(NURSING 4530) Mark Klimek Lectures 1 to 12 Latest Guide Graded 100%

(NURSING 4530) Mark Klimek Lectures 1 to 12 Latest Guide Graded 100%. What are toxic effects?  Mycin—Sounds like Mice (Think ears) … Monitor hearing (#1), balance, tinnitus (ringing of the ear, CN8 toxicity)  The human ears are shaped like a kidney so another toxic effect of aminoglycosides is nephrotoxicity (Toxic to the kidneys) o Therefore, monitor Creatinine What would be your answer if in a question, you have to choose which is the best between 24-hour creatinine and serum creatinine? The figure 8 drawn inside the ear should remind you of of 2 things They are toxic to CN8 Administer them q8 hour Do not give Mean Old Mycins PO because they are not absorbed, and therefore would not have any systemic effects There are 2 cases where Mean Old Mycins are given PO  Hepatic encephalopathy (or hepatic coma) where ammonia level gets too high  Pre-op bowel surgery: to sterilize the bowel before surgery  In both cases, the ABX stays in the gut (not absorbed), sterilizes the bowel, and would not be toxic  The #1 action of an “oral mycin” … Sterilize the bowel o Who can sterilize my bowel? Neo Kan o Neomycin and Kanamycin Note E. coli in the gut is the #1 producer of ammonia, which at toxic levels, leads to encephalopathy Troughs and Peaks  Troughs is when drugs is at their lowest concentration in the pt’s blood  Peaks is when drugs is at their highest concentration in a pt’s blood 1.Creatinine = Best indicator of kidney function 2. 24-hour creatinine clearance is better than Serum creatinine “A Mean Old Mycin” is given IM or IV because it is excreted in feces and not absorbed in the GI tract. It is used in hepatic encephalopathy to kill E. coli, and bowel surgery (to sterilize the bowel). Page 13 of 92 Mark Klimek Lectures 1 to 12 “TAP” Levels  A method to remember what is done before or after, when dealing with a medication with troughs and peaks  “TAP”—Trough, Administer, Peak o Trough before drug administration o Peak after drug administration o Trough and Peak levels are drawn because of a drug’s narrow therapeutic window or index o Narrow therapeutic window or index means that there is a small difference in what works and what kills Which one of the following medications would “trough and peak” important?  Lasix (furosemide) o Smaller dose: 5 or 10 o Larger dose: 80 or 120  Digitalis (digoxin) o Smaller dose: 0.125 o Larger dose: 0.25 o Would draw “TAP” (Trough, Administer, Peak) on digitalis When to Draw a Through and a Peak  Both Trough and Peak are not medication-dependent  The trough, it is always drawn 30 minutes before next dose  For the peak, it depends on the route o Peak SubL 5 to 10 minutes after drug is dissolved o Peak IV 15 to 30 minutes after drug is finished (bag empty) o Peak IM 30 to 60 minutes o Peak SubQ Depends on insulin (See diabetes lecture) o Peak for PO Not necessary, not tested Question You give 100 mL of a drug at 200 mL per hour (the drug takes 30 minutes to run). If you hang the drug at 10 a.m., it will finish running at 10:30 a.m. When will the drug peak? 1. 10:15 a.m. 2. 10:30 a.m. 3. 10:45 a.m. 4. 11:00 a.m. Answer: Two right answers—pick 11:00 a.m. In this case, play the “Price Is Right”—go with the highest time w/o going over Note  The same drug given by 2 different routes at the same time will have different peaks o Morphine  However, 2 different drugs given at the same time and route (IV) will peak together o Morphine and amphetamine Note 1. Draw TAP on Mean Old Mycins because of their narrow therapeutic index Page 14 of 92 Mark Klimek Lectures 1 to 12 Calcium Channel Blockers CCBs (Calcium channel blockers) are like Valium for the heart  They relax and slows down the heart  In other words, CCBs have negative inotropic, chronotropic, dromotropic effects on the heart (+) Inotropy, Chronotropy, Dromotropy (–) Inotropy, Chronotropy, Dromotropy Positive inotropy  Increase cardiac contractile force  Ventricles empty more completely  Cardiac output improved Positive chronotropy  Increase rate of impulse formation at SA node  Accelerate heart rate Positive dromotropy  Increase speed that impulses from SA node travel to AV node (increase conduction velocity) Negative inotropy  Weaken/decrease the force of myocardial contraction Negative chronotropy  Decrease rate of impulse formation at the SA node  decelerate heart rate Negative dromotropy  Decrease speed that impulses from SA node travel to AV node (decrease conduction velocity) When do you want to relax and slows down the heart? … To treat “A, AA, AAA”  Antihypertensive  AntiAnginal drugs (decreasing oxygen demand)  AntiAtrialArrhythmia Side Effects Headache and hypotension Name: ends in “dipine” … Not “pine”  Also, verapimil, Cardizem (diltiazem)  Cardizem (diltiazem) is given continuous IV drip What are the parameters to assess before putting a pt on CCBs?  Assess for BP  Hold if SBP <100 Cardiac arrhythmias  Knowing how to interpret rhythm  Must know the following 4 cardiac rhythms by sight Lecture 3 • Mark Klimek • 111:11 Page 15 of 92 Mark Klimek Lectures 1 to 12 Normal Sinus Rhythm  There is a P wave, followed by a QRS, followed be a T wave for every complex  Peaks of the P wave is equally distant to the QRS, and fall within 5 small boxes Ventricular Fibrillation  No pattern Ventricular Tachycardia  Sharp peaks with a pattern Asystole  A flat line If the question mentions  QRS depolarization = Ventricular  P wave = Atrial The 6 rhythms most tested on the NCLEX 1. A lack of QRS complexes is asystole—a flat line 2. P waves (atrial) in the form of saw tooth wave = atrial flutter 3. Chaotic P wave patterns = atrial fibrillation (a-fib) (Chaotic: word used to describe fibrillation) 4. Chaotic QRS complexes = ventricular fibrillation (v-fib) 5.Bizarre QRS complexes = ventricular tachycardia (v-tach) (Bizarre: word used to describe tachycardia) 6.Periodic wide bizarre QRS complexes = PVCs (Salvos of PVCs = A short runs of v-tach) There are 3 levels of nursing knowledge 1. Stuff you need to know 2. Stuff that is nice to know 3. Stuff that is nuts to know Page 16 of 92 Mark Klimek Lectures 1 to 12 PVCs (premature ventricular contractions) are usually low priority  However, elevate them to moderate priority if under the following 3 circumstances o There are 6 or more PVCs in a minute o More than 6 PVCs in a row o R on T phenomenon (a PVC falls on a T wave)  PVCs after an MI is common and is a low priority Lethal arrhythmias are high priority and will kill a pt in 8 minutes or less. They are:  Asystole and V-fib (ventricular fibrillation)  Both rhythms produce low or no cardiac output (CO), without which there is inadequate or no brain perfusion. This may lead to confusion and death Potentially Lethal Cardiac Arrhythmia  V-tach (ventricular tachycardia) is a potentially lethal cardiac rhythm but it has a CO How would a pt with or without CO presents?  CO is absent = there is no pulse  CO is present = there is a pulse Treatment of PVCs and V-tach  Ventricular = Lidocaine  Both are ventricular rhythms  Treat with Lidocaine  Amiodarone is eventually the NCLEX board will want as answer Supraventricular arrhythmias are Atrial arrhythmias (supra = above) Treatments are “ABCDs”  Adenocard (Adenosine) … Fast IV push (push in less than 8 seconds and 20 mL NS flush right after) … These pts will go into asystole for about 30 seconds and out of it  Beta-blockers (end in -olol)  CCBs  Digitalis (digoxin), Lanoxin (another digitalis analog) Beta-blockers have negative inotropic, chronotropic, dromotropic effects on the heart. They treat “A, AA, AAA”  Antihypertensive  AntiAnginal drugs (decreasing oxygen demand)  AntiAtrialArythmia  Side Effects = Headache and hypotension Treatment of V-fib and Asystole  Defib for V-fib (Defib = defibrillate = Shock em!)  Epinephrine and Atropine for Asystole Tx: Atrial arrhythmias  Adena  Beta  Calcium  Dig Tx: Ventricular arrhythmias  Lidocaine  Amiodarone Page 17 of 92 Mark Klimek Lectures 1 to 12 Chest Tubes Purpose: to reestablish negative pressure in the pleural space … Negative pressure in the pleural space makes thing stick so that the lung expands when the chest wall expands  Pleural space is the space between the lung (visceral pleura) and the chest wall (parietal pleura)  In a pneumothorax, chest tube removes air  In a hemothorax, chest tube removes blood  In a hemopneumothorax, chest tube removes air and blood Question A chest tube is placed in a pt for a hemothorax (blood). What would you (the LPN) report to the nurse? Or, what would you (the RN) report physician? a. Chest tube is not bubbling b.Chest tube drains 800 mL in the first 10 hours c. Chest tube is not draining d.Chest tube is intermittently bubbling What is the chest tube not supposed to do? The chest tube is supposed to drain instead of bubbling  Therefore answer (c) is the right answer. Question A chest tube is placed in a pt for a pneumothorax (air). What would you (the LPN) report to the nurse? Or, what would you (the RN) report physician? a. Chest tube is not bubbling b.Chest tube drains 800 mL in the first 10 hours c. Chest tube is not draining d.Chest tube is intermittently bubbling With a pneumothorax, bubbling is expected  Therefore, (a) is a good answer choice Page 18 of 92 Mark Klimek Lectures 1 to 12  Since this is a pneumothorax, not too much blood is expected  Consequently, 800 mL of blood over 10 hours (80 mL per hour) is too much blood and needs to be reported to the nurse or the physician Also, pay attention to the location the tube is placed  Apical (top) or Basilar (base)  Apical chest tube removes Air  Basilar chest tube removes Blood or fluid (due to gravity) Examples  An apical chest tube is draining 300 mL the first hour is bad … Bubbling (air) is expected  A basilar chest tube is draining 200 mL the first hour is expected  An apical chest tube is not bubbling … This is a bad sign because bubbling (air) is expected  A basilar chest tube is not bubbling … This is a good sign because bubbling (air) is not expected Example Pt presents with a unilateral hemopneumothorax. How to care for this pt?  Place an apical chest tube for the pneumothorax and a basilar for the hemothorax Bilateral pneumothorax needs apical chest tube one on the right and one on the left  Air tube = Apical = Top, on both sides Posttrauma or postsurgical pt needs  Pt presents with a unilateral hemopneumothorax. How to care for this pt? … Place an apical and a basilar chest tube on the side of the problem … Always assume trauma and surgery is unilateral unless otherwise specified Trick question Were would you place a chest tube for a postop right pneumonectomy? Page 19 of 92 Mark Klimek Lectures 1 to 12  Postop right pneumonectomy does not need a chest tube … Since the right lung was removed, there is no need for a chest tube  Chest tube will however be used for lobectomy (removal of a lobe of the lung), or wedge resection Closed chest drainage devices  Types: Jackson-Pratt, Emisson, pneumovac, hemovac, etc.  What happens if one of those drainage devices is knocked over? o Ask pt to take a deep breath and set the device back up o Not a medical emergency … No need to call the physician If the water seal of the chest tube breaks  Clamp o Clamping, unclamping, and placing the tube under water must be done in 15 seconds or less  Cut the tube away  Submerge (stick) the end of the tube under sterile water o The most important step  Unclamp the tube if it was initially clamped, (clamping the tube prevent air to get into the chest but does not allow anything from the chest to get out) Question The water seal chamber of the chest tube in a pt with a pneumothorax/hemothorax breaks. What is the first course of action for the nurse? a. Clamp the tube b.Cut the tube away c. Submerge (or stick) the end of the tube under sterile water d. Unclamp the tube if it was initially clamped In this case, the first course of action is the clamp the tube Question The water seal chamber of the chest tube in a pt with a pneumothorax/hemothorax breaks. What is the priority (best) action of the nurse? a. Clamp the tube b.Cut the tube away c. Submerge (or stick) the end of the tube under sterile water d. Unclamp the tube if it was initially clamped Knock someone or something over: to push or strike someone or something, causing the person or the thing to fall Note If for whatever reason the chest tube breaks, clamp, unclamping to placing the tube under water must be done in 15 seconds or less Page 20 of 92 Mark Klimek Lectures 1 to 12 In this question, the priory action for the nurse is to submerge the end of the tube under sterile water because doing so prevents air from getting into the chest. At the same time, this allows air or blood from the chest to get out  This solves the problem by reestablishing the water seal Note Clamping, unclamping, and placing the tube under water must be done in 15 seconds or less Question You notice on the monitor that a pt has v-fib. Pt is unresponsive and there is no pulse. What is the first step in the management of this pt? a. Place a backboard under pt’s back while pt is supine b. Start chest compression The first step is to place the backboard under pt’s back. “First” is about order. Question You notice on the monitor that a pt has v-fib. Pt is unresponsive and there is no pulse. What is the best step in the management of this pt? a. Place a backboard under pt’s back while pt is supine b. Start chest compression “Best” is about what is the priority. Chest compression is the priority action. If a chest tube gets pulled out … 1.Take a gloved hand and cover the opening (first step) 2.Take a sterile Vaseline gauze and tape 3 sides (best step) Chest tube is bubbling … Ask (1) where it is bubbling, and (2) when it is bubbling? Ask the following 2 questions  Bubbling … Where? In the water seal chamber o If it is intermittent, it is good (document it) o If it is continuous, it is bad and indicates a break/leak in the system (find it and tape it)  Bubbling … Where? In the suction control chamber o If it is intermittent, suction pressure is too low (increase it at the wall until it is continuous) o If it is continuous, it is good (document it) Analogies  A straight catheter is to a Foley catheter, as a thoracentesis is to a chest tube o A straight catheter goes in and out … A Foley goes in, secure it, and continuous drainage o Thoracocentesis = go in and out … Chest tubes = go in, secure it, and leave it in place  A Foley has a higher risk of infection than a straight cath  A chest tube has a higher risk of infection than thoracocentesis Page 21 of 92 Mark Klimek Lectures 1 to 12 Rules for clamping tubes  Do not clamp a tube for more than 15 seconds without a physician’s order  Use rubber tooth (will not puncture tubing), double clamps  Therefore, when the water seal breaks, the nurse has no more than 15 seconds to clamp, cut the tube, submerge it under sterile water, and then unclamp it Congenital Heart Defects  It’s either they cause a lot of trouble or no trouble o But nothing in between  Memorize one word: “TRouBLe” with the lower case vowels because congenital heart defects are either: o “TRouBLe” or o Nothing to worry about A pediatric pt with “TRouBLe” as congenital heart defect  Needs surgery now/soon to live  Has slowed/delayed growth and development (failure to thrive)  Has a shortened life expectancy  Parents will experience a lot of grief, financial and emotional stress  Pt is likely to be discharge home on a cardiac monitor  After, birth, pt will be in the hospital for weeks  Pediatrician or pediatric nurse will likely refer pt to a pediatric cardiologist Question The nurse is teaching the parent of an infant born with Tetralogy of Fallot. Which of the following should the nurse talked to the parents about in the teaching session?  The nurse should teach the newborn’s parents all of the choices listed above A “TRouBLe” congenital heart defect  “TRouBLe” shunts blood Right to Left  “TRouBLe” is Blue (cyanotic)  All “TRouBLe” start with the letter “T” o Tetralogy of Fallot o Truncus arteriosus o Transposition of the great vessels o Tricuspid atresia o Totally anomalous of pulmonary vasculature (TAPV) o Except, Left ventricular hypoplastic syndrome These are examples if No TRouBLe congenital heart defects  Ventricular septal defect (VSD)  Patent ductust arteriosus (PDA)  Patent foramen ovale