# Muscular Skeletal and Psychological Integrity

**Channel:** ABC
**Source:** https://www.youtube.com/watch?v=IZMgM2tx6ZM
**Transcript page:** https://www.withtranscript.ai/video/IZMgM2tx6ZM

## Chapters

- 0:02 — Phenytoin Basics and Safety Monitoring
- 5:56 — Carbamazepine Uses and Warnings
- 9:00 — Benzodiazepines and Muscle Relaxants
- 14:09 — Baclofen and Spasticity Care
- 15:42 — Eye Drop Administration and Glaucoma
- 23:14 — Musculoskeletal Assessment Fundamentals
- 28:21 — Fracture Care and Traction Basics
- 41:42 — Traction Pin Care and Positioning
- 45:11 — Fracture Complications and Cast Care
- 54:08 — Osteoarthritis Versus Rheumatoid Arthritis
- 58:32 — Osteoporosis, Vitamin D, and Fractures
- 1:11:31 — Psych Medications and Lithium Toxicity
- 1:28:06 — Antipsychotics and Neuroleptic Malignant Syndrome
- 1:33:11 — ADHD Drugs and Alzheimer Medications
- 1:37:45 — Smoking and Alcohol Cessation Medications
- 1:42:58 — Psych Review and Behavioral Disorders
- 1:49:11 — Course Wrap-Up and Exam Preparation

## Transcript

**[0:02]:** sorry

**[0:09]:** okay this is the number one the good old dilemma is the number one question they'll bring up for you so what do you need to know about phenotoid the number one it is used to prevent a seizure not to stop a seizure it's seizure prevention if the patient is use it so they don't cease um this drug is given can be given orally and in emergency we can give it iv as well if the infinity level is low but for the most part it's the first line the number one drug that we still use today years later for seizure seizure prevention phenotoid um must have a blood level and kathy what do you think the blood level is a phenotoid

**[1:08]:** therapeutic level i have no idea so okay i'm going to be very what's my default

**[1:20]:** what's my default number when i say when you don't know just the fault to it

**[1:29]:** 10 to 20.

**[1:34]:** but you don't know just roll down on my default and say 10 to 20. what's the default 10 to 20 pentatonic levels now it's crucial that we maintain this therapeutic range because if it's over 20 the patient can go into toxicity we'll talk about symptoms of toxicity under 10 they can seize

**[1:59]:** and um there are a lot of medications that can decrease the absorption of phenotoid we don't need to get into that because if you look at the list if you live in new york the list goes from new york to new jersey so we don't we just need to know there are medications that can decrease the phenotoid level and that's why it's crucial that when they're on pinator and they get levels checked routinely because once the level drop below the therapeutic range they can seize it's also important that if we're talking about a female patient that when they're on phenotoid they need to an indef um childbearing age that birth controls like um oral birth control they need to use two forms of birth control because the drug itself decreased the effectiveness of their birth control of almost all any birth control except condom of course anything with hormones in it phenotoid and decrease the

**[2:54]:** effectiveness

**[2:59]:** and you don't want the woman to get pregnant on phenotoid either because it can cause birth defects another very big thing with phenotoin is that it can cause gingival hyperplasia that's a nice fancy word for overgrowth of the gum

**[3:20]:** so we say gingival hyperplasia so big gums the gum get really big so uh and so of course that's very very common so they should see the dentist at least every four months every so so we know that the recommendation for the dentist is every six months for everybody but in these in this case when they're on penetoine it's more often than that so every three to four months and the question they'll also ask you on nclex is that they should be meticulous about oral care because of the gingival hyperplasia

**[4:04]:** toxicity phenotoid toxicity similar to similar to lithium

**[4:18]:** so they can again they can have ataxia confusion irritability blurred vision

**[4:32]:** now iv phenotoid because phenotoid can be given iv and off the record phenotoid is also an rhythmic drug so it's on in the crash cart it's the alacls drug so if we're giving it iv it needs to be on a pump and the patient needs to be on a cardiac monitor because it's an anti-dysrhythmic drug as well and remember when we talked about dysrhythmia we said any dysrhythmic drug any anti-dystrophy drug number one side effect is worse than dysrhythmia so it's an anti-dysrhythmic drug as well even though we're given it for seizures you need to make sure they're on a cardiac monitor and that it's on a pump and you're monitoring vital signs last thing i want to say about phenotoid is that iv version is only compatible with normal

**[5:36]:** saline if you mix it with anything else it will crystallize and it's basically they turn into like a bag of

**[5:50]:** salt

**[5:56]:** tegritol carbenzapine this one um we also use this for bipolar so you'll see this you can see this either way for you know bipolar patient or we use it to prevent seizures what is so unique about this one now carbenzapine is apart of toxic and it also affects the bone marrow so and most importantly is that the affection that it affects the bone marrow so it cause agranulocytosis so they need to get cbc drawn routinely and lfts routinely and they also need a level now this one the level is a little different so this is four to twelve not sure if they'll ask the level for this i know they asked the level for that lantern but i would just write it down just to have four to twelve for cabenza pin we use carbenzapine mainly for bipolar even though we do use it for seizure prevention because some patients with depending on their seizure

**[7:14]:** seizure medication is selected based on the type of seizure that they have there are many different types of seizure and some patient needs more than one seizure medication so they'll probably be in dilatin and carbenzapine now now because we're going to segue into um into psych i want to bring it up that if we're using this for bipolar uh remember if they're on an mao inhibitor we need to stop the mao inhibitor for at least two weeks we'd call that the washout period before we start this the tag that's not territorial i'm so used to that words

**[7:56]:** carbenzapine

**[8:01]:** it's also another big thing with carbenzapine even though it's an anti-seizure and i mentioned that we use it for bipolar it has a black box water about suicide ideation so early in treatment this rate for suicide can go

**[8:24]:** up and carbenzapine is one of another one of those drugs that um grapefruit juice can affect the absorption but i'm gonna tell you that on nclex the only drug that they seem to zone it with grapefruit juice or the statin drugs

**[8:45]:** nursing school everything grapefruit juice real life everything grapefruit juice nclex statins cholesterol drugs

**[9:00]:** dipper coat i won't go into that in a barbito i also won't go into that now let's say the patient is seasoned they actually seizing um what are what medications do we give to stop a seizure hidden

**[9:25]:** there's a problem any of the benzos anyone in the in the benzo families for nclex reality is different for nclex anything in this family we use so if they season actually season and we can stop the seizure it's a benzo to prevent the seizures we we talked about the phenotoid and carbenzapine any of those over there but they actually season benzodiazepine so what i thought let's say let's talk about benzos for a minute we use benzos for a lot of things a lot of things mahalia can you remind me of some of the things that we use benzos for i think they use them for like sedation or if somebody like uh alcohol withdrawal they use them to sedate them that i know and what else again use it to induce anesthesia right so if your patient is going to like surgery they'll give them like um that for like anxiety or something like that

**[10:43]:** so the anti-anxieties they use it for hypnotics use it for sleep too is it um shouldn't we use it to sleep we use it for um like you said we use it to stop seizure we use it for patients to prevent delirium it the alcoholics who stopped drinking or they had they admitted to the hospital and to prevent the teas we use these um we also use it for believe it or not chemo-induced nausea whatever you're using it for we use it as a muscle relaxant let's see um it also mostly relaxant whatever you're using it for remember there's there's um the high risk for addiction and their sedative so they should not you take benzos and operate machinery don't take it and drive depending on which state you're in under the influence of a benzo is same as under the influence of alcohol so they shouldn't take it with alcohol

**[11:54]:** those are the little questions they'll ask you to they say they're going to take their benzos with their alcohol now what if they're they do an overdose do we have an antidote for that

**[12:08]:** but if someone decide they're going to take a bottle full of benzos

**[12:17]:** yes there's an antidote so flamanthas is our antidote now for seizures we can give diazepam valium per rectum as well if they're in a nursing home a long-term period at home wherever and they have epilepsy and they have risks for seizures we usually have diathepian for rectum and we can give it in that case to prevent the seizures to stop the seizure so that thor stop the seizure medication um parkinson's disease we talked about the carbidopa levodopa the cinnamon we went over that yesterday um let's see what else i want to talk about the muscle relaxant the big one is cyclobenzaprine flexural of course um baclofen will always be there and there is a muscle relaxant they also especially cyclobenzoprene um can cause addiction they can also cause sedation and they should not be taken for a long period of time these are only supposed to be short term

**[13:38]:** but as you know so that's it this and this is what you teach your patient should be taken for a short period of time but they will be on it they'll have no reason to be on it they're all prescribed so they can't buy it and go over the contour they can't get it and they're not scheduled so it is not like they're not like um the benzos benches are select schedule three drugs so they have to be prescribed under special circumstances

**[14:09]:** so there's a high tendency for addiction with decide with this psychobenzoprene or or the muscle relaxant but let's talk about baclofen um baclofen we use a lot in patients with um who have a lot of spasticity like you're a stroke patient who gets your cerebral palsy patients that gets and it helps with the relax the muscle relaxant now of course we have botox which is you know it's taken over so we don't use baclofen that much anymore those patients can get botox botox is usually given like once every four months now with that i'm talking about botox if botox of course is going to relax the muscle just like baclofen and think about it anything that relaxes the muscle especially so significantly you worry about the diaphragm so be careful worry about swallowing for baclofen for patients with severe spasticity they can have a baclofen pump and again for those patients you want to make sure that they're not you know overdoing it and getting too much muscle relaxation and now they have

**[15:31]:** difficulty with swallowing or even breathing because of the relaxation of the diaphragm

**[15:42]:** uh so so yesterday we also talked about eyes and ears and i want to remind you about the medications get how to give make sure you go over the sequence and how to give an air drop three and older we use the same three years old and older so you do it like an adult so it's up and back and it's on the three down and back so watch for watch those age because usually they put that there the eye drops for your glaucoma patient most of these eye drops will be medication remember glaucoma is a chronic disease and is treated with medications for life and typically a person with glaucoma will be in about two or three high drops and here is what they'll ask you so they on three eye drops how long should you wait before you give the second one give the first one how long should you wait before you

**[16:52]:** give the second eye drop

**[16:59]:** kim not like a minute a little immediately it's longer than that actually three minutes five minutes

**[17:12]:** five minutes you're gonna stand there for you're not you're not gonna stand there you're gonna be doing a lot of other things in between but five minutes um how do you what if they have an ointment and a drop which one do you give first the drop

**[17:38]:** the drop because you don't want to wash it out right who's had that i didn't didn't catch the voice nick cadeon kadian yes the drop they give the drop first the ointment last because if you do it the other way around you're gonna wash off the ointment did we catch that kathy

**[18:10]:** cathy are you here no she's having not wi-fi issues okay so remember because they'll ask you that you have the patient is getting a drop in an ointment now kim remember i said all of these medication here um because a glaucoma is think of glaucoma as hypertension in the eyes so a lot of these medication here can lower the blood pressure systemically that's the reason why when you give an eye drop they tell you to after you give it to press in the lacrimal sac to decrease the systemic absorption it's still going to be absorbed systemically so if they're on a medication like for instance timolol which allow the beta blocker and they're on metropole there are two beta blockers so we may need to decrease the dose of one of these medication or we may need to get rid of one

**[19:12]:** also remember oh it's you know even though it's an eye drop and it gets absorbed systemically if they have allergies to cert to that that medication they'll still have allergies to it even when we're giving it as an eye drop and that's pretty much when it comes to eye drop that's why they want you to know how to give it the order of operation what if you're given a drop and an ointment and ointment remember ointment is the number one first thing you always clean the patient eyes first because especially when they're an eye drop they usually have crusted little areas clean it and the the ointment you go from inner to outer just like you is less just like you would do to clean inner to outer any question on that i have a question i saw a question about the given the eye drops that we had to put it in order um

**[20:11]:** it said do we press on on the criminal duct and or do we tell the patient to close their eyes then press on it so i don't you know you won't show up about the order to tell them to close the eyes first then press on it or they press on it for a certain period of time then tell the patient to close um kadian how would you answer that

**[20:40]:** so after the medication is instilled that's when you press on the lacrimal gland so she wants to know do i tell the patient to in the order do i tell the eyes before i press or do i press and then tell them to close their eyes oh um wow okay just i guess press and then close their eyes uh mahalia do you do right now first go towards your lacrimal sack and see what happened to your eyes so it evokes like close down

**[21:29]:** first and then press because naturally you're going to close because someone coming towards your eye your natural reflexes to protect your eyes so naturally you're going to lock up so might as well tell them to lock up before you press i don't know what kind of stupid question is that like i'm here to tell you that exam is stupid truth this yes naturally it's um that's why i my crazy unorthodox thing is do whatever it takes in that exam to pass an exam even if it means you have to stand up and touch yourself let them tell you to sit down because you have to i don't i don't know whether this is the right i don't know whether this is the left because they have you doing all kind of stuff you know asking yourself and you have to literally touch yourself to figure out where is this where is that do what it

**[22:23]:** takes to pass that exam they're not going to throw you out because you stand up touching yourself and they're not going to store you out i can guarantee you that unless you're in a re you know in a place where they mean but you know listen they're not going to throw you out i've had people had to do that you'd see they'll come and say oh no you know you're not supposed to stand sit down yeah also they'll just pretend they just think maybe you're getting ready to go to take a break so they won't say anything to you but whatever it takes to pathetic them when you see those questions like i just told you try to close your eye and see what happened whatever it takes any question kim you're here kathy got kicked off yeah i'm back i'm back i'm here okay nevin any question

**[23:14]:** nope okay now let's go to mfk um

**[23:27]:** hell you said i don't know what kind of stupid question is that yes i wish they would ask more of those type of questions in school though so prepare you for you know what's what's coming anyway let's talk about musculoskeletal so as far as assessment is concerned with musculoskeletal let's go back to the basic basic basic all the way back to basic msk assessment now um to assess do you want to assist the patient gait assessment of gait what would you do what's the nurse what um how would you assess the what would you have them do

**[24:08]:** walk walk for me walk and you watch how they walk watch how they walk um now i'm gonna tell you if there's an older adult don't you know um you want to walk side you want to walk a little behind them and watch them you don't want to have them walk all because sometimes they can you know be a little wobbly as you're assessing their gait so size them up also for musculoskeletal we also assess in their spine so you can have them bend over and you are going to run your hand down the remember kyphosis what is that what is kyphosis again how do you describe kyphosis somebody hunchback hunchback how would you describe that

**[25:05]:** carbohydrate everything scurvy of the spine and lower doses how would you describe that those are the three ones that we're going to see on assessment the musculoskeletal

**[25:24]:** what about lordosis that one is the inward curvature the inward curvature kyphosis by the way kyphosis is common as you age normal part of aging that you get a little kyphotic we call

**[25:54]:** it

**[25:59]:** okay so we notice um a part another part of your physical your physical assessment with musculoskeletal you want to assess range of motion

**[26:13]:** so um basically you will have the patient you know remember basic i said let's go back to fundamentals um we do we have a patient active range of motion and passive range of motion what's the difference malia between active and passive

**[26:34]:** so active is actually what they can do without um i guess um pushing um above like like if you're gonna extend the arm like whatever they could do yeah activities they're doing they're the one doing it and passive you're helping them and like physical therapy you're helping helping with the range of motion and we have active passive an active passive is you and the patient doing it together now um remember basic whenever you're doing range of motion you always support a joint don't have it flip it don't have things flapping like flapping tremors support the joint and usually with when you're assessing the range of motion you go to the point of where they start to hurt a little bit and you stop if the patient said oh that hurts don't continue because some patients are so that you know they're not able to give you like a 90 degrees they get to 30 and

**[27:39]:** you can't go any further so stop at the point of discomfort don't keep going with with that um with range of motion also you you can delegate the pcas can do range of motion you can delegate that you just need to show them how to do it there and if you have them do it you'll get a better outcome because they spend more time with the patient believe it or not than you do they don't want us doing the uh the adl they're the ones changing the patients they don't want this there so and you tell them just keep each time you do something just do some range of motion with the patient so again

**[28:21]:** they learn how to do this um in in their orientation but you can reinforce that that teaching so um before we go into the diseases that are common um that they will ask about let's talk about fracture any fracture fracture on and and nclex number one the patients usually with a fracture or sprain let's go just talk about sprain or strain first and fracture let's say someone fell down in front of your face your school nurse and you suspect they have an injury could be a sprain could be a strain could be a fracture what is your initial action what do you want to do first does that sound like a question that you're seeing somewhere in my ilia yes yes what should you do first well it says the person and the question is that the person has a broken leg so is i said call the ambulance but because it has immobile to

**[29:36]:** because you have to stabilize the fracture not mobilize it because mobile is moving it you can't move it if it's a fraction so i said call and then i i guess after you call you could mobilize it or remove whatever shoe or whatever the person had on any restriction but i wasn't sure if you call then you try to you know mobilize it or do your mobilize then call them so say mobilize immobilize immobilize um describe the scenario to the group again so someone could figure out what um so the the question is asking if you are on a playground and a child fell and has a fracture or a broken leg what would you do first one of the action option is immobilized for the ambulance take the child's shoes off and and something else i forgot the last one so i was in the order what would you do first from my understanding

**[30:51]:** with a sprained strain fracture you should mobilize the the the you want you should immobilize it to stable the fracture so i hope we call the ambulance because you could stabilize it while the ambulance is on its way so i wasn't sure about that one so kathy what do you think i would say um call someone first i would remove the shoe and then mobilize it immobilize it what would you do um i would

**[31:44]:** just put in the order in which i would do it or should choose one what do you do first um um or what do you do first what do you do first okay so if it's what do i do first then i will immobilize the fracture first immobilize the fracture first um i know you're saying called but who said they don't need 9-1-1 anyway i kind of feel like you would remove the shoe thinking of it now no you wouldn't no sorry i'm sorry but if you're in my opinion if you remove the shoe to me you can cause further injuries so immobilize it first like stabilize the fracture first and then remove the shoe then then remove the shoe so what the reason why i'm thinking of removing the shoe is because wouldn't the shoe cause some type of compression hold that thought right there kathy kathy what what do we use what's the intervention we use for um injury moscow skelter injury remember rice right right stand for again rest ice compression element elevation you said compression

**[33:07]:** okay got it now but so the question and my question is it clearly said it was a fracture within a key in a child plane so obviously the fracture with a child plane they probably need to go to the hospital to put to have a cast or something after work so you still have to go to the hospital but not by an ambulance specifically okay so you see it's still but even if it's a fracture because we're going to come back to how do you know it's a fracture how we're going to know it's a fracture because assessment will tell us the fact that it's a fracture before an x-ray even if it's a fracture still institute rice and rice is just you know something you're doing quick fast it's you're gonna rest it so you're not gonna move it and that's why you're not gonna take that shoes off first ice compression elevation so

**[34:06]:** stabilize it stabilize it first rest stabilize it first stabilize it all right immobilize it and then you can take the shoes off because you should you should take the shoes off because you want to be able to assess it sit you know to you you want to see their toes you want to do whenever it comes to fracture you want us you want to do neurovascular assessment and in part of your neurovascular assessment is doing your capillary refills and with the shoes on you're not going to be able to do that so you need you you will be taking the shoes off but you need to immobilize that thing first once it's immobilized and how you're going to immobilize it in so many ways you can be able to do that you can take the shoes off and then you remember you can always have somebody to call 911 that doesn't have to be you

**[34:56]:** and like you said the kid you can get the kid to the hospital without calling 9-1-1 it's a fracture

**[35:05]:** that was a good question and what did you pick melia i called i called the ambulance because i said i'll call and then i would immobilize it so that's what i was thinking a long time called you said you're gonna call you're gonna and then i could immobilize that that wouldn't be first but i will call and then mobilize the fracture why did i say yesterday what did i keep telling you guys to do first calling in ambulance is the same thing as calling the doctor and i keep saying what am i stressing to you guys to do first nursing intervention personal intervention call in 9-1-1 is the same thing as calling the doctor just so do your thing first do your thing first quick fast not gonna it you know it's amazing how you know because it's on in theory it looks like it's one it's happening one hour later and then the other

**[36:03]:** one is up in an hour later when everything is happening all at the same time but in theory you can't see it so just do your thing and then call that definitely do you wouldn't you know call 9-1-1 or calls ask somebody to call 911 but do your thing immobilize so remember rice now as you say that how do you know it's the fracture what are symptoms what are signs that will make us you think that know that this is a fracture okay swelling of the bone swelling you see some swelling what else um you can't bear any weight on it what else if you see like uh if it looks like um like deformed or anything like that deformities yeah deformities classic what else

**[37:03]:** pain pain oh yeah pain yeah sharp pain neuro pain is sharp bone pain is sharp so severe pain sharp pain he said overt deformities um also you can start to see some echomosis echomosis deformity are like the two things that say this is a fracture not so much the pain because you know pain is subjective some people will have a sprain and they'll be in more pain than anybody else but the deformity and the echomosis is classic that's bleeding around the tissue that this thing is broken and of course they're not able to use the the area the extremity whatever you know not able to use it now you do not need to know the different types of fracture for nclex like green stick you know compound you don't need to know that that was back then in nursing school you're not diagnosing so you just need to know how to take care of the

**[38:14]:** patient so always institute rice and you see this so don't have the patient try to get up and walk don't try to don't tell them to try to use it try to see if you can squeeze a ball no no no no you're gonna you're gonna rest it you're gonna ice it you're going to compress it and you're going to elevate it and yes seek medical attention now if they are in attraction we have two types of traction and you need to know the difference for nclex we have skin traction and skeletal attraction skin traction is the one that's like box traction oh gosh if you've taken them clicks and you didn't see bugs traction you didn't take in clicks i don't know why they're so obsessed with box traction box traction is the one that you especially for like the femur usually the one that's on the foot what's the purpose of the skin

**[39:16]:** traction attraction is to maintain alignment and to decrease um this fathom that's the reason for traction so skin traction a lot of times we'll do it you know to unlock so maybe the joint is out of alignment and we can't cast them yet so we need to align it a little bit or we can't take them to the or yet so we'll put them under skin traction whenever they're in skin traction that's complete immobilization they're immobile it's part of it's immobilizing the the joint so it's skin traction if you can vis visualize box traction that patient will be laying flat on their back the head is going to be about maybe 15 degrees no more than that and the leg is in traction slightly elevated and it's an attraction the weight for skin traction should never we're talking about adult here be more than 10 pounds or 4.5 kilos but i'm gonna go with pound

**[40:24]:** that's easier to remember the weight for the traction should not be more than 10 pounds could be less because if the person is smaller you may need less weight but we don't need more than that the weight should always be hanging freely should never be on a surface so it shouldn't be on the floor it shouldn't be on the bed shouldn't be on the chair you should not be messing with it so don't take it off don't remove it family member come to visit especially when they bring in kids kids should not play with it

**[41:04]:** now watch those questions even if the traction even even if the weight is one inch away from the floor that's fine as long as it's not directly on the floor shouldn't be on because if once it's on a surface then it's not working and that's why you make sure that the rope or the pulley as we call it is intact and it doesn't look like it's about to

**[41:32]:** break

**[41:42]:** okay also when they're in traction and this is also generally speaking pillow a pillow shouldn't or nothing underneath their leg underneath their knee sorry the knee we never want to put a pillow underneath a patient knee and the main reason for that is because the popliteal vein the probably you know you have um popliteal arteries right underneath the knee and you can actually compress it with a pillow underneath the knee so pill underneath the knee can affect circulation so never every anytime you see pillow underneath the knee that's wrong the pillow could be underneath the leg but not the knee also that patient foot should not be up against the head and edge of the end of the bed the bed board should be hanging freely

**[42:42]:** skeletal traction has pins skin traction does not have pins that's the difference skeletal attractions they have pins and your job with the skeletal fraction traction is to make sure that the pins the spin side is clean and intact you can clean it sterile

**[43:11]:** if it's loose if the pins are loose notify the provider you cannot tighten those pins

**[43:22]:** and you'll you'll be able to tell it's loose because you're doing your assessment you're cleaning it and you can see the pin just moving with with each time you're clean the pin is the pins are moving around so notify the provider

**[43:37]:** how would you clean the pins is there like a specific thing you have to do um the normal saline usually sometimes they'll order they'll order what they want but you know for nclex just go with normal saline and you can use like um those q-tips and go around and know from inner to outer very good question and then you can see when you you know if the when you're doing that if the if the pins are loose you can see once you're cleaning it the pins are actually moving with your cleaning and don't tighten it but don't tighten the pin now notify the provider the site could be sorry go ahead i have a question so they i have seen a question before where they're saying to clean the pins side one of the options you have to use sterile technique not clean technique correct yes different clean and circles there they were described in

**[44:35]:** stereotyping and then they were describing like clean technique so it has to be has to be sterile okay it has to be sterile because when one of the big complication of fracture and the spin is osteomyelitis any surgical case by the way guys anything surgical is sterile and those pins are surgically placed so sterile technique okay thank you

**[45:11]:** now the the problem with fracture is the fracture is bad but the other problems are the complications of fracture and some of the complications are compartment syndrome fat embolism and osteomyelitis that's the reason why you want to be able to see if you splint the patient or you put us you they have a cast on you they they're they're digits the toes or the fingers must be exposed because you you want to be able to do your capillary refill you want to check color so you were worrying about the five p's of compartment syndrome what are they again kim what are you looking for the five p's um color paraparative right now yeah it's parastasia yeah

**[46:18]:** yeah and pain we mean that the pain is worse than the initial pain that the patient have so there's you know you gave them pain medication and they're still in pain they give them more feed and they like this more pain being budged i'm still in pain so you should be thinking about compartment syndrome compartment syndrome is a medical emergency so if the pain that you see you see it the leg is cool cool to touch um the pulse is diminished pulses diminished here's my scenario there this i'm gonna get even more drastic than this um the leg is cool the capillary refill is six seconds and you can't feel the pulse kathy what are you gonna do

**[47:08]:** first you just did your assessment because that's how you've got all that information so what are you going to do

**[47:22]:** now would you elevate this leg mahalia would you elevate this leg this this situation that i just gave you that though you did the assessment and you get its pain cool cause attached no powers no pulse and uh kepler and the capillary force six seconds did you elevate the leg no what would you do well since it's an emergency at this point you would call the provider because they have to come in that's right that's it since it's an emergency at this point i'm gonna notify the provider because i have no pulse there's nothing i can do to get this back

**[48:15]:** so i'm going to notify the provider this is an emergency now let's before we go to fat embolism let's talk about caste cast care now most of the time with the pain when the patient has a cast they'll be in the cast for a couple of weeks depending on of course age children will be in there for a little shorter period than older people so with the cast you want to make sure they usually complain a lot about itching could be two reasons why they're itching they could be itching because it's um it's a normal part of the healing or they could be itching because it's dirty after a while it's it's a hygienic issue going on down there and they complain about itching a lot or it's hot and it's uncomfortable now how do you what do you tell them to do for the itching

**[49:18]:** you tap it or blow cold air with a blow dryer

**[49:31]:** um nevin were you saying something nope i was gonna say the exact same thing okay okay um so that's pretty much the okay also review walking with you know muscular skeletal crutch walking and pay attention to going up the stairs and coming down the stairs i'll put the good down with the bad now let's talk about fat embolism complication of fracture so fat embolism we can see this a lot in like long bone fractures fat is you know in the inside the bone marrow we have the yellow marrow and that yellow marrow is fat so it can happen um post fracture fat embolism will present exactly like pulmonary embolism they say in the textbook that usually fat embolism comes on 24 hours after the fracture that's what they say in the textbook in reality we see it's sometimes couple hours after the fracture but in regardless of what time

**[50:45]:** it comes on it's it's usually sick um comes on exactly looks exactly you don't know the difference between a fat embolism and a pulmonary embolism so initially we treatment will be the same until we figure out that this is a fat embolism they also get the patekia rash on the chest which pulmonary embolism gets they get severe dyspnea tachypnea and this you're gonna set them up you can administer oxygen high flow oxygen if your vital signs notify the provider once we know once we um we get the ct angio which is what we get for pe and we know the cities of fat um we don't give fat embolism will not get thrombolytic therapy so that we don't give anticoagulation to fat embolism fat embolism usually sometimes we'll treat it with steroids high dose steroids

**[51:48]:** but the symptoms are the same and the initial nursing intervention will be the same

**[51:57]:** any question on that

**[52:02]:** osteomyelitis the third complication of fracture so this happens this happens um osteomyelitis can happen because um it's common in patients who are malarish it's common in patients so and then remember let's go again think about malnutrition it's you know we usually use the labs to determine that your albumin and your protein um it's also common in diabetics poorly controlled they can get osteomyelitis and it's it's it can be because of poor nursing care god forbid they had the you know retraction and you didn't use sterile technique or you messed up your sterile feel and a bacteria gets in there or the patient have a cast and decide that they're gonna get a nice long pencil or something and push it down in the cast and scratch and they develop a cellulitis and bacteria gets into the bone so osteomyelitis is um infection of the bone and usually that takes a long time to heal it's

**[53:10]:** it takes a while for the antibiotics force they'll need antibiotics to get into the bone marrow and really work so they need iv antibiotics for at least two months with osteomyelitis osteomyelitis is a big deal because if we don't catch it and treat it properly it can turn into sepsis and sepsis is a bad word

**[53:41]:** so two to three so typically there are like two or three antibiotics and we're not gonna keep them in the hospital for three months or two months an iv antibiotics so they'll go home or go to a rehab with the iv antibiotics they usually give them a picc lime and they go home on iv antibiotics

**[54:08]:** question

**[54:15]:** okay let's talk about osteoarthritis we kind of alluded to it a little bit when we did a rheumatoid arthritis um the difference between osteoarthritis and rheumatoid arthritis is

**[54:36]:** canadian

**[54:41]:** upstairs this is in the board i fix the ball

**[54:50]:** want more yes what's the difference between osteo and rheumatoid um and rheumatoid arthritis it's a autoimmune disease is autoimmune disease we're not thought out right is the autoimmune disease where osteo is wear and tear of the joint so osteo can happen later on in life rheumatoid can happen anytime you could see it in children

**[55:19]:** there is no cure for rheumatoid not that there is any cure for osteo either but it's an autoimmune disease and they're probably going to be um on medications like high those steroids or they'll go to the immune modulators that we spoke about where osteoarthritis if um if you know you can slow down the progression with osteoarthritis by a if they're overweight lose weight so we see osteoarthritis is common with people with excessive you know overuse of the joint wear and tear excessive um use of the joint obesity is common with osteoarthritis

**[56:06]:** so earlier um we have an um herbs like uh we call it glucosamine and chondroitin have you heard of that glucosamine which you buy overnight i mean i've heard of yeah and conjoined costco yeah monday morning yes we use that a lot and it is on nclex it's basic it's it's herb um really no issues it slows down the progression with osteoarthritis

**[56:42]:** that's what they call osteoarthritis bone and bone disease because the the the cartilage in between we're out and that's what the chondroitin and the glucosamine is doing strengthening that cartilage so they have crepitus um that's a noisy sound that people joints make when they you know you know you know people i have one in my house you know when they come in it can't hide because they have the joints making that noise

**[57:14]:** so treat um another common difference um this to comparing osteo rheumatoid they both wake up a little stiff but osteo the stiffness goes the stiffness goes away within like half an hour whereas sorry osteo goes away within half an hour rheumatoid will take a longer time rheumatoid needs to warm up like they need a warm shower or wrapped up in a warm blanket or something for this um stiffness to go away so this stiffness could last like a couple of hours in the morning they'll tell you that that you know they must take a warm shower in order to feel for the stiffness to go away so they both wake up a little stiff they both wake up slip if they should ever give you that such scenario stiffness first thing in the morning but for osteo the stiffness goes away within the first 30 minutes of starting to use the joint where um rheumatoid

**[58:15]:** arthritis will need to use need something they need an intervention to get rid of their stiffness so they need a warm shower or they can rock you know so warm blanket around the area but something warm to get rid of the stiffness

**[58:32]:** so here is what they like to ask for osteoarthritis you're you know a good nursing intervention or a good nursing goal is to teach a patient to keep their bmi within normal or make sure your bmi is under 25 because it's very common in overweight

**[58:56]:** osteoporosis osteoporosis is porous that's calcium deficiency risk factors for osteoporosis

**[59:09]:** who are they mahalia i think women women menopausal woman

**[59:23]:** that's the person menopausal woman somebody with um less calcium in the bone like if they like what should you call them like they don't have a lot of calcium in the bone calcium deficiency menopausal women most common in women yeah woman on birth control birth control because because hormones help them that's why it's common in menopausal women and birth control has a lot of hormones cigarette smokers cigarette smokers small frame remember the petite ones small frame woman as they get as you get older with osteoporosis what medication there is a medication that is this whole sort of same medication we blamed on cataract yesterday which one is that it can cause osteoporosis

**[1:00:40]:** kim which medication did we say increase your risk of cataract yesterday

**[1:00:52]:** acadian which medication you remember increased risk for cataract long-term use let me make it easier cause calcium to leak out of the bone this medication causes calcium to leak out of the bone so if you're on it you need calcium and vitamin d supplement and weight bearing exercises i just gave you the answer alendronate no that's a treatment for osteoporosis if you're on this drug you need to do calcium and vitamin d supplements and weight bearing because it's increased risk for osteoporosis steroids

**[1:01:35]:** is that ringo bell yeah steroids

**[1:01:43]:** systemic steroids and make sure i say systemic steroids because if you're doing steroid inhalation that the that have no systemic side effects steroids steroids steroids steroid steroids are blamed for a lot of things and steroids can increase your risk of osteoporosis and we need it so if they we if we have to put you on it we are going to tell you calcium vitamin d supplements weight bearing exercises which one of the treatment for osteoporosis and as nevin was saying the biphosphonates are the treatment for osteoporosis biphosphonate with calcium and vitamin d the only thing is let's talk about biphosphonates those are called the dronates that's how you remember them they all end with a dronate at the end ronaids alandranate then benevolence all those other drugs they all and for this should be at an empty stomach first thing in the morning sit up for a half an hour at least or go for

**[1:02:52]:** a walk because the dronades biphosphonate they strengthen every bone in the body but they weaken the jawbone it can cause the cross necrosis of the jawbone and another thing that we that while we're telling you to sit up it cause esophagitis severe esophagitis erosive esophagitis we call it

**[1:03:29]:** what about if the patient has um vitamin d deficiency what do we call that it's not calcium deficiencies vitamin d very uncommon nowadays to see vitamin d deficiency

**[1:03:47]:** so osteoporosis is calcium deficiency vitamin d deficiency you heard of

**[1:03:56]:** osteomalacia so once you see osteomalacia is vitamin d deficiency which is very very common if you're not in a sunny state because the number one source of vitamin d is sunlight and also remember in order to absorb calcium we need vitamin d osteomalasia in children we call it rickets

**[1:04:30]:** so they need vitamin d supplements this osteoporosis increase your risk of what we call pathological fracture that's this fracture where you're doing nothing at all you're just sitting down and you go to sit down and your hip pop out of place or you go to move the patient up in bed and you just hear groups nothing extravagant just caused them to fracture with osteoporosis

**[1:05:03]:** also one risk factor that we didn't mention for osteoporosis immobility anything that causes calcium to leak out of the bone because calcium belongs in the bone so calcium immobility can cause osteoporosis as well so let's talk about hip fracture signs and symptoms of hip fracture what would you see classic we're going to use a elderly person

**[1:05:41]:** shortening of the leg or unevenness of the leg shorten up the leg and the heaviness of the leg i think eco moses come with the hit yeah you get for remember fracture and echomosis goes together it's like a little thing that say this is a fracture

**[1:06:01]:** don't have them walk don't have them usually the elderly those they you you'll be surprised they get up and walk they hit of course they have this you know unusual gait but they're still walking with it and when they when they stop pain is not very common especially in the older dog it can't really use pain with hip fracture that they may not be complaining of any pain but the shortening unevenness of the leg now that i'm there there is one pediatric disorder um congenital hip dysplasia that i want you to make sure you review congenital hip dysplasia that's the one mfk question they love to ask congenita this is the one where they're born with the extra gluteal fold and remember all babies when you're doing the assessment we do that and you get the hip click we call it odellano sign and barlow sign with congenital hip dysplasia

**[1:07:07]:** and what they love to ask an influx on that is the extra gluteal fold so go back let's go come back to hip hip fracture so they go on probably most likely they're going to need to go to the or and when they come back they'll have the abduction pillow we need to get them up as soon as possible with physical therapy

**[1:07:39]:** then when they get in they're going home or they go into rehab let's say they're going home you're going to teach them in some instruction you're going to give is not to bend the hip below 90 degrees so don't sit on no lows chair low toilet seats they can they can buy it or get a prescription for a toilet seat razor or even to get some um pads for their chair at home don't go up to any stairs that they have to raise the leg above 90 degrees because it of course that would pop out so go over the hip um instruction that you'll get the patient to post hip do not bend at the waist so if they need to put on their shoes or you know um they put on their socks they can they have little um gadgets that they can buy to help them like put on this they sit down and put it on and then to pull it up they have those little gadgets but you don't want them

**[1:08:47]:** bending

**[1:08:50]:** over

**[1:08:55]:** question kathy you're quiet soaking it all in katie you're quiet no questions no question no devin you're quiet no no questions sure okay all right so that's the end um we're gonna go to psych um before we go to psych i just want to show you the journey stroke just in case you run across these you know um if you have any question on the journey

**[1:09:44]:** um one second

**[1:09:54]:** okay pain medication to make sure you go over the insects because they are not going to give you an nsaid that is common that one you know right away um but i have to say though unless they change the ncx usually clues you as to what the medication is for also whenever you see salicylic acid remember aspirin is is part of the active ingredient so anytime you see this word aspirin is in the drug and you are going to make sure that they're not allergic to aspirin or that if they are not spring already you know you factor those in um what else with the opioids so the dronates the other day they all end with a dronate i'm not interested in um so with osteoporosis treatment they can take calcium they should take calcium and vitamin d as well as the dronate but remember these um the dronage it could be it could be

**[1:11:00]:** iv or oral we're talking about if it's oral that's when they take it and they should sit up for at least half an hour if it's given iv iv could be every six months or it could be once a year now in that case we you're not worried about the esophagitis but we worry about the necrosis of the jawbone so regardless of iv or oral it's necrosis of the jawbone with the dronates that we worry about the most

**[1:11:31]:** i please make sure you know mahalia make sure you know the other names for the vitamins okay because they don't always say vitamin k

**[1:11:52]:** so again know the other names just in case they decide to go with what they decide to go with all right now let's go to psych i told you i said with all the stuff that's going on and post we're not postponed them because we're not post yet um but we should say post lockdown that we have so many different issues going on psych so the first thing i want to do is go over the medications for the psych side drugs so let's talk about the um antidepressants the ssri the snri doesn't matter the tcas antidepressants or antidepressants number one it takes tell your patient it takes about two to three weeks to reach therapeutic effects

**[1:12:49]:** because they want quick fix i don't want to be depressed anymore sorry you have to hang in there with me you got to take it too make sure you take it and when it regards the food um take it with or without food but there is no it's up to the patient um also what time of day is also up to the patient some patients say it's they feel better when they take it in the morning some say it's better at night because it helps them sleep so it doesn't have to be morning or night it depends on the

**[1:13:30]:** patient all antidepressant have the black box warning the black box one is said that especially in young adults increased risk of suicide especially when you first start taking them watch out for these questions if you're giving it to a young adult and it's under 25 we're talking about that age group college um young kids in high school you don't want to give them too much at one time because you want to force them to have to come back to be evaluated because of the increased risk of suicide

**[1:14:11]:** they all have anticholinergic side effects those are the side effects so dry mouth dry mucous membrane urinary retention constipation blurred vision tachycardia kc kmp can't spit can't poop that's the anticholinergic side effects third vision and you group them because this is how nclex is going to come at you with the sata mahalia group them so they're pretty benign i would say for the anti-depressants except that the tcas and you know them because they're the triptylines that's how you remember them the trips the triptylines these are cardiotoxic that's why they stop using them they can actually cause heart failure

**[1:15:18]:** if i should tell you that all anti-depressants or all side drugs causes qt prolongation that's just a stretch and you don't need that but it's not unusual for you to be doing questions somewhere else out of the um nclex and they'll tell you that if they are an anti-depressant they should get um an ekg that's okay they should they should get an ekg and they usually get an ekg but that's a stretch for nclex so let's leave that alone and concentrate on the anticholinergic effects that they when the therapeutic effects when the medication works and let's now talk about the complication the bad part we call it serotonin syndrome serotonin syndrome is a medical emergency when they're on antidepressants any of the antidepressants can cause serotonin syndrome and serotonin syndrome is when they get severe tremors severe and um hypertensive crisis tachycardia

**[1:16:27]:** the dtr the 10 reflexes are like plus four they basically they're in a locked up position they stiff and they temperature hyperthermia temperature is going to go up really high blood pressure is high heart rate is high patient's tremorous so it's an emergency they go into the hospital we treat serotonin syndrome we give them a lot of fluids iv fluids preferably isotonic normal saline of course we will place them on the ekg monitor to make sure that we're monitoring the heart

**[1:17:11]:** and we can also give muscle relaxants the benzos once you relax the muscles and flush flush out the system the blood pressure the heart rate will go down of course it doesn't go down also the temperature but in the meantime you can do basic nursing intervention for hyperthermia like we can do um ice packs and the growing icebox underneath the arm may also get a cooling blanket can't go wrong with those

**[1:17:49]:** herbal um so we need to talk about the herbals and the most common one is saint john's worth for antidepressant valerian is also there now once the patient is doing herbs which most people do before they start antidepressant they need a washout period we need a two weeks washout period so if you're on saint john's worth and you're still depressed and you go see your doctor the doctor said okay i'm gonna start doing some um lexapro or celexa we want to make sure you if you're on any herbs you stop the herbs for at least two weeks before you start though that anti-depressant so remember that washout period

**[1:18:37]:** two weeks minimum two weeks if they know when answering question if they say four weeks the longer the better one week is not

**[1:18:52]:** enough moving down let's talk about the um know the mao the mao inhibitors we also use these for depression and don't beat up on yourself if you don't know the names you can't remember the names you cannot remember everything that's why i said you're gonna be in a situation and you're gonna figure out what situation am i in here and sometimes the answers will clue you if you can't remember the names of the maos you will be able to because i know that i know the bran but i don't know those generic names but what i usually use to answer the question is look at the answers so with mao inhibitors the big thing with those are um the foods taramine rich foods cause hypertensive crisis so focus on fresh foods fresh foods so you don't want to be nothing salty nothing aged nothing pickled um nothing dehydrated

**[1:20:06]:** so anything any of those aged wine cheese we call it the cheese effect can cause hypertensive crisis with mao inhibitors

**[1:20:22]:** the other thing with the mao inhibitors if we they don't respond to if let's say they were on this or they're not responding to this traditional antidepressant and they decide to do mao we also need the washout

**[1:20:44]:** period see how much i'm talking about that washout period that two weeks at least before we start anything else

**[1:20:59]:** question

**[1:21:04]:** nope so remember it's if you can't remember them look at this situation you're going to see it at your thought doing the question you're going to go this is an mao and the foods go for anything that's fresh

**[1:21:21]:** and foods are all over and plex they're obsessed with foods and they and you know what kind of makes sense because what what put us in problem in the first place always go back to diet so anything that's age anything that's not fresh will cause crisis when you're on these and the thing is they don't really use this many the mao inhibitors that much anymore but again ascend clicks let's talk about lithium lithium for bipolar lithium which is completely out of vogue but it's all over nclex now for lithium the you absolutely need a drug level and this is the one that is the same as creatinine lithium same as creatinine which is cathy go ahead go ahead devin point you yes and when do you consider lithium

**[1:22:36]:** toxicity that'd be two and over oh wait did you say 0.82 1.2 1.2 um so over 1.5 anything over 1.5 is that's when you start um they you know they when you're in when you were in nursing school they have different degrees of lithium toxicity which makes me laugh but it's anything over 1.5 is considered lithium toxicity so lithium toxicity affects which two systems which tool system again this you'll see symptoms of lithium toxicity

**[1:23:18]:** the gi mm-hmm

**[1:23:28]:** and the kidney i think

**[1:23:38]:** what happened with the gi i think it's diarrhea and abdominal pain argentine diarrhea what about the neuro

**[1:23:52]:** it's almost like they drunk ataxia difficulty with gay and they can get confusion

**[1:24:04]:** what is the number one cause of lithium toxicity and it's an electrolyte imbalance and i'm coming for kim

**[1:24:23]:** yeah what's the number one cause of lithium toxicity it's an electrolyte which electrolyte can cause lithium toxicity

**[1:24:42]:** that's for so kitten kim just spits it over to you kathy

**[1:24:52]:** um i don't know for some reason i'm thinking diuretics diuretics would do it but what what that yeah you're thinking about what can cause you know ahead of the game there yeah directed or ace enhanced sodium sodium yeah low sodium low sodium hyponatremia

**[1:25:22]:** that's why we call it lithium lithium so most of the time is referred to lithium sodium

**[1:25:32]:** that's why here this is why kathy while you're thinking diuretics that's why they are bipolar and they're lithium and they order the the patient is on diuretics you should question it so don't think you were in the wrong place for at the wrong time that's why that's why this is why that was in your head because on lithium who goes on diuretics you should go ah because they're going to lose their sodium and they can go into lithium toxicity also they don't you know you don't want them to do being the sauna that's another one they always bring or you know over exercise they tell you they're gonna go for three ma for three hour run and then lithium you say hold off on that because if you've ever seen lithium toxicity it breaks your heart um the person it looks like it they're drunk for real so when the cops bring them in and

**[1:26:37]:** arrested them for public drunkenness which is the case which i've seen in the er they look drunk but then if they wind up at the right hospital because all their medical information is there and you you know type them in you go wait a minute this is a patient who has bipolar and is on lithium and then you go and they you know you get a lithium level and lithium of course level is very low um or is it either high or you know their lithium is off and they could they bring them in because again public drunkenness because they look they act they confuse they don't know where they are they they walk like they're falling down it's clearing their speech those are all signs of lithium toxicity so remember it's sodium so you don't want them to do anything that's going to affect their sodium level or drastically affect their sodium level and

**[1:27:28]:** that's why the diuretics would be questioned that's why spending all that hours in the sauna would be questioned that's why going for a long run in the middle of the day should be questioned because you're at risk for losing losing your your um sodium any question on lithium we did the benzos already so we can pass up on that now let's talk about the antipsychotics any of them all of them you can just group them together

**[1:28:06]:** how to remember them don't really need to there's a lot of them now with the anti-psychotics clause of p and these are the newer ones they have older generation first generation which like the hal doll aloperinol those are the first generation but on nclex it doesn't matter if it's first second or typical with antipsychotics it's the agranulocytosis the lower white cell counts that is the big issue that they're going after

**[1:28:48]:** so when they first start on like clavine if you you know the clothing as uh is very good it's very helpful in treating psychosis but they have lawsuits like crazy because people die from sepsis because they didn't when they first came out they didn't they didn't mention anything about the agranulocytosis so when they first start out like the first week they get a cbc every week for a month and then every three months and while they're on it they're gonna be getting a cbc every three months and you and the nurse doing a home visit or you're doing a home call you're gonna ask them about signs of infection like do you have any sore throat any chills or if they tell you these things um in low grade fever you need them to come in and be checked out

**[1:29:48]:** the anti-psychotics can also cause the eps the extra pyramidal was the parkinsonian type symptoms and then that that another one that's big on the leaderboard is the tardive dyskinesia then the tardive is the lip smacking or the worm-like movement of the tongue

**[1:30:14]:** tardive is big on the on the list because starter could be permanent

**[1:30:26]:** the tremors and you know all the other symptoms will go away once you stop it but they they are tardive can be permanent and by the way if the patient developed um issues with the antipsychotics or the anti-depressant stop it you don't have to wean them off these you can stop it immediately so if they develop a granulocytosis and you know an infection and they are an antipsychotic stop the drug

**[1:31:07]:** none of these had none of these drugs here that when i'm talking about for psychosis or depression has antidote so if they if they you know gets depressed and suicidal and do overdose is activated

**[1:31:28]:** charcoal

**[1:31:35]:** the antidepressants they have a medical complication too called neuroleptic malignant syndrome nms

**[1:31:48]:** and nms neuroleptic malignant syndrome is everything like serotonin syndrome the only difference is that one is from antipsychotic and one is from antidepressant but pretty much the symptoms are exactly the same and if you do a new world they have some beautiful pictures and is that both of them are and is looking the same serotonin syndrome neolithic malignant syndrome it's anti-psychotic complication neuroleptic malignant syndrome and it starts it could start with a patient just complaining of you know muscle tightness muscle stiffness you need to take that seriously and it could be triggered by the patients not drinking enough fluids severe dehydration trigger nms and serotonin syndrome

**[1:32:43]:** and treatment for serotonin syndrome and nms will be exactly the same like i told you fluids cool them down if you have to and we mean we need to relax those muscles and if the blood pressure doesn't go down we may give an anti-depressant it's fast enough because the blood pressure goes up really high high enough to stroke

**[1:33:06]:** out

**[1:33:11]:** okay let's talk about the adhd medications let's talk about adhd medications a central nervous system stimulants so they are all of these are um and we whenever you're talking about adhd the ncx is always asking about children questions like adults get adhd too it focuses on the kids now when you're given adhd medication these are remember we don't cure adhd we just treat the symptoms so with these kids you want to make sure that you teach them about the side effects that not the kids the parents and the kids too um because these adhd medications cause profound anticholinergic side effects including palpitations tachycardia and they have black box warning yes they do that said it can cause a mi or stroke

**[1:34:16]:** so you should teach that tissue today you know the mom and a kid parents to the kids report any palpitation any headache any chest pain right away

**[1:34:30]:** another factor another thing i want you to write down with adhd medication is that they can cause weight loss and they can also stunt the kids growth so they should whenever they come in for their visit besides getting their vital signs you need to weigh them and you need to measure them and that's the question they love to ask they come in for visit vital signs weight and height

**[1:35:05]:** how do you know the medication is working the kid is able to concentrate they're able to finish their homework they're able to you know their grades have gone up in school they're able to concentrate sometimes the teacher didn't even know that they were on medication they said oh this kid is doing so much better and teachers taking credit you know yeah it takes credit but also it's a so you know it's working because they're able to function better and that's another question they'll ask how do you know the medication is working how do you test the effectiveness of the medication

**[1:35:41]:** any any question on adhd medications

**[1:35:47]:** remember the xr um usually they come in capsule most of the adhd medication xr cr they should not break it it should take it whole adhd medication should be taken in the mornings you should not take it after 5 p.m that's like that's another question because he will keep them up at night as a matter of fact a lot of the kids with adhd need melon need melatonin because they are so awake it can't go

**[1:36:36]:** down as far as the alzheimer's drug um the only thing i have to say about them is that they cause severe anticholinergic effects and they make the patient sleep all day long severe sedation and the and as far as the efficacy is very minimal to none it's um it's described as going on a diet and working out for a whole year and didn't you didn't lose a pound but you didn't gain any

**[1:37:13]:** so if you can tolerate so per a family member will say we'll go for it at least say this you know will slow down the progression but you know the person is going to be sleeping all the time and they always severely constipated so anticholinergic effects sedation but a big thing with the alzheimer's drugs

**[1:37:45]:** now the next thing i want to talk about is smoking cessation we have to deal with that now because people were smoking more during the lockdown and now they want to quit so we can do the nicotine nicotine patch if they do nicotine patch they should not smoke with the patch they should not smoke with the medication chantix that's also nicotine smaller

**[1:38:28]:** dose alcohol cessation patient who wants to go through um let's say um to prevent alcohol withdrawal we did mention the benzos and also for alcohol patience word um alcohol withdrawal also always we give them thiamine to be one you will also see thymine given when they come into the er and they're acutely intoxicated we give them thymine what does the timing help them to do good question so remember the b vitamins has a lot to do with the central nervous system and with alcohol um alcohol affects the central nervous system right and they can get this thing called encephalopathy where they get confused or wernickey encephalopathy that area of the brain so the b the b vitamins they're deficient so that kind of helps boost that area of the brain and help with that confusion and that irritability and the restlessness that they get with alcohol withdrawal

**[1:39:48]:** and thiamine seems to be the best seems to be the one that they tend to tend to kind of hold on to the enzymes a little bit more than b12 because they usually have b12 deficiency also the alcoholics but thiamine seems to be the drug of choice so we give them um the b we give them the thymine iv give them a bag of thymine we call it the banana bag okay

**[1:40:18]:** so let's say they decide that i don't want to drink anymore i want to go to alcohol cessation i want the program i come in and they say that to you what is the first question you want to ask them before you consider giving them the interviews that are

**[1:40:48]:** disulfiram malia patients showed up at your clinic or in your er in your urgent care and said i'm an alcoholic well when you give them that drug i know they cannot drink at all like off that um drinking all together perfect so accidentally if they can't why would you ask them

**[1:41:23]:** did they drink before they came in yeah that's right when was your last outfall when you when was your last church because you want to have at least a six hour window from the last drink before you give them that drug yeah okay all right see how you answer your own question

**[1:41:48]:** and you won't trust yourself you said it you know that they can't have so you want to know because some of them are you know they say you know what in reality i'm going to go to you know to go into this program and stop drinking but you know what they're going to do before they go drink drink

**[1:42:12]:** said to my my sister had the gastric sleeve you know what she did the the day before the sleeve she went to she went to the buffet my sister did the same thing don't worry that's just normal human being so they're going to have a few drinks before they come in so that's why you want to ask that's why you want to ask them so anytime you see i like alcohol cirrhosis alcoholic beats just go for the diamond diamond diamond all the way diamond all the way now let me go through this and i'm going to point to you i know this has a lot of pages but it's psych and

**[1:42:58]:** i told you yesterday that and psych used to be used to be five percent of nclex and it's now 15. why have they increased it so drastically it is because of all the stuff that's going on around us the personality disorder make sure you go over these the different types of personality disorders and they're so interesting that you this if nothing doesn't stick the personality disorder will stick because once you start to go over them you're going to know somebody who has one be the co-worker be the family member be somebody you don't like you go find somebody who this is this is this this is this this is this and these are interesting and make sure you know them am i going to tell you which one they're going to ask no because they're asking all of them

**[1:43:55]:** we talked about the medications you don't have to go with the cluster a plus to be close to c you don't have to do this you just need to just look at the different personality disorder and you know see pick out one thing that is ex that stands out like narcissistic

**[1:44:15]:** borderline personality histrionic see this a lot attention seeking that's the one who comes in the room and everybody should know i'm here i'm here it's trianic

**[1:44:33]:** ocd they ask a lot of that too so just go through these um let's see what else i want you let me go to the top and i want you to make sure you look over especially if your exam is around the corner hell yeah make sure you go through this as i say psych is big abuse work okay elderly abuse child abuse elderly abuse remember you don't need concrete evidence to call it to report it you just need suspicion suspicion is enough regardless domestic abuse elderly abuse child abuse take care of the patient first address the patient needs before you report anything

**[1:45:28]:** okay what else do i want you to make sure um you go through here open no stress some of these i would say we all experience this and we all kind of will just just okay the defense mechanism the ones that are in red and once you do make sure you pay attention to those

**[1:45:56]:** we are all using these a lot now more than ever

**[1:46:11]:** for crisis intervention um make sure you review what's considered a crisis and cri nurses responsibility for crisis intervention

**[1:46:22]:** is it i have to say social workers are there and i was saying social workers are not there at night social workers work nine to five in the er they work they finish at ten and they gone in an emergency do they have the social worker covering yes can you find that social worker no so the nurse is the social worker the nurse is the physical therapist the nurse is the nutritionist the nurse is everything so you have to be able to you know yes we're going to use the interdisciplinary team but everything comes down to your assessment and your intervention

**[1:47:06]:** we all know the stages of grief or no we need to need to make sure you review that as well as simple as that is they'll give you a scenario and they'll ask you this denial this anger this bargain in physics acceptance

**[1:47:28]:** as uh okay uh for a mental health um also under this i want you to go over anorexia bulimia

**[1:47:43]:** the symptoms of anorexia and the symptoms of bulimia there's the intervention for both

**[1:47:56]:** remember the one of the basic intervention that they they the nurses institute for both anorexia and and bulimia is that my son would say we plate watch like you sit with them when they eat and you don't let them go to the bathroom or go anywhere until at least half an hour at least half an hour after their meal because you don't want them to go purge and throw it back up

**[1:48:27]:** as far as therapeutic communication always put it back on the patient and always offer yourself tell me more that must be hard for you how did that make you feel and never ask why soon as you see why you just white it out

**[1:48:58]:** wrong

**[1:49:07]:** that's your psych

**[1:49:11]:** so next week we're doing health promotion and health promotion is the biggest and the most fluffiest and the least number of question on nclex so what are we going to do on saturday saturday we're going to do we're going to talk about like normal part of aging um we're gonna we're also going to talk about growth and development that comes on the health promotion we're also going to go over primary prevention secondary prevention tertiary prevention and then on sunday we're doing ob i think kaden is my ob expert guys i'm gonna put her on the spot she's old she did ob so she can fill in i am an expert please don't say that she is my ob expert my ob is coming straight from the book my ob has zero experience i have never worked a day in ob i'm coming straight from the book with ob um my or my abuse abuse guides

**[1:50:24]:** went to clinical in ob it was more of an observation than anything else they didn't want you to touch the patient so i did some observation but as far as or my er of course in the er you know when they come in sometimes we have delivery in the er so that's my ob experience but not i can't relate it to clinical practice but i i think i think i've gotten there cathy would you say that would you give me that much for ob cathy i'll give you all b you have a couple yeah my ob is all er my old like i said i always tell you when i'm doing ob i said guys let's go in the delivery room because that's where i am the expert we're in the delivery room but anywhere else i'm like okay all right what did the book say okay and what does they what are they what

**[1:51:19]:** are they looking for at nclex but that's how that's what we're doing next week and then after that we're doing questions questions questions questions some of us are going to be sitting the exam by then some of us are ready but scared and we need to get over to scared we need to give it's it's it's it's only natural to be afraid of this desk because personally if i had to sit and collect right now i would sit it but i would be like what you know what i don't want to do this i don't like standardized exams period because i don't think they fare but you're still going to do it you're still going to do well on it even though it's not fair because the only the only fairness about nclex is that they only want you to be above above 60 on

**[1:52:13]:** the content for rn for for lpn if they say about 55 but np is above 70. this which is fair you can you can get that you can you can give that much so other than that if we have our meeting kathy we're going to meet the same time like we did last week yep and i want you to start doing i said only the rain can stop you from doing what you've been doing on a rainy day not not even the rain i was outside today in the rain exactly not even that's good that's what i want to hear um and mahelia i'll see you later katie and i'll see you in the week actually i'll see you in the week nevin let's talk for a minute please all right all right bye-bye thank you thank you have a good one bye see ya see you hey jesus lord stop

**[1:53:20]:** it