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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 (v) 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 MAC kussmau’s (ONLY METABOLIC ACIDOSIS “MAC”) Heart block HYPERkalmia
CAUSES 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.
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
- 3 rd^ 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. 2. What if it is NOT A LUNG SCENARIO? It is METABOLIC
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: MANIPULATION
Manipulation: 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?
OVERDOSE AND WITHDRAWAL
QUESTION 1: Every abused drug is either an upper or a downer. Therefore, figure out if the drug is an UPPER or LOWER drug. What is the #1 most abused class of drug that is not an upper or downer? Laxatives in the elderly. When you get a question, establish if it’s an upper or a downer? UPPERS: THERE ARE FIVE Caffeine Cocaine PCP/LSD (psychedelic hallucinogen) Methamphetamines (crystal meth, pseudopheds, etc.) Adderol (ADD drug) SIGNS & SYMPTOMS: Make things go up; increased Euphoria Tachycardia Tachypnea Restlessness Hypertension Irritability Diarrhea Borborygmi 3+/4+ reflexes Spastic Seizures suction @ bedside DOWNERS: THERE ARE 135. Everything that’s not an UPPER. So ONLY memorize the UPPERS!!! SIGNS & SYMPTOMS: Make things go down; decreased Respiratory arrest is the biggest risk All symptoms above but opposite Example: Patient is high on cocaine. What is critically important to access? A. Reflexes B. Make sure respiratory rate is above 12 C. HR D. Bowel sounds Not B, because it’s not a downer. It’s an UPPER! Do not just use ABC’s. QUESTION 2: After you distinguish whether the drug is upper or downer, the second thing you ask is, are they talking about overdose or withdrawal? Overdose/intoxication: You have too much.
Overdosed on upper everything goes UP pick the UP things. Intoxication on downer everything goes DOWN pick the DOWN things. Withdrawal: You don’t have enough Withdrawal downer you don’t have enough downer pick the UP things. Withdrawal upper you don’t have enough upper pick the DOWN things. Upper overdose Downer withdrawal Downer overdose Upper withdrawal Which two situations would respiratory arrest be of concern? Downer overdose Upper withdrawal Which two situations would seizure be biggest risk? Upper overdose Downer withdrawal Example: Bringing patient who is overdosed on cocaine. What would you expect to see, SATA.
**1. Irritability
- 4+ reflexes 3.** Resp less than 12 4. Difficult to arouse **5. Borborygmi
- Increased temp Thought Process:** Patient is on UPPER drug. Overdose on UPPER. Therefore TOO MUCH UPPER. This is a CNS drug not an AUTONOMIC.
ALCOHOL WITHDRAWAL SYNDROME VERSUS DELIRIUM TREMONS
Not the same thing! A. Every alcoholic goes through alcohol withdrawal 24 hours after they stop drinking. Only a minority (under 20%) get delirium tremons. Occurs 72 hours after. Alcohol withdrawal always comes first within 24 hours. Alcohol withdrawal syndrome always precedes delirium tremons; however, delirium tremons does not always follow alcohol withdrawal syndrome. B. AWS is not life threatening. DT can kill you. C. Patients with AWS are not a danger to self or others. Patients with DT are dangerous to self and others. AWS DT Regular diet. NPO or clear liquids. Because RF seizure because withdrawing from downer UP S&S Semi-private anywhere on unit Private room near nurses station b/c dangerous and unstable. Usually on step down unit. Up ad lib. Go around anywhere they want to go. Strict bed rest. No washroom privileges. No restraints (not a danger). Restraints needed. Certain restraints are futile: Soft restraints not safe/strong enough. Four point restraints are not safe enough. Restraints appropriate: Vest or two point locked leathers (opposite arm and opposite leg). Rotate q2h. What would you do first? Lock the LEG first then the ARM, then release. BOTH RECEIVE: Antihypertensive: everything going up (withdrawal of downer) Tranquillizer Multivitamin containing Vitamin B1 to prevent WERNICKE KORSAKOFF
AMINOGLYCOSIDES
Powerful class of antibiotics, they are the BIG GUNS When nothing else works, pull out the aminoglycosides Think the following: A MEAN OLD MYCIN A) They are antibiotics used to treat A MEAN OLD INFECTION that is RESISTANT SERIOUS LIFETHREATENING RESISTANT GRAM NEGATIVE Sinusitis? No. It’s not a mean old infection. TB? Yes. Otitis Media? No. Bladder infection? No. Fulminan pyelonephritis? Yes. Septic shock? Yes. Burn wounds over 85% body? Yes. Viral pharyngitis? No. Strep throat? No. B) “Mycin” ALL aminoglycosides end in –mycin o Not all drugs that end in mycin are aminoglycosides but MOST are o There are three mycins that are not aminoglycosides Arithromycin Zithromycin Clarithromycin If it ends in MYCIN = Aminoglycoside If it ends in THROMYCIN = It is NOT an aminoglycoside, which you can use for regular type infections C) TWO TOXIC EFFECTS OF A MEAN OLD MYCIN / AMINOGLYCOSIDES Think MICE think EARS ototoxicicity o Hearing* o Ringing/Tinnitus o Vertigo (equilibrium) o Dizziness (equilibrium) Human ear is shaped like a KIDNEY nephrotoxicity o Creatinine is THE best indicator of kidney function (do not go for U/O, BUN) o 24 hr creatinine clearance is BETTER than serum creatinine o Serum creatinine comes next over anything else Think number 8 drawn inside the EAR o Toxic to Cranial Number 8 (ear nerve) o Administer them q8h Route: IM or IV Do not give them PO because they are not absorbed EXCEPT in o Hepatic Encephalopathy Oral mean old mycins will go in your gut and kill gram negative bacteria which produce ammonia This will help get rid of high ammonia levels At the same time, the drug will NOT go to the liver (since it’s not absorbed) which is GOOD in liver failure o Preop Bowel Surgery Clean out the gut
TAPS
TROUGH PEAK
SL 30 mins before next dose 5-10 minutes after drug dissolved IV 30 mins before next dose 15-30 minutes after drug is finished, not when you hang it IE: 100 ml at 200 ml/hr. It will be finished in 30 mins. You hang it at 1000hr, finishes at 1030hr. Draw peak from 1045-1100hr. If you get two correct values in range; play price is right. Choose the one that is the highest without going over. Therefore, 1100hr. IM 30 mins before next dose 30-60 minutes after injected. Choose 60 minutes, if both options given. SC 30 mins before next dose SEE diabetes lecture. Only SC peaks they talk about are insulins. PO 30 mins before next dose Forget about it because they don’t test it. Too variable.
CALCIUM CHANNEL BLOCKERS
CCB are like VALIUM for your heart. What does VALIUM do for your body? Calms you down. CCBs calm the heart down. o If your heart is tachycardic, can it stand a little relaxant YES CCB o If in shock, does it need to relax? NO CCB o Heart block NO CCB o Tacharrythmias YES CCB o Heart attack YES CCB A. CCBs are negative inotropic, negative chronotropic, and negative dromotropic It’s like VALIUM for your heart. Don’t freak out with the fancy words. They relax your heart. Positive ino/chrono/dromo Negative ino/chrono/dromo Cardiac stimulants Strengthen, speed up, make it work harder Cardiac depressant Slow down and depress the heart B. What do they treat? AAA! Antihypertensives: They relax your heart and blood vessels Antianginals: Relax the heart so it uses less oxygen; decreasing oxygen demand Anti atrial-arrhythmias: ONLY atrial arrhythmias NOT ventricular. Treats atrial flutter, atrial fib, paroxysmal atrial tachycardia… anything ATRIAL! o There’s a trick: supraventricular tachycardia. Would CCB treat this? YES. Why? “SUPRA” means above; therefore, ABOVE THE VENTRICLES = ATRIAL. o SVT = ATRIAL Side Effects o Hypotension: Vasodilation o Headache: Vasodilation in the brain Headache is usually always in SATA Always measure blood pressure due to risk for hypotension Parameters: Hold CCB if SYSTOLIC < 100 mmHg C. Names of CCB -dipine Has to be DIpine not PINE Two others: o Verapamil o Cardizem Cardizem can be given continuous IV o If SBP < 90 mmHg, slow and titrate the drip to keep SBP > 100 mmHg
QRS: VENTRICULAR
P WAVE: ATRIAL
6 RHYTHMS MOST TESTED ON NCLEX
1. A lack of QRS’s = no QRS asystole 2. Saw tooth = flutter atrial flutter 3. Chaotic = fibrillation atrial fibrillation with P wave 4. Chaotic = fibrillation ventricular fibrillation with QRS 5. Bizarre = tachycardia ventricular tachycardia 6. Periodic widened QRS PVC; one snapshot of tachycardia a. PVC’s are LOW priority unless… i. If there are more than 6 PVC’s in a minute ii. If there are more than 6 PVC’s in a row iii. If the PVC falls on the T wave of the previous beat b. If one of the three are true, you elevate priority of PVC client to MODERATE c. PVC’s never reach HIGH priority level LETHAL ARRHYTHMIAS: Kill you in 8 minutes or less, HIGH PRIORITY.
- Asystole
- Ventricular Fibrillation No cardiac output no brain perfusion dead in 8 minutes POTENTIALLY LIFE THREATENING
- Ventricular Tachycardia There IS cardiac output When the rhythm changes, doctor will ask… DO YOU GET A PULSE WITH THAT? If there is a pulse = THERE IS CARDIAC OUTPUT TREATMENT
- VENTRICULAR TACH and PVCs: Amiodarone or lidocaine.
- ATRIAL ARRHYTHMIAS/SUPRAVENTRICULAR TACHYCARDIA: ABCD’s A denosine/ADENOCARD push in less than 8 seconds FAST IV PUSH o IV PUSH: When you don’t know, you go slow BUT THIS IS ONE YOU HAVE TO KNOW!!! Use BIG vein. o Can go into asystole for 30 seconds since it’s such a fast push BUT they should come back!!! B eta-blockers “-lol” o Negative ino/chrono/drono = they are like valium for your heart o Treat AAA and AA o Therefore SE Hypotension & headache just like CCB C alcium Channel Blockers like VALIUM for your heart; same as Beta Blockers D igitalis digoxin, lanoxin KNOW NAMES!* *
- VFIB: For VFIB you DFIB Shock them!
- ASYSTOLE: Epinephrine and atropine in that order
CHEST TUBES
Re-establishes negative pressure in pleural space so that the lung expands when the chest wall moves Negative pressure is good in pleural space = makes things stick together (visceral and parietal layer) Positive pressure pulls things apart = more work; less air; because of positive pressure A. When you get a question, look for reason it was placed Pneumothorax : chest tube to remove air Hemothorax : chest tube removes blood Pneumo-hemo thorax : chest tube removes both air and blood Examples: CT for HEMOTHORAX – what would you report?
- No bubbling
- CT drained 800 ml in first 10 hours 3. CT is not draining b/c it is not doing what it’s supposed to do
- CT is intermittently bubbling CT for PNEUMOTHORAX – what would you report? 1 or 2.
- It’s supposed to bubble
- It’s not supposed to drain! B. Location of tube placement A for A, B for B! 1. Apical: chest tube is way up high draining air because air rises 2. Basilar : chest tube is at bottom of lungs draining blood because it is subject to gravity Examples: Your apical CT is draining 300ml/hr BAD! Your basilar CT is NOT bubbling GOOD! Hemo Basilar Pneumo Apical Pneumo/Hemo BOTH How many CT and where would they be placed for unilateral pneumohemothorax? Two. Apical for pneumo. Basilar for hemo. How many CT and where would they be placed for bilateral pneumothorax? Two. Both apical. How many CT and where would they be placed for post op chest sx? Two. Apical and basilar on side of sx.
CONGENITAL HEART DEFECTS
Every congenital heart defect is either trouble or no trouble. It either causes a lot of problems or it’s not big deal at all. There is no in between. Memorize ONE word TRouBLe Nurses role in defects teach about implications, NOT diagnosis. TROUBLE DEFECT NO TROUBLE DEFECT You need surgery, now, in order to live. You do not need surgery, you can possibly have it, years later, if it causes trouble, but usually does not cause trouble. Growth is slow and delayed. Growth is normal. Life expectancy short. Normal life expectancy. Parents stress, financial, grief, etc. Parents average life. D/C with apnea monitor. No apnea monitor. Pediatric cardiologist. Pediatrician/NP. Weeks in hospital after birth. 24-36 hours after birth. Shunts RIGHT TO LEFT because that’s the way T R OUB L E is spelled. Shunts blood LEFT TO RIGHT because it’s not the way TROUBLE is spelled. It is no trouble. TRou B Le RIGHT TO LEFT is BLUE Cyanotic; because TROUBLE is spelled that way. Acyanotic (pink). They will all have murmurs because of SHUNT. They will all have ECG done to find out why. There are 47 heart defects. All congenital heart defects that start with T are trouble. T RouBLe. Examples: Ventricular septal defect no trouble T etrallogy of Fallor TROUBLE Patent foramen ovale no trouble T runcus arteriosis TROUBLE T ransposition of great vessels TROUBLE Etc. Only ONE exception o LEFT VENTRICULAR HYPOPLASTIC SYNDROME o Boards will not bring this up FOUR DEFECTS OF TETRALLOGY OF FALLOR: “VarieD PictureS Of A RancH”
- VD ventricular defect
- PS pulmonary stenosis
- OA overriding aorta
- RH right hypertrophy Don’t memorize what they are. Just memorize the names.
INFECTIOUS DISEASE & TRANSMISSION BAS ED PRECAUTIONS
There are 4 precautions:
**1. Standard/Universal
- Contact** Private room preferred, cohort of same disease that are POSITIVE through CULTURE, no mask, gloves, gowns, hand washing, eye face shield no unless needed, special filter mask no, patient mask no, dedicated equipment (stethoscope, BP, etc, toy would be dedicated), negative airflow no. o Anything ENTERIC which means can be caught from intestine (fecal-oral) CDIFF Hepatitis A (A stands for ANUS = fecal oral) Cholera o Staph infections o RSV – respiratory syncytial virus which is fatal in babies How is it transmitted? DROPLET. But it is on CONTACT precaution. Because with little kids, they get it through contact of contaminated objects. o Herpes o Shingles (herpes zoster) 3. Droplet Private room preferred, cohort of same disease based on POSITIVE CULTURE, mask, gloves, NO gown, hand washing, eye face shield not unless needed, special filter mask no, patient mask needed when leaving room yes, dedicated equipment yes, negative airflow no. o Bugs that travel 3 feet o Meningitis o H flu which causes epiglottitis 4. Airborne Private room required unless cohorting, mask yes, gloves, gown not necessarily, hand washing, eye face shield not unless needed, special filter mask only for TB, patient mask needed when leaving room yes, dedicated equipment not necessarily, negative airflow yes. o Measles o Mumps o Rubella o TB o Spread by droplet, but airborne precaution. Varicella chicken pox
