Mark Klimek Audio Notes 1

Acid Base ABG’s

As pH goes, so does my Pt! Except for K

pH ↓ Pt goes ↓ (HR, RR, all vitals) K goes ↑

pH ↑ Pt goes ↑ K goes ↓
Except for K – it does the opposite

pH ↑ : Alkalosis
 Seizures, hyperactivity, borborgemy (↑BS)

Kausmal breathing = MacKausamal (Metabolic Acidosis breathing)

Lung: Respiratory
Everything else: Metabolic

When you don’t know: it’s probably metabolic acidosis (It’s super common)

Ventilators

High Pressure Alarm

 Obstructed airflow
 Having to use too much pressure
 Kinks, water collection in tube, mucous
 Turn, cough, deep breathe
Low Pressure Alarm
 ↓ Resistance – machine finding job too easy
 Disconnected tube
Mark Klimek Audio Notes 2

 02 sensor disconnected
If tube goes lower than pt level – contaminated

Amino Glycosides

A Mean Old Mycin

Amino Glycosides only treat Mean old Infections!

True mean old Mycins don’t have “Thro”

If it has “Thro” – Thro it away!
 Ex: Zithromycin

Mean Old Mycins destroy ears (ototoxicity) and kidneys (nephrotoxicity)

 Must check Creatinine for Nephrotoxicity – NOT urine output

8 Toxic to Cranial nerve 8 give q8h

Mean Old Mycins do NOT get absorbed – they go in and out and sterilize/clean

PO Mean Old Mycins are for bowel sterilizing

 NeoMYCIN
 KanoMYCIN
Who can sterilize my bowel?? NEO KAN!
Mark Klimek Audio Notes 3

Drawing TAP Levels (Peak and Trough)

For drugs that have a narrow therapeutic level and are toxic
Route determines TAP – Not the drug

TROUGH PEAK
IV 30 MIN BEFORE NEXT DOSE IV 15-30 min after its done
IM 30 MIN BEFORE NEXT DOSE IM 30-60 min after its given
SUB Q 30 MIN BEFORE NEXT DOSE Subling 5-10 min after its in the system
PO 30 MIN BEFORE NEXT DOSE

Heart Rhythms

Ca Channel Blockers are chill pills for the heart

 They end in DEPIM or ZEM

Rhythms
Asystole: No QRS – Lethal
Flutter: Sawtooth
Afib: Chaotic with QRS pattern
Vfib: Chaotic without QRS pattern – Lethal
Vent tachy: Wide bizarre QRS
SVT: Narrow QRS
PVC: random rhythm change – only concerned if > 6 or 6 in a row

Change in rhythm: check pulse or BP for cardiac output

Mark Klimek Audio Notes 4

Treat ventriculars with lidocaine

 V→L

Treat SVT (it’s actually an atrial)

A denosine – puts you in asystole for 20 seconds
B eta bockers – all end it “lol”
C a channel blockers
D igitalis

VFib: you DFib

Asystole: epinephrine then atropine

Chest Tubes

The only chest surgery that doesn’t require a chest tube is a pneumonectomy – because you remove the
entire lung
Water seal breaks
1. Clamp
2. Cut
3. Put in Water
4. Unclamp
Chest tube comes out
1. Cover with gloved hand
2. Vaseline gauze
3. Sterile dressing taped on 3 sides

Bubbling: Where? When?

Water Seal
 Intermittent: good
 Continuous: bad (air leak)
Suction Control
 Intermittent: bad (dial up suction)
 Continuous: Good
Do NOT clamp chest tube longer than 15 seconds
Mark Klimek Audio Notes 5

Congenital Heart Defects

Two classes: Trouble and No Trouble

Trouble defects all start with “T”

 R → L defects are Trouble

All CHD have a murmur

Tetralogy of Fallot: VarrieD PictureS Of A RancH

VD: ventricular defect
PS: pulmonary stenosis
OA: Over Riding aorta
RH: right hypertrophy

Crutches

Elbow at 30 degrees

2 pt: 2 touch
3 pt: 1 foot up
4 pt: everything moves separately
Swing: amputee

Stairs
 Up with good
 Down with bad
Cane
 Hold on good side
 Advance with bad side

Walkers: pick it up, put it down, walk towards it

Mark Klimek Audio Notes 6

Electrolytes

Kalemias – do SAME as prefix, except for HR and urine output

 Hyperkalemia: everything goes ↑ , HR and UO go ↓
o Get rid of excess K before the heart stops
o D5W with insulin R (saves you time)
o Then give K-excelate
 Hypokalemia: everything goes ↓ , HR and UO go ↑
o Give more K
o NEVER push IV
o NEVER more than 40 meg/L

Calcemias do OPPOSITE of prefix

 Hypercalcemia: everything goes ↓
 Hypocalcemia: everything goes ↑

Chvosteks: push and cheek spasms

Trousseau: BP cuff inflates, and causes spasm

Magnesium do OPPOSITE of prefix

 Hypermagnesium: Everything goes ↓
 Hypomagnesium: Everything goes ↑

Natremias: The one with the E is Dehydration, the one with the O is OverLoad
 Hypernatremia: Dehydration
 Hyponatermia: Fluid Overload (numbness/paresthesia)

Universal S/S of electrolyte imbalance – muscle weakness / paresis

Mark Klimek Audio Notes 7

Endocrine System

Thyroid & Adrenal

 Thyroid = Always metabolism

Hyperthyroid
 UP, UP, UP – Agitated, nervous diarrhea, etc
Most common: Graves
 You’re going to RUN yourself into the GROUND
 Radioactive iodine: urine is dangerous
PTU: Puts Thyroid Under (slows it down)

Total Thyroidectomy
 Lifelong thyroid hormones
 Tetany
Subthyroidectomy
 Thyroid storms
o Like Graves – but much worse.
o UP, UP, UP – super high vitals
o Psychotic delirium
o No meds ordered – just cooling blankets and O2 (just keep them alive!)

Total: can’t have thyroid storm when you don’t have a thyroid

Hypothyroid
 Tired, sluggish, slow
 Myexema
 Do NOT sedate!
Mark Klimek Audio Notes 8

Adrenal Cortex
All begin with A or C (Addison and Cushing)

Addison’s Disease
 Not enough adrenal hormones
 Super tanned / brown skin
 Don’t react well to stress
ADD A SONE: corticosteroids ending with “SONE”

Cushing’s Syndrome
 Too much adrenal hormones (cushy)
 Moon face
 Hairy
 Full of water
 Buffalo hump
 Muscle wasting
 Central obesity
 Bruising
 High glucose (but not diabetic)
Adrenalectomy
 Unilateral
 Bilateral

Precautions

Hep A: Anus Hep B: Blood

Contact
 RSV, hepatic, staph, enteric
 Private room, door open
 Gloves, gown if in contact
 Disposable supplies
Mark Klimek Audio Notes 9

Droplet
 Meningitis, influenza, diphtheria, pertussis, mumps
 Private room – door open
 Mask
 Out of room – pt wears a mask
 Disposable equipment

Airborne
 SARS, TB, Measles, varicella
 Private room – door closed
 Mask, gown, special filter mask
 Mask when leaving room
 Neg airflow

PPE – gloves, gown, goggles, mask

DONNING REMOVING
1. GOWN 1.Gloves
2. MASK 2.Goggles
3. GOGGLES 3.Gown
4. GLOVES 4.Mask

Neuro/Spine

Laminectomy – treats nerve root compression

- Cervical (Breathing / Arms)

- Thoracic (Coughing / BM, BS)

- Lumbar (Voiding / Legs)

Mark Klimek Audio Notes 10

Log roll, no sitting on side of bed

May stand, walk, lie down
No sitting for more than 30 min

Thoracic Lam: pheumonia, cough, aspiration, paralytic ilieus

Lumbar Lam: Urinary retention
Post Lam Teaching
 For 6 weeks
o Lie flat & log roll
o No driving
o No lifting > 5 lbs
o No sitting > 30 min

Mental Health

Non psychotic: insight and reality based

 Not all psych pt’s are psychotic
 Therapeutic communication

Delusion: false fixed belief

 No sensory component – it’s simply a thought
 Paranoid
 Grandiose
 Somatic – about the body (my arm is bionic, I am pregnant)

Hallucination: Pure sensation – no reality

 Auditory, visual, tactile (can feel cockroaches in arm), olfactory, gustatory

Illusion: Misinterpretation of reality

 Sensory experience
 I see a clock on the wall, but think it’s a bomb (the clock is REAL)
Mark Klimek Audio Notes 11

Functional Psychosis: Potential to learn reality

 Schizophrenia
 Schizoaffective
 Bipolar

Don’t treat all psych pt’s the same – half of them are not psychotic

Functional psychotic having a delusion

1. Acknowledge feelings and present reality
2. Set a limit
3. Enforce the limit – try to have reality based conversations
Psychosis of Dementia: Non Functional
 Alzheimer’s, dementia, Wernicke’s, senial
 Brain damaged people
Delirium can eventually become dementia if untreated

Dementia: will not talk reality

1. Acknowledge feelings
2. Redirect – take what pt is expressing inappropriately, and get them to express it appropriately

Delirium: chemical imbalance in brain – non permanent

 Example: being on drugs, being in withdrawal, or UTI

Word salad: bob, car, food, sleep

Functional – reinforce
Dementia – Redirect
Delerium – reassure

Ideas of reference: everyone is talking about me and laughing at me

Mark Klimek Audio Notes 12

Diabetes

Type 1 Diabetes (IJK)

 Insulin dependent
 Juvenile onset
 Makes Ketones
Type 2 Diabetes (Non IJK)
 Non insulin dependant
 Adult onset (not really true anymore)
 Doesn’t make Ketones

Diabetes Mellitus: error in glucose metabolism

 Polyuria, polydypsea, polyphagia (hunger)
Diabetes Insipidus: Not enough ADH or pituitary gland
Type 1: DIE
Diet (3) → Inulin (1) → Exercise (2)

Type 2: DOA
Diet (1) → Oral hypoglycemic (3) → activity (2)
 Restrict calories, 6 meals per day

Insulin

Regular: Rapid – peaks 2h

 Can be IV drip
 Rapid & Run (rapid and can run IV)
Insulin NPH – onset 6h, peak 8-10h
 Not so fast & not in the bag (intermittent and not IV)
Mark Klimek Audio Notes 13

Humalog (Lantis)
 The fastest insulin & long acting
 Onset 15 min, peak 30 min
 So fast that it needs to be given with meals, not before meals
 No peak, no risk for hypoglycemia – can be given at night
Refrigerate before opening, but after opening you don’t have to – at home always refrigerate

Dangers
Hypoglycemia – not enough food, too much insulin, too much exercise
 High priority – brain damage
 Drunk looking & shock s/s (pale, cold, rapid)
 Administer sugar & protein
DKA – too much food, not enough insulin, not enough exercise
 Illness or respiratory infections in a type 1
 Dehydration
 Ketones, MacKaussmaul, K
 Acidosis, acetone breath, anorexia
 Give dextrose & Insulin R at high rate (150-200ml/h)
Dehydration makes you hot – water is like a coolant for your car
HHNK (non ketonic coma): dehydration
 Treatment goal: rehydration, insulin not required
Peripheral neuropathy: nerve damage and poor tissue perfusion
Best indicator of long term glucose: HbgA1C < 7 (best is well controlled diabetics)

Drug Toxicity

Lithium – antimania
 Therapeutic: 0.6-1.2
 Toxic: >2.0
Lanoxin (digoxin) – CHF and Atrial arrhythmias
 Therapeutic: 1-2
 Toxic: >2.0
Aminophylline – Spasms of airway
 Therapeutic: 10-20
 Toxic: >20
Mark Klimek Audio Notes 14

Dilantin – anti seizure

 Therapeutic: 10-20
 Toxic: >20
Bilirubin
 Elevated level: 10-20
 Toxic: >20
Kernicterus – Bili >20 & in CSF
Opisthertonus – position of hypertension seen in Kernicterus
 Place baby on its side
 Arching of the neck – so neck rises off the bed

Dumping Syndrome

Hiatal Hernia
 Gastric content going in the wrong direction at the correct rate
 Regurgitation of acid into the esophagus
 s/s: GERD upon lying after meals
 Treatment – want stomach to empty faster
o Elevate head of bed, increase fluids PO, increase carbs
Dumping Syndrome
 Gastic content empty into duodenum in correct direction but too fast
 s/s:
o Acute abdominal distress
o Dumping (s/s drunkenness)
o Syndrome (s/s shock)
 Treatment: want stomach to slow down
o No fluids with meals, low carb, high protein, lay flat on side after meals

Lab Values

Kidney Function: Creatinine (common before dye)

 Normal: 0.6-1.2
Mark Klimek Audio Notes 15

INR – Warfarin therapy

 Therapeutic: 2-3
 If INR > 4
o Hold warfarin
o Assess bleeding
o Prepare to give K
o Call Dr

Potassium
 Normal: 3.5-5.3
 Below 3.5
o Assess heart
o Prepare to give K
o Call Dr
 Above 5.3
o Hold K IV
o Assess heart
o Prepare to give D5W IV with insulin
o Call Dr
 Above 6
o Can be deadly!
o Assess immediately, possibly call RR team
pH
 Normal: 7.35-7.45
 Under 6
o Deadly
o Assess vitals – still alive??
o Call Dr
 AS PH GOES, SO DOES MY PT – EXCEPT FOR K
BUN
 Normally 8 buns in a pack
 Normal: 8-30
 Elevated = Dehydrated
If a lab is high, you don’t know why – Dehydration
Mark Klimek Audio Notes 16

Hgb
 Normal: 12-18
 Below 8
o Assess bleeding
o Prepare blood transfusion
o Call Dr
 Above 18
o Dehydration
BiCarb (HC03)
 Normal: 22-26 (the bicarb years)

C02
 Normal: 35-45
 In the 50s (and non COPD)
o Assess RR – pursed lips
o Do NOT give 02
o If above not working, call Dr
 In the 60s
o Resp failure & death
o Intubate
Severe acidosis
 hyperkalemia – biggest priority
Hct
 normal: 36-54
P02
 Normal: 78-100
 70s
o Assess RR status
o Give 02
 Below 60
o Assess RR status
o Give 02
o Prepare for intubation
o Call RR therapy
o Call Dr
BNP indicator of CHF (normal <100) – Best indicator of CHF – ANF
Mark Klimek Audio Notes 17

Sodium
 Normal: 135-145
 Change in LOC?
WBC
 Normal: 5-11,000
 High – leukocytosis
 Low – leukopenia, neutropenia, immunosuppressed
o Strict handwashing, shower BID with antimicrobial, avoid crowds, private room, no flowers,
low bacteria diet
Platelet
 Normal: 150-400,000
 Below 90,000 – bleeding precautions
 Below 40,000 – platelet transfusion – call Dr
RBC
 Normal: 4-6 million
5 D’s (deadly)
pH < 6
Platelet < 40,000
K>6
O2 < 60s
C02 in 60s

Medication Tips

Insulin 70/30 rule

 70% N & 30% R
Always pressurize before you draw up
 Draw up – Clear before Cloudy
o R before N
 Pressurize N, pressurize R, draw up R, draw up N (NRRN)

IM – Looks like 1M
 Pick the needle that has 1 in gauge and 1 in length
Mark Klimek Audio Notes 18

SQ – look for 5 in gauge and 5 in length

 Ex: 25g 5/8 inch

Heparin – IV or SubQ
 Works fast
 Only use for 21 days
 Pregnancy – yes
 Lab – PTT (clotting)
 Antidote: protamine sulfate
Coumadin – PO
 Takes days to work
 Works for life
 Labs – PT INR
 Antidote: Vit K (think Koumadin)
 Pregnancy – NO
Prevent clots from forming and getting bigger, not a blood thinner

K wasting diuretics
 All end with X
o If it ends with X , it will X out K
o And diurel
o All others are K sparing

Baclofin / Flexoril
 Muscle relaxant
 Makes you drowsy
 Muscle weakness
 Teaching – no alcohol, no downers, no driving, don’t take care of kids < 12 years
 When you are on baclofen you’re on your BACK LOAFIN’

Piagets
0-2: sensory motor (only the right now)
 Only teach as you are doing right now
3-6: preschooler (fantasy, no reason or logic)
 Teach the day of so they don’t have time to imagine scary things
Mark Klimek Audio Notes 19

Over 6 or 7: concrete operational – by the rules

 Can teach day ahead
 Learn through play
 Can only know things one way – don’t try to change the rules all of a sudden
 Age appropriate games and reading
Over 12: can manage own care

Psych drugs

All cause: weight changes and low BP

Penothiazines
 All end with “zine”
 Do not cure disease – only control symptoms
 Large doses – psych med
 Small doses – antiemetic (n/v)
 Major tranquillizer
o Huge s/e – dry mouth
A: anticholinergic
B: Blurred vision
C: Constipation
D: Drowsiness
E: extrapyramidal syndrome (parkinsonian)
F: Fotosensitivity (skin sensitive to sun)
G: aGranulocytosis (low WBC, immunosuppression)
#1 concern: Safety

Deconoate
 Long acting IM for non-compliant client
 2-3 weeks
 Court ordered
Mark Klimek Audio Notes 20

Tricyclic Antidepressants
 Elavil, tofranil, aventyl, desryl
 Mood elevator
 Takes 2-3 weeks to work
A: Anticholinergic
B: Blurred vision
C: Constipation
D: Drowsiness
E: Euphoria (happiness)

Benzodiazepines
 Antianxiety – minor tranquillizer
 Have “zep” in name
o Diazepam plus Xanax
 Often pre-op , muscle relaxant, alcohol withdrawal, seizures, mechanical ventilation
 Don’t take for > 6 weeks
ZINES are majors, ZEPS are minors (zeppelin concert: minors all on tranquilizers)

Heparin is to Coumadin, as Tranquillizers are to Antidepressants

MAOI’s
 Antidepressants – happy pill
 Names: MAR, NAR, PAR (marplan, nardil, parnate)
A: Anticholinergic
B: Blurred vision
C: Constipation
D: Drowsiness
MAOI’s interact with LOTS
 Avoid all foods containing tyramine
 Salad BAR: bananas, avocados, raisins
 No organ meats: heart, lung, tongue…
 No preserved meats: smoked, dried, cured…
 No dairy, alcohol, tinctures, caffeine, chocolate, licorice, soy sauce
 No OTC medications
Mark Klimek Audio Notes 21

Lithium
 Bipolar disorder – decreases mania
 Peeing, Pooping, Paresthesia - Dehydration
 Toxicity – 2 or greater
o Tremors, metallic taste, severe diarrhea
o Intervention: fluids. If sweating: electrolytes
 Monitor: Sodium
Prozac
 SSRI – similar to Elavil. Long term antidepressant
A: Anticholinergic
B: Blurred vision
C: Constipation
D: Drowsiness
E: Euphoria
Also: Insomnia. Give in the morning!
Suicide warning

Haldol
 Major Tranquillizer – just like Thorizine
A, B, C, D, E, F, G

Clozaril (Clozapine)
 Schizophrenia
 Agranulocytosis really bad in susceptible
o Monitor WBC weekly for 1 month
ZINE: Major tranquillizer
ZEP: Minor tranquilizer
ZAP: atypical major tranquilizer

Zoloft
 SSRI like Prozac
 Antidepressant
o But doesn’t cause insomnia
 Interactions: St johns wart (serotonin syndrome) and coumadin
Mark Klimek Audio Notes 22

S: Sweating
A: Apprehension
D: Dizziness
HEAD: headache (↑BP)

Maternity & Newborn

Weight gain
 Total: 28 lbs (+ or -) 4
 1st trimester: 1 lbs per month (total 3 lbs)
 2nd & 3rd trimester: 1lbs per week
Week (-) 9 = weight gained
30 weeks – 9 = 21 lbs should be gained
Fundal height
 Not applicable until week 12
 20-22 weeks @ naval
Signs of pregnancy
 Xray, ultrasound
 Fetal HR
 Examiner palpated fetal movement
Hgb: will drop during pregnancy
Morning sickness: dry carbs
Urinary incontinence: void q2h (1st and 3rd trimester only)
Dyspnea: tripod position
Back pain: pelvic tilt (foot up on stool)

Labour and Delivery

Sign of labour: regular contractions

Dilation: opening of cervix
Effacement: thinning cervix
Station: presenting part vs mothers ischial spine
 How high or low baby is
 + is good and – is not good
Mark Klimek Audio Notes 23

Lie: vertical (good) transverse (not good)

Stages of giving birth
1. Labour (latent, active, transition)
2. Delivery
3. Placenta
4. Recovery
Stages of Labour
1. Latent: 0-4 cm, mild contractions
2. Active: 5-7cm, moderate contractions
3. Transition: 8-10cm, strong contractions
Trouble: Contractions longer than 90 seconds and closer than 2 minutes
Cord prolapse
1. Push head in
2. Knee-chest position
3. Not on left side
4. Cover cord with moist saline
All other complications: LION
 Stop pitosin then start LION
L: left side
I: increase IV
O: Oxygen
N: Notify Dr
Pain: no systemic medication if baby will come with medication peaks
 Example: morphine peaks in 15 minutes
FHR monitor
 LION < 110bpm FHR > 160 is fine
 LION no variability
 LION late decels Early decels are fine
 Variable decels are VERY BAD
Causes: Veal Chop
V: Variable C: Cord Compression
E: Early Decel H: Head Compression
A: Accels O: Okay
L: Late Decels P: Placenta

When guessing in OB: Check FHR

Mark Klimek Audio Notes 24

Delivery
1. Deliver head
2. Suction mouth → Suction nose
3. Check for cord around neck
4. Deliver shoulders → then body
Missing placenta
 0-72h → Hemorrhage
 Over 72h → Infection

Prioritization

Acute > Chronic

Post Op > Med Surg
Unstable > Stable
 Acute
 Post of > 12 h
 General anaesthesia
 Changed assessment findings
 New admin, new diagnosis, or unexpected findings
6 organs
1. Brain
2. Lungs
3. Heart
4. Liver
5. Kidney

Drugs

Maslow’s hierarchy
1. Physiological
2. Safety
3. Comfort (pain)
4. Psychological
5. Social
6. Spiritual
Mark Klimek Audio Notes 25

Alcohol
Wernicke’s
 Psychosis induced by Vit B1 deficiency (thiamine)
 Amnesia – non reversible
 Preventable by taking B1 vitamin
Aversion therapy
 Antabuse drug makes alcoholics extremely sick if they have a drink
 Onset 2 weeks
 Takes 2 weeks to leave system
Respiratory arrest: ambu bag
Seizure: suction

Drugs
Mom addicted to drugs, at birth baby is: intoxicated
If more than 24h since last drug was taken, baby is in: Withdrawal

Delirium tremens
 Life threatening
 Restraint, private room, NPO
 Happens 72+ hours after last drug (happens after withdrawal)
Withdrawal
 + 24h – non lethal and expected finding
2 point restraint
 one arm and opposite leg
 check on limbs q15 min
 rotate limbs q2 h