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