Endocrine System Overview & Hyperthyroidism

[Music] 60 M for drop no 60 drop per M and micro is the same they&#39;re no no no which Lady of yours is [Music] yes the one that goes by itself this is the weekly that goes together yeah and then like this and now I&#39;m on my bad one by which is cool the we that&#39;s better than [Music] here your quiet have a light [Music] [Music] [Music] CV you are all okay let&#39;s start endocrine overview endocrine glands uh this this lecture is going to be real helpful for hessie stuff because they love to test adrenals and uh thyroids the endocrine overview is only going to be about thyroids and adrenals you do not have to know the thymus the pineal the uh parathyroids you don&#39;t have to know all those just know your thyroid gland know your adrenal gland and you&#39;re good to go now if you don&#39;t know your thyroid you&#39;re in trouble you don&#39;t know your adrenal you&#39;re in trouble so focus on what you need to know so let&#39;s focus on those two glands the first one is hyper thyroidism that I will talk about whenever Mark kimik sees the word thyroidism he turns it into metabolism because that&#39;s what the thyroid does the thyroid regulates metabolism so when you see hyper thyroidism what do I want you to turn it into hyper metabolism if that is true do you see that now you do not have to memorize the signs and symptoms they&#39;re just logical what would be the logical set of signs and symptoms you would see if you had a high metabolic rate weight loss so they&#39;re skinny and weight loss what else what what would their pulse rate be blood pressure uh their personality irritable hyper obnoxious excitable life of the party for about 5 minutes till everybody gets sick of them uh heat what int intolerance and cold tolerance so they can to tolerate the cold because they&#39;re like a little furnace they cannot tolerate the heat cuz they&#39;re already burning up xof phalos what&#39;s X off phalos bulging eyes the word X ex x e x o h p or o p h t h a l m o s x offal uh soat are basically they&#39;re skinny they&#39;re hyper they&#39;re tacky they&#39;re hyper metabolic the person I remember this this dates me too you guys probably do not know him uh was a guy named Don knots that was uh what was he he was uh Barne Barney fight on Mayberry you know the the skinny little guy Sheriff Andy Andy always hyper M guys skinny classic hyperthyroid guy the name of this disease is Graves g r a v s Graves disease now they will not tell you they will not say Graves disease hyperthyroid they&#39;ll give you one name and you&#39;re supposed to know Graves is hyperthyroid the way I remember that is a saying my grandma used to say which is you&#39;re going to run yourself into the grave what two words does that link run with gray well if you&#39;re run run run run run run all the time what are you hyper thyroid so running yourself into the grave helps me remember it&#39;s hyperthyroid number three the problem here is hyperthyroidism so you have three treatment options you have three ways to treat hyperthyroidism number one radioactive iodine radioactive iodine now there&#39;s two things you need to know about radioactive I number one the patient should be by themselves for 24 hours they should be in a room by themselves for 24 hours and after that they have to be real careful with their urine they should flush three times if they spill their urine on the ground they need to call the HazMat team cuz somebody has to come with a guer counter to make sure it&#39;s all cleaned up so if you have a patient on radioactive iodine for hyperthyroidism and they spill urine on the floor in the hospital you can&#39;t call housekeeping you got to call your hospital hasm team and they come with all their paraphenalia it looks really really silly for them to go worrying about the urine but that&#39;s where the radioactivity is excreted is through the urine so this is the one place where they have glow-in-the-dark urine not really but you know you have to treat it like it&#39;s bad so the only risk to you the nurse for a patient who&#39;s had radioactive iodine is what there you and give them a private room in the first 24 hours okay the next treatment we have is PTU PTU a drug yes would you get family visitation on that is that an issue I&#39;ve seen several API questions um with with radioactive iodine no family visitation in the first 24 hours and if they go home they are supposed to stay in the family room and nobody else or they stay in their bedroom nobody else goes in for 24 hours so there&#39;s a restriction of visitors uh home restriction for 24 after 24 they can have all the visitors in the world as long as they don&#39;t pee on okay the second problem is PTU propy furil propy tho uracil now I don&#39;t want you to memorize that PT is propo uracil what&#39;s it used for hypo hyper thyroid so what must it do to your thyroids if it treats hyper what must it do bring it down so I want you to remember that PTU stands for puts thyroid under whenever you see PTU what should pop in your head puts thyroid under which tells you it treats hyper thyroid its primary use is for cancer it&#39;s a cancer drug but one of its special uses is for hyper thyroids because it will also put the thyroid under so what do you think the number one nursing thing is with this drug if it&#39;s a cancer drug immunosuppression so what count what blood values do you have to watch when they&#39;re on PTU they&#39;re white blood cell counts so it puts the thyroid under and it also knocks down your white count the most common way however that we treat hyperthyroid is surgical removal we do a thyroid ectomy thyroid ectomy we remove part of the thyroid or all of the thyroid now if you want to get your thyroidectomy questions correct you must pay attention to whether they&#39;re talking about a total thyroidectomy or a sub total thyroidectomy cuz that&#39;s going to make a huge difference in your answer if you just treat all thyroidectomies the same you will miss loads of questions so what&#39;s the most important thing in a thyroid thyroidectomy question total or sub now I taught this one time and a student called me the day after and said what you taught didn&#39;t help on thyroidectomies and I thought okay I said well what didn&#39;t help and she said well was a different kind of thyroid surgery on there that you didn&#39;t cover I said boy that&#39;s interesting total subtotal that pretty much covers it for me you know I can&#39;t think of you know it&#39;s either total or it&#39;s subtotal I mean what what third possibility could there be and I said well well what was it and she said it was a partial thyroidectomy subtotal is a partial total is a complete so a complete thyroidectomy is a total a partial is a subtotal now she passed you know so you don&#39;t have to be you know a real Shining Light you just have to do some shining you know she certainly was not a Shining Light why did she make such a dumb mistake she wasn&#39;t managing her anxiety and she was looking for total and subtotal and it wasn&#39;t there she panicked and she didn&#39;t say now wait a minute which of these is closest to what I do know right CU it may not say it exactly the way you want it remember the guy with the cracker and the carbohy dry carbohydrate you know they&#39;ll say things differently than you learned them but it means the same thing if you see something on the test it says means the same as something you learned but it&#39;s saying it differently guess what it is what you learn don&#39;t say well that sounds like the same thing but I didn&#39;t learn it that way so it&#39;s probably not that oh that is the worst thing to do what you should do the opposite you should say that sounds an awful lot like what I learned which was this it&#39;s not the same phrasing but it sounds like that so it must be that do you see the difference always assume that if they tell you something synonymous then it means the same as what you know don&#39;t assume it&#39;s something different always assume it&#39;s what you know okay so for totals totals need lifelong hormone replacement why cuz if I take your whole fyid out you don&#39;t have any so you got to have lifelong hormone replacement also letter B you are at risk for hypocalcemia why low calcium why after a total thyroid activ me do you have a low calcium CU it&#39;s almost impossible to spare the pair of thyroids when you take the whole thyroid out so you end up with low parathormone low calcium so they&#39;re at risk for low calcium what are the signs of symptoms of hypocalcemia we talked about that last hour calciums do the opposite so hypocalcemia is going to make everything go up so you&#39;re going to have tety spasm irritability clonus SE seure tacac cardia hypertension irritability jitteriness Tremor um right okay what&#39;s the first sign that&#39;s going to happen paresthesia excellent see once you start learning enough things start cycling around and it&#39;s all no new no news right it&#39;s old news what two signs will you have Chex and chos cuz your calcium is low okay subtotal thyroidectomies on the other hand do not need lifelong replacement why because you got some left and it&#39;s supposed to kick in might you be on hormone replacement for a little while yes till that other one kicks in then it&#39;s supposed to be off do you think you get the hypocalcemia much with this no because if you only take out part of it you can spare your parathyroids and your calcium spine however what these people are at risk for is something that totals never get and that is thyroid storm or thyroid crisis same thing it also has another name thyrotoxicosis which sounds like a toxic th thyroid so that sounds like hyperthyroidism to me thyroid storm now what are the symptoms of thyroid storm four really bad things number one super high temperatures of 105 and above number two extremely high blood pressures stroke category so you&#39;re probably talking 210 over 180 now I&#39;m just giving you that as a ball part that&#39;s that&#39;s no set in stone number severe tacac cardia probably in the 180s could be as high as 200 and there again that&#39;s just a ballpark there&#39;s nothing magical about that number and lastly they are psychotically Delirious they have psychotic delirium which we talked about before these people are in a medical emergency this thyroid storm is a very very bad thing because it can cause brain damage and brain damage is Perman you literally fry your brain to death with hypoxia and and our hypoxia so you must treat this immediately and what you treat it with is get the temperature down and get the oxygen up get the temperature down get the oxygen up well how do you get the temperature down what&#39;s the first way you would do it ice pack ice packs what&#39;s the best way cooling blanket cooling blanket cuz if you would pack him in ice without the cooling blanket use the cooling blanket without the ice which way would be better ice without the cooling blanket cooling blanket without the ice what&#39;s better cooling blanket without the ice so the best is the cooling blanket but what would you do first first I&#39;d put them in ice then I&#39;d order the cooling blanket and have it out there so you see there&#39;s another first best difference and what would you what would you give that how do you get the oxygen up oxygen per mask at 10 L just as a interest note what&#39;s the problem with that order what&#39;s what do you think you experience when you try to implement that order what&#39;s that me and these people are what Psy psychotically Delirious so How likely is it you&#39;re going to keep an oxygen mask on this paent yeah good luck good luck so this is a medical emergency you pack him in ice order the blanket throw a mask on them with high2 and they will come out of it themselves without treatment or they will die and there&#39;s nothing you can do to make it go either way it&#39;s just when that T3 T4 gets out of their system they&#39;ll be okay we don&#39;t want to medicate him because if we medicate him it could go the other way so this is a self-limiting condition all we&#39;re doing is sparing their brain until they come out of it now I&#39;ve seen this about five times in my career the longest lasted 12 hours the shortest lasted about less than 2 2 hours but when you&#39;re treating these people it&#39;s two on one meaning two staff for one patient you need an aid and yourself because you can&#39;t do it with just yourself yes what is Tylenol going to do Tylenol works in the hypothalamus and at this point the hypothalamus is is being severely uh threatened because it&#39;s right near the pituitary and the problem with the thyroid storm that caused it was the TSH from the pituitary so that pituitary hypothalamic access is part of the problem that&#39;s causing this situation and Tylenol Works in that hypothalamus and it&#39;s not going to work Tylenol just isn&#39;t going to do it so you really have to you you know pack them in ice so you really don&#39;t treat a lot of it it&#39;s it&#39;s kind of scary because you&#39;re just sitting there you know doing what you can all right but I would say that good nursing care is going to save their life why because medicine isn&#39;t yes question they said to clarify first ice packs then oxygen well I mean if you had to pick between the ice packs and the oxygen I would do the oxygen first the ice pack second the cooling blanket third but if I was between the ice packs and the cooling blanket the ice packs go first but I would always pick stay with my patient because you don&#39;t leave your patient to go get the oxygen you see what I&#39;m saying but it&#39;s a perfect world so it&#39;s sitting right there all right posttop risks they love to ask you about thyroidectomies and posttop risks because it depends on the type of surgery and it it depends upon the time frame so let&#39;s talk about this you&#39;ve got to know this you have to know this in the first 12 hours it doesn&#39;t matter whether it&#39;s a total or a subtotal it does not matter the top priority is Airway because where&#39;s your thyroid so if you have a Dema in the area what&#39;s it going to press on the airway the lyrics so tracha so you&#39;ve got to watch out second big problem is hemorrhage because it&#39;s an endocrine gland which has a lot of blood vessels so the top two in the first 12 hours for both types of thyroid surgery are Airway and Hemorrhage which is pretty much standard isn&#39;t it okay now where the difference comes in is in the 12 to 48h hour window if they give you a patient who&#39;s longer than 12 hours but less than 48 now you have to pay attention to what type of thyroidectomy was done letter A the posttop risks 12 to 48 hours after a total the big danger is tetany tetany due to the low calcium for a total they get the tetany because of the low calcium however letter B the posttop risks 12 to 48 hours for a subtotal is Storm What&#39;s storm thyroid storm so you see where they&#39;re different but they&#39;re the same in the first 12 hours but different in the next 36 so 12 to 48 hours after surgeries what do totals get what do Subs get totals get tetany Subs get stormed odal get T and Subs get storm so ttss total tetany sub storm total tetany sub storm ttss when 12 to 48 hours after surgery in the first 12 what is it Airway and hemr Airway bleeding for everybody right what&#39;s the big after 48 Hours by the way infection right how long does it have to be before you&#39;re allowed to pick infection as a high priority at least 42 hours we&#39; prefer 72 here&#39;s the deal never pick infection in the first 72 hours after anything so if they had a trauma and it&#39;s been 36 hours would you pick infection no they gave birth to to a baby 8 hours ago would you pick infection no never pick infection in the first 72 hours you only pick infection after 72 hours not in the first 72 question is T serious tet TNI is dangerous because your larynx can go into a tetanic laryng spasm which would close the vocal cords in an irreversible spasm which essentially cuts off your Airway and you die okay hypothyroid hypothyroid is hypo metabolism so if hypothyroid hypom metabolism what are the signs and symptoms of a low metabolic rate if your metabolic rate is really low what would you look like OB obese what would your personality be what&#39;s that what flat boring dull cold intolerance heat tolerance see you cannot tolerate what you are so if you&#39;re all if you&#39;re cold you can&#39;t Toler you have cold intolerance if you&#39;re hot you have heat intolerance do you see what I&#39;m saying so hypo thyroids are hypos are always what cold so they have cold intolerance hyper thyroids are always hot so they have heat intolerance so you cannot tolerate what you are what would the pulse be and the blood pressure be low if they were a test taker what kind of test taker would they be slow slow extremely slow test takers they tend to get lower grades in school not because they&#39;re not smart but because they can&#39;t process fast enough it could even affect nursing practice in the sense that you don&#39;t think fast enough okay the name of the disease is mix edema my YX M YX and then the word edema that&#39;s the name of it okay the treatment do you have too much hormone or not enough hormone not enough so what&#39;s the logical treatment give them thyroid hormones Synthroid Leo thyroxin number four caution do not sedate these people why do you not sedate them cuz they&#39;re already super slow you sedate them you&#39;ll actually put them in a coma it&#39;s called a mixed demic coma so what preop order would you question with this hypothyroid patient ambian at HS the sleeping pill before surgery the night before surgery because they don&#39;t need that now what let&#39;s say let me ask you this you got a hypothyroid client he&#39;s on thyroid pills every day he&#39;s going to have a open heart surgery he&#39;s scheduled for it in the morning doctor orders NP past midnight you got a problem with that what&#39;s your problem call and call and question what they&#39;re holding them okay because NPO means nothing and nothing means nothing including anything which would be a pill so nothing by mouth means they&#39;re not allowed to have any of their oral pills which means you would not give the person their morning thyroid which means they would be hypothyroid and very susceptible to any drug that would sedate them do you get any drugs during surgery that sedate you it&#39;s called an anesthetic agent do you see what I&#39;m saying so if you would follow that order and not give the thyroid pill the morning of surgery What could would likely happen to your patient never make it off the table they would die from these depressant effects of the anesthesia so you as a nurse would never hold what pill before surgery without Express orders to do so thyroid pills never hold your thyroid pills unless they tell you to do it and even if they told me to do it if I called the surgeon and he told me to hold the thyroid what would I do I&#39;d called the anesthesiologist and if he said hold it what would I do I&#39;d call the head of the anesthesi my supervisor and say hey look this is not cool now my supervisor should what contact the supervisor of the anesthesiology and say hey look what&#39;s going on here you see you you you aren&#39;t supposed to go up the ladder outside your department you go up your department and they go across do you see what I&#39;m saying uh if I really felt it was unsafe I would I would refuse to follow I would just refuse to I don&#39;t know if I you understand if I thought it meant a patient dying how far would you go you know what I&#39;m saying if it was your dad how what would you do to keep him from Gone surgery You&#39; lay down on the floor and not let him get the card over your body do know what I mean so I&#39;m just saying would you do the same for your patient okay enough set on that adrenal cortex the second gland we&#39;re going to talk about the adrenal cortex interestingly adrenal cortex diseases start with either the letter A or the letter c which are the initials of adrenal adrenal cortex so could Graves be the adrenal cortex could miedema be the adrenal cortex could foch chromosoma be the adrenal cortex could Cushings cons Addison cortico insufficiency adrenal insufficiency yes so all of those diseases start with an A or a c now I didn&#39;t say that all diseases start with an A or a c our adrenal cortex is asthma you know obviously no all right Addison&#39;s disease let&#39;s start with Addison it starts with an a it&#39;s under secretion of the adrenal cortex under secretion what are the signs of symptoms just two things you need to know they are hyperpigmented what does hyperpigmented mean very tan very tan so they look what many people call Healthy but they are the farthest thing from it because the second thing you need to know about it is these people do not adapt to stress they do not adapt to stress because their adrenal gland is under secreting so if they undergo any stress at all what could happen what&#39;s the purpose of the stress response I might ask what&#39;s the purpose of the stress response not to increase the metabolism necessarily although it will that&#39;s what mediates it but that&#39;s not the purpose of it that&#39;s what it does but that&#39;s not what the purpose what okay and and but what&#39;s the big when when you are under stress there&#39;s a threat to your brain and the purpose of the stress response is to profuse the brain with blood in other words support the blood pressure and give the brain glucose which means raise the blood glucose so the purpose of the stress response is to raise the glucose raise the blood pressure does everybody understand that your stress resp response is supposed to raise your glucose and raise your blood pressure that&#39;s what it its purpose is if these people do not have the adrenal cortex to carry out the stress response when they undergo stress what will happen okay what&#39;s the purpose of the stress response raise the and raise the and if you&#39;ve got a disease in that organ and cannot do that what will happen when you undergo stress your glucose will go down and your blood pressure will go down and you&#39;ll go into shock like that and it doesn&#39;t take much to put them into shock in fact these people have been known to go to the deest have the tooth filled and they go into full-blown shock because of that stress which wouldn&#39;t bother most of us um if you ever work Squad these are the people that you happen on the scene of a little fender bender and somebody&#39;s gone no blood pressure nothing they&#39;re gone and you think well they couldn&#39;t possibly been hurt that bad well what you&#39;ll search them and what will you find really nice a really nice a really tan Guy where in a bracelet and what does a bracelet say I have Addison&#39;s disease these people you look at them wrong and they go in shop no not really but I mean you know it&#39;s they are your time bombs waiting to go this is a very scary disease you&#39;re okay until something happens and then Wham they decompensate like that yes I thought it was rare do you see it it&#39;s very rare as far as as endocrine disorders it&#39;s one of the rarest it&#39;s one of the rarest it&#39;s like for every every 600 Cushings patients I would see I see one Addison and that&#39;s probably being generous I probably only taken care of two or three Addison&#39;s patients in my entire life Cushings you know all the time uh Kennedy was supposed to have had this disease JFK was uh rumored to have this disease so that means when he got shot what there was no chance there was no I mean even if he hadn&#39;t even it had been now and if he and hadn&#39;t gotten hit in the skull if he had gotten like a shoulder injury now he might not have made it so it was and think about this what&#39;s really dangerous to people with Addison&#39;s disease stress you&#39;re the president of the United States you know it&#39;s not the best he probably couldn&#39;t get elected right now because they would have made such a big deal of the metal you know what I mean it would have just it would have disqualified him but it was hidden people didn&#39;t know about it he didn&#39;t seem he didn&#39;t seem very tan well he was a little bronzer though when he early years he wasn&#39;t he was real pasty but then he got tanned as he as he went on and then he started taking story so he got puffy okay so the nice little puffy cheeks he had there near the end that was steroids that wasn&#39;t Jackie okay um well what&#39;s the treatment steroids yeah give him what he&#39;s low on which is what steroids not pump you all steroids but glucocorticoids all drugs that end in what what do all steroids end in sewn betamethasone bethos dexamethasone kosone mosone hydr cortisone FL cordone so drugs that end in are steroids so what do so you give drugs these drugs to people in Addison right so Addison&#39;s disease is it under secretion or over secretion under do you have to take something away from them or add something to them and what do you add a [Music] s in add a Suns you add aone and that tells you whether doesn&#39;t add aone tell you whether it&#39;s hyper or hypo sure CU if you&#39;re adding it&#39;s what hypo and it tells you you what drugs to pick anything ending in so so just remember add a Suns you add a s and that&#39;ll help you remember it Cushings Cushings syndrome this is over secretion of the adrenal cortex over secretion the way I remember this is if you have a cushy bank account do you have more or less money more more if you have a a cushy chair does it have more or less stuffing more if you have a cushy tushy do you have more or less more more yeah you got a whole lot more right lot so cushy just sounds like more to me doesn&#39;t it Cushings cushy over Addison you got to add cuz it&#39;s under I never forget which one&#39;s under and which one&#39;s over okay okay now the signs and symptoms of Cushing&#39;s Disease you have to know this they will test this and knowing this list gets you what we call Two for the Money which means when you memorize this list you&#39;re actually getting two things number one you&#39;re getting the signs and symptoms of Cushings and number two you&#39;re getting all the side effects of steroid medications so when you memorize this one list you&#39;re getting two things Cushing signs and symptoms and side effects of steroids any drug ending in some some so that&#39;s good for a lot of reasons now I am going to have you remember this by drawing a picture of a little man and I&#39;m serious I want you to draw this little guy over and over and over again until you draw him perfectly because if you can if you can draw him perfectly guess what you know the signs and symptoms of and you know the side effects of any drug ending in s so here&#39;s what it goes now this man is called kushman okay kushman now I&#39;m going to draw a head but don&#39;t draw the head real big because you need a really space for a really big body okay so don&#39;t take up all your space with the head okay the first thing on the head is you need to draw a moon face okay he&#39;s got a moon face and you say oh I can&#39;t draw okay well can you do this that&#39;ll do okay so draw a moon face whatever your skill set is just draw a moon face because that&#39;s the first symptom moon face puffy moon face then draw a beard on him what&#39;s the fancy term for excess hairiness on the body close here sueism here sism that means lots of hair here okay next draw a real big body and I mean a big one put a bump on the front oh and a bump on the back put a bump on the front and a bump on the back now what&#39;s the bump okay let me ask you this first what&#39;s the what do we call the big round body obesity but a certain type of obesity TR trun or central obesity they&#39;ll call it cuz see your arms and legs aren&#39;t aren&#39;t fat it&#39;s just your body your arms and legs are actually really skinny so it&#39;s trunkal or central obesity that&#39;s the big body what&#39;s the bump on the front no no that the buffalo hump is the bump on the back cuz buffalos have a bump on on their back so that&#39;s the buffalo hump right there this is the gy comasa gy co mtia those are female tight breasts on men and we&#39;ll start on page 35 lab values you have to know your lab values but the good news is you don&#39;t have to know them all just certain ones that everybody else knows the only well there&#39;s kind of more bad news and that is not only do you have to know lab values but you have to know which lab values are more dangerous than what other lab values so if you knew 10 lab values you need to know which ones are high priority which ones are middle priority and which ones are low priority because they will ask you to priority I people according to their lab values like they&#39;ll give you four different patients a patient with a pottassium of 7.4 pessan with a pH of 6.8 a person with a hemoglobin of 10 and a person with a bu of 54 and they want to know who&#39;s your highest priority patient that kind of thing so it&#39;s not good enough just to know the values themselves because they will give you four people all of them have AB normal lab values all of them do so what you have to do is then rank them you know and who&#39;s highest who&#39;s lowest priority so what I want to do is teach you that because I don&#39;t believe any school I know of teaches students how to prioritize lab values they teach you the lab values they teach you the numbers the ranges what&#39;s normal what&#39;s abnormal they teach you what high means what low means they teach you the significance of the test but they don&#39;t teach you that a hemoglobin of seven is a higher priority than a person with an INR of 3.4 do you see what I&#39;m saying they don&#39;t they don&#39;t get to that now does am I mistaken are some schools doing that are any schools doing thatan they just say pan is bad that&#39;s probably probably on board that&#39; probably be the least you should know at least that but well I&#39;m going to give you a a scheme here you see the legend at the top of the page where it says ABC d a means that it&#39;s not a priority I mean it&#39;s a low priority it&#39;s not a big deal yes it&#39;s abnormal the ab the lab is abnormal but really there&#39;s nothing you need to do about it in fact in real life if see what I&#39;m going to do is let me let back up what I&#39;m going to do is I&#39;m going to for every lab value I give you I&#39;ll tell you whether the abnormal is an a a b a c or a d I&#39;ll assign a priority letter to it are you understanding where we&#39;re headed with this and when I tell you that a lab abnormality is a level a what I&#39;m trying to communicate to you is that yes it is abnormal and yes it could mean there is the presence of disease but in the scheme of things this is really no big deal in fact you don&#39;t have to do anything about it in other words if a lab report came back and it&#39;s an a level you could ignore it all night long and have the doctor Discover it in the morning and you wouldn&#39;t be in any trouble for having that happen do you understand what I&#39;m saying however if I tell you it&#39;s a c level level C letter c and you do nothing about it all night long and the doctor finds out about it in the morning you are in major trouble so I&#39;m trying to give you a feel for how important it is that you must report these or do something immediately so an a is abnormal yes but you do nothing about it it&#39;s no big deal a letter B it is abnormal and you need to be concerned but there&#39;s nothing you need to do you just kind of watch them closer have you had the experience where you had a lab value that was abnormal but it really wasn&#39;t all that bad so you didn&#39;t have to do anything but you but that lab abnormality said to you watch them closer watch them closer that&#39;s what I&#39;m trying to tell you A B is when I tell you that a lab value is a c we&#39;ve now crossed a line from low priority to high priority when a lab reaches a c value it is critical you must do something about it you can&#39;t just sit on that lab value and do nothing if I tell you that a lab abnormality is a d I&#39;m trying to communicate to you that it is the highest priority that you can possibly have with a lab value so what&#39;s the lowest priority followed by and then what are two high priorities C and the highest of all is D okay just so everybody know where we&#39;re headed here okay now let&#39;s start into this lecture in the First Column there&#39;s the name and anything I want to tell you about it in the middle column you&#39;ll write the range the normal range and in the last column we&#39;ll assign the a the B the c or the D all righty let&#39;s talk about creatinin I told you two days ago that it is the best indicator of kidney or renal function now in this case I am talking about the serum creatinin because they will not talk about they will not give you the values for a creatinin clearance 24 hour creatin clearance they aren&#39;t going to test you that on that but they will test you on the serum creatin now the serum creatin is 0.6 to 1.2 which is actually the same numbers as the lithium range if you recall that from yesterday the lithium and the creatinin are the same range okay in the middle column I you have that in the last last column an abnormal creatinin is just a level a you would never prioritize a person with a high creatinin as your highest priority now do they have kidney disease if they have a high creatinin yes but are they going to die in the next 4 hours no the next morning the doctor could come in and go oh his creatinine is high he must have kidney disease and that&#39;s fine you&#39;re not going to be in any trouble for it probably the only time that I would ever make a high creatinin something that I would actually make a phone call to a doctor about is if they were going for a test that had a diey in it that next morning like for example if they&#39;re having a cardiac catheterization where they put the Dy in if they if the question tells you that they&#39;re to have a die procedure in the morning I might make a high creatinin something that I would report but it wouldn&#39;t be in the next hour it would just be sometime like like for example if you got the high creatinin back at midnight I wouldn&#39;t call the doctor till 5: or 6:00 in the morning at the earliest I might wait till 7: I certainly wouldn&#39;t call him at 1: in the morning but there are certain lab values you&#39;re going to see you call them right away so this would even then it wouldn&#39;t be a super high priority but it would be higher than just a plain high creatin so everybody understand that okay the INR the international normalized ratio it monitors cuman therapy it&#39;s like the PT it&#39;s a variation of the prothombin time its normal range should be two and three in the twos and threes in other words you want your eyes and r i and rs to be in the twos and the threes like 2.1 3.8 that&#39;s what you want in the last column anything that&#39;s above four or four and above is a c which means it&#39;s high priority you have to do something this is not one you can ignore you can ignore the creatin but you cannot ignore this one an INR of 4.2 would defeat would be a higher priority than a creatin of 30 now when you when I assign something a letter C what do I say are the implications of that it&#39;s critical and you have to what do something now the question you should be asking is what&#39;s the do that I should do well whenever you get a situation where they want to know what are you going to do about something there&#39;s a protocol you need to follow an order because this would be a drag and a click and drag you always hold that&#39;s the first thing you do what do I mean by hold if there&#39;s something that&#39;s causing a problem stop it first first after you hold then you assess what would you assess a whole complete head to toe physical exam yes or nooc no a focus assessment focused on what the area that the lab value is telling you there&#39;s some problem with with but do a focused assessment then you prepare which means you prepare to give now you don&#39;t always give but you prepare to and after you prepare then you call meaning call physician or call respiratory or call whomever is is appropriate but before you call the physician you always hold assess and prepare now if we apply this to the INR of 4.7 let&#39;s say you get an INR of 4.7 and they want to know what are you going to do in what order and you have to click and drag what would be what would you click first hold hold what hold cumin hold all cumin then what would you do assess for what bleeding then you would vitamin vitamin K prepare to give vitamin K and then you would call your doctor in that order now sometimes there may be nothing to hold you what I&#39;m saying there&#39;s nothing to hold there&#39;s no nothing causing a problem so you jump immediately to what assess and sometimes there may not be anything to prepare so you jump to call but you should intellectually go through that process with everything you you do something about so that you&#39;re thorough so that you don&#39;t miss a step all right potassium potassium there&#39;s nothing I want to say about it in the First Column except that it&#39;s not really a good indicator of anything but it is an indicator that something&#39;s wrong but you don&#39;t know what its range is 3.5 and then flip it around 5.3 3.5 to 5.3 now for hessie for hessie it&#39;s 3.5 to 5.0 for hessie it&#39;s 35 5.0 but for boards it&#39;s 3.5 to 5.3 why why the difference Fords is a nationalized hessie uses whatever else severe lab book says okay so to hessie a 5.1 potassium is an elevation on boards at 51 is not an elevation now let&#39;s talk about the last column a low potassium meaning lower than 3.5 is a see you have to do something okay now let&#39;s go through our protocol if your potassium is low is there anything you have to hold no so what do you do but what are you assessing what&#39;s your focus heart assess heart prepare to administer Vitamin K Vitamin K potassium I always do that I always used to do that vitamin anybody ever do vitamin K and potassium K I screwed that up for like 10 years okay and then I what the call the dock all right what if it&#39;s between 5.4 and 5.9 that gets a c so now you have to do something well is it high or low high so what do you think we would first do hold all potassium and that may mean ripping down down the D5W with 20 of KCl I mean getting that torn down then you assess the heart then you what now Lasix does make you lose potassium but we don&#39;t give Lasix for the purpose of losing potassium kx8 and D5W and regular insulin remember yesterday exate and D5W regular insulin and then you call your dock however in the last column if the potassium is greater than or equal to six it&#39;s a d it is deadly dangerous this person could die soon like in the next 2 minutes so what do you do um you do everything we just said you rip down the IV you assess the heart you prepare the D5W regular insulin and the KX and you call your doctor you do all that what stat so how many people have to be involved you probably got one nurse ripping out the what potassium you got somebody calling for an EKG coming you one nurse is preparing the D5W and regular insulin while the secretary&#39;s calling the doctor stat do you see I&#39;m saying and you stay with your patient got it cuz you cannot leave the you can&#39;t leave the bedside of a d you understand what I&#39;m saying can you leave the bedside of a c do you even know what I&#39;m talking about D&#39;s and C&#39;s okay got okay um can you leave the bedside of a c yes yeah can you leave the bedside of a d no no so one of the things you&#39;re going to have to remember when you&#39;re answering these D questions is you stay at the bedside and you do what you can do at the bedside but everybody else helps you do everything else you don&#39;t run out and get the EKG and leave your patient by themselves with a potassium of seven okay now I&#39;m not saying you do this in real life you should do it in real life but I&#39;m saying this is what the book wants you to do and really if you really did this you would you wouldn&#39;t get in trouble your patient would be in good shape okay um the pH 7.35 7.45 is the range which you told me the other day in the last column the only thing that matters is a pH in the sixes is a d now I don&#39;t mean 7.6 I&#39;m talking about 6 something in the sixes now you notice that I don&#39;t do you notice with the creatinin I didn&#39;t go I didn&#39;t talk about a low creatin did you notice that and in an INR I didn&#39;t talk about about a low INR and here I&#39;m not talking about a high pH because those aren&#39;t that clinically significant and they&#39;re not usually tested at all you I&#39;m saying these are the things that are tested over and over and over again so rather than have you learned everything let&#39;s focus on what&#39;s essential all righty pH in the sixes so what do you do is there anything to hold I can&#39;t think of anything what would you assess this is interesting what do you think you&#39;d assess somebody said respiration somebody said pulse V there you go lump them together check your Vital Signs because the pH is going in what direction down and as the pH goes Pati so goes your patient so the patient is going to be going what down and out and you check it I mean with the pH is in the 60s to be to transparent and honest with you you&#39;re doing the vitals to make sure they&#39;re still alive I I know that sounds ridiculous but you really are CU I mean they usually when you have a six you&#39;re dead so you&#39;re just making sure they&#39;re alive and then is there anything to prepare not really used to be years ago because they were severely acidotic we would prepare bicarbonate to give bicarb but you don&#39;t do that anymore you don&#39;t indiscriminately give bicarbon like if you&#39;ve ever been taught that no you don&#39;t do that you don&#39;t give bicarbon anymore to acidotic patients because it can fuses the whole issue the key is to correct this acidosis the only way you can correct it is to treat the underlying cause and there is nothing a nurse can do to treat the underlying cause the physician has to get here determine the cause and treat the cause so with a low PH you have to get the physician in on the case faster than anything else we&#39;ll talk about today so that&#39;s why you just assess their Vital Signs and you call your Dock and you skip hold and you skip prepare now why are you getting the vitals Tri life cuz when you call the doc what are they going to say is he alive you know is he brail what&#39;s his heart doing you know so get a set of Idols that&#39;s all you need set of Idols call the doc and you stay so who gets the vitals you do who calls the doc maybe some you know get a put on the light or whatever and however you communicate to your secretary unit secretary and have them call Stat okay bu blood Ura nitrogen bu it has a lot to do with waste nitrogen waste products in the blood its range is 8 to 25 8 to 25 the way I remember that is BU n spells what English word bun buns like hamburger buns hot dog buns when you buy hamburger buns or hot dog buns how many are in the pack eight eight there&#39;s your eight buns eight 8 to 25 and if the bu is elevated you it&#39;s no big deal all you do is assess them for dehydration assess them for dehydration by the way a little hint good guessing strategy here if they give you an elevated blood value and you have no clue what&#39;s going on and they ask you for what would you assess them dehydration is a great answer because when you dehydrate what happens to all blood values they go up because of concentration so it&#39;s just a really good good guess to say when the bu ends up oh I don&#39;t know what it is well pick dehydration good answer you may be wrong but it was a good answer might not have made the top 10 survey but you know it&#39;s not bad I don&#39;t know why I had an extra L on the end of elevated but you know hemoglobin is the next one it&#39;s 12 to 18 now it&#39;s yeah I know it&#39;s 12 to 16 for women and 14 to 18 for men but for humans it&#39;s 12 to 18 and Boards doesn&#39;t get into lab values vers men versus women children versus adults new BNS versus they they could be on your test but those are really hard questions and you do not have to get those right but if you don&#39;t know a normal adult hemoglobin you&#39;re in trouble if it&#39;s 8 to 11 if the hemoglobin is 8 to 11 it&#39;s a b and you would assess them for what low hemoglobin anemia a bleeding or malnutrition if the hemoglobin however Falls below an 8 it&#39;s a c and you must do something okay well what are you going to do you going to hold anything not that I know of you&#39;re going to assess for bleeding you&#39;re going to prepare to administer blood and you&#39;re going to call the doctor now LPNs you would you would prepare but you would call not on this but on everything where we&#39;ve said call Doctor you could substitute notify RN do you see what I&#39;m saying you could whever this could say hold assess prepare notify RN all right um buy carb the buy carb is what 2 + 2 + 2 = 6 right 2 22 to 26 and an abnormal by carb is an a we don&#39;t care so what you know I&#39;ve never in 37 years of being a nurse I have never been yelled at by anybody because I didn&#39;t tell them what somebody&#39;s bicarb was it&#39;s just not a major issue okay CO2 carbon dioxide this is in this you are getting from an arterial blood gas by the way the normal range is 35 to 45 it&#39;s the same as the pH just dropping off the 7 point correct in the last column a CO2 that&#39;s high but in the 50s like 51 57 56 59 those are C levels those are that&#39;s a c which means it&#39;s critical you can&#39;t just sit on it you got to do something about that that&#39;s not good now on I want to say a disclaimer I&#39;m not talking about COPD clients here at all that changes everything this is for people without COPD so what do you do well is there anything to hold a high CO2 anything to hold I don&#39;t think so what would you assess respiration respiratory status now when it comes to prepare on this one there is actually something you can do there&#39;s actually something you can independently as an LPN or an RN do what would that be okay breathing in a bag actually recirculates the CO2 so we don&#39;t want that that would be raising the CO2 what&#39;s that oxygen is used for low oxygen not for high CO2 down what&#39;s that down like on your I read that if you actually put your thumb in your mouth and blow oh yeah yeah yeah okay like like your yeah or they&#39;ll say the candle this is a candle blow out the candle that is called Pur lip breathing have you heard of that this is what you&#39;re going to pick first lip breathing because with P lip breathing you&#39;re you&#39;re prolonging the exhalation and if you prolong exhaling you&#39;re getting rid of CO2 now most of the time that will correct the problem so you never have to move to what call how do you know it&#39;s going to correct the problem they will breathe easier cuz when they&#39;re in the 50s it&#39;s going to be dnic they&#39;ll be dnic when there are co2&#39;s in the 50s so that will that will solve that problem however what of the CO2 is in the 60s that&#39;s a d that&#39;s one of the criteria for making the diagnosis respiratory failure have you heard of respiratory failure well how does how do you know someone&#39;s in respiratory failure well one of the ways you know is this the CO2 is 60 and above now here again we&#39;re not talking about cop deers so this is a medical emergency this is a super high priority patient so you do not what leave the room you stay with them so is there anything to hold in this case nope assess there respiratory status now Pate breathing isn&#39;t going to cut it now I will probably do it with them just to decrease their anxiety and maybe take the edge off of it but I&#39;m going to have to prepare for what two things CU they&#39;re in respiratory failure intubate and ventilate so you prepare to intubate and ventilate and then who do you call there&#39;s two people to call who do you call first respiratory therapy first call respiratory therapy first then call the physician but you stay with your patient yes at that youon like a code a pre code yeah um on boards they really don&#39;t have anything that&#39;s called an emergency response precode team they don&#39;t that&#39;s certain hospitals have that some don&#39;t and because it&#39;s not a universal phenomenon Across the Nation in every hospital they won&#39;t even go there but I would say if I were you and I had one of those teams in my at my disposal in a hospital yes at this point I would because this person is going to end up on event if and that&#39;s the best that&#39;s going to happen you know the worst could happen before so yeah all right uh hematocrit hematocrite is TW uh 36 to 54 36 to 54 now I don&#39;t remember that that&#39;s why I had to think for a few seconds before I said it I never remember that because that that&#39;s a clumsy number 3654 you know it&#39;s a sloppy well it&#39;s three times the hemoglobin so whatever the hemoglobin is multiply that by three and that&#39;s why I had to do the math in my head there for a second before I Told You So 12 * 3 is 36 and 18 * 3 is 54 so it&#39;s 36 to 54 okay an elevated hematocrite an an elevated hematocrite it&#39;s abnormal it&#39;s a b an elevated aat what would you assess for dehydration good job dehydration but it&#39;s no big deal okay let&#39;s talk about the oxygen level the P2 the oxygen level here again you&#39;re getting this from the arterial blood gas this is not what you&#39;re getting when you put on the pulse ox on their finger or their ear load that is not the P2 the po2 is from the blood gas now the P2 normally should be 78 to 100 78 to 100 is the normal range if it is low but still in the 70s like 70 to 77 that is a c which means you have to do something it&#39;s critical so is there anything to hold no you assess what respiratory now there is something you can do both LPM and RNs without a physician&#39;s order and what is that give them oxygen because their oxygen is low so now you give them oxygen and N9 times out of 10 what will happen will it correct it or not it will correct it and you will not have to call your physician and how will you know it corrects it because you&#39;re not having a continuous arterial blood gas measurement you&#39;ll know because the disia goes away and the restlessness and the anxiety and the TAC cardia by the way just just an interesting thing so that everybody so I know everybody knows this because they love to test this when someone is hypoxic which rate increases first the respiratory rate or the heart rate heart rate heart rate so when you go hypoxic your heart rate will speed up first first then when the heart can no longer compensate for it your respiratory rate goes up a lot of people think oh hypoxic your respiratory rate will go up first no it won&#39;t your heart rate goes up first if you ever work coronary care what are the two most common causes of episodic tacac cardia in heart patients hypoxia and dehydration so a coronary care nurse knows that when you get these episodic Tac of cardias all you have to do is increase the IV rate and give them some oxygen and it goes away and you never have to call your doctor I would have to say 90% of the time that I have episodic tacac cardia in the coronary Care Unit when I worked night shift there for 10 years it&#39;s at was at Mercy Medical Center in Springfield now called Springfield uh Regional whatever Mall um the uh I never had to call doctors because I would just up the IV rate or give them oxygen and i&#39; the T cardia go away you always could tell a new nurse who came into coronary care because they were calling doctors in the middle of the night for episodic tactic cardia and the doct could say well did you increase the IV rate no did you give them oxygen no well do that and call me me back if it doesn&#39;t work you know and that I&#39;m saying it politely okay okay well what if it&#39;s low in the 60s meaning 68 69 64 63 that&#39;s a d That&#39;s the other criteria for respiratory failure so what are the two defining characteristics for respiratory failure CO2 in the 60s and and O2 in the60s when they&#39;re both in the 60s that&#39;s when you need to intubate and ventilate them so if it&#39;s in the 60s there&#39;s nothing to hold you assess the respiratory status you prepare to intubate and ventilate you call respiratory therapy and you call the doctor now you can put oxygen on them during that time it&#39;s not going to solve the problem but it&#39;s going to make them a little more calm so if I had a click and drag on that one how would I put where would I put the oxygen I&#39;d probably do this I&#39;d probably hold I wouldn&#39;t hold anything I&#39;d assess well no I probably there&#39;s nothing to hold i&#39; probably throw on the O2 just to make them what comfortable then I&#39;d assess them and then I&#39;d prepare to intubate and ventilate call respiratory therapy and call the doctor yeah I always to always first and safe like any question no you&#39;re not that&#39;s a Gro for simplification okay she said that she was taught that you in an order question you always assess before you do and that&#39;s true 80% of the time 20% of the time it&#39;s wrong because there&#39;s something you need to hold before you assess for example uh you&#39;re giving a blood transfusion and somebody complains of itching and you see hies what do you do stop the blood then you do your assessment what about in this situation I would then that would probably that I&#39;m I don&#39;t think just in my impression I think if you asked 50 nurses you&#39;d have half and half on that and so I don&#39;t really I can&#39;t conceive that they would write that question on boards because it would be such an interpretive thing subjective subjective kind of thing but if if the INR is five every nurse says I&#39;m going to stop the cumin in and then I&#39;m going to find out a sex you know that they would all say that and if the pesum six they&#39;d say I turn off the IV then assess their heart okay that so yeah it&#39;s it&#39;s going to be there are certain things where I always tell people this assess before you do unless delaying doing puts your patient at higher risk and if you would assess for signs of blood Rea transfusion reaction both if you delayed stopping the blood to do an assessment of are they having a reaction you would be putting the person at increased risk so therefore you do before you assess does that so what&#39;s the rule everybody assess before you do unless delaying doing in order to assess puts the patient at risk for example a patient pulls out their arterial line they are bleeding in bright red spurts from their radial artery what&#39;s the first thing you do assess their Vital Signs apply pressure okay well ones assess ones do right well if you delay putting pressure in order to take a set of vitals are you increasing the risks of the patient yes therefore do will preed assess and that&#39;s an obvious one but I&#39;m I&#39;m trying to illustrate the principle are you seeing that yeah okay good good question I because that&#39;s one that everybody&#39;s taught how many were taught assess before you do assess before you do but you have to understand whenever you use a rule like that you have to understand there always an exception and what&#39;s the exception yes um not caral group always have a question or it would always catch us up and it was something about the ratory situation which you do first and it had head the bed yes oygen talking about the thing is is if I was between somebody&#39;s having dmia acute dmia one was Elevate the head of the bed the other was put on oxygen the other was uh call the doctor and the others do a respiratory assessment what would I do I would Elevate the head of the bed first all righty because if I do a respiratory assessment with him lying flat I&#39;m just it&#39;s just I&#39;m getting data that&#39;s not going to be helpful he&#39;s not going to cooperate with me I&#39;m not going to get good data not going to get full so I&#39;m going to elevate the head of the bed first I always like to do if I&#39;m between two dues I like to position first you know if I&#39;m between two does and one&#39;s a position and one&#39;s another action I find that the position usually wins over the other action how many have found that out sort of seen that so I would probably Elevate the head of the bed I would put the oxygen on I would do an assessment and then I would call The Physician now what did ATI say I wonder is that what ATI said because I almost always position first when I&#39;m between what two does I always position first and see my rule there would be would if somebody&#39;s in significant dnia and hypoxia would be would delaying putting their head up and delaying giving them oxygen while I did a respiratory assessment put them in greater risk and the answer is yes you would be you see so then I would precede the assess with the dues did do you see that yeah question so if you first what you do Bingo you&#39;re smart good job do you hear what she said she said but what if it&#39;s not a first question what if it&#39;s a best and you&#39;re between oxygen and rais head of B well in a best question and I&#39;m really glad are you here for a refresher or if you is this the first time you&#39;ve taken this class first time good job um because uh if you had to do one raise her head without giving her oxygen or keep her flat with oxygen she really will benefit better from the oxygen lying flat than she will up with no O2 so best would be O2 first would be raise head of B is everybody seeing that good call okay um the O2 set the oxygen set should be 93 to 100 anything less than 93 is a c critical there&#39;s nothing to hold you assess them you throw on the O2 now you could if I don&#39;t think with an seo2 unless they&#39;re in real real danger a low seo2 is not like an 88 there&#39;s no reason to throw on the O2 right away you know what I&#39;m saying I I don&#39;t there&#39;s no big deal there in fact I can&#39;t even believe I&#39;m telling you that an seo2 below 93 is that bad cuz I&#39;m happy with SE o2s of 88 and above if you think that you&#39;re going to run around calling doctors in the middle of the night for SE o2s of 91 you&#39;re not going to last long but on hessie particular and on boards if it&#39;s a 92 seo2 they&#39;re in bad shape and I&#39;m telling you that&#39;s not real love life but that&#39;s the book do you got me cuz hessie has a question on there where it says they give you poor patients I want to know who&#39;s your highest priority and I remember taking it in letter A was a patient with a 91 sao2 and I went oh that&#39;s fine you know and then I went to B and they were okay and I went to C and they were fine and I went to D and they were good too I thought oh my goodness they&#39;re all fine and I thought wait a minute wait a minute wait a minute 90 it&#39;s not 993 it&#39;s 91 so that&#39;s the bad the one that&#39;s in bad shape so I picked them I got it right so you&#39;re just going to have to go with that all right um now anybody ever want to work peeds no way in Pediatrics you better freak out when it&#39;s below 95 okay cuz little kids don&#39;t desaturate without older people we desaturate all the time you know it&#39;s just what we do um but little kids don&#39;t desaturated cop um they usually won&#39;t go to COPD because then that that anything could be there&#39;s no with COPD ear they&#39;re going to have abnormal blood gases but there&#39;s no pattern to tell you what it&#39;s going to be and how much of one thing means what you say like they can&#39;t say well you know for respiratory failure for a COPD or it&#39;s not 60 and 60 it&#39;s 70 and 50 there&#39;s no there are no parameters every COPD is their blood gases are individually judged on their level of functioning at that blood gas so if you have a COPD with a CO2 of 59 which it should never be and a O2 of 64 which is horrible but they&#39;re functioning okay then that&#39;s their Baseline do you see what I&#39;m saying and the hypercarbia is no issue because they don&#39;t have a hypercarbic drive tobr they have a hypoxic drive to breis so it doesn&#39;t even matter so that&#39;s the issue with a little hypoxia is good for a cop deer because it keeps them breathing that&#39;s why you don&#39;t want to give a lot of o2 to a cop de or they&#39;ll stop breathing on you so yeah I don&#39;t think that they could even ask a question that would be fair other than the fact to know that cop deers normally Run High on the CO2 low on the O2 so I guess I my question answer to you would be if they gave me four patients and they told me one was a cop deer with a CO2 of 55 and an O2 of 71 even those are those are letter letter c&#39;s for you and I I would not make them a high priority okay BNP oh by the way when is a when is your seo2 invalid what invalidates your finger probe seo2 reading what&#39;s that anemia anemia falsely elevates it so if somebody&#39;s anemic they&#39;re going to look a lot better than they actually are so when you if you have an anemic patient your sa2 is not helpful you need to look at other indicators of oxygenation the other thing that invalidates it is if they&#39;ve had a die procedure in the last 48 hours why what does the Dy do to blood color it and what does that read color so you&#39;re going to have falsely elevated S2s with anemia and after die procedures so in both cases you&#39;re going to when you get your sao2 you&#39;re going to think the patient is what better off than they actually are which is actually pretty dangerous okay BNP which is the brain natural utic peptide don&#39;t worry about that uh it&#39;s the best indicator of congestive heart failure it should be under 100 an elevated BNP is a b which just means you&#39;ve got congestive heart failure but you&#39;re not going to die you don&#39;t need to call the doctor in the middle of the night there&#39;s nothing you have to do just watch them for CHF see it sounds kind of funny that a heart value is not a high priority but this is a heart value because it&#39;s indicating a chronic condition you understand why it&#39;s not high priority because it indicates a chronic condition not an acute one sodium sodium is 135 to 145 if it&#39;s abnormal it&#39;s a b which means you assess if the sodium is high you assess for dehydration if the sodium is low you assess for overload remember hyper nutria hypon nmia the one with the E is dehydration the one with the O is overload however if the question tells you the sodium is abnormal and there is a change in Lo the priority of the patient shoots up to a level C and basically it&#39;s a safety issue at that point it&#39;s safety which brings us to the last three lab values yay you see why I didn&#39;t want to do this yesterday at 3:30 white blood cells there are three white counts you must know three white counts you must know the first one is the total white blood cell count which is 5,000 to 11,000 the other two are the a NC the absolute neutr pill count which needs to be above 500 there&#39;s no range here it&#39;s just a threshold limit you must have more than 500 anc&#39;s per cubic mm and the last one is the CD4 count and it needs to be above 200 CU remember when your CD4 Falls below 200 what do you have not HIV you got AIDS now so the the defining line between HIV disease and AIDS is the 200 CD4 if you&#39;ve got 201 you have HIV disease if you&#39;ve got 199 you have AIDS so all of those are low white counts and all of those are a letter C all of those below those levels ANC below 500 a white blood count below 5,000 and a CD4 count below 200 all of those are Level C&#39;s they all are and because of that there&#39;s nothing to hold you assess for signs of infection and instead of preparing what you do is you place them on these neutropenic precautions that are in your last column and it would be good for you to know those because they do test what&#39;s on the neutropenic precautions the one that I I mean I it&#39;s amazing how you could be a nurse for decades and certain facts you just never learned it was like 10 years ago after I&#39;ve been a nurse for 20 some years that I re learned uh the ninth wind I think it&#39;s the ninth wind down don&#39;t drink water that has been standing longer than 15 minutes I didn&#39;t realize on these neutropenic precautions they are not allowed to have a water picture if they want water you bring them fresh water that water isn&#39;t allowed to stand in fact the water bottles if they&#39;re unopened I think they&#39;re good for 4 hours if they&#39;re open they&#39;re good for an hour yes I um my leadership oncology I had patients with getting yes transpl I had patially two and the um neutropenic going to do like this patient the nurse and she had these patient he could only have one patient because exactly the precautions were so timly and rigorous and what did they what did they use for these the water bottles what did they use they you weren&#39;t allowed to have a water bottle open unless we you drank it right away and they had a special refrigerator that we were able to go like you couldn&#39;t just get them regular water we had to go to the BMC refrigerator which was always locked we unlock it get it out bring it to them watch them drink it throw it up throw it up so it wasn&#39;t even an hour okay I mean I think you have to 20 30 minutes let the PA drink it you know but there were certain and then we had to clean a room every like um I think it was every it either every 4 hours since you had to clean it down with this really special and they and so they can the point is they can really get more obsessive than this a lot more so this is sort of like the least you would do and this is so this is um see with balart transpant you got to be really really careful because they&#39;re really uh dangerous because what did we do what did we do to them we destroyed we total body radiation where you radiated all of their protection they have none zero I&#39;m surprised she had two I&#39;ve seen some with practically none okay so um neutropenic are really important okay platelets platelets I&#39;m not going to give you a normal range because I&#39;ve looked in five different books and they don&#39;t even overlap nobody knows what a normal plet count is I don&#39;t think but the key is What are the trigger values for thrombo cyop IC precautions or bleeding precautions and that is in your last column A platelet count below 90,000 is a c you need to put them on these these bleeding precautions and if the platelet Falls below 40,000 now you&#39;ll hear people say he has 40 platelets or 35 platelets they don&#39;t mean 35 they mean 35,000 so if they say his platelet count is three what do they they mean 3,000 they don&#39;t mean three okay now the ANC means what it says but this is usually in thousands and then red blood cells are 4 to 6 million red blood cells are 4 to 6 million and an abnormal red count is just a b it&#39;s no big deal okay now that&#39;s a lot of info here&#39;s what I want you to do with it memorize the 5Ds why should you memorize the 5Ds cuz those are the really high ones that if you don&#39;t know you&#39;re unsafe and you don&#39;t want to show that on this test so what are the five DS pH in the sixes not P car okay but there&#39;s one before that potassium in the so a potassium in the sixes a pH in the sixes got that now what are what&#39;s the next one CO2 in the 6s and then O2 in the 60s so a pH or a pottassium in the sixes or a CO2 or an O2 in the 60s so what pattern are you seeing already sixes and 60s you don&#39;t like and then what&#39;s the fifth one plet count of less than 40,000 those are your highest priority people nobody will beat them and Boards will not put those people against each other cuz it&#39;s not fair okay now what I would then do is learn all the Seas there&#39;s probably about a good eight of to 10 of them then I would not remember the priority on any of the other others why cuz that way if you don&#39;t remember them they are what priority low do you see what I&#39;m saying so just remember the high ons and everything else is low so remember your D&#39;s which I think are easy your 6s and 60s in the 40,000 and then your C&#39;s and probably what to do for them and then you you&#39;re good to go and I you really will be so much better prepared for the questions than anybody else sitting there you know so cuz everybody else is just going to what yes and say well potassium and then if it&#39;s not potassium they&#39;re dead in the water okay let&#39;s turn to something near the back of the book I want to get it done earlier cuz it&#39;s just a horrible lesson to do late in the day and that is Page 64 psych drugs we&#39;ll do this one then take a [Applause] break psychotropic drugs page 64 this is a big laundry list of Psych drugs that you have to know but don&#39;t panic because you&#39;re going to find that psych drugs even though the classes of drugs are different there&#39;s a lot in common between them and so you&#39;re not even though you may memorize 10 different classes there isn&#39;t going to be 10 totally different discreet pieces of information a lot of it&#39;s going to overlap which is nice and to start off with showing you this the note in the box is very important all how many does that mean all thank you all means all all Psych drugs cause low blood pressure and weight changes there isn&#39;t a psych drug made today day that does not lower your blood pressure and make your weight change now the vast majority of SE drugs will do what to your weight increase but Prozac and a couple others make you lose weight but even Prozac makes you gain weight in Prozac you can go either weight gain or weight loss weight loss is more common but you wouldn&#39;t rule out weight gain for Prozac either so if you really wanted to make it specific you could say all psych drugs cause low blood pressure and weight gain but you have to understand that proac and a couple others will also cause weight loss could cause weight loss if we just stopped right there you probably be do better on your Psy drugs because they like to test those Universal kinds of principles but let&#39;s not do that let&#39;s go into the major classes more specifically the first one are the phenazines this is an old class of drug speaking pharmacologically they&#39;re called the first generation antipsychotics or they&#39;re called the typical antis psychotics have you heard those words typical anticho first generation anticho those are your phenia Zen they all end in Zen z i n e which I love I think every drug should be that way I think every drug in a class should end with the same ending and should be the ending of the name of the class of the drug okay so all steroids should end in oid okay all calcium channel blockers should have Cal at the beginning of the name calcium you know what I&#39;m saying all beta blockers should have beta beginning in the name all F all benzo diazines should end in zapen you see what I&#39;m saying I I just think that&#39;s the way it should be and it isn&#39;t so we have to get over but anyhow this class it&#39;s great they all end in Zen like Thorazine stelazine phenazine hypine chlorpromazine hydroxyzine all those Zen are phenia Zen actions they do not cure psych diseases they just reduce your symptoms in large doses they are antipsychotics I remember this by saying we use Zen for the zany Zen for the zany so you see a drug ending in Zen what should you immediately think zany it&#39;s for an anticho for a crazy person in small doses they are anti-emetics have you ever given Compazine have you ever given feneran promethazine for nausea have you ever given uh Vil hydroxyzine for nausea but if you double the dose it will treat psychosis have you ever given thorine or psychosis if you cut the dose in half it will treat nausea letter C they are considered major tranquilizers major tranquilizers these are the big guns uh I&#39;m going to make an analogy here aminoglycosides are to infection like phenazines are to psychose tranquilizers okay I I should make it different antibiotics I mean aminoglycosides are to antibiotics like phenazines are to tranquilizers what&#39;s that mean they&#39;re both the big guns you pull these out when nothing else is going to work okay these major major tranquilizers have a major major side effect list in fact this has been the the the marketing dilemma manufacturers of these drugs have had for decades they they manufacture these drugs that really work well but they have this long list of side effects that really hinders their their marketability I&#39;m going to use the alphabet here to help you remember this side effects of the major tranquilizers a will stand for anti- energ primarily dry mouth anticholinergic dry mouth b stands for blurred vision C stands for constipation d stands for drowsiness anybody know what e stands for EP EP p ps extra paramal syndrome the thing that looks like Parkinson&#39;s extra paramal syndrome EPS like Parkinson&#39;s remember where they get the pill rolling and the Cog wheel rigidity and the shuffling gate and all that F I cheated I needed the f photos Sensitivity I know it&#39;s SP with a pH but I needed the F to work for me so photo sensitivity and then with the G I want you to put a little a in front of the G and write a granulo cytosis which means low white count so they have a dry mouth they have blurred vision they have constipation they have drowsiness they have the Parkinson extra parameters their their skin burns to light photosensitivity and they&#39;re immunosuppressed so that&#39;s the side effects of now those are all side effects not toxic effects what do you do when a patient displays a side effect what&#39;s the nursing action when a patient displays a side effect do you hold the drug no you teach the patient inform thect doctor and keep giving the pill when someone experiences a Toxic effect what&#39;s the nursing action hold the drug call the doctor immediately so for EPS would you call the doctor immediately and hold the drug no we have Parkinson&#39;s drugs like cenin and artane will give to them to treat the EPS the only problem is when you give Parkinson&#39;s drugs to treat the EPS do you know what two their major side effects are dry mouth and constipation so that gets worse but it&#39;s kind of a pain all right number five the nursing care is treating the side effects so what&#39;s the number one nursing diagnosis well they have blurred vision what&#39;s the number one nursing diagnosis related to blurred vision injury risk for injury safety right drowsiness what&#39;s the number one nursing diagnosis with that same thing extra paramal what&#39;s the number one diagnosis there same thing so what is the number one nursing diagnosis when a client is on a major tranquilizer risk for injury risk for injury safety issues number six is a vocabulary word I want you to know what the word decanate means decanate can come after the name of a lot of different drugs sometimes they&#39;ll abbreviate it they&#39;ll say uh thorine D or something D the d means deonate and what deonate means is after the name of a drug it means it is a long acting long acting sometimes it works for two weeks sometimes it works for a month one shot for a month it&#39;s an long acting I am form given to non-compliant clients in fact this is usually court ordered or could be court ordered what do I mean by that making yeah that probated the client and the judge ordered monthly Prix injections okay the it&#39;s court order so if the client does not come in to the psychiatrist office or the Community Mental Health Center for their prolix and shot because it is court ordered what can the staff at the clinic do put out a go contact the police who will put out a warrant because they&#39;re in viol violation of a court order and they will arrest them bring them in you stab their butt and they go home okay so that&#39;s the way it goes and the police just love that okay tricyclic antidepressives tricyclic antidepressants are an old class of anti-depressant and most of them have now been grandfathered into a new class of antidepressants called the nssr I which means what non selective serotonin reuptake inhib but you understand they were not invented as nssr I they were invented as tricyclic anti-depressants but chemically they&#39;re so much like the nssr that they&#39;ve sort of been grandfathered into that group they are mood elevators used to treat depression they are mood elevators happy pills examples of these are elville toonel avenil and desil elville tophill avenil desil elil tophill avenil desil it Rhymes they all rhyme you hear the rhyme I&#39;m serious about this I want you to put these on the 3x5 card I want you to tape them to your steering wheel and for the next 4 days every time you come to a red light or a stop sign I want you to stop texting and I want you to I want you to just say elville toel Avent till desel Lille toil ail desel elville toil Avil desil and after 3 or 4 days guess what we&#39;ll be forever linked in your brain elville toil Avil and desil now why do I want you to link those four because if you link the other three toil avantel and desil with elville elville is real easy to remember that eleville elevates eleville elevates well what&#39;s it elevate your mood so if you know eleville elevates your mood and you link toil avenil and desel with elville then you&#39;ll know toil avantel and desil are also mood elevators you see why I want you to link them so that you know what they do and tophill is a very famous one that they love to test what reason I don&#39;t know it&#39;s been decades since I&#39;ve given to now okay um fact I don&#39;t even know why they still test these drugs they&#39;re not given that much okay what are the side effects well Lille starts with the letter e so this group side effects use the alphabet but it only goes through the letter e a for anti energic primarily dry mouth B for blurred vision C for constipation D for drowsiness and E is Euphoria e p o r i a which means happy joy joy you know way too happy have you ever met anybody that&#39;s so happy it irritates you that&#39;s what this is what do you notice about that list it&#39;s very similar to the major tranquilizers but you don&#39;t have that extra parameter the photosensitivity of the a granular cytosis but the big thing they&#39;ll ask about these anti-depressants is you must take them for about 2 to 4 weeks before you get beneficial effects you take them for 2 to four weeks so do they work right away no so what&#39;s the patient going to say typically after one week of anti-depressant therapy what will they say it&#39;s not working and you need to teach them it&#39;s going to take a little while letter C the benzo diazines the benzos real famous everybody should know about the benzos the benzo diazines these are anti-anxiety meds they are considered to be minor tranquilizers as a opposed to what the Zen which were the majors the zeps are the miners number two they always have z p in the name Zep always so how do you tell a phenazine and zenine how do you tell a benzodiazapine z but both tranquilizers majors and minors the identifying syllable starts with what letter Z zeps and Zen are tranquilizers now the way I I remember that is in cartoons when somebody is tranquilized meaning they go to sleep what do they write on the page z z bunch of Z&#39;s right so if you want to put somebody to sleep give them Z&#39;s use the Z&#39;s what Z&#39;s the zeps and the Zen Z for the zany those are the what the majors and zeps are the minors uh the way I used to remember that when we were in school doesn&#39;t work as well for you guys cuz you&#39;re younger well back when I was in school uh the greatest rock band of all time was Led Zeppelin anybody ever hear lead zeppa who&#39;s never heard of lead zeppa oh wow I&#39;m still impressed you still have heard of it wow they must be in their wheelchairs still making music um it rock bands all those oh okay you mean that the game the game is bringing it all back okay yeah well I just remember Zeppelin we Zeppelin starts with what three Zep doesn&#39;t it Zep Zeppelin and we used to say what do you find at a Zeppelin concert a bunch of miners on tranquilizers so that linked what zap with minor tranquilizer so that we kind of remembered that okay um the Prototype is Valium diazapam lorazapam flu asaam chlorop Pam chloroxide they always have z in them indications they are are more than just minor tranquilizers these drugs are more than that yes that&#39;s their major use but letter A they can also be used as a preout to induce anesthesia letter B they can be used as a muscle relaxing letter C they&#39;re good for alcohol withdrawal D they&#39;re good for seizures and E they help people when they&#39;re fighting the ventilator they help them relax and calm down okay number five yes do they put the generic the brand name on um on boards they&#39;re going more and more for the generic used to be that they always put both about two years ago they started flooding the exam with experimental questions where they only gave generic name for drug cuz they were trying to find out which drugs is it reasonable to expect new graduates to know by just the generic and which ones would it be totally unfair to ask them by just the generic that happened a year and a half to two years ago it&#39;ll be two years this June so usually questions stay in the experimental phase for about 2 years maybe less so pretty soon all of those are going to start counting okay up until now I would have said no they don&#39;t count they&#39;re still in the experimental phase but it&#39;s been long enough that they&#39;ve been doing that that yes there probably will be questions on your board where you are given a drug just by its generic name and you have to know what it is that&#39;s why I&#39;m trying to do phenazines benzo asip Calum Channel BL you know I mean deines SS you know those kinds of things so that you learn the generic names the M rather than the actual trade now don&#39;t panic because if the only questions that that have generic name only the only questions that have made it into the the test pool are ones that are reasonable to expect a new graduate to know so it&#39;s not going to be one that you probably wouldn&#39;t know it&#39;s probably going to be one you would know anyhow like aamit okay or Warfarin or madine or aceta salicilic acid or you know those are you should have known what all those were what was Warfarin cumin what&#39;s uh acetamin what&#39;s aetos salicylic acid what is madine Deon so those are things that you need those ones would be like there they probably won&#39;t say something like uh I doubt that they would say pantozol they&#39;ll probably say protonics or protonics pantozol you see what I&#39;m saying so yes there&#39;s a big Trend to make it generic only and I don&#39;t like that I think that&#39;s stupid I don&#39;t understand the point of it you know uh cuz you always look a drug up so I don&#39;t understand why that&#39;s you know what&#39;s unsafe for nursing practice is not looking up a drug not having the PDR memorized you see so I don&#39;t know I don&#39;t know where they&#39;re headed with it but I&#39;d like you to really from now on if you work learn your generic names learn your generic names call them by their generic names until you take your boards then you can call it whatever you want yes oh I thought just praising the Lord I didn&#39;t know if that was it okay um number five they work quickly but you must must not take them for more than 2 to 4 weeks how many of you know people that have been on value for years that&#39;s not what the FDA ever approved so what&#39;s the relationship think about this what&#39;s the relationship between an anti-depressant and a minor tranquilizer you take weeks right so one takes how long to work two to four weeks and that one you can be on for how long rest of your life however the other one works right away but you can&#39;t be on it for longer than 2 to four weeks so if somebody comes in anxiously depressed they&#39;ll throw them on both an anti-depressant and a minor tranquilizer at the same time on admission why what&#39;s going to make them feel better right now the minor tranquilizer but somewhere in the next two to four weeks what&#39;s going to kick in they&#39;re anti-depressant and then you pull them off the minor tranquilizer and they go home on the anti-depressant so stay on your tranquilizer until your anti-depressant kicks in uh another analogy can I Pi another analogy for you heprin is tumin as a tranquilizer is for an anti-depressant heprin is to cumin as a tranquilizer is to an antidepressive did you get the analogy Hein Works how fast right away but you can&#39;t be on it for very long cumin takes longer to work but you could be on it for the rest of your life and you&#39;re only on your heer until your cumin in kicks in well that&#39;s the same relationship between a tranquilizer and an anti-depressant okay Turn the Page let&#39;s talk about the side effects AB B C D do I have to repeat them or can you write them down anti drve mou and gation and FL fish ABCD and the number one nursing diagnosis is because it&#39;s a tranquilizer safety injury are you seeing anything different from the major versus the minor just a few side [Applause] effects okay which brings up the monine oxidase Inhibitors the MAO inhibitors these are anti-depressants I don&#39;t understand why they&#39;re still being tested on boards it has been 17 years since I gave one of these and it&#39;s not cuz I didn&#39;t work site cuz I did and I held I taught site clinical too so I mean so I don&#39;t know why they give them now they still give them in in Veterans Administration hospitals you&#39;ll see the most likely place you&#39;ll see an MAO inhibitor given is a Veterans Administration Hospital why and they&#39;re dirt cheap dirt cheap compared to the other anti-depressants you can buy a month&#39;s worth of Meo inhibitor for the price of three days of Prozac you know they&#39;re pennies they cost pennies per pill now number two tells you how they work you can just read that yourself it&#39;s not a big issue but the drug names you need to spot an MAO inhibitor when you see it now you&#39;re going to spot it from the beginning of the name not the end of the name the beginnings of the names all rhyme they are Mar Nar and par marar par Mar plan Nar Dill parnate you see it there Mar plan naril parnate now the only problem with marar par is that is their trade name not their generic okay but I&#39;ve not I&#39;ve not seen a lot of generic names on these unstandardized tests almost every standardized test I ever see has the mar the Nar and the par there side effects write it down but the number one thing they test is on page 67 patient teaching do you remember these drugs letter A to prevent severe acute some times fatal hyper tensive crisis hypertensive crisis high blood pressure hypertensive crisis the patient must avoid all foods containing tyramine remember this one this is that diet that they&#39;re not allowed to have certain foods I saw this once and I was the one that took the blood pressure in the ER and I got 300 plus over 220 and the only reason why I wrote 300 plus was back in 1978 our manometers only went up to 300 so who knows what it really really was but it was three I wish I had had had a dynamap back then but they weren&#39;t invented yet um see when I went when I was a nurse all we had was metal IV needles we never had the plast the we had metal needles stuck in people for try to get somebody through a shift without a metal needle infiltrating well you care okay um so you have to know what foods have tyramine which foods they&#39;re not allowed to have they test this all the time every time I try to pull this out of my lecture somebody says it was on my test and I okay put it back in okay here are the foods you&#39;re not allowed to have in the fruit and veggie food group generally speaking fruits and veggies do not have tyy so these people can eat all the fruits all the veggies they want till the cows come home it&#39;s no problem just have at it however there are three fruit veggies that they&#39;re not allowed to have and I always say remember the salad bar b a r the salad bar B for bananas a for avocados and R for raisins which actually stands for any dried fruit they&#39;re not allowed to have any dried fruit now be careful cuz on C certain tests including the boards they&#39;re very likely to talk about guacamole which is what avocado see they always do that kind of thing where you almost have to be a cook to know what&#39;s in Foods uh but guacamole now number two grains are fine they can eat cookies pie cakes breads no big deal Meats they&#39;re not allowed to have organ meat so no liver kidney tripe intestine brains heart lung tongue no preserved Meats which means nothing smoked dried cured pickled or anything like that now they&#39;re not allowed to have hot dogs and certain processed lunch meats why what&#39;s on what&#39;s the last thing in the label on a hot dog and other assorted Parts which means heart lung tongue kidneys brains intestines the whole Sho match now I my entire family back one generation is Slovak my grandparents and my dad were not born in America so I&#39;m first generation American but in Slovak we ate Slovak foods and I heart tongue lung soup you know all that fantastic stuff and uh heart and tongue are great fantastic um back in when I was in high school the big rage in the 60s was to steal other kids&#39; lunches and eat them no one would touch my lunch I could leave my lunch out as long as I put mark clck on and nobody would touch that bag CU they never knew what was in it okay Dairy they&#39;re not allowed to eat cheeses except for cottage and mozzarella now there are a few other cheeses they are allowed to have but bards just really wants to know can they eat mozzarella can they eat cottage cheese yeah so those aged cheeses are no good for them and also they&#39;re not allowed to have yogurt this is probably the only diet where yogurt&#39;s bad and then number five uh I know this is not a food group but for some of you it is no alcohol or chocolate Okay um so no alcohol which rules out Elixir tinctures no caffeine which rules Out Chocolate licorice soy sauce all of that that so those are the things they&#39;re not allowed to happen and B teach the patients not to take overthe counter meds when they&#39;re on an MAO inhibitor have you ever read drug labels at a drugstore what are they all say don&#39;t take if you&#39;re on ano inhibit classic okay lithium we talked about it a little bit yesterday didn&#39;t we notice it&#39;s an electrolyte like potassium magnesium calcium isn&#39;t lithium on the Periodic Table of chemistry second row First Column Li I lithium it&#39;s used for treating bipolar disorder because it decreases what what did I say yesterday Mania it does not treat what depression it decreases the Mania you&#39;re going to find out that of all Psych drugs lithium is the most unique because its side effects are not a b c d or any variation thereof the reason is is all other psych drugs all other psych drugs other than lithium are what I called neurotransmitter Messer Withers okay they have their action by what altering neurotransmitters this drug is the only St drug which does not mess with neurot transmitters it stabilizes nerve cell membranes so because it has a unique action it will have a unique set of side effects and its side effects will act more like an electrolyte so it will have the three p&#39;s pein poopin and paresthesia peing poopin and paresthesia why paresthesia why will this drug have paresthesia as a side effect what did I say yesterday about electrolytes the earliest sign of all electrolyte imbalances is numbness and tingling paresthesia so if you give somebody large doses of lithium and make their lithium High first thing is numb and tingling now what do you do if someone on lithium is PE and poopin and paresthetic give the drug hold the drug call the doctor don&#39;t call the doctor which ones give and don&#39;t call you can tell him later on when he comes in however number three toxic effects what do we going to do with these hold and call okay Tremors a metallic taste and severe diarrhea Tremors a metallic taste and severe diarrhea those are the toxic effects now letter A should actually be pulled out to the margin it really doesn&#39;t belong under toxic I I need to switch that number one Intervention when someone is on lithium is increase fluids the number one nursing intervention when someone is on lithium is make sure these people get ample fluids why what are they doing all the time peeing and pooping which makes them lose fluid which makes them high risk for fluid volume deficit dehydration so what are you watching what other blood value are you watching dehydration what other blood value you watching sodium okay number letter B if they are sweating like they&#39;re outside working that they say you got a lithium patient he&#39;s maniy and he&#39;s out re-roofing everybody in the neighborhood&#39;s house you know because they get that way when they get maniy and it&#39;s 90° and they&#39;re sweating like crazy don&#39;t give them free water give them like Gatorade or some electrolyte solution because you you&#39;ll be in real trouble CU you you have to have a normal sodium for lithium to work number four note lithium is closely linked to sodium so when you&#39;re on lithium you must monitor the sodium levels low sodium makes lithium more toxic high sodium will not will will make lithium ineffective so if sodium&#39;s low lithium&#39;s toxic if sodium&#39;s High lithium won&#39;t work so the only way lithium will work is if sodium&#39;s what normal that&#39;s why in addition to monitoring the lithium level you got to monitor the sodium level otherwise you don&#39;t know what you&#39;re doing so watch that sodium level when somebody&#39;s have have his his own lithium they&#39;re called competitive binders have you ever heard of that term okay proac everybody&#39;s favorite drug Prozac is a selective serotonin reuptake inhibitor it is similar to elville the non-selective serotonin reuptake inhibitor so the same set of side effects belong so what are the side effects for Prozac A B C D and Euphoria however number three is more what they&#39;re going to test proac causes insomnia so give it before noon do not give Prozac at bedtime not a good idea number four when changing the dose of proac for an adolescent or young adult watch for increased suicidal risk what age group at L it&#39;s in young adults only now if I were on Prozac and the doctor changed my dose of FR act would you have to watch me for increased suicid liation yes or no no because I&#39;m not an adolescent or a young adult I may look it but I&#39;m not um you think that&#39;s true you need glasses the other thing is what if an adolescent is on proac does that make them increased risk for suicide no it&#39;s only when you you change the dose so you have to have both in order to say there&#39;s increased suicidal risk you have to have recently change the dose and they have to be an adolescent or a young adult if you change my dose it wouldn&#39;t be increased risk and if you kept their dose the same it wouldn&#39;t be a risk it&#39;s only when you change the dose for an adolescent which brings up the last three drugs then we&#39;ll take a break how doll My Favorite Drug I love how doll give me a how doll and a dark gun and I&#39;ll be happy and psych all year long it has a decanate farm form which means what long acting I am that you can zap somebody with it&#39;s basically the same as Thorazine so what are the side effects a b c d e FG this is also called a typical first generation antipsychotic just like the Zen are it&#39;s the old drugs the old antiyoy the big thing they&#39;ll test with Hol is nms and you must know nms do not go to boards not knowing what nms is elderly patients and young white schizophrenics Also may develop nms from an overdose of Hol nms is neuroleptic malignant syndrome it is a potentially fatal hyperpyrexia that word hyperpyrexia means fever with temps of potentially 106 to 108 certainly over 105 but you know I mean it could start at 102 but it&#39;s going to go up way up therefore the dose for elderly patients should be half the adult dose but the big thing they&#39;re going to do how they&#39;ll test this is this nms also has has some Tremors with it and an anxiety and Tremors EPS has anxiety and Tremors with it and you get EPs and nms with the same drugs so bores is going to want to know do you know the difference between EPs and nms EPS is a side effect no big deal nms is a medical emergency huge big deal patient could die so they&#39;re going to want to know do you know the difference between EPs and nms CU one&#39;s a big deal and one is not how do you tell the difference between EPs and nms take a temperature which any LPN and any nurse RN could do without a doctor&#39;s order so there&#39;s no excuse for any nurse missing EPS versus nms so if they tell you that you&#39;ve got a patient on one of these major tranquilizers and he&#39;s having Tremors and anxiety and confusion what would be the first thing you action you would take temperature take their temperature and if it&#39;s 102 1034 what do you do immediately call Squad if you&#39;re in a nursing home or a psych fa if you&#39;re in an Hospital call an emergency response them you know what I mean it&#39;s it&#39;s going to be a bad situation yes so temperature above 102 I would say yeah I even though classically it&#39;s the 106 to 108 range you if it&#39;s over 102 you call that you l in half the time when you call 102 they&#39;re going to be okay so you have to call them even though you know that not everybody with a 102 is going to be actually in mms you can&#39;t it&#39;s so lifethreatening you have to do it that actually happened to us uh La uh last spring when I was a nursing instructor at a certain hospital with some Cedarville students we had a guy that was just oh just I nervous Reon the N patients were saying he&#39;s not himself he&#39;s not himself the nurses were and they were trying to figure out what was wrong what&#39;s wrong what&#39;s wrong and so I told my student I said go measure his temperature you know so the student went meas temperature was 102.8 so we called the doctor came in got everything said and I I&#39;m thinking you know why didn&#39;t these nurses do this but sometimes you forget those basic kinds of things when you&#39;re a nurse you&#39;re thinking about a million things so you do see it and it&#39;s common all right how doll number three there are safety concerns related to the side effects I love how because if somebody comes in the ER and they&#39;re acutely psychotic and they&#39;re tearing the place up and they&#39;re wild and crazy hit them with some how doll and then what we like to do although I never have done this officially although unofficially I&#39;ve done it all the time um it&#39;s fun to take bets on when they&#39;re going to hit the floor 5 minutes 10 minutes 20 minutes because it&#39;s almost it&#39;s almost have you ever seen those uh Wildlife shows where they shoot the rhinoceros in the rear end with a dart gun you know and it runs around and then all of a sudden what&#39;s it do you know like that well that&#39;s what happens to these guys they they run around and all of a sudden they go bam and they hit you know it&#39;s kind of fun to watch no it is I don&#39;t make a good sers cuz I find things way too entertaining um and I&#39;ve got lots of advice and you&#39;re not supposed to give advice or think things are funny sorry they are funny sometimes okay clauser real clauser real claw upine what&#39;s the big danger with this drug name wise name wise look at the name what&#39;s the big danger with the name zap Za a p which if you&#39;re not careful you think says what Zep Z and you&#39;ll miss what this drug is question is there medical emergency with the NS would you like hit with like no just you just stay with your patient there&#39;s not much you can do just make sure the vital signs are stable you&#39;re with them the squad comes and then they&#39;ll manage the medically at the at the hospital many people die because there&#39;s not a whole lot we can do for it you know we just you know it&#39;s not a good thing clauser real Claus aine these are this is the Prototype do you know what I mean by prototype what do I mean by prototype the original first this is the original first second generation atypical anti- psychotic this is the new class for the zany number one it is used to treat severe schizophrenia which the Z it was meant to replace the Zen and hog it was originally de developed to replace the Zen and the hll and it looked real promising at first because it had an advantage number two it had an advantage it does not have the side effects a b c d e or F now it can have slight effects like that but but very very minor compared to the Zen and how patient doesn&#39;t even notice usually so originally we thought this was going to put the Zen and how doll out of business but then after it was on the market for about 6 months we started to see a problem and what was that problem number three no I mean number two the disadvantage it does have the side effect a granulocytosis in fact this drug is horrendous in trashing your bone marrow your white count can fall horribly low and you can get unbelievable infections from being on this drug so they really so they they then tried to they altered the formula came up with different drugs like Geodon Abilify Zyprexa alanine and all of those and those are variations of this clauser and they are some of them are less likely to mess up your white count some are just as bad the thing is is that not everybody gets the low white count when they&#39;re on these drugs so the the upshot is some people can take this drug and some people can&#39;t but the big thing you got to know is with any of your atypical Antico white count is a big deal measuring the white count is a very important nursing monitoring [Music] function the only thing I do want to say is I want to say something about Geodon Geodon has a black box warning which means a fatal drug situation and that is Geodon prolongs the QT interval and can cause sudden Cardiac Arrest godod Dawn prolongs the QT interval and C can cause sudden Cardiac Arrest therefore you shouldn&#39;t really use Geodon with people with heart problems in general your second generation atypicals end in the ending z a p i n e zapen so once again a tranquilizer glass ends in a z so you have your Zen what are your Zen what are your zes typical oldtime anticho what are the zines second generation atypical new anticho and what are the zeps the minor tranquilizers okay so Zen zapen and Zep are all your tranquilizers ones in Old Major new major minor did you got that can you match them minor old major new major Zep zapin and Z okay the last drug zolof they are loving zolof and they will call it caline zolof it&#39;s another SSRI like proac it also causes insomnia but you can give it at bedtime but the big thing they are now testing more and more with caline is the interactions has anyone ever heard of the cytochrome p450 system in the liver what is it responsible for cytochrome p450 system in the liver it&#39;s the major enzyme p pathway by which drugs are broken down and deactivated in the liver you remember how drugs are detoxified deactivated in the liver well the cytochrome p450 enzyme system does that you don&#39;t have to write this down zoff caline is notorious for interfering with that system the cytochrome p450 system so what does it do when you take other drugs increases toxicities because they aren&#39;t broken down so so the reason why boards and other ons are testing caline is because when you&#39;re on caline other drugs don&#39;t get metabolized and you have problems with two high levels of the other drugs so when you add caline to the drug regimen of a patient what do you probably have to do with all the other drugs they&#39;re on lower the dose okay so let&#39;s talk about this number three watch for interaction with St John&#39;s wart this herbal preparation that people people are taking right now if you take St John&#39;s wart and cine together you&#39;re going to get serotonin syndrome which is a potentially life-threatening problem it looks a lot like those Mao guys that eat the tyramine looks a lot like that so what are the symptoms I remember the symptoms from sad head s for sweating a for apprehension D for dizziness and heada a so they sweat they&#39;re apprehensive they&#39;re dizzy and they have a headache now apprehension is often called an impending sense of Doom have you heard of that that&#39;s what we mean by apprehension but the big one is it&#39;s interaction with Warfare and cinin and that is when you&#39;re on caline and cinin you&#39;re going to bleed out you got to reduce that cumin so watch for increased bleeding when they&#39;re on cumin and ceraline watch for increased bleeding because the cumin is going to go toxic all right take a break come back at 5 after we&#39;re getting [Music] there [Music] [Music] I before [Music] lunch I&#39;ve been trying page 41 the mother of all lectures maternal newborn overview oh by the way uh try to come back after lunch because after lunch we I actually do the most important review in the whole lecture in the whole review is this afternoon so don&#39;t you know what I mean it really I mean it&#39;s critical that you be there for that okay maternal newborn overview pregnancy uh you must be able to calculate a due date if you can&#39;t calculate a due date you&#39;re in trouble because everybody else knows how to do it so here&#39;s how you do it take the first day of the last menstrual period the first day of the last menstrual period add 7 Days subtract 3 months now you can do it another way but that&#39;s if you don&#39;t have a way that&#39;s a good way so I&#39;m going to give you a date and I want you to figure the due date and then talk to your buddy her last menstrual period was June 10 through June 15 her last menstrual period was June 10 through June 15 I want you to figure R do day and then see what your buddy said June 10 for June okay what do you say March 17 exactly because you got to start with June 10 because that&#39;s the first day of the last semester period add seven that&#39;s 17 subtract 3 from 6 is three that&#39;s March all right so that&#39;s how you do that letter B the weight gain you need to know how much weight a woman should or should not have gained do not worry about multiples don&#39;t worry about women that are underweight or overweight to begin with they don&#39;t go there they&#39;re just talking about an average typical pregnancy which no one has but the book describes okay the total weight gain for pregnancy is PL 28 lb plus or minus 3 28 lb plus or minus 3 that&#39;s the total weight game and here again we&#39;re not talking about multiples and we&#39;re not talking about women who are under or overweight to begin with number two in the first trimester she gains one pound each month one pound each month how long is the first trimester three months so she gains a total of 3 pounds in the whole first trimester so there&#39;s not much weight gain in the first trimester so if they give you a woman who&#39;s had fairly significant weight gain in the first trimester that&#39;s bad because you really should not be gaining much weight in the first trimester maybe 3 lb in the second and third trimester she&#39;s gaining much faster she&#39;s gaining one pound per week so how do you calculate because here&#39;s what you have to be able to do on your licensing exam if they give you a woman in a particular week of gestation you have to be able to predict what her weight gain should be for example what if they ask you this question a woman&#39;s in her 28th week she has gained 22 lbs what is your impression and then a says she&#39;s just fine B says she&#39;s underweight C says she&#39;s overweight and D says well she could be either way so do an assessment she gained 22 she&#39;s at 28 weeks how many of you know the answer know it how many don&#39;t know the answer how many aren&#39;t sure how many aren&#39;t voting okay the answer is I&#39;m going to show you an easy way to get that answer easy easy way here&#39;s how you do it how do you calculate a woman&#39;s eye ideal weight gain do you see the chart there we&#39;re going to fill in the chart at week 12 that&#39;s the end of the first trimester how many pounds should she have gained three so put three at 13 weeks she gained another week so she gained another pound for a total of four total of four to that point 14 another week another pound for a total of five 15 another week another pound for a total of six 16 another week another pound for a total of 7 17 another week another pound for a total of eight 18 another week another pound for a total of 9 19 another week another pound for a total of 10 20 another week another pound for a total of 11 do you notice how every time she gains a week she gains a pound now what is the constant mathematical relationship between the top row the weeks and the bottom row the weight gain a difference of nine a difference of nine take every top number and subtract nine from it what do you get the bottom number 12 - 9 is 3 13 - 9 is 4 14 - 9 is 5 14 - 15 - 5 is 6 16 - 5 is 7 17 - 5 is 8 18 - 5 9 I&#39;m saying five you know what I mean so if you want to know the ideal weight gain for a pregnant woman what do you do take the weak adj just and subtract n and that&#39;s what she should have gained plus or minus a couple pounds so let&#39;s go back to our example what week did I say the woman was that in the example 28 weeks I said she gained how many pounds 22 22 okay well what should she have gained 28 - 9 28 - 9 is 19B she gained three more than she was supposed to that is in the area of something could be wrong let&#39;s assess if she&#39;s within a pound or two she&#39;s okay if she&#39;s 3 lb off you need to assess her if she&#39;s 4 lb off there&#39;s trouble so if a woman is in her 31st week and she&#39;s gained 15 lbs 31st week 15b what answer will you pick well 31 - 9 is you don&#39;t have your calculators do you 22 she was supposed to have gained 22 the question said she gained 15 what do you think we better get we better what was what&#39;s that called a biophysical profile on the baby because the baby may have died last month do you see what I&#39;m saying and we don&#39;t know so that&#39;s bad so can you predict the ideal weight gain for every week of gestation sure just subtract nine from it which is a good OB number to begin with isn&#39;t it so ideal weight gain equals week minus 9 that&#39;s your formula letter C let&#39;s talk about the fundus fundle height what&#39;s the fundus not a river in India what is it the fundus is what upper part of the uterus it&#39;s the top part of the uterus well it&#39;s not palpable until week 12 so can you palpate the fundus anytime during the first trimester no so if they give you a woman for a first trimester checkup and they say you can&#39;t palpate or fund this should you panic no you&#39;re not supposed to feel abundance what if she&#39;s gained 10 pound in the first trimester and that fundus is way up here what do you think she&#39;s either not first trimester or she&#39;s got that high that tiap form mole that Moler pregnancy that cancer thing that&#39;s bad okay that&#39;s in the Blue Book all right uh second and third trimesters they want to know when&#39;s it at the belly button when is the fundus at the umbel liest the belly button and that is 20 to 22 weeks of gestation 20 to 22 weeks of gestation now why in the world would they want to know if you know those two things what two things well the fact that when do you palpate the fundus at the end of the first trimester when is it at the belly button about 22 weeks why is that important for a nurse to know think about those 12 weeks and 22 weeks what what&#39;s what are those weeks close because you&#39;re dealing with what idea date of viability which is 22 to 24 weeks which is in the second end of the second trimester so isn&#39;t 12 at the end of the first trimester and isn&#39;t 24 the end of the second so can you use fundle height to determine in what trimester a woman is in yes that&#39;s why they want to know it because if some woman comes in in an auto accident or an accident of some situation she&#39;s brought into the ER she could not tell you what trimester she is in CU either she&#39;s had no prenatal care she didn&#39;t know she was pregnant or she&#39;s unconscious and able to tell you she&#39;s pregnant you have no history she&#39;s positively pregnant you need to know what trimester she&#39;s in to know what that going on with that baby right well how can you real quickly put her in the correct trimester palpate her fundus because if she&#39;s pregnant and you cannot feel the fundus at all what trimester is she in and who&#39;s the priority the baby or her her if you can palpate the fundus but it&#39;s at or below the belly button you know she&#39;s in the what second and who&#39;s the priority her or the baby her but if that fundus is above the umble like cuz she know she&#39;s in the third who&#39;s the priority the baby or the mom the baby are you seeing how they&#39;ll work that and who will get the attention and what they&#39;ll decide so those are gross estimations of gational age okay signs of pregnancy there are do you remember learning probable presumptive and positive signs of pregnancy how many remember those three categories good news there aren&#39;t three categories onard boards there&#39;s only two positive and everything else so they lump the probables and presumptives together you are not going to be asked to tell the difference between a probable and a presumptive you will be asked to tell the difference between a positive and one of the other two so you&#39;ve got to know your four positive signs they are fetal Skeleton on x-ray if you X-ray the abdomen and there&#39;s a skeleton there you&#39;re pregnant you can protest all you want but you&#39;re pregnant number two a fetal SK a fetal presence on ultrasound if they do an ultrasound and there&#39;s a baby there you&#39;re pregnant see osculation of a fetal heart rate osculation of a fetal heart if they put a Doppler down there and there&#39;s a rate of 140 it&#39;s a baby your bladder doesn&#39;t have its own pacemaker you got a baby down there now when does that occur somewhere between 8 and 12 weeks you can hear it somewhere between 8 and 12 now it starts beating at 5: but you can&#39;t hear it until 8 which brings up a really important point about OB questions most OB most OB information because it&#39;s OB has a range where it occurs because every woman is different right and they give you a range for everything there&#39;s a range for quickening there&#39;s a range for lightning there&#39;s a range for viability there&#39;s a range for fetal heart there&#39;s a range for fundle Heights you know there&#39;s always a range for everything because of that be real careful in OB questions this is critically important to remember really carefully read your OB questions because there could be three different questions for every fact in OB the first question would be when would you first got that when would you first that&#39;s one form of the question the second question would be when would you most likely and the third question would be when should you buy when would you first when is it most likely and when should you buy those are three totally different questions for the same fact in other words when would you first osculate a fetal heart the answer is 8 weeks when would you most likely osculate a fetal heart 10 weeks when should you osculate a fetal heart by 12 weeks do you see that so whenever they say first first pick the earliest part of the range when they say most likely pick the midpoint of the range and when they say should buy pick the end of the range and a lot of times you&#39;re missing OB questions not because you don&#39;t know the correct range but you&#39;re not paying attention to which one of those they want so when is quickening when the baby kicks remember quick Kick quickening Kicking when does it happen 16 to 20 so when would you first feel quickening 16 when would it be most likely 18 when should you buy when do you see the difference three totally different questions for every single fact if you don&#39;t know that you&#39;re going to miss questions thinking you even though you know the information okay letter D the fourth positive sign of pregnancy is when The Examiner palpates fetal movement or outline so what does not count as a positive sign when Mom does it&#39;s when the examiner does okay let&#39;s turn the page and talk about the other signs the maybe signs we lump the probables and presumptives together and we call them Mayes letter A all urine and blood tests all urine and blood pregnancy tests are Mayes they are not positive signs of pregnancy I&#39;m going to make a statement you don&#39;t have to write it down but this is the reason why everybody gets confused about this here&#39;s the true statement a positive pregnancy test is not a positive sign of pregnancy that&#39;s true and that&#39;s why everybody gets confused about positive signs of pregnancy because they think a positive pregnancy test is a positive sign no it is not it&#39;s only probable or presumptive so a positive pregnancy test is not a positive sign of pregnancy everybody know that why not because it only means you have the hormones that go with pregnancy and many many times you may have the hormone increases that go with pregnancy but you don&#39;t have a fetus and so a lot of positive pregnancy tests are false positives but when you hear a heartbeat down there there&#39;s no false positives on that one okay it&#39;s a good question I could phrase it the other way in what relation to what you asked is positive signs of pregnancies have no false positives are things that never have a false positive okay let&#39;s talk about some other probable presumptive signs have you heard of Chadwick&#39;s Goodell&#39;s and hegar&#39;s signs hopefully you&#39;ve heard of this two things you need to know in what order do they occur it&#39;s easy they occur in alphabetical order so who comes first Chadwick followed by Goodell followed by hear see boards is more interested in if you know the order than if you know the exact weeks why weeks vary from woman to woman but the order never varies so BS is going to test what does not vary because it just is statistically more valid to test that or reliable I should say well what is Chadwick&#39;s sign Chadwick&#39;s sign is a cervical color change to cyanosis a cervical color change to cyanosis what do you notice about all those words they start with the letter c and what does Chadwicks begin with C so Chadwick is everything that starts with c a cervical color change to cyanosis it turns blue and if the cervix is doing it the vagina is too okay Goodell&#39;s sign is cervical softening and hears is uterine softening doesn&#39;t that order make sense what would happen first the service would turn blue then the cervix would soften then that softness would move up into the uterus so it kind of makes sense the order does okay let&#39;s talk about some patient teaching in pregnancy you need to teach the woman the pattern of office visits you good prenatal care is a major factor in reducing infant mortality so you need need to know how to teach a woman how often she should come in for good prenatal care so you teach her to come in once a month until week 28 so through the whole first trimester and the whole second trimester and even into the third trimester she&#39;s coming in once a month then at week 28 she should come in once every two weeks until week 36 then she should come in every week until delivery or week 42 what happens at week 42 you scheduled her for another office visit C-section or an induction so let me ask you this if a woman comes in for her 12th week checkup 12th week checkup when does she come in next month 16 if she comes in for 16 when she come in 20 if she comes in at 20 when she come in 24 if she comes in at 24 she comes at back at 28 at 28 she comes back at 30 at 30 she comes back at 32 34 36 30 7 38 39 40 41 42 take the baby so that&#39;s basically the way it goes all right another thing you have to teach her is that her hemoglobin will fall and that&#39;s normal we don&#39;t worry about low hemoglobins with with pregnant women until it gets really low the normal female hemoglobin level is 12 to 16 in the first trimester it can fall to 11 and be perfectly normal 11 is not low tolerable 11 is normal for a first trimester pregnant woman it&#39;s not low but tolerable it&#39;s actually normal it&#39;s not low it&#39;s normal in the second trimester it can drop to 10.5 and be normal not low but normal in the third trimester it can drop all the way to 10 and be normal so what would you call a 10.1 hemoglobin in a woman&#39;s 37th week acceptably low or normal normal so acceptably low might be as low as nine you see so I guess my point is this tolerate lower hemoglobins in pregnant women the further along they are than you would with other non- pregant people what was the number for the first trim 11 it can fall to 11 and be normal which brings up the discomforts of pregnancy that you need to teach her how do you treat morning sickness what trimester problem is it first and what do you treat it with crack dry Dr carbohydrates y dry carbohydrate for breakfast yes or no no it&#39;s dry carbohydrates before you get out of bed cuz once you&#39;re out of bed it&#39;s too late number two how do you deal with urinary incontinence this is a first and third trimester problem why do they not have a problem with urinary incontinence in the second trimester why do you not get urinary incontinence in the second trimester abdominal because the baby is in an abdominal pregnancy it&#39;s up high off the bladder but in the first it&#39;s right down on the bladder and the third it&#39;s right down on the bladder again how do you treat it void every two hours a pregnant woman should void at least every 2 hours all the way from the day she gets gets pregnant until 6 weeks after delivery every day all through Labor delivery postpartum pregnancy void at least every 2 hours number three difficulty breathing this is a second and third trimester problem and you teach them tripod position can anybody explain to me what tripod position is feet flat arms on the table arms on the table leaning forward so that&#39;s tripod or you can even put your arms on your your hands on your knees leaning forward it&#39;s what you see COPD clients doing okay how to back pain people with pregnancy get back pain it&#39;s usually second and third trimester it just keeps getting worse and worse and worse how do you treat it pelvic tilt exercises pelvic tilt exercises so what that means is tilt that the woman should tilt the pelvis forward you don&#39;t want them going like that because that hurts so you&#39;re going to see women do this that&#39;s what they do you know they put this and they tilt that pelvis that&#39;s classic pelvic tilt another way to do it is have them put their foot on a stool and that tilts the pelvis first boards usually says this one okay that&#39;s pregnancy you say that&#39;s all well there&#39;s some in the blue book but pregnancy is a great place to use your common sense because pregnancy is not a disease it&#39;s a healthy State and so do using good health patterns and ideas so when you get a pregnancy question you don&#39;t know the answer to what should you say dehydration well what would be good for anybody what would be a really good healthy response here for anyone pick it and you will be surprised at how well you do okay let&#39;s get this baby out of here now okay let&#39;s go into labor and birth now letter A what is the truest most valid sign that a woman is in labor how do you know a woman&#39;s in L what&#39;s the most valid sign she&#39;s in L what&#39;s that bloody show not bloody show not water breaking because you can have both those and never be in labor okay but the woman doesn&#39;t call you and say I&#39;m dilating and I&#39;m facing so what will they call what will they report they call that the onset of regular Progressive contractions the onset of regular Progressive contractions that&#39;s the most valid sign that women is in lab is it isn&#39;t it possible to have your membranes rupture and 2 days later you still don&#39;t aren&#39;t in labor and they have to C-section you so that&#39;s not a good indicator but it does it&#39;s associated with it but it&#39;s not the best okay terms here again you have to know a vocabulary you can&#39;t you have to know what the words mean in OB or you can&#39;t answer the questions so I just want be sure you guys know these words dilation is the opening of the cervix the opening of it and it goes from 0 to 10 cm so what is what a cervix that is zero is described as what closed closed a cervix that is 10 is described as fully dilated or because open&#39;s not the best fully dilated is the best um in America in the United States do we use uh uh centimeters or inches generally speaking in our lives we talk about inches we don&#39;t use centimeters most Americans don&#39;t know what a centimeter is they know what an inch is but they don&#39;t know what a centimeter is then why do we use 10 cm and 0 cm in OB why don&#39;t we use inches cuz most of our obstetric history comes from England and we use very much an English system but I also think in America just think about marketing and and I mean 10 cm is 4 in I don&#39;t know how many women would sign up where they have to push a baby out of 4-in hole do you get what I&#39;m saying so 10 cm sounds a lot more what generous doesn&#39;t it oh you&#39;re 10 cm oh I can do this so I know that&#39;s interesting okay easement effacement is thinning thinning t h i n n i n g thinning of the cervix it gets thinner and it goes from thick to 100% so a cervix that is not effaced is described as what thi a cervix that is completely effaced is called 100% so how does a woman begin labor thick thick and zero or thick and closed or thick and zero cenm how does she end labor fully dilated and fully effaced which what numbers 10 and 100% okay all right um station station is the relationship between the spine oh I me the fetal pres I&#39;m sorry sorry I was getting in lie station is the relationship of the fetal presenting part to Mom&#39;s isal spines and you must know the isal spines this word is very important to know in OB isal the isial spines are the smallest diameter through which the baby has to fit to be born vaginally it&#39;s the tight squeeze so to speak it&#39;s the narrowest part of the pelvis and if the baby can&#39;t fit through there it cannot be born vaginally if it can fit through there it can be bor born vaginally station will tell you that now negative stations negative stations means that the head the presenting part is above this tight squeeze positive numbers means the baby&#39;s presenting part is below has already made it through the tight squeeze so if a kid stays at1 -2 1 -21 -21 -2 for 17 hours after they&#39;re fully d ated in a face what do you know head&#39;s too big C-section that lady but what if a kid stays at plus 4+ 3+ 4 + 3+ 4+ 3 + 4 + 3 for 17 hours what&#39;s that tell you can the baby be born vaginally yes CU it&#39;s already made it through it needs a vacuum extractor you know it needs an extra little maybe in the photomy or just a forceps so how many of you have a hard time remembering positive numbers and negative numbers which one&#39;s High which one&#39;s low nobody does okay I used to screw that up all the time so I guess you don&#39;t okay I had a way to remember it but since you don&#39;t have that problem we&#39;ll go on um engagement is station zero so what&#39;s that mean if it&#39;s station zero what&#39;s that mean equal to the presenting part is where at the isal spots station zero yes will you give me your clue in case I get down I always remember that positive numbers are positive news negative numbers are negative news now what do I mean by that well if you go into a woman&#39;s room and she says what station am I at and I tell her a negative number like1 -6 that&#39;s negative news to her which means where&#39;s the baby way up and it&#39;s not coming down but if I walk into a woman&#39;s room and she says what station am I at and I give her a positive number like positive 4 positive two what kind of news is that positive news good news what&#39;s good news to woman in labor baby&#39;s coming out it won&#39;t be long now so negative numbers are negative news to a woman positive numbers are positive news negative negative positive positive that&#39;s the way I remember it otherwise I always got screwed up lie lie is the relationship between the spine of the mother and the spine of the baby in other words between the spine of the mom and the spine of the baby if Mom&#39;s spine is like this and baby&#39;s spine is like that that&#39;s good that&#39;s called a vertical lie that&#39;s compatible with a vaginal birth uncomplicated another lie is if Mom&#39;s spine is like this and the baby spine is perpendicular that is bad that is called a transverse lie and you see how I use the perpendicular is the T and that is also trouble it&#39;s bad so whenever they give you these questions about lie they&#39;ll tell you they will tell you where mom&#39;s spine is in relationship to babies all righty if they tell you that Mom&#39;s spine and baby spine are parallel touchdown we got a baby score good baby&#39;s coming out if they tell you the mom&#39;s spine is this way and the baby spine is that way make that and what that make a letter what which means it&#39;s trouble and transverse so you got a baby or you got trouble presentation presentation is the part of the baby that enters the birth canal first this is where you get all those wonderful little alphabet soups r o a l o a r o p l o p r m p RS a RSP punt all of that you do not need to know all of that let me just show you a little pull how many of you know all of that how many of you don&#39;t know that my point is is pro okay how many know that before you give digitalis you take an apical heart rate how many know that how many do not know that what do you need to know the presentations or the ditch because everybody else knows the Dig you better know it nobody else knows this other stuff so why would you spend two weeks memorizing it you&#39;re going to forget it anyhow right if they want to ask a hard OB question they pull this out what&#39;s the damage to you to miss a to missing a hard question there is none there is no danger to you in missing a hard question where&#39;s the danger to you missing and easy question everybody&#39;s going to get hard questions everybody will you can miss every single one of those and still pass with flying colors you cannot miss the easy ones so the goal is not to memorize or know everything the goal is to know what everybody else knows so that your knowledge doesn&#39;t look any different than everybody else&#39;s do you understand what I&#39;m saying it&#39;s sort of like a National Geographic special boards is and you&#39;re all a pack of zebras who gets picked off by the lion the one that&#39;s what lagging by itself all staying with the herd is good so in nursing stay with the herd okay so hopefully now the most common presentation is Roa or Loa right oxop put anterior left oxop put anterior okay now so if they ever give you a question where they say you palpate a bulge here and an irregular there and a lump here and a round there and and then they say what presentation is it hey I&#39;m pi Roa or Loa cuz I&#39;ve got much better chances picking those two than anything else and you&#39;ll probably be right so that&#39;s just a good guess Roa Loa and I&#39;d pick R before L four stages of labor and delivery there are four stages of labor and delivery and you must know them stage one is labor all of Labor is stage one and labor has three phases do you remember that there are four stages that are big and then three stages three phases that are small in the first stage so the first the phases are latent active and transition and those phases are all in the first stage which is called Labor question um yeah um going back about you know easy questions why do they if we get a bunch of hard questions that&#39;s good CU we&#39;re above that yeah if you get a whole bunch of hard questions you have passed because you can only you can only get to the hard questions by having mastered the easy ones and the only way you can fail is to for some reason mess up easy ones whether due to your anxiety uh just not understanding what they were asking or not having certain basic knowledge that you should have or not knowing how to answer certain kinds of questions but I I was sitting at a a table uh in um Cleveland at a National Conference of the national councils of State Boards of Nursing that write the test and there were eight of us at the table and an went was sitting right there two people away from me and an went is the president of the National Council of State Boards of Nursing she&#39;s the top enlex WR kind of person in the nation and I was asking we were asking her questions and one question I asked her I said an people are always asking me what do what do they need to do to pass in a nutshell what do they need to pass and she looked at me she says I&#39;ll answer that in one question one one short answer she said they have to get to the hard questions so if you want to pass you have to what get to the hard questions where you&#39;re going to miss a whole lot but you&#39;ve got to get to the hard questions because if you never get to the hard questions you will never pass you see what I&#39;m saying because you&#39;re always bouncing around down on the easy ones and I didn&#39;t think that was that helpful but at least it under it tells me that that is a very because it came from the source Authority on that so she she says you got to get to those hard questions so the the upshot of that is don&#39;t panic when they&#39;re asking you about stuff you don&#39;t think anyone&#39;s ever heard of because you&#39;re probably getting hard stuff and that&#39;s okay it&#39;s okay to get hard stuff you want to get hard stuff all right um stage number two oh by the way what are the three phases l l active transition in that order what&#39;s the first phase Leon what are the first three letters of the first phase l l a t what are those the initials of the phases in order L for latent a for active t for transition so the first phase the first three letters of the first phase tell you the order of the phases stage two is called delivery of the baby stage three is delivery of the placenta and stage four is recovery stage one is what labor stage two is delivery of baby stage three is delivery of placenta and Recovery is the fourth stage now I would ask you how long does recovery last does anybody know just two hours it lasts for Just 2 hours so let me ask you this what is the purpose of uterine and this is what hessie loves to ask what&#39;s the purpose of uterine contractions in the first stage in the first stage what&#39;s the purpose of uterine contractions no no no that&#39;s stage two dilate and a face the cervix what is the purpose of uterine contractions in the second stage push the baby out what&#39;s the purpose of uterine contractions in the third stage push the placenta out what is the purpose of uterine contractions in the fourth stage cont stop bleeding yeah to contract the uterus to stop bleeding so can anybody tell me when postpartum technically begins when does postpartum technically begin and and give me some more data on that 2 hours after 2 hours after hours after recovery not after recovery 2 hours after delivery of the placenta there you go so 2 hours after that placenta comes out they&#39;re in recovery and then when that ends they are now in postpartum postpartum does not begin when the baby comes out does everybody see that okay so do you see where people get messed up they get messed up between second phase and second stage cuz if I ask you what is the number one priority in the second phase of Labor number one priority in the second phase of Labor what would it be pay management right but if they change the word phase to stage and they said what&#39;s the number one priority in the second stage now what&#39;s the number one prior in the second stage clearing the baby&#39;s Airway you see what I&#39;m saying so you have to be careful if you know what would be a extremely important nursing action to undertake in the third phase what does what do nurses do what what kind of actions are nurses engaging in in the third phase we&#39;re checking dilation we&#39;re helping her with pain we&#39;re helping her with breathing cuz she&#39;s in the last intense part of Labor to dilate right but if I said what&#39;s a m major nursing action for the third stage what would you say yeah watching for blood loss what&#39;s the third stage okay so what do you do with that yeah make sure it&#39;s all there there make sure there&#39;s three vessels in the cord but you would never do that in the third phase cuz you don&#39;t do you say so you understand how if you&#39;re over paying attention to whether they&#39;re talking about stages or phases you&#39;re going to get messed up can you do that please keep phases separate from stages because you have a first phase and a first stage you have a second phase and a second stage and you have a third phase and a third stage but you only have a fourth stage all right now let&#39;s go through those and we&#39;ll go to lunch here in a little bit let&#39;s try to do the next two pages and then we&#39;ll be done but maybe we won&#39;t the rest of this moves fairly quickly because there&#39;s really not a whole lot I mean just a lot of fill in D says the first stage of Labor and Delivery what&#39;s it all about the first stage what&#39;s it called Labor so what you see here is what we call the labor chart bad news you have to know it all you have to know the whole labor Chart good news though I&#39;ll show you a way to remember it that&#39;s really easy so you don&#39;t have to memorize it all so let&#39;s talk about this labor chart how many phases do you see in the labor chart three CU how many phases are there to labor three and there&#39;s latent active and transition let&#39;s talk about latent in the latent phase you dial from 0 to 4 cm your contractions are every excuse me 3 to five I mean sorry 5 to 30 minutes apart that&#39;s the First Column we&#39;re going down the First Column so the contraction frequency is 5 to 30 minutes apart the contraction duration meaning how long they last is 15 to 30 seconds and the intensity of the contractions is described as mild now that&#39;s our word not hers now let&#39;s talk about active because if things pick up here dilation goes from 5 to 7 cm the frequency is every 3 to 5 minutes they la past 30 to 60 seconds and their intensity is moderate again our word however in transition things pick up even more the cervical dilation goes from 8 to 10 cm the frequency is every 2 to 3 minutes and the duration is 60 to 90 seconds and the intensity is strong now the way they will test your knowledge of this is they will say a woman comes into the labor and delivery Suite she is 5 cm her contractions are every 5 minutes apart and they last for 45 seconds what phase is she in active that&#39;s how you do it but you have to know the numbers to put her in the right one good news this chart is what we call a three column sequential table meaning there&#39;s three columns and where one leaves off the other picks up and where that leaves off the next one picks up the easiest way to master a three column sequential table is to ignore the sides and only memorize the middle column so I only want you to memorize active labor just active which is what 5 7 3 to 5 30 60 and you got the whole chart don&#39;t you because anything less intense would be what and anything more intense would be transition so 57 35 30 60 it can&#39;t be simpler than that note do you see where it says note contraction should not be longer than 90 seconds or closer than every 2 minutes you must know this they love to test this one how do you know a woman&#39;s in trouble in labor well when her contractions are longer than 90 seconds and closer than every 2 minutes you do not want to see that they would give you four women in labor and say who&#39;s the who&#39;s in trouble her contractions are going to be longer than 90 and closer than two minutes that&#39;s bad they&#39;ll also ask it what&#39;s the what what are the signs of uterine tetany well contraction is longer than 90 seconds closer than every 2 minutes what&#39;s uterine hypers stimulation contractions longer than 90 seconds closer than every 2 minutes what parameters would make you stop pcin 90 seconds 2 minutes 90 seconds two minutes remember that you&#39;re very likely to see that okay let&#39;s talk about assessment of contractions you have to tell the woman how to do this how to time her contractions well frequency is beginning that goes in the blank beginning of one contraction to the beginning of the next so if you&#39;re teaching a woman to time frequency and these are two contractions what letter interval would you tell her to time for frequency a beginning to C beginning that actually includes the contraction doesn&#39;t it so frequency is beginning to beginning duration on the other hand is beginning to end of one contraction beginning to end of one contraction so what number sequence would you tell her the time for dur A to B or C to D so frequency frequency would be a to c duration would be a to b c to D intensity is the strength of contraction and it&#39;s purely subjective however that next sentence is really important you see where it says palpate with this is very important teach her to palpate with one hand always one hand because the other hand is timing one hand over the fundus with the pads of the fingers so make sure you teacher to use one hand make sure you to teach her teach her to go over the fundus and make sure you tell her to use the pads of the fingers which are the fingertips okay let&#39;s talk about complications of label and then go to lunch bad news there are 18 complications that can occur in labor and delivery and you have to know them all good news there are only three protocols you need to know for all 18 so really what do you have to memorize 18 different things or three different things three so let&#39;s talk about these three things you need to know the first one is painful back labor have you heard of painful back labor it&#39;s usually when she&#39;s op oxop put posterior you know l o r o oxop put posterior I always tell people when you see op at the end of it think oain cuz they&#39;re going to have it op is opan so what do you do for it two things position then push you position her and then you push in what position would you place her anybody know which position you put a painful back labor in sign not sign knee chest she goes on her hands and knees with her rear end up and her head down because that brings the baby down off the sacrament toxics so knee chest get her around her hands and knees then push what do you push anybody know what you push take your fist and push into her sacrum that applies counter pressure and actually relieves some pain yes I&#39;m going you said need a chest but do you KNE chest then how you they&#39;re lay back they on all flors no see KNE chest yeah people get knee chest confused with lithotomy because in knee chest and lithotomy your knees are to your chest in both this is lithotomy this is not what we&#39;re talking about this is lithotomy okay okay that&#39;s lithotomy this is knee chest that&#39;s knee chest see so your knees are to your chest here and your knees are to your chest here but this is lithotomy this is and here&#39;s the nose that way and this is knee chest here cuz see the baby then will come down off the coxic so knee chest is okay that&#39;s the chest and that&#39;s what we mean we don&#39;t mean this next one prolapse cord this is bad this is a med OB emergency prolapse cord is bad because the baby can kill itself prolapse cord is when the cord is the presenting part which means comes out first so that when the head comes down what&#39;s the head do press on the cord and the baby dies baby literally commits suicide and kills itself so this is not cool uh painful back labor high priority low priority Low Low Pro left court high priority low priority High okay what do you do here push position now what was painful back position push this one is push position so they&#39;re just the flip-flop well what do you push you don&#39;t touch the core push the head back up push the head off the core then what do you position her in knee chest the one I just the one we just talked about so she&#39;s in knee chest you&#39;ve got your hand pushing the head and you stay that way till they pull it out C-section so it&#39;s kind of you have to ride on the heart with her you know so you just throw a blanket over everything you you just go like this you look like a float you know in a parade it&#39;s kind of weird so what do you do for painful back position position push what do you do for prolapse course push position do you remember I said usually I will always position before I do something else that has an exception too because in prolapse you push then you position why do you push first in prolapse and position second in prolapse why because delaying pushing in order to position would increase the risk to the baby see but it&#39;s the same principle so when you&#39;re sitting there not knowing what to do it&#39;s probably good to you to think about if I delay doing this to do that would it that&#39;s probably a good way to think all right number three interventions for all other complications and labor and birth and there&#39;s like 16 of them uterine tetany uterine atne uterine hypertension uterine hypotension uh uh uh maternal subclavian syndrome uh uh Vena syndrome uh um oh just you name it there&#39;s Boku complications they&#39;re all treated the same and they are treated with Lion l i o n l means first you turn them on their left side there&#39;s the L left side I is increase IV o is oxygenate them n is notify physician so first DET turn them on the left side you increase the IV you give them oxygen and you notify the physician now LPNs you will be able to do all of those except increase the IV so what do you do for maternal hypotension Li what do you do for eclampsia L what do you do for toxemia what do you do for uterine rupture Lon what do you do for you see what I&#39;m saying as long as it&#39;s not painful back or prolapse you&#39;re picking what line question question we were talking about first probably the first would be yeah the position and the best would be tough I would the left side there might be the best too cuz that gets the pressure off gets the placenta perused better so so that so even if you give oxygen and the per perent is not being profused it&#39;s not going to get to Baby so I would say that&#39;s one place where first and best of the same one left side would everybody agree with that sort of okay and sometimes it&#39;s the same it&#39;s just on occasion it&#39;s different and most of the time it&#39;s different on occasion it&#39;s the same okay um pit pit means in a crisis if po is running stop it in a ob crisis if pit is running stop it so could that be the first thing you would do so that would catapult all the way to where hold the pit with cap catapult to what order number one and that would be l so you&#39;d stop the pit then l i o n but most of the time they will not tell you pit is running so pit won&#39;t even be there so nine times out of 10 you&#39;ll be doing l i o n but if they tell you pits there stop pit l i o n okay pain medications in labor get this down word for word and then we&#39;ll go to lunch do not administer a pain medication to a woman in labor if the baby is likely to be born when the med Peaks do not give a pen medication to a woman in labor if the baby is likely to be born when the med Peaks let me illustrate how you&#39;re going to do this CU it&#39;s not going to be anything magical it&#39;s just going to be good Common Sense what about this question you have a prima gravada Prima gravada means what first timer Prima gravada at 5 cm who wants her IV push payment will you give it to her or not well the question is is it likely that a prima gravada at 5 cm is going to deliver in the next what well Ivy push meds we learned the other day that Ivy push meds Peak when IV meds Peak when 15 to 30 minutes after you give them so is it likely that a prima gravita at 5 cm will deliver the baby in the next 15 to 30 minutes so would you give her the med yes what about this question you have a multigravid at8 who wants her I am pain med well the question then is is it likely that a multigravid at 8 cm could deliver in the next well when do we know I im&#39;s Peak 3 3260 is it likely that a multigravid at 8 could deliver in the next hour so what would you say to her no are you getting it it&#39;s going to be obvious it&#39;s not going to be they&#39;re not going to play around with being real close like your teachers in school and ATI and stuff like that does you know what I mean you&#39;re going they&#39;re going to make it clear if you can pass seie you can pass ATI you can do boards you can they are much harder much I would rather take state boards any day of the week than take an ATI or a Hess hands I that&#39;d be a no-brainer be a no-brainer okay after lunch we&#39;ll come back and do fetal heart tracing be back at about try to be back at 5 to1 I&#39;m going to run over my is all right we&#39;re going to talky about fetal monitoring patterns okay there are seven of them that you should know don&#39;t panic because they&#39;re actually easy to remember I&#39;m going to go through here and tell you which ones are okay and which ones are bad and what to do for them all right so that&#39;s the way we&#39;re going to go go the first one is a low fetal heart rate that means under 110 this is bad when you see it you do lion l i o n left side IV O2 notifi and if pit were running what would you have done stop the pit High fetal heart rate that&#39;s a fetal heart rate over one 60 this is no big deal you would document it and take Mom&#39;s temperature because it&#39;s probably mom has a fever that&#39;s based but there&#39;s nothing wrong with who the baby baby&#39;s just fine you don&#39;t have to do anything specific if you did anything you&#39;d take Mom&#39;s temperature that&#39;s basically all you do it&#39;s no big deal it&#39;s not a high priority low Baseline variability this is bad this is when the fetal heart rate stays the same and does not change whether high or lower in the middle it just stays the same it doesn&#39;t change that&#39;s bad that&#39;s bad and what you do is lion l i o n left side IV O2 notifi High base Baseline variability what that means is baby&#39;s heart rate is always changing that&#39;s good documented now it&#39;s kind of interesting once a person is born if their Vital Signs stay the same over time what do we call them stable and they are in good shape or bad shape good but when you&#39;re before you&#39;re born if your Vital Signs stay the same over time it&#39;s low Baseline variability and it&#39;s bad you want to see so what we want to see before you&#39;re born we don&#39;t want to see after you&#39;re born and what we want to see after you&#39;re born we don&#39;t want to see before you&#39;re born so we want to see vital signs all over the map when the baby&#39;s in utero that&#39;s called high Baseline variability that&#39;s good we don&#39;t like to see stable Vital Signs which is low Baseline variability late decelerations decelerate means to slow down and late means near the end of a contraction so the heart rate slows down near the end or after a contraction this is bad so what you do is lion l i o n left side I V O2 notifi early decelerations what would this mean early decelerations baby&#39;s heart what slows why did you say slows decelerate when before a contraction or at the beginning of a contraction and this is fine this is normal it&#39;s no big deal so you just document it which brings up the last tracing variable decelerations this is very bad think of variable very very very variable very bad variable very bad so when you see variable think o very bad how very bad well this is prolapse cord this is what happens when you prolapse a cord so what do you do for this push position so of the seven abnormal fetal heart tracings of the seven abnormal fetal heart tracings which one is the most unique variable and it&#39;s very bad so it&#39;s the only one which is treated by push position cuz it&#39;s prolapse now if we look at the remaining six how many are good and how many are bad three are good three are bad what do you notice about all the ones which are bad they begin with the letter L which is the first letter in Lion so if you get a fetal heart tracing that begins with the letter L what do you do for IT lion and so is it good or bad bad so if it doesn&#39;t start with an L it&#39;s okay unless it&#39;s variable in which case it&#39;s very bad so if you want to know your fetal heart tracings just look at the first letter starts with L it&#39;s bad it needs line if it doesn&#39;t start with L it&#39;s okay but if it&#39;s variable it&#39;s very bad it needs the prolapse routine the push position so do you feel a little bit better about those um there&#39;s one other thing I want to show you that tells you what they are you know what are they what do they mean and I&#39;ll see uh you probably heard of it but for some of you that haven&#39;t heard of it this might work um I&#39;ve told you what they what the implications of them are but um what are they write the word ve you know like like young beef beef ve so write ve vertically down and and then write chop like lamb chops pork chops ve chop do you see what I&#39;m saying so ve chop now what this is is this is the first letter of the tracing and this is the first letter of what it means so variable would be what B would be variable that is cord compression you see that variable is cord compression what would this stand for the E early D cell and that&#39;s what it is what it&#39;s caused by starts with an H so what that what would that be head compression what would a be well we didn&#39;t talk about it but it&#39;s it&#39;s high fetal heart rate acceleration which is high fetal heart rate correct and that&#39;s okay okay meaning it&#39;s fine remember we said that high FAL heart rate was okay what would L stand for late D cell and what would that stand for starts with a P placental insufficiency plus cental insufficiency so V chop variable cord Early Head accelerate okay late placenta de CH yes so when we get into the class when having all these demonics and stuff what would you recommend the best time to be to write it down down when you need it oh okay not at the beginning okay they&#39;ll give you a little whiteboard kind of thing and you&#39;ll use that for your scratch P when you fill it up you raise your hand they bring you another one okay you don&#39;t erase they don&#39;t like you&#39;re erasing they&#39;ll freak out if you&#39;re erasing so I would I would erase just for that purpose fact what I would do is I go like this but I would be doing absolutely nothing you know I wouldn&#39;t really be erasing I&#39;d just be going this just a freak them out okay they can make me take this test they can make me sit there but they can&#39;t make me behave so that&#39;s I always think a little Civil Disobedience goes a long way you know you are you in control in this test no you have to go take this test you have to sit where they tell you to sit they have to take the questions you have to take they you have to do it so do something you know civil disobedient you know wear a wear you know a pair of clown ears I don&#39;t know don&#39;t wear underwear I don&#39;t know um do something that&#39;s you know where you&#39;re you can sit there and you can say I&#39;m in control you know to give you a little little Edge okay Ace of Spades and as of Spades means what answer always wins in a tie there are certain answers which they are always winners they just they just win all the time and in OB there is one answer that always wins and if you&#39;ve ever worked OB you&#39;ll know what it is and that is check what beetal heart rate you cannot work OB if you don&#39;t know know that no matter what happens in OB no matter what happens in OB what is the one question that surfaces all the time what&#39;s the fetal heart rate she&#39;s doing this and doing that well what&#39;s the fetal heart rate well this is doing that well what&#39;s the fetal heart rate so you&#39;ll always check a fetal heart rate all right that&#39;s the first stage of Labor and Delivery labor let&#39;s talk about the second stage of labor and delivery delivery of the baby this is all about order what do you do in what order well first you deliver the head and you say well what if it&#39;s breach come on don&#39;t go breach unless they say it&#39;s breach okay go with the common so it&#39;s a sealc so deliver the head number two suction the mouth then the nose it always goes alphabetical you suction the mouth first then you suction the nose then number three check for a nle nle and Nu c h l cord what does nucle mean around around the neck nucle means neck so check for a nucal cord then number four deliver the shoulders and the body in that order so first out comes the head then you suction the mouth then you suction the nose then you check for a cord around the neck and then you deliver the rest of the baby right that&#39;s the ideal number five the baby must have an ID band on before it leaves the delivery area a baby must have an ID band on before it leaves the delivery area okay third stage of labor and delivery delivery what&#39;s this about placenta two things you need to know here number one make sure it&#39;s all there number two check for a three vessel cord make sure the cord has three vessels three blood vessels how many of each two arteries one vein think of the woman&#39;s name Ava Ava how do you spell Ava a v a how many A&#39;s are there two that&#39;s two arteries how many V&#39;s one that&#39;s one vein so the woman&#39;s name Ava two arteries one vein okay that&#39;s all you really need to know about the placenta fourth stage of Labor and Delivery called recovery correct recovery that&#39;s what goes in that blank recovery it&#39;s the first first two hours after delivery of the placenta right now there are four things you do four times an hour in the fourth stage so you&#39;re going to write four three times there there are four things you do four times an hour in the fourth stage so what are the four things you do every 15 minutes which means four times an hour in the fourth stage well the first thing you do is vital signs Vital Signs and you&#39;re assessing for signs and symptoms of shock which is pressures go down rates go up you get pale cold and clammy pressures go down rates go up and you look pale cold and clamy those are the signs of shock anything that&#39;s called a pressure goes down anything that&#39;s called a rate goes up and that number two fundus check the fundus if it&#39;s boggy you massage it if it&#39;s displaced you catheterize number three the pads the paranal pads check the par neop pads look to see how much she&#39;s bleeding if she is bleeding excessively she will saturate a pad in 15 minutes or less so how often are you checking her every 15 and when you check her you put on a new pad you go back it&#39;s 98% saturated is she in trouble or not 98% saturated she in trouble or not how many say she&#39;s in trouble how many say she&#39;s not she&#39;s not in trouble because it has to be saturated 100% and 98 is not 100% And when you learn these rules you have to live and die by them you can&#39;t start fudging you know what I mean you can&#39;t say well that&#39;s close to that then pretty soon you start you know losing your anchors so 100% means 100% if it&#39;s not 100% it&#39;s okay but if you want if you give put a new pad on her check her in 15 minutes and it&#39;s it&#39;s fully saturated saturated if they say saturated what does that mean 100% she&#39;s in trouble but if they say 98% saturated I&#39;d say she&#39;s okay close but she&#39;s okay number four roll her over roll her over in other words check for bleeding underneath of her a lot of people will check the paths but won&#39;t roll her over and that&#39;s not safe cuz could you saturate half a pad and Bleed Out Underneath so you got to you got to do both so what do you do four times an hour in the fourth stage vitals fundus pads and roll vital fundus pads and roll you do those every 15 minutes in that stage that face stage okay turn the p page and let&#39;s do postpartum this is talking about postpartum assessment what do you assess and usually you&#39;re assessing this every 4 to 8 hours it&#39;s either 4 hours or 8 hours it just depends on whether she&#39;s stable or not and what you&#39;re assessing is Bubblehead now there&#39;s a whole bunch of stuff here but I only want you to highlight and know three of them and I&#39;ll tell you which three the first b stands for breasts this is not a real important one the U stands for uterine fundus and this is the one the first one you must highlight this is an important one here again you want it to be firm if it&#39;s boggy you massage you want it to be midline if it&#39;s not you cap them just like in the recovery but there&#39;s something new that they will ask here in postpartum and that is the height of the fundus related to the belly button where do you find it because what they&#39;ll do is they&#39;ll tell you how many postpartal days it is and you got to locate where fund this should be it&#39;s really simple all you do is is fundle height equals day postpartum fundle height equals day postpartum now what do I mean by that is this if a woman here&#39;s her abdomen here&#39;s her Naval this is -1 - 2 - 3 - 4 - 5 - 6 and it&#39;s the fourth postpartal day and they want you to point and click okay here&#39;s a hot spot here hot spot here hot spot here one here one here one here one here one here and one here you know a b c d e f g h i all right and she&#39;s fourth postpartal day which hotspot would you click on G G that&#39;s how many below four four below on the fourth day now be careful cuz F will be there too why would you not click on F it&#39;s displaced you want it midline so they will have hot spots so that you&#39;ll get the right letter but if you&#39;re not precise you&#39;ll be off to the side and you don&#39;t want to be off to the side you want to be in the middle okay the next two bees are bladder and bowel they&#39;re not a big deal bladder and bowel the L is loia l o CH h i a this one is is the second one you highlight this is the second important one they are rubra Sosa and Alba rubra Sosa and Alba rubra is r u r a Sosa is s r OA and Alba is a l ba a now it occurs in that order first the Lo by the way the Loki is the vaginal drainage rubra is first then Sosa is second and allba comes last now they want to know what color they are okay if you rub you see rubra has the word rub in it if you rub and rub and rub something what color will it turn red so rubra is red Sosa has the root Rosa for Rosie if your cheeks are are Rosy what color are they Pink So Rosa is pink and Alba if you are an albino what color are you white so Alba albino white so rub rub red Rosy pink albino white rubra Sosa Alba now the amount 4 to 6 in on a pad an hour is is okay excessive his saturated pad in 15 minutes or less it&#39;s the same idea the E stands for otomy otomy no big deal it&#39;s an incision the H stands for hemoglobin and hematocrite no big deal there they&#39;re not going to focus on that the E stands for ex extremity check checking the extremities this is the third important one you must highlight and right now on this one they&#39;re looking for thrombo fitis so they want to know what&#39;s the best way for you to to determine if a person has thrombol fitis or not what&#39;s the best way exactly bilateral Cal cir cerence measurement measuring their calves home how many have heard of Home ins sign that&#39;s not going to be the best answer now it&#39;s not a horrible answer but it&#39;s not the best one because you can have a positive hman sign and have equal calves and not have throp fitis and you can have throp fitis and not have a positive Homan sign so it&#39;s not as reliable or valid some places don&#39;t even want you to do it a stands for affect means you&#39;re emotional don&#39;t worry about bulby stages you know latching on letting go taking in throwing up I don&#39;t really know what they are you know you&#39;ve never heard of those don&#39;t worry about all that that&#39;s that&#39;s nuts and then D discomforts and that&#39;s just that&#39;s there&#39;s really no big deal there either so the three big things you&#39;re going to be tested on if postpartum are what the fundus theia and about thrombo fitis anybody ever worked postpartum that&#39;s the three big things you talk about in report you know where&#39;s the fundis how&#39;s the lokia and how are her legs she got thrus okay Turn the Page let&#39;s talk about variations in the newborn yes no the the number of days when things go all varies boards likes to test what does not vary the the lengths vary but the order never varies and what they are never varies so it&#39;s just like with Chadwicks goodells and hegar they&#39;re not going to say what week or what month they&#39;re just going to say what order and what is it okay um variations in the newborn all of these things are normal so I just wanted you to know that I&#39;m not going to read it so you don&#39;t have to have it read to but all of these things are normal even though they sound some of them sound bad look at number four aemma toxicum neum sounds horrible doesn&#39;t it but it&#39;s just a rash it&#39;s no big deal the only thing specifically I would need I would want you to know from this page other than the fact that all these are normal is the difference between number six and number seven cuz they always test about the differences between six and seven capit suidan and seah hematoma what do they always want to know what&#39;s that one&#39;s bleeding one&#39;s bleeding and that would be Hema and then also what else which one crosses sutures which one does not which one&#39;s symmetrical which one&#39;s not the easiest way I know that know to memorize that is look at their initials what are the initials of capit suidan Cs what could CS stand for crosses sutures so the one whose initials are CS is the one that indeed crosses the sutures so what about seil hematoma what are its initials C or C certainly not CS so it does not cross sutures and of course the one that crosses the sutures is also the one that is symmetrical so I always say CS stands for crosses sutures and cap it symmetrical and Leon on number eight uh it&#39;s talked about the hyperb rmia normal physiologic JIS appears after 24 hours so there&#39;s a there&#39;s a reminder of the difference between physiologic jice and path logic okay the last page OB meds top 10 group you&#39;ve got to know your OB meds now good news you don&#39;t have to know much about your obms because you&#39;re not expected to be an expert in obms but you&#39;ve got to know generally what they are and just a couple of things about them so rather than feel you full of all kinds of stuff you don&#39;t need to know let&#39;s focus on what you do need to know with these six different meds the first two meds are Toco lytics which stop labor they are terbutaline and mag sulfate these are drugs you give to women who are threatening prematurity and you want to stop their labor terbutaline the only thing you need to know about it is that it causes maternal tacac cardia it speeds Mom&#39;s heart rate up that&#39;s really all they&#39;ll test on that one that it stops lab and speeds up the heart mag sulfate will also stop labor if you give a person a lot of magnesium what electrolyte imbalance will you create hyper magnesia and you know that Magnesia do the opposite so a high magnesium makes everything go down so the uterine contractions will go down well the only problem is so will everything else so what will your heart rate do go down write that down what will your blood pressure do go down write that down what will your reflexes do go down write that down what will your respiratory rate do go down write that down and what will your loc do go down write that down so mag sulfate yes the good news is it stops the uterine contraction the bad news is it brings everything else down too which of those two do you think are the top two that boards will will check your knowledge on respiratory and reflexes they&#39;ll want to know what does mag sulfate do to the respirations and what does mag sulfate do to the breathing and it&#39;s it lowers both of them so when you&#39;re giving mag sulfate to a patient you must monitor what two things reflexes reflexes and respiration what are your parameters for titrating the mag sulfate and lpn&#39;s what parameters would you use when you notify the RN about it 12 what do you mean 12 12 respiration yes so as long as the respir are above 12 what do we know about the mag is it okay or not it&#39;s okay but if it goes below 12 what do we need to do with the mag slow it down LPN you notify the RN of that what about the reflexes what do we want for reflexes two we want plus two so if it&#39;s plus one what do we do to the mag slow it down if it&#39;s plus three what do we do to the mag speed it up so what do we want 12 and two we want at least 12 respirations and we want two reflexes what we don&#39;t want to see is 11 and one we don&#39;t want to see 11 respirations and lower and we don&#39;t want to see one reflex and lower plus one and lower so 12 and two is good 11 and one is bad okay the next class of of OB drugs are the opposite of the too litics they are the oxyx now the oxytoxin stimulate and strengthen labor remember the too litics stopped it these ones started the most famous is pin we&#39;ve talked about it before the big thing you need to know about pin is it can cause uterine hypers stimulation which which would be defined as what uterine hypers contraction what longer than 90 seconds closer than every 2 minutes if you see that back off your pit remember that before from the last couple of pages longer than 90 seconds closer than 2 minutes the next drug that will cause your uterus to contract is methe and the only thing you need to know about methene is it causes high blood pressure now if it&#39;s going to contract blood vessels and contract the uterus if it contracts blood vessels what&#39;s it going to do with the blood pressure increase does it make sense that vasil constriction increases blood pressure so do you see the two M&#39;s methene and mag they&#39;re both used in OB methene and mag right what does one do to the blood pressure lowers it one the other one does what to the blood pressure raises it so one of it low one of the M&#39;s lowers the BP The Other M increases the BP okay the next two meds are the fetal lung maturing meds the meds to make a fal&#39;s lungs mature faster the first one is beta methone what is it steroid and the other is cant which is surfactant so just let me talk about three things you need to know about each with beta methasone number one it is given to the mother mom gets the beta methone number two it is given I am and number three it is given before the baby is born before the baby is born and you can repeat it as long as the baby is in utero however servant on the other hand three things about it number one it is given to the neonate to the baby not to the mother it&#39;s given to the baby number two it is given trans tracheal which means blown in through the trachea and number three it is given after the baby is born not before cervant is given to the baby trans trally after the baby is born whereas betamethasone is given to the mother I am before the baby is Thor they both are given given to make the baby&#39;s lungs mature faster cant is blown in what they use they use a nebulizer kind of thing they can even put it in a connection to a ventilator pump it in okay that&#39;s it on OB we&#39;re done with ob that&#39;s the longest lecture of whole review that&#39;s why I like to split it up with lunch okay we&#39;re going to go to page 51 medication helps and hints this is a very short lecture just designed to help you get some basic basic basic facts down because if you don&#39;t know these facts and you miss these questions you&#39;re in a major hurt the first one is what is Humulin 7030 what is it it&#39;s a mix of insulins of R and N now you can have lispro 7030 but but that&#39;s a variation when they say 7030 they&#39;re talking about n and R basically now 70 and 30 are percentages so it means it&#39;s 70% one and 30% the other which one is which 70% is n and 30% is R so if you give 100 units which you would never do it&#39;s way too much but if you gave 100 units of 7030 how many units of n would there be and how many units of R would there be if you gave 50 units of 70 30 how many units of n would there be 35 how many of of R would there be 15 you see it&#39;s just you just multiply the percentages you know how to get a percentage just take that number and multiply by 7 for 703 for 30 the way I remember that n is the 70 is 7030 is like a fraction what do you call the top term in a fraction what letter does that begin with N so n is in the numerator number two can you draw up can you mix insulins in the same syringe yes or no yes when you draw it up is there a certain way to do it which one comes first everybody says clear to cloudy boards doesn&#39;t use the words clear or cloudy they talk about n and they talk about R now those of you that are taking the enlex RN this this will work better for you but is that what you want to be then do it that way r ends will do it this way meaning draw up the what first R followed by the N that way you don&#39;t get into this clear cloudy garbage okay RNs do it that way now if you&#39;re talking about pressurizing the vial which vial would you inject the air into first the end then inject excuse me then inject the air into the r r then draw up the r then draw up the N so it&#39;s n r RN but it always ends in RN injections they will tell you what injection you&#39;re giving and they will ask you what needle you&#39;re going to use What needle will you use for giving a partic particular injection here&#39;s how you do that if they say you&#39;re giving an IM injection and they want to know which needle you&#39;ll use 21 gauge 5/8 in 22 gauge 1 in 21 gauge g 1 in 25 gauge 5/8 in they want to know what which one of those needles will you use for I am the clue is in the abbreviation look at the first letter of the abbreviation what number does that look like a one go pick the answer in which both parts have a one in it which which one would that be C would be your answer did you see that why is see the answer because both the first the gauge and the length both have a number one because an i looks like a one okay but what about this what if they changed it to subq here again look at the first letter in the abbreviation what is the first letter in the abbreviation s s what number does an s look like a five go pick the answer that has a five in both of the parts and the answer would be D because you&#39;ve got 25 and 58 so when you&#39;re you&#39;re asked to pick a needle just look at the abbreviation look at the first letter and go find the numbers okay Turn the Page we&#39;re got to talk about Hein and cinin because they&#39;re in the top three most commonly tested drugs on boards if you don&#39;t know these you&#39;re in trouble heprin versus cumin very very important Hein it is given IV or subq Kuman is given only po see I&#39;m comparing and contrasting is what I&#39;m doing everybody go back to Hein Hein is working immediately Works immediately go to cumin cumin takes a few days to a week to work anywhere between a few days to a week go back to heprin heprin cannot be given for longer than 3 weeks and in parenthesis put except for Lenox remember the Lenox can be given for a long time regular heprin cannot be yes four weeks three three because in 21 days you start making heper and antibodies which could be really life-threatening cumin can be given for the rest of your life can you not you can take cumin forever go back to heprin the antidote to heprin overdose is protamine sulfate they love that kind of stuff cumin what&#39;s the antidote to cinin Vitamin K Vitamin K how do you remember that yeah C and P P hearin protamine cumin K go back to Hein the lab test that monitors Hein is the PTT PTT which is the partial thromboplastin times they&#39;ll give you both names the one that monist the kumant is the PT which is the INR from which the INR is derived now the way y remember that is several ways if you have your hands you can go what h e p a r i n how many fingers are left three PTT okay let&#39;s spell cumed c o u m a d i n how many fingers are left two PT or you can cross you can write P TT cross them together what letter does that make which stands for Hein any of you guys computer people have you ever seen this HTTP read it backwards PTT is H which is Hein okay so you can do it either way any way you want to do on that one Hein can be given to pregnant women cinin cannot be given to pregnant women Hein can be given to pregnant women cinin cannot be given to pregnant women but by the way speaking of pregnant women what&#39;s the only major antipsychotic tranquilizer that can be given to pregnant women remember all those Zen and zapin the only one that can be given is how doll how doll is the only one you can give and a psychotic can give to pregnant women has nothing to do what we&#39;re talking about but I just thought we&#39;d throw it in the next thing is the K wasting and case bearing diuretics K wasting and case bearing diuretics probably the only question you&#39;ll ever get about a diuretic is does it waste K or does it spare K the easiest way I know to do this is this any drug ending in x any diuretic ending in the letter X X&#39;s out K so if it ends in X it xes out K so what is it a waster or a sparer if it ends in X it X&#39;s out K it wastes it yes plus diuril so the K wasters are all the diuretics that end in the letter X Plus Diel if it does not end in an X and it&#39;s not Diel it&#39;s a sparer so I&#39;m going to give you a bunch of drugs and you tell me whether they&#39;re wasters or SP bearers spironolactone aldactazide mtic motic sparing Las six bux clotri edrex Demodex di real wasting and uh yeah so you got it and backofen backofen is the last drug I want to talk about boards tests muscle relaxing as a class and you need to know your muscle relaxing now the only thing they test about muscle relaxing is the two side effects and the three teachers teachings two side effects and three things to teach the two side effects of a muscle relaxant are fatigue and muscle weakness does that make sense that a muscle relaxant would make you tired and relax your muscles fatigue and muscle weakness the three things you teach are Don&#39;t drink don&#39;t drive and don&#39;t operate heavy machinery so what do you have to know about back Leen what are the side effects fatigue or drowsiness right drowsiness fatigue same thing right and muscle weakness what do you teach them don&#39;t drink don&#39;t drive don&#39;t operate heavy machinery now the other drug that they test is Flexeril f e l f l x e r i l that&#39;s that&#39;s the other muscle relaxant they test Flexeril and bphen are the two muscle relaxants they test I am not going to teach you how to remember that Flexeril is a muscle relaxing because if you can&#39;t figure that one out I can&#39;t help you right so Flex surel you should remember a what mus cuz you flex your muscles well how in the world are you going to remember that backlin is a muscle relaxing well I always say this when you are on your back Len you are on your back loen which means you&#39;re doing what if you&#39;re loafing what are you doing aren&#39;t you relaxing so there&#39;s your clue it&#39;s a muscle relaxing cuz back Lett puts you on your back loen it&#39;s a muscle relaxing di yeah things more generic the the semid SC mid scmid are the ex&#39;s semis are typically X&#39;s semis m t m i d s not all of them but most of them okay let&#39;s talk about pediatric teaching on the next page we&#39;ve only got three left guys actually three and a half left so we&#39;re cool this takes about 5 10 minutes this one CU it&#39;s very short it&#39;s just a review of P&#39;s theory of cognitive development have you heard of that you do need to know P&#39;s Theory but they will never mention P&#39;s name they will test your knowledge of P&#39;s theory of cognitive development by asking you how you would teach children and you&#39;re supposed to if you get a pediatric teaching question that&#39;s a chance for you to show your knowledge of P so let&#39;s talk about it P has four stages for kids thinking the first one is the 0 to 2y olds who are in the stage of sensory motor thinking in in the middle column P says these kids are totally present oriented they don&#39;t think about the past they don&#39;t understand the future they only think about what they are sensing or doing right now so when do you teach these kids can you teach them ahead of time why why not they don&#39;t understand the future can you teach them after you do it no they can&#39;t understand the past so when do you teach them while you do it so when while you do it you teach them as you do it what do you teach them what you are doing do you notice the present tense there what you are doing and how verbally just tell them don&#39;t use play they don&#39;t understand play so if you get a kid from 0 to 2 years of age and he&#39;s going to have a spinal lumbar puncture and they want to know how you going to teach him what are you going to say while we do it we&#39;re going to tell them tell him what we are doing Bingo that&#39;s all you do there really is no such thing as preop or preest teaching for this age group for this age group who do you preach the parents not the kid okay the second stage of a is the 3 to 6year olds he calls them the pre-operational which I like because 3 to six is a preschooler correct and he calls it pre-operational so the two pre go together prechool or pre-operational they are fantasy oriented they are imaginative they are illogical their thinking obeys no rules you cannot reason with a preschooler if they can think it it can happen I mean they just they&#39;re just you can&#39;t it is whatever well do they understand the future yes do they understand the past yes so when would you teach these kids would you teach them before yes how long before or doesn&#39;t it matter how long shortly before so here&#39;s the is pick an answer that says the morning of or the day of or something like 2 hours before that is fantastic preschool because you don&#39;t want to give these kids a whole lot of time to what get their imagination going on it do you see what I&#39;m saying my kids never at this age my kids never knew they were gone to the doctor&#39;s office until they pulled into the parking lot of the doctor&#39;s office otherwise we&#39;d have had disaster that&#39;s why they never rode with me after that no um what do you teach them what you are going to do what you are going to do what tense are we talking in now future what did we talk what tense to we talking with the younger ones present so now so how old does a kid have to be before you can start using future tense verbs three at least three good how play these are the kids that learn through play so in a nutshell if you&#39;ve got a four-year-old who&#39;s going for a lumbar puncture how do you teach him when the day of you tell them what you&#39;re going to do using play some kind of a play thing all righty a story a book equipment whatever dolls okay okay the next stage are these 7 to 11year old concrete operations kids the way I remember that 711 age is conrete is have you ever seen a 7-Eleven grocery store what&#39;s it surrounded by any flowers grass trees no just a bunch of concrete 7-Elevens so just think of concrete 7-Elevens you got 7-Eleven age concrete operations these kids are rule oriented they live and die by the rule they cannot abstract with these kids they are so rigid if you tell them this is the way it&#39;s going to be that&#39;s the way it has to be how many at 7 to 11 that age group how many ways are there to do things one one and only one and every other way is wrong this is the age where the parent hears the teacher said and the teacher hears my parents said now have you ever taken care of these kids this age group did you ever change a dress in for them or something like that what do they always tell you when you change their dressing you&#39;re doing it wrong which means what you&#39;re not doing it like the other person did now are you doing it wrong no but they don&#39;t know that they&#39;re they&#39;re so rigid so when do you teach them days ahead because they&#39;re not going to blow it out of proportion if you tell them this is what&#39;s going to happen 3 days later that&#39;s what they think is going to happen so you can teach them a day or two ahead of time so how old does a child need to be before you can teach them the day before seven now you can give a little one a three or four-year-old a tour of the facility you just don&#39;t tell them what&#39;s going to happen there do you understand what I&#39;m saying tours are okay you can give anybody a tour what are you going to teach them what you&#39;re going to do plus skills what you&#39;re going to do plus you can teach a 7 to 11 year old how to do skills you cannot teach a 3 to six-year-old how to do skills why if you teach a 7 to 11 yearold how to do a skill how will they do it every time exactly the way you taught them because they&#39;re rigid concrete if you teach a 3 to six-year-old how to do a skill how will they do it anyway they can imagine you know I can you teach a three four 5-year-old how to give themselves insulin they&#39;ll do it just fine for you then the next day what&#39;ll they do well I think I&#39;ll not put anything in there and I&#39;ll just jab and out and then the next day they go oh why don&#39;t I give it to the dog that&#39;ll work you know and they just don&#39;t they just so what age does a child have to be before you could teach him a skill so seven how use age appropriate reading and demonstration use age appropriate reading and demonstration okay the next age group are the 12 to 15 year olds and they are formal operations these kids can abstract that&#39;s the big huge thing that they can do that the younger ones can&#39;t they can abstract and they can think cause and effect so here&#39;s the good news as soon as a kid hits 12 and they ask you about teaching it&#39;s not a pediatric question anymore it&#39;s an adult Med searge question because how do you when do you teach a 12-year-old and above like an adult what do you teach them like an adult how do you teach them like an adult so at what age is a child first taught like an adult 12 12 trick question when&#39;s the first age that a child would be able to manage their own care 12 why can&#39;t a can a seven-year-old do the skills related to their care could they manage it no what does manage mean make what decisions which require abstraction because if you tell if if you got a board question like this which of the following four children could manage their own care a 7-year-old with cystic fibrosis no an 8-year-old with diabetes melus no a 10-year-old with a scraped knee no a 13-year-old with chronic renal failure yes why did they put the 10-year-old with a scraped knee in there to fool you because it&#39;s not the severity of the illness that determines who can manage but the age of the kid why could a 10-year-old not manage a scraped knee what will you teach a 10-year-old to do about a straight knee you&#39;ll tell them to do what w wash it dry it put on Neosporin and a bandit okay what will he do the next day wash dry NEP and B it because they do it exactly the way you said so what do they do the third day wash dry knp and Band-Aid the fourth day it&#39;s swollen what will they do wash dry Neosporin band the next day there&#39;s pus coming out of it what will they do wash dry Neosporin bandage the next day it&#39;s swollen twice the size of the other leg what will they do wash dry knee is forign Band-Aid the next day they&#39;re semicom to and they&#39;ve got red streaks coming up and down the leg they can barely get out of bed what will they do wash dry are they managing no no that&#39;s why they can&#39;t do it but if 13-year-old with a chronic renal failure if they are taught osculate your shunt every day to hear a brewery if they don&#39;t hear a brewery what will they do get help that&#39;s managing managing doesn&#39;t mean doing everything managing means knowing when you can and when you can&#39;t and what&#39;s necessary so just be careful if they say manage it&#39;s a 13-year-old if they say skills it&#39;s a 7-year-old all right let&#39;s go to page 58 I want you to read this this is for you to read about and learn about I want it&#39;s about how to take psych tests all it is is a bunch of seven principles you have to obey the first principle says make sure you know what phase of the relationship you&#39;re in remember the nurse patient relationship pre-interaction introduction or orientation working and termination phase remember that this tells you how to answer in each of those phases the second principle is gift giving which means don&#39;t give gifts in Psych don&#39;t accept gifts in Psych if your psych if you&#39;re schizophrenic gives you flowers don&#39;t accept them why cuz to you it&#39;s just flowers to them it may be a marriage proposal and when you accept it you&#39;re in trouble okay number three don&#39;t give advice if the patient says what do you think I should do what should you say what do you think you should do I know it sounds corny but that&#39;s what they want you to say don&#39;t give them advice now can you give advice in Med surgeon PE sure but not in sight CU if a mother says to you how should I care for my child &#39;s pick line when she goes into the shower you should not say how do you think you should care for the pick line when she go you see what I&#39;m saying it&#39;s stupid in Med surge it makes sense in Psych number four don&#39;t give guarantees in Psych don&#39;t say if you cry you&#39;ll feel better if you talk to me we can help you remember all those St those are those are guarantees don&#39;t do that on that next page IM immediacy and you can read all about this I&#39;m just showing you what it&#39;s about immediacy says if a patient says something what&#39;s the best answer the one that keeps them talking if you&#39;re between two psych answers and you don&#39;t know which one to pick pick the one that keeps the patient talking the one that says let&#39;s talk about it right here and right now let&#39;s keep talking don&#39;t pick answers that say refer them to the social social worker why if you&#39;re referring to the social worker what are you doing to the communication right then and right there shutting it off don&#39;t do that even if it&#39;s appropriate for the social worker to deal with do you see what I&#39;m saying keep them talking it&#39;s never wrong to get your patient to talk did you hear what I said it&#39;s never wrong to get your patient to talk so if one of the answers gets that patient to talk you better pick that CU if you don&#39;t you&#39;re saying it&#39;s wrong to get a patient to talk it&#39;s never wrong to get a patient to talk that rule alone can really help you onsight questions if you&#39;re sitting there and you&#39;re between two answers for example like a woman has has had a breast biopsy and she says to you when will when will the results come back do you think I have cancer my sister had cancer she died of breast cancer what&#39;s your best response and you&#39;re between a which says your results will come back in 2 to three days and the doctor will discuss them with you or B which says you&#39;re concerned about what the results May Show both of those are okay but one of them doesn&#39;t get her to talk the other one gets her to talk which one gets her to talk B now is there anything wrong with a it&#39;s absolutely 100% correct but it says the results will come back in two to three days the doctor will talk to you talk to the hand that cares you know I mean talk to someone who cares CU I don&#39;t care whereas you&#39;re concerned about what the results May show gets her to talk but you see those are that&#39;s a real dilemma that a lot of people get into so when you&#39;re between two site question answers remember it&#39;s never right to get the patient to so it&#39;s probably always right okay concreteness number six means don&#39;t use slang you know if the patient says I feel rotten about what I did don&#39;t say you feel rotten cuz then they go oh maybe I have you know maybe I&#39;m you know rotting away and don&#39;t tell an upset patient to chill out you&#39;ll probably find them in the refrigerator because psych patients take you what literal and concrete so use don&#39;t say to a a client oh you know what goes around comes around now they&#39;re going like this all day long you know cuz they&#39;re worried about something going around and coming around that&#39;s figurative speech that stinks in site if a patient says to you you&#39;re a real Brin slabic what did you say um what&#39;s res ah I tricked you brinc is not what concrete so you wouldn&#39;t say what&#39;s a brinc you&#39;d say you&#39;re confused about what my role is here I know it sounds really stupid but that&#39;s what they&#39;re going to say or or you&#39;re a real brinc I see you&#39;re angry you see what I&#39;m saying that&#39;s perfect you don&#39;t use the dumb word they used you know what I mean you&#39;re a shabos what&#39;s a shabaz no no you don&#39;t go there you know don&#39;t go you don&#39;t believe me you don&#39;t want to go there now you may want to go there because sometimes it&#39;s really fun to hear about it it could be very entertaining but that&#39;s what makes me a bad psych nurse okay um the one I want to camp out on is empathy here you got to know empathy because they won&#39;t license a nurse who&#39;s not empathetic believe me they won&#39;t empathy says the best like answers are those answers that communicate to the patient that the nurse accepts the patient&#39;s feelings feelings as being valid real and worthy of action empathy is all about feeling do you remember we talked about this the other day acknowledge feeling you&#39;re empathetic always be empathetic here are some really bad answers if you ever see an answer written this way don&#39;t even finish reading it it isn&#39;t worth your time here&#39;s a really horrible one don&#39;t worry don&#39;t feel you shouldn&#39;t feel I would feel feel anybody would feel nobody would feel most people feel all of those are as stupid as stupid gets I saw a question in a review book that shall remain nameless called Saunders that said that a woman had a miscarriage and was crying and they wanted to know what the nurse should say and they said that you should say I know how you feel I had a miscarriage too now it&#39;s true you did have a miscarriage you know what I&#39;m saying it&#39;s not that you&#39;re lying but they said you should say that I&#39;m telling you you never say that that is the stupidest answer I&#39;ve ever heard you say something like what tell me how you feel well remember I don&#39;t like tell me how you feel that&#39;s very upsetting yeah that is so sad everything that has happened is so devastating you see I don&#39;t we don&#39;t like to say how are you feeling we want you to look at the scenario and assume remember you&#39;re always told don&#39;t read into questions but on these ones you have to read the feeling into what&#39;s going on this is the one place where you have to read into the question if you don&#39;t read in you&#39;re going to miss it cuz see if you&#39;re she crying you say how do you feel that&#39;s kind of how do you think I feel you know what I mean but I see you&#39;re so sad everything is just this is just devastating you know that&#39;s good you don&#39;t say I know how you feel I did it too you know who cares who cares okay turn the page I want to teach you a four-step process for answering empathy questions and if you use this you will do really well with them number one recognize that it&#39;s an empathy question empathy questions always have a quote in the question and each of the answers is a quote have you seen that format patient says quote da da da d da da da what would you say a quote B quote C quote D quote when you see that format what should you say to yourself every single time chance for me to show my empathy okay now here&#39;s how you do it because you&#39;re going to have to read aren&#39;t you going to have to read the feeling into it number two put yourself in the client&#39;s Place their shoes and say their words as though you really really really really me them be an actor get into it role play it number three then ask yourself if I said those words and really meant them how would I be feeling right now okay now you got your answer now you got your answer all you have to do now is number four go and choose the answer that reflects that feeling or anything close do not choose the answer that reflects their words because these empathy questions always have what I call the sucker answer there it&#39;s an answer that&#39;s wrong but it&#39;s there to sucker you into answering it and what it will reflect is what the patient said but it will ignore what the patient felt you&#39;re supposed to pick the answer that reflects what they felt and ignore what they said did you hear that empathy ignores what is said and goes with what is felt don&#39;t get it switched around when people have a hard time answering empathy questions it&#39;s usually because they respond directly to what the patient said rather than how the patient feels do you remember when um I don&#39;t know your name but I said you&#39;re a real Brin liic if you respond to what they said you&#39;ll say a brinck but if you respond to how they feel you&#39;ll say I see you&#39;re angry do you see the difference now I want you to do the next three questions practice questions and I want you to use these rules put yourself in the client&#39;s Place say the words as though you really meant them ask yourself how would I be feeling if I said these words pick the answer that reflects that feeling I also want you to identify at least one sucker answer that overemphasizes what the patient said but missed how the patient was feeling so do that and then talk to your buddy stay on task I&#39;ll be right back yeah I more more this the third one is really hard that third one the problem with it is when you put yourself in the patient shoes and say those words no feeling really pops out so what you have to do is go to the answers and see what feeling the answers are reflecting and see which one has the best the most likely feeling so go to your answers and see if you can get it that way well let me ask you about the first one she said you&#39;re Killers you all killed my mother whatever you know you she died before I was born how does she feel if you said those words and believed them how would you feel scared okay now go to the answers and find the answer that reflects being scared which one is it B what is the sucker answer c c cuz that focused on what she said she isn&#39;t concerned about her mother she&#39;s scared she&#39;s frightened so the answer is B the sucker answer is C the next one what&#39;s the right answer d d and a sucker answer is any of the others cuz the others focused on what he said D focused on how he feels did anybody get an answer on the third one what is you say the answer is C what&#39;s the sucker answer B Because B says religious he&#39;s not feeling religious he&#39;s using a bunch of religious what words that&#39;s the hint that it&#39;s the wrong answer he&#39;s feeling out of control so that&#39;s why C is the answer because with those words I can prove to to you that he has a control issue I can&#39;t prove to you that he feels religious so C is the right answer how many got C on that one wow that&#39;s great how many got all three terrific if you missed any do you see why you missed it what were some of the problems you had with that anybody or you you&#39;ve learned from it any questions you have to me about those did you use the process did the process help okay that&#39;s what I want you to start doing I don&#39;t want you guessing on psych answers I want you to know the answer you understand what I&#39;m saying so many times you guys just guess on psych answers I want you to know why you&#39;re picking what you&#39;re picking okay take a quick break come back at 25 after and we&#39;ll just do the last lecture and a wrap up and be done okay and the sooner you&#39;re back the sooner we&#39;ll get done page 54 this is the most important lecture in the whole review everyone will get at least 15 questions on this you&#39;ll think this is all your test was sometimes most people just dead guess on these ones I don&#39;t want you dead guessing and if they don&#39;t get dead guess they use ABCs I don&#39;t want you using abcs on this so talk about how you prioritize prioritization delegation and staff management the first skill is prioritization they will be testing to see how you prioritize four different patients number one you are deciding which patient is sickest or healthiest now be sure you know which one you&#39;re looking for cuz sometimes they they have you looking for the sickest highest priority and sometimes they have you looking for the low lowest healthiest priority for example if they said there&#39;s been a disaster in your town and you have to discharge one of the following people to make room for incoming wounded who would you discharge would you be looking for the highest priority client or the lowest priority client lowest but if they said to you you receive report on all of the following four patients which patient will you check first when you get out of report what would you pick highest so the the point is sometimes you&#39;re picking the highest sometimes you&#39;re picking the lowest make sure you keep that in your mind because sometimes you can start out looking for the lowest and halfway through the question start looking for the highest you see so don&#39;t get turned around in the middle of the question okay examp now four rules for PRI okay that&#39;s that um oh L is not there um sorry I have to write this way I just don&#39;t have any more open transparencies um what they will do in the answers the will always have four parts they&#39;ll have an age a gender a diagnosis and a modifying phrase so the answers will always be a 10-year-old male with hypospadius who&#39;s throwing up Billy B stained emesis well the age is the age the gender is the gender the diagnosis is hypospadius and the modifying phrase was who&#39;s throwing up vile stain emesis did you got that they always have an age a gender a diagnosis and a modifying phrase two of those are totally irrelevant and you do not use them in your answer which two are irrelevant age and gender when you prioritize complet completely get rid of the age completely get rid of the gender you understand though in Pediatrics in a pediatric question you got to pay attention to the age but in a prioritization question you don&#39;t pay attention to the age because a 2-year-old is not more valuable than a 90y old they&#39;re both humans do you understand what I&#39;m saying so age is not a criteria whereby you prioritize gender is not a Criterion by which you prioritize women are not more valuable than men and men are not more valuable than women they&#39;re it&#39;s irrelevant okay the diagnosis is important and the modifying phrase is important which one is more important the modifying phrase the modifying phrase is always more important so if the patient had sorry I get rid of this okay if the patient had angina hectus versus myocardial infarction Ang ginis versus myocardial infarction who&#39;s the higher priority person the heart attack the Mi however look at this with unstable BP with stable vital signs I added a modifying phrase did you see that now who&#39;s a higher priority angina cuz he has what unable blood pressure the myoc caral infarction they told me was stable CU he has stable vital science so here we have low priority high priority high priority low priority we always pay more attention to which one modifying phrase so he&#39;s the higher priority he&#39;s the lower priority regardless of this do you see that that that&#39;s why you can&#39;t use ABC that&#39;s one of the many reasons why you can&#39;t so this person is more stable this is more unstable here&#39;s your higher priority here&#39;s your lower so always break the tie in favor of the modifying phrase all right now let&#39;s go to the four rules for prioritization the four rules rule number one acute beats chronic acute beats chronic what do I mean by beats is is a higher priority than in other words an acutely ill person is a higher priority than a chronically ill person now let&#39;s look at this how this works out if you had the following patients a COPD a CHF and an appen detis who would be the higher priority exactly why because what are the other two chronic illnesses the atitis is acute if you used ABCs who would be your highest priority client cop COPD and you&#39;d be dead wrong are you seeing what I&#39;m talking about so acutely ill PE would you agree with me that an acute gut is a higher priority than a chronic love absolutely so acute beats chronic it&#39;s not ABC okay next one rule number two on the next page rule number two fresh posttop fresh posttop now how fresh would fresh be how many hours 24 12 12 not 24 12 so any posttop in the first 12 hours is a fresh posttop Fresh posttop Beats medical or other surgical fresh posttop beefs Medical or other surgical okay so what about this of those people who is your highest priority a COPD a Cher an acute appendicitis a 2hour postcystectomy and a second postop day coronary artery bypass craft who&#39;s your highest priority the 2hour post coli why they&#39;re fresh posttop and that beats what medical and other surgical what about this and a radical neck dissection who would win hour post coli and a bilateral above the knee amputation who would win toour post coli and a right frontal craniotomy who would win the 2hour post coli what&#39;s my point it does matter doesn&#39;t matter how bad the surgery is or how involved the surgery is if you aren&#39;t 12 hours in you aren&#39;t high risk you&#39;re recovery that fresh posttop is much more unstable than this guy no matter what was done so don&#39;t go on all of this stuff go on these time frames are you seeing that okay rule number three this is my favorite rule I use it I don&#39;t even I I use it this is the one I use and that is unstable beats stable unstable beats stable so that means unstable people are a higher priority than stable people duh who knew that before you went to nursing school who knew that in seventh grade so then why don&#39;t you get these questions right all the time if you knew that why because you don&#39;t get them right why don&#39;t you get them right you know this then why don&#39;t you get it right the word St yeah in the question there&#39;s all these words and you were never taught what words count for stability and what words count for instability no school teaches that I&#39;m going to teach you that right now it&#39;s Cedarville I always tell this tell the faculty when faculty me we got to teach the students what stable and unstable means oh we do we do no they don&#39;t I go in their classes I listen they talk in platitudes you know if it&#39;s lifethreatening it&#39;s high well then tell me what&#39;s lifethreatening guys I mean you can&#39;t just be I I need concrete specific things to look at so we&#39;re going to generate some concrete specific lists here words to look for in an answer do you see the two lists one list says things that make a patient stable and the other says things that make a patient unstable what do I mean by things words in and answer or modifying phrase that makes the patient either what stable or unstable so you can actually take this to a question and use it and you&#39;ll know what you&#39;re talking about okay let&#39;s go through the list of things that makes a patient stable let&#39;s start there what makes an answer stable number one let&#39;s start real easy use of the word stable no I&#39;m serious people I don&#39;t know how many people will say well it says they&#39;re stable but you know they could just like you know a second later they could just like decompensate and and they could herniate and then they could die and and that could happen in seconds so while it&#39;s saying it&#39;s stable now they&#39;re really like a ticking Time Bomb so I&#39;m going to put them high priority no they said they were stable they&#39;re stable don&#39;t argue with the fact that they said they were stable you have to answer it at this moment in time for this patient if they said this patient was stable right now what are they and if they destabilize in one second we&#39;re not talking about that do you understand what I&#39;m saying we&#39;re talking about right now when they&#39;re talking about this patient so let&#39;s go across to the other list things that make a patient unstable what do you think number one is there unable use of the word unstable and don&#39;t argue whether you think they would be unstable or not they said they were okay next go back to stable go back to the stable column we&#39;re going to bounce back and forth between stable you see what we&#39;re going to do here okay stable one thing that makes a patient stable number two chronic illness chronic illness makes you stable so go to the unstable side number two what makes a patient unstable acute illness what rule is that that was rule number one wasn&#39;t it the reason why I like this rule is because it&#39;s it grandfathers rule number one into it okay go back to the stable side a phrase that makes you stable posttop greater than 12 hours if the patient is posttop greater than 12 hours they are stable so what makes a patient unstable postop less than 12x now what rule is that that was rule number two so I use rule number three because it includes rule number one and Rule Number Two okay go back to something that makes you stable go back to the stable local or Regional anesthesia if you had a procedure with local or Regional anesthesia you are stable so what makes you unstable general anesthesia but only in the first 12 hours go back to stable things that make you stable lab abnormalities of an A or B level lab abnormalities of an A or B level what am I talking about remember this morning if you got a lab abnormality yes it&#39;s abnormal but it&#39;s an A or a B guess what the patient is stable okay then what makes you unstable lab abnormalities of a c or a d so who&#39;s unstable a client with a creatin of 17.8 or a client with a potassium of 6.1 that&#39;s 6.1 because that&#39;s a d versus an a right there go back to things that make you stable the phrases ready for discharge and don&#39;t argue oh I don&#39;t really think they&#39;d be ready for discharge that soon I really don&#39;t think they would be they said they were they are so don&#39;t argue it okay ready for discharge uh to be discharged to be discharged or admitted longer than 24 hours ago admitted longer than 24 hours ago so if the patient has been here longer than 24 hours we assume they are what stable and don&#39;t say well I don&#39;t think it would take that long to stabilize them they said it you go with it so what makes a patient unstable what phrases not ready for discharge newly admitted newly diagnosed or or what admitted less than 24 hours ago exactly admitted less than 24 hours ago another one stable unchanged assessments unchanged assessments meaning the assessment is unchanged it&#39;s the same as it&#39;s been there&#39;s nothing new okay what makes a patient unstable changing or changed assessments there&#39;s something new there&#39;s something something different okay we&#39;re almost done go back to stable this is a long one so get it down word for word the patient is stable don&#39;t write it down the patient is stable if they are here we go experiencing the typical expected signs and symptoms of the disease with which they were diagnosed experiencing the typical expected signs and symptoms of the disease with which they were diagnosed a patient is stable if they are experiencing the typical expected signs and symptoms of the disease with which they were diagnosed go to unstable the patient is unstable if they are and get this down now experiencing unexpected signs and symptoms unexpected signs and symptoms the mistake that most students make when they prioritize patients is they prioritize based on symptom severity rather than symp symptom expectedness in other words if somebody has severe pain and somebody has mild pain they will always prioritize the severe pain higher than the mild pain and that&#39;s wrong if somebody has kidney stones and they&#39;re having severe colic pain are they stable or unstable stable why do you expect severe kicy pain with kidney stones right yes but somebody&#39;s having mild pain with a chest x-ray should you have mild pain with a chest x-ray you should have no pain with a chest x-ray so who&#39;s unstable the mild pain with the chest x-ray is unstable the guy with the severe pain with the kidney stone is stable do you see what I&#39;m saying okay um all right let&#39;s look at let&#39;s look at how we apply this how do we apply this I want you to tell me who the highest priority patient is here and I want you to use the rules I taught you okay you have a 16year old female with Menin cacal menius right who has had a temp of 103.8 since admission 3 days ago that&#39;s your first patient 16-year-old girl manin cacom menitis she&#39;s had a temperature of 103.8 since she was admitted 3 days ago the next patient is a 67-year-old male with irritable bow syndrome who spiked a temp of 100.3 this afternoon I want you to talk to your buddy and decide who on the basis of the rules I gave gave you not guessing but on the basis of the rules I gave you I want you to site who is higher priority and why what he said then but I would have the other one if I now there&#39;s a change yeah 103 [Music] this how many would say what what are you guys saying a or B is the answer now what do we rule out right away here okay so we can rule this out and we can rule that out okay now mininal mantis high or low priority High because it&#39;s what acute irritable bowel syndrome high or low low because it&#39;s okay now that&#39;s our diagnosis let&#39;s go to our modifying phrase which are going to be more or less important more important okay who has had what kind of language is that who has had but what what criteria are we talking about in your list there who said it unchanged unchanged who has had so automatically that puts her what up or down down down a temp of 1038 now when you get a symptom when you get a symptom on these questions do not look at how bad it is look at whether it is what expected or not remember that typical expected do you expect kids with do you expect anybody with Menin Cal menitis to have a fairly high fever yes yes so is this expected yes so does that make her high or low low priority low and to put the nail in the coffin what phrase comes next days ago and that puts her what remember admitted more than 24 hours ago so she&#39;s low so how many highs does she have one how many lows does she have three two or three and all the lows are in what area modifying phrase so we&#39;re thinking thinking she&#39;s what low priority okay who spiked changing changed hi okay temp of 103 how do you deal with that what do you say to yourself is it expected for an IBS no not low don&#39;t say low remember I told you it&#39;s not severity so don&#39;t be talking high and low ask is it expected for an ibser irritable vow to have a temp of 100.3 no actually for them it&#39;s high it&#39;s not low 100.3 so that&#39;s unexpected so does that make him high or low priority high high unexpected and then to put the nail in the coffin what did it end with this afternoon which means it was new changed not been happening so how many highs does he have two or three how many lows one the highs are all in the modifying phrase who&#39;s your higher priority B now let me ask you that does that make sense to you now in real life I said this was low and this was high low priority high priority right so who could go home if it&#39;s true that this one&#39;s low she can go home this one&#39;s high he cannot go home is that true yes it is absolutely true why if she goes home do we know what&#39;s happening with her yeah everything yes we know the symptom we know why she&#39;s got a 1038 we know what it is it&#39;s been that way we&#39;re going to send her home with a home health referral for what IV antibiotics and she&#39;s good to go she can go home cuz she&#39;s stable can I send this guy home why can I not send him home you don&#39;t know what&#39;s going on do you know what this is It&#39;s not that so what is it you don&#39;t know do you know what this is do you know what this is yes it&#39;s a symptom of that right well I knew she had that tell me something I didn&#39;t know I can&#39;t send this guy home this guy could probably probably ruptured an ulceration probably is developing septic peritonitis and we&#39;re just catching his temperature on the way up if I send him home he&#39;s going to come in dead because he&#39;s going to go into septic shock and fade out during the night and no one knows it you see why this guy you can&#39;t send him home he may die this one you can send home how many of you would have picked the menitis an hour ago how many would have picked the erable B an hour ago nobody nobody would have picked it do you see what I&#39;m saying but does it make sense and do you see why it&#39;s true okay um do you see where it says always unstable I want to give you four things that are always unstable regardless of whether it&#39;s expected or not so remember I told you when you look get a symptom don&#39;t qualify how bad it is but ask is it is it expected or not well there are four things that just because they&#39;re there makes you unstable number one Hemorrhage if you are hemorrhaging even if I expect it you&#39;re unstable right yeah for example if I said a client had DIC and hemophilia which would be rare but let&#39;s say they did and I said he&#39;s hemorrhaging I don&#39;t want you to say well you know hemorrhaging I would expect a client with DIC and hemophilia to Hemorrhage so since it&#39;s expected it&#39;s low priority do you see the absurdity in that there are certain things that even if they are expected are what serious serious and bad so hemorrhaging is always bad even if you expect it does that make sense now do not confuse hemorrhaging with bleeding those are two different things boards thinks bleeding hemorrhaging you know to them it&#39;s it&#39;s there&#39;s a huge difference between bleeding and hemorrhaging so if you see bleeding high or low no it depends on whether it&#39;s expected or not gotcha gotcha hemorrhaging high or low high cuz it&#39;s one of those things okay second one high fevers over 105 105 and over why even if it&#39;s expected what will a person with a fever of 105 and overdo Sease so that&#39;s high priority even like now what what could I have done to this menitis girl to make her a high priority made her temp 105 and then then she&#39;s she&#39;s there okay hypoglycemia is the third one a low blood glucose a patient has hypoglycemia their blood glucose is eight don&#39;t do this don&#39;t say well you know I would expect a low glucose with hypoglycemia so an eight is stable you see how stupid that is if you got a low sugar it doesn&#39;t matter if it&#39;s expected or not you are in trouble okay so hemorrhaging high fever hypoglycemia so far they&#39;re all hes right and the last ones are pulselessness or breathlessness if you are pulseless or breathless even if it&#39;s expected you are high priority now how would that ever happen well could you imagine a question like this the patient has viib ventricular fibrillation or a and you don&#39;t get a pulse high or low priority well you know if they had asy I would expect them not to have a pulse so they&#39;re okay you see how stupid that is you can&#39;t you can&#39;t take this to the obsurd do you see what I&#39;m saying I&#39;m trying to show you where the line is drawn so with pulselessness breathlessness hypoglycemia hemorrhaging and high fevers what are are they unstable regardless of expected or not but everything else obeys the rule of expectedness or not do you understand that that&#39;s that&#39;s the way to go with it hey just a real quick question when is pulselessness and breathlessness actually the lowest priority at the scene of an unwitnessed accident at the scene of an unwitnessed accident if you find anyone who is pulseless or breathless guess what they are what what&#39; you say they&#39;re dead they&#39;re the lowest priority but if you witness the problem who&#39;s the highest priority pulseless breathless so knowing whether to prioritize pulselessness and breathlessness highest or lowest depends on witness or not was it witnessed was it not witnessed by the way what are the three things that result in a black tag in an accid and at an unwitnessed accident what are the three things that result in a black tag you know what I mean by a black tag tag them black and ship them last add an unwitnessed accident pulselessness breathlessness fixed and dilated pupils even if they&#39;re breathing and have a pulse those are the three things you have any one of those they&#39;re black tag at an unwitnessed and the hardest one is someone who has fixed and dilated pupil who&#39;s still breathing you know that&#39;s the hard one to leave alone you know what I&#39;m saying but you got to go to somebody else somebody else needs your help more all right rule number three no rule number four on the next page rule number four this is a tie breaker this is a tie breaker caution only use this as a tie breaker I want to I I&#39;m totally trying to be totally honest with you a lot of times when you use those previous rules you end up with one or about two or three that could be it so you need a tiebreaker the tiebreaker says the more vital the organ the higher the price priority the more vital the organ the higher the priority now just a caution here the organ we&#39;re talking about is it the organ of the diagnosis or the organ of the modifying phrase the organ of the modifying phrase is what we&#39;re talking to when you do your tiebreaker do the tiebreaking with the organ in which the modifying phrase is happening not the diagnosis itself you got that okay now what I need to give you is the order of organ Vitality so here it is the most vital organ in your body is your brain the second most vital organ is your lung the third most vital is your heart the fourth is the liver the next is the kidney and the next is the pancreas after that no one agrees so that but that&#39;s good enough that&#39;ll get you what you need brain lung heart liver kidney pancreas in that order so you have a 23y old does that matter male no with CHF high or low priority low cuz it&#39;s what chronic with a potassium of 6.6 High why it&#39;s a CD it&#39;s one of those CD levels okay and no EKG changes what would that do increase his priority or lower his priority lower lower because it&#39;s saying at least he&#39;s not affecting the what yet the heart okay a chronic renal failure with a creatinin of 24.7 high or low low high or low it&#39;s high no I mean high priority low priority oh low why for two reasons it&#39;s an a level plus it&#39;s exected and this is really not expected with that and pink frothy sputum why high priority are feeling is a classic symptom of chronic renal failure pink froy sputum so this person is unstable this guy&#39;s unstable but asymptomatic this guy is unstable and having unstable and having symptoms so this guy could be beating this guy it will see all right a patient with acute hepatitis high or low priority acute hepatitis high high with jaundice high or low low why you expect jaundice with hepatitis an increased ammonia level expected who you cannot arouse expected or unexpected with a hepatitis unexpected unexpected okay so that&#39;s a unexpected so that&#39;s what hot so we got an unstable here an unstable here and an unstable there we got three unstable people right okay who&#39;s our highest priority okay potassium what organ system are we worried about so we got a heart number one is a heart number two we got a what no we don&#39;t have a kidney uh-uh uhuh we got a lung remember you go with the modifying phrase you don&#39;t go with the disease so we got a lung right and then number three we got a what don&#39;t say liver right we got a brain okay so I go to my tiebreaker correct and who wins he wins are you seeing this does that help you can you replicate that can you actually do that when you go to take your boards okay does this change some of the ways you might do things does it make sense to you why you do it that way do you see why it&#39;s valid okay just say tell me if they&#39;re stable or unstable Ang ginop Pectus why chronic okay with crushing substernal chest pain stable because that is expected with angina not relieved by rest or three nitroglycerin unable unstable because the definition of angina is chest pain relieved by rest and Nitro so if it&#39;s unrelieved it&#39;s not angina anymore it&#39;s Mi now they&#39;re unstable does everybody see what I&#39;m saying on that okay delegation do not delegate the following responsibilities to an LPN and lpn&#39;s your not allowed to assume the following responsibilities if an RN delegates it to you now don&#39;t yell at me I didn&#39;t write the list okay I&#39;m just recorded so don&#39;t shoot the messenger I know that 99% of the hospitals in in Ohio don&#39;t do this but this is what the book saith okay do not delegate the following to an LPN starting an IV and you say but what if they have IV certification it didn&#39;t say they did so you&#39;re not allowed to assume that they did hanging or mixing IV meds they&#39;re not allowed to hang or mix IV meds number three pushing IV push meds so what can they do in regard to an IV maintain maintain and document the flow that&#39;s what they can do D they cannot administer blood or mess with Central lines they cannot administer blood or mess with Central lines so no central line flushing if I had to go down to the wire on it I would say they&#39;re not allowed to change change of Central Line dressing but if that was the only thing that they possibly could do then I might let them do it but it&#39;s going to be you know I&#39;m going to really seriously not let him do that unless it&#39;s the only option letter the next one they&#39;re not allowed to plan care the RN makes the care plan the LPN can implement it but the RN does the care plan the next one they&#39;re not allowed to perform or develop teaching what they can do is reinforce teaching what&#39;s the difference between performing and reinforcing yeah so so if somebody needs taught about their diabetes who should do the patient teaching regarding the diabet diabetes they are in but can an LPN reinforce the necessity of doing an acue check before you give insulin to a patient yes they&#39;re not allowed to take care of unstable patients so LPN that&#39;s why you need to know this stable unstable thing because you&#39;re supposed to know what you&#39;re allowed to accept and what you&#39;re not allowed to accept you&#39;d have taken the minin COO manius kid but you wouldn&#39;t take the IVs person if you remember that illustration they&#39;re not allowed to do the first of anything if they&#39;re doing the first I mean if there&#39;s something that&#39;s being done for the very first time who should do the very first the RN cuz what are they going to do assess and care plan so can an LPN perform tube feedings yes or no sure can they do the first tube feed after a g tube was inserted no can they change postoperative dressings sure should they change the first posttop dressing the day of surgery no can they feed stroke patients sure but they shouldn&#39;t do the first feeding of the stroke patient after the the feed can they ambulate post off clients of course should they get the patient out of bed the very first time after surgery no can they take Vital Signs should they take the first set of vital signs after a patient came back from surgery no and that&#39;s one that nobody ever does but I do it as an RN I even see hospitals that are so stupid that they let AIDS take the first set of vital signs after surgery that&#39;s ridiculous somebody&#39;s waiting for a lawsuit to happen on that one you won&#39;t stand up 5 minutes in court if that happens yes changes is it that insur that is our ends boards would allow an RN to do the first dressing change it is tradition to allow the surgeon to do the first one do you see my point but board is more we is Nurses We are the world you know that kind of thing you know more assertive kind of thing and you are you at the last one now they&#39;re not allowed to do the following assessments they&#39;re not allowed to do the following assessments admission discharge transfer or the first one after a change the first assessment after there has been a change who has to do the first assessment after there has been a change the RN because they have to assess plan the whole bit so what about this in report a nurse says I think I heard crackles on that guy in 52 he&#39;s never had him before I think that he has had them I mean no he&#39;s I think I heard them who would be the person that should go assess that person in the morning the RN something may have changed okay um so who should the LPN check who would you send the LPN to check and lpn&#39;s who would you go check a patient with angina Pectus with crushing substernal chest pain who was admitted three days ago and is on nitroglycerin a patient with a subtotal thyroidectomy two days ago who says why are they washing elephants in the parking lot who should the LPN check who should the RN check a for the LPN B for the RN YB for the RN what&#39;s going on man subtotal subtotals gety storm storm and what&#39;s a symptom of storm delirum it could be that that person&#39;s going into storm we don&#39;t know it but the angina with the substernal crushing chest pain in the night that&#39;s all totally but why are they doing that why do they always give you the crushing sub substernal chest pain versus somebody says why are elephants in the parking lot come on they they know that people including nurses when they hear crushing substernal chest pain they go what w you know and and but don&#39;t go wo because it&#39;s no big deal it&#39;s expected and you&#39;re going to treat it and it&#39;s nothing does everybody understand that make sense okay um now do not delegate the following responsibilities to an aid they won&#39;t call it an aid they&#39;ll call them a u AP an unlicensed assisted Personnel when they talk about a UAP it&#39;s an aid a tech here&#39;s what they&#39;re not allowed to do charting now they can chart what they did but they can&#39;t chart about the patient they can chart what they did but they can&#39;t chart about the patient so could they chart side rails up bed in low cite in reach bed bath given CU they chart patient less an today tolerated ambulation well no secondly they&#39;re not allowed to give meds except for what what meds can they give topical overthe counter barrier creames AIDS can independently apply topical over-the counter barrier creases so can they give nitroglycerin ointment it&#39;s topical but it&#39;s not over the GS okay good job can they apply Neosporin ointment technically what because it&#39;s what not a barrier do you see what I&#39;m saying what about hydrocortisone cream probably not what about a andd ointment yes Alpha carry lotion yeah see what I&#39;m saying so those bear creams they can do what about elce ointment for the skin Ace sounds like a what enzyme it&#39;s probably not over the counter okay but don&#39;t get bogged down on that because that&#39;s the one the least test because different states are somewhat different on that okay the next one is they&#39;re not allowed to do assessments except for vitals and ACU checks which I think is stupid why do I think that&#39;s stupid why do we delegate the measurement of something called Vital Signs and acue check which can go to brain damage why do we delegate those two most critical most important assessments to the least prepared person I don&#39;t understand I&#39;d rather have them do my bow sounds and and uh pulses frankly my peripheral pulses and my bowel sounds I&#39;d rather have them listen to those than do the ACU checks and the vus but why why can we do them why do they do them what&#39;s the reason money it&#39;s all money so we&#39;re jeopardizing patients to save money I do all my own vital signs I do all my own AC checks when I&#39;m an RN working and I work and I never get out late I can count on one hand the number of times I&#39;ve been out after my quitting time I am not one of those nurses an hour after quitting shift I&#39;m still there doing my charting I never do that ask anybody that&#39;s work with me I&#39;m out of there I don&#39;t stay late but yet I do all my own AC checks and all my own vience so you can&#39;t tell me that it&#39;s that that you don&#39;t have time to do them you do I think the reason why I&#39;m out on time is because I do my own stuff what do I mean by that I know what&#39;s going on I&#39;m on top of it nothing surprises me it it nothing hits me at 6 o00 when I look at the sheet and I go oh my goodness his blood pressure is 90 over 10 you see I&#39;m saying nobody told me his blood glucose was 15 you see what I&#39;m saying I know it I can tell like boom boom boom so watch pots never boil so I&#39;m just telling you you know I I don&#39;t I don&#39;t buy it so anyhow but here&#39;s the deal if if somebody comes back from surgery and I do a set of vitals and I do all my own set of vitals when they come back from surgery and the vital signs are unchanged from the PAC you you the recovery room discharge vitals they&#39;re unchanged relatively I know my patient is what St stable so then I will tell an aid check them do you see what I&#39;m saying but I I do it sparing when I know what&#39;s going on and I&#39;m checking on it okay enough said on that one uh next thing they&#39;re not allowed to do treatments except for enemis figure that out doesn&#39;t take a rocket scientist they can do enus but they can&#39;t do other things here&#39;s the deal be real cautious of allowing them to catheterize but I I&#39;m not willing to say never let them cize I&#39;m just telling you if you can pick any other answer other than catheterize pick the other answer but if it would say catheterize a patient give an IV push medication intubate the client and irrigate at the tea tube what would you have them do c do you see what I&#39;m saying but if there&#39;s anything else that they could do don&#39;t pick C because Bo doesn&#39;t like him capping one uh Aid on I know there&#39;s one big question on ATI that was talking about what would you let an aid do and you were between having them empty the bag on an ilal conduit continent pouch and versus somebody or versus uh evaluating the effects of range of motion I think it&#39;s said everybody was freaking out between this emptying this bag they never heard of let alone you know and a doing it versus range of motion but that question was not about that the question was about doing versus evaluating you see and people missed it so look at your verbs not just your nouns on your Aid things maybe it&#39;s some like evaluating the effectivess of a bed bath can they do a bed bath can they evaluate the no so sometimes that verb can get you off a hook on that one all right did we cover all that what an aid is not allowed to do well then what is an aid allowed to do you may delegate deleg at ADLs beds baths and activities of daily living however they should never do the first of any of that why who does the first R right now why in a Extended Care Facility why are lpn&#39;s allowed to do a lot of these things I said that they cannot do why could they do them in an Extended Care Facility fac what is assumed about the patient clientele in an in a Extended Care Facility they are stable and therefore an LPN can do many of the things that I said you can&#39;t do in those settings so keep that in mind all right staff manage oh Turn the Page do not delegate to the Family Safety responsibilities do not delegate to the family that&#39;s on the next page safety responsibilities now what do I mean by thaty who&#39;s responsible for the safety of the patient you are so if a family member says would you leave the restraints off my dad while I&#39;m here I&#39;ll watch him make sure nothing happens and I&#39;ll call you when I leave and you can put the restraints back on him yes or no no no Saunders says yes I&#39;m telling you no the book is wrong you cannot delegate safety to a nonhospital caregiver what about a sitter yes why can you delegate to a sitter what does a sitter have to what has to happen for them to be designated a sitter you have to teach them and you have to put in the chart documentation that you what taught them so the second sentences they can only do what you teach them to do so if you decide and the doctor says that the mother can give this three-year-old kid the insulin shot okay can you do it yes as long as you what document in the chart that you taught them you put them through the same checklist that you would do with any new grad new hire on competency for insulin injection and then you put that in the record and you&#39;re good to go but you can&#39;t just let them do it without documenting teaching and their competency what if a mother says this oh would you I I&#39;m not done finishing my baby yet this is in the nursery would you just leave the side rail down and I&#39;ll finish bathing then I&#39;ll put it up when I&#39;m done you can leave the room and go do need go do what you need to do what do you say to them no I&#39;ll stay with you to help you with this bath and when you&#39;re finished I&#39;ll put the side rails up and then we&#39;ll be done because what will happen if do she get an inservice on putting up the side rails on a crib no so if she doesn&#39;t click it right and the baby rolls and Bam and slam who&#39;s going to be in trouble you well she ask me yeah right like they&#39;re going to say oh then I give up the lawsuit cuz I ask you you know like that&#39;ll never happen so you can&#39;t do it I can&#39;t understand why that book said has anyone seen that answer where you&#39;re allowed to do that I what book I mean not book was it a book or was it a teacher test it&#39;s actually online on the website I know believe that I mean are you kidding me just unbelievable yes with um going back infl know you want to evaluate and do be evaluated before you every single time they are hospitalized if a person&#39;s been giving their own insulin injections for 90 years every single time they&#39;re hospitalized we have to go through the documentation for confidenc the inhabitant part of the chart I know it&#39;ll drive them crazy but they&#39;ll know the drill okay staff management how do you intervene how do you intervene with inappropriate behavior of Staff how do you intervene with inappropriate behavior of Staff this is not prioritizing this is not delegating this is handling your staff when they do stupid things and Boards will give you those questions too have you ever seen that you&#39;re a nurse manager you&#39;re the charge nurse You&#39;re the LPN in charge or you&#39;re an LPN and the nurse does this and how you deal with it okay number one number two there are always four answers the same answers show up all the time the first answer usually is something like tell supervisor okay have you seen that as an answer to these kind of questions the the staff member is doing something stupid what do you do tell the supervisor that&#39;s always there number two another one that&#39;s always there is confront them and take over immediately that&#39;s always there and a third one that&#39;s always there is at a later date just talk to them about it you don&#39;t have to do anything right now you don&#39;t have to report it to anybody just talk to them and the last one that is always there is ignore it just let it go ignore it now one of those is never the answer which one is never the answer ignore because you never ignore inappropriate behavior of Staff you always take it as an opportunity to teach and change Behavior now the other three could be right or could be wrong depending upon the situation so what I want to teach you is how to choose between the remaining three options when you get a stack question the first question you should ask yourself is number one is what they are doing illegal you see where I&#39;m at is what they&#39;re doing illegal that&#39;s number one if the answer is yes they are engaging in illegal activity what is the answer that you always choose tell supervisor that&#39;s always the answer however what if the answer is no it is not illegal well then go to the next question the second question you ask yourself is is anyone the patient or the staff member in immediate danger of physical or psychological harm in other words is anyone In Harm&#39;s Way is anyone in danger of physical or Psych olical harm if the answer is yes what do you pick confront immediately and take over because you don&#39;t want anybody to get hurt why don&#39;t you want to tell the supervisor yes cuz delaying confronting in order to go tell the supervisor would put the patient at risk so you go right now you may have to tell who later on supervisor but you got to deal with it right then and right there yes so if it&#39;s illegal to come yeah if it&#39;s illegal and we&#39;re not there yet but you&#39;re you&#39;re ahead of me but sometimes in certain situations it is both illegal and harmful in that case you do both but in what order confront then tell but if it&#39;s but look at this if it&#39;s not harmful and illegal what do you do not harmful but illegal tell supervisor but if it&#39;s illegal and harmful you do both but first you intervene and then you tell supervisor good point that&#39;s a good question okay next one what if the answer is no nobody is In Harm&#39;s Way well then go to the next question the last one the third question says is this Behavior legal not harmful but simply inappropriate if the answer is yes what do you do what do you pick approach them later on and talk to them just counsel them later on no hurry no rush okay now I&#39;m going to give you some scenarios and I want you to tell me which one you&#39;ll pick and I want you to ask those questions of yourself okay you suspect you suspect that a nurse You&#39;re an LPN you suspect that an RN with whom you work is diverting narcotics for private sale and use well is that illegal so what do you do the super um you&#39;re an LPN you walk by the room of an aid who is giving paranal care to a patient and the aid is not wearing gloves is that illegal no no is anybody In Harm&#39;s Way who the a so what do you do is the LPN you go right in and say let me take over you wash your hands you get gloves on and I&#39;ll help you finish got it you&#39;re an LPN you notice an RN going home every day with with bulging Pockets what do you do is that illegal yeah could be stealing right so you what tell the supervisor okay uh you are an LPN in the O you&#39;re a circulating LPN in the O and you notice the surgeon during surgery contaminates the pinky of his left hand what do you do is that illegal no is anybody In Harm&#39;s Way yes who patient patient so what do you say excuse me you&#39;re just contaminated the pinky of your left hand I have a glove right here for you see what I&#39;m saying uh you&#39;re an LPN and an RN always gives report at change of shift and this L RN always says say exasperation instead of exacerbation when referring to COPD so the RN is saying he&#39;s having exasperations of COPD and they&#39;re saying it over and over again all the time so what do you do about it well is that illegal it should be but it&#39;s not um is anybody being harmed so what would you do as an LPA say hey come here some later at a good time You&#39; say Hey you know I noticed you&#39;re always you&#39;re always saying exasperation am I wrong but I kind of thought it was exacerbation now I could be wrong but what you know what do you think you know I mean that kind of thing CU remember when you have a problem with somebody else what do you always talk in I not you you know as LP you would say you&#39;re wrong you&#39;re always saying the wrong not a good idea I mean it&#39;s okay okay to do that but that&#39;s the wrong phrasing okay um are you getting it kind of getting the idea of how you&#39;re going to do that yes question the first example that you said was uh that the RN is diverting drugs so does that imply that the patients that she that are in scar for are not getting that medication no that does not imply that now if it says this you are an RN one of your fellow RN&#39;s was passing narcotics to a bunch of patients you notice that he is somewhat incoherent and not as attentive as usual what would you do yeah I would there you&#39;ve got illegality and the patients that he&#39;s caring for could be in Jeopardy so you&#39;ve got what you were talking about harm and illegality so first you would say to him you you you&#39;re over here you stay over here you&#39;re don&#39;t touching any patients anymore and then you call the supervisor and get it get it going okay but if they want harm to be there don&#39;t don&#39;t imagine it to second degree just kind of it&#39;ll be pretty clear for you question what if it was an LPN and you seen a another a nurse taking the patient&#39;s pill an RN or an LPN so you&#39;re an LPN and You observe an RN taking a pill would you confront them right there or would you go tell the supervisor okay yeah I would probably at that point in time there could be harm because what is that being taken and could it affect their care you see what I&#39;m saying cuz I actually saw him take it now if they&#39;re diverting narcotics with the accounts I don&#39;t know what they&#39;re doing there they could be just you know falsifying records but I saw him take a pill I so I go up and say what is that pill you just took you see what I&#39;m saying and then I might tell the supervisor if it wasn&#39;t something that was logical explanation or if I thought was a problem did you see what I&#39;m saying yeah so you confront them you confront yeah even even if you see a doctor comes out on the medication rooms and swallows a pill what do you say what are you doing and you&#39;re an LPN what was that pill you just swalled and and even though you may not feel oh it&#39;s a doctor no boards want you to go after them boards just gets Goosebumps when you go after doctors they love it it makes them quiver you know what on a hessie test would it be the answer the same way yeah I think so I think so hess&#39;s favorite question about inappropriate Bor is not stack their favorite one is you&#39;ve got two patients who are engaging in sexual intercourse in a room what do you do you shut the door no that&#39;s the hessy answer you shut the door and let him do it that&#39;s the that&#39;s that&#39;s the answer no I&#39;m so that&#39;s the answer on hessie I&#39;m telling you wow isn&#39;t it have you T have you had the hessie and taken that one was that the answer that was the answer yeah so anyhow that they love that one that one shows up all the time I think it&#39;s one of their questions okay um and also they&#39;ll or they&#39;ll say masturbation you know which is you just shut the door you know that&#39;s another big one okay let&#39;s go to the last lecture and we&#39;ll be done last lecture before I started I want to direct you to the last two pages sorry this belt is not the right size oh right have pants on the ground pull them up okay the first one is do you see the abdomen there it&#39;s divided into four quadrants what this is about is they will ask you to point and click where you would find the organs where&#39;s the liver where&#39;s the pancreas where&#39;s the right kidney where&#39;s the left kidney where&#39;s the spleen where&#39;s the ascending colon where&#39;s the descending colon where&#39;s the you see what I&#39;m saying and so what you got to be able to do is click on the cor quadrants now they give you a little bit of leeway with this one as long as you&#39;re in the general vicinity they&#39;re going to count it now the next one the next page is a point and click for escalating the valves of the heart the atic aortic the aortic the pulmonic the tricuspid and the mitro a PM now this one when you have to get exactly over the spot there&#39;s no leeway on this one so the aortic is in the second right intercostal space ponic is in the second left intercostal space the tri at the sternal border these are all at the sternal border the tricuspid is in the fourth intercostal space at the left sternal border and the mitro valve is in the fifth intercostal space in the mid clavicular line so let me go over those again the aortic is in the second intercostal space second intercostal space at the right sternal border the pulmonic is in the second intercostal space at the left sternal border the tricuspid is in the fourth intercostal space at the left sternal border and the mitro valve is in the fifth intercostal space in the midclavicular line meaning the line down from the midpoint of the clavicle so those are the things that that those are the point and now the other point and click they always have is uh the pulses where&#39;s the kateed where&#39;s the brachial where&#39;s the radial where&#39;s the femoral you I&#39;m not even giving you that because I think you should know that question are they ask herb herbs point they don&#39;t they don&#39;t usually talk about herbs but that&#39;s the third intercostal space at the left sternal border it&#39;s right between the pulmonic and the tricuspid so actually it goes a pet m a pet and pet goes down that border line p and then M goes off to the side a pet M but they&#39;ve never asked about herbs question excuse me the apical pulse would be the mital area yeah the apical pulse would be where then fifth intercostal space mid clavicular line now go back back to page 70 and we&#39;ll finish up I have given you a lot of information and I&#39;ve given you a lot of application of that information and that&#39;s going to serve you well but I can&#39;t teach you everything that they could possibly ask because if I taught you more they would just ask harder stuff and if I taught that they would just ask harder stuff and if I taught that they would just ask harder stuff so where do we stop well we&#39;re not getting on that Maro around I&#39;m teaching you the basic stuff that you need to know to pass now you all are going to have to guess everybody in this room is going to have to guess an awful lot on this test because it is a computer adaptive test and that is the nature of computer adaptive testing if I took the test would I fail no way it&#39;s impossible for me to fail I could never fail this test but would it be really would I have to guess a lot on it yes why because it&#39;s computer adapted and it would try to camp out on stuff I didn&#39;t know which would be Pediatrics you know nothing that would be the area I would be weakest in okay so let&#39;s talk about how you guess because I want to help you out there too how do you guess now what I am concerned about is a lot of reviews give you a lot of guessing skills and guessing strategies and that&#39;s dangerous because when your anxiety goes up what do you revert to using fancy little guessing skills and guessing strategies instead of using your knowledge and your common sense so what do I want you to use first when you answer a question knowled knowledge if your knowledge is failing you what do you use common sense when Common Sense fails you what do you use a guessing strategy and some of these reviews just tell tell you all these guessing strategies and then you go to take the boards and you&#39;re trying to figure out what guessing strategy to use instead of answering the question and it actually makes you worse okay so I don&#39;t I don&#39;t I&#39;m just cautioning you about these These are what you use when you don&#39;t know what&#39;s going on okay site questions the best psych question if you&#39;re totally clueless on it the best psych answer is the nurse will Ex examine their own feelings about why is that the best why is it best that the nurse examine their own feelings about something in Psych nursing yeah CU that way you don&#39;t counter transfer remember counter transference the patient reminds you of your dad so you treat him dirty because you didn&#39;t like your dad you know what I&#39;m saying so you have to examine your own feelings before you&#39;re a good therapist in sight secondly in Psych another really really good answer in Psych is establish a trust relationship why would that be a good guess in pych establish a trust relationship because if you pick something else what would you be saying it&#39;s not that important to establish TR oh I don&#39;t think so now now don&#39;t use your you know understand what I&#39;m saying don&#39;t use here&#39;s here here&#39;s where Common Sense should be applied before this rule you have a schizophrenic client who has a knife who is about to stab you what is the most important thing to do establish a trust relationship run the other way what&#39;s the answer run the other way but Mark said establish a do you hear what I&#39;m saying about using these cutesy little rules before you use your common sense okay nutrition I tell you what I have to I have to guess all the time in nutrition particularly in those answers where they say what meal would be good and then a would be like baked potato boiled bacon and fried cheese and a guacamole peanut butter milkshake and the other one is a chicken tenders green leafy vegetable salad tofu custard and a slice of bread see you know what I&#39;m saying and they got all the oh man I just crash and burn on nose but I figured out a guessing strategy that gets me about 75% right even when I don&#39;t know anything about it my rule is in a tie pick chicken I&#39;m serious I know this works I it should never work it has no right working but I&#39;m telling you on these nutrition questions if answer B has chicken in it I&#39;m heading for it and I get it right like three half or four times and I&#39;m just totally dead guessing of course I don&#39;t go with fried chicken because I know that I mean I&#39;m bad but I know that&#39;s bad you know fried&#39;s no good but if it&#39;s baked chicken oh man that&#39;s the meal I&#39;m picking now if chicken&#39;s not there I pick fish but I don&#39;t pick shellfish like lobsters and why cuz they&#39;re high in cholesterol so I I pick just the regular fish the non the scale fish not the shell fish number two never pick casseroles for children if they ask you what&#39;s a good meal for this child and it&#39;s a little kid don&#39;t pick a casserole tuna tofu and Alfalfa casserole it may be wonderfully nutritious but they won&#39;t eat it so they&#39;ll pick a casserole for them number two never mix medication in children&#39;s food by the way before you mix medication in anyone&#39;s food what must you ask for permission you never Mickey Finn patients food okay and I know that when you I I&#39;ve worked in nursing homes and I Mickey pinned 90% of my patients food but on the boards I won&#39;t do it okay toddlers it&#39;s finger food it&#39;s finger food in other words what&#39;s a better meal for a toddler hot dogs and french fries or a tofu bean curd and alala sprout salad the hot dog and the french fries even though the other one is much more nutritious see when they give you a toddler question it&#39;s not about nutrition content it&#39;s about what can they eat on the run so it&#39;s it may be not very healthy but it&#39;s finger food so go for it I have to laugh they always say I I I love statistics and research projects but this research big research project came out of Ann Arbor well I should have known already um that hot dogs and popcorn are the top two things that toddlers choke on duh what are the top two things that toddlers eat hot dogs and popcorn do you see I&#39;m saying if if if uh tofu tofu squares and bok choy were the top two things toddlers ate what would be the top two things they choke off tofu squares and H choice so you got to watch that stuff but it&#39;s just kind of crazy anyhow preschoolers leave them alone leave them alone what&#39;s that mean one meal a day is okay what do you know about toddler at preschool eating habits they&#39;re eat when they&#39;re hungry and they may not eat but one meal a day and they eat the same thing every day for 7even weeks then they change it and eat that for 7 weeks so what do you do as as healthcare workers and parents leave them alone there&#39;s no such thing as anorexia nervosa of preschool they don&#39;t say o I look that no they don&#39;t they eat when they are hungry why do they not need the food that the toddler needed exactly what&#39;s the growth curve of an infant like that what&#39;s the growth curve of a toddler like that what&#39;s the growth curve curve of a preschooler that who needs more this when a kid went from toddler to preschool what happened to his nutritional needs they bought him out what do parents always freak out he isn&#39;t eating like he used to he&#39;s a preschooler he&#39;s not growing like he used to and parents don&#39;t get that that when you shift from toddler to preschool they&#39;re going to stop eating and that&#39;s okay one meal a day is okay we have a rule at our house you take one bite of everything on your plate but you don&#39;t have to eat anything else if you don&#39;t want to but you have to take one bite of everything and if that&#39;s when you&#39;re done you&#39;re done my brother who was a pediatrician who should have known better he had kids too and his rule was you eat everything on your plate and you are not getting off this table till everything your plate is licked clean it is really really interesting that my daughters are all perfect weight for size I mean they&#39;re all the they could walk through the hourglass figure for the you know perfect 20-year-old female friend no not an ounce of fat here or there that shouldn&#39;t be there his kids are you know what I&#39;m talking about and I&#39;m I&#39;m just saying I I have my suspicions of where that started CU in their lives what made them good and obedient food and food was what reinforced if you were good or bad obedient or disobedient and so you know what I&#39;m saying and my kids food was just food you know so I don&#39;t know it&#39;s interesting okay who cares let&#39;s move on um pharmacology but I&#39;m just telling you that for your own thoughts okay um pharmacology I have to guess all the time in farm the most commonly tested area in farm is side effects you do not have to memorize dosages please don&#39;t do that don&#39;t memorize routes don&#39;t memorize frequencies if you&#39;re going to do any memorization of drugs please memorize side effects why because you are a nurse your job is to assess for side effects and see if things are working you&#39;re not job is not to prescribe the dose prescribe the frequency prescribe the route now there are some where they might give you a dose that makes sense or doesn&#39;t make sense you know what I&#39;m saying like dig 10,000 milligrams you know that kind of thing so number two number two if you know what a drug does but you don&#39;t know the side effects how should you proceed have you ever been in that situation you go oh I I know that drug it&#39;s protonics it&#39;s a proton pump inhibitor it it prevents ulceration in the gut and then it says what are the side effects and you go oh I didn&#39;t know that if You&#39; asked me what it was I KN you see saying have you ever been there you know the drug but you don&#39;t know the side effects great guessing rule that would give you the answer almost 80% of the time four out of five times pick a side effect in the same body system where the drug is working let me illustrate this if you got a question about a drug you let&#39;s say you knew the drug was a GI drug but you didn&#39;t know the side effects would you pick drowsiness tardia or diarrhea diarhea if you knew it was a heart drug but you didn&#39;t know what the side effects were would you pick drowsiness Tac cardia or diarrhea tardia if you knew it was a central nervous system drug but you didn&#39;t know what the side effects were would you pick drowsiness Tac cardia or diarrhea drowsiness that works so much for me it&#39;s really really big doesn&#39;t it make sense though if a drug is having a therapeutic effect in certain areas it&#39;s also going to have some side effects there too so why would a CNS drug have a problem with your gut you know what I mean that that&#39;s kind of the question we&#39;d ask what about number three do you think this might happen to you if you have absolutely no clue what the drug even is you swear you&#39;ve never heard of it have you could that happen okay you&#39;re not dead yet you&#39;re close but you&#39;re not dead yet uh look to see if it&#39;s po if they said it was po I think you might have dodged the bullet two out of three times at least 50/50 you&#39;re going to dodge the bullet pick a GI side effect if it&#39;s po pick a GI side effect that works about 50/50 and you say well that&#39;s not very good it&#39;s better than one and four isn&#39;t it so that helps me with some questions particularly the really hard ones number four never tell a child that medicine is candy CU if you tell them oh this is candy this is candy when they go home what do they going to think medicine is candy so when you run out of Halloween candy at Halloween time they&#39;re going to pass out Grandma&#39;s value right to all these little kids now that actually happened to my brother he pediatrician he was working in Chicago he worked at the High Park Clinic in Chicago and Hall he was working in the ER area and this one little kid came in with these symptoms that looked an awful lot like uh toef foral poisoning you know an antidepressant poisoning and they thought that&#39;s interesting so then about 10 minutes later another kid came in with the exact symptoms and then an hour later another kid came in and then about a half hour later a fourth kid came in what happened was they all all four of those kids had gone to the same house and there was a little kid literally passing out out his parents toe fril to all the little kids for Halloween candy because he had been in the hospital the week before and was told it was candy so he said I thought that was a real interesting he got a article in the American Journal of Medicine on that one okay um OB what&#39;s the Ace of Spain&#39;s answer in OB check fet heart rate yeah check be heart R Med surge what&#39;s the first first thing you assess in a med surge situation what&#39;s the first thing you assess in Med surge level of Consciousness Bingo not Airway Airway is not the first thing you assess think about a code you&#39;re in a code you&#39;re doing basic life support all righty or Advanced cardiac life support what&#39;s the first thing you do what name Annie Annie Annie or what&#39;s your name are you okay what&#39;s that level of Consciousness then you do your a b c&#39;s so ABC doesn&#39;t even win there okay but number two what is the first thing you do now what&#39;s the first thing you do in a med search situation if you&#39;re guessing establish an airway so that will work there okay let&#39;s turn the page pediatric guessing skills for growth and development how many of you in here aren&#39;t really good at growth and development you&#39;re joining me I wish I had these rules that I&#39;m going to give you right now when I was in peeds cuz I&#39;d had done a lot better because my experience in Peds was particularly growth and development I could always narrow it down to two and after that I was dead because it seemed like two Ages were reasonable two tasks were reasonable here&#39;s the deal three rules of growth and development questions they are all based on the principle always give the child more time always give the child more time more time to what grow and develop in other words don&#39;t rush children&#39;s growth and development don&#39;t rush it always give the child more time to grow and develop so let&#39;s talk about these rules rule number one when when in doubt call it normal now this is radically different than Med surge in Med surge what&#39;s the rule when in doubt call it abnormal so you don&#39;t make a a safety mistake but in growth and development when in doubt call it normal so what would be the right answer to the question see why did I why is the question written the way it is what age did they give you what task did they say what&#39;s the problem with that question H it varies it&#39;s on the line so some six-year-olds can read and some six-year-olds can&#39;t read so it was purposely written to confuse you so that you didn&#39;t know what to pick and since you didn&#39;t know what to pick they were waiting to see if you would give the child More Time by calling it normal and that&#39;s exactly what they do they purposefully give you ages and Tas where it could go either way and ask you what&#39;s going on here and so you always call it normal now what about this you have a 13-year-old who isn&#39;t potty trained did I say call that normal but you shouldn&#39;t be in doubt I said when in doubt call it normal I didn&#39;t say to call everything normal that&#39;s using your knowledge first is are son understand that okay second rule rule number two when in doubt pick the older age I don&#39;t know about you guys but whenever they ask at what age should a kid be able to do a certain thing I could always narrow it down to how many two and I never knew which one to pick when I started using this rule my scores went through the roof went way up I picked the older age not the not the oldest but the older age in the two that it could be so in the question here at what age should a child be able to walk there are two ages where it could be what could those be 14 B and C 12 and what 14 months was it so what would you pick 14 because you&#39;re giving the kid more time yeah some kids could walk at 12 but give them a couple more months are you seeing the principle and then rule number three when in doubt pick the easier task I always got questions where they said a kid is a certain age what task have they mastered and those they&#39;ll give me four tasks I could always narrow it down to how many two and I never knew which one to pick if once I started using this rule my scores went way up why do I pick the easier task easier cuz I&#39;m giving him more time to do the harder one now look at a six-month-old kid there are two tasks there that a six-month-old kid probably would be doing working on or trying to to do what would be those two that they would be working on or trying to do B and C rolling over and sitting up okay so what&#39;s the answer roll over because that&#39;s easier than sit up do you understand that in growth and development they always give you two right answers on purpose see I thought there was one right answer and one wrong one and I just was stupid and didn&#39;t know the difference no they always give you these in growth or development in particular they give you two right answers and they want to see are you going to going to call it normal pick the older age and pick the easier task when you get growth and development questions what do I want you to be chanting in your head normal older easier normal older easier okay literally my scores on a growth and development test went from an average between 38 and 48% to 70 to 78% in a day when I started using these rules and I didn&#39;t learn any more information it just I finally figured out what they were up to okay General guessing skills rule out absolutes why are absolutes not good answers you have to be able app yeah and all you have to do is find one situation where it doesn&#39;t apply and it&#39;s wrong now did I say never pick an absolute as your answer because aren&#39;t there some absolutes that you should know like never push potassium IV never give a med to a patient unless you can identify right right those are absolutes and they&#39;re correct why can you pick them because if you&#39;re knowledge but I&#39;m saying if you&#39;re guessing don&#39;t pick them number two if answers say the same thing neither one is right why can it be this I had a hessie test last spring and it asked me about a disease I never heard of before and it asked me what would you see a said increased vowel sounds B said something else C said borberg me and D said something else well I immediately ruled out increased bow sounds in borberg me because they were the same thing then I figured which one of the remaining ones would be logical I picked it and got it right and I that was just a guess number three if two answers are opposite one of them is probably right if two answers are opposite one of them is probably right number four the umbrella strategy I like this one this one helps me out a lot it says one answer which answer is more Global have you ever had the experience and I have it a lot on tests where I want to say all of the above but that&#39;s not there have you ever had that experience I want to say all the above but that&#39;s not an option if that&#39;s the experience you&#39;re having look for an look for an umbrella answer what do I mean by an umbrella answer is an an answer that covers like an umbrella covers all the others without saying it does an answer that&#39;s so Broad that when you do it you do all the others so look at our example what is the umbrella answer B because if you do that you do all the others um I was I was doing a test with a student that had some trouble with testing uh we ran across one the other day it said when you transfer a patient from a bed to a wheelchair always a meds Pub test question when you transfer a patient from a bed to a wheelchair what&#39;s important to do a bring the chair as close to the bed as possible B remove the foot pedal from the chair so you don&#39;t trip over it C use safety and good body mechanics when transferring D lead into the bed with the strong foot well all of them are correct and I&#39;m going well they&#39;re all right they&#39;re all right wait a minute mark look for an umbrella the answer was C use safety and good body mechanics when cuz all those work do you see how that works I I&#39;m surprised that it works as much as it really does number five if the question gives you four right answers right answers and asked you to pick the one with the highest priority now you realize that an hour ago we talked about prioritization right what were we prioritizing four what different patients when you get a question that&#39;s prioritization of four different patients use the rules I taught you an hour ago however if they give you one patient and ask you which of the following needs is highest priority don&#39;t use what I what I taught you before won&#39;t work that&#39;s for prioritizing different patients what do you do here well you do what I call the worst consequences gain take each option a b c and d and ask yourself if I did not do this what is the worst thing that would happen then the best answer is the one that has the worst outcome if you don&#39;t do it now let me I know that sounds crazy but let me illustrate it in the question below which of the following is highest priority in caring for a suicidal patient how many patients do you have one one so those rules I taught you about before do those apply no no so let&#39;s take each answer if you do not give him a tranquilizer what is the worst thing that would happen he&#39;d be agitated okay if you don&#39;t Orient him to the unit what&#39;s the worst thing would happen he&#39; get lost and disoriented if you don&#39;t put him on suicide precautions what&#39;s the worst that would happen he&#39;d be dead if you don&#39;t introduce him to the staff what&#39;s the worst that would happen when know anybody so of being agitated lost dead and not knowing anybody what&#39;s the worst dead so what&#39;s the highest priority suicide precaution so let&#39;s do it with the next one ask yourself what&#39;s the worst thing would happen if I didn&#39;t have sips of water what&#39;s the worst thing that would happen if I didn&#39;t have payments what&#39;s the worst thing that would happen if the side rails weren&#39;t what&#39;s the worst thing that would happen if I didn&#39;t use the abductor pillow not just something bad but the worst thing that would happen what&#39;s your answer side side rails yeah because if you didn&#39;t what&#39;s the worst thing that would happen if you didn&#39;t do the sips of water DEH not thirsty is not bad enough they get dehydrated okay if they didn&#39;t have pain meds they&#39;d be in severe pain if you didn&#39;t put the side rails up what would happen fall break hips head multiple injuries if you didn&#39;t use an abductor pill pillow what&#39;s the worst thing that would happen mess up the hip so of being dehydrated severe pain messing up the hip and everything else and messing up the hip what&#39;s the worst of the worst messing up the hip and other injuries so the side rails is number one are you seeing that okay you could also juxtapose CN D couldn&#39;t you you could say if I put the side rails up but didn&#39;t use the abductor pillow or I used the abductor pillow but left the side rails down you hear that which would be better use put the side rails up and don&#39;t use an abductor pillow or use an abductor pillow and leave the side rails down what would be better you get the side rails you know you re you&#39;re getting more hot water for the side rails down okay uh eight when you&#39;re stuck between two answers read the question where&#39;s the clue to the answers in the question not the answers so quit reading and rereading answers go back and read the question you probably missed something okay the last page right the Sesame Street rule you have my permission to use this rule when and only when your only remaining option is to do this okay if you&#39;re at that point what should you use Sesame Street rule but if you use it before then you will fail boards because this is a dangerous one to use but it&#39;s the one you use when nothing else Works do you remember Sesame Street three of these things belong with the others one of these things just isn&#39;t the same remember that and they show you three sailboats and a cumquat and you had to figure out which one was different right okay well right answers tend to be different than the others why right the right answer tends to be different than the others why because it is the only one which is right correct exactly however the wrong answers all are similar because they share something in common and that is that they are all wrong so by virtue of that the right answer is the most unique or different answer so in our question below what would be the correct answer C would be the correct answer all right number eight don&#39;t be tempted to answer a question based on your ignorance instead of your knowledge and you guys say oh I don&#39;t do that oh yes you do you do it I know you do it I want to illustrate something really quickly do you see this question below about Amma I&#39;m going to do something here what I&#39;m going to do is this I&#39;m going to role play a student who answers that question based on ignorance meaning what they don&#39;t know then I&#39;m going to role play a another student who answers it based on what they do know but the interesting thing you&#39;re going to notice about those two students is they know the exact same amount one does not know any more than the other so let me illustrate this who am I right now the student is answering based on what IGN ignorance okay here we go here&#39;s here&#39;s what ignorance answers do which of the following is important to do in the administration of Amic case and IV piggyback oh my goodness amicas oh man I knew I was going to get these stupid drugs I don&#39;t know why does it always happen to me why I knew ohin ma ma Max Max ah Max oh man I knowe okay am case now be pick up cover the bag with f to protect from light what okay use you use a ivy pump Amic case and Ivy pigy that stupid Mount Caramel pharmacology class never taught us if Mark why didn&#39;t mark tell us about this if it was going to be on her why didn&#39;t he mention it wasn&#39;t in the blue book or the yellow book Emma Emma oh man cover the bag with foil to protect from light H now you know if I wanted to protect it from light covering with foil would work H and I know some drugs are biodegraded by UV radiation I&#39;ve never heard of amicas and I&#39;ve never heard of covering bags with foil so they probably go together because had I heard of amicas I would immediately know if you did or did not do that and if I had heard of doing that I would have known which drug it was like Amma so since I don&#39;t know either one this is probably some obscure fact about some obscure drug and I&#39;m not going to let him trick me so I&#39;m going to pick cover the bag with ball to protect from WR all right now second student this is going to base his answer on what what they know not what they don&#39;t know okay let&#39;s go um what is important to do in the administration of Emma Cas IP Emma Cas oh man Emma why do I always get these drug WIS I don&#39;t know I knew this was going to happen what I took fors I would get all these drugs I didn&#39;t know aminin Max kiss am amus oh man okay cover the bag of for to protect from light H use a I pump oh Amma stupid M caramel pharmacology never taught us about this Mark should have told us it wasn&#39;t in the yellow book it wasn&#39;t in the blue book if it was going to be on who should have let us know man why is this always happening to me Cas okay all right I don&#39;t know Amma I don&#39;t know it I can&#39;t answer this question based on Amma because I don&#39;t know it so let me take Amma out of the question see what&#39;s left see if there&#39;s anything I do know something about okay what is important in the administration of IV piggyback oh IV piggybacks I know IV e piggybacks I&#39;ve given them I&#39;ve seen them given and every time I&#39;ve seen them given 99% of the time they&#39;re on a pump so I&#39;m picking pump now who got the question right first one or second one and did they know anything more about Amma than they did no what did they learn about the first person what did the boards learn about the first person when they don&#39;t know what to do what do they do they go around covering bags in foil what did they learn about the second person when they don&#39;t know what a drug is they put it on a pump who would you license no I&#39;m serious who would you license do you see what I&#39;m saying but don&#39;t see here&#39;s the deal if you don&#39;t know what something is what should you do pull it what away out of the question read the question without it there and see what happens I I had a student that was really bad at this I knew she finally got it when we did a question like this and she finally said it said what is important to do to teach parents of a kid going home on pen VK suspension and she sweat pen VK for like 20 minutes not really but you know for a minute or two sweating what penv K was what&#39;s pen VK what&#39;s penk I don&#39;t know penk I don&#39;t know penk and then she looked at me and she said oh I don&#39;t know what it is do I and I said do you and she said no and she says I&#39;m supposed to pull that out of the question aren&#39;t I and I said do you think you are she said yeah I think I am and I says should she said should I do it and I said do you think you should do it and she said she said yeah I&#39;ll do it so she reread the question what did it do what did it read when she pulled out pen VK what&#39;s important to teach the parents of a child going home on a suspension and she said oh my goodness it&#39;s letter D isn&#39;t it and I said yeah you know what D said shake well before giving and now was the right answer do you see you understand boards will give you things you&#39;ve never heard of for the purpose of seeing if you use common sense see if I want to measure your common sense this if I want to measure this whole class is common sense I have to ask something about which none of you know you none of you have knowledge because if you don&#39;t have knowledge what do you have to use common sense so I have to ask you about a drug nobody&#39;s ever what heard of a disease that no one&#39;s ever heard of or a treatment that no one&#39;s ever heard of and that way I can measure what common sense so when you get something you don&#39;t know use your common sense it&#39;s probably a really really easy question so don&#39;t freak out that it&#39;s hard and that happens a lot in the first 10 use your common sense in the first 10 do not overanalyze those first 10 questions take them as though you weren&#39;t even a nurse say to yourself what I think Aunt Billy would answer for this one you know it&#39;s just they&#39;re so they&#39;re they&#39;re ambiguous but they are very clear not clear but they&#39;re very everybody gets them right even though they&#39;re vague all right now last things if something really seems right it probably is my point there is are do I have any gut Changers here people who go against their gut answer stop it you have no right to go away from your gut answer unless you could prove why the other one is superior not just as good but what Superior so if you have a gut draw to letter B your gut answer is B and but you think oh well well well maybe it&#39;s C should you pick c not unless what not unless you could articulate a reason why C is what Superior not just as good there is a mini mark on your shoulder when you take this step I am there I&#39;m sitting right there little mini Mark is right there and when you go to change from your gut what is mini Mark going to say why is that Superior why is that Superior and if you cannot tell me why you get your hand off that button and you pick your gut all righty so don&#39;t go research has shown that you change from right to wrong twice as much as you Chang from wrong to right so it&#39;s a losing battle don&#39;t do it number 10 if you don&#39;t know the answer you do know the answer use your common sense all right that&#39;s it for the review I just wanted to give you three parting shots on that last page just three things and then we&#39;re done okay Mark move it three expectations you&#39;re not allowed to have do you know what fails the people fails people a lot they get taken the test and during the test it wasn&#39;t what they expected it wasn&#39;t what they were hoping for it wasn&#39;t what they wanted and that breeds negativity and then that negativity affects their what performance and then what happens they fail so what failed there their negativity where did their negativity come from it didn&#39;t live up to their expectations it wasn&#39;t what I expected well here are three expectations you are not allowed to have if you have these expectations get rid of them right now they are dangerous they will kill you on this test first expectation don&#39;t expect 75 for the RN or 85 for the LPN don&#39;t expect 75 or 85 questions don&#39;t expect it go there expecting 265 or 205 depending on whether you&#39;re an LPN or an RN go there and prepare yourself psychologically mentally physically emotionally to go for the whole maximum you know what happens I know this happens I&#39;ve heard people say it all the time they say oh I I I want 75 questions I hope I get 75 questions they&#39;ve got the whole church praying dear Lord let Sally have 75 questions you know it&#39;s on the Church website you know pray for Sally that she has 75 questions when she Tak that&#39;s so stupid because what happens when you go take that test and you hit 70 5 and you answer it and you hit the button and it goes 76 what do you do and then you hit 110 and then you&#39;re and then it&#39;s 198 and then 215 you start going what this is horrible this is terrible this I&#39;m doing so bad this is horrible I just can&#39;t stand this so what&#39;s entering your mind negativity what happens to your performance it&#39;s going down why do you fail you failed because you had this unrealistic goal of 75 expect 265 in fact the longer you go you&#39;re doing fine everybody says oh I want 75 well that&#39;s dumb because somebody said no here&#39;s here&#39;s what they say I got to 200 and I knew I was failing that was that&#39;s the stupidest thing ever Ed by a human being because this is a computer adaptive test if you got to 200 and you were failing what would it have done and if you were failing what would it have done shut off so the only way you&#39;re getting to 200 is if you&#39;re not what failing you aren&#39;t failing now are you doing a bang up job no but who do you think you are who do you think are you God&#39;s gift to nursing no you&#39;re average so you&#39;re going to be average so don&#39;t do you see what I&#39;m saying if you get 220 if you&#39;re on question 220 what did you say okay I&#39;m still I&#39;m still in the game 223 I&#39;m still in the game 224 I&#39;m still in the game 225 oh it shut off and everybody says to me Mark well when you tell me that when it shuts off I&#39;m going to freak out my reply to them is I don&#39;t care I do not care what you do after it shuts off all I care about is what you do before it shuts off so freak out all you want after word don&#39;t freak out before the reality is the same number of PE same percentage of people pass at 265 as pass at 75 and every number in between and there&#39;s this rumor out there that says if you go to 265 the percentage of people failing is like two or three times at 75 that&#39;s that&#39;s a person that&#39;s never looked at the statistics the scattergrams of the tests which I have done every year since it was its Inception so they&#39;re wrong and the myth about every once in a while somebody randomly gets 265 is baloney that is that&#39;s baloney if you ever heard that from somebody that&#39;s a myth it&#39;s not true you get everybody gets a computer adaptive test everyone does and the number you get is based on on your performance okay all right so don&#39;t expect what expect how many the whole bit okay number two don&#39;t expect to know everything why cuz it&#39;s computer adaptive you&#39;re not going to know everything even if you&#39;re acing it they&#39;re going to bring out stuff you&#39;ve never heard of so don&#39;t worry about not knowing everything number three don&#39;t expect everything to go right what I mean by is don&#39;t expect the birds to sing sunshiny you get a parking spot right up front sometimes you got a person sitting next to you that goes every 5 minutes you know I don&#39;t let that fail you now you do have a option to say would you get this snort snotter out of here but you I&#39;m saying no listen think about it just last thing last thing I&#39;m going to say isn&#39;t it true that everybody in this room in your program would have had at least three or four or five times in your program to legitimately quit if you just just stopped you&#39;d have been totally legitimate cuz it was it was ridiculous but you and you would have had a reason to quit is that true but what did you do you stuck it out was it pretty did it get ugly at times did it get messy was it hard but what did you do you stuck it out so you know what that tells me about you everybody in this room you have perseverance you have a strength of character and a perseverance to Slug It Out when it gets tough or you wouldn&#39;t even be sitting here when you take this test it&#39;s going to be hard it&#39;s going to be tough it may not be pretty it may be sloppy it may be messy but you have what perseverance and an intense and uh strength of character to get through that you can get through it and get through it one question at a time just to answer one forget about it move to the next that&#39;s how you got through school that&#39;s how you get through here correct because at the beginning if you thought about the whole thing you would have quit so just go there okay uh thank you for this opportunity I appreciate all you guys and if you see me around if you see me around just say who can sterilize my bow and I&#39;ll you okay also I go by word of mouth so if you want to tell other people about their view that&#39;s fine with me

[Music] 60 M for drop no 60 drop per M and micro is the same they&amp;#39;re no no no which Lady of yours is [Music] yes the one that goes by itself this is the weekly that goes together yeah and then like this and now I&amp;#39;m on my bad one by which is cool the we that&amp;#39;s better than [Music] here your quiet have a light [Music] [Music] [Music] CV you are all okay let&amp;#39;s start endocrine overview endocrine glands uh this this lecture is going to be real helpful for hessie stuff because they love to test adrenals and uh thyroids the endocrine overview is only going to be about thyroids and adrenals you do not have to know the thymus the pineal the uh parathyroids you don&amp;#39;t have to know all those just know your thyroid gland know your adrenal gland and you&amp;#39;re good to go now if you don&amp;#39;t know your thyroid you&amp;#39;re in trouble you don&amp;#39;t know your adrenal you&amp;#39;re in trouble so focus on what you need to know so let&amp;#39;s focus on those two glands the first one is hyper thyroidism that I will talk about whenever Mark kimik sees the word thyroidism he turns it into metabolism because that&amp;#39;s what the thyroid does the thyroid regulates metabolism so when you see hyper thyroidism what do I want you to turn it into hyper metabolism if that is true do you see that now you do not have to memorize the signs and symptoms they&amp;#39;re just logical what would be the logical set of signs and symptoms you would see if you had a high metabolic rate weight loss so they&amp;#39;re skinny and weight loss what else what what would their pulse rate be blood pressure uh their personality irritable hyper obnoxious excitable life of the party for about 5 minutes till everybody gets sick of them uh heat what int intolerance and cold tolerance so they can to tolerate the cold because they&amp;#39;re like a little furnace they cannot tolerate the heat cuz they&amp;#39;re already burning up xof phalos what&amp;#39;s X off phalos bulging eyes the word X ex x e x o h p or o p h t h a l m o s x offal uh soat are basically they&amp;#39;re skinny they&amp;#39;re hyper they&amp;#39;re tacky they&amp;#39;re hyper metabolic the person I remember this this dates me too you guys probably do not know him uh was a guy named Don knots that was uh what was he he was uh Barne Barney fight on Mayberry you know the the skinny little guy Sheriff Andy Andy always hyper M guys skinny classic hyperthyroid guy the name of this disease is Graves g r a v s Graves disease now they will not tell you they will not say Graves disease hyperthyroid they&amp;#39;ll give you one name and you&amp;#39;re supposed to know Graves is hyperthyroid the way I remember that is a saying my grandma used to say which is you&amp;#39;re going to run yourself into the grave what two words does that link run with gray well if you&amp;#39;re run run run run run run all the time what are you hyper thyroid so running yourself into the grave helps me remember it&amp;#39;s hyperthyroid number three the problem here is hyperthyroidism so you have three treatment options you have three ways to treat hyperthyroidism number one radioactive iodine radioactive iodine now there&amp;#39;s two things you need to know about radioactive I number one the patient should be by themselves for 24 hours they should be in a room by themselves for 24 hours and after that they have to be real careful with their urine they should flush three times if they spill their urine on the ground they need to call the HazMat team cuz somebody has to come with a guer counter to make sure it&amp;#39;s all cleaned up so if you have a patient on radioactive iodine for hyperthyroidism and they spill urine on the floor in the hospital you can&amp;#39;t call housekeeping you got to call your hospital hasm team and they come with all their paraphenalia it looks really really silly for them to go worrying about the urine but that&amp;#39;s where the radioactivity is excreted is through the urine so this is the one place where they have glow-in-the-dark urine not really but you know you have to treat it like it&amp;#39;s bad so the only risk to you the nurse for a patient who&amp;#39;s had radioactive iodine is what there you and give them a private room in the first 24 hours okay the next treatment we have is PTU PTU a drug yes would you get family visitation on that is that an issue I&amp;#39;ve seen several API questions um with with radioactive iodine no family visitation in the first 24 hours and if they go home they are supposed to stay in the family room and nobody else or they stay in their bedroom nobody else goes in for 24 hours so there&amp;#39;s a restriction of visitors uh home restriction for 24 after 24 they can have all the visitors in the world as long as they don&amp;#39;t pee on okay the second problem is PTU propy furil propy tho uracil now I don&amp;#39;t want you to memorize that PT is propo uracil what&amp;#39;s it used for hypo hyper thyroid so what must it do to your thyroids if it treats hyper what must it do bring it down so I want you to remember that PTU stands for puts thyroid under whenever you see PTU what should pop in your head puts thyroid under which tells you it treats hyper thyroid its primary use is for cancer it&amp;#39;s a cancer drug but one of its special uses is for hyper thyroids because it will also put the thyroid under so what do you think the number one nursing thing is with this drug if it&amp;#39;s a cancer drug immunosuppression so what count what blood values do you have to watch when they&amp;#39;re on PTU they&amp;#39;re white blood cell counts so it puts the thyroid under and it also knocks down your white count the most common way however that we treat hyperthyroid is surgical removal we do a thyroid ectomy thyroid ectomy we remove part of the thyroid or all of the thyroid now if you want to get your thyroidectomy questions correct you must pay attention to whether they&amp;#39;re talking about a total thyroidectomy or a sub total thyroidectomy cuz that&amp;#39;s going to make a huge difference in your answer if you just treat all thyroidectomies the same you will miss loads of questions so what&amp;#39;s the most important thing in a thyroid thyroidectomy question total or sub now I taught this one time and a student called me the day after and said what you taught didn&amp;#39;t help on thyroidectomies and I thought okay I said well what didn&amp;#39;t help and she said well was a different kind of thyroid surgery on there that you didn&amp;#39;t cover I said boy that&amp;#39;s interesting total subtotal that pretty much covers it for me you know I can&amp;#39;t think of you know it&amp;#39;s either total or it&amp;#39;s subtotal I mean what what third possibility could there be and I said well well what was it and she said it was a partial thyroidectomy subtotal is a partial total is a complete so a complete thyroidectomy is a total a partial is a subtotal now she passed you know so you don&amp;#39;t have to be you know a real Shining Light you just have to do some shining you know she certainly was not a Shining Light why did she make such a dumb mistake she wasn&amp;#39;t managing her anxiety and she was looking for total and subtotal and it wasn&amp;#39;t there she panicked and she didn&amp;#39;t say now wait a minute which of these is closest to what I do know right CU it may not say it exactly the way you want it remember the guy with the cracker and the carbohy dry carbohydrate you know they&amp;#39;ll say things differently than you learned them but it means the same thing if you see something on the test it says means the same as something you learned but it&amp;#39;s saying it differently guess what it is what you learn don&amp;#39;t say well that sounds like the same thing but I didn&amp;#39;t learn it that way so it&amp;#39;s probably not that oh that is the worst thing to do what you should do the opposite you should say that sounds an awful lot like what I learned which was this it&amp;#39;s not the same phrasing but it sounds like that so it must be that do you see the difference always assume that if they tell you something synonymous then it means the same as what you know don&amp;#39;t assume it&amp;#39;s something different always assume it&amp;#39;s what you know okay so for totals totals need lifelong hormone replacement why cuz if I take your whole fyid out you don&amp;#39;t have any so you got to have lifelong hormone replacement also letter B you are at risk for hypocalcemia why low calcium why after a total thyroid activ me do you have a low calcium CU it&amp;#39;s almost impossible to spare the pair of thyroids when you take the whole thyroid out so you end up with low parathormone low calcium so they&amp;#39;re at risk for low calcium what are the signs of symptoms of hypocalcemia we talked about that last hour calciums do the opposite so hypocalcemia is going to make everything go up so you&amp;#39;re going to have tety spasm irritability clonus SE seure tacac cardia hypertension irritability jitteriness Tremor um right okay what&amp;#39;s the first sign that&amp;#39;s going to happen paresthesia excellent see once you start learning enough things start cycling around and it&amp;#39;s all no new no news right it&amp;#39;s old news what two signs will you have Chex and chos cuz your calcium is low okay subtotal thyroidectomies on the other hand do not need lifelong replacement why because you got some left and it&amp;#39;s supposed to kick in might you be on hormone replacement for a little while yes till that other one kicks in then it&amp;#39;s supposed to be off do you think you get the hypocalcemia much with this no because if you only take out part of it you can spare your parathyroids and your calcium spine however what these people are at risk for is something that totals never get and that is thyroid storm or thyroid crisis same thing it also has another name thyrotoxicosis which sounds like a toxic th thyroid so that sounds like hyperthyroidism to me thyroid storm now what are the symptoms of thyroid storm four really bad things number one super high temperatures of 105 and above number two extremely high blood pressures stroke category so you&amp;#39;re probably talking 210 over 180 now I&amp;#39;m just giving you that as a ball part that&amp;#39;s that&amp;#39;s no set in stone number severe tacac cardia probably in the 180s could be as high as 200 and there again that&amp;#39;s just a ballpark there&amp;#39;s nothing magical about that number and lastly they are psychotically Delirious they have psychotic delirium which we talked about before these people are in a medical emergency this thyroid storm is a very very bad thing because it can cause brain damage and brain damage is Perman you literally fry your brain to death with hypoxia and and our hypoxia so you must treat this immediately and what you treat it with is get the temperature down and get the oxygen up get the temperature down get the oxygen up well how do you get the temperature down what&amp;#39;s the first way you would do it ice pack ice packs what&amp;#39;s the best way cooling blanket cooling blanket cuz if you would pack him in ice without the cooling blanket use the cooling blanket without the ice which way would be better ice without the cooling blanket cooling blanket without the ice what&amp;#39;s better cooling blanket without the ice so the best is the cooling blanket but what would you do first first I&amp;#39;d put them in ice then I&amp;#39;d order the cooling blanket and have it out there so you see there&amp;#39;s another first best difference and what would you what would you give that how do you get the oxygen up oxygen per mask at 10 L just as a interest note what&amp;#39;s the problem with that order what&amp;#39;s what do you think you experience when you try to implement that order what&amp;#39;s that me and these people are what Psy psychotically Delirious so How likely is it you&amp;#39;re going to keep an oxygen mask on this paent yeah good luck good luck so this is a medical emergency you pack him in ice order the blanket throw a mask on them with high2 and they will come out of it themselves without treatment or they will die and there&amp;#39;s nothing you can do to make it go either way it&amp;#39;s just when that T3 T4 gets out of their system they&amp;#39;ll be okay we don&amp;#39;t want to medicate him because if we medicate him it could go the other way so this is a self-limiting condition all we&amp;#39;re doing is sparing their brain until they come out of it now I&amp;#39;ve seen this about five times in my career the longest lasted 12 hours the shortest lasted about less than 2 2 hours but when you&amp;#39;re treating these people it&amp;#39;s two on one meaning two staff for one patient you need an aid and yourself because you can&amp;#39;t do it with just yourself yes what is Tylenol going to do Tylenol works in the hypothalamus and at this point the hypothalamus is is being severely uh threatened because it&amp;#39;s right near the pituitary and the problem with the thyroid storm that caused it was the TSH from the pituitary so that pituitary hypothalamic access is part of the problem that&amp;#39;s causing this situation and Tylenol Works in that hypothalamus and it&amp;#39;s not going to work Tylenol just isn&amp;#39;t going to do it so you really have to you you know pack them in ice so you really don&amp;#39;t treat a lot of it it&amp;#39;s it&amp;#39;s kind of scary because you&amp;#39;re just sitting there you know doing what you can all right but I would say that good nursing care is going to save their life why because medicine isn&amp;#39;t yes question they said to clarify first ice packs then oxygen well I mean if you had to pick between the ice packs and the oxygen I would do the oxygen first the ice pack second the cooling blanket third but if I was between the ice packs and the cooling blanket the ice packs go first but I would always pick stay with my patient because you don&amp;#39;t leave your patient to go get the oxygen you see what I&amp;#39;m saying but it&amp;#39;s a perfect world so it&amp;#39;s sitting right there all right posttop risks they love to ask you about thyroidectomies and posttop risks because it depends on the type of surgery and it it depends upon the time frame so let&amp;#39;s talk about this you&amp;#39;ve got to know this you have to know this in the first 12 hours it doesn&amp;#39;t matter whether it&amp;#39;s a total or a subtotal it does not matter the top priority is Airway because where&amp;#39;s your thyroid so if you have a Dema in the area what&amp;#39;s it going to press on the airway the lyrics so tracha so you&amp;#39;ve got to watch out second big problem is hemorrhage because it&amp;#39;s an endocrine gland which has a lot of blood vessels so the top two in the first 12 hours for both types of thyroid surgery are Airway and Hemorrhage which is pretty much standard isn&amp;#39;t it okay now where the difference comes in is in the 12 to 48h hour window if they give you a patient who&amp;#39;s longer than 12 hours but less than 48 now you have to pay attention to what type of thyroidectomy was done letter A the posttop risks 12 to 48 hours after a total the big danger is tetany tetany due to the low calcium for a total they get the tetany because of the low calcium however letter B the posttop risks 12 to 48 hours for a subtotal is Storm What&amp;#39;s storm thyroid storm so you see where they&amp;#39;re different but they&amp;#39;re the same in the first 12 hours but different in the next 36 so 12 to 48 hours after surgeries what do totals get what do Subs get totals get tetany Subs get stormed odal get T and Subs get storm so ttss total tetany sub storm total tetany sub storm ttss when 12 to 48 hours after surgery in the first 12 what is it Airway and hemr Airway bleeding for everybody right what&amp;#39;s the big after 48 Hours by the way infection right how long does it have to be before you&amp;#39;re allowed to pick infection as a high priority at least 42 hours we&amp;#39; prefer 72 here&amp;#39;s the deal never pick infection in the first 72 hours after anything so if they had a trauma and it&amp;#39;s been 36 hours would you pick infection no they gave birth to to a baby 8 hours ago would you pick infection no never pick infection in the first 72 hours you only pick infection after 72 hours not in the first 72 question is T serious tet TNI is dangerous because your larynx can go into a tetanic laryng spasm which would close the vocal cords in an irreversible spasm which essentially cuts off your Airway and you die okay hypothyroid hypothyroid is hypo metabolism so if hypothyroid hypom metabolism what are the signs and symptoms of a low metabolic rate if your metabolic rate is really low what would you look like OB obese what would your personality be what&amp;#39;s that what flat boring dull cold intolerance heat tolerance see you cannot tolerate what you are so if you&amp;#39;re all if you&amp;#39;re cold you can&amp;#39;t Toler you have cold intolerance if you&amp;#39;re hot you have heat intolerance do you see what I&amp;#39;m saying so hypo thyroids are hypos are always what cold so they have cold intolerance hyper thyroids are always hot so they have heat intolerance so you cannot tolerate what you are what would the pulse be and the blood pressure be low if they were a test taker what kind of test taker would they be slow slow extremely slow test takers they tend to get lower grades in school not because they&amp;#39;re not smart but because they can&amp;#39;t process fast enough it could even affect nursing practice in the sense that you don&amp;#39;t think fast enough okay the name of the disease is mix edema my YX M YX and then the word edema that&amp;#39;s the name of it okay the treatment do you have too much hormone or not enough hormone not enough so what&amp;#39;s the logical treatment give them thyroid hormones Synthroid Leo thyroxin number four caution do not sedate these people why do you not sedate them cuz they&amp;#39;re already super slow you sedate them you&amp;#39;ll actually put them in a coma it&amp;#39;s called a mixed demic coma so what preop order would you question with this hypothyroid patient ambian at HS the sleeping pill before surgery the night before surgery because they don&amp;#39;t need that now what let&amp;#39;s say let me ask you this you got a hypothyroid client he&amp;#39;s on thyroid pills every day he&amp;#39;s going to have a open heart surgery he&amp;#39;s scheduled for it in the morning doctor orders NP past midnight you got a problem with that what&amp;#39;s your problem call and call and question what they&amp;#39;re holding them okay because NPO means nothing and nothing means nothing including anything which would be a pill so nothing by mouth means they&amp;#39;re not allowed to have any of their oral pills which means you would not give the person their morning thyroid which means they would be hypothyroid and very susceptible to any drug that would sedate them do you get any drugs during surgery that sedate you it&amp;#39;s called an anesthetic agent do you see what I&amp;#39;m saying so if you would follow that order and not give the thyroid pill the morning of surgery What could would likely happen to your patient never make it off the table they would die from these depressant effects of the anesthesia so you as a nurse would never hold what pill before surgery without Express orders to do so thyroid pills never hold your thyroid pills unless they tell you to do it and even if they told me to do it if I called the surgeon and he told me to hold the thyroid what would I do I&amp;#39;d called the anesthesiologist and if he said hold it what would I do I&amp;#39;d call the head of the anesthesi my supervisor and say hey look this is not cool now my supervisor should what contact the supervisor of the anesthesiology and say hey look what&amp;#39;s going on here you see you you you aren&amp;#39;t supposed to go up the ladder outside your department you go up your department and they go across do you see what I&amp;#39;m saying uh if I really felt it was unsafe I would I would refuse to follow I would just refuse to I don&amp;#39;t know if I you understand if I thought it meant a patient dying how far would you go you know what I&amp;#39;m saying if it was your dad how what would you do to keep him from Gone surgery You&amp;#39; lay down on the floor and not let him get the card over your body do know what I mean so I&amp;#39;m just saying would you do the same for your patient okay enough set on that adrenal cortex the second gland we&amp;#39;re going to talk about the adrenal cortex interestingly adrenal cortex diseases start with either the letter A or the letter c which are the initials of adrenal adrenal cortex so could Graves be the adrenal cortex could miedema be the adrenal cortex could foch chromosoma be the adrenal cortex could Cushings cons Addison cortico insufficiency adrenal insufficiency yes so all of those diseases start with an A or a c now I didn&amp;#39;t say that all diseases start with an A or a c our adrenal cortex is asthma you know obviously no all right Addison&amp;#39;s disease let&amp;#39;s start with Addison it starts with an a it&amp;#39;s under secretion of the adrenal cortex under secretion what are the signs of symptoms just two things you need to know they are hyperpigmented what does hyperpigmented mean very tan very tan so they look what many people call Healthy but they are the farthest thing from it because the second thing you need to know about it is these people do not adapt to stress they do not adapt to stress because their adrenal gland is under secreting so if they undergo any stress at all what could happen what&amp;#39;s the purpose of the stress response I might ask what&amp;#39;s the purpose of the stress response not to increase the metabolism necessarily although it will that&amp;#39;s what mediates it but that&amp;#39;s not the purpose of it that&amp;#39;s what it does but that&amp;#39;s not what the purpose what okay and and but what&amp;#39;s the big when when you are under stress there&amp;#39;s a threat to your brain and the purpose of the stress response is to profuse the brain with blood in other words support the blood pressure and give the brain glucose which means raise the blood glucose so the purpose of the stress response is to raise the glucose raise the blood pressure does everybody understand that your stress resp response is supposed to raise your glucose and raise your blood pressure that&amp;#39;s what it its purpose is if these people do not have the adrenal cortex to carry out the stress response when they undergo stress what will happen okay what&amp;#39;s the purpose of the stress response raise the and raise the and if you&amp;#39;ve got a disease in that organ and cannot do that what will happen when you undergo stress your glucose will go down and your blood pressure will go down and you&amp;#39;ll go into shock like that and it doesn&amp;#39;t take much to put them into shock in fact these people have been known to go to the deest have the tooth filled and they go into full-blown shock because of that stress which wouldn&amp;#39;t bother most of us um if you ever work Squad these are the people that you happen on the scene of a little fender bender and somebody&amp;#39;s gone no blood pressure nothing they&amp;#39;re gone and you think well they couldn&amp;#39;t possibly been hurt that bad well what you&amp;#39;ll search them and what will you find really nice a really nice a really tan Guy where in a bracelet and what does a bracelet say I have Addison&amp;#39;s disease these people you look at them wrong and they go in shop no not really but I mean you know it&amp;#39;s they are your time bombs waiting to go this is a very scary disease you&amp;#39;re okay until something happens and then Wham they decompensate like that yes I thought it was rare do you see it it&amp;#39;s very rare as far as as endocrine disorders it&amp;#39;s one of the rarest it&amp;#39;s one of the rarest it&amp;#39;s like for every every 600 Cushings patients I would see I see one Addison and that&amp;#39;s probably being generous I probably only taken care of two or three Addison&amp;#39;s patients in my entire life Cushings you know all the time uh Kennedy was supposed to have had this disease JFK was uh rumored to have this disease so that means when he got shot what there was no chance there was no I mean even if he hadn&amp;#39;t even it had been now and if he and hadn&amp;#39;t gotten hit in the skull if he had gotten like a shoulder injury now he might not have made it so it was and think about this what&amp;#39;s really dangerous to people with Addison&amp;#39;s disease stress you&amp;#39;re the president of the United States you know it&amp;#39;s not the best he probably couldn&amp;#39;t get elected right now because they would have made such a big deal of the metal you know what I mean it would have just it would have disqualified him but it was hidden people didn&amp;#39;t know about it he didn&amp;#39;t seem he didn&amp;#39;t seem very tan well he was a little bronzer though when he early years he wasn&amp;#39;t he was real pasty but then he got tanned as he as he went on and then he started taking story so he got puffy okay so the nice little puffy cheeks he had there near the end that was steroids that wasn&amp;#39;t Jackie okay um well what&amp;#39;s the treatment steroids yeah give him what he&amp;#39;s low on which is what steroids not pump you all steroids but glucocorticoids all drugs that end in what what do all steroids end in sewn betamethasone bethos dexamethasone kosone mosone hydr cortisone FL cordone so drugs that end in are steroids so what do so you give drugs these drugs to people in Addison right so Addison&amp;#39;s disease is it under secretion or over secretion under do you have to take something away from them or add something to them and what do you add a [Music] s in add a Suns you add aone and that tells you whether doesn&amp;#39;t add aone tell you whether it&amp;#39;s hyper or hypo sure CU if you&amp;#39;re adding it&amp;#39;s what hypo and it tells you you what drugs to pick anything ending in so so just remember add a Suns you add a s and that&amp;#39;ll help you remember it Cushings Cushings syndrome this is over secretion of the adrenal cortex over secretion the way I remember this is if you have a cushy bank account do you have more or less money more more if you have a a cushy chair does it have more or less stuffing more if you have a cushy tushy do you have more or less more more yeah you got a whole lot more right lot so cushy just sounds like more to me doesn&amp;#39;t it Cushings cushy over Addison you got to add cuz it&amp;#39;s under I never forget which one&amp;#39;s under and which one&amp;#39;s over okay okay now the signs and symptoms of Cushing&amp;#39;s Disease you have to know this they will test this and knowing this list gets you what we call Two for the Money which means when you memorize this list you&amp;#39;re actually getting two things number one you&amp;#39;re getting the signs and symptoms of Cushings and number two you&amp;#39;re getting all the side effects of steroid medications so when you memorize this one list you&amp;#39;re getting two things Cushing signs and symptoms and side effects of steroids any drug ending in some some so that&amp;#39;s good for a lot of reasons now I am going to have you remember this by drawing a picture of a little man and I&amp;#39;m serious I want you to draw this little guy over and over and over again until you draw him perfectly because if you can if you can draw him perfectly guess what you know the signs and symptoms of and you know the side effects of any drug ending in s so here&amp;#39;s what it goes now this man is called kushman okay kushman now I&amp;#39;m going to draw a head but don&amp;#39;t draw the head real big because you need a really space for a really big body okay so don&amp;#39;t take up all your space with the head okay the first thing on the head is you need to draw a moon face okay he&amp;#39;s got a moon face and you say oh I can&amp;#39;t draw okay well can you do this that&amp;#39;ll do okay so draw a moon face whatever your skill set is just draw a moon face because that&amp;#39;s the first symptom moon face puffy moon face then draw a beard on him what&amp;#39;s the fancy term for excess hairiness on the body close here sueism here sism that means lots of hair here okay next draw a real big body and I mean a big one put a bump on the front oh and a bump on the back put a bump on the front and a bump on the back now what&amp;#39;s the bump okay let me ask you this first what&amp;#39;s the what do we call the big round body obesity but a certain type of obesity TR trun or central obesity they&amp;#39;ll call it cuz see your arms and legs aren&amp;#39;t aren&amp;#39;t fat it&amp;#39;s just your body your arms and legs are actually really skinny so it&amp;#39;s trunkal or central obesity that&amp;#39;s the big body what&amp;#39;s the bump on the front no no that the buffalo hump is the bump on the back cuz buffalos have a bump on on their back so that&amp;#39;s the buffalo hump right there this is the gy comasa gy co mtia those are female tight breasts on men and we&amp;#39;ll start on page 35 lab values you have to know your lab values but the good news is you don&amp;#39;t have to know them all just certain ones that everybody else knows the only well there&amp;#39;s kind of more bad news and that is not only do you have to know lab values but you have to know which lab values are more dangerous than what other lab values so if you knew 10 lab values you need to know which ones are high priority which ones are middle priority and which ones are low priority because they will ask you to priority I people according to their lab values like they&amp;#39;ll give you four different patients a patient with a pottassium of 7.4 pessan with a pH of 6.8 a person with a hemoglobin of 10 and a person with a bu of 54 and they want to know who&amp;#39;s your highest priority patient that kind of thing so it&amp;#39;s not good enough just to know the values themselves because they will give you four people all of them have AB normal lab values all of them do so what you have to do is then rank them you know and who&amp;#39;s highest who&amp;#39;s lowest priority so what I want to do is teach you that because I don&amp;#39;t believe any school I know of teaches students how to prioritize lab values they teach you the lab values they teach you the numbers the ranges what&amp;#39;s normal what&amp;#39;s abnormal they teach you what high means what low means they teach you the significance of the test but they don&amp;#39;t teach you that a hemoglobin of seven is a higher priority than a person with an INR of 3.4 do you see what I&amp;#39;m saying they don&amp;#39;t they don&amp;#39;t get to that now does am I mistaken are some schools doing that are any schools doing thatan they just say pan is bad that&amp;#39;s probably probably on board that&amp;#39; probably be the least you should know at least that but well I&amp;#39;m going to give you a a scheme here you see the legend at the top of the page where it says ABC d a means that it&amp;#39;s not a priority I mean it&amp;#39;s a low priority it&amp;#39;s not a big deal yes it&amp;#39;s abnormal the ab the lab is abnormal but really there&amp;#39;s nothing you need to do about it in fact in real life if see what I&amp;#39;m going to do is let me let back up what I&amp;#39;m going to do is I&amp;#39;m going to for every lab value I give you I&amp;#39;ll tell you whether the abnormal is an a a b a c or a d I&amp;#39;ll assign a priority letter to it are you understanding where we&amp;#39;re headed with this and when I tell you that a lab abnormality is a level a what I&amp;#39;m trying to communicate to you is that yes it is abnormal and yes it could mean there is the presence of disease but in the scheme of things this is really no big deal in fact you don&amp;#39;t have to do anything about it in other words if a lab report came back and it&amp;#39;s an a level you could ignore it all night long and have the doctor Discover it in the morning and you wouldn&amp;#39;t be in any trouble for having that happen do you understand what I&amp;#39;m saying however if I tell you it&amp;#39;s a c level level C letter c and you do nothing about it all night long and the doctor finds out about it in the morning you are in major trouble so I&amp;#39;m trying to give you a feel for how important it is that you must report these or do something immediately so an a is abnormal yes but you do nothing about it it&amp;#39;s no big deal a letter B it is abnormal and you need to be concerned but there&amp;#39;s nothing you need to do you just kind of watch them closer have you had the experience where you had a lab value that was abnormal but it really wasn&amp;#39;t all that bad so you didn&amp;#39;t have to do anything but you but that lab abnormality said to you watch them closer watch them closer that&amp;#39;s what I&amp;#39;m trying to tell you A B is when I tell you that a lab value is a c we&amp;#39;ve now crossed a line from low priority to high priority when a lab reaches a c value it is critical you must do something about it you can&amp;#39;t just sit on that lab value and do nothing if I tell you that a lab abnormality is a d I&amp;#39;m trying to communicate to you that it is the highest priority that you can possibly have with a lab value so what&amp;#39;s the lowest priority followed by and then what are two high priorities C and the highest of all is D okay just so everybody know where we&amp;#39;re headed here okay now let&amp;#39;s start into this lecture in the First Column there&amp;#39;s the name and anything I want to tell you about it in the middle column you&amp;#39;ll write the range the normal range and in the last column we&amp;#39;ll assign the a the B the c or the D all righty let&amp;#39;s talk about creatinin I told you two days ago that it is the best indicator of kidney or renal function now in this case I am talking about the serum creatinin because they will not talk about they will not give you the values for a creatinin clearance 24 hour creatin clearance they aren&amp;#39;t going to test you that on that but they will test you on the serum creatin now the serum creatin is 0.6 to 1.2 which is actually the same numbers as the lithium range if you recall that from yesterday the lithium and the creatinin are the same range okay in the middle column I you have that in the last last column an abnormal creatinin is just a level a you would never prioritize a person with a high creatinin as your highest priority now do they have kidney disease if they have a high creatinin yes but are they going to die in the next 4 hours no the next morning the doctor could come in and go oh his creatinine is high he must have kidney disease and that&amp;#39;s fine you&amp;#39;re not going to be in any trouble for it probably the only time that I would ever make a high creatinin something that I would actually make a phone call to a doctor about is if they were going for a test that had a diey in it that next morning like for example if they&amp;#39;re having a cardiac catheterization where they put the Dy in if they if the question tells you that they&amp;#39;re to have a die procedure in the morning I might make a high creatinin something that I would report but it wouldn&amp;#39;t be in the next hour it would just be sometime like like for example if you got the high creatinin back at midnight I wouldn&amp;#39;t call the doctor till 5: or 6:00 in the morning at the earliest I might wait till 7: I certainly wouldn&amp;#39;t call him at 1: in the morning but there are certain lab values you&amp;#39;re going to see you call them right away so this would even then it wouldn&amp;#39;t be a super high priority but it would be higher than just a plain high creatin so everybody understand that okay the INR the international normalized ratio it monitors cuman therapy it&amp;#39;s like the PT it&amp;#39;s a variation of the prothombin time its normal range should be two and three in the twos and threes in other words you want your eyes and r i and rs to be in the twos and the threes like 2.1 3.8 that&amp;#39;s what you want in the last column anything that&amp;#39;s above four or four and above is a c which means it&amp;#39;s high priority you have to do something this is not one you can ignore you can ignore the creatin but you cannot ignore this one an INR of 4.2 would defeat would be a higher priority than a creatin of 30 now when you when I assign something a letter C what do I say are the implications of that it&amp;#39;s critical and you have to what do something now the question you should be asking is what&amp;#39;s the do that I should do well whenever you get a situation where they want to know what are you going to do about something there&amp;#39;s a protocol you need to follow an order because this would be a drag and a click and drag you always hold that&amp;#39;s the first thing you do what do I mean by hold if there&amp;#39;s something that&amp;#39;s causing a problem stop it first first after you hold then you assess what would you assess a whole complete head to toe physical exam yes or nooc no a focus assessment focused on what the area that the lab value is telling you there&amp;#39;s some problem with with but do a focused assessment then you prepare which means you prepare to give now you don&amp;#39;t always give but you prepare to and after you prepare then you call meaning call physician or call respiratory or call whomever is is appropriate but before you call the physician you always hold assess and prepare now if we apply this to the INR of 4.7 let&amp;#39;s say you get an INR of 4.7 and they want to know what are you going to do in what order and you have to click and drag what would be what would you click first hold hold what hold cumin hold all cumin then what would you do assess for what bleeding then you would vitamin vitamin K prepare to give vitamin K and then you would call your doctor in that order now sometimes there may be nothing to hold you what I&amp;#39;m saying there&amp;#39;s nothing to hold there&amp;#39;s no nothing causing a problem so you jump immediately to what assess and sometimes there may not be anything to prepare so you jump to call but you should intellectually go through that process with everything you you do something about so that you&amp;#39;re thorough so that you don&amp;#39;t miss a step all right potassium potassium there&amp;#39;s nothing I want to say about it in the First Column except that it&amp;#39;s not really a good indicator of anything but it is an indicator that something&amp;#39;s wrong but you don&amp;#39;t know what its range is 3.5 and then flip it around 5.3 3.5 to 5.3 now for hessie for hessie it&amp;#39;s 3.5 to 5.0 for hessie it&amp;#39;s 35 5.0 but for boards it&amp;#39;s 3.5 to 5.3 why why the difference Fords is a nationalized hessie uses whatever else severe lab book says okay so to hessie a 5.1 potassium is an elevation on boards at 51 is not an elevation now let&amp;#39;s talk about the last column a low potassium meaning lower than 3.5 is a see you have to do something okay now let&amp;#39;s go through our protocol if your potassium is low is there anything you have to hold no so what do you do but what are you assessing what&amp;#39;s your focus heart assess heart prepare to administer Vitamin K Vitamin K potassium I always do that I always used to do that vitamin anybody ever do vitamin K and potassium K I screwed that up for like 10 years okay and then I what the call the dock all right what if it&amp;#39;s between 5.4 and 5.9 that gets a c so now you have to do something well is it high or low high so what do you think we would first do hold all potassium and that may mean ripping down down the D5W with 20 of KCl I mean getting that torn down then you assess the heart then you what now Lasix does make you lose potassium but we don&amp;#39;t give Lasix for the purpose of losing potassium kx8 and D5W and regular insulin remember yesterday exate and D5W regular insulin and then you call your dock however in the last column if the potassium is greater than or equal to six it&amp;#39;s a d it is deadly dangerous this person could die soon like in the next 2 minutes so what do you do um you do everything we just said you rip down the IV you assess the heart you prepare the D5W regular insulin and the KX and you call your doctor you do all that what stat so how many people have to be involved you probably got one nurse ripping out the what potassium you got somebody calling for an EKG coming you one nurse is preparing the D5W and regular insulin while the secretary&amp;#39;s calling the doctor stat do you see I&amp;#39;m saying and you stay with your patient got it cuz you cannot leave the you can&amp;#39;t leave the bedside of a d you understand what I&amp;#39;m saying can you leave the bedside of a c do you even know what I&amp;#39;m talking about D&amp;#39;s and C&amp;#39;s okay got okay um can you leave the bedside of a c yes yeah can you leave the bedside of a d no no so one of the things you&amp;#39;re going to have to remember when you&amp;#39;re answering these D questions is you stay at the bedside and you do what you can do at the bedside but everybody else helps you do everything else you don&amp;#39;t run out and get the EKG and leave your patient by themselves with a potassium of seven okay now I&amp;#39;m not saying you do this in real life you should do it in real life but I&amp;#39;m saying this is what the book wants you to do and really if you really did this you would you wouldn&amp;#39;t get in trouble your patient would be in good shape okay um the pH 7.35 7.45 is the range which you told me the other day in the last column the only thing that matters is a pH in the sixes is a d now I don&amp;#39;t mean 7.6 I&amp;#39;m talking about 6 something in the sixes now you notice that I don&amp;#39;t do you notice with the creatinin I didn&amp;#39;t go I didn&amp;#39;t talk about a low creatin did you notice that and in an INR I didn&amp;#39;t talk about about a low INR and here I&amp;#39;m not talking about a high pH because those aren&amp;#39;t that clinically significant and they&amp;#39;re not usually tested at all you I&amp;#39;m saying these are the things that are tested over and over and over again so rather than have you learned everything let&amp;#39;s focus on what&amp;#39;s essential all righty pH in the sixes so what do you do is there anything to hold I can&amp;#39;t think of anything what would you assess this is interesting what do you think you&amp;#39;d assess somebody said respiration somebody said pulse V there you go lump them together check your Vital Signs because the pH is going in what direction down and as the pH goes Pati so goes your patient so the patient is going to be going what down and out and you check it I mean with the pH is in the 60s to be to transparent and honest with you you&amp;#39;re doing the vitals to make sure they&amp;#39;re still alive I I know that sounds ridiculous but you really are CU I mean they usually when you have a six you&amp;#39;re dead so you&amp;#39;re just making sure they&amp;#39;re alive and then is there anything to prepare not really used to be years ago because they were severely acidotic we would prepare bicarbonate to give bicarb but you don&amp;#39;t do that anymore you don&amp;#39;t indiscriminately give bicarbon like if you&amp;#39;ve ever been taught that no you don&amp;#39;t do that you don&amp;#39;t give bicarbon anymore to acidotic patients because it can fuses the whole issue the key is to correct this acidosis the only way you can correct it is to treat the underlying cause and there is nothing a nurse can do to treat the underlying cause the physician has to get here determine the cause and treat the cause so with a low PH you have to get the physician in on the case faster than anything else we&amp;#39;ll talk about today so that&amp;#39;s why you just assess their Vital Signs and you call your Dock and you skip hold and you skip prepare now why are you getting the vitals Tri life cuz when you call the doc what are they going to say is he alive you know is he brail what&amp;#39;s his heart doing you know so get a set of Idols that&amp;#39;s all you need set of Idols call the doc and you stay so who gets the vitals you do who calls the doc maybe some you know get a put on the light or whatever and however you communicate to your secretary unit secretary and have them call Stat okay bu blood Ura nitrogen bu it has a lot to do with waste nitrogen waste products in the blood its range is 8 to 25 8 to 25 the way I remember that is BU n spells what English word bun buns like hamburger buns hot dog buns when you buy hamburger buns or hot dog buns how many are in the pack eight eight there&amp;#39;s your eight buns eight 8 to 25 and if the bu is elevated you it&amp;#39;s no big deal all you do is assess them for dehydration assess them for dehydration by the way a little hint good guessing strategy here if they give you an elevated blood value and you have no clue what&amp;#39;s going on and they ask you for what would you assess them dehydration is a great answer because when you dehydrate what happens to all blood values they go up because of concentration so it&amp;#39;s just a really good good guess to say when the bu ends up oh I don&amp;#39;t know what it is well pick dehydration good answer you may be wrong but it was a good answer might not have made the top 10 survey but you know it&amp;#39;s not bad I don&amp;#39;t know why I had an extra L on the end of elevated but you know hemoglobin is the next one it&amp;#39;s 12 to 18 now it&amp;#39;s yeah I know it&amp;#39;s 12 to 16 for women and 14 to 18 for men but for humans it&amp;#39;s 12 to 18 and Boards doesn&amp;#39;t get into lab values vers men versus women children versus adults new BNS versus they they could be on your test but those are really hard questions and you do not have to get those right but if you don&amp;#39;t know a normal adult hemoglobin you&amp;#39;re in trouble if it&amp;#39;s 8 to 11 if the hemoglobin is 8 to 11 it&amp;#39;s a b and you would assess them for what low hemoglobin anemia a bleeding or malnutrition if the hemoglobin however Falls below an 8 it&amp;#39;s a c and you must do something okay well what are you going to do you going to hold anything not that I know of you&amp;#39;re going to assess for bleeding you&amp;#39;re going to prepare to administer blood and you&amp;#39;re going to call the doctor now LPNs you would you would prepare but you would call not on this but on everything where we&amp;#39;ve said call Doctor you could substitute notify RN do you see what I&amp;#39;m saying you could whever this could say hold assess prepare notify RN all right um buy carb the buy carb is what 2 + 2 + 2 = 6 right 2 22 to 26 and an abnormal by carb is an a we don&amp;#39;t care so what you know I&amp;#39;ve never in 37 years of being a nurse I have never been yelled at by anybody because I didn&amp;#39;t tell them what somebody&amp;#39;s bicarb was it&amp;#39;s just not a major issue okay CO2 carbon dioxide this is in this you are getting from an arterial blood gas by the way the normal range is 35 to 45 it&amp;#39;s the same as the pH just dropping off the 7 point correct in the last column a CO2 that&amp;#39;s high but in the 50s like 51 57 56 59 those are C levels those are that&amp;#39;s a c which means it&amp;#39;s critical you can&amp;#39;t just sit on it you got to do something about that that&amp;#39;s not good now on I want to say a disclaimer I&amp;#39;m not talking about COPD clients here at all that changes everything this is for people without COPD so what do you do well is there anything to hold a high CO2 anything to hold I don&amp;#39;t think so what would you assess respiration respiratory status now when it comes to prepare on this one there is actually something you can do there&amp;#39;s actually something you can independently as an LPN or an RN do what would that be okay breathing in a bag actually recirculates the CO2 so we don&amp;#39;t want that that would be raising the CO2 what&amp;#39;s that oxygen is used for low oxygen not for high CO2 down what&amp;#39;s that down like on your I read that if you actually put your thumb in your mouth and blow oh yeah yeah yeah okay like like your yeah or they&amp;#39;ll say the candle this is a candle blow out the candle that is called Pur lip breathing have you heard of that this is what you&amp;#39;re going to pick first lip breathing because with P lip breathing you&amp;#39;re you&amp;#39;re prolonging the exhalation and if you prolong exhaling you&amp;#39;re getting rid of CO2 now most of the time that will correct the problem so you never have to move to what call how do you know it&amp;#39;s going to correct the problem they will breathe easier cuz when they&amp;#39;re in the 50s it&amp;#39;s going to be dnic they&amp;#39;ll be dnic when there are co2&amp;#39;s in the 50s so that will that will solve that problem however what of the CO2 is in the 60s that&amp;#39;s a d that&amp;#39;s one of the criteria for making the diagnosis respiratory failure have you heard of respiratory failure well how does how do you know someone&amp;#39;s in respiratory failure well one of the ways you know is this the CO2 is 60 and above now here again we&amp;#39;re not talking about cop deers so this is a medical emergency this is a super high priority patient so you do not what leave the room you stay with them so is there anything to hold in this case nope assess there respiratory status now Pate breathing isn&amp;#39;t going to cut it now I will probably do it with them just to decrease their anxiety and maybe take the edge off of it but I&amp;#39;m going to have to prepare for what two things CU they&amp;#39;re in respiratory failure intubate and ventilate so you prepare to intubate and ventilate and then who do you call there&amp;#39;s two people to call who do you call first respiratory therapy first call respiratory therapy first then call the physician but you stay with your patient yes at that youon like a code a pre code yeah um on boards they really don&amp;#39;t have anything that&amp;#39;s called an emergency response precode team they don&amp;#39;t that&amp;#39;s certain hospitals have that some don&amp;#39;t and because it&amp;#39;s not a universal phenomenon Across the Nation in every hospital they won&amp;#39;t even go there but I would say if I were you and I had one of those teams in my at my disposal in a hospital yes at this point I would because this person is going to end up on event if and that&amp;#39;s the best that&amp;#39;s going to happen you know the worst could happen before so yeah all right uh hematocrit hematocrite is TW uh 36 to 54 36 to 54 now I don&amp;#39;t remember that that&amp;#39;s why I had to think for a few seconds before I said it I never remember that because that that&amp;#39;s a clumsy number 3654 you know it&amp;#39;s a sloppy well it&amp;#39;s three times the hemoglobin so whatever the hemoglobin is multiply that by three and that&amp;#39;s why I had to do the math in my head there for a second before I Told You So 12 * 3 is 36 and 18 * 3 is 54 so it&amp;#39;s 36 to 54 okay an elevated hematocrite an an elevated hematocrite it&amp;#39;s abnormal it&amp;#39;s a b an elevated aat what would you assess for dehydration good job dehydration but it&amp;#39;s no big deal okay let&amp;#39;s talk about the oxygen level the P2 the oxygen level here again you&amp;#39;re getting this from the arterial blood gas this is not what you&amp;#39;re getting when you put on the pulse ox on their finger or their ear load that is not the P2 the po2 is from the blood gas now the P2 normally should be 78 to 100 78 to 100 is the normal range if it is low but still in the 70s like 70 to 77 that is a c which means you have to do something it&amp;#39;s critical so is there anything to hold no you assess what respiratory now there is something you can do both LPM and RNs without a physician&amp;#39;s order and what is that give them oxygen because their oxygen is low so now you give them oxygen and N9 times out of 10 what will happen will it correct it or not it will correct it and you will not have to call your physician and how will you know it corrects it because you&amp;#39;re not having a continuous arterial blood gas measurement you&amp;#39;ll know because the disia goes away and the restlessness and the anxiety and the TAC cardia by the way just just an interesting thing so that everybody so I know everybody knows this because they love to test this when someone is hypoxic which rate increases first the respiratory rate or the heart rate heart rate heart rate so when you go hypoxic your heart rate will speed up first first then when the heart can no longer compensate for it your respiratory rate goes up a lot of people think oh hypoxic your respiratory rate will go up first no it won&amp;#39;t your heart rate goes up first if you ever work coronary care what are the two most common causes of episodic tacac cardia in heart patients hypoxia and dehydration so a coronary care nurse knows that when you get these episodic Tac of cardias all you have to do is increase the IV rate and give them some oxygen and it goes away and you never have to call your doctor I would have to say 90% of the time that I have episodic tacac cardia in the coronary Care Unit when I worked night shift there for 10 years it&amp;#39;s at was at Mercy Medical Center in Springfield now called Springfield uh Regional whatever Mall um the uh I never had to call doctors because I would just up the IV rate or give them oxygen and i&amp;#39; the T cardia go away you always could tell a new nurse who came into coronary care because they were calling doctors in the middle of the night for episodic tactic cardia and the doct could say well did you increase the IV rate no did you give them oxygen no well do that and call me me back if it doesn&amp;#39;t work you know and that I&amp;#39;m saying it politely okay okay well what if it&amp;#39;s low in the 60s meaning 68 69 64 63 that&amp;#39;s a d That&amp;#39;s the other criteria for respiratory failure so what are the two defining characteristics for respiratory failure CO2 in the 60s and and O2 in the60s when they&amp;#39;re both in the 60s that&amp;#39;s when you need to intubate and ventilate them so if it&amp;#39;s in the 60s there&amp;#39;s nothing to hold you assess the respiratory status you prepare to intubate and ventilate you call respiratory therapy and you call the doctor now you can put oxygen on them during that time it&amp;#39;s not going to solve the problem but it&amp;#39;s going to make them a little more calm so if I had a click and drag on that one how would I put where would I put the oxygen I&amp;#39;d probably do this I&amp;#39;d probably hold I wouldn&amp;#39;t hold anything I&amp;#39;d assess well no I probably there&amp;#39;s nothing to hold i&amp;#39; probably throw on the O2 just to make them what comfortable then I&amp;#39;d assess them and then I&amp;#39;d prepare to intubate and ventilate call respiratory therapy and call the doctor yeah I always to always first and safe like any question no you&amp;#39;re not that&amp;#39;s a Gro for simplification okay she said that she was taught that you in an order question you always assess before you do and that&amp;#39;s true 80% of the time 20% of the time it&amp;#39;s wrong because there&amp;#39;s something you need to hold before you assess for example uh you&amp;#39;re giving a blood transfusion and somebody complains of itching and you see hies what do you do stop the blood then you do your assessment what about in this situation I would then that would probably that I&amp;#39;m I don&amp;#39;t think just in my impression I think if you asked 50 nurses you&amp;#39;d have half and half on that and so I don&amp;#39;t really I can&amp;#39;t conceive that they would write that question on boards because it would be such an interpretive thing subjective subjective kind of thing but if if the INR is five every nurse says I&amp;#39;m going to stop the cumin in and then I&amp;#39;m going to find out a sex you know that they would all say that and if the pesum six they&amp;#39;d say I turn off the IV then assess their heart okay that so yeah it&amp;#39;s it&amp;#39;s going to be there are certain things where I always tell people this assess before you do unless delaying doing puts your patient at higher risk and if you would assess for signs of blood Rea transfusion reaction both if you delayed stopping the blood to do an assessment of are they having a reaction you would be putting the person at increased risk so therefore you do before you assess does that so what&amp;#39;s the rule everybody assess before you do unless delaying doing in order to assess puts the patient at risk for example a patient pulls out their arterial line they are bleeding in bright red spurts from their radial artery what&amp;#39;s the first thing you do assess their Vital Signs apply pressure okay well ones assess ones do right well if you delay putting pressure in order to take a set of vitals are you increasing the risks of the patient yes therefore do will preed assess and that&amp;#39;s an obvious one but I&amp;#39;m I&amp;#39;m trying to illustrate the principle are you seeing that yeah okay good good question I because that&amp;#39;s one that everybody&amp;#39;s taught how many were taught assess before you do assess before you do but you have to understand whenever you use a rule like that you have to understand there always an exception and what&amp;#39;s the exception yes um not caral group always have a question or it would always catch us up and it was something about the ratory situation which you do first and it had head the bed yes oygen talking about the thing is is if I was between somebody&amp;#39;s having dmia acute dmia one was Elevate the head of the bed the other was put on oxygen the other was uh call the doctor and the others do a respiratory assessment what would I do I would Elevate the head of the bed first all righty because if I do a respiratory assessment with him lying flat I&amp;#39;m just it&amp;#39;s just I&amp;#39;m getting data that&amp;#39;s not going to be helpful he&amp;#39;s not going to cooperate with me I&amp;#39;m not going to get good data not going to get full so I&amp;#39;m going to elevate the head of the bed first I always like to do if I&amp;#39;m between two dues I like to position first you know if I&amp;#39;m between two does and one&amp;#39;s a position and one&amp;#39;s another action I find that the position usually wins over the other action how many have found that out sort of seen that so I would probably Elevate the head of the bed I would put the oxygen on I would do an assessment and then I would call The Physician now what did ATI say I wonder is that what ATI said because I almost always position first when I&amp;#39;m between what two does I always position first and see my rule there would be would if somebody&amp;#39;s in significant dnia and hypoxia would be would delaying putting their head up and delaying giving them oxygen while I did a respiratory assessment put them in greater risk and the answer is yes you would be you see so then I would precede the assess with the dues did do you see that yeah question so if you first what you do Bingo you&amp;#39;re smart good job do you hear what she said she said but what if it&amp;#39;s not a first question what if it&amp;#39;s a best and you&amp;#39;re between oxygen and rais head of B well in a best question and I&amp;#39;m really glad are you here for a refresher or if you is this the first time you&amp;#39;ve taken this class first time good job um because uh if you had to do one raise her head without giving her oxygen or keep her flat with oxygen she really will benefit better from the oxygen lying flat than she will up with no O2 so best would be O2 first would be raise head of B is everybody seeing that good call okay um the O2 set the oxygen set should be 93 to 100 anything less than 93 is a c critical there&amp;#39;s nothing to hold you assess them you throw on the O2 now you could if I don&amp;#39;t think with an seo2 unless they&amp;#39;re in real real danger a low seo2 is not like an 88 there&amp;#39;s no reason to throw on the O2 right away you know what I&amp;#39;m saying I I don&amp;#39;t there&amp;#39;s no big deal there in fact I can&amp;#39;t even believe I&amp;#39;m telling you that an seo2 below 93 is that bad cuz I&amp;#39;m happy with SE o2s of 88 and above if you think that you&amp;#39;re going to run around calling doctors in the middle of the night for SE o2s of 91 you&amp;#39;re not going to last long but on hessie particular and on boards if it&amp;#39;s a 92 seo2 they&amp;#39;re in bad shape and I&amp;#39;m telling you that&amp;#39;s not real love life but that&amp;#39;s the book do you got me cuz hessie has a question on there where it says they give you poor patients I want to know who&amp;#39;s your highest priority and I remember taking it in letter A was a patient with a 91 sao2 and I went oh that&amp;#39;s fine you know and then I went to B and they were okay and I went to C and they were fine and I went to D and they were good too I thought oh my goodness they&amp;#39;re all fine and I thought wait a minute wait a minute wait a minute 90 it&amp;#39;s not 993 it&amp;#39;s 91 so that&amp;#39;s the bad the one that&amp;#39;s in bad shape so I picked them I got it right so you&amp;#39;re just going to have to go with that all right um now anybody ever want to work peeds no way in Pediatrics you better freak out when it&amp;#39;s below 95 okay cuz little kids don&amp;#39;t desaturate without older people we desaturate all the time you know it&amp;#39;s just what we do um but little kids don&amp;#39;t desaturated cop um they usually won&amp;#39;t go to COPD because then that that anything could be there&amp;#39;s no with COPD ear they&amp;#39;re going to have abnormal blood gases but there&amp;#39;s no pattern to tell you what it&amp;#39;s going to be and how much of one thing means what you say like they can&amp;#39;t say well you know for respiratory failure for a COPD or it&amp;#39;s not 60 and 60 it&amp;#39;s 70 and 50 there&amp;#39;s no there are no parameters every COPD is their blood gases are individually judged on their level of functioning at that blood gas so if you have a COPD with a CO2 of 59 which it should never be and a O2 of 64 which is horrible but they&amp;#39;re functioning okay then that&amp;#39;s their Baseline do you see what I&amp;#39;m saying and the hypercarbia is no issue because they don&amp;#39;t have a hypercarbic drive tobr they have a hypoxic drive to breis so it doesn&amp;#39;t even matter so that&amp;#39;s the issue with a little hypoxia is good for a cop deer because it keeps them breathing that&amp;#39;s why you don&amp;#39;t want to give a lot of o2 to a cop de or they&amp;#39;ll stop breathing on you so yeah I don&amp;#39;t think that they could even ask a question that would be fair other than the fact to know that cop deers normally Run High on the CO2 low on the O2 so I guess I my question answer to you would be if they gave me four patients and they told me one was a cop deer with a CO2 of 55 and an O2 of 71 even those are those are letter letter c&amp;#39;s for you and I I would not make them a high priority okay BNP oh by the way when is a when is your seo2 invalid what invalidates your finger probe seo2 reading what&amp;#39;s that anemia anemia falsely elevates it so if somebody&amp;#39;s anemic they&amp;#39;re going to look a lot better than they actually are so when you if you have an anemic patient your sa2 is not helpful you need to look at other indicators of oxygenation the other thing that invalidates it is if they&amp;#39;ve had a die procedure in the last 48 hours why what does the Dy do to blood color it and what does that read color so you&amp;#39;re going to have falsely elevated S2s with anemia and after die procedures so in both cases you&amp;#39;re going to when you get your sao2 you&amp;#39;re going to think the patient is what better off than they actually are which is actually pretty dangerous okay BNP which is the brain natural utic peptide don&amp;#39;t worry about that uh it&amp;#39;s the best indicator of congestive heart failure it should be under 100 an elevated BNP is a b which just means you&amp;#39;ve got congestive heart failure but you&amp;#39;re not going to die you don&amp;#39;t need to call the doctor in the middle of the night there&amp;#39;s nothing you have to do just watch them for CHF see it sounds kind of funny that a heart value is not a high priority but this is a heart value because it&amp;#39;s indicating a chronic condition you understand why it&amp;#39;s not high priority because it indicates a chronic condition not an acute one sodium sodium is 135 to 145 if it&amp;#39;s abnormal it&amp;#39;s a b which means you assess if the sodium is high you assess for dehydration if the sodium is low you assess for overload remember hyper nutria hypon nmia the one with the E is dehydration the one with the O is overload however if the question tells you the sodium is abnormal and there is a change in Lo the priority of the patient shoots up to a level C and basically it&amp;#39;s a safety issue at that point it&amp;#39;s safety which brings us to the last three lab values yay you see why I didn&amp;#39;t want to do this yesterday at 3:30 white blood cells there are three white counts you must know three white counts you must know the first one is the total white blood cell count which is 5,000 to 11,000 the other two are the a NC the absolute neutr pill count which needs to be above 500 there&amp;#39;s no range here it&amp;#39;s just a threshold limit you must have more than 500 anc&amp;#39;s per cubic mm and the last one is the CD4 count and it needs to be above 200 CU remember when your CD4 Falls below 200 what do you have not HIV you got AIDS now so the the defining line between HIV disease and AIDS is the 200 CD4 if you&amp;#39;ve got 201 you have HIV disease if you&amp;#39;ve got 199 you have AIDS so all of those are low white counts and all of those are a letter C all of those below those levels ANC below 500 a white blood count below 5,000 and a CD4 count below 200 all of those are Level C&amp;#39;s they all are and because of that there&amp;#39;s nothing to hold you assess for signs of infection and instead of preparing what you do is you place them on these neutropenic precautions that are in your last column and it would be good for you to know those because they do test what&amp;#39;s on the neutropenic precautions the one that I I mean I it&amp;#39;s amazing how you could be a nurse for decades and certain facts you just never learned it was like 10 years ago after I&amp;#39;ve been a nurse for 20 some years that I re learned uh the ninth wind I think it&amp;#39;s the ninth wind down don&amp;#39;t drink water that has been standing longer than 15 minutes I didn&amp;#39;t realize on these neutropenic precautions they are not allowed to have a water picture if they want water you bring them fresh water that water isn&amp;#39;t allowed to stand in fact the water bottles if they&amp;#39;re unopened I think they&amp;#39;re good for 4 hours if they&amp;#39;re open they&amp;#39;re good for an hour yes I um my leadership oncology I had patients with getting yes transpl I had patially two and the um neutropenic going to do like this patient the nurse and she had these patient he could only have one patient because exactly the precautions were so timly and rigorous and what did they what did they use for these the water bottles what did they use they you weren&amp;#39;t allowed to have a water bottle open unless we you drank it right away and they had a special refrigerator that we were able to go like you couldn&amp;#39;t just get them regular water we had to go to the BMC refrigerator which was always locked we unlock it get it out bring it to them watch them drink it throw it up throw it up so it wasn&amp;#39;t even an hour okay I mean I think you have to 20 30 minutes let the PA drink it you know but there were certain and then we had to clean a room every like um I think it was every it either every 4 hours since you had to clean it down with this really special and they and so they can the point is they can really get more obsessive than this a lot more so this is sort of like the least you would do and this is so this is um see with balart transpant you got to be really really careful because they&amp;#39;re really uh dangerous because what did we do what did we do to them we destroyed we total body radiation where you radiated all of their protection they have none zero I&amp;#39;m surprised she had two I&amp;#39;ve seen some with practically none okay so um neutropenic are really important okay platelets platelets I&amp;#39;m not going to give you a normal range because I&amp;#39;ve looked in five different books and they don&amp;#39;t even overlap nobody knows what a normal plet count is I don&amp;#39;t think but the key is What are the trigger values for thrombo cyop IC precautions or bleeding precautions and that is in your last column A platelet count below 90,000 is a c you need to put them on these these bleeding precautions and if the platelet Falls below 40,000 now you&amp;#39;ll hear people say he has 40 platelets or 35 platelets they don&amp;#39;t mean 35 they mean 35,000 so if they say his platelet count is three what do they they mean 3,000 they don&amp;#39;t mean three okay now the ANC means what it says but this is usually in thousands and then red blood cells are 4 to 6 million red blood cells are 4 to 6 million and an abnormal red count is just a b it&amp;#39;s no big deal okay now that&amp;#39;s a lot of info here&amp;#39;s what I want you to do with it memorize the 5Ds why should you memorize the 5Ds cuz those are the really high ones that if you don&amp;#39;t know you&amp;#39;re unsafe and you don&amp;#39;t want to show that on this test so what are the five DS pH in the sixes not P car okay but there&amp;#39;s one before that potassium in the so a potassium in the sixes a pH in the sixes got that now what are what&amp;#39;s the next one CO2 in the 6s and then O2 in the 60s so a pH or a pottassium in the sixes or a CO2 or an O2 in the 60s so what pattern are you seeing already sixes and 60s you don&amp;#39;t like and then what&amp;#39;s the fifth one plet count of less than 40,000 those are your highest priority people nobody will beat them and Boards will not put those people against each other cuz it&amp;#39;s not fair okay now what I would then do is learn all the Seas there&amp;#39;s probably about a good eight of to 10 of them then I would not remember the priority on any of the other others why cuz that way if you don&amp;#39;t remember them they are what priority low do you see what I&amp;#39;m saying so just remember the high ons and everything else is low so remember your D&amp;#39;s which I think are easy your 6s and 60s in the 40,000 and then your C&amp;#39;s and probably what to do for them and then you you&amp;#39;re good to go and I you really will be so much better prepared for the questions than anybody else sitting there you know so cuz everybody else is just going to what yes and say well potassium and then if it&amp;#39;s not potassium they&amp;#39;re dead in the water okay let&amp;#39;s turn to something near the back of the book I want to get it done earlier cuz it&amp;#39;s just a horrible lesson to do late in the day and that is Page 64 psych drugs we&amp;#39;ll do this one then take a [Applause] break psychotropic drugs page 64 this is a big laundry list of Psych drugs that you have to know but don&amp;#39;t panic because you&amp;#39;re going to find that psych drugs even though the classes of drugs are different there&amp;#39;s a lot in common between them and so you&amp;#39;re not even though you may memorize 10 different classes there isn&amp;#39;t going to be 10 totally different discreet pieces of information a lot of it&amp;#39;s going to overlap which is nice and to start off with showing you this the note in the box is very important all how many does that mean all thank you all means all all Psych drugs cause low blood pressure and weight changes there isn&amp;#39;t a psych drug made today day that does not lower your blood pressure and make your weight change now the vast majority of SE drugs will do what to your weight increase but Prozac and a couple others make you lose weight but even Prozac makes you gain weight in Prozac you can go either weight gain or weight loss weight loss is more common but you wouldn&amp;#39;t rule out weight gain for Prozac either so if you really wanted to make it specific you could say all psych drugs cause low blood pressure and weight gain but you have to understand that proac and a couple others will also cause weight loss could cause weight loss if we just stopped right there you probably be do better on your Psy drugs because they like to test those Universal kinds of principles but let&amp;#39;s not do that let&amp;#39;s go into the major classes more specifically the first one are the phenazines this is an old class of drug speaking pharmacologically they&amp;#39;re called the first generation antipsychotics or they&amp;#39;re called the typical antis psychotics have you heard those words typical anticho first generation anticho those are your phenia Zen they all end in Zen z i n e which I love I think every drug should be that way I think every drug in a class should end with the same ending and should be the ending of the name of the class of the drug okay so all steroids should end in oid okay all calcium channel blockers should have Cal at the beginning of the name calcium you know what I&amp;#39;m saying all beta blockers should have beta beginning in the name all F all benzo diazines should end in zapen you see what I&amp;#39;m saying I I just think that&amp;#39;s the way it should be and it isn&amp;#39;t so we have to get over but anyhow this class it&amp;#39;s great they all end in Zen like Thorazine stelazine phenazine hypine chlorpromazine hydroxyzine all those Zen are phenia Zen actions they do not cure psych diseases they just reduce your symptoms in large doses they are antipsychotics I remember this by saying we use Zen for the zany Zen for the zany so you see a drug ending in Zen what should you immediately think zany it&amp;#39;s for an anticho for a crazy person in small doses they are anti-emetics have you ever given Compazine have you ever given feneran promethazine for nausea have you ever given uh Vil hydroxyzine for nausea but if you double the dose it will treat psychosis have you ever given thorine or psychosis if you cut the dose in half it will treat nausea letter C they are considered major tranquilizers major tranquilizers these are the big guns uh I&amp;#39;m going to make an analogy here aminoglycosides are to infection like phenazines are to psychose tranquilizers okay I I should make it different antibiotics I mean aminoglycosides are to antibiotics like phenazines are to tranquilizers what&amp;#39;s that mean they&amp;#39;re both the big guns you pull these out when nothing else is going to work okay these major major tranquilizers have a major major side effect list in fact this has been the the the marketing dilemma manufacturers of these drugs have had for decades they they manufacture these drugs that really work well but they have this long list of side effects that really hinders their their marketability I&amp;#39;m going to use the alphabet here to help you remember this side effects of the major tranquilizers a will stand for anti- energ primarily dry mouth anticholinergic dry mouth b stands for blurred vision C stands for constipation d stands for drowsiness anybody know what e stands for EP EP p ps extra paramal syndrome the thing that looks like Parkinson&amp;#39;s extra paramal syndrome EPS like Parkinson&amp;#39;s remember where they get the pill rolling and the Cog wheel rigidity and the shuffling gate and all that F I cheated I needed the f photos Sensitivity I know it&amp;#39;s SP with a pH but I needed the F to work for me so photo sensitivity and then with the G I want you to put a little a in front of the G and write a granulo cytosis which means low white count so they have a dry mouth they have blurred vision they have constipation they have drowsiness they have the Parkinson extra parameters their their skin burns to light photosensitivity and they&amp;#39;re immunosuppressed so that&amp;#39;s the side effects of now those are all side effects not toxic effects what do you do when a patient displays a side effect what&amp;#39;s the nursing action when a patient displays a side effect do you hold the drug no you teach the patient inform thect doctor and keep giving the pill when someone experiences a Toxic effect what&amp;#39;s the nursing action hold the drug call the doctor immediately so for EPS would you call the doctor immediately and hold the drug no we have Parkinson&amp;#39;s drugs like cenin and artane will give to them to treat the EPS the only problem is when you give Parkinson&amp;#39;s drugs to treat the EPS do you know what two their major side effects are dry mouth and constipation so that gets worse but it&amp;#39;s kind of a pain all right number five the nursing care is treating the side effects so what&amp;#39;s the number one nursing diagnosis well they have blurred vision what&amp;#39;s the number one nursing diagnosis related to blurred vision injury risk for injury safety right drowsiness what&amp;#39;s the number one nursing diagnosis with that same thing extra paramal what&amp;#39;s the number one diagnosis there same thing so what is the number one nursing diagnosis when a client is on a major tranquilizer risk for injury risk for injury safety issues number six is a vocabulary word I want you to know what the word decanate means decanate can come after the name of a lot of different drugs sometimes they&amp;#39;ll abbreviate it they&amp;#39;ll say uh thorine D or something D the d means deonate and what deonate means is after the name of a drug it means it is a long acting long acting sometimes it works for two weeks sometimes it works for a month one shot for a month it&amp;#39;s an long acting I am form given to non-compliant clients in fact this is usually court ordered or could be court ordered what do I mean by that making yeah that probated the client and the judge ordered monthly Prix injections okay the it&amp;#39;s court order so if the client does not come in to the psychiatrist office or the Community Mental Health Center for their prolix and shot because it is court ordered what can the staff at the clinic do put out a go contact the police who will put out a warrant because they&amp;#39;re in viol violation of a court order and they will arrest them bring them in you stab their butt and they go home okay so that&amp;#39;s the way it goes and the police just love that okay tricyclic antidepressives tricyclic antidepressants are an old class of anti-depressant and most of them have now been grandfathered into a new class of antidepressants called the nssr I which means what non selective serotonin reuptake inhib but you understand they were not invented as nssr I they were invented as tricyclic anti-depressants but chemically they&amp;#39;re so much like the nssr that they&amp;#39;ve sort of been grandfathered into that group they are mood elevators used to treat depression they are mood elevators happy pills examples of these are elville toonel avenil and desil elville tophill avenil desil elil tophill avenil desil it Rhymes they all rhyme you hear the rhyme I&amp;#39;m serious about this I want you to put these on the 3x5 card I want you to tape them to your steering wheel and for the next 4 days every time you come to a red light or a stop sign I want you to stop texting and I want you to I want you to just say elville toel Avent till desel Lille toil ail desel elville toil Avil desil and after 3 or 4 days guess what we&amp;#39;ll be forever linked in your brain elville toil Avil and desil now why do I want you to link those four because if you link the other three toil avantel and desil with elville elville is real easy to remember that eleville elevates eleville elevates well what&amp;#39;s it elevate your mood so if you know eleville elevates your mood and you link toil avenil and desel with elville then you&amp;#39;ll know toil avantel and desil are also mood elevators you see why I want you to link them so that you know what they do and tophill is a very famous one that they love to test what reason I don&amp;#39;t know it&amp;#39;s been decades since I&amp;#39;ve given to now okay um fact I don&amp;#39;t even know why they still test these drugs they&amp;#39;re not given that much okay what are the side effects well Lille starts with the letter e so this group side effects use the alphabet but it only goes through the letter e a for anti energic primarily dry mouth B for blurred vision C for constipation D for drowsiness and E is Euphoria e p o r i a which means happy joy joy you know way too happy have you ever met anybody that&amp;#39;s so happy it irritates you that&amp;#39;s what this is what do you notice about that list it&amp;#39;s very similar to the major tranquilizers but you don&amp;#39;t have that extra parameter the photosensitivity of the a granular cytosis but the big thing they&amp;#39;ll ask about these anti-depressants is you must take them for about 2 to 4 weeks before you get beneficial effects you take them for 2 to four weeks so do they work right away no so what&amp;#39;s the patient going to say typically after one week of anti-depressant therapy what will they say it&amp;#39;s not working and you need to teach them it&amp;#39;s going to take a little while letter C the benzo diazines the benzos real famous everybody should know about the benzos the benzo diazines these are anti-anxiety meds they are considered to be minor tranquilizers as a opposed to what the Zen which were the majors the zeps are the miners number two they always have z p in the name Zep always so how do you tell a phenazine and zenine how do you tell a benzodiazapine z but both tranquilizers majors and minors the identifying syllable starts with what letter Z zeps and Zen are tranquilizers now the way I I remember that is in cartoons when somebody is tranquilized meaning they go to sleep what do they write on the page z z bunch of Z&amp;#39;s right so if you want to put somebody to sleep give them Z&amp;#39;s use the Z&amp;#39;s what Z&amp;#39;s the zeps and the Zen Z for the zany those are the what the majors and zeps are the minors uh the way I used to remember that when we were in school doesn&amp;#39;t work as well for you guys cuz you&amp;#39;re younger well back when I was in school uh the greatest rock band of all time was Led Zeppelin anybody ever hear lead zeppa who&amp;#39;s never heard of lead zeppa oh wow I&amp;#39;m still impressed you still have heard of it wow they must be in their wheelchairs still making music um it rock bands all those oh okay you mean that the game the game is bringing it all back okay yeah well I just remember Zeppelin we Zeppelin starts with what three Zep doesn&amp;#39;t it Zep Zeppelin and we used to say what do you find at a Zeppelin concert a bunch of miners on tranquilizers so that linked what zap with minor tranquilizer so that we kind of remembered that okay um the Prototype is Valium diazapam lorazapam flu asaam chlorop Pam chloroxide they always have z in them indications they are are more than just minor tranquilizers these drugs are more than that yes that&amp;#39;s their major use but letter A they can also be used as a preout to induce anesthesia letter B they can be used as a muscle relaxing letter C they&amp;#39;re good for alcohol withdrawal D they&amp;#39;re good for seizures and E they help people when they&amp;#39;re fighting the ventilator they help them relax and calm down okay number five yes do they put the generic the brand name on um on boards they&amp;#39;re going more and more for the generic used to be that they always put both about two years ago they started flooding the exam with experimental questions where they only gave generic name for drug cuz they were trying to find out which drugs is it reasonable to expect new graduates to know by just the generic and which ones would it be totally unfair to ask them by just the generic that happened a year and a half to two years ago it&amp;#39;ll be two years this June so usually questions stay in the experimental phase for about 2 years maybe less so pretty soon all of those are going to start counting okay up until now I would have said no they don&amp;#39;t count they&amp;#39;re still in the experimental phase but it&amp;#39;s been long enough that they&amp;#39;ve been doing that that yes there probably will be questions on your board where you are given a drug just by its generic name and you have to know what it is that&amp;#39;s why I&amp;#39;m trying to do phenazines benzo asip Calum Channel BL you know I mean deines SS you know those kinds of things so that you learn the generic names the M rather than the actual trade now don&amp;#39;t panic because if the only questions that that have generic name only the only questions that have made it into the the test pool are ones that are reasonable to expect a new graduate to know so it&amp;#39;s not going to be one that you probably wouldn&amp;#39;t know it&amp;#39;s probably going to be one you would know anyhow like aamit okay or Warfarin or madine or aceta salicilic acid or you know those are you should have known what all those were what was Warfarin cumin what&amp;#39;s uh acetamin what&amp;#39;s aetos salicylic acid what is madine Deon so those are things that you need those ones would be like there they probably won&amp;#39;t say something like uh I doubt that they would say pantozol they&amp;#39;ll probably say protonics or protonics pantozol you see what I&amp;#39;m saying so yes there&amp;#39;s a big Trend to make it generic only and I don&amp;#39;t like that I think that&amp;#39;s stupid I don&amp;#39;t understand the point of it you know uh cuz you always look a drug up so I don&amp;#39;t understand why that&amp;#39;s you know what&amp;#39;s unsafe for nursing practice is not looking up a drug not having the PDR memorized you see so I don&amp;#39;t know I don&amp;#39;t know where they&amp;#39;re headed with it but I&amp;#39;d like you to really from now on if you work learn your generic names learn your generic names call them by their generic names until you take your boards then you can call it whatever you want yes oh I thought just praising the Lord I didn&amp;#39;t know if that was it okay um number five they work quickly but you must must not take them for more than 2 to 4 weeks how many of you know people that have been on value for years that&amp;#39;s not what the FDA ever approved so what&amp;#39;s the relationship think about this what&amp;#39;s the relationship between an anti-depressant and a minor tranquilizer you take weeks right so one takes how long to work two to four weeks and that one you can be on for how long rest of your life however the other one works right away but you can&amp;#39;t be on it for longer than 2 to four weeks so if somebody comes in anxiously depressed they&amp;#39;ll throw them on both an anti-depressant and a minor tranquilizer at the same time on admission why what&amp;#39;s going to make them feel better right now the minor tranquilizer but somewhere in the next two to four weeks what&amp;#39;s going to kick in they&amp;#39;re anti-depressant and then you pull them off the minor tranquilizer and they go home on the anti-depressant so stay on your tranquilizer until your anti-depressant kicks in uh another analogy can I Pi another analogy for you heprin is tumin as a tranquilizer is for an anti-depressant heprin is to cumin as a tranquilizer is to an antidepressive did you get the analogy Hein Works how fast right away but you can&amp;#39;t be on it for very long cumin takes longer to work but you could be on it for the rest of your life and you&amp;#39;re only on your heer until your cumin in kicks in well that&amp;#39;s the same relationship between a tranquilizer and an anti-depressant okay Turn the Page let&amp;#39;s talk about the side effects AB B C D do I have to repeat them or can you write them down anti drve mou and gation and FL fish ABCD and the number one nursing diagnosis is because it&amp;#39;s a tranquilizer safety injury are you seeing anything different from the major versus the minor just a few side [Applause] effects okay which brings up the monine oxidase Inhibitors the MAO inhibitors these are anti-depressants I don&amp;#39;t understand why they&amp;#39;re still being tested on boards it has been 17 years since I gave one of these and it&amp;#39;s not cuz I didn&amp;#39;t work site cuz I did and I held I taught site clinical too so I mean so I don&amp;#39;t know why they give them now they still give them in in Veterans Administration hospitals you&amp;#39;ll see the most likely place you&amp;#39;ll see an MAO inhibitor given is a Veterans Administration Hospital why and they&amp;#39;re dirt cheap dirt cheap compared to the other anti-depressants you can buy a month&amp;#39;s worth of Meo inhibitor for the price of three days of Prozac you know they&amp;#39;re pennies they cost pennies per pill now number two tells you how they work you can just read that yourself it&amp;#39;s not a big issue but the drug names you need to spot an MAO inhibitor when you see it now you&amp;#39;re going to spot it from the beginning of the name not the end of the name the beginnings of the names all rhyme they are Mar Nar and par marar par Mar plan Nar Dill parnate you see it there Mar plan naril parnate now the only problem with marar par is that is their trade name not their generic okay but I&amp;#39;ve not I&amp;#39;ve not seen a lot of generic names on these unstandardized tests almost every standardized test I ever see has the mar the Nar and the par there side effects write it down but the number one thing they test is on page 67 patient teaching do you remember these drugs letter A to prevent severe acute some times fatal hyper tensive crisis hypertensive crisis high blood pressure hypertensive crisis the patient must avoid all foods containing tyramine remember this one this is that diet that they&amp;#39;re not allowed to have certain foods I saw this once and I was the one that took the blood pressure in the ER and I got 300 plus over 220 and the only reason why I wrote 300 plus was back in 1978 our manometers only went up to 300 so who knows what it really really was but it was three I wish I had had had a dynamap back then but they weren&amp;#39;t invented yet um see when I went when I was a nurse all we had was metal IV needles we never had the plast the we had metal needles stuck in people for try to get somebody through a shift without a metal needle infiltrating well you care okay um so you have to know what foods have tyramine which foods they&amp;#39;re not allowed to have they test this all the time every time I try to pull this out of my lecture somebody says it was on my test and I okay put it back in okay here are the foods you&amp;#39;re not allowed to have in the fruit and veggie food group generally speaking fruits and veggies do not have tyy so these people can eat all the fruits all the veggies they want till the cows come home it&amp;#39;s no problem just have at it however there are three fruit veggies that they&amp;#39;re not allowed to have and I always say remember the salad bar b a r the salad bar B for bananas a for avocados and R for raisins which actually stands for any dried fruit they&amp;#39;re not allowed to have any dried fruit now be careful cuz on C certain tests including the boards they&amp;#39;re very likely to talk about guacamole which is what avocado see they always do that kind of thing where you almost have to be a cook to know what&amp;#39;s in Foods uh but guacamole now number two grains are fine they can eat cookies pie cakes breads no big deal Meats they&amp;#39;re not allowed to have organ meat so no liver kidney tripe intestine brains heart lung tongue no preserved Meats which means nothing smoked dried cured pickled or anything like that now they&amp;#39;re not allowed to have hot dogs and certain processed lunch meats why what&amp;#39;s on what&amp;#39;s the last thing in the label on a hot dog and other assorted Parts which means heart lung tongue kidneys brains intestines the whole Sho match now I my entire family back one generation is Slovak my grandparents and my dad were not born in America so I&amp;#39;m first generation American but in Slovak we ate Slovak foods and I heart tongue lung soup you know all that fantastic stuff and uh heart and tongue are great fantastic um back in when I was in high school the big rage in the 60s was to steal other kids&amp;#39; lunches and eat them no one would touch my lunch I could leave my lunch out as long as I put mark clck on and nobody would touch that bag CU they never knew what was in it okay Dairy they&amp;#39;re not allowed to eat cheeses except for cottage and mozzarella now there are a few other cheeses they are allowed to have but bards just really wants to know can they eat mozzarella can they eat cottage cheese yeah so those aged cheeses are no good for them and also they&amp;#39;re not allowed to have yogurt this is probably the only diet where yogurt&amp;#39;s bad and then number five uh I know this is not a food group but for some of you it is no alcohol or chocolate Okay um so no alcohol which rules out Elixir tinctures no caffeine which rules Out Chocolate licorice soy sauce all of that that so those are the things they&amp;#39;re not allowed to happen and B teach the patients not to take overthe counter meds when they&amp;#39;re on an MAO inhibitor have you ever read drug labels at a drugstore what are they all say don&amp;#39;t take if you&amp;#39;re on ano inhibit classic okay lithium we talked about it a little bit yesterday didn&amp;#39;t we notice it&amp;#39;s an electrolyte like potassium magnesium calcium isn&amp;#39;t lithium on the Periodic Table of chemistry second row First Column Li I lithium it&amp;#39;s used for treating bipolar disorder because it decreases what what did I say yesterday Mania it does not treat what depression it decreases the Mania you&amp;#39;re going to find out that of all Psych drugs lithium is the most unique because its side effects are not a b c d or any variation thereof the reason is is all other psych drugs all other psych drugs other than lithium are what I called neurotransmitter Messer Withers okay they have their action by what altering neurotransmitters this drug is the only St drug which does not mess with neurot transmitters it stabilizes nerve cell membranes so because it has a unique action it will have a unique set of side effects and its side effects will act more like an electrolyte so it will have the three p&amp;#39;s pein poopin and paresthesia peing poopin and paresthesia why paresthesia why will this drug have paresthesia as a side effect what did I say yesterday about electrolytes the earliest sign of all electrolyte imbalances is numbness and tingling paresthesia so if you give somebody large doses of lithium and make their lithium High first thing is numb and tingling now what do you do if someone on lithium is PE and poopin and paresthetic give the drug hold the drug call the doctor don&amp;#39;t call the doctor which ones give and don&amp;#39;t call you can tell him later on when he comes in however number three toxic effects what do we going to do with these hold and call okay Tremors a metallic taste and severe diarrhea Tremors a metallic taste and severe diarrhea those are the toxic effects now letter A should actually be pulled out to the margin it really doesn&amp;#39;t belong under toxic I I need to switch that number one Intervention when someone is on lithium is increase fluids the number one nursing intervention when someone is on lithium is make sure these people get ample fluids why what are they doing all the time peeing and pooping which makes them lose fluid which makes them high risk for fluid volume deficit dehydration so what are you watching what other blood value are you watching dehydration what other blood value you watching sodium okay number letter B if they are sweating like they&amp;#39;re outside working that they say you got a lithium patient he&amp;#39;s maniy and he&amp;#39;s out re-roofing everybody in the neighborhood&amp;#39;s house you know because they get that way when they get maniy and it&amp;#39;s 90° and they&amp;#39;re sweating like crazy don&amp;#39;t give them free water give them like Gatorade or some electrolyte solution because you you&amp;#39;ll be in real trouble CU you you have to have a normal sodium for lithium to work number four note lithium is closely linked to sodium so when you&amp;#39;re on lithium you must monitor the sodium levels low sodium makes lithium more toxic high sodium will not will will make lithium ineffective so if sodium&amp;#39;s low lithium&amp;#39;s toxic if sodium&amp;#39;s High lithium won&amp;#39;t work so the only way lithium will work is if sodium&amp;#39;s what normal that&amp;#39;s why in addition to monitoring the lithium level you got to monitor the sodium level otherwise you don&amp;#39;t know what you&amp;#39;re doing so watch that sodium level when somebody&amp;#39;s have have his his own lithium they&amp;#39;re called competitive binders have you ever heard of that term okay proac everybody&amp;#39;s favorite drug Prozac is a selective serotonin reuptake inhibitor it is similar to elville the non-selective serotonin reuptake inhibitor so the same set of side effects belong so what are the side effects for Prozac A B C D and Euphoria however number three is more what they&amp;#39;re going to test proac causes insomnia so give it before noon do not give Prozac at bedtime not a good idea number four when changing the dose of proac for an adolescent or young adult watch for increased suicidal risk what age group at L it&amp;#39;s in young adults only now if I were on Prozac and the doctor changed my dose of FR act would you have to watch me for increased suicid liation yes or no no because I&amp;#39;m not an adolescent or a young adult I may look it but I&amp;#39;m not um you think that&amp;#39;s true you need glasses the other thing is what if an adolescent is on proac does that make them increased risk for suicide no it&amp;#39;s only when you you change the dose so you have to have both in order to say there&amp;#39;s increased suicidal risk you have to have recently change the dose and they have to be an adolescent or a young adult if you change my dose it wouldn&amp;#39;t be increased risk and if you kept their dose the same it wouldn&amp;#39;t be a risk it&amp;#39;s only when you change the dose for an adolescent which brings up the last three drugs then we&amp;#39;ll take a break how doll My Favorite Drug I love how doll give me a how doll and a dark gun and I&amp;#39;ll be happy and psych all year long it has a decanate farm form which means what long acting I am that you can zap somebody with it&amp;#39;s basically the same as Thorazine so what are the side effects a b c d e FG this is also called a typical first generation antipsychotic just like the Zen are it&amp;#39;s the old drugs the old antiyoy the big thing they&amp;#39;ll test with Hol is nms and you must know nms do not go to boards not knowing what nms is elderly patients and young white schizophrenics Also may develop nms from an overdose of Hol nms is neuroleptic malignant syndrome it is a potentially fatal hyperpyrexia that word hyperpyrexia means fever with temps of potentially 106 to 108 certainly over 105 but you know I mean it could start at 102 but it&amp;#39;s going to go up way up therefore the dose for elderly patients should be half the adult dose but the big thing they&amp;#39;re going to do how they&amp;#39;ll test this is this nms also has has some Tremors with it and an anxiety and Tremors EPS has anxiety and Tremors with it and you get EPs and nms with the same drugs so bores is going to want to know do you know the difference between EPs and nms EPS is a side effect no big deal nms is a medical emergency huge big deal patient could die so they&amp;#39;re going to want to know do you know the difference between EPs and nms CU one&amp;#39;s a big deal and one is not how do you tell the difference between EPs and nms take a temperature which any LPN and any nurse RN could do without a doctor&amp;#39;s order so there&amp;#39;s no excuse for any nurse missing EPS versus nms so if they tell you that you&amp;#39;ve got a patient on one of these major tranquilizers and he&amp;#39;s having Tremors and anxiety and confusion what would be the first thing you action you would take temperature take their temperature and if it&amp;#39;s 102 1034 what do you do immediately call Squad if you&amp;#39;re in a nursing home or a psych fa if you&amp;#39;re in an Hospital call an emergency response them you know what I mean it&amp;#39;s it&amp;#39;s going to be a bad situation yes so temperature above 102 I would say yeah I even though classically it&amp;#39;s the 106 to 108 range you if it&amp;#39;s over 102 you call that you l in half the time when you call 102 they&amp;#39;re going to be okay so you have to call them even though you know that not everybody with a 102 is going to be actually in mms you can&amp;#39;t it&amp;#39;s so lifethreatening you have to do it that actually happened to us uh La uh last spring when I was a nursing instructor at a certain hospital with some Cedarville students we had a guy that was just oh just I nervous Reon the N patients were saying he&amp;#39;s not himself he&amp;#39;s not himself the nurses were and they were trying to figure out what was wrong what&amp;#39;s wrong what&amp;#39;s wrong and so I told my student I said go measure his temperature you know so the student went meas temperature was 102.8 so we called the doctor came in got everything said and I I&amp;#39;m thinking you know why didn&amp;#39;t these nurses do this but sometimes you forget those basic kinds of things when you&amp;#39;re a nurse you&amp;#39;re thinking about a million things so you do see it and it&amp;#39;s common all right how doll number three there are safety concerns related to the side effects I love how because if somebody comes in the ER and they&amp;#39;re acutely psychotic and they&amp;#39;re tearing the place up and they&amp;#39;re wild and crazy hit them with some how doll and then what we like to do although I never have done this officially although unofficially I&amp;#39;ve done it all the time um it&amp;#39;s fun to take bets on when they&amp;#39;re going to hit the floor 5 minutes 10 minutes 20 minutes because it&amp;#39;s almost it&amp;#39;s almost have you ever seen those uh Wildlife shows where they shoot the rhinoceros in the rear end with a dart gun you know and it runs around and then all of a sudden what&amp;#39;s it do you know like that well that&amp;#39;s what happens to these guys they they run around and all of a sudden they go bam and they hit you know it&amp;#39;s kind of fun to watch no it is I don&amp;#39;t make a good sers cuz I find things way too entertaining um and I&amp;#39;ve got lots of advice and you&amp;#39;re not supposed to give advice or think things are funny sorry they are funny sometimes okay clauser real clauser real claw upine what&amp;#39;s the big danger with this drug name wise name wise look at the name what&amp;#39;s the big danger with the name zap Za a p which if you&amp;#39;re not careful you think says what Zep Z and you&amp;#39;ll miss what this drug is question is there medical emergency with the NS would you like hit with like no just you just stay with your patient there&amp;#39;s not much you can do just make sure the vital signs are stable you&amp;#39;re with them the squad comes and then they&amp;#39;ll manage the medically at the at the hospital many people die because there&amp;#39;s not a whole lot we can do for it you know we just you know it&amp;#39;s not a good thing clauser real Claus aine these are this is the Prototype do you know what I mean by prototype what do I mean by prototype the original first this is the original first second generation atypical anti- psychotic this is the new class for the zany number one it is used to treat severe schizophrenia which the Z it was meant to replace the Zen and hog it was originally de developed to replace the Zen and the hll and it looked real promising at first because it had an advantage number two it had an advantage it does not have the side effects a b c d e or F now it can have slight effects like that but but very very minor compared to the Zen and how patient doesn&amp;#39;t even notice usually so originally we thought this was going to put the Zen and how doll out of business but then after it was on the market for about 6 months we started to see a problem and what was that problem number three no I mean number two the disadvantage it does have the side effect a granulocytosis in fact this drug is horrendous in trashing your bone marrow your white count can fall horribly low and you can get unbelievable infections from being on this drug so they really so they they then tried to they altered the formula came up with different drugs like Geodon Abilify Zyprexa alanine and all of those and those are variations of this clauser and they are some of them are less likely to mess up your white count some are just as bad the thing is is that not everybody gets the low white count when they&amp;#39;re on these drugs so the the upshot is some people can take this drug and some people can&amp;#39;t but the big thing you got to know is with any of your atypical Antico white count is a big deal measuring the white count is a very important nursing monitoring [Music] function the only thing I do want to say is I want to say something about Geodon Geodon has a black box warning which means a fatal drug situation and that is Geodon prolongs the QT interval and can cause sudden Cardiac Arrest godod Dawn prolongs the QT interval and C can cause sudden Cardiac Arrest therefore you shouldn&amp;#39;t really use Geodon with people with heart problems in general your second generation atypicals end in the ending z a p i n e zapen so once again a tranquilizer glass ends in a z so you have your Zen what are your Zen what are your zes typical oldtime anticho what are the zines second generation atypical new anticho and what are the zeps the minor tranquilizers okay so Zen zapen and Zep are all your tranquilizers ones in Old Major new major minor did you got that can you match them minor old major new major Zep zapin and Z okay the last drug zolof they are loving zolof and they will call it caline zolof it&amp;#39;s another SSRI like proac it also causes insomnia but you can give it at bedtime but the big thing they are now testing more and more with caline is the interactions has anyone ever heard of the cytochrome p450 system in the liver what is it responsible for cytochrome p450 system in the liver it&amp;#39;s the major enzyme p pathway by which drugs are broken down and deactivated in the liver you remember how drugs are detoxified deactivated in the liver well the cytochrome p450 enzyme system does that you don&amp;#39;t have to write this down zoff caline is notorious for interfering with that system the cytochrome p450 system so what does it do when you take other drugs increases toxicities because they aren&amp;#39;t broken down so so the reason why boards and other ons are testing caline is because when you&amp;#39;re on caline other drugs don&amp;#39;t get metabolized and you have problems with two high levels of the other drugs so when you add caline to the drug regimen of a patient what do you probably have to do with all the other drugs they&amp;#39;re on lower the dose okay so let&amp;#39;s talk about this number three watch for interaction with St John&amp;#39;s wart this herbal preparation that people people are taking right now if you take St John&amp;#39;s wart and cine together you&amp;#39;re going to get serotonin syndrome which is a potentially life-threatening problem it looks a lot like those Mao guys that eat the tyramine looks a lot like that so what are the symptoms I remember the symptoms from sad head s for sweating a for apprehension D for dizziness and heada a so they sweat they&amp;#39;re apprehensive they&amp;#39;re dizzy and they have a headache now apprehension is often called an impending sense of Doom have you heard of that that&amp;#39;s what we mean by apprehension but the big one is it&amp;#39;s interaction with Warfare and cinin and that is when you&amp;#39;re on caline and cinin you&amp;#39;re going to bleed out you got to reduce that cumin so watch for increased bleeding when they&amp;#39;re on cumin and ceraline watch for increased bleeding because the cumin is going to go toxic all right take a break come back at 5 after we&amp;#39;re getting [Music] there [Music] [Music] I before [Music] lunch I&amp;#39;ve been trying page 41 the mother of all lectures maternal newborn overview oh by the way uh try to come back after lunch because after lunch we I actually do the most important review in the whole lecture in the whole review is this afternoon so don&amp;#39;t you know what I mean it really I mean it&amp;#39;s critical that you be there for that okay maternal newborn overview pregnancy uh you must be able to calculate a due date if you can&amp;#39;t calculate a due date you&amp;#39;re in trouble because everybody else knows how to do it so here&amp;#39;s how you do it take the first day of the last menstrual period the first day of the last menstrual period add 7 Days subtract 3 months now you can do it another way but that&amp;#39;s if you don&amp;#39;t have a way that&amp;#39;s a good way so I&amp;#39;m going to give you a date and I want you to figure the due date and then talk to your buddy her last menstrual period was June 10 through June 15 her last menstrual period was June 10 through June 15 I want you to figure R do day and then see what your buddy said June 10 for June okay what do you say March 17 exactly because you got to start with June 10 because that&amp;#39;s the first day of the last semester period add seven that&amp;#39;s 17 subtract 3 from 6 is three that&amp;#39;s March all right so that&amp;#39;s how you do that letter B the weight gain you need to know how much weight a woman should or should not have gained do not worry about multiples don&amp;#39;t worry about women that are underweight or overweight to begin with they don&amp;#39;t go there they&amp;#39;re just talking about an average typical pregnancy which no one has but the book describes okay the total weight gain for pregnancy is PL 28 lb plus or minus 3 28 lb plus or minus 3 that&amp;#39;s the total weight game and here again we&amp;#39;re not talking about multiples and we&amp;#39;re not talking about women who are under or overweight to begin with number two in the first trimester she gains one pound each month one pound each month how long is the first trimester three months so she gains a total of 3 pounds in the whole first trimester so there&amp;#39;s not much weight gain in the first trimester so if they give you a woman who&amp;#39;s had fairly significant weight gain in the first trimester that&amp;#39;s bad because you really should not be gaining much weight in the first trimester maybe 3 lb in the second and third trimester she&amp;#39;s gaining much faster she&amp;#39;s gaining one pound per week so how do you calculate because here&amp;#39;s what you have to be able to do on your licensing exam if they give you a woman in a particular week of gestation you have to be able to predict what her weight gain should be for example what if they ask you this question a woman&amp;#39;s in her 28th week she has gained 22 lbs what is your impression and then a says she&amp;#39;s just fine B says she&amp;#39;s underweight C says she&amp;#39;s overweight and D says well she could be either way so do an assessment she gained 22 she&amp;#39;s at 28 weeks how many of you know the answer know it how many don&amp;#39;t know the answer how many aren&amp;#39;t sure how many aren&amp;#39;t voting okay the answer is I&amp;#39;m going to show you an easy way to get that answer easy easy way here&amp;#39;s how you do it how do you calculate a woman&amp;#39;s eye ideal weight gain do you see the chart there we&amp;#39;re going to fill in the chart at week 12 that&amp;#39;s the end of the first trimester how many pounds should she have gained three so put three at 13 weeks she gained another week so she gained another pound for a total of four total of four to that point 14 another week another pound for a total of five 15 another week another pound for a total of six 16 another week another pound for a total of 7 17 another week another pound for a total of eight 18 another week another pound for a total of 9 19 another week another pound for a total of 10 20 another week another pound for a total of 11 do you notice how every time she gains a week she gains a pound now what is the constant mathematical relationship between the top row the weeks and the bottom row the weight gain a difference of nine a difference of nine take every top number and subtract nine from it what do you get the bottom number 12 - 9 is 3 13 - 9 is 4 14 - 9 is 5 14 - 15 - 5 is 6 16 - 5 is 7 17 - 5 is 8 18 - 5 9 I&amp;#39;m saying five you know what I mean so if you want to know the ideal weight gain for a pregnant woman what do you do take the weak adj just and subtract n and that&amp;#39;s what she should have gained plus or minus a couple pounds so let&amp;#39;s go back to our example what week did I say the woman was that in the example 28 weeks I said she gained how many pounds 22 22 okay well what should she have gained 28 - 9 28 - 9 is 19B she gained three more than she was supposed to that is in the area of something could be wrong let&amp;#39;s assess if she&amp;#39;s within a pound or two she&amp;#39;s okay if she&amp;#39;s 3 lb off you need to assess her if she&amp;#39;s 4 lb off there&amp;#39;s trouble so if a woman is in her 31st week and she&amp;#39;s gained 15 lbs 31st week 15b what answer will you pick well 31 - 9 is you don&amp;#39;t have your calculators do you 22 she was supposed to have gained 22 the question said she gained 15 what do you think we better get we better what was what&amp;#39;s that called a biophysical profile on the baby because the baby may have died last month do you see what I&amp;#39;m saying and we don&amp;#39;t know so that&amp;#39;s bad so can you predict the ideal weight gain for every week of gestation sure just subtract nine from it which is a good OB number to begin with isn&amp;#39;t it so ideal weight gain equals week minus 9 that&amp;#39;s your formula letter C let&amp;#39;s talk about the fundus fundle height what&amp;#39;s the fundus not a river in India what is it the fundus is what upper part of the uterus it&amp;#39;s the top part of the uterus well it&amp;#39;s not palpable until week 12 so can you palpate the fundus anytime during the first trimester no so if they give you a woman for a first trimester checkup and they say you can&amp;#39;t palpate or fund this should you panic no you&amp;#39;re not supposed to feel abundance what if she&amp;#39;s gained 10 pound in the first trimester and that fundus is way up here what do you think she&amp;#39;s either not first trimester or she&amp;#39;s got that high that tiap form mole that Moler pregnancy that cancer thing that&amp;#39;s bad okay that&amp;#39;s in the Blue Book all right uh second and third trimesters they want to know when&amp;#39;s it at the belly button when is the fundus at the umbel liest the belly button and that is 20 to 22 weeks of gestation 20 to 22 weeks of gestation now why in the world would they want to know if you know those two things what two things well the fact that when do you palpate the fundus at the end of the first trimester when is it at the belly button about 22 weeks why is that important for a nurse to know think about those 12 weeks and 22 weeks what what&amp;#39;s what are those weeks close because you&amp;#39;re dealing with what idea date of viability which is 22 to 24 weeks which is in the second end of the second trimester so isn&amp;#39;t 12 at the end of the first trimester and isn&amp;#39;t 24 the end of the second so can you use fundle height to determine in what trimester a woman is in yes that&amp;#39;s why they want to know it because if some woman comes in in an auto accident or an accident of some situation she&amp;#39;s brought into the ER she could not tell you what trimester she is in CU either she&amp;#39;s had no prenatal care she didn&amp;#39;t know she was pregnant or she&amp;#39;s unconscious and able to tell you she&amp;#39;s pregnant you have no history she&amp;#39;s positively pregnant you need to know what trimester she&amp;#39;s in to know what that going on with that baby right well how can you real quickly put her in the correct trimester palpate her fundus because if she&amp;#39;s pregnant and you cannot feel the fundus at all what trimester is she in and who&amp;#39;s the priority the baby or her her if you can palpate the fundus but it&amp;#39;s at or below the belly button you know she&amp;#39;s in the what second and who&amp;#39;s the priority her or the baby her but if that fundus is above the umble like cuz she know she&amp;#39;s in the third who&amp;#39;s the priority the baby or the mom the baby are you seeing how they&amp;#39;ll work that and who will get the attention and what they&amp;#39;ll decide so those are gross estimations of gational age okay signs of pregnancy there are do you remember learning probable presumptive and positive signs of pregnancy how many remember those three categories good news there aren&amp;#39;t three categories onard boards there&amp;#39;s only two positive and everything else so they lump the probables and presumptives together you are not going to be asked to tell the difference between a probable and a presumptive you will be asked to tell the difference between a positive and one of the other two so you&amp;#39;ve got to know your four positive signs they are fetal Skeleton on x-ray if you X-ray the abdomen and there&amp;#39;s a skeleton there you&amp;#39;re pregnant you can protest all you want but you&amp;#39;re pregnant number two a fetal SK a fetal presence on ultrasound if they do an ultrasound and there&amp;#39;s a baby there you&amp;#39;re pregnant see osculation of a fetal heart rate osculation of a fetal heart if they put a Doppler down there and there&amp;#39;s a rate of 140 it&amp;#39;s a baby your bladder doesn&amp;#39;t have its own pacemaker you got a baby down there now when does that occur somewhere between 8 and 12 weeks you can hear it somewhere between 8 and 12 now it starts beating at 5: but you can&amp;#39;t hear it until 8 which brings up a really important point about OB questions most OB most OB information because it&amp;#39;s OB has a range where it occurs because every woman is different right and they give you a range for everything there&amp;#39;s a range for quickening there&amp;#39;s a range for lightning there&amp;#39;s a range for viability there&amp;#39;s a range for fetal heart there&amp;#39;s a range for fundle Heights you know there&amp;#39;s always a range for everything because of that be real careful in OB questions this is critically important to remember really carefully read your OB questions because there could be three different questions for every fact in OB the first question would be when would you first got that when would you first that&amp;#39;s one form of the question the second question would be when would you most likely and the third question would be when should you buy when would you first when is it most likely and when should you buy those are three totally different questions for the same fact in other words when would you first osculate a fetal heart the answer is 8 weeks when would you most likely osculate a fetal heart 10 weeks when should you osculate a fetal heart by 12 weeks do you see that so whenever they say first first pick the earliest part of the range when they say most likely pick the midpoint of the range and when they say should buy pick the end of the range and a lot of times you&amp;#39;re missing OB questions not because you don&amp;#39;t know the correct range but you&amp;#39;re not paying attention to which one of those they want so when is quickening when the baby kicks remember quick Kick quickening Kicking when does it happen 16 to 20 so when would you first feel quickening 16 when would it be most likely 18 when should you buy when do you see the difference three totally different questions for every single fact if you don&amp;#39;t know that you&amp;#39;re going to miss questions thinking you even though you know the information okay letter D the fourth positive sign of pregnancy is when The Examiner palpates fetal movement or outline so what does not count as a positive sign when Mom does it&amp;#39;s when the examiner does okay let&amp;#39;s turn the page and talk about the other signs the maybe signs we lump the probables and presumptives together and we call them Mayes letter A all urine and blood tests all urine and blood pregnancy tests are Mayes they are not positive signs of pregnancy I&amp;#39;m going to make a statement you don&amp;#39;t have to write it down but this is the reason why everybody gets confused about this here&amp;#39;s the true statement a positive pregnancy test is not a positive sign of pregnancy that&amp;#39;s true and that&amp;#39;s why everybody gets confused about positive signs of pregnancy because they think a positive pregnancy test is a positive sign no it is not it&amp;#39;s only probable or presumptive so a positive pregnancy test is not a positive sign of pregnancy everybody know that why not because it only means you have the hormones that go with pregnancy and many many times you may have the hormone increases that go with pregnancy but you don&amp;#39;t have a fetus and so a lot of positive pregnancy tests are false positives but when you hear a heartbeat down there there&amp;#39;s no false positives on that one okay it&amp;#39;s a good question I could phrase it the other way in what relation to what you asked is positive signs of pregnancies have no false positives are things that never have a false positive okay let&amp;#39;s talk about some other probable presumptive signs have you heard of Chadwick&amp;#39;s Goodell&amp;#39;s and hegar&amp;#39;s signs hopefully you&amp;#39;ve heard of this two things you need to know in what order do they occur it&amp;#39;s easy they occur in alphabetical order so who comes first Chadwick followed by Goodell followed by hear see boards is more interested in if you know the order than if you know the exact weeks why weeks vary from woman to woman but the order never varies so BS is going to test what does not vary because it just is statistically more valid to test that or reliable I should say well what is Chadwick&amp;#39;s sign Chadwick&amp;#39;s sign is a cervical color change to cyanosis a cervical color change to cyanosis what do you notice about all those words they start with the letter c and what does Chadwicks begin with C so Chadwick is everything that starts with c a cervical color change to cyanosis it turns blue and if the cervix is doing it the vagina is too okay Goodell&amp;#39;s sign is cervical softening and hears is uterine softening doesn&amp;#39;t that order make sense what would happen first the service would turn blue then the cervix would soften then that softness would move up into the uterus so it kind of makes sense the order does okay let&amp;#39;s talk about some patient teaching in pregnancy you need to teach the woman the pattern of office visits you good prenatal care is a major factor in reducing infant mortality so you need need to know how to teach a woman how often she should come in for good prenatal care so you teach her to come in once a month until week 28 so through the whole first trimester and the whole second trimester and even into the third trimester she&amp;#39;s coming in once a month then at week 28 she should come in once every two weeks until week 36 then she should come in every week until delivery or week 42 what happens at week 42 you scheduled her for another office visit C-section or an induction so let me ask you this if a woman comes in for her 12th week checkup 12th week checkup when does she come in next month 16 if she comes in for 16 when she come in 20 if she comes in at 20 when she come in 24 if she comes in at 24 she comes at back at 28 at 28 she comes back at 30 at 30 she comes back at 32 34 36 30 7 38 39 40 41 42 take the baby so that&amp;#39;s basically the way it goes all right another thing you have to teach her is that her hemoglobin will fall and that&amp;#39;s normal we don&amp;#39;t worry about low hemoglobins with with pregnant women until it gets really low the normal female hemoglobin level is 12 to 16 in the first trimester it can fall to 11 and be perfectly normal 11 is not low tolerable 11 is normal for a first trimester pregnant woman it&amp;#39;s not low but tolerable it&amp;#39;s actually normal it&amp;#39;s not low it&amp;#39;s normal in the second trimester it can drop to 10.5 and be normal not low but normal in the third trimester it can drop all the way to 10 and be normal so what would you call a 10.1 hemoglobin in a woman&amp;#39;s 37th week acceptably low or normal normal so acceptably low might be as low as nine you see so I guess my point is this tolerate lower hemoglobins in pregnant women the further along they are than you would with other non- pregant people what was the number for the first trim 11 it can fall to 11 and be normal which brings up the discomforts of pregnancy that you need to teach her how do you treat morning sickness what trimester problem is it first and what do you treat it with crack dry Dr carbohydrates y dry carbohydrate for breakfast yes or no no it&amp;#39;s dry carbohydrates before you get out of bed cuz once you&amp;#39;re out of bed it&amp;#39;s too late number two how do you deal with urinary incontinence this is a first and third trimester problem why do they not have a problem with urinary incontinence in the second trimester why do you not get urinary incontinence in the second trimester abdominal because the baby is in an abdominal pregnancy it&amp;#39;s up high off the bladder but in the first it&amp;#39;s right down on the bladder and the third it&amp;#39;s right down on the bladder again how do you treat it void every two hours a pregnant woman should void at least every 2 hours all the way from the day she gets gets pregnant until 6 weeks after delivery every day all through Labor delivery postpartum pregnancy void at least every 2 hours number three difficulty breathing this is a second and third trimester problem and you teach them tripod position can anybody explain to me what tripod position is feet flat arms on the table arms on the table leaning forward so that&amp;#39;s tripod or you can even put your arms on your your hands on your knees leaning forward it&amp;#39;s what you see COPD clients doing okay how to back pain people with pregnancy get back pain it&amp;#39;s usually second and third trimester it just keeps getting worse and worse and worse how do you treat it pelvic tilt exercises pelvic tilt exercises so what that means is tilt that the woman should tilt the pelvis forward you don&amp;#39;t want them going like that because that hurts so you&amp;#39;re going to see women do this that&amp;#39;s what they do you know they put this and they tilt that pelvis that&amp;#39;s classic pelvic tilt another way to do it is have them put their foot on a stool and that tilts the pelvis first boards usually says this one okay that&amp;#39;s pregnancy you say that&amp;#39;s all well there&amp;#39;s some in the blue book but pregnancy is a great place to use your common sense because pregnancy is not a disease it&amp;#39;s a healthy State and so do using good health patterns and ideas so when you get a pregnancy question you don&amp;#39;t know the answer to what should you say dehydration well what would be good for anybody what would be a really good healthy response here for anyone pick it and you will be surprised at how well you do okay let&amp;#39;s get this baby out of here now okay let&amp;#39;s go into labor and birth now letter A what is the truest most valid sign that a woman is in labor how do you know a woman&amp;#39;s in L what&amp;#39;s the most valid sign she&amp;#39;s in L what&amp;#39;s that bloody show not bloody show not water breaking because you can have both those and never be in labor okay but the woman doesn&amp;#39;t call you and say I&amp;#39;m dilating and I&amp;#39;m facing so what will they call what will they report they call that the onset of regular Progressive contractions the onset of regular Progressive contractions that&amp;#39;s the most valid sign that women is in lab is it isn&amp;#39;t it possible to have your membranes rupture and 2 days later you still don&amp;#39;t aren&amp;#39;t in labor and they have to C-section you so that&amp;#39;s not a good indicator but it does it&amp;#39;s associated with it but it&amp;#39;s not the best okay terms here again you have to know a vocabulary you can&amp;#39;t you have to know what the words mean in OB or you can&amp;#39;t answer the questions so I just want be sure you guys know these words dilation is the opening of the cervix the opening of it and it goes from 0 to 10 cm so what is what a cervix that is zero is described as what closed closed a cervix that is 10 is described as fully dilated or because open&amp;#39;s not the best fully dilated is the best um in America in the United States do we use uh uh centimeters or inches generally speaking in our lives we talk about inches we don&amp;#39;t use centimeters most Americans don&amp;#39;t know what a centimeter is they know what an inch is but they don&amp;#39;t know what a centimeter is then why do we use 10 cm and 0 cm in OB why don&amp;#39;t we use inches cuz most of our obstetric history comes from England and we use very much an English system but I also think in America just think about marketing and and I mean 10 cm is 4 in I don&amp;#39;t know how many women would sign up where they have to push a baby out of 4-in hole do you get what I&amp;#39;m saying so 10 cm sounds a lot more what generous doesn&amp;#39;t it oh you&amp;#39;re 10 cm oh I can do this so I know that&amp;#39;s interesting okay easement effacement is thinning thinning t h i n n i n g thinning of the cervix it gets thinner and it goes from thick to 100% so a cervix that is not effaced is described as what thi a cervix that is completely effaced is called 100% so how does a woman begin labor thick thick and zero or thick and closed or thick and zero cenm how does she end labor fully dilated and fully effaced which what numbers 10 and 100% okay all right um station station is the relationship between the spine oh I me the fetal pres I&amp;#39;m sorry sorry I was getting in lie station is the relationship of the fetal presenting part to Mom&amp;#39;s isal spines and you must know the isal spines this word is very important to know in OB isal the isial spines are the smallest diameter through which the baby has to fit to be born vaginally it&amp;#39;s the tight squeeze so to speak it&amp;#39;s the narrowest part of the pelvis and if the baby can&amp;#39;t fit through there it cannot be born vaginally if it can fit through there it can be bor born vaginally station will tell you that now negative stations negative stations means that the head the presenting part is above this tight squeeze positive numbers means the baby&amp;#39;s presenting part is below has already made it through the tight squeeze so if a kid stays at1 -2 1 -21 -21 -2 for 17 hours after they&amp;#39;re fully d ated in a face what do you know head&amp;#39;s too big C-section that lady but what if a kid stays at plus 4+ 3+ 4 + 3+ 4+ 3 + 4 + 3 for 17 hours what&amp;#39;s that tell you can the baby be born vaginally yes CU it&amp;#39;s already made it through it needs a vacuum extractor you know it needs an extra little maybe in the photomy or just a forceps so how many of you have a hard time remembering positive numbers and negative numbers which one&amp;#39;s High which one&amp;#39;s low nobody does okay I used to screw that up all the time so I guess you don&amp;#39;t okay I had a way to remember it but since you don&amp;#39;t have that problem we&amp;#39;ll go on um engagement is station zero so what&amp;#39;s that mean if it&amp;#39;s station zero what&amp;#39;s that mean equal to the presenting part is where at the isal spots station zero yes will you give me your clue in case I get down I always remember that positive numbers are positive news negative numbers are negative news now what do I mean by that well if you go into a woman&amp;#39;s room and she says what station am I at and I tell her a negative number like1 -6 that&amp;#39;s negative news to her which means where&amp;#39;s the baby way up and it&amp;#39;s not coming down but if I walk into a woman&amp;#39;s room and she says what station am I at and I give her a positive number like positive 4 positive two what kind of news is that positive news good news what&amp;#39;s good news to woman in labor baby&amp;#39;s coming out it won&amp;#39;t be long now so negative numbers are negative news to a woman positive numbers are positive news negative negative positive positive that&amp;#39;s the way I remember it otherwise I always got screwed up lie lie is the relationship between the spine of the mother and the spine of the baby in other words between the spine of the mom and the spine of the baby if Mom&amp;#39;s spine is like this and baby&amp;#39;s spine is like that that&amp;#39;s good that&amp;#39;s called a vertical lie that&amp;#39;s compatible with a vaginal birth uncomplicated another lie is if Mom&amp;#39;s spine is like this and the baby spine is perpendicular that is bad that is called a transverse lie and you see how I use the perpendicular is the T and that is also trouble it&amp;#39;s bad so whenever they give you these questions about lie they&amp;#39;ll tell you they will tell you where mom&amp;#39;s spine is in relationship to babies all righty if they tell you that Mom&amp;#39;s spine and baby spine are parallel touchdown we got a baby score good baby&amp;#39;s coming out if they tell you the mom&amp;#39;s spine is this way and the baby spine is that way make that and what that make a letter what which means it&amp;#39;s trouble and transverse so you got a baby or you got trouble presentation presentation is the part of the baby that enters the birth canal first this is where you get all those wonderful little alphabet soups r o a l o a r o p l o p r m p RS a RSP punt all of that you do not need to know all of that let me just show you a little pull how many of you know all of that how many of you don&amp;#39;t know that my point is is pro okay how many know that before you give digitalis you take an apical heart rate how many know that how many do not know that what do you need to know the presentations or the ditch because everybody else knows the Dig you better know it nobody else knows this other stuff so why would you spend two weeks memorizing it you&amp;#39;re going to forget it anyhow right if they want to ask a hard OB question they pull this out what&amp;#39;s the damage to you to miss a to missing a hard question there is none there is no danger to you in missing a hard question where&amp;#39;s the danger to you missing and easy question everybody&amp;#39;s going to get hard questions everybody will you can miss every single one of those and still pass with flying colors you cannot miss the easy ones so the goal is not to memorize or know everything the goal is to know what everybody else knows so that your knowledge doesn&amp;#39;t look any different than everybody else&amp;#39;s do you understand what I&amp;#39;m saying it&amp;#39;s sort of like a National Geographic special boards is and you&amp;#39;re all a pack of zebras who gets picked off by the lion the one that&amp;#39;s what lagging by itself all staying with the herd is good so in nursing stay with the herd okay so hopefully now the most common presentation is Roa or Loa right oxop put anterior left oxop put anterior okay now so if they ever give you a question where they say you palpate a bulge here and an irregular there and a lump here and a round there and and then they say what presentation is it hey I&amp;#39;m pi Roa or Loa cuz I&amp;#39;ve got much better chances picking those two than anything else and you&amp;#39;ll probably be right so that&amp;#39;s just a good guess Roa Loa and I&amp;#39;d pick R before L four stages of labor and delivery there are four stages of labor and delivery and you must know them stage one is labor all of Labor is stage one and labor has three phases do you remember that there are four stages that are big and then three stages three phases that are small in the first stage so the first the phases are latent active and transition and those phases are all in the first stage which is called Labor question um yeah um going back about you know easy questions why do they if we get a bunch of hard questions that&amp;#39;s good CU we&amp;#39;re above that yeah if you get a whole bunch of hard questions you have passed because you can only you can only get to the hard questions by having mastered the easy ones and the only way you can fail is to for some reason mess up easy ones whether due to your anxiety uh just not understanding what they were asking or not having certain basic knowledge that you should have or not knowing how to answer certain kinds of questions but I I was sitting at a a table uh in um Cleveland at a National Conference of the national councils of State Boards of Nursing that write the test and there were eight of us at the table and an went was sitting right there two people away from me and an went is the president of the National Council of State Boards of Nursing she&amp;#39;s the top enlex WR kind of person in the nation and I was asking we were asking her questions and one question I asked her I said an people are always asking me what do what do they need to do to pass in a nutshell what do they need to pass and she looked at me she says I&amp;#39;ll answer that in one question one one short answer she said they have to get to the hard questions so if you want to pass you have to what get to the hard questions where you&amp;#39;re going to miss a whole lot but you&amp;#39;ve got to get to the hard questions because if you never get to the hard questions you will never pass you see what I&amp;#39;m saying because you&amp;#39;re always bouncing around down on the easy ones and I didn&amp;#39;t think that was that helpful but at least it under it tells me that that is a very because it came from the source Authority on that so she she says you got to get to those hard questions so the the upshot of that is don&amp;#39;t panic when they&amp;#39;re asking you about stuff you don&amp;#39;t think anyone&amp;#39;s ever heard of because you&amp;#39;re probably getting hard stuff and that&amp;#39;s okay it&amp;#39;s okay to get hard stuff you want to get hard stuff all right um stage number two oh by the way what are the three phases l l active transition in that order what&amp;#39;s the first phase Leon what are the first three letters of the first phase l l a t what are those the initials of the phases in order L for latent a for active t for transition so the first phase the first three letters of the first phase tell you the order of the phases stage two is called delivery of the baby stage three is delivery of the placenta and stage four is recovery stage one is what labor stage two is delivery of baby stage three is delivery of placenta and Recovery is the fourth stage now I would ask you how long does recovery last does anybody know just two hours it lasts for Just 2 hours so let me ask you this what is the purpose of uterine and this is what hessie loves to ask what&amp;#39;s the purpose of uterine contractions in the first stage in the first stage what&amp;#39;s the purpose of uterine contractions no no no that&amp;#39;s stage two dilate and a face the cervix what is the purpose of uterine contractions in the second stage push the baby out what&amp;#39;s the purpose of uterine contractions in the third stage push the placenta out what is the purpose of uterine contractions in the fourth stage cont stop bleeding yeah to contract the uterus to stop bleeding so can anybody tell me when postpartum technically begins when does postpartum technically begin and and give me some more data on that 2 hours after 2 hours after hours after recovery not after recovery 2 hours after delivery of the placenta there you go so 2 hours after that placenta comes out they&amp;#39;re in recovery and then when that ends they are now in postpartum postpartum does not begin when the baby comes out does everybody see that okay so do you see where people get messed up they get messed up between second phase and second stage cuz if I ask you what is the number one priority in the second phase of Labor number one priority in the second phase of Labor what would it be pay management right but if they change the word phase to stage and they said what&amp;#39;s the number one priority in the second stage now what&amp;#39;s the number one prior in the second stage clearing the baby&amp;#39;s Airway you see what I&amp;#39;m saying so you have to be careful if you know what would be a extremely important nursing action to undertake in the third phase what does what do nurses do what what kind of actions are nurses engaging in in the third phase we&amp;#39;re checking dilation we&amp;#39;re helping her with pain we&amp;#39;re helping her with breathing cuz she&amp;#39;s in the last intense part of Labor to dilate right but if I said what&amp;#39;s a m major nursing action for the third stage what would you say yeah watching for blood loss what&amp;#39;s the third stage okay so what do you do with that yeah make sure it&amp;#39;s all there there make sure there&amp;#39;s three vessels in the cord but you would never do that in the third phase cuz you don&amp;#39;t do you say so you understand how if you&amp;#39;re over paying attention to whether they&amp;#39;re talking about stages or phases you&amp;#39;re going to get messed up can you do that please keep phases separate from stages because you have a first phase and a first stage you have a second phase and a second stage and you have a third phase and a third stage but you only have a fourth stage all right now let&amp;#39;s go through those and we&amp;#39;ll go to lunch here in a little bit let&amp;#39;s try to do the next two pages and then we&amp;#39;ll be done but maybe we won&amp;#39;t the rest of this moves fairly quickly because there&amp;#39;s really not a whole lot I mean just a lot of fill in D says the first stage of Labor and Delivery what&amp;#39;s it all about the first stage what&amp;#39;s it called Labor so what you see here is what we call the labor chart bad news you have to know it all you have to know the whole labor Chart good news though I&amp;#39;ll show you a way to remember it that&amp;#39;s really easy so you don&amp;#39;t have to memorize it all so let&amp;#39;s talk about this labor chart how many phases do you see in the labor chart three CU how many phases are there to labor three and there&amp;#39;s latent active and transition let&amp;#39;s talk about latent in the latent phase you dial from 0 to 4 cm your contractions are every excuse me 3 to five I mean sorry 5 to 30 minutes apart that&amp;#39;s the First Column we&amp;#39;re going down the First Column so the contraction frequency is 5 to 30 minutes apart the contraction duration meaning how long they last is 15 to 30 seconds and the intensity of the contractions is described as mild now that&amp;#39;s our word not hers now let&amp;#39;s talk about active because if things pick up here dilation goes from 5 to 7 cm the frequency is every 3 to 5 minutes they la past 30 to 60 seconds and their intensity is moderate again our word however in transition things pick up even more the cervical dilation goes from 8 to 10 cm the frequency is every 2 to 3 minutes and the duration is 60 to 90 seconds and the intensity is strong now the way they will test your knowledge of this is they will say a woman comes into the labor and delivery Suite she is 5 cm her contractions are every 5 minutes apart and they last for 45 seconds what phase is she in active that&amp;#39;s how you do it but you have to know the numbers to put her in the right one good news this chart is what we call a three column sequential table meaning there&amp;#39;s three columns and where one leaves off the other picks up and where that leaves off the next one picks up the easiest way to master a three column sequential table is to ignore the sides and only memorize the middle column so I only want you to memorize active labor just active which is what 5 7 3 to 5 30 60 and you got the whole chart don&amp;#39;t you because anything less intense would be what and anything more intense would be transition so 57 35 30 60 it can&amp;#39;t be simpler than that note do you see where it says note contraction should not be longer than 90 seconds or closer than every 2 minutes you must know this they love to test this one how do you know a woman&amp;#39;s in trouble in labor well when her contractions are longer than 90 seconds and closer than every 2 minutes you do not want to see that they would give you four women in labor and say who&amp;#39;s the who&amp;#39;s in trouble her contractions are going to be longer than 90 and closer than two minutes that&amp;#39;s bad they&amp;#39;ll also ask it what&amp;#39;s the what what are the signs of uterine tetany well contraction is longer than 90 seconds closer than every 2 minutes what&amp;#39;s uterine hypers stimulation contractions longer than 90 seconds closer than every 2 minutes what parameters would make you stop pcin 90 seconds 2 minutes 90 seconds two minutes remember that you&amp;#39;re very likely to see that okay let&amp;#39;s talk about assessment of contractions you have to tell the woman how to do this how to time her contractions well frequency is beginning that goes in the blank beginning of one contraction to the beginning of the next so if you&amp;#39;re teaching a woman to time frequency and these are two contractions what letter interval would you tell her to time for frequency a beginning to C beginning that actually includes the contraction doesn&amp;#39;t it so frequency is beginning to beginning duration on the other hand is beginning to end of one contraction beginning to end of one contraction so what number sequence would you tell her the time for dur A to B or C to D so frequency frequency would be a to c duration would be a to b c to D intensity is the strength of contraction and it&amp;#39;s purely subjective however that next sentence is really important you see where it says palpate with this is very important teach her to palpate with one hand always one hand because the other hand is timing one hand over the fundus with the pads of the fingers so make sure you teacher to use one hand make sure you to teach her teach her to go over the fundus and make sure you tell her to use the pads of the fingers which are the fingertips okay let&amp;#39;s talk about complications of label and then go to lunch bad news there are 18 complications that can occur in labor and delivery and you have to know them all good news there are only three protocols you need to know for all 18 so really what do you have to memorize 18 different things or three different things three so let&amp;#39;s talk about these three things you need to know the first one is painful back labor have you heard of painful back labor it&amp;#39;s usually when she&amp;#39;s op oxop put posterior you know l o r o oxop put posterior I always tell people when you see op at the end of it think oain cuz they&amp;#39;re going to have it op is opan so what do you do for it two things position then push you position her and then you push in what position would you place her anybody know which position you put a painful back labor in sign not sign knee chest she goes on her hands and knees with her rear end up and her head down because that brings the baby down off the sacrament toxics so knee chest get her around her hands and knees then push what do you push anybody know what you push take your fist and push into her sacrum that applies counter pressure and actually relieves some pain yes I&amp;#39;m going you said need a chest but do you KNE chest then how you they&amp;#39;re lay back they on all flors no see KNE chest yeah people get knee chest confused with lithotomy because in knee chest and lithotomy your knees are to your chest in both this is lithotomy this is not what we&amp;#39;re talking about this is lithotomy okay okay that&amp;#39;s lithotomy this is knee chest that&amp;#39;s knee chest see so your knees are to your chest here and your knees are to your chest here but this is lithotomy this is and here&amp;#39;s the nose that way and this is knee chest here cuz see the baby then will come down off the coxic so knee chest is okay that&amp;#39;s the chest and that&amp;#39;s what we mean we don&amp;#39;t mean this next one prolapse cord this is bad this is a med OB emergency prolapse cord is bad because the baby can kill itself prolapse cord is when the cord is the presenting part which means comes out first so that when the head comes down what&amp;#39;s the head do press on the cord and the baby dies baby literally commits suicide and kills itself so this is not cool uh painful back labor high priority low priority Low Low Pro left court high priority low priority High okay what do you do here push position now what was painful back position push this one is push position so they&amp;#39;re just the flip-flop well what do you push you don&amp;#39;t touch the core push the head back up push the head off the core then what do you position her in knee chest the one I just the one we just talked about so she&amp;#39;s in knee chest you&amp;#39;ve got your hand pushing the head and you stay that way till they pull it out C-section so it&amp;#39;s kind of you have to ride on the heart with her you know so you just throw a blanket over everything you you just go like this you look like a float you know in a parade it&amp;#39;s kind of weird so what do you do for painful back position position push what do you do for prolapse course push position do you remember I said usually I will always position before I do something else that has an exception too because in prolapse you push then you position why do you push first in prolapse and position second in prolapse why because delaying pushing in order to position would increase the risk to the baby see but it&amp;#39;s the same principle so when you&amp;#39;re sitting there not knowing what to do it&amp;#39;s probably good to you to think about if I delay doing this to do that would it that&amp;#39;s probably a good way to think all right number three interventions for all other complications and labor and birth and there&amp;#39;s like 16 of them uterine tetany uterine atne uterine hypertension uterine hypotension uh uh uh maternal subclavian syndrome uh uh Vena syndrome uh um oh just you name it there&amp;#39;s Boku complications they&amp;#39;re all treated the same and they are treated with Lion l i o n l means first you turn them on their left side there&amp;#39;s the L left side I is increase IV o is oxygenate them n is notify physician so first DET turn them on the left side you increase the IV you give them oxygen and you notify the physician now LPNs you will be able to do all of those except increase the IV so what do you do for maternal hypotension Li what do you do for eclampsia L what do you do for toxemia what do you do for uterine rupture Lon what do you do for you see what I&amp;#39;m saying as long as it&amp;#39;s not painful back or prolapse you&amp;#39;re picking what line question question we were talking about first probably the first would be yeah the position and the best would be tough I would the left side there might be the best too cuz that gets the pressure off gets the placenta perused better so so that so even if you give oxygen and the per perent is not being profused it&amp;#39;s not going to get to Baby so I would say that&amp;#39;s one place where first and best of the same one left side would everybody agree with that sort of okay and sometimes it&amp;#39;s the same it&amp;#39;s just on occasion it&amp;#39;s different and most of the time it&amp;#39;s different on occasion it&amp;#39;s the same okay um pit pit means in a crisis if po is running stop it in a ob crisis if pit is running stop it so could that be the first thing you would do so that would catapult all the way to where hold the pit with cap catapult to what order number one and that would be l so you&amp;#39;d stop the pit then l i o n but most of the time they will not tell you pit is running so pit won&amp;#39;t even be there so nine times out of 10 you&amp;#39;ll be doing l i o n but if they tell you pits there stop pit l i o n okay pain medications in labor get this down word for word and then we&amp;#39;ll go to lunch do not administer a pain medication to a woman in labor if the baby is likely to be born when the med Peaks do not give a pen medication to a woman in labor if the baby is likely to be born when the med Peaks let me illustrate how you&amp;#39;re going to do this CU it&amp;#39;s not going to be anything magical it&amp;#39;s just going to be good Common Sense what about this question you have a prima gravada Prima gravada means what first timer Prima gravada at 5 cm who wants her IV push payment will you give it to her or not well the question is is it likely that a prima gravada at 5 cm is going to deliver in the next what well Ivy push meds we learned the other day that Ivy push meds Peak when IV meds Peak when 15 to 30 minutes after you give them so is it likely that a prima gravita at 5 cm will deliver the baby in the next 15 to 30 minutes so would you give her the med yes what about this question you have a multigravid at8 who wants her I am pain med well the question then is is it likely that a multigravid at 8 cm could deliver in the next well when do we know I im&amp;#39;s Peak 3 3260 is it likely that a multigravid at 8 could deliver in the next hour so what would you say to her no are you getting it it&amp;#39;s going to be obvious it&amp;#39;s not going to be they&amp;#39;re not going to play around with being real close like your teachers in school and ATI and stuff like that does you know what I mean you&amp;#39;re going they&amp;#39;re going to make it clear if you can pass seie you can pass ATI you can do boards you can they are much harder much I would rather take state boards any day of the week than take an ATI or a Hess hands I that&amp;#39;d be a no-brainer be a no-brainer okay after lunch we&amp;#39;ll come back and do fetal heart tracing be back at about try to be back at 5 to1 I&amp;#39;m going to run over my is all right we&amp;#39;re going to talky about fetal monitoring patterns okay there are seven of them that you should know don&amp;#39;t panic because they&amp;#39;re actually easy to remember I&amp;#39;m going to go through here and tell you which ones are okay and which ones are bad and what to do for them all right so that&amp;#39;s the way we&amp;#39;re going to go go the first one is a low fetal heart rate that means under 110 this is bad when you see it you do lion l i o n left side IV O2 notifi and if pit were running what would you have done stop the pit High fetal heart rate that&amp;#39;s a fetal heart rate over one 60 this is no big deal you would document it and take Mom&amp;#39;s temperature because it&amp;#39;s probably mom has a fever that&amp;#39;s based but there&amp;#39;s nothing wrong with who the baby baby&amp;#39;s just fine you don&amp;#39;t have to do anything specific if you did anything you&amp;#39;d take Mom&amp;#39;s temperature that&amp;#39;s basically all you do it&amp;#39;s no big deal it&amp;#39;s not a high priority low Baseline variability this is bad this is when the fetal heart rate stays the same and does not change whether high or lower in the middle it just stays the same it doesn&amp;#39;t change that&amp;#39;s bad that&amp;#39;s bad and what you do is lion l i o n left side IV O2 notifi High base Baseline variability what that means is baby&amp;#39;s heart rate is always changing that&amp;#39;s good documented now it&amp;#39;s kind of interesting once a person is born if their Vital Signs stay the same over time what do we call them stable and they are in good shape or bad shape good but when you&amp;#39;re before you&amp;#39;re born if your Vital Signs stay the same over time it&amp;#39;s low Baseline variability and it&amp;#39;s bad you want to see so what we want to see before you&amp;#39;re born we don&amp;#39;t want to see after you&amp;#39;re born and what we want to see after you&amp;#39;re born we don&amp;#39;t want to see before you&amp;#39;re born so we want to see vital signs all over the map when the baby&amp;#39;s in utero that&amp;#39;s called high Baseline variability that&amp;#39;s good we don&amp;#39;t like to see stable Vital Signs which is low Baseline variability late decelerations decelerate means to slow down and late means near the end of a contraction so the heart rate slows down near the end or after a contraction this is bad so what you do is lion l i o n left side I V O2 notifi early decelerations what would this mean early decelerations baby&amp;#39;s heart what slows why did you say slows decelerate when before a contraction or at the beginning of a contraction and this is fine this is normal it&amp;#39;s no big deal so you just document it which brings up the last tracing variable decelerations this is very bad think of variable very very very variable very bad variable very bad so when you see variable think o very bad how very bad well this is prolapse cord this is what happens when you prolapse a cord so what do you do for this push position so of the seven abnormal fetal heart tracings of the seven abnormal fetal heart tracings which one is the most unique variable and it&amp;#39;s very bad so it&amp;#39;s the only one which is treated by push position cuz it&amp;#39;s prolapse now if we look at the remaining six how many are good and how many are bad three are good three are bad what do you notice about all the ones which are bad they begin with the letter L which is the first letter in Lion so if you get a fetal heart tracing that begins with the letter L what do you do for IT lion and so is it good or bad bad so if it doesn&amp;#39;t start with an L it&amp;#39;s okay unless it&amp;#39;s variable in which case it&amp;#39;s very bad so if you want to know your fetal heart tracings just look at the first letter starts with L it&amp;#39;s bad it needs line if it doesn&amp;#39;t start with L it&amp;#39;s okay but if it&amp;#39;s variable it&amp;#39;s very bad it needs the prolapse routine the push position so do you feel a little bit better about those um there&amp;#39;s one other thing I want to show you that tells you what they are you know what are they what do they mean and I&amp;#39;ll see uh you probably heard of it but for some of you that haven&amp;#39;t heard of it this might work um I&amp;#39;ve told you what they what the implications of them are but um what are they write the word ve you know like like young beef beef ve so write ve vertically down and and then write chop like lamb chops pork chops ve chop do you see what I&amp;#39;m saying so ve chop now what this is is this is the first letter of the tracing and this is the first letter of what it means so variable would be what B would be variable that is cord compression you see that variable is cord compression what would this stand for the E early D cell and that&amp;#39;s what it is what it&amp;#39;s caused by starts with an H so what that what would that be head compression what would a be well we didn&amp;#39;t talk about it but it&amp;#39;s it&amp;#39;s high fetal heart rate acceleration which is high fetal heart rate correct and that&amp;#39;s okay okay meaning it&amp;#39;s fine remember we said that high FAL heart rate was okay what would L stand for late D cell and what would that stand for starts with a P placental insufficiency plus cental insufficiency so V chop variable cord Early Head accelerate okay late placenta de CH yes so when we get into the class when having all these demonics and stuff what would you recommend the best time to be to write it down down when you need it oh okay not at the beginning okay they&amp;#39;ll give you a little whiteboard kind of thing and you&amp;#39;ll use that for your scratch P when you fill it up you raise your hand they bring you another one okay you don&amp;#39;t erase they don&amp;#39;t like you&amp;#39;re erasing they&amp;#39;ll freak out if you&amp;#39;re erasing so I would I would erase just for that purpose fact what I would do is I go like this but I would be doing absolutely nothing you know I wouldn&amp;#39;t really be erasing I&amp;#39;d just be going this just a freak them out okay they can make me take this test they can make me sit there but they can&amp;#39;t make me behave so that&amp;#39;s I always think a little Civil Disobedience goes a long way you know you are you in control in this test no you have to go take this test you have to sit where they tell you to sit they have to take the questions you have to take they you have to do it so do something you know civil disobedient you know wear a wear you know a pair of clown ears I don&amp;#39;t know don&amp;#39;t wear underwear I don&amp;#39;t know um do something that&amp;#39;s you know where you&amp;#39;re you can sit there and you can say I&amp;#39;m in control you know to give you a little little Edge okay Ace of Spades and as of Spades means what answer always wins in a tie there are certain answers which they are always winners they just they just win all the time and in OB there is one answer that always wins and if you&amp;#39;ve ever worked OB you&amp;#39;ll know what it is and that is check what beetal heart rate you cannot work OB if you don&amp;#39;t know know that no matter what happens in OB no matter what happens in OB what is the one question that surfaces all the time what&amp;#39;s the fetal heart rate she&amp;#39;s doing this and doing that well what&amp;#39;s the fetal heart rate well this is doing that well what&amp;#39;s the fetal heart rate so you&amp;#39;ll always check a fetal heart rate all right that&amp;#39;s the first stage of Labor and Delivery labor let&amp;#39;s talk about the second stage of labor and delivery delivery of the baby this is all about order what do you do in what order well first you deliver the head and you say well what if it&amp;#39;s breach come on don&amp;#39;t go breach unless they say it&amp;#39;s breach okay go with the common so it&amp;#39;s a sealc so deliver the head number two suction the mouth then the nose it always goes alphabetical you suction the mouth first then you suction the nose then number three check for a nle nle and Nu c h l cord what does nucle mean around around the neck nucle means neck so check for a nucal cord then number four deliver the shoulders and the body in that order so first out comes the head then you suction the mouth then you suction the nose then you check for a cord around the neck and then you deliver the rest of the baby right that&amp;#39;s the ideal number five the baby must have an ID band on before it leaves the delivery area a baby must have an ID band on before it leaves the delivery area okay third stage of labor and delivery delivery what&amp;#39;s this about placenta two things you need to know here number one make sure it&amp;#39;s all there number two check for a three vessel cord make sure the cord has three vessels three blood vessels how many of each two arteries one vein think of the woman&amp;#39;s name Ava Ava how do you spell Ava a v a how many A&amp;#39;s are there two that&amp;#39;s two arteries how many V&amp;#39;s one that&amp;#39;s one vein so the woman&amp;#39;s name Ava two arteries one vein okay that&amp;#39;s all you really need to know about the placenta fourth stage of Labor and Delivery called recovery correct recovery that&amp;#39;s what goes in that blank recovery it&amp;#39;s the first first two hours after delivery of the placenta right now there are four things you do four times an hour in the fourth stage so you&amp;#39;re going to write four three times there there are four things you do four times an hour in the fourth stage so what are the four things you do every 15 minutes which means four times an hour in the fourth stage well the first thing you do is vital signs Vital Signs and you&amp;#39;re assessing for signs and symptoms of shock which is pressures go down rates go up you get pale cold and clammy pressures go down rates go up and you look pale cold and clamy those are the signs of shock anything that&amp;#39;s called a pressure goes down anything that&amp;#39;s called a rate goes up and that number two fundus check the fundus if it&amp;#39;s boggy you massage it if it&amp;#39;s displaced you catheterize number three the pads the paranal pads check the par neop pads look to see how much she&amp;#39;s bleeding if she is bleeding excessively she will saturate a pad in 15 minutes or less so how often are you checking her every 15 and when you check her you put on a new pad you go back it&amp;#39;s 98% saturated is she in trouble or not 98% saturated she in trouble or not how many say she&amp;#39;s in trouble how many say she&amp;#39;s not she&amp;#39;s not in trouble because it has to be saturated 100% and 98 is not 100% And when you learn these rules you have to live and die by them you can&amp;#39;t start fudging you know what I mean you can&amp;#39;t say well that&amp;#39;s close to that then pretty soon you start you know losing your anchors so 100% means 100% if it&amp;#39;s not 100% it&amp;#39;s okay but if you want if you give put a new pad on her check her in 15 minutes and it&amp;#39;s it&amp;#39;s fully saturated saturated if they say saturated what does that mean 100% she&amp;#39;s in trouble but if they say 98% saturated I&amp;#39;d say she&amp;#39;s okay close but she&amp;#39;s okay number four roll her over roll her over in other words check for bleeding underneath of her a lot of people will check the paths but won&amp;#39;t roll her over and that&amp;#39;s not safe cuz could you saturate half a pad and Bleed Out Underneath so you got to you got to do both so what do you do four times an hour in the fourth stage vitals fundus pads and roll vital fundus pads and roll you do those every 15 minutes in that stage that face stage okay turn the p page and let&amp;#39;s do postpartum this is talking about postpartum assessment what do you assess and usually you&amp;#39;re assessing this every 4 to 8 hours it&amp;#39;s either 4 hours or 8 hours it just depends on whether she&amp;#39;s stable or not and what you&amp;#39;re assessing is Bubblehead now there&amp;#39;s a whole bunch of stuff here but I only want you to highlight and know three of them and I&amp;#39;ll tell you which three the first b stands for breasts this is not a real important one the U stands for uterine fundus and this is the one the first one you must highlight this is an important one here again you want it to be firm if it&amp;#39;s boggy you massage you want it to be midline if it&amp;#39;s not you cap them just like in the recovery but there&amp;#39;s something new that they will ask here in postpartum and that is the height of the fundus related to the belly button where do you find it because what they&amp;#39;ll do is they&amp;#39;ll tell you how many postpartal days it is and you got to locate where fund this should be it&amp;#39;s really simple all you do is is fundle height equals day postpartum fundle height equals day postpartum now what do I mean by that is this if a woman here&amp;#39;s her abdomen here&amp;#39;s her Naval this is -1 - 2 - 3 - 4 - 5 - 6 and it&amp;#39;s the fourth postpartal day and they want you to point and click okay here&amp;#39;s a hot spot here hot spot here hot spot here one here one here one here one here one here and one here you know a b c d e f g h i all right and she&amp;#39;s fourth postpartal day which hotspot would you click on G G that&amp;#39;s how many below four four below on the fourth day now be careful cuz F will be there too why would you not click on F it&amp;#39;s displaced you want it midline so they will have hot spots so that you&amp;#39;ll get the right letter but if you&amp;#39;re not precise you&amp;#39;ll be off to the side and you don&amp;#39;t want to be off to the side you want to be in the middle okay the next two bees are bladder and bowel they&amp;#39;re not a big deal bladder and bowel the L is loia l o CH h i a this one is is the second one you highlight this is the second important one they are rubra Sosa and Alba rubra Sosa and Alba rubra is r u r a Sosa is s r OA and Alba is a l ba a now it occurs in that order first the Lo by the way the Loki is the vaginal drainage rubra is first then Sosa is second and allba comes last now they want to know what color they are okay if you rub you see rubra has the word rub in it if you rub and rub and rub something what color will it turn red so rubra is red Sosa has the root Rosa for Rosie if your cheeks are are Rosy what color are they Pink So Rosa is pink and Alba if you are an albino what color are you white so Alba albino white so rub rub red Rosy pink albino white rubra Sosa Alba now the amount 4 to 6 in on a pad an hour is is okay excessive his saturated pad in 15 minutes or less it&amp;#39;s the same idea the E stands for otomy otomy no big deal it&amp;#39;s an incision the H stands for hemoglobin and hematocrite no big deal there they&amp;#39;re not going to focus on that the E stands for ex extremity check checking the extremities this is the third important one you must highlight and right now on this one they&amp;#39;re looking for thrombo fitis so they want to know what&amp;#39;s the best way for you to to determine if a person has thrombol fitis or not what&amp;#39;s the best way exactly bilateral Cal cir cerence measurement measuring their calves home how many have heard of Home ins sign that&amp;#39;s not going to be the best answer now it&amp;#39;s not a horrible answer but it&amp;#39;s not the best one because you can have a positive hman sign and have equal calves and not have throp fitis and you can have throp fitis and not have a positive Homan sign so it&amp;#39;s not as reliable or valid some places don&amp;#39;t even want you to do it a stands for affect means you&amp;#39;re emotional don&amp;#39;t worry about bulby stages you know latching on letting go taking in throwing up I don&amp;#39;t really know what they are you know you&amp;#39;ve never heard of those don&amp;#39;t worry about all that that&amp;#39;s that&amp;#39;s nuts and then D discomforts and that&amp;#39;s just that&amp;#39;s there&amp;#39;s really no big deal there either so the three big things you&amp;#39;re going to be tested on if postpartum are what the fundus theia and about thrombo fitis anybody ever worked postpartum that&amp;#39;s the three big things you talk about in report you know where&amp;#39;s the fundis how&amp;#39;s the lokia and how are her legs she got thrus okay Turn the Page let&amp;#39;s talk about variations in the newborn yes no the the number of days when things go all varies boards likes to test what does not vary the the lengths vary but the order never varies and what they are never varies so it&amp;#39;s just like with Chadwicks goodells and hegar they&amp;#39;re not going to say what week or what month they&amp;#39;re just going to say what order and what is it okay um variations in the newborn all of these things are normal so I just wanted you to know that I&amp;#39;m not going to read it so you don&amp;#39;t have to have it read to but all of these things are normal even though they sound some of them sound bad look at number four aemma toxicum neum sounds horrible doesn&amp;#39;t it but it&amp;#39;s just a rash it&amp;#39;s no big deal the only thing specifically I would need I would want you to know from this page other than the fact that all these are normal is the difference between number six and number seven cuz they always test about the differences between six and seven capit suidan and seah hematoma what do they always want to know what&amp;#39;s that one&amp;#39;s bleeding one&amp;#39;s bleeding and that would be Hema and then also what else which one crosses sutures which one does not which one&amp;#39;s symmetrical which one&amp;#39;s not the easiest way I know that know to memorize that is look at their initials what are the initials of capit suidan Cs what could CS stand for crosses sutures so the one whose initials are CS is the one that indeed crosses the sutures so what about seil hematoma what are its initials C or C certainly not CS so it does not cross sutures and of course the one that crosses the sutures is also the one that is symmetrical so I always say CS stands for crosses sutures and cap it symmetrical and Leon on number eight uh it&amp;#39;s talked about the hyperb rmia normal physiologic JIS appears after 24 hours so there&amp;#39;s a there&amp;#39;s a reminder of the difference between physiologic jice and path logic okay the last page OB meds top 10 group you&amp;#39;ve got to know your OB meds now good news you don&amp;#39;t have to know much about your obms because you&amp;#39;re not expected to be an expert in obms but you&amp;#39;ve got to know generally what they are and just a couple of things about them so rather than feel you full of all kinds of stuff you don&amp;#39;t need to know let&amp;#39;s focus on what you do need to know with these six different meds the first two meds are Toco lytics which stop labor they are terbutaline and mag sulfate these are drugs you give to women who are threatening prematurity and you want to stop their labor terbutaline the only thing you need to know about it is that it causes maternal tacac cardia it speeds Mom&amp;#39;s heart rate up that&amp;#39;s really all they&amp;#39;ll test on that one that it stops lab and speeds up the heart mag sulfate will also stop labor if you give a person a lot of magnesium what electrolyte imbalance will you create hyper magnesia and you know that Magnesia do the opposite so a high magnesium makes everything go down so the uterine contractions will go down well the only problem is so will everything else so what will your heart rate do go down write that down what will your blood pressure do go down write that down what will your reflexes do go down write that down what will your respiratory rate do go down write that down and what will your loc do go down write that down so mag sulfate yes the good news is it stops the uterine contraction the bad news is it brings everything else down too which of those two do you think are the top two that boards will will check your knowledge on respiratory and reflexes they&amp;#39;ll want to know what does mag sulfate do to the respirations and what does mag sulfate do to the breathing and it&amp;#39;s it lowers both of them so when you&amp;#39;re giving mag sulfate to a patient you must monitor what two things reflexes reflexes and respiration what are your parameters for titrating the mag sulfate and lpn&amp;#39;s what parameters would you use when you notify the RN about it 12 what do you mean 12 12 respiration yes so as long as the respir are above 12 what do we know about the mag is it okay or not it&amp;#39;s okay but if it goes below 12 what do we need to do with the mag slow it down LPN you notify the RN of that what about the reflexes what do we want for reflexes two we want plus two so if it&amp;#39;s plus one what do we do to the mag slow it down if it&amp;#39;s plus three what do we do to the mag speed it up so what do we want 12 and two we want at least 12 respirations and we want two reflexes what we don&amp;#39;t want to see is 11 and one we don&amp;#39;t want to see 11 respirations and lower and we don&amp;#39;t want to see one reflex and lower plus one and lower so 12 and two is good 11 and one is bad okay the next class of of OB drugs are the opposite of the too litics they are the oxyx now the oxytoxin stimulate and strengthen labor remember the too litics stopped it these ones started the most famous is pin we&amp;#39;ve talked about it before the big thing you need to know about pin is it can cause uterine hypers stimulation which which would be defined as what uterine hypers contraction what longer than 90 seconds closer than every 2 minutes if you see that back off your pit remember that before from the last couple of pages longer than 90 seconds closer than 2 minutes the next drug that will cause your uterus to contract is methe and the only thing you need to know about methene is it causes high blood pressure now if it&amp;#39;s going to contract blood vessels and contract the uterus if it contracts blood vessels what&amp;#39;s it going to do with the blood pressure increase does it make sense that vasil constriction increases blood pressure so do you see the two M&amp;#39;s methene and mag they&amp;#39;re both used in OB methene and mag right what does one do to the blood pressure lowers it one the other one does what to the blood pressure raises it so one of it low one of the M&amp;#39;s lowers the BP The Other M increases the BP okay the next two meds are the fetal lung maturing meds the meds to make a fal&amp;#39;s lungs mature faster the first one is beta methone what is it steroid and the other is cant which is surfactant so just let me talk about three things you need to know about each with beta methasone number one it is given to the mother mom gets the beta methone number two it is given I am and number three it is given before the baby is born before the baby is born and you can repeat it as long as the baby is in utero however servant on the other hand three things about it number one it is given to the neonate to the baby not to the mother it&amp;#39;s given to the baby number two it is given trans tracheal which means blown in through the trachea and number three it is given after the baby is born not before cervant is given to the baby trans trally after the baby is born whereas betamethasone is given to the mother I am before the baby is Thor they both are given given to make the baby&amp;#39;s lungs mature faster cant is blown in what they use they use a nebulizer kind of thing they can even put it in a connection to a ventilator pump it in okay that&amp;#39;s it on OB we&amp;#39;re done with ob that&amp;#39;s the longest lecture of whole review that&amp;#39;s why I like to split it up with lunch okay we&amp;#39;re going to go to page 51 medication helps and hints this is a very short lecture just designed to help you get some basic basic basic facts down because if you don&amp;#39;t know these facts and you miss these questions you&amp;#39;re in a major hurt the first one is what is Humulin 7030 what is it it&amp;#39;s a mix of insulins of R and N now you can have lispro 7030 but but that&amp;#39;s a variation when they say 7030 they&amp;#39;re talking about n and R basically now 70 and 30 are percentages so it means it&amp;#39;s 70% one and 30% the other which one is which 70% is n and 30% is R so if you give 100 units which you would never do it&amp;#39;s way too much but if you gave 100 units of 7030 how many units of n would there be and how many units of R would there be if you gave 50 units of 70 30 how many units of n would there be 35 how many of of R would there be 15 you see it&amp;#39;s just you just multiply the percentages you know how to get a percentage just take that number and multiply by 7 for 703 for 30 the way I remember that n is the 70 is 7030 is like a fraction what do you call the top term in a fraction what letter does that begin with N so n is in the numerator number two can you draw up can you mix insulins in the same syringe yes or no yes when you draw it up is there a certain way to do it which one comes first everybody says clear to cloudy boards doesn&amp;#39;t use the words clear or cloudy they talk about n and they talk about R now those of you that are taking the enlex RN this this will work better for you but is that what you want to be then do it that way r ends will do it this way meaning draw up the what first R followed by the N that way you don&amp;#39;t get into this clear cloudy garbage okay RNs do it that way now if you&amp;#39;re talking about pressurizing the vial which vial would you inject the air into first the end then inject excuse me then inject the air into the r r then draw up the r then draw up the N so it&amp;#39;s n r RN but it always ends in RN injections they will tell you what injection you&amp;#39;re giving and they will ask you what needle you&amp;#39;re going to use What needle will you use for giving a partic particular injection here&amp;#39;s how you do that if they say you&amp;#39;re giving an IM injection and they want to know which needle you&amp;#39;ll use 21 gauge 5/8 in 22 gauge 1 in 21 gauge g 1 in 25 gauge 5/8 in they want to know what which one of those needles will you use for I am the clue is in the abbreviation look at the first letter of the abbreviation what number does that look like a one go pick the answer in which both parts have a one in it which which one would that be C would be your answer did you see that why is see the answer because both the first the gauge and the length both have a number one because an i looks like a one okay but what about this what if they changed it to subq here again look at the first letter in the abbreviation what is the first letter in the abbreviation s s what number does an s look like a five go pick the answer that has a five in both of the parts and the answer would be D because you&amp;#39;ve got 25 and 58 so when you&amp;#39;re you&amp;#39;re asked to pick a needle just look at the abbreviation look at the first letter and go find the numbers okay Turn the Page we&amp;#39;re got to talk about Hein and cinin because they&amp;#39;re in the top three most commonly tested drugs on boards if you don&amp;#39;t know these you&amp;#39;re in trouble heprin versus cumin very very important Hein it is given IV or subq Kuman is given only po see I&amp;#39;m comparing and contrasting is what I&amp;#39;m doing everybody go back to Hein Hein is working immediately Works immediately go to cumin cumin takes a few days to a week to work anywhere between a few days to a week go back to heprin heprin cannot be given for longer than 3 weeks and in parenthesis put except for Lenox remember the Lenox can be given for a long time regular heprin cannot be yes four weeks three three because in 21 days you start making heper and antibodies which could be really life-threatening cumin can be given for the rest of your life can you not you can take cumin forever go back to heprin the antidote to heprin overdose is protamine sulfate they love that kind of stuff cumin what&amp;#39;s the antidote to cinin Vitamin K Vitamin K how do you remember that yeah C and P P hearin protamine cumin K go back to Hein the lab test that monitors Hein is the PTT PTT which is the partial thromboplastin times they&amp;#39;ll give you both names the one that monist the kumant is the PT which is the INR from which the INR is derived now the way y remember that is several ways if you have your hands you can go what h e p a r i n how many fingers are left three PTT okay let&amp;#39;s spell cumed c o u m a d i n how many fingers are left two PT or you can cross you can write P TT cross them together what letter does that make which stands for Hein any of you guys computer people have you ever seen this HTTP read it backwards PTT is H which is Hein okay so you can do it either way any way you want to do on that one Hein can be given to pregnant women cinin cannot be given to pregnant women Hein can be given to pregnant women cinin cannot be given to pregnant women but by the way speaking of pregnant women what&amp;#39;s the only major antipsychotic tranquilizer that can be given to pregnant women remember all those Zen and zapin the only one that can be given is how doll how doll is the only one you can give and a psychotic can give to pregnant women has nothing to do what we&amp;#39;re talking about but I just thought we&amp;#39;d throw it in the next thing is the K wasting and case bearing diuretics K wasting and case bearing diuretics probably the only question you&amp;#39;ll ever get about a diuretic is does it waste K or does it spare K the easiest way I know to do this is this any drug ending in x any diuretic ending in the letter X X&amp;#39;s out K so if it ends in X it xes out K so what is it a waster or a sparer if it ends in X it X&amp;#39;s out K it wastes it yes plus diuril so the K wasters are all the diuretics that end in the letter X Plus Diel if it does not end in an X and it&amp;#39;s not Diel it&amp;#39;s a sparer so I&amp;#39;m going to give you a bunch of drugs and you tell me whether they&amp;#39;re wasters or SP bearers spironolactone aldactazide mtic motic sparing Las six bux clotri edrex Demodex di real wasting and uh yeah so you got it and backofen backofen is the last drug I want to talk about boards tests muscle relaxing as a class and you need to know your muscle relaxing now the only thing they test about muscle relaxing is the two side effects and the three teachers teachings two side effects and three things to teach the two side effects of a muscle relaxant are fatigue and muscle weakness does that make sense that a muscle relaxant would make you tired and relax your muscles fatigue and muscle weakness the three things you teach are Don&amp;#39;t drink don&amp;#39;t drive and don&amp;#39;t operate heavy machinery so what do you have to know about back Leen what are the side effects fatigue or drowsiness right drowsiness fatigue same thing right and muscle weakness what do you teach them don&amp;#39;t drink don&amp;#39;t drive don&amp;#39;t operate heavy machinery now the other drug that they test is Flexeril f e l f l x e r i l that&amp;#39;s that&amp;#39;s the other muscle relaxant they test Flexeril and bphen are the two muscle relaxants they test I am not going to teach you how to remember that Flexeril is a muscle relaxing because if you can&amp;#39;t figure that one out I can&amp;#39;t help you right so Flex surel you should remember a what mus cuz you flex your muscles well how in the world are you going to remember that backlin is a muscle relaxing well I always say this when you are on your back Len you are on your back loen which means you&amp;#39;re doing what if you&amp;#39;re loafing what are you doing aren&amp;#39;t you relaxing so there&amp;#39;s your clue it&amp;#39;s a muscle relaxing cuz back Lett puts you on your back loen it&amp;#39;s a muscle relaxing di yeah things more generic the the semid SC mid scmid are the ex&amp;#39;s semis are typically X&amp;#39;s semis m t m i d s not all of them but most of them okay let&amp;#39;s talk about pediatric teaching on the next page we&amp;#39;ve only got three left guys actually three and a half left so we&amp;#39;re cool this takes about 5 10 minutes this one CU it&amp;#39;s very short it&amp;#39;s just a review of P&amp;#39;s theory of cognitive development have you heard of that you do need to know P&amp;#39;s Theory but they will never mention P&amp;#39;s name they will test your knowledge of P&amp;#39;s theory of cognitive development by asking you how you would teach children and you&amp;#39;re supposed to if you get a pediatric teaching question that&amp;#39;s a chance for you to show your knowledge of P so let&amp;#39;s talk about it P has four stages for kids thinking the first one is the 0 to 2y olds who are in the stage of sensory motor thinking in in the middle column P says these kids are totally present oriented they don&amp;#39;t think about the past they don&amp;#39;t understand the future they only think about what they are sensing or doing right now so when do you teach these kids can you teach them ahead of time why why not they don&amp;#39;t understand the future can you teach them after you do it no they can&amp;#39;t understand the past so when do you teach them while you do it so when while you do it you teach them as you do it what do you teach them what you are doing do you notice the present tense there what you are doing and how verbally just tell them don&amp;#39;t use play they don&amp;#39;t understand play so if you get a kid from 0 to 2 years of age and he&amp;#39;s going to have a spinal lumbar puncture and they want to know how you going to teach him what are you going to say while we do it we&amp;#39;re going to tell them tell him what we are doing Bingo that&amp;#39;s all you do there really is no such thing as preop or preest teaching for this age group for this age group who do you preach the parents not the kid okay the second stage of a is the 3 to 6year olds he calls them the pre-operational which I like because 3 to six is a preschooler correct and he calls it pre-operational so the two pre go together prechool or pre-operational they are fantasy oriented they are imaginative they are illogical their thinking obeys no rules you cannot reason with a preschooler if they can think it it can happen I mean they just they&amp;#39;re just you can&amp;#39;t it is whatever well do they understand the future yes do they understand the past yes so when would you teach these kids would you teach them before yes how long before or doesn&amp;#39;t it matter how long shortly before so here&amp;#39;s the is pick an answer that says the morning of or the day of or something like 2 hours before that is fantastic preschool because you don&amp;#39;t want to give these kids a whole lot of time to what get their imagination going on it do you see what I&amp;#39;m saying my kids never at this age my kids never knew they were gone to the doctor&amp;#39;s office until they pulled into the parking lot of the doctor&amp;#39;s office otherwise we&amp;#39;d have had disaster that&amp;#39;s why they never rode with me after that no um what do you teach them what you are going to do what you are going to do what tense are we talking in now future what did we talk what tense to we talking with the younger ones present so now so how old does a kid have to be before you can start using future tense verbs three at least three good how play these are the kids that learn through play so in a nutshell if you&amp;#39;ve got a four-year-old who&amp;#39;s going for a lumbar puncture how do you teach him when the day of you tell them what you&amp;#39;re going to do using play some kind of a play thing all righty a story a book equipment whatever dolls okay okay the next stage are these 7 to 11year old concrete operations kids the way I remember that 711 age is conrete is have you ever seen a 7-Eleven grocery store what&amp;#39;s it surrounded by any flowers grass trees no just a bunch of concrete 7-Elevens so just think of concrete 7-Elevens you got 7-Eleven age concrete operations these kids are rule oriented they live and die by the rule they cannot abstract with these kids they are so rigid if you tell them this is the way it&amp;#39;s going to be that&amp;#39;s the way it has to be how many at 7 to 11 that age group how many ways are there to do things one one and only one and every other way is wrong this is the age where the parent hears the teacher said and the teacher hears my parents said now have you ever taken care of these kids this age group did you ever change a dress in for them or something like that what do they always tell you when you change their dressing you&amp;#39;re doing it wrong which means what you&amp;#39;re not doing it like the other person did now are you doing it wrong no but they don&amp;#39;t know that they&amp;#39;re they&amp;#39;re so rigid so when do you teach them days ahead because they&amp;#39;re not going to blow it out of proportion if you tell them this is what&amp;#39;s going to happen 3 days later that&amp;#39;s what they think is going to happen so you can teach them a day or two ahead of time so how old does a child need to be before you can teach them the day before seven now you can give a little one a three or four-year-old a tour of the facility you just don&amp;#39;t tell them what&amp;#39;s going to happen there do you understand what I&amp;#39;m saying tours are okay you can give anybody a tour what are you going to teach them what you&amp;#39;re going to do plus skills what you&amp;#39;re going to do plus you can teach a 7 to 11 year old how to do skills you cannot teach a 3 to six-year-old how to do skills why if you teach a 7 to 11 yearold how to do a skill how will they do it every time exactly the way you taught them because they&amp;#39;re rigid concrete if you teach a 3 to six-year-old how to do a skill how will they do it anyway they can imagine you know I can you teach a three four 5-year-old how to give themselves insulin they&amp;#39;ll do it just fine for you then the next day what&amp;#39;ll they do well I think I&amp;#39;ll not put anything in there and I&amp;#39;ll just jab and out and then the next day they go oh why don&amp;#39;t I give it to the dog that&amp;#39;ll work you know and they just don&amp;#39;t they just so what age does a child have to be before you could teach him a skill so seven how use age appropriate reading and demonstration use age appropriate reading and demonstration okay the next age group are the 12 to 15 year olds and they are formal operations these kids can abstract that&amp;#39;s the big huge thing that they can do that the younger ones can&amp;#39;t they can abstract and they can think cause and effect so here&amp;#39;s the good news as soon as a kid hits 12 and they ask you about teaching it&amp;#39;s not a pediatric question anymore it&amp;#39;s an adult Med searge question because how do you when do you teach a 12-year-old and above like an adult what do you teach them like an adult how do you teach them like an adult so at what age is a child first taught like an adult 12 12 trick question when&amp;#39;s the first age that a child would be able to manage their own care 12 why can&amp;#39;t a can a seven-year-old do the skills related to their care could they manage it no what does manage mean make what decisions which require abstraction because if you tell if if you got a board question like this which of the following four children could manage their own care a 7-year-old with cystic fibrosis no an 8-year-old with diabetes melus no a 10-year-old with a scraped knee no a 13-year-old with chronic renal failure yes why did they put the 10-year-old with a scraped knee in there to fool you because it&amp;#39;s not the severity of the illness that determines who can manage but the age of the kid why could a 10-year-old not manage a scraped knee what will you teach a 10-year-old to do about a straight knee you&amp;#39;ll tell them to do what w wash it dry it put on Neosporin and a bandit okay what will he do the next day wash dry NEP and B it because they do it exactly the way you said so what do they do the third day wash dry knp and Band-Aid the fourth day it&amp;#39;s swollen what will they do wash dry Neosporin band the next day there&amp;#39;s pus coming out of it what will they do wash dry Neosporin bandage the next day it&amp;#39;s swollen twice the size of the other leg what will they do wash dry knee is forign Band-Aid the next day they&amp;#39;re semicom to and they&amp;#39;ve got red streaks coming up and down the leg they can barely get out of bed what will they do wash dry are they managing no no that&amp;#39;s why they can&amp;#39;t do it but if 13-year-old with a chronic renal failure if they are taught osculate your shunt every day to hear a brewery if they don&amp;#39;t hear a brewery what will they do get help that&amp;#39;s managing managing doesn&amp;#39;t mean doing everything managing means knowing when you can and when you can&amp;#39;t and what&amp;#39;s necessary so just be careful if they say manage it&amp;#39;s a 13-year-old if they say skills it&amp;#39;s a 7-year-old all right let&amp;#39;s go to page 58 I want you to read this this is for you to read about and learn about I want it&amp;#39;s about how to take psych tests all it is is a bunch of seven principles you have to obey the first principle says make sure you know what phase of the relationship you&amp;#39;re in remember the nurse patient relationship pre-interaction introduction or orientation working and termination phase remember that this tells you how to answer in each of those phases the second principle is gift giving which means don&amp;#39;t give gifts in Psych don&amp;#39;t accept gifts in Psych if your psych if you&amp;#39;re schizophrenic gives you flowers don&amp;#39;t accept them why cuz to you it&amp;#39;s just flowers to them it may be a marriage proposal and when you accept it you&amp;#39;re in trouble okay number three don&amp;#39;t give advice if the patient says what do you think I should do what should you say what do you think you should do I know it sounds corny but that&amp;#39;s what they want you to say don&amp;#39;t give them advice now can you give advice in Med surgeon PE sure but not in sight CU if a mother says to you how should I care for my child &amp;#39;s pick line when she goes into the shower you should not say how do you think you should care for the pick line when she go you see what I&amp;#39;m saying it&amp;#39;s stupid in Med surge it makes sense in Psych number four don&amp;#39;t give guarantees in Psych don&amp;#39;t say if you cry you&amp;#39;ll feel better if you talk to me we can help you remember all those St those are those are guarantees don&amp;#39;t do that on that next page IM immediacy and you can read all about this I&amp;#39;m just showing you what it&amp;#39;s about immediacy says if a patient says something what&amp;#39;s the best answer the one that keeps them talking if you&amp;#39;re between two psych answers and you don&amp;#39;t know which one to pick pick the one that keeps the patient talking the one that says let&amp;#39;s talk about it right here and right now let&amp;#39;s keep talking don&amp;#39;t pick answers that say refer them to the social social worker why if you&amp;#39;re referring to the social worker what are you doing to the communication right then and right there shutting it off don&amp;#39;t do that even if it&amp;#39;s appropriate for the social worker to deal with do you see what I&amp;#39;m saying keep them talking it&amp;#39;s never wrong to get your patient to talk did you hear what I said it&amp;#39;s never wrong to get your patient to talk so if one of the answers gets that patient to talk you better pick that CU if you don&amp;#39;t you&amp;#39;re saying it&amp;#39;s wrong to get a patient to talk it&amp;#39;s never wrong to get a patient to talk that rule alone can really help you onsight questions if you&amp;#39;re sitting there and you&amp;#39;re between two answers for example like a woman has has had a breast biopsy and she says to you when will when will the results come back do you think I have cancer my sister had cancer she died of breast cancer what&amp;#39;s your best response and you&amp;#39;re between a which says your results will come back in 2 to three days and the doctor will discuss them with you or B which says you&amp;#39;re concerned about what the results May Show both of those are okay but one of them doesn&amp;#39;t get her to talk the other one gets her to talk which one gets her to talk B now is there anything wrong with a it&amp;#39;s absolutely 100% correct but it says the results will come back in two to three days the doctor will talk to you talk to the hand that cares you know I mean talk to someone who cares CU I don&amp;#39;t care whereas you&amp;#39;re concerned about what the results May show gets her to talk but you see those are that&amp;#39;s a real dilemma that a lot of people get into so when you&amp;#39;re between two site question answers remember it&amp;#39;s never right to get the patient to so it&amp;#39;s probably always right okay concreteness number six means don&amp;#39;t use slang you know if the patient says I feel rotten about what I did don&amp;#39;t say you feel rotten cuz then they go oh maybe I have you know maybe I&amp;#39;m you know rotting away and don&amp;#39;t tell an upset patient to chill out you&amp;#39;ll probably find them in the refrigerator because psych patients take you what literal and concrete so use don&amp;#39;t say to a a client oh you know what goes around comes around now they&amp;#39;re going like this all day long you know cuz they&amp;#39;re worried about something going around and coming around that&amp;#39;s figurative speech that stinks in site if a patient says to you you&amp;#39;re a real Brin slabic what did you say um what&amp;#39;s res ah I tricked you brinc is not what concrete so you wouldn&amp;#39;t say what&amp;#39;s a brinc you&amp;#39;d say you&amp;#39;re confused about what my role is here I know it sounds really stupid but that&amp;#39;s what they&amp;#39;re going to say or or you&amp;#39;re a real brinc I see you&amp;#39;re angry you see what I&amp;#39;m saying that&amp;#39;s perfect you don&amp;#39;t use the dumb word they used you know what I mean you&amp;#39;re a shabos what&amp;#39;s a shabaz no no you don&amp;#39;t go there you know don&amp;#39;t go you don&amp;#39;t believe me you don&amp;#39;t want to go there now you may want to go there because sometimes it&amp;#39;s really fun to hear about it it could be very entertaining but that&amp;#39;s what makes me a bad psych nurse okay um the one I want to camp out on is empathy here you got to know empathy because they won&amp;#39;t license a nurse who&amp;#39;s not empathetic believe me they won&amp;#39;t empathy says the best like answers are those answers that communicate to the patient that the nurse accepts the patient&amp;#39;s feelings feelings as being valid real and worthy of action empathy is all about feeling do you remember we talked about this the other day acknowledge feeling you&amp;#39;re empathetic always be empathetic here are some really bad answers if you ever see an answer written this way don&amp;#39;t even finish reading it it isn&amp;#39;t worth your time here&amp;#39;s a really horrible one don&amp;#39;t worry don&amp;#39;t feel you shouldn&amp;#39;t feel I would feel feel anybody would feel nobody would feel most people feel all of those are as stupid as stupid gets I saw a question in a review book that shall remain nameless called Saunders that said that a woman had a miscarriage and was crying and they wanted to know what the nurse should say and they said that you should say I know how you feel I had a miscarriage too now it&amp;#39;s true you did have a miscarriage you know what I&amp;#39;m saying it&amp;#39;s not that you&amp;#39;re lying but they said you should say that I&amp;#39;m telling you you never say that that is the stupidest answer I&amp;#39;ve ever heard you say something like what tell me how you feel well remember I don&amp;#39;t like tell me how you feel that&amp;#39;s very upsetting yeah that is so sad everything that has happened is so devastating you see I don&amp;#39;t we don&amp;#39;t like to say how are you feeling we want you to look at the scenario and assume remember you&amp;#39;re always told don&amp;#39;t read into questions but on these ones you have to read the feeling into what&amp;#39;s going on this is the one place where you have to read into the question if you don&amp;#39;t read in you&amp;#39;re going to miss it cuz see if you&amp;#39;re she crying you say how do you feel that&amp;#39;s kind of how do you think I feel you know what I mean but I see you&amp;#39;re so sad everything is just this is just devastating you know that&amp;#39;s good you don&amp;#39;t say I know how you feel I did it too you know who cares who cares okay turn the page I want to teach you a four-step process for answering empathy questions and if you use this you will do really well with them number one recognize that it&amp;#39;s an empathy question empathy questions always have a quote in the question and each of the answers is a quote have you seen that format patient says quote da da da d da da da what would you say a quote B quote C quote D quote when you see that format what should you say to yourself every single time chance for me to show my empathy okay now here&amp;#39;s how you do it because you&amp;#39;re going to have to read aren&amp;#39;t you going to have to read the feeling into it number two put yourself in the client&amp;#39;s Place their shoes and say their words as though you really really really really me them be an actor get into it role play it number three then ask yourself if I said those words and really meant them how would I be feeling right now okay now you got your answer now you got your answer all you have to do now is number four go and choose the answer that reflects that feeling or anything close do not choose the answer that reflects their words because these empathy questions always have what I call the sucker answer there it&amp;#39;s an answer that&amp;#39;s wrong but it&amp;#39;s there to sucker you into answering it and what it will reflect is what the patient said but it will ignore what the patient felt you&amp;#39;re supposed to pick the answer that reflects what they felt and ignore what they said did you hear that empathy ignores what is said and goes with what is felt don&amp;#39;t get it switched around when people have a hard time answering empathy questions it&amp;#39;s usually because they respond directly to what the patient said rather than how the patient feels do you remember when um I don&amp;#39;t know your name but I said you&amp;#39;re a real Brin liic if you respond to what they said you&amp;#39;ll say a brinck but if you respond to how they feel you&amp;#39;ll say I see you&amp;#39;re angry do you see the difference now I want you to do the next three questions practice questions and I want you to use these rules put yourself in the client&amp;#39;s Place say the words as though you really meant them ask yourself how would I be feeling if I said these words pick the answer that reflects that feeling I also want you to identify at least one sucker answer that overemphasizes what the patient said but missed how the patient was feeling so do that and then talk to your buddy stay on task I&amp;#39;ll be right back yeah I more more this the third one is really hard that third one the problem with it is when you put yourself in the patient shoes and say those words no feeling really pops out so what you have to do is go to the answers and see what feeling the answers are reflecting and see which one has the best the most likely feeling so go to your answers and see if you can get it that way well let me ask you about the first one she said you&amp;#39;re Killers you all killed my mother whatever you know you she died before I was born how does she feel if you said those words and believed them how would you feel scared okay now go to the answers and find the answer that reflects being scared which one is it B what is the sucker answer c c cuz that focused on what she said she isn&amp;#39;t concerned about her mother she&amp;#39;s scared she&amp;#39;s frightened so the answer is B the sucker answer is C the next one what&amp;#39;s the right answer d d and a sucker answer is any of the others cuz the others focused on what he said D focused on how he feels did anybody get an answer on the third one what is you say the answer is C what&amp;#39;s the sucker answer B Because B says religious he&amp;#39;s not feeling religious he&amp;#39;s using a bunch of religious what words that&amp;#39;s the hint that it&amp;#39;s the wrong answer he&amp;#39;s feeling out of control so that&amp;#39;s why C is the answer because with those words I can prove to to you that he has a control issue I can&amp;#39;t prove to you that he feels religious so C is the right answer how many got C on that one wow that&amp;#39;s great how many got all three terrific if you missed any do you see why you missed it what were some of the problems you had with that anybody or you you&amp;#39;ve learned from it any questions you have to me about those did you use the process did the process help okay that&amp;#39;s what I want you to start doing I don&amp;#39;t want you guessing on psych answers I want you to know the answer you understand what I&amp;#39;m saying so many times you guys just guess on psych answers I want you to know why you&amp;#39;re picking what you&amp;#39;re picking okay take a quick break come back at 25 after and we&amp;#39;ll just do the last lecture and a wrap up and be done okay and the sooner you&amp;#39;re back the sooner we&amp;#39;ll get done page 54 this is the most important lecture in the whole review everyone will get at least 15 questions on this you&amp;#39;ll think this is all your test was sometimes most people just dead guess on these ones I don&amp;#39;t want you dead guessing and if they don&amp;#39;t get dead guess they use ABCs I don&amp;#39;t want you using abcs on this so talk about how you prioritize prioritization delegation and staff management the first skill is prioritization they will be testing to see how you prioritize four different patients number one you are deciding which patient is sickest or healthiest now be sure you know which one you&amp;#39;re looking for cuz sometimes they they have you looking for the sickest highest priority and sometimes they have you looking for the low lowest healthiest priority for example if they said there&amp;#39;s been a disaster in your town and you have to discharge one of the following people to make room for incoming wounded who would you discharge would you be looking for the highest priority client or the lowest priority client lowest but if they said to you you receive report on all of the following four patients which patient will you check first when you get out of report what would you pick highest so the the point is sometimes you&amp;#39;re picking the highest sometimes you&amp;#39;re picking the lowest make sure you keep that in your mind because sometimes you can start out looking for the lowest and halfway through the question start looking for the highest you see so don&amp;#39;t get turned around in the middle of the question okay examp now four rules for PRI okay that&amp;#39;s that um oh L is not there um sorry I have to write this way I just don&amp;#39;t have any more open transparencies um what they will do in the answers the will always have four parts they&amp;#39;ll have an age a gender a diagnosis and a modifying phrase so the answers will always be a 10-year-old male with hypospadius who&amp;#39;s throwing up Billy B stained emesis well the age is the age the gender is the gender the diagnosis is hypospadius and the modifying phrase was who&amp;#39;s throwing up vile stain emesis did you got that they always have an age a gender a diagnosis and a modifying phrase two of those are totally irrelevant and you do not use them in your answer which two are irrelevant age and gender when you prioritize complet completely get rid of the age completely get rid of the gender you understand though in Pediatrics in a pediatric question you got to pay attention to the age but in a prioritization question you don&amp;#39;t pay attention to the age because a 2-year-old is not more valuable than a 90y old they&amp;#39;re both humans do you understand what I&amp;#39;m saying so age is not a criteria whereby you prioritize gender is not a Criterion by which you prioritize women are not more valuable than men and men are not more valuable than women they&amp;#39;re it&amp;#39;s irrelevant okay the diagnosis is important and the modifying phrase is important which one is more important the modifying phrase the modifying phrase is always more important so if the patient had sorry I get rid of this okay if the patient had angina hectus versus myocardial infarction Ang ginis versus myocardial infarction who&amp;#39;s the higher priority person the heart attack the Mi however look at this with unstable BP with stable vital signs I added a modifying phrase did you see that now who&amp;#39;s a higher priority angina cuz he has what unable blood pressure the myoc caral infarction they told me was stable CU he has stable vital science so here we have low priority high priority high priority low priority we always pay more attention to which one modifying phrase so he&amp;#39;s the higher priority he&amp;#39;s the lower priority regardless of this do you see that that that&amp;#39;s why you can&amp;#39;t use ABC that&amp;#39;s one of the many reasons why you can&amp;#39;t so this person is more stable this is more unstable here&amp;#39;s your higher priority here&amp;#39;s your lower so always break the tie in favor of the modifying phrase all right now let&amp;#39;s go to the four rules for prioritization the four rules rule number one acute beats chronic acute beats chronic what do I mean by beats is is a higher priority than in other words an acutely ill person is a higher priority than a chronically ill person now let&amp;#39;s look at this how this works out if you had the following patients a COPD a CHF and an appen detis who would be the higher priority exactly why because what are the other two chronic illnesses the atitis is acute if you used ABCs who would be your highest priority client cop COPD and you&amp;#39;d be dead wrong are you seeing what I&amp;#39;m talking about so acutely ill PE would you agree with me that an acute gut is a higher priority than a chronic love absolutely so acute beats chronic it&amp;#39;s not ABC okay next one rule number two on the next page rule number two fresh posttop fresh posttop now how fresh would fresh be how many hours 24 12 12 not 24 12 so any posttop in the first 12 hours is a fresh posttop Fresh posttop Beats medical or other surgical fresh posttop beefs Medical or other surgical okay so what about this of those people who is your highest priority a COPD a Cher an acute appendicitis a 2hour postcystectomy and a second postop day coronary artery bypass craft who&amp;#39;s your highest priority the 2hour post coli why they&amp;#39;re fresh posttop and that beats what medical and other surgical what about this and a radical neck dissection who would win hour post coli and a bilateral above the knee amputation who would win toour post coli and a right frontal craniotomy who would win the 2hour post coli what&amp;#39;s my point it does matter doesn&amp;#39;t matter how bad the surgery is or how involved the surgery is if you aren&amp;#39;t 12 hours in you aren&amp;#39;t high risk you&amp;#39;re recovery that fresh posttop is much more unstable than this guy no matter what was done so don&amp;#39;t go on all of this stuff go on these time frames are you seeing that okay rule number three this is my favorite rule I use it I don&amp;#39;t even I I use it this is the one I use and that is unstable beats stable unstable beats stable so that means unstable people are a higher priority than stable people duh who knew that before you went to nursing school who knew that in seventh grade so then why don&amp;#39;t you get these questions right all the time if you knew that why because you don&amp;#39;t get them right why don&amp;#39;t you get them right you know this then why don&amp;#39;t you get it right the word St yeah in the question there&amp;#39;s all these words and you were never taught what words count for stability and what words count for instability no school teaches that I&amp;#39;m going to teach you that right now it&amp;#39;s Cedarville I always tell this tell the faculty when faculty me we got to teach the students what stable and unstable means oh we do we do no they don&amp;#39;t I go in their classes I listen they talk in platitudes you know if it&amp;#39;s lifethreatening it&amp;#39;s high well then tell me what&amp;#39;s lifethreatening guys I mean you can&amp;#39;t just be I I need concrete specific things to look at so we&amp;#39;re going to generate some concrete specific lists here words to look for in an answer do you see the two lists one list says things that make a patient stable and the other says things that make a patient unstable what do I mean by things words in and answer or modifying phrase that makes the patient either what stable or unstable so you can actually take this to a question and use it and you&amp;#39;ll know what you&amp;#39;re talking about okay let&amp;#39;s go through the list of things that makes a patient stable let&amp;#39;s start there what makes an answer stable number one let&amp;#39;s start real easy use of the word stable no I&amp;#39;m serious people I don&amp;#39;t know how many people will say well it says they&amp;#39;re stable but you know they could just like you know a second later they could just like decompensate and and they could herniate and then they could die and and that could happen in seconds so while it&amp;#39;s saying it&amp;#39;s stable now they&amp;#39;re really like a ticking Time Bomb so I&amp;#39;m going to put them high priority no they said they were stable they&amp;#39;re stable don&amp;#39;t argue with the fact that they said they were stable you have to answer it at this moment in time for this patient if they said this patient was stable right now what are they and if they destabilize in one second we&amp;#39;re not talking about that do you understand what I&amp;#39;m saying we&amp;#39;re talking about right now when they&amp;#39;re talking about this patient so let&amp;#39;s go across to the other list things that make a patient unstable what do you think number one is there unable use of the word unstable and don&amp;#39;t argue whether you think they would be unstable or not they said they were okay next go back to stable go back to the stable column we&amp;#39;re going to bounce back and forth between stable you see what we&amp;#39;re going to do here okay stable one thing that makes a patient stable number two chronic illness chronic illness makes you stable so go to the unstable side number two what makes a patient unstable acute illness what rule is that that was rule number one wasn&amp;#39;t it the reason why I like this rule is because it&amp;#39;s it grandfathers rule number one into it okay go back to the stable side a phrase that makes you stable posttop greater than 12 hours if the patient is posttop greater than 12 hours they are stable so what makes a patient unstable postop less than 12x now what rule is that that was rule number two so I use rule number three because it includes rule number one and Rule Number Two okay go back to something that makes you stable go back to the stable local or Regional anesthesia if you had a procedure with local or Regional anesthesia you are stable so what makes you unstable general anesthesia but only in the first 12 hours go back to stable things that make you stable lab abnormalities of an A or B level lab abnormalities of an A or B level what am I talking about remember this morning if you got a lab abnormality yes it&amp;#39;s abnormal but it&amp;#39;s an A or a B guess what the patient is stable okay then what makes you unstable lab abnormalities of a c or a d so who&amp;#39;s unstable a client with a creatin of 17.8 or a client with a potassium of 6.1 that&amp;#39;s 6.1 because that&amp;#39;s a d versus an a right there go back to things that make you stable the phrases ready for discharge and don&amp;#39;t argue oh I don&amp;#39;t really think they&amp;#39;d be ready for discharge that soon I really don&amp;#39;t think they would be they said they were they are so don&amp;#39;t argue it okay ready for discharge uh to be discharged to be discharged or admitted longer than 24 hours ago admitted longer than 24 hours ago so if the patient has been here longer than 24 hours we assume they are what stable and don&amp;#39;t say well I don&amp;#39;t think it would take that long to stabilize them they said it you go with it so what makes a patient unstable what phrases not ready for discharge newly admitted newly diagnosed or or what admitted less than 24 hours ago exactly admitted less than 24 hours ago another one stable unchanged assessments unchanged assessments meaning the assessment is unchanged it&amp;#39;s the same as it&amp;#39;s been there&amp;#39;s nothing new okay what makes a patient unstable changing or changed assessments there&amp;#39;s something new there&amp;#39;s something something different okay we&amp;#39;re almost done go back to stable this is a long one so get it down word for word the patient is stable don&amp;#39;t write it down the patient is stable if they are here we go experiencing the typical expected signs and symptoms of the disease with which they were diagnosed experiencing the typical expected signs and symptoms of the disease with which they were diagnosed a patient is stable if they are experiencing the typical expected signs and symptoms of the disease with which they were diagnosed go to unstable the patient is unstable if they are and get this down now experiencing unexpected signs and symptoms unexpected signs and symptoms the mistake that most students make when they prioritize patients is they prioritize based on symptom severity rather than symp symptom expectedness in other words if somebody has severe pain and somebody has mild pain they will always prioritize the severe pain higher than the mild pain and that&amp;#39;s wrong if somebody has kidney stones and they&amp;#39;re having severe colic pain are they stable or unstable stable why do you expect severe kicy pain with kidney stones right yes but somebody&amp;#39;s having mild pain with a chest x-ray should you have mild pain with a chest x-ray you should have no pain with a chest x-ray so who&amp;#39;s unstable the mild pain with the chest x-ray is unstable the guy with the severe pain with the kidney stone is stable do you see what I&amp;#39;m saying okay um all right let&amp;#39;s look at let&amp;#39;s look at how we apply this how do we apply this I want you to tell me who the highest priority patient is here and I want you to use the rules I taught you okay you have a 16year old female with Menin cacal menius right who has had a temp of 103.8 since admission 3 days ago that&amp;#39;s your first patient 16-year-old girl manin cacom menitis she&amp;#39;s had a temperature of 103.8 since she was admitted 3 days ago the next patient is a 67-year-old male with irritable bow syndrome who spiked a temp of 100.3 this afternoon I want you to talk to your buddy and decide who on the basis of the rules I gave gave you not guessing but on the basis of the rules I gave you I want you to site who is higher priority and why what he said then but I would have the other one if I now there&amp;#39;s a change yeah 103 [Music] this how many would say what what are you guys saying a or B is the answer now what do we rule out right away here okay so we can rule this out and we can rule that out okay now mininal mantis high or low priority High because it&amp;#39;s what acute irritable bowel syndrome high or low low because it&amp;#39;s okay now that&amp;#39;s our diagnosis let&amp;#39;s go to our modifying phrase which are going to be more or less important more important okay who has had what kind of language is that who has had but what what criteria are we talking about in your list there who said it unchanged unchanged who has had so automatically that puts her what up or down down down a temp of 1038 now when you get a symptom when you get a symptom on these questions do not look at how bad it is look at whether it is what expected or not remember that typical expected do you expect kids with do you expect anybody with Menin Cal menitis to have a fairly high fever yes yes so is this expected yes so does that make her high or low low priority low and to put the nail in the coffin what phrase comes next days ago and that puts her what remember admitted more than 24 hours ago so she&amp;#39;s low so how many highs does she have one how many lows does she have three two or three and all the lows are in what area modifying phrase so we&amp;#39;re thinking thinking she&amp;#39;s what low priority okay who spiked changing changed hi okay temp of 103 how do you deal with that what do you say to yourself is it expected for an IBS no not low don&amp;#39;t say low remember I told you it&amp;#39;s not severity so don&amp;#39;t be talking high and low ask is it expected for an ibser irritable vow to have a temp of 100.3 no actually for them it&amp;#39;s high it&amp;#39;s not low 100.3 so that&amp;#39;s unexpected so does that make him high or low priority high high unexpected and then to put the nail in the coffin what did it end with this afternoon which means it was new changed not been happening so how many highs does he have two or three how many lows one the highs are all in the modifying phrase who&amp;#39;s your higher priority B now let me ask you that does that make sense to you now in real life I said this was low and this was high low priority high priority right so who could go home if it&amp;#39;s true that this one&amp;#39;s low she can go home this one&amp;#39;s high he cannot go home is that true yes it is absolutely true why if she goes home do we know what&amp;#39;s happening with her yeah everything yes we know the symptom we know why she&amp;#39;s got a 1038 we know what it is it&amp;#39;s been that way we&amp;#39;re going to send her home with a home health referral for what IV antibiotics and she&amp;#39;s good to go she can go home cuz she&amp;#39;s stable can I send this guy home why can I not send him home you don&amp;#39;t know what&amp;#39;s going on do you know what this is It&amp;#39;s not that so what is it you don&amp;#39;t know do you know what this is do you know what this is yes it&amp;#39;s a symptom of that right well I knew she had that tell me something I didn&amp;#39;t know I can&amp;#39;t send this guy home this guy could probably probably ruptured an ulceration probably is developing septic peritonitis and we&amp;#39;re just catching his temperature on the way up if I send him home he&amp;#39;s going to come in dead because he&amp;#39;s going to go into septic shock and fade out during the night and no one knows it you see why this guy you can&amp;#39;t send him home he may die this one you can send home how many of you would have picked the menitis an hour ago how many would have picked the erable B an hour ago nobody nobody would have picked it do you see what I&amp;#39;m saying but does it make sense and do you see why it&amp;#39;s true okay um do you see where it says always unstable I want to give you four things that are always unstable regardless of whether it&amp;#39;s expected or not so remember I told you when you look get a symptom don&amp;#39;t qualify how bad it is but ask is it is it expected or not well there are four things that just because they&amp;#39;re there makes you unstable number one Hemorrhage if you are hemorrhaging even if I expect it you&amp;#39;re unstable right yeah for example if I said a client had DIC and hemophilia which would be rare but let&amp;#39;s say they did and I said he&amp;#39;s hemorrhaging I don&amp;#39;t want you to say well you know hemorrhaging I would expect a client with DIC and hemophilia to Hemorrhage so since it&amp;#39;s expected it&amp;#39;s low priority do you see the absurdity in that there are certain things that even if they are expected are what serious serious and bad so hemorrhaging is always bad even if you expect it does that make sense now do not confuse hemorrhaging with bleeding those are two different things boards thinks bleeding hemorrhaging you know to them it&amp;#39;s it&amp;#39;s there&amp;#39;s a huge difference between bleeding and hemorrhaging so if you see bleeding high or low no it depends on whether it&amp;#39;s expected or not gotcha gotcha hemorrhaging high or low high cuz it&amp;#39;s one of those things okay second one high fevers over 105 105 and over why even if it&amp;#39;s expected what will a person with a fever of 105 and overdo Sease so that&amp;#39;s high priority even like now what what could I have done to this menitis girl to make her a high priority made her temp 105 and then then she&amp;#39;s she&amp;#39;s there okay hypoglycemia is the third one a low blood glucose a patient has hypoglycemia their blood glucose is eight don&amp;#39;t do this don&amp;#39;t say well you know I would expect a low glucose with hypoglycemia so an eight is stable you see how stupid that is if you got a low sugar it doesn&amp;#39;t matter if it&amp;#39;s expected or not you are in trouble okay so hemorrhaging high fever hypoglycemia so far they&amp;#39;re all hes right and the last ones are pulselessness or breathlessness if you are pulseless or breathless even if it&amp;#39;s expected you are high priority now how would that ever happen well could you imagine a question like this the patient has viib ventricular fibrillation or a and you don&amp;#39;t get a pulse high or low priority well you know if they had asy I would expect them not to have a pulse so they&amp;#39;re okay you see how stupid that is you can&amp;#39;t you can&amp;#39;t take this to the obsurd do you see what I&amp;#39;m saying I&amp;#39;m trying to show you where the line is drawn so with pulselessness breathlessness hypoglycemia hemorrhaging and high fevers what are are they unstable regardless of expected or not but everything else obeys the rule of expectedness or not do you understand that that&amp;#39;s that&amp;#39;s the way to go with it hey just a real quick question when is pulselessness and breathlessness actually the lowest priority at the scene of an unwitnessed accident at the scene of an unwitnessed accident if you find anyone who is pulseless or breathless guess what they are what what&amp;#39; you say they&amp;#39;re dead they&amp;#39;re the lowest priority but if you witness the problem who&amp;#39;s the highest priority pulseless breathless so knowing whether to prioritize pulselessness and breathlessness highest or lowest depends on witness or not was it witnessed was it not witnessed by the way what are the three things that result in a black tag in an accid and at an unwitnessed accident what are the three things that result in a black tag you know what I mean by a black tag tag them black and ship them last add an unwitnessed accident pulselessness breathlessness fixed and dilated pupils even if they&amp;#39;re breathing and have a pulse those are the three things you have any one of those they&amp;#39;re black tag at an unwitnessed and the hardest one is someone who has fixed and dilated pupil who&amp;#39;s still breathing you know that&amp;#39;s the hard one to leave alone you know what I&amp;#39;m saying but you got to go to somebody else somebody else needs your help more all right rule number three no rule number four on the next page rule number four this is a tie breaker this is a tie breaker caution only use this as a tie breaker I want to I I&amp;#39;m totally trying to be totally honest with you a lot of times when you use those previous rules you end up with one or about two or three that could be it so you need a tiebreaker the tiebreaker says the more vital the organ the higher the price priority the more vital the organ the higher the priority now just a caution here the organ we&amp;#39;re talking about is it the organ of the diagnosis or the organ of the modifying phrase the organ of the modifying phrase is what we&amp;#39;re talking to when you do your tiebreaker do the tiebreaking with the organ in which the modifying phrase is happening not the diagnosis itself you got that okay now what I need to give you is the order of organ Vitality so here it is the most vital organ in your body is your brain the second most vital organ is your lung the third most vital is your heart the fourth is the liver the next is the kidney and the next is the pancreas after that no one agrees so that but that&amp;#39;s good enough that&amp;#39;ll get you what you need brain lung heart liver kidney pancreas in that order so you have a 23y old does that matter male no with CHF high or low priority low cuz it&amp;#39;s what chronic with a potassium of 6.6 High why it&amp;#39;s a CD it&amp;#39;s one of those CD levels okay and no EKG changes what would that do increase his priority or lower his priority lower lower because it&amp;#39;s saying at least he&amp;#39;s not affecting the what yet the heart okay a chronic renal failure with a creatinin of 24.7 high or low low high or low it&amp;#39;s high no I mean high priority low priority oh low why for two reasons it&amp;#39;s an a level plus it&amp;#39;s exected and this is really not expected with that and pink frothy sputum why high priority are feeling is a classic symptom of chronic renal failure pink froy sputum so this person is unstable this guy&amp;#39;s unstable but asymptomatic this guy is unstable and having unstable and having symptoms so this guy could be beating this guy it will see all right a patient with acute hepatitis high or low priority acute hepatitis high high with jaundice high or low low why you expect jaundice with hepatitis an increased ammonia level expected who you cannot arouse expected or unexpected with a hepatitis unexpected unexpected okay so that&amp;#39;s a unexpected so that&amp;#39;s what hot so we got an unstable here an unstable here and an unstable there we got three unstable people right okay who&amp;#39;s our highest priority okay potassium what organ system are we worried about so we got a heart number one is a heart number two we got a what no we don&amp;#39;t have a kidney uh-uh uhuh we got a lung remember you go with the modifying phrase you don&amp;#39;t go with the disease so we got a lung right and then number three we got a what don&amp;#39;t say liver right we got a brain okay so I go to my tiebreaker correct and who wins he wins are you seeing this does that help you can you replicate that can you actually do that when you go to take your boards okay does this change some of the ways you might do things does it make sense to you why you do it that way do you see why it&amp;#39;s valid okay just say tell me if they&amp;#39;re stable or unstable Ang ginop Pectus why chronic okay with crushing substernal chest pain stable because that is expected with angina not relieved by rest or three nitroglycerin unable unstable because the definition of angina is chest pain relieved by rest and Nitro so if it&amp;#39;s unrelieved it&amp;#39;s not angina anymore it&amp;#39;s Mi now they&amp;#39;re unstable does everybody see what I&amp;#39;m saying on that okay delegation do not delegate the following responsibilities to an LPN and lpn&amp;#39;s your not allowed to assume the following responsibilities if an RN delegates it to you now don&amp;#39;t yell at me I didn&amp;#39;t write the list okay I&amp;#39;m just recorded so don&amp;#39;t shoot the messenger I know that 99% of the hospitals in in Ohio don&amp;#39;t do this but this is what the book saith okay do not delegate the following to an LPN starting an IV and you say but what if they have IV certification it didn&amp;#39;t say they did so you&amp;#39;re not allowed to assume that they did hanging or mixing IV meds they&amp;#39;re not allowed to hang or mix IV meds number three pushing IV push meds so what can they do in regard to an IV maintain maintain and document the flow that&amp;#39;s what they can do D they cannot administer blood or mess with Central lines they cannot administer blood or mess with Central lines so no central line flushing if I had to go down to the wire on it I would say they&amp;#39;re not allowed to change change of Central Line dressing but if that was the only thing that they possibly could do then I might let them do it but it&amp;#39;s going to be you know I&amp;#39;m going to really seriously not let him do that unless it&amp;#39;s the only option letter the next one they&amp;#39;re not allowed to plan care the RN makes the care plan the LPN can implement it but the RN does the care plan the next one they&amp;#39;re not allowed to perform or develop teaching what they can do is reinforce teaching what&amp;#39;s the difference between performing and reinforcing yeah so so if somebody needs taught about their diabetes who should do the patient teaching regarding the diabet diabetes they are in but can an LPN reinforce the necessity of doing an acue check before you give insulin to a patient yes they&amp;#39;re not allowed to take care of unstable patients so LPN that&amp;#39;s why you need to know this stable unstable thing because you&amp;#39;re supposed to know what you&amp;#39;re allowed to accept and what you&amp;#39;re not allowed to accept you&amp;#39;d have taken the minin COO manius kid but you wouldn&amp;#39;t take the IVs person if you remember that illustration they&amp;#39;re not allowed to do the first of anything if they&amp;#39;re doing the first I mean if there&amp;#39;s something that&amp;#39;s being done for the very first time who should do the very first the RN cuz what are they going to do assess and care plan so can an LPN perform tube feedings yes or no sure can they do the first tube feed after a g tube was inserted no can they change postoperative dressings sure should they change the first posttop dressing the day of surgery no can they feed stroke patients sure but they shouldn&amp;#39;t do the first feeding of the stroke patient after the the feed can they ambulate post off clients of course should they get the patient out of bed the very first time after surgery no can they take Vital Signs should they take the first set of vital signs after a patient came back from surgery no and that&amp;#39;s one that nobody ever does but I do it as an RN I even see hospitals that are so stupid that they let AIDS take the first set of vital signs after surgery that&amp;#39;s ridiculous somebody&amp;#39;s waiting for a lawsuit to happen on that one you won&amp;#39;t stand up 5 minutes in court if that happens yes changes is it that insur that is our ends boards would allow an RN to do the first dressing change it is tradition to allow the surgeon to do the first one do you see my point but board is more we is Nurses We are the world you know that kind of thing you know more assertive kind of thing and you are you at the last one now they&amp;#39;re not allowed to do the following assessments they&amp;#39;re not allowed to do the following assessments admission discharge transfer or the first one after a change the first assessment after there has been a change who has to do the first assessment after there has been a change the RN because they have to assess plan the whole bit so what about this in report a nurse says I think I heard crackles on that guy in 52 he&amp;#39;s never had him before I think that he has had them I mean no he&amp;#39;s I think I heard them who would be the person that should go assess that person in the morning the RN something may have changed okay um so who should the LPN check who would you send the LPN to check and lpn&amp;#39;s who would you go check a patient with angina Pectus with crushing substernal chest pain who was admitted three days ago and is on nitroglycerin a patient with a subtotal thyroidectomy two days ago who says why are they washing elephants in the parking lot who should the LPN check who should the RN check a for the LPN B for the RN YB for the RN what&amp;#39;s going on man subtotal subtotals gety storm storm and what&amp;#39;s a symptom of storm delirum it could be that that person&amp;#39;s going into storm we don&amp;#39;t know it but the angina with the substernal crushing chest pain in the night that&amp;#39;s all totally but why are they doing that why do they always give you the crushing sub substernal chest pain versus somebody says why are elephants in the parking lot come on they they know that people including nurses when they hear crushing substernal chest pain they go what w you know and and but don&amp;#39;t go wo because it&amp;#39;s no big deal it&amp;#39;s expected and you&amp;#39;re going to treat it and it&amp;#39;s nothing does everybody understand that make sense okay um now do not delegate the following responsibilities to an aid they won&amp;#39;t call it an aid they&amp;#39;ll call them a u AP an unlicensed assisted Personnel when they talk about a UAP it&amp;#39;s an aid a tech here&amp;#39;s what they&amp;#39;re not allowed to do charting now they can chart what they did but they can&amp;#39;t chart about the patient they can chart what they did but they can&amp;#39;t chart about the patient so could they chart side rails up bed in low cite in reach bed bath given CU they chart patient less an today tolerated ambulation well no secondly they&amp;#39;re not allowed to give meds except for what what meds can they give topical overthe counter barrier creames AIDS can independently apply topical over-the counter barrier creases so can they give nitroglycerin ointment it&amp;#39;s topical but it&amp;#39;s not over the GS okay good job can they apply Neosporin ointment technically what because it&amp;#39;s what not a barrier do you see what I&amp;#39;m saying what about hydrocortisone cream probably not what about a andd ointment yes Alpha carry lotion yeah see what I&amp;#39;m saying so those bear creams they can do what about elce ointment for the skin Ace sounds like a what enzyme it&amp;#39;s probably not over the counter okay but don&amp;#39;t get bogged down on that because that&amp;#39;s the one the least test because different states are somewhat different on that okay the next one is they&amp;#39;re not allowed to do assessments except for vitals and ACU checks which I think is stupid why do I think that&amp;#39;s stupid why do we delegate the measurement of something called Vital Signs and acue check which can go to brain damage why do we delegate those two most critical most important assessments to the least prepared person I don&amp;#39;t understand I&amp;#39;d rather have them do my bow sounds and and uh pulses frankly my peripheral pulses and my bowel sounds I&amp;#39;d rather have them listen to those than do the ACU checks and the vus but why why can we do them why do they do them what&amp;#39;s the reason money it&amp;#39;s all money so we&amp;#39;re jeopardizing patients to save money I do all my own vital signs I do all my own AC checks when I&amp;#39;m an RN working and I work and I never get out late I can count on one hand the number of times I&amp;#39;ve been out after my quitting time I am not one of those nurses an hour after quitting shift I&amp;#39;m still there doing my charting I never do that ask anybody that&amp;#39;s work with me I&amp;#39;m out of there I don&amp;#39;t stay late but yet I do all my own AC checks and all my own vience so you can&amp;#39;t tell me that it&amp;#39;s that that you don&amp;#39;t have time to do them you do I think the reason why I&amp;#39;m out on time is because I do my own stuff what do I mean by that I know what&amp;#39;s going on I&amp;#39;m on top of it nothing surprises me it it nothing hits me at 6 o00 when I look at the sheet and I go oh my goodness his blood pressure is 90 over 10 you see I&amp;#39;m saying nobody told me his blood glucose was 15 you see what I&amp;#39;m saying I know it I can tell like boom boom boom so watch pots never boil so I&amp;#39;m just telling you you know I I don&amp;#39;t I don&amp;#39;t buy it so anyhow but here&amp;#39;s the deal if if somebody comes back from surgery and I do a set of vitals and I do all my own set of vitals when they come back from surgery and the vital signs are unchanged from the PAC you you the recovery room discharge vitals they&amp;#39;re unchanged relatively I know my patient is what St stable so then I will tell an aid check them do you see what I&amp;#39;m saying but I I do it sparing when I know what&amp;#39;s going on and I&amp;#39;m checking on it okay enough said on that one uh next thing they&amp;#39;re not allowed to do treatments except for enemis figure that out doesn&amp;#39;t take a rocket scientist they can do enus but they can&amp;#39;t do other things here&amp;#39;s the deal be real cautious of allowing them to catheterize but I I&amp;#39;m not willing to say never let them cize I&amp;#39;m just telling you if you can pick any other answer other than catheterize pick the other answer but if it would say catheterize a patient give an IV push medication intubate the client and irrigate at the tea tube what would you have them do c do you see what I&amp;#39;m saying but if there&amp;#39;s anything else that they could do don&amp;#39;t pick C because Bo doesn&amp;#39;t like him capping one uh Aid on I know there&amp;#39;s one big question on ATI that was talking about what would you let an aid do and you were between having them empty the bag on an ilal conduit continent pouch and versus somebody or versus uh evaluating the effects of range of motion I think it&amp;#39;s said everybody was freaking out between this emptying this bag they never heard of let alone you know and a doing it versus range of motion but that question was not about that the question was about doing versus evaluating you see and people missed it so look at your verbs not just your nouns on your Aid things maybe it&amp;#39;s some like evaluating the effectivess of a bed bath can they do a bed bath can they evaluate the no so sometimes that verb can get you off a hook on that one all right did we cover all that what an aid is not allowed to do well then what is an aid allowed to do you may delegate deleg at ADLs beds baths and activities of daily living however they should never do the first of any of that why who does the first R right now why in a Extended Care Facility why are lpn&amp;#39;s allowed to do a lot of these things I said that they cannot do why could they do them in an Extended Care Facility fac what is assumed about the patient clientele in an in a Extended Care Facility they are stable and therefore an LPN can do many of the things that I said you can&amp;#39;t do in those settings so keep that in mind all right staff manage oh Turn the Page do not delegate to the Family Safety responsibilities do not delegate to the family that&amp;#39;s on the next page safety responsibilities now what do I mean by thaty who&amp;#39;s responsible for the safety of the patient you are so if a family member says would you leave the restraints off my dad while I&amp;#39;m here I&amp;#39;ll watch him make sure nothing happens and I&amp;#39;ll call you when I leave and you can put the restraints back on him yes or no no no Saunders says yes I&amp;#39;m telling you no the book is wrong you cannot delegate safety to a nonhospital caregiver what about a sitter yes why can you delegate to a sitter what does a sitter have to what has to happen for them to be designated a sitter you have to teach them and you have to put in the chart documentation that you what taught them so the second sentences they can only do what you teach them to do so if you decide and the doctor says that the mother can give this three-year-old kid the insulin shot okay can you do it yes as long as you what document in the chart that you taught them you put them through the same checklist that you would do with any new grad new hire on competency for insulin injection and then you put that in the record and you&amp;#39;re good to go but you can&amp;#39;t just let them do it without documenting teaching and their competency what if a mother says this oh would you I I&amp;#39;m not done finishing my baby yet this is in the nursery would you just leave the side rail down and I&amp;#39;ll finish bathing then I&amp;#39;ll put it up when I&amp;#39;m done you can leave the room and go do need go do what you need to do what do you say to them no I&amp;#39;ll stay with you to help you with this bath and when you&amp;#39;re finished I&amp;#39;ll put the side rails up and then we&amp;#39;ll be done because what will happen if do she get an inservice on putting up the side rails on a crib no so if she doesn&amp;#39;t click it right and the baby rolls and Bam and slam who&amp;#39;s going to be in trouble you well she ask me yeah right like they&amp;#39;re going to say oh then I give up the lawsuit cuz I ask you you know like that&amp;#39;ll never happen so you can&amp;#39;t do it I can&amp;#39;t understand why that book said has anyone seen that answer where you&amp;#39;re allowed to do that I what book I mean not book was it a book or was it a teacher test it&amp;#39;s actually online on the website I know believe that I mean are you kidding me just unbelievable yes with um going back infl know you want to evaluate and do be evaluated before you every single time they are hospitalized if a person&amp;#39;s been giving their own insulin injections for 90 years every single time they&amp;#39;re hospitalized we have to go through the documentation for confidenc the inhabitant part of the chart I know it&amp;#39;ll drive them crazy but they&amp;#39;ll know the drill okay staff management how do you intervene how do you intervene with inappropriate behavior of Staff how do you intervene with inappropriate behavior of Staff this is not prioritizing this is not delegating this is handling your staff when they do stupid things and Boards will give you those questions too have you ever seen that you&amp;#39;re a nurse manager you&amp;#39;re the charge nurse You&amp;#39;re the LPN in charge or you&amp;#39;re an LPN and the nurse does this and how you deal with it okay number one number two there are always four answers the same answers show up all the time the first answer usually is something like tell supervisor okay have you seen that as an answer to these kind of questions the the staff member is doing something stupid what do you do tell the supervisor that&amp;#39;s always there number two another one that&amp;#39;s always there is confront them and take over immediately that&amp;#39;s always there and a third one that&amp;#39;s always there is at a later date just talk to them about it you don&amp;#39;t have to do anything right now you don&amp;#39;t have to report it to anybody just talk to them and the last one that is always there is ignore it just let it go ignore it now one of those is never the answer which one is never the answer ignore because you never ignore inappropriate behavior of Staff you always take it as an opportunity to teach and change Behavior now the other three could be right or could be wrong depending upon the situation so what I want to teach you is how to choose between the remaining three options when you get a stack question the first question you should ask yourself is number one is what they are doing illegal you see where I&amp;#39;m at is what they&amp;#39;re doing illegal that&amp;#39;s number one if the answer is yes they are engaging in illegal activity what is the answer that you always choose tell supervisor that&amp;#39;s always the answer however what if the answer is no it is not illegal well then go to the next question the second question you ask yourself is is anyone the patient or the staff member in immediate danger of physical or psychological harm in other words is anyone In Harm&amp;#39;s Way is anyone in danger of physical or Psych olical harm if the answer is yes what do you pick confront immediately and take over because you don&amp;#39;t want anybody to get hurt why don&amp;#39;t you want to tell the supervisor yes cuz delaying confronting in order to go tell the supervisor would put the patient at risk so you go right now you may have to tell who later on supervisor but you got to deal with it right then and right there yes so if it&amp;#39;s illegal to come yeah if it&amp;#39;s illegal and we&amp;#39;re not there yet but you&amp;#39;re you&amp;#39;re ahead of me but sometimes in certain situations it is both illegal and harmful in that case you do both but in what order confront then tell but if it&amp;#39;s but look at this if it&amp;#39;s not harmful and illegal what do you do not harmful but illegal tell supervisor but if it&amp;#39;s illegal and harmful you do both but first you intervene and then you tell supervisor good point that&amp;#39;s a good question okay next one what if the answer is no nobody is In Harm&amp;#39;s Way well then go to the next question the last one the third question says is this Behavior legal not harmful but simply inappropriate if the answer is yes what do you do what do you pick approach them later on and talk to them just counsel them later on no hurry no rush okay now I&amp;#39;m going to give you some scenarios and I want you to tell me which one you&amp;#39;ll pick and I want you to ask those questions of yourself okay you suspect you suspect that a nurse You&amp;#39;re an LPN you suspect that an RN with whom you work is diverting narcotics for private sale and use well is that illegal so what do you do the super um you&amp;#39;re an LPN you walk by the room of an aid who is giving paranal care to a patient and the aid is not wearing gloves is that illegal no no is anybody In Harm&amp;#39;s Way who the a so what do you do is the LPN you go right in and say let me take over you wash your hands you get gloves on and I&amp;#39;ll help you finish got it you&amp;#39;re an LPN you notice an RN going home every day with with bulging Pockets what do you do is that illegal yeah could be stealing right so you what tell the supervisor okay uh you are an LPN in the O you&amp;#39;re a circulating LPN in the O and you notice the surgeon during surgery contaminates the pinky of his left hand what do you do is that illegal no is anybody In Harm&amp;#39;s Way yes who patient patient so what do you say excuse me you&amp;#39;re just contaminated the pinky of your left hand I have a glove right here for you see what I&amp;#39;m saying uh you&amp;#39;re an LPN and an RN always gives report at change of shift and this L RN always says say exasperation instead of exacerbation when referring to COPD so the RN is saying he&amp;#39;s having exasperations of COPD and they&amp;#39;re saying it over and over again all the time so what do you do about it well is that illegal it should be but it&amp;#39;s not um is anybody being harmed so what would you do as an LPA say hey come here some later at a good time You&amp;#39; say Hey you know I noticed you&amp;#39;re always you&amp;#39;re always saying exasperation am I wrong but I kind of thought it was exacerbation now I could be wrong but what you know what do you think you know I mean that kind of thing CU remember when you have a problem with somebody else what do you always talk in I not you you know as LP you would say you&amp;#39;re wrong you&amp;#39;re always saying the wrong not a good idea I mean it&amp;#39;s okay okay to do that but that&amp;#39;s the wrong phrasing okay um are you getting it kind of getting the idea of how you&amp;#39;re going to do that yes question the first example that you said was uh that the RN is diverting drugs so does that imply that the patients that she that are in scar for are not getting that medication no that does not imply that now if it says this you are an RN one of your fellow RN&amp;#39;s was passing narcotics to a bunch of patients you notice that he is somewhat incoherent and not as attentive as usual what would you do yeah I would there you&amp;#39;ve got illegality and the patients that he&amp;#39;s caring for could be in Jeopardy so you&amp;#39;ve got what you were talking about harm and illegality so first you would say to him you you you&amp;#39;re over here you stay over here you&amp;#39;re don&amp;#39;t touching any patients anymore and then you call the supervisor and get it get it going okay but if they want harm to be there don&amp;#39;t don&amp;#39;t imagine it to second degree just kind of it&amp;#39;ll be pretty clear for you question what if it was an LPN and you seen a another a nurse taking the patient&amp;#39;s pill an RN or an LPN so you&amp;#39;re an LPN and You observe an RN taking a pill would you confront them right there or would you go tell the supervisor okay yeah I would probably at that point in time there could be harm because what is that being taken and could it affect their care you see what I&amp;#39;m saying cuz I actually saw him take it now if they&amp;#39;re diverting narcotics with the accounts I don&amp;#39;t know what they&amp;#39;re doing there they could be just you know falsifying records but I saw him take a pill I so I go up and say what is that pill you just took you see what I&amp;#39;m saying and then I might tell the supervisor if it wasn&amp;#39;t something that was logical explanation or if I thought was a problem did you see what I&amp;#39;m saying yeah so you confront them you confront yeah even even if you see a doctor comes out on the medication rooms and swallows a pill what do you say what are you doing and you&amp;#39;re an LPN what was that pill you just swalled and and even though you may not feel oh it&amp;#39;s a doctor no boards want you to go after them boards just gets Goosebumps when you go after doctors they love it it makes them quiver you know what on a hessie test would it be the answer the same way yeah I think so I think so hess&amp;#39;s favorite question about inappropriate Bor is not stack their favorite one is you&amp;#39;ve got two patients who are engaging in sexual intercourse in a room what do you do you shut the door no that&amp;#39;s the hessy answer you shut the door and let him do it that&amp;#39;s the that&amp;#39;s that&amp;#39;s the answer no I&amp;#39;m so that&amp;#39;s the answer on hessie I&amp;#39;m telling you wow isn&amp;#39;t it have you T have you had the hessie and taken that one was that the answer that was the answer yeah so anyhow that they love that one that one shows up all the time I think it&amp;#39;s one of their questions okay um and also they&amp;#39;ll or they&amp;#39;ll say masturbation you know which is you just shut the door you know that&amp;#39;s another big one okay let&amp;#39;s go to the last lecture and we&amp;#39;ll be done last lecture before I started I want to direct you to the last two pages sorry this belt is not the right size oh right have pants on the ground pull them up okay the first one is do you see the abdomen there it&amp;#39;s divided into four quadrants what this is about is they will ask you to point and click where you would find the organs where&amp;#39;s the liver where&amp;#39;s the pancreas where&amp;#39;s the right kidney where&amp;#39;s the left kidney where&amp;#39;s the spleen where&amp;#39;s the ascending colon where&amp;#39;s the descending colon where&amp;#39;s the you see what I&amp;#39;m saying and so what you got to be able to do is click on the cor quadrants now they give you a little bit of leeway with this one as long as you&amp;#39;re in the general vicinity they&amp;#39;re going to count it now the next one the next page is a point and click for escalating the valves of the heart the atic aortic the aortic the pulmonic the tricuspid and the mitro a PM now this one when you have to get exactly over the spot there&amp;#39;s no leeway on this one so the aortic is in the second right intercostal space ponic is in the second left intercostal space the tri at the sternal border these are all at the sternal border the tricuspid is in the fourth intercostal space at the left sternal border and the mitro valve is in the fifth intercostal space in the mid clavicular line so let me go over those again the aortic is in the second intercostal space second intercostal space at the right sternal border the pulmonic is in the second intercostal space at the left sternal border the tricuspid is in the fourth intercostal space at the left sternal border and the mitro valve is in the fifth intercostal space in the midclavicular line meaning the line down from the midpoint of the clavicle so those are the things that that those are the point and now the other point and click they always have is uh the pulses where&amp;#39;s the kateed where&amp;#39;s the brachial where&amp;#39;s the radial where&amp;#39;s the femoral you I&amp;#39;m not even giving you that because I think you should know that question are they ask herb herbs point they don&amp;#39;t they don&amp;#39;t usually talk about herbs but that&amp;#39;s the third intercostal space at the left sternal border it&amp;#39;s right between the pulmonic and the tricuspid so actually it goes a pet m a pet and pet goes down that border line p and then M goes off to the side a pet M but they&amp;#39;ve never asked about herbs question excuse me the apical pulse would be the mital area yeah the apical pulse would be where then fifth intercostal space mid clavicular line now go back back to page 70 and we&amp;#39;ll finish up I have given you a lot of information and I&amp;#39;ve given you a lot of application of that information and that&amp;#39;s going to serve you well but I can&amp;#39;t teach you everything that they could possibly ask because if I taught you more they would just ask harder stuff and if I taught that they would just ask harder stuff and if I taught that they would just ask harder stuff so where do we stop well we&amp;#39;re not getting on that Maro around I&amp;#39;m teaching you the basic stuff that you need to know to pass now you all are going to have to guess everybody in this room is going to have to guess an awful lot on this test because it is a computer adaptive test and that is the nature of computer adaptive testing if I took the test would I fail no way it&amp;#39;s impossible for me to fail I could never fail this test but would it be really would I have to guess a lot on it yes why because it&amp;#39;s computer adapted and it would try to camp out on stuff I didn&amp;#39;t know which would be Pediatrics you know nothing that would be the area I would be weakest in okay so let&amp;#39;s talk about how you guess because I want to help you out there too how do you guess now what I am concerned about is a lot of reviews give you a lot of guessing skills and guessing strategies and that&amp;#39;s dangerous because when your anxiety goes up what do you revert to using fancy little guessing skills and guessing strategies instead of using your knowledge and your common sense so what do I want you to use first when you answer a question knowled knowledge if your knowledge is failing you what do you use common sense when Common Sense fails you what do you use a guessing strategy and some of these reviews just tell tell you all these guessing strategies and then you go to take the boards and you&amp;#39;re trying to figure out what guessing strategy to use instead of answering the question and it actually makes you worse okay so I don&amp;#39;t I don&amp;#39;t I&amp;#39;m just cautioning you about these These are what you use when you don&amp;#39;t know what&amp;#39;s going on okay site questions the best psych question if you&amp;#39;re totally clueless on it the best psych answer is the nurse will Ex examine their own feelings about why is that the best why is it best that the nurse examine their own feelings about something in Psych nursing yeah CU that way you don&amp;#39;t counter transfer remember counter transference the patient reminds you of your dad so you treat him dirty because you didn&amp;#39;t like your dad you know what I&amp;#39;m saying so you have to examine your own feelings before you&amp;#39;re a good therapist in sight secondly in Psych another really really good answer in Psych is establish a trust relationship why would that be a good guess in pych establish a trust relationship because if you pick something else what would you be saying it&amp;#39;s not that important to establish TR oh I don&amp;#39;t think so now now don&amp;#39;t use your you know understand what I&amp;#39;m saying don&amp;#39;t use here&amp;#39;s here here&amp;#39;s where Common Sense should be applied before this rule you have a schizophrenic client who has a knife who is about to stab you what is the most important thing to do establish a trust relationship run the other way what&amp;#39;s the answer run the other way but Mark said establish a do you hear what I&amp;#39;m saying about using these cutesy little rules before you use your common sense okay nutrition I tell you what I have to I have to guess all the time in nutrition particularly in those answers where they say what meal would be good and then a would be like baked potato boiled bacon and fried cheese and a guacamole peanut butter milkshake and the other one is a chicken tenders green leafy vegetable salad tofu custard and a slice of bread see you know what I&amp;#39;m saying and they got all the oh man I just crash and burn on nose but I figured out a guessing strategy that gets me about 75% right even when I don&amp;#39;t know anything about it my rule is in a tie pick chicken I&amp;#39;m serious I know this works I it should never work it has no right working but I&amp;#39;m telling you on these nutrition questions if answer B has chicken in it I&amp;#39;m heading for it and I get it right like three half or four times and I&amp;#39;m just totally dead guessing of course I don&amp;#39;t go with fried chicken because I know that I mean I&amp;#39;m bad but I know that&amp;#39;s bad you know fried&amp;#39;s no good but if it&amp;#39;s baked chicken oh man that&amp;#39;s the meal I&amp;#39;m picking now if chicken&amp;#39;s not there I pick fish but I don&amp;#39;t pick shellfish like lobsters and why cuz they&amp;#39;re high in cholesterol so I I pick just the regular fish the non the scale fish not the shell fish number two never pick casseroles for children if they ask you what&amp;#39;s a good meal for this child and it&amp;#39;s a little kid don&amp;#39;t pick a casserole tuna tofu and Alfalfa casserole it may be wonderfully nutritious but they won&amp;#39;t eat it so they&amp;#39;ll pick a casserole for them number two never mix medication in children&amp;#39;s food by the way before you mix medication in anyone&amp;#39;s food what must you ask for permission you never Mickey Finn patients food okay and I know that when you I I&amp;#39;ve worked in nursing homes and I Mickey pinned 90% of my patients food but on the boards I won&amp;#39;t do it okay toddlers it&amp;#39;s finger food it&amp;#39;s finger food in other words what&amp;#39;s a better meal for a toddler hot dogs and french fries or a tofu bean curd and alala sprout salad the hot dog and the french fries even though the other one is much more nutritious see when they give you a toddler question it&amp;#39;s not about nutrition content it&amp;#39;s about what can they eat on the run so it&amp;#39;s it may be not very healthy but it&amp;#39;s finger food so go for it I have to laugh they always say I I I love statistics and research projects but this research big research project came out of Ann Arbor well I should have known already um that hot dogs and popcorn are the top two things that toddlers choke on duh what are the top two things that toddlers eat hot dogs and popcorn do you see I&amp;#39;m saying if if if uh tofu tofu squares and bok choy were the top two things toddlers ate what would be the top two things they choke off tofu squares and H choice so you got to watch that stuff but it&amp;#39;s just kind of crazy anyhow preschoolers leave them alone leave them alone what&amp;#39;s that mean one meal a day is okay what do you know about toddler at preschool eating habits they&amp;#39;re eat when they&amp;#39;re hungry and they may not eat but one meal a day and they eat the same thing every day for 7even weeks then they change it and eat that for 7 weeks so what do you do as as healthcare workers and parents leave them alone there&amp;#39;s no such thing as anorexia nervosa of preschool they don&amp;#39;t say o I look that no they don&amp;#39;t they eat when they are hungry why do they not need the food that the toddler needed exactly what&amp;#39;s the growth curve of an infant like that what&amp;#39;s the growth curve of a toddler like that what&amp;#39;s the growth curve curve of a preschooler that who needs more this when a kid went from toddler to preschool what happened to his nutritional needs they bought him out what do parents always freak out he isn&amp;#39;t eating like he used to he&amp;#39;s a preschooler he&amp;#39;s not growing like he used to and parents don&amp;#39;t get that that when you shift from toddler to preschool they&amp;#39;re going to stop eating and that&amp;#39;s okay one meal a day is okay we have a rule at our house you take one bite of everything on your plate but you don&amp;#39;t have to eat anything else if you don&amp;#39;t want to but you have to take one bite of everything and if that&amp;#39;s when you&amp;#39;re done you&amp;#39;re done my brother who was a pediatrician who should have known better he had kids too and his rule was you eat everything on your plate and you are not getting off this table till everything your plate is licked clean it is really really interesting that my daughters are all perfect weight for size I mean they&amp;#39;re all the they could walk through the hourglass figure for the you know perfect 20-year-old female friend no not an ounce of fat here or there that shouldn&amp;#39;t be there his kids are you know what I&amp;#39;m talking about and I&amp;#39;m I&amp;#39;m just saying I I have my suspicions of where that started CU in their lives what made them good and obedient food and food was what reinforced if you were good or bad obedient or disobedient and so you know what I&amp;#39;m saying and my kids food was just food you know so I don&amp;#39;t know it&amp;#39;s interesting okay who cares let&amp;#39;s move on um pharmacology but I&amp;#39;m just telling you that for your own thoughts okay um pharmacology I have to guess all the time in farm the most commonly tested area in farm is side effects you do not have to memorize dosages please don&amp;#39;t do that don&amp;#39;t memorize routes don&amp;#39;t memorize frequencies if you&amp;#39;re going to do any memorization of drugs please memorize side effects why because you are a nurse your job is to assess for side effects and see if things are working you&amp;#39;re not job is not to prescribe the dose prescribe the frequency prescribe the route now there are some where they might give you a dose that makes sense or doesn&amp;#39;t make sense you know what I&amp;#39;m saying like dig 10,000 milligrams you know that kind of thing so number two number two if you know what a drug does but you don&amp;#39;t know the side effects how should you proceed have you ever been in that situation you go oh I I know that drug it&amp;#39;s protonics it&amp;#39;s a proton pump inhibitor it it prevents ulceration in the gut and then it says what are the side effects and you go oh I didn&amp;#39;t know that if You&amp;#39; asked me what it was I KN you see saying have you ever been there you know the drug but you don&amp;#39;t know the side effects great guessing rule that would give you the answer almost 80% of the time four out of five times pick a side effect in the same body system where the drug is working let me illustrate this if you got a question about a drug you let&amp;#39;s say you knew the drug was a GI drug but you didn&amp;#39;t know the side effects would you pick drowsiness tardia or diarrhea diarhea if you knew it was a heart drug but you didn&amp;#39;t know what the side effects were would you pick drowsiness Tac cardia or diarrhea tardia if you knew it was a central nervous system drug but you didn&amp;#39;t know what the side effects were would you pick drowsiness Tac cardia or diarrhea drowsiness that works so much for me it&amp;#39;s really really big doesn&amp;#39;t it make sense though if a drug is having a therapeutic effect in certain areas it&amp;#39;s also going to have some side effects there too so why would a CNS drug have a problem with your gut you know what I mean that that&amp;#39;s kind of the question we&amp;#39;d ask what about number three do you think this might happen to you if you have absolutely no clue what the drug even is you swear you&amp;#39;ve never heard of it have you could that happen okay you&amp;#39;re not dead yet you&amp;#39;re close but you&amp;#39;re not dead yet uh look to see if it&amp;#39;s po if they said it was po I think you might have dodged the bullet two out of three times at least 50/50 you&amp;#39;re going to dodge the bullet pick a GI side effect if it&amp;#39;s po pick a GI side effect that works about 50/50 and you say well that&amp;#39;s not very good it&amp;#39;s better than one and four isn&amp;#39;t it so that helps me with some questions particularly the really hard ones number four never tell a child that medicine is candy CU if you tell them oh this is candy this is candy when they go home what do they going to think medicine is candy so when you run out of Halloween candy at Halloween time they&amp;#39;re going to pass out Grandma&amp;#39;s value right to all these little kids now that actually happened to my brother he pediatrician he was working in Chicago he worked at the High Park Clinic in Chicago and Hall he was working in the ER area and this one little kid came in with these symptoms that looked an awful lot like uh toef foral poisoning you know an antidepressant poisoning and they thought that&amp;#39;s interesting so then about 10 minutes later another kid came in with the exact symptoms and then an hour later another kid came in and then about a half hour later a fourth kid came in what happened was they all all four of those kids had gone to the same house and there was a little kid literally passing out out his parents toe fril to all the little kids for Halloween candy because he had been in the hospital the week before and was told it was candy so he said I thought that was a real interesting he got a article in the American Journal of Medicine on that one okay um OB what&amp;#39;s the Ace of Spain&amp;#39;s answer in OB check fet heart rate yeah check be heart R Med surge what&amp;#39;s the first first thing you assess in a med surge situation what&amp;#39;s the first thing you assess in Med surge level of Consciousness Bingo not Airway Airway is not the first thing you assess think about a code you&amp;#39;re in a code you&amp;#39;re doing basic life support all righty or Advanced cardiac life support what&amp;#39;s the first thing you do what name Annie Annie Annie or what&amp;#39;s your name are you okay what&amp;#39;s that level of Consciousness then you do your a b c&amp;#39;s so ABC doesn&amp;#39;t even win there okay but number two what is the first thing you do now what&amp;#39;s the first thing you do in a med search situation if you&amp;#39;re guessing establish an airway so that will work there okay let&amp;#39;s turn the page pediatric guessing skills for growth and development how many of you in here aren&amp;#39;t really good at growth and development you&amp;#39;re joining me I wish I had these rules that I&amp;#39;m going to give you right now when I was in peeds cuz I&amp;#39;d had done a lot better because my experience in Peds was particularly growth and development I could always narrow it down to two and after that I was dead because it seemed like two Ages were reasonable two tasks were reasonable here&amp;#39;s the deal three rules of growth and development questions they are all based on the principle always give the child more time always give the child more time more time to what grow and develop in other words don&amp;#39;t rush children&amp;#39;s growth and development don&amp;#39;t rush it always give the child more time to grow and develop so let&amp;#39;s talk about these rules rule number one when when in doubt call it normal now this is radically different than Med surge in Med surge what&amp;#39;s the rule when in doubt call it abnormal so you don&amp;#39;t make a a safety mistake but in growth and development when in doubt call it normal so what would be the right answer to the question see why did I why is the question written the way it is what age did they give you what task did they say what&amp;#39;s the problem with that question H it varies it&amp;#39;s on the line so some six-year-olds can read and some six-year-olds can&amp;#39;t read so it was purposely written to confuse you so that you didn&amp;#39;t know what to pick and since you didn&amp;#39;t know what to pick they were waiting to see if you would give the child More Time by calling it normal and that&amp;#39;s exactly what they do they purposefully give you ages and Tas where it could go either way and ask you what&amp;#39;s going on here and so you always call it normal now what about this you have a 13-year-old who isn&amp;#39;t potty trained did I say call that normal but you shouldn&amp;#39;t be in doubt I said when in doubt call it normal I didn&amp;#39;t say to call everything normal that&amp;#39;s using your knowledge first is are son understand that okay second rule rule number two when in doubt pick the older age I don&amp;#39;t know about you guys but whenever they ask at what age should a kid be able to do a certain thing I could always narrow it down to how many two and I never knew which one to pick when I started using this rule my scores went through the roof went way up I picked the older age not the not the oldest but the older age in the two that it could be so in the question here at what age should a child be able to walk there are two ages where it could be what could those be 14 B and C 12 and what 14 months was it so what would you pick 14 because you&amp;#39;re giving the kid more time yeah some kids could walk at 12 but give them a couple more months are you seeing the principle and then rule number three when in doubt pick the easier task I always got questions where they said a kid is a certain age what task have they mastered and those they&amp;#39;ll give me four tasks I could always narrow it down to how many two and I never knew which one to pick if once I started using this rule my scores went way up why do I pick the easier task easier cuz I&amp;#39;m giving him more time to do the harder one now look at a six-month-old kid there are two tasks there that a six-month-old kid probably would be doing working on or trying to to do what would be those two that they would be working on or trying to do B and C rolling over and sitting up okay so what&amp;#39;s the answer roll over because that&amp;#39;s easier than sit up do you understand that in growth and development they always give you two right answers on purpose see I thought there was one right answer and one wrong one and I just was stupid and didn&amp;#39;t know the difference no they always give you these in growth or development in particular they give you two right answers and they want to see are you going to going to call it normal pick the older age and pick the easier task when you get growth and development questions what do I want you to be chanting in your head normal older easier normal older easier okay literally my scores on a growth and development test went from an average between 38 and 48% to 70 to 78% in a day when I started using these rules and I didn&amp;#39;t learn any more information it just I finally figured out what they were up to okay General guessing skills rule out absolutes why are absolutes not good answers you have to be able app yeah and all you have to do is find one situation where it doesn&amp;#39;t apply and it&amp;#39;s wrong now did I say never pick an absolute as your answer because aren&amp;#39;t there some absolutes that you should know like never push potassium IV never give a med to a patient unless you can identify right right those are absolutes and they&amp;#39;re correct why can you pick them because if you&amp;#39;re knowledge but I&amp;#39;m saying if you&amp;#39;re guessing don&amp;#39;t pick them number two if answers say the same thing neither one is right why can it be this I had a hessie test last spring and it asked me about a disease I never heard of before and it asked me what would you see a said increased vowel sounds B said something else C said borberg me and D said something else well I immediately ruled out increased bow sounds in borberg me because they were the same thing then I figured which one of the remaining ones would be logical I picked it and got it right and I that was just a guess number three if two answers are opposite one of them is probably right if two answers are opposite one of them is probably right number four the umbrella strategy I like this one this one helps me out a lot it says one answer which answer is more Global have you ever had the experience and I have it a lot on tests where I want to say all of the above but that&amp;#39;s not there have you ever had that experience I want to say all the above but that&amp;#39;s not an option if that&amp;#39;s the experience you&amp;#39;re having look for an look for an umbrella answer what do I mean by an umbrella answer is an an answer that covers like an umbrella covers all the others without saying it does an answer that&amp;#39;s so Broad that when you do it you do all the others so look at our example what is the umbrella answer B because if you do that you do all the others um I was I was doing a test with a student that had some trouble with testing uh we ran across one the other day it said when you transfer a patient from a bed to a wheelchair always a meds Pub test question when you transfer a patient from a bed to a wheelchair what&amp;#39;s important to do a bring the chair as close to the bed as possible B remove the foot pedal from the chair so you don&amp;#39;t trip over it C use safety and good body mechanics when transferring D lead into the bed with the strong foot well all of them are correct and I&amp;#39;m going well they&amp;#39;re all right they&amp;#39;re all right wait a minute mark look for an umbrella the answer was C use safety and good body mechanics when cuz all those work do you see how that works I I&amp;#39;m surprised that it works as much as it really does number five if the question gives you four right answers right answers and asked you to pick the one with the highest priority now you realize that an hour ago we talked about prioritization right what were we prioritizing four what different patients when you get a question that&amp;#39;s prioritization of four different patients use the rules I taught you an hour ago however if they give you one patient and ask you which of the following needs is highest priority don&amp;#39;t use what I what I taught you before won&amp;#39;t work that&amp;#39;s for prioritizing different patients what do you do here well you do what I call the worst consequences gain take each option a b c and d and ask yourself if I did not do this what is the worst thing that would happen then the best answer is the one that has the worst outcome if you don&amp;#39;t do it now let me I know that sounds crazy but let me illustrate it in the question below which of the following is highest priority in caring for a suicidal patient how many patients do you have one one so those rules I taught you about before do those apply no no so let&amp;#39;s take each answer if you do not give him a tranquilizer what is the worst thing that would happen he&amp;#39;d be agitated okay if you don&amp;#39;t Orient him to the unit what&amp;#39;s the worst thing would happen he&amp;#39; get lost and disoriented if you don&amp;#39;t put him on suicide precautions what&amp;#39;s the worst that would happen he&amp;#39;d be dead if you don&amp;#39;t introduce him to the staff what&amp;#39;s the worst that would happen when know anybody so of being agitated lost dead and not knowing anybody what&amp;#39;s the worst dead so what&amp;#39;s the highest priority suicide precaution so let&amp;#39;s do it with the next one ask yourself what&amp;#39;s the worst thing would happen if I didn&amp;#39;t have sips of water what&amp;#39;s the worst thing that would happen if I didn&amp;#39;t have payments what&amp;#39;s the worst thing that would happen if the side rails weren&amp;#39;t what&amp;#39;s the worst thing that would happen if I didn&amp;#39;t use the abductor pillow not just something bad but the worst thing that would happen what&amp;#39;s your answer side side rails yeah because if you didn&amp;#39;t what&amp;#39;s the worst thing that would happen if you didn&amp;#39;t do the sips of water DEH not thirsty is not bad enough they get dehydrated okay if they didn&amp;#39;t have pain meds they&amp;#39;d be in severe pain if you didn&amp;#39;t put the side rails up what would happen fall break hips head multiple injuries if you didn&amp;#39;t use an abductor pill pillow what&amp;#39;s the worst thing that would happen mess up the hip so of being dehydrated severe pain messing up the hip and everything else and messing up the hip what&amp;#39;s the worst of the worst messing up the hip and other injuries so the side rails is number one are you seeing that okay you could also juxtapose CN D couldn&amp;#39;t you you could say if I put the side rails up but didn&amp;#39;t use the abductor pillow or I used the abductor pillow but left the side rails down you hear that which would be better use put the side rails up and don&amp;#39;t use an abductor pillow or use an abductor pillow and leave the side rails down what would be better you get the side rails you know you re you&amp;#39;re getting more hot water for the side rails down okay uh eight when you&amp;#39;re stuck between two answers read the question where&amp;#39;s the clue to the answers in the question not the answers so quit reading and rereading answers go back and read the question you probably missed something okay the last page right the Sesame Street rule you have my permission to use this rule when and only when your only remaining option is to do this okay if you&amp;#39;re at that point what should you use Sesame Street rule but if you use it before then you will fail boards because this is a dangerous one to use but it&amp;#39;s the one you use when nothing else Works do you remember Sesame Street three of these things belong with the others one of these things just isn&amp;#39;t the same remember that and they show you three sailboats and a cumquat and you had to figure out which one was different right okay well right answers tend to be different than the others why right the right answer tends to be different than the others why because it is the only one which is right correct exactly however the wrong answers all are similar because they share something in common and that is that they are all wrong so by virtue of that the right answer is the most unique or different answer so in our question below what would be the correct answer C would be the correct answer all right number eight don&amp;#39;t be tempted to answer a question based on your ignorance instead of your knowledge and you guys say oh I don&amp;#39;t do that oh yes you do you do it I know you do it I want to illustrate something really quickly do you see this question below about Amma I&amp;#39;m going to do something here what I&amp;#39;m going to do is this I&amp;#39;m going to role play a student who answers that question based on ignorance meaning what they don&amp;#39;t know then I&amp;#39;m going to role play a another student who answers it based on what they do know but the interesting thing you&amp;#39;re going to notice about those two students is they know the exact same amount one does not know any more than the other so let me illustrate this who am I right now the student is answering based on what IGN ignorance okay here we go here&amp;#39;s here&amp;#39;s what ignorance answers do which of the following is important to do in the administration of Amic case and IV piggyback oh my goodness amicas oh man I knew I was going to get these stupid drugs I don&amp;#39;t know why does it always happen to me why I knew ohin ma ma Max Max ah Max oh man I knowe okay am case now be pick up cover the bag with f to protect from light what okay use you use a ivy pump Amic case and Ivy pigy that stupid Mount Caramel pharmacology class never taught us if Mark why didn&amp;#39;t mark tell us about this if it was going to be on her why didn&amp;#39;t he mention it wasn&amp;#39;t in the blue book or the yellow book Emma Emma oh man cover the bag with foil to protect from light H now you know if I wanted to protect it from light covering with foil would work H and I know some drugs are biodegraded by UV radiation I&amp;#39;ve never heard of amicas and I&amp;#39;ve never heard of covering bags with foil so they probably go together because had I heard of amicas I would immediately know if you did or did not do that and if I had heard of doing that I would have known which drug it was like Amma so since I don&amp;#39;t know either one this is probably some obscure fact about some obscure drug and I&amp;#39;m not going to let him trick me so I&amp;#39;m going to pick cover the bag with ball to protect from WR all right now second student this is going to base his answer on what what they know not what they don&amp;#39;t know okay let&amp;#39;s go um what is important to do in the administration of Emma Cas IP Emma Cas oh man Emma why do I always get these drug WIS I don&amp;#39;t know I knew this was going to happen what I took fors I would get all these drugs I didn&amp;#39;t know aminin Max kiss am amus oh man okay cover the bag of for to protect from light H use a I pump oh Amma stupid M caramel pharmacology never taught us about this Mark should have told us it wasn&amp;#39;t in the yellow book it wasn&amp;#39;t in the blue book if it was going to be on who should have let us know man why is this always happening to me Cas okay all right I don&amp;#39;t know Amma I don&amp;#39;t know it I can&amp;#39;t answer this question based on Amma because I don&amp;#39;t know it so let me take Amma out of the question see what&amp;#39;s left see if there&amp;#39;s anything I do know something about okay what is important in the administration of IV piggyback oh IV piggybacks I know IV e piggybacks I&amp;#39;ve given them I&amp;#39;ve seen them given and every time I&amp;#39;ve seen them given 99% of the time they&amp;#39;re on a pump so I&amp;#39;m picking pump now who got the question right first one or second one and did they know anything more about Amma than they did no what did they learn about the first person what did the boards learn about the first person when they don&amp;#39;t know what to do what do they do they go around covering bags in foil what did they learn about the second person when they don&amp;#39;t know what a drug is they put it on a pump who would you license no I&amp;#39;m serious who would you license do you see what I&amp;#39;m saying but don&amp;#39;t see here&amp;#39;s the deal if you don&amp;#39;t know what something is what should you do pull it what away out of the question read the question without it there and see what happens I I had a student that was really bad at this I knew she finally got it when we did a question like this and she finally said it said what is important to do to teach parents of a kid going home on pen VK suspension and she sweat pen VK for like 20 minutes not really but you know for a minute or two sweating what penv K was what&amp;#39;s pen VK what&amp;#39;s penk I don&amp;#39;t know penk I don&amp;#39;t know penk and then she looked at me and she said oh I don&amp;#39;t know what it is do I and I said do you and she said no and she says I&amp;#39;m supposed to pull that out of the question aren&amp;#39;t I and I said do you think you are she said yeah I think I am and I says should she said should I do it and I said do you think you should do it and she said she said yeah I&amp;#39;ll do it so she reread the question what did it do what did it read when she pulled out pen VK what&amp;#39;s important to teach the parents of a child going home on a suspension and she said oh my goodness it&amp;#39;s letter D isn&amp;#39;t it and I said yeah you know what D said shake well before giving and now was the right answer do you see you understand boards will give you things you&amp;#39;ve never heard of for the purpose of seeing if you use common sense see if I want to measure your common sense this if I want to measure this whole class is common sense I have to ask something about which none of you know you none of you have knowledge because if you don&amp;#39;t have knowledge what do you have to use common sense so I have to ask you about a drug nobody&amp;#39;s ever what heard of a disease that no one&amp;#39;s ever heard of or a treatment that no one&amp;#39;s ever heard of and that way I can measure what common sense so when you get something you don&amp;#39;t know use your common sense it&amp;#39;s probably a really really easy question so don&amp;#39;t freak out that it&amp;#39;s hard and that happens a lot in the first 10 use your common sense in the first 10 do not overanalyze those first 10 questions take them as though you weren&amp;#39;t even a nurse say to yourself what I think Aunt Billy would answer for this one you know it&amp;#39;s just they&amp;#39;re so they&amp;#39;re they&amp;#39;re ambiguous but they are very clear not clear but they&amp;#39;re very everybody gets them right even though they&amp;#39;re vague all right now last things if something really seems right it probably is my point there is are do I have any gut Changers here people who go against their gut answer stop it you have no right to go away from your gut answer unless you could prove why the other one is superior not just as good but what Superior so if you have a gut draw to letter B your gut answer is B and but you think oh well well well maybe it&amp;#39;s C should you pick c not unless what not unless you could articulate a reason why C is what Superior not just as good there is a mini mark on your shoulder when you take this step I am there I&amp;#39;m sitting right there little mini Mark is right there and when you go to change from your gut what is mini Mark going to say why is that Superior why is that Superior and if you cannot tell me why you get your hand off that button and you pick your gut all righty so don&amp;#39;t go research has shown that you change from right to wrong twice as much as you Chang from wrong to right so it&amp;#39;s a losing battle don&amp;#39;t do it number 10 if you don&amp;#39;t know the answer you do know the answer use your common sense all right that&amp;#39;s it for the review I just wanted to give you three parting shots on that last page just three things and then we&amp;#39;re done okay Mark move it three expectations you&amp;#39;re not allowed to have do you know what fails the people fails people a lot they get taken the test and during the test it wasn&amp;#39;t what they expected it wasn&amp;#39;t what they were hoping for it wasn&amp;#39;t what they wanted and that breeds negativity and then that negativity affects their what performance and then what happens they fail so what failed there their negativity where did their negativity come from it didn&amp;#39;t live up to their expectations it wasn&amp;#39;t what I expected well here are three expectations you are not allowed to have if you have these expectations get rid of them right now they are dangerous they will kill you on this test first expectation don&amp;#39;t expect 75 for the RN or 85 for the LPN don&amp;#39;t expect 75 or 85 questions don&amp;#39;t expect it go there expecting 265 or 205 depending on whether you&amp;#39;re an LPN or an RN go there and prepare yourself psychologically mentally physically emotionally to go for the whole maximum you know what happens I know this happens I&amp;#39;ve heard people say it all the time they say oh I I I want 75 questions I hope I get 75 questions they&amp;#39;ve got the whole church praying dear Lord let Sally have 75 questions you know it&amp;#39;s on the Church website you know pray for Sally that she has 75 questions when she Tak that&amp;#39;s so stupid because what happens when you go take that test and you hit 70 5 and you answer it and you hit the button and it goes 76 what do you do and then you hit 110 and then you&amp;#39;re and then it&amp;#39;s 198 and then 215 you start going what this is horrible this is terrible this I&amp;#39;m doing so bad this is horrible I just can&amp;#39;t stand this so what&amp;#39;s entering your mind negativity what happens to your performance it&amp;#39;s going down why do you fail you failed because you had this unrealistic goal of 75 expect 265 in fact the longer you go you&amp;#39;re doing fine everybody says oh I want 75 well that&amp;#39;s dumb because somebody said no here&amp;#39;s here&amp;#39;s what they say I got to 200 and I knew I was failing that was that&amp;#39;s the stupidest thing ever Ed by a human being because this is a computer adaptive test if you got to 200 and you were failing what would it have done and if you were failing what would it have done shut off so the only way you&amp;#39;re getting to 200 is if you&amp;#39;re not what failing you aren&amp;#39;t failing now are you doing a bang up job no but who do you think you are who do you think are you God&amp;#39;s gift to nursing no you&amp;#39;re average so you&amp;#39;re going to be average so don&amp;#39;t do you see what I&amp;#39;m saying if you get 220 if you&amp;#39;re on question 220 what did you say okay I&amp;#39;m still I&amp;#39;m still in the game 223 I&amp;#39;m still in the game 224 I&amp;#39;m still in the game 225 oh it shut off and everybody says to me Mark well when you tell me that when it shuts off I&amp;#39;m going to freak out my reply to them is I don&amp;#39;t care I do not care what you do after it shuts off all I care about is what you do before it shuts off so freak out all you want after word don&amp;#39;t freak out before the reality is the same number of PE same percentage of people pass at 265 as pass at 75 and every number in between and there&amp;#39;s this rumor out there that says if you go to 265 the percentage of people failing is like two or three times at 75 that&amp;#39;s that&amp;#39;s a person that&amp;#39;s never looked at the statistics the scattergrams of the tests which I have done every year since it was its Inception so they&amp;#39;re wrong and the myth about every once in a while somebody randomly gets 265 is baloney that is that&amp;#39;s baloney if you ever heard that from somebody that&amp;#39;s a myth it&amp;#39;s not true you get everybody gets a computer adaptive test everyone does and the number you get is based on on your performance okay all right so don&amp;#39;t expect what expect how many the whole bit okay number two don&amp;#39;t expect to know everything why cuz it&amp;#39;s computer adaptive you&amp;#39;re not going to know everything even if you&amp;#39;re acing it they&amp;#39;re going to bring out stuff you&amp;#39;ve never heard of so don&amp;#39;t worry about not knowing everything number three don&amp;#39;t expect everything to go right what I mean by is don&amp;#39;t expect the birds to sing sunshiny you get a parking spot right up front sometimes you got a person sitting next to you that goes every 5 minutes you know I don&amp;#39;t let that fail you now you do have a option to say would you get this snort snotter out of here but you I&amp;#39;m saying no listen think about it just last thing last thing I&amp;#39;m going to say isn&amp;#39;t it true that everybody in this room in your program would have had at least three or four or five times in your program to legitimately quit if you just just stopped you&amp;#39;d have been totally legitimate cuz it was it was ridiculous but you and you would have had a reason to quit is that true but what did you do you stuck it out was it pretty did it get ugly at times did it get messy was it hard but what did you do you stuck it out so you know what that tells me about you everybody in this room you have perseverance you have a strength of character and a perseverance to Slug It Out when it gets tough or you wouldn&amp;#39;t even be sitting here when you take this test it&amp;#39;s going to be hard it&amp;#39;s going to be tough it may not be pretty it may be sloppy it may be messy but you have what perseverance and an intense and uh strength of character to get through that you can get through it and get through it one question at a time just to answer one forget about it move to the next that&amp;#39;s how you got through school that&amp;#39;s how you get through here correct because at the beginning if you thought about the whole thing you would have quit so just go there okay uh thank you for this opportunity I appreciate all you guys and if you see me around if you see me around just say who can sterilize my bow and I&amp;#39;ll you okay also I go by word of mouth so if you want to tell other people about their view that&amp;#39;s fine with me

Transcript for:Endocrine System Overview & Hyperthyroidism

Transcript for:
Endocrine System Overview & Hyperthyroidism