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Mark K lecture #2

Etohism

The #1 problem in etohism is the same in all abusive situations. DENIAL


Denial allows the abuser to continue to do it. We can use the etohism for all
abuses. Denial is the #1 problem in all abusive situation. You cant treat someone
who doesn’t recognize that they have a problem.
Denial- refusal to accept the reality of the problem. “Im not a alecolic, I can quit
anytime I want” “I am not a spousal abuser, we just have a really physical
relationship”
How to tx denial we have to CONFRONT it. Point out what they say vs what they
do.
“you say you are not an alcoholic, but yet you have already drank a 12 pack
of etoh before noon?” “you say you are not an abuser but yet your wife has
a restraining order against you?”
Don’t get aggression and confrontation confused. Aggression attacks the person.
Confrontation attacks the problem.
On NCLEX never attack the person! “you are dealing with a staff nurse and they
are finding fault with everything that we do…” what do we say? You vs I. we don’t
say “why don’t you like me?” we do say “ I seem to be frustrating you.” When
dealing with staff or physicians always you I instead of you so that it is not
confrontational. “I am having difficult time figuring out what you want is correct”
DENY=CONFRONT
Denial is also present with loss and grief. “DABDA” (denial, anger, bargaining,
depression, acceptance)
Denial is an accepted healthy reaction to grief and loss. What do we do with
denial when it applies to grief and loss? We SUPPORT it. To get the question
correct denial on the NCLEX we think like this…. “with loss we support, and with
abuse we confront”
For example if a farmer comes in and his hand is amputated and you are taking
care of him as a nurse and he says “I cant wait to get home to play the piano” the
patient is in denial so we would say “well how long have you played piano, what is
your favorite music?” because this is denial that is dealing with loss so therefore
we would support him NOT confront him by saying “you only have one hand, you
cant play”.
Loss=support

#2 psychological problems that abusers have is dependency and codependency:


 When the abuser gets their significant other person to do something for
them or makes decisions for them. “would you go and call my boss, and
then they go and do it” the abuser in this case would be dependent.
 Codependency is when significant other derives positive self esteem from
making decisions or doing things for the abuser. “call my boss tell them
their spouse is sick, hangs up the phone and the spouse says see aint I a
very good spouse because I did that for them?” one is dependant and gets
the positive self esteem out of the relationship. The abuser keeps be able
to have a life without responsibility. We would tell the significant other to
leave the abuer but they don’t want to get out of the relationship because
they are getting positive self esteem from it.
o How would you treat this? We would set limits and enforce them.
You would start teaching the significant other to tell their spouse the
abuser “NO”. if we don’t work with the codependant first then it will
never work. The dependant person is going to start to say “you don’t
love me, etc” . in order for this to work the codependant has to say
“no” and stick with it no matter what the dependant person says.
The codependant (spouse) has to say “I said no and I am a good
person for saying no” . the dependant person will say whatever they
can to try to make the codependant feel bad but the other person
has to stay strong.
Manipulation: when the abuser gets the significant other to do things for him or
her that are not in the best interest for the significant other… the nature of the
act is harmful or dangerous. So how is manipulation like dependency? In both
situations the abuser is getting the other person to do something for them.
o Dependancy: If what the significant other is asked to do is neutral,
then it is no harm no foul. It is simply dependency, co dependency.
“a 30 year old woman who is an alcoholic tells her 35 year old
husband to go to the store and buy alcohol for her. This is NOT illegal
so this is simply dependency.
o Manipulation: But if the abuser is asking the significant other to do
is harmful or dangerous to the significant other then the significant
other is being manipulated. “a 30 year old woman is an alcoholic
tells her 17 year old daughter to go to the store and buy her alcohol”
this is manipulation bc this puts the child at risk bc this is illegal for
the child to do to benefit her mother. This is harm to the child!
 How do you treat manipulation? You set limits and enforce
them. You start saying “no”. most people who are being
manipulation they always say, “I cant believe I fell for that, or I
cant believe that I did that for them”. Manipulation is easier to
treat than dependency bc you only have 1 person to deal with,
the person who is being manipulated, where in the other
situations above you have more than one person to treat or
deal with. Denial=1 patient/ dependency=2 patients bc you
have to get the co dependant/manipulation= 1 patient

Things specific to alcoholism. Wornikes and korsoffs: (these are typically different,
but NCLEX seems to put them together bc you may see them both present in the
same patient)
 Wornikes= is encepalopothy

 Korsoffs=
o #1 s/s= is a psychosis induced by vitamin B1 or Thymin deficiency.
This is when you lose touch with reality and you go insane bc you
don’t have enough B1. These patients are psychotics.
o #2 s/s is amnesia with confabulation. Memory loss and making up
stories. They make up stories bc they forgot and they believe it.
When normal people make up details or whatever bc they have
forgot simple little details this does not mean that everyone who
makes up details or forgets details is psychotic. The difference is that
these psychotic patients believe the details that are made up. These
psychotic patients will forget entire decades of their memory so they
make up stories (like what they did in the 90s) (someone thinks he
was a security officer for ronald Reagan) They have an entire
psychotic story made up about a specific time.
 So how do we deal with these people? (someone thinks he is
obamas secretary of defense so he has to get up and go to a
cabinet meeting. We don’t present reality because they cant
learn it bc this is an actual brain deformity. A good thing to do
would be to redirect this patient with something that he CAN
do in place of what he CANT do. He cant go to a cabinet
meeting with the president, but you can say “ lets go get a
shower and afterwards we will go watch the CNN news”
 When a patient who has wornskees and korsoffs = we as the
nurse will redirect them.
 Characteritics: this is preventable. You never have
to get this in the first place. You can simply take
vitamin B1. Vitamin B1 protects the brain so when
they drink etoh the vitamin B1 prrotects the brain
cells and prevent the entire disease from
happening. Simply put just take their one a day
vitamin in the morning before they start to drink
their etoh and you will be perfectally fine. You can
stop it from getting worse by taking B1. About
70% irreversible. * on boards always go with the
majority meaning….. if a specific disease is 70%
fatal, then you would just say on boards that it is
fatal**

Some drugs that have to do with etoh (Antabuse ((dysulfaram))or Revia):


1. This is a form of eversion therapy= eversion means a really strong hatred
for something. We want alcoholics to have a gut wrenching hate for etoh.
When the alcoholic to take this medication and build up in their system,
then when the alcholic takes any kind of etoh they will become severly
sick!!!! We want the alcoholic to be like this…. We as a nurse could not
even pay them to drink etoh. This normally happens when the patient
drinks even the slightest bit of etoh and they become severly sick. They
remember that feeling of sickness and they NEVER want to feel that way
again so they say, “you could not pay me enough to drink!” the theory in
this medication is that it is a miracle drug for alcoholics but in reality it is
different bc we would have had a cure for alcoholism years ago but still
make sure that we know how it is supposed to work. *** what NCLEX
wants you to know about this medication is what is the onset and the
duration for this medication? The answer is it takes 2 weeks to get into
their system. They have to be on the medication for 2 full weeks before it
starts to work. They have to be off Anabuse for an entire 2 weeks before
they can drink again without any s&s to occur. You have to teach the pt
what all has etoh in it. You have to teach them about the stuff that they
would not typically think has etoh in it. The pt knows that wine, beer, wisky
etc have etoh in it.
a. mouthwash =and they swish and spit it out they are still going to get
sick bc there is etoh in it.
b. Aftershaves= even when put on topically they will become
nauseated.
c. Perfumes and colognes
d. Insect repellants
e. Any otc that ends with “elixir” bc all elixir has etoh in them.
f. Etoh based hand sanitizers
g. Uncooked icings (this has powder sugar which is powerful etoh)
h. Do not pick the red wine vingerette on NCLEX as a choice of
something they cant have. They try to sucker you into this bc of the
word “wine”
37:18 stopped

Overdose and the withdrawals:


Every abused drug is either an upper or a downer. Other drugs don’t do anything
for the pt so therefore they will not choose those. What is the #1 drug that is
most abused class of drug that is not an upper or downer? Laxatives in the
elderly. But this drug is not an upper or downer drug.

1. When you get an overdose or withdrawl question you need to ask yourself
first is this an upper or a downer drug?

the names of uppers are:


caffeine
cocaine
PCP/LSD
Methanfedamines
*Adderal – this is the ADD drug (a lot of kids with ADD are selling
their Adderall to their friends at school instead of taking it.)
 s/s of uppers:
uppers make you go up because they are uppers.
Euphoria, tachycardia, restlessness, irritability,
bowels status= borgarigmy/diahrrhea, 3 and 4
reflexles, spastic, seize=should have a suction
machine at beside.
The names of the downers are:
Everything that is NOT an upper IS a downer! There are 135 downers
but we don’t have to learn these if we just KNOW the 5 uppers.
 s/s of downers:
downers make you go down bc they are downers.
Lethargy, (everything that is above for uppers just
flip it for downers) ** the #1 complication is
respiratory depression leading to respiratory
arrest.**
 what do you think about if yorue patient is
high on cocaine. What is critically important
to assess? Check their reflexes!! Their
respiratons only being at a rate of 12 are
NOT important bc this is a wrong answer bc
cocaine is an upper drug so it makes
everything go up, so their respiratorty rate
will be a lot higher than 12.

2. Once you know if the answer to the question is either an upper or a downer
The second thing you have to ask yourself is are they talking about is this
question talking about withdrawl(which is not enough) or overdose (which
is too much)?
a. Is the questions being asked either an upper or a downer?
b. Are they talking about withdrawl(which is not enough) or overdose
(which is too much)?
Overdose(too much)- example overdose on an upper: we know that the
answer is going to be all of the upper answers.

Withdrawl(not enough)- example withdrawl on a downer: too little upper


makes everything go down. Not enough downer maker everything go up.
Upper overdose looks like what other situation? Downer withdrawld
Downer overdose looks like what other situation? Upper withdrawl.
In which two situations would respiratory depression be youre highest
priority ? downer overdose and upper withdrawl.
Which two with adding in seizure would be youre biggest risk? Upper
overdose and downer withdrawl.
EMS calls and says patient is overdose on cocaine. What would you expect
to see SATA?
** first question ask yourself is this upper or downer? Second
questions to ask yourself is this overdose or withdrawal.
This is an upper, and overdose. (too much upper)
 Irritability
 Respirations of <12
 Borgaramy (hyperactive bowel sounds)
 +4 reflexes
 Difficult to arouse
 Increase temperature
You are caring for a patient who is withdrawaling from cocaine what would
you expect to see SATA?
** first question ask yourself is this upper or downer? Second
questions to ask yourself is this overdose or withdrawal.
This is upper and withdrawal. (too little upper) so choose for the
answer all of the choices that are ??
 Irritability
 Respirations of <12
 Borgaramy (hyperactive bowel sounds)
 +4 reflexes
 Difficult to arouse (you best to move here
and start using some Narcan!)
 Increase temperature
Drug abuse/addiction in the newborn:
Always assume intoxication not withdrawal at birth. The baby has to be at least 24
hours old before you can start to think this is withdrawal not intoxication.
You are caring for an infant who is born to an Quelude addicted mom, 24
hours after birth SATA.
** first question ask yourself is this upper or downer? Second
questions to ask yourself is this overdose or withdrawal.
(Quelude is a downer bc it is not one of the 5 uppers listed by
Mark K. and the baby is withdrawing bc it has been at least 2
hours. The baby does not have enough downer so everything is
going to go up.)
 Difficult to console
 Low core body temp
 Exaggerated startle reflex
 Respiratory depression
 Seizure risk
 Shrill high pitched cry
** NCLEX expects you to know that a CNS depressants in a newborn 24 hours
after birth will make the baby go the opposite way. *** just know the principles
of the 5 medications

Etoh withdrawal syndrome vs. deliurum tremors (DT’s):


You have to know the differences between them. Sometimes people think that
DT’s is etoh withdrawl and it is not they are completely different things.
Every alcoholic goes through etoh withadrawal within 24 hours they will go into
withdrawal syndrome. Every single one of them go through etoh withdrawal
syndrome, but only a few of them go through deliurum tremors (within 72 hours).
So what comes first?
1. Etoh withdrawal (within 24 hours after stop drinking etoh)
2. Deliurem tremors (within 72 hours after stop drinking etoh)
A. Etoh withdrawl syndrome always precedes deliurum tremors however
deliurem tremors not always follow etoh withdrawal syndrome. So if you
have DT’s means you had to have etoh withdrawal, but you can have etoh
withdrawal and not have DT’s.
B. AWS (etoh withdrawal syndrome) is not life threatening but DT’s can kill
you.
C. Pts with AWS are not a danger to self or other but pts with DT’s are
dangerous and are dangerous to self and others. AWS wont hurt you, but
DT’s will hurt you and are dangerous to themselves and others.
The differences between AWS and DT:
AWS:
 Semi-private room anywhere on the unit (you can put a AWS patient on the
pediatric overflow unit bc they wont hurt anyone)
 Regular diet
 Up ad lib (can go around anywhere they want to go)
 No restraints (bc they are not a danger to self or others)
DT’s:
 NPO or clear liquids (seizure bc they are on an upper and have R/O
aspiraton so they need to be NPO/clear liquids)
 Private room near nurse’s station (bc they are dangerous and are unstable
and should be probably in an ICU bed bc they are unstable and dangerous,
but they usually get put on a stepdown unit.) * an LPN could NOT accept
the assignment of this patient bc they are unstable. RN could YES accept
this patient assignment bc they are unstable. But if the RN on a medsurg
unit took the patient assignment of a DT patient then they would need to
have their work load decreased from 7 patients to 3 patients. On NCLEX
you have the perfect environment.
 Restricted bed rest. No bathroom visits. Only on bedpans and urinals.
 Must be restrained bc they are dangerous (need to be in a vest or two point
((two extremities= meaning 1 arm and the opposite leg which remember
you would switch this to the other arm and the other leg every two hours.
DON’T release the locked down leg and then the arm always keep one arm
and one leg restrained. dont release them first you wont make that mistake
but once.)) locked leather restraints. The soft wrist restraints, and the 4
point restraints these pts will come out of these.
Both DT’s and AWS get:
 Antihypertensive (beta blocker BP pill) = bc everything is going up bc both
DT and AWS are going through withdrawls.
 Tranquilizers= bc they are up bc they are withdrawl from a downer.
 A multivitamin of B1= to prevent wornseks and kosscoffs (**think “no B1
you will B1”)

DRUGS:
Aminoglycosides
Stopped @70:18/101:54
This is a powerful class of abx, these are the big guns. When nothing else works
the MD will pull out these aminoglycosides. Don’t use these until nothing else
works. NCLEX likes to test on these drugs bc they are dangerous and NCLEX tests
us on safety. Top 5 most commonly tested group of drugs. There are 10 big
groups of meds you must know for NCLEX.
Aminoglycocosides :
Think the following “a mean old mycin” when we hear aminoglycocsiedes. These
are abx that are used to treat “mean old drugs” .
 What does that tell us? These are abx that are used to treat serious
infections, life threatening, resistant, gram negative infections. These
“a mean old mycin” is treated by “a mean ole drugs”.
 We would NOT use these drugs to tx a sinus infection? NO bc a sinus
infection is not a mean old infection.
 TB= yes we would use “a mean old drug” bc this is a “mean ole
infecctiobn”
 Otitis media (middle ear infection) = NO we wont use it here.
 Bladder infection= no
 Fulminating pyleonephrotis = yes use it
 Septic shock= yes use it
 Infection of 3rd degree of burn wounds over the entire body= yes
 Steph throat= no
** use “a mean old mycin” when you have “a mean ole infection”
and no other time but then!**

**ALL aminoglycosides end in “mycin” , BUT not all drugs that end in
“mycin” are aminoglycosides. There are 3 of the mycins that are NOT
aminoglycosides (“a mean old infection”) are:
 Arithromycin
 Zithromycin
 Clarithromycin
** if it ends in “mycin” then it is “a mean old mycin”, but if it has “thro” in it then
throw it off the list it is NOT “a mean ole mycin”
You would use the three above arithromycin, zithromycin, and clarithromycin
drugs for things like sinusitits, but NOT for TB!
What are the two toxic effects of mycin drugs? When we see these drugs think
about the most famous mouse… MICKEY MOUSE… what is the biggest thing on
MM? his ears!!!! So these “mycin” drugs are ALL ototoxic (ear) drugs. “OTO”
means ears. ORO means oral/mouth.
 Monitor hearing
 monitor ringing in the ears (tinnitus)
 monitor Vertigo/dizziness (bc of the the equilibrium and harming the
ear)
but if we had to pick between the three **Hearing** would be the most
important one to monitor for.
The human ear is shaped like a kidney so think the second toxic effect of
these drugs would be nephrotoxicity. NOT daily weight, urine, daily output,
GO for creatinine bc Creatinine is the BEST indicator for kidney fx.
If they ask which one is better the serum creatinine or the 24 hour
creatinine which one is better to show nephrotoxicity? The 24 hour
creatinine clearance would be better to show a better indicator of
nephrotoxicity.
“please feel free to record at 81:20**
So you see the ear/kidney image? Think of the number 8 and that it fits
nicely inside the ear reminds me of two things about the drugs:
 they are toxic to cranial nerve number 8 (ear nerve)
 you administer these drugs Q8hours.
What is the route for these drugs?
 IM or IV
Don’t give these drugs PO bc these drugs are not absorbed! If you give an
PO “mycin” you will just have an expensive poop bc it is not being
absorbed.
Except in two cases we DO want to give these “mean ole mycin” drugs PO:
 Hepatic encepalopothy (hepatic coma) liver coma: when the
ammonia level gets too high and it pickles youre brain and you
could die. The tx goal with this is to reduce the ammonia level
in the brain, so oral mycins will do that! and dissolve in youre
mouth, and travel to your gut and destroy gram negative
bacteria in youre gut and sterilize youre bowel. The #1
producer of ammonia in youre body is? Is the ecoli in youre
gut. If I can kill the ecoli in the gut then it will decrease the
ammonia level and it will help with the hepatic coma. Bc these
patients have liver damage w e don’t wont this medication to
get to the damaged liver. If wont get to their liver if taken
orally. It will go in one end and come out the other end and
sterilize the gut.
 In preop bowel surgery: you would want to give this oral mycin
drug before bowel surgery bc this medication sterilizes the
bowel before bowel surgery. For a few days before bowel
surgery the pt may take “a mean ole mycin” via PO. Since it is
given PO the patient will NOT have ototoxicity or
nephrotoxicity with this PO medication bc it is given PO in this
situation and is NOT given IM or IV bc given PO it is NOT
absorbed.
In both cases both preop bowel surgery and hepatic encepaloptology what does
the oral mycin drug do? It sterilizes the bowel in both cases. These are called the
“bowel sterilizers”. These two are called Neomycin and Canomycin. Just know
that these two drugs are only used PO and are only used for bowel sterilization.
Remember that by this:
 Think of a military cadence. The question the drill sgt asks the troop
is “who can sterilize my bowel?” the troop will shout back “neo can”
for neomycin and canomycin!
________________________________________________________

Trough and peak levels:


Trough is when the medication is at its lowest and peak is when the medication is
at its highest. TAP (trough is drawn after the peak) easy way to remember when
is the trough drawn? Trough is drawn after the peak..
What is the reason for drawing trough levels? Bc there is a very small window of
what will works and what kills on them so we would draw TAP on them. If there is
a wide range window we would not draw TAP on them.

What is the smallest of Lasix that I have ever seen given? Furisomide. 5 or 10
What is the largest amount of Lasix that I have ever seen given? 120
So is this a narrow or a wide range? Wide range so we would NOT draw a TAP on
them bc this is a wide window range of medication.

What about Digoxin? 0.125 -0.25


Is this a narrow or a wide range? Narrow range window so we would draw a TAP
on them. Bc they are only 0.125 difference on a digoxin.
So these mean ole mycin drugs all have taps drawn on them bc they all have taps
drawn on them.
When do you draw a trough or a peak? You don’t have to know what the drug
even is what matters is What the route is . so if it is given IV you would draw a
trough.
When would you draw the trough before you give a SL med? 30 mins before the
next dose.
When would you draw the trough before an IV med? 30 mins before the next
dose.

When would you draw the trough for IM med? 30 mins before the next dose
PO and IM are both given 30 mins before the next dose.

The peak….
The depends on the route not the drug.
When do you draw a SL peak? 5-10 mins after the drug is dissolved.
IV? 15-30 mins after the drug is finished. Don’t start when you hang the drug.
Start the clock 15-30 mins after the medication is finished given in the bag.
Whenever you get two values in the correct range play the price is right. The
highest person without going over always wins. So always choose the highest
value but within the correct range.

The IM is 30-60 mins after you give it. If Demerol for pain is given and the md
wants to know when the medication is provided relief 30-60 mins what would you
pick? I would pick 60 mins bc it is the highest without going over.
SQ = SEE diabetes lecture ! the only SQ meds they talk about is diabetic meds and
forget about the PO also bc they don’t test on this part.

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