mark klimek revised notes for High Scoring Grades

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ACID BASE BALANCE RULE OF THE B’S 1. If the pH and the Bicarb are in the same direction  METABOLIC 2. If the pH and the Bicarb are in different directions  RESPIRATORY Examples: pH 7.25 (... av) HCO3 20 (v) Metabolic Acidosis pH 7.21 (v) HCO3 38 (^) Respiratory Acidosis pH 7.50 (^) HCO3 30 (^) Metabolic Alkalosis pH 7.50 (^) HCO3 25 (normal) Respiratory Alkalosis (NORMAL) SIGNS & SYMPTOMS Know the principles, not the lists. PRINCIPLE: “As the pH goes, so does my patient, except for potassium” ALKALOSIS (^) ACIDOSIS (v) Hyperreflexia Headache Irritability Hyporeflexia Tachypnea Bradycardia Tachycardia Bradypnea Borborygmi Paralytic/adynamic ileus Seizures *need suction Coma Hypokalemia Respiratory arrest *need ambu bag HYPOkalemia MACkussmau’s (ONLY METABOLIC ACIDOSIS  “MAC”) Heart block HYPERkalmiaCAUSES OF IMBALANCES   OVER-VENTILATING UNDER-VENTILATING   RESPIRATORY ALKALOSIS RESPIRATORY ACIDOSIS Examples: - Pregnant woman hyperventilating. - Ventilator setting is TOO HIGH. Examples: - Emphysema - Drowning - Pneumonia - PCA pump (toxicity) - Ventilator setting is TOO LOW. 2. What if it is NOT A LUNG SCENARIO? It is METABOLIC   PROLONGED SUCTIONING OR VOMITING ANYTHING ELSE!   METABOLIC Alkalosis METABOLIC Acidosis Examples: - Surgery with NG tube suction for 3 days - Hyperemesis gravidum Examples: - Acute RF - Infantile diarrhea - 3rd degree burns over 60% of body - Hyperemesis gravidum with dehydration NOTE: Always pay attention to MODIFYING PHRASE rather than original statement. . 1. Is it a LUNG SCENARIO? YES. It is RESPIRATORY.VENTILATORS AND ALARMS HIGH PRESSURE ALARM Ventilator is working too hard to get air into lungs. There is INCREASED RESISTANCE due to OBSTRUCTIONS. 1. Kinks  unkink 2. Water condensing into dependent loops  empty 3. Mucus in airway  turn, cough and deep breathe, suction PRN. LOW PRESSURE ALARM Ventilator finds that it is working too easy to get air into lungs. There is DECREASED RESISTANCE due to DISCONNECTIONS. 1. Main tubing is disconnected  reconnect 2. Oxygen sensor tubing, which senses FiO2, is disconnected. This is the black coated wire  reconnect Question MD orders to disconnect ventilator in AM @ 0900hr. At 0600hr, ABC reveals respiratory acidosis. What do you do? a. Follow order b. Call MD and hold order c. Call RT d. Begin to decrease settings. B is the answer because the patient is not able to breathe without the ventilator. The settings are TOO low. Patient should be in respiratory ALKALOSIS.ALCOHOLISM #1 PROBLEM: DENIAL Psychological problem in abuse is denial, which is refusal to accept the reality of a problem. Denial is the #1 problem in all abuse situations.  It is #1 because how can you treat someone who can’t admit that they have a problem? You treat denial by confronting it by pointing out the difference between what they say and what they do. Confrontation attacks the problem. Aggression attacks the person.  You say you’re not an alcohol, but it’s 10AM and you already drank a 6-pack.  You say you’re not a spouse abuser, but she has a restraining order against you. They deny, you confront. Denial of loss + grief is different. Stages of Grief: DABDA: Denial, anger, bargaining, depression, and acceptance You want to support this type of denial.  Guy lost one hand and wants to play piano. You do not tell him he can’t. You ask him more about piano. Pay attention to the question, is it loss or abuse?  With loss you support. With abuse you confront. #2 PROBLEM: DEPENDENCY VERSUS CODEPENDENCY Dependency: Abuser gets significant other to do things for them. The abuser is dependent on others.  Call in sick for me. Go buy me this. Drop me off here. Codependency: Significant other derives positive self-esteem from making decisions for or doing things for the abuser.  Aren’t I such a great wife for calling in sick for you?  Abuser: Life without responsibility  Significant Other: Positive self esteem Treatment:  Set limits and enforce them. Teach significant other to say NO.  Work on self-esteem of the codependent person to solve the issue. o I’m saying no and I’m a good person because I’m saying no.  May solve the problem but may lose relationship. #3 PROBLEM: MANIPULATIONManipulation: Abuser gets significant other to do something that is not in the best interest of significant other. Nature of act is dangerous or harmful. How is manipulation like dependency? In both situations, the abuser is getting them to do something for them. The difference is neutral versus negative. Look at what they’re being asked to do. If what the s/o is being asked to do is neutral = dependency/codependency.  A 49y/o alcoholic gets her 50y/o husband to go to the store to buy alcohol for her, because this is legal.  Last week, your sister in law calls you and says, “Would you pick up little Billy from basketball practice at school? So he can spend the night at your house b/c of the snow.” You have a 4x4 Hummer and you live 3 blocks from the school, and you do it. If what the s/o is being asked to do is harmful/dangerous to s/o = manipulation.  A 49y/o alcoholic gets her 17y/o daughter to go to the store and buy alcohol for her, because this is illegal as she is under age.  What if your sister in law calls you and she has the 4x4 Hummer and she lives 3 blocks from school and she asks you to pick up her son and you have a KIA that is breaking down and you live 20 miles away. This is dangerous. She can do it herself more safely. Treatment:  Set limits and enforce them. You say NO.  Easier to treat because nobody likes being manipulated.  No positive self-esteem issue with manipulation like there is with codependency/dependency. How many patients do you have with DENIAL? 1. How many patients do you have with DEPENDENCY/CODEPENDENCY? 2. How many patients do you have with MANIPULATION? 1. WERNICKE-KORSAKOFF SYNDROME – encephalopathy psychosis  Psychosis induced by Vitamin B1/thiamine deficiency  Lose touch with reality  Psychotic people  Primary symptom: amnesia with confabulation (memory loss, making up stories) because they forgot and they believe it  Memory loss is “what happened in the 1990’s?” not “I got drunk last night, what happened?” so they make up stories of what they were doing in the 90’s Treatment:  Do not present reality because they won’t learn it.  Redirect  rechannel it into something they can do not telling them what they can’t do: o Pt: “I’m going to presidential meeting at 8AM?” o Well why don’t we take a shower then watch CNN and watch what’s going on in Washington?Characteristics:  Preventable  take vitamin B1 which is a coenzyme needed for metabolism for alcohol; if deficient, alcohol will be stored and ruin brain cells.  Arrestable  They don’t have to stop drinking; they just have to take vitamin B1. o Stop it from getting worse? Take vitamin B1  Irreversible  70% irreversible (on boards, answer with majority). ANTABUSE ARABIA (DISULFIRAM)  Aversion therapy  Aversion: Really strong hatred for something; gut hatred for something; we want alcoholics to really hate alcohol  Works in theory better than in real life  Onset and Duration: Two weeks before effectiveness and two weeks off drug until they can drink again Patient Teaching  Avoid all forms of alcohol to avoid nausea, vomiting, death including:  Mouthwash even if they swish and spit  Aftershaves even if they put it on topically b/c causes nausea  Perfumes and colognes for the same reason  Insect repellants  Any OTC that ends in –elixir  Alcohol based hand sanitizers  Uncooked icings because they have vanilla extract  They CAN have red wine vinaigrette [Show More]

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