Event 18: Respiratory Emergencies – Nursing Pathophysiology Review – Live with Professor Lawes

00:04 Hey, welcome. I've just been talking to you guys, and we weren't really live, I completely misunderstood.

00:09 So, hello. Glad to have you with us here tonight.

00:13 This is just kind of a practice run.

00:15 If you guys like this format and there's other things you want me to pop on and do, would love to do it. Because I really like hanging out with nursing students.

00:24 Ben, I saw your, um, history there and that you're doing a career change.

00:28 Excellent. Dude. That is, you are phenomenally wired for some of the toughest conversations in nursing.

00:35 So the rest of this stuff is just learning the content right alongside your peers, and you should be in really good shape.

00:41 But tonight we're talking about respiratory emergency.

00:44 So if you could see Nurse Liz right now, which you can't, she is holding your little one because her little one's not been feeling good and she's running StreamYard and Discord for us.

00:55 And so if you have questions, go ahead and pop them in and Nurse Liz is going to help me. Amazing.

01:01 She's a mom and a nurse practitioner.

01:03 And she's doing all this at the same time.

01:05 And this is my first time on StreamYard.

01:08 So just be patient with us.

01:09 We're going to do the very best for you that we can.

01:12 And here's what I want you to keep in mind.

01:15 If we're talking about respiratory emergencies, you want to be able to recognize when your patient's in trouble.

01:21 Now there's lots of things that can get them in trouble, right? They can be, um, there can be asthma.

01:27 They can be a COPD, or they can have emphysema.

01:30 They can have taken a drug overdose.

01:33 But really, when you're thinking about taking questions on respiratory emergencies, that bottom line is we've got to increase the oxygen that's in their bloodstream because they've got to deliver that to the tissues.

01:47 Right. So there's the bottom line.

01:49 We want to figure out what's causing the respiratory emergency and fix that.

01:54 But pretty much I want you to start from that platform where we all start with respiratory emergencies or we're not getting oxygen to the patient's cells.

02:04 It's not getting what they need.

02:06 And we have to figure out how to resolve that.

02:09 Now, those of you that are in pathophysiology, you're probably not studying treatments yet.

02:14 Those of you that are in med surge, you are studying treatments.

02:18 So if you have a specific treatment question, just go ahead and ask us.

02:21 Be happy to talk to you about it.

02:23 But I want you to know that if your patho, you likely don't have to know the treatments.

02:28 But we're going to talk about other key concepts in there.

02:31 Let me see if I can get our slides to advance.

02:34 There we go. So let's take a quick review.

02:38 The major functions of the respiratory system.

02:40 We've just got this on here.

02:41 Don't worry about olfaction and speech.

02:43 I just went into some of our slide presentations and pulled some pictures.

02:47 So you're thinking in your mind, you see you've got lungs on the right and left side of your heart.

02:52 Remember, those two are really involved together.

02:57 Hey, I just saw that we have, like, 35 people here tonight.

03:00 Glad to have you. So welcome.

03:03 So this is where we're starting thinking about this is what the respiratory systems job is. If you're like, uh, I already knew that.

03:11 That's the place to celebrate, right? Whenever you know something already, that's brilliant.

03:16 Because we're going to do what you call cumulative learning.

03:20 Today, I just defended a really weird educational psychology dissertation.

03:24 So I love educational psychology.

03:26 I won't bore you with the details, but I'll always help you learn how to study something. So that's what we have to start.

03:33 The whole purpose is to get oxygen to the cells and to remove carbon monoxide dioxide out. So you breathe in oxygen, breathe out carbon dioxide.

03:45 Right. That's what we're looking at now since the heart and lungs, they're buddies, right? They're right there together.

03:50 And that's the first place that the heart pumps the blood to get oxygenated.

03:55 They really can impact each other.

03:58 Now you start up here with your mouth and nose goes all the way down, obviously to your lungs.

04:03 Remember, it goes to the bronchi and bronchioles and it gets smaller, smaller and smaller. Right.

04:10 And it also gets more and more and more fragile.

04:12 Like by the time we get down to the bronchioles, you've got like these little elastic fibers. So that's what's keeping all those grape like clusters together. Now those are alveoli right.

04:23 That is the only place where we're going to be talking about O2.

04:27 And CO2 exchange is right there down in the alveoli.

04:30 They kind of look like blueberries to me there.

04:32 But the idea is what you're looking at is you have this big airway coming down.

04:38 It gets smaller and smaller and smaller.

04:40 You see on the airway there are some, you know what? Um, how about this? I think we need to add it to the stream.

04:50 Here we go. Guys. It was very clear here when you're looking at this drawing.

04:56 Now that you can see it.

04:57 Oh, nurse Liz, we're going to remember all these things that Rob forgets.

05:02 When you look at right here, here's the airway.

05:04 Now we've got these dark pink bands here.

05:07 The reason we have those there is that we want you to remember that there is smooth muscle wrapped around those airways.

05:13 Now, if I have asthma, that's part of what constricts.

05:17 Right? Because asthma is two things.

05:19 It is bronchoconstriction.

05:21 Those smooth muscles will clamp down and it's also an inflammatory response.

05:26 Now anytime your body has an inflammatory response, there's usually all these invaders and things that come out to protect you and to fight for you. In asthma, it's going to be this kind of mucus stuff.

05:37 Now, that mucus shouldn't be a funky color, right? It seemed pretty clear, maybe whitish, but if it's green, we likely have some type of infection going on there.

05:48 So that's more like leaning towards some type of infection in the lung.

05:51 So where we're starting is lungs and heart.

05:54 They're buddies, right? The lung is the one that receives the blood directly from the heart.

06:00 So into your right atrium, right ventricle over to the lungs, gets oxygenated, comes back to the left atrium, to the left ventricle, and then out to the body.

06:13 So in through your nose is where air comes in.

06:16 And it's going to go right down to these tiny little alveoli.

06:20 And that's where the gas exchange happens.

06:23 Now, what I'm trying to get you to do is to picture things in your mind so that you look at things from all different kinds of angles, because that's where test questions can get really hard when they start talking about things called interrelatedness.

06:38 As a nurse, we want you to be able to understand that, hey, if someone has a respiratory problem, if their lungs you have COPD, you have emphysema, you have some type of pressure in your lung is going to be higher.

06:56 So if I have COPD the pressures in my lungs are going to be higher.

07:03 Think about the part of my heart that is moving blood over to my lungs.

07:10 Well, it's not the right atrium exactly.

07:12 Oh, it's the right ventricle.

07:15 So that right ventricle is trying to move blood to my lungs.

07:18 And if the pressure is super elevated in my lungs, that right ventricle has to work harder.

07:25 So those of you that are in pathophysiology, if your faculty are talking to you about interrelatedness, cor pulmonale is cor for heart coronary pulmonary lungs.

07:37 It's right sided heart failure and it's caused by the lungs.

07:43 So that's another thing to keep in mind.

07:45 Why is that that way. Well let's pause for just a minute.

07:49 I'm going to give you about 15 seconds to see if you can say in your own words, how does COPD over a long period of time cause cor pulmonale? What is it and how is it caused? Ready? 15 seconds. Go.

08:20 Okay. Beautiful. How much of that were you able to explain? Maybe you already knew that.

08:25 Going over it again is never a bad thing.

08:28 In fact, your brain loves it.

08:30 Your neurons want to get together and make really strong relationships, so it loves it when you do things like that and you repeat them.

08:38 Now you guys know about surfactant.

08:40 Remember that preemie babies don't have enough surfactant.

08:43 And our lungs are, as I always tell students, moist. Right. It needs to be moist for that gas exchange.

08:51 And that's why surfactant matters.

08:53 Because as you see in the picture, you see water likes to like pull together.

08:58 It's super strong. So water is attracted to each other and it pulls itself all together well inside your alveoli you have water.

09:08 And if you didn't have surfactant to break up that surface tension, your alveoli would collapse.

09:15 Okay, so if I leave water to itself, it's going to pull itself all together because it's got a pretty strong attraction. If we have surfactant in there, it's going to not allow that water to pull so tightly together.

09:28 And that's what helps keep the alveoli open.

09:31 So that is why your body needs surfactant.

09:34 That's why preemies struggle because they don't have it okay.

09:38 So we're kind of thinking about we know the anatomy of the of the lungs.

09:43 We know the airways go from bigger tubes down to tiny tiny tiny tiny bronchioles down to the alveoli. And remember the remember, the alveoli are very fragile.

09:52 They have just single walls like this.

09:54 So one little kind of cell wall bumps right up against the capillary, which is also very thin.

09:59 And that's why the oxygen can go past.

10:02 Now what difference does this make if I'm trying to pass a path of test or I'm trying to pass my med surge test? Sometimes students jump too quickly to like, what are the interventions? How do I need to treat it? If you understand what's going on in the body, that's why patho really is more important than it might feel.

10:24 You're going to be able to recognize what is the most important thing that you should do.

10:28 How should you do that? So that's why we kind of went over this review.

10:33 For those of you that are in med surg.

10:35 If you look at remember when we talked about the smooth muscle that was around here? If you're looking at how to treat an asthma attack, we know that an exacerbation of asthma is going to cause two things in their lungs.

10:51 It's going to cause bronchoconstriction.

10:54 That's the clamping down of that smooth muscle around the airways.

10:58 And it's going to cause. All that kind of gross mucus.

11:02 Now, mucus is helpful.

11:04 You want mucus, but when you have too much of it.

11:06 It makes it really hard to breathe through.

11:09 So we know if you're going to try and treat an asthma attack. You're going to have to treat it with something that's going to relieve the bronchoconstriction something like a bronchodilator.

11:18 And you're going to want one that works quick, and you're also going to want something to calm down the inflammation, some type of steroid or any other type of anti leukotriene type of medication.

11:29 Now I know patho people.

11:31 You do not have to know meds.

11:32 So just celebrate that.

11:34 You don't have to do that.

11:35 But we have other students who are going to be in med surg, and they needed just a little bit of an orientation to that.

11:42 So now think back how does surfactant work? How does surfactant in keep an alveoli from collapsing.

11:52 You can answer it to yourself.

11:53 You can type it in the chat, but make sure you have that concept solid in your mind, because a alveoli has to stay open in order for CO2 and O2 exchange to happen.

12:10 Remember, surfactant kind of breaks up the water power.

12:13 So the water has to kind of help keep the alveoli open instead of causing it to collapse. And we need alveoli to stay open in order to have the gas exchange.

12:24 Which is why let's put some dots together.

12:27 What COPD which part of COPD goes right after the walls.

12:33 You got it. Nice. Keeps it from collapsing.

12:35 What part of COPD goes after the walls of the alveoli just destroys them.

12:44 Anybody want to throw it in.

12:49 Good. I'm seeing some responses.

12:52 Emphysema. Remember, there's two parts.

12:54 Yes. And he got it. Hey, now, we may have a delay.

12:58 If you see your answer, come up or you might not see your answer come up. That's okay. We're always going to make sure that we give you the answer.

13:04 Because I'm telling you, if you saw what Nurse Liz is doing, she's amazing. She's taking care of her kid, doing all this stuff for us.

13:10 So don't worry if your particular answer doesn't come up.

13:13 We're just going to snag some of them and put them up on the screen so you can see them.

13:18 So COPD, emphysema, you end up with those walls being destructed destroyed.

13:25 So does that change somebody externally? If I'm taking care of someone who's had COPD for a really, really, really long time, they've had emphysema and they have been pretty sick. They're now elderly.

13:38 Is there anything externally that I could observe about them? Anything that might make them look different physically than someone who didn't have it.

13:51 I see it. Barrel. Chest.

13:53 You've got it, remember? Because those alveolar walls are getting so just just obliterated. They start to develop what we call a barrel chest.

14:03 So instead of being wider this way than they are deep, they all become really rounded because that actual lung tissue is changing.

14:11 Good job. Now we're going to get to questions.

14:14 Um, where you get to work through some test questions and I'll show you kind of how to do that. I just wanted to do this quick review of the key points where you could be tested on respiratory. So you may not have known this.

14:25 And it's a fun fact. I don't see it coming up on your test, but it's pretty cool that CO2 is 20 times more soluble in plasma than an alveolar fluid than oxygen.

14:35 Just a fun fact. Don't memorize that, but I put this in here to remind us this is where all the magic has to happen.

14:43 This alveoli has to be intact.

14:46 This has to be receiving blood flow.

14:48 Things have to be flowing through here smoothly in order for your patient to be able to survive, to live, to thrive, to have the oxygen that they need.

15:00 Okay. So we've gone over simple review and hopefully that was just a refresher for you.

15:06 Those concepts were pretty similar.

15:09 You have you've heard them before.

15:11 Now talk to me about what's the system we discussed.

15:14 Our topic tonight is respiratory.

15:16 But what is an interrelated system that can be impacted by the lungs? Oh, I flipped you all the way back on that.

15:27 Let me just tell you. Oh, sometimes that question made much more sense in my head. Remember we talked about what cor pulmonale is.

15:33 So it's the heart is impacted by what happens in the lungs.

15:37 So let's talk about that oxygen transport.

15:41 Now you have Of molecular oxygen is carried in blood in two ways.

15:46 Right. So just a tiny, tiny bit of it is in the plasma.

15:50 Majority of it is on the hemoglobin.

15:53 And another weird fact, like newborns have six hemi's.

15:58 And as adults we just have four.

16:00 So we can carry about four of those at a time.

16:03 Red blood cells. Remember, there's not a lot to them.

16:06 They're just kind of like these empty sacs that carry red blood cells to the tissues.

16:11 So every time you're thinking about respiratory emergencies, let's talk about that red blood cell.

16:18 If I have low red blood cells, the medical term for that is a anemia, right. Low red blood cells.

16:25 Anemia. So how could that make me short of breath? How would not having enough red blood cells make me short of breath? Ah! Anyone who has not enough red blood cells is not going to have enough carriers of oxygen to get the oxygen to the tissues.

16:48 Now, how do I have things like anemia? Well, there's lots of causes of anemia, but that's going to look at specifically.

16:56 You don't have enough red blood cells.

16:58 What if I'm hemorrhaging.

17:00 Well, that's another way I can have not enough red blood cells.

17:03 We don't call that anemia, but that is another way a patient.

17:07 So we know if someone is bleeding.

17:09 The biggest problem is that we know we're not going to be able to keep their blood pressure up. That means blood is leaking out of the intravascular space, and they're going to be at risk because they're not getting oxygen to the cells.

17:22 So it brings up a quick point.

17:24 I want you to have the mind of a child when you're studying.

17:27 Try to make it fun. Because I know sometimes studying is not fun.

17:30 But there's two questions I recommend to every student, and I recommend to the med students when I teach with them.

17:36 Why would a nurse or a health care person need to know this.

17:41 How would it help them keep a patient safe with this? You know that red blood cells carry oxygen.

17:48 When you're reviewing your patient's lab work, and you notice their H and H, their hemoglobin, hematocrit is down.

17:54 You know that. Uh oh. This patient is likely going to not have enough energy.

17:59 They're going to feel really tired.

18:02 So I would go in and ask them those types of questions.

18:05 When you're taking exam questions, those are the things they're going to ask you about. Do you recognize how a patient would describe how something feels.

18:14 So can you speak to yourself? You can type it in if you want to, but you don't have to.

18:19 But if I had low red blood cells, can you say why? I would feel tired. So if I had low red blood, low red blood cells, why would I feel so tired? Okay, now, I hope you're trying to answer that on your own, because I swear to you, I could bore you to death with the research, but just the effort of you trying to predict an answer or answer a question will help your brain be ready to receive it.

18:57 So the rationale was, well, you would feel tired because red blood cells carry oxygen. You need oxygen in your cells to survive.

19:03 If you don't have enough of that, you don't have enough oxygen and you're going to feel very fatigued.

19:09 So here's six key signs that you want to look for.

19:12 And I posted that in our discord.

19:14 So you guys have that picture right in the discord if you want to go back and look at it. But these are bad signs okay.

19:20 When you see things like flaring nostrils, that's just what it sounds like.

19:24 That's the body's attempt trying to to let you know I cannot get enough air in.

19:30 So I'm going to do everything I can to get as much air in as possible.

19:34 If you hear noisy breathing, you should not have normal noisy breathing if you're awake and alert, right? So if you're hearing noisy breathing, that can be a real problem.

19:45 Someone in our discord asked about, hey, can we talk about Epiglottitis? Yeah, yes, we can talk about that.

19:52 Um, that's a little flap, right? That goes. It protects my trachea, which goes down into my lungs if I want to swallow food or my spit.

20:00 The idea is that little flap will protect my trachea and allow it to go down in my esophagus. If that gets swollen, if my epiglottis gets swollen, okay, now it's affecting my airway.

20:13 So when I try to breathe, you're going to hear a weird noise like that.

20:17 That's never normal in a patient.

20:20 So when you hear some changes to their breathing, it's audible. It's noisy.

20:25 That's when you want to immediately follow up and find out what is the cause of that.

20:30 Now pursed lip breathing.

20:36 That's what COPD ers pretty much instinctively do, because they're trying to get all of that air out of their lungs that might be trapped.

20:46 Okay. So that's why they extend that usually go.

20:50 We breathe in we breathe out.

20:51 They're trying to breathe in. And then having a longer exhale, trying to make sure they can empty out their lungs more efficiently.

20:59 Now accessory muscles.

21:01 That means they're trying to use everything as they normally would not have to because they're not getting enough oxygen.

21:09 So think of what this person would look like. What's happening to their nostrils? They're flaring. Flaring? What do they sound like? They've got this weird noisy breathing.

21:17 Their mouth might look funny. They might be doing pursed lip breathing.

21:20 If they're using these muscles here, they're literally trying to raise their chest wall so they can get more air in.

21:27 All of these are dangerous signs.

21:29 You're going to need to intervene and do something to help this patient.

21:33 This could be a real emergency now with Tachypnea.

21:39 Oh, and Nurse Liz, the, um, there is a we can we can post this somewhere here for them to.

21:46 Okay. Thanks. We're going to upload all the slides.

21:49 So I told you Nurse Liz has this. And I love the picture of your dog.

21:52 Uh, both Nurse Liz and I have dogs, and we love them.

21:54 She also loves her children, but she does love her dog, too, if they're tachypnic. Hey, guys.

22:01 Remember in medical terminology, anytime you see tachy, that means fast, right? Tachycardia is fast. Heart Tachypnea is fast breathing, usually about 24 breaths a minute over than that.

22:13 Now, keep in mind, in real practice, Tachypnea is for the patient.

22:18 Not everybody breathes exactly the same rate.

22:21 So maybe I'm someone who breathes at a faster rate at my resting rate.

22:25 Always knowing your patient's baseline is important, but that's a good rule of thumb for a test.

22:30 Now, cheyne-stokes is some really weird breathing and you would recognize it if you saw it. It's irregular breathing.

22:37 This tells you your patient is in trouble.

22:39 And sometimes we see that for other reasons. But if you see any one of these things in a test question, your red flag should go up, right? You should be on alert that this is going to be a big problem.

22:53 Now you guys want to know about nasal cannula and low flow.

22:55 I picked up some of those questions.

22:57 When we talk about low flow or high flow.

23:00 This is pretty much the patient bringing the oxygen in and out on their own.

23:04 If somebody is on something like a BiPAP, you know those big masks that have different pressure set on them, they're on a ventilator that's considered high flow oxygen. So on this I just put this chart in here.

23:15 So you know, that room air is about 21% oxygen.

23:18 And then you see as we go up on one liter, two liter, three liter, four liter, you see the percentages of oxygen as it increases. So right now you and I are breathing in whatever room we're in.

23:32 We're getting about 21% oxygen.

23:35 There's a lot of other stuff that's not oxygen in the air, but 21% of that is oxygen, and it's enough to sustain us.

23:43 As I keep adding one, two, three, four, five, six liters, you see how that goes up.

23:49 So another thing to keep in mind that nasal cannulas are not magic, right? You have to put them on correctly.

23:56 The patient has to be willing to keep them on.

24:01 And then, uh, oxygen is off the wall.

24:06 Yeah. Um, you think, uh, Nurse Liz, my guess would be that it means when they are. I know you didn't ask that question, but I would guess that when they say it's off the wall, it means they it's not hooked up to a tank.

24:17 It's actually attached to the wall. Let me see if I have a picture here for you guys to see that I do not. So, um, in most hospitals, they have these outlets that are usually by the head of the bed.

24:28 Some of them are medical air, like compressed air.

24:31 Some of them are oxygen, some of them are suction.

24:35 You don't ever really want to get those mixed up.

24:37 They're all labeled the same no matter what the hospital is.

24:40 So if they say it's off the wall, that would be my guess is they're saying that the nasal cannula is hooked up to the oxygen that's coming from the hospital system.

24:49 Otherwise, you could have oxygen hooked up to a tank.

24:53 Not my favorite, because, um, they're really kind of problematic.

24:56 If they get bounced around or not handled correctly, they can become missiles.

25:01 So that's why you always want to be really careful when you're transporting a patient with oxygen and you have a tank, you can't transport a patient when it's to the wall because we don't have tubing that that is that long.

25:13 Now, I put this up here really quick about cannula to remind you that you want the prongs to go down the airway.

25:19 You don't want the prongs to go up into their nose and back out.

25:23 So when you put it on, the patient has to put it on the right way.

25:27 So if they're messing with it and fussing with it, that's going to affect their ability to get that oxygen. Also know that that tubing is is not nice, right? Wherever it touches, their ear can become really sore where it touches their nose. Nose can become really sore.

25:42 So it's not easy, particularly wearing a cannula.

25:46 It's not natural. Some people are really accustomed to it.

25:49 But just be patient with your patients, especially if they're not used to wearing oxygen before. Now back to our two main forms of COPD.

25:57 Chronic bronchitis is this massive amounts of of mucus right.

26:03 And that happens over chronic means a long period of time.

26:07 Itis means inflammation.

26:11 Nasal cannulas are not usually going to be on a patho test.

26:14 If they are, I would check with your individual faculty because seems like every faculty has an opinion, but I would guess that, uh, nasal cannulas would actually be more on a med surge test.

26:26 But now you'll know what they are when you go to clinicals. So chronic bronchitis, emphysema, the two parts that we consider COPD.

26:34 Can you in your own mind if I give you about 10s.

26:38 What are the differences between emphysema and chronic bronchitis.

26:42 Ready. Go.

26:56 Okay. Differences. Well, chronic bronchitis, um, happens at least like three months a year.

27:02 And they have all this goopy stuff in their lungs, and they're coughing and hacking all the time.

27:07 Emphysema. They likely are coughing also, but they don't have as much mucus.

27:12 Their bigger problem is the alveolar walls are destroyed.

27:17 So keeping that in mind as we go through, let's start with some simple questions.

27:21 Now let me give you some test taking strategies. You may wonder, like, well, how long has it been since you've been in nursing school? Uh, that's a very personal question.

27:31 It's been a long time, but actually, I've been in nursing school for the last 20 years, just not as a student.

27:38 So these are lower level questions.

27:40 These are simple questions. Here's a couple of them that I snagged from our platform on Lecturio. But let me walk you through the principles on how to raise your test scores, no matter what the topic is.

27:51 Now you call this the stem.

27:53 It's pretty short, right? Please don't look at these answer choices yet.

27:58 The best thing you can do for yourself is stop looking at the answer choices until you've done a couple of things in the stem.

28:04 First, read it once. What's the cause of the majority of acute bronchitis infections that do not require antibiotic treatment? Okay, so you want to put that into your own words.

28:16 That's the first step.

28:18 So it's asking me what's the cause of most or majority of the acute bronchitis infections that don't require an antibiotic? Okay. Now I'm going to look at the answer choices.

28:30 If it doesn't require an antibiotic.

28:33 Oh well it can't be a bacteria right.

28:35 So I would eliminate this and say it can't be bacteria because bacteria would require an antibiotic. Could it be viruses? Yeah, that's an option I'm going to leave it in.

28:50 Contaminated water. Oh, that seems odd.

28:56 But is that a risk factor for developing acute bronchitis infections? No it's not. So I'm going to eliminate that one because that is not a known risk factor which you know pathophysiology revolves around risk factors.

29:11 Now what about a fungi.

29:13 I like those on my pizza.

29:14 I do not like them in my lungs.

29:16 But that is not a major risk factor or cause of the infections in chronic bronchitis.

29:23 So I eliminated this one, this one and this one.

29:26 So I'm left with viruses.

29:28 You go back and say, does that make sense? So do it again once more in my words.

29:34 What's the cause of the majority of acute bronchitis infections that do not require antibiotic treatment? The answer would be viruses.

29:43 Okay, everybody with me.

29:45 Now, I know this was a short question, but it's going to feel like you are swimming through Jell-O. But I promise you, slowing down on your exams, focusing your mind on what the question is asking you before you look at the answer choices. You know we're doing it tonight for you for free.

30:04 But I've taught these in high dollar NCLEX review courses and I would teach you the same thing. Slow down, read the question, put it in your own words.

30:13 If you jump down to the answer choices first, some question item writers are really good and you know how they write those other choices. They think, huh? What would a nursing student be most likely to pick if they're not really paying close attention to the stem of the question, and that's how they write the wrong answer options. So as long as you know how the game is played and that is how the game is played.

30:39 Don't get caught up by those know what the question is asking you.

30:44 Put it into your own words.

30:46 And then one by one, evaluate every answer choice and saying does this answer the question yes or no? In or out? And you also say why? All right.

30:58 Cool. I'm glad you're enjoying it. I promise you, I have worked with students who have failed the NCLEX.

31:04 I had one student that failed the NCLEX five times, wasn't in the nursing program where I taught.

31:09 That wouldn't have mattered if they were, I would work with them. These are the types of things that help them be successful when they started applying these.

31:18 But I'm just telling you, they're not super fun because I have a very short attention span and I hate tests.

31:25 I mean, the minute I started thinking, I just want this to be over.

31:29 I'm the one. When I was taking my GRE for grad school, I looked I literally looked in the camera and said, I don't want to do this anymore.

31:37 I want to go home. And then I sat back and just waited for somebody to come and take me because I didn't want to be there.

31:44 They never came. And hence I ended up going to grad school.

31:47 But still, tests are uncomfortable.

31:50 Learning is uncomfortable, but that's where you really get to show your stuff. Now I want to talk about that purpose of mucus, right? So when you see a picture like this, what do you see? Well, this looks like oh, kind of a different angle, right. Because what must these be down here? Well, I think the artist is trying to make these alveoli. Right.

32:12 This is the airway. So here we've got those smooth muscles wrapping around there.

32:18 Now mucus is a good thing.

32:20 It's my least favorite body substance.

32:22 My least favorite body substance because it's just goopy and hawking up a loogie and all that stuff. But I mean, it's necessary.

32:29 I just don't like it when there's too much of it.

32:32 Now it's purpose is to protect those tissues, right? And sometimes we can get stuff in that mucus.

32:37 We can capture it. You know, that's not a bad thing.

32:41 But what are the respiratory diagnoses that have too much mucus? Which ones can you remember the diagnoses that will have too much mucus.

32:57 Hopefully you said something like chronic bronchitis.

33:01 That's a killer one. Your attention span is the size of a grain of rice.

33:06 We could hang. We could hang.

33:08 I believe it. Alright, let's try another one.

33:11 I'm going to be quiet and let you practice putting in your own choice word choices, then working through each answer choice, keeping it in or throwing it out.

33:20 But saying why? Ready? I'm going to give you about 40s.

33:26 Go.

34:04 Okay. So let's take a look at this question.

34:07 The client is laying flat in bed and complaining of difficulty breathing.

34:12 Some of you are saying I already know what the problem is.

34:14 That's right. But what should the nurse do? What I call this is the f word, right? The F word is first, because what I want you to do when you see that is just do this like nama stay there is more than one right answer.

34:30 And on some pretty tough nursing school tests and NCLEX exams, there could be four right answers.

34:36 They're asking you to say what is the top priority? What should you do first? Not what will you be the loneliest? But what should you do first? So that's one of the things that students complain about most in nursing school is that like, there's more than one right answer.

34:50 Yep, there is. So let us help you learn the strategy so that you can pick the best one.

34:56 Now apply oxygen. Let's see the clients lying in bed complaining of difficulty breathing.

35:02 Applying oxygen doesn't sound like such a bad idea, but call a code blue. No, they're not coding and I'm not really comfortable with that answer, but I know for sure we're not going to call it Code Blue. You'll obtain an oxygen saturation level on the client.

35:17 Well, that's not a bad idea, but what is the problem? What's the topic of the question? They can't breathe. Well, getting an oxygen saturation.

35:27 Help them breathe or resolve the problem.

35:29 Nope. That's why it's not an answer choice.

35:32 Encourage the client to use their incentive. Spirometer.

35:35 While that's not wrong, we might have a better answer.

35:39 Let's be sure, because we've got rid of number one.

35:41 We're not going to call it code number two.

35:44 Oxygen stat is not going to fix the problem.

35:48 Number three could impact the problem.

35:49 But let's look at number four.

35:51 You got it. And I've seen some things to elevate the head of the bed.

35:56 Now why is that. Now think about what it's like if you're laying down right.

36:00 If you're laying down, that's all pushing on your chest.

36:03 It's harder for the patient to breathe.

36:05 So if you can get the head of their bed up, that's better for anyone when it comes to breathing. If the patient's alert, they're having a really hard time breathing.

36:15 They usually won't lay there.

36:17 And just. If they're having a hard time breathing, they will just instinctively do that.

36:22 But remember that as a nurse, one of the first things you can do is to elevate the head of the bed.

36:27 Now is to elevate the head of the bed.

36:28 Always the right answer.

36:30 No, no, it is not. It's always relative, right? There is not one answer that's always right.

36:38 Now, you may have a faculty and you figured them out.

36:40 You know how they test.

36:42 That works in individual programs and individual classes.

36:45 But it won't serve you well on standardized tests.

36:48 Like you know that you sometimes have to take. Most of you take while you're in nursing school. And it definitely won't work on a on a test, on an NCLEX test. Most part of the lungs are more posterior to the back.

36:59 Yeah. Hey, so if you're going to be listening for pulmonary edema, that's why you always want to listen in the back and in the bases, because that is where it's going to develop first.

37:09 Okay. Here's another one.

37:12 I'll give you about 40s again for you to work through the process practice.

37:17 And then I'll come back and walk you through the question.

37:39 Just about another 15 seconds left.

37:42 Don't cut corners.

38:07 Okay. If these were answers one, two, three and four, think about the one that you picked.

38:14 Actually, none of these are completely incorrect.

38:18 What it's asking us for is what is the first nursing intervention inertia complete when someone who has pulmonary edema.

38:25 Now let's go back to. Why is pulmonary edema a bad thing? Well think about the alveoli right.

38:31 They're little round guys with the appropriate amount of water.

38:34 They're moist with the right amount of surfactant.

38:37 The alveoli are open. We know the alveoli need to stay open so they can have that gas exchange between the alveoli and the capillaries that are around it.

38:47 If someone has pulmonary edema they've got too much water in there, too much fluid. Think of it as that in there.

38:55 And it's going to be really difficult for the lungs to function.

38:58 So ask about fluid intake for the day.

39:01 That's actually correct because we want to probably know how much they're getting in and out. We know that elevating the head of the bed, what does that have to do with the problem? Well, we know that helps people breathe better giving diuretics.

39:14 Well, that would help pull off extra fluid.

39:16 That's correct. Or supplemental oxygen? Well, that sounds like a good thing.

39:21 Now, if this was an NCLEX question, if you saw an answer choice like that, then you assume that you have an order in your nursing programs.

39:28 Ask your faculty because they're not always consistent. But on the NCLEX, that's how it would be.

39:33 So now I've got the problem where yep, these are all four are probably correct.

39:37 How do I make what's most important? Well, right now I know they have pulmonary edema.

39:42 They're short of breath. So I'll ask about their fluid intake later because that does not address the problem.

39:47 Elevate the head of the bed.

39:49 That helps them breathe better immediately.

39:51 So I'm going to keep that one there because it's asking me what should I do.

39:55 What f Word first nursing intervention giving diuretics that will help, but I shouldn't. That isn't a better answer to do first than elevating the head of the bed. So I'm going to eliminate that now.

40:09 Oxygen. Gosh, that's the one I want to go to.

40:11 Right. That is the one I want to go to.

40:13 But in this question, they're splitting hairs, as they say, those angry elves that write questions.

40:19 First thing you should do is elevate that head of the bed that can have an immediate response for the patient, and then you would do the other things.

40:26 And that is what is so frustrating about nursing school exams, because we would probably do all these things.

40:33 I'd want to know if they're ahead on fluids. I would probably need to give a diuretic if they got pulmonary edema, it's time to be given that, and supplemental oxygen would be a good idea.

40:42 But the whole game of nursing school questions is they're trying to figure out, do you recognize what you should do immediately? Yeah. That's a great tip from Nurse Liz.

40:52 Do you guys see that? I always remember giving meds or trying to find equipment for something like oxygen takes time, so sometimes they want the quickest thing first, particularly when it comes to respiratory questions.

41:04 Yep. Great tip, Nurse Liz.

41:06 Thank you. Okay, uh, this one might be a little hard for you to read, but I just want to show you, like, this is what questions look like in our qbank. But I want to use this one as an example.

41:16 And then we're going to go through a couple more because you see what the right answer is there. And I want to talk to you about why it is the right answer.

41:23 The nurse checks on a client's beeping monitor.

41:26 The alarm shows the client's oxygen saturation to be 89%.

41:30 Okay, guys, anytime you see a number in a test question, I don't care what class you're in.

41:35 You ask yourself, is it high, low or normal? Those of you that are in patho classes, you're going to need to know what a normal respiratory rate is, what a normal blood pressure is.

41:46 Those of you there in med surg classes, you're going to know that this saturation is not really what we'd be looking for, but we need to know a little bit more about the patient. Okay. So we know their set is 89%.

41:59 That's low. But the client who is diagnosed with chronic obstructive pulmonary disease is reading and looks comfortable.

42:07 Okay. So for this particular patient 89% may not be that bad.

42:11 So which is the nurses next action? Well, it tells us in the question the patient doesn't appear to be in respiratory distress.

42:20 So, um, placing the pulse ox on a different finger might be an option I would consider.

42:25 But look at the last half of that, since the reading must be wrong.

42:29 No, it's probably not wrong because patients who have COPD are used to running at lower oxygen levels all the time.

42:35 Increase the oxygen delivery up by a liter and continue monitoring.

42:40 Now, 89% is probably okay for a COPD.

42:44 Place the client in a left side lying position.

42:47 Okay, well, if they're here for respiratory problems, I don't want to lie them down. I always want the head of the bed to be elevated.

42:55 Now look at D. It's saying turn off the alarm and continue to monitor the client.

43:00 Really that option should say reset the alarm, not turn off the alarm.

43:04 So we're going to change the wording on that question.

43:07 But I just wanted you to get the idea from this question that sometimes things will be abnormal and they're going to assess if you recognize that that abnormal for someone who doesn't have CB, COPD might be normal for someone else.

43:21 Okay. Let's try this one.

43:23 The nurse is speaking to a client with congestive heart failure.

43:27 Which statement by the client causes the nurse to intervene? Okay, now this is that congestive heart failure.

43:34 It can involve the lungs, which is why I threw this one in here just to kind of see what you did.

43:40 So, um, I gained a few kilos in the last four days.

43:44 Well, what does that have to do with CHF? You would think congestive heart failure means they could be building up extra fluid.

43:53 I gained a few kilos in the last four days.

43:56 Okay. That might cause me to intervene.

43:59 If I put my feet up, the swelling goes down.

44:04 Well, that doesn't seem like a bad thing.

44:06 I usually sleep flat on my back.

44:09 Or my blood pressure fluctuates, but it is stable overall.

44:15 Okay, now this is how it goes when a brain is tired.

44:17 And I would bet most of us have tired brains by this point in the evening.

44:21 So what do you do when you hit a wall like this on a test? You stop and say, what do I know about answering these questions? Make sure I know what's in the stem.

44:30 So speaking to a client with CHF, which statement by the client causes the nurse to intervene. That means since this is a four option multiple choice, one of these has to be the sign, the best sign, the most clear, concise, objective sign of the four.

44:50 That tells me this patient is in danger.

44:53 What do I know about this patient? They have CHF. Okay. So I'm going to say, um, fluctuating blood pressure, but stable overall.

45:03 Is that the biggest concern for someone? Is that the worst case scenario? No, that seems relatively normal.

45:09 So I'm going to get rid of D.

45:11 Um, I usually sleep flat on my back.

45:16 Well, you think that wouldn't be? That wouldn't be a good idea for them. But if they're having problems, they would probably have the ability to to, like, change their position and they wouldn't stay that way longer. But A and B get my attention because they they both kind of talk about extra fluid because I know when someone asks CHF we have issues with their feet being swollen. However, is it a bigger problem that they have extra fluid in their tissues and it does go down if they put their legs up, but I gained a few kilos in the last four days. That may be something that we want to follow up on.

45:54 And the reason is this is one of the indicators we use with CHF.

45:58 Now, I know we're talking about pulmonary today, but I just want to throw this one in there for you to see how we kind of walk through questions of these four, that's going to be the answer that I'm going to follow up on most. And look at the stats here.

46:13 Only a third of the people picked it.

46:15 Most people went for this one.

46:17 Now here's why they missed this question and why I put it in here.

46:21 Which statement by the client causes the nurse to intervene? That means you're looking for something that's wrong or unsafe for your patient.

46:30 So I'm looking for the wrongest or the unsafest.

46:33 That's really what I'm looking for.

46:35 When you see those, if you see the things that say which requires the need for further teaching, that means one of the patient statements the patient is wrong or unsafe.

46:45 Okay, so that last part, this last statement is always your last chance to really focus on what the question is asking you.

46:54 So almost half of the people.

46:58 I'm sudden weight gain is an indication that um, that they're having the condition is worsening.

47:04 They're in fluid volume overload.

47:06 So that's one way you measure it. It's not the most accurate, but it can be done in the home. But this one here, it's not really a problem.

47:13 And it clipped this many people because they didn't pay attention to this.

47:17 I was asking what's more dangerous to your patient gaining weight a couple kilos.

47:22 That's a lot of weight. In four days.

47:24 We're going to follow up and check on that patient.

47:26 Now, in our qbank we have our rationales here and then it'll recommend videos for you.

47:30 We're also mapped to Saunders if you guys are interested in looking at that.

47:35 Alright. So this one I'm going to be absolutely quiet and let you answer this question all by yourself, and I'll come back and walk you through it.

48:32 Okay. Ready? Let's see how you did.

48:37 The nurse cares for Klein, who has had an MRI, a myocardial infarction, or a heart attack.

48:42 The client states anytime you see that in an exam question, pay attention. If the client is communicating something to you, that's really important.

48:51 But here's what they said. I don't understand why I feel short of breath.

48:56 Don't I have a problem with my heart, not my lungs? Which is the best response by the nurse? Well, how about if you look at all four of these and go, that's nothing I would say.

49:07 I would not say any of those.

49:09 I always tell students, this is not a script for how you should be a nurse. This is a test to see if you can pick the most important answer, the one that keeps the patient the safest.

49:22 So this person is telling me, like I had an MRI, why can't I breathe? Because I should be a problem with my heart and not my lungs.

49:30 A you should not be short of breath after myocardial infarction because it only affects the heart, not the lungs.

49:36 Okay, well, myocardial infarction initially affects the heart.

49:40 But we know as we talked earlier, those guys are right together.

49:43 Heart and lungs. That could be a problem before the myocardial infarction.

49:48 Your lungs didn't work well, which caused the heart attack and shortness of breath. Um, that's really stretching it.

49:55 That's not going to be our best answer.

49:57 So I'm hoping we got something better in C or D.

50:01 So this one is talking about anxiety, which if I had a heart attack, I would be really anxious.

50:08 This one is talking about it affected your heart muscle.

50:11 That would make sense that a myocardial infarction would.

50:15 Now, if the heart cannot pump effectively, remember when we talked about that fluid is going to back up and it can back up into the lungs and that leads to pulmonary edema.

50:26 So the answer the best response by the nurse is this one.

50:32 The myocardial infarction affected your heart muscle.

50:35 And now because that heart muscle can't pump effectively the rest of the statement causes fluid to back up from your heart into your lungs leading to shortness of breath.

50:44 And this is not a good sign after an MRI.

50:46 If somebody's developing pulmonary edema after an MRI, that is not a good sign.

50:52 So keep that in mind if you see that.

50:54 If someone tells you they're short of breath after having a heart attack, you really need to look into that further.

51:01 Oh, here's your favorite.

51:02 Select all that apply. Let me give you the strategy.

51:04 First you do the same thing with the stem. You answer that stem of the question and then each one of these. Think of this as five questions, not one question. And when you know what that's asking, the nurse is assessing a client with an exacerbation of asthma.

51:19 So there's our diagnosis.

51:21 Which assessment finding is consistent with this condition.

51:24 Does the nurse chart. So really what they're asking you here with kind of some awkward wording is which of these would you expect to find.

51:33 Who's someone who's having an exacerbation of asthma.

51:36 That means they're having an asthma attack.

51:39 So would you expect dyspnea? You would say yes or no.

51:43 Go on to the next one.

51:45 Would you expect a barrel chest for somebody with an exacerbation of asthma? Yes or no? Go on to the next one.

51:52 Would you expect green mucus production? Yes or no? Would you expect a cough with an exacerbation of asthma.

52:02 Yes or no? Would you expect tachypnea with an exacerbation of asthma? Yes or no? I promise you, the biggest challenge that students have with select all that apply questions is that the first half, they're looking for things that would go with asthma.

52:19 And the last half they look for things that aren't with asthma. Somehow their brain just flips while they're doing it.

52:25 So difficulty breathing.

52:27 Yep. Barrel chest no that is COPD emphysema green mucus.

52:35 Hey descriptor words really matter.

52:37 Remember when we talked about mucus before. You can see aha.

52:40 There was a method to my madness.

52:42 The reason we're talking about mucus is I was trying to get you prepared for this with the review. Green is no good so we would expect it not to be green.

52:50 That's a problem. So just with an exacerbation of asthma so far I would have dyspnea. Would I have a cough.

52:56 Yes. What I have to keep me remember that's fast breathing.

53:00 Yes. So a, D and E. Good job Ben.

53:06 You got it right. Okay, now here's one.

53:09 I want you to do it on your own.

53:10 We're getting close to the hour, so do this one on your own.

53:44 Okay, now. No shortcuts.

53:46 Make sure you're forcing yourself as much as you can to eliminate answer choices and say why. Let's look at that stem.

53:54 The nurses assessing a client with pulmonary edema who has a pulse oximetry level of 88%.

54:00 Now, I know that Nurse Liz put some great steps in there like, hey, COPD ers can kind of live like that all the time.

54:07 But we don't know that this person has COPD right.

54:11 We just know that they have pulmonary edema.

54:14 And we know that their saturation is low.

54:16 But here's the next part of assessment.

54:19 Cannot speak in full sentences that would be into that.

54:25 They can't breathe well okay.

54:27 So that's telling us oh they're symptomatic with that 88%.

54:31 Not like the COPD that was sitting there chilling and reading.

54:34 This person is symptomatic.

54:36 So which is the priority intervention.

54:39 All of these would be considered correct.

54:41 So which one would we do first.

54:45 Now this can be oh is this a first question or a priority.

54:52 It's a priority question.

54:53 And those can be different.

54:55 Well this means if I can only do one thing.

54:59 So I see you guys already have.

55:00 I can only do one thing.

55:02 It's not asking me. What should you do first? It's saying what's most important? What's the priority intervention? And for this one, it would be to make sure that you give oxygen.

55:15 Oh, wouldn't that be frustrating? Because you're like, wait, what about the head of the bed? That's what I would do first.

55:20 But if I can only do one thing, the most important thing would be to get some oxygen on that patient.

55:26 Okay. We are at the our nurse.

55:29 Liz, if you can help me with.

55:31 Are there some questions that we need to follow up on? Hey, while Nurse Liz and I are communicating, if you guys would like to do more of these, can you let us know? Oh. Uh, Hussein, um, you know, it's really kind of more of a colloquialism.

55:50 People use that. That's usually an older term, but it makes sense. It helps it remember.

55:55 So remember. So I would use it for studying. I just would never talk to a patient using that as a reference. But cool question.

56:02 Yeah, so I could use it to study to help you remember, but I would obviously not use it with the patient.

56:08 And your faculty may clearly still be using it.

56:13 Any other questions that I missed? Oh, I'll look at the starred ones.

56:16 She gave me directions to it. Oh, and that was what it was.

56:19 Nurse Liz already had that.

56:22 Okay. Well, then, um, Nurse Liz, can you give us some directions on how we can submit topics or ideas in discord for what they'd like the next topic to be? Uh, maybe just post it in discord? Or can you talk live? Or better to post it in discord? Hi, friends. Um, maybe just post it in discord? Or can you talk live? Or I can try to talk live.

56:49 Hold on, let me. Oh, there she is.

56:51 Oh, we just posted in discord.

57:03 Okay, well, you know, we're not perfect on the technical stuff.

57:06 Not really sure what's going on here, but, um, if you're here tonight, we would love for you to join us on our discord. Uh, you can. And again, I'm not cool enough to know what discord was.

57:18 Nurse Liz had to tell me what it was.

57:20 Um, it's not as, um, esthetically pleasing as I thought it would be.

57:25 It's pretty much a black screen and lots of discussion threads, but there are some really, really cool people on there.

57:33 And this is meant for nursing students.

57:35 We don't invite faculty to this channel.

57:37 This is just meant for nursing students.

57:39 So if you're looking for a study buddy, here's a place to find someone.

57:42 If you have questions that you want to ask us, both Nurse Liz and I will do our best to answer those, um, in a timely fashion.

57:49 That's really our goal.

57:51 This is where we'll post other ideas.

57:53 So we just realized that she can't talk without muting the discord.

57:58 So it gets really kind of, um, overwhelming.

58:00 We do that, we'll get that figured out. But, uh, we will link to the discord below in this video.

58:05 Yes. Oh, absolutely. It is 100% free.

58:09 There's no now we both, um, we work with Lecturio, so we'll use examples from there.

58:16 But the purpose of this is not to push you to buy anything.

58:19 No sales pitches here.

58:21 But full disclosure, we do work with Lecturio.

58:24 That's kind of how Nurse Liz and I met.

58:26 And we, um, actually really enjoy.

58:29 I wish you guys could hang out with Nurse Liz. She's pretty cool.

58:31 She's one of my favorite people to hang out with and go to conferences with, and I even got to go do pumpkins with her.

58:38 But I do teach patho in pharm courses.

58:41 I teach critical care.

58:43 Um, I teach the advanced pathophis, chronic illnesses.

58:46 Yeah. So I love all that stuff.

58:48 Uh, nurse Liz is a peds expert.

58:50 She's been a nurse practitioner.

58:52 So bring it on. You know, if you guys are interested in farm stuff, we'll do that again. We also have free stuff on our site.

58:59 So we just want to support you all the ways that we can.

59:03 So, um, Nurse Liz, have you been able to post the link to discord or.

59:09 Oh, you put it in the video. Is that what you said? I promise we'll get better at technology. This was my first time, so I am just learning all this stuff.

59:20 But I'm going to end the broadcast.

59:22 It'll give us about 10s left.

59:24 Are there any other questions you guys want to ask before we call it a night for tonight? Yes. Okay, we'll post it to the video as soon as we're done here and join us on our discord. Let us know. She has a special thread there that's asking like, what would you like to know? So go ahead and let us know there.

59:42 So night guys. I hope you give us ideas on how you want us to come back and we'll keep doing study sessions. Bye.

59:49 Alright. Thanks for coming.

59:51 We're wrapping up.