ANTICHOLINERGIC vs.

CHOLINERGIC EFFECTS

ANTICHOLINERGIC CHOLINERGIC

Mucus Bronchorrhea (large amounts of
Bronchodilation mucus in airway)
Drymouth Bronchoconstriction
Dryeyes Salivation
Urinaryretention Lacrimating
Dryskin Urination
Constipation Diaphoresis/Diarrhea
ShutdownGI GI Upset
PreventsVwhentryingtointubate Emesis

 ACID BASE GASES

A. ABG Interpretation
a. Rule of the Bs
i. Ifthe
pHandtheBICARB (HCO3)
ii. AreBOTH inthesamedirection,
iii. Thenitis
METABOLIC
b. pH=acidosis

c.
pH=alkaline
B. Values
a. NormalpH=7.357.45
b. NormalBicarb=2226
c. PaO2=80100mmHg
d. PaCO2=3545mmHg
e. SaO2=95100%
C. Signs & Symptoms of Acid-Base Imbalance
a. As the pH goes, so goes
the patient
exceptfor
Potassium
(bc it
willtrytocompensate)
pH UP

K
[ALKALOSIS] pH DOWN

K
[ACIDOSIS]
Tachycardia Bradycardia
Tachypnea Bradypnea
Diarrhea Hypotension
Tremors
lucidity
Seizure anorexia
Hyperreflexia coma
Agitated lethargy
Borborygmi(
bowelsounds) cardiaarrest
Hypertension suppressed,decreased,falling
Palpitations
Tetany
Anxiety/Panic
Poly
D. Causes of Acid-Base Imbalance
a. Firstask,Isit
Lung?
i. IfYES thenitis
Respiratory
b. Thenaskyourself:
i. Arethey Overventilating or
Underventilating?
1. If
Overventilating pick
Alkalosis
2. If
Underventilating pick
Acidosis
c. Ifnotlung,thenits
Metabolic
i. If the patient has
prolonged gastric vomiting or suction,
pickMetabolic Alkalosis
ii. Foreverythingelsethatisntlung,pickMetabolic Acidosis
1. Also,ifyoudontknowwhattopickchoose Metabolic
Acidosis
 VENTILATOR ALARMS

1. High Pressure Alarms aretriggeredby

resistancetoairflowandcan
becausedby
obstructions ofthreetypes:
a. Kinked Tube
i. NRSACTION:
Unkink it
b. Water in tubing (caused by condensation)
i. NRSACTION : Empty it/Remove H2O
c. Mucus in airway
i. NRSACTION: Turn, C&DB; only use suction if C&DB
fails, as a last resort

2. LowPressureAlarms aretriggeredby
resistancetoairflowandcanbe
causedbydisconnectionsofthe:
a. Tubing
i. NRSACTION: Pay attention to where tubing

is(contamination)
ii. Ifonfloor,changeout
iii. Ifonchest,cleanwithalcoholthenputbackon
3. Respiratory Alkalosis (Overventilation) meansventilatorsettingsmay
betoo
HIGH.
4. Respiratory Acidosis (Underventilation) meansventilatorsettingsmay
betoo
LOW.
5. To Wean Tograduallyandincrementallydecreasewiththegoalof

riddingalltogether

 ALCOHOLISM
Note:Remember in a psych question if you are asked to prioritize DO NOT
forget Maslow! Use the following priorities:
1. Physiological
2. Safety
3. Comfort
4. Psychological
5. Social
6. Spiritual

Also, ALL PSYCH PATIENTS START AS MED SURG PATIENTSRULE OUT

ALL FEASIBLE MED ANSWERS BEFORE PICKING PSYCH ANSWERS

1. Psychodynamics of Alcoholism
a. The#1psychologicalprobleminabuseis DENIAL.
i. Definition:
1. Refusaltoaccepttherealityoftheirproblem.
ii. Treatment:
1. Confrontitbypointingouttothepersonthedifference
betweenwhattheysayandwhattheydo.
2. Incontrast,supportthedenialoflossandgrief(BC
theuseofdenialisservingafunctioningperson)

b. DEPENDENCY/CODEPENDENCY
i. Dependency: Whenthe abuser getsthesignificantotherto
dothingsforthemormakedecisionsforthem.
ii. Codependency: Whenthesignificantotherderivespositive
self-esteem fromdoingotherthingsforormakingdecisions
forthe
abuser .
iii. Treatment:
1. Setboundary (limits) andenforce them.Agreein
advanceonwhatrequestsareallowedthenenforce
theagreement
2. Workonthe self-esteem ofthecodependentperson.


c. MANIPULATION
i. Definition:
Whentheabusergetsthesignificantothertodo
thingsforhim/herthatarenotinthebestinterest
ofthe
SignificantOther.Thenatureoftheactisdangerousor
harmful tothesignificantother
ii. Treatment:
1. Setlimitsandenforce
2. Itseasiertotreatthandependency/codependency
because nobody likestobemanipulated

2.
Wernickes (Korsakoffs) Syndrome
a. Psychosis inducedby
Vitamin B1 (Thiamine)deficiency.
b. Primarysymptom:
amnesia
with
confabulation (makingupstories
tofillinmemorylossbelieveastrue)
c. Characteristics:
i. Preventable
1. BygivingB1vitamins
ii. Arrestable
1. Canstopfromgettingworsenotimplybetter
iii. Irreversible
1. Dementiasymptomsdontgetbetteronlyworse

3. Antabuse/Revia
a. Disulfiram(drugsusedforalcoholism
b. AversionTherapy
c. Onsetanddurationofeffectiveness: 2 weeks
i. Takedrugs2weeksandbuildsupinbloodtoalevelthat
whendrinkingalchwillbecomehorriblysickifofffortwo
weeks,willbeabletodrinkwithoutsicknessagain
d. Patientteaching:AvoidALLformsof alcoholtoavoid
nausea,
vomiting, and possibly death ,including:
i. Mouthwash,aftershave,perfumes/cologne,insectrepellant,
vinigarettes(saladdressings),vanillaextract,elixirs
(containsalchOTCmed),alcoholpreppad,alchsanitizer
 OVERDOSE VS. WITHDRAWAL
Firstaskyourself,isthe
drugan
upper
ora
downer?

UPPERS DOWNERS
Names: Names
:
Caffeine Everything else
Cocaine
PCP/LSD (Psychedelic
hallucinogens)
Methamphetamines-speed
ADHD- adderrall/Ritalin
Bath Salts (Cath-Kath)
Signs/Symptoms: Signs/Symptoms:
Tachycardia Bradycardia
Hypertension Hypotension
Diarrhea Constipation
Agitation Constricted pupils
Tremors Flaccidity
Clonus Respiratory arrest
Belligerence Decreased core body temp
Seizures
Exaggerated, shrill, high pitched
cry
Difficult to console


Thenaskyourself,Aretheytalkingabout
overdose
or
withdrawal?
Overdose/Intoxication Withdrawal
I have too much I dont have enough..

Too much upper: Too little upper:

Everything is UP Everything is DOWN

Too much downer Too little downer:

Everything is DOWN Everything is UP

Drug Addiction in the Newborn

Alwaysassumeintoxication (first 24 hours after birth),

thenafterthistime,
assumewithdrawal

Alcohol Withdrawal Syndrome vs. Delirium Tremens

1. Differences:
a. Everyalcoholicgoesthrough alcohol withdrawal syndrome
(AWS) (after24hours)
b. Onlyaminorityget delirium tremors (DT)
c. AWS isnotlifethreatening.
DTs
cankillyou.
AWS DTs BOTH
Semi-private-anywhere Private-near nurses station Anti-hypertensives
Regular diet Clear liquids or NPO Tranquilizer
Up Ad Lib (no activity Restricted bedrest (no B1 multi-vitamin (to prevent
restriction) bathroom privileges) dementia)
Do not restrain Should be restrained (2 pt
leather restraints)
2 extremity restrictedarm
on one side and leg on one,
one upper extremity and one
opposite lower extremity
d. Patientswith
AWSare not

dangeroustothemselvesorothers.
Patientswith are
DTs

dangeroustoselfandothers.

 AMINOGLYCOSIDES

1. Think A mean old mycin

2. Powerful antibioticsto treat severe, life-threatening, resistant
infections
3. All aminoglycosides end in mycin, but not all drugs that end in
mycin
areaminoglycosides.Forexample..
a. Azithromycin,clarithromycin,erythromycin thromycin NOT
4. Examples of aminoglycosides : Streptomycin, Cleomycin, Tobramycin,
Gentamicin,Vancomycin,Clindamycin
5. Toxic Effects :
a. Themostfamousfeatureoftheworldsmostfamousmouse(ears)
i. Toxiceffect:ototoxicity
ii. Mustmonitor hearing, balance, tinnitus
b. Thehumanearisshapedlikea kidney
i. Toxiceffect:nephrotoxicity
ii. Monitor: creatinine
1. Bestindicatorofkidneyfunction
2. 0.61.2mg/dL
c. Thenumber 8
drawninsidetheearremindsyouof:
i. Cranialnerve 8(Drugtoxicto)
ii. Frequencyofadministration: Every 8 hours
6. Route of Administration
a. GiveIMor
IV
b. DonotgivePO (not absorbed) exceptinthesetwocases:
i. Hepaticencephalopathy
1. Also called Liver Coma, AmmoniaInduced
Encephalopathy
2. Whenwantasterilebowel
3. Duetoahigh ammonia level
ii. PreopBowelsurgery
1. REMEMBERthismilitarysoundoff:
a. NEOmycin
b. KANmycin
c. WHO CAN STERILIZE MY BOWEL? NEO
KAN
d. ^PO,2bowelsterilizers

 7. Trough and Peak Levels

a. ReasonfordrawingTAPlevels:
narrow therapeutic range
b. Timetable:
ROUTE TROUGH (lowest) PEAK (highest)
Sublingual 30 min before next dose 5-10 mins after drug dissolve

IV 30 min before next dose 15-30 min after drug finished

IM 30 min before next dose 30-60 min after drug given

SQ 30 min before next dose See diabetes lecture

PO 30 min before next dose Forget about it.

 BIOTERRORISM

1. Categories of Biological Agents

a. Category A (Most serious)
i. Smallpox
ii. Tularemia
iii. Anthrax
iv. P lague
v. H emorrhagicfever[Ebola]
vi. B otolism
b. Category B
i. Allothers.Alonglist.
c. Category C
i. Hanta virus
ii. Nipeh virus
2. Category A Biological Agents
a. Smallpox
i. Inhaledtransmission/onAirbornePrecautions
ii. Diesfromsepticemia.Bloodinfection.*onlyclassAthatdies
fromthis.
iii. Rashstartsaroundmouthfirst(earlyID&isolationiscrucial
tocontain)
b. Tularemia
i. Inhaled
ii. Chestsymptoms(coughing,chestpain,sputum)
iii. Diesfromrespiratoryfailure
iv. TreatwithStreptomycin(watchhearingandcreatinine)
c. Anthrax
i. Spreadbyinhalation
ii. Lookslikeflu(chestsymptomsandachymuscles)
iii. Diesfromrespiratoryfailure
iv. TreatwithCipro,PCN,andstreptoycin
d. Plague
i. Spreadbyinhalation
ii. Hasthe3Hs:
1. Hemoptysis(coughingupblood)
2. Hematemesis(vomitingblood)
3. Hematochezia(bloodydiarrhea)
iii. DiesfromrespiratoryfailureandDIC
iv. TreatwithDoxycyclineandMycins
v. Nolongercommunicableafter24hoursoftreatment
e. Hemorrhagic Fever [Ebola]
i. 21daytimeframe
ii. Primarysymptomsarepetechairandecchymosis
iii. High%fatal
 iv. DieofDIC
f. Botolism
i. Ingested(drink/eat)
ii. Has3majorsymptoms:
1. Descending paralysis(startsatheadgoesdownto
diaphragm)
2. Fever
3. Butisalert
iii. Diesfromrespiratoryfailure
3. Chemical Agents
a. MustardGas Blisters(Vesicant,eventuallycoverairway)
b. Cyanide Respiratoryarrest.TreatwithSodiumThiosulfateIV
c. Phosginechloride Choking
d. SarinNerveagent.
i. Symptoms(CholinergicEffects)
1. Bronchorrhea
2. Bronchoconstriction
3. S
alivation
4. L
acrimating
5. Urination
6. Diaphoresis/diarrhea
7. GIupset
8. E
mesis
4. Allchemicalagentsrequireonlysoapandwatercleansingexceptfor
Sarin,whichrequiresableach
a. NursingActions:BioterrorismIsolation,Antibiotics
b. Chemical:Decontamination
i. Sendallsuspectedcasestodecontaminationcenter
ii. Removeallclothing
iii. Chemicalhazarddoublebag
iv. Incinerated
v. Showerinsoapandwater(bleachsarin)
vi. Dischargedingovernmentclothes

 CALCIUM CHANNEL BLOCKERS

Note: They are like Valium for your heart

1. CalciumChannelBlockers: Negative[ino,chrono,dromo]
Digisonlydrugthatmixes+&effectsother99%eitherhave+or
ACTION DEFINITION POSITIVE NEGATIVE
Inotropic Strengthof Strong Weak
heartbeat
Chronotropic Rateofheartbeat Fast Slow
Dromotropic Conductivity Excitable Blocks/Slows
conduction
2. WhatdoCalciumChannelBlockerstreat?(Indications)
a. Antihypertensives(BPwayUPrelaxesbloodvessels)
b. Antianginal(relaxesreducesO2demand)
c. Anti
A
trial
A
rrthymia(doesnottxventriculararrthymias)
3. SideEffects(
):
a. Headache
b. Hypotension
c. Bradycardia
4. NamesofCalciumChannelBlockers
a. soptin(Verapeunil)
b. zem
c. dipine
5. NursingActions:beforeadministratingBPsystoliclowerthan100..if<
100holdandcallDr

 CARDIAC ARRYTHMIAS
1. Terminology
a. QRS depolarization alwaysrefertoventricular(notatrial,
junctional,ornodal)
b. P wave referstoatrial
2. Six rhythms tested on NCLEX
a. Asystole
i. AlackofQRSdepolarizations(astraightline)
b. Atrial flutter
i. RapidPwavedepolarizationsinasawtooth(flutter)
c. Atrial fibrillation
i. Chaotic Pwavedepolarizations(lacksanydiscernable
pattern)
d. Ventricular fibrillation
i. Chaotic QRSdepolarizations
e. Ventricular tachycardia
i. Wide, bizarre QRSs
ii. Tachyisalwaysdiscernablerepeatingpattern
f. Premature ventricular contractions (PVC)
i. Periodic wide,bizarreQRSs
ii. Generallylowtomoderatepriority.unlesseveryoneelsehas
anormalrhythm
iii. Be concerned, if:
1. Morethan 6 perminute
2. 6 inarow
3. PVCfallsof T-waveofpreviousbeat
3. Lethalarrhythmias
a. Asystole
b. Vfib
4. Potentiallylifethreateningarrhythmia: V-tach
a. Pulselessvtachsameasasystoleandv.fibandwoulddependon
howlongdown
b. After8minsconsiderdead
5. Treatment
a. PVCs
i. Lidocaine (Ventricular,lastslonger), Amiodorone
b. VTach
i.
Lidocaine
c. Supraventriculararrhythmias
i. Adenosine (pushfastIVpushusually8sorfaster)
ii. Beta-Blockers (lol)
iii. Calcium Channel Blockers
iv. Digoxin (Digitalis) Lanocin
d. VFib
i. Besttreatmentelectrically
 ii. Shock=200Defibrillate
e. Asystole
i. Epinephrine
ii. Atropine
iii. S/Eanticholinergics
 CHEST TUBES

Thepurposeforchesttubesistoreestablish negative pressureinthepleural

space
1. Ina
pneumothorax, thebesttuberemoves air
2. Ina
hemothorax, thechesttuberemoves blood
3. Ina
pnemohemothorax, thechesttuberemoves air
and
blood

Locationofchesttubes:
1. Apicals (HIGH)forAir
a. LabelAuphigh
2. Basilar (LOW)forBlood
a. LabelBplacedatbasebottomoflung

Examples
1. Howmanychesttubes(andwhere)forunilateralpneumohemothorax?
a. 2; apical and basilar all on same side
2. Howmanychesttubes(andwhere)forbilateralpneumothorax?
a. 2; apical right and left
3. Howmanychesttubes(andwhere)forpostopchestsurgery?
a. 2; apical and basilar unilateral
b. Exception:Ifsurgerytotalpneymonectomythen nochesttube
bcnopleuralspace
c. Alwaysassumechesttraumaandsurgeryisunilateral

ProblemSolving

1. Whatdoyoudoifyoukickoverthecollectionbottle?
a. Notabigdealcanjustsititrightbackuphavetakeacoupledeep
breaths
2. Whatdoyoudoifthewatersealbreaks?
a. Thisismoreserious,becauseitisallowingairincreatinga2way
b. First: Clampchesttube(Betternowaythan2wayforbriefperiodof
time)**inroutinecareneverclampchesttube!!
c. Best: Submerge
i. Cuttubeaway(down)bydevicesubmergeunderwater
preferablysterilethenunclamp
3. Whatdoyoudoifthechesttubecomesout?
a. First: coverholewithglovedhandVaselinegauzedressing4
sidedsteriledressingtape
b. Best: Vaselinegauze
4. Bubbling
a. Askyourselftwoquestions:
i. WHEN isitbubbling
 ii. WHERE
isitbubbling

5. Rulesforclampingthetube:

a. Neverclampforlongerthan
15 seconds
withoutaDr.sorder
b. Use
rubber tipped double clamp

 CONGENITAL HEART DEFECTS

Everycongenitalheartdefectiseither
TROUBLE
or
NO TROUBLE

TRouBLe
R-L
Blood shunts

BCyanotic

TAll CHDs beginning with T are trouble

Exception
Left ventricular hyperplasic syndrome
Examples of Trouble Examples of No Trouble

Tricuspid Ventricular septal defect

Tricuspid arterioles Patent foramen ovale
Tetralogy of Fallot Patent ductus arterioles
Pulomary

AllCHDkidshavetwothingswhethertroubleornot:
1. Murmur
2. Allgetechocardiogramdone(@least1)

FourdefectspresentinTetralogyofFallot:
1. V
arieD Ventricular Defect
2. P
ictureSPulmonic Stenosis
3. O
fA Overriding Aorta
4. R
anc H Right Hypertrophy
 CRUTCHES, CANES, & WALKERS

1. Howtomeasure: 2-3 finger widths belowanterioranxillaryfoldtoapoint

lateral toandslightlyinfrontoffoot
2. Whenthehandgripisproperlyplaced,theangleofelbowflexionwillbe 30
degrees
3. Typesofgaits:
a. 2-Point Gait
i. StepOne: Moveonecrutchandoppositefoot together
ii. StepTwo: Moveothercrutchandotherfoottogether
iii. Remember :2pointstogetherfora2pointgait
iv. Examples :onekneereplacement
b. 3-Point Gait
i. StepOne: Movetwocrutchesandbadlegtogether
ii. StepTwo: movegoodfootbyself
iii. Remember: 3pointiscalled3pointbecausethreepoints
touchdownatonce
iv. Examples: Stairs
c. 4-Point Gait
i. StepOne: Onecrutch
ii. StepTwo: Oppositefoot
iii. StepThree: OtherCrutch
iv. StepFour: Otherfood
v. Examples: totalbothkneerightaftersurgery
d. Swing-through: fortwobracedextremities
i. Examples :arthritisbracedlegs
4. Whentouseeachgait
a. Usethe even numberedgaits(2&4point)whenweaknessis
evenly distributed(bilateral).Twopointformildproblemfourpoint
forsevereproblem
b. Usethe odd numberedgait(3point)whenonelegis odd
(unilateralproblem)
5. Stairs:whichfoot leadswhengoingupanddownstairsoncrutches?
a. Remember: UPwiththegood DOWN withthebad
b. Thecrutchesalwaysmovewiththe badleg
6. Cane
a. Holdcanonthe strong (unaffected) side
b. Advancecanewiththe weak sideforawidebaseofsupport
7. Walkers
a. Pickitup,setitdown, walk toit
b. Tie belongings to side of walker, not front
c. Gettingoutofchairtowalkeralwayspush,neverpull(samefor
cane,crutches)


DELUSIONS, HALLUCINATIONS, & ILLUSIONS
1. PsychoticvsNonPsychotic
non-psychotic
a. A personhas insight&is
reality based
psychotic
b. A personhas NO insightandisNOT realitybased
2. Delusions
a. Definition: adelusionisa false, fixed belieforideaorthought.
Thereisno sensory component.
b. Threetypesofdelusions:
i. Paranoid or Persecutory :
false,fixedbeliefthatpeopleare
outtoharm you.
ii. Grandiose: False,fixedbeliefthatyouare superior
iii. Somatic: False,fixedbeliefabout parts of your body
3. Hallucinations
a. Definition: ahallucinationisafalse,fixed sensory experience
b. Fivetypesofhallucinations:
i. Auditory(mostcommon*hearing)
ii. Visual
iii. Tactile
iv. Olfactory
v. Gustatory
4. Illusions
a. Definition: Anillusionisa misinterpretation of
reality.Itisa
sensory experience.
b. Differentiationbetweenillusions&hallucinations: with illusions
there is a referent inreality
5. Whendealingwithapatientexperiencingdelusions,hallucinationsor
illusions,firstaskyourself,Whatistheirproblem?
a. Functional Psychosis
b. Psychosisof Dementia
c. Psychotic Delirium
6. Functional Psychosis
a. Theseare:
i. Schizophrenia
ii. SchizoaffectiveDisorder
iii. MajorDepression
iv. Mania
b. Patienthasthepotentialtolearn reality
c. Foursteps:
i. Acknowledge how they feel
ii. Present reality
iii. Set alimit
iv. Enforce the limit
7. Psychosis of dementia
a. Theseare:
 i. Alzheimers
ii. Senility
iii. OrganicBrainSyndrome
iv. PostStroke
v. Wernickes
b. Thispatienthasa destructiveproblemandcannotlearnreality.
c. Twosteps:
i. Acknowledge their feelings
ii. Redirect
8. Psychotic delirium
a. Description:Episodic,temporary,suddenonset,dramatic,lossof
reality,secondarytoachemicalimbalance
b. Twosteps:
i. Acknowledgetheirfeeling
ii. Reassure(itwillgetbetter,Iwillkeepthemsafe)
9. Loosening of association
a. Flight of Ideas: stringingphrasestogether
b. Word salad:
stringwordstogether
c. Neologisms: makingupnewwords
10. Narrowed self-concept:
a. whena PSYCHOTIC refusesto:
i. Leavetheroomandrefusestochangetheirclothing
ii. Actiondonotmakethem!Tellthemtheycanwaituntilthey
areready
11. Ideas of reference
a. Whenyouthinkeveryoneistalkingaboutyou

 DIABETES MELLITUS

1. Definition:
DMisaerrorof glucose metabolism
a. (vsDiabetesInsipidus polyuria, polydipsia leading to
dehydration)
2. Types:
a. Type I
i. I
nsulindependent
ii. JuvenileOnset
iii. Ketosisprone(tendtomakeketones)
b. Type II
i. Nonalltheabove
ii. Noninsulindependent
iii. Nonjuvenileonset
iv. Nonketosisprone
3. SignsandSymptoms
a. P olyuria
b. P olydipsia
c. P olyphagia
4. Treatment
a. Type I
i. Diet(3)
ii. Insulin(1)
iii. Exercise(2 )
b. Type II
i. Diet(1)
ii. Oralhypoglycemics(3)
iii. Activity(2)
c. Diet (type II)
i. Calorierestriction
ii. Needtoeat6xaday
d. Insulinactsto lower bloodsugar
i. Typesofinsulin

Type of Insulin Onset Peak Duration

REGULAR (clear, 1 hour 2 hours 4 hours
short acting, rapid;
IV)
NPH (cloudy, 6 hours 8-10 hours 12 hours
intermediate acting)
HUMALOG (Insulin 15 minutes 30 minutes 3 hours
Lispro) (Worlds
fastest acting; give
with meals)
Lantus (Glargine) Slow absorption No peak, therefore no 12-24 hours
(long acting insulin) risk of hypoglycemia

ii. Check expiration date

1. Afteropennewexpirationdate2030daysafter
opening
iii. Refrigeration:optional for opened; necessary for
unopened
e. Exercise Potentiates (decreases) insulin:
i. Ifmoreexercise,need decrease insulin
ii. Iflessexercise,need increaseinsulin
f. Sickdays
i. Take insulin
(evenifnoteating!)
ii. Take sips of H20 to prevent dehydration
iii. Stayasactiveaspossible
5. ComplicationsofDM
a. Low Blood Sugar in Type I DM (=insulin shock) [Hypoglycemia]
i. Causes:
1. Notenough food
2. Toomuch exercise
3. Toomuch insulin
ii. Danger:
1. Permanentbraindamage
iii. SignsandSymptoms
1. Cerebralimpairment&vasomotorcollapse(blood
vesselwallmusclesdonthaveenoughEtomaintain
tone)
slurredspeech,staggeredgait,abnormal
reactiontime,uncontrolledemotions,loweredBP,
increasedpulse,skinpale,cold,clammy,inattentive
tosocialboundaries
iv. Treatment
1. Administerrapidlymetabolizable Carbohydrates
(sugar)
 2. Idealcombination: food with sugar and protein (&
maybe starch)
3. Ifunconsciousness: Nothing! Glucagon IM,
Dextrose IV, never anything in mouth!
b. High Blood Sugar in Type I DM- DKA Diabetic Coma
[Hyperglycemia]
i. Causes:
1. Toomuch food
2. Notenough insulin
3. Notenough exercise
4. #1 cause is acute viral upper respiratory infection
within the last week or two
ii. SignsandSymptoms
1. D ehydration(appeardry,hot,flush,HA,pulseweak,
thready,increaseintemp)
2. K etones(inurine&blood)increaseinK+Kussmaul
respirations
3. A cidodicacetone(fruity)breathanorexiawith
nausea
iii. Treatment
1. IVwithregularinsulin@200/hrathighflowrate
c. Low Blood Sugar in Type II DM (Hypoglycemia)
i. TreatmentisthesameasforlowBGMinTypeIDiabetes
d. High Blood Sugar in Type II DM (Hyperglycemia)
i. CalledHHNK(orHHNC):
1. Hyperosmolar,hyperglycemic,nonketoticcoma
ii. Thisis
dehydration
iii. Signs&symptomsarelikeS&Sof dehydration
1. Including: increased temp
iv. Treatment:
rehydrate (glucose will usually turn to normal
on own)
e. Longtermcomplicationsarerelatedtotwoproblems:
i. Problemswithtissueperfusion
ii. Peripheralneuropathy(nervedamage)
f. WhichlabtestisthebestindicatorofLTBGMcontrol
(compliance/effectiveness)? Hemoglobin A1C
i. HA1C for dx >6.5
DM/pre DM
ii. Monitoring tx >7.0 out of control
 DRUG TOXICITIES

DRUG THERAPEUTIC LEVEL TOXIC LEVEL

Lithium (antimania) 0.6-1.2 >
2.0
Lanoxin (uses #1 CHD #2 1-2 >
2
atrial arrhythmias)
Aminophylline (airway 10-20 >
20
antispasmodic)
Dilantin (seizures) 10-20 >
20
Bilirubin (not a drug) Elevated hyperemibilirubin Kernicterus
10-20 Bilirubin >20; crosses
Toxic >20 BBB in CSF- invaded
brain causes
encephalitis meningitis
Opisthotonos
Position of extension
seen with kernicterus
Arching d/t bili
irritation in brain
Place this child on
his/her side

Totalbilirubin:01.0mg/dl
Direct(conjugated)bilirubin:00.3mg/dL
Indirect(unconjugated)bilirubin:00.3mg/dL

 DUMPING SYNDROME VERSUS HIATAL HERNIA
HIATAL HERNIA (2
chambered stomach)
DEFINITION Regurgitation of acid into
esophagus, because
upper stomach herniates
upward through the
diaphragm
Gastric contents move in
the wrong direction (UP
instead of DOWN)
direction at the
correct
rate
SIGNS & SYMPTOMS Upper GI S/S:
Indigestion
Heart burn
GERD
Chest pain
Treatment 1. Raise HOB (High
1. HOB during & 1 hour Fowlers)
after meals 2. High Fluids
2. Amount of fluids with 3. High Carbs (Decrease
meals Protein)
3. Carbohydrate content of
meals
DUMPING SYNDROME
Post op gastric surgery
complication in which
gastric contents dump
too quickly into the
duodenum
Gastric contents move in
the correct (DOWN)
direction at the wrong
(too fast) rate
Lower GI S/S
Acute lower abdominal
distress: diarrhea,
cramping, gas, abdominal
pain, cramping, guarding,
splinting, rigidity,
distension
Drunk (look), all blood
going to gut not brain (
cerebrally impaired;
confused
S
hock: blood in
parasympathetic system;
pale, cold, clammy,
decreased BP, rapid pulse
D&S hypoglycemis
1. Low HOB
2. Low/Restricted
fluids- in between
meals
3. Low Carbs (Increase
Protein)


ELECTROLYTES

KALEMIAS
do the the prefix except for
same and
heart rate urine output

HYPERKALEMIA

HR

UO
HYPOKALEMIA HR

UO

CALCEMIAS
do the
opposite
the prefix. No exceptions. [& anything to BP]

HYPERCALCEMIA

HYPOCALCEMIA

Two signs of neuromuscular irritability

associated with
low calcium:
1. Chovosteks sign
Tapcheek
spasm

2. Trousseaus sign

Put on BP cuff and arm goes into carpal
spasm( arm looks like swan neck)


MAGNESEMIAS do the
opposite
the prefix
Note: In a tie, never pick Mg. If symptom involves nerve or skeletal muscle, pick
Calcium
. For
any other symptom, pick
Potassium
HYPERMAGNESEMIA HYPOMAGNESEMIA

NATREMIAS

HYPERNATREMIA HYPONATREMIA
E
dehydration O
overload
Poor skin turgor Increased weight
Dark urine edema
Hot flushed skin
Increase urine specific gravity
Weak, thready pulse


Theearliest
signofanyelectrolytedisorderis
numbness (paresthesia) &
tingling

The
universal
sign/symptomofelectrolyteimbalanceis
muscle (paresis)
weakness

ELECTROLYTE TREATMENT
1. Never pushPotassium IV [Fatal]
2. Notmorethan 40 mEq ofK+perliterofIVfluid[clarifyifover40]
3. GiveD5W with regular insulin todecreaseK+[carriermediated
transport]
4. Kayexalate [Kexitlate]
a. Putsdrugingut,fullofsodiumNapickedupbybloodstream
Doesntneedthatmuch+charge,sobodyexchangesforK,
diarrhea)
b. B/Cisslow dothiswithD5W+insulin

 ENDOCRINE OVERVIEW
Thyroid

1. Hyperthyroidism(HyperMetabolism)
i. Signs & Symptoms
1.
weight

tachycardia
BP

Agitation

Restlessness
nervousness
diarrhea


energy

bulgingeyes
warm
<3organmosteffective

ii. GravesDisease[literallyrunselfintograve]
iii. Theproblemishyperthyroidism.Treatmentoptions:
1. Radioactive Iodine
a. Watchoutforurine[DANERGOUS]
i. Useprivatebathroom
ii. Flush23times
2. PTU (Protothyroidircil) *sp
a. Cancerdrugknocksoutcellsmetastizing
problemagranulocytosis(
WBC)
b. Educationisolation,wearmask,nokids
3. Surgical removal
a. Thyroidectomy(removethyroid)
i. Total thyroidectomy
1. Needlifelong T3, T4 hormone
replacement
2. Atriskfor hypocalcemia (bcat
riskforloosingparathyroidgland)
3. S/Shypocalcemia: tetany
a. Earliestsign:paresthesia
ii. Subtotal thyroidectomy
1. Atriskfor thyroid storm
2. S/Sthyroidstorm:
a. Veryhighfever>104F
b. VeryhighV/S
c. PsychoticDelirium*life
threateningpriority
3. Treatment
a. Waitout:eitherdie,come
out,giveO2andlower
bodytemp
b. Txfocusesonsavingthe
brainuntiltheycomeout
ofit
 c. Loweringbodytemp:
i. Icepacks:onaxilla,
axilla,groin,groin,
back,neck
ii. Coolingblanket

iii. Postoprisks 1st
12 hours
airway&hemorrhage
**afterfirst12oursitisassumed
thatthepatientisstable
Postoprisks
12-48 hours for
TOTAL: calcium (tetany)
Postoprisks
12-48 for
SUB-TOTAL: Thyroid storm
2. Hypothyroidism (HypoMetabolism)
a. Signs & Symptoms
i.
weight

cold

sluggish
slow
decreasedBP bradycardia
hairandnailsbrittle
decreasedE

b. Nameofdisease: mxyedema
c. Treatment:
thyroid pills
d. Caution: DO NOT sedatethesepatients!(already)
e. Surgical Implication:
callanesthesiologistandaskifthyroidpills
shouldbeheld.Donotdowellwithanesthesia

Adrenal Cortex Diseases (startwithlettersAorC)

1. AddisonsDisease
a. Under secretion (toolittle)ofadrenalcortex
b. Signs & Symptoms
Hyperpigmented(3or4shadesdarkerthanbefore)
Inabilitytoadaptnormallytostresssendsoff
limitshock

c. Treatment
i. Givesteroids[glucocorticoidsandmineralcorticoids]
1. Steroidsallendinsone
2. CushingsSyndrome
a. Over secretion ofadrenalcortex
b. Signs & Symptoms [alsoreflexS/Sofsteroids]
c. Treatment: adrenoectomy
 INFECTIOUS DISEASE & TRANSMISSIONN-BASED PRECAUTIONS
Select all that apply
Private Room Eye/Face Shields
Mask Special Filter Respirator Masks

Gloves Pt wear mask when leaving room

Gown Disposable supplies

Handwashing Negative air flow

Contact:
For:
1. Herpes,
2. anything Staph (MRSA),
3. Enteric (intestinal) [cholera, shigellosis, rotovirus],
4. RSV (Respiratory Synctial Virus)
a. [spreaddropletbutresearchfoundthisisbestfor
precautions]

Droplet:
For
1. ALLViruses
2. ALLInfluenzas[DTaP,Pertussis,Mumps]
Select all that apply
Private Room Eye/Face Shields
Mask Special Filter Respirator Masks

Gloves Pt wear mask when leaving room

Gown Disposable supplies

Handwashing Negative air flow

Select all that apply

Private Room Eye/Face Shields
Mask most important Special Filter Respirator Masks

Gloves Pt wear mask when leaving room

Gown Disposable supplies

Handwashing Negative air flow

Airborne:
For:
1. TB*spreaddrolet
2. ChickenPox(varicella)
3. Measles
4. SARS(Severeacuterespiratorysystem)

Select all that apply

Private Room Eye/Face Shields
Mask Special Filter Respirator Masks
w/TB only N95
Gloves Pt wear mask when leaving room

Gown Disposable supplies

Handwashing Negative air flow
 PERSONAL PROTECTIVE EQUIPMENT (PPE)

Unlessotherwisespecified,assumethatPPEincludes:
Gowns, Goggles, Mask,
Gloves

Theproper
place
fordonning(puttingon)PPEis
outside of the room

TheproperorderfordonningPPEis:
1. Putongown
2. Putonmask
3. Putongoggles
4. Putongloves

Theproper
place
forremoving(doffing)PPEis
inside room

TheproperorderforremovingPPEis:
1. Gloves
2. Goggles
3. Gown
4. Maskneedtotakemaskoffoutsidesoyoudontbreathein
contaminatedair
Inairborneprecautions
ONLY ,themaskisremoved
outside of the room
 HANDWASHING AND GLOVING

Handwashing
HandwashingversusScrubbing
Handwashing Scrubbing
Position Hands below elbows Elbows below hands
Length Seconds Minutes
Handles Yes; sink with handles No sink with handles
When Upon entry or leaving room When patient is
before and after gloving, immunosuppressed for any
when soil hands reason

Use Soap and water Something with chloro in it

Use an Alcohol-Based Solution

1. Onenteringorleavingaroom
2. Beforeputtingongloves,aftertakingoffgloves
3. Cannotaftersoilhands!!

What about after using the rest room? mustusesoapandwater

Dryfrom
cleanest (hand)
to
dirtiest (elbow)

Turnwateroffwith new papertowel

Sterile Gloving
Glove dominant handfirst.
Grasp outside ofcuff.
Touchonlythe inside ofglovesurface.
Donot rollcuff.
Fingers inside of secondglovecuff.
Keepthumb abducted back .
Onlytouch outside surfaceofglove
Sk intouches insideofglove
Out sideofgloveonlytouches out
sideofglove
Remove glove to
glove

Skinto
skin

 INTERDISCIPLINARY CARE

Identifyingwhichpatientsneedinterdisciplinarycare
different than
prioritizing
who would most benefit from a team working together on
their care

Patientswhodonotneedinterdisciplinarycare:
Patients who need or have
multiple doctors

PatientwhoDOneedinterdisciplinarycare:
1. MajorCriteria
a. Patientswithmulti-dimensional needs
i. Forexample:
1. Physical
2. Psychological
3. Social
4. Spiritual
5. Intellectualneeds
b. Patientswhoneed rehabilitation
2. MinorCriteria[choosingbetweenpatients]
a. Apatientwhosecurrent treatment isineffective
b. Apatientwhoispreparingfordischarge

 LAB VALUES

A=ABNORMAL Do Nothing
B= BE CONCERNED Assess/Monitor
C=CRITICAL
Do Something
D = DEADLY DANGEROUS Do Something NOW

Creatinine
Best indicator of Kidney Function
0.6-1.2
Elevated = A

INR (International Normalized Ratio)

Monitors Coumadin (Warfarin) Therapy [Anticoagulant]
Therapeutic 2-3
> 4=C
o Patient could bleed to death
o Hold all warfarin
o Assess for bleeding
o Prepare to administer Vitamin K
o Call Physician

Potassium (K+)
3.5-5.3
Low=C [Hypokalemia]
o Assess the heart (may include EKG which aid can do)
o Prepare to give K+
o Call physician
5.4-5.9 = C [Hyperkalemia]
High but still in the 5s
o Hold K+
o Assess heart (may include EKG which aid can do)
o Prepare Kayexelate and d5W with regular insulin
o Call physician
>6 = D Cardiac Danger Zone
o Do steps simultaneously
o Need help once levels hit 6; if cardiac symptomatic call rapid
response team

pH
7.35-7.45 (as pH drops so does the patient)
K+ can increase which can stop the heart
Low pH in the 6s = D [severe acidosis]
Immediately assess vital signs
 Call dr if v/s bad, also call rapid response team

BUN [Blood Urea Nitrogen]

8-30
Elevated =B
Check for dehydration

HgB [Hemoglobin]
12-18
8-11 = B
<8 = C
Assess for bleeding (may transfuse <8)
Call Dr

HCO3 (Bicarb)
22-26
Abnormal =A

CO2
35-45
In 50s = C
o Assess respiratory status
o Do have patient do pursed lip breathing (like blowing out
candle)
In 60s = D Respiratory failure
o Assess respiratory status; if symptomatic call rapid response
o Do pursed lip breathing
o Prepare ventilate and intubate
o Call DR
o Cal respiratory therapist

Hct (Hematocrit)
36-54
Abnormal = B; Assess for bleeding

PO2 (Oxygen level in blood; obtained from ABG)

78-100
Low 70-77 =C Respiratory insufficiency
o Assess respiratory status
o Give oxygen
Low <60s =D Respiratory failure
o Assess respiratory status
o Give oxygen
o Prepare intubate and ventilate
o Call Dr
 o Call respiratory therapist

O2 Sat
93-100
<93=C
o Assess RR
o Give O2

BNP
Good indicator of CHF
Normal <100
Elevated=B

Sodium
135-145
Abnormal =B (Hypo-Overload) (Hyoer-dehydration)
If change in LOC=C
o Fall risk * Implement precautions and call dr

WBCs
WBCs 5,000-10,000
o WBC < 5000 = C
Absolute Neutrophil Count (ANC) >500
o ANC <500 =C
CD4 Count (T Cells)
o Should be greater than 200
o <200= AIDS
o CD4 < 200 =C
For top three implement (NP) reverse isolation precautions:
o Neutropenic Precautions:
Stricthandwashing
ShowerBIDwithantimicrobialsoap
Avoidcrowds
Privateroom
Limitnumberofstaffenteringtheroom
Limitvisitorstohealthyadults
Nofreshflowersorpottedplants
Lowbacteriadiet
Norawfruits,veggies,salads
Noundercookedmeat
Donotdrinkwaterthathasbeenstandinglongerthan15
minutes
Vitalsigns(temp)every4hours
CheckWBC(ANC)daily
Avoiduseofindwellingcatheter
 Donotreusecups..mustwashinbetweenuse
Usedisposableplates,cups,straws,plasticknife,fork,
spoon
Dedicateditemsinroom:stethoscope,BPcuff,
Thermometer,Gloves
Terminology
:
o High WBC Count
Leukocytosis
o Low WBC Count
Leukopenia
Neutropenia
Agranulocytosis
Immunosuppression
BoneMarrowSuppression

Platelets (Thrombocyte Clotting Cell)

Wide range 150,000-400,000
o <90,000 = C
Assess for bleeding
Bleeding precautions
Call Dr
o <40,000 = D
could spontaneously hemorrhage to death
Assess for bleeding
Bleeding precautions
Prepare for transfusion
Call DR
o Bleeding Precautions(Thrombocytopenic Protocol):
NounnecessaryvenipunctureinjectionorIV.Usesmall
gauge
Handlepatientgentlyusedrawsheet
Useelectricrazor
Notoothbrushorflossing
Nohardfoods
Wellfittingdentures(norub)
Blownosegently
Norectaltemp,enema,suppository
Noaspirin
Nocontactsports
Nowalkinginbarefeet
Notightclothesorshoes
Usestoolsoftener.Nostraining
NotifyMDofbloodinurine,stool

RBCs
 4-6
Abnormal =B (check for bleeding)

Summary/Analysis
Knowthe5Dswhicharethemostdangerous
K+ >6
pH6&<6
CO260sandup
pO260sanddown
Plt<40,000
KnowwhattodofortheCs
DontspendtimememorizingtheA&Bs
WhenshouldyoucallaRapidResponseTeam?When symptomatic! ASAP!
Dont call before assessing
 LACINECTOMY AND SPINAL CORD
1. Definition :
a. Ectomy=removalof
b. Lamina=Vertebralspinousprocesses
2. Reasonforlaminectomy:totreatnerveroot compression
3. Signs&Symptomsofnerverootcompression
a. Pain[usuallydistalextremities]
b. Paresthesia[numbnessandtingling]
c. Paresis[muscleweakness]
4. Locations:
a. Cervical(neck)
b. Thoracic(upperback)
c. Lumbar(lowerback)
5. Pre-op Cervical Laminectomy
a. cervicalspineinnervatesdiaphragmandarms!
b. Mostimportantassessment:
i. Breathing
ii. 2nd
:
howarearmsfunctioning
6. Pre-op Thoracic Laminectomy
a. Thoracicinnervatesabdomenandbowelfunctions
b. Mostimportantassessment:
i. Cough mechanism and bowel function
7. Pre-op Lumbar Laminectomy
a. Innervatesbladderandlegs
b. Mostimportantassessment:
i. Bladder retention and leg function
8. Post-Op Care
a. #1 post op answer on NCLEX with spinal cord:
log roll (move
spine in ONE piece)
b. Specificactivity/mobilizationstrategypostop
i. DoNOTdangle(sittingworstpositionforspine/back)
ii. Limitsittingfor30minutesatatime
iii. Maywalk,stand,orlaywithoutrestrictions
c. Post-Op Complications
i. Cervical: Watchfor
pneumonia (diaphragm and arm probs)
ii. Thoracic: Watchfor
asirational pnemonia
(abdominal-paralytic ileus [bowel])
iii. Lumbar: Watchforurinary retention (bladder retention and
lower extremity probs)
d. Laminectomywithfusioninvolvestakinga bone graftfromthe
iliac
crest (mostcommonsite).(andfusethem)
i. Ofthetwositeswhichsitehasthemost:
1. Pain? Hip
2. Bleeding/drainage? Hip
3. Riskforinfection?
50/50 equal spine and hip
 4. Riskforinjection?
Spine site
Surgeonsareusingcadaverbonefrombonebanks.Why?
So dont have to do grafts, reducing rejection and infection rate. Bone has
decreased protein with antigens and wont be as easily rejected. Decrease
pain in patients post op as well.

9. Discharge Teaching
a. Temporaryrestrictions[normallyalways6weeks]
i. Dontsit
forlongerthan30 minutes
ii. Lie flat & Log roll for6weeks
iii. Nodriving for6weeks
iv. Liftingrestrictions:donotlifemorethan
5lbs for 6 weeks
b. Permanentrestrictions[forever]
i. Laminectomypatientswillneverbeallowedtoliftby
bending at waist [must use knees]
ii. Cervicallaminectomypatientswillneverbeallowedtolife
objectsabove head
iii. Nohorsebackriding,offtrailbiking,jerkyamusementpark
rides,etc

Piagets Stages of Intellectual Development
Age/Stage
Age: 0-2 years old
Stage: Sensorimotor
Age: 3-6 years old
Stage: Pre-Operational
Age: 7-11 years old
Stage: Concrete Operations
Age: 12-15 years old
Stage: Formal Operations
PEDIATRIC TEACHING
Characteristics Teaching Guidelines
Totally present-oriented. When As you do it
Only think about when they What You are currently
SENSE or are DOING right doing
now. Dont understand past How Verbally explained
or future
Fantasy oriented When teach ahead of time
Illogical (not too far, a hour or two;
No rules day of or morning before)
What you are going to do
How using play [doll,
story..]
Rule-oriented When can teach days
Live & Die by the rules! ahead
Cannot abstract What you are going to do
Only 1 way to do things + skills
*Perfect age to teach skills How dont use toys and
play!
Internet
Use age appropriate reading
and audio visual material
Able to think abstractly When like adult
Understand cause-effect What like adult
Adult when it comes to How like adult
thinking Like any other med surg pt
 KIDS TOYS

Threeprinciplestoconsiderwhenchoosingappropriatetoys..
1. Isit
safe
2. Isit
age appropriate
3. Isit
feasible

Safety considerations:
1.Nosmalltoysforchildren4andunder
2.Nometalboyswhereoxygenisinuse
3.Bewareoffomites[soifimmunocompromised nostuffedanimals!]
AgeAppropriateness:
1.First year of life
a.
0-6 months (sensorimotor)
1)
Besttoy:musicalmobile
nd
2)
2Besttoy: Somethinglarge,soft(cantbeswallowed,nofomites)

b. 6-9 months (object permanence)
1)
Besttoy:cover/uncovertoys[peakaboo]jackinthebox
2nd
2) Besttoy: large,hard,plasticmetal

c. 9-12 months
1)
Besttoy:verbaltoy[toywhichtalks]
2)
Purposefulactivitywith objects[@9mosfirststartdoingpurposeful
things]
Avoidanswerswiththefollowingwordsinthemforchildren9monthsand
younger:
Build
Sort
Stack
Make
Construct

2. Toddler (1-3 years)

a. Besttoy push/pulltoy[wagon]
b. Workon Grossmotor
c. Characterizedby parallelplay[nexttoeachotherbutnotwith]

3. Preschoolers (3-6 years)

a. Workon finemotor[puzzles,chalk,crayons]
b. Workon balance[dance,skate]
c. Characterizedby cooperativeplay
d. TheyLiketopretend

4. School age (7-11 years)

Characterizedbythe3Cs
1. C ollective[liketocollectex.Beaniebabies]
2. C reative[blankpaper,coloringpencils,legosneedtomakethings
intootherthings]
3. C ompetitive[winners&losers]

5. Adolescents (12-18 years)

Theirplayis
peer group association (hangoutinlargegroups,doingnothing)

Allowadolescentstobeineachothersroomsunlessoneofthemis:
1. Immunosuppressed
2. Contagious
3. Freshpostop(12hours)
 MEDICATION HELPS & HINTS

1. Humulin 70/30

2. Drawing up Insulin

1) PressurizeNormal
2) PressurizeRegular
3) DrawupRegular[clearbeforecloudy]
4) DrawupNormal

3. Injections

IM SQ
4.
Heparin & Coumadin
HEPARIN COUMADIN(WARFARIN)
Works right away (so start right Takes days (therefore start heparin
away) too at same time)
IV & SQ Kicked in when INR 2-3
21 days [ after that body makes own PO
enzymes-dangerous] Antidote:
Vitamin K
o therefore, notify MD if at PT (INR)
it 2 weeks and ask if time Cannot give in pregnancy
to switch to Warfarin o Can cross placenta
o when start may be on bed o Class X
rest 5-10 days until
bodies enzymes adapt
Antidote: protamine sulfate
PTT
Can be given in pregnancy
o Not safe however
o Class C: use with caution

K+ sparing vs K+ wasting Diuretics

Baclofen (Lioresal)
Musclerelaxants
CantakewithOxycodone&cutdose
1)Causesdrowsiness
2)Relaxesmuscles(muscleweakness)
3)Noalcohol
4)Nodriving
5)Cannotsupervisekidsunder12alone

 PSYCHIATRIC NURSE TEST-TAKING

PRINCIPLES
PhaseSpecificity
Thebestpsychanswersarethoseanswersthataremostappropriatetothe
phaseofthenursepatienttherapeuticrelationshipthatyouarein

Ifthequestiontellsyouthephaseoftherelationship,thephasewillbethe
determinantofwhichansweriscorrect
The phases of the nurse-patient relationship:

The Pre-Interaction Phase

Purpose: Forthenursetoexplorehis/herownfeelings.Topreventjudgmental,
intolerantreactions.
Length:Beginswhenyoulearnyouaregoingtobecaringforsomeoneandends
whenyoumeetthem.
CorrectAnswer(s): Thenursewillexploreher/hisownfeelingsabout

The Introductory Phase

Purpose:Toestablishtrustandexplore/assess
Length:
Beginswhenyoufirstmeetthepatientandendswhenamutually
agreeduponcareplanisinplace
KeyWords:
Thesephrasesaredesignedtohinttoyouthatyouareintheintroductory
phase:
o 1.During the initial interview
o 2.Upon admitting the patient..
o 3. On admission
o 4.At your first few meeting with..
o 5.While assessing
o 6.On the day of admission
o 7. While formulating nursing diagnoses
Correctanswers: Shouldbeverytolerant,accepting,explorative,probing,nosy.
Bewarmandfuzzy

The Working Phase (Therapeutic Phase)

Purpose:Toimplementtheplanofcare
Length:
Fromthefinishedcareplanuntildischarge
KeyWords:
1.Duringthetherapeuticinterview
 2.Whileimplementingthecareplan..
3.Whileworkingonthecareplangoals
4.Duringtreatmentsessions..
5.Duringtherapy..
6.Inyourweeklysession..
7.Threedaysafteradmission
8.Afterimproving..
CorrectAnswers:
Shouldbeveryfocused,directive,tough.Insomewaystheseanswerswill
seemsternandslightlyunfriendly.Setlimits.Enforcepropercommunication.

The Termination Phase

Theonlyquestionaskedherehasbeen,Whendoestheterminationphase
begin?
TheanswerOnadmission

GIFT GIVING
Inpsych,donotgivesomethingofvaluetothepatient.Conversely,donot
acceptsomethingofvaluefromthepatient

Agiftissomethingoftangibleorintangiblevaluegivenfromonepersonto
another.

Giftsinclude:hugs,kisses,compliments,opinions,holdinghands,placinganarm
around,etc

DO NOT dothesebehaviorsinpsych.(Maybeappropriateinmedsurg)
Differencebetweencomplimentingandobservingprogress

ADVICE-GIVING
DONOTGIVEADVICE.Letthepatientformulateownsolutionsandalternatives.

Remember,givingadviceandsettinglimitsarenotthesame.Theformerisbad,
thelatterisgood.

KEY WORDS TO AVOID:

1.
Suggestthat..
2.Advisethepatientto..
3.
Tellthepatientto..
4.
IfIwereyou,Iwould
5.Youshoulddo..
6.Yououghtto..
7.YoushouldNOTdo..
8.Dontdo
9.Recommendthat

AnywordswiththesephrasesviolatethisprincipleandareWRONG.RULE
THEM OUT!
Alwayssay,Andwhatdo you
thinkyoushoulddo,Mr.Smith?

GUARANTEE GIVING
DONOTGIVEGUARANTEESINPSYCH.Youcannotpredictthehumanmind
ofknowanothersexperience

GivingguaranteesisokayinMed/Surgiftrue

KEY WORDS:
1.
Ifyouthen
2.Youwillimproveifyou..
3.Wecan

Aguaranteeviolatestrustwhenthepromisedresultsdonotappear

Onlythingscanguarantee:1)medswillwork2)youaresafe

IMMEDIACY
Thebestpsychanswerscommunicatetothepatientthatthenurseiswillingto
dealwiththepatientsproblemrightthenandrightthere

Key Phrases:
AVOID answerslikethese
1.Referpatientto
2.Haveyouspokentoyouraboutthis?
3.Whydontyoutalktoyouraboutthis?

Avoidchangingthesubjectunlessyouarerefocusingapatientwhoisavoiding
thesubjectoftherapeuticsession

CONCRETENESS
Thebestpsychanswersarethoseanswersthatsayexactlywhattheymeanina
literalsensewordforword

KEY PHRASES: Avoidslang,figurativespeech,sayings,proverbs,verses,

poetry,stories,parables,allegories,neologisms.

Tie-Breakers

1.Whyquestionsarenotasgood
2.Reflectionisgood.
3.Openendedisbetterthanclosedended.
4.Answerswith I, me, we, us
inthesubjectarenotgood.
5.Shortestanswersarethebest

 PSYCH TREATMENT PROTOCOLS

CATEGORY PROTOCOL
DEPRESSION Most cases not psychotic
Suicide rates high
o If even slightest indication
must bluntly ask, have you
ever thought of..
Psychomotor retardation: sit around
and dont do anything, slow, inactive
o Must push these patients to
do things and be very
directive
Activities: in a group, but does not
require interaction ex. Movie, craft

SCHIZOPHRENIA High suicide rate

Activities: group, requiring
interaction-this brings pt to reality

BIPOLAR Hypomania:
minor; preceding; admit
at this phase to prevent full mania. Pt
hyperexaggerated but still functioning

Mania:
full blown; when stops ADLs
and other responsibilities
o Major problems:
dehydration, malnutrition,
lack of sleep
o Actions: high cal finger
foods, allow sleep/naps
 whenever they want, gross
motor activities alone

ANXIETY DISORDER
most common psych Phobias: treatment: desensitization
prob in U.S. (gradual exposure)
4 levels:
o 1. Talk about it
o 2. See pics of it
o 3. Be in environment with
is
o 4. Actually experience it
Patient has to be calm and ready to
experience each next level

SUBSTANCE ABUSE Denial

Dependency

Manipulation

VIOLENT CLIENTS Deal with violence as a team (of 5-1

person for each extremity)
In de-escalation process- only one
person talks
Always give patient a chance to gain
control of self before taking action
EMPATHY
Thebestpsychanswersarethoseanswersthatcommunicatetothepatientthat
thenurseacceptsthatpatientsfeelingsasbeingvalid,real,andworthyofaction.

Key Phrases: Alowempathyanswerisalwayswrong

AvoidSaying:
1.Dontworry
2.Dontfeel
3.Youshouldntfeel
4.Iwouldfeel
5.Anybodywouldfeel
6.Nobodywouldfeel
7.Mostpeoplewouldfeel

Four Steps to Answering Empathy Questions

1.Recognizethatitisanempathyquestion
Empathy questions have a quote in the question, and each of the answers
contains a quote.

2.Putyourselfintheclientsshoes.Saytheirwordsasifyoureallymeantthem.

3.Askyourself,IfIsaidthosewordsandreallymeantthem,howwouldIbe
feelingrightnow?

4.Choosetheanswerthatreflectsthe feelings...nottheanswerthatreflectstheir
words.
 PSYCHOTROPIC DRUGS
Note: All psych drugs cause a decrease in BP and weight change

1. Phenothiazines
a. Allendin zine
b. Verypotent
c. Immediateonset
d. Ex.Thorazine,Compazine
e. Actions :
i. Doesnotcuredisease.Reducessymptoms
ii. Large doses: Psychoticsymptoms(Hallucinations
iii. Small doses: Nausea/Vomiting
iv. Major:
Tranquilizers
f. SideEffects: (rememberABCDEFG)
i. A nticholinergicEffects
ii. B lurredvisionandB
ladderretention
iii. C onstipation
iv. D rowsiness
v. E xtraPyramidalSyndrome(EPS)
vi. F Photosensitivity
vii. A Granulocytosis(lowWBCcountimmunosuppression)
viii. Teach patient to report sore throat and any S/S of infection
toDR
g. Nursing Care: treat side effects. Number one nursing diagnosisis
safety.
h. Deconate after name of drug means it is long acting (at least 2
weekstomonth)IMformgivento non-compliant patients

2. Tricyclic Antidepressants
a. Antidepressant
b. mood elevators totreatdepression
c. Ex.Elavil,Tofranil,Aventyl,Desyrel
d. pram,trip
e. SideEffects:(ElavilstartswithEsothisgroupgoesthroughE)
i. A
nticholinergicEffects
ii. B
lurredvisionand Bladderretention
iii. C
onstipation
iv. Drowsiness
v. Euphoria
f. Musttakemedsfor 2-4 weeks beforebeneficialeffects
3. Benzodiazepines
a. Antianxietymeds(considered minor tranquilizers)
b. Alwayshave pam, -lam inthename
c. Prototype:Diazepam(Valium)
d. Indications:
 i. Inductionofanesthetic
ii. Musclerelaxant
iii. Alcoholwithdrawal
iv. Seizuresespeciallystatusepilepticus
v. Facilitatesmechanicalventilation
e. Tranquilizersworkquickly
i. Mustnottakeformorethan 90 days/3 weeks-3 mos
ii. KeeponValiumuntilElavilkicksin
f. SideEffects:
i. AnticholinergicEffects
ii. BlurredvisionandB
ladderretention
iii. Constipation
iv. D rowsiness
g. #1NursingDX: Safety

4. Monoamine Oxidase (MAO) Inhibitors

a. Antidepressants
b. Depression is thought to be caused by a deficiency of
norepinephrine, dopamine, and serotonin in the brain. Monoamine
oxidase is the enzyme responsible for breaking down
norepinephrine, dopamine, and serotonin. MAO inhibitors prevent
the breakdown of these neurotransmitters and thus restore more
normallevelsanddecreasedepression.
c. 24weeks
d. DrugNames:
i. Mar plan
ii. Nar dil
iii. Parnate
e. SideEffects
i. AnticholinergicEffects
ii. Blurredvisionand Bladderretention
iii. Constipation
iv. D rowsiness
f. Interactions: (PatientTeaching)
i. To prevent severe, acute, sometimes fatal hypertensive
(stroke) crisis , the patient MUSTavoidallfoods containing
TYRAMINE.
1. Foods containing TYRAMINE:
a. Fruits and veggies (remembersaladBAR)
i. AVOID:
1. B ananas
2. A vocados
3. R aisins(anydriedfruits)
 b. Grains: all okay except things made from
activeyeast
c. Meats
i. No organ meats: liver, kidney, tripe,
heart,etc
ii. No preserved meats: smoked, dried,
cured,pickled,hotdogs
d. Dairy
i. Noagedcheese
ii. Noyogurt
iii. Cannoteatbrickcheese
e. Other
i. No alcohol, elixirs, tinctures, caffeine,
chocolate,licorice,soysauce
ii. DrugInteractions:
1. Teach patient not to take OTC meds unless theyare
prescribed

5. Lithium
a. Anelectrolytenotice ium endingasinpotassium,etc
b. UsedfortreatingBPD(manicdepression)itdecreases mania
c. SideEffects:(The3Ps)
i. Peeing(Polyuria)
ii. Pooping(Diarrhea)
iii. Paresthesia(Firstsignofelectrolyteimbalance)
d. Toxic:
i. Tremors, metallic taste, severe diarrhea or any otherneuro
signsbesidesparesthesia
ii. #1intervention:keep hydrated
iii. Ifsweating,giveelectrolyte drink aswellasfluids
e. Note: Closelylinked tosodium.Monitor sodiumlevels. Low sodium
levelsprolonglithiums halflife,causinglithiumtoxicity.
Highsodium
levelsdecreasetheeffectivenessofLithium.
i. WillonlyworkasprescribedifSodiumnormal!!
6. Prozac (Fluoxetine)
a. ProzacisaSSRI(Antidepressant)
b. SimilartoElavil(Atricyclicantidepressant)sameinfo
c. SideEffects:
i. A nticholinergicEffects
ii. B lurredvisionandB ladderretention
iii. C onstipation
iv. D rowsiness
v. E uphoria
d. Prozaccauses insomnia ,sogivebefore12noon
i. IfBIDgiveat6A&12N
e. Whenchangingthe doseof Prozacforaadolescentoryoungadult
watchfor suicidal ideation

7. Haldol (Haloperidol)
a. Also hasdeconateform[IM,longacting,giventoptswhowonttake
pills
b. SameinfoasThorazine
c. Verypotent
d. Immediateonset
e. Actions :
i. Doesnotcuredisease.Reducessymptoms
ii. Large doses: Psychoticsymptoms(Hallucinations
iii. Small doses: Nausea/Vomiting
iv. Major:
Tranquilizers
f. SideEffects: (rememberABCDEFG)
i. A nticholinergicEffects
ii. B lurredvisionandB
ladderretention
iii. C onstipation
iv. D rowsiness
v. E xtraPyramidalSyndrome(EPS)
vi. F Photosensitivity
vii. A Granulocytosis(lowWBCcountimmunosuppression)
viii. Teach patient to report sore throat and any S/S of infection
toDR
g. Nursing Care: treat side effects. Number one nursing diagnosisis
safety.
h. **Elderly patients may develop Neuroleptic Malignant
Syndrome (NMS), a potentially fatal hyperpyrexia (fever) with a
temp of >104 F from overdose. Dose for elderly patient should
be HALF of usual adult dose.
8. Clozaril (Clozapine)
a. Secondgenerationatypicalantipsychotic
b. Usedtotreatsevereschizophrenia
c. Advantage : it does
nothaveside effects A, B, C, D, E, orF (much
less)
d. Disadvantage: it DOES have side effect: Agranulocytosis(worse
thancancerdruginsusceptiblepatients)
e. ForfirstmonthneedWBCcountsweekly.IfWBCLOWSTOP!
f. DonotconfusewithKlonopin(Clona zepam)

9. Zoloft (Sertraline)
a. AnotherSSRIlikeProzac
b. S/EABCDE
c. 24weekstowork
d. AlsocausesinsomniabutCANbegiveninevenings
e. Watchforinteractionwith:
i. St. Johns wort-serotonin syndrome *deadly
1. Sweating
2. Apprehension
impendingsenseofdoom
3. Dizziness
4. HEAD- ache
ii. Warfarin (Coumadin)- watch for bleeding (may need to
lowerwarfarindose)
1. WhentakeZoloftwarfarinandINRstaysUP