Mark Klimek Lectures 1 to 12 for High Scoring Grades

Lecture 1— Acid-Base Balance Ventilators Lecture 2— Alcohol Wernicke Overdose and Withdrawal S/Sx Aminoglycosides Peak and Trough Lecture 3— Drug Toxicities (Lithium, Lanoxin, Dilantin, Bilirubin, Aminophylline ...

Lecture 1— Acid-Base Balance Ventilators Lecture 2— Alcohol Wernicke Overdose and Withdrawal S/Sx Aminoglycosides Peak and Trough Lecture 3— Drug Toxicities (Lithium, Lanoxin, Dilantin, Bilirubin, Aminophylline) Kernicterus Dumping/HH Electrolytes: K+, CA, MG, and NA TX for HyperKalemia Lecture 4— Crutches Canes Walkers Delusions Hallucinations Psychosis Psychotic and Non-Psychotic Hallucination Illusion Delusion Lecture 5— Diabetes Mellitus Diabetes Insipidus SIADH Insulin DKA HHNK Lecture 6— Drug Toxicities (Lithium, Lanoxin, Dilantin, Bilirubin, Aminophylline) Kernicterus Dumping/HH Electrolytes: K+, CA, MG, and NA TX for HyperKalemia Lecture 7— Thyroid (Hyper-, Hypo-) Adrenal Cortex (Addison Disease, Cushing) Toys Laminectomy Lecture 8— Lab Values Five Deadly Ds Neutropenic Precaution Lecture 9— Psych Drugs Tri Benzo MAOI Lithium Prozac Haldol Clozaril Zoloft Lecture 10— Maternity and Neonatology Lecture 11— Fetal Complications Stages of Labor Assessments Variations for NB Maternity Meds Medication Hints Psych Tips Operational Stages Lecture 12— Prioritization Delegation Staff Management Guessing Strategies GUIDE • Mark Klimek’s LecturePage 2 of 92Page 3 of 92 Acid/Base Balance (Start times: 30:00) In order to solve acid-base disorders, it is important to know the normal values for pH, CO2 and HCO3 (bicarbonate), which are shown below • pH 7.35 to 7.45 • CO2 35 to 45 • HCO3 22 to 26 The first value to look at in an acid-base disorder is the pH • If pH is <7.35, the acid-base imbalance is acidotic • If pH is <7.45, the acid-base imbalance is alkalotic Now, to determine if the imbalance is metabolic or respiratory, determine whether HCO3 goes in the same or opposite direction with pH • Rule of the Bs: If pH and Bicarb move both in the same direction, then the acid-base imbalance is metabolic … Otherwise, it is respiratory Example #1 • pH 7.3 Acidotic • HCO3 20 Metabolic • This is an example of metabolic acidosis Example #2 • pH 7.58 Alkalotic • HCO3 32 Metabolic • This is an example of metabolic alkalosis Example #3 • pH 7.22 Acidosis • HCO3 35 Respiratory • This is an example of respiratory acidosis As the pH goes, so goes my patient, except for Potassium … That means • If pH is low, everything is low, except potassium • If pH is high, everything is high, except potassium Lecture 1 • Mark Klimek • 92:21Page 4 of 92 If pH goes over 7.45, this is alkalosis • Therefore everything is up: tachycardia, tachypnea, HTN, seizures, irritability, spastic, diarrhea, borborygmi (increase bowel sounds), hyperreflexia (3+, 4+) • However, potassium is opposite. Therefore, hypokalemia • What is the nursing intervention? o Pt need suctioning because of seizures If pH goes below 7.35, this is acidosis • Therefore, everything is down: bradycardia, constipation, absent bowel sounds, flaccid, obtunded, lethargy, coma hyporeflexia (0, 1+), bradypnea, low BP • However, potassium is high (hyperkalemia) • What is the nursing intervention? o Pt needs to be ventilated with an Ambu bag—respiratory arrest So, remember that “MAC Kussmaul” is the only acid-base imbalance to cause Metabolic ACidosis with Kussmaul respirations Causes of Acid/Base imbalance First ask yourself, “Is it LUNG? … If yes, then it is respiratory • Then ask yourself, “Are they overventilating or underventilating? o If UNDERventilating, then pick acidosis—pH is under 7.35 o If OVERventilating, then it is alkalosis, pH is over 7.45 What type of acid-base derangement is present in the following condition? • In labor? o Respiratory alkalosis … Overventilating—pH increases … Alkalosis) • Drowning? o Respiratory acidosis … Underventilating—pH decreases … Acidosis • Pt is on PCA (patient-controlled anesthesia) pump? o Ventilation is down … Respiratory acidosis If it is not LUNG, then it is metabolic. If the patient has prolonged gastric vomiting or suction (sucking out acid), pick alkalosis • For everything else that isn’t lung, pick metabolic acidosis • So, when you don’t know what to pick, pick metabolic acidosis Tip • Set your default setting to Metabolic Acidosis • Always pay attention to modifying phrase rather than original noun Figure 1. Patientcontrolled anesthesia (PCA) pump.Page 5 of 92 Ventilator A ventilator is a machine designed to move breathable air into and out of the lungs, aids patients who are physically unable to breathe, or breathing insufficiently to breathe … A ventilators is equipped with a high and a low-pressure alarm High pressures alarms are always triggered by increased resistance to air flow. Look for obstructions, i.e., • Kinks in tubing … Solution: unkink the tube • Condensed water in the dependent tube … Solution: empty it • Mucus plugs … Solution: Ask pt to turn, cough, deep breathe; or suction the tubing PRN What is the appropriate order to address high pressure alarm in a mechanical ventilator? • (1) Unkink. (2) Empty water out of tubing. (3) turn pt, ask pt to cough or deeply breathe, and (4) suction Low pressures alarms are always triggered by decrease in resistance. This can be caused by • Main tubing disconnection • O2 sensor tube disconnection • In both cases, reconnect the disconnected tubing unless tube is on floor … Bag pt and call Respiratory Therapist The ventilator may be set too high or too low • Setting is too high … Pt is overventilated o Respiratory Alkalosis … Panting • Setting is too low … Pt is underventilated o Respiratory Acidosis … Pt is retaining CO2 Question The physician wants to wean pt off vent in the morning. At 6 am, the ABGs say respiratory acidosis. What would you do next? • Notify the physician that the pt is not ready to be weaned off the respirator o Pt is is respiratory acidosis, which means that he is underventilated … Therefore not ready to be weaned off the ventilator o If pt were in respiratory alkalosis (overventilated), he should be ready to be weaned offPage 6 of 92 Alcoholism • The #1 psychological problem is DENIAL • How do you respond/treat to pts in denial? o Confront them by pointing out the difference b/w what they say and what they do o For instance, say something like: “Ok, you say you’re not an alcoholic but it is 10 a.m. and you’ve already had a 6 pack” … It is not the same as aggression. Don’t attack the person o Good answer has “I” … Bad answer has “YOU” o One place where denial is ok—loss and grief Stages of grief are “DABDA”—Denial, anger, bargaining, depression, acceptance o So when the question is about pt in denial, pay attention to whether you are dealing with loss or abusive situation Support = Loss Confront = Abuse Dependency vs. Co-dependency • The #2 psychological problem is Dependency or Co-Dependency • Dependency: when the get the significant other to do things or make decisions for them o The abuser is dependent • Co-dependency: when the significant other derive self-esteem for doing things or making decisions for the abuser o The significant other is the co-dependent • Dependency and co-dependency has a symbiotic, yet a pathological relationship o The dependent pt get a free ride on the co-dependent o The co-defendant pt feels good from “doing stuff” for the abuser • How do you treat dependency/codependency? o Dependent pts are “abusers” … Confront them o Co-dependent pts have self-esteem issues … Teach pts how to set limits and enforce them o Agree in advance on what requests are allowed then enforce o Teach significant other to say no o Work on self-esteem on the co-dependent person Manipulation • Manipulation is when the abuser gets the significant other to do things or make decisions that are not in the best interests of the significant other o The nature of the act is dangerous and harmful to the significan