Mark Klimek Lectures 2023

LECTURE 1

ACID BASES

• learn how to convert lab values to words

• the rule of the B’s

= if the pH and the BiCarb are both in the same

 direction -> metabolic

 Hint: draw arrows beside each to see directions

 * down = acidosis

 * up = alkalosis

- respiratory -> has no b in it; if in other directions

 (or if bicarb is normal value)

- KNOW NORMAL pH, BiCarb, CO2

• Hint: DON’T MEMORIZE LISTS…know principles

(they test knowledge of principles by having you

generate lists..) - for “select all” questions

- ex. in general/principle what do opioids/pain

 meds do? = sedate you, CNS depressors

 * ex. what does dilaudid do? don’t memorize specifics

 or a list of dilaudid, know principles of opioids (such

 as sedation, CNS depression -> lethargy, flaccidity,

 reflex +1, hypo-reflexia, obtunded)

- boards don’t test by lists because all books/

 classes have different lists

• principles of S&S acid bases: as the pH goes so

goes my patient (except K+)

- pH up = PT up -> body system gets more

 irritable, hyper-excitable (EXCEPT K+)

 -> alkalosis - think of a body system and go

 high: hyper-reflexive (+3, +4 [2 is normal]),

 tachypnea, tachycardia, borborygmi, seizure

- pH down = PT down -> body systems shut

 down (EXCEPT K+)

 -> acidosis - think of a system and go low:

 hypo-reflexive (+1, 0), bradycardia, lethargy,

 obtunded, paralytic illeus, respiratory arrest

• ex. which acid-base disorders need an ambu-bag at

the bedside? = acidosis (resp. arrest)

• ex. which acid-base disorders need suction at the

bedside? = alkalosis (seize and aspirate)

• Mac Kussmaul - Kussmaul’s (compensatory

respiratory mechanism) is only present in only 1 of

the 4 metabolic (acid-base) disorders

* M = metabolic AC = acidosis

• most common mistake with select all questions = selecting

one more than you should (stop when you select the ones

you know! don’t get caught up on the “could be’s”)

• Hint: don’t select none or all on select all that apply

questions (never only one and never all)

• Causes of Acid-Base Imbalance:

- scenarios and what acid-base disorder would

 result (what would cause an imbalance)

 ** DON’T MIX UP S&S and CAUSATION

- often what causes something is the opposite of the S&S

- ex. diarrhea will cause a metabolic acidosis but once

 you are acidotic your bowel shuts down and you get a

 paralytic illeus

• when you get scenarios:

 -> if it’s a lung scenario = respiratory

 - then check if the client is over-ventilating

 (alkalosis) or under-ventilating (acidosis)

 - remember to look at the words (ex. over, under,

 ventilating) -> “as the pH goes so goes my PT”

 -> VENTILATING DOESN’T MEAN RESPIRATORY

 RATE; resp. rate is irrelevant w/ acid-base,

 ventilation has to do with gas exchange not resp.

 rate (look at the SaO2 -> if your resp. rate is fast

 but SaO2 is low you are under-ventilating)

 -> ex. PCA pump - What acid-base disorder

 indicates they need to come off of it? = respiratory

 acidosis (resp. depression -> resp. arrest)

—> if it’s not lung, it’s metabolic

• metabolic alkalosis - really only one scenario = if

the PT has prolonged gastric vomiting/suctioning

- because you are losing ACID

 * ex. GI surgery w/ NG tube with suctioning for

 3 days; hyperemesis graviderum

- otherwise everything else that isn’t lung you

 pick metabolic acidosis (DEFAULT)

 * ex. hyperemesis graviderum w/ dehydration

 acute renal failure, infantile diarrhea

• remember, you only have 4 to pick from:

- respiratory alkalosis - respiratory acidosis

- metabolic alkalosis - metabolic acidosis

• pay more attention to the modifying phrases than

the original noun

- ex. person w/ OCD who is now psychotic (psychotic

 trumps OCD); hyperemesis with dehydration (pay

 attention to dehydration)

VENTILATION

• ventilators -> know alarm systems (you set it up so

that the machine doesn’t use less than or more than

specific amounts of pressure)

 a) high pressure alarm = increased resistance

 to airflow (the machine has to push too hard to

 get air into lungs)

 - from obstructions:

 i. kinks in tubing (unkink it)

 ii. water condensation in tube (empty it!)

 iii. mucous secretions in the airway (change

 positions/turn, C&DB, and THEN suction)

*** suction is only PRN!!!

 -> priority questions = you would check

 kinks first, suction is not first

 b) low pressure alarm = decreased resistance

 to airflow (the machine had to work too little

 to push air into lungs)

 - from disconnections:

 i. main tubing (reconnect it duh!)

 ii. O2 sensor tubing (which senses FiO2 at

 the airway/trach area; black coated wire

 coming from machine right along the

 tubing - reconnect!)

• ventilators -> know blood gases

- resp. alkalosis = ventilation settings might be

 set too high (OVER-VENTILATING)

- resp. acidosis = ventilation settings might be set

 too low (UNDER-VENTILATING)

• ex. weaning a PT off ventilator -> should not be

under-ventilated, they need the ventilator; if they are

over-ventilating then they can be weaned

• never pick an answer where you don’t do something

and someone else has to do something

I 11 .

Iftube disconnects From pt

→

wrap with 3 Sided occublue

tape Lor petroleum dressing)

LECTURE 2

ABUSE (Psych and Med-Surge)

Psychological Aspect/Psycho-Dynamics

• # 1 psychological problem is the same in any/all

abusive situations = DENIAL

- abusers have an infinite capacity for denial so that

 they can continue the behavior w/o answering for it

• can use the alcoholism rules for any abuse

- ex. # 1 psych problem in child abuse, gambling or

 cocaine abuse is denial

• why is denial the problem? HOW CAN YOU TREAT

SOMEONE WHO DENIES/DOESN’T RECOGNIZE

THEY HAVE A PROBLEM

• denial = refusal to accept the reality of a problem

• treat denial by CONFRONTING the problem (it’s not

the same as aggression which attacks the person, not

the problem) = they DENY you CONFRONT

- pointing out to the person the difference between

 what they say and what they do

- Hint: never pick answers that attack the person

 -> ex. bad answers have bad pronouns - “you”

 -> ex. good answers have good pronouns - “I”, “we”

 -> ex. “you wrote the order wrong” vs. “I’m having

 difficulty interpreting what you want”

• loss and grief -> for this denial you must SUPPORT it

- DABDA = denial, anger, bargaining, depression, acceptance

• Hint: for questions about denial, you must look to see

if it is LOSS or ABUSE

- loss/grief = support

- abuse = confront

• #2 psychological problem in abuse = DEPENDENCY,

CO-DEPENDENCY

- dependency = when the abuser gets significant other

 to do things for them or make decisions for them

 -> the dependent = abuser

- co-dependency = when the significant other derives

 positive self-esteem from making decisions for or

 doing things for the abuser

 -> the abuser gets a life w/o responsibilities

 -> the sig. other gets positive self-esteem (which is

 why they can’t get out of the relationship)

• how do you treat it?

- set limits and enforce them

 -> start teaching sig. other to say NO (and they

 have to keep doing it)

- must also work on the self-esteem of the co-dependent

 (ex. I’m a good person because I’m saying “no”)

• manipulation = when the abuser gets the sig. other

to do things for them that are not in the best interest of

the sig. other

- the nature of the act is dangerous/harmful

- how is manipulation like dependency?

 -> in both the abuser is getting the other person to

 do something for them

- how do you tell the difference between manipulation

 & dependency?

 -> NEUTRAL vs. NEGATIVE (look at what they’re

 being asked to do)

 -> if the sig. other is being asked to do something

 neutral (no harm) its dependency/co-dependency

 -> if the sig. other is being asked to do something

 that will harm them or is dangerous to them they

 are manipulated

• how do you treat manipulation?

- set limits and enforce them -> “NO”

- easier to treat than dependency/co-dependency

 because no one likes to be manipulated (no positive

 self-esteem issue going on)

• ex. how many PT’s do you have w/ denial? = 1

ex. how many PT’s do you have w/ dependency/co-

 dependency = 2

ex. how many PT’s do you have w/ manipulation = 1

Alcoholism

Wernicke’s & Korsakoff’s

- typically separate BUT boards lumps them together

- wernicke’s = encephalopathy

- korsakoff’s = psychosis (lose touch with reality)

 -> tend to go together, find them in the same PT

• Wernicke Korsakoff’s syndrome:

a) psychosis induced by Vit. B1 (Thiamine) deficiency

 - lose touch w/ reality, go insane because of no B1

b) primary symptom -> amnesia w/ confabulation

 - significant memory loss w/ making up stories

 - they believe their stories

• How do you deal w/ these PT’s?

- bad way = confrontation (because they believe what

 they are saying and can’t see reality)

- good way = redirection (take what the PT can’t do

 and channel it into something they can do)

• Characteristics of Wenicke Korsakoff’s:

a) it’s preventable = take Vit. B1 (co-enzyme needed

 for the metabolism of alcohol which keeps alcohol

 from accumulating and destroying brain cells)

 * PT doesn’t have to stop drinking

b) it’s arrestable = can stop it from getting worse by

 taking Vit. B1

 * also not necessary to stop drinking

c) it’s irreversible (70% of cases) -> Hint: On boards,

 answer w/ the majority (ex. if something is majority

 of the time fatal, you say it’s fatal even if 5% of the

 time it’s not)

• Drugs for Alcoholism:

DISULFIRAM (Antabuse)

= aversion therapy -> want PT’s to develop a gut

 hatred for alcohol

 -> interacts w/ alcohol in the blood to make you very ill

 -> works in theory better than in reality

 -> onset & duration: 2 weeks (so if you want to

 drink again, wait 2 weeks)

or reunbum?

- PT teaching = avoid ALL forms of alcohol to avoid

 nausea, vomiting & possibly death

 -> including mouthwash, aftershaves/colognes/perfumes

 (topical stuff will make them nauseous), insect

 repellants, any OTC that ends with “-elixer”, alcohol-

 based hand sanitizers, uncooked (no-bake) icings

 which have vanilla extract, red wine vinaigrette

• Overdoses & Withdrawals:

- every abused drug is either an UPPER or DOWNER

 -> the other drugs don’t do anything

 -> #1 abused class of drug that is not an upper or

 downer = laxatives in the elderly

a) first establish if the drug is an upper or downer

 - uppers (5) = caffeine, cocaine, PCP/LSD (psychedelic

 hallucinogens), methamphetamines, adderol (ADD drug)

 * S&S -> make you go up; euphoria, tachycardia,

 restlessness, irritability, diarrhea, borborygmi,

 hyper-reflexia, spastic, seize (need suction)

 - downers = don’t memorize names -> anything that

 is not an upper is a downer! if you don’t know what

 the med is, you have a high chance that it’s a

 downer if it’s not part of the uppers list

 * S&S -> make you go down; lethargy, respiratory

 depression (& arrest)

 - ex. The PT is high on cocaine. What is critical to assess?

 -> NOT resps below 12 because they will be high

 -> maybe check reflexes

b) are they talking about overdose or withdrawal

 - overdose/intoxication = too much

 - withdrawal = not enough

 - ex. the PT has overdosed on an upper -> pick the

 S&S of too much upper

 - ex. the PT has overdosed on a downer -> pick the

 S&S of too much downer

 - ex. the PT is withdrawing from an upper -> not

 enough upper makes everything go down

 - ex. the PT is withdrawing from a downer -> not

 enough downer makes everything go up

• upper overdose looks like = downer withdrawal

• downer overdose looks like = upper withdrawal

• In what 2 situations would resp. depression & arrest

be your highest priority:

 - downer overdose

 - upper withdrawal

• In what 2 situations would seizure be the biggest risk:

 - upper overdose

 - downer withdrawal

• Drug Abuse in the Newborn:

- always assume intoxication, NOT withdrawal at birth

- after 24 hrs -> withdrawal

- ex. caring for infant of a Quaalude addicted mom 24

 hrs. after birth, select all that apply:

 -> downer withdrawal so everything is up = exaggerated

 startle, seizing, high pitched/shrill cry

• Alcohol Withdrawal Syndrome vs. Delirium Tremens

- they are both different! not the same

a) every alcoholic goes through withdrawal 24 hrs.

 after they stop drinking

 - only a minority get delirium tremens

 - timeframe -> 72 hrs. (alcohol withdrawal comes 1st)

 - alcohol withdrawal syndrome ALWAYS precedes

 delirium tremens, BUT delirium tremens does not

 always follow alcohol withdrawal syndrome

b) AWS is not life-threatening; DT’s can kill you

c) PT’s w/ AWS are not a danger to self/others; PT’s

 w/ DT’s are dangerous to self/others

 - they are withdrawing from a downer so they will

 be exhibiting upper S&S

 - DT’s are dangerous

• RN’s can accept but RPN’s can’t (because PT is unstable)

- on med-surge, the RN who takes them must decrease

 their workload (i.e. reduce PT load if they take a DT PT)

 -> Hint: on boards, the setting is always perfect

 (i.e. enough staff/time/resources on the unit etc.)

Differences

in Care

AWS DT

Diet Regular diet NPO/clear liquids

(because of risk for seizures which

can cause risk of aspiration)

Room Semi-private

anywhere on

the unit

Private near nurses station

(dangerous & unstable)

Ambulation Up ad lib Restricted bed rest -> no bathroom

privileges (use bedpans/urinals)

Restraints No restraints

(because not

dangerous)

Restraints (because dangerous)

- not soft wrist or 4 point soft

 because they’ll get out

- need to be in vest or 2-pt. locked

 leathers (opposite 1 arm & leg,

 rotate Q2hrs, lock the free

 limbs 1st before releasing the

 locked ones)

They both get ANTI-HYPERTENSIVES &

TRANQUILIZERS

- because everything is up (downer withdrawal)

They both get MULTIVITAMIN w/ B1

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DRUGS

AMINOGLYCOCIDES

• powerful class of antibiotics (when nothing else

works pull these outs, the big guns)

- don’t use unless anything else works

• boards love to test these drugs because they’re

dangerous and are a test of safety

• think: A MEAN OLD MYCIN

-> a mean old = they treat serious, life-threatening,

 resistant, Gram-neg bacteria infections (i.e. a mean

 old antibiotic for a mean old infection)

-> mycin = what they end with (all end w/ -mycin)

** not all -mycin’s are aminoglycosides BUT most

 are (the 3 that are not are erythromycin,

 azithromycin, clarithromycin = throw it off the list!)

• 2 toxic effects:

i) when you see ‘-mycin’, think mice

 - mice -> ears -> otto toxic

 - monitor hearing, tinnitus, vertigo/dizziness

ii) the human ear is shaped like a kidney so next

 effect is nephrotoxicity

 - monitor creatinine (not BUN, output, daily weight)

 * creatinine = the best indicator of kidney/renal

 function (pick 24 hr. creatinine clearance over

 serum creatinine if both available)

• #8 (fits nicely in the kidney) reminds you about 2

things about these drugs

- toxic to cranial nerve 8 = ear nerve

- administer Q8

• route:

- IM or IV

• do not give PO -> they are not absorbed

- if you give an oral ‘-mycin’ it will go into gut, dissolve,

 go through and come out as expensive stool (won’t

 have any systemic effect)

- EXCEPT in 2 cases = bowel sterilizers:

 * hepatic encephalopathy (hepatic coma) = to get

 ammonia down, oral ‘-mycin’s’ will sterilize the

 bowel by killing Gram-neg bacteria (E. coli) to help

 bring down ammonia and won’t harm the

 damaged liver because it doesn’t go through the

 liver (also gives diarrhea, more poop out is good)

 * pre-op bowel surgery = it sterilizes the gut by

 killing the E. coli bacteria

- if oral, no otto or nephro toxicity because not absorbed

- these are neomycin & kanamycin

 * Who can sterilize my bowels? NEO KAN

• Trough and Peak levels:

- trough = drug at lowest

- peak = drug at highest

** TAP levels - trough administer peak

 -> draw trough levels first

 -> administer your drug

 -> draw peak levels after drug administration

• Why draw levels? = narrow therapeutic window

- small difference between what works and what kills

- if the drug has a wide range then you wouldn’t

 need to draw TAP levels

 * ex. Lasix doses range from 5-80mg thus a wide

 range so you won’t need TAP levels

 * ex. Dig doses range from 0.125 - 0.25 so this

 narrow range needs TAPS levels

• A MEAN OLD MYCINS = major class that needs

TAPs drawn because of narrow window

• When do you draw TAPS?

-> depends on the route (don’t focus on the med)

a) Trough Levels

** doesn’t matter which route or med, always 30 mins.

- sublingual = 30 mins. before next dose

- IV = 30 mins. before next dose

- IM = 30 mins. before next dose

- Sub-Q = 30 mins. before next dose

- PO = 30 mins. before next dose

b) Peak Levels

** different but depends on the route (not the med)

- Sublingual = 5-10 mins after drug is dissolved

- IV = 15-30 mins after drugs is finished infusing

 * Hint: if you get two values that are correct (i.e. a

 15 min. answer and a 30 min. one) pick the highest

 without going over so 30 mins.

- IM = 30-60 mins. after administration

- Sub-Q = SEE (see diabetes lecture -> because the

 only Sub-Q peaks are Insulins)

- PO = forget about it, too variable so not tested

The BIG 10 Drugs to Know:

1. psych drugs

2. insulins

3. anti-coagulants

4. digitalis

5. aminoglycosides

6. steroids

7. calcium-channel blockers

8. beta-blockers

9. pain meds

10. OB drugs

LECTURE 3

Cardiac DRUGS

CALCIUM-CHANNEL BLOCKERS

Calcium-Channel Blockers are like Valium for your heart

• Valium -> calm’s you down; so CCB’s calm your heart

down (ex. if tachycardic, give CCB’s but not in shock)

- to REST YOUR HEART

- not stimulants

• calcium-channel blockers are negative inotropic,

chronotropic, & dromotropic drugs

- fancy way of saying that they calm the heart down

• When do you want to “depress” the heart? What do

CCB’s treat?

A: anti-hypertensives

 - relax heart & blood vessels to bring down BP

AA: anti-angina’s

 - relax heart to use less O2 to make angina go away

 - treats angina by addressing oxygen demand

AAA: anti-atrial arrhythmia

 - ex. atrial flutter, A-fib, premature atrial contractions

 - never ventricular

*** what about supra-ventricular tachycardia??

 -> because it means ‘above the ventricles’ (which

 are the atria)

• Side-Effects:

H & H = headache & hypotension

 -> hypoTN - from relaxed heart & vessels

 -> headache - vasodilation to brain

 ** Hint: headache is a good thing to select for

 ‘select all that apply’ questions (ex. low Na & high

 Na = headache, high & low glucose = headache, high &

 low BP = headache)

• Names of Calcium-Channel Blockers:

- anything ending in ‘-dipine’

- ex. amlodipine, nifedipine

- NOT just ‘-pine’

- also includes: VERAPAMIL & CARDIZEM

- which can be given as continuous IV drip??

 = Cardizem

• What VS needs to be assessed before giving a CCB?

- BP = because of risk of hypoTN

 -> parameters/guidelines - hold CCB if systolic is

 under 100

 -> so you need to monitor BP if PT is on a Cardizem

 continuous drip (if it’s under 100 then you may

 have to stop or change the drip rate)

CARDIAC-ARRYTHMIAS

• Interpreting Rhythm Strips (4 that need to be known

by sight):

a) Normal Sinus Rhythm

 = P wave before every QRS & followed by a T

 wave for every single complex

 -> all P wave peaks are equally distant from each

 other, QRS evenly spaced

b) V-Fib = chaotic squiggly line, no pattern

c) V-Tach = sharp peaks, has a pattern

d) A-Systole = flat-line

• Terminology:

- if QRS depolarization, it’s talking about ventricular

 (so rule out anything atrial)

- if it says P-wave then it’s talking about atrial

• 6 Rhythms most tested on N-CLEX:

1. “a lack of QRS’s” = A-systole

 - flat-line, no QRS

2. “P-wave” = Atrial

 - if it’s a sawtooth wave, always pick atrial flutter

3. “chaotic” - A-fib if w/ P-wave

4. “chaotic” - V-fib if w/ QRS

 - Hint: the word ‘chaos’ is used for fibrillation

5. “bizarre” = atrial tachycardia if w/ P-wave

6. “bizarre” = ventricular tachycardia if w/ QRS

 - Hint: the work ‘bizarre’ is used for tachycardias

• PVC’s (premature ventricular contractions)

= a.k.a. periodic wide bizarre QRS

- ventricular because QRS

- bizarre -> tachycardia

- you can call a group of PVC’s a short run of V-tach

- do Physician’s care about PT’s having PVC’s?

 -> NO, not a high priority = low priority

 -> 3 circumstances when you could elevate these

 PT’s to moderate priority (never reach high)

 i. if there are more than 6 PVC’s in a minute

 ii. if there are more than 6 PVC’s in a row

 iii. if the PVC fall on the T-wave of the previous

 beat (R on T phenomenon)

 -> most common order if you call the MD about a

 PT w/ PVC’s = D/C monitor (because then you

 can’t see the PVC’s and then you won’t call them)

• Lethal Arrhythmia’s:

- HIGH PRIORITY, 2 main ones (will kill you in 8 mins

 or less) -> these PT’s will probably be top priorities

a) A-Systole

b) V-Fib

** both have in common = no cardiac output

 -> no brain perfusion (and you’ll be dead in 8 mins)

• V-tach = potentially life-threatening (but not actually

life-threatening), but still makes it a fairly high priority

 - difference is that these PT’s have cardiac output

• in codes, even if the rhythm changes, if there is no

cardiac output it’s just as bad as the previous rhythm

POSITIVE NEGATIVE

Inotropes Cardiac Stimulants

- stimulate, speed

 up the heart

Cardiac Depressants

- calm the heart down, Chronotropes weaken & slow down

Dromotopes

• Treatment (more drugs):

a) PVC’s b) V-tach

= for ventricular use LIDOCAINE/AMIODARONE

 * in rural areas more Lidocaine use (cheaper &

 longer shelf-life)

c) Supra-Ventricular Arrhythmia’s

= atrial arrhythmia’s use ABCD’s

 • A -> ADENOCARD (Adenosine)

 - have to push in less than 8 seconds (FAST IV

 push) -> slam this drug, followed by a flush; use a

 big vein; BUT the problem w/ slamming it fast is

 the risk of PT going into A-Systole (for 30 seconds

 but they will come out of it so don’t worry [unless

 longer than 30 sec…])

** for IV pushes: when you don’t know you go slow

 • B -> BETA-BLOCKERS

 - all end in ‘-lol’

 - every ‘-lol’ is a BB & every BB is a ‘-lol’

 - are negative inotropes, chronotropes, &

 dromotropes like calcium-channel blockers (a.k.a.

 valium for your heart so they treat A, AA, AAA &

 have same side-effects)

 ** generally speaking, don’t make a big difference

 between Beta- & Calcium channel blockers;

 except that CCB are better for PT’s w/ asthma

 or COPD -> Beta-B’s bronchoconstrict

 • C -> CALCIUM-CHANNEL BLOCKERS

 - see Beta-Blockers & CCB’s earlier

 • D -> DIGITALIS (DIGOXIN, LANOXIN)

d) V-Fib

= for V-fib you D-fib (shock them!)

e) A-Systole

= use EPINEPHRINE & ATROPINE (in this order!)

 -> if epinephrine doesn’t work then use atropine

CHEST TUBES

• purpose is to re-establish negative pressure in the

pleural space (so that the lung expands when the

chest wall moves)

- pleural space -> negative is good (negative pressure

 makes things stick together)

- ex. gun shot to the lung add positive pressure

• Hint: when you get a chest tube question, look at the

reason for which it was placed (will tell you what to

expect & what not to expect)

- ex. pneumothorax = to remove air (because air

 created the positive pressure)

- ex. hemothorax = to remove blood

- ex. pneumohemothorax = to remove blood & air

• Hint: Also, pay attention to the location of the tubes:

a) Apical = the chest tube is way up high, thus it is

 removing air (because air rises)

- ex. it’s bad if you’re apical tube is draining 200 mL or

 it is not bubbling

b) Basilar = at the bottom of the lungs, thus it is

 removing blood/liquid (because of gravity)

- ex. it’s bad if your basilar tube is bubbling or not

 draining any mL

• ex. How many chest tubes & where would you place them

for a unilateral pneumohemothorax?

 - 2 chest tubes (apical for pneumo, basilar for hemo)

• ex. How many chest tubes & where would you place them

for a bi-lateral pneumothorax?

 - 2 tubes (apical on left, apical on right)

• ex. How many chest tubes & where would place them for

post-op chest surgery?

 - 2 tubes (apical & basilar on the side of the surgery)

 ** you are to assume that chest surgery/trauma is

 unilateral unless otherwise specified (they will

 say bilateral)

• Trick Question: How many chest tubes would you

need and where would you place them for a post-op

right pneumonectomy?

- NONE! because you are removing the lung so you

 don’t need to re-establish any pressure (there is not

 pleural space)!

Troubleshooting Chest Tubes:

• What do you do if you knock over the plastic

containers that certain tubes are attached to?

 -> set it back up & have PT take some deep breaths

 -> NOT a medical emergency! (don’t call MD)

• What do you do if the water seal breaks (the

actual device breaks?)

-> first = CLAMP it!!! because now positive pressure

 can get in! don’t let anything get in

-> 2nd = cut the tube away from the broken device

-> 3rd = stick that open end into sterile water

-> then unclamp it because you’ve re-established the

 water seal (doesn’t need clamp if it’s under water

 *** better for the tube to be under water than

 clamped! -> air can’t go in and stuff can still keep

 coming out (if clamped, nothing can come out

 which is what the tube is for)

• Ex. If they ask what the first thing is to do if the seal

breaks -> Clamp! BUT, if they ask what’s the best

thing to do -> put end of tube under water! (because it

actually solves the problem, clamping is a temp. fix)

• Hint: ‘BEST’ vs. ‘FIRST’ questions

- first questions = are about what order

- best questions = what’s the one thing you would do if

 you could only do 1 of the options

-> ex. You notice the PT has V-fib on the monitor. You

 run to the room and they are non-responsive with

 no pulse. What is the first thing you do?

 A) place a backboard?

 B) begin chest compressions?

 - “first” is about order so = pick A (because you

 wouldn’t start chest compressions first)

 - BUT, if the question ask “What’s the best thing to

 do?” -> you only get to do 1 thing not the other so

 you would pick B

• What do you do if the chest tube gets pulled out?

- first = take a gloved hand and cover the hole

- best = cover the hole with vaseline gauze

• Bubbling chest tubes: (ask yourself 2 questions)

a) Where is it bubbling?

b) When is it bubbling?

= the answer will depend on these 2 questions

 (sometimes bubbling is good, sometimes bad but

 depends on where & when)

- ex. Intermittent bubbling in the water seal -> GOOD

 (document it, never bad!)

- ex. Continuous bubbling in the water seal -> BAD

 (you don’t want this, means a leak in the system that

 you need to find and tape it until it stops leaking)

 ** in RPN scope

- ex. Intermittent in suction control chamber -> BAD

 (means suction is not high enough, turn it up on the

 wall until bubbling is continuous)

- ex. Continuous in suction control chamber -> GOOD

 (document it)

- Hint: both locations are opposites of each other

 (memorize one & deduce the others)

 —> if there is a seal it should not be continuous

 (ex. a sealed bottle of pop continuously

 bubbling means it’s leaking!)

• A straight catheter is to a foley catheter as a

thoracentesis is to a chest tube.

- in-&-out vs. continuous secured

- thoracentesis -> also helps re-establish neg.

 pressure (in-&-out chest tube)

- higher risk for infections are continuous

Rules for Clamping Tubes:

• a) Never clamp a tube for more than 15 seconds

 without a doctors order.

 - so if you break the water seal -> you have 15

 seconds to get that tube under water

• b) Use rubber-tipped doubled clamps.

 - the teeth of the clamp need to be covered w/

 rubber so that you don’t puncture the tube

CONGENITAL HEART DEFECTS

• every congenital heart defect is either TROUBLE or

NO TROUBLE (ALL BAD or NO BAD)

- either causes a lot of problems or it’s no big deal (no

 in-between defect)

• memorize one word: TRouBLe

• ex. You are teaching the parents about a heart defect: