NCLEX: Mark Klimek - Lecture 2 (Alcoholism vs. Delirium Tremens, Aminoglycosides, & Troughs/Peaks)

The #1 psychological problem in any abuse situation is...

Denial

How do you respond to and treat patients in abusive denial?

Confront them by pointing out the different between what they say and what they do.

"I know you say you aren't an alcoholic, but it's 10am and you've already finished a 6-pack."

It is NOT the same as aggression. Do not attack the person.

In therapeutic communication, good answers begin with ______. Bad answers begin with ______.

"I" is good, "You" is bad.

Where is the one stage where denial would be okay?

Loss and grief

What are the stages of grief?

DABDA:

Denial

Anger

Bargaining

Depression

Acceptance

How do you respond to and treat patients in loss and grieving denial?

Support them, don't confront them.

The #2 psychological problem in any abusive situation is...

Dependency or Co-dependency

What does dependency mean?

When someone gets the significant other to do things for them or make decisions.

The abuser is dependent and gets a free ride.

What does co-dependency mean?

When the significant other derive self-esteem for doing things or making decisions for the abuser.

The significant other is the co-dependent and gains positive self-esteem by doing stuff for the abuser.

Co-dependency treats 2 patients.

How do you treat dependency and co-dependency?

- Confront the abusers.

- Work on the co-dependent patient's self-esteem.

- Teach co-dependent patients to set limits, enforce them, and learn to say "NO." (important to work with them!)

What is manipulation?

When the abuser gets the significant other to do things for them that is not in the best interest of the significant other.

This can be dangerous and harmful to the significant other.

How is manipulation like dependency?

In both situations, the dependent person gets the co-dependent to do things or make decisions.

If what the significant other is being asked to do is NOT inherently dangerous and harmful, is this dependency/co-dependency or manipulation?

Dependency/co-dependency

If what the significant other is being asked to do IS inherently dangerous and harmful, is this dependency/co-dependency or manipulation?

Manipulation

Dependent/co-dependent or manipulation problem? A 49-year-old alcoholic gets her 17-year-old son to go to the store and buy alcohol for her.

Manipulation

Dependent/co-dependent or manipulation problem? A 49-year-old alcoholic asks her 50-year-old husband to go to the store and buy alcohol for her.

Dependent/co-dependent

Wernicke is a _______ disorder.

Encephalopathy (pathology affecting brain function)

Korsakoff is a _______ disorder.

Psychosis (Loss of contact with reality)

What is Wernicke-Korsakoff syndrome?

A neurological disorder, psychosis induced by Vitamin B1 (Thiamine) deficiency.

Thiamine plays a role in metabolizing glucose to produce energy for the brain.

What is the primary s/s of Wernicke-Korsakoff syndrome?

Amnesia and confabulation (made-up stories; they believe the lie)

How do you deal with a patient with Wernicke-Korsakoff syndrome who is confabulating about going to a meeting with Barack Obama this morning?

Re-direct the patient to something they can do.

"Let's go watch TV to see what is on the news today."

What are the 3 characteristics of Wernicke-Korsakoff syndrome?

(1) Preventable = Take Vitamin B1

(2) Arrestable (Stop it from getting worse) = Take Vitamin B1

(3) Irreversible (70%) = Will kill brain cells

*Don't have to stop drinking, just take B1

What is the medication Antabuse (Disulfiram)?

Alcohol deterrent, aversion therapy

What is the medication Revia (Naltrexone)?

Antidote for alcoholism. Renders alcohol useless (prevents feeling pleasure)

What is aversion therapy?

A type of behavior therapy designed to make a patient give up an undesirable habit by causing them to associate it with an unpleasant effect.

What is the onset and duration of effectiveness of Antabuse/Revia?

2 weeks. Patient must be off drug for 2 weeks until they can safely drink again.

What is the patient teaching for alcoholism?

Avoid all forms of alcohol to avoid nausea, vomiting, and death. Things that they wouldn't expect to have alcohol in it:

Mouthwash, cologne/perfume, aftershave, -elixir (Robitussin), OTC medications, insect repellent, hand-sanitizers, vanilla extract (cannot have cupcake with unbaked icing).

* Tricky: RED WINE VINIAGRETTES do NOT have alcohol in it. *

What is the first question you ask in an overdose question?

"Is it an upper or downer?"

Which abuse is neither an upper nor a downer?

Laxative abuse in the elderly

What are the 5 main drugs that are UPPERs?

Caffeine

Cocaine

PCP/LSD (Psychedelics/hallucinogens)

Methamphetamines

Adderall

What are some drugs that are DOWNERs?

Heroin, alcohol, marijuana... There's over 135 drugs... If it's not one of the upper drugs, it's a downer.

What are the s/s of UPPER drugs?

Things go UP!

Euphoria, seizures, restlessness, irritability, hyperreflexia (3+, 4+), tachycardia, borborygmic (increased bowel sounds), diarrhea

What are the s/s of DOWNER drugs?

Things go DOWN!

Lethargic, coma, respiratory depression/arrest, hyporeflexia (0, 1+), bradycardia, absent bowel sounds, constipation

What is the highest nursing priority to anticipate in an Upper?

Suctioning due to seizures

What is the highest nursing priority to anticipate in a Downer?

Intubation/ventilation and ambubag due to respiratory arrest

One of your patients is "high on cocaine." What is critically important to assess?

Assess reflexes, irritability, borborygmi, increased temperature, etc.

What is the second question you ask after a drug is upper/downer?

"Is it an overdose or a withdrawal?"

If you have an overdose on an UPPER, you are too _______, so everything goes _______.

Much; UP.

If you have an overdose on a DOWNER, you are too _______, so everything goes _______.

Little; DOWN.

If you have a withdrawal on an UPPER, you are too _______, so everything goes _______.

Little; DOWN.

Too little upper makes everything down.

If you have a withdrawal on a DOWNER, you are too _______, so everything goes _______.

Much; UP.

Too little downer makes everything go up.

In which two drug cases would respiratory depression/arrest be a HIGH priority?

Overdose on a downer & Withdrawal on an upper.

In which two drug cases would seizures be a HIGH risk?

Overdose on an upper; withdrawal on a downer.

The driver of a squad car calls the ER and says he is bringing a patient who OD'd on cocaine. What do you expect to see?

Seizures, irritability, hyperreflexia, borborygmi, increased temperature, etc.

The driver of a squad car calls the ER and says he is bringing a patient who is withdrawing from cocaine. What do you expect to see?

Respiratory depression, hyporeflexia, absent bowel sounds, difficult to arouse... GIVE Naloxone (Narcan) and make sure RR above 12.

Always assume intoxication or withdrawal in a newborn less than 24 hours after birth?

Intoxication

Always assume intoxication or withdrawal in a newborn more than 24 hours after birth?

Withdrawal

You are caring for an infant born to a Quaalude-addicted mother 24 hours after birth. What are the s/s?

Don't know the drug, but it's a downer.

24 hours after birth = withdrawal.

Withdrawal from a downer = Too little downer, UP.

S/s: Irritability, crying, seizure risk, shrills, exaggerated startle cries, etc.

Are Alcohol Withdrawal Syndrome and Delirium Tremens the same?

NO.

How long does it take for EVERY alcoholic to go through alcohol withdrawals?

24 hours after the person stops drinking. They are stable; not life-threatening.

How long does it take for an alcoholic in alcohol withdrawals to progress to delirium tremens?

72 hours after the person stops drinking. They are unstable; can kill.

This occurs in less than 20% alcoholics.

True or false: Delirium tremens always precedes alcohol withdrawals.

False.

Which of the following is life-threatening to self and others - alcohol withdrawal syndrome or delirium tremens?

Delirium tremens

What is the nursing care plan for a patient with alcohol withdrawals?

Regular diet

Semiprivate room anywhere on unit

Pt is up ad lib

No restraints

What is the nursing care plan for a patient with delirium tremens?

NPO or clear liquid diet (Seizure risk)

Private room near nursing station

Restricted bed rest - no bathroom (bed pans/urinals only)

Restraints (vest or 2-point locked leathers, 1 arm and opposite leg *must rotate every 2 hr)

What medications would you give to a patient with alcohol withdrawal syndrome or delirium tremens?

Anti-HTN medications (everything up, so keep it down)

Tranquilizer (up)

Multivitamin containing Vitamine B1 (Thiamine) to prevent WKS (no B1 --> you'll be one)

What drugs are the powerful, BIG GUNS of antibiotics?

Aminoglycosides

What are aminoglycosides used to treat?

Serious, resistant, life-threatening, Gram-negative infections

Treat a mean old infection with...

A Mean Old Mycin

What are examples of mean old infections?

TB, septic peritonitis, fulminating pyelonephritis, septic shock, infection from 3rd degree wound covering >80% of the body.

What are NOT examples of mean old infections?

Sinusitis, otitis media, bladder infection, viral pharyngitis, strep throat, etc.

All aminoglycosides end in:

-mycin

What drugs ending in -mycin are NOT aminoglycosides?

Drugs that have "thro" in the middle:

Azithromycin, Clarithromycin, Erythromycin

THRO them off the "Mean Old Mycin" list

What are toxic effects of aminoglycosides?

Ototoxicity and nephrotoxicity

Mycin sounds like mice, so think big ears = monitor hearing, tinnitus, vertigo

Human ears are shaped like kidneys, so think kidneys = monitor creatinine (best indicator for kidney function)

8 fits in kidney = CN8

Which is better: 24hr creatinine clearance or serum creatinine?

24hr creatinine clearance

What does the figure 8 drawn in your EAR remind you of?

Aminoglycosides are toxic to CN8.

Administer them Q8 hrs through IM/IV. Don't give PO because they are not absorbed and have no systemic effect.

What is the #1 action of an "Oral Mycin?"

Sterilize the bowels

What are the two cases in which Mean Old Mycins are given PO?

Hepatic encephalopathy/coma (high ammonia) = Kills E.coli, which is the #1 producer of ammonia.

Pre-op bowel surgery = Sterilize the bowels before surgery.

Who can sterilize my bowels?

NEO KAN!! Neomycin and Kanamycin.

What are troughs?

When drugs are at its lowest concentration in the blood.

What are peaks?

When drugs are at its highest concentration in the blood.

What does "TAP" stand for?

Trough, administer, peak.

Draw trough level before meds.

Administer meds.

Draw peak level after meds depending on route.

What is the importance of TAP?

Narrow therapeutic window for meds means that there is a small difference in what works and what kills.

Aminoglycosides are major class to draw TAP.

When do you draw troughs?

Always draw 30 minutes before dose regardless of route.

When do you draw peak for SubL?

5-10 minutes after drug is dissolved.

When do you draw peak for IV?

15-30 minutes after drug is finished (empty bag).

When do you draw peak for IM?

30-60 minutes

When do you draw peak for SubQ?

Depends on insulin (See diabetes lecture)

When do you draw peak for PO?

Not necessary, not tested.

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.

Tricky question: Play the "Price Is Right" and go with the highest time without going over.

IV Peaks at 15-30 minutes. Go with 30 minutes.

Answer: (4) 11:00 a.m.

If two values within the same range of peak, what do you do?

Pick the highest without going over.