Mark Klimek Comprehensive NCLEX Review: Lectures 1-12 Notes

Acid-Base Balance and the Rule of the Bs

• To solve acid-base disorders, the normal values are: $pH$ level $7.35$ to $7.45$; $CO2$ level $35$ to $45$; $HCO3$ (bicarbonate) level $22$ to $26$.
• The first step is checking the $pH$. If $pH < 7.35$, it is acidosis. If $pH > 7.45$, it is alkalosis.
• Rule of the Bs: If $pH$ and Bicarb ($HCO3$) move in the same direction, the imbalance is Metabolic. If they move in opposite directions, it is Respiratory.
• Example #1: $pH$ $7.3$ (Down/Acid) and $HCO3$ $20$ (Down). Same direction = Metabolic Acidosis.
• Example #2: $pH$ $7.58$ (Up/Alkalotic) and $HCO3$ $32$ (Up). Same direction = Metabolic Alkalosis.
• Example #3: $pH$ $7.22$ (Down/Acidosis) and $HCO3$ $35$ (Up). Opposite direction = Respiratory Acidosis.
• General Rule: "As the $pH$ goes, so goes my patient, except for Potassium ($K^{+}$)."     * High $pH$ (Alkalosis): Everything goes up (tachycardia, tachypnea, seizures, irritability, spasticity, diarrhea, borborygmi, hyperreflexia $3+$ or $4+$). $K^{+}$ goes down (hypokalemia).     * Low $pH$ (Acidosis): Everything goes down (bradycardia, constipation, absent bowel sounds, flaccid, obtunded, lethargy, coma, hyporeflexia $0$ or $1+$, bradypnea, low BP). $K^{+}$ goes up (hyperkalemia).
• Macro Kussmaul: MAC Kussmaul is the only acid-base imbalance causing Metabolic ACidosis with Kussmaul respirations.
• Cause Identification Strategy:     * Is it Lung? If yes, it is Respiratory. Ask: Overventilating (Alkalosis) or Underventilating (Acidosis)?     * Is it Gastric Vomiting or Suction? If yes, pick Metabolic Alkalosis.     * For everything else that is not lung, pick Metabolic Acidosis. If you don't know, default to Metabolic Acidosis.

Ventilator Management and Alarms

• High Pressure Alarms: Triggered by increased resistance to airflow. Causes: Kinks in tubing (unkink), Condensed water in dependent tube (empty water), Mucus plugs (turn pt, cough, deep breathe, then suction PRN).
• Low Pressure Alarms: Triggered by decreased resistance. Causes: Main tubing disconnection, $O2$ sensor tube disconnection. Reconnect unless on floor (if on floor, bag pt and call RT).
• Ventilation Settings:     * Too High: Pt is overventilated, leading to Respiratory Alkalosis (Panting).     * Too Low: Pt is underventilated, leading to Respiratory Acidosis ($CO2$ retention).
• Weaning Scenario: If ABGs show Respiratory Acidosis at $6$ a.m., the patient is not ready to be weaned because they are underventilating.

Alcoholism and Personality Disorders

• Denial: The #1 psychological problem in abuse. Treatment: Confront by pointing out the discrepancy between words and actions. In Loss/Grief, support denial; in Abuse, confront it.
• Dependency vs. Co-dependency: Dependency is the abuser getting the significant other (S.O.) to do things for them. Co-dependency is the S.O. deriving self-esteem from doing those things. Treatment: Confront the abuser and teach the S.O. to set and enforce limits.
• Manipulation: Abuser gets S.O. to do something dangerous or harmful. Treatment: Set limits and enforce them.
• Wernicke-Korsakoff Syndrome: Psychosis induced by Vitamin $B1$ (Thiamine) deficiency. Symptoms: Amnesia and Confabulation. Characteristics: Preventable (take $B1$), Arrestable (take $B1$), and Irreversible ($70\%$ of cases).
• Antabuse and Revia (Disulfiram): Alcohol deterrent and antidote. Requires $2$ weeks to start and $2$ weeks to clear. Pt teaching: Avoid ALL alcohol (mouthwash, cologne, aftershave, elixirs, OTC liquids, insect repellant, vanilla extract, hand sanitizer). Red wine vinaigrette is safe.

Drug Overdose and Withdrawal

• Category Identification: Is the drug an Upper or Downer?     * Uppers: Caffeine, Cocaine, PCP/LSD, Methamphetamines, Adderall. S/Sx: Euphoria, seizures, hyperreflexia ($3+/4+$), tachycardia, borborygmi.     * Downers: Everything else. S/Sx: Lethargy, respiratory depression, constipation.
• Overdose vs. Withdrawal:     * Overdose on Upper: Too much (seizure risk).     * Overdose on Downer: Too little (respiratory arrest risk).     * Withdrawal on Upper: Too little (respiratory arrest risk).     * Withdrawal on Downer: Too much (seizure risk, shrill cry in newborns).
• Newborn Addiction: Assume intoxication at birth and for the first $24$ hours. After $24$ hours, assume withdrawal.
• Alcohol Withdrawal Syndrome (AWS) vs. Delirium Tremens (DT):     * AWS: Occurs within $24$ hours. Non-life threatening. Diet regular, semi-private room, up ad lib, no restraints.     * DT: Occurs after $72$ hours. Life-threatening. NPO/Clear liquids, private room near station, bed rest, restraints ($2$-point leather lock).

Aminoglycosides and TAP Levels

• Aminoglycosides: "A Mean Old Mycin." Used for serious, life-threatening, Gram-negative infections.
• Naming: End in "mycin." If the name contains "thro" (Erythromycin, Azithromycin), throw it off the list (not an aminoglycoside).
• Toxicity: Mycin sounds like Mice (monitor hearing/CN8, balance, tinnitus). The ear shape matches a kidney (monitor nephrotoxicity via serum Creatinine).
• Administration: Give $q8$ hours. Do not give PO except for Hepatic Encephalopathy (to kill $E. coli$ and lower ammonia) or Pre-op Bowel Surgery (Neomycin and Kanamycin: "Who can sterilize my bowel? Neo-Kan").
• TAP (Trough, Administer, Peak): Drawn for narrow therapeutic windows.     * Trough: Always $30$ minutes before next dose.     * Peak: Sublingual ($5$-$10$ mins), IV ($15$-$30$ mins after bag is empty), IM ($30$-$60$ mins).

Cardiac Medications and Arrhythmias

• Calcium Channel Blockers (CCB): Valium for the heart. Negative Inotropic, Chronotropic, Dromotropic. Used for "A, AA, AAA" (Antihypertensive, Anti-Anginal, Anti-Atrial Arrhythmia). Side effects: Headache and Hypotension. Hold if SBP $<100$. Names: "-dipine" plus Verapamil and Cardizem.
• Arrhythmia Rhythms:     * Asystole: Flat line.     * Atrial Flutter: Sawtooth P-waves.     * Atrial Fibrillation: Chaotic P-waves.     * Ventricular Fibrillation: Chaotic QRS complexes.     * Ventricular Tachycardia: Bizarre QRS complexes.     * PVCs: Periodic wide bizarre QRS. Moderate priority if $>6$ in a minute or in a row.
• Lethal Arrhythmias: Asystole and V-fib (no CO, no brain perfusion).
• Treatments:     * Ventricular (PVCs/V-tach): Lidocaine or Amiodarone.     * Atrial (Supraventricular): ABCDs (Adenocard, Beta-blockers, CCBs, Digoxin).     * V-fib: Defib (Shock).     * Asystole: Epinephrine then Atropine.

Chest Tubes and Congenital Heart Defects

• Purpose: Reestablish negative pressure. Pneumothorax (removes air), Hemothorax (removes blood).
• Location: Apical (removes air/Top), Basilar (removes blood/Base).
• Troubleshooting: If water seal breaks, clamp, cut, submerge in sterile water, unclamp ($15$ sec limit). If tube pulls out, cover with gloved hand first, then Vaseline gauze taped on $3$ sides.
• Bubbling:     * Water Seal Chamber: Intermittent is good; Continuous is bad (leak).     * Suction Control Chamber: Intermittent is bad (suction too low); Continuous is good.
• Congenital Heart Defects: "TRouBLe" (T-prefix = bad). Right to Left shunts, Blue (cyanotic). Defects: Tetralogy of Fallot (PROVe: Pulmonary stenosis, RVH, Overriding aorta, VSD).

Locomotion Aids and Psychosis Categories

• Crutches: Length is $2$-$3$ finger widths below axilla. Handgrip flexion is $30$ degrees.     * Gaits: $2$-point (mild bilateral), $3$-point (one leg affected), $4$-point (severe bilateral), Swing-through (non-weight bearing).     * Stairs: "Up with the Good, Down with the Bad."
• Categories of Psychosis:     * Functional: (Schizophrenia, Mania). Treatment: Acknowledge feelings, Present reality, Set limits, Enforce.     * Dementia: (Alzheimer's). Treatment: Acknowledge feelings, Redirect (do not present reality, but use orientation).     * Delirium: (UTI, Drug reaction). Treatment: Acknowledge feelings, Reassure of safety and transience.

Diabetes Mellitus, Insipidus, and SIADH

• Diabetes Insipidus (DI): Low ADH, high urine output, dehydration, low specific gravity.
• SIADH: High ADH, low urine output, fluid excess, high specific gravity.
• Type 1 DM: Insulin dependent, Juvenile onset, Ketosis prone. Treatment: DIE (Diet, Insulin, Exercise).
• Type 2 DM: Non-insulin dependent, Adult onset. Treatment: DOA (Diet, Oral hypoglycemics, Activity). Diet is most important (calorie restriction, $6$ small meals).
• Insulin Types:     * Regular (R): Clear, can be IV. Onset $1$, Peak $2$, Duration $4$.     * NPH (N): Cloudy, suspension. Onset $6$, Peak $8$-$10$, Duration $12$.     * Humalog (Lispro): Give with meal. Onset $15$ min, Peak $30$ min, Duration $3$ hrs.     * Lantus (Glargine): Long-acting, no peak. Duration $12$-$24$ hrs.
• DKA (Type 1): S/Sx are DKA (Dehydration, Ketones/Kussmaul/High K, Acidosis/Acetone/Anorexia). Treatment: IV Fluids ($200$ mL/hr) and Regular Insulin IV.
• HHNK (Type 2): Severe dehydration. Treatment: Rehydration. Mortality is higher than DKA, but DKA is a higher clinical priority.
• A1C: Normal $< 6$, Out of control $> 8$, Borderline $7$.

Drug Toxicities and Electrolytes

• Levels:     * Lithium: $0.6$ to $1.2$ (Toxic $> 2.0$).     * Lanoxin (Digoxin): $1$ to $2$ (Toxic $> 2.0$).     * Aminophylline: $10$ to $20$ (Toxic $> 20$).     * Dilantin (Phenytoin): $10$ to $20$ (Toxic $> 20$).     * Bilirubin (Newborn): $10$ to $20$ (Toxic $> 20$).
• Kernicterus: Bilirubin in the brain ($> 20$). Causes opisthotonos (hyperextension); place child on side.
• Dumping Syndrome: Gastric contents move too fast. Symptoms: Drunk, Shock, Abdominal distress. Treatment: Lower HOB, low fluids with meals, low carbs, high protein.
• Hiatal Hernia: Gastric contents move in wrong direction at right rate. Symptoms: GERD when lying down after eating. Treatment: High HOB, high fluids, high carbs, low protein.
• Electrolyte Rules:     * Kalemias: Same as prefix except HR and UO (opposite). Hyperkalemia: Heart stops. Treatment: $D5W$ with Regular Insulin (fast) and Kayexalate (enters late/long-term).     * Calcemias: Opposite of prefix. Parathyroid/Muscle issues. Chvostek's (cheek tap) and Trousseau's (BP cuff spasm).     * Magnesemias: Opposite of prefix.     * Natremia: HypErnatremia = DEhydration. HypOnatremia = Overload.

Thyroid and Adrenal Disorders

• Hyperthyroidism: Hypermetabolism. Graves Disease. Treatment: Radioactive Iodine, PTU ("Puts Thyroid Under" - monitor WBC), or Thyroidectomy.     * Total Thyroidectomy: Risk for hypocalcemia (tetany).     * Subtotal Thyroidectomy: Risk for Thyroid Storm ($Temp > 105$, $BP > 210/180$, tachycardia, delirium). Treatment: Ice packs and cooling blankets.
• Hypothyroidism: Hypometabolism. Myxedema. Treatment: Synthroid (levothyroxine). Never hold thyroid meds before surgery.
• Addison's Disease: Under-secretion of adrenal cortex. Pts can't adapt to stress; risk of shock. S/Sx: Hyperpigmentation. Treatment: Steroids ("Add-a-sone").
• Cushing's Syndrome: Over-secretion of adrenal cortex. S/Sx (S/E of Steroids): Moon face, hirsutism, truncal obesity, buffalo hump, wasting of limbs, sodium/water retention, hypokalemia, striae, high glucose (Accu-checks $q6h$), bruising, grouchy, immunosuppressed.

Lab Value Prioritization (ABCD Scheme)

• Level A: Low priority. (Creatinine, BUN, Bicarb).
• Level B: Monitor. (Hb $8$-$11$, Hct, Na, RBCs).
• Level C: High priority; do something. (INR $> 4$, K Low or High, Hb $< 8$, $CO2$ in $50s$, $PO2$ in $70s$, $O2$ Sat $< 93$, high WBC, Low Platelets $< 90,000$).
• Level D: Highest priority; stay at bedside. ($K > 6$, $pH$ in $6s$, $CO2$ in $60s$, $PO2$ in $60s$, Platelets $< 40,000$).
• Five Deadly Ds: $K > 6$, $pH$ in $6s$, $CO2 > 60$, $PO2 < 60$, Platelets $< 40,000$.

Psychopharmacology

• Phenothiazines: "-zines" for the Zany. Major tranquilizers. S/E: ABCDEFG (Anticholinergic, Blurred vision, Constipation, Drowsiness, EPS, Foto sensitivity, aGranulocytosis).
• Tricyclic Antidepressants (TCAs): Mood elevators (Elavil). S/E: ABCDE (Euphoria).
• Benzodiazepines: "-zep" (Valium). Minor tranquilizers. Used for pre-op, muscle relaxant, alcohol withdrawal. Do not take for more than $2$-$4$ weeks.
• MAOIs: (Marplan, Nardil, Parnate). Avoid Tyramine (Salad BAR: Bananas, Avocados, Raisins/Dried fruit). No liver, no aged cheese, no yogurt, no alcohol.
• Lithium: Treatment for Bipolar (Mania). S/E: $3$ Ps (Peeing, Pooping, Paresthesia). Toxicity: Metallic taste, tremors, severe diarrhea. Maintain normal Sodium.
• Prozac (SSRIs): Causes insomnia; give before noon.
• Haldol: NMS (Neuroleptic Malignant Syndrome) risk. Hyperpyrexia ($Temp > 105$). Differentiate from EPS by checking temperature.
• Clozaril: Atypical antipsychotic. Risk of severe agranulocytosis.

Maternity and Pediatrics

• Naegele's Rule: Last Menstrual Period + $7$ days - $3$ months.
• Weight Gain: Total $28 \pm 3$ lbs. $1$ lb/month in 1st trimester; $1$ lb/week thereafter. Quick check: Weeks gestation $minus 9$.
• Fundal Height: Palpable at $12$ weeks. At umbilicus by $20$-$22$ weeks.
• Signs of Pregnancy: Positive (ultrasound, fetal heart, skeletal x-ray). Maybe (Chadwick: Blue cervix; Goodell: Soft cervix; Hegar: Soft uterus).
• Labor Stages:     * Stage 1: Latent ($0$-$4$ cm), Active ($5$-$7$ cm, contractions $3$-$5$ min), Transition ($8$-$10$ cm).     * Stage 2: Delivery of baby.     * Stage 3: Delivery of placenta ($3$-vessel cord).     * Stage 4: Recovery ($4$ things $4$ times an hour: V/S, Fundus, Pads, Roll).
• Fetal Monitor: "LION" for Bad patterns (Low HR, Low Variability, Late Decelerations). Variable Decelerations = Prolapsed cord (Push/Position).
• Pediatric Development:     * $0$-$2$ yrs (Sensorimotor): Teach in the present.     * $3$-$6$ yrs (Pre-operational): Use play/fantasy; teach morning of.     * $7$-$11$ yrs (Concrete): Rule-oriented; teach ahead of time with demos.     * $12+$ yrs (Formal): Abstract thinking; teach like adults.

Prioritization and Delegation Rules

• Prioritization: 1. Acute beats Chronic. 2. Fresh Post-op ($< 12$ hrs) beats Medical. 3. Unstable beats Stable.
• Always Unstable: Hemorrhage, hypoglycemia, high fever ($> 105$), pulseless/breathless.
• Organ Priority: Brain, Lung, Heart, Liver, Kidney, Pancreas.
• Delegation LPN: Cannot: start IV, hang/mix meds, push meds, give blood, do central lines, do care plans, do first teaching, or take unstable pts.
• Delegation UAP: Cannot: meds (except OTC barrier creams), chart assessment, or do any ADL task FIRST.
• Staff Management: If Illegal (Tell Supervisor). If Immediate Danger (Confront/Takeover). If just Inappropriate (Talk later).

Heart Valve Auscultation and Guessing Strategies

• Aortic: $2nd$ ICS, Right sternal border.
• Pulmonic: $2nd$ ICS, Left sternal border.
• Tricuspid: $4th$ ICS, Left sternal border.
• Mitral (Apical): $5th$ ICS, Midclavicular line.
• Guessing: In Psych (pick "keep them talking"); In Med/Surg (First thing to assess: LOC; First thing to do: Airway); In Peds (Rule of "Normal, Older, Easier").