Comprehensive Exam Prep Notes: Psychiatric and Medical-Surgical Focus

National Patient Safety Goals and Psychiatric Content Overview

• Emphasis on quality and safety, with focus on the national patient safety goals (NPSGs) and caring for the complex patient.
• Recommend reviewing two short flippity PowerPoints on NPSGs; material is testable and largely memorization-based around what is discussed in the National Patient Safety Goals.
• Prior exam emphasis topics mentioned: critical results, suicide, and related safety concerns.
• Instructor will post related psych content and announcements in Brightspace (for example, involuntary commitment, de-escalation, APD vs BPD, consistency of care, schizophrenia symptoms, tardive dyskinesia, lithium toxicity, extrapyramidal symptoms, neuroleptic malignant syndrome, agranulocytosis, and other major side effects of antipsychotics).
• Focus on pharmacology tables, especially bolded medications; aim to understand big ideas rather than memorizing everything.
• Real-world relevance: safety, crisis intervention, and crisis prevention are core to clinical practice and accreditation.

Psychiatric Content to Review and Concepts Mentioned

• Involuntary commitment and de-escalation as key topics; understand differences between APD (antipsychotic drugs) and BPD (borderline personality disorder).
• Schizophrenia: negative and positive symptoms; management and maintenance of consistency of care for complex patients.
• Side effects and toxicities to know well:
  • Tardive dyskinesia
  • Lithium toxicity
  • Extrapyramidal symptoms (EPS)
  • Neuroleptic malignant syndrome (NMS)
  • Agranulocytosis and risk with antipsychotics
  • Serotonin syndrome (as a potential adverse effect with some psych meds)
• Additional pharmacology highlights:
  • Important adverse effects of antipsychotics and medications for anxiety disorders and bipolar disorder; focus on major, high-impact side effects.
• Quick connections to emergencies and safety:
  • Suicide risk assessment and interventions are a core safety topic on every safety goal list.
  • Crisis care and de-escalation strategies to prevent escalation and maintain safety.
• Resources for treatment and discharge planning for:
  • APD (antipsychotic drugs) and BPD (borderline personality disorder)
  • Schizophrenia, suicide risk, and bipolar mood disorders
• DIG content: DIG toxicity and DIG levels were mentioned as not needed for the current session; DIG toxicity is not testable in this module.
• Practical note: If you have questions, contact Professor Rodriguez; the instructor will post the relevant lists in Brightspace.

Therapeutic Communication: Open-Ended Questions and Active Listening

• Core test-taking principle: the correct answer in therapeutic communication often appears to be the simplest or most conservative option.
• Use open-ended questions (avoid yes/no questions) to elicit more information and promote engagement.
• Active listening and verification are essential:
  • Do not validate hallucinations with parallel experiences unless true; instead validate the patient’s experience by restating what they said and asking for clarification.
  • Example of a therapeutic response:
  • Patient says, "I'm seeing spiders on the walls." Therapist: "What you're telling me is that you're seeing spiders crawling on the walls. Tell me how that is making you feel or how we can help you stay safe."
• Affirmation and validation without endorsing false beliefs; avoid saying you see them too unless it is accurate.
• De-escalation and environment management: assess whether removing the patient from the environment would help.
• Emphasis on safety and calming the patient through listening, empathy, and validation, not through giving false assurances.
• Suicide content emphasizes asking about experiences related to suicidality (ideation, plan, means) and safety planning.

Suicide Risk Assessment and Intervention

• Suicide is consistently a national patient safety goal; high priority across all patient populations, not just psychiatric units.
• Key assessment questions:
  • Do you have a plan or means to harm yourself?
  • Do you have access to means (guns, medications, etc.)?
• Safety planning and continuous observation:
  • Some patients require one-to-one observation or a sitter; regular checks may be needed but not always on a strict clock—assess risk and adjust accordingly.
• Interventions focus on ensuring safety, not guaranteeing everything will be all right; use reassuring statements that convey presence and support without giving false hope.
• Nursing and clinical responsibilities include documenting risk, ensuring safety protocols, and coordinating with mental health professionals.

Pharmacology: Antipsychotics, Mood Stabilizers, and Major Adverse Effects

• Major adverse effects to know:
  • Extrapyramidal symptoms (EPS)
  • Tardive dyskinesia
  • Agranulocytosis
  • Neuroleptic malignant syndrome (NMS)
  • Serotonin syndrome (when combining serotonergic medications)
  • Lithium toxicity
• Critical safety questions on psych meds:
  • Which meds cause EPS and how to manage them?
  • Which meds have the highest risk of tardive dyskinesia?
  • What are the signs and management strategies for NMS?
  • What are the signs of lithium toxicity and how to respond?
  • What is the risk of agranulocytosis with antipsychotics and how to monitor?
• Therapeutic strategy: when adverse effects threaten adherence, treat EPS or other side effects with additional medications while maintaining the primary psychotropic therapy when possible.
• Acute management notes:
  • For EPS, there are medications to help control symptoms (e.g., anticholinergic agents) while continuing antipsychotics as clinically appropriate.
  • For NMS and serotonin syndrome, rapid identification and withdrawal of triggering agents; initiate supportive care and medical treatment per protocol.

Involuntary Commitment, De-Escalation, and Consistency of Care

• Involuntary commitment processes and de-escalation strategies are important components of safety and care planning.
• Focus on consistency of care for patients with chronic psychiatric illness to prevent crises and ensure reliable treatment planning.

Schizophrenia and Related Symptomatology

• Positive symptoms (e.g., hallucinations, delusions) and negative symptoms (e.g., flat affect, apathy) are central features to monitor.
• Medication management aims to reduce positive symptoms while minimizing adverse effects; adherence can be challenged by side effects such as EPS and metabolic concerns.
• Therapeutic goals include safety, symptom control, and functional recovery; ongoing assessment of mood, cognition, and behavior.

Respiratory and Airway Management: Acute Care Focus

• Airway and ventilation basics emphasized; test focus is not on ventilator modes but on key concepts:
  • PEEP: know what PEEP is and its benefits (e.g., alveolar recruitment, improved oxygenation).
  • Tracheostomy care and emergencies:
  • Obturator helps with tracheostomy tube insertion.
  • In an emergency, bag the patient and call for help; do not leave the patient.
  • Endotracheal tube depth (lip level): rest approximately 2–4 cm above the carina.
  • Post-intubation assessment: if breath sounds are only on the right, suspect right mainstem intubation; if only left, consider tension pneumothorax or left-sided issue.
  • Hypoxia signs: early signs include tachycardia, tachypnea, agitation, anxiety; cyanosis is a late sign.
  • If the patient is deteriorating, prioritize sitting them up to improve ventilation when appropriate.
• ARDS vs acute respiratory failure:
  • ARDS features refractory hypoxemia (PaO2 not responsive to oxygen therapy) with PaO2 < 60 mmHg on FiO2, and characteristic chest imaging (ground-glass opacity / white-out).
  • Normal PaO2: 80–100 mmHg; PaO2 goal in ARDS often > 60 mmHg or SaO2 > 92% depending on context.
  • PaCO2 and acid-base: PaCO2 > 45 mmHg is hypercapnia; higher CO2 often correlates with acidosis (pH down if CO2 high) — remember the relationship: high PaCO2 tends to lower pH (respiratory acidosis).
• Oxygenation targets:
  • For ARDS: target SaO2 > 92–90%; for many ventilated patients, aim for > 92% as part of optimal gas exchange management.
• Proning:
  • Proning improves oxygenation by redistributing pulmonary perfusion and improving ventilation; typical duration can be up to 18 hours per session, with periods of proning tailored to the patient.
  • Benefits include improved PaO2, reduced shunting, enhanced secretion mobilization, and reduced atelectasis.
• VAP bundle and stress ulcer prophylaxis:
  • Know components of the ventilator-associated pneumonia (VAP) prevention bundle; stress ulcer prophylaxis is a commonly included element.
• Post-intubation nursing priorities:
  • Ensure airway patency, suction as needed (PRN), listen to breath sounds, monitor for tube dislodgement, watch lip line for migration, and check for signs of pneumothorax via auscultation and imaging.

Tracheostomy and Ventilator Emergencies: Key Procedures

• Tracheostomy obturator usage for insertion; decannulation and troubleshooting require understanding the obturator's function.
• In emergencies:
  • Bag-valve-mask ventilation with oxygen and proper ventilation technique.
  • Use a humidified oxygen source and monitor vitals continuously.
• Airway assessment priorities:
  • Lip level depth (ET tube position) and chest rise symmetry; ensure both lungs are being ventilated.

Nutrition, Metabolism, and Refeeding Considerations

• BMI and nutritional risk:
  • BMI < 18 suggests underweight/nutrition risk; test values are often gross (not hyper-specific), so focus on recognizing undernutrition.
• Protein-energy malnutrition and refeeding:
  • Refeed slowly to prevent refeeding syndrome: risk of hypokalemia and hypophosphatemia with potential seizures and altered LOC.
  • Signs to monitor: electrolyte disturbances; monitor labs and adjust plan with the physician and nutrition team.
• Total Parenteral Nutrition (TPN): key operational points
  • TPN is hypertonic; glucose content can be up to ~$70\%$; peripheral TPN allows $glucose \le 20\%$; central TPN uses glucose > $20\%$.
  • Peripheral TPN must be delivered via a pump, brought to room temperature, and require two RNs to verify orders.
  • If lipids are present (lipid emulsions), watch for separation and signs of intolerance (lipid emulsions may appear as white, yellow streaks or oiling out).
  • TPN infusion with central line is dedicated to TPN and cannot be used for other meds or blood draws.
  • D5 may be hung peripherally if no new TPN bag is available; if central TPN is used, D10 is typically the appropriate starting solution.
  • Labs drawn daily to guide TPN formulation include renal panel and basic metabolic panel; nutrition-related indicators include albumin and prealbumin (prealbumin more sensitive for acute changes).
  • Glucose monitoring: check blood glucose every 4–6 hours due to high glucose content.
  • Infection risk: malnutrition is linked to impaired immune function; strict infection prevention is essential.
• Lipids and allergies: lipid components are often derived from eggs and soy; check for allergies; if uncertainty exists, rely on available options and clinical judgment.
• Labs and monitoring specifics:
  • BUN tends to be low with protein malnutrition, reflecting reduced protein metabolism.
  • Regular lipid monitoring and insulin management may be required for hyperglycemia.
• Practical approach to TPN management:
  • Do not accelerate or decelerate TPN rapidly; adjust only with physician and nutrition team input.
  • Always check for a dedicated line; do not use for other purposes (blood draws, medication administration).

Central Venous Catheter (CVC) Care and Safety

• Key safety and infection prevention measures:
  • Hand hygiene is critical to prevent catheter-related bloodstream infections.
  • The CVC line is a dedicated line and cannot be used for other purposes.
• Line placement verification and initial checks:
  • After placement, obtain an x-ray to confirm position; immediately assess breath sounds to detect pneumothorax during insertion.
  • Insertion steps involve asking the patient to bear down (Valsalva maneuver) or coughing to reduce air embolism risk.
• Immediate post-placement assessments:
  • If the patient’s lip line changes or hemodynamics worsen, reassess catheter position and potential complications.

Intranet and Test Strategy: DIG, IV Push, and Pharmacology Focus

• DIG content: Not required for this exam segment; it may be addressed later in DIG discussions (no need to memorize DIG levels for this test).
• IV push competency reminder:
  • Testing will include recognizing urgent issues that require immediate nursing action.
  • Incompatibilities and rapid identification of adverse reactions are critical components.
• Practical exam tips:
  • Expect questions that require prioritizing safety and timely interventions when acute changes occur (e.g., respiratory distress, suicidality, sepsis risk, electrolyte disturbances).

Quick Reference: Key Numerical and Conceptual Thresholds (LaTeX-formatted)

• Oxygenation and PaO2 targets:
  • Hypoxemia threshold:
    PaO_2 < 60\ \text{mmHg}
  • Target oxygen saturation (SaO2):
    $SaO_2 \ge 92\%$
  • Normal PaO2 range:
    $80 \le PaO_2 \le 100\ \text{mmHg}$
• Hypercapnia and acid-base:
  • Hypercapnia threshold:
    PaCO_2 > 45\ \text{mmHg}
  • Relationship to pH (respiratory acidosis):
    $pH \downarrow \quad \text{when} \quad PaCO_2 \uparrow$
• ARDS and oxygenation goals:
  • Target oxygenation:
    SaO_2 > 92\% (general) or > 90% as per protocol in ARDS management
  • PaO2 threshold for ARDS emphasis:
    PaO_2 < 60\ \text{mmHg} despite adequate FiO2
• Nutrition and TPN thresholds:
  • Peripheral TPN glucose content:
    $\text{glucose content} \le 20\%$
  • Central TPN glucose content:
    \text{glucose content} > 20\%
  • Lipids in TPN should show no sign of separation; if present, observe emulsification status (lipid lines/colors may appear as yellow streaks)
  • D5 vs D10 rules for peripheral central conversions:
    $\text{Peripheral: } D5 \text{ (or D10 if appropriate) with safe rate}$
    $\text{Central: } D10 \text{ or higher as ordered}$
• Malnutrition and lab indicators:
  • BUN with protein malnutrition:
    $\text{BUN} \downarrow$
  • Albumin vs prealbumin:
    $\text{Albumin (general nutrition marker)}$
    $\text{Prealbumin (more sensitive for acute status)}$
• Tracheostomy and airway:
  • Lip level depth for ET tube: approximately
    $2\text{--}4\ \text{cm above the carina}$
  • Right mainstem intubation signs: breath sounds only on the right
  • Pneumothorax signs: decreased or absent breath sounds on the affected side
• ARDS features and care:
  • Refractory hypoxemia definition: hypoxemia that persists despite appropriate oxygenation
  • ARDS hallmark imaging: ground-glass/white-out appearance on chest imaging
• Suicidality safety actions:
  • Assess plan and means; implement one-to-one observation if needed; ensure firearm safety and secure medications

Practical Takeaways and Exam Mindset

• Focus on big-picture safety concepts: suicide prevention, crisis de-escalation, and preventing adverse events.
• For therapeutic communication questions, remember: open-ended questions + active listening + validation without false reassurance.
• Be prepared to identify high-risk pharmacology adverse effects (EPS, NMS, agranulocytosis, serotonin syndrome) and appropriate responses.
• For respiratory content, prioritize recognizing airway emergencies, understanding PEEP benefits, and applying ARDS principles (refractory hypoxemia, proning, VAP bundle).
• For nutrition, understand peripheral vs central TPN, critical lab indicators (albumin, prealbumin, BUN), and refeeding syndrome risks; know glucose monitoring and line safety.
• In vascular access, maintain strict hand hygiene, verify line placement with imaging, and keep TPN lines dedicated to TPN.
• If any questions arise, reach out to Professor Rodriguez and review Brightspace announcements and associated psych content to ensure readiness.