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Scrubcheats by NRSNG (nursing cheatsheets podcast)

Updated 5 days ago

Education
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Medicine
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Short. To the point. Episodes for nurses and nursing students about critical clinical tips and information.

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Short. To the point. Episodes for nurses and nursing students about critical clinical tips and information.

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By MAVH13 - Apr 26 2018
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Very helpful content listened to with the Scrubcheats.

iTunes Ratings

9 Ratings
Average Ratings
5
3
0
1
0

Helpful

By MAVH13 - Apr 26 2018
Read more
Very helpful content listened to with the Scrubcheats.
Cover image of Scrubcheats by NRSNG (nursing cheatsheets podcast)

Scrubcheats by NRSNG (nursing cheatsheets podcast)

Latest release on May 09, 2019

The Best Episodes Ranked Using User Listens

Updated by OwlTail 5 days ago

Rank #1: Ep004: Cardiac Labs and Meds for Nurses

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In addition to the three main classes of anti-hypertensives we already discussed, ACE Inhibitors like Lisinopril and Captopril, Beta Blockers like Metoprolol and Propranolol, and Calcium Channel Blockers like Nicardipine and Diltiazem, there are a number of other classes of medications we can anticipate when caring for a cardiac patient.

These include Anticoagulants like Heparin, Warfarin, Eliquis, and Xarelto, or Antiplatelet agents like Aspirin and Plavix. These are used to decrease and prevent clotting and may be seen in patients with atrial fibrillation, cardiac stents, or artificial heart valves.  

You may also see ARBs like Losartan and Valsartan as well as Combined Alpha and Beta Blockers like carvedilol to supplement the functions we’ve already seen with Beta Blockers and ACE inhibitors. You may also see Digitalis agents like Digoxin to improve the efficiency of the heart and Vasodilators which help to decrease preload (which you’ll learn about on another card).

There are also some common lab values that are important to monitor with cardiac patients.  First and foremost is Potassium. The normal potassium level is 3.5 to 5 and any deviation from that most commonly presents with EKG changes and dysrhythmias like V-Fib or V-Tach.

Low potassium causes a U wave (a dip after the T wave) or ST depression (it goes down) and can also increase the risk of digoxin toxicity. High potassium causes Peaked T waves and a Widened QRS (high = bigger and taller). It’s also important to monitor magnesium because it has a direct effect on the contractility of the heart muscle and can cause heart blocks or even V-Tach.  

The BNP or B-Natriuretic Peptide is indicative of how severely the heart muscle is being stretched. The higher it is, the worse the heart failure and volume overload. We also monitor H&H for volume status and possible anemia, as well as a Lipid and cholesterol panel due to the risks associated with atherosclerosis.

The post Ep004: Cardiac Labs and Meds for Nurses appeared first on NRSNG.

May 03 2018

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Rank #2: Ep003: Antihypertensive Medications and Blood Pressure Ranges

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Let’s talk Blood Pressure and Antihypertensive medications.  A normal BP is defined as a systolic pressure of less than 120 over a diastolic pressure of less than 80.  If the blood pressure ranges from 120-139 over 80-90, the patient is considered to be pre-hypertensive. Stage 1 hypertension is classified by a pressure of 140-159 over 90-99.  Stage 2 hypertension is defined as 160-180 over 100-110. Anything above 180 over 110 is often considered a hypertensive crisis. Sometimes this is narrowed further into hypertensive urgency or hypertensive emergency depending on the level of end-organ involvement, or how symptomatic the patient is.  Sometimes, patients can experience relative hypotension at “normal” pressures when they are used to living with a very high blood pressure.

To treat hypertension, there are three main classes of antihypertensives, which we often supplement with other medications such as diuretics.

First is ACE Inhibitors, or medications that end in -PRIL (Enalapril, Lisinopril, Captopril).  These work by inhibiting the conversion of angiotensin 1 to angiotensin 2, thus preventing fluid retention and vasoconstriction.  Common side effects include dizziness, headache, drowsiness, low BP, rash, and a dry, hacking (very annoying) cough.

Second is Beta Blockers which act to slow heart rate and heart muscle contractility. These medications end in -OLOL, including propranolol, atenolol, metoprolol, esmolol, and timolol. Beta blockers can also cause dizziness, headache, fatigue, and low BP, and can also cause a masking of symptoms of hypoglycemia (so take caution in diabetic patients). They can also counteract bronchodilators in asthmatic patients, so keep this in mind.

Finally, calcium channel blockers decrease the contractility of the heart by blocking calcium uptake in the cardiac muscle. Most of them end is -IPINE with a couple exceptions. There’s Nifedipine, Nicardipine, and Amlodipine, but also Verapamil and Diltiazem. Calcium Channel Blockers can cause low BP and heart rate as well as drowsiness, orthostatic hypotension, and some GI symptoms.

Choosing an antihypertensive depends on the etiology of the patient’s hypertension and will be determined by the provider. It is important that you know how to evaluate for side effects and effectiveness of the medication.

The post Ep003: Antihypertensive Medications and Blood Pressure Ranges appeared first on NRSNG.

Apr 30 2018

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Rank #3: Ep009: Cardiac Biomarkers for Nurses

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In addition to EKG’s, we utilize cardiac biomarkers to determine extent of ischemia and infarction. There are a few main cardiac biomarkers, or also called cardiac enzymes, that we will monitor. As you’ll see, each one has a specific timeline of when it presents, peaks, and returns to normal. Therefore the most accurate way to determine the extent of the injury is to trend them over 12-24 hours.

The first one is myoglobin. Myoglobin is a protein which becomes elevated with any muscle damage. It begins to rise within 1-4 hours from damage, peaks at 6-12, and returns to normal within 1-2 days. However, myoglobin is not specific to the myocardium or cardiac muscle so it could be indicative of other muscle damage.

The second is CK-MB. This isoenzyme is released in the presence of ischemia within muscle tissue. It is not specific to cardiac muscle, but is more specific than myoglobin and highly likely to be elevated with cardiac ischemia. It begins to elevate within 6-10 hours, peaks at 12-24, and days a few days to return to normal.

Third is troponin I. Troponin I is an enzyme specific to cardiac muscle that is released with ischemia and damage.  It is the most consistently specific to cardiac muscle and, due to it’s trend timing, is the most reliable. It begins to rise within 4-6 hours, peaks at 18, and takes a couple weeks to return fully to normal.

In addition to these three main cardiac enzymes, there is also an isoenzyme called LDH that can be monitored. There are 5 types of LDH, and each one will be elevated for different reasons, for example muscle or liver damage. It begins to elevate within 8-12 hours, peaks at 72, and begins to return to normal after a week or two. LDH1 is specific to cardiac muscle damage. However, it is difficult and expensive to test.

Understanding these enzymes will help you to follow lab trends for your MI patient.

The post Ep009: Cardiac Biomarkers for Nurses appeared first on NRSNG.

May 21 2018

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Rank #4: Ep0012: Hierarchy of O2 Delivery

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Let’s simplify oxygen delivery devices. Nasal cannulas fit inside the patient’s nose to deliver a little extra FiO2, like for patients having chest pain. Simple face masks are great for patients needing extra FiO2 but tend to breathe through their mouths. Non-rebreathers have one-way valves preventing re-breathing room air thus delivering a very high amount of FiO2 in emergencies for patients in respiratory distress. Venturi masks are perfect for COPD patients because they deliver a very specific amount of FiO2. The respiratory drive for COPD patients is hypoxemia, so if we give them too much O2, they stop breathing! Trach masks fit over tracheostomy openings and deliver humidified O2. T-pieces are used for patients who have passed a series of weaning trials and are almost ready to come off the ventilator. CPAP and BiPAP give the patient positive airway pressure. “C” stands for continuous meaning the patient gets the same amount of pressure on inspiration and expiration. Sleep apnea patients use these at night. “Bi” means there are two levels of pressure. Patients with CHF exacerbations benefit from positive pressure via bi-pap. SIMV is synchronized intermittent mandatory ventilation and we use this to start ventilator weaning. In SIMV the patient gets a pre-set tidal volume on vent-initiated breaths but their own tidal volume on breaths they initiate. Finally, assist-control is maximum ventilator support where the patient gets a pre-set tidal volume on vent and patient-initiated breaths. We’ll see this used for newly-intubated, post-code patients for example.

The post Ep0012: Hierarchy of O2 Delivery appeared first on NRSNG.

May 31 2018

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Rank #5: Ep0026: Med Math Equations

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Dosage calculation is something that every nursing student either loves or dreads! We all have to pass math exams every semester. It’s either easy points or makes you a nervous wreck! If you’re the second type, I hope this little explanation helps simplify it a bit for you. Because after all, we believe here at NRSNG that nursing school shouldn’t be that hard.  There are four main types of questions we get. 1 is drip rate or drops per minute. 2 is total infusion time, 3 is dosage, and 4 is IV pump rate – always in mililiters per hour. Let’s talk through the basics of how to do each of these.

Calculating drip rate, while not used very often anymore, is very important to know in case pumps fail or the power goes out. The information you need for this formula is the total volume to be infused, total time in minutes, and the drip factor. The drip factor can be found on the packaging for the tubing and will likely be given to you in the problem in nursing school. So let’s say you need to administer 200 mL over 2 hours or 120 minutes. The drip factor is 15 drops per mL.  You multiply the total volume in mL by the drip factor (200 x 15) to get a total number of drops. Divide that by the time in minutes and you’ll be left with drops per minute. In this cast 200 x 15 / 120 = 25 drops per minute. Always round to the nearest whole drop. To titrate that on a roller clamp, you’d think that’s approximately 1 drop every 2 seconds, then time it for a whole minute for accuracy.

To find total infusion time, you will divide the total volume to be infused by the rate. For example “How long would it take to infuse 400 mL at 75 mL per hour?”.  400 divided by 75 = 5.333 or 5 ⅓ hours, which is 5 hrs and 30 minutes. Or how about this. The nurse is infusing a bolus of normal saline. She starts the bolus at 2pm and will run 500 mL at 200 mL per hour.  At what time will the bolus be completed? It’s not a trick question, just has an extra step. We’ll still divide total volume to be infused over the rate in mL per hour. So 500 / 200 = 2 ½. So just find out what time 2 ½ hours later is. In this case, 4:30pm.

3rd, to determine a dose or volume to be administered, you need to know the desired dose, the available dose, and the quantity that dose is in – also known as the concentration. For example, the nurse needs to administer 20 mEq of Potassium Chloride. The available dose is 40 mEq of Potassium Chloride in 30 mL of liquid.  So, desired dose is 20, divided by available dose which is 40, times the quantity which is 30. 20 / 40 x 30 = 15 mL of liquid.

Finally, to find the rate to set on the pump, you need to find the total volume to be infused in a certain amount of time and divide volume by hours. This one may require extra steps to find the total volume or dose – which is the problem we just did!  Once you’ve calculated the volume required, simply divide that over total time in hours to get mL per hour. Here’s an example: The nurse is to administer 1g of Vancomycin over 2 hours. The bag contains 2g of Vancomycin in 500mL. First – how much total volume is required? If you have 2g in 500mL, then 1g is in 250mL. So now we know that we need a total of 250 mL to infuse over a total time of 2 hours. 250 / 2 = 125 mL/hr.

I hope this has helped to make med math a bit simpler. Make sure convert all units before starting these formulas, know your rounding rules and weight-based calculations for pediatric doses, and always double and triple check your answers if you aren’t sure.

The post Ep0026: Med Math Equations appeared first on NRSNG.

Jul 19 2018

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Rank #6: Ep0014: Levels of Consciousness

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Levels of Consciousness
*Alert
Normal
*Patients who are alert is awake or easily awakened by voice from a normal sleep stage are considered alert.
*Lethargic
*Drowsy
*Patients who awaken briefly and answer questions appropriately but easily fall asleep care considered lethargic.
Somnolent
*Very drowsy
*Somnolent patients show excessive drowsiness and respond to stimuli with incoherent mumbles or disorganized movements.
Obtunded
Severely decreased alertness; slowed psychomotor responses
*Obtunded patients have decreased interest in their surroundings, very slow responses, and excessive sleepiness.
Stuporous
Sleep-like state (not unconscious); little/ no spontaneous activity
*Stuporous patients only respond by grimacing or withdrawing from painful stimuli.
Comatose
*Unarousable
*No response to any stimuli
*Mental Status
Oriented
Normal
*Patients who are able to spontaneously state their name, location, and date or time correctly are considered oriented X 3.
*Confused
Disoriented
*Patients who are not able to respond quickly with information about their name, location, or time are confused.
Delirious
Disoriented, restless, hallucinations, sometimes delusions
*Patients who are confused as well as agitated, restless, or hallucinating are considered delirious.

Two really important parts of neurological assessment are level of consciousness and mental status. In fact, level of consciousness is THE most basic and sensitive indicator of altered brain function. If we have a patient who is awake and alert for the 0700 assessment, but becomes lethargic or somnolent as the day progresses, this tells us that something is most definitely NOT RIGHT! While Level of Consciousness (LOC) describes how awake the patient is, mental status describes how oriented to their surroundings a patient is. A patient that is awake, watching TV, and able to state their name, location, and the time accurately is considered awake, alert and oriented X 3 (AAO X 3). This patient’s level of consciousness and mental status are considered normal. What about a patient who is awake but unable to state where they are or what year it is? This patient is alert, but confused to place and location. The Glasgow Coma Scale is the tool we use to assign a numerical value for patients with altered LOC or mental status. It gives us an objective, measurable baseline assessment of the patient’s neuro status so we are able to easily identify and document changes.

The post Ep0014: Levels of Consciousness appeared first on NRSNG.

Jun 07 2018

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Rank #7: Ep0025: Insulin Administration

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Dosage calculation is something that every nursing student either loves or dreads! We all have to pass math exams every semester. It’s either easy points or makes you a nervous wreck! If you’re the second type, I hope this little explanation helps simplify it a bit for you. Because after all, we believe here at NRSNG that nursing school shouldn’t be that hard.  There are four main types of questions we get. 1 is drip rate or drops per minute. 2 is total infusion time, 3 is dosage, and 4 is IV pump rate – always in mililiters per hour. Let’s talk through the basics of how to do each of these.

Calculating drip rate, while not used very often anymore, is very important to know in case pumps fail or the power goes out. The information you need for this formula is the total volume to be infused, total time in minutes, and the drip factor. The drip factor can be found on the packaging for the tubing and will likely be given to you in the problem in nursing school. So let’s say you need to administer 200 mL over 2 hours or 120 minutes. The drip factor is 15 drops per mL.  You multiply the total volume in mL by the drip factor (200 x 15) to get a total number of drops. Divide that by the time in minutes and you’ll be left with drops per minute. In this cast 200 x 15 / 120 = 25 drops per minute. Always round to the nearest whole drop. To titrate that on a roller clamp, you’d think that’s approximately 1 drop every 2 seconds, then time it for a whole minute for accuracy.

To find total infusion time, you will divide the total volume to be infused by the rate. For example “How long would it take to infuse 400 mL at 75 mL per hour?”.  400 divided by 75 = 5.333 or 5 ⅓ hours, which is 5 hrs and 30 minutes. Or how about this. The nurse is infusing a bolus of normal saline. She starts the bolus at 2pm and will run 500 mL at 200 mL per hour.  At what time will the bolus be completed? It’s not a trick question, just has an extra step. We’ll still divide total volume to be infused over the rate in mL per hour. So 500 / 200 = 2 ½. So just find out what time 2 ½ hours later is. In this case, 4:30pm.

The post Ep0025: Insulin Administration appeared first on NRSNG.

Jul 16 2018

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Rank #8: Ep0021: ABG ROME Chart

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There are many tricks to interpreting ABG’s, the ROME chart is just one of them. ROME stands for “Respiratory Opposite Metabolic Equal”. What that means is that if your pH is High, which is alkalosis, then you would either see a Low CO2 (opposite) or a High Bicarb (equal). On the other hand if your pH is Low, or acidotic, you will either see a High CO2 (opposite) or a Low Bicarb (equal). Remember that our CO2 indicates Respiratory source and Bicarb indicates a Metabolic source.  If the numbers you see are reversed, you are likely looking at compensation. Let’s look at an example.

If the pH is 7.5, the pCO2 is 39 and the Bicarb is 32. Normal pH is 7.35 to 7.45, so this pH is high, or alkalotic (draw an up arrow). Normal pCO2 is 35-45, so this pCO2 is normal (draw a flat line). Finally, normal bicarb is 22-26, so this Bicarb is high (draw an up arrow). So what we see is two up arrows – so the arrows are equal – so it is a Metabolic Alkalosis. Let’s look at another example:

If the pH is 7.3, the PCO2 is 55 and the Bicarb is 26. Normal pH is 7.35 to 7.45, so this pH is low, or acidic (draw a down arrow).  Normal pCO2 is 35-45, so this pCO2 is high (draw an up arrow). And normal bicarb is 22-26 so this Bicarb is normal (draw a flat line). What we’re left with is a down arrow and an up arrow – so the arrows are opposite – so it is a Metabolic Alkalosis.  Now, I mentioned compensation – what would this look like in the ROME method? Well, let’s use this same problem, but change the Bicarb to 32 (change the number and draw an up arrow next to it).  In THIS case, you would see a down arrow on the pH, an up arrow on the pCO2, AND an up arrow on the HCO3. Since you know that metabolic arrows are supposed to be equal, you can see that this is a Respiratory sourced Acidosis with metabolic compensation. And since the pH is still out of range, we know it is only partially compensated.

And that’s the ROME method for interpreting ABGs!

The post Ep0021: ABG ROME Chart appeared first on NRSNG.

Jul 02 2018

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Rank #9: Ep0028: Therapeutic Drug Levels

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There are some medications that we give our patients that require close monitoring through testing the blood for levels of the drug.

The goal is to make sure the drug is at therapeutic levels in the system so that it produces the optimum effect with minimal side effects. This also applies to some drugs that can cause toxicity at higher levels.

For drugs like Vancomycin, we draw these drug levels with what we call a trough level. This means we draw the blood right before a dose is due.

The provider or pharmacist will tell you which dose to draw a trough before. Others, like digoxin, lithium, and phenytoin, are drawn at specific intervals after the medication is started.

These timings are based on the half-life of the drug, so it’s important that you draw the level at the time it is ordered.  If you notice results that show a drug is non-therapeutic (below range) or supratherapeutic (above range), notify the provider immediately.

The post Ep0028: Therapeutic Drug Levels appeared first on NRSNG.

Jul 26 2018

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Rank #10: Ep0027: IM Injection Sites

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There are 4 sites we can use for Intramuscular or IM injections, though 3 of them are the most common.  The dorsogluteal, is rarely used due to its risk of damaging the sciatic nerve.

The other three sites are the vastus lateralis, found in the middle third of the lateral aspect of the thigh, the ventrogluteal, on the outside of the hip, and the deltoid muscle of the upper arm.  Let’s look at these sites in detail.

To locate the vastus lateralis, visually divide the thigh into thirds vertically and draw a line directly down the front. You will inject in the lateral aspect of the middle third section.

To locate the ventrogluteal site, place the plam of your hand over the greater trochanter with your middle finger pointing toward the iliac crest and index finger toward the anterior superior iliac spine. Both of these sites can take up to 3mL of medication with a 1 to 1 ½ inch needle, depending on the size of your patient. The injection site for the deltoid muscle is 2-5cm (or about 3 fingers) below the lower edge of the acromion process.

For this site, use 1mL of medication and a 1 inch needle. This site has the most variance based on the size of your patient. A very large patient could handle 2mL and a 1 ½ inch needle.

However, a very small, frail patient, would require a ⅝ inch needle and no more than 1 mL. And remember, intramuscular injections should be administered at a 90 degree angle, with a gentle dart-like motion.

The post Ep0027: IM Injection Sites appeared first on NRSNG.

Jul 23 2018

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