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MARK K Lecture Notes 2025, Exams of Nursing

Walden UniversityNursing

MARK K Lecture Notes 2025 MARK K Lecture Notes 2025

Typology: Exams

2025/2026

Available from 01/04/2026

frinyoo
frinyoo 🇺🇸

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bg1
LECTURE 1
ACID BASES
•learn how to convert lab values to words
•the rule of the B’s!
= if the pH and the BiCarb are both in the same !
direction -> metabolic!
Hint: draw arrows beside each to see directions!
* down = acidosis!
* up = alkalosis!
- respiratory -> has no b in it; if in other directions !
(or if bicarb is normal value)!
- KNOW NORMAL pH, BiCarb, CO2 !
•Hint: DON’T MEMORIZE LISTS…know principles
(they test knowledge of principles by having you
generate lists..) - for “select all” questions!
- ex. in general/principle what do opioids/pain !
meds do? = sedate you, CNS depressors!
* ex. what does dilaudid do? don’t memorize specifics !
or a list of dilaudid, know principles of opioids (such !
as sedation, CNS depression -> lethargy, flaccidity, !
reflex +1, hypo-reflexia, obtunded)!
- boards don’t test by lists because all books/!
classes have different lists!
•principles of S&S acid bases: as the pH goes so
goes my patient (except K+)!
- pH up = PT up -> body system gets more !
irritable, hyper-excitable (EXCEPT K+)!
-> alkalosis - think of a body system and go !
high: hyper-reflexive (+3, +4 [2 is normal]), !
tachypnea, tachycardia, borborygmi, seizure!
- pH down = PT down -> body systems shut !
down (EXCEPT K+)!
-> acidosis - think of a system and go low: !
hypo-reflexive (+1, 0), bradycardia, lethargy, !
obtunded, paralytic illeus, respiratory arrest
•ex. which acid-base disorders need an ambu-bag at
the bedside? = acidosis (resp. arrest)
•ex. which acid-base disorders need suction at the
bedside? = alkalosis (seize and aspirate)
•Mac Kussmaul - Kussmaul’s (compensatory
respiratory mechanism) is only present in only 1 of
the 4 metabolic (acid-base) disorders!
* M = metabolic AC = acidosis!
•most common mistake with select all questions = selecting
one more than you should (stop when you select the ones
you know! don’t get caught up on the “could be’s”)
•Hint: don’t select none or all on select all that apply
questions (never only one and never all)
•Causes of Acid-Base Imbalance:!
- scenarios and what acid-base disorder would !
result (what would cause an imbalance)!
** DON’T MIX UP S&S and CAUSATION!
- often what causes something is the opposite of the S&S!
- ex. diarrhea will cause a metabolic acidosis but once !
you are acidotic your bowel shuts down and you get a !
paralytic illeus
•when you get scenarios: !
-> if it’s a lung scenario = respiratory!
- then check if the client is over-ventilating !
(alkalosis) or under-ventilating (acidosis)!
- remember to look at the words (ex. over, under, !
ventilating) -> “as the pH goes so goes my PT”!
-> VENTILATING DOESN’T MEAN RESPIRATORY !
RATE; resp. rate is irrelevant w/ acid-base, !
ventilation has to do with gas exchange not resp. !
rate (look at the SaO2 -> if your resp. rate is fast !
but SaO2 is low you are under-ventilating)!
-> ex. PCA pump - What acid-base disorder !
indicates they need to come off of it? = respiratory !
acidosis (resp. depression -> resp. arrest)!
—> if it’s not lung, it’s metabolic
•metabolic alkalosis - really only one scenario = if
the PT has prolonged gastric vomiting/suctioning!
- because you are losing ACID!
* ex. GI surgery w/ NG tube with suctioning for !
3 days; hyperemesis graviderum!
- otherwise everything else that isn’t lung you !
pick metabolic acidosis (DEFAULT)!
* ex. hyperemesis graviderum w/ dehydration !
acute renal failure, infantile diarrhea
•remember, you only have 4 to pick from:!
- respiratory alkalosis - respiratory acidosis!
- metabolic alkalosis - metabolic acidosis
•pay more attention to the modifying phrases than
the original noun!
- ex. person w/ OCD who is now psychotic (psychotic !
trumps OCD); hyperemesis with dehydration (pay !
attention to dehydration)
VENTILATION
•ventilators -> know alarm systems (you set it up so
that the machine doesn’t use less than or more than
specific amounts of pressure)!
a) high pressure alarm = increased resistance !
to airflow (the machine has to push too hard to !
get air into lungs)!
- from obstructions: !
i. kinks in tubing (unkink it)!
ii. water condensation in tube (empty it!)!
iii. mucous secretions in the airway (change !
positions/turn, C&DB, and THEN suction)!
*** suction is only PRN!!!!
-> priority questions = you would check !
kinks first, suction is not first!
!
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Download MARK K Lecture Notes 2025 and more Exams Nursing in PDF only on Docsity!

LECTURE 1

ACID BASES

  • learn how to convert lab values to words
  • the rule of the^ B’s = if the pH and the B iCarb are b oth in the same direction -> metabolic Hint: draw arrows beside each to see directions * down = acidosis * up = alkalosis
    • respiratory -> has no b in it; if in other directions (or if bicarb is normal value)
    • KNOW NORMAL pH, BiCarb, CO
  • Hint:^ DON’T MEMORIZE LISTS…know principles (they test knowledge of principles by having you generate lists..) - for “select all” questions
    • ex. in general/principle what do opioids/pain meds do? = sedate you, CNS depressors * ex. what does dilaudid do? don’t memorize specifics or a list of dilaudid, know principles of opioids (such as sedation, CNS depression -> lethargy, flaccidity, reflex +1, hypo-reflexia, obtunded)
    • boards don’t test by lists because all books/ classes have different lists
  • principles of S&S acid bases:^ as the pH goes so goes my patient (except K+)
    • pH up = PT up -> body system gets more irritable, hyper-excitable (EXCEPT K+) -> alkalosis - think of a body system and go high : hyper-reflexive (+3, +4 [2 is normal]), tachypnea, tachycardia, borborygmi, seizure
    • pH down = PT down -> body systems shut down (EXCEPT K+) -> acidosis - think of a system and go low : hypo-reflexive (+1, 0), bradycardia, lethargy, obtunded, paralytic illeus, respiratory arrest
  • ex. which acid-base disorders need an ambu-bag at the bedside? = acidosis (resp. arrest)
  • ex. which acid-base disorders need suction at the bedside? = alkalosis (seize and aspirate) - Mac^ Kussmaul^ - Kussmaul’s (compensatory respiratory mechanism) is only present in only 1 of the 4 metabolic (acid-base) disorders
    • M = metabolic AC = acidosis
  • most common mistake with^ select all questions^ =^ selecting one more than you should (stop when you select the ones you know! don’t get caught up on the “could be’s”) - Hint:^ don’t select^ none^ or^ all^ on select all that apply questions (never only one and never all)
  • Causes of Acid-Base Imbalance:
    • scenarios and what acid-base disorder would result (what would cause an imbalance) **** DON’T MIX UP S&S and CAUSATION**
  • often what causes something is the opposite of the S&S
  • ex. diarrhea will cause a metabolic acidosis but once you are acidotic your bowel shuts down and you get a paralytic illeus
  • when you get scenarios: -> if it’s a lung scenario = respiratory
  • then check if the client is over-ventilating (alkalosis) or under-ventilating (acidosis)
  • remember to look at the words (ex. over, under, ventilating) -> “as the pH goes so goes my PT” -> VENTILATING DOESN’T MEAN RESPIRATORY RATE; resp. rate is irrelevant w/ acid-base, ventilation has to do with gas exchange not resp. rate (look at the SaO2 -> if your resp. rate is fast but SaO2 is low you are under-ventilating) -> ex. PCA pump - What acid-base disorder indicates they need to come off of it? = respiratory acidosis (resp. depression -> resp. arrest) —> if it’s not lung, it’s metabolic
  • metabolic alkalosis^ - really only one scenario =^ if the PT has prolonged gastric vomiting/suctioning
  • because you are losing ACID
  • ex. GI surgery w/ NG tube with suctioning for 3 days; hyperemesis graviderum - otherwise everything else that isn’t lung you pick metabolic acidosis (DEFAULT)
  • ex. hyperemesis graviderum w/ dehydration acute renal failure, infantile diarrhea
  • remember, you only have 4 to pick from:
  • respiratory alkalosis - respiratory acidosis
  • metabolic alkalosis - metabolic acidosis
  • pay more attention to the^ modifying phrases^ than the original noun
  • ex. person w/ OCD who is now psychotic (psychotic trumps OCD); hyperemesis with dehydration (pay attention to dehydration) VENTILATION
  • ventilators ->^ know alarm systems^ (you set it up so that the machine doesn’t use less than or more than specific amounts of pressure) a) high pressure alarm = increased resistance to airflow (the machine has to push too hard to get air into lungs)
  • from obstructions : i. kinks in tubing (unkink it) ii. water condensation in tube (empty it!) iii. mucous secretions in the airway (change positions/turn, C&DB, and THEN suction) *** suction is only PRN!!! -> priority questions = you would check kinks first, suction is not first

b) low pressure alarm = decreased resistance to airflow (the machine had to work too little to push air into lungs)

  • from disconnections : i. main tubing (reconnect it duh!) ii. O2 sensor tubing (which senses FiO2 at the airway/trach area; black coated wire coming from machine right along the tubing - reconnect!)
  • ventilators^ -> know blood gases
  • resp. alkalosis = ventilation settings might be set too high (OVER-VENTILATING)
  • resp. acidosis = ventilation settings might be set too low (UNDER-VENTILATING)
  • ex. weaning a PT off ventilator -> should not be under-ventilated, they need the ventilator; if they are over-ventilating then they can be weaned
  • never pick an answer where you don’t do something and someone else has to do something
  • PT teaching = avoid ALL forms of alcohol to avoid nausea, vomiting & possibly death -> including mouthwash, aftershaves/colognes/perfumes (topical stuff will make them nauseous), insect repellants, any OTC that ends with “-elixer”, alcohol- based hand sanitizers, uncooked (no-bake) icings which have vanilla extract, red wine vinaigrette
  • Overdoses & Withdrawals:
  • every abused drug is either an UPPER or DOWNER -> the other drugs don’t do anything -> #1 abused class of drug that is not an upper or downer = laxatives in the elderly a) first establish if the drug is an upper or downer
  • uppers (5) = caffeine, cocaine, PCP/LSD (psychedelic hallucinogens), meth amphetamines , add erol (ADD drug)
  • S&S -> make you go up; euphoria, tachycardia, restlessness, irritability, diarrhea, borborygmi, hyper-reflexia, spastic, seize (need suction)
  • downers = don’t memorize names -> anything that is not an upper is a downer! if you don’t know what the med is, you have a high chance that it’s a downer if it’s not part of the uppers list
  • S&S -> make you go down; lethargy, respiratory depression (& arrest)
  • ex. The PT is high on cocaine. What is critical to assess? -> NOT resps below 12 because they will be high -> maybe check reflexes b) are they talking about overdose or withdrawal
  • overdose/intoxication = too much
  • withdrawal = not enough
  • ex. the PT has overdosed on an upper -> pick the S&S of too much upper
  • ex. the PT has overdosed on a downer -> pick the S&S of too much downer
  • ex. the PT is withdrawing from an upper -> not enough upper makes everything go down
  • ex. the PT is withdrawing from a downer -> not enough downer makes everything go up _- upper overdose looks like = downer withdrawal
  • downer overdose looks like = upper withdrawal_
  • In what 2 situations would resp. depression & arrest be your highest priority:
  • downer overdose
  • upper withdrawal
  • In what 2 situations would seizure be the biggest risk:
  • upper overdose
  • downer withdrawal
  • Drug Abuse in the Newborn:
  • always assume intoxication, NOT withdrawal at birth
  • after 24 hrs -> withdrawal
  • ex. caring for infant of a Quaalude addicted mom 24 hrs. after birth, select all that apply: -> downer withdrawal so everything is up = exaggerated startle, seizing, high pitched/shrill cry
  • Alcohol Withdrawal Syndrome vs. Delirium Tremens
  • they are both different! not the same a) every alcoholic goes through withdrawal 24 hrs. after they stop drinking
  • only a minority get delirium tremens
  • timeframe -> 72 hrs. (alcohol withdrawal comes 1st)
  • alcohol withdrawal syndrome ALWAYS precedes delirium tremens, BUT delirium tremens does not always follow alcohol withdrawal syndrome b) AWS is not life-threatening; DT’s can kill you c) PT’s w/ AWS are not a danger to self/others; PT’s w/ DT’s are dangerous to self/others
  • they are withdrawing from a downer so they will be exhibiting upper S&S
  • DT’s are dangerous
  • RN’s can accept but RPN’s can’t (because PT is unstable)
  • on med-surge, the RN who takes them must decrease their workload (i.e. reduce PT load if they take a DT PT) -> Hint: on boards, the setting is always perfect (i.e. enough staff/time/resources on the unit etc.) Differences in Care AWS DT Diet Regular diet NPO/clear liquids (because of risk for seizures which can cause risk of aspiration) Room Semi-private anywhere on the unit Private near nurses station (dangerous & unstable) Ambulation Up ad lib Restricted bed rest -> no bathroom privileges (use bedpans/urinals) Restraints No restraints (because not dangerous) Restraints (because dangerous)
  • not soft wrist or 4 point soft because they’ll get out
  • need to be in vest or 2-pt. locked leathers (opposite 1 arm & leg, rotate Q2hrs, lock the free limbs 1st before releasing the locked ones) They both get ANTI-HYPERTENSIVES & TRANQUILIZERS
  • because everything is up (downer withdrawal) They both get MULTIVITAMIN w/ B

DRUGS

AMINOGLYCOCIDES

  • powerful class of^ antibiotics^ (when nothing else works pull these outs, the big guns)
    • don’t use unless anything else works
  • boards love to test these drugs because they’re dangerous and are a test of safety
  • think:^ A MEAN OLD MYCIN -> a mean old = they treat serious, life-threatening, resistant, Gram-neg bacteria infections (i.e. a mean old antibiotic for a mean old infection ) -> mycin = what they end with ( all end w/ -mycin) ** not all -mycin’s are aminoglycosides BUT most are (the 3 that are not are ery thro mycin, azi thro mycin, clari thro mycin = throw it off the list! )
  • 2 toxic effects: i) when you see ‘-mycin’, think mice - mice -> ears -> otto toxic - monitor hearing, tinnitus, vertigo/dizziness ii) the human ear is shaped like a kidney so next effect is nephrotoxicity - monitor creatinine (not BUN, output, daily weight) * creatinine = the best indicator of kidney/renal function (pick 24 hr. creatinine clearance over serum creatinine if both available)
  • #8 (fits nicely in the kidney) reminds you about 2 things about these drugs
    • toxic to cranial nerve 8 = ear nerve
    • administer Q
  • route:
    • IM or IV
  • do not give PO -> they are not absorbed
    • if you give an oral ‘-mycin’ it will go into gut, dissolve, go through and come out as expensive stool (won’t have any systemic effect)
    • EXCEPT in 2 cases = bowel sterilizers :
      • hepatic encephalopathy (hepatic coma) = to get ammonia down, oral ‘-mycin’s’ will sterilize the bowel by killing Gram-neg bacteria (E. coli) to help bring down ammonia and won’t harm the damaged liver because it doesn’t go through the liver (also gives diarrhea, more poop out is good)
      • pre-op bowel surgery = it sterilizes the gut by killing the E. coli bacteria
    • if oral, no otto or nephro toxicity because not absorbed
    • these are neomycin & kanamycin *** Who can sterilize my bowels? NEO KAN**
  • Trough and Peak levels:
    • trough = drug at lowest
    • peak = drug at highest ** TAP levels - trough administer peak -> draw trough levels first -> administer your drug -> draw peak levels after drug administration - Why draw levels?^ =^ narrow therapeutic window - small difference between what works and what kills - if the drug has a wide range then you wouldn’t need to draw TAP levels * ex. Lasix doses range from 5-80mg thus a wide range so you won’t need TAP levels * ex. Dig doses range from 0.125 - 0.25 so this narrow range needs TAPS levels - A MEAN OLD MYCINS = major class that needs TAPs drawn because of narrow window - When do you draw TAPS? -> depends on the route (don’t focus on the med) a) Trough Levels ** doesn’t matter which route or med, always 30 mins. - sublingual = 30 mins. before next dose - IV = 30 mins. before next dose - IM = 30 mins. before next dose - Sub-Q = 30 mins. before next dose - PO = 30 mins. before next dose b) Peak Levels ** different but depends on the route (not the med) - Sublingual = 5-10 mins after drug is dissolved - IV = 15-30 mins after drugs is finished infusing * Hint: if you get two values that are correct (i.e. a 15 min. answer and a 30 min. one) pick the highest without going over so 30 mins. - IM = 30-60 mins. after administration - Sub-Q = SEE (see diabetes lecture -> because the only Sub-Q peaks are Insulins ) - PO = forget about it, too variable so not tested The BIG 10 Drugs to Know: 1. psych drugs 2. insulins 3. anti-coagulants 4. digitalis 5. aminoglycosides 6. steroids 7. calcium-channel blockers 8. beta-blockers 9. pain meds 10. OB drugs

- Treatment^ (more drugs): a) PVC’s b) V-tach = for ventricular use LIDOCAINE/AMIODARONE * in rural areas more Lidocaine use (cheaper & longer shelf-life) c) Supra-Ventricular Arrhythmia’s = atrial arrhythmia’s use ABCD’s - A -> ADENOCARD (Adenosine) - have to push in less than 8 seconds (FAST IV push) -> slam this drug, followed by a flush; use a big vein; BUT the problem w/ slamming it fast is the risk of PT going into A-Systole (for 30 seconds but they will come out of it so don’t worry [unless longer than 30 sec…]) ** for IV pushes: when you don’t know you go slow - B -> BETA-BLOCKERS - all end in ‘-lol’ - every ‘-lol’ is a BB & every BB is a ‘-lol’ - are negative inotropes, chronotropes, & dromotropes like calcium-channel blockers (a.k.a. valium for your heart so they treat A, AA, AAA & have same side-effects) ** generally speaking, don’t make a big difference between Beta- & Calcium channel blockers; except that CCB are better for PT’s w/ asthma or COPD -> Beta-B’s bronchoconstrict - C -> CALCIUM-CHANNEL BLOCKERS - see Beta-Blockers & CCB’s earlier - D -> DIGITALIS (DIGOXIN, LANOXIN) d) V-Fib = for V-fib you D-fib (shock them!) e) A-Systole = use EPINEPHRINE & ATROPINE (in this order!) -> if epinephrine doesn’t work then use atropine **CHEST TUBES

  • purpose is to**^ re-establish negative pressure^ in the pleural space (so that the lung expands when the chest wall moves)
    • pleural space -> negative is good (negative pressure makes things stick together)
    • ex. gun shot to the lung add positive pressure - Hint:^ when you get a chest tube question, look at the reason for which it was placed (will tell you what to expect & what not to expect)
    • ex. pneumothorax = to remove air (because air created the positive pressure)
    • ex. hemothorax = to remove blood
    • ex. pneumohemothorax = to remove blood & air - Hint:^ Also, pay attention to the^ location^ of the tubes : a) Apical = the chest tube is way up high, thus it is removing air (because air rises)
    • ex. it’s bad if you’re apical tube is draining 200 mL or it is not bubbling b) Basilar = at the bottom of the lungs, thus it is removing blood /liquid (because of gravity) - ex. it’s bad if your basilar tube is bubbling or not draining any mL - ex. How many chest tubes & where would you place them for a unilateral pneumohemothorax?
  • 2 chest tubes (apical for pneumo, basilar for hemo) - ex. How many chest tubes & where would you place them for a bi-lateral pneumothorax?
  • 2 tubes (apical on left, apical on right) - ex. How many chest tubes & where would place them for post-op chest surgery?
  • 2 tubes (apical & basilar on the side of the surgery) ** you are to assume that chest surgery/trauma is unilateral unless otherwise specified ( they will say bilateral ) - Trick Question:^ How many chest tubes would you need and where would you place them for a post-op right pneumonectomy?
  • NONE! because you are removing the lung so you don’t need to re-establish any pressure (there is not pleural space)! **Troubleshooting Chest Tubes:
  • What do you do if you knock over the plastic containers that certain tubes are attached to?** -> set it back up & have PT take some deep breaths -> NOT a medical emergency! (don’t call MD) - What do you do if the water seal breaks (the actual device breaks?) -> first = CLAMP it!!! because now positive pressure can get in! don’t let anything get in -> 2nd = cut the tube away from the broken device -> 3rd = stick that open end into sterile water -> then unclamp it because you’ve re-established the water seal (doesn’t need clamp if it’s under water *** better for the tube to be under water than clamped! -> air can’t go in and stuff can still keep coming out (if clamped, nothing can come out which is what the tube is for) - Ex. If they ask what the^ first^ thing is to do if the seal breaks -> Clamp! BUT, if they ask what’s the best thing to do -> put end of tube under water! (because it actually solves the problem, clamping is a temp. fix) - Hint:^ ‘BEST’ vs. ‘FIRST’ questions
  • first questions = are about what order
  • best questions = what’s the one thing you would do if you could only do 1 of the options -> ex. You notice the PT has V-fib on the monitor. You run to the room and they are non-responsive with no pulse. What is the first thing you do? A) place a backboard? B) begin chest compressions?
  • “first” is about order so = pick A (because you wouldn’t start chest compressions first)
  • BUT, if the question ask “What’s the best thing to do?” -> you only get to do 1 thing not the other so you would pick B

- What do you do if the chest tube gets pulled out? - first = take a gloved hand and cover the hole - best = cover the hole with vaseline gauze - Bubbling chest tubes:^ (ask yourself 2 questions) a) Where is it bubbling? b) When is it bubbling? = the answer will depend on these 2 questions (sometimes bubbling is good, sometimes bad but depends on where & when) - ex. Intermittent bubbling in the water seal -> GOOD (document it, never bad! ) - ex. Continuous bubbling in the water seal -> BAD (you don’t want this, means a leak in the system that you need to find and tape it until it stops leaking) ** in RPN scope - ex. I ntermittent in suction control chamber -> BAD (means suction is not high enough, turn it up on the wall until bubbling is continuous) - ex. Continuous in suction control chamber -> GOOD (document it) - Hint: both locations are opposites of each other (memorize one & deduce the others) —> if there is a seal it should not be continuous (ex. a sealed bottle of pop continuously bubbling means it’s leaking!) - A straight catheter is to a foley catheter as a thoracentesis is to a chest tube. - in-&-out vs. continuous secured - thoracentesis -> also helps re-establish neg. pressure (in-&-out chest tube) - higher risk for infections are continuous Rules for Clamping Tubes: - a)^ Never clamp a tube for more than^ 15 seconds without a doctors order. - so if you break the water seal -> you have 15 seconds to get that tube under water - b)^ Use^ rubber-tipped^ doubled clamps. - the teeth of the clamp need to be covered w/ rubber so that you don’t puncture the tube

CONGENITAL HEART DEFECTS

- every congenital heart defect is either TROUBLE or NO TROUBLE (ALL BAD or NO BAD) - either causes a lot of problems or it’s no big deal ( no in-between defect ) - memorize one word:^ TRouBLe - ex. You are teaching the parents about a heart defect: - pick all the options that cause trouble - Hint:^ Boards will not give pictures of defects and ask you what they are. - not our job, we don’t diagnose - our role is teaching parents the implications -> so if it’s trouble = teach them things that it’s going to be a lot of trouble -> if it’s not trouble = pick the things saying it’s not going to be trouble - There are 40+ congenital heart defects so just remember TRouBLe (don’t memorize all of them!): - Hint: all congenital heart defects that start w/ the letter T are Trouble Defects - we don’t care about the defect, we care about what we’re teaching the parents - All congenital heart defect kids (trouble or no trouble) will have 2 things: a) Murmur - why? = because of the shunting of the blood (regardless of direction of shunt) b) all have an Echocardiogram done (to find out what the defect is or why there’s a murmur) - 4 Defects of Tetralogy of Fallout: - V arie D P icture S O f A R anc H (or Valentines Day Pick Someone Out A Red Heart) 1. VD = ventricular defect 2. PS = pulmonary stenosis 3. OA = overriding aorta 4. RH = right hypertrophy - don’t have to^ recall^ these,^ RECOGNIZE^ them - recall -> remember from nothing - RECOGNIZE -> spot it when you see it (use the initials to recognize them in questions) - ONLY DEFECT where they ask you^ what^ it is Heart Defects TRouBLe (95% of all heart defects) No Trouble Surgery NEED surgery now to live - don’t need surgery right away; possibly need it years later if it causes a Trouble (but we don’t expect it to) Growth & Dev. slow, delayed normal Life Expectancy short normal Parent’s Experiencing grief, stress, financial issues, lots of caregiving issues regular average person issues Going Home apnea monitor no apnea monitor Hospital Stay at Birth weeks 24-48 hours Who Follows Your Care Paediatric Cardiologist Paediatrician, paediatric NP Shunting R to L (T R ouB L e) L to R Cyanosis Cyanotic -> Blue (TRou B Le) Acyanotic

LECTURE 4

CRUTCHES, CANES, WALKERS

- major area of human function is^ locomotion^ so they test these even though not a major emphasis in school - area to test PT teaching & risk reduction Crutches: - How do you^ measure crutches? ** need to know for risk reduction -> so you don’t cause nerve damage a) length of crutch = 2-3 finger-widths below anterior axillary fold to a point lateral to & slightly in front of the foot -> many questions ask where you measure from/to (so for crutches, if they ask anything measuring from axilla to foot -> rule out, they’re wrong instructions for length) b) hand grip = can be adjusted up & down; when properly placed, should be apx. 30 degrees elbow flexion - How to teach^ crutch gaits^ (4 kinds): ** names are pretty obvious w/ a few exceptions a) 2-point - move a crutch and opposite foot together followed by other crutch & opposite foot - moving 2 things together b) 3-point - moving 2 crutches & the bad leg together - moving 3 things together c) 4-point - moving everything separately - move any crutch, then opposite foot, followed by next crutch then other foot - very slow but very stable d) Swing-through - for non-weight bearing injuries (ex. amputations) - plant crutches and swing the injured limb through (never touches down) - When do they use them? - ask yourself “how many legs are affected?” - even for even, odd for odd * even point gaits when a weakness is evenly distributed (i.e. even # of legs messed up) - 2-point = mild problems (bilateral) - 4-point = severe problems (severe, bilateral weaknesses) - 3-point = only odd one , when only 1 leg is affected - Ex.^ Early stages of rheumatoid arthritis^ = 2-point Ex. Left, above the knee amputation = swing-through Ex. First day post-op right knee replacement, partial weight- bearing allowed = 3-point Ex. Advanced stages of ALS = 4-point Ex. Left hip replacement, 2nd day post-op, non weight-bearing = swing-through Ex. Bilateral total knee replacement, 1st day post-op, weight- bearing allowed = 4-point Ex. Bilateral total knee replacement, 3 weeks post-op = 2 point - Going up & down stairs: - up with the good, down with bad - crutches move with the bad leg Cains: - hold the cain on the^ strong side - a lot of people use it the wrong way Walkers: - pick it up, set it down, walk to it - if they^ must^ tie their belongings to the walker, tie it at the sides, not the front - boards doesn’t like things on the front (even tho most people do that anyways; they don’t like wheels or tennis ball on the bottom either)

DELUSIONS, HALLUCINATIONS, & ILLUSIONS (Psych) Neurosis Non-Psychotic vs. Psychosis

- Hint:^ the^ first thing^ you have to do to get a psych questions correct is decide: “ Is my PT non-psychotic or psychotic? ” = this will determine treatment, goals, prognosis, medication, length of stay, legalities…everything Psychotic Symptoms: - a)^ Delusions = false, fixed, idea or belief; no sensory component (all in the brain, thinking it) i. Paranoid Delusions -> people are out to harm me - ex. the mafia are out to get me ii. Grandiose Delusions -> you are superior or you are the world’s smartest/greatest person - ex. thinking you are Christ, Genghis Khan iii. Somatic Delusions -> about a body part - ex. x-ray vision; there are worms in my body - b)^ Hallucinations = a false, fixed, sensory experience (purely sensory); 5 senses so 5 for (1 for each sense) i. Auditory -> hearing things that aren’t there (primarily voices telling you to hurt yourself); most common ii. Visual -> seeing; 2nd most common iii. Tactile -> feeling things; 3rd most common iv. Gustatory -> tasting things that are not there v. Olfactory -> smelling things that are not there *** last 2 are relatively rare - c)^ Illusions = misinterpretation of reality ; sensory experience - difference from hallucination -> with an illusion there is a referent in reality -> referent = something in reality to which a person refers when they say something (they just misinterpret it) - ex.^ PT says: “I hear demon voices”^ -> hallucination ex. PT overhears nurses & MD’s laughing & talking at the nurse’s station & says: “Listen, I hear demon voices” -> illusion (there is a referent) ex. person staring at a wall & says: “I see a bomb” -> hallucination ex. person looks at fire extinguisher on the wall and says: “I see a bomb” -> illusion (referent) - Hint:^ On the test, they will tell you that there is something there thus, you can differentiate between a hallucination & an illusion. How do you deal with these Psychotic Symptoms? - first thing you ask after determining if PT is psychotic: What is their problem? —> **what kind of psychosis do they have?

  • 3 Types of Psychosis:**
  1. Functional Psychosis
  • can function in everyday life (i.e. have jobs, a marriage, etc.)
  • 4 diseases: Schizo Schizo Major Manics i. Schizophrenia ii. Schizoaffective Disorder iii. Major Depression (if it’s major, test will say) iv. Manic (Acute) -> so bi-polar is functional, only psychotic during manic phase
  • these PT’s have the potential to learn reality (because no damage) -> may need meds or set boundaries for structure -> nurse role = teach reality (4 steps) a) acknowledge feeling -> “I see you’re angry; “You seem upset”, “Tell me how you are feeling”, often uses the word feeling or shows a feeling b) PRESENT REALITY -> “I know that those voices are real to you but I don’t hear them” or telling them what is real (“I’m a nurse & this is a hospital”) c) set a limit -> “That topic/behavior is off-limits”, “We are not going to talk about that right now”, “Stop talking about that” d) enforce the limit -> “I see you’re too ill to stay reality based so our convo is over” (ending the conversation NOT taking away a privilege [i.e. punishment]; continuing to talk may enforce the non-reality) *** on the test, they won’t ask these specific steps but instead, will ask “how should the nurse respond…” *** try to pick the more positive statements (i.e. what they can have/do, not what they can’t); if between 2 statements go w/ the positive one - 2.^ Psychosis of Dementia
  • psychosis because of actual damage to the brain
  • in Functional Dementia, there is no brain damage; it’s just messed up chemicals
  • include PT’s w/ Alzeimer’s, psychosis after a stroke, organic brain syndrome; anything w/ “senile” or “dementia”
  • cannot learn reality -> major difference from functional (which is why you have to determine type of psychosis) NON-PSYCHOTIC PSYCHOTIC Definition Has insight & is reality-based
  • even w/ emotional distress/illness, mental/behavioral disorder
  • recognize what the problem is and how it affects their life Has no insight & is not reality-based
  • don’t think/know their sick
  • think everyone else has the problem but not them (blame anyone else)
  • even if they say they’re sick but then they say the martians made them sick they don’t have insight Treatment/ Techniques
  • good therapeutic communication (like any PT that displays good comm. skills) ** there’s nothing special that you need to do/know compared to any med-surge, paeds, or OB PT
  • good therapeutic communication does not work because they are not rational
  • need unique, specific strategies Symptoms don’t have delusions, hallucinations, or illusions DELUSIONS, HALLUCINATION, ILLUSIONS
  • only in psychotic PT’s
  • as soon as they get any of these they’ve crossed the line to being psychotic

LECTURE 5

DIABETES M.

- definition^ =^ an error of glucose metabolism - causes issues because glucose is the primary fuel source and if your body can’t metabolize glucose, cells will die - does^ not^ include^ diabetes insipidus^ =^ polyuria, polydipsia leading to dehydration due to low ADH -> it’s just similar with the fluids, not the glucose part (similar symptoms) - opposite syndromes of diabetes i. = SIADH - relationship between^ amount of urine^ &^ specific gravity of urine : - they are opposites/inverse - i.e. the less urine out, the higher the specific gravity; the more urine out, the lower the specific gravity * so diabetes = has more urine & low specific gravity (opposite with SIADH) TYPE I vs. TYPE II: Diet: - primarily Type II - a)^ It is a calorie restriction. - tells you that calorie’s are important because the diet’s are named (ex. 1500 calorie…) *** this is the best strategy for them - b)^ They need 6 small feedings a day. - keeps blood sugar levels more normoglycemic throughout the day instead of 3 big peaks Insulin: - lowers^ blood glucose - 4 main types you really need to know: 1. Regular Insulins -> the “R” is important - ex. Humulin R, Novalin R - onset = 1 hr. - peak = 2 hrs. - duration = 4 hrs. - is clear (solution) so it can be IV dripped (this is the one used if using IV’s) - short, rapid acting insulin (but Hesi will call it intermediate because we now have Lispro which acts faster)

2. N P H

  • true intermediate acting insulin
  • onset = 6 hrs.
  • peak = 8-10 hrs.
  • duration = 12 hrs.
  • is cloudy (suspension)
    • the issue w/ suspensions is that it precipitates -> the particles fall to the bottom over time so you CANNOT give via IV (or the PT will overdose & the brain will die)
    • Hint: general rule => never put anything cloudy in an IV bag
  1. Lispro (Humalog)
  • fastest acting, rapid
  • onset = 15 mins.
  • peak = 30 mins.
  • duration = 3 hrs.
  • you give this as they being to eat so with meals ( not ac) -> interrupt them while eating!
  1. Lantus (Glargine)
  • long acting
  • peak = no essential peak because it’s so slowly absorbed -> thus, little to no risk for hypoglycemia
  • duration = 12-24 hrs.
  • only insulin you can safely & routinely give at bedtime because it will not cause them to go hypoglycemic during the night (YOU CANNOT ROUTINELY GIVE THE OTHERS AT BEDTIME) ** Hint: boards likes to test peaks & tend to test it by giving you a time when insulin was given & asking when they reach hypoglycemia (which is the peak). - CHECK^ EXPIRY DATES^ ON INSULIN!!!
  • What action by the nurse invalidates the manufacturer’s expiration date? = opening it -> the minute you open it the date is irrelevant because now you have 30 days from opening (have to write the date of opening & new expiry)
  • refrigeration is optional in the hospital BUT you need to teach PT’s to refrigerate at home -> though at the hospital the ones that should be refrigerated should be the un-opened vials
  • better to give warm, non-expired insulin than cold, expired insulin Exercise: - exercise potentiates insulin = meaning, it does the same thing as insulin —> think of exercise as another shot of insulin
  • if you have more exercise during the day, you need less insulin shots (and bring easily metabolized carbs/snacks to sports games) Differences TYPE 1 DM TYPE 2 DM Names - Insulin dependent
  • Juvenile onset
  • Ketosis prone
  • Non-insulin dependent
  • Adult-onset
  • Non-ketosis prone S&S - polyuria
  • polydipsia
  • polyphagia (increased swallowing, but in context of DM it also relates to eating)
  • same Treatment D = diet —> least important (less restrictions than before) I = insulin —> MOST IMPORTANT E = exercise D = diet —> MOST IMPORTANT O = oral hypoglycemic (pills) A = activity

Sick Days:

- when a diabetic is sick -> GLUCOSE GOES UP - need to take their insulin even if they’re not eating - need to take sips of water because diabetics get dehydrated - any sick diabetic is going to have the 2 problems of hyperglycemia & dehydration -> ALWAYS! - stay as active as possible because it helps lower glucose (even if they’re not eating when sick) Complications of Diabetes: = 3 acute and a boatload of chronics **ACUTE

  • 1.**^ Low Blood Glucose^ (in^ both^ types)
    • a.k.a. insulin shock, insulin reaction, hypoglycemia, hypoglycemic shock
    • What causes this? -> not enough food -> too much insulin/medication (primary cause) -> too much exercise
    • the danger is brain damage which becomes permanent (so be careful not overmedicate!)
    • S & S: -> drunk in shock = think of how people look while drunk -> slurring, staggering, impaired judgement, delayed reaction time, labile (emotions all over) ** from cerebrocortical compromise = shock -> low BP, tachycardia, tachypnea, cold/ pale/clammy skin, mottled extremities ** from vasomotor compromise
    • Treatment: a) Administer rapidly metabolizable carbohydrate (i.e. sugars) -> ex. any juice, reg. pop, chewable candy, milk, honey, icing, jam b) BUT combine/follow w/ a starch or protein -> ex. cracker, slice of turkey *** skim milk is great because it gives both
  • bad combo is too much simple sugars (like pop & candy)
  • if unconscious give Glucagon (IM) or IV Dextrose (D10, D50) -> how do you determine which to give? = the setting (i.e. family calling from home, tell them to give IM but if in ER give IV) ** hard to get a vein because of vasoconstriction - 2.^ High Blood Glucose in^ TYPE I^ = Diabetic Coma/ DKA (Diabetic Keto-acidosis) -> Hint: Type I is also called “ketosis-prone”
    • What causes this? -> too much food -> not enough medication -> not enough exercise *** none of these are the #1 cause because it is acute viral upper respiratory infections (w/in the last 2 weeks) - PT contracts upper resp. infection -> recovers w/in 3-5 days like everyone BUT after initial recovery, they start going downhill & getting more lethargic * so, if they come into the ER you should ask if they’ve had a viral upper resp. infection in the last 2 weeks -> what causes the high glucose is the stress of the illness that was not “shut off” and they start burning fats for fuel -> ketosis
  • S & S: -> spell out D K A
  • D = dehydration
  • K = k etones (in blood ), k ussmaul’s, high K +
  • you can have ketones in your urine & not have DKA
  • A = a cidotic (metabolic), a cetone breath, a norexia (due to nausea) -> hot & flushed, dry = water is a coolant! if you lose water (as in dehydrate) you loose coolant
  • Treatment: -> fast rate IV fluids (ex. 200/hr.), w/ reg. insulin in the bag - 3.^ High Blood Glucose in^ TYPE II^ = HHNK/HHS (Hyperglycemic Hyperosmolar Non-Ketotic Syndrome) = this is dehydration (for any HHNK/HHS question just call it DEHYDRATION)
  • so think of the S&S of dehydration (low water, hot temp, flushed, dry)
  • nursing diagnosis = fluid volume deficit
  • #1 intervention -> giving fluids!
  • outcomes you want to see = increased output, BP coming up, moist mucus membranes etc. ** so all the outcomes of a PT coming out of dehydration
  • Why do these PT’s only get the D (& not the K & A)? -> they don’t burn fats (which make the ketones) - Which one is insulin the most essential in treating? = DKA -> you don’t have to use insulin w/ HHNK because you mostly need to re-hydrate them - Which has a higher mortality rate? = HHNK -> DKA’s tend to be a higher priority and symptoms are much more acute; HHNK’s tend to come in to ER later than they should because symptoms are not as visible & they end up getting worse (so by the time they come in it might be too far gone) - Who would die first if didn’t treat them? (more life- threatening) = DKA -> but they tend to get treated in time

LECTURE 6

DRUG TOXICITY

- 5 main ones to know -> tests nurse safety -> remember, they don’t test units

  1. LITHIUM - for the^ mania^ in bi-polar **- therapeutic level = 0.6 - 1.
  • toxic level =**^ >^2 - What about between 1.2 - 2??? -> no books agree on what is going on in between those levels (grey area) -> boards would not give you any values in the grey area (because item writers for the NCLEX need to test on what the books agree and books agree that over 2 is toxic)
  1. DIGOXIN (LANOXIN) - used to basically treat 2 things: a) A-fib -> remember the ABC D ’s of treating atrial arrythmias b) **congestive heart failure
  • therapeutic level = 1 - 2
  • toxic level =**^ >^2 *** NOTE: both have 2! -> so if the question uses the value of 2, call it toxic (safer to call something toxic when it may not be than to say that it’s therapeutic when it might not be) - take the apical heart rate^ before^ giving Dig
  1. AMINOPHYLLINE - airway antispasmodic
    • technically not a bronchodilator -> it doesn’t stimulate beta-2 agonist cells to bronchodilate
    • it just relaxes a muscle spasm -> in spasms = airway is narrow -> when you relax a spasm, airways widen (which is why it looks like a bronchodilator) * ex. epinephrine is a bronchodilator - ex.^ sometimes PT’s come in w/ an acute asthamatic attack & the bronchodilators aren’t working -> because they are in an acute, lock-down spasm & the spasm is in the way of the bronchodilator = give them aminophylline first to relieve the spasm = then you can give the bronchodilator after and it will work **- therapeutic level = 10 - 20
  • toxic level =**^ >^20
  1. DILANTIN (PHENYTOIN) - anticonvulsant; treat seizures **- therapeutic level = 10 - 20
  • toxic level =**^ >^20

5. BILIRUBIN

- waste product from the breakdown of RBC’s - Hint:^ Boards will^ only^ test^ bili’s in newborns - normal adult bili = 1-2 (low) - newborns have higher levels from breaking down RBC’s from mom = 5 + - therapeutic level -> elevated level = 10 - 20 - ex. if newborn has 9.9 it’s high but still “normal” - bilirubin toxicity =^ >^20 - right around 14-15 is when MD’s start thinking about hospitalization because once you’re at 15, you’re halfway to toxic (don’t want it to get to 18 or 19, too close to toxic) - pathologic^ jaundice^ = bili high & infant yellow at birth - come out yellow - physiologic^ jaundice^ = bili is normal at birth but over the next 2-3 days it goes high - becomes yellow - HINT: - for the two “L” drugs = 2 (pick the l ower number) - the other one’s = 20 (pick the higher #) **Kernicterus & Opisthotonos:

  • kernicterus**^ =^ bilirubin in the^ brain^ when it crosses the BBB ( condition ) -> is in the brain, in the CSF, in the meninges
    • different from jaundice = yellow color from too much bilirubin in the skin
    • usually occurs when you reach levels of 20
    • bili in the brain causes aseptic meningitis & aseptic encephalitis; can be lethal - opisthotonos^ =^ position^ the baby assumes when they have bilirubin in the brain = severe hyperextension due to the irritation of the meninges w/ the bilirubin -> newborns have high flexibility so when they hyperextend they’re heels will touch their ears & they will be rigid -> if you see a kid w/ levels of 15 extending the neck they need follow-up immediately (medical emergency) - ex.^ In what position do you place an opisthotonic child? = on their side

ABDOMINAL

DUMPING SYNDROME vs. HIATAL HERNIA

- both gastric emptying issues & are kind of opposites -> memorize one & you have the other Hiatal Hernia: - regurgitation of acid into the esophagus because the upper part of your stomach herniates upward through the diaphragm - your stomach should stay in the abdominal cavity - w/ this, you have a^ 2-chamber stomach^ (like having 2 stomachs) -> band around the middle - gastric contents move in the^ wrong direction at the correct rate -> rate is not the problem, it’s the direction -> **going the wrong way on a one way street

  • S & S:**
    • just plain GERD (gastro-esophageal reflux disease) -> heartburn & indigestion *** but just because you have GERD doesn’t mean you have hiatal hernia
    • hiatal hernia is GERD when you lie down after you eat (the GERD only occurs after lying down)
    • you cannot have hiatal hernia if your symptoms occur before lying down because hiatal hernia is dependent on position & meal time - Treatment: —> goal = want the stomach to empty faster
      • because if it’s empty, it won’t reflux ** see table Dumping Syndrome: - gastric contents dump too quickly into the duodenum
    • usually follows gastric surgery - gastric contents move in the^ right direction at the wrong rate -> the rate is the problem -> **speeding
  • S & S:** ** long list of issues so take what you know & combine them to equal dumping syndrome
    • drunk person -> staggering, slurring, impaired judgment, delayed reactions, labile emotions -> from decreased blood flow to the brain because all the blood is going to the gut (because it dumped into the duodenum)
    • shock -> classic sigs such as hypotension, tachycardia, tachypnea, pale, cold & clammy
    • acute abdominal distress -> cramping pain, doubling over, guarding, borborygmi, diarrhea, bloating, distention, tenderness
    • so, think drunk + shock + acute abdominal distress - Treatment: —> goal = want the stomach to empty slower ** see table - Three things to play around w/ to effect stomach emptying time: a) change the head of the bed b) change the water content of the meal c) change the carbohydrate content of the meal - Hint:^ Whatever carbs is, protein is the opposite. Gastric Emptying Issue Treatments HIATAL HERNIA DUMPING SYNDROME Head of Bed - HIGH position during & after meals (gravity helps empty faster) - LOW position (lie flat and turn to side to eat) Water Content - high fluids - low fluids (don’t give fluid w/ the meals -> an hour before or after) Carb Content - high carbs because they go through faster - low carbs to help stomach empty slow Protein? - low protein - high protein

c) Give D5W w/ regular insulin ( K enters early )

  • fastest way to lower K+ -> this will drive the K+ into the cells out of the blood (it’s the K+ in the blood that kills you, not the ones in the cells) -> this doesn’t get rid of the extra K+ but it hides it well (doesn’t really solve the problem BUT it saves their the PT’s life) *** buys time to solve the underlying problem (but if you don’t fix it the K+ will eventually leak back into the blood) - temporary fix d) Kayexalate ( K exits late )
  • full of sodium ; sits in the gut
  • route: oral ingestion or rectal enema
  • trades sodiums for K+ so you can poop out K+ -> PT ends up w/ high sodium (hyp e rnatremia) *** which is then dehydration which is easier to treat (trading a life-threatening imbalance w/ a non life-threatening one BUT the PT will still have an electrolyte imbalance) -> pro's of kayexalate = get’s rid of excess K+ permanently as it leaves the body -> con’s of kayexalate = takes a long time (HOURS) & the PT may not live that long
  • best way to get rid of K+ to fix the imbalance by using both D5W w/ reg. insulin + Kayexalate

LECTURE 7

ENDOCRINE

- focus on the^ thyroid^ &^ adrenal^ glands -> what you need to know most for the test - Hint:^ change the word ‘thyroid’ to ‘ metabolism ’ (the thyroid regulates metabolism) THYROID Hyperthyroidism: - a.k.a.^ **hypermetabolism

  • think of all the S & S that you would see in a**^ high metabolism such as:
    • weight loss, high BP & heart rate, anxious & irritable, hyper, heat intolerance (cold tolerance), exophthalmus -> think Don Knotts
    • called Grave’s disease ( run yourself into the grave ) - 3 treatment options for^ too much hormone: a) radioactive iodine i. PT should be in a room by themselves for 24 hrs. -> no visits for the first 24 hrs. ii. after that, PT needs to be extra careful with their urine (i.e. flush 3 times after voiding, if urine spills on the floor the hazmat team must be called) -> radioactive material is excreted via urine -> biggest risk to nurse is the urine b) PTU -> Propylthiouracil
      • “ p uts t hyroid u nder” = slows thyroid down
      • primary use as a cancer drug BUT is used specially for hyperT
      • nursing role: -> be aware that it is an immunosuppresent so WBC count needs to be monitored c) Thyroidectomy (most common way)
      • partial or total removal -> PAY ATTENTION TO THIS IN THE TEST ( most important )
      • total = need lifelong hormone replacement -> at risk for hypocalcemia (because of parathyroid, hard to save it in a total) -> check Trousseau’s & Chvostek’s
      • sub-total = don’t need lifelong replacement because but may need it for a bit before the leftover thyroid starts “kicking in” -> less risk for hypocalcemia -> at risk for thyroid storm/crisis; thyrotoxicosis (total’s never get this) - Thyroid Storm:
    1. super high temps. (105 & up)
    2. extremely high BP’s (stroke category; ex. 210/180)
    3. severe tachycardia (ex. could be in the 180’s)
    4. have psychotic delirium —> MEDICAL EMERGENCY!!! can cause brain damage (can fry the brain to death)
    • immediate treatment = get the temperature down & get the O2 up -> first way - ice packs -> best way - cooling blanket -> O2 per mask at 10L (BUT, remember they are psychotic so good luck keeping that mask on) ** maybe pick this first if picking between O2 & ice packs
  • will come out of it themselves or die -> self-limiting
  • don’t medicate
  • 2 on 1 (need 2 people to care for these PT’s) Post-Op Risks: —> depends on type of surgery & timeframe (HAVE TO KNOW THIS) - 1st 12 hours: a) does not matter if total or partial; priority is airway
  • thyroid is in the neck
  • any edema can cause constriction of airway b) hemorrhage
  • endocrine gland -> has a lot of blood vessels - 12-48 hours:
  • need to pay attention to the type of thyroidectomy a) T otal = tetany due to the low Ca
  • can cause constriction of airway b) S ub-total/Partial = **thyroid storm
  • after 48 hrs:**
  • big risk is infection *** but never pick infection in the first 72 hours Hypothyroidism: - a.k.a.^ **hypometabolism
  • think of all the S & S seen in**^ low metabolism :
  • obese (weight gain), flat/boring personality, cold intolerance (heat tolerance), low BP & heart rate
  • called Myxedema - treatment option for^ not enough hormone:
  • give thyroid hormones -> Synthroid (levothyroxine) - DO NOT SEDATE THESE PT’S^ - because they’re body is already super slow & you could put them into a coma = myxedema coma
  • question any pre-op orders that have sedation (i.e. Ambien before surgery)
  • if PT is NPO before surgery you need to call the MD because they need to be able to take their morning thyroid hormone PO ( never hold thyroid pills pre- op without express order to do so ) -> if no hormone replacement they will be hypothyroid & that will cause issues when being given sedative agents (anesthetics) for surgery