves, ST elevated, tachypnea Bowel: diarrhea, borborygmi Muscle: spasticity, increase tone, hyperreflexia (3+, 4+) Heart rate: down (bradycardia) UO: down (oligouria) Some S/Sx of Hypokalemia Lethargy, bradypnea, paralytic ileus, constipation, muscle flaccidity, hyporeflexia (0, 1+) Tachycardia (HR is up) Polyuria (UO is up) Page 42 of 92 Question Your patient has hyperkalemia, select all that apply a. Adynamic ileus b. Obtunded c. 1+ reflex d. Clonus (irritable) e. U wave f. Depressed ST g. Polyuria h. Bradycardia Answer Kalemia goes in the same direction, except HR and urine output … therefore, Clonus are bradycardia are right Calcemia(s) Go in the opposite direction as the prefix Hypo—Symptoms go high with hypo Hyper—Symptoms go low with hyper Calcemias do the opposite of the prefix—it is a sedative So Hypercalcemia is bradycardia, bradypnea, flaccid, hypoactive reflexes, lethargy, constipation, etc. So Hypocalcemia is agitation, irritability, 3+ or 4+ reflexes, spasm, seizure, tachycardia, Chvostek sign (tap the cheek), Trousseau (inflate BP cuff), etc. Choosing answers for potassium and calcium For potassium pick answers related to heart problems For calcium pick answers related to muscle problems Magnesemia(s) Magnesium goes in the opposite direction of the prefix—it is also a sedative It is possible that S/Sx are from several electrolytes imbalances. In that case, Choose CALCIUM if nerve or skeletal involvement Pick POTASSIUM for any other symptom o Generally anything effecting blood pressure Your patient has diarrhea … Which one of the following electrolyte imbalances causes diarrhea? Hyperkalemia, hypokalemia, hypocalcemia, or hypomagnesemia Tetany? Hypocalcemia Test tip Common mistake Tetany = Hyperkalemia—prefix example. Pay attention Page 43 of 92 Natremia(s)—Sodium HypErnatrema = DEhydration o Hot, flushed, dry skin, thready pulse, rapid HR … Give fluid o Associate “E” in hypernatremia with DEhydration HypOnatremia = Overload o Crackles, distended neck veins … Fluid restriction, Lasix o Associate “O” in hyponatremia with Overload o Nursing Dx: Fluid Volume Excess Question In addition to a high potassium, what other electrolyte abnormality can be seen in DKA? Hypernatremia = Dehydration DKA should make you think of DEhydration, which is also associates with hypErnatremia Question In addition to High Potassium what other electrolyte imbalance is possible in DKA? Answer: Hypernatremia Review—Think dehydration or Fluid overload SIADH: Hyponatremia DI: Hypernatremia HHNK: Hypernatremia How to spot early signs of electrolyte imbalance? The earliest sign of any electrolyte disturbance is o Numbness and tingling = Paresthesia o Circumoral paresthesia = Numbness and tingling around the lips The universal sign of all electrolyte imbalances is o Muscle weakness = Paresis Treatment Potassium is the only one Boards will test Never Push Potassium IV Potassium 40 mEq/L, clarify dosage with physician How do you lower potassium? Of all electrolyte imbalance, high potassium is the most problematic High potassium can stop the heart The fastest way to lower potassium level is to o Give D5W and regular insulin to decrease potassium o This will drive the potassium into the cell and out of the blood o Temporary solution but quick Kayexalate is long-term solution o Through enema or ingestion, Kayexalate exchanges potassium for sodium Page 44 of 92  o Potassium is eliminated through feces and pt becomes hypernatremic o Hypernatremia is managed with IV fluid administration o The downside is it takes hours to work To solve this problem o Give D5W, Regular insulin, and Kayexalate and the same time D5W and Regular insulin work instantly Kayexalate works in a few hours—K Exits Late Page 45 of 92  Lecture 7 Mark Klimek 115:33 Thyroid and Adrenals Since the thyroid gland regulate metabolism, whenever you see the word “thyroid,” change it to “metabolism” Hyperthyroidism Hypermetabolism So, what are the S/Sx of hypermetabolism? o Weight loss o HR up, BP up o Hyperpersonality o They have heat intolerance … Can tolerate cold because body is like a furnace o Exophthalmos (bulging eyes) … Think Susan Sarandon, or Don Knotts Exophthalmos is seen in Graves disease Run yourself into the Graves disease Figure 5. Don Knotts with Exophthalmos or Hyperthyroidism—3 Treatment Modalities bulging eyes. 1. Nuke it with radioactive iodine o Pt must flush three times after urinating o Call hazmat team if urine is spilled on the floor o Pt needs a private room in the first 24 hours o Visitors restriction and in hospital and at home in first 24 hours 2. PTU (Propylthiouracil) o PTU “Puts Thyroid Under” o PTU’s primary use is for cancer—Monitor WBC b/c pt is immunosuppress 3. Thyroidectomy o Surgical removal of the thyroid is the most common treatment o To answer questions on the Board correctly, pay attention whether it is a Total, Sub (a.k.a. Partial) thyroidectomy o Total thyroidectomy needs lifelong hormone replacement, and pt is risk for hypocalcemia due to difficulty to spare the parathyroid glands Page 46 of 92 Question What are the symptoms of hypocalcemia? Paresthesia, tetany, twitching, spasm, clonus, seizure, jitteriness, tremor (all UP!). also, Chvostek and Trousseau signs Treatment of Subthyroidectomy Do not need lifelong hormone replacement May need to supplement at first HOWEVER, they are at risk for thyroid storm S/Sx of thyroid storm — A medical emergency Temps of 105 or above o Get temp down, bring oxygen up o Bring body temperature down using ice packs/cooling blankets o Oxygen per mask at 10L o Stay with patient High BP, stroke level — about 210/180 Severe tachycardia 180 as high as 200 Psychotically delirious Lowering body temperature in thyroid storm First step is ice pack Best step is cooling blanket Postop Risks in total thyroidectomy and subtotal thyroidectomy First 12 hours—risks are the same for both total and subtotal 1. Top priority is airway, due to edema 2. Next is hemorrhage because it is an endocrine gland—very vascular Next 12 to 48 hours—It matters what kind of surgery you’ve had now 1. Total: big danger is tetany due to low calcium TOTAL = TETANY … Can close off airway with an irreversible spasm 2. Subtotal: big danger is thyroid storm SUBTOTAL = STORM (Severe) After 48 hours—risk is infection Note: For any type of procedure, the risk of infection significantly increases after 72 hours Hypothyroidism Hypometabolism So, what are the S/Sx of hypomatabolism? o Obesity o HR down, BP down o Personality: Flat, boring, dull o They have cold intolerance … Can tolerate heat o Academically challenged Page 47 of 92 Myxedema This is when a pt with severe hypothyroidism presents with skin involvement Myxedema coma Severe hypothyroidism leading to decreased mental status, hypothermia, and other symptoms related to slowing of function in multiple organs Medical emergency Treatment of hypothyroidism Levothyroxine (Synthroid) Taken in the morning 30 minutes to 1 hour before breakfast Taken alone on an empty stomach with water Do not sedate these pts They’re already super slow. They can go into a coma Question What pre-op order from the physician would you question? Ambien (zolpidem) at hs (at hs = at bedtime) Question A pt dx with hypothyroidism will be undergoing surgery the next morning. The physician ordered the pt NPO at 12:00 am. Pt is on Synthroid and multivitamin pills. What should the nurse question? Clarify the NPO order for the Synthroid … Why? o The pt needs the Syntroid medication to get through surgery. Otherwise, the condition may potentiate the suppressing effects of the anesthesia during surgery o Therefore, don’t hold thyroid pills unless explicitly orders Adrenal Cortex Disease Interestingly, all adrenal cortex diseases either start with an “A” or a “C” Addison Disease (a.k.a. hypoadrenalism or adrenal insufficiency), Cushing Addison disease Under secretion of steroids (they are a time bomb!) S/Sx: pts are Hyperpigmented (very tan) They do NOT adapt to stress Question What is the purpose of the stress response in an individual? To maintain o A normal blood pressure to perfuse the brain and other organs Page 48 of 92  o An adequate level of glucose to feed the body Question What could happen if these pts can’t adapt to stress? Under stress, pts with Addisson disease will go into shock and have an hypoglycemic episode (Addisonian crisis) Treatment Give steroids Glucocorticoids drugs that end in -SONE o Prednisone o Methylprednisone “In Addison, you ADD-a-SONE” Cushings Syndrome If you have a cushy touchie … You got more Figure 6. Cushings disease. Oversecretion of adrenal cortex (steroids) All the S/Sx of Cushings are the S/E of Steroid medications Draw picture of a little man Important! … Draw this picture over and Give man a MOON FACE over, while repeating the list on the left such that to commit to memory the S/Sx of Give him a beard—hirsutism Cushings and the S/E of steroid medications Draw a big body—truncal or central obesity Arms and legs are skinny—muscle atrophy Bump on front—gynecomastia (big breast) Bump on back—buffalo hump Fill him full of water (he is retaining Na+ and water) He is losing K+ out the back Give him some striae—stretch marks Most important one of all—high serum glucose o Do Accu-Checks q6h. They look like diabetics Easy bruising—put bruises all over him Make him say something in a speech balloon … “I’M MAD, BECAUSE I HAVE AN INFECTION” o Grouchy (“Roid rage”) o Immunosuppressed Question A pt comes in with an acute exacerbation of COPD. The pt is being treated with Solu-Medrol (methylprednilosone) IV push q8 hours to reduce the inflammation in the airway. What nursing action needs to be taken while the pt is on the medication? Do an Accu-Checks q6 hours Since pt is on steroid, his condition is similar to diabetes even though he is not diabetics Page 49 of 92  The complications are worse if pt is diabetic Treatment for Cushings Adrenalectomy What happens with a bilateral adrenalectomy? o Now pt has Addison disease o Now give steroids (ending in SONE) to treat. o Pt will start looking like Cushman (Cushinoid-like) o It takes about a year or so—after a lot of titration—for the pt to start looking normal Kids Toys (50:16) When you select toys and play activities for children, there are three things to consider 1. Is it safe? 2. Is it age appropriate? 3. Is it feasible? o Is it possible to do easily or conveniently? o For instance, swimming in hospital with body cast Safety Size (no small toys for kids under 4) Over 4 small pieces are fine NO Metal (or dye-cast) if oxygen is in use o Think of a flint-sparks! Beware of fomites o A fomite is a non-living object that harbors microorganisms, such as stuffed animals—the worst type of fomites o Hard plastic toys are fine … They can easily be disinfected Note If you have a child who is immunosuppressed … Give them a hard plastic action figure. It can easily be disinfected Age appropriate toys (See Piaget’s Theory of Cognitive Development on page 79) Infants 0 to 6 months— Sensorimotor. Best toy is a musical mobile (Best choice) Toy should be large but soft (2nd best choice) 6 to 9 months— Object permanence. Best toy teach them to Cover/Uncover This is to teach them that the object is still there even if they can’t see it Examples are: Jack-in-the-Box and Peek-a-Boo Toy should be large but firm Worse toy after 6 months is the Musical Mobile because of the risk of strangulation Page 50 of 92  9 to 12 months— Vocalization. Best toys are speaking or verbal toys Good list of toys are: Tickle me Elmo, Woody Cowboy, See and Say- Barnyard Friends, Talking books For purposeful play, the infant should be at least 9 months or older These words mean purposeful play: build, sort, stack, make, and construct Baby in womb for 9 months, another 9 months for purposeful play Toddlers 1 to 3 years— Work on Gross Motor skills, which is running, jumping Best toys for this age group are Push/Pull toys Examples are: Lawn mowers, Wagon, dog with floppy feet They can paint (They use the hand to paint) They are characterized Parallel Play (think terrible two) Preschoolers 3 to 6 years— Work on fine motor skills Therefore, preschoolers have finger dexterity; hence, can write, draw, use colored pencils, scissors Work on balance—Dance, ice skates, tricycles, tumbling They are characterized by Cooperative Play Need to cooperate in Preschool (= Pretend) You’d be the sheriff, I’ll be robber … Highly imaginative School age 7 to 11 years— Concrete Characterized by the “3 Cs” 1. Creative—Give them blank paper to draw, they like to get involved … Toys: Legos, Transformers 2. Collective—Baseball cards, Webkinz, Barbies, Beanie Babies 3. Competitive—Winner/losers Adolescents 12 to 18 years— Peer group association Allow adolescents to be in each other’s rooms unless one of them has been/is 1. Recently post-op for 30 minutes 2. Lie flat, log roll for 6 weeks 3. Don’t drive for 6 weeks 4. Don’t lift more than 5 lbs for 6 weeks (gallon of milk) Permanent restrictions Permanent restrictions 1. Laminectomy patients will never be allowed to lift by bending at waist (use knees) 2. Cervical laminectomy should never be allowed to lift anything over the head 3. No horseback riding, off trail biking, jerky amusement park rides, etc. … Note This lecture on laminectomy can be used to get any spinal cord question correct … Pay attention to location Page 54 of 92  Lecture 8 Mark Klimek 53:53 You will be asked to prioritize different pts based on lab values Therefore, it is not good enough to simply know the normal/abnormal lab values You would have to rank or prioritize pts based on abnormally critical lab values Use the “ABCD” scheme to prioritize pt based on lab values Low priority o A is low priority … This lab result can be ignored for a few hours or, if late at night, until very early morning o B is concerning … This lab result needs to be closely monitored High priority o C is critical … You need to do something The RN does the first set of assessments for this lab for Levels C or D … Example: V/S, lung o D is highest priority … Stay at the bedside and heart auscultations, abdominal exam, etc. Lab Values (05:11) Lab Range “ABCD” Scheme Creatinine (Cr) Best indicator of kidney or 0.6 to 1.2 Level A renal function Level B if dye procedure (such as a catheterization) is involved INR Monitors coumadin … Also 2 to 3 Level C when 4 and above reflects PT (or Prothrombin time) Action to take in following order … Hold Coumadin ! Focus Assessment for bleeding ! Prepare to give vit K ! Call HCP Potassium (K+) Blood chemistry 3.5 to 5.3 Level C if Low Level C if High Level D if over 6 LOW potassium … Action to take in the following order … Nothing to hold ! Assess heart (EKG) ! Prepare to give K+ ! Call HCP HIGH potassium (bet 5.4 and 5.9) … Action to take in the following order … Hold K+ ! Assess heart (EKG) ! Prepare to give Insulin/Kayexelate ! Call HCP HIGH potassium (6 or more) … Action to take in the following order … Hold K+ ! Assess heart (EKG) ! Prepare to give Insulin/Kayexelate STAT ! Call HCP, stay with pt pH Blood chemistry 7.35 to 7.45 Level D if pH in the 6s Action to take … Nothing to hold ! Assess V/S ! Nothing to prepare ! Call HCP Page 55 of 92 BUN Waste product in blood 8 to 25 Level A (Blood urea nitrogen) Action to take … Nothing to hold ! Assess for dehydration ! Prepare IV fluid ! Call HCP Hemoglobin (Hb) Blood 12 to 18 Level B if 8 to 11 Level C if