Comprehensive Nursing Study Guide: Acid-Base, Cardiac, Psychiatric, and Maternal Care

Acid-Base Imbalances and Ventilation Fundamentals

Distinction Between Signs/Symptoms vs. Causes: There is a critical clinical difference between the manifestations (s/s) and the underlying etiologies of acid-base imbalances.
Physiological Priotization: In respiratory assessment, the respiratory rate is less critical than the $SaO_2$ (Oxygen Saturation).
Modifying Phrase Rule: The modifying phrase in a patient description always trumps the original noun. - Example: An "OCD patient who is now psychotic"; prioritize the psychosis. - Example: A "vomiting patient who is now dehydrated"; prioritize the dehydration.
The Rule of "B": The Bicarb Rule: If the pH and the Bicarb ( $HCO_3$ ) move in the same direction, the imbalance is Metabolic.
The Relationship Between pH and Patient Presentation: - General Rule: "As the pH goes, so goes my patient," except for Potassium ( $K^+$ ). - High pH (Alkalosis): The body is irritable and hyper-excitable. Symptoms include borborygmi (hyperactive bowel sounds). Potassium ( $K^+$ ) levels decrease. - Low pH (Acidosis): The body shuts down. Symptoms include decreased heart rate (HR), decreased respiratory rate (RR), and lethargy. Potassium ( $K^+$ ) levels increase.
Identifying the Cause (Lungs vs. Everything Else): - If it is caused by the lungs, it is Respiratory. - Over-ventilating leads to Respiratory Alkalosis (pH up). - Under-ventilating leads to Respiratory Acidosis (pH down). - Prolonged vomiting or suctioning leads to Metabolic Alkalosis. - For "Everything Else" (not lung-related, not vomiting/suctioning), the answer is Metabolic Acidosis.
Ventilation vs. Respiration: Ventilation specifically refers to gas exchange. If a patient's $SaO_2$ is fine but they are over-breathing, look at the gas exchange context.
Ventilator Alarms: - High Pressure Alarm: Triggered by increased resistance (obstruction). 1. Check for kinks in the tubing; unkink them. 2. Check for water condensation; empty the tube. 3. Check for mucus in the airway; have the patient turn, cough, and deep breathe. 4. Suctioning is the absolute last resort. - Low Pressure Alarm: Triggered by decreased resistance (disconnection). 1. Check the main tubing and reconnect. 2. Check the oxygen sensor tubing (which senses $FiO_2$ at the trachea) and reconnect.
Bedside Safety Equipment: - Alkalosis: Keep suction at the bedside due to the risk of seizures. - Acidosis: Keep an Ambu bag at the bedside due to the risk of respiratory depression.

Alcoholism and Substance Abuse Psychology

Denial: The primary psychological problem in all abuse. - Intervention: Confront the patient by pointing out the discrepancy between what they say and what they do. - Note: In cases of loss (grief), support the denial; in cases of abuse, confront it.
Dependency vs. Codependency: - Dependency: The abuser relies on the significant other to perform tasks or make decisions (e.g., "Call my boss for me"). - Codependency: The significant other derives positive self-esteem from fulfilling the abuser's needs. This is harder to treat because the spouse feels like a "good person" for helping. - Intervention: Set limits and say "No."
Manipulation: The abuser induces the significant other to perform acts that are dangerous, harmful, or not in the significant other's best interest. Manipulation has no positive self-esteem component for the victim, making it easier to treat than codependency.
Wernicke-Korsakoff Syndrome: Psychosis induced by Vitamin $B_1$ (Thiamine) deficiency. - Symptoms: Amnesia with confabulation (making up stories to fill memory gaps). The patient truly believes their lies. - Intervention: Do not confront or present reality; instead, redirect the patient. - Characteristics: It is preventable (take Vitamin $B_1$ ), arrestable (take Vitamin $B_1$ ), and often irreversible.
Aversion Therapy (Antabuse/ReVia): - Disulfiram (Antabuse) and Naltrexone (ReVia) make the patient deathly ill upon alcohol ingestion. - Onset/Offset: Takes $2$ weeks to build up in the system and $2$ weeks to clear before it is safe to drink again. - Patient Teaching: Avoid ALL alcohol products, including mouthwash, aftershave, perfumes, insect repellent, elixirs, alcohol-based hand sanitizer, and unbaked icing (vanilla extract). Note: Red wine vinaigrette is typically safe.

Substance Abuse: Toxicity and Withdrawal

The Most Abused Drug: Laxatives (especially among the elderly).
Uppers (5): Caffeine, Cocaine, PCP/LSD (hallucinogens), Methamphetamines, and Adderall. - Signs/Symptoms: Everything goes up (euphoria, tachycardia, tachypnea, restlessness, irritable, borborygmi, diarrhea, reflexes $+3$ or $+4$ , seizures).
Downers: Everything that is not an upper (Heroin, Marijuana, Alcohol, Benzodiazepines). - Signs/Symptoms: Everything goes down (lethargy, respiratory depression, bradycardia, bradypnea).
Overdose vs. Withdrawal: - Overdose on an Upper: Everything goes UP. - Withdrawal from an Upper: Everything goes DOWN. - Overdose on a Downer: Everything goes DOWN. - Withdrawal from a Downer: Everything goes UP.
Critical Risk: Respiratory depression is the primary risk in Downer Overdose and Upper Withdrawal.

Drug Addiction in Newborns

At Birth: Always assume intoxication, not withdrawal.
After $24$ Hours: The infant can go through withdrawal.
Symptoms of Withdrawal: Shrill high-pitched cry, difficult to console, exaggerated startle reflex, and seizure risk.

Alcohol Withdrawal vs. Delirium Tremens (DTs)

Alcohol Withdrawal Syndrome: Occurs within $24$ hours of cessation. Not life-threatening. Patient is not a danger to self/others. - Care: Regular diet, semi-private room, ad-lib activity, no restraints.
Delirium Tremens: Occurs within $72$ hours of cessation. Can be fatal and is dangerous to self/others. - Care: NPO or clear liquids (due to seizure/aspiration risk), private room near nurses' station, strict bed rest (bed pans/urinals), and restraints (vest or $2$ -point locked leathers, rotated every $2$ hours).
Shared Medications: Both receive antihypertensives, tranquilizers, and Vitamin $B_1$ .

Aminoglycosides: Antibiotic Therapy

Definition: A powerful class of antibiotics used for "mean old infections" (life-threatening, resistant, gram-negative).
Naming Convention: All end in "-mycin." - Exceptions: If it has "thro" (e.g., Erythromycin, Azithromycin, Clarithromycin), it is NOT a "mean old mycin."
Toxicities: - Ototoxicity: Monitor hearing, tinnitus, and vertigo. - Nephrotoxicity: Monitor serum creatinine (best indicator of kidney function).
Administration: Administered every $8$ hours. Route is typically IM or IV.
Oral Aminoglycosides (The Exceptions): Used to "sterilize the bowel." 1. Hepatic Encephalopathy: Kills ammonia-producing $E. coli$ . 2. Pre-op Bowel Surgery. - Mnemonic: "Who can sterilize my bowel? Neo-Kan!" (Neomycin and Kanamycin).

Cardiac Care and Calcium Channel Blockers

Calcium Channel Blockers (CCB): Function as "Valium for the heart." They are negative inotropics, negative dromotropics, and negative chromotropics (they weaken, slow down, and depress the heart).
Uses: The "A, AA, AAA" rule: 1. Anti-hypertensive. 2. Anti-Angina. 3. Anti-Atrial-Arrhythmia (treats everything atrial, including SVT).
Side Effects: Headache and Hypotension.
Common Names: Names ending in "-dipine," plus Verapamil and Cardizem (Diltiazem). - Nursing Action: Monitor Blood Pressure. If systolic is below $100$ , hold the dose. Titrate IV drips if BP drops.

Cardiac Arrhythmias and EKG Interpretation

Key Terms: - QRS Depolarization: Refers to Ventricular issues. - P-wave: Refers to Atrial issues. - Chaotic: Fibrillation. - Bizarre: Tachycardia. - Lack of P-wave: Ventricular.
Priority Levels: - Lethal: Asystole and V-fib (no pulse). - Life-Threatening: V-tach with a pulse. - Moderate Priority: Multiple PVCs (more than $6$ in a minute or a row).
Treatments: - SVT/Atrial: ABCD (Adenosine - push fast; Beta-blockers; CCBs; Digoxin/Lanoxin). - V-fib: D-fib (Defibrillation). - Asystole: Epinephrine then Atropine. - PVCs/V-tach: Amiodarone.

Chest Tube Management

Purpose: Re-establishes negative pressure in the pleural space. - Pneumothorax: Removes air. - Hemothorax: Removes blood.
Placement: - Apical: High (for Air). - Basilar: Low (for Blood).
Troubleshooting: - Device knocked over: Set it back up; have the patient deep breathe. - Water seal breaks: This is an emergency. 1. Clamp (briefly). 2. Cut the tube from the device. 3. Submerge in sterile water. 4. Unclamp. - Tube dislodged: Cover with a gloved hand (first), then apply Vaseline gauze (best).
Bubbling Rules: - Water Seal: Intermittent bubbling is good; continuous bubbling is bad (indicates a leak). - Suction Chamber: Intermittent bubbling is bad (suction too low); continuous bubbling is good.

Infection Control and Precautions

Enteric (Contact): For C. diff, Hepatitis A, Herpes, Staph, and RSV. Uses private room, gloves, gown, and dedicated equipment.
Droplet: For Meningitis and H-flu. Uses private room, mask, and patient mask during transport.
Airborne: For Measles, Mumps, Rubella, TB, and Varicella. Uses private room, negative airflow, and N95 masks (for TB).
PPE Donning/Doffing: Take off in alphabetical order (Gloves, Goggles, Gown, Mask).

Congenital Heart Defects (CHD)

"TRouBLe" Defects: - T: All defects starting with T are Trouble. - R-L: Right-to-Left shunting. - B: Blue/Cyanotic. - Characteristics: Surgery required, growth delays, decreased life expectancy.
Tetralogy of Fallot: Mnemonic "VarieD PictureS Of A RancH." 1. Ventricular Defect. 2. Pulmonary Stenosis. 3. Overriding Aorta. 4. Right Hypertrophy.

Mobility Aids: Crutches, Canes, and Walkers

Crutch Measurement: $2-3$ finger widths below the anterior axillary fold to a point lateral to and slightly in front of the foot. Elbow flexion should be $30$ degrees.
Gaits: - $2$ -point: Move crutch and opposite foot together (mild bilateral weakness). - $3$ -point: Two crutches and the bad leg together (unilateral weakness). - $4$ -point: Right crutch, left leg, left crutch, right leg (severe bilateral weakness). - Swing-through: For non-weight bearing.
Stairs: "Up with the good, down with the bad." Lead with the strong leg going up, lead with the crutches and weak leg going down.
Canes: Use on the strong side (COAL: Cane Opposite Affected Leg).
Walkers: Pick it up, set it down, walk to it. Do not use wheels or tennis balls.

Psychiatric Assessment and Delusions

Non-Psychotic: Has insight and is reality-based. Use therapeutic communication.
Psychotic: No insight; does not think they are sick. Features include delusions, hallucinations, and illusions. - Delusion: A false, fixed belief (Paranoid, Grandiose, Somatic). - Hallucination: A false, fixed sensory experience without a stimulus (Auditory is most common). - Illusion: A misinterpretation of a real sensory stimulus.
Types of Psychotics: - Functional (Schizo, Schizo, Major, Manic): Potential to learn reality. Process: Acknowledge feelings -> Present reality -> Set limits -> Enforce limits. - Dementia: Brain damage; cannot learn reality. Process: Acknowledge feelings -> Redirect. Do not present reality, but you can reality-orient. - Delirium: Temporary loss of reality. Process: Acknowledge feelings -> Reassure of safety.

Diabetes Mellitus (DM)

Diabetes Insipidus (DI): High urine output, dehydration, low specific gravity. (High and Dry).
SIADH: Low urine output, fluid retention, high specific gravity.
Type 1 DM: Insulin-dependent, Ketosis-prone. Treatment is "DIE" (Diet, Insulin, Exercise).
Type 2 DM: Non-insulin-dependent. Treatment is "DOA" (Diet, Oral hypoglycemics, Activity).
Insulin Types: - Regular (R): Onset $1$ hr, Peak $2$ hrs, Duration $4$ hrs. Clear, can be IV. - NPH: Onset $6$ hrs, Peak $8-10$ hrs, Duration $12$ hrs. Cloudy, never IV. - Humalog (Lispro): Rapid; Onset $15$ min, Peak $30$ min, Duration $3$ hrs. Give with meals. - Lantus (Glargine): Long-acting, no peak, safe at bedtime.
Insulin Mixing: Draw clear before cloudy (R before N).
Complications: - Hypoglycemia: Symptoms of "Drunk + Shock." Treat with rapid carbs and protein/starch. If unconscious, IM Glucagon or IV Dextrose. - DKA (Type 1): Caused by Upper Respiratory Infection. Symptoms: Dehydration, Ketones, Kussmaul, $K^+$ high, Acidosis, Acetone breath. Treat with IV fluids and Regular insulin. - HHNK (Type 2): Severe dehydration. Treat with IV fluids.
$HbA1c$ : Goal is $6$ and lower; $8$ and up is out of control.

Gastrointestinal and Electrolytes

Hiatal Hernia: Gastric acid moves up into the esophagus. Treatment (Everything High): High HOB, High fluids, High carbs.
Dumping Syndrome: Gastric contents move too fast into the duodenum. Treatment (Everything Low): Low HOB (lay flat), Low fluids (between meals), Low carbs.
Electrolyte Signs: - Paresthesia (Numbness/Tingling) is the first sign. - Potassium ( $K^+$ ): Follows the prefix except for HR and urine output. Hyperkalemia (agitation, tachypnea, diarrhea, bradycardia); Hypokalemia (lethargy, constipation, tachycardia). - Calcium ( $Ca$ ) & Magnesium ( $Mg$ ): Do the opposite of the prefix. In Hyper-, everything goes down. In Hypo-, everything goes up (includes Chvostek and Trousseau signs).
Treatment for Hyperkalemia: - Fast/Temporary: $D_5W$ with Regular Insulin. - Permanent/Slow: Kayexalate ("K-exits-late").

Endocrine and Laminectomy

Hyperthyroidism (Grave’s Disease): Hyper-metabolism. Symptoms: Weight loss, high HR, heat intolerance, exophthalmos. - Thyroid Storm: High temp ( $105+$ ), high BP, tachycardia, delirium. Treat with ice packs and $10L$ oxygen.
Hypothyroidism (Myxedema): Hypo-metabolism. Symptoms: Weight gain, cold intolerance, low BP. Do not sedate.
Adrenal Cortex: - Addison's: Under-secretion. Needs steroids ("Add-a-sone"). Risk for shock under stress. - Cushing’s: Over-secretion. Symptoms: Moon face, buffalo hump, central obesity, striae, high glucose, low $K^+$ .
Pediatric Toys: - $0-6$ months: Musical mobile (best), large/soft. - $6-9$ months: Object permanence (Jack-in-the-box). - $9-12$ months: Speaking toys, purposeful activity. - Toddlers ( $1-3$ ): Push/pull toys, gross motor, parallel play.
Laminectomy: - Post-Op: Log roll is the priority. Do not dangle legs. Do not sit for longer than $30$ minutes. - Location-Specific Risks: Cervical (Airway/Arms); Thoracic (Cough/Bowels); Lumbar (Bladder/Legs).

Laboratory Values and Priorities

Class C (Critical) Values: - $INR ≥ 4$ - Potassium < 3.5 or $High (5.4-5.9)$ - $CO_2$ in the $50s$ - $PO_2$ in the $70s$ - $O_2$ Saturation < 93 - Platelets < 90,000
Class D (Deadly) Values: - $Potassium ≥ 6$ - $pH$ in the $6s$ - $CO_2 ≥ 60$ - $PO_2 ≤ 60$ - Platelets < 40,000

Psychotropic Medications

Phenothiazines (Typical Antipsychotics): End in "-zine." Cause anticholinergic effects, blurred vision, constipation, drowsiness, EPS, photosensitivity, and agranulocytosis.
Benzodiazepines: Contain "-zep-." Used for anxiety, seizures, and alcohol withdrawal. Should not be taken for more than $2-4$ weeks.
MAOIs: (Marplan, Nardil, Parnate). Avoid dietary Tyramine (aged cheese, organ meats, alcohol, chocolate) to prevent hypertensive crisis.
Lithium: Used for Bipolar mania. Therapeutic range: $0.6-1.2$ . Toxic: > 2.0. Watch for Sodium levels; low sodium makes Lithium toxic.
Haldol: Similar to Phenothiazines. Risk for NMS (Neuroleptic Malignant Syndrome) – extreme hyperpyrexia ( $105-108$ ).

Maternal and Newborn Nursing

Nagele's Rule: First day of LMP $+ 7$ days $- 3$ months.
Weight Gain: Total 28 3 lbs.
Fundus Location: Palpable at $12$ weeks; at umbilicus at $20-22$ weeks.
Labor Stages: - Stage $1$ : Dilation and Effacement (Phases: Latent, Active, Transition). - Stage $2$ : Delivery of Baby. - Stage $3$ : Delivery of Placenta (check for $3$ vessels: $2$ arteries, $1$ vein). - Stage $4$ : Recovery ( $2$ hours after placenta).
Fetal Monitoring (VEAL CHOP): - Variable = Cord Compression (Very Bad). - Early Decels = Head Compression (Fine). - Accelerations = Okay. - Late Decels = Placental Insufficiency (Bad - use LION: Left side, IV up, Oxygen, Notify).
Postpartum Check (BUBBLE): Focus on Breasts, Uterus (fundus height = days postpartum), Bowel, Bladder, Lochia (Rubra, Serosa, Alba), and Extremities (thrombophlebitis).