Category Archives: Study Skills

Medical-Surgical: Left versus Right Heart Failure

LEFT HEART FAILURE

  • left = “lungs” = respiratory symptoms
  • blood backs up into the lungs due to failure of the left side of the heart
  • classic symptoms: dyspnea, crackles in lungs

RIGHT HEART FAILURE

  • blood backs up into the periphery due to failure of the right side of the heart
  • classic symptoms: edema, jugular vein distention (JVD), hepatomegaly, splenomegaly
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Psych Medications: Mood Stabilizers

Anti-manic and Mood Stabilizing drugs (Lithium, Depakote, Lamictal, Tegretol, Trileptal)

  • LITHIUM is the drug of choice for controlling manic episodes
  • lithium has a narrow therapeutic index (~0.6-1.2), familiarize yourself with the different LEVELS OF TOXICITY
  • normal SE of lithium include fine tremors, mild thirst, mild nausea and general discomfort – if they persist, may indicate toxicity
  • remember that DEHYDRATION (excess nausea, diarrhea, sweating, diuretics) may cause lithium TOXICITY
  • SE of toxicity include coarse tremors, persistent GI upset, confusion, muscle irritabbility, ECG changes, incoordination
  • lithium level of > 2.5 may = DEATH
  • Tegretol may cause agranulocytosis – monitor WBCs
  • Lamictal may cause Steven-Johnson’s – monitor platelets
  • Depakote may cause hepatotoxicity and thrombocytopenia – monitor LFTs and platelets
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Psych Medications: Benzodiazepines

Benzodiazepines/Non-benzodiazepine Anxiolytics (Ativan, Klonopin, Valium, Xanax, Librium, Buspar, Inderal)

  • [Val and Xan the Klo Ind the Bus] “Val and Xan the Klown In the Bus”
  • benzos increase GABA, have rapid onset
  • few drug interactions, but can interact with other CNS depressants (alcohol) and manifest as sedation or death
  • there is potential for ABUSE, be cautious when giving to patients with history of substance abuse
  • benzos must be tapered to lessen S&S of withdrawal (fatigue, irritability, insomnia, tremors)
  • BUSPAR is a special drug: takes a while to work, so often is taken with a benzo while waiting for therapeutic effect; no potential for abuse; high cost
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Psych Medications: Antidepressants


I. Selective Serotonin Re-uptake Inhibitors
SSRIs (Lexapro, Celexa, Prozac, Paxil, Zoloft, Luvox)

  • [Luv Zolo Proz, Lexa Cel Pax] “Love solo pros. Lexa sells packs.”
  • SSRIs are FIRST LINE for depression
  • has fewer side effects than TCAs or MAOIs
  • no anticholinergic side effects, usual S&S include nausea, insomnia, sexual dysfunction

II. Atypical Antidepressants (new generation) (Cymbalta, Desyrel, Effexor, Remeron, Wellbutrin, Pristiq)

  • [Cymba Des Well Effex. Remer is imPrist] “Cymba does well effects. Rem is impressed.”
  • DESYREL can also be used for insomnia
  • EFFEXOR and CYMBALTA may cause HTN
  • CYMBALTA also used for neuropathic pain
  • WELLBUTRIN also used for smoking cessation

III. Tricyclic Antidepressants (Elavil, Anafranil, Norpramin, Tofranil, Vivactil, Pamelor, Sinequan)

  • Sounds like female names: Ela, Ana, Pam, Viv …; some end in -FRANIL or -IL
  • may take about 1-3w for effect and 6-8w for max response
  • have strong ANTICHOLINERGIC EFFECTS, so use with caution in elderly patients or patients with constipation, glaucoma or BPH
  • these medications also have strong CARDIOTOXIC effects
  • NORPRAMINE has low anticholinergic effects, which would be appropriate for the above
  • once daily dosing at bedtime helps to promote sleep through sedation effects and reduce daytime sleepiness
  • check the patient for HOARDING, especially if they are at RISK FOR SUICIDE

IV. Monamine Oxidase Inhibitors (MAOIs) (Nardil, Marplan, Parnate, EMSAM-patch)

  • [PaNaMA] or [No Popular Meds (N.P.M.)]
  • only used as a 2nd or 3rd choice for treatment of depression b/c of dietary restrictions and SE
  • dietary restriction of foods high in TYRAMINE (dried fruits, almost all cheeses, processed meats, soy products, avocados)
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Maternal/Child Health (OB): The Basics

There is a lot of newly introduced vocabulary alongside a different conceptual view in the care of both the pregnant woman and the unborn child or newborn.

The content is organized into 3 main phases of peripartum care:
Antepartum (before the pregnancy)
Intrapartum (during pregnancy)
Postpartum (after pregnancy) 

Below is an abbreviated outline of the content typically covered in this course:

  • Fetal conception and development
    – Phases of the menstrual cycle
    – Process of fertilization
    – Fetal and Maternal changes
  • Risk factor and fetal assessment
    – Maternal and paternal psychosocial responses to pregnancy
    – Prenatal care: GTPAL, office visits, labs
    – Fundal height assessment
    – Anticipatory guidance for the first, second and third trimesters,
    – Fetal and maternal assessment methods: ultrasound, chorionic villi sampling (CVS), amniocentesis, electronic fetal monitoring, nonstress test (NST), contraction stress test (CST), biophysical profile (BPP), fetal pH blood sampling
  • Labor and Delivery
    – Leopold maneuvers – helps to determine fetal presentation, fetal position, fetal lie and fetal engagement
    – True vs False labor
    – The four stages of labor
    – The 3 phases of the first stage of labor: latent, active, transition
    – Analgesia and anesthesia – local, regional, peridural, intradural blocks
  • High risk pregnancies
    – Miscarriage/spontenous abortion – emergency!
    – Hydatiform Mole – developmental anomaly, “grape-like” clusters
    – Abruptio placentae – premature complete or partial detachment of the placenta from the uterine wall
    – Placenta previa – abnormal implantation of the placenta
    – Anemia
    – Ectopic pregnancy – abnormal implantation of fertilized egg outside of the uterus
    – Infection – TORCH (Toxoplasmosis, Other [HIV, Varicella, Parvo, Syphillis, Coxsackievirua], Rubella, Cytomegalovirus, Herpes simplex)
    – Preterm labor
    – Dystocia – difficult birthing
    – Preeclampsia, eclampsia
    – Hyperemesis gravidarum
    – Gestational diabetes
  • Postpartum
    – Normal postpartum changes of the uterus, cervix, breasts, CV, hematologic, integumentary, musculoskeletal system
    – Normal postpartum vital signs: high temp, low pulse, normal BP, rare changes in RR
    – Measuring fundal height – height decreases 1 cm per day
    – Assessing lochia (postpartum discharge) – rubra → serosa → alba
    – Assessing perineal area and episiotomies (incision of the posterior vaginal wall)
    – Examine breasts for tenderness, engorgement, breastfeeding techniques
    – Assist with mother-baby bonding
    – Assess urinary, bowel movements
    – Determine needs for RhoGAM, rubella vaccine, medications
  • Newborn care
    – APGAR assessment
    – The 5 symptoms of respiratory distress: retractions, tachypnea ( > 60), dusky color, expiratory grunt, flaring nares
    – Newborn prophylactic eye care with erythromycin ointment
    – Physical assessment: vitals, measurements, head-to-toe, reflexes
    – Primary concerns of: aspiration, infection, hypothermia, hypoglycemia, hemorrhagic disorders, hyperbilirubinemia
    – Assess elimination and feeding patterns
    – Screen for genetic disorders such as phenylketonuria (PKU) after breast milk/formula ingestion
    – Provide teaching about newborn care concerning bathing, diapering, crying and comfort

Under each area of content, familiarize yourself with the associated vocabulary, consider the type of care the mother and/or child should receive at this stage in pregnancy and what the nurse should be aware for in terms of possible complications.

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Content derived from HESI Comprehensive Review for NCLEX-RN Examination.

Pediatrics: The Basics

Think of Pediatrics as the baby version of Med/Surg. Much of the content applied in med/surg parallels that of pediatric care. However, it is important to consider the factor of developmental care when studying the content.

The course introduces the basics of development in the lifespan of infant to 18 years of age. Two main revisited concepts include Erikson’s stages of psychosocial development and Piaget’s developmental theory.

Erikson’s Stages of Psychosocial Development
[0-2 years] : Trust vs Mistrust
[2-4 years] : Autonomy vs Shame & Doubt
[4-5 years] : Initiative vs Guilt
[5-12 years] : Industry vs Inferiority
[13-19 years] : Identify vs Role confusion
[20-24 years] : Intimacy vs Isolation
[25-64 years] : Generativity vs Stagnation
[65-death] : Ego Integrity vs Despair

Piaget’s Stages of Cognitive Development
[birth-2 years] : Sensori-motor
[2-7 years] : Preoperational
[7-11 years] : Concrete operational
[11 years +] : Formal operational

In studying for this course, relay back to the information you learned in Med/Surg, Assessment and Foundations, but apply them in a developmental context. For example, when caring for a child with respiratory disease, consider the capacity of their lungs or their cognitive ability to learn how to use an inhaler. Also consider the complexity of giving medications to a young population. Often times, the dosages must be calculated precisely based on their body surface area. In the clinical setting, medications are given in carefully set IV pumps which administer the medications in precise amounts.

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Pediatric Math Calculations: Fluid Maintenance, Caloric Intake, Dilutions and Concentrations

Math in pediatrics includes prior knowledge in addition to some new material. First, it would be important to know the essentials when it comes to calculating pediatric dosages. Keep in mind the following:

  • All medication dosages are rounded to TWO DECIMAL PLACES. Keep in mind that previous math exams mostly required one decimal place rounding.
  • Only round your final answer. If for example, you need to calculate a patient’s weight, don’t round that off to 2 decimal places.
  • IV infusion raes, daily fluid maintenance and calorie amounts are rounded to WHOLE NUMBERS.

It would be beneficial to know these conversions:

  • 1 kg = 2.2 lbs
  • 1 in = 2.54 cm
  • 1 oz = 30 mL
  • 1 lb = 16 oz
  • 1 cup = 240 mL
  • 1 L = 1000 mL
  • 1 mg = 1000 mcg
  • 1 g = 1000 mg
  • 1 mL = 1 gm (when weighing diapers)

Now to introduce the new material:

DAILY FLUID MAINTENANCE NEEDS

In pediatrics, patients are under strict intake and output as the potential for overload or deficit is high in this population. It is important for us to know the daily fluid requirements for each patient to maintain that balance between fluid consumption and release. This may be helpful to determine the amount of fluids a child needs orally without the need of IV infusions.

The following is the forumla:
First 10 kg of body weight – x 100 mL/kg/day
Second 10 kg of body weight – x 50 mL/kg/day
Anything above 20 kg of body weight – x 20 mL/kg/day

It may seem complicated, but it may be easier to see a visual. Let’s try out this problem:

A child weighs 18.60 lb. What would be this patient’s daily fluid maintenance needs?

First, you would need to convert pounds to kilograms. Recall that 1 kg = 2.2 lbs. Therefore, 18.60 lb/2.2 = 8.454545 kg (remember don’t round up at this point).
Next, looking at the forumla, multiply the first 10 kg by 100. (in this example, the patient weighs less than 10 kg, therefore you would only multiply his weight by 100 and you would have your answer.

8.454545 x 100 = 845.4545 = 845 mL/day (round to whole number)

Let’s try a heavier child.

A child weighs 45 kg. What would be this patient’s daily fluid maintenance needs?

Since this patient’s weight is in kg, we don’t need to convert.
Take the first 10 kg and multiply by 100. (10 x 100 = 1000 mL/day)
Now, you have “35 kg left over”. Multiply the second 10 kg by 50. (10 x 50 = 500 mL/day)
Now, you have “25 kg” left over”. Multiple this 25 by 20. (25 x 20 = 500 mL/day)
Finally, add all the values to get your total fluid maintenance needs for this child: 1000 + 500 + 500 + = 2000 mL/day.

Simple, right?!

CALORIC INTAKE

Daily caloric intake is a simple calculation. It is important to know how many calories in one ounce, how many ounces of formula in one bottle and how bottles consumed in 24 hours. Take this sample question:

Infant’s total intake for 24 hours: 4 bottles
Each bottle contained: 2 oz of forumla
Formula: 25 calories/oz
Infant weight: 2.5 kg
Infant age: 4 weeks
How many calories did the infant receive in 24 hours?
In the past 24 hours, did the infant receive calories at or above the minimum?

I bolded text above is the information needed for the first part of the question – the infant’s total caloric intake for 24 hours. All you need to do is simply multiply calories/oz by total oz in one bottle (25 calories/oz x 2 oz/bottle = 50 calories/bottle). Next multiple this value by the number of bottle the infant consumed in 24 hours (50 cals/bottle x 4 bottles/day = 200 calories/day)

Now you need to determine whether this patient’s total caloric intake is sufficient for estimated total caloric intake. Here is the formula: 108 cal/kg/day. All you need to do is simply multiply 108 by how many kg the patient weighs, like so: 108 x 2.5 kg = 270 cals/day.

Now compare, does the patient’s caloric intake (200 calories/day) equal or exceed the expected caloric intake (270 calories/day)? In this situation, NO. Therefore, the answer would be no, caloric intake is BELOW the minimum.

DILUTIONS AND CONCENTRATIONS

It is important to know how much diluent to add to a medication to have the correct concentration. Take the following example:

Ordered: Ciprofloxacin 200 mg IV q12h
Available in vial: 200 mg in 1.6 mL
Correct concentration: 10 mg/mL
How many mL of normal saline would you need to add to dilute 200 mg of Ciprofloxacin and have the correct concentration?

The answer is simple.
First, use the ratio method to determine how many mL are in 200 mg of Cipro – cross multiple to get 20 mL.

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Now you know that the total volume needed for correct concentration is 20 mL. Now look at what is available – 200 mg of Cipro in 1.6 mL vial. Now you need to subtract the amount of mL in the available vial (1.6 mL) from the volume needed for correct concentration (20 mL). 20 mL – 1.6 mL = 18.4 mL.

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Psychiatric/Mental Health: The Basics

The focus of this psychiatric/mental health nursing is usually around 4 main concepts:

  • therapeutic communication
  • safety
  • medications
  • specific psychiatric disorders

Therapeutic communication:
Communication is vital to the general nursing field, not just in psych, but it is especially important when interacting with a patient in the psychiatric setting. Much of the techniques learned in assessment applies such as reflection, active listening, empathy, etc. However, it is important to first look at the overall patient situation and determine which statement is most appropriate. For example, for a patient who is suicidal, you would want to ask more direct questions even if they seem very blunt such as “have you thought about harming yourself?”

Safety:
Recall that in the model Maslow’s Hierarchy of Needs, the care of the patient follows a stairstep priority list starting with physiological needs, followed by safety, emotional needs, self esteem. In psych, safety is always the priority. Consider interacting with an escalating angry patient. First step would  be to escort other patients away from the angry patient. Think about a patient who just told you he wants to kill himself. First thing would be to remove all objects that he could use to harm himself, such as ropes, bedsheets, even coke cans. Safety of the patient, other patients and nurse is crucial in these settings.

Medications:
Medications aren’t administered by students during the clinical shift, however, it is important for us as nurses to know the ins and outs of psych medications. There are several classes of medications covered in this course:

  • Antidepressants – Selective Serotonin Reuptake Inhibitors (SSRIs), Tricyclics (TCAs), Monoamine Oxidase Inhibitors (MAOIs) and Atypicals
  • Antipsychotics – Conventionals and Atypicals
  • EPS drugs
  • Benzodiazepeines and related anxiolytics
  • Mood Stabilizers – Lithium, antiseizure medications
  • ADHD meds
  • Alzheimer’s agents
  • Herbals
  • Hypnotics
It isn’t enough to simply know what kind of drug it is, but also what is the specific name. Prozac is a SSRI, Geodon is an atypical antipsychotic.  There are several techniques to memorize the different drug names. I’ve seen pictures, acronyms and color coding. Once you know the different names and correlating class of drug, know their mechanism of action. Majority of these drugs work on neurotransmitters in the brain which in turn may produce the therapeutic effect as needed to relieve symptoms. Knowing the side effects is especially important. Some of these medications produce very uncomfortable side effects which may contribute to noncompliance. Teaching patients how to manage the side effects and administering the appropriate treatment is a critical part of medication administration.

Psychiatric Disorders:
There are several different psychiatric disorders covered in this coursed, including:

  • Schizophrenia
  • Anxiety disorders
  • Addictions
  • Depression
  • Bipolar disorder
  • Somatoform, Factitious, Dissociative disorders
  • Cognitive disorders
  • Personality disorders
  • Child/Adolescent disorders
  • Eating disorders

Alongside, there are other topics including death and dying, abuse, crisis intervention, etc. For each of the psych disorders, concentrate on the manifestations of the disorder, medications and relevant treatments, role of the nurse in caring for this particular patient, appropriate diagnoses and outcomes and patient teaching in managing their illness.

Whether you’re interested in working in the field of psychiatric nursing or not, the skills learned in this course may apply to all fields of nursing. Whether you’re working in critical care or general med/surg, there is a high possibility that some patients you meet may have comorbid psychiatric problems. Viewing the patient holistically includes addressing mental health and a efficient nurse is one who is competent in not only the medical, but the emotional and mental aspects of nursing care.

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Medical-Surgical Nursing: The Basics

Med/Surg is like the meat and potatoes of nursing, with Foundations being the dinner plate and Assessment being the mashed potatoes. It’s important to get a grasp of the general med/surg content, concentrating on:

  • pathophysiology of certain conditions and clinical manifestations
  • nursing interventions R/T the pathophys
  • related medications and treatment options
  • patient teaching

The Lewis textbook does a great job of organizing the content in a comprehensive and flowing manner. The chapters begin with basic pathophys related to a certain disease process followed by clinical manifestations. By now, much of the terminology used should be familiar post-Foundations. It’s important to differentiate specific clinical manifestations with a specific disease, because there are quite a few that overlap with other conditions. For example, nausea and vomiting may be a common symptom amongst several GI conditions, but a symptom like pain relieved by food is more specific to duodenal ulcers (as opposed to gastric ulcers).

Once you’re familiar with the clinical manifestations of the disease, relevant diagnoses and outcomes are important to address those symptoms. It’s also important to recognize what symptom that diagnosis addresses and if they match. For example, the diagnosis Ineffective airway clearance is more relevant to excess mucus in the airway as opposed to Ineffective breathing pattern which is more relevant to labored breathing. Remember, as nurses we don’t necessarily treat the disease, rather we treat the symptoms.

Following that, knowing the role of the nurse and responsibilities in the collaborative care is critical. A simple way to study for this is by linking the pathophy with the clinical manifestations and then link that to a specific nursing intervention. For example, a patient with COPD often displays dyspnea (difficulty breathing). The pathophysiology behind that is chronic inflammation of the airway and excess mucus. As a nurse, what are some interventions you can do? Let’s start with the obvious – oxygen. Assuming there is a standing order, the nurse would apply oxygen to the patient (FYI: patients with COPD should never be given oxygen more than 2-3 liters/minute as it may cause them to stop breathing!). Alright, so give the patient oxygen, what else is relevant? How about raising the head of the bed to allow for the lungs to expand? Often times a test question will ask for a priority intervention. In this case, what is the one action that the nurse can do immediately? It usually would be raising the head of the bed. Once envision in your mind yourself as the nurse caring for this patient, it may help facilitate the way you study for this course.

In addition, patient teaching is important. What does the patient need to know about self care before he or she is discharged? Using the above COPD example, I could teach the patient to take his/her medications regularly, turn/cough/deep breathe to facilitate lung clearance and pursed-lip breathing to prevent air trapping.

The exams for Med/Surg focus mainly on nursing care with some assessment and patient teaching. When reading the question, picture that patient in your mind. It’s important to differentiate real world from NCLEX world. Often times, these questions are in a setting where you have as much time as you have and can only do one thing in the room before leaving. Remember to identify positive from negative questions, as well as priority questions. What can the nurse do immediately? Before I call the doctor, what information have I gathered? If the question does not have any assessment findings/information in the root of the question, usually you would need to assess first.

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[Pre-Nursing/FYS NURS 1335] Prezi Presentations

For all current & future freshman pre-nursing students, here are the Prezi presentations for the 7 lessons covered during the semester:

GOAL SETTING.

TIME MANAGEMENT.

READING & NOTE-TAKING.

STUDY SKILLS & TEST TAKING.

HEALTHY LIFESTYLES.

CAMPUS RESOURCES & LIBRARY RESEARCH.

MONEY MANAGEMENT.

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