● Acid base gasses
○ ABG interpretation
■ Rule of the B’’s
● If the pH and the Bicarb (HCO3) are both in the same direction then it is
metabolic
● Decrease in pH = acidosis
● Increase in pH = alkaline
○ Values
■ Normal pH = 7.35-7.45
■ Normal Bicarb = 22-26
■ PaO2 = 80-100 mmHg
■ PaCO2 = 35-45 mmHg
■ SaO2 = 95-100%
○ Signs and symptoms of Acid-Base imbalances
■ As the pH goes, so goes the patient except for potassium (because it will try to
compensate)
■ pH UP K+ DOWN (alkalosis)
● Tachycardia
● Tachypnea
● Diarrhea
● Tremors
● Seizure
● Hyperreflexia
● Agitated
● Borborygmi (increased bowel sounds)
● Hypertension
● Palpitations
● Tetany
● anxiety/panic
● Die due to seizure
■ pH DOWN K+ UP (Acidosis)
● Bradycardia
● Bradypnea
● Hypotension
● Decreased lucidity
● Anorexia
● Coma
● Lethargy
● Cardiac arrest
● Suppressed, decreased, falling
● Die due to respiratory arrest
○ Kussmaul (MacKussmaul)
■ Rapid and deep respirations
■ Only seen in metabolic acidosis
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■ This is a compensatory mechanism
○ Causes of acid-base imbalance
■ First ask “it is lung?’
● Yes -> then it is respiratory
■ Then ask yourself
● Are they over ventilating or under ventilating?
○ If over ventilating -> pick alkalosis
○ If under ventilating -> pick acidosis
○ Rate has nothing to do with ventilation (high rate and low SaO2
= under ventilating)
○ Low rate and high SaO2 is over ventilating
■ If not lung, then it’s metabolic
● If the patient has prolonged gastric vomiting or suction, pick metabolic
alkalosis
● For everything else that isn’t lung pick metabolic acidosis
○ Also, if you don’t know what to pick choose metabolic acidosis
● Alcoholism/any form of abuse
○ Note: remember in psych question if you are asked to prioritize DO NOT forget Maslow!
Use the following priorities:
■ Physiological
■ Safety
■ Comfort
■ Psychological
■ Social
■ Spiritual
○ Also, all psych patients start as med surg patient… rule out all feasible med answers
before picking psych answers
○ Pain is not the priority, pain falls under the “comfort”
■ We don’t give pain medication until we know what is happening
○ Psychodynamics of Alcoholism
■ The #1 psychological problem in abuse is DENIAL
● Definition: refusal to accept the reality of their problem
● Treatment:
○ Confront it by pointing out to the person the difference between
what they say and what they do
○ In contrast, support the denial of loss and grief (BC the use of
denial is serving a functioning process)
■ dependency/Codependency
● Dependency: when the abuser gets the significant other to do things for
them
● Codependency: when the significant other derives positive self-esteem
from doing other things for or making decisions for the abuser
● Treatment:
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○ Set boundaries (limits) and enforce them. Agree in advance on
what requests are allowed then enforce the agreement
○ Work on the self-esteem of the codependent person
■ Manipulation
● Definition: when the abuser gets the significant other to do things for
him/her that are not in the best interest of the significant other. The
nature of the act is dangerous or harmful to the significant other
● Treatment:
○ Set limits and enforce
○ It’s easier to treat than dependency/codependency because
nobody likes to be manipulated
○ Wernicke’s (Korsakoff’s) Syndrome- only seen in alcoholism
■ Psychosis induced by Vitamin B1 (Thiamine) deficiency
● Thiamine is necessary for the metabolism of alcohol to occur
■ Primary symptom: amnesia with confabulation (making up stories to fill in
memory loss– believe as true)
■ Characteristics:
● Preventable: by giving B1 vitamins
● Arrestable: can stop from getting worse- not imply better
● Irreversible: dementia symptoms don’t get better– only worse
■ Psychotic doesn’t know when they are confabulating and the truth
■ Our goal with dementia is maintenance/slowing of symptoms
○ antabuse/Revia
■ Disulfiram (drugs used for alcoholism)
■ Aversion therapy
● You get a patient to associate something that you want them to stop
doing with a very negative experience
■ Onset and duration of effectiveness: 2 weeks
● Take drugs 2 weeks and builds up in blood to a level that when drinking
alcohols will become horribly sick; if off for two weeks, will be able to
drink without sickness again
■ Patient teaching: avoid ALL forms of alcohol to avoid nausea, vomiting, and
possibly death including:
● Mouthwash, aftershave, perfumes/cologne, insect repellant, vinaigrettes
(salad dressing), vanilla extract, elixirs (contains alcohol-OTC med),
alcohol prep pad, alcohol sanitizers
○ Overdose vs Withdrawal
■ Uppers: MEMORIZE
● Names:
○ Caffeine
○ Cocaine
○ PCP/LSD (psychedelic hallucinogens)
○ Methamphetamines
○ ADHD- adderall/Ritalin
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○ Bath salts (Cath-Kath)
● signs/symptoms:
○ Tachycardia
○ Hypertension
○ Diarrhea
○ Agitation
○ Tremors
○ Clonus
○ Belligerent
■ Increase in the symptomatology on the violence scale
○ Seizures
○ Exaggerated, shrill, high pitched cry
○ Difficult to console
■ Downers
● Names: everything else
● Signs/Symptoms:
○ Bradycardia
○ Hypotension
○ Constipation
○ Constricted pupils
○ Flaccidity
○ Respiratory arrest
○ Decreased core body temperature
■ Then ask yourself, “Are they talking about overdose or withdrawal?”
● overdose/intoxication
○ “I have too much”
○ Too much upper: everything is UP
○ Too much downer: everything is DOWN
● Withdrawal
○ “I don’t have enough”
○ Too little upper: everything is DOWN
○ Too little downer: everything is UP
○ Drug addiction in the newborn
■ Always assume intoxication (first 24 hours after birth), then after this time
assume withdrawal
○ Alcohol Withdrawal Syndrome vs Delirium Tremens
■ Differences:
● Every alcoholic goes through alcohol withdrawal syndrome (AWS) (after
24 hours)
● Only a minority get delirium tremens (DT)
● AWS is not life threatening. DT’s can kill you
● Patients with AWS are not dangerous to themselves or others. Patients
with DTS are dangerous to self and others
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