Lecture 1 • Mark Klimek • 92:21
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 belo
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Lecture 1 • Mark Klimek • 92:21
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
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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. Patient-
controlled anesthesia
(PCA) pump.
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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 off
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The title of this section is alcoholism. However, this rule can be used for any abuse situation
1. So, what it the number 1 psychological problem in child abuse? … In gambling? … In cocaine abuse? … In spousal abuse? … In elder abuse?
a. The answer is denial
Lecture 2 • Mark Klimek • 101:54
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 significant other
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