Mark K Lectures

If the pH is low, what happens to everything else?

Everything else would also be low, except for potassium

If the pH is high, what happens to everything else?

Everything else would also be high, except for potassium

List some SE for a pt that has a pH of 7.50

tachycardia, tachypnea, HTN, seizures, irritability, spasticity, diarrhea, borborygmi, hyperreflexia (3+/4+), HYPOkalemia

List some SE for a pt who has a pH of 7.30

bradycardia, bradypnea, HOTN, constipation, absent BS, flaccid, obtunded, lethargy, coma, hyporeflexia (0,1+), HYPERkalemia

What is a nursing intervention for a pt in alkalosis?

Suctioning bc of seizures

What is a nursing intervention for a pt in acidosis?

ventilate pt with ambu bag bc of respiratory arrest

What is the significance of “MAC Kussmaul?”

Kussmaul resp is only seen in Metabolic ACidosis

If a pt is overventilating, are they in acidosis or alkalosis?

alkalosis

If a pt is underventilating, are they in acidosis or alkalosis?

acidosis

If a pt is on a PCA, what would their ABG interpretation be?

respiratory acidosis

If a pt has prolonged gastric vomiting, what would their ABG interpretation be?

metabolic alkalosis

What triggers high pressure alarms on a ventilator?

increased resistance to air flow

What is the appropriate order for addressing a high pressure alarm on a mech vent?

1. unkink the tubing

2. empty the water out of the tubing

3. turn the pt and ask them to cough or deep breathe

4. suction the tubing PRN

What are low pressure alarms on a vent triggered by?

decreased resistance to air flow caused by main tubing disconnection and O2 sensor disconnection

How do you respond to a low pressure alarm on a vent?

Reconnect all disconnected tubing

If the vent tubes are on the floor, what do you do?

bag the pt and call RT

If the vent setting is too high, is the pt in resp acid or resp alk?

resp alk bc they are overventilating/panting

If the vent setting is too low, is the pt in resp acid or resp alk?

resp acid bc they are underventiling/retaining CO2

The PCP wants to wean a pt off the vent in the morning. The ABG results say resp acid. What do you do next and why?

Notify PCP and let them know that the pt is not ready to be weaned off vent bc pt is underventilating.

The PCP wants to wean a pt off the vent in the morning. The ABG results say resp alk. What do you do next and why?

Notify PCP that the pt is ready to be weaned off bc pt is overventilating the vent

What is the #1 psychological problem?

Denial

How should a nurse respond to denial?

Confront the pt without aggression

A nurse tells the pt “Ok. You say you’re not an alcoholic but it’s 10 AM and you’ve have a 6 pack.” What did the nurse demonstrate?

Confrontation

What are the 5 stages of grief?

1. Denial

2. Anger

3. Bargaining

4. Depression

5. Acceptance

What is psychological problem #2?

Dependency or co-dependency

Define dependency.

This is when the abuser gets their SO to do things for them or make decisions for them, meaning the abuser is dependent on their SO

Define co-dependency.

This is when the SO obtains positive self-esteem from doing things for the abuser or making decisions for the abuser; SO is co-dependent since they feel food for “doing stuff” for abuser

How do you treat dependency/co-dependency?

• Confront the abuser (dependent pt)

• Tech co-dependent pts to set limits and enforce the, and work on self esteem

• Teach SO to say no

What is the difference bw co-dependency and manipulation?

In co-dependency, the abuser tells SO to do things for them or make decisions for them, and the SO gets a self-esteem boost while manipulation is when the SO is not interested in doing what the abuser tells them to do bc it can be harmful for them

How do you treat manipulation?

Set limits and enforce them

Determine is the following scenario is a dependent/co-dependent issue or a manipulation issue: A 49-year-old alcoholic gets her 17-year-old son to go to the store and buy alcohol for her

Manipulation

Determine is the following scenario is a dependent/co-dependent issue or a manipulation issue: A 49-year-old alcoholic asks her 50 yo husband to go to the store and buy alcohol for her.

Dependency/co-dependency

What is Wernicke and Korsakoff induced by?

Vitamin B1 (Thiamine) deficiency

What are the primary s/sx of Wernicke and Korsakoff syndrome?

Amnesia (memory loss) and confabulation (making up stories)

If a pt with Wernicke and Korsakoff is confabulating about going to a meeting with Barack Obama this morning, what would you do?

Redirect the pt into doing something they can do

What are the characteristics of Wernicke and Korsakoff syndrome?

1. Preventable… Take B1

2. Arrestable (stop it from getting worse)… Take B1

3. Irreversible (70%)… Will kill brain cells

What does disulfiram do?

Helps someone stop drinking alcohol

What does Naltrexone do?

Acts as an antidote for alcoholism

What is Aversion Therapy?

a type of behavior therapy that makes a pt give up an undesirable habit by causing them to associate it with an unpleasant effect

What is the onset and duration of effectiveness for disulfiram and naltrexone?

2 weeks

Why should pts avoid all forms of alcohol while taking disulfiram or naltrexone?

It can cause N/V or death

List some not-so-obvious items that contain alcohol.

• mouthwash

• cologne/perfume

• aftershave

• elixir

• most OTC liquid meds

• insect repellant

• hand sanitizer

• vanilla extract

Does Red Wine vinaigrettes have alcohol in them?

No

List the “Upper” drugs.

• Caffeine

• Cocaine

• PCP/LSD

• Methamphetamines

• Adderall

What are the s/sx of upper drugs?

Euphoria, seizures, restlessness, irritability, hyperreflexia, (3+/4+), tachycardia, borborygmi, diarrhea

What are the s/sx of downer drugs?

Lethargy, respiratory depression/arrest, constipated, etc.

What is the highest priority to anticipate for those on an upper drug?

suctioning d/t seizures

What is the highest priority to anticipate for those on a downer drug?

intubation/ventilation d/t resp arrest

If your pt is high on cocaine, is having a RR of 12 important? If not, then what should be assessed instead?

No; assess for reflexes (3+/4+), irritability, borborygmi, or inc temp

What s/sx are expected if a pt has overdosed on cocaine?

Irritability, 4+ reflexes, borborygmi, inc temp, etc.

What s/sx are expected if a pt is withdrawing from cocaine?

RR < 12, difficult to arouse

What drug should be given if a pt was withdrawing from cocaine?

Naloxone

When should you assume a newborn is intoxicated?

If the newborn is less than 24 hours old after birth

When should you assume a newborn is in withdrawal?

If the newborn is 24 hours old or more

If an infant is born to a Quaalude addicted mother 24 hours after birth, what s/sx are expected to be seen in the newborn?

difficulty to console, seizure risk, shrill, high-pitched cry, exaggerated startle reflex

When do pts go through AWS and is it life-threatening??

Approx. 24 hours after pt stops drinking; it’s not life-threating

When do pts go through DT and is it life-threatening?

Approx 72 hours after pt stops drinking; it’s life-threatening

What is included in the nursing care plan for AWS?

• Regular diet

• Semiprivate room, anywhere on the unit

• Pt is up ad lib (free to move around)

• No restraints

What is included in the nursing care plan for DT?

• NPO (seizures) or clear liquid diet

• Private room, near nursing station

• Restricted bedrest (pt not free to move around and can’t use bathroom)

• Restraints (vest or 2-point lock letters)

What meds can you give for both AWS and DT?

• Anti-HTN meds

• tranquilizers

• Multivitamin with Vitamin B1

In what two situations would resp arrest be a priority?

• overdose on a downer

• withdrawal of an upper

In what two situations would seizure be a priority?

• overdose of an upper

• withdrawal of a downer

What do aminoglycosides treat?

Serious, resistant, life-threatening, gram negative infx.

Ex: TB, septic peritonitis, fulminating pyelonephritis, septic shock, infx from 3rd degree wound covering >80% of body

What do aminoglycoside drug names have in common?

End in “-mycin” BUT NOT “-thromycin”

What are the top two toxic effects of aminoglycosides?

1. Ototoxicity

2. Nephrotoxicity

Is 24 hour Cr clearance better than serum Cr?

Yes

What admin route are aminoglycosides given through?

IM or IV

When are aminoglycosides given PO?

• hepatic encephalopathy (high ammonia levels)

• Pre-op bowel surgery (to sterilize bowel b4 surgery)

Which drugs can sterilize bowel?

Neomycin and Kanamycin

What is “TAP” and what is the purpose?

• Trough

• Administer

• Peak

Trough and peak are drawn bc of a drug’s Narrow Therapeutic Index, which means there is a small difference in what works and what kills

What drugs should you draw troughs and peaks for?

Furosemide, Digoxin, and Aminoglycosides

When do you draw a trough?

30 min before next dose of a med

When do you draw the peak?

Depends on the route:

• SubL: 5-10 min after drug dissolved

• IV: 15-30 min after drug is done (bag empty)

• IM: 30-60 min

• SubQ: depends on insulin

• PO: not necessary, not tested

You give 100 mL of a drug at 200 mL/hr (drug takes 30 min to run). If you hang it at 1030, when will the drug peak?

1100

What is the purpose of CCB?

Relax and slow down the heart by having negative chronotropic, inotropic, and dromotropic properties

When do you want to relax and slow down the heart?

To treat: A, AA, AAA

• Antihypertensive

• Anti Anginal drugs (dec O2 demand)

• Anti Atrial Arrythmia

What are some common SE of CCB?

HA and HoTN

Name some CCB.

• “-dipine”

• Diltiazem

• Verapamil

When should CCB be held and not given?

If SBP < 100

Which cardiac rhythm is shown?

NSR

Which cardiac rhythm is shown?

V-Fib

Which cardiac rhythm is shown?

V-tach

Which cardiac rhythm is shown?

Asystole

Which cardiac rhythm is shown?

Atrial Flutter

Which cardiac rhythm is shown?

A-fib

What does a P wave represent?

Atrial depolarization

What does a QRS complex represent?

Ventricular depolarization

Are PVCs a low or high priority and why?

Low priority bc it is common to see PVCs after an MI

When do you elevate PVCs to moderate priority?

1. More than 6 PVCs in a min

2. More than 6 PVCs in a row

3. R on T phenomenon (a PVC falls on a T wave)

Which arrythmias are high priority and why?

Asystole and A-fib bc they both produce low or no CO, which means no brain perfusion so confusion and death may occur

Which arrythmia can be potentially lethal?

V-tach bc even tho it has CO

How do you treat PVCs and V-tach?

Lidocaine or Amiodarone

How do you treat supraventricular arrythmias?

• Adenosine (SVT)

• Beta-Blockers (-olol)

• CCBs (-dipine + diltiazem, verapamil)

• Digoxin, Lanoxin

Does Beta blockers have positive or negative tropic effects on the heart?

negative

How do you treat V-fib?

Defib/shock them

How do you treat asystole?

Epinephrine and Atropine

What is the purpose of chest tubes?

To reestablish negative pressure in the pleural space

Define pleural space

space bw the lung (visceral pleura) and chest wall (parietal pleura)

In a pneumothorax, what does the chest tube remove?

Air

In a hemothorax, what does the chest tube remove?

Blood