Mark Klimek Audio Notes_Acid Base ABG’s. Lecture Notes.

Mark Klimek Audio Notes: Acid Base ABG’s As pH goes, so does my Pt! Except for K pH and HCO3 in same direction Metabolic pH and HCO3 in different direction: Respiratory pH ↓ Pt goes ↓ (HR, RR, all vitals) K goes ↑ hy ...

Mark Klimek Audio Notes: Acid Base ABG’s As pH goes, so does my Pt! Except for K pH and HCO3 in same direction Metabolic pH and HCO3 in different direction: Respiratory pH ↓ Pt goes ↓ (HR, RR, all vitals) K goes ↑ hypoexcitable pH ↑ Pt goes ↑ K goes ↓ hyperexcitable Except for K – it does the opposite pH ↑ : Alkalosis  Seizures, hyperactivity, borborgygmi (↑BS) Kausmal breathing = MacKausamal (Metabolic Acidosis breathing) Causes of imbalance: 1. Is lung affected? a. Yes-Respiratory 2. Is pt overventilating or underventilating? a. Over-alkalosis b. Under-acidosis 3. Not the lung? a. Then it is Metabolic 4. If pt has prolonged vomiting or suctioning a. Alkalosis 5. If you don’t know: it’s probably metabolic acidosis (It’s super common) Alcoholism Psychological  #1 problem psychologically in alcoholism and all other abusers is denial  Denial-refusal to accept the reality of a problem o Treat denial by confronting o Differentiate what they say versus what they do  DO NOT confuse confrontation with aggression (attacks the person)  Questions about staff problem interactions: Never choose YOU, choose I  Denial is okay in loss/grief o Treat this denial with support-Do NOT confrontMark Klimek Audio Notes 2  Denial Anger Bargaining Depression Acceptance  #2 problem dependency/codependency o Dependency-abuser gets significant other to do things for them o Codependency-positive self esteem significant other receives from doing things for the abuser o Treat by setting limits and enforce them, say no  Manipulation-abuser gets significant other for to do things them that is not in the best interest of the SO o Interest and harmful o If what being asked to do is neutral-dependency o If what being asked is harmful or not in best interest-manipulation o Treat manipulation by setting limits and enforce, say no  Wernicke’s and Korsakoff o Wernickes’-encephalopathy induced by vit B1/ thiamine deficiency o Korsakoff-psychosis induced by vit B1/ thiamine deficiency  Primary symptom- amnesia with confabulation  Redirect pt to other things  Preventable-take vitamin B1/thiamine  Arrestable-take vitamin B1/thiamine  Irreversible  Antabuse (disulfiram) and Revia (naltrexone) o Aversion therapy o Onset: 2 weeks, Duration 2 weeks o Pt teaching  avoid all forms of alcohol-mouthwash, aftershave, perfumes/colognes/ insect repellants, OTC ending with elixir, alcohol based hand sanitizer, uncooked icing  DO NOT pick red wine vinaigrette  Overdose and Withdrawal o Every abused drug is either upper or downer o 1. Is drug upper or downer?  Upper: caffeine, cocaine, pcp/lsd, methamphetamines, Adderall (amphetamine)  Things go up: euphoria, tachycardia, restlessness, irritability, borborygmic, diarrhea, hypereflexia 3+ or 4+, seizures (have suction at bedside)  Downer: If not upper, it is a downer  Things go down: lethargic, bradycardia, respiratory arrest (have ambu-bag at bedside) o 2. Overdose or withdrawal?  Overdose/intoxication-Overdose on an upper- everything goes up  Overdose downer- everything goes down  Withdrawal downer-everything go up  Wthdrawal upper-everything go down  Drug Addiction in Newborns o Always assume intoxication not withdrawal at birth (before 24 hours)  Alcohol withdrawal syndrome vs delirium tremens (DT)Mark Klimek Audio Notes 3 o Every alcoholic goes through alcohol withdrawal after 24 hr of not drinking, only minority go through DT (72 hrs) o Alcohol withdrawal-not life-threatening, not a danger to self or others o DT-life-threatening, danger to self and others AWS DT Regular diet NPO; clear liquids Semi-private anywhere Private, near nurse’s station No restraints Restricted bedrest (bedpans, urinals) Must be restrained (vest or 2 point lock leather) Antihypertensive/tranquilizer/Vitamin B1 Antihypertensive/tranquilizer/Vitamin B1 Ventilators High Pressure Alarm  Obstruction-Increased resistance to airflow o Kinks (unkink) o Water condensation (open system and drain tubing) o Mucous secretions in airway (TCDB, suction)  Low Pressure Alarm-↓ Resistance – machine finding job too easy  Disconnected o Main tubing (reconnect) o Oxygen sensor (reconnect)  If tube goes lower than pt level – contaminated  Ventilator overventilating pt can result in resp. alkalosis  Ventilator underventilating pt can result in resp. acidosis Amino Glycosides A Mean Old Mycin Amino Glycosides only treat Mean old Infections! Serious, resistant, gram-negative, life-threatening True mean old Mycins don’t have “Thro” If it has “Thro” – Thro it away!  Ex: Zithromycin , erythromycin, clarithromycin Mean Old Mycins (mice) destroy ears (ototoxicity) and kidneys (nephrotoxicity)  Must check Creatinine (0.6 -1.3) for Nephrotoxicity – NOT urine output  Check hearing, tinnitus, vertigo, dizzinessMark Klimek Audio Notes 4 8 Toxic to Cranial nerve 8 (vestibulocochlear) give q8h, IM/IV Mean Old Mycins do NOT get absorbed – they go in and out and sterilize/clean Hepatic (encephalopathy)coma-reduce ammonia levels. Oral mycins redcues ammonia PO Mean Old Mycins are for bowel sterilizing  NeoMYCIN  KanoMYCIN Who can sterilize my bowel?? NEO KAN! Drawing TAP Levels (Peak and Trough) For drugs that have a narrow therapeutic window/level and are toxic Digitalis Route determines TAP – Not the drug TROUGH PEAK IV 30 MIN BEFORE NEXT DOSE IV 15-30 min after its done IM 30 MIN BEFORE NEXT DOSE IM 30-60 min after its given SubQ-See SUB Q 30 MIN BEFORE NEXT DOSE Subling 5-10 min after its in the system PO 30 MIN BEFORE NEXT DOSE No PO peak Heart Rhythms Calcium channel blockers are like valium for the heart Ca Channel Blockers are chill pills for the heart  They end in -DEPINE or ZEM  Verapamil, Cardizem (Cardizem can be continuous IV drip) Calcium channel blockers are negative inotropic, negative chronotropes, negative dromotropes- fancy way of saying valium for the heart Positive inotropes- are cardiac stimulant Negative- cardiac depressantsMark Klimek Audio Notes 5 Calcium Channel Blockers Treats: Antihypertensive Antianginals Antiatrial Arrythmia Side Effects: Headache, Hypotension Measure BP: Hold if systolic <100 Rhythms Normal sinus rhythm Ventricular fibrillation Vfib: Chaotic without QRS pattern – Lethal (No cardiac output) Ventricular tachycardia Vent tachy: Wide bizarre QRS -Potentially lethal (Has cardiac output) Bizarre-tachycardia Asystole Asystole: No QRS – Lethal (No cardiac output) QRS depolarization-Ventricular P wave-atrial related Flutter: SawtoothMark Klimek Audio Notes 6 Afib: Chaotic with QRS pattern SVT: Narrow QRS PVC: random rhythm change – Periodic wide and bizarre QRS-PVC. Only concerned if1:  More than 6,  6 in a row,  PVC falls on t wave on the previous beat Change in rhythm: check pulse or BP for cardiac output Treat ventriculars (PVC, Vtach) with lidocaine/amiodarone  V → L Treat SVT (it’s actually an atrial) A denosine –PUSH it fast; puts you in asystole for 20-30 seconds B eta blockers – all end it “lol”. Side effect: headache, hypotension C a channel blockers D igitalis (lanoxin)- VFib: you DFib Asystole: epinephrine then atropine Chest Tubes Re-establish negative pressure in the pleural space The only chest surgery that doesn’t require a chest tube is a pneumonectomy – because you remove the entire lung A. Pneumothorax- apical air; Needs to bubble B. Hemothorax- basilar blood; Report no drainage from chest tube, no bubbles C. Pneumohemothorax-Blood and air Knock System Down 1. Pick system back up 2. Have pt take a few deep breaths Water seal breaks 1. Clamp 2. CutMark Klimek Audio Notes 7 3. Put in sterile water 4. Unclamp Chest tube comes out 1. Cover with gloved hand 2. Vaseline gauze 3. Sterile dressing taped on 3 sides Bubbling: Where? When? Water Seal  Intermittent: good; document  Continuous: bad (air leak) Suction Control  Intermittent: bad (dial up suction)