Acid-base balance/ventilators

1. Acid-base balance/ventilators Rule of the B’s.. If the pH & the bicarb are both in the same direction = meta bolic If they are in different directions = respiratory pH = 7.35-7.45 acidosis/alkalosis HCO3 (bicarb) = 22-26 (2+2+2 = 6) CO2 = 45-35 ex: pH: 7.30 = bicarb: 20 = = metabolic acidosis ex: pH: 7.58 = bicarb: 32 = = metabolic alkalosis ex: pH: 7.22 = bicarb: 30 = = respiratory acidosis ex: You are providing care to a client with the following blood gas results: pH 7.32, CO2 49, HCO3 29, PO2 80 & SaO2 90%. Based on the results, the client is experiencing: = acidosis, = respiratory -opioid: CNS depressant.. know the symptoms (sedation, respiratory depression, etc).. *principle: acid base signs/symptoms.. as the pH goes… so goes my patient!!! -when pH goes up; patient goes up.. (everything gets irritable!) -when pH goes down; patient goes down! (systems in your body shut down) …except with potassium: when pH goes up; potassium goes down… when pH goes down; potassium goes up! (up) alkalosis: irritibility, hyper-reflexia (3 & 4), tachypnea, tachycardia, borborygmi (increased bowel sounds), seizure, aspirate.. (down) acidosis: hypo-reflexia, bradycardia, lethergy (obtunded), paralytic ileus (decreased bowel sounds), coma, respiratory arrest (ambu-bag!!) Kussmaul breathing is a deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also kidney failure… MAC Kussmaul! ! M: metabolic AC: acidosis ex: pT has respiratory acidosis… (select all that apply).. +1 reflexes diarhhea adynamic ileus spasm urinary retention tachycardia 2nd degree mobits type 2 heart block hypokalemia SATA questions: *never only 1… never all of them* diarhhea will cause a metabolic acidosis.. but once you get acidodic, it will shut your bowels down = paralytic ileus …with scenarios.. always ask first “is it lung?” = respiratory …then ask if the pt is over-ventilating or under-ventilating? over-ventilating = alkalosis under-ventilating = acidosis …it’s about the SaO2!!! (pay attention!!) if it isn’t lung = metabolic.. if pt has prolonged gastric vomiting or suctioning… it’s alwaysmetabolic alkalosis… why? losing acid = becomes basic.. for everything else that is not lung - choosemetabolic acidosis.. -if you don’t know the answer… always answermetabolic acidosis.. ventilators alarms.. high pressure alarm… triggered by increasure resistance to air flow.. (machine is pushing too hard to get air into the lungs).. respiratory alkalosis 3 obstructions: kink in tubing (get kink out), water condensing within the tube (empty tube),mucus secretions in the airway (turn, cough, deep breathe… then suction).. suction as needed!! *in that order*… low pressure alarm.. decreased resistance (too easy for the machine..) respiratory acidosis Low pressure alarms are triggered by decreased resistance to airflow & can be caused by disconnections of the main tubing or oxygen sensor tubing… Tubing (reconnect it!) - oxygen sensor tube (reconnect it UNLESS tube is on t the floor - bag them & call Respiratory therapist if this happens) Respiratory alkalosis = ventilator setting may be too high. Respiratory acidosis = ventilator setting may be too low. What does “wean” mean? gradually decrease with the goal of getting off altogether ex: Doc says wean off vent in AM… 6am ABG’s show resp. acidosis… a) follow order b) call respiratory c) hold order.. call doc d) begin to decrease the settings MASLOW ’s Priorities (HIGHest - LOWest) physiological safety comfort psychological (problems within the person) social (problems with other people) spiritual ex: Arrange from HIGHest - LOWest… denial, spiritual distress, pain in elbow, fall risk, pathological family dynamics & electrolyte imbalance… = electrolyte imbalance (psyiological), fall risk (safety), pain in elbow (comfort), denial (psychological), pathological family dynamics (social) & spiritual distress (spiritual) 2. alcoholism.. (or any abuse) #1 problem = denial *refusal to accept the reality of a problem* You treat denial by confronting it… pronouns ~ good: i… bad: you… positions ~ good: i’m having a difficult time reading this… bad: you wrote it wrong.. loss & grief: Denial Anger BarginingDepression Acceptance don’t confront it; support it.. ex: You have a pt that just hand a hand amputated & they say, “I can’t wait to get back to playing the piano”… You say “Oh, how long have you played, etc? - youNEVER say “You can’t because you only have 1 hand” abuse = confront loss = support #2 problem = dependency *when the abuser get the significant other to do something.. “Call my boss, i’m sick”* (abuser gets to keep abusing..) = co-dependency *calls the boss*… (positive self esteem) How to treat this?!? Set limits and enforce them… Learn to say NO! manipulation = when the abuser gets the significant other to do things for him or her… the nature of the act is dangerous or harmful how is it like dependency? the abuser is getting the other person to do something no harm = dependent / co-dependent (wife buying alcohol for husband) dangerous/harmful =manipulated (kid buying alcohol for father) …depends on legal/illegal…………. Wernicke-Korsakoff Syndrome (WKS) is a neurological disorder. Wernicke's Encephalopathy and Korsakoff's Psychosis are the acute and chronic phases, respectively, of the same disease. WKS is caused by a deficiency in the B1 vitamin thiamine. Thiamine (B1) plays a role in metabolizing glucose to produce energy for the brain. primary symptom of WKS = amnesia with confabulation (making up stories) *they believe the lie..* ex: You have a pt who believes he is Ronald Regan’s Natioal Security Officer… And they want to go to a cabinet meeting… :/ WHAT DO YOU DO?!? Redirect!! (“well, why don’t you get a shower and then we’ll go watch CNN and see what the news is in Washington D.C.”) WKS is… -It’s preventable & arrestable (stop it from getting worse) - Take vitamin B1 -Irreversible… *About 70%* Antibuse (disulfiram) -alcoholism medication *aversion therapy!* It can treat problem drinking by creating an unpleasant reaction to alcohol. It's used in recovery programs that include medical supervision and counseling. How long does it take to get into & out of their system… 2 weeks Patient teaching - teach how to avoid NAUSEA, VOMITING & DEATH NO: mouthwash, aftershaves, perfumes/colognes, insect repellants, -elixer (Robitussin), alcohol-based hand santizers, un-cooked icings (vanilla extract)… However, they CAN have RED WINE VINAGERETTE! Overdoses/Withdrawals… Every abused drug is either an upper or a downer… *Laxative (not upper or downer) but can be abused by the elderly.. UPPERS: caffiene, cocaine, PCP/LSD, methaphetamines, adderall.. Signs/symptoms: things go up… euphoria, tachycardia, restlessness, irritibility, diarhhea, reflex 3/4, spastic - suction!!! DOWNERS: heroin, alcohol, marijuana, etc. Sign/symptoms: things go ~ lethargic, respiratory depression, bradycardia, reflex 1/2, - ambubag!!! 2 steps… Step 1: ask yourself, is it an Upper or Downer Step 2: ask yourself, is it an Overdose (too much) or Withdrawal (not enough) If they say: “overdosed on an upper” (too much upper)… pick things!! If they say: “downer & intoxication” (too much DOWNER)… pick things!! If they say: “withdrawal downer” (don’t have enough downer; too little!) Too little downer makes everything go up.. Too little upper makes everything go down.. Upper overdose LOOKS LIKE downer withdrawal… Downer overdose LOOKS LIKE upper withdrawal… 2 situtions (highest priority) = Respiratory depression/arrest: Downer overdose/upper withdrawal.. Seizure: Upper overdose/downer withdrawal… ex: Overdose on cocaine: UPPER/OVERDOSE.. (too much UPPER) *aka everything goes * What would you expect to see? (select all that apply) -irritability, reflex 3/4, increased temp, borborygmi (increased bowel sounds) Withdrawing from cocaine.. -Make sure the RR is above 12! Need NARCAN!!! Drug addiction in the NEWBORN  Always assume intoxication, not withdrawal at birth …After 24 hours - it’s in withdrawal.. You are caring for an infant born to a equaline (pain killer) addicted mother… It is 24 hours after the birth… What do you expect to see.. SELECT ALL THAT APPLY: difficult to console, low core body temp, exaggerated startle reflex, respiratory depression, seizure risk, shrill high pitch cry… alcohol withdrawls = 24 (stable; not life threatening) *AWS* delirium tremens = 72 hours (unstable; can kill you) *DTS* AWS: regular diet, semi-private anywhere, up ad lib, no restraints.. DTS: NPO/clear liquid (seizure), private/near nurse’s station, restricted bed rest (bed pans/urinals), restrained (VEST or 2 point locked leathers *1 arm & opposite leg*)… AWS & DTS get a anti-hypertensive (BP pill) - everything is going up - keep everything down… They both get a tranquilizer, because their up… multivitamin *b1* to prevent WKS. DRUGS: aminoglycocides - powerful antibiotics (the BIG GUNS!!!) think: a mean old mycin = serious, life threatening, resistent, gram negative (TB, etc.)… if it ends in mycin = mean old mycin *not mean old mycins: ery thromycin, zithromycin, clarithromycin (thro) if it has thro = throw it off the list… toxic effects: mycin = mice (ears)… oto-toxic!! -monitor hearing, tinnitus, vertigo (equalibrium) human ear shaped like kidney… nephro-toxicity ! -monitor creatinine (best indicator for kidney function)… 8 (fits in a kidney) toxic to cranial #8 and you administer them Q8H… route: IM or IV.. do not give PO, because they are not absorbed.. ORALmycins: hepatic coma (liver coma) amonia level gets too high.. pre-op bowel surgery (to clean the bowel)… #1 action: sterilize the bowel… which?! neomycin and canomycin… “ Who can sterilize my bowel?! NEO KAN!!!” ☺ T: trough: when the drug is at its lowest… A: adminster P: peak : when the drug is at its highest… Why do we do a TAP?! ( narrow therapeutic window ) what works/what kills… Lasiks: 10-120 (wide) Dig: 0.125 - 0.25 (narrow) DO a TAP! IV push.. TROUGH: b4 sub: 30 mins.. b4 iv: 30 mins.. b4 IM: 30 mins… b4 subQ: 30 mins.. b4 PO: 30 mins.. PEAK: after sub: 5-10 mins.. after iv: 15-30 mins.. after IM: 30-60 mins… after subQ: SEE Diabetes lecture.. after PO: DON’T WORRY ABOUT IT.. 3. Calcium Channel Blockers: are like VALIUM for your !!! …calms you down.. calms the heart down! Tachy = yes shock = no negative inotropic, negative chronotropic, negative dromotropic = calm/relax… cardiac depressant -what do they treat: antihypertensives, anti-angina, anti-atrial-aarrhythmia, SVT (atrial) Side effects: HA, HTN Name: ends in -dapine… + Cardizem & Verapimil… Cardizem (can be continous IV) -Check BP: Hold CCB if SYSTOLIC is 100! Cardiac Arrthymias - knowing how to read EKG strips… Know these 4 patterns!! 1) normal sinus rhythm 2) v-fib (no pattern) 3) v-tach (there’s a pattern) 4) asystole normal sinus rhythm a-fib a flutter v-fib v-tach asystole QRS de-polarization = ventricular P wave = atrial 6 rhythms… -a lack of QRS’s = asystole -saw tooth = a flutter -chaotic = atrial fibrilation -chaotic = ventricular fibrilation -QRS = ventricular tachycardia (bizzarre) - periodic bizarre wide QRS = PVC (low priority… can elevate to moderate: if there are more than 6/min.. or more than 6 PVC’s in a row.. or if the PVC falls on the T wave of the previous beat) PVC’s never reach HIGH.. LETHAL arrhytmias.. (they will kill you in 8 minutes or less) -asystole (HIGH) -v fib (HIGH) …have in common: NO cardiac output (pulse).. NO brain perfusion. *Potentially* LIFE threatening v-tach… (they have a cardiac output) TREATMENTS… PVCs/V-TACH: Ventricular… A (amioderone) Atrial: ABCD’s adenocard (adenosine); push in 8 seconds… *asystole for about 30 seconds!* beta blockers (side effects: HA/HTN) *no asthma!* calcium channel blockers… digitalis (digoxin, lanoxin) V-FIB: you D-FIB… Shock them! Asystole: EPI & atropine.. CHEST TUBES -purpose: re-establish negative pressure in the pleural space (need negative pressure for air exchange) *Look for the reason why it was placed!* pnemothorax (air = positive pressure.. put chest tube in to re-establish negative pressure!) hemothorax (blood= positive pressure.. put chest tube in to re-establish negative pressure!) pneumohemo (air & blood = positive pressure.. put chest tube in to re-establish negative pressure!) …what do you expect from a hemo chest tube: drain blood… LOCATION of the tube.. APICAL (high; air) & B ASILAR ( bottom; blood) example: unilateral pneumohemo.. apical for pneumo & basilar for hemo bilateral pneumo: 2 apicals chest trauma: unilateral (always assume its unilateral) post op R pneumonectomy (no chest tube!!) TROUBLE SHOOTING: Knocked it over… DON’T freak out! Water seal breaks…? CLAMP IT!!! (so nothing gets in).. CUT IT AWAY FROM BROKEN DEVICE… SUBMERGE TUBE UNDER STERILE WATER!!! UNCLAMP IT… FIRST: CLAMP BEST: SUBMERGE (re-establishes water seal) KNOW FIRST vs BEST… V-Fib.. BAD! FIRST: place backboard.. BEST: chest compressions.. What do you do if the chest tube gets pulled out? FIRST: takes a gloved hand and cover the hole.. BEST: cover it with vaseline gauze!! BUBBLING (chest tubes) Ask where & when… …Sometimes bubbline is good & sometimes it’s bad - depends on where & when! Bubbling, bubbling, bubbling… Where? Water seal.. When? Intermittent = GOOD! Document that! Bubbling, bubbling, bubbling… Where? Water seal… When? Continous = BAD! = LEAK… You do not want continous bubbling in the water seal. Bubbling, bubbling, bubbling… Where? Suction control chamber.. When? Intermittent = BAD… Suction is not high enough Bubbling, bubbling, bubbling… Where? Suction control chamber.. When? Continous = GOOD.. Document that! *If something is sealed, should you have a continous bubbling?NO. straight cath is to a foley catheter as a thorocentesis is to a chest tube.. Rules for clamping a tube: do NOT clamp longer than 15 seconds without a doctor’s order… What happens if you break the water seal? CLAMP it! How long do you have to get it under water? 15 seconds, or you gotta unclamp.. Have sterile water bottles nearby! Use rubber tip double clamps… CONGENITAL HEART DEFECTS (trouble or no trouble; either causes a lot of problems or it’s no big deal at all - there is no in between) TRo uBLe Trouble defect shunts blood: RIGHT to LEFT (cyanotic); needs surgery, delayed growth, decreased life expectancy, needs more time in the hospital/pediatric cardiologist NO-trouble defect shunts blood: LEFT to RIGHT (pink); doesn’t need surgery, normal growth, normal life expectancy, only 24-36 hours in the hospital/pediatrician/NP.. 40 some congential heart defects.. TROUBLE: All start with the letter “T”; if it does not start with a “T”; it’s not trouble. TROUBLE: tetrology of fallot, truncus arteriosus, transposition on the great vessels, transposition on the great arteries, tricuspid atresia, total anomalous pulmonary venous return (TAPV), left ventricular hypoplastic syndrome… NO TROUBLE: ventricular septal defect, patent ductus arteriosis, patent foramen ovale, atrial septal defect, pulmonic stenosis… …ALL congenital heart defect kids (whther trouble or not) will have 2 things in common: they will all have a murmur (because the shunt of the blood) & they all have an ECHO done. 4 defects of tetrology of fallot : - VD (ventricular defect) - PS (pulmonary stenosis) - OA (over-riding aorta) - RH (right hypertrophy) Va rieD PictureS Of A Ra ncH (initials) INFECTIOUS DISEASE & TRANSMISSION BASED PRECAUTIONS 4 types… STANDARD/UNIVERSAL: CONTACT : for anything enteric (fecal/oral); c-diff, hep a, cholera, staph infections, RSV (however it is transmitted via droplet), herpes.. PRIVATE ROOM IS PREFERRED.. GLOVES, GOWN, HAND WASHING, DISPOSABLE SUPPLIES.. DROPLET: bugs that travel (sneezing/coughing); menegitis, h flu (causes epiglotitis)… PRIVATE ROOM IS PREFERRED, MASK, GLOVES, HAND WASHING, PATIENT WEARING MASK - WHEN LEAVING ROOM, DISPOSABLE SUPPLIES.. AIRBORNE: measles, mumps, rhubella, TB & varicella chickenpox.. PRIVATE ROOM REQUIRED, MASK, GLOVES, HAND WASHING, SPECIAL FILTER MASK (only for TB), PATIENT WEARING MASK - IF LEAVING ROOM, NEGATIVE AIR FLOW.. TB: (transmitted through droplet though).. PPE: Order to put on/take off… TAKE OFF: in ABC order… gloves, goggles, gown, mask! PUT ON: reverse ABC for the G’s, but mask comes 2nd.. gown, mask, goggles, gloves! MATH IV DRIP RATES… volume x drop factor / t ime in minutes (volume/hours) micro drips: 60 drop/ml macro drips: 10 drops /ml PEDIATRIC DOSE childs weight… 2.2 lbs/kg… IV REPLACEMENT… Always ROUND at the END!!! (NCLEX will tell you to where) 4. CRUTCHES, CANES, WALKERS Locomotion (human functioning): cast, traction, canes, crutches, walkers… CRUTCHES: how do you measure? (for risk reduction; nerve damange)… Length of crutch: 2-3 finger widths below the anterior axillary fold to a point lateral to and slightly in front of the foot.. Hand grip: when properly set, the elbox flexion will be about 30 degrees.. -How to teach how to use the different type of crutch GATES: 2 point, 3 point, 4 point & swing through… 2 point: 1 crutch/opposite foot.. other crutch/other foot.. 3 point: moving 2 crutches & the bad leg… 4 point: move everything separately… Swing through: NON-weight bearing.. *amputations* plant the crutches & swing through… WHEN DO THEY USE THESE…?? Even for even; odd for odd = use the even # of gates when the weakness is evenly distributed… Use 2 point (mild), 4 point (severe).. use odd # gate (3), when 1 leg is odd.. can’t bear weight/amputation = swing through! early stages of RA: 2 left above knee amptuee: swing through 1st day post op R knee replacement; partial weight bearing allowed: 3 advanced stages: 4 left hip replacement; 2nd day post op non weight bearing: swing through bilateral knee replacement: 4 bilateral total knee; 3 weeks post op: 2 Going up and down stairs with crutches: UP with the GOOD, DOWN with the BAD! CANES: Hold the cane on the strong side… WALKERS: Pick them up, set them down… If they must tie belongings to the walker; have them tie it to the side & not the front (can tip over); no wheels/tennis balls (per boards!) DELUSIONS, HALLUCINATIONS & ILLUSIONS: *PSYCH* Is my patient NON-psychotic vs. psychotic? (1st thing you must decide) NON psychotic (neurotic): has insight and reality based; they know they have a problem… they need “good general therapuetic communication”; that must be very difficult, how are you feeling, what do you mean by, can you tell me more? psychotic: has NO insight & is not reality-based; they don’t have a problem/they aren’t sick; they blame everyone else… “unique specific strategies” SYMPTOMS: delusions, hallucinations & illusions… delusion = a false fixed idea or belief; there is no sensory component. 3 types: paranoid, grandiose (you’re christ) & somatic (x-ray vision) hallucination = false fixed sensory (hear, feel, taste, smell, see) most common hallucination = auditory.. then visual… then tactile (feeling), gustatory (taste).. olfactory (smell) most common auditory = voices telling you to harm yourself. illusion = misinterpretation of reality.. (sensory) *there is a referent in reality* (something to which a person refers) HOW DO YOU DEAL WITH THESE PATIENTS?!? If, psychotic - what is their problem? (What kind of psychosis do they have?) A FUNCTIONAL psychosis: they can function in every day life (schizophrenia, schizoaffective disorder, major depression,manic) DEMENTIA : the brain is damaged (senile, alzheimers, organic brain syndrome) DELIRIUM: FUNCTIONAL: this person has the potential to learn reality/improve.. Teach reality… Use 4 step process.. acknowledge feeling, present reality, set a limit, enforce the limit.. Example (answer): FEELING: I see you’re angry, you seem upset, tell me more of how you’re feeling… REALITY: I know that the voices are real to you, but they are not real… I’m a nurse, this is a hospital… SET LIMIT: That topic is off limits in our converstion.. We aren’t going to talk about that.. ENFORCE LIMIT: I see you are too ill to stay reality based, so our conversation is over (it ends the conversation). DEMENTIA: this person can NOT learn reality … 2 steps: acknowledge feeling & redirect them (channel them from something they can’t do to something they can do)… REALITY ORIENTATION: person, place & time (always appropriate)… but DON’T present reality… DELIRIUM: this is a temporary sudden dramatic secondary loss of reality… usually due to some kind of chemical imbalance in the body.. (*crazy for the short term; ex: A.T. on Feb. 3rd *, UTI, post-anesthesia, thyroid storm, adrenal crisis, delirium tremens)… REMOVE the underlying cause = 2 steps: acknowledge the feeling & then reassure (this is temporary and you will be kept safe). LOOSELY ASSCOCIATED = YOUR THOUGHTS ARE ALL OVER THE PLACE… Flight of ideas: go from thought to thought to thought… Word salad: babble random words (sicker) Neologism: making up words Narrowed self concept: when a (functional) psychotic refuses to leave their room or change their clothes… NURSE would say: “I see you feel uncomfortable.. You do not have to change your clothes or leave the room until you feel comfortable or are ready.” Ideas of reference: when you think everyone is talking about you… 5. DIABETES INSIPIDUS: polyuria & polydipsia leading to dehydration, due to low ADH. SIADH: oliguria (low urine output) and retaining water (gains weight) DIABETES (mellitus) Diabetes = error of glucose metabolism. polyuria, polydipsia the less the urine out; the higher the specific gravity… the more the urine out; the lower the specific gravity… Type 1: insulin dependent, ketosis prone… Type 2: non-insulin dependent, non-ketosis prone… polyuria (increased urine), polydipsia (increased thirst), polyphagia (increased eating) TREATMENT Type 1: DIE… diet, insulin, exercise Type 2: DOA… diet, oral hypoglycemic, activity DIET, INSULIN & EXERCISE Type 2: calorie restriction, 6 small meals… What does insulin do to the blood glucose? LOWERS it! HYPOGLYCEMIA = PEAK… 4 types… Regular (R) : onset: 1 hr.. peak: 2 hrs.. duration: 4 hrs. clear solution (can be IV drip) *rapid short acting* RAPID & RUN Lantus (Glargine): onset: 1 hr.. peak: NONE .. duration: 12-24 hrs. *LITTLE to NO RISK for HYPOGLYCEMIA* (can SAFELY give at BEDTIME) *LONG acting* NPH: *intermediate acting* onset: 6 hrs.. peak: 8-10 hrs.. duration: 12 hrs. cloudy.. suspension * N EVER put anything in an IV bag!* NOT so fast & NOT in the bag Humalog (Lispro): onset: 15 mins.. peak: 30 mins.. duration: 3 hrs. *give it WITH MEALS!* ALWAYS check expiration dates!! (manufacturer’s expiration date is only good when the bottle is closed… after it’s open; it expires in 30 days!) *make sure you write the date on the bottle with EXP!* You should teach patients to refridgerate their insulin at home, but it doesn’t need to be refridgerated in the hospital. …EXERCISE (like another shot of insulin) ex: “and he exercised…” aka “and he got another shot of insulin”………. “she’s going to play soccer this afternoon”.. “she’s going to get a shot of insulin this afternoon!” more exercise (more insulin) = really need less insulin less exercise = need more insulin SICK days: glucose is going to go up.. still take insulin, even if they’re not eating.. take sips of water; they get dehydrated fast.. (HYPERGLYCEMIA & DEHYDRATION).. needs to stay active as possible. COMPLICATIONS of diabetes (mellitus) Acute -low blood glucose (type 1/type 2) HYPOGLYCEMIA.. not enough food, too much insulin/meds, too much exercise.. danger = brain damage (permanent).. S/S: drunk in shock = staggerin’ gait, slurred speech, impaired judgement, delayed reaction time, labile (emotions all over the place), loud/obnoxious.. (vasomotor) low BP, tachycardia, tachpnea, cold, pale, clammy, mottled.. WHAT DO YOU DO?! adminster rapidly metabolizable carbohydrates (sugars); any juice, candy, milk, honey, icing, jam… ideal combo = sugar plus a starch or protein.. ORANGE juice & crackers! apple juice & slice of turkey… 1/2 cup skim milk (has both sugars & protein). if UNCONSCIOUS, give GLUCAGON; IM injection.. DEXTROSE D10/D50; given IV.. - DKA (diabetic ketoacidosis/diabetic coma) *only type 1’s*… glucose goes HIGH.. too much food, not enough medication, not enough exercise.. #1 cause = acute viral upper respiratory infections (in the last 2 weeks).. So, when they come into the hospital & their BS is850 * A LWAYS ask the parents “have they had a viral infection in the last 2 weeks!!!* S/S: DKA = dehydration, ketones in their blood/kussmaul breathing (deep & rapid)/K (high) potassium, acidosis (metabolic)/acetone breath/anorexia due to nausea… WHAT DO YOU DO!?! HYDRATE! ! (IV fluids; fast!! 200ml/hour; regular insulin; normal saline/D5?) D5 doesn’t stay in veins; goes into the tissues.. won’t cause HYPERGLYCEMIA (D10 & D50 will!) hyperglycemic hyperosmolar nonketotic coma HHNK (type 2) = DEHYDRATION… HYDRATE them!!!! insulin is most essential in treating DKA !!! higher mortality rate = HHNK, however DKA has higher priority. **long term complications of diabetes are related to: poor tissue perfusion & peripheral neuropathy … *lab test: A1c (average glucose rate over 3 months)… you want it to be 6 & !! 7 = need to check on it 8 & = out of control 6. DRUG TOXICITIES (5) Lithium: ANTImania drug for BiPolar.. Therapuetic level: 0.6-1.2 Toxic level: 2 & Lanoxin (Digoxin): A-Fib & CHF Therapuetic level: 1-2… 2 can be toxic! Toxic level: 2 & Aminophylline: Airway Anti-Spasmodic *NOT a bronchodilator* (when a bronchodilator doesn’t work in an acute airway problem, give them aminophylline to relax the spasm; then give the bronchodilator). Therapuetic level: 10-20… 20 can be toxic! Toxic level: 20 & Dilantin: Used for Seizures Therapuetic level: 10-20… 20 can be toxic! Toxic level: 20 & Bilirubin: Waste product from the breakdown of RBCs (only tested in NEWBORNS on the NCLEX) Normal: 9.9 and Elevated level: 10-20… 20 can be toxic! 14-15 *is when they need to be hospitalized* Toxic level: 20 & Jaundice: yellowing; bilirubin in the skin Kernicterus: bilirubin the the brain… usually occurs when the level gets around 20.. Opisthotonus: a position the baby assumes when they have bilirubin on the brain; HYPEREXTEND.. In what position do you place an opisthotonic child? On their side! DUMPING SYNDROME vs. HIATAL HERNIA Hiatal hernia: regurgitation of acid into the esophagus, because the upper part of your stomach herniates upward through the diaphragm… *moves in the wrong direction in the correct rate* (you want it to empty faster; so it doesn’t reflux) S/S: GERD (heartburn & indegestion) *when lying down after eating* Treatment: play around with the head of the bed (raise), play around with water content with the meal (flush faster) & you can play around with the carbohydrate content of the meal (carbs go fast)… LOW protein!! Dumping syndrome: gastric contents dump too quickly into the duodenum… *moves in the right direction, but at the wrong rate* (you want it to empty slower) S/S: *DRUNK* (staggering gait, slurred speech, impaired judgement) & *SHOCK* (tachycardia, tachypnea, cold, clammy, pale) DRUNK + SHOCK = HYPOGLYCEMIA * ACUTE ABDOMINAL DISTRESS* (cramping, pain, doubling over, borborygmi *increased bowel sounds*, diarhhea, bloating, distension) Treatment: Eat with head low & turned to the side, low fluids with meal and low carb content in the meals. HIGH protein!! ELECTROLYTES Kalemias do the SAME AS the prefix, except for heart rate & urine output!! S/S… HYPERkalemia: brain: irritability, restlessness, agitation… lungs: tychpnea heart: low heart rate urine: oliguria bowel: diarhhea, borborygmi muscles: spasticity reflexes: +3/+4 HYPOkalemia: brain: lethergy lungs: bradypnea heart: tachycardia urine: polyuria bowel: constipation muscles: flaccidity reflexes: 1/2 -Cushings: immonosuppressed (needs PRIVATE room) (aldosterone; retain sodium & water; low on potassium) ex: SATA: HYPERkalemia - clonus (muscle spasm), bradycardia Calcemias do the OPPOSITE AS the prefix… (if it skeleton or nerve, blame it on calcium!) S/S… HYPERcalemia: brain: lethergy lungs: bradypnea heart: bradycardia urine: oliguria bowel: constipation muscles: flaccidity reflexes: 1/2 HYPOcalemia: brain: irritability, restlessness, agitation… lungs: tachypnea heart: tachycardia urine: polyuria bowel: diarhhea muscles: spasms reflexes: +3/+4 Chvostek sign: when you touch their CHEEK, they go into a spasm of the face (neuromuscular irritability associated with a LOW calcium) Trousseau sign: when you put a blood pressure cuff on, blow it up & they go into a spasm of the hand. Magnesiums do the OPPOSITE AS the prefix… (in a tie, DON’T pick magnesium!) S/S… HYPERmagnesium: brain: lethergy lungs: bradypnea heart: bradycardia urine: oliguria bowel: constipation muscles: flaccidity reflexes: 1/2 HYPOmagnesium: brain: irritability, restlessness, agitation… lungs: tachypnea heart: tachycardia urine: polyuria bowel: diarhhea muscles: spasms reflexes: +3/+4 Sodiums S/S… HYPERnatremia: DEHYDRATION *DKA* DI… HHNK? HYPOnatremia: OVERLOAD*Fluid volume excess* SIADH NUMBNESS & TINGLING ( paresthesia) = earliest sign of any electrolyte disorder “circumoral ” = numb & tingling lips UNIVERSAL sign of any electrolyte disorder =MUSCLE weakness ( paresis) TREATMENT: (boards should only test potassium) HIGH potassium (will stop your heart) Rules for Potassium: -NEVER push IV ! -NEVER more than 40 of K per liter of IV fluid.. Ifmore than 40, question & clarify with DOC first! - HIGH POTASSIUM = worst electrolyte imbalance! *can STOP heart!*