Mark K Lectures

pH

7.35-7.45

PaCO2

35-45

HCO3

22-26

PaO2

80-100

02 sat

> 95%

acidosis

pH < 7.35

alkalosis

> 7.45

S/S of acidosis

if pH is low, everything is low except potassium

• bradycardia, constipation, absent bowel sounds, flaccid, obtunded, lethargy, coma, hyporeflexia, bradypnea, low BP, hyperkalemia

acidosis nursing intervention

ventilate with ambu bag due to respiratory depression

S/S of alkalosis

if pH is high, everything is high except potassium

• tachycardia, tachypnea, HTN, muscle cramps, tetany, paresthesia, irritability, seizures, hyperreflexia, borborygmi, spastic, diarrhea, hypokalemia

alkalosis nursing intervention

suctioning due to seizures

respiratory acidosis

underventilation

respiratory alkalosis

overventilation

metabolic acidosis

everything else

metabolic alkalosis

prolonged gastric suctioning or vomiting

ventilator

a machine designed to move breathable air into and out of the lungs, aids patients who are physically unable to breathe, or breathing insufficiently

high pressure alarm

triggered by increased resistance to air flowca

causes of high pressure alarm

kinks in tubing, condensed water in dependent tube, mucus plugs

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 deep breathe

4. suction

low pressure alarm

triggered by decrease in resistance

causes of low pressure alarms

main tubing disconnection, O2 sensor disconnection

interventions for low pressure alarm

reconnect the tubing unless tube is on the floor, then call RT and bag pt

what is the number one psychological problem in any abuse situation?

denialis commonly the number one psychological problem in any abuse situation, as it prevents the acknowledgment of the abuse and the need for help.

how to respond to patients in denial

confront them by pointing out the difference in what they say and what they do; don’t attack the person; good answer has “I”, bad answer has “you”

stages of loss and grief

denial, anger, bargaining, depression, acceptance

one place where denial is okay, provide support

dependency

when they get the significant other to do things or make decisions for them; the abuser is dependent

co-dependency

when the significant other derives self-esteem for doing things or making decisions for the abuser; the significant other is co-dependent

how to treat dependency/codependency

-dependent pts are abusers; confront them

-co-dependent pts have self-esteem issues; teach pts how to set limits and enforce them

-agree in advance on what requests are allowed, then enforce

-teach significant other to say no

-work on self-esteem on the co-dependent person

manipulation

when the abuser gets the significant other to do things or make interests that are not in the best interests of the significant other; the nature of the act is dangerous and harmful to the significant other

wernicke and korsakoff

-wernicke is an encephalopathy

-korsakoff is a psychosis

-they tend to go together

-psychosis induced by vitamin B1, thiamine deficiency

-the patient loses touch with reality due to vitamin B1 deficiency

S/S of wernicke/korsakoff

amnesia and confabulation

how to deal with a patient w/ wernicke & korsakoff

-redirect the pt to something they can do

characteristics of wernicke & korsakoff syndrome

1. preventable

2. arrestable (stop it from getting worse)

3. irreversible (70%) ~ will kill brain cells

antabuse and revia (disulfiram)

antabuse: alcohol deterrent, revia: antidote

aversion therapy: a type of behavior therapy designed to make a patient give up an undesirable habit by causing them to associate it with an unpleasant effect (works better in theory than in reality)

antabuse/revia onset and duration

takes 2 weeks to start working and lasts for 2 weeks

antabuse/revia pt teaching

-teach pt to avoid all forms of ETOH, not doing so may lead to symptoms of n/v or even death

-mouth wash, cologne, perfume, aftershave, elixir, most OTC liquid medicine, insect repellant, hand sanitizer, vanilla extract (NOT red wine vinaigrette)

upper drugs

caffeine, cocaine, PCP/LSD (psychedelics/hallucinogenics), methamphetamines, adderall

downer drugs

anything that is not an upper

upper overdose/withdrawal

overdose: things go up (euphoria, seizures, restlessness, irritability, hyperreflexia, tachycardia, increased bowels (borborygmi), diarrhea)

withdrawal: opposite

downer overdose/withdrawal

overdose: things go down (lethargic, respiratory depression/arrest, constipated, etc)

withdrawal: opposite

drug abuse in newborn

always assume intoxication, not withdrawal, in a newborn less than 24 hours after birth; more than 24 hours after birth, you can assume the newborn is in withdrawal

alcohol withdrawal syndrome

-occurs 24 hours after the person stops drinking

-non life threatening to self and others

-nursing care plan:

• regular diet

• semiprivate room anywhere on unit

• pt is up ad lib

• no restraints

delirium tremens

-occurs in less than 20% of AWS, 72 hours after drinking

-life-threatening to self and others

-nursing care plan

• NPO or clear liquid diet

• private room, near nursing station

• restricted bed rest

• restraints (vest or 2-point lockers)

aminoglycosides

“a mean old mycin”, used to treat serious, resistant, life-threatening, gram negative infections; unsafe at toxic levels; does NOT include mycins with “thro” in them; administer q8 hours

aminoglycoside toxic effects

ototoxicity: monitor hearing, balance, tinnitus (CN8 toxicity)

nephrotoxicity: monitor creatinine (24-hour Cr clearance better than serum Cr)

why are aminoglycosides only given IV/IM

they are not absorbed through the GI tract, therefore would not have any effects

only two cases when aminoglycosides are given PO

hepatic encephalopathy (decrease ammonia production by E. coli) and pre-op bowel surgery (sterilizes bowel)

who can sterilize my bowel

Neo Kan (neomycin and kanamycin)

why are troughs and peaks drawn

a drug has a narrow therapeutic window or index, which means there is a small difference between what works and what kills

when are troughs drawn

30 minutes before next dose

sublingual med peak

5 to 10 minutes after drug is dissolved

IV med peak

15 to 30 minutes after drug is finished (bag empty)

IM peak

30 to 60 minutes

positive inotropy

increase cardiac contractile force → ventricles empty more completely → cardiac output improved

positive chronotropy

increased rate of impulse formation at SA node → accelerate heart rate

positive dromotropy

increase speed that impulses from SA node travel to AV node

negative inotropy

weaken/decrease force of myocardial contractionne

negative chronotropy

decrease rate of impulse formation at the SA node → decelerate heart rate

negative dromotropy

decrease speed that impulses from SA node travel to AV node

calcium channel blockers

negative inotropic, chromotropic, and dromotropic effects on the heart

when do you want to use CCBs

antihypertensive

antianginal drugs

antiatrial arrhythmia

CCB side effects

headache and hypotension

names of CCBs

anything that ends in “dipine”, verapamil, cardizem (diltiazem): given continuous IV drip

parameters to assess before administering CCBs

BP (hold is SBP < 100)

normal sinus rhythm

-there is a p wave, followed by a QRS, followed by a t wave for every complex

-peaks of the p wave is equally distant to the QRS and fall within 5 small boxes

ventricular fibrillation

-no pattern

-chaotic QRS complexes

ventricular tachycardia

-sharp peaks with a pattern

-bizarre QRS complexes

asystole

-a flat line

-a lask of QRS complexes

atrial flutter

-P waves in the form of saw tooth wave

atrial fibrillation

-chaotic P wave patterns

1st degree AV block

-prolonged PR interval

2nd degree AV block type 1

-progressive lengthening of PR interval until P wave is dropped

2nd degree AV block type 2

-p waves with missing QRS

3rd degree AV block

-no correlation between atria and ventricles

PVC

-periodic, wide, bizarre QRS complexes

-common after MI and is a low priority

QRS depolarization

ventricular

P wave

atrial

when should PVCs be elevated from low priority to moderate priority?

-there are more than 6 PVCs in a minute

-more than 6 PVCs in a row

-R on T phenomenon (falls on a T wave)

lethal arrhythmias

-asystole

-v-fib

-potentially v-tach (check for pulse to determine CO)

treatment of ventricular arrhythmias

amiodarone (used to be lidocaine as well)

treatment of atrial arrhythmias (supraventricular)

-Adenocard (adenosine): push in less than 8 seconds, 20 mL of NS right after; asystole will occur for about 3 seconds

-Beta blockers (end in -olol)

-CCBs

-Digitalis (digoxin), Lanoxin

beta blockers

-negative inotropic, chronotropic, and dromotropic effects on the heart

-antihypertensive, antianginal, antiatrial arrhythmia

-side effects: headache, hypotension

treatment of v-fib

defibrillate

treatment for asystole

epinephrine and atropine

chest tubes

purpose is to reestablish negative pressure in the pleural space, which makes things stick so that the lung expands when the chest wall expands

-in a pneumothorax, chest tube removes air

-in a hemothorax, chest tube removes blood

-in a hemopneumothorax, chest tube removes blood and air

apical chest tube

on top, removes air

basilar chest tube

at base, removes blood

post trauma or postsurgical patient needs

-always assume trauma and surgery in unilateral unless otherwise specified

-no need for a chest tube with a pneumectomy

-chest tube will be used for lobectomy or wedge resection

closed chest drainage devices

Jackson-Pratt, emission, pneumovac, hemovac, etc

what happens if a closed chest drainage device is knocked over?

-ask the patient to take a deep breath and set the device back up

-not a medical emergency, no need to call the physician

if the water seal of the chest tube breaks:

-clamp the tube

-cut the tube away

-submerge the end of the tube under sterile water

-unclamp the tube if it was initially clamped

-this all must be done in 15 seconds or less

if a chest tube get pulled out:

-take and gloved hand and cover the opening

-take a sterile vaseline gauze and tape 3 sides

bubbling in the water seal chamber

-if it is intermittent, it is good (document it)

-if it is continuous, it is bad and indicates a break/leak in the system (find it and tape it)

bubbling in the suction control chamber

-if it is intermittent, suction pressure is too low (increase it at the wall until it is continuous)

-if it is continuous, it is good (document it)

rules for clamping tubes

-do not clamp a tube for more than 15 seconds without a physician’s order

-use rubber, double clamps (will not puncture tubing)

parent teaching for patients with TRouBLe congenital heart defects

-needs surgery now/soon to live

-has slowed/delayed growth and development (failure to thrive)

-has a shortened life expectancy

-parents will experience a lot of grief, financial, and emotional stress

-patient is likely to be discharged home on a cardiac monitor

-after birth, patient will be in the hospital for weeks

-pediatrician or pediatric nurse will likely refer patient to a pediatric cardiologist

what is a TRouBLe congenital heart defect?

-shunts blood from Right to Left

-Blue (cyanotic)

examples of TRouBLe:

-tetralogy of fallot

-truncus arteriosus

-transposition of the great vessels

-tricuspid atresia

-totally anomalous of pulmonary vasculature (TAPV)

-left ventricular hypoplastic syndrome

examples of no TRouBLe heart defects

-ventricular septal defect (VSD)

-patent ductus arteriosus (PDA)

-patent foramen ovale

-arterial septal defect

-pulmonic stenosis

what do all children with a congenital heart defect have? (TRouBLe or no TRouBLe)

a murmur (an echocardiogram needs to be done to find out cause of murmur)