MDC II Exam 2

MDC II Exam 2 look at pH What is your first step when interpreting ABGs? Respiratory acidosis What acid-base imbalance would you expect to see in an asthmatic patient? COPD asthma muscle weakness ▪ inadequate chest expansion ▪ pneumonia ▪ pulmonary edema ▪ sleep apnea ▪ respiratory depression r/t: drugs, alcohol, anesthesia, electrolyte imbalance ▪ high ICP Common causes of Respiratory Acidosis Vital Signs, think LOW & SLOW ▪ bradycardia, thready weak pulses ▪ hypotension ▪ hypoxia Electrolyte Imbalance ▪ hyperkalemia Skin ▪ pale, cyanotic CNS Depression, think LOW & SLOW ▪ lethargy ▪ confusion ▪ stupor ▪ coma ▪ headache Musculoskeletal, think LOW & SLOW ▪ hyporeflexia ▪ muscle weakness ▪ flaccid paralysis Cardiac ▪ heart dysrhythmias (due to hyperkalemia) ▪ increased cardiac output ▪ EKG changes - tall T waves, wide QRS, prolonged PR interval S/S of Respiratory Acidosis (acidosis has similar s/s no matter if met. or resp.) stabilize airway (patent) bronchodilators ▪ O2 ▪ Pulmonary hygiene (positioning and breathing/coughing techniques) ▪ Suction PRN ▪ If on ventilation, increase ventilation rate. ▪ Endotracheal intubation For underlying causes: ▪ Correct electrolyte balance (hyperkalemia) ▪ Antibiotics (if it's infection) Treatment for Respiratory Acidosis ▪ increase respirations to increase pH What does your body do to compensate for respiratory acidosis? ▪ impaired gas exchange Nursing Diagnosis for Respiratory Acidosis respiratory acidosis low pH, high CO2 metabolic acidosis low pH, low HCO3 respiratory alkalosis high pH, low CO2 metabolic alkalosis high pH, high HCO3 Uncompensated pH and one other value are abnormal. Fully compensated pH is normal, but the other 2 are abnormal. Partially compensated all 3 values are abnormal overproduction of hydrogen ions aspirin toxicity ▪ kidney failure, liver failure, pancreatitis ▪ diarrhea (ACI-dosis sounds like ASS) ▪ dehydration ▪ ingestion of acids: ethanol, methanol, salicylate acid ▪ lactic acidosis ▪ diabetic ketoacidosis, starvation ▪ hypermetabolism: excessive exercises, seizures, fever, hypoxia Causes of Metabolic Acidosis Vital Signs, think LOW & SLOW Kussmaul respirations ▪ bradycardia, thready weak pulse ▪ hypotension ▪ hypoxia Electrolyte Imbalances ▪ hyperkalemia ▪ hyperglycemia (if the cause is DKA) Skin ▪ warm, flushed, dry (due to vasodilation) CNS depression, think LOW and SLOW ▪ lethargy ▪ confusion ▪ stupor ▪ coma ▪ Headache Musculoskeletal, think LOW and SLOW ▪ hyporeflexia ▪ muscle weakness ▪ flaccid paralysis Cardiac ▪ heart dysrhythmias (due to hyperkalemia) ▪ increased cardiac output ▪ EKG changes - tall T waves, wide QRS, prolonged PR interval S/S of Metabolic Acidosis (acidosis has similar s/s no matter if met. or resp.) Peaked T waves Wide QRS Prolonged PR interval How does the EKG change for a patient with metabolic acidosis? administer sodium bicarbonate ▪ insulin (if cause is DKA) ▪ fluid/electrolyte replacement (remember some causes are dehydration/diarrhea) ▪ treat underlying cause... Treatment for Metabolic Acidosis Mechanical ventilation question will ask which intervention is NOT included in treatment for Metabolic Acidosis Mechanical ventilation Treat underlying cause Fluid replenishment I & O ▪ Monitor ABGs, electrolytes (especially potassium) ▪ Monitor neuro status for decline ▪ Monitor I&O ▪ Perform skin assessment ▪ Seizure precautions ▪ Provide periods of rest ▪ Provide oral care Nursing Interventions for Metabolic Acidosis excessive loss of CO2 from hyperventilation (tachypnea) ▪ fear ▪ anxiety ▪ shock ▪ high altitude ▪ fever ▪ embolism ▪ aspirin toxicity ▪ salicylate toxicity ▪ mechanical ventilation: improper vent settings ▪ early stage acute pulmonary problems Causes of Respiratory Alkalosis Vital Signs ▪ Tachycardia ▪ Tachypnea ▪ Normal or low BP (hypotension) ▪ Fever (if that's a cause) ▪ Increased rate and depth of ventilation (fast RR) Electrolytes ▪ Hypocalcemia ▪ Hypokalemia CNS Excitement ▪ increased activity ▪ anxiety ▪ irritability ▪ tetany ▪ seizures Musculoskeletal ▪ Hyperreflexia: - Positive Chvostek's sign - Positive Trousseau's sign ▪ Muscle cramps/weakness/twitching ▪ Parathesia Cardiac