NUR 490 Mark Klimek Lecture Notes new.

NUR 490 Mark Klimek Lecture Notes new. Mark Klimek Lecture Notes LECTURE 1: Acid Base Balance & Ventilator Interpreting blood gases (remember the rules of the B’s) • If the pH and the bicarb are both in the same direction then it’s metaBolic (Bicarb Both Bolic), if they are in different directions then it is respiratory • If bicarb is normal and the pH is low or high then its respiratory • You will be given 8 values for arterial blood gas, always first look at the pH and the bicarb first • You get acidosis and alkalosis from the pH LABS: ABG’s The normal pH is 7.35-7.45 The normal bicarb is 22-26 (the bicarb years where you make all the decisions [22-26 years old], or 2+2+2=6) The normal CO2 is 35-45 (same as pH) Signs and Symptoms with ABG’s • As the pH goes up so does my patient o If the pH goes up, every system in your body gets more irritable/hyperexcitable • As the pH goes down so does my patient o If the pH goes down, systems in your body shut down • Except for potassium- When pH goes down, potassium goes up • If the pH goes up (alkalosis): you will find irritability, hyperreflexia (3&4), tachypnea, tachycardia, borborygmi (increased bowel sounds), seizure (need suctioning at the bed side because they can seize and aspirate) • If pH goes down (acidosis): hyporeflexia, bradycardia, lethargy, obtunded, paralytic ileus, coma, respiratory arrest (need bag-mask ventilation bag at bedside for respiratory arrest), +1 reflexes • MACkussmal- compensatory and respiratory pattern for only acid base disorder: MAC- Metabolic ACidosis Respiratory Acidosis multiple choice example: What would you see with a patient who is in respiratory acidosis? a. +1 reflex, b. diarrhea, c. adynamic ileus (no movement), d. spasm, e. urinary retention, f. paraxysmol atrial tachycardia, g. second degree lovitz, type 2 heart block (impulse is being slowed), h. hypokalemia LAB: REFLEXES 0&1-hyporeflexia 2-normal 3&4- hyperreflexia EXAMPLE: (In general what do pain meds do? ANSWER: They sedate you, they are CNS depressants: lethargy, lucidity, reflexes at +1, hyporeflexia, obtundent Causes of Acid Base Imbalance • Don’t get signs and symptoms mixed up with causation!!! • What causes something is the opposite of what the signs and symptoms are o EXAMPLE: diarrhea will cause a metabolic acidosis but once you get acidotic, it will shut your bowels down and you will get a paralytic ileus. • The first question you should ask yourself if the scenario involves a lung problem. o Is it a respiratory problem? BUT remember it can still be respiratory acidosis/alkalosis… • Next question you ask yourself… o is the client overventilating or underventilating? o If the patient is overventilating pick alkalosis o If they are underventilating pick acidosis • If the client is overventilating.. it has an attachment to the word- alkalosis (because they are both OVER)… ventilating OVER becomes respiratory ALKALOSIS • If the client is undeventilating.. it has an attachment to the word- acidosis (because they are both UNDER)- ventilating UNDER becomes respiratory ACIDOSIS Examples: 1) A woman is overzealously using her breathing techniques during labor, what acid base disorder will she exhibit? Overventilation o Respiratory Alkalosis 2) A child is near drowning, what acid base disorder would it be? Underventilating o Respiratory Acidosis 3) Your patient has emphysema, what acid base disorder would it be? Underventilating o Respiratory Acidosis Ventilating does not mean respiratory rate.. respiratory rate is irrelevant- ventilation has to do with gas exchange!! Examples: 1) Patient has pneumonia in 4 lobes of the lung, breathing at 50/min and their SO2 is at 78 on 8 liters per max o Explanation: Breathing really fast while still having a low O2 level means that the patient is still underventilating because respiratory rate has nothing to do with it. Everyone pays so much attention to rate when they should be paying closer attention to the SO2. o If your SO2 is good and you are breathing slow, you are fine but if your SO2 is low and you’re breathing fast, you are actually underventilating. A lot of times the respiratory rate compensates- pay attention to SO2!!! 2) Patient is on a PCA pump, what acid base imbalance would tell you they need to come off that thing? o A PCA pump depresses respirations. So, patients need to come off of it as soon as possible because if they were getting too much it would make their respiratory rate go really down which would make the patient underventilate so the answer would be respiratory acidosis. o So respiratory acidosis would tell you that you need to come off the PCA pump. What if its not lung? It would be Metabolic. Only one scenario that you will answer metabolic alkalosis: if the patient has prolonged gastric vomiting or suctioning pick metabolic alkalosis.. Why? o Pt is losing acid... pt will become basic Otherwise everything else that is not lung or the above, pick metabolic acidosis Ex. 1) Patient had GI surgery and has had an NG tube to low intermittent gone post suctioning for 3 days, what acid base disorder would he most likely exhibit? o Metabolic alkalosis 2) Patient has hyper emesis gravidarum , what acid base disorder are they going to exhibit o Metabolic alkalosis 3) Continuation: Pt is going to be dehydrated- what acid base disorder would they have? o Metabolic acidosis 4) Pt has acute renal failure, what acid base disorder would this be? o Metabolic acidosis- its not lung or vomiting or suctioning so it has to be metabolic acidosis 5) A pt with infantile diarrhea would have what acid base disorder? o Metabolic acidosis 6) A pt with third degree burns over 60 percent of the body? o First phase- metabolic acidosis If you don’t know what it is, just choose metabolic acidosis!! RECAP What do you have to know for Acid Base? • If the pH and the Bicarb are both in the same direction, its metabolic • The direction my pH goes, so does my patient, except for potassium • MACkussmal- compensatory and respiratory pattern for only acid base disorder: MAC- Metabolic Acidosis • Overventilate: (alkalosis) - translate the word • Underventalate: (acidosis) - (translate the word) • Vomiting or suctioning=metabolic alkalosis • Everything else is metabolic acidosis if I don’t know what it is *always pay attention to the modifying phrase than the original noun example* • Person with OCD who is now psychotic… what is more important? Obpsychotic and not OCD VENTILATION Alarms and how blood gases articulate with ventilates • High pressure alarm is set off by increased resistance to air flow (machine is having to push too hard to get the air into the lungs) – machine will set off a high pressure alarm ( set alarms for appropriate pressures) • What would cause the high pressure alarm? OBSTRUCTIONS 1) Kinks in the tubing (unkink the tube) 2) Water condensing within the tube/dependent loops (empty water out of tubing) 3) Mucus secretions in the airway (change position, turn, cough, deep breath and if that doesn’t work… THEN you suction) • Nurses must only suction patients as necessary and only when you have already turned, cough and helped patient deep breath ***good example for drag and drop question*** Low pressure alarms- decreased resistance- (too easy to push breath in) two disconnections. DISCONNECTION 1) main tubing (reconnect) 2) oxygen sensor tubing (senses the FIO2 right at the trache area- wire black coated.. goes right alone the tubing and comes right to the trache and hooks into the hole into the tubing) Acid Base disorders Respiratory alkalosis : Overventilating means ventilator settings may be too high Respiratory acidosis: Underventilating means the settings are too low Example 1) Dr. says to wean pt off vent in AM- 6 am ABGs show respiratory acidosis, what would you do? A. Follow the order B. Call respiratory therapy (**never pick answer where you don’t do something and someone else has to do something**) C. Hold the order and call the doctor D. Begin to decrease the settings ANSWER: C. Hold the order and call the doctor: because pt underventilating on the ventilator and without it he’d be even worse. If he has respiratory alkalosis it could mean he’s being overventalated, which means he doesn’t need the machine. Lecture 2: Alcoholism, Delirium Tremors & Peak and Trough Alcoholism: Psych + Med surg Psychodynamics- The number one problem of psychological in alcoholism is the same exact problem for any abuse: DENIAL • Abusers have an infinite capacity to deny • Denying allows the abuser to keep doing it without having to answer for it • It is number 1 because how can you treat someone who denies they have a problem and until they admit they have a problem. • Definition of denial: refusal to accept the reality of a problem How do you treat denial? • Confronting it by pointing out the difference to the person of what they say and what they do o “okay, you say you are not an alcoholic but its 10 am and you already drank a 6 pack” o “You say you’re not a child abuser but protective services has your children” • confrontation (attacks the problem) is not the same as aggression (attacks the person) • Don’t ever choose answer that uses the word YOU with confrontations only the letter I Deny -- confront • Not with loss and grieving (DABDA- denial, anger, bargaining, depression, acceptance) What do you do for the denial of loss and grief? • Support it because it serves a function Dependency and Codependency • Dependency- when the abuser gets the significant other to do things for them or make decisions for them (the abuser is dependent) • Codependency- when the significant other derives positive self-esteem from making decisions for or doing things for the abuser o Pathologic and yet symbiotic relationship o Abuser gets a life without responsibility and a SO gets positive self- esteem Treatment? • Set limits and enforce it- teach SO to start saying NO and to keep doing it • Must work on self-esteem of codependent person first or it will never work- the dependent abuser is going to make them feel bad when they start saying NO and emotionally manipulate them • Codependent person has to say.. I AM saying NO because I’m a good person- (usually the relationship will break up in the end) Manipulation • abuser gets SO to do things for him or her that is not in the best interest of the significant other. • Nature of the act is interest and harmful • This is like dependency because in both situations the abuser is getting the SO to do things for them and you can tell the difference by Neutral vs. Negative • If what the significant other is being asked to do is inherently harmful or dangerous to the SO it is manipulation • If what the significant other is being asked to do is neutral, NO HARM NO FOUL- it is dependency and codependency Examples 1) A 49 yr old alcoholic gets her 17 yr old daughter to go to the store and buy alcohol for her • manipulation because minor buying alcohol is illegal 2) A 49 yr old alcoholic asks her 50 yr old husband to go to the store and buy alcohol for her. • Dependency because there is no harm Treatment for manipulation- • Set limits and enforce them- start saying NO • It is easier to treat than dependency and codependency because nobody likes being manipulated and there is no positive self-esteem issue How many pts do you have with denial if bob is in denial? 1 If bob is dependent how many patients do you have? 2 ( dependent + codependent) If Bob is the manipulator how many patients do you have? 1 ALCOHOLISM • Wernicke’s-Korsakoff syndrome o Wernicke’s encephalopathy o Korsakoff psychosis But they tend to go together because you find them in the same patient Wernicke’s korsakoff is 1) Psychosis induced by vitamin B1 or thiamine deficiency – you lose touch with reality and go insane (loss of touch with reality) because you don’t have B1 2) Amnesia (memory loss) with confabulation (making up stories)- make up stories because they forget. They are psychotic because they believe it. Lie is just as real as reality and their memory loss is “what happened to the 90’s and they’ll lose entire decades of their memories”. Will often have an entire psychotic reality- real as anything else that is happening How would a nurse deal with this? Bad: confronting is wrong because it’s due to brain damage and most likely permanent Good: redirect the patient- take what the patient can/cant do and channel it to something that he can do “well why don’t you go shower so we can watch what the news of the day Washington D.C. TV” if he’s insisting he’s part of government. DO NOT present reality because they cannot learn it. Characteristics: ▪ Preventable: take Vitamin B1- coenzyme necessary for the metabolism of alcohol so if you don’t have B1 you will not metabolize alcohol and you will not go into KREB cycle where it would get used up for energy so it will instead accumulate and go into the brain and destroy brain cells ▪ Arrestable: which means you can stop it from getting worse by giving B1, stopping drinking is not necessary ▪ Irreversible: 70 % irreversible (go with the majority, 2 good news one bad news) DRUGS that have to do with alcohol Antabuse (revia)- DISULFURAM 1) What is it used for? • Aversion therapy - want alcoholics to develop a gut hatred for alcohol- when you take this drug it will interact with the alcohol level in your blood and make you horribly ill – to the point you couldn’t even pay them to drink- works in theory better than it works in reality – doesn’t work as well as it says it does 2) What is the onset and duration of its effectiveness- • 2 weeks. 2 weeks before they can drink safely on and off the drug. Usually Dr. will prescribe pill, then pt is taken to a transition home for 2 weeks to assure that they take the drug and then let out to the community where every time they drink they will get deathly ill but if they decide they want to want to drink at a (lets say) high school reunion, pt will need to stop taking it two weeks before. Teach these patients to avoid all forms of alcohol to avoid nausea, vomiting and possibly death 3) What do they need to avoid? • need to avoid mouthwash and aftershaves because they will get sick- nauseated • perfumes and colognes, insect repellents, any over the counter that ends in the word ELIXIR (all have alcohol), alcohol based hand sanitizers, no unbaked icings (all have vanilla extract which will make them sick) • DO NOT pick the red wine vinaigrette if it’s on a multiple choice question because it has no alcohol and they can have it OVERDOSES AND WITHDRAWS Every abused drug is either an UPPER or a DOWNER- because they are the only drugs that do anything Most abused type of drug that’s not an upper or a downer is laxatives in the elderly When you get an overdose question the first question you should ask yourself is… 1) is the drug an upper or a downer? UPPERS • Caffeine • Cocaine • PCP/LSD (psychedelic hallucinogens) • Methamphetamines (crystal meth) • Adderall- ADD drug Signs and symptoms: • Things go UP- • Examples: euphoria, tachycardia, restlessness, irritability, borborgimi, diarrhea, 3&4, spastic, seizure (suction bag needed) DOWNERS Everything that is not an upper is a downer Patients looking for an in between effect people will take both together 135 all together Examples: • Dilaudid • Morphine sulfate • Codeine • Demerol • Fentanyl • Ambien • Ativan • Xanax • Valium • Librium • Phenobarbital Downers make you go down because they are downers • lethargic- big danger is respiratory depression leading to respiratory arrest Example question: 1) PT is high on cocaine, what is most important to assess? • check reflexes – because it is an UPPER After you know whether the drug is an upper or a downer what is the second thing you ask yourself? 2) Are they talking about overdose (too much) or withdrawal (not enough)- because they are opposites RECAP QUESTIONS TO ASK YOURSELF 1) is the drug an upper or downer 2) is it overdose or withdrawal Overdose or intoxication- too much RECAP: • Overdose on an upper- everything goes up • Downer and intoxication- makes everything go down • Withdrawal- not enough/too little- too little upper makes everything go down and too little downer makes everything go up • Upper overdose looks like what other situation: downer withdrawal • Downer overdose looks like - upper withdrawal What two situations would respiratory arrest and depression be the highest priority? • Downer overdose and upper withdrawal Which two would seizure be your biggest risk? • Upper overdose and downer withdrawal Example 1) Squad calls you about pt who has overdosed on cocaine what would you expect to see? • upper • overdose-too much upper • CNS drug not autonomic drug • Seizure