Mark Klimek NCLEX Review: Drug Toxicities, Kernicterus, Dumping, Electrolytes

Mark Klimek NCLEX Review: Drug Toxicities (Lithium, Lanoxin, Dilantin, Bilirubin, Aminophylline), Kernicterus, Dumping / HH Electrolytes: K+, CA, MG, and NA, Treatment for Hyperkalemia.

Drug Toxicities—Know these FIVE medications

 1. Lithium (anti-mania drug)

- Used for Bipolar

   - Specifically, for the manic episodes but not for the depression

- Therapeutic level: 0.6 to 1.2

- Toxic level: >2.0

- Notice gray area: 1.3 to 2

  

2. Lanoxin or Digoxin

- Used to treat A-Fib and CHF

- Therapeutic level: 1 to 2

- Toxic level: >2

 

 3. Aminophylline—muscle spasm relaxer for the airway

- Compound of the bronchodilator theophylline

- Therapeutic level: 10 to 20

- Toxic level: >20

- Non-therapeutic level: <10 … if it is not therapeutic, increase

   dose of medication, and assess for compliance

 

 4. Dilantin (phenytoin)

- Seizure medication

- Therapeutic level: 10-20

- Toxic level: >20

  

5. Bilirubin

- Breakdown product of Red Blood Cells

- Normal level in adults: 0.2 to 1.2

- Always tested in the Newborns on the NCLEX

- In Newborns bilirubin is much higher than in adults

   - Elevated level: 10 to 20

   - Toxicity: >20

- When do physicians want to hospitalize these newborns?

   - When bilirubin level is about 14 to 15

 

Patterns

- 1s and 10s

- 2s and 20s

   - 2s: Low # (Lithium and Lanoxin)

   - 20s: High # (Aminophylline, Dilantin and Bilirubin)

 

Jaundice—Yellow skin from excess bilirubin in the blood

- It appears as yellow skin and sclera

 

Kernicterus—Excess bilirubin in the brain

- Occurs when level in the blood gets >20

- In the brain, it may cause aseptic (sterile) meningitis or encephalopathy (don’t need to know)

- It can be DEADLY

 

Opisthotonos

- Position the newborn assume due to irritation of the meninges from kernicterus

- Presentation: hyperextended posture … (Is a medical emergency)

 

Question

In what position do you place an opisthotonic newborn?

A: Put newborn on the side

Pathological vs. Physiological Jaundice

- If the newborn comes out yellow, something is wrong = Pathologic jaundice

- If the newborn turns yellow 2 to 3 days postpartum, that’s ok = Physiologic jaundice

 

Dumping Syndrome vs. Hiatal Hernia

- Both gastric emptying problems and are opposites

 

Hiatal Hernia

Regurgitation of gastric acid upward or backward into esophagus

- “Like a cow with 2 stomachs,” gastric contents go in wrong direction at the correct rate

- S/Sx of hiatal hernia is similar to GERD (Heartburn and indigestion)

- S/Sx of hiatal hernia = S/Sx of GERD when lying down after a meal

   - In other words, Heartburn, Indigestion on lying down after eating

Treatment

- Can do 3 things, as shown below

1. Elevate HOB (head of bed) during and 1 hour after meals

2. Increase the amount of fluids with meals

3. Increase the amount of Carb content

- These cause the stomach to empty quickly so its content doesn’t back up

- High-atal Hernia … Everything high

 

Dumping Syndrome

- Gastric contents are dumped too quickly into duodenum

   - Right direction but at wrong rate

- S/Sx of dumping syndrome

    - Drunk: Staggering gate, impaired judgment, labile—all blood gone to gut

   - Also get Shock: cold/clammy, tachycardia, pale

   - Now add Acute abdominal distress: n/v, diarrhea, cramping, guarding, borborygmi, bloating, distention

- Dumping syndrome = Drunk, Shock, Acute Abdominal Distress

 

Note

- Drunk is what it is

- Shock is what it is

- Drunk + Shock = Hypoglycemia

- Drunk + Shock + Acute abdominal distress = Dumping syndrome

 

Treatment of Dumping Syndrome

Can do 3 things, as shown below

1. Lower HOB (head of bed) during meals and turn patient on the side

2. Decrease the amount of fluids 1 or 2 hours before or after meals

3. Decrease the amount of Carb content

- These 3 things prevent the stomach to empty quickly or dump its content into the duodenum

Dumping syndrome … Everything low

Why is protein added in the diet?

- Protein does the opposite of carbohydrate

- Protein bulks gastric content, takes longer to digest, and moves slower through the gut

- Therefore, give

   - Low protein in hiatal hernia

   - High protein for dumping syndrome

 

Electrolytes

Memorize these 3 sentences

1. Kalemias do the same as the prefix (hypo-, hyper-), except for HR and urine output which go opposite

2. Calcemias do the opposite as the prefix

3. Magnesemias do the opposite as the prefix

- Natremias

HypoNatremia = Volume overload … HyperNatremia = Dehydration

 

  

Kalemia(s)

- Go in the same direction as the prefix, except for HR and urine output (UO), which go in the opposite direction

- Hypo—Symptoms go low with hypo, except HR and UO

- Hyper—Symptoms go high with hyper, except HR and UO

 

Some S/Sx of Hyperkalemia

- Brain: seizures, agitation, irritability, loud down

- Heart: tented T waves, ST elevated, tachypnea

- Bowel: diarrhea, borborygmi

- Muscle: spasticity, increase tone, hyperreflexia (3+, 4+)

- Heart rate: down (bradycardia)

- UO: down (oliguria)

 

Some S/Sx of Hypokalemia

- Lethargy, bradypnea, paralytic ileus, constipation, muscle flaccidity, hyporeflexia (0, 1+)

- Tachycardia (HR is up)

- Polyuria (UO is up)

 

Question

Your patient has hyperkalemia, select all that apply

a. Adynamic ileus

b. Obtunded

c. 1+ reflex

d. Clonus (irritable)

e. U wave

f. Depressed ST

g. Polyuria

h. Bradycardia

Answer:

- Kalemia goes in the same direction, except HR and urine output … therefore,

- Clonus are bradycardia are right

 

 

 

 

Calcemia(s)

- Go in the opposite direction as the prefix

- Hypo—Symptoms go high with hypo

- Hyper—Symptoms go low with hyper

Calcemias do the opposite of the prefix—it is a sedative

- So Hypercalcemia is bradycardia, bradypnea, flaccid, hypoactive reflexes, lethargy, constipation, etc.

- So Hypocalcemia is agitation, irritability, 3+ or 4+ reflexes, spasm, seizure, tachycardia, Chvostek sign (tap the cheek), Trousseau (inflate BP cuff), etc.

 

Choosing answers for potassium and calcium

- For potassium pick answers related to heart problems

- For calcium pick answers related to muscle problems

 

Magnesemia(s)

Magnesium goes in the opposite direction of the prefix—it is also a sedative

 

It is possible that S/Sx are from several electrolytes imbalances. In that case:

- Choose CALCIUM if nerve or skeletal involvement

- Pick POTASSIUM for any other symptom

   - Generally anything effecting blood pressure

 

Your patient has diarrhea … Which one of the following electrolyte imbalances causes diarrhea? Hyperkalemia, hypokalemia, hypocalcemia, or hypomagnesemia

- Tetany? Hypocalcemia

 

Test tip - Common mistake

- Tetany = Hyperkalemia—prefix example. Pay attention

 

Natremia(s)—Sodium

- HypErnatrema = DEhydration

   - Hot, flushed, dry skin, thready pulse, rapid HR … Give fluid

    - Associate “E” in hypernatremia with DEhydration

- HypOnatremia = Overload

   - Crackles, distended neck veins … Fluid restriction, Lasix

   - Associate “O” in hyponatremia with Overload

   - Nursing Dx: Fluid Volume Excess

Question

In addition to a high potassium, what other electrolyte abnormality can be seen in DKA?

- Hypernatremia = Dehydration

- DKA should make you think of DEhydration, which is also associates with hypErnatremia

 

Question

In addition to High Potassium what other electrolyte imbalance is possible in DKA?

A: Hypernatremia

Review—Think dehydration or Fluid overload

- SIADH: Hyponatremia

- DI: Hypernatremia

- HHNK: Hypernatremia

 

How to spot early signs of electrolyte imbalance?

- The earliest sign of any electrolyte disturbance is

   - Numbness and tingling = Paresthesia

   - Circumoral paresthesia = Numbness and tingling around the lips

- The universal sign of all electrolyte imbalances is

   - Muscle weakness = Paresis

 

Treatment

- Potassium is the only one Boards will test

- Never Push Potassium IV

- Potassium <40 mEq/L of IV fluid

   - If >40 mEq/L, clarify dosage with physician

 

How do you lower potassium?

- Of all electrolyte imbalance, high potassium is the most problematic

- High potassium can stop the heart

- The fastest way to lower potassium level is to

   - Give D5W and regular insulin to decrease potassium

   - This will drive the potassium into the cell and out of the blood

   - Temporary solution but quick

- Kayexalate is long-term solution

   - Through enema or ingestion, Kayexalate exchanges potassium for sodium

   - Potassium is eliminated through feces and patient becomes hypernatremic

   - Hypernatremia is managed with IV fluid administration

   - The downside is it takes hours to work

- To solve this problem

    - Give D5W, Regular insulin, and Kayexalate and the same time D5W and Regular insulin work instantly

Kayexalate works in a few hours—K Exits Late