Acid-Base Balance and pH

so goes my pt (except for k+)

irritable/hyper-excitable,
borborygmi*

shut down

You see Kussmauls with metabolic acidosis

Then it's respiratory

For Over- pick alkalosis

Under- pick acidosis

gas exchange.

Sao2 matters.

Then it's metabolic.

If pt has prolonged vomiting or suctioning

metabolic acidosis

Metabolic acidosis

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)

a. Main tubing: reconnect
b. O2 sensor tubing (senses fio2 @ trachea area): reconnect

ventilating over (settings are too high)

ventilating under (settings are too low)

denial

#1 problem psychologically is denial.

Treat it by confronting it. Point out the difference from what they say and
what they do.

With abuse you confront, with loss you support.

the abuser gets to keep using

the significant other feels positive self esteem from
supporting the habit

Set limits & enforce them, teach them to say no. "I'm saying no because I'm
a good person."

Abuser gets significant other to do things for him/her that's not
in the best interest for the significant other. The nature of the act is
dangerous or harmful.

Set limits & enforce them, teach them to say no.
Manipulation is easier to treat than dependency because there's no positive
self esteem issue with manipulation.

dependency/codependency has 2 pts.

manipulation has 1 pt.

Amnesia with confabulation (memory loss with making up stories)

Don't confront them or present reality. Redirect them.

To prevent/stop it from getting worse: Take vitamin B1.

They don't have to stop drinking, and it's irreversible.

Makes you hate alcohol and if you drink it you'll get deathly ill.

Takes 2 weeks to get into the system.

Need 2 weeks to get out of system to safely drink again

1. Mouthwash
2. Aftershave
3. Perfumes/Cologne4. Insect repellent
5. Anything that ends in elixir
6. Alcohol based hand sanitizer
7. Unbaked icing (vanilla extract)
**They can have red wine vinegarette!

upper or downer

laxative

Caffeine, Cocaine, PCP/LSD (hallucinogens), Methamphetamines, Adderral

S/s: (Things go up) euphoria, tachycardia, tachypnea, restlessness,
irritability, borborygmi/diarrhea, reflexes +3/+4 (spastic), seizure

Heroin, Marijuana, Alcohol, Benzos (everything not an upper)

S/s: Lethargy, respiratory depression, bradycardia, bradypnea,

everything goes down

everything goes up

downer overdose and upper withdrawal

Always assume intoxication, not withdrawal at birth.

Baby has to be 24hrs old to go through withdrawal.

Withdrawal: difficult to console, exaggerated startle reflex, seizure risk, shrill
high pitch cry

withdrawal, **only a small amount get delirium
tremens**.
You go into alcohol withdrawal within 24 hrs.
You go into delirium
tremens within 72 hrs.

not life threatening, DT's can kill you

self or others, DT's are dangerous to self and
others.

Regular diet, semi-private room anywhere on unit, up adlib (go anywhere
they want), no restraints.

Meds: Antihypertensive pill, Tranquilizer, Vitamin B1

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

A mean old mycin for a mean old infection.

Life threatening, resistant, serious, and gram negative infections.

All end in mycin, but not all that end in mycin are mean old mycins

Arithromycin, Zythromycin, and Clarithromycin.

If it has thro, throw it off the list!!

They are ototoxic (ear toxic) mycin (mice- ears).

Monitor for hearing, tinnitus, vertigo/dizziness.

The human ear is shaped like the kidney, so watch for nephrotoxicity. Best indicator of liver funct: 24hr creatinine clearance** #2 serum creatinine.

Administer them q8hr. Route: IM or IV. Don't give PO for infection!

1. Hepatic encephalopathy/hepatic coma/liver coma (when ammonia level gets too high & gets to your brain) Kills the E. coli in the gut & lower the ammonia level

2. Pre-op bowel surgery to sterilize the bowelOral mycins will kill gram-negative bacteria in your gut (sterilize bowel)

Sargent asks: Who can sterilize my bowel? Neo can! NEOMYCIN and CANOMYCIN!

When drug is at its lowest (Draw before drug admin)

When drug is at its highest (Draw after drug admin)

(trough, administer drug, peak) for narrow therapeutic windows

Draw 30 mins before the next dose

5-10 mins after drug is dissolved

15-30 mins after drug is finished

30-60 mins

see diabetes lectur

They don't test PO peaks

pick the highest without going over

Valium for your heart (calms your heart down)

inotropics, negative dromotropics, and negative chromotropics.

Weaken, slow down, and depress the heart. Cardiac depressant.

-Anti-hypertensive -Anti-angina
-Anti-atrial-arrhythmia= it treats everything atrial related, EXCEPT
supra ventricular tachycardia (supra means above, above the ventricle is the
atrial).

Side effects: Headache & hypotension

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.

Peaks of p waves are evenly spaced

Chaotic squiggly line. No pattern

Sharp peak & jags. There's a pattern

Flat line

Answer will always be ventricular

Answer will always be atrial

Answer will always be ventricular

Asystole

Saw tooth

fibrillation

tachycardia

Premature ventricular contraction (PVC)
-A bunch of PVC's is like a short run of V-Tach

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!

V-Tach- Pt has a pulse

Kills you in 8 mins or less
-Asystole- No pulse
-V-fib- No pulse

ABCD's
1. 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
2. Beta blockers (ending in "lol")
Just like CCB's, same treatment, same side effects
3. Calcium channel blockers
-Better for asthmatics
4. Digoxin/Digitalis (Lanoxin)

dfib

Epinephrine & Atropine (In that order if Epi doesn't work)

Use Amiodarone for Ventricular

Reestablish negative pressure in the pleural space

Pneumothorax- The chest tube removes air

Hemothorax- The chest tube removes blood

Pneumohemothorax- The chest tube removes air & blood

Report in Hemothorax if- The chest tube isn't draining

Report in Pneumothorax if: The chest tube isn't bubbling

Apical (up high) removes air

Basilar (bottom of lungs) removes blood

Use both locations for Pneumohemothorax

Place apical & basilar on same side of surgery

Always assume chest sx / trauma is unilateral unless otherwise specified

The only time its bilateral is when they say it's bilateral

NOWHERE because that is the removal of the lung LOL

(Ex: Pneumovac, Pleur-evac, etc.)

Set it back up have pt take deep breaths, NOT an emergency*

It's an emergency* because positive pressure can get in plural space.
1. Clamp the water seal
2. Cut it away
3. Submerge in sterilized water
4. Unclamp because we reestablished the water seal.

**In a best/priority question you only get to pick one. In a first question you get to do the rest of the options, but you have to pick which one is first**

First** Cover hole with gloved hand

Best** Cover with Vaseline gauze

Intermittent bubbling: Always good, document*

Continuous bubbling: Always BAD, tape it*
-If it's sealed should it be continuously bubbling? No, it's leaking!

Intermittent bubbling: Always bad, suction isn't high enough*

Continuous bubbling: Always good, document*

Never clamp a tube for longer than 15 secs w/o a Dr order
-Use rubber tip double clamps

trouble or no trouble

need surgery to live, everything is bad, short life expectancy,
delayed growth & development, exercise intolerance, financial difficulties, pediatric cardiologist.

right to left, because R comes before L.

A no-trouble defect is left to right.

blue (cyanotic), left to right means acyanotic.

All trouble heart defects that are trouble start with T.

All heart defects (trouble or not) have a murmur and they all have an echocardiogram done.

-Ventricular Defect -Pulmonary Stenosis
-Overriding Aorta
-Right Hypertrophy

Anything enteric (fecal/oral)
-C-diff, Hep A (stands for anus), Herpes, Staph infections, and RSV (Respiratory Syncytial Virus, babies get it) transmitted by droplet but works best still on contact precautions

-Private room, but can be in the same room if in cohort

PPE- Gloves, Gown, Disposable supplies/dedicated supplies

(sneezing/coughing): Meningitis, H-flu (causes epiglottis)

-Private room, unless cohort
- They need a lumbar puncture for cultures

PPE- Gloves, Mask, Pt wears mask when leaving room, Disposable
supplies/dedicated supplies, No gown

Measles, Mumps, Rubella, TB, and Varicella.

-Private room required unless cohort.

Mask, Gloves, Special filter mask (ONLY FOR TB), Pt wear mask when
leaving room, Negative airflow room. TB is spread by droplet but airborne precaution.

Always take off in alphabetical order
-Gloves, goggles, gown, mask

Put on in the reverse alphabetical in the G's, but mask comes second Gown, mask, goggles, gloves

2-3 finger widths below the anterior axillary fold to a point lateral to and
slightly in front of the foot
*No landmarks on the foot or axilla**

Measure Hand Grip: up and down. The angle of elbow flexion is 30 degrees

move a crutch and opposite foot together

two crutches and bad leg together

left crutch followed by right foot, right crutch followed by left foot

non-weight bearing (amputation)

can bear weight

Use the even # gaits when the weakness is
evenly distributed (you have an even # of legs messed up)

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.

mild bilateral weakness

severe bilateral weakness

Up with the good, down with the bad.

Going upstairs, lead with good foot
(crutches move with bad legs)

Hold cane on strong side.

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**

Has insight (know that they're sick & know it's messing up their life)

Use good therapeutic communication (like normal people)

Doesn't think they're sick & has no insight

S/s: Delusions, Hallucinations, Illusions

A false, fixed idea or belief. Thinking, not sensing

False, fixed belief that people are out to harm you

False, fixed belief that you are superior

False belief about your body (X-ray vision)

False, fixed belief another person (usually famous or
powerful) is in love with them.

False, fixed belief that their partner is unfaithful

False, fixed of being treated in a malicious way

False, fixed sensory experience (5 senses)

Most common in order- Auditory, Visual, Tactile.

Rare ones -Gustatory (tasting) & Olfactory (smelling)

Misinterpretation of reality (sensory experience)

with an illusion there's a referent in reality. There's actually something there, but they just misinterpreted it. With a hallucination there's actually NOTHING there

Can be married, have a family, job, live alone, pay bills...
-90% of functionals are Schizo Schizo Major Manic
- Schizophrenia
-Schizo-affective Disorder
-Major Depression
-Manic Bipolar

brain damage

Temporary, sudden dramatic secondary loss of reality usually due
to a chemical imbalance in the body.

(Ex- Ppl high on uppers, withdrawal from downers, drugs like Tegamet, post
op pt, occult UTI in elderly, thyroid storm, adrenal crisis, etc)

Acknowledge their feelings

Present reality

Set a limit

Enforce the limit

Acknowledge their feelings

Redirect them

Acknowledge their feelings

Reassure them

Treat them like a functional. Set limits!

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

Polyuria, polydipsia leading to dehydration due to low ADH, low specific gravity, fluid volume deficit

Low urine output, oliguria, not thirsty, high specific gravity, fluid volume
excess

An error in glucose metabolism

Insulin dependent
-Ketosis Prone

S/s: Polyuria, polydipsia, polyphagia

Tx for type 1: Diet (least important), Insulin (most important), Exercise (DIE)

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)

Insulin lowers glucose levels (PEAK is tested more)

(Peak question)

has "R"
Onset is 1hr, peak 2hrs, duration 4hrs
-Clear solution
-Can be IV dripped
-R- Rapid & run
-Taken before a meal*

Onset 6hr, Peak 8-10hrs, Duration 12hrs
-Cloudy, suspension
-Never IV
-NPH- Not so fast & not in the bag
-Taken after a meal*

Onset 15 min, Peak 30 min, Duration 3 hours.
-Give insulin with meals*

Slowly absorbed, it has no essential peak, duration 12-24 hours
-Low risk of hypoglycemia
-Safely given at bedtime

30 days after that. Write the date you opened it and "exp" or "opened".

at home. Hospitals keep unopened bottles of insulin in the fridge, but they can come out of the fridge once opened.

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)

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.

percentages mixed of R and N (N is in the numerator, the bigger portion). If they ask you "x" units of 70/30, "x"*.7 and "x"*.3 = the % they get.

Yes. Clear to cloudy is R to N. RN's do it!

inject air into the N bottle, then inject the air into R,
then draw up the R, followed by the N= NRRN

Good = 6 & lower Needs work up / evaluation = 7
Out of control = 8 & up

Causes: Too much insulin/meds***, not enough food, too much exercise

S/s: [Drunk] Staggering gait, slurred speech, impaired judgment, delayed
reaction times, labile (emotions all over the place)
[Shock] Low BP, tachycardia, tachypnea, pallor, clammy, mottled skin

Tx: Rapidly metabolized carbs (sugar), juice, soda, candy, 1/2 skim milk,
orange juice & crackers, apple juice & turkey.
One sugar & one starch // one sugar & one protein. NOT two SUGARS!

*If unconscious give glucagon IM, D10W / D50W IV
*If you're talking to parents over the phone tell them give glucagon IM If they're in the ER, say IV dextrose

Higher Priority

Causes: Acute viral upper resp. infection within last 2 weeks***, too much food, not enough meds or exercise.

S/s: Dehydrated (hot, flushed, dry skin), Ketones in blood, Kussmaul, ^ K+, Acidotic, Acetone breath (fruity breath), Anorexia due to nausea

Tx: IV fluid fast rate w/ Regular Insulin

More Fatal

Causes: Dehydration

Tx: IV fluids

-Poor Tissue Perfusion
-Peripheral Neuropathy

Therapeutic lvl 0.6-1.2 // Toxic lvl Greater than 2

Therapeutic lvl 1-2 // Toxic lvl Greater than or equal to 2

Therapeutic lvl 10-20 // Toxic lvl Greater than or equal to 20

Therapeutic 10-20 Toxic lvl Greater than or equal to 20

Therapeutic lvl <9.9 Elevated lvl 10-20
(Hospitalize when you get halfway in the elevated lvl) Toxic lvl greater or = 20

Bilirubin in the brain. Occurs when bilirubin gets around 20

Position baby goes in when they have kernicterus

-They hyperextend due to irritation of the meninges
-What position should you put them in? On their side

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)

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

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

S/S Hypokalemia- Lethargy, tachycardia, bradypnea, dynamic ileum, constipation, flaccid muscles, hyporeflexia, polyuria

Do the opposite. Muscles & nerves

S/S Hypercalcemia- bradycardia, bradypnea, flaccid muscles, hypoactive
reflexes, lethargy, constipation

S/S hypocalcemia- Tachycardia, agitation, irritability, tachypnea, diarrhea, borborygmi, spastic muscles, hyperreflexia, seizure, chvostek (cheek, face spasm) sign & trousseau sign (BP hand spasm), gay french man* lol

Do the opposite. In a tie between Calcemia & Magnesium, don't pick Magnesium*

S/S: Hypermagnesima- Bradycardia, bradypnea, flaccid muscles, hypoactive reflexes, lethargy, constipation

S/S: Hypomagnesima- Tachycardia, agitation, irritability, tachypnea, diarrhea, borborygmi, spastic muscles, hyperreflexia, seizure

**The one with the E is dehydration, the one with the O is overload**

Dehydration- HypErnatremia, hot flushed skin give lots of fluids, hot/flushed
skin

Overload- HypOnatremia, fluid restriction & give Lasix

numbness/tingling aka Paresthesia

Nclex Vocab Word: Circumoral Parasthesia- Numb/tingling lips

All electrolyte imbalances cause muscle weakness AKA paresis

-Never IV push K+ --Never give more than 40 of K+ per liter of IV fluid

-Give D5W with regular insulin
-K+ enters early
-K+ in blood will kill you, not K+ in cells
-D5W with insulin will push the K+ into the cell
- Temporary but works fast ***

-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 ***

-Turn thyroid into metabolism (hyper metabolism)
-"You're going to run yourself into the grave".
-Missy Elliot is a closet Elsa, the cold never bothered her anyway,
and she hates the beach.

S/S:
-Weight loss, high HR, low BP, irritable/hyper, heat intolerance, cold tolerance, exophatalmos (bulging eyes)

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

-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, flatoring/dull personality, heat tolerance, cold intolerance, pulse &

Tx: BP low, slow people, myxedema
-Thyroid hormone Synthroid (levothyroxine)
-Do not sedate these people! They will get into a myxedema coma

-NEVER HOLD THYROID HORMONES THE DAY OF SURGERY!

S/s:
Hyper pigmented (very tan), does not adapt to stress
-If they undergo any stress they might go into shock
-Glucose goes down & BP goes down

Tx:
Steroids (-sones) ADD i SONe LOL :)

If you have a cushy bank account you have more \$

S/s of Cushing's & side effects of steroids:
-High glucose** (hyperglycemic)(insulin resistant)
-Moon face -Hirsutism
-Big body / buffalo hump
-Gynecomastia
-Central obesity (apple body)
-Skinny extremities due to muscle atrophy
-Retains sodium & water
-Loses potassium
-Bruises and striae
-Irritable
-Immunosuppressed
- "I'm mad. I have an infection"

Tx:
Adrenalectomy- Bilateral: You get Addison's

-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)

Musical mobile, Soft & large, Teething soft books

Teach object permanence (looks for the toy when you hide it)

-Best option is a "coverncover 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

Learning to speak

-Speaking toys
-Talking books

Push/pull toy

(Ex: Popper, stroller, doggie, wagon, etc)
-Work on gross motor skills: running/jumping
-DO NOT choose answers with finger dexterity
(Ex: Cut, use pencils, color) *NOT INCLUDING FINGER PAINTING!*
-Parallel play-play alongside other kids, but not together

Finger dexterity/work on balance

-Tricycles
-Tumbling Class/Dance Class
-Coloring
-Play together
-They like to pretend (Imaginative thinkers)

Characterized by Triple C's

-Create: Let them make it (Blank paper & colored pencils, Legos)
-Collective (Pokemon cards, digimon, beanie babies)
-Competitive: Play games that they can win

Peer group association

-Hang out with friends
-Let this happen unless pt is fresh out of post op (<12 hrs), contagious
disease, or immunosuppressed

-Removal of vertebral spinal processes (winged ends of vertebrae)
-Relieves nerve root compression

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**

Cervical, Thoracic, Lumbar

-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

Cervical: Pneumonia

Thoracic: Pneumonia & Paralytic Ileus

Lumbar: Urinary retention followed by leg problems

-Don't sit for longer than 30 mins
-Lie flat & log roll
-No driving
-Do not lift more than 5 pounds (gallon of milk)

-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

From the front thru the chest to the spine

-Bone graft from the iliac crest 2 incisions, one on the hip & one on the spine
-Hip has most painleeding/draining
-Both have equal risk for infection
-Spine has highest risk of rejection

0.6-1.2 (A)

2-3

anything above 4 (C)

3.5-5.3

high or low (C). If it reaches 6 (D)

7.35- 7.45

anything in 6's (D)

8-25 (A)

12-18

22-26 (A)

35-45

36-54

78-100

93-100

< 100

135-145

hypotension & weight gain

All end in zines*
-They don't cure psych diseases, only reduce symptoms
-*Zines for the zaney*
-ZzZ.. zines (sedatives)
-Small doses are anti-emetics
-Major tranquilizers
-*DO NOT confuse *zeps for *zines

Side Effects: Non-toxic
-Anticholinergic (dry mouth)
-Blurred vision
- Constipation
-Drowsiness
-EPS- extrapyramidal syndrome (Pill rolling, cogwheel rigidity, shuffling gait)
-Fotosensitivity
-aGranulocytosis (Low WBC immunosuppressed)

-Teach pt to keep taking the drug
- Inform the Dr
-Keep taking the pill
-Treat the side effects

-Hold the drug & call the Dr immediately
-Nursing dx risk for injury/safety issues

Grandfathered into a new class called NSSRI's
-**Take for 2-4 weeks before you see effects**
-Elavil, Tofranil*, Avatil, Desyrel
-Elavil elevates your mood
-Anticholinergic (dry mouth)
-Blurred vision
-Constipation
-Drowsiness
-Euphoria (way too happy)

-They always have "zep" in the name
-ZzZ.. Zep (sedative)
-A- Pre-op to induce anesthesia
-B- Muscle Relaxer
-C- Alcohol Withdrawal
D- Seizures
E- Help when pt is fighting the ventilator to calm down
-They work quickly but DON'T take them for more than 2-4 weeks
-AD's take a long time to work but you can take it for the rest of your life -Mild tranquilizers work right away but can't be on long
-Heparin is to Coumadin as to tranquilizer is to an antidepressant
-*DO NOT confuse *zeps for *zines

Side effects:
-Anticholinergic (dry mouth)
-Blurred vision
-Constipation
-Drowsiness
-#1 Dx is injury

-Beginning of the names all rhyme
-Partite, Nardil, Marplan, (Par, Nar, Mar) or PaNaMa
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

Bipolar disorder
-Decreases mania, not depression
-Only psych drug that doesn't mess with neurotransmitters
Side Effects: 3 P's- Peeing, Pooping, Paresthesia
-Give & don't call the Dr
Toxic effects: Tremors, metallic taste, severe diarrhea
-Hold & call Dr.
#1 Intervention while on the med:
-Increase fluids
-If they're sweating don't give water. Give Gatorade/PowerAde (electrolytes)
-Monitor for dehydration & sodium levels
-(Low sodium = makes lithium toxic / High sodium = lithium won't work)

SSRI. Similar to Elavil
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

Schizophrenic, similar to Thorazine, Typical 1st Gen Antipsychotic
Side Effects:
-Anticholinergic (dry mouth)
-Blurred vision
-Constipation
-Drowsiness
-EPS- extrapyramidal syndrome (parkinson's symptoms) no big deal
-Fotosensitivity
-aGranulocytosis (immunosuppressed) (destroys marrow)

-Haldol overdose
-Young white men & elderly dudes can get it from overdose
-Potentially fatal hyperpyrexia (105-108)
-Includes anxiety and tremors
-Give elderly half of adult dose
-Take the temp to tell the difference from EPS

2nd Gen Atypical Antipsychotic
-Used to treat severe schizophrenia, made to replace the *zines and haldol
-Does NOT have the side effects (A-F)
-Has SEVERE agranulocytosis (immunosuppressed)
-Monitor WBCs, they can fall very low

Black box warning- Prolongs QT interval and can cause sudden cardiac arrest, DON'T give to people with heart conditions.

-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

+ 7 days - 3 months

28 lbs plus or minus 3 lbs

1 lb/month, total: 3 lbs
-Fundus not palpable. Mother is Priority
-If you can palpate the fundus or she gains 10lb,
she might have a hydatiform mole, or not really be in the 1st tri
-You can palpate the fundus at the end of the 1st tri

1lb/week
-Fundus at umbilicus or below it. Mother is Priority
-At 20-22 weeks the fundus is at the umbilicus

1lb/week
-Fundus above umbilicus. Baby is Priority

[Week of gestation] - 9 plus or minus a couple lbs
-If more than 3 lbs, you need to assess, something could be wrong
Positive

Fetal
skeleton on x-ray, fetal presence on ultrasound, auscultation of FHR, examiner
palpates fetal movement

5 weeks, but you can hear it at 8-12 weeks, and when
the examiner palpates fetal movement

8 weeks

10 weeks

12 weeks

pick earliest part of range

pick mid part of range

pick end of range

16-20 weeks

-Positive Prego Test
-Chadwick, Goodells, Hegar signs (Alphabetical in that order)
-Chadwick: Cervical color change to cyanosis (\$4 blue candle)
-Goodells: Cervical softening (good when your cervix softens, 2 ll's =2 month)
-Hegar: Uterine softening (upside down g for 6 months)

-Come once/month until week 28 (3 tri)
-Week 28 come once every 2 weeks until week 36
-Week 36 every week until delivery until week 42.
-Hemoglobin will fall, it can fall to 10 & still be normal
-Treat morning sickness w/ dry carbs before you get out of bed, not for
breakfast
-Frequent urination during 1st & 3rd tri. Tx: void q2hr min
-Difficulty breathing during 2nd & 3rd tri. Tx: Tripod position.
(Feet flat, arms on table leaning forward)
-Back pain: 2nd & 3rd tri. Tx: Pelvic tilt exercises

Onset of regular progressive contractions

Opening of cervix 0-10 cm

Thinning of the cervix. From thick to 100%

Relationship between the fetal presenting part & the ischial spines

Presenting part is above the tight squeeze (-1, -2) BAD

Presenting part is below the tight squeeze (+1, +2) GOOD

Relationship between the spine of mom & spine of baby

Compatible for natural birth

trouble

good

Part of baby that enters the birth canal first

ROA or LOA

-Phase 1 (Latent) 0-4 cm, frequency 5 - 30 mins apart, lasts 15-30secs,
intensity mild
-Phase 2 (Active) 5-7 cm, frequency 3-5 mins apart, lasts 30-60 secs,
intensity moderate
-Phase 3 (Transition) 8-10 cm, frequency 2-3 mins, lasts 60-90 secs,
intensity strong

**Only memorize phase 2. 1st 3 letters in latent tell u the order of phases** The purpose of uterine contractions in 1st stage: dilate & efface the cervix

-Delivery of the baby
-Deliver head
-Suction the mouth then nose
-Check for nuchal (around the neck) cord
-Deliver shoulders then body
-Baby must have ID band on before leaving the delivery area

-Delivery of the placenta
-Make sure it's all there
-Check for a 3 vessel cord- 2 arteries 1 vein- AVA

-Recovery, contract the uterus to stop bleeding
-Postpartum technically begins 2 hours after the placenta comes out
-4 things you do 4 times (q 15 min) an hour in the 4th stage:
-Vital Signs: Looking for S/S of shock (pressures go down, rates go up, cold
and clammy)
-Fundus check: If boggy=massage, if displaced= void / catheterize
-Pads: check pad saturation. If bleeding excessively she will saturate a
whole pad (100%) in 15 mins or less, if 98% saturated it's okay. She should
not soak a pad in one hour or less due to risk of hemorrhage.
-Roll her over: check for bleeding underneath her

PHASES ARE NOT STAGES

Contractions shouldn't be longer than 90 seconds & closer than every 2 mins

-Frequency: The beginning of one to the beginning of the next
-Duration: Beginning to end of one contraction
-Intensity: How strong they are & subjective
(Palpate w/ 1 hand over the fundus w/ the pads of the fingers)

-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

LION (left side, increase IV, O2, notify)

**If Pitocin is running stop the Pitocin first! & then do LION

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

Variable
Early decels
Acceleration
Late decels

Cord compression
Head compression
OK
Placental insufficiency

-Low fetal HR- under 1
-10- bad, do LION, if pitocin is running, stop the pitocin
-High fetal HR- over 160, normal, document take moms temp
-Low baseline variability- stays the same, does not fluctuate, bad, do LION
-High baseline variability- always changing, good, document
Late decels- baby's heart slows after contraction, bad, do LION
-Early decels- baby's heart slows before or at contraction, good
-Variable decels- very bad, prolapsed cord, put mom in push position

***Any position that starts with L, do LION, except variable (push position)*** L's and V's = VERY BAD
-Check fetal heart rate*** always a good choice on test

-Uterine Fundus: If boggy, massage. If displaced, catheterize.
-Fundal height = Day postpartum (ex-4 hotspot below) Make sure it's midline! -
Lochia: Rubra (Red), Serosa (Pinkish), Alba (White)
-Extremity Check: look for thrombophlebitis via bilateral calf measurements

-Caput Succedaneum- Crosses Sutures
-Cephalohematoma- doesn't cross & asymmetrical
-Pathological Jaundice- normal
-Physiological Jaundice- 24hrs after birth

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

Stimulate & strengthen labor

Pitocin- Causes uterine hyper stimulation (longer then 90, closer then q 2
mins)

Methergine- Causes high BP

Betamethasone (steroid)- Mom gets it, given IM, given before the baby is
born

Servanta (surfactant)- Given to the neonate, given trans-tracheal (blown
into the trachea), given after the baby is born

haldol

21 gauge/1inch (1M- always pick the gauge/inch with the 1 in it)

25gauge/5/8ths (Slookslike5)

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.

Any diuretic ending in X X's out K+ (wastes) + Direril
-All others are sparing

-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'

Present oriented (0-2 y/o): teach while you do it verbally, pre-teach parents

Pre-operational (3-6 y/o): fantasy oriented pick answer with "the
morning/day of" or "two hours before" teach what you are going to do (future
tense) through play

Concrete operational (7-11 y/o): "concrete 7-11's" rule oriented, teach
days ahead, teach what your going to do + skills with age appropriate
reading and demonstration

Formal Operational (12+ y/o): adult m/s question, teach like an adult, can
manage their own care