Mark Klimek Lecture Notes Guide Latest 2023 / 2024 (Graded A+)

LECTURE 1 ACID BASES•learn how to convert lab values to words•the rule of the B’s
= if the pH and the BiCarb are both in the same direction -> metabolic Hint: draw arrows beside each to see directions * down = acidosis * up = alkalosis
- respiratory -> has no b in it; if in other directions (or if bicarb is normal value)
- KNOW NORMAL pH, BiCarb, CO2 •Hint: DON’T MEMORIZE LISTS…know principles (they test knowledge of principles by having you generate lists..) - for “select all” questions
- ex. in general/principle what do opioids/pain meds do? = sedate you, CNS depressors * ex. what does dilaudid do? don’t memorize specifics or a list of dilaudid, know principles of opioids (such as sedation, CNS depression -> lethargy, flaccidity, reflex +1, hypo-reflexia, obtunded)
- boards don’t test by lists because all books/ classes have different lists
•principles of S&S acid bases: as the pH goes so goes my patient (except K+)
- pH up = PT up -> body system gets more irritable, hyper-excitable (EXCEPT K+) -> alkalosis - think of a body system and go high: hyper-reflexive (+3, +4 [2 is normal]), tachypnea, tachycardia, borborygmi, seizure
- pH down = PT down -> body systems shut down (EXCEPT K+) -> acidosis - think of a system and go low: hypo-reflexive (+1, 0), bradycardia, lethargy, obtunded, paralytic illeus, respiratory arrest•ex. which acid-base disorders need an ambu-bag at the bedside? = acidosis (resp. arrest)•ex. which acid-base disorders need suction at the bedside? = alkalosis (seize and aspirate) •Mac Kussmaul - Kussmaul’s (compensatory respiratory mechanism) is only present in only 1 of the 4 metabolic (acid-base) disorders
* M = metabolic AC = acidosis
•most common mistake with select all questions = selecting one more than you should (stop when you select the ones you know! don’t get caught up on the “could be’s”)•Hint: don’t select none or all on select all that apply questions (never only one and never all)•Causes of Acid-Base Imbalance:
- scenarios and what acid-base disorder would result (what would cause an imbalance) ** DON’T MIX UP S&S and CAUSATION
- often what causes something is the opposite of the S&S
- ex. diarrhea will cause a metabolic acidosis but once you are acidotic your bowel shuts down and you get a paralytic illeus•when you get scenarios: -> if it’s a lung scenario = respiratory - then check if the client is over-ventilating (alkalosis) or under-ventilating (acidosis) - remember to look at the words (ex. over, under, ventilating) -> “as the pH goes so goes my PT” -> VENTILATING DOESN’T MEAN RESPIRATORY RATE; resp. rate is irrelevant w/ acid-base, ventilation has to do with gas exchange not resp. rate (look at the SaO2 -> if your resp. rate is fast but SaO2 is low you are under-ventilating) -> ex. PCA pump - What acid-base disorder indicates they need to come off of it? = respiratory acidosis (resp. depression -> resp. arrest)
—> if it’s not lung, it’s metabolic•metabolic alkalosis - really only one scenario = if the PT has prolonged gastric vomiting/suctioning
- because you are losing ACID * ex. GI surgery w/ NG tube with suctioning for 3 days; hyperemesis graviderum
- otherwise everything else that isn’t lung you pick metabolic acidosis (DEFAULT) * ex. hyperemesis graviderum w/ dehydration acute renal failure, infantile diarrhea•remember, you only have 4 to pick from:
- respiratory alkalosis - respiratory acidosis
- metabolic alkalosis - metabolic acidosis•pay more attention to the modifying phrases than the original noun
- ex. person w/ OCD who is now psychotic (psychotic trumps OCD); hyperemesis with dehydration (pay attention to dehydration) VENTILATION•ventilators -> know alarm systems (you set it up so that the machine doesn’t use less than or more than specific amounts of pressure) a) high pressure alarm = increased resistance to airflow (the machine has to push too hard to get air into lungs) - from obstructions: i. kinks in tubing (unkink it) ii. water condensation in tube (empty it!) iii. mucous secretions in the airway (change positions/turn, C&DB, and THEN suction)
*** suction is only PRN!!! -> priority questions = you would check kinks first, suction is not first b) low pressure alarm = decreased resistance to airflow (the machine had to work too little to push air into lungs) - from disconnections: i. main tubing (reconnect it duh!) ii. O2 sensor tubing (which senses FiO2 at the airway/trach area; black coated wire coming from machine right along the tubing - reconnect!)•ventilators -> know blood gases
- resp. alkalosis = ventilation settings might be set too high (OVER-VENTILATING)
- resp. acidosis = ventilation settings might be set too low (UNDER-VENTILATING)•ex. weaning a PT off ventilator -> should not be under-ventilated, they need the ventilator; if they are over-ventilating then they can be weaned•never pick an answer where you don’t do something and someone else has to do something LECTURE 2ABUSE (Psych and Med-Surge)Psychological Aspect/Psycho-Dynamics•# 1 psychological problem is the same in any/all abusive situations = DENIAL
- abusers have an infinite capacity for denial so that they can continue the behavior w/o answering for it•can use the alcoholism rules for any abuse
- ex. # 1 psych problem in child abuse, gambling or cocaine abuse is denial•why is denial the problem? HOW CAN YOU TREAT SOMEONE WHO DENIES/DOESN’T RECOGNIZE THEY HAVE A PROBLEM•denial = refusal to accept the reality of a problem•treat denial by CONFRONTING the problem (it’s not the same as aggression which attacks the person, not the problem) = they DENY you CONFRONT
- pointing out to the person the difference between what they say and what they do
- Hint: never pick answers that attack the person -> ex. bad answers have bad pronouns - “you” -> ex. good answers have good pronouns - “I”, “we” -> ex. “you wrote the order wrong” vs. “I’m having difficulty interpreting what you want”•loss and grief -> for this denial you must SUPPORT it
- DABDA = denial, anger, bargaining, depression, acceptance•Hint: for questions about denial, you must look to see if it is LOSS or ABUSE
- loss/grief = support
- abuse = confront•#2 psychological problem in abuse = DEPENDENCY, CO-DEPENDENCY
- dependency = when the abuser gets significant other to do things for them or make decisions for them -> the dependent = abuser
- co-dependency = when the significant other derives positive self-esteem from making decisions for or doing things for the abuser -> the abuser gets a life w/o responsibilities -> the sig. other gets positive self-esteem (which is why they can’t get out of the relationship)•how do you treat it?
- set limits and enforce them -> start teaching sig. other to say NO (and they have to keep doing it)
- must also work on the self-esteem of the co-dependent (ex. I’m a good person because I’m saying “no”)•manipulation = when the abuser gets the sig. other to do things for them that are not in the best interest of the sig. other
- the nature of the act is dangerous/harmful
- how is manipulation like dependency? -> in both the abuser is getting the other person to do something for them
- how do you tell the difference between manipulation & dependency? -> NEUTRAL vs. NEGATIVE (look at what they’re being asked to do) -> if the sig. other is being asked to do something neutral (no harm) its dependency/co-dependency -> if the sig. other is being asked to do something that will harm them or is dangerous to them they are manipulated•how do you treat manipulation?
- set limits and enforce them -> “NO”
- easier to treat than dependency/co-dependency because no one likes to be manipulated (no positive self-esteem issue going on)•ex. how many PT’s do you have w/ denial? = 1
ex. how many PT’s do you have w/ dependency/co- dependency = 2
ex. how many PT’s do you have w/ manipulation = 1Alcoholism
Wernicke’s & Korsakoff’s
- typically separate BUT boards lumps them together
- wernicke’s = encephalopathy
- korsakoff’s = psychosis (lose touch with reality) -> tend to go together, find them in the same PT•Wernicke Korsakoff’s syndrome:
a) psychosis induced by Vit. B1 (Thiamine) deficiency - lose touch w/ reality, go insane because of no B1
b) primary symptom -> amnesia w/ confabulation - significant memory loss w/ making up stories - they believe their stories•How do you deal w/ these PT’s?
- bad way = confrontation (because they believe what they are saying and can’t see reality)
- good way = redirection (take what the PT can’t do and channel it into something they can do)•Characteristics of Wenicke Korsakoff’s:
a) it’s preventable = take Vit. B1 (co-enzyme needed for the metabolism of alcohol which keeps alcohol from accumulating and destroying brain cells) * PT doesn’t have to stop drinking
b) it’s arrestable = can stop it from getting worse by taking Vit. B1 * also not necessary to stop drinking
c) it’s irreversible (70% of cases) -> Hint: On boards, answer w/ the majority (ex. if something is majority of the time fatal, you say it’s fatal even if 5% of the time it’s not)•Drugs for Alcoholism:
DISULFIRAM (Antabuse)
= aversion therapy -> want PT’s to develop a gut hatred for alcohol -> interacts w/ alcohol in the blood to make you very ill -> works in theory better than in reality -> onset & duration: 2 weeks (so if you want to drink again, wait 2 weeks) - PT teaching = avoid ALL forms of alcohol to avoid nausea, vomiting & possibly death -> including mouthwash, aftershaves/colognes/perfumes (topical stuff will make them nauseous), insect repellants, any OTC that ends with “-elixer”, alcohol- based hand sanitizers, uncooked (no-bake) icings which have vanilla extract, red wine vinaigrette
•Overdoses & Withdrawals:
- every abused drug is either an UPPER or DOWNER -> the other drugs don’t do anything -> #1 abused class of drug that is not an upper or downer = laxatives in the elderly
a) first establish if the drug is an upper or downer - uppers (5) = caffeine, cocaine, PCP/LSD (psychedelic hallucinogens), methamphetamines, adderol (ADD drug) * S&S -> make you go up; euphoria, tachycardia, restlessness, irritability, diarrhea, borborygmi, hyper-reflexia, spastic, seize (need suction) - downers = don’t memorize names -> anything that is not an upper is a downer! if you don’t know what the med is, you have a high chance that it’s a downer if it’s not part of the uppers list * S&S -> make you go down; lethargy, respiratory depression (& arrest) - ex. The PT is high on cocaine. What is critical to assess? -> NOT resps below 12 because they will be high -> maybe check reflexes
b) are they talking about overdose or withdrawal - overdose/intoxication = too much - withdrawal = not enough - ex. the PT has overdosed on an upper -> pick the S&S of too much upper - ex. the PT has overdosed on a downer -> pick the S&S of too much downer - ex. the PT is withdrawing from an upper -> not enough upper makes everything go down - ex. the PT is withdrawing from a downer -> not enough downer makes everything go up•upper overdose looks like = downer withdrawal•downer overdose looks like = upper withdrawal•In what 2 situations would resp. depression & arrest be your highest priority: - downer overdose - upper withdrawal•In what 2 situations would seizure be the biggest risk: - upper overdose - downer withdrawal
•Drug Abuse in the Newborn:
- always assume intoxication, NOT withdrawal at birth
- after 24 hrs -> withdrawal
- ex. caring for infant of a Quaalude addicted mom 24 hrs. after birth, select all that apply: -> downer withdrawal so everything is up = exaggerated startle, seizing, high pitched/shrill cry•Alcohol Withdrawal Syndrome vs. Delirium Tremens
- they are both different! not the same
a) every alcoholic goes through withdrawal 24 hrs. after they stop drinking - only a minority get delirium tremens - timeframe -> 72 hrs. (alcohol withdrawal comes 1st) - alcohol withdrawal syndrome ALWAYS precedes delirium tremens, BUT delirium tremens does not always follow alcohol withdrawal syndrome
b) AWS is not life-threatening; DT’s can kill you
c) PT’s w/ AWS are not a danger to self/others; PT’s w/ DT’s are dangerous to self/others - they are withdrawing from a downer so they will be exhibiting upper S&S - DT’s are dangerous
•RN’s can accept but RPN’s can’t (because PT is unstable)
- on med-surge, the RN who takes them must decrease their workload (i.e. reduce PT load if they take a DT PT) -> Hint: on boards, the setting is always perfect (i.e. enough staff/time/resources on the unit etc.) Differences in CareAWSDTDietRegular dietNPO/clear liquids
(because of risk for seizures which can cause risk of aspiration)RoomSemi-private anywhere on the unitPrivate near nurses station (dangerous & unstable)AmbulationUp ad libRestricted bed rest -> no bathroom privileges (use bedpans/urinals)RestraintsNo restraints (because not dangerous)Restraints (because dangerous)
- not soft wrist or 4 point soft because they’ll get out
- need to be in vest or 2-pt. locked leathers (opposite 1 arm & leg, rotate Q2hrs, lock the free limbs 1st before releasing the locked ones)They both get ANTI-HYPERTENSIVES & TRANQUILIZERS
- because everything is up (downer withdrawal)
They both get MULTIVITAMIN w/ B1