Nclex study guide pdf PDF

Preview

Summary

this is a study guide for Nclex study guide...

Description

NCLEX STUDY GUIDE Acid Base As the ph goes the patient goes and except for potassium pH goes up potassium goes down pH goes down potassium goes up pH up(alkalosis)… Hyper, tachy, increased, elevated, exaggerated, increasing, excessive. Irritability, diarrhea, borborygmi= increased bowel sounds. pH down(acidosis)… hypo, decreased, scant, absent, a-, brady, depressed, suppressed, oligo, Pt has acidosis what heart rhythm would you see- second degree heart block Tetany- muscle spasms, hyper muscles, hyper hyper contractility Cardiac arrest- slow down MAC-Kussmal Kussmal only occurs in Metabolic ACidosis Causes of acid base imbalances: Ask yourself is it Lung? If it does= respiratory Is the client overventilating or under?? If they are over---Alkalosis… If under—acidosis. Too much PCA pump what acid base can result… depress respirations, underventilation… respiratory ACIDOSIS. Near drowning—Respiratory acidosis Acute panic anxiety- Respiratory alkalosis If it isn’t lung its metabolic. If client has PROLONGED gastric vomiting or suctioning—METABOLIC ALKALOSIS For everything else that isn’t lung pic metabolic acidosis that doesn’t have to do with suctioning or vomiting Metabolic Acidosis if we don’t know what to pick!

Respiratory rate is highly unreliable use your gases, lung sounds and saturation!!! VentilatorHigh pressure alarm= increased resistance to airflow. High pressure to push through so look for OBSTRUCTION!!! 3 obstructions, DO IN THIS ORDER!! Least invasive to most! 1. Kink. - UNKINK 2. Water condensing in tubing. GET WATER OUT 3. Mucous. Suction is not best answer… TURN COUGH AND DEEP BREATHE. If that doesn’t work SUCTION! Low pressure alarm! Due to DISCONNECTIONS! 1. Main tube disconnected2. Oxygen Sensor line! Plug back in. If tubing hits the floor call respiratory and start bagging!! If it falls on them then on the bed then clean off with alcohol and reconnect Respiratory Alkalosis- Over Ventilating Respiratory Acidosis- Under Ventilating DON’T ASK ANOTHER PEOPLE. DON’T USE CHICKEN QUESTIONS. TAKE CARE OF IT YOURSELF

ETOH,Abuse,Overdose vs. Withdrawal, & Mycin In abuse** “Maslow” Ranking 1. Physiologic needs 2. Safety needs 3. Comfort needs 4. Psychological needs 5. Sociological needs 6. Spiritual needs Alcoholic with fractured foot which would be priority? His denials? His pain? His break*** Adequate pain control is number one for palliative care Psychodynamic- what’s their major malfunction? Abusers- greatest psychological priority is denial! Refusal to accept reality with problem. Confront denial in abusers!

“You say you aren’t an alcoholic but it’s 10 am and you’ve drank a fifth of whiskey and a 6 pack.” Denial during loss and grief: Don’t confront. You support and allow them to continue because it serves a purpose and function. Dependency=abuser gets significant other to make decisions for them or do things for them because they can spend their time drinking. Codependency=significant other derives positive self esteem from doing things for or making decisions for the abuser. So abuser says will you do this for me and the codependent does it and then says to themselves “I’m a wonderful person because I do this for them and no one else would” Set limits for the abuser and enforce them. No you call your boss, etc. Work on self esteem of the codependent person. Abusers manipulate people to do stuff that is harmful to significant other. Dependency vs manipulate Dependency- not harmful husband buys wife alcohol Manipulative- harmful 17-year-old buys alcohol for mom Wernickes-Korsakoff - Psychosis induced by vitamin b1 deficiency –thiamine - Lose touch with reality because you lack the B vitamin - Amnesia with confabulation- memory loss with making up stories because you can’t remember. They don’t know they made it up that’s what makes them psychotic. The believe their stories. - These people have dementia-break from reality due to brain damage - DON’T ARGUE WITH THEM, PLAY ALONG!! Characteristics!!! - Preventable by taking vitamin b1. Don’t have to stop drinking. - Megadose on B1 your blood alcohol will be lower. - Arrestable- you can keep it from getting worse by starting to take your b1 - Its irreversible because its brain damage. GOAL: For wernickes client memory- client will maintain current memory. DEMENTIA- NEVER IMPROVEMENT!! MAINTAIN! Antabuse/Disulfiram - Form of aversion therapy - If you take this and you drink alcohol, it makes you sick.

-

Onset and duration is 2 weeks. If you start taking it today it takes 2 weeks. If you stop today it takes 2 weeks to be able to drink again. It’s any alcohol. Avoid all forms of alcohol like insect repellents, aftershave, perfumes, colognes, mouthwash, any OTC elixir (Dayquil, Nyquil, etc), vinaigrettes, vanilla extracts (uncooked vanilla icing), alcohol based hand sanitizer.

Overdose/Withdrawal Principles: - Every abused is an upper or downer - Is it upper or downer?? Uppers: - Caffeine - Cocaine - PCP/LSD (psychedelic hallucinogens) - Amphetamines (METH) “speed” - Bath salts - ADHD drugs Adderall and Ritalin These are all stimulants. Make things go up because they are uppers. You will see hyper, tachy, irritable, diarrhea, tremors, seizures. Downers: Everything else. Qualudes- downers Fentanyl Things go down WORST THING= respiratory distress You go opposite way drug does during withdrawal!!! You withdrawal from upper you go down. You withdrawal from downer you go up. Overdose on upper- tachycardia Overdose on lower- bradycardia Withdrawal from an upper- bradycardia Withdrawal from a downer- tachycardia Clonus- very jumpy reflexes ALWAYS ASSUME BABY IS INTOXICATED AND NOT WITHDRAWING at birth or in first 24 hours unless they tell you differently.

Newborn after 24 hours they are in withdrawal. An infant at 10 min APGAR- intoxicated 3 days after birth- withdrawal Child born to alcohol addicted mom 48 hours after delivery- everything is up bc of withdrawal to downer. Every alcoholic goes through alcohol withdrawals 24 hours from last drink Delirium Tremens “DT’s” 72 hours after last drink…. Not everyone goes through this. AWS is not life threatening DT’s can kill you. AWS is stable DT’s is not stable AWS is not danger to themselves and others DT’s are danger to self and others AWS: Up at lib Regular Diet Semi private room No restraints Antihypertensive B1vitamin Tranquilizer b/c of withdrawal stage – minor DT’s: Private, near nurse’s station NPO or Clear liquid Restricted Bedrest- no getting up to go to the bathroom urinal and bedpan Restrained, vest or leather restraints, two point leather restraints. Antihypertensive B1 vitamin Tranquilizer b/c withdrawal stage –major Aminoglycosides- powerful antibiotics “A mean old mycin” Hard to treat infections: mRSA, TB, Septic Doesn’t treat UTI, bladder infection, sinusitis, pharyngitis Only antibiotic used to treat cancers ALL IN MYCIN!!!!!!! Not all drugs that end with -mycin are aminoglycosides. NOT AMINOGLYCOCIDES: EryTHROmycin

AziTHROmycin ClariTHROmycin MEAN OLD MYCIN END IN MYCIN IF THEY HAVE THRO THROW THEM OFF THE LISTS. First toxicity with aminoglycosides- ototoxicity Monitor hearing Balance Equilibrium Tinnitus HOLD DRUG AND CALL DOCTOR Side effect- give and notify Toxic- hold and call This is also nephrotoxicity- monitor CREATINE. CREATINE IS THE BEST INDICATOR OF KIDNEY FUNCTION!!!!!!!!!!!! Fluid balance is measured best by daily weight. TOXIC TO CRANIAL NERVE NUMBER 8 GIVE EVERY 8 HOURS GIVEN IM AND IV DO NOT GIVE PO BC NOT ABSORBED. TAKE MYCIN ORALLY FOR STERILE BOWEL. Hepatic Coma- give oral mycin Bowel surgery- give oral mycin Cdiff- give oral mycin Oral forms are: neomycin and canamycin (bowel sterilizer) Peak Trough, Calcium Channel Blockers, Arrhythmias, Chest Tubes Peak and Trough are drawn because of narrow therapeutic range. Peak and Trough on toxic drugs. In peak and trough drug is irrelevant! You have to know the route. Sublingual Trough- 30 minutes before the next dose IV Trough- 30 minutes before next dose IM Trough- 30 minutes before next dose SubQ Trough- 30 min before next dose PO Trough- 30 min before next dose Sublingual Peak- 5-10 min after drug is in IV Peak- 15-30 min…..that’s 15 to 30 minutes after drug is finished!!! IM Peak- 30-60 min

RN is hanging 100 ml of an IV antibiotic. Its running at 200 an hour. Hung at 10. What time will remind the RN that the Peak needs drawn. Answer: 10:45-11:00. If you get two right answers in the right pick the most number!! Calcium Channel Blockers: Like valium for your heart. Valium calms you down. If heart needs to chill out and calm down you give them a CCB. Low BP: no you don’t give CCB HTN: give HTN Paroxysmal AFIB: give CCB Heartblock: No CCB CCB have negative inotropic effects on the help which means like valium for the heart! Positive inotropic stimulates the heart. Treat: A-Antihypertensive-- relaxes heart AA- Anti-angina—relax the heart so it doesn’t wok as hard so it doesn’t need that much oxygen. They decrease the oxygen demand!!! Not increase oxygen supply. AAA- Anti-Atrial-Arrhythmic- treats afib, PAC, ATACH, Aflutter. SVT!!!! -Dipine-CCB -Zem-CCB -Verapimil-CCB Side Effects- H&H headache and HTN Arrhythmias: If question talks about QRS its always VENTRICULAR!!! If the question talks about the P wave its ATRIAL!! -

A lack of QRS- Asystole (high priority, lethal) Saw tooth- Aflutter Chaotic pattern in P, chaos- Afib Chaotic QRS- Vfib (high priority, lethal) Bizarre, QRS continuous- VTACH (potentially life threatening) Episodic bizarre QRS- PVC (low priority)

PVC can ride to moderate priority if these 3 things occur: More than 6 in a minute More than 6 in a row If PVC falls on T wave (R on T)

Have to have a 60 systolic pressure to get a carotid Have to have a 70 systolic pressure to get femoral Have to have an 80 systolic pressure to get a radial PVC and VTACHLidocaine, amiodorone AtrialsA-adenocard(adenosine slam it in. 8-10 seconds) B- betablockers all end in –lol C- CCB D- Digitalis, Digoxin, Lanoxin Asystole- Epinephrine and Atropine Chest tubes: Reestablishes negative pressure in the pleural space Air and blood enters pleural space creating positive pressure. Positive pressure is bad. That’s why we have chest tubes to create negative pressure. Straight catheter is to a foley catheter Thoracentesis is to a chest tube Chest tube placed for a pneumothorax it is removing air so it should bubble Hemothorax- you should blood and no air meaning less air. Pneumohemothorax- bubble and blood. Apical chest tube- implanted really high. Stab low and thread to apex. Removing air. So put this in for pneumothorax Basilar chest tube- At the base, blood because of gravity, use for hemothorax, little bubbling. Apical chest tube-----no drainage(GOOD) 800 ml in last hour (BAD!) Basilar chest tube----- no drainage (BAD) 800 ml in last hour (GOOD) All chest surgeries or chest traumas are unilateral pneuomohemo chestube Troubleshooting chest tubes: Chambers: First one (closest to patient)-collection Middle one- water seal one way flow Furthest from client one(optional)- suction control

If you knock it over- sit it up and have them take some deep breaths. What if you break it/ crack water seal?- clamp tube so nothing can get in. Cut tube away from broken device. Submerge end of tube under water. Then unclamp it. Best answer is submerge the tube in water. If chest tube gets pulled out- Cover hole with gloved hand, then cover hole with Vaseline gauze. Then put dry sterile dressing and then tape it on three sides. Bubbling chest tubes: where and when? Bubble bubble bubble where?? Water seal-intermittent bubbling is good!! Water seal- continuous bubbling is bad!! Means leak. Tape! Suction control- intermittent bubbling is bad!! Suction is too low. Dial up wall suction. Suction control- continuous bubbling is good, just record it. Do not clamp chest tubes for longer than 15 seconds unless doctors order says. When you do clamp do double clip rubber tip clamps.

Crutches, Canes, & Walkers, Congenital Heart Disease, Psych Ambulatory assistive device= crutches, cane, or walker. Crutches: Mismeasured crutches cause nerve damage. So measure correctly. You measure length of crutch= 2-3 fingerwidths or 2-3 centimeters below the axillary fold. To a point lateral to and slightly infront of the foot. Not to the heel or the ball of foot. NEVER USE LANDMARK ON THE FOOT!!! Position on handgrip: elbow flexion would be 30 degrees little less than 45 degrees Gait- 4 different ways 1. 2 point gait- two points are touching down together. Step one move a crutch and the opposite leg together. Step two you advance the other crutch and other leg together. 2. Three point gait- three things hit ground together…Bad leg and both crutches hit ground together good leg hits alone. 3. Four point gait- everything touches separately. You move nothing together. 4. Swing through. Crutch neutral position- every crutch begins in this position. Swing through- is for two braced extremities: Cerebral palsy Amputation: bc can’t bare weight on stump Even for even odd for odd: There are even number crutch gaits: 2 and 4. Bilateral.

Unilateral pick one or 3. Use the even number gates (2 and 4) when the weakness is evenly distributed. 2 point for a mild problem and 4 for more severe Use an odd number gait when the weakness is uneven. Systemic weakness- bilateral. (2 or 4) Stairs- up with good down with the bad. Lead with good go down with the bad. CanesIf you have a weak left leg you hold cane on the right side. Right CVA tell them to hold the cane on the right hand. Right hemiplegia hold in left hand WalkersPick it up set it down then walk to it. Belongings on the sides of walker not the front.

Congenital Heart Defects: Trouble or no trouble Worst or best TRouBLe: BAD Trouble defects are Right to Left Shunt Need Surgery Cyanotic(Blue) Delayed growth Longer hospitilizaton Less life expectancy Medicine If they don’t start with the letter T they are not trouble *TRANSPOTION OF THE GREAT VESSELS *truncus arteriosis *Tetrot of Fallot *Tricuspid atresia *TAPV No Trouble: Left to right shunting Acyanotic (Pink)

Everything is normal. *Patent Ductus Arteriosis *atrial septal defect *ventricle septal defect

Tetralogy of Fallot: VarieD PictureS Of A RancH - VD-Ventricular defect - PS-Pulmonic stenosis - OA-Overriding aorta - RH-Right hypertrophy PsychPsychotic symptoms: - Delusions-False fixed(they don’t change it) belief or idea of thought. No sensory component. “People are out to kill me” “Martians are invading earth” they don’t see it they think it. o Paranoid- “out to get me” o Grandiose- you are superior. “I am jesus christ” o Somatic- false fixed beliefs about body parts. “my arm is bionic” “my ears are ultrasonic” - Hallucinations- false fixed sensory component. Sensations that aren’t real. Hearing, feeling, seeing, and smelling things people aren’t. o MOST COMMON IS AUDITORY HALLUCINATION(COMMAND SELF DESTRUCTIVE.) at least once every hour. o Second most common is VISUAL hallucinations. Less common like once a day. o Tactile- somatic sensation. One a week of these. Weekly. o Olfactory-monthly o Gustatory(taste)- monthly - Illusions- misinterpretation of reality. The patient is experiencing something that’s real but they misinterpret what it is. Sensory experience. With an illusion there is a referent in reality. This means they refer to something when they have their sensory experience. If they are having a sensory experience and refer to something there but misinterpret it. When you have psych patient that those people are dived in two fundamentally different groups: - Smallest groups= psychotics - Largest groups= non psychotics A nonpsychotic patient has insight and is reality based….they know that their problem is.

Psychotic is not reality is based. What they say doesn’t make sense. Off the wall stuff. No insight. They don’t know they’re sick.

My children are trying to kill me-PARANOID DELUSIONS Demons talk to me- PARANOID DELUSIONS I hear demon voices- AUDITORY HALLUCINATIONS Angels appear to me- DELUSIONS My arm has words- SOMATIC DELUSIONS During your therapeutic interview with a schizophrenic a client sees a nurse walk past the door and they say “look I see a demon”- ILLUSION Delusion- no referent, no sensation Hallucination- no referent, sensation yes Illusion- yes referent, yes sensation How do you deal with it? Ask yourself what is their problem?? 3 fundamental types of psychotics: 1. Functional- They can function. They can have normal life if on medications. Problems learning reality but we try to teach it to them. Acknowledge how they feel but then present reality. Set a limit. Don’t let them talk crazy when they talk to you. Enforce limit. If they keep doing it stop the conversation. a. Schizophrenia (Teach reality) b. Schizoaffective c. Major Depression or psychotic depression d. Mania 2. Psychosis of dementia 3. Psychotic delirium Nonpsychotic- good therapeutic answer like any other patient. “You sound upset can you tell me more on how you’re feeling”

Demented psychotics: Alzheimer’s, senility, dementia, organic brain syndrome Brain Damage problem. They cannot learn reality. No matter how much you try to teach they can’t learn. Don’t present reality.

Acknowledge their feeling, then redirect them (take what their all about that isn’t real and direct it in a way that’s real) Alzheimer patient cooking a thanksgiving dinner at 3 am in April what do you say? “This sounds stressful lets get you dressed and make you breakfast so you have enough energy for your big events today” patient will forget by the time she’s done Psychotic delirium- temporary episodic dramatic secondary loss of reality due to a chemical imbalance. “Not in touch with reality” Came on suddenly that threw off their chemical balance. Secondary to the Primary imbalance of the body. TEMPORARY. HYPOXIA. DRUGS. ANESTESIA. - Acknowledge - Reassure- reassure them their safety and that it’s temporary and that it will go away. Patient determines your answer in psych. Functional- reality Dementia- Redirect Temp Delirium- reassure Flight of ideas- they are loosely associated Word salad- so sick they can’t make phrases they just say words. This person is sicker Neolochism- makeup words Narrowed self concept- psychotic refuses to change their clothes or leave the room because they are terrified of what will happen when they do. Don’t make them. Because it will escalate. Say I see you are uncomfortable you do not have to change your clothes or leave the room until you are ready Ideas of references- think people are talking about you. The only time you say “what are the voices saying to you” is during the first stage. Diabetes insipidus- low ADH leading to polyuria, polydipsia and dehydration. SIADH- oliguria, not thirsty, fluid overload

Diabetes Mellitus Type 1- insulin dependent, ketosis prone. Fat burners. Type 2- non-insulin dependent, non ketosis, not fat burners Both have polyuria, polydipsia, polyphagia (frequent swallowing but mean eats a lot with DM)

TX: Type 1- could die it you don’t treat, insulin, exercise, diet. INSULIN IS MOST IMPORTANT!! Insulin pumps. Type 2- Diet, oral hypoglycemic, activity. DIET IS MOST IMPORTANT. THEN ACTIVITY. THEN PILL. Calorie restricted diet and space out over time into 6 feedings!! They eat 6 small meals a day. InsulinR insulin- look for the letter R! Rapid acting. Clear you can give IV. - Onset is within one hour - Peak is 2 hours!!! Go with 2!!! - Duration is 4 hours!! NPH- intermediate acting. CLOUDY. NO IV. - Onset is 6 hours - Peak 8-10 hours - Duration 12 hours 1,2,4,6,8,10,12 Humalog- Lispro- RAPID ACTING GIVE WITH MEALS or at least 15 min before they eat. AC NO!!!! AC MEANS 30 MINUTES BEFORE!! Onset- 15 min Peak- 30 min Duration- 3 hours Lantus- long acting insulin PEAKLESS!! No risk for hypoglycemia! BEDTIME INSULIN. Check exp of all insulin. Unopened insulin’s exp is the manufacturers exp date. Once you open it that is no longer valid and new exp is 30 days after you open it!!! Refrigeration is not essential in the institution for opened insulin but is essentially required at home!! UNOPENED IS REFRIDGERATED EVERYWHERE. Exercise potentiates insulin. E...